Fertility Changes During Perimenopause
The slight but real persistence of fertility in a woman’s later reproductive years poses a contraceptive challenge for some and a reproductive opportunity for others, representing a clinical balancing act for patient and physician.
The functional activity of the ovary changes more with age than almost any other organ in the body. This translates into a significant decline in fertility in women starting at age 35 to 38 years, or 10 to 15 years before menopause.
OVARIAN CHANGES
The ovary attains the maximum number of germ cells during fetal development, and follicular loss begins in utero. Women are born with 1 to 2 million follicles. By menopause, there are only several hundred to several thousand remaining. Most follicular loss results from atresia (cell death and degeneration) and not ovulation, which accounts for (FSH) during perimeno-pause.
The higher FSH levels recruit relatively more follicles per cycle, and for a time, this feedback loop sustains follicular development and ovulatory function. It may also promote the acceleration in follicular atresia seen at this age. Thus, the increase in FSH values reflects the quality and quantity of aging follicles.
However, as the relationships among the monotropic FSH rise, accelerated follicular atresia, shortened follicular phase, and oocyte quality remain to be determined. In addition to oocyte quality, which is the primary determinant of reproductive potential, age-related uterine changes may contribute to decreased fertility without creating any major shift in the menstrual cycle.
Together, the ovarian and uterine changes contribute to the increased risks of spontaneous miscarriage (greater than 50% by age 45 years), fetal chromosomal abnormalities (approximately one in eight at age 49 years), and other pregnancy complications (eg, premature labor, fetal mortality) in women of advanced maternal age.
Despite the decline in fertility during perimenopause, women should be aware that pregnancy is still possible until FSH levels are consistently elevated (greater than 30 mIU/mL) and menopause occurs. Therefore, it is important to consider appropriate contraception if pregnancy is not desired.
For women who want contraception, the choice should be individualized based on medical history, lifestyle, and sexual habits. Because of the difficulty in assessing when menopause actually occurs in hormonal contraceptive users, many clinicians advise women to continue contraceptive use until at least age 51 years.
Fertility at perimenopause is decreased but not absent, representing a reproductive risk to some women and a prospect to others. As this transition may cover 10 to 15 years, it is important for the physician to discuss each woman’s desires and goals in the context of her hormone levels, medical profile, and lifestyle.
Photo credit: Her son, by taliesin
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Category: Fertility, menopause, ovaries, perimenopause
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