Contraception for women aged over 40 years


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for women aged
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Contraception for women aged over 40 years

  1. 1. Benha University Hospital, Egypt Aboubakr Elnashar
  2. 2.  Over the age of 40 years 1. Although a natural decline in fertility (from the age of 37 years), effective contraception is required to prevent unplanned pregnancy (Grade B). 2. There is increased risks of: 1. congenital and chromosomal abnormalities, 2. spontaneous abortion, 3. pregnancy complications, and of 4. maternal morbidity and mortality (Grade B). Aboubakr Elnashar
  3. 3.  Contraceptive options: 1. Combined hormonal contraception 2. Progesterone only contraception 3. Tubal occlusion 4. Vasectomy 5. Barrier contraception 6. Intrauterine device Aboubakr Elnashar
  4. 4.  History & examination: 1. Sexual history 2. Cardiovascular and cerebrovascular disease 3. Neoplasia (Good Practice Point). Aboubakr Elnashar
  5. 5. I. Combined hormonal contraception  can be used unless there are co-existing diseases or risk factors (Grade B). Aboubakr Elnashar
  6. 6.  Risks: 1. Cardiovascular and cerebrovascular disease: a. Although the relative risk of venous thromboembolism can increase up to five-fold, in absolute terms the risk is still very small (Grade B). b. A very small increase in the absolute risk of ischaemic stroke c. No increase in hemorrhagic stroke (Grade B). Aboubakr Elnashar
  7. 7. Can be given 1. Non-smokers at any age with no specific risk factors have no increased risk of myocardial infarction (MI) with COC use (Grade B). 2.Women aged ≥35 years with no other risk factors who have stopped smoking more than a year ago. {The excess risk of MI associated with smoking falls significantly 1 year after stopping and is gone 3–4 years later, regardless of the amount smoked}(Grade B).Aboubakr Elnashar
  8. 8. Contraindications 1. The risks of using combined hormonal contraception outweigh the benefits for smokers aged ≥35 years (Grade C). 2. Women aged over 40 years with cardiovascular disease, stroke or migraine (even without aura) (Grade C). Monophasic pill with ≤30 µg ethinylestradiol with a low dose of norethisterone or levonorgestrel as a suitable firstline option (Good Practice Point). Aboubakr Elnashar
  9. 9. 2. Breast cancer increase in risk is small Reduced to no excess risk 10 years after stopping Risk increases with age (Grade B). Aboubakr Elnashar
  10. 10. 3. Cervical cancer Increase the risk of cervical cancer and cervical intraepithelial neoplasia after 5 years’ use (Grade B). Aboubakr Elnashar
  11. 11.  Benefits 1. An increase in bone mineral density (Grade B). 2. 50% reduction in risk of ovarian and endometrial cancer which continues for 15 years after stopping (Grade B). 3. Reduction in the risk of colorectal cancer (Grade B). Aboubakr Elnashar
  12. 12. 4. Reduction in the incidence of benign breast disease (Grade B). 5. Reduction of menstrual bleeding and pain (Grade B). 6. Reduce hot flushes (Grade C). Aboubakr Elnashar
  13. 13. Risks 1. Cardiovascular and cerebrovascular disease No increase in risk of CVD (MI,VTE) or stroke (Grade B). Contraindicated: 1. Current VTE {risks of progestogen-only methods outweigh the benefits}. Women with previous VTE: the benefits of using progestogen-only methods outweigh the risks (Grade C). 2. History of ischaemic heart disease or stroke: {risks of initiating a progestogen-only injectable outweigh the benefits, however, the benefits of initiating POPs, implants or the LNG-IUS outweigh the risks} (Grade C). II. Progestogen-only contraception Aboubakr Elnashar
  14. 14. 2. Breast cancer: No significant increase in the risk of breast cancer with POPs and injectables. The use of implants and the LNG-IUS are unlikely to pose an increased risk (Grade C). Aboubakr Elnashar
  15. 15. 3. long-term use of progestogen-only injectable contraception is associated with a reduction in BMD but this returns to normal after cessation (Grade B). The relationship between bone densitometry and fracture risk in women aged over 40 years who are using injectable POC is unclear (Grade C). Aboubakr Elnashar
  16. 16. III. Tubal occlusion  Approaches: 1.Laparoscopy: previous abdominal surgery or obesity, laparotomy may be necessary (Grade B). 2. Hysteroscopic methods of tubal occlusion are still under evaluation (Grade C). Aboubakr Elnashar
