Clinical Editor's comments (September 2017)
Dr Hayley Willacy recommends the Faculty of Sexual and Reproductive Health's latest guidelines on Contraception for women aged over 40 years. The guideline updates information relating to when women no longer require contraception. Progestogen-only pills, progestogen-only implants, levonorgestrel intrauterine systems and copper intrauterine devices can safely be used until the age of 55 and may confer non-contraceptive benefits such as reduced menstrual pain and bleeding and endometrial protection. During perimenopause, isolated serum estradiol, FSH and luteinising hormone levels can be misleading and should not be used as the basis for advice about stopping contraception; ovulation may still occur with a risk of pregnancy.
No contraceptive method is contra-indicated by age alone. Although a natural decline in fertility occurs from the age of about 37 years, effective contraception is still required to prevent unplanned pregnancy.
2008/2009 data indicated that, of women aged 40-49 years in the UK, the four most commonly reported methods were sterilisation (either own or partner's), the pill, male condoms and intrauterine methods. Women and their partners can be advised that very long-acting reversible contraception can be as effective as sterilisation.
Prescribing should be guided by the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC). Factors other than age may rule out certain methods of contraception in individual women.
Consider other benefits when helping women decide on the best method of contraception for them:
- The progestogen-only intrauterine system (IUS) may help with the management of heavy periods.
- Combined oral contraceptive (COC) pills may help with hot flushes and maintaining bone density. They may also help in keeping menses more regular and less heavy.
- Progestogen-only methods may help in reducing dysmenorrhoea.
Combined hormonal contraception
Combined hormonal contraception (CHC), which comprises COC pills, the combined contraceptive patch and the vaginal ring, can be used for women over the age of 40 years unless there are co-existing diseases or risk factors.
CHC should not be used (UKMEC category 4) by:
- Women aged 35 years or older who smoke 15 or more cigarettes a day.
- Women who have migraine with aura.
- Women who have high blood pressure (systolic ≥160 mm Hg and/or diastolic ≥100 mm Hg).
- Women who have cardiovascular disease, a history of stroke, venous thromboembolism (VTE), or congenital/valvular heart disease with complications.
- Women who have atrial fibrillation or impaired cardiac function.
- Women with known thrombogenic mutations (eg, factor V Leiden deficiency, prothrombin mutation, proteins S, C and antithrombin deficiencies).
- Women with current breast cancer.
- Women aged 50 years or older.
See the UKMEC criteria for the complete list of contra-indications.
CHC is not normally recommended (UKMEC category 3) for:
- Women aged 35 years or older who smoke fewer than 15 cigarettes a day, or who stopped smoking less than one year previously.
- Women aged 35 years or older who develop migraine (with or without aura) while using CHC.
- Women with a past history of migraine with aura.
- Women with a body mass index ≥35 kg/m2.
- Women with adequately controlled hypertension.
- Women with consistently elevated blood pressure; systolic >140-159 mm Hg or diastolic >90-99 mm Hg.
- Women with multiple risk factors for cardiovascular disease (smoking, diabetes, obesity, hypertension, dyslipidaemia).
- Women with a family history of a first-degree relative with a history of VTE under the age of 45 years.
- Women with immobility.
- Women with breast disease (past history of breast cancer, or known to be carriers of gene mutations associated with breast cancer). CHC would not normally be initiated in a woman with an undiagnosed breast mass.
- Women with diabetes with complications (nephropathy, retinopathy, neuropathy or other vascular disease).
- Women with gallbladder disease (unless treated by cholecystectomy).
See the UKMEC criteria for the full list of conditions where risk normally outweighs benefits.
There may be additional benefits including an increase in bone mineral density, reduction of menstrual pain, bleeding and irregularity, and reducing vasomotor symptoms (hot flushes).
Progestogen-only contraceptive methods include the POPs, the progestogen-only IUS, the progestogen-only implant and the progestogen-only injectables. All may be considered as suitable methods of contraception for older women.
- There are few UKMEC category 3 or 4 conditions where progestogen-only methods should not be used. Theoretical concerns that the higher dose in injectables may pose a higher risk mean that women with multiple risk factors for cardiovascular disease should not normally use injectable methods (category 3.) No progestogen-only method should normally be continued in women who have developed coronary heart disease or had a stroke.
- Women with a past history of VTE, as well as those with current VTE on anticoagulants, can be advised that the benefits of using progestogen-only methods outweigh the risks.
- Women with current breast cancer or a past history of breast cancer are not usually advised to use progestogen-only contraception.
- Long-term use of progestogen-only injectable contraception is associated with a reduction in bone mass density but this appears to return to normal after cessation. The relationship between bone densitometry and fracture risk in women aged over 40 years, who are using injectable progestogen-only contraception, is unclear. It is sensible to review other risk factors for osteoporosis when making a decision.
- Irregular bleeding is a common side-effect with progestogen-only contraception. This may make the management of abnormal vaginal bleeding more difficult, and women may be either wrongly investigated or wrongly reassured.
- Information should be given regarding efficacy and correct method of use.
- Diaphragms and caps are used in conjunction with spermicide.
- Long-acting contraceptive methods are superior in terms of efficacy.
- When used consistently and correctly:
- Male condoms are 98% effective.
- Female condoms are 95% effective.
