Contraception for women aged over 40 years Susanna Hall Research Doctor Clinical Effectiveness Unit of the Faculty of Sexual and Reproductive Health 23 November 2010

Contraception for the over 40’s Is contraception necessary? Is contraception necessary? Choosing contraception Choosing contraception Specific contraceptive methods for women over 40 Specific contraceptive methods for women over 40 STIs and safer sex STIs and safer sex Menopause and stopping contraception Menopause and stopping contraception Conclusions Conclusions

Is contraception over 40 years of age necessary? 28 February 2008

Conception vs infertility As age increases, fertility decreases in women Declines to lesser degree in men At 40-44, 36% likelihood of spontaneous pregnancy Source: Management of the Infertile Woman, Helen A Carcio

In 2009 In ,976 live births to women aged 40 and over in England and Wales (ONS) 26,976 live births to women aged 40 and over in England and Wales (ONS) 8132 Abortions to women over 40 years in England and Wales (ONS) 8132 Abortions to women over 40 years in England and Wales (ONS) Similar story in Scotland Similar story in Scotland

Pregnancy outcomes Pregnancy later in life is associated with worse reproductive outcomes: Pregnancy later in life is associated with worse reproductive outcomes: Maternal Maternal Gestational diabetes Gestational diabetes Placenta previa Placenta previa Placental abruption Placental abruption Caesarean section Caesarean section Fetal Fetal Chromosomal abnormalities (eg Trisomy 21) Chromosomal abnormalities (eg Trisomy 21) Miscarriage Miscarriage Low birth weigh Low birth weigh Preterm delivery Preterm delivery Increased perinatal mortality Increased perinatal mortality

Wish for continued fertility? Be aware not all women in their 40’s have finished their family Be aware not all women in their 40’s have finished their family Realism about declining fertility after 40 Realism about declining fertility after 40 Increased potential mortality and morbidity for mother and fetus, especially if any co- morbidities Increased potential mortality and morbidity for mother and fetus, especially if any co- morbidities Decreased success for fertility treatment Decreased success for fertility treatment Fertility treatment not NHS funded over 40 years Fertility treatment not NHS funded over 40 years

Changes in partner Divorce average age is 41.2 years for women in England and Wales Divorce average age is 41.2 years for women in England and Wales New relationships may start after long term monogamous relationships New relationships may start after long term monogamous relationships Support for review of sexual health, including contraception and STIs Support for review of sexual health, including contraception and STIs

Choosing contraception Wide range of contraceptive methods available Wide range of contraceptive methods available No contraceptive method is contraindicated based on age alone No contraceptive method is contraindicated based on age alone Age may become a more significant risk factor in conjunction with other medical conditions Age may become a more significant risk factor in conjunction with other medical conditions

Choosing contraception Clinical history Clinical history UK Medical Eligibility Criteria for contraceptive Use (UKMEC) UK Medical Eligibility Criteria for contraceptive Use (UKMEC) Evidence based recommendations for use of contraceptive methods in presence of medical conditions Evidence based recommendations for use of contraceptive methods in presence of medical conditions Does not take into account multiple conditions Does not take into account multiple conditions

Women’s choice of method Aged 40-44y, 75% used at least 1 method Aged 40-44y, 75% used at least 1 method Aged 45-49y, 72% used at least 1 method Aged 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 condom Male condom Pills Pills IUD IUD Office for National Statistics, Contraception and Sexual Health Survey,

Long Acting Reversible methods of Contraception Methods that require administration less than once per month Methods that require administration less than once per month Typical failure rates are lower than for shorter acting contraception Typical failure rates are lower than for shorter acting contraception Cost effective at 1 year of use Cost effective at 1 year of use Failure rates comparable to female sterilisation, offering a reliable alternative Failure rates comparable to female sterilisation, offering a reliable alternative No delay in fertility return except with progestogen- only injectable (delay of up to 1 year) No delay in fertility return except with progestogen- only injectable (delay of up to 1 year) Effective and Appropriate Use of Long Acting Reversible Contraception, NICE 2005

Combined Hormonal Contraception 3 forms of combined hormonal contraception Most evidence relates to the combine hormonal pill UKMEC assumes all risks are similar Age over ≥40y UKMEC 2

Health Benefits of Combined Hormonal Contraception Dysmenorrhoea and cycle control Dysmenorrhoea and cycle control Menopausal symptoms Menopausal symptoms Bone health Bone health Ovarian and endometrial cancer Ovarian and endometrial cancer Benign breast disease Benign breast disease Colorectal cancer Colorectal cancer

