Dr Katie Boog and Valerie Warner Findlay discuss FSRH recommendations on contraception for women aged over 40 years, and explain the benefits and risks associated with different methods

boog katie

Dr Katie Boog

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Dr Valerie Warner Findlay

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Read this article to learn more about:

  • which methods of contraception are safe and suitable for women aged over 40 years
  • when contraception should be stopped
  • how contraception should be used with hormone replacement therapy.

Key points

Commissioning messages

After reading this article, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. Earn 0.5 CPD credits.

Women aged over 40 years have a distinct set of needs regarding contraception. Perimenopausal symptoms (e.g. vasomotor symptoms, mood changes, irregular and/or heavy bleeding) combined with increased background risks of certain health conditions (e.g. cardiovascular disease, obesity, breast cancer, most gynaecological cancers) mean that the benefits and risks of contraception for this population are different from those relevant to younger women. Clinicians must also consider any treatments—medical or alternative—that the woman may be using for perimenopausal symptoms. In addition, women should continue using contraception until menopause in order to avoid unwanted pregnancy, yet many healthcare professionals are unsure about when contraception should be stopped, or which contraception is safe to prescribe alongside, or in place of, hormone replacement therapy (HRT).

FSRH guidance

In October 2017, the Faculty of Sexual and Reproductive Healthcare (FSRH) updated its guideline on Contraception for women aged over 40 years.1 The guideline provides evidence-based recommendations on contraception in this population, including:

  • the suitability and safety of each method
  • how it should be used
  • when it should be stopped
  • how it should be used with HRT.

While there is a natural decline in fertility with age, women should be counselled about effective contraception until menopause or age 55 years, whichever occurs first.1 The guideline also reminds clinicians that many women aged over 40 years enter new relationships and conversations regarding condom use and protection from sexually transmitted infections (STIs) are equally important as for younger women.1

Contraceptive methods and their suitability

Many methods of contraception confer non-contraceptive benefits; contraceptives that improve regularity of bleeding, reduce heavy menstrual bleeding (HMB), or reduce perimenopausal symptoms may be particularly beneficial to women over 40. The use of contraception does not affect the onset or duration of menopausal symptoms, but it may mask the signs and symptoms of menopause.1

The suitability of contraceptive methods should be considered on an individual basis, taking into account the woman’s clinical history and contraceptive preferences.

The FSRH guideline on Contraception for women aged over 40 years provides information about the different options available and their suitability for use in this population. FSRH UK medical eligibility criteria for contraceptive use (UKMEC)2 includes some recommendations specific to women aged over 40 years. Method-specific guidelines developed by FSRH may also help to inform contraceptive choice.

This article focuses on the recommendations made in the FSRH guideline on Contraception for women aged over 40 years, with discussion of other FSRH guidelines where relevant.1

Note: Not all of the treatments discussed in this article currently (January 2018) have UK marketing authorisation for the indications mentioned. The prescriber should follow relevant professional guidance, taking full responsibility for all clinical decisions. Informed consent should be obtained and documented. See the General Medical Council’s guidance on Good practice in prescribing and managing medicines and devices3 for further information.

Copper intrauterine device

Most copper intrauterine devices (Cu-IUDs) are licensed for 5 or 10 years. Given the natural decline in fertility with age, the FSRH recommends extended use when fitted in women aged 40 years and over. A Cu-IUD inserted at or after age 40 can remain in situ until 1 year after the last menstrual period (LMP) if it occurs when the woman is 50 years or older. If a woman is aged under 50, the Cu-IUD can remain in situ for 2 years after the LMP.1,4

The Cu-IUD does not contain hormones and therefore does not affect frequency of bleeding. Some women find this beneficial as they know when they have reached menopause. However, as Cu-IUD can cause longer, heavier, more painful menses, it may not be an appropriate method of contraception for women experiencing problematic bleeding in perimenopause.1

Levonorgestrel intrauterine systems

In addition to providing highly effective contraception, levonorgestrel intrauterine systems (LNG-IUS) can help manage problematic HMB.1,4 FSRH guidance supports extended use of LNG-IUS for women aged over 40 years as follows:

