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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. Natural family planning is not recommended because of irregular menstrual cycles when approaching the menopause.
2008/2009 data indicated that, of women aged 40-49 years, the four most commonly reported methods were sterilisation (either own or partner's), the pill, male condoms and intrauterine methods. Women and their partners should 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).
Combined oral contraception
Combined hormonal contraception can be used for women over the age of 40 unless there are co-existing diseases or risk factors.
- Combined oral contraceptive pills (COCPs) and the combined contraceptive patch should not be used by:
- Women aged 35 years or older who smoke 15 or more cigarettes a day.
- Women who have migraine without aura.
- Women who have high blood pressure (systolic ≥160 mm Hg and/or diastolic ≥95 mm Hg).
- Women who have cardiovascular disease, a history of stroke, venous thromboembolism, or congenital/valvular heart disease with complications.
- Women with a body mass index above 40 kg/m2.
- Women aged 50 years or older.
- See the UKMEC criteria for the complete list of contra-indications.
- COCPs and the combined contraceptive patch are not normally recommended for:
- Women aged 35 years or older who smoke fewer than 15 cigarettes a day, or who stopped smoking less than one year ago.
- Women aged 35 years or older who have had migraine without aura, or a past history of migraine at any age.
- Women with a body mass index of 35-39 kg/m2.
- Women with immobility.
- Women with breast disease.
- 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 pills (POCPs) are often considered a suitable method of contraception for older women.
- Women with a past history of VTE, as well as those with current venous thromboembolism (VTE) on anticoagulants, can be advised that the benefits of using progestogen-only methods outweigh the risks.
- Women can be advised there is no evidence that progestogen-only contraception increases the risk of stroke, myocardial infarction or thromboembolism. The risks of initiating a progestogen-only injectable for women with a history of ischaemic heart disease or stroke outweigh the benefits due to its theoretical effect on lipid metabolism. However, the benefits of initiating POCPs, implants or the intrauterine progestogen-only system (IUS) outweigh the risks.
- 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.
- Women should be advised to use condoms with a spermicidal lubricant where possible.
- 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 inevitable choice is whether the woman or her 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 5 in 1,000.  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 increased hysterectomy rate, although there is no evidence that tubal occlusion leads to problems that require hysterectomy.
- The failure rate is approximately 1 in 1,000 after clearance has been given.
- Effective contraception is required until azoospermia has been confirmed.
- There is no increase in testicular cancer or heart disease associated with vasectomy. The association in some reports of an increased risk of being diagnosed with prostate cancer is at present considered to be non-causative.
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, one or two months apart, may predict ovarian failure and be helpful in some situations when advising women when to stop contraception.
- Stopping non-hormonal contraception:
- Women using non-hormonal contraception can be advised to stop contraception after one year of amenorrhoea (or two years if the last menstrual period occurred for a woman 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.
- Stopping combined contraception:
- Women using combined contraception 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 POCPs and implants:
- The POCP 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 POCP or implant and have FSH levels checked on two occasions one or two months 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 POCP, 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.
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 POCP 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 & references
- Hormonal contraceptives; Medicine and Healthcare products Regulatory Agency (MHRA)
- 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 (2010)
- Contraception and Sexual Health 2008/09; Office for National Statistics, 2009
- Long-acting reversible contraception; NICE Clinical Guideline (October 2005)
- UK Medical Eligibility Criteria for Contraceptive Use; Faculty of Sexual and Reproductive Healthcare (2009)
- Trussell J; Contraceptive failure in the United States, Contraception (2011)
- Male and female sterilisation; Royal College of Obstetricians and Gynaecologists (2004)
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
|Original Author: Dr Colin Tidy||Current Version: Dr Mary Harding||Peer Reviewer: Prof Cathy Jackson|
|Last Checked: 18/02/2014||Document ID: 2006 Version: 25||© EMIS|