Contraception for women
aged over 40 years
Susanna Hall
Research Doctor
Clinical Effectiveness Unit of the Faculty of Sexual and
Reproductive Health
23 November 2010
Contraception for the over 40’s
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Is contraception necessary?
Choosing contraception
Specific contraceptive methods for women over
40
STIs and safer sex
Menopause and stopping contraception
Conclusions
Is contraception over 40 years of age
necessary?
www.statistics.gov.uk
28 February 2008
Conception vs infertility
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As age increases, fertility
decreases in women
Declines to lesser degree in
men
At 40-44, 36% likelihood of
spontaneous pregnancy
Source: Management of the
Infertile Woman, Helen A
Carcio
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In 2009
26,976 live births to women aged 40 and over in
England and Wales (ONS)
8132 Abortions to women over 40 years in
England and Wales (ONS)
Similar story in Scotland
Pregnancy outcomes
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Pregnancy later in life is associated with worse reproductive
outcomes:
Maternal
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Gestational diabetes
Placenta previa
Placental abruption
Caesarean section
Fetal
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Chromosomal abnormalities (eg Trisomy 21)
Miscarriage
Low birth weigh
Preterm delivery
Increased perinatal mortality
Wish for continued fertility?
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Be aware not all women in their 40’s have
finished their family
Realism about declining fertility after 40
Increased potential mortality and morbidity for
mother and fetus, especially if any comorbidities
Decreased success for fertility treatment
Fertility treatment not NHS funded over 40
years
Changes in partner
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Divorce average age is 41.2 years for women in
England and Wales
New relationships may start after long term
monogamous relationships
Support for review of sexual health, including
contraception and STIs
Choosing contraception
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Wide range of contraceptive methods available
No contraceptive method is contraindicated
based on age alone
Age may become a more significant risk factor
in conjunction with other medical conditions
Choosing contraception
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Clinical history
UK Medical Eligibility Criteria for contraceptive
Use (UKMEC)
Evidence based recommendations for use of
contraceptive methods in presence of medical
conditions
 Does not take into account multiple conditions
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Women’s choice of method
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Aged 40-44y, 75% used at least 1 method
Aged 45-49y, 72% used at least 1 method
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Most commonly used methods:
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Sterilisation (male and female)
Male condom
Pills
IUD
Office for National Statistics, Contraception and Sexual Health
Survey, 2008-9
Long Acting Reversible methods of
Contraception
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Methods that require administration less than once per
month
Typical failure rates are lower than for shorter acting
contraception
Cost effective at 1 year of use
Failure rates comparable to female sterilisation, offering
a reliable alternative
No delay in fertility return except with progestogenonly injectable (delay of up to 1 year)
Effective and Appropriate Use of Long Acting Reversible
Contraception, NICE 2005
Combined Hormonal Contraception
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3 forms of combined hormonal contraception
Most evidence relates to the combine hormonal pill
UKMEC assumes all risks are similar
Age over ≥40y UKMEC 2
Health Benefits of Combined
Hormonal Contraception
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Dysmenorrhoea and cycle control
Menopausal symptoms
Bone health
Ovarian and endometrial cancer
Benign breast disease
Colorectal cancer
Health Risks with CHC
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Breast cancer
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Annual risk of breast cancer increases with increasing age
There may be a small additional risk of breast cancer with
CHC use
Any risk reduces to no risk 10 years after stopping CHC
Current breast cancer UKMEC 4
Family history of breast cancer UKMEC 1
BRCA 1 and 2 mutation carrier UKMEC3- expert clinical
judgement and/or referral to specialist provider
Health Risks with CHC
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Cervical cancer
Small increased risk (invasive and in situ)
 Long term users can be reassured that benefits
outweigh risks
 Risk of invasive cancers declines after stopped using
(after 10 years, return to never user risk)
 HVP and condom use
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Health Risks with CHC
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Venous thromboembolism (VTE)
VTE is rare in women of reproductive age
 VTE risk increases with increasing age
 Relative risk of VTE is increased with use of the
COC
 Uncertainty about the risks of patch and risks of
CVR unknown
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Health Risks with CHC
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UKMEC categories for CHC
Personal history of VTE UKMEC 4
 Current VTE (on anticoagulants) UKMEC 4
 Family history of VTE
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 1st
degree relative aged <45y UKMEC 3
 1st degree relative aged ≥45 y UKMEC 2
Health Risks for CHC
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Cardiovascular disease: MI and Stroke
MI and stroke are rare in women of reproductive
age
 Risk increases with increasing age
 Conflicting evidence regarding risk
 Cumulative additional risk if multiple risk factors
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Health Risks for CHC