Health Risks with CHC Breast cancer Breast cancer Annual risk of breast cancer increases with increasing age Annual risk of breast cancer increases with increasing age There may be a small additional risk of breast cancer with CHC use There may be a small additional risk of breast cancer with CHC use Any risk reduces to no risk 10 years after stopping CHC Any risk reduces to no risk 10 years after stopping CHC Current breast cancer UKMEC 4 Current breast cancer UKMEC 4 Family history of breast cancer UKMEC 1 Family history of breast cancer UKMEC 1 BRCA 1 and 2 mutation carrier UKMEC3- expert clinical judgement and/or referral to specialist provider BRCA 1 and 2 mutation carrier UKMEC3- expert clinical judgement and/or referral to specialist provider

Health Risks with CHC Cervical cancer Cervical cancer Small increased risk (invasive and in situ) Small increased risk (invasive and in situ) Long term users can be reassured that benefits outweigh risks Long term users can be reassured that benefits outweigh risks Risk of invasive cancers declines after stopped using (after 10 years, return to never user risk) Risk of invasive cancers declines after stopped using (after 10 years, return to never user risk) HVP and condom use HVP and condom use

Health Risks with CHC Venous thromboembolism (VTE) Venous thromboembolism (VTE) VTE is rare in women of reproductive age VTE is rare in women of reproductive age VTE risk increases with increasing age VTE risk increases with increasing age Relative risk of VTE is increased with use of the COC Relative risk of VTE is increased with use of the COC Uncertainty about the risks of patch and risks of CVR unknown Uncertainty about the risks of patch and risks of CVR unknown

Health Risks with CHC UKMEC categories for CHC UKMEC categories for CHC Personal history of VTE UKMEC 4 Personal history of VTE UKMEC 4 Current VTE (on anticoagulants) UKMEC 4 Current VTE (on anticoagulants) UKMEC 4 Family history of VTE Family history of VTE 1 st degree relative aged <45y UKMEC 3 1 st degree relative aged <45y UKMEC 3 1 st degree relative aged ≥45 y UKMEC 2 1 st degree relative aged ≥45 y UKMEC 2

Health Risks for CHC Cardiovascular disease: MI and Stroke Cardiovascular disease: MI and Stroke MI and stroke are rare in women of reproductive age MI and stroke are rare in women of reproductive age Risk increases with increasing age Risk increases with increasing age Conflicting evidence regarding risk Conflicting evidence regarding risk Cumulative additional risk if multiple risk factors Cumulative additional risk if multiple risk factors

Health Risks for CHC UKMEC categories for CHC UKMEC categories for CHC Stroke (CVA including TIA) UKMEC 4 Stroke (CVA including TIA) UKMEC 4 Hypertension Hypertension Adequately controlled hypertension UKMEC 3 Adequately controlled hypertension UKMEC 3 Consistently elevated blood pressure Consistently elevated blood pressure Systolic > mmHg or diastolic >90-94mmHg UKMEC 3 Systolic > mmHg or diastolic >90-94mmHg UKMEC 3 Systolic ≥160 mmHg or diastolic ≥95mmHg UKMEC 4 Systolic ≥160 mmHg or diastolic ≥95mmHg UKMEC 4 Vascular disease UKMEC 4 Vascular disease UKMEC 4 Multiple risk factors for CV disease (older age, smoking, diabetes, obesity, hypertension) UKMEC 3/4 Multiple risk factors for CV disease (older age, smoking, diabetes, obesity, hypertension) UKMEC 3/4

Progestogen-only Contraception Progestogen-only pill Injectable Sub-dermal implant Levonorgestrel-releasing intrauterine system

Health Benefits for POC Dysmenorrhoea Dysmenorrhoea Bleeding patterns Bleeding patterns Menopausal symptoms Menopausal symptoms

Health Risks of POC Reproductive cancers- no conclusive evidence Reproductive cancers- no conclusive evidence Current breast cancer UKMEC4 Current breast cancer UKMEC4 Previous breast cancer UKMEC3 Previous breast cancer UKMEC3 Bone health Bone health

Health Risks associated with POC Cardiovascular and cerebrovascular disease Cardiovascular and cerebrovascular disease Limited data suggest no increased risk of MI and stroke Limited data suggest no increased risk of MI and stroke Venous thromboembolism Venous thromboembolism Little or no effect on risk of VTE Little or no effect on risk of VTE Effect of DMPA on lipid metabolism Effect of DMPA on lipid metabolism Theoretical risk of vascular disease in women with additional risk factors Theoretical risk of vascular disease in women with additional risk factors

UKMEC 2009

Non-Hormonal contraception Copper IUD Sterilisation Barrier contraception Fertility awareness methods Withdrawal

