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The Menopause Exchange Blog

CONTRACEPTION FOR THE OVER-40s

It’s a common assumption that women can stop using contraception in their 40s because their fertility is declining. But contraception shouldn’t be abandoned just because your periods become irregular and sex may be less frequent, because women do still become pregnant in their 40s and even into their 50s (naturally, without fertility treatment).

This article was included in issue 77 (summer 2018) of The Menopause Exchange newsletter.

Combined oral contraceptives
Women sometimes think they’re ‘too old to take the pill’ or it’s best to take a break from the hormones. But a summary of the most up-to-date evidence indicates that women can safely continue to take the combined hormonal contraceptives until they reach 50 if they’re healthy (with no risk factors for cardiovascular disease). The combined hormonal patch, Evra, and the combined hormonal vaginal ring, Nuvaring, are easy-to-use alternatives to the combined oral contraceptive pill.

Combined oral contraceptives have many benefits, including a 50% reduced risk of endometrial and ovarian cancers, less bleeding and pain with periods, less anaemia and fewer hot flushes. Newer contraceptive pills contain lower doses of hormones and some contain oestradiol (a bio-identical oestrogen hormone) so may have fewer side effects. It’s convenient and safe to take the combined pill continuously as this avoids withdrawal bleeds and other nuisance symptoms associated with pill-free intervals.

Progestogen-only pills
Progestogen-only pills may be suitable if you can’t take the oestrogen-containing combined pill. A traditional progestogen-only pill works mainly by thickening cervical mucus and doesn’t stop ovulation as reliably as the newer, more modern progestogen-only pills containing desogestrel. Desogestrel pills have a 12-hour ‘window’ in which you need to remember to take them, compared to the traditional brands, which still have a three-hour window. However, the missed pill rules are the same. Progestogen-only pills sometimes cause irregular bleeding. It’s worth persevering for a few months to see if this settles. If a woman over 50 needs contraception alongside HRT, a progestogen-only pill is a convenient way to do so.  All progestogen-only pills can be taken safely until you’re 55.

LARC: long acting reversible contraception
Contraceptive implant (rod)
Nexplanon can be used until age 55 and with HRT. It releases a very low dose of progestogen, preventing ovulation for up to three years. Periods may stop in about 20% of women, but unpredictable irregular bleeding can be a problem, as well as other annoying side effects.

Progestogen only injection
Depo Provera is an intramuscular progestogen injection given every 13 weeks. You can give yourself a newer version (Sayana Press) with a tiny needle into your lower tummy or thigh. It’s easy to learn and doesn’t hurt. You’ll be prescribed three injections to take home so you go back to your doctor or clinic every 12 months. A few women may develop a dimple where the injection was given. Long-term use is associated with a small loss of bone density. Recent medical evidence suggests that there’s no limit to the number of years a woman can use the injection as long as her bone health is assessed every two years. Periods often stop with this type of contraception but some women have irregular bleeding that may take two or three injections to settle down.

Intrauterine contraception
An intrauterine device (copper IUD) fitted at age 40 can remain in place until you’re post menopausal or 55. Many women appreciate the non-hormonal method, but sometimes periods can be heavier with an IUD, making it less suitable if you already have heavy periods or fibroids. Generally you’ll have a framed T-shaped device fitted but you can also have the Gynefix and soon the Intrauterine ball, the IUB.

Different types of intrauterine system (IUS, the hormone coil) are available – the Mirena (licensed for five years) and an identical version called Levosert (licensed for four years). These IUS are
extremely good at reducing heavy bleeding but only Mirena has the licence for endometrial protection with HRT. Any initial progestogen side effects usually disappear over time as the amount of hormone in the bloodstream is very small. The new Jaydess (three years) and Kyleena (five years) are smaller with a narrow insertion tube, so fitting is very easy. The lower hormone content means most women will have a normal or lighter period with Jaydess and Kyleena, and less chance of periods stopping.

Barrier contraception
Male condoms, when used consistently, protect against sexually transmitted infections. Female condoms are less effective and can be trickier to use correctly. A diaphragm or cap should be fitted by an expert and always used with a spermicide for maximum effectiveness. They should be replaced yearly or if your weight changes by 6 kg.

Natural Family Planning
This can be continued if the couple are experienced in this method and have been taught to interpret menstrual cycle changes during the perimenopause. Withdrawal isn’t a reliable method of contraception.

Emergency contraception
Emergency contraception is needed if you forget to use contraception, or use it incorrectly. The copper IUD is the most effective choice, but there are also two different tablets available.

Stopping contraception
Continue contraception for one year after your last natural period if this was after age 50, and for two years if your periods stop before age 50. Periods can sometimes restart after a gap of several months. Use effective contraception until age 55. Even if you have an occasional period at that age, it’s safe to stop because the risk of pregnancy is very low. HRT alone shouldn’t be relied on as a contraceptive.

About the author
Dr Nicola Mullin is a consultant in sexual and reproductive health in East Cheshire NHS Trust.

Created Summer 2018

Copyright © The Menopause Exchange

References:

FSRH Clinical Guidance: Combined Hormonal Contraception (August 2012)

FSRH Clinical Guidance: Progestogen-only pill (March 2015)

FSRH Clinical Guidance: Progestogen-only injectable contraception (Dec 2014)

 

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