The contraceptive options for women in midlife cater for a variety of physical and social circumstances.

The challenge of finding an ideal contraceptive in midlife is often complicated by other comorbidities and gynaecological conditions, as well as varied social and relationship issues.

Fertility decreases in midlife, which allows consideration of options not suitable for younger, more fertile women.

Permanent contraception is often a valid choice for couples who have completed their families, while the risk of sexually transmitted infections should be considered in those in new relationships. A careful assessment of these factors will determine the optimum choice for individual women.

A useful tool in helping to determine the safety of contraceptive use is the WHO publication, Medical eligibility criteria for contraceptive use, which uses four safety categories (1-4). Recent updates include conditions such as systemic lupus erythematosus (SLE) and obesity.

Oestrogen-Containing Contraception

The combined oral contraceptive pill (COCP) is classified as WHO category 2 for women older than 40.

Increased risk of thrombotic events occurs with smokers older than 35, obesity, cardiovascular disease, hypertension, hyperlipidaemia, diabetes and women older than 50. The lipid profile can be altered and hypertension can occur, along with an increased stroke risk.

Women who are healthy, non-smoking and have no increased risk of heart disease or thrombosis may continue on the COCP. There is no absolute rule on the age that it should be ceased.

The COCP can regulate the menstrual cycle and improve PMS and some menopausal symptoms. Evidence suggests decreased endometrial and ovarian cancer and no increase in breast cancer among COCP users.

The lower dose (20 g) COCP pill is preferred. The vaginal ring (NuvaRing) is an alternative with theoretical advantages of a lower dose and less thrombotic effect with good cycle control.

Progestogen-Only Contraception

Mirena

Mirena is very popular due to its role as an effective contraceptive and the improvements it delivers for menorrhagia, endometrial hyperplasia and cycle irregularities.

Initial spotting may last three to six months, but following this 20%-40% of women experience amenorrhoea. In this age group it provides effective endometrial protection if HRT is required and remains effective as a contraceptive for up to seven years.

Progesterone-only pill (minipill)

This is highly effective in women older than 40 due to their naturally declining fertility. They may find it easier to take it within the three-hour period required but irregular cycle control may be an issue.

Etonogestrel implant (Implanon)

This has the advantage of being progestogen only and lasts for three years.

Menstrual irregularities can occur in the first three months with subsequent amenorrhoea in many women. However, 20% of women experience enough bleeding abnormalities to have the implant removed.

In women with cycle abnormalities or menorrhagia, Implanon may not be suitable.

Condoms

These are a valid form of contraception given the lower fertility rate in this age group. They are very relevant for women in new relationships as protection against STIs. Vaginal dryness and erectile dysfunction may cause difficulties.

Sterilisation

• Tubal ligation: A popular option but an invasive procedure and cycle abnormalities may still occur.
• Hysteroscopic sterilisation: Essure is currently the only method available in Australia. It consists of small pellets inserted into the fallopian tubes via a hysteroscope, and can be performed under local or general anaesthetic.
• Vasectomy: One in four Australian men older than 40 have had a vasectomy, with 31% of these men aged 40-49 years. This method is popular if family size has been completed permanently (as agreed by both partners) and should not be based on the possibility of reversal.

Other Methods

The copper IUD has the advantages of being a non-hormonal method and may remain in situ for eight years. Side-effects include heavy painful bleeding and it is contraindicated when fibroids are present. IUD lifespan doubles if it is inserted after the age of 40.

Fertility awareness methods are an option but access to adequate training is limited and it is unreliable with irregular periods.

DMPA injection is not often used due to concerns regarding the possible decrease of bone density during periods of prolonged amenorrhoea.

Diaphragms and caps are not often used but they are a valid option for women who are confident in their use.

Emergency Contraception

Older women may need to be updated on the availability of the levonorgestrel method, which is available over the counter.

When to Stop Contraception

Menopause cannot be confirmed until at least 12 months of amenorrhoea for women older than 50, or 24 months for women younger than 50. For those on the COCP, periods will continue until it is ceased. The only way to assess the cycle is to cease the COCP to determine if periods will resume.

In early post-menopausal women, there is a small chance of spontaneous ovulation, and the patient should be informed of this possibility. An alternative non-hormonal method of contraception can be used during this time.

 Midlife Contraceptive Choice 132.91 Kb

References

See Medical Observer http://www.medicalobserver.com.au/

Content Updated July10, 2009