While women's fertility is declining in this stage of life, there is still a risk of pregnancy so reliable contraception is still needed. Many women chose to have babies in their 40s and most will have healthy pregnancies. However, risk of complications for both Mum and baby is higher as we age. Also, in this age group there is a rising likelihood of women having another illness in the background such as cardiovascular disease, high blood pressure, breast cancer or gynaecological cancers, which can influence their choice of contraceptive.
I am going to talk about what the options for contraception are for this age group and then about when contraception can be stopped. Information for this post is taken from the guideline 'Contraception for Women Aged Over 40 Years' published by the Faculty for Sexual and Reproductive Health (FSRH).
Combined pills
Women are often under the impression that they can't use the combined pill in their 40s, and for some women this is the case. However, if you have no other risk factors, age over 40 alone is not a reason not to use it. The risks that would make us not prescribe the combined pill apply regardless of age and include BMI 35 or more, breast cancer, high blood pressure, heart disease, stroke and migraines with aura. Smoking is another risk which applies from the age of 35. A woman with no contraindications to combined pill can be prescribed it until they turn 50. The doctor might chose to prescribe a lower oestrogen dose pill to women in their 40s.
The advantage of being able to be on the combined pill in this age group are that it may ameliorate some menopause symptoms once they start to emerge. It can also regulate cycles and make periods lighter, and, if used continuously, women may have no periods. Women's periods start to change in perimenopause and sometimes can be heavier or more painful, so the the combined pill can be a very effective way of managing this.
Progesterone-only contraception
All the progesterone-only contraceptives are an option in this age group. The Depo Provera 3-monthly contraceptive injection is a high-dose progesterone and so it is recommended to stop it at age 50. Lots of women will not have periods with the progesterone-only pill (POP), the Depo injection and the Implanon, though the opposite can be the case, and some women will have bothersome irregular bleeding with any of these methods. The POP and the Implanon have the advantage of being able to be used until age 55.
Hormonal coils include the Mirena, Kyleena and Jaydess. These can be a great option for women whose family is complete as they last for years. The Mirena in particular is now licensed for 8 years for contraception, or if inserted from age 45 is licensed for 10 years or until no longer needed (age 55). Kyleena can be kept for 5 years, and Jaydess for 3. They are useful for women who are very sensitive to hormones and get side-effects with them. They are also physically smaller so may be useful for women who haven't had pregnancies. Mirena has the highest amount of progesterone of the three hormonal coils and as such often really lightens the periods and many women will have no periods. For the same reason as mentioned before this can be a blessing for women whose periods may have becomes heavier. If women are using a Mirena for contraception and then start to experience symptoms of peri-menopause and chose to start HRT, they would only need to be prescribed oestrogen as the Mirena can act as the progesterone component of the HRT (in this case it is only licensed for 5 years).
Copper coils
The non-hormonal copper coils can be used until menopause for women who wish not to use hormonal contraception or perhaps can't use hormones due to something such as breast cancer. They is a very effective method, the main downside being that it can often cause periods to be heavier and more painful, especially in the first few months. There are a number of different brands and they can be kept until menopause if inserted from age 40. The new Ballerine intra-uterine ball is licensed for 5 years. (Note: I have a blog post planned on all the different types of coils).
When to stop contraception
Knowing when to stop contraception can be tricky. In women using no hormonal contraception it's a bit more straightforward as they can diagnose menopause (and stop contraception) 2 years after their last period under the age of 50, and 1 year after the last period from age of 50. In women using hormonal contraception, if their periods stop they can't be sure if they have stopped due to the contraceptive or natural menopause. The FSH (Follicle Stimulating Hormone) blood test can be used in women over 50 who want to stop their contraception to see if it is safe to do so. The level goes up after menopause. If the FSH level is raised, women should continue using contraception for a year and then they can stop. If the FSH level is normal, they should continue contraception for a year, then repeat the test. If the repeat test is raised, continue contraception for another year, then stop. If the FSH is still normal, continue for another year and then repeat the test again, and so on.
No woman needs contraception from the age of 55.
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