Contraceptive choice for over 40s depends on risk-benefit profile

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Although fertility declines sharply once a woman reaches her mid-thirties, natural conception can occur at any age up to the menopause. Pregnancy in later reproductive years is associated with increased risks of maternal and foetal complications. Older women with an unintended pregnancy face difficult decisions that can impact significantly on social, psychological, and physical wellbeing.

The fifth decade is the average age for men and women to divorce, and individuals entering new relationships at this point may need to consider contraception and prevention of sexually transmitted infections (STIs) for the first time in many years. Contraceptive and sexual health needs should not be underestimated in women aged over 40 years and providers of these services should be able to offer appropriate advice. The Faculty of Sexual & Reproductive Healthcare (FSRH) has published updated evidence-based guidance on Contraceptive choices for women aged over 40 years.^1,2 The document provides recommendations for healthcare professionals on advising women of the available methods of contraception, how to use them appropriately, and when they can be stopped. This article describes the range of methods available to women aged over 40 years and highlights the factors that may influence contraceptive choice.

Contraceptive options

With increasing age, women are more likely to have medical conditions and risk factors that need to be taken into account and balanced against the benefits of the contraceptive method for each individual. A useful resource for guiding clinical judgement is provided by the UK medical eligibility criteria for contraceptive use (UKMEC).³ This evidence-based document classifies the use of a method in the context of a particular medical condition or circumstance into one of four risk categories. An example of the UKMEC criteria for common cardiovascular risk factors is shown in Table 1 (see below). The UKMEC guidance includes many other medical conditions and risk factors (e.g. migraine, uterine fibroids, personal or family history of cancer). Other factors that can influence contraceptive choice in older women are listed in Box 1 (see below).^1,3

Box 1: Factors influencing contraceptive choice in women aged over 40 years1,3
Family history Other risk factors for cardiovascular disease, thrombosis, stroke, cancer, or osteoporosis Possibility of future planned conception Menstrual dysfunction Menopausal symptoms Use of hormone replacement therapy Frequency of intercourse Risk of sexually transmitted infection.

Non-contraceptive benefits

The non-contraceptive benefits of some methods of contraception may be of particular importance to women aged over 40 years. Explaining the potential benefits may encourage uptake and adherence, and can help to allay fears about side-effects and risks. Combined hormonal contraception (CHC) (e.g. combined pill, transdermal patch, and vaginal ring), the progestogen-only injectable (e.g. depot medroxyprogesterone acetate [DMPA]), and the levonorgestrel-releasing intrauterine system (LNG-IUS) have been shown to reduce menstrual blood loss and are recommended by the National Institute for Health and Care Excellence (NICE) for treatment of heavy menstrual bleeding.⁴

Other benefits of CHC include a reduced risk of ovarian and endometrial cancer, and possibly colorectal cancer.^1,5 There is a small amount of evidence suggesting that CHC^6,7 and the progestogen-only injectable^8,9 may improve menopausal symptoms.

Table 1: UK medical eligibility criteria for contraceptive use: categories related to age, common cardiovascular risk factors, and hormonal/intrauterine contraception3
	Age (years)			Smoking age ?35 years (depending on smoking age, number of cigarettes smoked, and time elapsed since quitting)	Obesity in terms of body mass index (kg/m2)		Adequately controlled hypertension	Multiple risk factors for cardiovascular disease (e.g. older age, smoking, hypertension, obesity)
	?40	18–45	>45		?30–34	?35
CHC	2			2/3/4	2	3	3	3/4
POP	1			1	1	1	1	2
IMP	1			1	1	1	1	2
DMPA or NET-EN		1	2	1	1	1	2	3
Cu-IUD	1			1	1	1	1	1
LNG-IUS	1			1	1	1	1	2
Definition of UKMEC categories: UKMEC 1: A condition for which there is no restriction on the use of the contraceptive method UKMEC 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks UKMEC 3: A condition where the theoretical or proven risks generally outweigh the advantages of using the method. The provision of a method requires expert clinical judgment and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or acceptable UKMEC 4: A condition that represents an unacceptable risk if the contraceptive method is used
CHC=combined hormonal contraception; POP=progestogen-only pill; IMP=implant (progestogen-only); DMPA=depot medroxyprogesterone acetate; NET-EN=norethisterone enantate; Cu-IUD=copper-bearing intrauterine device; LNG-IUS=levonorgestrel-releasing intrauterine system; UKMEC=UK medical eligibility criteria Faculty of Sexual & Reproductive Healthcare. UK medical eligibility criteria for contraceptive use. FSRH, 2009. Reproduced with kind permission of FSRH

Risks of contraceptive methods

Women should be informed of the potential risks associated with contraception. However, even in the over 40s age group, healthy women can be reassured that the absolute risk of serious adverse events is generally low. Combined hormonal contraception is associated with an increased risk of venous thromboembolism and there is a possible link with cardiovascular and cerebrovascular disease, and breast and cervical cancer.¹ There is no consistent evidence to suggest that these conditions are increased with use of progestogen-only contraception. Depot medroxyprogesterone acetate is, however, associated with unfavourable changes in lipid profiles and reduction in bone mineral density (BMD).¹⁰ Younger women usually regain BMD on stopping DMPA, but there is a concern that bone loss may not recover in women approaching the menopause.¹⁰

Women aged 50 years and over are theoretically at greater risk from the adverse effects of CHC and DMPA, and the FSRH guideline recommends switching to other methods at the age of 50 years.¹

