e-Learning | Contraception in the over 40s

This was an updated guideline from the FSRH on contraception in the over 40s. It came out in Nov 17, but as it is so useful, I thought it worth doing a summary. There were a few things that were new for me:

  • If women over 50 are amenorrheic AND using a progesterone only method of contraception, then you can measure their FSH to gauge when to safely stop contraception. Only a 1 off measurement is now advised (they used to suggest 2).
  • Depot injection. There are circumstances where you can continue to use the depot after age 50. See below.
  • COC. There are circumstances where the COC can be continued for non-contraceptive benefits after age 50. See below.
  • Women can safely stop contraception after age 55, even if they are still having menstrual bleeding.

What is the rate of pregnancy in the over 40s?

  • 10 - 20% per year if 40 - 45
  • 12% per year if 45 - 50
  • Very rare in the over 50s

Why do over 40yr old women need to be considered separately?

The background risks of various diseases increase, hence the contraception that is appropriate changes.

  • CVD risks. Start to rise in perimenopause. An early menopause is associated with an increased risk.
  • VTE risk rises 10 fold between age 40 and 60 (from 1 in 10,000 to 1 in 1000).
  • Breast, ovarian and endometrial cancer rates increase.
  • Osteoporosis risk increases.

If women over 50 are amenorrheic AND using a progesterone only method of contraception, then you can measure their FSH to gauge when to safely stop contraception. Only a one-off measurement is now advised.

What contraception can women over 40 use?

Any, though the:

  • combined oral contraceptive (COC) is contraindicated over 50.
  • depot should be discouraged over 50 (though can sometimes be used - see below).

HRT and contraception use

Sequential HRT can be used alongside any progesterone only method of contraception, though the depot injection should be discouraged.

The COC can be used instead of HRT until age 50. It should not be used with HRT.

When can women stop contraception?

  • At age 55, even if they are still having menstrual bleeding.
  • At age 50 or over if there is no bleeding for 1 yr (if on no contraception).
  • Under age 50 if there is no bleeding for 2 yrs (if on no contraception).

Can you use a blood test to determine when contraception can safely be stopped?

FSH > 30 suggests some ovarian insufficiency, but doesn't preclude pregnancy.

If a woman is over 50 and is using a progesterone only method of contraception (including the depot), AND if they are amenorrheic, then you can you check FSH. If it is > 30, then continue using contraception for a further year and then it can be safely stopped. If it is < 30, then consider retesting again in a year.

If women are under 50, then using FSH to try to estimate when contraception can be stopped is unreliable.

Advice regarding specific methods of contraception

Copper coil

If they have over 300m2 of copper and they are inserted over age 40, then they can stay in until 1 yr after the LMP in over 50s and 2 yrs after the LMP in under 50s.

They shouldn't be left in indefinitely as they become a focus of infection.

Mirena coil

If used as the progestogenic component of HRT, they must be replaced every 5 yrs.

There are increased risks if used after endometrial ablation (eg of perforation).

If they are not being used for HRT and are inserted after age 45, they can be used for contraception until age 55, though should not be left in indefinitely as they become a focus of infection.

Implant

Can be used until age 55 and can be left in after that if wanted.

POP

Can be continued until age 55.

COC

They should be stopped at age 50. However, they do advise that if women want to continue to use it for 'non-contraceptive benefits', that they should be considered individually using 'clinical judgement and informed choice'.

Choice of COC. Levonorgestrel and norethisterone pills should be first line as they have the lowest VTE risk. Use 30mg or less of ethinylestradiol first line as they have lower VTE, CVD and CVA risks.

Regimes. You can advise extended use regimes to help with menstrual or menopausal symptoms. The VTE risk is greatest on starting the COC, so if women stop for a month and then restart, the risk is higher again. Women over 40 should be counselled about the signs and symptoms of VTE.

Benefits and risks. The COC lowers the risk of ovarian and endometrial CA and this effect lasts decades after cessation. It may help to maintain bone mineral density compared to women using no hormones in the perimenopause. There is a small increase in breast CA, but this effect has disappeared within 10 yrs of cessation. The VTE risk is described above.

DMPA - depot injection

There is initial loss of bone mineral density when DMPA is started. There is then very little extra loss at menopause. The loss is recovered when it is stopped.

Assess patients' risk every 2 yrs.

Women over 40 with other risk factors (eg smoking, inactivity, a family history of osteoporosis, vitamin D deficiency etc), should be advised to consider other methods.

After age 45, it becomes UKMEC 2.

Women over age 50 should be counselled on other methods. However, if they wish to continue the depot, then it can be considered. The risks and benefits for the individual should be discussed. The decision to continue should then be reassessed regularly at review visits.

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