Contraception consultation and assessment for women over 40

A woman's reproductive age is defined as being between 15 and 49 years of age, and, in 2017, there were 1.9 billion women of reproductive age in the world (World Health Organization (WHO), 2020).

Conception is defined as the successful fertilisation of ova by spermatozoa. According to the WHO, successful use of contraception enables women to determine how and when they want to have children. In healthcare practice this is usually referred to as ‘family planning’. Worldwide, the number of women using modern contraception has increased, rising from 73.6% in 2000 to 76.8 % in 2020, equating to over 842 million women (WHO, 2020).

Contraception works in a variety of ways (NHS Inform, 2022):

• Stopping egg production
• Stopping spermatozoa reaching the egg
• Stopping a fertilised egg from attaching to the wall of the uterus.

There are multiple forms of contraception, of which 15 are available in the UK; however, the only one that can prevent both pregnancy and the transmission of sexually transmitted infections is the condom (WHO, 2020; NHS Inform, 2022).

The most popular form of contraception in the UK overall continues to be the oral contraceptive pill. However, there has been an increase in the use of long-acting reversible contraceptives (LARCs), with intrauterine devices becoming more popular in women over the age of 35 (NHS Digital, 2022). It may be that the longer-acting properties of this group of contraceptives are a more attractive proposition due to the longer periods between administration and being less prone to user error (National Institute for Health and Care Excellence (NICE), 2022a).

Assessing a patient for contraception: General principles

Discussing contraception can be an emotive issue for certain patient groups, and health professionals need to be supportive of women's personal and religious beliefs, and mindful of the terminology they use during consultations.

It is good practice to ask how patients identify their gender and to be clear on the pronouns they prefer (as certain patients may be trans or non- binary individuals). This is clinically relevant as combined hormonal methods should not be prescribed for trans men and non-binary people who are taking testosterone. This does not apply to other methods (British Association of Sexual Health and HIV (BASHH), 2019; Faculty of Sexual and Reproductive Healthcare (FSRH), 2017a). Screening a woman for combined hormonal contraception, progestogen-only contraception, or intrauterine contraception should always be undertaken using the UK Medical Eligibility Criteria for Contraceptive Use (FSRH, 2016).

Recommendations are presented using categories of safety, from Category 1 where there is no restriction for use to Category 4 where there is an unacceptable health risk. Ideally, the structure of a contraception consultation should include the following principles of discussion and assessment (NICE, 2022a):

• Why contraception is required
• Religious and personal beliefs, and attitudes about differing methods of contraception
• Current/previous methods of contraception used and preference.

Before prescribing contraception discuss (NICE, 2022a):

• Comorbidity
• Previous and future pregnancy planning:
• If fertility may be delayed; for example, there may be up to a 1-year delay after discontinuing progestogen-only injectable contraceptives
• Current pregnancy risk
• Exclude and if unable to do so, assess for emergency contraception
• Screening for cervical cancer if appropriate
• Urogenital or sexual symptoms, abnormal bleeding, or fibroids:
• Abnormal/unexplained bleeding should be investigated further
• For women with abnormal bleeding or fibroids some methods of contraceptive will not be appropriate
• Risk of sexually transmitted infection (STI):
• Evidence suggests that people over 40 are less likely to use condoms (Grech et al, 2017)
• Appropriate methods in women with current STIs
• Potential abuse:
• Certain subgroups of the population, such as those from disadvantaged backgrounds and trans individuals are at a higher risk of abuse (BASHH, 2019; Government Equalities Office, 2019; NICE, 2022a).

Managing lifestyle factors

It is important that a holistic outlook is employed during any consultation and to make use of opportunities to discuss improvement of general health. Lifestyle factors that may be relevant to contraceptive prescribing include (NICE, 2022a):

• Weight and nutrition
• Alcohol intake
• Smoking cessation
• Adverse risk is higher in women aged over 35 who smoke (FSRH, 2019a)
• Regular exercise
• Perimenopause/menopause symptoms, particularly relevant for women over 40 years.

Once a contraceptive is chosen, information (written if possible) should be provided on the following (FSRH, 2019a):

• Chosen method use
• Potential/adverse side effects
• Potential drug interactions (including herbal remedies)
• Managing missed pills or adverse events such as detachment
• Emergency contraception
• Signposting for local out of hours services and further information
• Date for review.

‘Menopause is associated with multiple symptoms; for example, those that affect mood and the urogenital, vasomotor and muscular systems, and some of these symptoms may present in perimenopause’

What to consider when prescribing contraception in women over 40

Risks in pregnancy when over 40

Women aged 40 years and over should be advised that there is a higher risk of maternal mortality, neonatal and maternal abnormality and loss, making pregnancy potentially dangerous for both mother and baby (FSRH, 2019a; MBRRACE UK, 2021).

