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Contraception for women aged over 40 years

Contraception for women aged over 40 years. Susanna Hall Research Doctor Clinical Effectiveness Unit of the Faculty of Sexual and Reproductive Health 23 November 2010. Contraception for the over 40’s. Is contraception necessary? Choosing contraception

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Contraception for women aged over 40 years

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  1. Contraception for women aged over 40 years Susanna Hall Research Doctor Clinical Effectiveness Unit of the Faculty of Sexual and Reproductive Health 23 November 2010

  2. Contraception for the over 40’s • Is contraception necessary? • Choosing contraception • Specific contraceptive methods for women over 40 • STIs and safer sex • Menopause and stopping contraception • Conclusions

  3. Is contraception over 40 years of age necessary? www.statistics.gov.uk 28 February 2008

  4. Conception vs infertility • As age increases, fertility decreases in women • Declines to lesser degree in men • At 40-44, 36% likelihood of spontaneous pregnancySource: Management of the Infertile Woman, Helen A Carcio

  5. In 2009 • 26,976 live births to women aged 40 and over in England and Wales (ONS) • 8132 Abortions to women over 40 years in England and Wales (ONS) • Similar story in Scotland

  6. Pregnancy outcomes • Pregnancy later in life is associated with worse reproductive outcomes: • Maternal • Gestational diabetes • Placenta previa • Placental abruption • Caesarean section • Fetal • Chromosomal abnormalities (eg Trisomy 21) • Miscarriage • Low birth weigh • Preterm delivery • Increased perinatal mortality

  7. Wish for continued fertility? • Be aware not all women in their 40’s have finished their family • Realism about declining fertility after 40 • Increased potential mortality and morbidity for mother and fetus, especially if any co-morbidities • Decreased success for fertility treatment • Fertility treatment not NHS funded over 40 years

  8. Changes in partner • Divorce average age is 41.2 years for women in England and Wales • New relationships may start after long term monogamous relationships • Support for review of sexual health, including contraception and STIs

  9. Choosing contraception • Wide range of contraceptive methods available • No contraceptive method is contraindicated based on age alone • Age may become a more significant risk factor in conjunction with other medical conditions

  10. Choosing contraception • Clinical history • UK Medical Eligibility Criteria for contraceptive Use (UKMEC) • Evidence based recommendations for use of contraceptive methods in presence of medical conditions • Does not take into account multiple conditions

  11. Women’s choice of method • Aged 40-44y, 75% used at least 1 method • Aged 45-49y, 72% used at least 1 method • Most commonly used methods: • Sterilisation (male and female) • Male condom • Pills • IUD Office for National Statistics, Contraception and Sexual Health Survey, 2008-9

  12. Long Acting Reversible methods of Contraception • Methods that require administration less than once per month • Typical failure rates are lower than for shorter acting contraception • Cost effective at 1 year of use • Failure rates comparable to female sterilisation, offering a reliable alternative • No delay in fertility return except with progestogen-only injectable (delay of up to 1 year) Effective and Appropriate Use of Long Acting Reversible Contraception, NICE 2005

  13. Combined Hormonal Contraception • 3 forms of combined hormonal contraception • Most evidence relates to the combine hormonal pill • UKMEC assumes all risks are similar • Age over ≥40y UKMEC 2

  14. Health Benefits of Combined Hormonal Contraception • Dysmenorrhoea and cycle control • Menopausal symptoms • Bone health • Ovarian and endometrial cancer • Benign breast disease • Colorectal cancer

  15. Health Risks with CHC • Breast cancer • Annual risk of breast cancer increases with increasing age • There may be a small additional risk of breast cancer with CHC use • Any risk reduces to no risk 10 years after stopping CHC • Current breast cancer UKMEC 4 • Family history of breast cancer UKMEC 1 • BRCA 1 and 2 mutation carrier UKMEC3- expert clinical judgement and/or referral to specialist provider

  16. Health Risks with CHC • Cervical cancer • Small increased risk (invasive and in situ) • Long term users can be reassured that benefits outweigh risks • Risk of invasive cancers declines after stopped using (after 10 years, return to never user risk) • HVP and condom use

  17. Health Risks with CHC • Venous thromboembolism (VTE) • VTE is rare in women of reproductive age • VTE risk increases with increasing age • Relative risk of VTE is increased with use of the COC • Uncertainty about the risks of patch and risks of CVR unknown

  18. Health Risks with CHC • UKMEC categories for CHC • Personal history of VTE UKMEC 4 • Current VTE (on anticoagulants) UKMEC 4 • Family history of VTE • 1st degree relative aged <45y UKMEC 3 • 1st degree relative aged ≥45 y UKMEC 2

