Contraception in Over 50s

In today’s world, with divorce and separation becoming reality in the life of many couples, as well as a growing number of never-married women, the need for contraception is present even among older women. Women above 50 have a very low rate of pregnancy, but this event is accompanied by a high pregnancy-related morbidity, an increased mortality rate, and a higher risk of fetal congenital abnormality.

96 percent of women experience menopause by the age of 55 years. For this reason, cessation of contraception is advised after a year of amenorrhea especially if the woman does not have any perimenopausal symptoms. It is important to realize that hormonal contraception itself may disguise the features of menopause and of menstrual period cessation.

Women who are less than 45 years at the time of presumed menopause, and are on contraception are sometimes advised to continue using contraceptives for two years more, rather than one. This is justified based on the possibility of irregular ovulation even after regular periods have stopped.

Another school of thought considers that non-hormonal contraception may be stopped if the woman has had six months and is now experiencing hot flushes, and if withdrawal bleeds fail to occur in the pill-free interval. These vasomotor symptoms are a classic symptom of estrogen deficiency, hence of ovarian failure. In other cases, when more or less regular menstruation is still continuing after the age of 55, and the woman is sexually active, contraception may be considered.

There are various suggestions as to how to distinguish women who need contraception from those who can safely stop it. One test relies on FSH levels assayed at least two times at an interval of six months, to make this distinction. FSH levels above 30 IU/L normally indicate ovarian failure and therefore the absence of ovulation. This is not reliable in the women who are on hormonal methods of contraception.

Hormonal contraception

This includes the following methods:

1. Combined hormonal methods

In general, these contain both estradiol and progestogen, and should be considered only if the woman has no personal or family history of contraindications to their use. Previous recommendations were that combined hormonal contraceptives should be stopped at 50 years and another method adopted. Now, however, women at low risk for estrogen-related complications, such as venous thromboembolism or cardiovascular disease, migraine, or smoking, should be advised that they can continue combined hormonal contraception until menopause.

• Combined oral contraceptive pills
• Vaginal contraceptive ring
• Combined contraceptive skin patch

2. Progestin-only methods

These contain only progestins, but the dose delivered varies between different forms, being least with the pills and highest with the implants.

• Progestin-only pill (mini-pill or POP)
• Progestin subdermal implant
• Progestin injectables – only recommended if the woman cannot use any other form, and after ruling out risk factors for osteoporosis
• Progestin intrauterine system (IUS)

Progestin-only pills or implants may be continued until the age of 55 years, after which pregnancy is not expected to occur due to natural waning of fertility levels. However, because progestin-only methods are often accompanied by amenorrhea, FSH testing may be done in such women to confirm menopause. If this suggests that ovarian function is poor, she may continue with the previous method or adopt a barrier method for one more year.

Progestogen-only injectables should be reconsidered after the age of 50 years, and other appropriate methods switched to if the risks are greater than the benefits. Other progestin-only methods are considered suitable for women with a past history of or current ischemic heart disease or stroke. All progestin-only methods are contraindicated in women who have current venous thromboembolism (VTE). Past VTE is not considered to be a barrier.

The IUS may be retained if it had already been inserted before the age of 50 years. If the woman is amenorrheic, and FSH levels are high, removal may be considered. Failing this, the device may be left in situ for a total of seven years.

Women on hormone replacement therapy (HRT) should not consider it as being of any contraceptive value. They may continue contraception until the age of 55 or if FSH levels on two occasions, measured after 6 weeks of HRT cessation, are high enough to suggest the onset of menopause.

The POP is effective for women on HRT. The IUS is also useful in acting both as a progestogen donor for HRT, to protect the endometrium from hyperplasia induced by estradiol, and as a means of contraception, offering four years of protection.
 

3. Emergency contraception

• A pill that  contains high levels of estradiol and should not be used for women with contraindications to the use of estrogen
• Progestin-only morning-after pill
• Ulipristal acetate pill

Non-hormonal methods

1. Barrier methods

These are the safest in terms of side effects, but have higher failure rates because of the possibility of non-usage or improper use during the act of intercourse. They are suitable for use at any age and offer protection against sexually transmitted infections (STIs). All barrier methods should be considered as an alternative or additional means of contraception for women who have STIs or are at risk of acquiring STIs, even if they have been sterilized or are using another method of contraception. Barrier methods should not be used with the spermicide non-oxynol-9 which actually increases the risk of STIs by producing genital ulceration on repeated use.

Vaginal lubrication may be necessary for older women whose partners use the male condom, because of discomfort due to vaginal dryness. Oil-based lubricants should be avoided to prevent failure due to condom breakage, which can cause both pregnancy and STI transmission.

The female condom, diaphragm, or cap, may be difficult to use if initiated by the older woman, but have the advantage of being well-lubricated.

• Male condom
• Female condom
• Vaginal diaphragm or cervical cap
• Contraceptive sponge
• Spermicides

2. Copper intrauterine device (IUD)

These devices are suitable for older women if they are not at an increased risk of STIs, and if they have no uterine anomalies. If the uterus is very small, the risk of perforation may be increased. Non-hormonal methods of contraception may be safely stopped after the age of 50 years if the woman does not have her period for a year.

Women above 50 years, who have an IUD which has been inserted after they turned 40, can continue to use it until one year after menopause sets in (the last period).

3. Natural methods

These are safe in relation to adverse effects, and are also acceptable to most cultures and religious groups. They have a higher failure rate because of the care and effort required to use them properly, but can be used to increase a woman’s perceptions of her own fertility, and to plan pregnancies when desired.  Method include:

• Periodic abstinence (rhythm or fertile period method, or Billing’s technique)
• Coitus interruptus or withdrawal method

The rhythm method becomes difficult in women above 50 years due to alterations in the regularity of ovulation and of menstrual cycles. This may mean that a greater proportion of the cycle is considered suitable for abstinence, which may increase the difficulty of adhering to this method.

Using multiple indicators such as basal body temperature and cervical mucus characteristics to determine the fertile period is recommended to improve method effectiveness, which can be as high as 99 percent per year if all indicators are taken properly into account.

4. Permanent methods

Female and male sterilization, by tubal ligation/occlusion and vasectomy, respectively, provide an effective and permanent contraceptive method. Vasectomy is simpler and more effective than female sterilization, though tubal occlusion is quick and easy to perform in the right setting.

Factors to be considered

Older women who wish to initiate or continue contraceptive measures should be evaluated with respect to the following:

• The woman’s age
• Health status and medical history
• Level of sexual activity
• Presence of menstrual cycles – in many women this is more reliable as an indicator of ovarian activity than FSH levels
• Risk of sexually transmitted infections
• History of contraception use
• Lifestyle factors
• Attitude towards abortion if unintended pregnancy occurs

References

1. http://patient.info/doctor/contraception-from-40-to-the-menopause-pro
2. https://www.ncbi.nlm.nih.gov/pubmed/12288572
3. http://www.cochrane.org/CD003939/STI_nonoxynol-9-for-preventing-vaginal-acquisition-of-sexually-transmitted-infections-by-women-from-men