Long-acting reversible contraception

Long-acting reversible methods of contraception (LARC) (i.e. progestogen-only injectable, implant, and intrauterine methods) have lower typical-use failure rates than shorter-acting methods.¹¹ The progestogen-only implant and intrauterine methods are at least as effective as female sterilisation. The NICE guideline on LARC has highlighted the efficacy and cost effectiveness of these methods and advises that all women requesting contraception are informed of their benefits.¹²

Sterilisation

Sterilisation is an option for women who are sure that they will not want more children in the future and who have considered the full range of alternative contraception methods. They should be fully informed of the irreversibility and risks of sterilisation and of the higher risk of contraceptive failure and major complications associated with female laparoscopic sterilisation compared with vasectomy.¹³

Contraception and hormone replacement therapy

Women receiving hormone replacement therapy (HRT) should be advised not to rely on this as a mode of contraception.¹ The progestogen-only pill (POP) can be used to provide contraception along with combined HRT. Women using estrogen-only replacement therapy may use the LNG-IUS to provide endometrial protection but should not rely on other progestogen-only methods for such protection. When used as the progestogen component of HRT, the LNG-IUS should be changed no later than 5 years after insertion (although the product licence states 4 years) irrespective of age at time of insertion.¹

Duration of contraceptive use

There are no limits on the number of years a woman may use a particular method. However, women using CHC or the progestogen-only pill should be assessed for new medical problems or risks factors at least annually.^14,15 Women using DMPA should be reviewed at least every 2 years to re-evaluate the risks and benefits of treatment.^9,16 With regards to intrauterine methods, the FSRH guidance recommends that:¹

• a copper-bearing intrauterine device (Cu-IUD) containing ?300 mm² copper that is inserted at age 40 years or over can be retained until the menopause
• the LNG-IUS can be used for up to 7 years (off licence) if inserted at age 45 years or over, and if bleeding patterns are acceptable. If the woman remains amenorrhoeic after 7 years of use, she can continue using the device until the menopause.

Stopping contraception

The FSRH guideline on stopping contraception is summarised in Table 2 (see Table 2, below). In general, contraception may be stopped when menopause is diagnosed or at the age of 55 years if the woman is on hormonal contraception and is amenorrhoeic.¹ For women using non-hormonal contraception, the menopause can be diagnosed after 1 year of amenorrhoea in women over the age of 50 and after 2 years in women under the age of 50 years. Women who have been using DMPA should continue using contraception for an additional year because of the delay in return of ovulation associated with this drug.

For women using hormonal methods, amenorrhoea alone cannot be used to diagnose the menopause. Follicle-stimulating hormone (FSH) levels can be used to guide when contraception can be stopped (see below). Use of FSH testing for this purpose is only advised in women over the age of 50 years and in women using progestogen-only methods.³

Table 2: Recommendations on stopping contraception1
	Advice on stopping contraception
Contraceptive method	Age of <50 years	Age ?50 years
Non-hormonal	Stop contraception after 2 years of amenorrhoea	Stop contraception after 1 year of amenorrhoea
Combined hormonal contraception	Can be continued up to age 50 years	Stop contraception at age 50 years and switch to a non-hormonal method or progestogen-only method and follow the appropriate advice
Depot medroxyprogesterone acetate	Can be continued up to age 50 years	Stop at age 50 years and switch either to: a non-hormonal method and stop after 2 years of amenorrhoea OR the progestogen-only pill, implant, or levonorgestrel-releasing intrauterine system and follow the advice below
Progestogen only implant, pill or levonorgestrel- releasing intrauterine system	Can be continued up to age 50 years or longer	Continue method If amenorrhoeic: check FSH levels and stop method after 1 year if serum FSH is ?30 IU/L on two occasions 6 weeks apart OR stop at age 55 years when natural loss of fertility can be assumed for most women If not amenorrhoeic, consider investigating any abnormal bleeding or changes in bleeding pattern and continue contraception beyond age 55 years until amenorrhoeic for 1 year
FSH=follicle-stimulating hormone Faculty of Sexual & Reproductive Healthcare. UK medical eligibility criteria for contraceptive use. FSRH, 2009. Reproduced with kind permission of FSRH

Sexually transmitted infections

There has been a rise in the number of diagnoses of STIs in women aged over 40 years.¹⁷ Healthcare professionals should:

• avoid making assumptions about an individual’s level of risk based on age alone
• remind patients about the use of condoms for protection against STIs even after contraception is no longer required.

Implications for primary care

As 75% of contraceptive care is provided in general practice,¹⁸ primary care clinicians have an important role to play in implementation of the FSRH guideline. The Government’s allocation of 10 points to contraceptive interventions in the 2009/10 quality and outcomes framework is likely to improve provision of information on contraception, particularly LARC methods.¹⁹ Currently, the majority of women choosing an implant or intrauterine contraception must access these methods from community contraception clinics.

Further incentives and facilitation of training for healthcare professionals are likely to be required to encourage wider implementation of evidence-based practice and improvements in contraceptive provision for women aged over 40 years. The development of an e-learning programme for the theoretical component of the diploma of the Faculty of Sexual & Reproduction Healthcare (www.ffprhc.org.uk) may help training of staff.

Conclusion

Women should be aware that they are potentially fertile until they reach the menopause and should be provided with information on all contraceptive options. Contraceptive advice should be tailored to individual women, taking into account risks and benefits.

Acknowledgments

The assistance of Julie Craik, Clinical Effectiveness Unit Researcher, in the preparation of this article is gratefully acknowledged.