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Take Home Messages

o Long-acting reversible contraception (LARC) has definite advantages for older women.

o If combined contraception is chosen, then the lowest dose of oestrogen is preferable, such as the 20ug ethinyl oestradiol pill or a vaginal ring that contains 15ug ethinyloestrodiol.

DR TERRI FORAN MB BS (Syd), MClin Ed (UNSW), FAChSHM

Dr Terri Foran is a Sexual Health Physician with special interests in contraception, menopause issues and the

management of sexually transmitted infections. She is presently engaged in clinical and research work at

the Royal Hospital for Women in Sydney and also in clinical practice in an inner Sydney private practice. Terri

is currently the monthly Women’s Health columnist for Australian Doctor Magazine, and has contributed to

a 2011 Australian textbook on Sexual and Reproductive Health.

This article discusses the safest forms of contraception for older women, how to maximise the clinical advantages of these and when it is safe to discontinue the chosen method.

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Introduction

One hardly hears the term anymore, but the prospect of a ‘change-of-life’ baby was a real concern for previous generations of women who relied on less effective methods of birth control. However, the annual rate of

in Australia of surgical abortions in women aged thirty-years and older gradually rose from eight per thousand in 1994 to eleven per thousand in 2010,1 suggesting that even now, the contraceptive needs of this group are not being fully met.

When is contraception no longer necessary? The Faculty of Sexual and Reproductive Health Care (FSRH) suggests contraception can be safely discontinued after twelve months of amenorrhoea in sexually active women over fifty years of age.2 However, since the annual conception rate at the age of fifty years is less than one in one hun-dred, individualised discussions about acceptable risks are worth having. For women who are sexually active and whose periods stop earlier than age fifty years, the advice is a little more conservative and contraception should be continued for two years after the last menstrual period. 2 This is because evidence from a number of older studies indicates that during perimenopause, menses can resume

even after quite prolonged periods of amenorrhoea3 and that these

cycles are occasionally ovulatory.4 An important clinical point is that

conventional menopausal hormone therapy does not provide reli-

able contraception.

The main problem with the FSRH advice is that many women are us-

ing contraceptive methods that make it impossible to use amenor-

rhoea as a measure of underlying fertility. For instance, if the woman

is using a combined contraceptive pill or a contraceptive ring, she

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Contraception and the Older Woman

may continue to experience regular withdrawal bleeds for a long time as she continues this method. Similarly, women using the hor-monal IUD or the contraceptive injection may experience amenor-rhoea and this is in no way indicative of ovarian failure.

What about Tests? Estimation of serum follicle stimulating hormone (FSH) levels cannot be considered a reliable indicator of menopause in women using combined contraception, even if it is measured in the pill-free inter-val.2 It can be useful in women using progestogen-only contracep-tion, but only for those who are over fifty years of age and who are amenorrhoeic. In that case, if the serum FSH level is over 30 IU/mL on two occasions at least six weeks apart, then contraception can safely be discontinued twelve months later.2

Combined Hormonal Contraception in the Older WomenProvided there are no risk factors for this, combined oestrogen and progestogen contraceptive methods can be used until a woman’s fifty-first birthday. They have some definite non-contraceptive ad-vantages for older women, since they also help to maintain bone density, regulate bleeding patterns and reduce vasomotor symptoms. However, older women have higher a background rate of ischaemic heart disease, stroke and venous thromboembolism and combined hormonal contraception may further increase these risks. Women often ask if using combined hormonal contraception increases their risk of breast cancer. The best evidence currently is that there may be a small additional risk of breast cancer in those using combined methods, but that this decreases to the background risk ten years after ceasing it.2

If combined contraception is chosen, then the lowest dose of

oestrogen is preferable

If combined contraception is chosen, then the lowest dose of oestro-gen is preferable, perhaps a 20ug ethinyl oestradiol pill or a vaginal ring that contains 15ug ethinyloestrodiol. Increasingly, many clini-cians are opting for an oestradiol-containing combined oral contra-ceptive pill for older women, since these utilise the same oestrogen used in menopausal hormone therapy but at a dose that is contra-ceptive. However, it must be understood that oestradiol pills pres-ently have exactly the same contraindications as ethyinyloestradiol pills. Older women are sometimes troubled by vasomotor symptoms during the hormone-free interval. In such cases, extended cycling of the active pills or shortening the hormone free interval to only three to four days are worth consideration. Both practices represent off-

licence advice for most pills but the safety of extended cycling is supported by a 2014 Cochrane review.5 Another strategy, though again off-licence, is to apply an oestradiol patch (50-100mcg) during the hormone-free days. This has not been studied for the prevention of vasomotor symptoms but draws from a number of studies which indicate a reduction in oestrogen-withdrawal migraines with the use of oestradiol patches during the hormone-free week.6,7 A new extended use preparation about to be introduced to the Australian market supplies seven days of low dose ethyinyl oestradiol-only pills every four months in place of the conventional placebo week and may be an alternative in the future.

