Contraception for Women Aged Over 40 Years

Overview

This Guidelines summary gives clinical guidance for health professionals on the use of contraception for women over the age of 40 years.

The guidance is intended for use by healthcare professionals (HCPs) working in sexual and reproductive healthcare, general practice, and obstetric and gynaecology settings.

Reflecting on Your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Main Sexual and Reproductive Health Issues Facing Women Over 40

Fertility

• Women should be informed that although a natural decline in fertility occurs with age and spontaneous pregnancy is rare after age 50, effective contraception is required until menopause to prevent an unintended pregnancy.

Pregnancy

• HCPs should advise women that pregnancy and childbirth after age 40 confer a greater risk of adverse maternal and neonatal outcomes than in women under 40.

Sexual Relationships

• HCPs should discuss sexually transmitted infections (STIs) and sexual health with women over 40. This population should be advised about condom use and protection from STIs even after contraception is no longer required
• It is essential that HCPs facilitate discussion about safe sex practices with individuals over 40. 

Transition to Menopause

• Women over 40 with a significant change in their bleeding pattern should have appropriate gynaecological assessment and investigations, whether or not they are using a contraceptive method
• Women over 40 should be asked about any urogenital symptoms or sexual issues they may be experiencing
• NICE produced updated guidance in 2015 regarding diagnosing and managing menopause. The FSRH recommends that HCPs refer to the NICE document for comprehensive guidance on this topic.

Perimenopause

• It is important to emphasise that all women experience perimenopause individually with different combinations, frequency and intensity of symptoms
• HCPs need to consider each woman’s personal situation when discussing any contraceptive and other therapeutic or lifestyle options
• Due to the changing and often erratic hormone levels, perimenopausal women frequently experience intermittent or persistent vasomotor symptoms, such as hot flushes and night sweats, and mood changes, including mood swings, anxiety, and depression
• Sleep disturbance and chronic tiredness are common complaints, primarily influenced by nocturnal vasomotor symptoms and mood changes
• Women may experience joint and/or muscular pain and/or changes in the severity of pre-existing migraines.

Bleeding Patterns

• Perimenopause is characterised by irregular menstrual cycles. As intermittent ovulation and anovulation occur, women going through perimenopause experience a rise in follicle-stimulating hormone levels and a shortening and/or lengthening of their menstrual cycle. Women may experience changes in blood loss as well as bleeding patterns during this time
• Heavy menstrual bleeding, postcoital bleeding, and intermenstrual bleeding may require appropriate gynaecological assessment and investigations irrespective of whether women are using a contraceptive method or not.

Problems Surrounding Sexual Function

• Loss of libido is also a common symptom presenting at this time. Women may often attribute this to hormone levels, but libido is multifactorial. Tiredness, work and family stress, self-image as the body ages, and physical changes in their partner all contribute to how a woman feels about sexual activity
• Many women begin to experience urogenital issues such as vaginal dryness, dyspareunia, and bladder problems during this stage, which can further affect both the woman’s desire to have sex and her sexual function. However, women are often hesitant to present with these symptoms due to embarrassment
• HCPs should ask women about urogenital symptoms associated with the hypoestrogenic state during consultations with women in the perimenopause and menopause, as these symptoms can effectively be treated with simple lubricants and local vaginal estrogen. The NICE menopause guideline states that vaginal estrogen may be used long term as the systemic absorption from the small dose is unlikely to cause adverse effects. It can be used alongside systemic hormone-replacement therapy (HRT) if required
• HCPs should be prepared to discuss a variety of issues around sexual function related to ageing and hormonal changes.

Why Do Women Over 40 Need Separate Guidance?

• Women over 40 experience a natural decline in fertility, yet require contraception until they reach menopause if they wish to avoid an unplanned pregnancy. As women in the perimenopause often experience symptoms relating to fluctuating hormone levels (for example, vasomotor symptoms, mood changes, irregular/heavy menstrual cycles) and have different background risks than younger women, HCPs need to consider contraceptive options specifically with this population in mind
• As women age they have an increased risk of certain health conditions which, combined with the symptoms and treatments for any perimenopausal symptoms, means they may have a distinctly different set of needs from younger women. Choosing and stopping appropriate contraception requires an understanding of the health benefits and risks of each method, and the noncontraceptive advantages and disadvantages for this age group
• HCPs should inform women over 40 of the age-related increased background risk of cardiovascular disease, obesity, breast cancer, and most gynaecological cancers as this may affect choice of contraceptive method. 

Suitability of Contraceptive Methods for Women Over 40

• HCPs should discuss the effectiveness, risks, benefits (contraceptive and non-contraceptive), and side effects of all available methods. All methods become increasingly effective with age due to lower fertility and can be considered after individual assessment. The very long-acting reversible contraceptive methods include the copper-intrauterine device, levonorgestrel intrauterine system (LNG-IUS), and progestogen-only implant (IMP), and these are the most effective methods of contraception with typical use
• Women should be informed that contraception does not affect the onset or duration of menopausal symptoms but may mask the signs and symptoms of menopause.

