Contraception for Contraception for women aged over 40 women aged over 40

yearsyearsSusanna HallSusanna Hall

Research Doctor Research Doctor Clinical Effectiveness Unit of the Faculty of Clinical Effectiveness Unit of the Faculty of

Sexual and Reproductive HealthSexual and Reproductive Health23 November 201023 November 2010

Contraception for the Contraception for the over 40’sover 40’s

Is contraception necessary?Is contraception necessary? Choosing contraceptionChoosing contraception Specific contraceptive methods for Specific contraceptive methods for

women over 40women over 40 STIs and safer sexSTIs and safer sex Menopause and stopping Menopause and stopping

contraceptioncontraception ConclusionsConclusions

Is contraception over 40 Is contraception over 40 years of age necessary? years of age necessary?

www.statistics.gov.uk

28 February 2008

Conception vs infertilityConception vs infertility As age increases, As age increases,

fertility decreases in fertility decreases in womenwomen

Declines to lesser Declines to lesser degree in mendegree in men

At 40-44, 36% At 40-44, 36% likelihood of likelihood of spontaneous pregnancyspontaneous pregnancy

Source: Management Source: Management of the Infertile Woman, of the Infertile Woman, Helen A CarcioHelen A Carcio

In 2009 In 2009 26,976 live births to women aged 40 26,976 live births to women aged 40

and over in England and Wales and over in England and Wales (ONS)(ONS)

8132 Abortions to women over 40 8132 Abortions to women over 40 years in England and Wales (ONS)years in England and Wales (ONS)

Similar story in ScotlandSimilar story in Scotland

Pregnancy outcomesPregnancy outcomes Pregnancy later in life is associated with worse Pregnancy later in life is associated with worse

reproductive outcomes:reproductive outcomes: MaternalMaternal

Gestational diabetesGestational diabetes Placenta previaPlacenta previa Placental abruptionPlacental abruption Caesarean sectionCaesarean section

FetalFetal Chromosomal abnormalities (eg Trisomy 21)Chromosomal abnormalities (eg Trisomy 21) MiscarriageMiscarriage Low birth weighLow birth weigh Preterm deliveryPreterm delivery Increased perinatal mortalityIncreased perinatal mortality

Wish for continued Wish for continued fertility?fertility?

Be aware not all women in their 40’s Be aware not all women in their 40’s have finished their familyhave finished their family

Realism about declining fertility after 40Realism about declining fertility after 40 Increased potential mortality and Increased potential mortality and

morbidity for mother and fetus, morbidity for mother and fetus, especially if any co-morbiditiesespecially if any co-morbidities

Decreased success for fertility treatment Decreased success for fertility treatment Fertility treatment not NHS funded over Fertility treatment not NHS funded over

40 years40 years

Changes in partnerChanges in partner

Divorce average age is 41.2 years Divorce average age is 41.2 years for women in England and Walesfor women in England and Wales

New relationships may start after New relationships may start after long term monogamous relationshipslong term monogamous relationships

Support for review of sexual health, Support for review of sexual health, including contraception and STIsincluding contraception and STIs

Choosing contraceptionChoosing contraception

Wide range of contraceptive Wide range of contraceptive methods availablemethods available

No contraceptive method is No contraceptive method is contraindicated based on age alonecontraindicated based on age alone

Age may become a more significant Age may become a more significant risk factor in conjunction with other risk factor in conjunction with other medical conditionsmedical conditions

Choosing contraceptionChoosing contraception

Clinical historyClinical history UK Medical Eligibility Criteria for UK Medical Eligibility Criteria for

contraceptive Use (UKMEC)contraceptive Use (UKMEC) Evidence based recommendations for Evidence based recommendations for

use of contraceptive methods in use of contraceptive methods in presence of medical conditionspresence of medical conditions

Does not take into account multiple Does not take into account multiple conditionsconditions

Women’s choice of Women’s choice of methodmethod

Aged 40-44y, 75% used at least 1 methodAged 40-44y, 75% used at least 1 method Aged 45-49y, 72% used at least 1 methodAged 45-49y, 72% used at least 1 method

Most commonly used methods:Most commonly used methods: Sterilisation (male and female)Sterilisation (male and female) Male condomMale condom PillsPills IUDIUD

