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contraception (during perimenopause)

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Although there is reduced fertility in the perimenopausal period, pregnancy is still possible. Maternal mortality is increased in older women and there is a higher incidence of pregnancy associated morbidity e.g. pre-eclampsia. There is also a higher incidence of congenital abnormality with increasing maternal age.

Contraceptive methods available include:

  • intrauterine progesterone-only system
  • progestogen-only pill (POP) - many women over 40 years of age develop amenorrhoea with this form of contraception
  • progestogen implants
  • depot progestogen injections
  • combined oral contraceptive pill - FDA regulations now permit the use of the combined oral contraceptive pill to women at low-risk (non-smokers, no cardiovascular risk factors) up to the age of 50
  • barrier methods
  • conventional intrauterine devices
  • natural methods

Notes (1):

  • women aged over 40 years can be advised that no contraceptive method is contraindicated by age alone
  • combined contraceptive pill
    • women aged over 40 years can be advised that combined hormonal contraception can be used unless there are co-existing diseases or risk factors
    • risks of using combined hormonal contraception outweigh the benefits for smokers aged >=35 years
    • women aged >=35 years with no other risk factors who have stopped smoking more than a year ago may consider using combined hormonal contraception. The excess risk of MI associated with smoking falls significantly 1 year after stopping and is gone 3-4 years later, regardless of the amount smoked
    • women aged over 40 years with cardiovascular disease, stroke or migraine (even without aura) should be advised against the use of combined hormonal contraception
    • clinicians prescribing COC to women aged over 40 years should consider a monophasic pill with <=30 µg ethinylestradiol with a low dose of norethisterone or levonorgestrel as a suitable firstline option
    • women using combined contraception should be advised to switch to another suitable contraceptive method at the age of 50 years
    • FSH is not a reliable indicator of ovarian failure in women using combined hormones, even if measured during the hormone-free or oestrogen-free interval
  • progestogen only methods
    • women with current venous thromboembolism (VTE) should be advised that the risks of using progestogen-only methods outweigh the benefits. Women with previous VTE, however, can be advised that the benefits of using progestogen-only methods outweigh the risks
    • women with a history of ischaemic heart disease or stroke should be advised that the risks of initiating a progestogen-only injectable outweigh the benefits, however, the benefits of initiating POPs, implants or the intrauterine progesterone-only system outweigh the risks
    • women can be advised that a POP or implant can be continued until the age of 55 years when natural loss of fertility can be assumed. Alternatively, the woman can continue with the POP or implant and have FSH levels checked on two occasions 1 or 2 months apart, and if both levels are >30 IU/l this is suggestive of ovarian failure. In this case the woman may continue with the POP, implant or barrier contraception for another year (or 2 years if aged <50 years)
    • women should be counselled about the risks and benefits of continuing with the progestogen-only injectable at the age of 50 years and be advised to switch to a suitable alternative
    • women who have the intrauterine progesterone-only system inserted at age >=45 years for contraception or for the management of menorrhagia can be counselled about retaining the device for up to 7 years
    • women can be advised that a POPcan be used with HRT to provide effective contraception
    • women using oestrogen replacement therapy may choose the intrauterine progesterone-only system to provide endometrial protection

Reference:

  1. FFPRHC Guidance (January 2005) Contraception for women aged over 40 years Journal of Family Planning and Reproductive Health Care 2005; 31(1): 51?64

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