Contraception for older, 'higher risk' women

Dr Anne Connolly, RCGP Clinical Champion for Women's Health

The recently published FSRH Guideline for Contraception for women aged over 40 is free to access and contains important recommendations about contraceptive choices for 'older women', advice on when contraception can be discontinued and contraception use with hormone replacement therapy (HRT).

Although natural fertility declines steeply after the mid-30s women continue to be at risk of pregnancy until the menopause. Contraceptive consultations become complex because of the increased background health risks of these 'older women' restricting the use of some contraceptive methods while others become more useful for their additional non-contraceptive benefits.  

Combined Hormonal Contraception (CHC) is frequently used in women aged over 40 offering non-contraceptive benefits of menstrual control, treatment of perimenopausal symptoms and providing some protection against endometrial and ovarian cancer. However, caution is required when prescribing ethinylestradiol containing products because of the increased thrombotic potential in women who are at higher risk of cardiovascular and thrombotic disease in view of their age. The guidance uses the UK Medical Eligibility Criteria (UKMEC) to assess individual health concerns and provide recommendations about the use or avoidance of CHC. This updated FSRH guidance also recommends specific constituents of products, using lower dose oestrogen and levonorgestrel containing products where possible to minimise risk. CHC use should be discontinued at the age of 50 and replaced with a progestogen-only or non-hormonal method.

Progestogen-only pills and sub-dermal implant have few safety concerns and should be continued until age 55 when spontaneous conception becomes extremely rare, or until one year after an elevated FSH level when tested after age 50.

Depo-medroxyprogesterone acetate (DMPA) use is considered separately and should be changed to an alternative method at age 50 because of the reduction in bone density this may cause. Women can be reassured that any bone loss when using this method is matched by non-users when they become post-menopausal.

Of the 3 currently available intra-uterine system products in the UK it is only Mirena® that is licensed as treatment for endometrial protection when used with oestrogen as HRT. The new guidance recommends that if inserted after the age of 45 this will provide contraception until no longer required but will require earlier changing, after 5 years, if oestrogen is added for treatment of menopausal symptoms.

All copper intra-uterine devices (IUD) inserted after the age of 40 for routine or emergency contraception can be left until the age of 55 when removal is recommended.

The section on perimenopause adds clarity to the confusion that surrounds contraception requirements at this time. Sequential combined HRT is not contraceptive and sexually active women either require the use of progestogen-only pill or sub-dermal implant in addition or insertion of a Mirena® and estrogen-only HRT.

One last reminder from the guidance is that sexually transmitted infections are increasing in the over 40’s and sexual health advice and condom use, even when over the age of requiring contraception, should be encouraged.

Contact

Clinical Innovation and Research Centre: 020 3188 7597
circ@rcgp.org.uk

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