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Dr Katie Boog on Contraception for Women Aged over 40 Years
Date: 05 Sep 2017
Author: Dr Katie Boog
This month has seen the launch of the updated guidance on Contraception for Women Aged Over 40 years. Written and published by the FSRH CEU, it is a resource for healthcare professionals working in Sexual And Reproductive Health, General Practice and Obstetrics and Gynaecology. In her blog below, Dr Katie Boog gives us an overview of how this guideline can be used in every day practice.
I’m not sure who felt most awkward that morning –the medical student (me!), worried about coming across as a precocious teenager; or the 48-year-old patient in front of me that I had just offered condoms to. I doubt she expected our small talk about the lovely man she had started seeing after splitting from her awful-sounding husband of 25 years would lead to this moment: her face crimson when I offered her condoms and then the mumble ‘I wouldn’t have a clue what to do with them’ that followed.
Well despite our embarrassment, she left happily 10 minutes later with a bag of assorted lubes and condoms, leaflets on her contraception options and sticky fingers from the condom demo we had just done - not bad when she had only attended for a diabetes review! Many years later with a few hundred more condom demonstrations under my belt I no longer need to feel flustered or embarrassed discussing sexual health needs with women in the latter part of their reproductive years. Women themselves may find a lack of relevant information, with media campaigns primarily aimed at Under 25s; but as practitioners we now have an updated guideline from the faculty on Contraception for Women Aged Over 40 Years, with advice and guidance on areas specific to this population.
Allow me to show you how useful this guideline can be in practice, as I welcome you to my morning surgery...
Do women over 40 really need contraception?
Susan was my first patient of the day. Attending for her smear, she was quite baffled when I asked her what contraception she was using.
‘I don’t think I’ll be needing that – I’m 46! I’m going to be a granny next month!’
It is a myth that women over 40 do not require contraception. Although fertility reduces with age, and steeply after age 35, women in their 40s do become pregnant. A woman Susan’s age would have around a 12% chance of becoming pregnant over a one year period. The guideline has information in section 3 around fertility rates, as well as the increased rates of adverse outcomes (maternal mortality, miscarriage, ectopic, stillbirth, congenital anomalies), which is a helpful resource for discussing risks with women over 40.
“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”
“Healthcare Practitioners should advise women that pregnancy and childbirth after 40 confer a greater risk of adverse maternal and neonatal outcomes than in women under 40”
Is contraception safe? What about the risks of taking hormones?
Magdalena has just turned 50 and is angry that her GP will no longer prescribe her the combined pill. Once we get past some initial hostility, she explains she had an unplanned pregnancy with an IUS in-situ age 44, resulting in a late termination due to congenital anomalies. She is anxious that if she stops the pill, she will become pregnant again and cannot imagine having to have another termination. She is a perfect pill-taker (she admits borderline obsessive!) and likes to be in control of her fertility having been let down by a LARC method in the past. She also has had great relief from her heavy, painful periods while using the pill and worries about what will happen when she stops.
We know from the UKMEC that age alone is not a contraindication for any method of contraception. The guideline goes into further detail, advising women should stop combined hormonal contraception (CHC) age 50 and use an alternative, safer method of contraception; with a caveat that women receiving non-contraceptive benefits from the method should be reviewed on an individual basis.
The difference for women over 40 with regards to safety of using hormonal methods of contraception is that they have an increased background risk of multiple co-morbidities (for example, cardiovascular disease, breast cancer, osteoporosis) which may be exacerbated or improved by the different contraceptive methods. The new guidance gives an overview of these in Section 4, leading on to Section 5 which goes through each method individually to discuss the risks and non-contraceptive benefits for women in this age group. This is very practical tool for weighing up risks vs. benefits with patients.
So how does this help Magdalena? After reviewing her medical and menstrual history further, we looked at the guidance together, discussed the risks and benefits and looked at alternatives. She decided to trial the progestogen-only pill (POP), meaning she could keep in control of her contraception, with a plan for early review and alternative treatments if her periods became problematic again.
“CHC can reduce menstrual bleeding and pain, which may be particularly relevant to women over 40”
“Women aged 50 and over should be advised to stop taking CHC for contraception and use an alternative, safer method”
Is contraception necessary when using HRT?
Helen is a 47-year-old woman who came for her first review after starting sequential HRT. She was pleased to report her symptoms had improved a lot and she was feeling very positive. When we reviewed her medication, she told me she had stopped taking her POP:
‘I’m not needing contraception anymore if I’m menopausal, and surely the hormones in the HRT would do the job anyway. Besides, it can’t be safe taking so many hormones!’
There is a helpful explanation and summary of perimenopause in Sections 3 and 6 of the guidance, which is what I needed to discuss with Helen to help her understand her symptom better, the HRT, and what this meant in terms of fertility. She does still need contraception, as HRT cannot be relied upon as a contraceptive and her POP can be safely used alongside her HRT. The POP (and the implant and injection) are not licensed for endometrial protection in HRT and therefore the HRT she is prescribed needs to be a combined regimen (contain progestogen as well as estrogen).
“Women using sequential hormonal replacement therapy (HRT) should be advised not to rely on this for contraception”
“All progestogen-only methods are safe to use as contraception alongside sequential HRT”
“At the present time, POP, IMP, DMPA are not licensed for and cannot be recommended as endometrial protection with estrogen-only HRT”
When should contraception be stopped?
Usha, a 51-year-old woman, was my final patient. She had had a Mirena fitted 5 years ago and wondered:
‘Should I have it out now? I haven’t had a period in 4 years. Or do I need a blood test to check I’ve gone through the change?’
Menopause is a diagnosis made one year after a woman’s periods stop. However, women using hormonal contraception or HRT are likely to have altered bleeding patterns or amenorrhoea, making it difficult or impossible to make this diagnosis from the menstrual history. Historically, FSH measurements have been taken to diagnose menopause, however this guideline, in keeping with guidance from NICE, recommends that blood tests are not routinely required. Section 6 of the guideline gives an overview and summary table of when each method of contraception can/should be stopped, as well as providing information about how different methods of contraception and HRT may affect FSH results, if blood tests were to be taken. A Mirena fitted at or after age 45 for contraception or heavy menstrual bleeding can remain in situ until age 55, at which time natural loss of fertility can be assumed. It should not remain in indefinitely, however, as it could become a focus of infection. I discussed this with Usha, who was only just starting to have the odd hot flush. She was relieved to not need bloods and leave things as they were, and we agreed to see her back when she was 55, unless she had any unscheduled bleeding or was wishing to start HRT in the meantime.
“Menopause is a clinical diagnosis made retrospectively after 1 year of amenorrhoea. Most women do not require measurement of their serum hormone levels to make a diagnosis.”
“In general, all women can cease contraception at age 55 as spontaneous conception after this age is exceptionally rare even in women still experiencing menstrual bleeding”
“IUC should not be left in situ indefinitely after it is no longer required as it could become a focus of infection”
This is a small snapshot of the updated guidelines and how they may help you in practice. For more information, register for the Webinar on 27th September 2017. This webinar is free for members (log in and navigate to 'My Webinars' to attend for free).