Contraception for Midlife Women: A Review

Taniqua A. Miller, MD; Rebecca H. Allen, MD, MPH; Andrew M. Kaunitz, MD; Carrie A. Cwiak, MD, MPH

Menopause. 2018;25(7):817-827.

Abstract and Introduction

Abstract

Family planning represents a key component of reproductive health care. Accordingly, the provision of contraception must span the reproductive age spectrum, including perimenopause. The risk of pregnancy is decreased, but not trivial, among women over 40 years of age. Evidence-based guidelines for contraceptive use can assist clinicians in counseling their patients in this population. Intrauterine contraception is one of the most effective methods and is safe to use in midlife women with few exceptions. Progestin-only contraception is another safe option for most midlife women because it is not associated with an increased risk of cardiovascular complications. Combined (estrogen-containing) contraception can be safely used by midlife women who do not have cardiovascular risk factors. Unique noncontraceptive benefits for this population include: improvement in abnormal uterine bleeding, decreased hot flashes, and decreased cancer risk. Finally, guidelines state that contraception can be used by midlife women without medical contraindications until the age of menopause, at which time they may consider transition to systemic hormone therapy.

Introduction

Family planning represents a key component of reproductive health care: since the average woman in North America desires two children, she will spend about 3 years pregnant, postpartum, or attempting to become pregnant, and over 30 years trying to avoid pregnancy.^[1] Accordingly, the provision of contraception must span the reproductive age spectrum, including perimenopause. In this article, we review the need for contraception among women over 40 years of age and present evidence-based guidelines for contraceptive use in this population. We detail the contraceptive options available to women over 40, and also the unique contraceptive and noncontraceptive benefits and health risks associated with contraceptive use in this population. Finally, we assist clinicians as they provide guidance for women transitioning from contraception to their menopausal years, including possible initiation of systemic hormone therapy (HT).

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Table 1. US medical eligibility criteria for contraceptive use based on age
Method	Age range, y	US MEC category
Estrogen-containing contraception	≥40	2
Progestin-only pill	≥40	1
Progestin implant	≥40	1
DMPA	≥40 to 45	1
	>45	2
Cu-IUD	≥40	1
LNG-IUS	≥40	1

Adapted from US Medical Eligibility Criteria for Contraceptive Use, 2016.¹²
1, A condition for which there is no restriction for the use of the method;
2, a condition for which the advantages if using the method generally outweigh the disadvantages of using the method; 3, a condition for which the theoretical or proven risks usually outweigh the advantages of using the method; 4, a condition that represents an unacceptable health risk if the method is used.
Cu-IUD, copper intrauterine device; DMPA, depot-medroxyprogesterone acetate; LNG-IUS, levonorgestrel intrauterine system; US MEC, US
Medical Eligibility for Contraceptive Use.

Table 2. US medical eligibility criteria for contraceptive use for the use of CHC
Medical condition	US MEC category
Smoking age ≥35 y
<15 cigarettes/d	2
≥15 cigarettes/d	4
Obesity
BMI 30–34	2
BMI ≥35	2
Hypertension
Controlled hypertension	3
Elevated BP	3
Systolic >140–159mm Hg or diastolic >90–94mm Hg
Systolic ≥160mm Hg or diastolic ≥95mm Hg	4
Vascular disease	4
Diabetes
No vascular disease	2
Vascular disease or >20 y duration	3, 4 (based on severity of condition)
Stroke	4
Current or history of ischemic heart disease	4
Multiple risk factors for cardiovascular disease (older age, smoking, obesity, diabetes, hypertension)	3, 4 (based on severity of condition)

Adapted from US Medical Eligibility Criteria for Contraceptive Use, 2016.¹²
1, A condition for which there is no restriction for the use of the method;
2, a condition for which the advantages if using the method generally outweigh the disadvantages of using the method; 3, a condition for which the theoretical or proven risks usually outweigh the advantages of using the method; 4, a condition that represents an unacceptable health risk if the method is used.
BMI, body mass index; BP, blood pressure; CHC, combined hormonal contraceptive; US MEC, US Medical Eligibility for Contraceptive Use.

Table 3. Noncontraceptive benefits of hormonal contraceptives for perimenopausal women
Restoration of regular bleeding (CHC)
Decreased dysmenorrhea
Reduced heavy menstrual bleeding
Reduced pain associated with endometriosis
Suppression of vasomotor symptoms (CHC)
Enhanced bone mineral density and possible prevention of osteoporotic fractures (CHC)
Decreased need for biopsies for benign breast disease (CHC)
Prevention of epithelial ovarian, and endometrial malignancies
Improvements in acne that may flare up with perimenopause (CHC)