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Contraception: Special Considerations in the Mature Woman
GYNAECOLOGY
CONTRACEPTION: SPECIAL CONSIDERATIONS IN THE MATURE WOMAN Dorothy Shaw, MB, ChB, FRCSC, Clinical Professor, Departments of Obstetrics and Gynaecology and Medical Genetics, University of British Columbia ABSTRACT
Unplanned pregnancy at the upper end of the reproductive age range may have more potential risk both medically and psychosocially, yet the contraceptive methods available w these women, or chosen by them, are more limited than those for women in the middle of the reproductive years. It is important w consider the complex factors involved in contraceptive decision-making for the mature woman, including the changing physiology that characterizes the climacteric. In the 1990s, consideration must be given both to the provision of a birth control method and the prevention of sexually transmitted diseases, though this is often forgotten when counselling mature women. An assessment of the medical and personal his wries will guide discussion as w which methods might be appropriate and which are contra-indicated. Sterilization is the most common method used by this group, with no method and barriers the next most common, yet few are planning w become pregnant. As with couples at any age, the method of birth control which works best is the one they will use, and efficacy is optimized by identifying potential barriers w effective use as part of the decision-making process. RESUME
Pendant les dernieres annees OU une femme est en age de procn:er, une grossesse imprevue peut se traduire par un risque potentiel accru pour des motifs d' ordre medical et psychologique; les femmes de cet age disposent pourtant de methodes ou de choix contraceptifs plus limites que celles dont I' age se situe au milieu de cette periode. II importe de tenir compte des facteurs complexes qui entrent en jeu dans la prise de decisions relatives ala contraception chez la femme d' age mur, notamment les modifications physiologiques qui caracterisent le climatere. A notre epoque (les annees 1990), il faut prevoir une methode ala fois de contraception et de prevention des maladies sexueUement transmissibles, meme si on I' oubUe souvent au moment de conseiUer les femmes d' age mur. Une evaluation des antecedents medicaux et personnels orientera la discussion des methodes appropriees ou contre-indiquees. La steriUsation est la methode contraceptive a laquelle les femmes de ce groupe ont le plus frequemment recours, viennent ensuite l'absence de methode et les obturateurs. Pourtant, peu de femmes prevoient une grossesse. Comme les couples de tout age, elles utiliseront la methode contraceptive qui donne les meilleurs resultats et on optimisera I' efficacite de celle-ci en identifiant les obstacles eventuels ason utilisation efficace dans le cadre du processus decisionnel. J soc OBSTET GYNAECOL CAN 1998;20:133-38 KEY WORDS
Contraception, mature, sexually transmitted diseases Received on May 17th, 1997. Revised and accepted on July 14th, 1997.
JOURNAL SOGe
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FEBRUARY 1998
, , , INTRODUCTION
STDs, but how often is this issue raised with individuals who have chosen this method of birth control?
More women are delaying their childbearing into their thirties and even forties; yet scant attention is paid to their need for reliable, reversible methods of birth control either before or between pregnancies. The population of women in the age range from 35 to 44 has increased by about 60 percent in the last 15 years, and this growth is expected to continue over the next 10 to 20 years. The recent Canadian Contraceptive Study surveyed Canadian women and examined the prevalence of various contraceptive methods. 1 Sterilization was the most commonly used method, accounting for 65 percent of married women and 38 percent of unmarried women over age 35. This leaves a group of women wishing to preserve their fertility or not wanting permanent contraception. The average age of menopause is 50 and although fertility declines with age, especially over age 35, unplanned pregnancy in this age group may be extremely stressful, particularly when a couple has older children and a completed family. Thus, less reliable methods of birth control may be unacceptable to some older women. In the later reproductive years, there is a decline in cyclic ovulatory function and accompanying steroidogenesis. Anovulatory perimenopausal cycles may result in abnormal bleeding patterns due to unopposed estrogen which can be addressed by hormonal methods of contraception, however, only two percent of married and ten percent of unmarried women over age 35 use oral contraceptives (OCS).l
ORAL CONTRACEPTIVES
The Directions for Use of Estrogen-Progestin Combination Oral Contraceptives published by the Health Protection Branch (HPB) of Health Canada in 1994 stated: "Cigarette smoking increases the risk of serious adverse effects on the heart and blood vessels. This risk increases with age and becomes significant in OC users older than 35 years of age. Women should be counselled not to smoke." These directions are more consistent with the FDA guidelines in place since 1989 which removed the labelling requirement to stop OCs at age 40 in healthy, non-smoking women. Previous recommendations to discontinue OC use over the age of 35 years were based mostly on the use of pills containing 100 mcg or more of estrogen, as well as higher progestin doses. In addition, women with risk factors for cardiovascular disease were given OCs during the period of study and this was not corrected for in the original analysis of the data. When Mann et al. re-analysed their data, they found no significant difference between OC users and controls in the incidence of myocardial infarction in women over 40 years of age, providing no other risk factors were presentY Smoking was the most important risk factor, with hypertension, hyperlipidaemia and diabetes being the other risk factors for cardiovascular disease. The Royal College of General Practitioners study4 confirmed that the only significant increase in circulatory disease mortality rates was in women over 35 years who smoked. The Walnut Creek Contraceptive Drug studyS found no increased risk for myocardial infarction in past or current users. The risk of cerebrovascular disease was only significantly increased in OC users who smoked. Although certain OC fonnulations have been shown to lower HDL-cholesterollevels, an interesting study using these preparations in cynomologous monkeys suggested that the estrogen component (ethinyl estradiol) appeared to protect against atherosclerosis. 6 Meade et al. and Mann have observed that the incidence of arterial and venous thrombosis is lower than expected in women taking 30mcg estrogen preparations as opposed to 50mcg of estrogen. 7,8 Furthermore, there is some evidence suggesting that the induced coagulation changes in smoking OC users are decreased by a reduction in estrogen dose from 35 to 20 mcg. 9