  19. Health Risks for CHC • Cardiovascular disease: MI and Stroke • MI and stroke are rare in women of reproductive age • Risk increases with increasing age • Conflicting evidence regarding risk • Cumulative additional risk if multiple risk factors

  20. Health Risks for CHC • UKMEC categories for CHC • Stroke (CVA including TIA) UKMEC 4 • Hypertension • Adequately controlled hypertension UKMEC 3 • Consistently elevated blood pressure • Systolic >140-159mmHg or diastolic >90-94mmHg UKMEC 3 • Systolic ≥160 mmHg or diastolic ≥95mmHg UKMEC 4 • Vascular disease UKMEC 4 • Multiple risk factors for CV disease (older age, smoking, diabetes, obesity, hypertension) UKMEC 3/4

  21. Progestogen-only Contraception • Progestogen-only pill • Injectable • Sub-dermal implant • Levonorgestrel-releasing intrauterine system

  22. Health Benefits for POC • Dysmenorrhoea • Bleeding patterns • Menopausal symptoms

  23. Health Risks of POC • Reproductive cancers- no conclusive evidence • Current breast cancer UKMEC4 • Previous breast cancer UKMEC3 • Bone health

  24. Health Risks associated with POC • Cardiovascular and cerebrovascular disease • Limited data suggest no increased risk of MI and stroke • Venous thromboembolism • Little or no effect on risk of VTE • Effect of DMPA on lipid metabolism • Theoretical risk of vascular disease in women with additional risk factors

  25. UKMEC 2009

  26. Non-Hormonal contraception • Copper IUD • Sterilisation • Barrier contraception • Fertility awareness methods • Withdrawal

  27. Copper Intrauterine device • Menstrual bleeding problems are common in women over 40 and IUD users • Spotting, heavier periods and pain in first 3-6 months • Seek medical advice if symptoms persist or occur as new event, to exclude gynaecolgical pathology

  28. Sterilisation • Advice about all methods of contraception including LARCs should be provided • Advantages and disadvantages, including lower failure rate and major complications with vasectomy compared to laparoscopic sterilisation

  29. Barrier contraception • No restriction on use • Use of spermicide is recommended with caps and diaphragms • Condoms with spermicidal lubricant should not be used • Lubricant should be non-oil based

  30. Fertility Awareness methods • Numbers using fertility awareness unknown • May become more difficult as approaching the menopause • Irregular cycles • Anovulatory cycles

  31. Withdrawal • Not promoted as a method of contraception • Reported by ~6% women aged 40-44y • If used correctly, may work for couples, particularly as backup to other methods • Should be aware not as effective as other methods of contraception

  32. Emergency contraception • No restrictions on use of EC based on age alone • Women should be made aware of the different types of EC available

  33. Sexually transmitted infections • STIs are not confined to younger people • There has been an increase in diagnoses in over 40 year olds • Condoms protect against STIs even after contraception no longer required

  34. Diagnosing the Menopause • Retrospective diagnosis: 1 year amenorrhoea • No single reliable marker of perimenopause

  35. Stopping contraception • In general contraception may be stopped at the age of 55 years • Advice need tailored to the individual • If having regular menstrual cycles at 55 y- should continue on some contraception

  36. Non-hormonal methods • If over 50 years • After 1 year of amenorrhoea (1 year after LMP) • If under 50 years • After 2 years of amenorrheoa (2 years after LMP) • Cu-IUD- if inserted ≥40y, may be retained until the menopause (outside license)

  37. Hormonal Methods • Amenorrhoea is not a reliable indicator of ovarian failure if taking exogenous hormones • FSH: for those over 50y and taking POC • Not reliable with combined methods • If over 50y and wishing to stop POC, check FSH • If level ≥30IU/L, repeat FSH in 6 weeks. If second FSH ≥30IU/L- stop contraception after 1 year

  38. Removing the LNG-IUS • Amenorrhoea and light bleeding common after first year of use • Need to check FSH levels over the age of 50y as previously

  39. Hormone Replacement Therapy • HRT is not contraceptive • May use POP • HRT must contain a progestogen in addition to estrogen • LNG-IUS may be used for endometrial protection from estrogen therapy • May be changed no later than 5 years (4 y license) • FSH levels are not reliable if taking HRT

  40. Conclusions • No method is contraindicated by age alone • UKMEC is useful to provide recommendations for contraceptive use • Remember does not take into account multiple risk factors • CEU guidance available: Over 40’s and specific methods • Continue to assess most appropriate method with changing medical history and requirements

  41. Any questions?

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