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Emergency contraception and contraception for the older woman

In the last article in this series, Professor John Guillebaud explains the guidelines for emergency contraception, and outlines the contraceptive choices for mature women

In the last article in this series, Professor John Guillebaud explains the guidelines for emergency contraception, and outlines the contraceptive choices for mature women

Currently, the best oral method uses levonorgestrel alone. Every 12 hours' delay increases the failure rate by 50 per cent. WHO studies support giving the whole 1500µg (now a single tablet) in one dose.

When to treat?

First, always establish the earliest possible exposure, which is not necessarily the one the patient is worried about. WHO's 2002 protocol allowed use up to five days, and there were eight failures among 314 women (2.5 per cent) treated with 1500µg levonorgestrel between 72 and 120 hours after a single coital exposure. WHO concluded this is 'prevention of a high proportion of pregnancies even up to five days after coitus'.

However, other data suggests the prime mechanism that hormonal emergency contraception uses is to stop or delay ovulation, and it rarely (if ever) operates by implantation-block after fertilisation.

Therefore, if the risk has probably been taken during the approximate five days between ovulation and implantation, it is usually unwise to treat (as above) more than 72 hours after intercourse.

With that caveat, use of Levonelle up to five days after exposure is acceptable as an unlicensed use of a licensed product, but on a named-patient basis only. For medicolegal safety, there should be a record that the woman understood this lack of licensing and gave informed verbal consent, ideally backed by a written handout to explain the difference(s) from the patient information leaflet of Levonelle. It should also be recorded that she understood that a copper intrauterine contraceptive device (IUCD), which is capable of blocking implantation, would definitely be a more effective method of emergency contraception, especially in these particular circumstances, with a failure rate about 0.1 per cent.

Copper IUCDs are usable in good faith for emergency contraception up to five days after the calculated day of ovulation, regardless of the number of acts of intercourse up to that time.

Aside from current pregnancy, the only absolute contraindications (WHO 4) to hormonal levonorgestrel-only emergency contraception are:

• known severe allergy (moderate/dubious allergy would be WHO 3) to a constituent

• known acute porphyria with previous attack(s).

Caution (WHO 3) also applies if:

• any enzyme-inducer is in use (including St John's wort), indicating a 3000µg (two-tablet) dose

• used in women on warfarin; enhanced anti-coagulation has been reported, so check the INR post-treatment.

Contraception for older women

Given that follicle-stimulating hormone (FSH) levels are unreliable for diagnosis of complete loss of ovarian function, (reversible) contraception may cease:

Method one

• After the age of 50, and after waiting for the officially approved one year of amenorrhoea after stopping all hormones.

• This is the obvious plan for:

– copper IUCDs

– condoms

– sponge or spermicides (which appear to be adequate in the presence by this age of drastically reduced if not absent fertility).

But what should be done if the woman is using one of the other hormonal methods or HRT, which mask the menopause?

• If on depot medroxyprogesterone acetate (DMPA) or a combined oral contraceptive (COC) or Evra patch – age 50 is the time to stop. These are needlessly strong, contraceptively, and their known risks increase with age (see below).

• If using the progestogen-only pill (POP), or an implant, or the levonorgestrel intrauterine system (LNG-IUS), or a sponge/spermicide with ongoing HRT – these contraceptives will add no known medical risks that increase with age – even to age 60!

Method two

For the POP, or an implant, or the LNG-IUS, or a sponge/spermicide with ongoing HRT:

• It would be acceptable (risk-wise) simply to continue any of these four till the latest age of potential fertility has been reached, and then the woman can just stop the contraception (no tests needed).

When is the latest age of potential fertility?

• A good guess is 55. The Faculty of Family Planning and Reproductive Health Care in their guidance quotes Treloar's evidence that 95.9 per cent have ceased menstruation forever by then and the likelihood of a later fertile ovulation in the remainder is vanishingly small.

• The Guinness Book of Records reports one or two older mothers (into their early 60s) but authentication is uncertain.

All women must report back if a period happens. The very anxious may continue using a sponge or spermicide for a final year.Another option for older women using the COC, contraceptive patch or DMPA is as follows.

Method three

If women have passed their 50th birthday, and after a trial of discontinuation using barriers or spermicides they have:

• vasomotor symptoms (can usefully also ask COC users if they used to get flushes at the end of their pill-free interval)

• two separate high FSH levels, say a week apart

• continuing amenorrhoea thereafter.

If all these apply, then women over 50 can cease all contraception earlier than the approved one year, with due warnings of lack of certainty. Alternatively they could switch to using one of the methods that is suitable for method two (carrying on until the age of 55).

John Guillebaud is emeritus professor of family planning and reproductive health, University College London

Competing interests Professor Guillebaud has received research grants from pharmaceutical companies interested in contraception, and payments for lecturing and providing consultancy advice

This article is based on a presentation on Top tips on reproductive health given by Professor Guillebaud at the Pulse seminar on clinical challenges on 26 November 2006 at the Royal College of Physicians, London.

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Key points key points

• Hormonal emergency contraception prevents fertilisation primarily by stopping or delaying ovulation. It rarely, if ever, operates by implantation block after fertilisation
• Copper IUCDs – which do also block implantation – are usable in good faith for emergency contraception up to five days after the calculated day of ovulation, regardless of the intercourse history
• Given that FSH measurements are very unreliable for the diagnosis of complete loss of fertility, there are three main methods for managing perimenopausal contraception
• In all contraception consultations, ignorance, especially about conditions not yet categorised on WHO's 1 to 4 scale by UKMEC should be admitted, during what should be 'a consultation between two experts' on equal terms with the user, or couple (download the PDF from tinyurl.com/2vulgk )

HRT and LNG-IUS

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