Office for National Statistics, Contraception and Office for National Statistics, Contraception and Sexual Health Survey, 2008-9Sexual Health Survey, 2008-9

Long Acting Reversible Long Acting Reversible methods of Contraceptionmethods of Contraception

Methods that require administration less Methods that require administration less than once per monththan once per month

Typical failure rates are lower than for Typical failure rates are lower than for shorter acting contraceptionshorter acting contraception

Cost effective at 1 year of useCost effective at 1 year of use Failure rates comparable to female Failure rates comparable to female

sterilisation, offering a reliable alternativesterilisation, offering a reliable alternative No delay in fertility return except with No delay in fertility return except with

progestogen-only injectable (delay of up progestogen-only injectable (delay of up to 1 year)to 1 year)

Effective and Appropriate Use of Long Acting Effective and Appropriate Use of Long Acting Reversible Contraception, NICE 2005Reversible Contraception, NICE 2005

Combined Hormonal Combined Hormonal Contraception Contraception

3 forms of combined hormonal contraception3 forms of combined hormonal contraception Most evidence relates to the combine hormonal Most evidence relates to the combine hormonal

pillpill UKMEC assumes all risks are similarUKMEC assumes all risks are similar Age over ≥40y UKMEC 2Age over ≥40y UKMEC 2

Health Benefits of Health Benefits of Combined Hormonal Combined Hormonal

ContraceptionContraception Dysmenorrhoea and cycle controlDysmenorrhoea and cycle control Menopausal symptomsMenopausal symptoms Bone healthBone health Ovarian and endometrial cancerOvarian and endometrial cancer Benign breast diseaseBenign breast disease Colorectal cancerColorectal cancer

Health Risks with CHCHealth Risks with CHC Breast cancerBreast cancer

Annual risk of breast cancer increases with Annual risk of breast cancer increases with increasing ageincreasing age

There may be a small additional risk of breast There may be a small additional risk of breast cancer with CHC usecancer with CHC use

Any risk reduces to no risk 10 years after Any risk reduces to no risk 10 years after stopping CHCstopping CHC

Current breast cancer UKMEC 4Current breast cancer UKMEC 4 Family history of breast cancer UKMEC 1Family history of breast cancer UKMEC 1 BRCA 1 and 2 mutation carrier UKMEC3- BRCA 1 and 2 mutation carrier UKMEC3-

expert clinical judgement and/or referral to expert clinical judgement and/or referral to specialist providerspecialist provider

Health Risks with CHCHealth Risks with CHC

Cervical cancerCervical cancer Small increased risk (invasive and in Small increased risk (invasive and in

situ)situ) Long term users can be reassured that Long term users can be reassured that

benefits outweigh risksbenefits outweigh risks Risk of invasive cancers declines after Risk of invasive cancers declines after

stopped using (after 10 years, return to stopped using (after 10 years, return to never user risk)never user risk)

HVP and condom useHVP and condom use

Health Risks with CHCHealth Risks with CHC

Venous thromboembolism (VTE)Venous thromboembolism (VTE) VTE is rare in women of reproductive VTE is rare in women of reproductive

ageage VTE risk increases with increasing ageVTE risk increases with increasing age Relative risk of VTE is increased with Relative risk of VTE is increased with

use of the COCuse of the COC Uncertainty about the risks of patch Uncertainty about the risks of patch

and risks of CVR unknownand risks of CVR unknown

Health Risks with CHCHealth Risks with CHC

UKMEC categories for CHCUKMEC categories for CHC Personal history of VTE UKMEC 4Personal history of VTE UKMEC 4 Current VTE (on anticoagulants) Current VTE (on anticoagulants)

UKMEC 4UKMEC 4 Family history of VTEFamily history of VTE

11stst degree relative aged <45y UKMEC 3 degree relative aged <45y UKMEC 3 11stst degree relative aged ≥45 y UKMEC 2 degree relative aged ≥45 y UKMEC 2

