Justify the need for contraception in a woman age over 40 years and
critically evaluate the methods available.
➢ Why contraception is important in women aged over 4o years
a. Fertility declined. 40-44 – 10-20%, 45-49 – 12%
b. No reliable method to predict loss of fertility or menopause with
declined fertility.
i. Serum FSH, estradiol levels misleading. Should not be based
not to use the contraceptive method.
c. Associated non communicable diseases – increase the pregnancy
complications.
d. Unsatisfactory sexual life associated with fear of pregnancy leading
to family dispute.
e. Pregnancy associated morbidity and mortality
f. Maternal mortality x 3 – Higher rates of PPH, placenta previa,
GDM, Gestational hypertension. IHD, placenta accreta, LSCS
i. Miscarriage >50% – in women >45 years, Unwanted
pregnancies can lead to illegal terminations and its implications.
g. Ectopic pregnancies x 3
h. Congenital abnormalities – Downs syndrome constituites half. >40
– 146. >45 – 1/28
i. Still birth risk, increased perinatal mortality, increased preterm delivery.
➢ HRT prescribed during the perimonpausal age does not cover.
Contraceptive cover given by only 40%.
➢ Continuing trend for women to have children in later life.
➢ Social taboos and family disputes associated with pregnancy in elderly
parents with already grown up children.
➢ Impact on the younger child to look after older parents. (Marks 4 x 10)
➢ All contraceptive methods can be used until menopause except COCP
and injectables.
➢ No method is contraindicated based on age alone upto 50 years.
➢ Choice of method depends on availability, fertility wishes, cormobidities,
side effects, patient preference, non contraceptive benefits and STI
screening history.
METHODS
- COCP
a. Not recommended after age 50.
b. Regular bleeding pattern, reduction in menstrual bleeding and hot
flushes.
c. Slightly increased risk of thrombosis, breast & cervical cancer.
d. Breast cancer family history does not preclude use.
e. ovarian and endometrial cancer.
f. VTE risk x 6.
g. Lowest risk: levonorgestrel, norethisterone and norgestimate.
h. Risk increases exponentially after age 50.
i. ≤30 mcg ethinylestradiol should be considered.
j. MI risk.
k. Smokers should stop at age 35. - POP
a. Effective alternative to COCP in women with comorbidities.
b. Very few contraindications.
c. Can be used in smokers after age 35.
d. Unlike COCP, does not improve menopausal hot flushes.
e. Disadvantages: Irregular bleeding, daily dosing needed.
3. Implants – Levonorgestrel & Etonogestrel
a. Most effective, reversible, very few contraindications.
b. Duration – 3-5 years.
c. Immediate return of fertility.
d. Can be used up to the menopause even with comorbidities
(VTE/MI).
e. No effect on bone mineral density.
f. 1 in 5 – Amenorrhoea
g. 1 in 5 – persistent/irregular bleeding needing removal within 1
year
4.DMPA
a. >50% amenorrheic after 1 year and nearly 70% after 2 years.
b. Dysmenorrhea, HMB and endometriosis.
c. Masks menopause.
d. Main concern: bone health.
e. ~5% lost bone within first 2 years.
f. 2-year bone loss is equivalent to that during pregnancy and
breastfeeding for 6 months.
g. Not reversible if side effects or health concerns arise.
h. Regular risk assessment is needed.
5. IUCD
a. Can cause HMB and pelvic cramps.
b. Does not mask menopause.
c. When inserted in women after age 40, can be used until
menopause (outside manufacturer’s license.)
d. Can be used with comorbidities.
e. Unsuitable for in a distorted uterine cavity.
f. Should not be left in situ indefinitely.
g. STI screening is advisable.
6. LNG IUS
a. Safe option for perimenopausal women, especially with HMB.
b. Endometrial protection with HRT. Change every 5 years.
c. Inserted after 45 yrs -> Can keep till age 55.
d. No clear evidence for a link between breast cancer and LNG IUS.
e. No risk of VTE, weight gain, stroke or ischaemic heart disease
f. Can cause irregular bleeding.
g. Reduced menstrual bleeding, dysmenorrhea and ovarian cancer.
h. Unsuitable in a distorted uterine cavity.
7.Condoms
a. Use alone or in combination with another method.
b. Prevent STI – useful even after menopause.
c. Suitable for older women because of reduced fertility.
d. Highly user dependent.
e. Older partners with erectile dysfunction.
f. Women with vaginal prolapse.
8.Natural methods
a. Less reliable during perimenopause.
b. Ovulation is more unpredictable.
c. Cycles become irregular.
d. Ovulation markers are less difficult to interpret.
e. Withdrawal method is not reliable and not recommended
9. Emergency contraception – offered when needed.
10.Sterilization
a. Women considering sterilization must be counselled on LARC methods, as they are as reliable as sterilization.
b. Close to natural sterility and menopause, non surgical method preferred.
6 x 10 – 60 marks
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