Contraception for Women Aged Over 40 Years FSRH Aug 2017

Question 1

What are the main sexual and reproductive health issues facing women over 40?

Answer 1

• Inform: natural decline fertility, spontaneous pregnancy rare > 50, effective contraception until menopause.
• Advise: pregnancy & childbirth., greater risk of adverse maternal and neonatal outcomes than <40.
• Discuss: STIs and sexual health.condom even if contraception is not required.
• Assess & investigate: significant change bleeding pattern, even if not using contraception.
• Ask: urogenital symptoms or sexual issues

Question 2

Why do women over 40 need separate guidance?

Answer 2

Inform age-related increased background risk of

• cardiovascular disease,
• obesity
• breast cancer
• most gynaecological cancers
• this may affect choice of contraceptive method.

Question 3

Suitability of contraceptive methods for women over 40

menopausal symptoms

Answer 3

• Inform: contraception not affect onset/duration of menopausal symptoms but may mask signs /symptoms of menopause.

Question 4

When is contraception no longer needed?

menopuase diagnosis

Answer 4

• Menopause:clinical retrospective diagnosis after 1 year. Mostly not required FSH for diagnosis.
• If needed, > 50 using progestogen-only contraception, including DMPA, can have serum FSH to check menopausal status.
• using CHC or HRT:suppressed levels of estradiol and gonadotrophins; not give accurate information regarding menopause and when to stop contraception.
• In general, all women can cease contraception at age 55 (exceptionally rare pregnancy even if still periods.
• If a woman aged 55 or over does not wish to stop a particular method, consideration can be given to continuation providing the benefits and risks for her as an individual have been assessed and discussed with her.

Question 5

Can hormone replacement therapy be used alongside or in place of contraception?

Answer 5

• sequential HRT can’t be relied for contraception.
• All progestogen-only methods of contraception are safe as contraception alongside sequential HRT.
• may use Mirena with estrogen only HRT up to 5 years (endometrial protection) Mirena for this purpose changed every 5 years.
• At the present time, POP, IMP and DMPA are not licensed / recommended as endometrial protection with estrogen-only HRT.
• CHC can be used in eligible women < 50 as an alternative to HRT for relief of menopausal symptoms and prevention of loss of BMD.

Question 6

Suitability of contraceptive methods for women over 40

IUC

Answer 6

• FSRH supports extended use of copper IUD, until menopause when inserted at or > 40.
• Advice: after endometrial ablation, potential risk of complications if IUC used.
• FSRH supports extended use of a Mirena® (LNG-IUS) for contraception until the age of 55 if inserted at age 45 or over, provided it is not being used as the progestogen component of (HRT) for endometrial protection.
• IUC should not be left in situ indefinitely after it is no longer required as it could become a focus of infection.

Question 7

Suitability of contraceptive methods for women over 40

DMPA

Answer 7

• Women over 40 using DMPA should be reviewed regularly to assess the benefits and risks of use. Women > 50 should be counselled on alternative methods of contraception.
• Compared to non-DMPA users, women using DMPA experience initial loss of bone density due to the hypoestrogenic effects of DMPA but the evidence suggests that this initial bone loss is not repeated or worsened by onset of menopause.

Question 8

Suitability of contraceptive methods for women over 40

IMP

Answer 8

• Inform: progestogen-only implant (IMP) is not associated with increased risks of (VTE), stroke or (MI) and has not been shown to affect (BMD).

Question 9

Suitability of contraceptive methods for women over 40

POP

Answer 9

• Women can be informed that the POP not associated with increased risks of VTE, stroke or MI and has not been shown to affect BMD.

Question 10

Suitability of contraceptive methods for women over 40

Sterilization

Answer 10

sterilisation does not alter or eliminate menstrual periods.
- using another method of contraception, bleeding pattern change after sterilisation b/c stopped contraceptive method.

Question 11

Suitability of contraceptive methods for women over 40

EC

Answer 11

• Women over 40 who still require contraception should be offered emergency contraception after unprotected sexual intercourse if they do not wish to become pregnant.

Question 12

Suitability of contraceptive methods for women over 40

COC, which type of hormone

Answer 12

• COC with LNG or norethisterone first-line COC > 40 due to lower VTE risk compared to other progestogens.
• COC with ≤30 μg ethinylestradiol first-line COC > 40 due to lower risks of VTE, cardiovascular disease and stroke compared to higher doses of estrogen.

Question 13

Suitability of contraceptive methods for women over 40

Answer 13

• CHC can reduce menstrual bleeding and pain, which may be particularly relevant for > 40.
• extended or continuous CHC regimen for contraception and also to control menstrual or menopausal symptoms.
• A CHC may help to maintain BMD compared with non-use of hormones in the perimenopause.

Question 14

Suitability of contraceptive methods for women over 40

COC, cancers

Answer 14

• COC reduced risk of ovarian and endometrial cancer for several decades after cessation.
• slight increased risk of breast cancer among COC user, but no significant risk by 10 years after cessation.

Question 15

Suitability of contraceptive methods for women over 40
CHC
smoker

Answer 15

• smoker: advise to stop CHC at age 35 (age when excess risk of mortality with smoking starts to become clinically significant.

Question 16

Suitability of contraceptive methods for women over 50

CHC

Answer 16

• > or over 50: advise to stop CHC for contraception and use an alternative.