Copper Intrauterine Devices

• The FSRH supports extended use of the copper intrauterine device until menopause when inserted at age 40 or over.

LNG-IUS

• Women using a 52 mg LNG-IUS for endometrial protection as part of an HRT combination must have the device changed every 5 years
• Women who have undergone endometrial ablation should be advised about the potential risk of complications if intrauterine contraception (IUC) is used
• The FSRH supports extended use of a 52 mg LNG-IUS for contraception until the age of 55 if inserted at age 45 or over, provided it is not being used as the progestogen component of HRT for endometrial protection.

Noncontraceptive Benefits

• The 52 mg LNG-IUS offers very significant non-contraceptive benefits. It has been shown to be highly effective in reducing menstrual blood loss. It will also reduce pain associated with primary menstrual pain, endometriosis, and adenomyosis. An IUS can also be an effective medical treatment for endometrial hyperplasia.

Problematic Bleeding and Pain

• If bleeding is not controlled in women using a LNG-IUS for HMB after 3–6 months’ duration of use, it may be necessary to exclude underlying pathology with appropriate gynaecological assessment and investigations.

IMP

• Women can be informed that the IMP is not associated with increased risks of venous thromboembolism (VTE), stroke, or myocardial infarction and has not been shown to affect bone mineral density (BMD).

Progestogen-only Injectable

• Women over 40 using depot medroxyprogesterone acetate (DMPA) should be reviewed regularly to assess the benefits and risks of use. Women over 50 should be counselled on alternative methods of contraception.

Progestogen-only Pills

• Women can be informed that the progestogen-only pill (POP) is not associated with increased risks of VTE, stroke, or myocardial infarction, and has not been shown to affect BMD.

Combined Hormonal Contraception

• Combined oral contraception (COC) with levonorgestrel or norethisterone should be considered first-line COC preparations for women over 40, due to the potentially lower VTE risk compared to formulations containing other progestogens
• COC with ≤30 μg ethinyloestradiol should be considered first-line COC preparations for women over 40, due to the potentially lower risks of VTE, cardiovascular disease and stroke compared to formulations containing higher doses of oestrogen
• CHC can reduce menstrual bleeding and pain, which may be particularly relevant for women over 40
• HCPs can offer an extended or continuous CHC regimen to women for contraception and also to control menstrual or menopausal symptoms
• Women aged 50 and over should be advised to stop taking CHC for contraception and use an alternative, safer method. A COC is associated with a reduced risk of ovarian and endometrial cancer that lasts for several decades after cessation
• CHC may help to maintain BMD compared with non-use of hormones in the perimenopause
• Meta-analyses have found a slight increased risk of breast cancer among women using COC, but with no significant risk of breast cancer by 10 years after cessation
• Women who smoke should be advised to stop combined hormonal contraception (CHC) at age 35 as this is the age at which excess risk of mortality associated with smoking starts to become clinically significant.

Other Methods

• HCPs should advise women that sterilisation does not alter or eliminate menstrual periods. Women who have been using another method of contraception should be made aware that bleeding patterns may well change after sterilisation because they have stopped a contraceptive method.

Emergency Contraception

• Women over 40 who still require contraception should be offered emergency contraception after unprotected sexual intercourse if they do not wish to become pregnant.

When Is Contraception No Longer Needed?

Diagnosing Menopause

• Menopause is usually a clinical diagnosis made retrospectively after 1 year of amenorrhoea. Most women do not require measurement of their serum hormone levels to make the diagnosis
• If needed, women over 50 using progestogen-only contraception, including DMPA, can have serum follicle-stimulated hormone measurements undertaken to check menopausal status
• Women using CHC or HRT have suppressed levels of oestradiol and gonadotrophins; measuring these hormones does not give accurate information on which to base advice regarding menopausal status and when to stop contraception.

When Should Contraception Be Stopped?

• In general, all women can cease contraception at the age of 55 as spontaneous conception after this age is exceptionally rare, even in women still experiencing menstrual bleeding
• If a woman age 55 or over does not wish to stop a particular method, consideration can be given to continuation providing the benefits and risks for her as an individual have been assessed and discussed with her
• IUC should not be left in situ indefinitely after it is no longer required as it could become a focus of infection.

Table 1: Recommendations Regarding Stopping Contraception

Can Hormone Replacement Therapy Be Used Alongside or in Place of Contraception?

• Women using sequential HRT should be advised not to rely on this for contraception
• Women may use a 52 mg LNG-IUS with oestrogen for up to 5 years for endometrial protection as part of an HRT regimen. Women using a 52 mg LNG-IUS for this purpose must have the device changed every 5 years
• At the present time, POP, IMP, and DMPA are not licensed for and cannot be recommended as endometrial protection with oestrogen-only HRT
• All progestogen-only methods of contraception are safe to use as contraception alongside sequential HRT
• CHC can be used in eligible women under 50 as an alternative to HRT for relief of menopausal symptoms and prevention of loss of BMD.