In the second in this three-part series, Dr Toni Hazell discusses some of the issues to consider when prescribing contraception for a woman aged over 40
Why do we need to think differently for this cohort?
In women over the age of 40, there are a few extra things to consider when prescribing contraception. Age itself is a risk factor, and co-morbidities (which can affect our contraception risk assessment) become more common with age; these might include obesity, cardiovascular disease and its risk factors, and cancers of the breast or endometrium.
Some women will enter the perimenopause in their 40s and need advice on how to combine contraception and HRT; unplanned pregnancies are not uncommon in this age group and so it’s important that we are clear that the start of the perimenopause doesn’t coincide with the end of fertility.
When can women safely stop using contraception?
For those having natural cycles it’s straightforward – contraception is needed for two years after the last menstrual period (LMP), if that occurs before the age of 50, or one year if the LMP is over 50.1
Things are more complicated for those using contraception that causes amenorrhoea, such as the implant or progestogen-only pill (POP); combined hormonal contraception (CHC) taken continuously can also cause amenorrhoea as well as masking menopausal symptoms. Those who are amenorrhoeic due to their contraception clearly can’t know when their natural LMP would be.
This group has two options. They can either continue contraception until 55, at which point spontaneous contraception would be extremely unusual, and the Faculty of Sexual and Reproductive Healthcare (FSRH) says that contraception can stop. Alternatively, they can do a one-off FSH at ≥50. If this is in the menopausal range, the date of the blood test can essentially be considered to be the date of the LMP, and contraception stopped one year later. FSH can be done while using any method of contraception other than CHC; those on CHC who want to know their FSH for this purpose need to come off the method for six weeks before testing, or the FSH will be artificially suppressed.
A levonorgestrel intrauterine device (LNG-IUD) used as part of HRT has the benefit of also providing contraception; it’s a good way to easily move between the reproductive and menopausal years.
What’s the deal with levonorgestrel intrauterine devices for contraception and as part of HRT? It feels like it has all changed recently
There are five LNG-IUDs available in the UK – brand names Mirena, Levosert, Benilexa (all 52mg), Jaydess (13.5mg) and Kyleena (19.5mg).2-4 Jaydess and Kyleena cannot be used as part of HRT and so are less useful in this age group.
The three 52mg LNG-IUDs all have different licences but the FSRH’s 2024 update of their intrauterine contraception guidance made life a lot easier by treating them all the same. Table 1 below summarises the licence and real-life use of each of these devices.
For women using a 52mg LNG-IUD for both contraception and HRT, it must be changed at five years rather than eight and it’s important to document that this information has been given. A sensible precaution is also to record the date when the 52mg LNG-IUD is due to be changed in the dosage instructions for the oestrogen prescription, which might say something like: ‘Use 2 measures of gel daily. This should only be used with a progestogen, currently provided by a Mirena which is due for change in May 2029.’
52mg LNG-IUD brand Licensed indication Real-life use as per FSRH guidance5 Mirena2 Contraception (8 years). Progestogenic component of HRT (4 years). Idiopathic menorrhagia (8 years). Contraception – 8 years (or until menopause if inserted ≥45). Progestogenic component of HRT – 5 years. Levosert3 Contraception (8 years). Treatment of heavy menstrual bleeding (3 years). Benilexa4
Table 1. Licensed and FSRH recommended use of 5mg LNG-IUD products
I have a woman in her mid-40s who really wants to stay on the combined pill – can she do so safely? What other methods might I suggest?
Those who prescribe contraception should all be familiar with the FSRH UK Medical Eligibility Criteria (UKMEC),6 which is due to be updated later in 2025. This puts every method into a category 1-4 for any given co-morbidity, as per Table 2 below.
| UKMEC | Definition of category |
| Category 1 | A condition for which there is no restriction for use of the method |
| Category 2 | A condition where the advantages of using the method generally outweigh the theoretical or proven risks |
| Category 3 | A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable |
| Category 4 | A condition which represents an unacceptable health risk if the method is used |
Table 2. Definition of UKMEC categories.6
Medicine is an art not a science, and this is well illustrated when considering women who have more than one relative contraindication in the UKMEC 2 category. In this instance, two plus two doesn’t necessarily equal four, and the UKMEC advises us to use our clinical judgment; more caution is advisable if there are multiple UKMEC 2s, all of which relate to the same risk.
For CHC, age over 40 is a UKMEC 2; other UKMEC 2s include a BMI of 30-34, being an ex-smoker who stopped more than one year ago, having raised lipids, a history of hypertension during pregnancy, or a first-degree relative who had a venous thromboembolism at ≥45 years. A shared decision-making process should be used, considering the benefits and risks of the method.
The UKMEC only considers contraceptive use and the introduction to the document reminds us that the risk:benefit balance might change if the method has a dual use – for example, if it is also being used to control endometriosis. CHC use should stop for all women at age 50, as should use of the injectable depot progestogen; other progestogen-only methods can continue past 50. A woman stopping her CHC because she has reached 50 could move to the POP or implant (which could be continued until no longer needed) or could use the depot if she is stopping POP before 50 due to other contraindications.
Another concern with CHC among women generally is that it may increase their risk of cancer; however its use is at worst neutral for cancer risk, and in some cases the overall effect on cancer risk is beneficial. For example, CHC use for >10 years reduces the risk of ovarian cancer by 50%, a protection that persists for at least 30 years after stopping. In contrast, the relative risk of breast cancer is 1.19 in CHC users (increasing over time from 1.09 with less than one year of use to 1.38 with more than 10 years of use) compared with non-users of CHC, and any extra risk has gone by 10 years after stopping the pill.7 The increased risk of cervical cancer is also very small and does not persist for many years after stopping.
For women with a concerning family history of cancer, a known gene mutation that increases risk (such as BRCA 1 or 2) is a UKMEC 3 for CHC, but only 2 for POP. A family history with no known gene is UKMEC 1 for both methods.
