1. Contraception in the over 40s Ruth Adams Clinical Educator Leicester Sexual Health

2. Can women conceive in their 40s? Cherie Blair was 45 when she had baby Leo

3. Stats Conceptions in over 40s more than doubled from 1990 to 2013 From 6.6/1000 to 14.2/1000 Conceptions of over 40s leading to TOP fell from 43% to 28% (Office of National Statistics 2015)

4. Specific issues for over 40s May have other medical issues May have menorrhagia as menopause approaches Menopause normal age 45-55 Usually family is complete More likely to be compliant with OC May be more likely to have amenorrhoea with progestagen only methods In case of IMB must have gynae assessment prior to starting method Less aware of STI, many women in this age group have new partners

5. Contraceptive options No contraceptive method is contraindicated by age alone Consider UKMEC however clinical judgement is required particularly when prescribing for women with multiple medical and social factors Women should be advised LARCs are as effective as sterilisation

6. Stopping Contraception Using non-hormonal methods can stop contraception after 1 year of amenorrhoea if aged >50 or 2 years if <50. If UPSI within these time frames PCC must be offered If taking hormones, amenorrhoea is not a reliable indicator of ovarian failure If aged >50 and on POC can have FSH levels checked. If level is >30 IU/L FSH can be repeated after 6 weeks. If 2 nd result also >30 contraception can be stopped after 1 year. If on CHC test is not reliable, must stop 6 weeks prior to test. Menopause can be assumed at age 55 NB: HRT in the peri-menopause is not reliable contraception. POC can be used alongside

7. Combined Hormonal Contraception Age 40 = UKMEC 2 COC may help maintain bone density Will mask menopausal symptoms If symptoms in PFI may consider tri-cycling May wish to prescribe <30mcg COC Smokers UKMEC 3 Not recommended over aged 50

8. Safe until any age, including over 50s May be more likely to have amenorrhoea than younger women but no guarantees 3 hour pill is as effective in this age group Desogestrel pill may benefit women with menorrhagia Progestagen only pill

9. Contraceptive Implant No age restrictions Safe to use over age 50 When counselling regarding bleeding pattern check for contra-indication for COC Will need changing at 3 year interval regardless of age.

10. IUS Mirena - 5 years. Jaydess – 3 years Mirena can be kept until menopause if fitted at age 45 Jaydess remains 3 yearly whatever the age Mirena is also licenced for control of menorrhagia If used for menorrhagia but not contraception Mirena doesn’t necessarily need changing at 5 years even if fitted age <45 Mirena can be used as endometrial protection alongside oestrogen HRT, but must be replaced at 5 years (licence is 4 years ) New FSRH Guidance April 2015

11. IUD If fitted >age 40 can keep until menopause Safe in case of most medical conditions Will have natural menopause

12. Injectable contraception Depo-provera licence is up to age 45. Age 18-45 = UKMEC 1 Age >45 = UKMEC 2 Not recommended age >50 Bone density needs to be discussed and reviewed every 2 years. (NICE guidance) Recent evidence suggests BMD is the same in post menopausal women who have and haven’t used depo. Depo-provera and Sayana Press can routinely be given at 13 weeks and can be given up to 14 weeks without extra precautions Multiple risk factors for cardiovascular disease = UKMEC 3

13. Case study 51 year old lady having oligmenorrhoea has a new partner Multiple UPSI Not suitable for PCC IUD so given levonelle Start POP, Femulen Seen 3 weeks later for PT and screen, all negative At 3m review - amenorrhoea. Good compliance with POP Aged 53, some hot flushes, FSH levels checked. First test result = 44. 2 nd test result 6 weeks later = 25 Continue POP, review FSH levels again in another year or so unless symptomatic