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 abortions Age 45-49; 662 abortions Age 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 (or 2 years if under 50) 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 but faculty guidance says ok to use for 5 yrs.

Diagnosing the menopause Debbie, 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........