Contraception in the over 40’s

Contraception in older women; issues

Method choice may be affected by age and risk factors.

When can the method be discontinued?

How is the menopause diagnosed?

Typical scenario....

49 yr old Debbie , on progesterone only pill.Amenorrhoea 2+ yrs.Having some hot flushes, reduced libido, mood

swings.She wonders if this may be due to the

menopause.Can she have a blood test?Does she need to continue contraception?

Transition to menopause ( 40-50)

Intermittent ovulation/anovulation with variable FSH levels.

Cycle length may reduce or increase. Amenorrhoea not a reliable indicator of

menopause when using hormonal contraception

FSH levels; not an exact science!

Contraceptive method.

No method is contraindicated by age alone up to 50 yrs.

Some methods become less safe but this is dependent on other risk factors.

Need to use UKMEC guidance but if there are multiple risk factors this may affect advice.

Sexual health in the over 40’s

Sexual health in over 40’s

Average age divorce in women is 41 yrs. New relationships common. Conception rates in over 40’s more than

doubled in 2 decades. Older women may not be well informed

regarding sexual health and contraception.

Abortion rates 2012, England and Wales

Age 40-44; 7737 abortionsAge 45-49; 662 abortionsAge 50 +; 27 abortions!

Method choice; Combined hormonal contraception

Use lowest dose that provides adequate cycle control; try to reduce to 20 mcg pill over 40.

May protect bone density Likely to mask symptoms of menopause. Careful consideration risk factors ( eg women

with hypertension, UKMEC 3)

Method choice; Depo -provera Caution in women with CV risk factors; high

dose progesterone may have adverse effects on lipid metabolism.

This becomes UKMEC 2 in over 45’s

But remember need to follow MHRA guidance;

Re-evaluate risks and benefits every 2 yrs. Assess osteoporosis risks; this may influence

patient decision to continue.

When can contraception be stopped? Menopause usually diagnosed after 1 yr

amenorrhoea. In general, CEU advised contraception may be

stopped at age 55. Non hormonal methods can be stopped 1 yr

after LMP in 50+ yrs. Non hormonal methods can be stopped 2 yrs

after LMP if <50 yrs.

IUD/IUS; when to remove?

IUD inserted after age 40 can be left until menopause diagnosed ( >300mm copper)

If IUS inserted over age 45, may continue for up to 7 yrs or until menopausal if amenorrhoea.

IUS endometrial protection license for HRT; 4 yrs.

Diagnosing the menopauseDebbie, 49, amenorrhoea on POP.Some menopausal symptoms.

Women using PO methods ; FSH levels can be checked.

If FSH>30 on 2 occasions, 6 weeks apart then contraception can be safely discontinued 1 yr later.

Alternatively; just continue POP until 55, when natural loss fertility can be assumed for most women.

Women using CHC.

FSH is not a reliable indicator of ovarian failure in women using combined hormones, even if

measured during the hormone-free interval. At age 50 switch to non hormonal or PO

method.

Prepare for the worst........