Women 40 plus for advice Canada

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Try out PMC Labs and tell us what you think. Learn More. Despite declining fertility, women over 40 years of age require effective contraception if they wish to avoid pregnancy. Women of older reproductive age may be experiencing perimenopausal symptoms that could be managed with contraceptives.

In addition, such women may have medical conditions that make some contraceptive methods inappropriate. Women over 40 are also more likely than younger women to desire a permanent form of contraception. Finally, older women of reproductive age have lower rates of contraceptive failure than younger women because of lower fecundity probability of achieving a live birth per menstrual cycleless frequent sexual intercourse and higher compliance with contraceptive regimens.

In this article, we outline the risks and benefits of contraceptive methods for women over 40, and we review when it is appropriate to stop contraception. Most of the recommendations are based on guidelines that used systematic reviews. Where appropriate, we specify the types of studies e. Study findings reported are statistically ificant unless otherwise stated.

Box 1 outlines the evidence used in this review; details of the search strategy are given in Appendix 1 available at www. Details of our search strategy are given in Appendix 1. The risk of pregnancy among women over 40 years of age is low. Women in this age group have lower fecundity compared with younger women and therefore take longer to conceive.

For example, in one study involving women undergoing insemination with frozen donor Women 40 plus for advice Canada, the fecundity was 0. Women of older reproductive age who no longer desire children still need to use effective contraception until menopause has occurred. Menopausal hormone therapy does not provide effective contraception. When they conceive, women over 40 are more likely than younger women to have adverse consequences. The risk of spontaneous abortion and chromosomal abnormalities increases markedly over age These data underscore the Women 40 plus for advice Canada of effective contraception for women of older reproductive age who desire it.

The contraceptive methods used by women over 40 years old vary by country Appendix 2, available at www. The benefits of use outweigh the risks for most contraceptive methods used by women over 40 years of age. Even for women with risk factors for complications, there are methods available that can be safely used to prevent unintended pregnancy.

As ly discussed, the medical risks of unintended pregnancy are greater for older women than for younger women, and so the risks of contraceptive use need to be weighed against the risks of pregnancy. In addition, the most effective contraceptive methods should Women 40 plus for advice Canada emphasized in order to maximally decrease the medical risks of unintended pregnancy among older women. However, because contraceptive failure rates are lower among older women, less effective, short-acting methods such as oral contraceptives or coitally dependent methods male and female condoms, diaphragms, emergency contraception may be acceptable for some older women.

Venous e. Because progestin-only contraceptive methods do not appear to increase the risk of venous thromboembolism, they represent safe options for women at increased risk of cardiovascular events, whether because of age, obesity or medical comorbidities such as diabetes mellitus and hypertension.

In a multinational case—control study, no increased risk of venous thromboembolism or myocardial infarction was found among women who used progestin-only injections or progestin-only pills compared with nonusers. The small subset of users of progestin-only methods who had pre-existing hypertension were noted to have an increased risk of stroke odds ratio [OR] Use of estrogen-containing contraceptives increases the risk of venous and arterial thromboembolic events.

Other risk factors include, but are not limited to, age, obesity, smoking, diabetes, hypertension, migraine headaches with or without aura and thrombogenic mutations. Estrogen-containing methods should be used with caution in women over 40 who have additional cardiovascular risk factors. Recent studies of estrogen-containing contraceptives and venous thromboembolism are consistent in several findings. Although arterial events are less common than venous thromboembolism in women of reproductive age, the sequelae of stroke and myocardial infarction may be more devastating than those of venous thromboembolism.

A large Danish Women 40 plus for advice Canada study found that women aged 45—49 years had 20 times the risk of stroke and times the risk of myocardial infarction as women aged 15— In this cohort, estrogen-containing contraceptive use increased the overall risk of stroke by as much as 2. Risks were not increased with past use. This was shown in a Dutch case—control study in which the OR for stroke among obese users was 4. Because rates of both venous and arterial events are still lower with estrogen-containing methods than during pregnancy, these methods have no upper age limit for use.

The incidence of cancer increases with age. A large cohort study by the Royal College of General Practitioners found that use of oral contraceptives estrogen-containing or progestin-only pills was associated with a decreased overall risk of cancer OR 0.

Of particular concern to women and their clinicians is any association between hormonal contraceptives and breast cancer. A large case—control study found no association between past or ever use of oral contraceptives and risk of breast cancer, although a nonificant trend was noted between current use and breast cancer risk. Only 2 studies found recent DMPA use to be associated with an increased risk of breast cancer, with an OR as high as 2.

A large case—control study involving women over 35 years of age found no increased risk of breast cancer associated with current or past use of either the levonorgestrel-releasing or copper IUD. With regard to risk of cervical cancer, a systematic review found that an elevated risk was associated with long-term use of oral contraceptives relative risk [RR] 1.

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Bone mineral density begins to decline during perimenopause because of inconsistent production of endogenous estrogens. Use of DMPA is associated with relative hypoestrogenemia and decreased bone mineral density during use. Bone density levels decline rapidly during the first year of DMPA use but then plateau with long-term use and recover after discontinuation. Use of progestin-only methods such as implants, pills and the IUD have been associated with either no change or a slight increase in bone density.

The noncontraceptive benefits associated with contraceptive methods that may be relevant to women over 40 years of age are outlined in Table 1. Noncontraceptive benefits associated with contraceptive methods among women over 40 years of age. About 4—6 years before their final menses, women will enter perimenopause and will likely experience changes in menstrual bleeding that lead to excessive or irregular menstruation. Estrogen-containing oral contraceptives Women 40 plus for advice Canada menstrual regularity 42 and prevent the development of endometrial hyperplasia and endometrial cancer.