In 2019, the number of women over 40 becoming pregnant increased for the second year in a row, and Office for National Statistics data (ONS) (2020) showed that 34% of pregnancies in women over 40 ended in termination. Thus, it is important to explain the risks of becoming pregnant in this age group so that an informed choice can be made, and the physical and psychological trauma that may be involved with terminating an unwanted pregnancy can be avoided.

Perimenopause and menopause

Menopause refers to the time at which menstruation stops, caused by the loss of ovarian follicular activity. Menopause is clinically confirmed after 1 year of amenorrhea. For most women, menopause occurs between the age of 45 and 55 and, in the UK the mean age for menopause is 51 (NICE, 2015; FSRH, 2019). The time before menopause is known as perimenopause. During perimenopause, menstrual frequency and flow may become less predictable and/or heavy (known as heavy menstrual bleeding) (HMB) (NICE, 2022b).

Menopause is associated with multiple symptoms; for example, those that affect mood and the urogenital, vasomotor and muscular systems, and some of these symptoms may present in perimenopause (Baldwin and Jensen, 2013; NICE, 2015; 2022b). While contraception does not affect the course of a woman's menopause, it may mask the symptoms of perimenopause or the beginning of menopause (FSRH, 2019a).

Where symptoms are exhibited during the expected age range (over 45 years), serum follicle-stimulating hormone (FSH) measurements are not recommended, and diagnosis should be based on symptoms (NICE, 2022b). FSH measurements may be used to check menopause status for women over 50 who are using progestogen-only contraception if required, or for younger women, or those with atypical presentation to confirm menopause. FSH measurements are not recommended in women taking combined hormonal contraception or hormone replacement therapy (HRT), as suppressed levels of estradiol and gonadotrophins can make results inaccurate (FSRH, 2019a; NICE, 2022b).

Early menopause is determined as occurring between the age of 40 and 45 years, (following the exclusion of secondary causes). Specific health risks are linked to early menopause including an increased risk of coronary vascular disease, which may be relevant when prescribing certain contraceptive methods (NICE, 2015; 2022b).

Despite a decline in fertility, which occurs naturally with age (particularly over 40), and the rarity of naturally occurring pregnancy over 50, there is still a continued risk of pregnancy until menopause (NICE, 2022a). Contraception is not required over the age of 55 years in women who are still experiencing menstruation as natural conception is unlikely. However, some women may still wish to continue contraception for personal reasons, and this should be discussed (FSRH, 2019a).

Hormone replacement therapy and contraception

Unless there are safety implications such as an increased cardiovascular risk, all methods of contraception can be considered in perimenopausal women, including combined hormonal contraception (CHC), which includes the COC pill, patch and vaginal ring (NICE, 2022a). Since pregnancy risk lowers with age, some women may prefer switch to a non-hormonal method of contraception such as condoms. For women experiencing perimenopausal symptoms, some contraceptive methods may manage these better than others, and may be useful alternatives to HRT (FSRH, 2019a; NICE, 2022b). CHCs may be useful for women under 50 as an alternative to HRT in managing symptoms, particularly when use is extended or continuous (no hormone-free break), which is an off-license indication (FSRH, 2019a; NICE, 2022b). While making lifestyle adaptations and using non-hormonal methods may be sufficient to manage some menopausal symptoms, hormone replacement therapy (HRT) is the viable treatment option for many women (Table 1). HRT is prescribed as either a combination of oestrogen and progestogen, or as oestrogen alone.

HRT prescribing should be guided by the following (NICE, 2015; 2022c):

• Women with an intact uterus – combined oestrogen and progestogen preparations. The components may be split, with the progestogen component given separately as either:
• A tablet (common forms include dydrogesterone, medroxyprogesterone, norethisterone, levonorgestrel, norgestrel and drospirenone) or
• Mirena (the levonorgestrel-releasing intrauterine system)
• Women without an intact uterus – oestrogen-only preparations.

