1. GP Education Meeting September 2018

2. Contraception For women Aged over 40 years
FSRH Guidance August 2017

3. Aims
To provide an updated knowledge of contraception for women over 40 in order to apply this to safe prescribing and management

4. Objectives:
Be able to identify the key issues to consider when prescribing for women over 40
Be able to discuss with women over 40 the risks and benefits of their contraceptive choices of CHC, injectables and IUC
Be able to advise women of their contraceptive choices during the perimenopause and at the menopause

5. Why is it importance to have a guide?
Still need reliable contraception
Peak age for menstrual problems
Onset of perimenopause
Risk of STI’s – if new relationships
Higher background medical risks

6. Contraceptive choices may be influenced by many factors:
Frequency of sexual intercourse
Natural decline in fertility
Wish for contraceptive benefits
Sexual problems

7. Why do women over 40 need separate guidance from the medical perspective?
Increased background risks:
Cardiovascular disease – Increased VTE risk after age 40
Breast and gynaecological cancers
Osteoporosis
Obesity

8. CHC: key issues for women over 40
Alternative to HRT as may improve vasomotor symptoms associated with menopause
Small increased risk breast cancer – declines once CHC stopped
Some protection against osteoporosis, ovarian and endometrial cancer
Eligible women can continue to age 50

9. CHC: key issues for women over 40
Therapeutic option for menstrual problems - can reduce dysmenorrhoea and menorrhagia. - consider continuous/extended regimes
Use progestogen with lowest VTE risk – Levonorgestrel or Northisterone
Use COC with ≤ 30 micrograms as first line (lower VTE, Cardiovascular and stroke risks)

10. DMPA key issues for women over 40
Bone health - loss of BMD with DMPA
But Initial loss of BMD due to hypoestrogenic effects of DMPA is not repeated or worsened by onset of menopause
Women over 40 with additional risk factors (e.g. FH, inactivity, vit D deficiency, smoking etc.) are advised to use alternative methods
Routine bone density scans or use of oestrogen in users has not been established

11. DMPA key issues for women over 40
Weak and conflicting evidence relating to CV disease and breast cancer. Recent review found no evidence of a link with stroke or MI
Therapeutic option for menstrual problems
Review women ˃ 40 regularly to assess benefits/risks of use
Women ˃ 50 should be counselled on alternative, safer, equally effective methods

12. Intrauterine Contraception - key issues
IUS offers very significant benefits for women over 40
If Mirena inserted at age 45 or over can remain in situ until age 55 for contraception even if the woman is still bleeding
If used for HRT Mirena should be changed every 5 years
IUS likely to protect against endometrial cancer
Women who have endometrial ablation should be advised about potential risks if IUC is used – adhesions – may lead to difficult insertion/removal with higher risk of perforation

13. Intrauterine Contraception - key issues
If mirena inserted at ˂ 45 may have an immediate replacement at 5-7 years if PDT negative. Repeat PDT if any si in the proceeding 3/52. If ˃ 7 years, delay replacement until a conclusive PDT
If Cu-IUD inserted at ≥ 40 can remain in situ until the menopause
Don’t leave IUC in indefinitely once not needed as may become a focus of infection

14. Diagnosing menopause - Recommendations
Clinical diagnosis made retrospectively after one year of amenorrhoea. FSH levels not required for diagnosis in most women
For amenorrhoeic women over 50 using progestogen-only methods including DMPA, who are keen to stop contraception it may be useful to measure FSH levels.
If FSH ˃30 on one occasion in women over 50 advise to continue contraception for one further year

15. Diagnosing menopause - Recommendations
FSH measurements not accurate if using CHC or HRT
Optimum time to measure FSH if using DMPA is just before repeat injection is administered
If FSH ˂ 30 in women over 50 advise to continue contraception and repeat a year later

16. Stopping contraception:
All women can cease contraception at age 55 as conception after this age is exceptionally rare even if still bleeding
Could continue POP/Implant after age 55 after assessment and discussion of risks and benefits if preferred

17. HRT and contraception - key points
Sequential HRT is not contraceptive.
An implant, POP or DMPA are not licensed for use as the progestogen component of HRT
Can use all progestogen –only methods (implant, POP, IUS or DMPA) alongside sequential HRT for contraception - a Mirena IUS offers convenient option for both contraception and endometrial protection as part of HRT regimen

18. Key Learning - Points from new guidance:
Women over 40 may have more complex needs due to menstrual problems and perimenopause; may have more background medical risks
Discuss STIs and offer screening
Stop contraception at age chance of pregnancy thereafter exceptionally rare

19. Key Learning - Points from new guidance:
Discontinue CHC and DMPA in most women at age of 50 and change onto another method in the meantime
Can get valid single FSH level in women over 50 with amenorrhoea using POP, implant, IUS and DMPA
Caution with IUS after endometrial ablation

20. Resources FSRH Guideline – Contraception for women aged over 40 years
FSRH webinar