One study including perimenopausal women showed that estrogen-containing oral contraceptives reduced the risk of blood clots and heavy bleeding. Furthermore, observational studies have shown that oral contraceptives can reduce menstrual blood loss and increase hemoglobin concentrations, and their use is supported in clinical practice guidelines.

The use of the levonorgestrel-releasing IUD has been proven effective in treating heavy menstrual bleeding, including when it is associated with adenomyosis and leiomyomas. Use of DMPA le to high rates of amenorrhea and is an option for the treatment of heavy menstrual bleeding, although it may be less effective than the levonorgestrel-releasing IUD.

Many perimenopausal women experience vasomotor symptoms such as hot flashes and night sweats.

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Estrogen-containing contraceptives are likely an effective treatment, especially for severe vasomotor symptoms. Older clinical trials have shown that DMPA also alleviates vasomotor symptoms. This approach provides an excellent option for women experiencing hot flashes who also need contraception or suppression of abnormal uterine bleeding, or both.

Overall, oral contraceptives appear to have little impact on bone mineral density in premenopausal women. Women who use combined oral contraceptives have a reduced risk of endometrial cancer compared with nonusers. There is robust evidence that use of oral contraceptives estrogen-containing or progestin-only reduces subsequent risk of Women 40 plus for advice Canada cancer. This protection may result from the suppression of ovulation associated with such use. A recent collaborative meta-analysis reviewed 45 studies that compared women who had ever used oral contraceptives with those who had never used them.

Although a meta-analysis showed a ificant risk reduction of ovarian cancer among women with BRCA1 and BRCA2 mutations who had ever used oral contraceptives, 67 the evidence regarding the effect of oral contraceptives on the risk of breast cancer among women with these mutations was inconsistent. A lesser-known benefit of estrogen-containing oral contraceptives is the possible modest protection against colon cancer. A nested case—control study found that ever use of oral contraceptives was associated with a marginally reduced risk of colorectal cancer, but the effect was not statistically ificant hazard ratio [HR] 0.

Most women will be able to use contraception safely until they are assured of menopause. Determining when to stop a contraceptive method should include an evaluation of the benefits of the method, the health risks resulting from its use as age increases, the diminishing risk of pregnancy and the availability of alternative methods Table 2. For progestin-only methods, the potential benefits of decreased menstrual bleeding and endometrial protection outweigh the Women 40 plus for advice Canada of continuing use, because arterial and venous cardiovascular events are not increased.

When to stop contraception European guidelines suggest that natural sterility can be assumed after age 55 in amenorrheic women. These hormone levels are not suppressed substantially during DMPA use, but similarly they may be an unreliable al of menopause in younger users. In the absence of contraindications or risk factors, estrogen-containing and progestin-only hormonal contraception can be safely continued until age The availability of safe, effective options suggests that estrogen-containing methods should increasingly be used with caution in older women who have cardiovascular risk factors.

US and UK medical eligibility criteria for the use of contraceptive methods in older women 29 Available: www. Tubal sterilization for women and vasectomy for male partners are also options for women over 40 years of age who have completed childbearing. Older women are less likely to regret permanent sterilization. There are several important questions about contraception in women over the age of 40 that need further investigation. Several of these centre on the safety of ethinyl-containing oral contraceptives. Are formulations of oral contraceptives containing estradiol valerate safer than those containing ethinyl estradiol in this age group?

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With the advent of newer contraceptive methods, such as the patch and vaginal ring, more information is needed on their noncontraceptive benefits. Although fertility declines with age, effective contraception is still required in women over 40 years of age who wish to avoid pregnancy. According to international guidelines, there are no contraceptive methods that are contraindicated based on age alone. Effective nonhormonal and progestin-only methods provide safe options for women who should avoid estrogen-containing contraceptives.

For women who are using hormonal contraceptives, menopausal status and lack of need for contraception can be assumed at age Competing interests: Rebecca Allen has received fees from Merck as a trainer for Nexplanon implantation. Carrie Cwiak has been a paid consultant for Shook, Hardy and Women 40 plus for advice Canada litigation related to a Women 40 plus for advice Canada intrauterine systemand her institution has received a research grant from Medicines Andrew Kaunitz has been a paid consultant for Agile Therapeutics, Bayer and Merck; he has received royalties for chapters on contraceptives in the clinical decision support resource UpToDate; and his institution has received research grants from Agile Therapeutics, Bayer and Teva.

This article has been peer reviewed. Contributors: All of the authors contributed substantially to the conception and de of the article, the drafting and revising of the manuscript and the approval of the final version submitted for publication. National Center for Biotechnology InformationU. Rebecca H.

KaunitzMD. Author information Copyright and information Disclaimer. Correspondence to: Rebecca H. Allen, irhiw nellahr. This article has been cited by other articles in PMC. Box 1: Evidence used in this review. What is the risk of pregnancy? What contraceptive methods are used by women over 40? How safe are contraceptives in women over 40? Pregnancy As ly discussed, the medical risks of unintended pregnancy are greater for older women than for younger women, and so the risks of contraceptive use need to be weighed against the risks of pregnancy.

Cardiovascular events Venous e. Cancer The incidence of cancer increases with age. Fracture risk Bone mineral density begins to decline during perimenopause because of inconsistent production of endogenous estrogens.

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What are the noncontraceptive benefits of contraceptives in this age group? Table 1: Noncontraceptive benefits associated with contraceptive methods among women over 40 years of age.

Women 40 plus for advice Canada

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Pregnancy After Age 35