Contraception in later life

Shelly Mehigan outlines special considerations when choosing a contraceptive method for women over 40 years

The high rate of unwanted pregnancies in teenagers is, quite rightly, receiving a great deal of attention from the government and health authorities at the moment. But a rising number of requests for terminations from women in their 40s has been largely ignored. It is important that the contraceptive needs of these women are assessed and met as effectively as those of teenagers.

Recent data show that termination rates during 1997 were similar in women aged 40 years and over (37.2 per cent) as in those under the age of 20 (37.3 per cent)¹. Of the total of 14800 conceptions recorded in women over 40 in 1997, over 5500 legal abortions were conducted¹. The increase in terminations reflects the increasing conception rate in this age group. During the 1990s, conception rates for older women have risen, while rates for women under 30 have generally fallen¹.

There are many possible reasons for the increase in conceptions and abortions in women over the age of 40. Many women are leaving it later to have children, until they have established a career. Some women may take more risks with contraception as they get older because they feel, incorrectly, that they have less chance of conceiving as they approach the menopause. Some may be finding new partners and starting a new sexual relationship, meaning that they may have to start using contraception again after a break. But whatever the reasons, the high rate of terminations indicates that many women over 40 are not using appropriate contraception effectively.

Priorities

Contraceptive needs change as women become older, with efficacy, good tolerability and ease of use often becoming even greater priorities. Older women tend to have completed their families, so require particularly reliable methods of contraception, making methods such as the condom or the diaphragm less attractive than may have been the case for the previous generation.

Research has indicated that women in their thirties are generally happier with oral contraception than other methods². Older women may be less keen on using this method of contraceptionÑthe demands of juggling a home, children and a job may mean that a woman no longer wants to have to remember to take a pill every day. Older women may also be particularly concerned about the risk of possible side-effects, although these tend to be minimal and there are some benefits from the combined pill, such as protection against cancer of the ovary and womb.

It is very important to explain the range of contraceptive options available to each woman and to explore what she wants from contraception. A woman is much more likely to use a form of contraception that suits her and that she is happy using. Do not assume that women will know about more recently developed methods; these are not always communicated positively to the general public, which means that women may not be fully informed about the full range of possible choices.

Contraceptive choices

There is a good range of contraceptive methods suitable for older women, including the combined oral contraceptive pill, the progestogen-only pill (see Family Medicine 1999; 3; 6: 15-17), condoms, sterilisation, injections, implants, intrauterine devices (IUDs) and the intrauterine system (IUS).

.Sterilisation is a popular choice with older women, because of the efficacy and convenience it offers. More than one in ten (12 per cent) women aged 16-49 years old taking part in the 1995 General Household Survey reported that they or their partner had been sterilised. It is the form of contraception chosen by nearly half of couples over the age of 40³. However, it requires careful thought by both partners, because it is a permanent step that is extremely difficult to reverse. Male or female sterilisation should only be considered when a couple is absolutely certain they do not wish to have a baby. Unfortunately, around one in twenty (five per cent) people sterilised later seeks a reversal². Female sterilisation is associated with a small increased risk of ectopic pregnancy and a slightly higher risk of failure (1 in 200 lifetime failure rate) than previously thought⁴.
. IUDs offer very effective long-term contraception. They can last for five to ten years, depending on which device is chosen. The advantages of this method are that it is effective, easy to use (no pills to remember every day or condom to grapple with!) and does not cause the hormone-related side-effects that some women experience on oral contraceptives. The disadvantages of this method are that some women have increased bleeding and some suffer more painful periods. IUDs are not an ideal method in new or changing relationships because of the increased risk of sexually transmitted infections.
. IUS (Mirena) provides another choice that is particularly suitable for older women who are seeking an effective, long-term, reversible form of contraception. The IUS consists of a small plastic T-shaped frame containing a tiny cylinder which slowly releases the hormone levonorgestrel. It is effective for up to five years⁵ and is as reliable as female sterilisation⁶, but with the reassurance of a full return to fertility on removal. Pregnancy rates with the IUS are significantly lower than with conventional IUDs, such as the Nova-T, which has one- and five-year rates of 1 per cent and 5.9 per cent respectively (compared to 1-0.2 per cent and 0.5-1.1 per cent for the IUS)⁷.