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UKMEC categories for CHC
Stroke (CVA including TIA) UKMEC 4
Hypertension
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Adequately controlled hypertension UKMEC 3
Consistently elevated blood pressure
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Systolic >140-159mmHg or diastolic >90-94mmHg UKMEC 3
Systolic ≥160 mmHg or diastolic ≥95mmHg UKMEC 4
Vascular disease UKMEC 4
Multiple risk factors for CV disease (older age,
smoking, diabetes, obesity, hypertension) UKMEC 3/4
Progestogen-only Contraception
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Progestogen-only pill
Injectable
Sub-dermal implant
Levonorgestrel-releasing intrauterine system
Health Benefits for POC
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Dysmenorrhoea
Bleeding patterns
Menopausal symptoms
Health Risks of POC
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Reproductive cancers- no conclusive evidence
Current breast cancer UKMEC4
Previous breast cancer UKMEC3
Bone health
Health Risks associated with POC
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Cardiovascular and cerebrovascular disease
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Venous thromboembolism
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Limited data suggest no increased risk of MI and
stroke
Little or no effect on risk of VTE
Effect of DMPA on lipid metabolism
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Theoretical risk of vascular disease in women with
additional risk factors
UKMEC 2009
Non-Hormonal contraception
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Copper IUD
Sterilisation
Barrier contraception
Fertility awareness methods
Withdrawal
Copper Intrauterine device
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Menstrual bleeding problems are common in
women over 40 and IUD users
Spotting, heavier periods and pain in first 3-6
months
Seek medical advice if symptoms persist or
occur as new event, to exclude gynaecolgical
pathology
Sterilisation
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Advice about all methods of contraception
including LARCs should be provided
Advantages and disadvantages, including lower
failure rate and major complications with
vasectomy compared to laparoscopic
sterilisation
Barrier contraception
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No restriction on use
Use of spermicide is recommended with caps
and diaphragms
Condoms with spermicidal lubricant should not
be used
Lubricant should be non-oil based
Fertility Awareness methods
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Numbers using fertility
awareness unknown
May become more
difficult as approaching
the menopause
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Irregular cycles
Anovulatory cycles
Withdrawal
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Not promoted as a method of contraception
Reported by ~6% women aged 40-44y
If used correctly, may work for couples,
particularly as backup to other methods
Should be aware not as effective as other
methods of contraception
Emergency contraception
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No restrictions on use of EC based on age alone
Women should be made aware of the different types of
EC available
Sexually transmitted infections
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STIs are not confined to younger people
There has been an increase in diagnoses in over
40 year olds
Condoms protect against STIs even after
contraception no longer required
Diagnosing the Menopause
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Retrospective diagnosis: 1 year amenorrhoea
No single reliable marker of perimenopause
Stopping contraception
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In general contraception may be stopped at the
age of 55 years
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Advice need tailored to the individual
If having regular menstrual cycles at 55 yshould continue on some contraception
Non-hormonal methods
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If over 50 years
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If under 50 years
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After 1 year of amenorrhoea (1 year after LMP)
After 2 years of amenorrheoa (2 years after LMP)
Cu-IUD- if inserted ≥40y, may be retained until
the menopause (outside license)
Hormonal Methods
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Amenorrhoea is not a reliable indicator of ovarian
failure if taking exogenous hormones
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FSH: for those over 50y and taking POC
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Not reliable with combined methods
If over 50y and wishing to stop POC, check FSH
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If level ≥30IU/L, repeat FSH in 6 weeks. If second FSH
≥30IU/L- stop contraception after 1 year
Removing the LNG-IUS
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Amenorrhoea and light bleeding common after
first year of use
Need to check FSH levels over the age of 50y as
previously
Hormone Replacement Therapy
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HRT is not contraceptive
May use POP
 HRT must contain a progestogen in addition to
estrogen
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LNG-IUS may be used for endometrial
protection from estrogen therapy
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May be changed no later than 5 years (4 y license)
FSH levels are not reliable if taking HRT
Conclusions
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No method is contraindicated by age alone
UKMEC is useful to provide recommendations
for contraceptive use
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Remember does not take into account multiple risk
factors
CEU guidance available: Over 40’s and specific
methods
Continue to assess most appropriate method
with changing medical history and requirements
Any questions?