‘Recommended use of hormonal contraception (and intrauterine devices) is usually divided by age into the following groups: 40–50 years and over 50 years’

Box 1.Useful resources

• Brook: www.brook.org.uk
• National Institute for Health and Care Excellence Clinical Knowledge Summaries: https://cks.nice.org.uk
• Family Planning Association: www.fpa.org.uk/professionals/resources
• Faculty of Sexual and Reproductive Healthcare: www.fsrh.org
• NHS your contraception guidance: www.nhs.uk/conditions/contraception
• National Institute for Health and Care Excellence (2019) Menopause: diagnosis and management: www.nice.org.uk/guidance/ng23
• Sexwise, a website produced by the Family Planning Association for the National Health Promotion Programme for Sexual Health and Reproductive Health: www.sexwise.org.uk

The progestogen-only pill (POP), like the progestogen-only implant (IMP) and depot medroxyprogesterone acetate (DMPA) are not licensed for use as endometrial protection with oestrogen- only HRT. However, all progestogen-only methods of contraception may be used with sequential HRT (FRSH, 2019a). Postmenopausal women should be advised that they do not need to use contraception alongside HRT. If bleeding occurs in postmenopausal women using cyclical HRT, reassurance should be given that pregnancy will not occur (FSRH, 2019a).

Which contraceptive is best for women over 40?

For the advantages, disadvantages and failure rates of contraceptive methods in perimenopausal women see Table 2 (Bakour et al, 2017). Some forms of contraception can be continued and potentially extended until menopause, which may be a good option for women who would prefer to continue using their current ‘tried and tested’ method.

Recommended use of hormonal contraception (and intrauterine devices) is usually divided by age into the following groups: 40–50 years and over 50 years. Many forms of contraception can potentially be used until age 55 (Table 3). For trans men and non-binary people, progestogen-only methods, intrauterine systems and the intrauterine device can all be used (BASHH, 2019). While some contraceptives may confer health benefits, some come with additional health risks.

For women over 40 the following risks are increased:

• Venous thromboembolism (VTE) – risk increases from 1 in 10 000 to 1 in 1000 from 40–60 years (Scottish Intercollegiate Guidelines Network, 2014). The risk is further increased once over 50 (Stegeman et al, 2013)
• Osteoporotic fracture – risk increases due to a decline in oestrogen levels, leading to a loss of bone mass and lower bone mineral density (National Institutes of Health (NIH), 2015).

Contraceptive methods: Hormonal and intrauterine contraception

Intrauterine contraception

The two methods of intrauterine contraception (IUC) available in the UK are the levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (Cu-IUD). Both are LARCs. Before IUCs are inserted a full assessment is required, which excludes pregnancy and STI risk. In general, IUCs should be removed following menopause (and at age 55) as they can cause infection if left in situ (NICE, 2022d).

There are three intrauterine systems available in the UK: Mirena, Levosert and Jaydess. Mirena is licensed for contraceptive use for 5 years, and Levosert and Jaydess for 3 years (FSRH, 2015; NICE, 2022d; FPA, 2020a). The 52 mg LNG-IUS may be useful for symptomatic treatment for women with heavy or erratic menstrual blood loss, as it may cause amenorrhea (FSRH, 2019a).

Mirena 52 mg levonorgestrel intrauterine system (LNG-IUS) may be used for contraception purposes until the age of 55 if inserted at age 45 or over. It can also be used for endometrial protection as part of an HRT regimen when combined with oestrogen and is the only LNG-IUS licensed for this. While it is only licensed for use for 4 years with HRT, it can be used for up to 5 years off label; however, the device must be changed every 5 years (FSRH, 2019a).

The Cu-IUD is a safe and effective choice of contraceptive (and emergency contraception) and is particularly useful for women with additional comorbidities for whom hormonal methods of contraception cannot be safely used. Use can be extended until menopause if it has been inserted after the age of 40 (FSRH, 2014; 2019a).

Progestogen-only methods of contraception

There are three progestogen-only methods available in the UK: the pill (POP), the implant (IMP) and the injectable (POI) (FSRH, 2014; 2019b; 2021; NICE, 2022d). The POP and IMP are not associated with increased risks of VTE, stroke or MI and have not been shown to adversely affect bone mineral density (Mantha et al, 2012).

Progestogen-only pills

There are several POPs licensed in the UK. Formulations include levonorgestrel, norethisterone, desogestrel, or drospirenone (FSRH, 2019b; NICE, 2022d). POPs can be used up to age 55 and are a viable alternative to combined oral contraceptives (COCs) for many women who prefer an oral method of contraception.

They are also a useful substitution for women who have additional risk factors such as smoking or migraine (Nappi et al, 2013).

Progestogen-only injectables

Three injectable contraceptives are available in the UK: Depo Provera, Sayana Press (both containing medroxyprogesterone) and Noristerat (norethisterone enantate) (FSRH, 2014; FPA, 2020a). Amenorrhoea affects up to 50% of women after 1 year of use of certain POIs (Table 4), which may be a useful side effect for those who experience bleeding irregularities (FSRH, 2019a).

