No contraceptive method is contra-indicated by age alone.¹

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.

Methods used

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.²
Women and their partners should be advised that very long-acting reversible contraception can be as effective as sterilisation.³

Combined oral contraception

See also separate article Combined Hormone Contraception and HRT (Risks vs Benefits).

• Combined hormonal contraception can be used for women over the age of 40 unless there are coexisting diseases or risk factors. See separate article Combined Oral Contraceptive (First Prescription).
  For women aged over 40 years a monophasic pill with 30 micrograms or less of ethinylestradiol with a low dose of norethisterone or levonorgestrel is a suitable first-line option.¹
  1. Combined oral contraceptives (COCs) 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 aged 35 years or older who develop migraine without aura while using combined hormonal contraception.
     • Women who have cardiovascular disease, hypertension or history of stroke.
     • Women aged 35 years or older with a body mass index above 30 kg/m².⁴
     • Women aged 50 years or older.
  2. COCs and the combined contraceptive patch are not 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.
  3. The combined contraceptive vaginal ring is not currently recommended for women aged over 40 years because the safety and efficacy of NuvaRing® has currently only been established for women aged 18 to 40 years.
  4. 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 contraception

• Progestogen only pills (POPs) are often considered a suitable method of contraception for older women. See separate article Progestogen-only Contraceptive Pill.
• Women with current venous thromboembolism (VTE) should be advised that the risks of using progestogen-only methods outweigh the benefits. For women with a past history of VTE, the benefits of using progestogen-only methods outweigh the risks.¹
• The risks of initiating a progestogen-only injectable for women with a history of ischaemic heart disease or stroke outweigh the benefits, but the benefits of initiating POPs, implants or the intrauterine progestogen-only device outweigh the risks.¹
• Long-term use of progestogen-only injectable contraception is associated with a reduction in bone mass density but this returns 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.¹
• 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.

Barrier contraception

• Women should be advised to use condoms with a spermicidal lubricant where possible.

Intrauterine contraception

• Menstrual abnormalities (including spotting, light bleeding, heavy or longer menstrual periods) are common in the first 3-6 months of intrauterine contraception device (IUCD) use.
• The intrauterine progestogen-only device (Mirena® coil) 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.

Sterilisation

• 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.
• 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 increased hysterectomy rate, although there is no evidence that tubal occlusion leads to problems that require hysterectomy.¹
• Vasectomy:
  • The failure rate is approximately 1 in 2,000 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.¹

When contraception can be stopped

Women can be advised to stop contraception at the age of 55 years, as most (95.9%) will have reached the menopause by this age. 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.¹

• 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 intrauterine contraceptive device (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 progestogen-only pills (POPs) and implants:
  • 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 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 POP, implant or barrier contraception for another year (or two years if aged less than 50 years).¹
• 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 intrauterine progestogen-only device:
  • Women who have the intrauterine progestogen-only device 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 their FSH measured on two occasions in order to confirm menopause.¹
• A POP can be used with HRT to provide effective contraception.
• The intrauterine progestogen-only device can be used as the progestogen component for HRT for four years, and provide concurrent contraception.

Document references

1. Contraception for women aged over 40 years, Faculty of Family Planning and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists (July 2010)
2. Contraception and Sexual Health, Office for National Statistics, 2008/09
3. Long-acting reversible contraception, NICE Clinical guideline (October 2005); (the effective and appropriate use of long-acting reversible contraception)
4. British National Formulary; 58th Edition (September 2009) British Medical Association and Royal Pharmaceutical Society of Great Britain, London.

Acknowledgements