  • Contraception—women who are aged over 45 years at the time of fitting can retain a Mirena® until age 55, even if they are not amenorrhoeic, providing it is not being used for endometrial protection as part of an HRT regimen1
  • HRT—Mirena is licensed for use as endometrial protection with oestrogen replacement for 4 years.1,4,5 (NB FSRH guidance on Intrauterine contraception supports off-licence use of Mirena for up to 5 years for this indication.4)
  • HMB—a 52 mg LNG-IUS (Mirena or Levosert®) is highly effective in reducing HMB and menstrual pain.1,4 If only being used for HMB and/or menstrual pain (not contraception or endometrial protection), a 52 mg LNG-IUS can remain in situ for as long as it controls symptoms, regardless of age at insertion.1 The IUS should be removed once it is no longer required; the timing of this should be considered on an individual basis. The IUS should not be left in situ indefinitely because of possible risk of infection.1

There is limited evidence demonstrating that LNG-IUS may protect against endometrial and ovarian cancers.1

Prescribing LNG-IUSs

There is currently insufficient evidence for the FSRH to support extended use of Levosert or Jaydess® for contraception, and they are not licensed for use as endometrial protection with oestrogen replacement.1,4,6,7

Progestogen-only implant

There are no specific age-related concerns for women over 40 using a progestogen-only implant (IMP).8 Progestogen-only implants can alleviate menstrual and ovulatory pain,1,8 but some women find the irregular bleeding associated with IMP unacceptable.

Prescribing IMPs

There is no age restriction for IMP and it can be used safely until a woman no longer requires contraception. It is licensed for 3 years and extended use is not supported, regardless of age.

IMP is not licensed for use as endometrial protection and should not be used as the progestogen component of HRT.1

Progestogen-only injectable contraceptives

Depot medroxyprogesterone acetate (DMPA) is associated with a reduction in bone mineral density (BMD) in women of all ages.1 Reassuringly, studies looking at women over 40 who use DMPA have shown that although users experience an initial loss in BMD with use, this is not repeated or worsened by menopause.1 Women over 40 with additional risk factors for osteoporosis are advised to consider alternative methods.

Women over 40 who use DMPA for contraception should be reviewed regularly to assess the benefits and risks of continuing use.1 Routine monitoring of serum oestrogen levels, lipids, or bone density  is not currently recommended. For women aged 18–45 years, DMPA is considered UKMEC category 1; whereas for women aged over 45 years, DMPA is considered UKMEC category 2.2 For women aged over 50, the guideline recommends that women should be advised to switch to an alternative method.1

DMPA can reduce menstrual pain and HMB and will often cause amenorrhoea, which many women find advantageous.1 It may also lower the risk of endometrial and ovarian cancers, although the evidence is limited.1 There is a weak positive association between cervical cancer and use of DMPA for 5 years or longer (the evidence may be subject to confounding factors). Risk appears to reduce with time after stopping.1

Prescribing DMPA

Women aged over 40 years with additional risk factors for osteoporosis are advised to consider alternative contraceptive methods. At age 50, all women should be advised to switch to an alternative method. Any woman receiving non-contraceptive benefits who wishes to continue after age 50 must be considered on an individual basis.1

DMPA is not licensed for use as endometrial protection with oestrogen replacement and should not be used as the progestogen component of HRT.1

Progestogen-only pill (POP)

There are no specific age-related concerns for women aged over 40 using the progestogen-only pill (POP).1

Desogestrel POP can alleviate menstrual and ovulatory pain; 97% of women become anovulatory.1 However, nearly half of women using all types of POP have altered bleeding patterns,1 which some women may find unacceptable.

Prescribing POP

There is no age restriction for the POP and it can be used safely until a woman no longer requires contraception.

The POP is not licensed for use as endometrial protection with oestrogen replacement and should not be used as the progestogen component of HRT.

