The European Society of Human Reproduction & Embryology (ESHRE) Capri Workshop Group has recently published a summary and recommendations on female contraception over the age of 40 years [1]. The number of women aged 40–49 years has increased by 58% in the last five decades in developed countries and by 32% in Europe. Although most women do not want to conceive after the age of 40, they find it takes longer to conceive after this age. The monthly conception rate declines from around 20% at age 25–30 to a significantly lower 8% at age 40. In addition, 33% of pregnancies started at age 45 do not end in a live birth [2]. Thus, the age-related decline in fecundity may severely limit the choices of women who are trying to conceive; however, this decline is insufficient to avoid the need for contraception among older women who do not wish to conceive, and family planning methods are therefore needed.
An increasing number of women remain childless by the age of 45. Throughout the developed countries, women who do have children are increasingly having their first child later in life. Delaying child-bearing inevitably means that some couples will have fewer children than they want and some will have none. A number of studies have investigated women’s fertility intentions; their main reasons for postponing child-bearing are the lack of a suitable partner and financial reasons. Other frequently quoted reasons include other distractions in life, work/training issues, own interest/desire for having children and their partner’s interest/desire for having children. Due to the delayed age of child-bearing, the proportion of live births to women aged 40 or more is increasing dramatically, but also the number of unwanted pregnancies is increasing in women in this age group. Although the risk of pregnancy is lower in this age group, the acceptability of pregnancy among most women over 40 is also lower; additionally, pregnancy at this age has many risks including miscarriage, chromosomal abnormalities at birth, maternal complications in pregnancy, maternal mortality and neonatal complications [3,4].
As a result of this delaying child-bearing, the increased number of women aged 40–49 years, and fewer of these women wanting children, the demand for contraception in this age group has certainly increased. In most countries, among couples where the woman is aged 40–45 years, by far the most frequently used method of family planning is sterilization, both in women (7% in Italy, 53% in Canada) and men (over 20% in The Netherlands, UK, USA and New Zealand). Male or female sterilization is an excellent contraceptive option since these methods have the lowest failure rates. Other common methods include oral contraceptives (up to 28% in France), the intrauterine device (up to 30% in France), the condom (up to 20% in Greece and Spain), or natural methods. Overall, between 66 and 90% of women aged 40–44 years use some method of family planning.
The contraceptive method for a woman in her forties should be individually tailored for an appropriate balance of effectiveness and the non-contraceptive benefits and risks. Special considerations include the frequency of menstrual irregularity, sexual problems and the possibility of menopausal symptoms, all of which may respond to hormonal methods of contraception [5]. The presence of hot flushes in women who have entered the perimenopause may suggest oral contraception for its beneficial impact; infrequent sexual intercourse may indicate a barrier method such as the condom, with its freedom from systemic side-effects and protection from sexually transmitted infections. Diaphragms with spermicide are more effective than natural methods and may be acceptable options in older couples when fertility is declining; however, barrier methods do not counteract climacteric symptoms.
Hormonal contraception can be continued until the menopause in low-risk, non-smoking women, since recent studies have indicated its safety beyond the age of 40 years. Those women who have contraindications for estrogen use or personal reasons for avoiding combined hormonal methods can use barrier methods, progestogen-only contraceptives, including pills, copper or levonorgestrel intrauterine systems, depot injectables and implants. The World Health Organization Medical Eligibility Criteria for Contraceptive Use provide evidence-based recommendations to select the most appropriate method of contraception in women with potential medical barriers.
One important issue is when to advise discontinuation of contraception in perimenopausal women. In a woman on hormonal contraceptives, the non-contraceptive benefits should be taken into account as well as her interest in hormone replacement therapy. In non-hormonal contraception, discontinuation may be considered after 2 years of amenorrhea in women below 50, and after 1 year in women over 50 years of age. Ovarian exhaustion is likely if the concentration of follicle stimulating hormone is 30 IU/l on two occasions, 6–8 weeks apart. After the age of 55, natural sterility can be presumed.
In summary, the decline in fertility with age does not protect against unwanted pregnancy; thus effective contraception is needed to avoid unintended and unwanted pregnancies. Perimenopausal women may consider all contraceptive methods, as no method is contraindicated by advanced reproductive age alone. Therefore, there is a need to discuss the effectiveness, risks and non-contraceptive benefits of all contraceptive methods for women in this age group. Women should be advised to continue with a contraceptive method until they have reached the menopause.
Author(s)
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Camil Castelo-Branco
Ob Gyn Senior Consultant, Hospital Clínic Barcelona, and Full Professor, University of Barcelona, Spain
Citations
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ESHRE Capri Workshop Group. Female contraception over 40. Hum Reprod Update 2009 [Epub ahead of print May 20].
http://www.ncbi.nlm.nih.gov/pubmed/19458038 -
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http://www.ncbi.nlm.nih.gov/pubmed/15525717 -
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http://www.ncbi.nlm.nih.gov/pubmed/15458893 -
Blümel JE, Castelo-Branco C, Binfa L, Aparicio R, Mamani L. A scheme of combined oral contraceptives for women more than 4 years old. Menopause 2001;8:2869.
http://www.ncbi.nlm.nih.gov/pubmed/11449087