Health Risks for CHCHealth Risks for CHC

Cardiovascular disease: MI and Cardiovascular disease: MI and StrokeStroke MI and stroke are rare in women of MI and stroke are rare in women of

reproductive agereproductive age Risk increases with increasing ageRisk increases with increasing age Conflicting evidence regarding riskConflicting evidence regarding risk Cumulative additional risk if multiple Cumulative additional risk if multiple

risk factorsrisk factors

Health Risks for CHCHealth Risks for CHC UKMEC categories for CHCUKMEC categories for CHC Stroke (CVA including TIA) UKMEC 4Stroke (CVA including TIA) UKMEC 4 HypertensionHypertension

Adequately controlled hypertension UKMEC 3Adequately controlled hypertension UKMEC 3 Consistently elevated blood pressureConsistently elevated blood pressure

Systolic >140-159mmHg or diastolic >90-94mmHg Systolic >140-159mmHg or diastolic >90-94mmHg UKMEC 3UKMEC 3

Systolic ≥160 mmHg or diastolic ≥95mmHg UKMEC 4Systolic ≥160 mmHg or diastolic ≥95mmHg UKMEC 4 Vascular disease UKMEC 4Vascular disease UKMEC 4

Multiple risk factors for CV disease (older Multiple risk factors for CV disease (older age, smoking, diabetes, obesity, age, smoking, diabetes, obesity, hypertension) UKMEC 3/4hypertension) UKMEC 3/4

Progestogen-only Progestogen-only ContraceptionContraception

Progestogen-only pillProgestogen-only pill InjectableInjectable Sub-dermal implantSub-dermal implant Levonorgestrel-releasing intrauterine systemLevonorgestrel-releasing intrauterine system

Health Benefits for POCHealth Benefits for POC

DysmenorrhoeaDysmenorrhoea Bleeding patternsBleeding patterns Menopausal symptomsMenopausal symptoms

Health Risks of POCHealth Risks of POC

Reproductive cancers- no conclusive Reproductive cancers- no conclusive evidenceevidence

Current breast cancer UKMEC4Current breast cancer UKMEC4 Previous breast cancer UKMEC3Previous breast cancer UKMEC3 Bone healthBone health

Health Risks associated Health Risks associated with POCwith POC

Cardiovascular and cerebrovascular Cardiovascular and cerebrovascular diseasedisease Limited data suggest no increased risk Limited data suggest no increased risk

of MI and strokeof MI and stroke Venous thromboembolismVenous thromboembolism

Little or no effect on risk of VTELittle or no effect on risk of VTE Effect of DMPA on lipid metabolismEffect of DMPA on lipid metabolism

Theoretical risk of vascular disease in Theoretical risk of vascular disease in women with additional risk factorswomen with additional risk factors

UKMEC 2009UKMEC 2009

Non-Hormonal Non-Hormonal contraceptioncontraception

Copper IUDCopper IUD SterilisationSterilisation Barrier contraceptionBarrier contraception Fertility awareness methodsFertility awareness methods WithdrawalWithdrawal

Copper Intrauterine Copper Intrauterine devicedevice

Menstrual bleeding problems are Menstrual bleeding problems are common in women over 40 and IUD common in women over 40 and IUD usersusers

Spotting, heavier periods and pain in Spotting, heavier periods and pain in first 3-6 months first 3-6 months

Seek medical advice if symptoms Seek medical advice if symptoms persist or occur as new event, to persist or occur as new event, to exclude gynaecolgical pathologyexclude gynaecolgical pathology

SterilisationSterilisation

Advice about all methods of Advice about all methods of contraception including LARCs contraception including LARCs should be providedshould be provided

Advantages and disadvantages, Advantages and disadvantages, including lower failure rate and including lower failure rate and major complications with vasectomy major complications with vasectomy compared to laparoscopic compared to laparoscopic sterilisationsterilisation

Barrier contraceptionBarrier contraception

No restriction on useNo restriction on use Use of spermicide is recommended Use of spermicide is recommended

with caps and diaphragmswith caps and diaphragms Condoms with spermicidal lubricant Condoms with spermicidal lubricant

should not be usedshould not be used Lubricant should be non-oil basedLubricant should be non-oil based

Fertility Awareness Fertility Awareness methodsmethods

Numbers using Numbers using fertility awareness fertility awareness unknownunknown