Combined hormonal contraception

With increasing age comes increasing background risk for multiple morbidities that can be exacerbated by combined hormonal contraception (CHC). For this reason, the guideline recommends that women aged over 40 should be counselled regarding alternative effective methods of contraception, and switch to a safer method at age 50. Any woman receiving non-contraceptive benefits who wishes to continue after age 50 must be considered on an individual basis.1

Evidence suggests that CHC has a positive effect on BMD and reducing perimenopausal symptoms (such as irregular and/or heavy bleeding, and vasomotor symptoms).1 It can also be used as an alternative to HRT. Women who use CHC have a reduced risk of ovarian and endometrial cancers, the benefit of which lasts years after cessation.1

Conversely, CHC is associated with a slight increased risk of breast cancer, the incidence of which also increases with age. There is no apparent increased risk 10 years after cessation of CHC.1

Prescribing CHC

The risk of venous thromboembolism (VTE) increases sharply over the age of 40 years, which means that consideration of other risk factors for VTE is essential when considering CHC in this age group. Weight is an important risk factor; body mass index should be reviewed on a regular basis.1 The risk of VTE is highest on initiation of CHC and this increased risk recurs if CHC is stopped and restarted.1 The guideline therefore advises against repeated episodes of stopping/starting CHC, for example, to measure follicle stimulating hormone (FSH) levels. Pills containing higher doses of oestrogen are linked to greater risk of VTE, stroke, and cardiovascular disease.1 When prescribing COC for women over 40, first choice should be a preparation with ≤30 mcg ethinylestradiol. This should be combined with either levonorgestrel or norethisterone as this combination confers the lowest VTE risk (see Table 1).9

Extended or continuous CHC use may provide better control of menstrual and perimenopausal symptoms by avoiding a hormone-free interval.1 The FSRH CHC guideline provides information around tailoring regimens.10

Women aged over 35 who smoke and all women aged over 50 (regardless of smoking status) should be advised to stop CHC as risks outweigh benefits.1

Table 1: Venous thromboembolism risk for all women by type of combined hormonal contraception used1
Type of CHC usedRisk of VTE per 10,000 healthy women over 1 year

No CHC, not pregnant

2

No CHC, pregnant

29

Ethinylestradiol with levonorgestrel, norgestimate, or norethisterone

5–7

Ethinylestradiol with etonogestrel (ring), or norelgestromin (patch)

6–12

Ethinylestradiol with gestodene, desogestrel, drospirenone, or cyproterone acetate

9–12

CHC containing dienogest, nomegestrol, or mestranol

Unknown

CHC=combined hormonal contraception; VTE=venous thromboembolism 

Faculty of Sexual & Reproductive Healthcare. Contraception for Women Aged Over 40 Years. FSRH, 2017. Available at: www.fsrh.org/standards-and-guidance/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/

Reproduced with permission

Emergency contraception

All women who still require contraception and do not wish to become pregnant should be offered emergency contraception (EC) when indicated. There are no specific age-related concerns for women over 40 years using EC.1

When is contraception no longer needed?

Recommendations regarding stopping contraception are summarised in Table 2.

Women who are not using a hormonal method of contraception are advised to continue using contraception after their LMP for:1

  • 1 year if they are aged over 50 years
  • 2 years if they are aged under 50 years.

Where timing of menopause is unclear due to use of contraception or HRT, women can continue using contraception until age 55 and then stop (spontaneous conception at this age is rare even if a woman continues to have menstrual bleeding).1 If a woman wishes to continue using a method of contraception for non-contraceptive reasons after age 55 or menopause, this can be reviewed on an individual basis.1 Intrauterine contraception should not be left in situ indefinitely as it can become a focus of infection,1 or confuse the clinical picture if the woman later presents with post-menopausal bleeding.

The guideline encourages practitioners to assess and treat women based on their symptoms and needs rather than their serum hormone markers.1 For example, a woman aged 53, amenorrhoeic with a 52 mg LNG-IUS inserted 3 years ago for contraception and HMB can keep the device and have it removed after age 55; there is no indication for hormone testing. However, if required, a single FSH level >30 IU/L in a woman over 50 is sufficient to confirm ovarian insufficiency and contraception can be stopped 1 year later. Progestogen-only methods of contraception do not prevent the menopausal rise in FSH levels.1 FSH levels are usually suppressed in women using CHC or HRT and are not therefore clinically useful.1

Table 2: Recommendations regarding stopping contraception1
Contraceptive methodAge 40–50 yearsAge >50 years

Non-hormonal

Stop contraception after 2 years of amenorrhoea

Stop contraception after 1 year of amenorrhoea.

Combined hormonal contraception

Can be continued

Stop at age 50 and switch to a non-hormonal method or IMP/POP/LNG-IUS, then follow appropriate advice.

Progestogen-only injectable

Can be continued

Women ≥50 should be counselled regarding switching to alternative methods, then follow appropriate advice.

