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Contraception in the over 40’s

Contraception in the over 40’s. Contraception in older women; issues. Method choice may be affected by age and risk factors. When can the method be discontinued? How is the menopause diagnosed?. Typical scenario. 49 yr old Debbie , on progesterone only pill. Amenorrhoea 2+ yrs.

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Contraception in the over 40’s

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  1. Contraception in the over 40’s

  2. Contraception in older women; issues • Method choice may be affected by age and risk factors. • When can the method be discontinued? • How is the menopause diagnosed?

  3. Typical scenario.... 49 yr old Debbie , on progesterone only pill. Amenorrhoea 2+ yrs. Having some hot flushes, reduced libido, mood swings. She wonders if this may be due to the menopause. Can she have a blood test? Does she need to continue contraception?

  4. Transition to menopause ( 40-50) • Intermittent ovulation/anovulation with variable FSH levels. • Cycle length may reduce or increase. • Amenorrhoea not a reliable indicator of menopause when using hormonal contraception • FSH levels; not an exact science!

  5. Contraceptive method. • No method is contraindicated by age alone up to 50 yrs. • Some methods become less safe but this is dependent on other risk factors. • Need to use UKMEC guidance but if there are multiple risk factors this may affect advice.

  6. Sexual health in the over 40’s

  7. Sexual health in over 40’s • Average age divorce in women is 41 yrs. • New relationships common. • Conception rates in over 40’s more than doubled in 2 decades. • Older women may not be well informed regarding sexual health and contraception.

  8. Abortion rates 2012, England and Wales • Age 40-44; 7737 abortions • Age 45-49; 662 abortions • Age 50 +; 27 abortions!

  9. Method choice; Combined hormonal contraception • Use lowest dose that provides adequate cycle control; try to reduce to 20 mcg pill over 40. • May protect bone density • Likely to mask symptoms of menopause. • Careful consideration risk factors ( eg women with hypertension, UKMEC 3)

  10. Method choice; Depo -provera • Caution in women with CV risk factors; high dose progesterone may have adverse effects on lipid metabolism. • This becomes UKMEC 2 in over 45’s • But remember need to follow MHRA guidance; • Re-evaluate risks and benefits every 2 yrs. • Assess osteoporosis risks; this may influence patient decision to continue.

  11. When can contraception be stopped? • Menopause usually diagnosed after 1 yr amenorrhoea. • In general, CEU advised contraception may be stopped at age 55. • Non hormonal methods can be stopped 1 yr after LMP in 50+ yrs. • Non hormonal methods can be stopped 2 yrs after LMP if <50 yrs.

  12. IUD/IUS; when to remove? • IUD inserted after age 40 can be left until menopause diagnosed ( >300mm copper) • If IUS inserted over age 45, may continue for up to 7 yrs or until menopausal if amenorrhoea. • IUS endometrial protection license for HRT; 4 yrs.

  13. Diagnosing the menopause Debbie, 49, amenorrhoea on POP. Some menopausal symptoms. Women using PO methods ; FSH levels can be checked. If FSH>30 on 2 occasions, 6 weeks apart then contraception can be safely discontinued 1 yr later. Alternatively; just continue POP until 55, when natural loss fertility can be assumed for most women.

  14. Women using CHC. • FSH is not a reliable indicator of ovarian failure in women using combined hormones, even if measured during the hormone-free interval. • At age 50 switch to non hormonal or PO method. • Prepare for the worst........

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