For women over 40 there is a risk of reduction in bone mineral density due to the hypoestrogenic effects of depot medroxyprogesterone acetate. Regular patient review and discussion regarding changing to an alternative contraceptive method is recommended, more so where there is an increased risk of osteoporosis due to additional reasons such as smoking or inactivity (FSRH, 2014). Women over 50 should be counselled about changing to an alternative method (FSRH, 2014; 2019a).

Progestogen-only implant

Nexplanon is the only IMP available in the UK and contains etonogestrel 68 mg.The IMP should be replaced every 3 years. IMPs can cause amenorrhea which may suit some, but it can also cause irregular bleeding, an undesirable outcome in a patient group who may already be experiencing this issue (FSRH, 2021; NICE, 2022d).

Combined hormonal contraception

In the UK the following CHCs are available:

• Combined oral contraceptive (COC)
• Combined transdermal patch (patch)
• Combined vaginal ring (CVR).

CHCs can be used up to the age of 50, but women aged 35 and over who smoke have an increased mortality risk and should be advised to switch to an alternative method, such as the POP or an IUS (FRSH, 2019a).

Women over 40 are prone to menstrual problems, and CHCs can help to reduce menstrual bleeding and pain, so may be useful for the under 50s who are unable to take HRT. Where irregular bleeding during the hormone-free break occurs, the use of continuous or extended dosing (i.e., not having a hormone-free break) may be useful to help manage this (off-license indication) (FRSH, 2019a; FPA, 2020a).

The risks associated with CHC use include an increased risk of VTE, which is variable depending on the dose and type of progestogen used, and potentially the product (Weill et al, 2016). For the COC, the risk overall continues to be small and is highest when the COC is first started, or when restarted after a 1-month break (FSRH, 2019b).

COCs containing levonorgestrel or norethisterone, which have a lower dose of oestrogen (less than ≤30 mg ethinylestradiol) may be more advantageous and are advocated as first-line in women aged over 40 years due to the lower potential risk of VTE (FRSH, 2019a; 2019b). CHC use may offer a reduced risk of ovarian, endometrial and colorectal cancer, and in some cancers this protection may continue for many years after use has been stopped. CHC may also confer support in terms of bone mineral density in perimenopause (FRSH, 2019a; 2019b).

Emergency contraception in women over 40

Emergency contraception (EC) is used to prevent unintended pregnancy, when either unprotected sexual intercourse has occurred or where there has been contraceptive failure for varying reasons (WHO, 2021). In the UK, all three licensed forms of EC can be used in perimenopausal women (FSRH, 2017; FPA, 2020b). These are:

• Ulipristal acetate EC (UPA-EC) 30 μg tablet- licensed to be taken up to 120 hours after unprotected sex
• Levonorgestrel EC (LNG-EC) 1.5 mg tablet- licensed to be taken up to 72 hours after unprotected sex
• Cu-IUD-can be inserted up to 5 days after unprotected sexual intercourse or up to 5 days after earliest ovulation time (FPA, 2020b). It is the most effective form of EC, is immediately effective and can be left in situ until menopause (Bakour et al, 2017). In women over 50 the Cu-IUD is specifically recommended as first line (FSRH, 2019a).

Conclusion

Helping a woman to choose an appropriate form of contraception that suits her lifestyle, age, medical history, personal beliefs and future pregnancy plans can be difficult, and special consideration is needed for women over 40 whose requirements may be more complex than younger women.

The main considerations for women in this age group are the changes that occur to the menstrual cycle including HMB, timing irregularities and perimenopause and menopause. Determining how to provide contraception that is both effective and safe, and which doesn't cause additional side effects or interact with HRT, is a challenge. As a practitioner in this area, maintaining a contemporary knowledge of contraception for this patient group is not only a professional requirement but is an essential component of reflective practice and continued personal development.

Patients are much more ‘information aware’ now, due to the multiple data avenues available to them and practitioners need to use contemporary contraceptive guidance which will support and promote collaborative dialogue with their patients.

Key Points

• Contraception is required until menopause
• Hormone replacement therapy does not provide contraceptive cover
• Methods of contraception may need to change during perimenopause
• Some forms of contraception are useful alternatives to hormone replacement therapy
• Contraception is not routinely required over the age of 55

CPD reflective questions

• Why might you avoid prescribing medroxyprogesterone long-acting reversible contraception injection in a woman over 40 who has osteoporosis?
• Would you undertake follicle-stimulating hormone levels in a woman who was 48, on the combined pill (COC) and who had menopausal symptoms?
• What strength dose of oestrogen should ideally be used for COCs for women over 40 and why?
• Name two specific methods of hormonal contraception that can potentially be used in women over 50 and discuss why chosen.
• What are the benefits of the using the CU-IUD for emergency contraception?