Compared with IUDs, its use generally results in less bleeding and therefore less painful periods. Overall, women are likely to have fewer days bleeding in each month and may eventually have no periods at all. The IUS is also associated with a lower incidence of ascending pelvic inflammatory disease, even in high-risk groups⁸. Its local action should minimise the risk of systemic effects.
. Injectable contraception offers another useful option in women who have completed their families. It provides a convenient and reliable methodÑalthough fertility can take up to one year or more to return to normal after stopping injections, so women must be warned about this prior to having an injection. Depo-Provera (medroxyprogesterone acetate) and Noristerat (norethisterone oenanthate) are given by deep intramuscular injection during the first three days of the cycle. They should then be repeated at twelve and eight week intervals respectively. Side-effects include irregular, absent, prolonged or heavy vaginal bleeding during the first few cycles; delayed return to fertility on discontinuing treatment and other hormone-related side-effects.
. Implants have been useful in some older women and although Norplant is no longer available in the UK, a new version, Implanon, is now available. It remains to be seen how popular this method will be with older women with a similar profile but as yet there are no recorded pregnancies.
. Barrier methods. Contraceptives designed to be used at the time of intercourse tend to be less popular with older women than with younger ones. Older women tend to be in stable relationships, so generally prefer ongoing contraceptive cover. They are also less concerned about protection against sexually transmitted infections provided by barrier methods, because they are often less aware of the risks. The diaphragm was one of the main forms of contraception used by older women 10 to 15 years ago but has become much less popularÑprobably because of the more effective and less intrusive methods now available.
.The combined pill. The combined pill was traditionally considered unsuitable for older women, with many having to stop taking it at the age of 35 in the past. This has now changed, as research has shown that, providing there are no contraindications, the combined pill can be used by women up to the age of 50 years, providing additional health benefits and very low risk. Women who have been happy on the pill for some time may be keen to continue, however, some are less content to remain on it for a long time as they get older. It is important to reassure them about the risks and explain the possible health benefits, but then offer alternatives if this is appropriate.
. The progestogen-only pill has long been considered suitable for older women, along with breast-feeding women. Women often move from a combined to a progestogen-only method when they reach 35 and/or if they are smokers and have risk factors such as raised blood pressure, obesity, migraine or a family history of heart disease. The reduced efficacy of the progestogen-only pill compared with the combined method tends to be compensated for by the decreasing fertility that accompanies the ageing process, which makes it a very effective method for this group of women. Drawbacks tend to be the need to take the pill at the same time every day and irregular bleedingÑwhich can be as much of a nuisance for this age group as for younger women.

Contraceptive services

GPs and nurses specialising in family planning are in an ideal position to counsel older womenÑas well as younger onesÑabout their contraceptive choices. It is important that we ensure that the needs of older women are not overshadowed by the current emphasis on services for young people, that we inform them of all available choices and that we do our best to provide them. There should be a strong emphasis on providing adequate counselling before providing any form of contraception. Women are more likely to stick with a method if they know what to expect, particularly in terms of possible side-effects. It is important to note that some methods preferred by older women such as IUDs or the IUS require the healthcare profession to have specialised training.

Cost remains an important element in contraceptive services but it is important to consider it in terms of cost-effectiveness. This emphasises the importance of adequate counselling to help a woman select a contraceptive method with which she is happy and thus use effectively and for the long term. An IUD or IUS left in place for the recommended time is much more cost-effective than one that has to be removed early because a woman was unprepared for possible side-effects. Sterilisation costs around £500, compared to just under £100 for an IUS5, but reversal of sterilisation costs around three times as much as the initial procedure, and may often not be funded on the NHS.

At the end of the day, the ultimate price for any woman is failure of contraception and an unplanned pregnancy. This must be considered in the assessment of contraceptive provision for older women, just as much as in younger ones.


Conclusion

For older women, the most difficult hurdle to overcome may be to persuade them of the need for contraception, because they may not appreciate that they can still conceive. It could be useful in such situations to highlight the health benefits of some of the various methods available, highlighting contraceptive cover as an added bonus. The key to success is to provide each woman with information about all of the options, because a woman who feels she has made her own, informed decision is much more likely to comply with the method she has chosen

Shelley Mehigan is a Clinical Nurse Specialist in Family Planning, The Garden Clinic for Sexual Health, East Berkshire, and Chair of the Royal College of Nursing Sexual Health Forum

References
1 Office for National Statistics in Population Trends 95: Spring 1999
2 Family Planning Association
3 General Household Survey, 1995
4 RCOG National Evidence Based Guidelines, 1999
5 Haymarket Medical Publications. MIMS. 1999; (June): 327; Schering. MirenaÑYour Questions Answered
6 Guillebaud, J. Contraception: your questions answered. Churchill Livingstone. 1994: 11
7 Mirena Product Platform, page 19
8 Andersson K, et al. Contraception 1994; 49: 56-72