Contraception and the Mature Woman

Although a natural decline in fertility occurs from the age of about 37 years, effective contraception is still required to prevent unplanned pregnancy. No contraceptive method is contraindicated by age alone.¹

• Combined hormonal contraception can be used for women over the age of 40 unless there are co-existing diseases or risk factors. 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
• Smoking: the risks of using combined hormonal contraception outweigh the benefits for smokers aged 35 years or more. However women aged 35 years or more, with no other risk factors who have stopped smoking more than a year before, may consider using combined hormonal contraception.
• Any increase in risk of breast cancer is likely to be small and is reduced to no excess risk 10 years after stopping. However this risk must be considered in addition to the individual woman's background risk which increases with age.
• There may be additional benefits including a reduction in menstrual bleeding and pain, and the combined contraceptive pill may reduce hot flushes.

• Progestogen only pills are often considered a suitable method of contraception for older women.
• Women with current venous thromboembolism should be advised that the risks of using progestogen-only methods outweigh the benefits. For women with a past history of venous thromboembolism, 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 intra-uterine 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.

• 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 IUCD use.
• The intra-uterine progestogen-only device (Mirena coil) is increasingly popular and provides a reduction in bleeding in addition to the contraception benefit.
• If menstrual abnormalities occur after the first 6 months of use then infection and gynaecological pathology must be excluded.

• The inevitable choice is whether the woman or her partner have a sterilization. Vasectomy carries a lower failure rate and less overall risk then 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 2000 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

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 on at least two occasions 1 or 2 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 1 year of amenorrhoea (or 2 years if the last menstrual period occurred for a woman aged less than 50 years).
  • Women who have an IUD with more than 300 mm2 of copper inserted at age 40 years or more can be advised to retain the device until the menopause.
• Stopping combined contraception
  • Women using combined contraception should be advised to switch to another suitable contraceptive method at the age of 50 years.
  • 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 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 1 or 2 months apart, and if both levels are less 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 2 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 intra-uterine progestogen-only device
  • Women who have the intra-uterine progestogen-only device inserted at age 45 years or more for contraception or for the management of menorrhagia can be counselled about retaining the device for up to 7 years.

• Women using combined HRT cannot be advised to rely on this as contraception.
• Women on HRT should continue contraception until 55 yrs old, or can stop before if the woman stops HRT for 6 weeks to have their FSH measured on 2 occasions in order to confirm menopause.¹
• A POP can be used with HRT to provide effective contraception.
• Women using oestrogen replacement therapy may use the intra-uterine progestogen-only device to provide endometrial protection.