Progestogen-only implant (IMP)

 

Progestogen-only pill (POP)

 

Levonorgestrel intrauterine system (LNG-IUS)

Can be continued to age 50 and beyond

Stop at age 55 when natural loss of fertility can be assumed for most women:

  • If a woman over 50 with amenorrhoea wishes to stop before age 55, FSH level can be checked
  • If FSH level is >30 IU/l the IMP/POP/LNG-IUS can be discontinued after 1 more year
  • If FSH level is in premenopausal range then method should be continued and FSH level checked again 1 year later.

A Mirena® LNG-IUS inserted ≥45 can remain in situ until age 55 if used for contraception or heavy menstrual bleeding.

IMP=progestogen-only implant; POP=progestogen-only pill; LNG-IUS=levonorgestrel intrauterine system; FSH=follicle-stimulating hormone; IU=international unit

Faculty of Sexual & Reproductive Healthcare. Contraception for women aged over 40 years. FSRH, 2017. Available at: www.fsrh.org/standards-and-guidance/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/

Reproduced with permission

Contraception and HRT

Sequential HRT is not an effective form of contraception as it does not reliably suppress ovulation.1 Women who do not wish to become pregnant should use contraception alongside HRT. Table 3 summarises the contraceptive options that can be used in conjunction with HRT.

Hormone replacement therapy may induce cyclical bleeding in postmenopausal women but it does not restore fertility. Women who are post-menopausal do not need to commence contraception when using HRT, even if bleeding resumes.1

Table 3: Contraceptive options in conjunction with hormone replacement therapy1
Contraceptive methodSafety with hormone replacement therapyRole in hormone replacement therapy
Women aged <50Women aged ≥50

Levonorgestrel intrauterine system (LNG-IUS)

 

Safe to use as contraception alongside oestrogen of choice.

Mirena® is licensed for endometrial protection when combined with oestrogen. It is currently the only LNG-IUS approved for this purpose.

It may be used up to 5 years for endometrial protection and needs to be replaced regularly when used for this purpose, regardless of age at insertion.

Progestogen-only injectable

Safe to use as contraception alongside sequential HRT but consider change to lower-dose progestogen-only method.

Highly likely to be effective for endometrial protection with oestrogen as part of HRT but cannot be recommended as unlicensed for this indication.

Progestogen-only implant (IMP)

Safe to use as contraception alongside sequential HRT.

Cannot be recommended at the present time for endometrial protection as part of HRT as no evidence to support efficacy.

Progestogen-only pill (POP)

Safe to use as contraception alongside sequential HRT.

Cannot be recommended at the present time for endometrial protection as part of HRT as no evidence to support efficacy.

Combined hormonal contraception (CHC)

Do not use in combination with HRT.

Can be used in eligible women <50 as an alternative to HRT.

Women should be advised to switch to a progestogen-only method of contraception at age 50; see above for alternative options as they relate to HRT.

LNG-IUS=levonorgestrel intrauterine system; HRT=hormone replacement therapy; IMP=progestogen-only implant; POP=progestogen-only pill; CHC=combined hormonal contraception

Faculty of Sexual & Reproductive Healthcare. Contraception for women aged over 40 years. FSRH, 2017. Available at: www.fsrh.org/standards-and-guidance/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/

Reproduced with permission

Red flags

If problematic bleeding is not controlled within 3 to 6 months of fitting a LNG-IUS then underlying pathology should be considered and excluded.

Women aged over 40 years who experience a sudden, significant change in bleeding pattern, whether or not they are using hormonal contraception, should have appropriate assessment and investigation.

Conclusion

The FSRH guideline on Contraception for women aged over 40 years1 collates current evidence, expert opinion, and best practice. The guideline provides information on the safety and suitability of different contraceptive methods for women over 40, how contraception should be used with HRT, and when contraception should be stopped. In doing so, the guideline aims to equip healthcare professionals with necessary information to support women in choosing an appropriate contraceptive method for their individual risk–benefit profile.