Copper Intrauterine device Menstrual bleeding problems are common in women over 40 and IUD users Menstrual bleeding problems are common in women over 40 and IUD users Spotting, heavier periods and pain in first 3-6 months Spotting, heavier periods and pain in first 3-6 months Seek medical advice if symptoms persist or occur as new event, to exclude gynaecolgical pathology Seek medical advice if symptoms persist or occur as new event, to exclude gynaecolgical pathology

Sterilisation Advice about all methods of contraception including LARCs should be provided Advice about all methods of contraception including LARCs should be provided Advantages and disadvantages, including lower failure rate and major complications with vasectomy compared to laparoscopic sterilisation Advantages and disadvantages, including lower failure rate and major complications with vasectomy compared to laparoscopic sterilisation

Barrier contraception No restriction on use No restriction on use Use of spermicide is recommended with caps and diaphragms Use of spermicide is recommended with caps and diaphragms Condoms with spermicidal lubricant should not be used Condoms with spermicidal lubricant should not be used Lubricant should be non-oil based Lubricant should be non-oil based

Fertility Awareness methods Numbers using fertility awareness unknown May become more difficult as approaching the menopause Irregular cycles Anovulatory cycles

Withdrawal Not promoted as a method of contraception Not promoted as a method of contraception Reported by ~6% women aged 40-44y Reported by ~6% women aged 40-44y If used correctly, may work for couples, particularly as backup to other methods If used correctly, may work for couples, particularly as backup to other methods Should be aware not as effective as other methods of contraception Should be aware not as effective as other methods of contraception

Emergency contraception No restrictions on use of EC based on age alone Women should be made aware of the different types of EC available

Sexually transmitted infections STIs are not confined to younger people STIs are not confined to younger people There has been an increase in diagnoses in over 40 year olds There has been an increase in diagnoses in over 40 year olds Condoms protect against STIs even after contraception no longer required Condoms protect against STIs even after contraception no longer required

Diagnosing the Menopause Retrospective diagnosis: 1 year amenorrhoea Retrospective diagnosis: 1 year amenorrhoea No single reliable marker of perimenopause No single reliable marker of perimenopause

Stopping contraception In general contraception may be stopped at the age of 55 years In general contraception may be stopped at the age of 55 years Advice need tailored to the individual Advice need tailored to the individual If having regular menstrual cycles at 55 y- should continue on some contraception If having regular menstrual cycles at 55 y- should continue on some contraception

Non-hormonal methods If over 50 years If over 50 years After 1 year of amenorrhoea (1 year after LMP) After 1 year of amenorrhoea (1 year after LMP) If under 50 years If under 50 years After 2 years of amenorrheoa (2 years after LMP) After 2 years of amenorrheoa (2 years after LMP) Cu-IUD- if inserted ≥40y, may be retained until the menopause (outside license) Cu-IUD- if inserted ≥40y, may be retained until the menopause (outside license)

Hormonal Methods Amenorrhoea is not a reliable indicator of ovarian failure if taking exogenous hormones Amenorrhoea is not a reliable indicator of ovarian failure if taking exogenous hormones FSH: for those over 50y and taking POC FSH: for those over 50y and taking POC Not reliable with combined methods Not reliable with combined methods If over 50y and wishing to stop POC, check FSH If over 50y and wishing to stop POC, check FSH If level ≥30IU/L, repeat FSH in 6 weeks. If second FSH ≥30IU/L- stop contraception after 1 year If level ≥30IU/L, repeat FSH in 6 weeks. If second FSH ≥30IU/L- stop contraception after 1 year

Removing the LNG-IUS Amenorrhoea and light bleeding common after first year of use Amenorrhoea and light bleeding common after first year of use Need to check FSH levels over the age of 50y as previously Need to check FSH levels over the age of 50y as previously

Hormone Replacement Therapy HRT is not contraceptive HRT is not contraceptive May use POP May use POP HRT must contain a progestogen in addition to estrogen HRT must contain a progestogen in addition to estrogen LNG-IUS may be used for endometrial protection from estrogen therapy LNG-IUS may be used for endometrial protection from estrogen therapy May be changed no later than 5 years (4 y license) May be changed no later than 5 years (4 y license) FSH levels are not reliable if taking HRT FSH levels are not reliable if taking HRT

Conclusions No method is contraindicated by age alone No method is contraindicated by age alone UKMEC is useful to provide recommendations for contraceptive use UKMEC is useful to provide recommendations for contraceptive use Remember does not take into account multiple risk factors Remember does not take into account multiple risk factors CEU guidance available: Over 40’s and specific methods CEU guidance available: Over 40’s and specific methods Continue to assess most appropriate method with changing medical history and requirements Continue to assess most appropriate method with changing medical history and requirements

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