Women 40+ still need effective contraception

Women over age 40 might underestimate their need for effective birth control; however, despite declining fertility, such women can be at risk for unintended pregnancy.

This population has special attributes that influence contraceptive choice, notes a new review that outlines birth control options for older women, as well as their benefits and disadvantages.1 Women of older reproductive age might be experiencing perimenopausal symptoms that could be managed with contraceptives. However, they also might have medical conditions that make estrogenic methods inappropriate, the review notes.

Older women are more likely than younger women to have adverse consequences should they become pregnant. The risk of spontaneous abortion and chromosomal abnormalities rises for those older than age 40.2 Older age also is associated with higher risk of obstetric complications, including gestational diabetes, hypertension, placenta previa, cesarean delivery, perinatal death, and maternal death.3

Review authors present data from an extensive review of the literature, and they provide evidence on risks and benefits, as well as practical pointers on how to best use contraception in the over-40 population, notes review co-author Carrie Cwiak, MD, MPH, associate professor of obstetrics and gynecology at Emory University in Atlanta. The review can serve as a tool to complement a clinician in-service training or a resident lecture on how to address the contraceptive needs of women over 40, she notes.

Contraception remains an important concern for older reproductive age women, says co-author Andrew Kaunitz, MD, professor and associate chair in the Obstetrics and Gynecology Department at the University of Florida College of Medicine — Jacksonville. “This new review provides evidence-based guidance that will help clinicians counsel older reproductive age women regarding sound contraceptive choices,” notes Kaunitz.

Offer effective options

Women older than age 40 need to talk with their clinicians about which choice of contraception is best for them given their health, says lead author Rebecca Allen, MD, MPH, assistant professor of obstetrics and gynecology at the Warren Alpert Medical School of Brown University in Providence, RI. Even if they have used a specific method in the past, it might be less appropriate now because of other medical conditions, she notes.

Current evidence supports the safety of combination methods, such as birth control pills, the contraceptive patch, and the contraceptive vaginal ring, in those older reproductive age women who are lean, healthy nonsmokers, notes Kaunitz.

For women who medically are not appropriate candidates for combination hormonal methods, progestin-only and nonhormonal methods such as intrauterine devices (IUDs), the contraceptive implant, contraceptive injections, and minipills represent safe contraceptive choices, states Kaunitz. Tubal sterilization for women and vasectomy for male partners are also options for women over 40 years of age who have completed their families, the reviewers note. Older women are less likely to regret permanent sterilization.4

Susan Wysocki, WHNP-BC, FAANP, president & chief executive officer of iWomansHealth in Washington, DC, which focuses on information on women’s health issues for clinicians and consumers, says, “It is important not to assume that the woman over 40 knows what all her options for contraception might be. Even if she has successfully used a method for a number of years, she may be happier with another option.”

Also, remember to provide information about emergency contraception and provide an advance prescription as one would for a younger woman, Wysocki advises.

More than birth control

There are many potential noncontraceptive benefits of birth control methods in this age group, says Allen. For example, the oral contraceptive pill can treat perimenopausal hot flashes and perimenopausal anovulatory uterine bleeding, she notes.

The levonorgestrel IUD alleviates heavy menstrual bleeding caused by conditions such as adenomyosis and uterine fibroids, which become more common in women over age 40, states Allen. Since 2009, the U.S. labeling of the device carries a specific indication for treatment of heavy menstrual bleeding in women who desire contraception. (Contraceptive Technology Update reported on the approval; see “Options for treatment of heavy bleeding in focus,” December 2009, p. 137.) Its use leads to a 97% reduction in menstrual blood loss by 12 months, and the method offers high satisfaction rates.5

Evidence indicates many of the available contraceptive methods, including oral contraceptives, intrauterine devices, and the contraceptive injection, reduce a woman’s risk of endometrial and ovarian cancer, notes Allen.

When to stop?

When should women stop using contraception? Most women will be able to use contraception safely until they are assured of menopause, the review authors note.

“Determining when to stop a contraceptive method should include an evaluation of the benefits of the method, the health risks resulting from its use as age increases, the diminishing risk of pregnancy, and the availability of alternative methods,” the authors state.

The median age of menopause is approximately 52 years, meaning 50% of women age 52 will continue to have ovulatory function, says Kaunitz Because FSH (follicle stimulating hormone) testing is unreliable in women using combination estrogen-progestin contraceptives, the authors point out that one approach is to arbitrarily continue contraception until age 55, when the likelihood of ovulation/conception becomes remote.1

References

1. Allen RH, Cwiak CA, Kaunitz AM. Contraception in women over 40 years of age. CMAJ 2013. Doi: 10.1503/cmaj.121280.

2. Cleary-Goldman J, Malone FD, Vidaver J, et al. Impact of maternal age on obstetric outcome. Obstet Gynecol 2005; 105:983-990.

3. Joseph KS, Allen AC, Dodds L, et al. The perinatal effects of delayed childbearing. Obstet Gynecol 2005; 105:1,410-1,418.

4. Hillis SD, Marchbanks PA, Tylor LR, et al. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol 1999; 93:889-895.

5. Jensen JT, Nelson AL, Costales AC. Subject and clinician experience with the levonorgestrel-releasing intrauterine system. Contraception 2008; 77:22-29.