Contraception for the over 40’s

As women get older their contraceptive needs change  for many different reasons. this is at a time  when their natural fertility is declining as they approach menopause but contraception is still  important should they not wish an unplanned pregnancy, 10-12% of women between 40 and 49, not using any method of contraception can expect to become pregnant.

When women enter their forties,  they may begin to experience symptoms of menopause, as well as developing other health issues in addition to changes taking place in their  personal lives,  all of this can impact on their contraceptive choice.

As women get older they have an increased risk of obesity, cardiovascular disease and breast and gynaecological cancers.

No method of contraception is contraindicated by age alone, until 50 when women are advised against oestrogen containing methods.

In this article i will talk through the various options, the risk of failure and an unwanted pregnancy and pregnancy itself should always be set against the risk of the method used.

Non-Hormonal methods

There are 3 types, barrier methods, natural family planning and withdrawal.

Barrier methods

These literally provide a barrier between the sperm and the egg preventing fertilisation. there is no age barrier and minimal contraindications

They include, male and female condoms, diaphragms and cervical caps , and  are usually more effective in older women due to better compliance , coupled with a decline in fertility.

The main disadvantage is that they are highly dependant on the user, and may not be suitable for women suffering with any type of genital prolapse, more common in older women,  or if their  partners suffer with erectile dysfunction, diaphragms and cervical caps need to be fitted initially by a properly trained clinician.

Condom use, either alone or in conjunction with other methods should also be advised for women who at high risk of STIs.

Natural Family Planning

This becomes less reliable as women age , periods often become unpredictable and “safe time” cannot easily be calculated , cycles may become anovulatory and the cervical secretions are more difficult to interpret

Withdrawal

This is not promoted but never less is still used by by about 5% of women, it has a high failure rate , approximately 20%.

Hormonal Methods

Hormonal methods are contraceptives which contain either an oestrogen and a progestogen, progestogen alone.  They  can be administered in a number of different guises, depending on the type used.

Combined methods, containing both oestrogen and progestogens, are commonly given as a pill but are also available in the form of patches and vaginal rings. They are given cyclically and induce a monthly bleed, in some circumstances patients may be advised to use them continually and then no withdrawal bleed occurs. In women over 40, they  should only be prescribed after consulting the UKMEC categories and ideally be a brand that contains levonorgestrel or or norethisterone, rather than other progestogens.

Progesterone only contraception can be in the form of pills, taken daily without a break , injections, every three months, implants inserted into the upper arm, which lasts for 3yrs and finally progesterone containing intrauterine devices .

Progesterone only pills are soon to be available via pharmacists in much the same way as the after sex pill and negate the need to see a doctor or a nurse.

Menstrual bleeding problems increase with age and women should be encouraged to seek advice for their doctor if there is any change in their usual bleeding pattern

How different hormonal methods of contraception may affect the menopause

In women using contraception containing oestrogen , the symptoms of the menopause are often, masked and blood measurements of both estradiol and follicle stimulating hormone, the main marker for menopause, are suppressed and so cannot be used to base advice about stopping contraception or menopausal status.

In women using progesterone only methods , then FSH can be used to diagnose menopause but generally speaking blood tests are not required to diagnose the menopause over the age of 45.

The diagnosis of menopause is made on the basis of menstrual change and the development of menopausal symptoms. Menopausal symptoms are not masked in the same way using progesterone only methods, and hormone replacement therapy can be added into the progesterone contraceptive.

If a women is using a  Mirena levonorgestrel IUS ,she is likely to be amenorrhoeic and this could also confer endometrial protection as well as ongoing contraception. Hormone replacement therapy alone is not a method of contraception.

The IUS only has a license to confer endometrial protection for five and so the women should be advised either a change of device or be prescribed HRT containing both oestrogen and progesterone, thus providing contraception until 55. The progesterone only pill , implant and injectable are not recommended for endometrial protection as part of HRT

If the women is using progesterone only method then hormone replacement therapy can simply be added in sequential form, either as a patch of a gel.

It is important to remember that younger women can become menopausal, 1% of women under the age of 40 and 5% under the age of 45, will develop premature ovarian insufficiency,(POI) and if these women continue taking the pill unknowingly there is clearly the possibility they have had the menopause and it has gone unnoticed and,  5% under the age of 45 and whilst this is not diagnosed as POI, the diagnosis may be missed depending on their chosen method on contraception.

When to stop using contraception?

Generally all women can stop contraception over 55yrs of age, as spontaneous conception is very rare even in the presence of regular bleeds.

For women under 55yrs of age, the simple answer is when the menopause is reached but it may be masked by hormones and is only a retrospective diagnosis , made by amenorrhea lasting12m after the last period.

If taking progesterone only contraception and the patient is period free and keen to stop using contraception , it may be helpful to measure the FSH level and if raised , advised further use for 12m before discontinuing their pills.

Article written by Dr Joanne Hobson