Progestogen-only Pills Progestogen-only pills (POPs), also known as the “minipill”, may be a useful contraceptive choice for women in whom identified risk factors make the use of combined contraception inadvisable. Older women can be reassured that there is no clinical evidence that the use of any of the progestogen-only contraceptive methods increase the risk of breast cancer2 and cohort studies suggest no increased risk of either stroke or myocardial infarct.8 Evidence on the risk of venous thromboembolism (VTE) in otherwise healthy women using progestogen-only contraception is both limited and inconsistent. However, the Faculty of Sexual and Reproductive Health Care re-gards progestogen-only contraception as broadly usable even for women with VTE currently on anticoagulant therapy.8 Progestogens reduce the endometrium lining and this generally results in lighter, though sometimes unpredictable bleeding. Contrary to common per-ception, POPs are just as effective as combined pills, but the problem is that they need to be taken strictly within three hours of the usual administration time to ensure this. Many countries, though unfortu-nately not Australia, have access to a POP containing desogestrel and this has a twelve-hour leeway, making contraceptive efficacy more assured. In women with troublesome vasomotor symptoms, menopausal hormone therapy can be used concurrently with POPs, but it should always contain both oestrogen and progestogen.

Long-Acting Reversible Contraception (LARC)Long-acting reversible contraception (LARC) has definite advan-tages for older women. The hormonal intrauterine device (IUD) is a good choice for certain older women, since it provides very con-venient, extremely effective contraceptive cover, as well as reduc-ing the amount of menstrual bleeding by up to 90%.9 It can also be used as the progestogen component of menopausal hormone therapy, should this be required. A hormonal IUD inserted after age forty-five can be left in situ for seven years, rather than five (al-though this is off licence use).2 Contraceptive implants are also very safe for women in this age group to use, but are associated with a more irregular bleeding pattern. They have no effect on vasomotor symptoms and are not presently licensed for use in conjunction with menopausal oestrogen therapy.

Interestingly, the dose of progestogen in the contraceptive depo in-jection is sufficient to reduce the severity of hot flushes in many

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women, but there remain some concerns about its use in older

women, given its suppressive effect on bone density.

Copper IUDs have the advantage of not masking natural menopause,

but the fact that they tend to increase the amount and duration

of bleeding can be a distinct disadvantage at a time when heavier

bleeding associated with anovulatory cycles is more common. How-

ever, when a woman over the age of forty opts for a copper IUD,

the Faculty of Sexual and Reproductive Health Care suggests it can

safely be left in situ until menopause, though this is at present an

off-licence use of the device.2

Unintended pregnancy may result in difficult decisions at any age,

but perhaps even more so when a woman thinks child bearing and

rearing is long behind her. Modern contraception provides security

until menopause delivers the permanent solution.

Further Reading

FSRH Clinical Effectiveness Unit. Contraception of women aged over

40 years. 2010 Jul. Faculty of Sexual and Reproductive Healthcare.

Available online at: https://www.fsrh.org/documents/cec-ceu-guid-

ance-womenover40-jul-2010/

Declaration

Dr Terri Foran was commissioned by Healthed for this article. The

ideas, opinions and information presented are solely those of the

author. The advertiser does not necessarily endorse or support the

views expressed in this article.

The author’s competing interests statement can be viewed at www.

healthed.com.au/monographs.

References1. Medicare Australia Item 35643. Source: www.medicareaustra-

lia.gov.au/statistics/mbs_item.shtml (Denominator determined by ABS population estimates) Accessed September 2016

2. FSRH Clinical Effectiveness Unit. Contraception of women aged over 40 years. 2010 Jul. Faculty of Sexual and Repro-ductive Healthcare. Available online at: https://www.fsrh.org/documents/cec-ceu-guidance-womenover40-jul-2010/

3. Wallace RB, Sherman BM, Bean JA, Treloar AE, Schlabaugh L. Probability of menopause with increasing duration of amenor-rhea in middle-aged women. Am J Obstet Gynecol. 1979 Dec; 135(8): 1021-1024

4. Sherman BM, Korenman SG. Hormonal characteristics of the human menstrual cycle throughout reproductive life. J Clin In-vest. 1975 Apr; 55(4): 699-706.

5. Edelman A, Micks E, Gallo MF, Jensen JT, Grimes DA. Continu-ous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception. Cochrane Database Syst Rev. 2014 Jul; (7): CD004695

6. MacGregor EA, Hackshaw A. Prevention of migraine in the pill-free interval of combined oral contraceptives: a double-blind, placebo-controlled pilot study using natural oestrogen supple-ments. J Fam Plann Reprod Health Care. 2002 Jan; 28(1): 27-31

7. Calhoun AH. A novel specific prophylaxis for menstrual-associ-ated migraine. South Med J. 2004 Sep; 97(9): 819-822

8. FSRH Clinical Effectiveness Unit. UK medical eligibility crite-ria for contraceptive use 2016. Section B- Progestogen-only contraception. Faculty of Sexual and Reproductive Healthcare. 2016 Jul. Available online at: https://www.fsrh.org/standards-and-guidance/external/ukmec-2016-digital-version/

9. Luukkainen T, Toivonen J. Levonorgestrel-releasing IUD as a method of contraception with therapeutic properties. Contra-ception. 1995 Nov; 52(5): 269-76

Video Resources

Hormonal Contraception and Venous Thromboembolic Risk by Dr Terri Foran

Hormonal Contraception – Ask the Expert by Dr Terri Foran

Watch the full lectures on the Healthed website. Visit www.healthed.com.au/video