CONTRACEPTION FOR THE OVER-40s

A number of hormonal and non-hormonal contraceptive methods are suitable for women over 40. Age isn’t a contraindication, but some medical problems such as high blood pressure or cardiovascular disease may limit the choice.

This article was included in issue 100 (Spring 2024) of The Menopause Exchange newsletter.

Permanent contraception
Sterilisation is an option for couples who don’t want children or are certain they don’t want any more children. Female sterilisation can be performed laparoscopically under general anaesthetic and has a failure rate of 1 in 400 to 500 procedures. Vasectomy is a popular choice for couples as it’s an outpatient procedure using local anaesthetic, with a failure rate of 1 in 2000 procedures.

Barrier methods
Female and male condoms, diaphragms and caps can be used without restrictions in women over 40, but the failure rates are much higher as you get older.

Fertility awareness
Fertility awareness can be used by women with regular cycles but may not be suitable for women with erratic and irregular periods, as it’s difficult to accurately predict the date of ovulation.

Copper Intrauterine Device
The Copper Intrauterine Device (Cu-IUD) is a highly effective, reversible, non-hormonal method that isn’t associated with hormonal side effects. Users have been found to have a lower incidence of endometrial (womb lining) cancer. Its main disadvantage is that periods can become heavier and more painful, which may already be a problem for some women over 40.

Withdrawal method
Around 10% of women over 40 use withdrawal as their main contraception method. Failure rates vary, with many suggesting that 4% to 22% of couples become pregnant using withdrawal. This method is unreliable and not recommended if pregnancy would be a disaster.

Emergency contraception
Emergency contraception can be used by women in their 40s if they forget to use contraception or don’t use it properly. The Cu-IUD is the most effective form, preventing most pregnancies. Oral ulipristal acetate can be taken for up to five days after unprotected sex but may interact with hormonal contraception if this is started at the same time. Oral levonorgestrel isn’t quite so effective and should only be used up to 72 hours after unprotected sex.

Combined hormonal contraceptives
The combined hormonal contraceptives (CHCs) contain oestrogen and progestogen in a pill, patch or vaginal ring. These can have various health benefits for women over 40. CHCs may ease flushes and sweats, positively affect bone mineral density and make periods lighter, less painful and more regular. CHCs have a known protective effect against ovarian and endometrial cancer, and may decrease the risk of colorectal cancer.

CHCs can be used by women over 35 as long as they are non-smokers, have no arterial or venous risk factors, and a normal weight and blood pressure. CHCs may be associated with a small increased risk of breast and cervical cancers, but any potential risk returns to that of a ‘never user’ 10 years after stopping CHCs. CHCs can raise blood pressure and double the risk of blood clots in the legs. Some studies suggest that they may increase the risk of cardiovascular disease and stroke by a small amount. Women who suffer from migraine with aura appear to have an increased risk of stroke, so shouldn’t take CHCs. CHCs are also unsuitable for women with a current or past history of blood clots, heart disease or stroke, with high blood pressure, and with multiple risk factors for cardiovascular disease.

Progestogen-only contraception
Progestogen-only contraception can be administered as a pill, injection (depot medroxyprogesterone acetate), implant or intrauterine system. Women can buy a desogestrel progestogen-only pill (POP) directly over the pharmacy counter. From 2024, the Pharmacy First England initiative enables community pharmacists to issue certain oral contraceptives without a prescription or charge.

POC may ease period pain. The 52mcg levonorgestrel intrauterine device (LNG-IUD) can be used for contraception, to treat heavy periods and as the progestogen component of HRT. There’s no known link between POC and blood clots, cardiovascular disease or cerebrovascular disease. Some POC methods may cause irregular vaginal bleeding. It’s not known whether there’s any link between POC and breast cancer since there’s limited evidence. The injection may be associated with a slight loss of bone mineral density, which resolves when you stop using it.

When to stop contraception
Women are recommended to use contraception until age 55, which is when a loss of fertility is assumed. HRT isn’t a contraceptive. Sexually active users who start HRT before their periods stop must use contraception as well.

CHC and the injection aren’t generally recommended after age 50. When a 52mg LNG-IUD is inserted in a woman aged over 45, national guidance states that it’s effective until age 55 when contraception can be discontinued. A Cu-IUD fitted after age 40 can stay in place until after the menopause.

Some hormonal contraception stops periods completely, so diagnosing the menopause can be difficult. There’s no reliable test, but many clinicians advise checking follicle stimulating hormone (FSH) levels in these women if they’re over 50. Women using non-hormonal contraception can stop this one year after their last menstrual period if they’re over 50, or two years after their last period if under 50.

About the author
Dr Diana Mansour is a consultant in community gynaecology & reproductive healthcare at Newcastle upon Tyne Hospitals NHS Foundation Trust. She’s been an associate clinical lecturer at Newcastle University since 1997.

Created Spring 2024
Copyright © The Menopause Exchange 2024

Tags: barrier methods, combined hormonal contraceptives, contraception for the over-40s, Copper Intrauterine Device, Emergency contraception, Fertility awareness, menopause, Progestogen-only contraception, Sterilisation, vasectomy, withdrawal method