- Diaphragms and caps, used with spermicide are 92-96% effective.
- Menstrual abnormalities (including spotting, light bleeding, heavy or longer menstrual periods) are common in the first 3-6 months of intrauterine contraceptive device (IUCD) use.
- The IUS releasing levonorgestrel is increasingly popular and provides a reduction in menstrual bleeding in addition to the contraceptive benefit.
- If menstrual abnormalities occur after the first six months of use then infection and gynaecological pathology must be excluded.
The choice must be made as to which partner should have a sterilisation. Vasectomy carries a lower failure rate and less overall risk than tubal occlusion.
- The lifetime risk of failure is estimated to be 1 in 200. If tubal occlusion fails, the resulting pregnancy may be ectopic.
- Tubal occlusion is not associated with an increased risk of heavier or longer periods when performed after 30 years of age.
- There is an association with subsequent worsening of menstrual symptoms and increased hysterectomy rate, although there is no evidence of causation.
- The failure rate has been reported to be 0.03-1.2% after clearance has been given. Guidance from the Faculty of Sexual Health and Reproductive Healthcare (FSRH) of the Royal College of Obstetricians and Gynaecologists advises quoting 1 in 2,000 as the failure rate.
- Vasectomy is normally performed under local anaesthesia.
- Effective contraception is required until azoospermia has been confirmed.
- The weak association in some reports with testicular or prostate cancer is considered to be non-causative.
Natural family planning
Menstrual irregularities are common in the perimenopause and this may complicate the teaching and interpretation of fertility indicators. Fertility awareness methods may be more difficult to learn at this time, or may be considered unsuitable. Women with irregular cycles have to abstain for longer time periods and therefore may find calendar indicators more difficult to adhere to.
Where fertility indicators are used, women should be advised that using a combination of indicators improves efficacy of the method. The failure rate of using basal body temperature alone as an indicator is estimated at 6.6%; when used perfectly in combination with other indicators such as cervical secretions, the failure rate can be as low as 1% over one year.
When contraception can be stopped
Women can normally be advised to stop contraception at the age of 55 years, as most (95.9%) will have reached the menopause by this age. However, this advice may need to be tailored to the individual woman and if she is still having regular menstrual bleeding at this age, she may need to continue contraception. Measuring follicle-stimulating hormone (FSH) on at least two occasions, two or six weeks apart, may predict ovarian failure and be helpful in some situations when advising women when to stop contraception.
- Stopping non-hormonal contraception:
- Women aged ≥50 years using non-hormonal contraception can be advised to stop contraception after one year of amenorrhoea (or two years if aged less than 50 years).
- Women who have an IUCD inserted at age 40 years or more may retain the device until they no longer require contraception. It should be removed a year after the last period if this occurs after the age of 50 years, two years after if the last period occurs before the age of 50 years.
- Stopping CHC:
- Women using CHC should be advised to switch, at the age of 50 years, to another suitable contraceptive method.
- FSH is not a reliable indicator of ovarian failure in women using combined hormones, even if measured during the hormone-free or oestrogen-free interval.
- Stopping POPs and implants:
- The POP or implant can be continued until the age of 55 years when natural loss of fertility can be assumed.
- Alternatively, the woman can continue with the POP or implant and have FSH levels checked on two occasions two or six weeks apart and, if both levels are greater than 30 IU/L, this is suggestive of ovarian failure. In this case, the woman may continue with the POP, implant or barrier contraception for another year (or two years if aged less than 50 years).
- Stopping progestogen-only injectables:
- Women should be counselled about the risks and benefits of continuing with the progestogen-only injectable at the age of 50 years and be advised to switch to a suitable alternative.
- Removing the IUS:
- Women who have the IUS inserted at age 45 years or more for contraception or for the management of menorrhagia may retain the device until they no longer require contraception. If amenorrhoeic, menopause can be verified by checking FSH levels as above, and then the device may be removed. If not amenorrhoeic, the device may be used for up to seven years before removal.
For women using hormone replacement therapy
- Women using combined hormone replacement therapy (HRT) cannot be advised to rely on this as contraception.
- Women on HRT should continue contraception until 55 years old, or can stop before if the woman stops HRT for six weeks to have her FSH measured on two occasions in order to confirm menopause.
- A POP can be used with HRT to provide effective contraception.
- The IUS can be used as the progestogen component for HRT for four years, and provide concurrent contraception.
Further reading and references
PRAC confirms that benefits of all combined hormonal contraceptives continue to outweigh risks; European Medicines Agency, October 2013
Contraception for Women Aged over 40 Years; Faculty of Sexual and Reproductive Healthcare (2017)
Contraception for Women Aged Over 40 Years; Faculty of Sexual and Reproductive Healthcare (2010)
Contraception and Sexual Health 2008/09; Office for National Statistics
UK Medical Eligibility Criteria for Contraceptive Use; Faculty of Sexual and Reproductive Healthcare (2016)
Contraception - assessment; NICE CKS, August 2016 (UK access only)
Barrier methods for contraception and STI prevention; Faculty of Sexual and Reproductive Healthcare (August 2012 - updated October 2015)
Male and female sterilisation; Faculty of Sexual and Reproductive Healthcare (September 2014)
Fertility Awareness Methods; Faculty of Sexual and Reproductive Healthcare (June 2015 - updated November 2015)