Women over the age of 40 know that it is unlikely that they will conceive spontaneously, however, gynecologists recommend that women use contraception until one year after the last menstrual period.
Although conception over 40 may be difficult, US census data demonstrated 26 births per 1000 women over the age of 40. Of these, one-third are unintended. Therefore, there is a need for contraception during this age group. Additionally, women over 40 experience a high risk of spontaneous miscarriage: 34% up to age 44, and 53% over the age of 45. Increased maternal complications include hypertension and diabetes, For the fetus, there is a high risk of chromosomal defects. Therefore, the need for effective contraception in this age group is an important consideration.
So what does the data tell us?
The CDC (Center for Disease Control) has important data regarding safety considerations and contraindications to contraceptive use.
IUD’s are considered in the top tier of recommended contraceptives. There are two types of IUD’s, those with progesterone, and those with no hormones. IUD’s are placed in the office and there are few contraindications. They are highly effective and remain in place for 5 or 10 years. They are easily reversible. Risk of infection and expulsion are quite small, and the continuation rate is higher than oral contraceptives.
The copper IUD is considered to be effective for 10-12 years. The failure rate is less than !%. It is the recommended IUD for women who have had breast cancer and should not be exposed to progesterone. Although in the first 6 months of use menstrual bleeding can be heavier, the bleeding tends to normalize in the first year of use.
Progesterone containing IUD’s have become very popular. They are effective for 3-5 years, depending the the type used. There are therapeutic benefits beside the contraceptive one. The progesterone in the IUD thins the lining of the uterus, therefore making menstrual bleeding less. The effectiveness of the decrease in bleeding is similar to an endometrial ablation, and therefore reduces the need for surgery in women with bothersome, heavy bleeding. The progesterone containing IUD can also be used in postmenopausal women on estrogen therapy to protect the endometrium.
Progesterone only contraceptive products can be used in women in whom estrogen is contraindicated. Contraindications to the use of estrogen would be tobacco use, obesity, migraines with aura, long-standing diabetes, hypertension, and a history of thromboembolism.
Options include the progesterone only oral contraceptive, the progesterone implant, and injections of depo-progesterone which are administered every 3 months. Contraindications to progesterone contraceptives are a recent history of breast cancer.
The progesterone implant is inserted in the office with local anesthesia. It is effective for at least three years, and the failure rate is less than !%. The shots of depo-progesterone are administered every three months. The longer the injections are given, the more likely that menses will stop. After stopping the injections, it can take more than 6 months for menses to resume. Users of this form of contraception were noted to have an 80% decreased risk of endometrial cancer, and a 40% deceased risk of ovarian cancer. Most studies have not demonstrated an increased risk of breast cancer.
What about combined estrogen and progesterone contraceptives? Oral contraceptives are safe in most patients, except for those with the medical problems mentioned previously. The failure rate for OC’s is stated to be 9%, but with close to perfect use, the risk is much lower. OC’s are often used in the peri-menopausal women to control irregular cycles and heavy bleeding. OC’s can also treat the symptoms or irregular hormone levels often found in the peri-menopause. These symptoms can include headaches, hot flashes, and mood changes. The risk of thromboembolism is increased with OC users, and the risk if about 8-10 per 10,000 women/years of use. The greatest risk is in the first 3 months of use.
When oral contraceptives are used in women over 40, careful considerations must be given to medical situations that might increase the risk of heart attack and stroke, since these are rare but significant side effects. OC’s should be avoided in smokers and hypertensives, and also in women who have migraines with aura.
Combined estrogen and progesterone can also be administered as a patch or intra-vaginal ring. The patch is considered to provide higher levels of estrogen and an increased risk of blood clots than a similar OC.
The benefit of reducing cancer risk is impressive and lasts for at least 15 years after discontinuation. The decreased risk of endometrial cancer is 56% after 4 years of use, and 72% after 12 years of use. Women who used OC’s more than 10 years reduced their risk of ovarian cancer by more than 50%, and the benefit lasted 20 years. A reduction of colon cancer was found to be 18%. The most reliable study done on OC effect on breast cancer risk was done by the NIH, which demonstrated no increased risk, although several other studies have demonstrated a small increased risk. Women who carry the BRCA gene did not have an increased risk of breast cancer if the formulation contained 35 mcg or less of estrogen, while the OC also decreases the risk of ovarian cancer in this high risk group.
As far as peri-menopausal symptom control, contraception has significant medical benefits.
The progesterone IUD controls heavy bleeding better than oral contraceptives, and can be used to decrease bleeding in women with fibroids, although the expulsion rate is higher. For vasomotor symptoms of hot flashes and night sweats, oral contraceptives are very effective, especially if giving continuously. Standard hormone replacement will not provide contraception.
Permanent sterilization is always an option for women after childbearing is complete. Traditional tubal ligation performed laparoscopically or after a vaginal delivery or at the time of C-section has been found to reduce the risk of ovarian cancer. Many doctors are now performing bilateral removal of the fallopian tubes, as many ovarian cancers are thought to begin the the tubes. Another option is a metal coil placed through the uterus into the fallopian tubes.
Emergency contraception is an option after unprotected intercourse. Progesterone emergency contraceptive can be used within 72 hours of intercourse, and a copper IUD can be inserted within 5 days of intercourse. Inserting an IUD is 99% effective in preventing pregnancy if inserted within 5 days.
Use of contraception can be continued until age 55, or sooner if a blood test, FSH, demonstrates evidence of menopause. The FSH should be checked at least 14 days after discontinuation of oral contraceptives.
This article provides general considerations, but medical decisions regarding the best contraception options should be made with your personal physician who can consider your history, examination, family history, and your goals.
Menopause: The Journal of the North American Menopause Society, value 25, Number 7, July 2018. Contraception for midlife women: a review. Miller, et al.