Contraception
Corner
Beyond Forty: Do Contraceptive Needs Change?
Miriam Zieman, MD; Anita L. Nelson, MD
Primary care physicians are accustomed to caring for women at different
stages in their lives. Recognizing how women’s needs change
across the reproductive lifespan is paramount. But how does this
affect contraceptive choices?
UNINTENDED PREGNANCIES
Fertility declines in the later reproductive years due to decreased
quality of ovulation, reduction in sexual activity, and an increase
in spontaneous abortion. The percentage of pregnancies that are unintended
and that end in abortion in women over 40 years of age is very high:
51% of pregnancies are unintended for this age group, which is second
only to adolescents, in whom 82% of pregnancies were classified as
unintended by the National Survey of Family Growth.1 Therefore,
although fertility declines, women must be reminded that they can
have unintended pregnancies in their later reproductive years, and
that continued attention to contraception is essential.
Women over 40 years of age with an unintended pregnancy have the
highest abortion rate of any age group, with 65% of the unintended
pregnancies in this age group ending in termination.1 The
high proportion choosing abortion may reflect the unique challenges
that an unplanned pregnancy may pose for a woman at this stage of
life. Women in their 40s may have substantial financial responsibilities,
and may be parenting children while they care for aging parents.
An unintended pregnancy at this advanced maternal age may be particularly
stressful and challenging.
THE ROLE OF COMBINATION ORAL CONTRACEPTIVES
Many women over 40 years of age may have received a prescription
for OCs at age 20 years and were told that it would be advisable
to discontinue at age 35 or 40 years. This may partly explain the
high rates of sterilization in this age group. For 60% of US couples
older than age 40 years, either the male or female partner has been
sterilized.2 Regarding combination oral contraceptives
(COCs), the US Food and Drug Administration approved their use up
to menopause in healthy, nonsmoking women in 1990. While all COC
formulations contain ethinyl estradiol in combination with various
progestational agents, no specific formulation or dose has been shown
to be safer in older women—provided the estrogen dosage is
35 mcg or less. Specific advantages of using COCs or any other combination
hormonal product in this age group include highly effective contraception,
regulation of menstrual cyclicity, decreased perimenopausal symptoms,
decreased risk of endo-metrial and ovarian cancers, increased bone
mineral density, and decreased acne and dysmenorrhea.
Because COCs serve to regulate menstrual cycles and can often control
vasomotor symptoms, the question arises as to how patient and physician
know when menopause occurs. This is important because women want
to know when they no longer need contraception. Several approaches
are possible. Some experts suggest continuing low-dose combination
hormonal products in healthy women at low risk of cardiovascular
disease until age 55 years, when virtually all women will be menopausal.3 This
approach has not been tested in a large population of women for safety,
and assumes that safety is not compromised between ages 50 and 55
years.
Another approach is to stop using combined hormonal contraceptives
(OCs, patches, or rings) at the median age of menopause, which is
51.3 years. The patient should be advised to use barrier methods
until she is amenorrheic for at least 6 months, confirming menopause.
One cannot rely on blood tests to evaluate the individual patient’s
menopausal status because there are significant (almost daily) swings
in serum levels of follicle-stimulating hormone (FSH) and estradiol
(E2) throughout the perimenopause.4 If she
experiences vasomotor symptoms during this time and chooses postmenopausal
hormone therapy, this can be provided in conjunction with barrier
methods. One investigator did find that a serum ratio of FSH to luteinizing
hormone of more than 1, or an E2 value of less than 20
pg/mL on the seventh day of the pill-free interval, correctly identified
menopause in almost all menopausal women studied.5 The
testing was not performed in women whose status was not known.
INTRAUTERINE CONTRACEPTION
Intrauterine contraception is an excellent choice for many women
in their 40s, because it is effective and convenient. The ideal candidate
is a woman in a monogamous relationship at low risk of sexually transmitted
infections. The copper T-380A has no hormonal component, and is therefore
an excellent choice for women with any complicating medical conditions,
and is effective for 10 to 12 years.6
For selected patients, the levonorgestrel-releasing intrauterine
system (LNG IUS) offers the advantage of decreased menstrual blood
loss. This may serve the off-label purpose of treating menorrhagia,
which is very common in women in this age group, and may possibly
reduce the need for hysterectomy. The LNG IUS is good for at least
5 years.7
PROGESTIN-ONLY OPTIONS
Other progestin-only methods are often appropriate for women who
cannot use estrogen. For example, according to guidelines published
by the World Health Organization (WHO), a woman who smokes can generally
use any progestin-only method.8
OTHER METHODS
Barrier methods are suitable for women over 40 years of age and may
be used alone or as part of dual method used to provide contraception
and protection from sexually transmitted diseases. Special attention
should be placed on women who may be divorced or widowed who are
having sex with new partners. A review of how to negotiate male condom
use, as well as instructions for correct use, may be necessary.
Behavioral methods such as withdrawal may be effective enough, but
fertility awareness methods are not generally reliable. Menstrual
cycling during the 40s generally becomes too erratic and unpredictable
to permit accurate timing of ovulation. All women should be routinely
counseled and, if approriate, offered emergency contraception by
advance prescription.
CONCLUSION
The National Survey of Family Growth noted that the rate of unplanned
pregnancy can only be reduced by decreasing risky behavior, promoting
the use of effective contraceptive methods, and improving the effectiveness
with which these methods are used. Acknowledging special needs across
the reproductive lifespan will help clinicians and patients to meet
this goal.
References
- Henshaw SK. Unintended pregnancy in the
United States. Fam Plann Perspect. 1998;30(1):24-29,46.
- Abma JC, Chandra A, Mosher WD, Peterson
LS, Piccinino LJ. Fertility, family planning, and women’s
health: new data from the 1995 National Survey of Family Growth.
National Center for Health Statistics. Vital Health Stat.
1997;23(19):1-114.
- How to make the switch from OC use to
HRT. Contracept Technol Update. 2000;21(3):33.
- Santoro N, Brown JR, Adel T, Skurnick
JH. Characterization of reproductive hormonal dynamics in the
perimenopause. J Clin Endocrinol Metab. 1996;81(4):1495-1501.
- Creinin MD. Laboratory criteria for menopause
in women using oral contraceptives. Fertil Steril.
1996;66(1): 101-104.
- Hatcher RA, Nelson AL, Zieman M. A pocket
guide to managing contraception. Dawsonville, Ga: Bridging
the Gap Foundation; 2003.
- Mirena [package insert]. Montville, NJ:
Berlex; 2003.
- Department of Reproductive Health and
Research, World Health Organization. Summary Tables of Medical
Eligibility Criteria for Contraceptive Use. 3rd ed. Available
at: http://www.who.int/reproductive-health/publications/MEC_3/index.htm.
Accessed March 22, 2004.
back to top
|
