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At the heart of general practice since 1960

Study backs referral to alcohol centres

The number of women over 40 conceiving has increased by

50 per cent in the last 10 years, according to the Office for National Statistics ­ Dr Susan Brechin of the Faculty of Family Planning and Reproductive Health Care's Clinical Effectiveness Unit (CEU) gives the latest advice on hormonal and

non-hormonal contraception options for this group and dispels some myths surrounding the risks

Test yourself

Could you reliably provide advice for the following scenarios?

1A 42-year-old woman with a recent thrombotic stroke, requiring long-term contraception.

2A 46-year-old local licensee, a smoker of more than 15 cigarettes per day, with a family history of osteoporosis. She has used Depo-Provera for 15 years and is reluctant to make any changes to either her lifestyle or her contraception method.

3A 46-year-old woman, distraught to find herself pregnant, as she had not had any periods for six months.

The average age of the onset of perimenopause (the transition from normal ovulatory cycles to cessation of ovulation) is 46 years. During this time intermittent ovulation and anovulation occur and therefore contraception is required for sexually active women to prevent unintended pregnancy.

It is only when the postmenopause is confirmed (after one year of amenorrhoea) that contraception can be stopped (two years' amenorrhoea if under 50). The CEU advises that no contraceptive method is contraindicated by age alone (grade C).

Combined hormonal contraception

Women over 40 can be advised that combined hormonal contraception can be used unless there are co-existing diseases or risk factors (grade B).

Most evidence relates to combined oral contraception (COC) but risks associated with patch use are likely to be similar.

Risks associated with combined hormonal contraception

Cardiovascular and cerebrovascular disease

Non-smokers at any age with no specific risk factors can be advised that they have no increased risk of myocardial infarction (MI) with COC use (grade B).

The risks of using combined hormonal contraception outweigh the benefits for smokers aged 35 and over (grade C).

Women 35 and over with no other risk factors who have stopped smoking for more than a year may consider using combined hormonal contraception. The excess risk of MI associated with smoking falls significantly one year after stopping and is gone three to four years later, regardless of the amount smoked (grade B).

Although the relative risk of venous thromboembolism with COC use can increase up to five-fold, in absolute terms the risk is still very small (grade B).

There is a very small increase in the absolute risk of ischaemic stroke but no increase in haemorrhagic stroke with COC use (grade B).

Women over 40 with cardiovascular disease, stroke or migraine (even without aura) should be advised against the use of combined hormonal contraception (grade C).

Clinicians prescribing the COC to women over 40 should consider a monophasic pill with no more than 30µg ethinylestradiol with a low dose of norethisterone or levonorgestrel as a first-line option (Good Practice Point).

Breast cancer

Women over 45 have a background risk of developing breast cancer of one in 100. Women should be informed that any increase in risk of breast cancer associated with COC use is likely to be small, is reduced to no excess risk 10 years after stopping, but is in addition to their own background risk which increases with age

(grade B).

Cervical cancer

COC use appears to increase the risk of cervical cancer and cervical intraepithelial neoplasia (CIN) after five years' use. A small, increased risk is also seen with increasing duration of use for women who were HPV negative and may disappear after stopping oral contraception.

Non-contraceptive benefits associated with combined hormonal contraception

Bone health

COC use over the age of 40 may be associated with an increase in bone mineral density (BMD) (grade B). However, it does not appear to reduce overall risk of fractures before the menopause, but may reduce the risk of hip fracture postmenopause.

Ovarian and endometrial cancers

There is at least a 50 per cent reduction in the risk of ovarian and endometrial cancer with COC use which continues for 15 years after stopping (grade B).

Colorectal cancer

There is a reduction in the risk of colorectal cancer with COC use (grade B).

Vasomotor symptoms

The COC may reduce hot flushes (grade C).

Other benign conditions

There may be a reduction in the incidence of benign breast disease with COC use. Case-control and cohort studies suggest a reduction in the incidence of functional ovarian cysts and benign ovarian tumours. Small randomised trials have shown significant reductions in acne lesions with COCs. A Cochrane Review found no causal association between COC and additional weight gain. There is some evidence that the COC can be used to manage menorrhagia and dysmenorrhoea.