May become more May become more difficult as difficult as approaching the approaching the menopausemenopause Irregular cyclesIrregular cycles Anovulatory cyclesAnovulatory cycles

WithdrawalWithdrawal

Not promoted as a method of Not promoted as a method of contraceptioncontraception

Reported by ~6% women aged 40-44yReported by ~6% women aged 40-44y If used correctly, may work for If used correctly, may work for

couples, particularly as backup to couples, particularly as backup to other methodsother methods

Should be aware not as effective as Should be aware not as effective as other methods of contraceptionother methods of contraception

Emergency Emergency contraceptioncontraception

No restrictions on use of EC based on age No restrictions on use of EC based on age alonealone

Women should be made aware of the Women should be made aware of the different types of EC availabledifferent types of EC available

Sexually transmitted Sexually transmitted infectionsinfections

STIs are not confined to younger STIs are not confined to younger peoplepeople

There has been an increase in There has been an increase in diagnoses in over 40 year oldsdiagnoses in over 40 year olds

Condoms protect against STIs even Condoms protect against STIs even after contraception no longer after contraception no longer requiredrequired

Diagnosing the Diagnosing the MenopauseMenopause

Retrospective diagnosis: 1 year Retrospective diagnosis: 1 year amenorrhoeaamenorrhoea

No single reliable marker of No single reliable marker of perimenopauseperimenopause

Stopping contraceptionStopping contraception

In general contraception may be In general contraception may be stopped at the age of 55 yearsstopped at the age of 55 years Advice need tailored to the individualAdvice need tailored to the individual

If having regular menstrual cycles at If having regular menstrual cycles at 55 y- should continue on some 55 y- should continue on some contraceptioncontraception

Non-hormonal methodsNon-hormonal methods

If over 50 yearsIf over 50 years After 1 year of amenorrhoea (1 year After 1 year of amenorrhoea (1 year

after LMP)after LMP) If under 50 yearsIf under 50 years

After 2 years of amenorrheoa (2 years After 2 years of amenorrheoa (2 years after LMP)after LMP)

Cu-IUD- if inserted ≥40y, may be Cu-IUD- if inserted ≥40y, may be retained until the menopause retained until the menopause (outside license)(outside license)

Hormonal MethodsHormonal Methods

Amenorrhoea is not a reliable indicator of Amenorrhoea is not a reliable indicator of ovarian failure if taking exogenous hormonesovarian failure if taking exogenous hormones

FSH: for those over 50y and taking POCFSH: for those over 50y and taking POC Not reliable with combined methodsNot reliable with combined methods

If over 50y and wishing to stop POC, check If over 50y and wishing to stop POC, check FSHFSH If level ≥30IU/L, repeat FSH in 6 weeks. If second If level ≥30IU/L, repeat FSH in 6 weeks. If second

FSH ≥30IU/L- stop contraception after 1 yearFSH ≥30IU/L- stop contraception after 1 year

Removing the LNG-IUSRemoving the LNG-IUS

Amenorrhoea and light bleeding Amenorrhoea and light bleeding common after first year of usecommon after first year of use

Need to check FSH levels over the Need to check FSH levels over the age of 50y as previouslyage of 50y as previously

Hormone Replacement Hormone Replacement TherapyTherapy

HRT is not contraceptiveHRT is not contraceptive May use POPMay use POP HRT must contain a progestogen in addition HRT must contain a progestogen in addition

to estrogento estrogen LNG-IUS may be used for endometrial LNG-IUS may be used for endometrial

protection from estrogen therapyprotection from estrogen therapy May be changed no later than 5 years (4 y May be changed no later than 5 years (4 y

license)license) FSH levels are not reliable if taking HRTFSH levels are not reliable if taking HRT

ConclusionsConclusions No method is contraindicated by age No method is contraindicated by age

alonealone UKMEC is useful to provide UKMEC is useful to provide

recommendations for contraceptive userecommendations for contraceptive use Remember does not take into account Remember does not take into account

multiple risk factorsmultiple risk factors CEU guidance available: Over 40’s and CEU guidance available: Over 40’s and

specific methodsspecific methods Continue to assess most appropriate Continue to assess most appropriate

method with changing medical history method with changing medical history and requirementsand requirements

Any questions?Any questions?