Dr Katie Boog 

Senior Registrar in Community Sexual and Reproductive Health 

Leicestershire Sexual Health Service; Staffordshire and Stoke on Trent Partnership Trust; Nottingham Integrated Sexual Health Service, Nottingham University Hospitals Trust 

Valerie Warner Findlay 

Researcher at the Faculty of Sexual and Reproductive Healthcare’s Clinical Effectiveness Unit

Key points

  • Despite a natural decline in fertility with age, effective contraception is required until menopause to prevent unintended pregnancies
  • Mirena LNG-IUS is supported by FSRH for contraceptive use until age 55, even in women without amenorrhoea, when the device has been inserted at age 45 or over
  • Cu-IUD, LNG-IUS, IMP, and POP can be used safely until contraception is no longer required
  • Women using DMPA should be regularly assessed during their 40s and counselled on alternative methods when they reach 50
  • Women who are aged 50 and over and taking CHC should be advised to stop and switch to a safer alternative
  • Contraception does not affect the onset or duration of menopause but may mask its signs and symptoms
  • Most women do not need serum hormone levels measured in order to diagnose menopause and clinicians should focus on a woman’s symptoms and needs, rather than biochemical markers
  • All women can stop contraception at age 55 when natural sterility can be assumed, even if menstrual bleeding still occurs
  • Sequential HRT cannot be relied upon for contraception
  • All progestogen-only methods are safe to use as contraception alongside sequential HRT. CHC can be used in women under 50 as an alternative to HRT.

LNG-IUS=levonorgestrel intrauterine system; FSRH=Faculty of Sexual and Reproductive Healthcare; Cu-IUD=copper intrauterine device; IMP=progestogen-only implant; POP=progestogen-only pill; DMPA=depot medroxyprogesterone acetate; CHC=combined hormonal contraception; HRT=hormone replacement therapy

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GP commissioning messages

written by Dr David Jenner, GP, Cullompton, Devon

  • Contraception in women over 40 years is a complex area for primary care clinicians to understand
  • Clinicians should keep the FSRH guidance and algorithms close to hand so they can be referred to during a patient consultation
    • the guidance could be imbedded as links in local formulary websites or on apps for rapid and easy access
  • Commissioners should ensure that patients and clinicians have access to specialist advice through CASH services
  • Public health clinicians should be involved in the commissioning of CASH services to address the rising incidence of sexually transmitted disease in women aged 40 years and over
  • Commissioners should ensure patients have consistent and easy access to IUD and IUS provision either through general practice or local CASH services

FSRH=Faculty of Sexual & Reproductive Healthcare; CASH=contraception and sexual health; IUD=intrauterine device; IUS=intrauterine system

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References

  1. Faculty of Sexual & Reproductive Healthcare. Contraception for women aged over 40 years. FSRH, 2017. Available at: www.fsrh.org/standards-and-guidance/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/
  2. Faculty of Sexual & Reproductive Healthcare. UK medical eligibility criteria for contraceptive use (UKMEC). FSRH, 2016. Available at: www.fsrh.org/standards-and-guidance/external/ukmec-2016-digital-version/.
  3. General Medical Council. Good practice in prescribing and managing medicines and devices. GMC, 2013. Available at: www.gmc-uk.org/Prescribing_guidance.pdf_59055247.pdf
  4. Faculty of Sexual & Reproductive Healthcare. Intrauterine contraception. FSRH, 2015. Available at: www.fsrh.org/standards-and-guidance/documents/ceuguidanceintrauterinecontraception/
  5. Bayer plc. Mirena—summary of product characteristics. January 2018. www.medicines.org.uk/emc/product/1132
  6. Gedeon Richter (UK) Ltd. Levosert 20 micrograms/24 hours IDS—summary of product characteristics.  June 2017. Available at: www.medicines.org.uk/emc/product/1789
  7. Bayer plc. Jaydess 13.5 mg intrauterine delivery system—summary of product characteristics. August 2017. www.medicines.org.uk/emc/product/5297
  8. Faculty of Sexual & Reproductive Healthcare. Progestogen-only implants. FSRH, 2014. Available at: www.fsrh.org/documents/cec-ceu-guidance-implants-feb-2014/
  9. Faculty of Sexual & Reproductive Healthcare. Statement from the Clinical Effectiveness Unit: combined hormonal contraception and venous thromboembolism. FSRH, 2016. Available at: www.fsrh.org/standards-and-guidance/documents/ceu-statement-combined-hormonal-contraception-and-venous/
  10. Faculty of Sexual & Reproductive Healthcare. Combined hormonal contraception. FSRH, 2012. Available at: www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception/