GP Education Meeting September 2018

Contraception For women Aged over 40 years FSRH Guidance August 2017

Aims To provide an updated knowledge of contraception for women over 40 in order to apply this to safe prescribing and management

Objectives: Be able to identify the key issues to consider when prescribing for women over 40 Be able to discuss with women over 40 the risks and benefits of their contraceptive choices of CHC, injectables and IUC Be able to advise women of their contraceptive choices during the perimenopause and at the menopause

Why is it importance to have a guide? Still need reliable contraception Peak age for menstrual problems Onset of perimenopause Risk of STI’s – if new relationships Higher background medical risks

Contraceptive choices may be influenced by many factors: Frequency of sexual intercourse Natural decline in fertility Wish for contraceptive benefits Sexual problems

Why do women over 40 need separate guidance from the medical perspective? Increased background risks: Cardiovascular disease – Increased VTE risk after age 40 Breast and gynaecological cancers Osteoporosis Obesity

CHC: key issues for women over 40 Alternative to HRT as may improve vasomotor symptoms associated with menopause Small increased risk breast cancer – declines once CHC stopped Some protection against osteoporosis, ovarian and endometrial cancer Eligible women can continue to age 50

CHC: key issues for women over 40 Therapeutic option for menstrual problems - can reduce dysmenorrhoea and menorrhagia. - consider continuous/extended regimes Use progestogen with lowest VTE risk – Levonorgestrel or Northisterone Use COC with ≤ 30 micrograms as first line (lower VTE, Cardiovascular and stroke risks)

DMPA key issues for women over 40 Bone health - loss of BMD with DMPA But Initial loss of BMD due to hypoestrogenic effects of DMPA is not repeated or worsened by onset of menopause Women over 40 with additional risk factors (e.g. FH, inactivity, vit D deficiency, smoking etc.) are advised to use alternative methods Routine bone density scans or use of oestrogen in users has not been established

DMPA key issues for women over 40 Weak and conflicting evidence relating to CV disease and breast cancer. Recent review found no evidence of a link with stroke or MI Therapeutic option for menstrual problems Review women ˃ 40 regularly to assess benefits/risks of use Women ˃ 50 should be counselled on alternative, safer, equally effective methods

Intrauterine Contraception - key issues IUS offers very significant benefits for women over 40 If Mirena inserted at age 45 or over can remain in situ until age 55 for contraception even if the woman is still bleeding If used for HRT Mirena should be changed every 5 years IUS likely to protect against endometrial cancer Women who have endometrial ablation should be advised about potential risks if IUC is used – adhesions – may lead to difficult insertion/removal with higher risk of perforation

Intrauterine Contraception - key issues If mirena inserted at ˂ 45 may have an immediate replacement at 5-7 years if PDT negative. Repeat PDT if any si in the proceeding 3/52. If ˃ 7 years, delay replacement until a conclusive PDT If Cu-IUD inserted at ≥ 40 can remain in situ until the menopause Don’t leave IUC in indefinitely once not needed as may become a focus of infection

Diagnosing menopause - Recommendations Clinical diagnosis made retrospectively after one year of amenorrhoea. FSH levels not required for diagnosis in most women For amenorrhoeic women over 50 using progestogen-only methods including DMPA, who are keen to stop contraception it may be useful to measure FSH levels. If FSH ˃30 on one occasion in women over 50 advise to continue contraception for one further year

Diagnosing menopause - Recommendations FSH measurements not accurate if using CHC or HRT Optimum time to measure FSH if using DMPA is just before repeat injection is administered If FSH ˂ 30 in women over 50 advise to continue contraception and repeat a year later

Stopping contraception: All women can cease contraception at age 55 as conception after this age is exceptionally rare even if still bleeding Could continue POP/Implant after age 55 after assessment and discussion of risks and benefits if preferred

HRT and contraception - key points Sequential HRT is not contraceptive. An implant, POP or DMPA are not licensed for use as the progestogen component of HRT Can use all progestogen –only methods (implant, POP, IUS or DMPA) alongside sequential HRT for contraception - a Mirena IUS offers convenient option for both contraception and endometrial protection as part of HRT regimen

Key Learning - Points from new guidance: Women over 40 may have more complex needs due to menstrual problems and perimenopause; may have more background medical risks Discuss STIs and offer screening Stop contraception at age 55 - chance of pregnancy thereafter exceptionally rare

Key Learning - Points from new guidance: Discontinue CHC and DMPA in most women at age of 50 and change onto another method in the meantime Can get valid single FSH level in women over 50 with amenorrhoea using POP, implant, IUS and DMPA Caution with IUS after endometrial ablation

Resources FSRH Guideline – Contraception for women aged over 40 years FSRH webinar