Potential risks associated with progestogen-only contraception (POC)

Cardiovascular and cerebrovascular disease

Although data is limited there is no apparent increase in risk of cardiovascular disease or stroke with POC (grade B).

Breast cancer

The limited evidence currently available does not suggest a 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).

Bone health

Long-term use of progestogen-only injectable contraception is associated with a reduction in bone mineral density but this returns to normal after cessation (grade B).

The relationship between bone densitometry and fracture risk in women over 40 who are using an injectable POC is unclear (grade C).

Bleeding patterns

Abnormal bleeding patterns are a common reason for discontinuing POC. Some progestogen-only methods, however, may be useful in the management of menorrhagia which is common in this age group.

Amenorrhoea can be expected in up to 60 per cent of women using the progestogen-only injectable depot medroxyprogesterone acetate after 12 months' use. Large epidemiological studies have shown amenorrhoea can be expected in up to 25 per cent of women six months after insertion of the LNG-IUS and continuation rates are high in women aged 39-48. Clinicians should carefully consider when to investigate abnormal bleeding in women over 40.

Non-contraceptive benefits of POC

Endometrial and ovarian cancers

Progestogen-only methods may reduce the risk of endometrial and ovarian cancers but evidence is limited.

Sterilisation

Tubal occlusion

The Royal College of Obstetricians and Gynaecologists recently published guidance on male and female sterilisation. Women should be counselled about the lifetime risk of failure of tubal occlusion, estimated to be one in 200 with a longer-term failure rate after 10 years of two or three per 1,000 procedures.

In addition women should be counselled on the potential irreversibility of the procedure, the small risk of ectopic pregnancy if the procedure fails and the less than one in 1,000 risk from undergoing laparotomy. Reassuringly, tubal occlusion is not associated with an increased risk of heavier or longer periods when performed after age 30.

Vasectomy

Men should be informed that vasectomy has a failure rate of approximately one in 2,000 after clearance has been given and a longer-term failure rate of one in 5,000. They should be told the procedure is intended to be permanent but given information on the success rates of reversal should this procedure be necessary. An effective contraceptive method should continue to be used until azoospermia has been confirmed. Reassuringly there is no increase in testicular cancer, prostate cancer or heart disease associated with vasectomy. Men should be informed about the possibility of chronic testicular pain after vasectomy.

Barrier contraception

Women over 40 commonly rely on male condoms (29 per cent), while female condoms and spermicides alone are unpopular (1 per cent). Diaphragms and cervical caps are used by 3 per cent. In a recent publication, the WHO recommends condoms without nonoxynol-9 spermicidal lubricant for prevention of pregnancy or STI.

This is due to risks associated with mucosal irritation with frequent nonoxynol-9 use. Where possible women and men should be advised to use non-spermicidally lubricated condoms, but spermicide is still recommended with diaphragms or caps. All couples relying on barrier contraception should be counselled on emergency contraception.

Natural family planning methods

Fertility awareness-based methods can be used by women over 40 but should be taught by a fertility awareness teacher. Learning to use this during the perimenopause can be more difficult.

IUCD

Intrauterine methods are an effective long-term option for women.

An IUCD with no more than 300mm2 copper inserted at or after age 40 can continue to be used until one year after the menopause.

Asymptomatic women of 40 and over who are having an IUCD inserted and have been identified as being at higher risk for STI (more than two sexual partners in the last year) should have an endocervical swab for Chlamydia trachomatis as a minimum, and for Neisseria gonorrhoea depending on local prevalence. There is no indication to test for other lower genital tract organisms (grade C).

Menstrual abnormalities are common in the first three to six months of IUCD use. Exclude infection and gynaecological pathology if abnormalities occur after this period (grade C).

What follow-up is required for women over 40?

Women over 40 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 (grade C).

Grades of evidence

The faculty's guidance is based on appraised evidence wherever possible ­ evidence tables are available on www.ffprhc.org.uk

Grades of recommendation

A Evidence based on randomised controlled trials

B Evidence based on other robust experimental or observational studies

C Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities

Good Practice Point ­ where no evidence exists but where best practice is based on the clinical expertise of the expert group

Susan Brechin is unit

co-ordinator for the Faculty of Family Planning and Reproductive Health Care Clinical effectiveness unit and a senior clinical lecturer

at the University of Abderdeen

When patients can stop using contraception

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