Check contraceptive options for women 40+
Your next patient is a healthy, fit 45-year-old nonsmoking woman. She says her menstrual periods are now less regular, and she reports having intermittent hot flashes. Newly divorced, she is now sexually active and wonders which contraceptive is right for her. What's your recommendation?
For healthy, lean women of older reproductive age who are nonsmokers, clinicians can consider use of combination hormonal contraception, such as low-dose oral contraceptives (OCs), says Andrew Kaunitz, MD, professor and associate chair in the obstetrics and gynecology department at the University of Florida College of Medicine — Jacksonville. Benefits include effective contraception, as well as reductions in irregular bleeding and vasomotor symptoms associated with the perimenopausal transition. Kaunitz reviews use of hormonal contraception in women of older reproductive age in a just-published report.1
There are a lot of reasons that more women in the 40-plus age group are using OCs, says Mary Jane Minkin, MD, clinical professor in the Department of Obstetrics and Gynecology at the Yale University School of Medicine in New Haven, CT. "Much of it has to do with the fact that health care providers are much more on board as to the benefits of OCs and discuss these with women, and I think women are more receptive," she says.
Contraception is as important for older women as their younger counterparts, notes Kaunitz. While women in their later reproductive years have slightly higher risks from use of hormonal contraception, older women also are more likely to have adverse consequences when they do conceive. In the United States, pregnancy-related mortality ratios (deaths per 100,000 live births) among women ages 40 and older are five times those of women between ages 25-29.2 The risk for coexisting conditions during pregnancy, such as diabetes and hypertension, also increase with maternal age, he states.
Safety issues must be reviewed in considering combination hormonal contraception in older women. Older age and obesity are independent risk factors for venous thromboembolism (VTE) among women using combination OCs, notes Kaunitz.
VTE risk is higher
The risk for VTE jumps in women older than age 39 who use combination birth control. There is an estimated incidence of more than 100 cases per 100,000 person-years among women who are older than age 39, compared with 25 cases per 100,000 person-years among adolescents.3 The risk almost doubles among obese women in comparison to nonobese women who receive oral contraceptives.4
There is a trend against using estrogen-containing methods of birth control in women who are older than 35 and have body mass indexes greater than 30, notes Anita Nelson, MD, professor in the obstetrics and gynecology department at the University of California in Los Angeles (UCLA) and medical director of the women's health care programs at Harbor-UCLA Medical Center in Torrance. The benefits of using such methods, including pregnancy prevention, must be balanced against the cardiovascular risk factors of obesity and age, particularly as they relate to the risk of venous thromboembolism, she notes.
Implanon implants (Organon USA; Roseland, NJ), progestin-only pills, and Depo-Provera injections (DMPA, Depo-Provera; Pfizer, New York City, and Medroxyprogesterone Acetate Injection, Teva Pharmaceuticals USA; North Wales, PA) are three other progestin-only options for women who are not good candidates for combined pills, says Robert Hatcher, MD, MPH, professor of obstetrics and gynecology at Emory University in Atlanta.
Here are some options
In terms of contraceptive options for older obese women, take a look at the levonorgestrel-releasing intrauterine system (Mirena IUS, Bayer HealthCare Pharmaceuticals; Wayne, NJ). Because obese women have an elevated risk of dysfunctional uterine bleeding and endometrial neoplasia, the IUS may be a beneficial choice for these women.5
Low-dose oral contraceptives offer many benefits for older women, says Minkin, who presented on the subject at the recent Contraceptive Technology conference in Boston.6 One benefit is control of menorrhagia, she notes.
The days where physicians saw hysterectomy as a leading option for menorrhagia in this age group are waning, observes Minkin. More providers will try methods such as OCs, or the levonorgestrel-releasing intrauterine system, to control bleeding, she states.
Another potential use of oral contraceptives in older reproductive-age women is for relief of premenstrual dysphoric disorder (PMDD), notes Minkin. It is estimated 3%-8% of women suffer from PMDD.7 The advent of Yaz (3 mg drospire-none/20 mcg ethinyl estradiol, Bayer HealthCare Pharmaceuticals) and its PMDD indication gives clinicians a non-SSRI (selective serotonin reuptake inhibitor) option for women, says Minkin.
Consider use of low-dose pills, particularly some extended-cycle pills, if older women are seeking relief from perimenopausal symptoms, suggests Minkin. Such pills can be used very effectively, particularly for hot flashes, sleep issues, and headaches, she notes.
Extended cycles may mean 84 days on and seven days off of hormones, or it might mean taking a monophasic pill continuously, says Hatcher.
When should clinicians consider discontinuing use of oral contraceptives in women of older reproductive age? While there is no standard for discontinuation, Kaunitz suggests the following strategy: For lean, healthy women who are nonsmokers and who are doing well using combination pills, discontinue use of pills in their early to mid-50s, when the likelihood of ovulation is low. Barrier contraception until age 55 is prudent for menstruating women who discontinue pill use closer to age 50, he notes. Remember to counsel all women, regardless of other contraceptive use, that consistent use of condoms is encouraged for all women at risk for sexually transmitted infections.
References
- Kaunitz AM. Clinical practice. Hormonal contraception in women of older reproductive age. N Engl J Med 2008; 358:1,262-1,270.
- Callaghan WM, Berg CJ. Pregnancy-related mortality among women aged 35 years and older, United States, 1991-1997. Obstet Gynecol 2003; 102:1,015-1,021.
- Nightingale AL, Lawrenson RA, Simpson EL, et al. The effects of age, body mass index, smoking and general health on the risk of venous thromboembolism in users of combined oral contraceptives. Eur J Contracept Reprod Health Care 2000; 5:265-274.
- Sidney S, Petitti DB, Soff GA, et al. Venous thromboembolic disease in users of low-estrogen combined estrogen-progestin oral contraceptives. Contraception 2004; 70:3-10.
- Armstrong C. ACOG releases guidelines on hormonal contraceptives in women with coexisting medical conditions. Am Fam Physician 2007. Accessed at www.aafp.org/afp.
- Minkin MJ. Contraceptive options for women over 40: Case studies. Presented at the Contraceptive Technology conference. Boston; March 2008.
- Halbreich U, Borenstein J, Pearlstein T, et al. The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology 2003; 28 (Suppl 3):1-23.
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