  17. 17.  Failure rate: 1 in 200. Filshie clip: a failure rate after 10 years of 2 or 3 per 1000 procedures (Grade B). If tubal occlusion fails, the resulting pregnancy may be ectopic (Grade B). Aboubakr Elnashar
  18. 18.  Risks: 1. No increased risk of heavier or longer periods when performed after 30 years of age. 2. Subsequent increased hysterectomy rate, although there is no evidence that tubal occlusion leads to problems that require hysterectomy (Grade B) Aboubakr Elnashar
  19. 19. IV. Vasectomy  Failure rate: 1 in 2000 after clearance has been given (Grade B). Men should use effective contraception until azoospermia has been confirmed.  Although men requesting vasectomy should understand that the procedure is intended to be permanent, they should be given information on the success rates associated with reversal should this procedure be necessary (Grade B).Aboubakr Elnashar
  20. 20. Risks: 1. No increase in testicular cancer or heart disease. 2. Increased risk of prostate cancer, vasectomy is non- causative (Grade B). 3. Chronic testicular pain (Grade B). Aboubakr Elnashar
  21. 21. V. Barrier contraception  Women should be advised to use condoms with non-spermicidal lubricant where possible (Grade C). Aboubakr Elnashar
  22. 22. VI. Copper intrauterine contraception  Asymptomatic women aged ≥40 years who are having an IUD inserted and have been identified as being at higher risk for STI should have an endocervical swab for Chlamydia trachomatis as a minimum, together with an endocervical swab for Neisseria gonorrhoea depending on local prevalence.  There is no indication to test for other lower genital tract organisms (Grade C). Aboubakr Elnashar
  23. 23.  Menstrual abnormalities (including spotting, light bleeding, heavy or longer menstrual periods) are common in the first 3–6 months of IUD use.  Exclude infection and gynaecological pathology, if menstrual abnormalities occur after the first 6 months of use (Grade C). Aboubakr Elnashar
  24. 24. When can a woman over the age of 40 years be advised to stop contraception? 1. At the age of 55 years as most (95.9%) will be menopausal by this age (Grade C). 2. Measuring follicle-stimulating hormone on at least two occasions 1 or 2 months apart may predict ovarian failure (Grade C). Aboubakr Elnashar
  25. 25. I. Stopping non-hormonal contraception 1. After 1 year of amenorrhoea (or 2 years if the last menstrual period occurred for a woman aged <50 years) (Grade C). 2. IUD with >300 mm2 of copper inserted at age ≥40 years is retained until menopause (Grade C). Aboubakr Elnashar
  26. 26. II. Stopping hormonal contraception  Amenorrhoea is not a reliable indicator of ovarian failure (Good Practice Point).  Women using combined contraception should be advised to switch to another suitable contraceptive method at the age of 50 years (Good Practice Point).  FSH is not a reliable indicator of ovarian failure in women using combined hormones, even if measured during the hormone-free or oestrogen-free interval (Good Practice Point).Aboubakr Elnashar
  27. 27.  POP or implant can be continued until the age of 55 years when natural loss of fertility can be assumed.  Alternatively, the woman can continue with the POP or implant and have FSH levels checked on two occasions 1 or 2 months apart, and if both levels are >30 IU/l this is suggestive of ovarian failure.  In this case the woman may continue with the POP, implant or barrier contraception for another year (or 2 years if aged <50 years) Aboubakr Elnashar
  28. 28. III. Removing the LNG-IUS  Women who have the LNG-IUS inserted at age ≥45 years for contraception or for the management of menorrhagia can be counselled about retaining the device for up to 7 years (Good Practice Point). Aboubakr Elnashar
  29. 29. For women using HRT is contraception also required?  Women using combined HRT cannot be advised to rely on this as contraception (Grade B).  POP can be used with HRT to provide effective contraception (Good Practice Point).  Women using oestrogen replacement therapy may Aboubakr Elnashar
  30. 30. What follow-up is required for women over 40 years using contraception? Women aged over 40 years should be advised to return for follow-up if they develop any problems with contraception or develop any new medical history that may influence contraceptive choice or when they reach the age of 50 years (Grade C). Aboubakr Elnashar
  31. 31. Aboubakr Elnashar THANKS