SEXUALLY TRANSMITTED DISEASE PREVENTION
While prevention of sexually transmitted diseases (STDs) may seem less of an issue for the mature woman, a consideration of our society today shows this not to be the case. Women in this age group may be single, divorced, or in a relationship which is not mutually monogamous whether within the confines of marriage or not. It requires a sensitive approach to detennine the risk of STD and, even when a woman appears to be in a monogamous married relationship, she should be cautioned to protect herself and her partner should she ever have a sexual encounter outside the primary relationship. This applies equally to the male partner who should receive similar counsel. Sterilization is no protection from
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, , , Venous thrombo-embolism (VTE) is a rare condition which is increased three-to four-fold in low-dose oral contraceptive users and has been reported to be increased approximately six-fold with OCs containing new progestins.lO However, concern exists over bias in the user population who may have had additional risk factors. Women at high risk of VTE, including Protein C or S deficiency should not use OCs. The newer progestins-desogestrel, gestodene and norgestimate-are reported to have fewer potentially negative metabolic effects and may prove to be particularly useful in mature women. 11 The metabolic effects include no influence on blood pressure by cycle six, and no negative consequences for lipid and lipoprotein biosynthesis-indeed there may be a possible improvement in the LDL/HDL ratio. As the new progestins are more specific for the progesterone receptor, and have lower affinity for the androgen receptor, the effects on lipids would be expected to be more favourable than currently available products, though the clinical significance of these changes remains to be clarified. Another interesting finding was that OC use in women aged 40 to 44 increased both axial and peripheral bone density, though this effect only persisted for one to two years postmenopause. 12 In summary, low-dose combined 0Cs are a safe option for women over age 35 who have no risk factors and particularly non-smokers. Prior to prescribing OCs for members of this group, full personal and family histories are necessary as are physical assessments, including pelvic examinations. The provision of an effective, reversible method of contraception is, of course, a major benefit. Progestin-only pills may be chosen by women with estrogen-related side effects from combined OCs. While the theoretical risk might be expected to be lower than those of a combined OC, research data are unavailable to confirm this. The failure rate is reported as 0.5 to 2.5 per 100 woman years, though in older women it is lower--
monogamous relationship. Unfortunately, the experience with the Dalkon shield has contributed to widespread paranoia regarding pelvic inflammatory disease (PID) which is mostly undeserved with the current copper IUDs. It is important to understand that many studies purporting to show an association between IUD use and subsequent PID or tubal infertility are fraught with methodological flaws. Because the use of any other method offers some protection from STDs, the IUD user can only reasonably be compared with a non-contraceptor. Whether or not this is a fair comparison is also open to question. Furthermore, the diagnosis of PID is often subjective, and more likely to be made when an IUD is present in the uterus. A study of laparoscopically diagnosed PID in young women by Westrom, found IUD users to have a relative risk 1.5 times that of sexually active women using no contraception. IS The Women's Health Study found no significantly increased risk of PID in married monogamous IUD users compared with non-contraceptors. 16 These and other recent studies with copper-bearing IUDs appear to show that any associated increased risk for PID occurs within the first four months after insertion. This underlines the need for cervical cultures (especially for chlamydia and gonorrhoea) prior to insertion and careful aseptic technique during insertion. The use of prophylactic antibiotics at the time of insertion is controversial and, based on information in the two reported studies, currently cannot be recommended routinelyy,18 Pelvic inflammatory disease occurring after a few months is probably due to an STD, and the problem with the IUD is that it offers no protection in this situation. Three IUDs are currently available in Canada-the Nova-T, the Gyne-T and the GyneT 380 slimline. At present, copper IUDs in Canada are required to be changed every 30 months, although clinical trials have shown the lifespan of current copper IUDs to be at least five years. 19 This clearly makes no sense when the insertion time carries a recognized (albeit small) risk for PID. The US Food and Drug Administration (FDA) has approved the GynT 380A for six to eight years. zo Pregnancy rates with current copper IUDs are very low-less than one per 100 women per year. After six years use of the TCu 380A, the cumulative pregnancy rate was 1.4 per 100 women per year in a WHO international study.19 Studies also suggest a lower pregnancy rate for the older woman. Older women and women with children are reported to have lower rates of removal because of pain
THE INTRA-UTERINE DEVICE
The intra-uterine device (IUD) is a highly effective method of birth control and well-suited to the mature woman, with the proviso that she is in a mutually
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, , , and bleeding. 21 ,22 Although fibroids and menstrual problems are more common in the mature woman and may be contra-indications to IUD use, in general this is a good method for the older woman in a mutually faithful sexual relationship. The IUD may be particularly suitable for the smoker, the breastfeeding mother and those undecided about further pregnancies. If an IUD is inserted after the age of 40, it is unnecessary to change it or remove it prior to menopause, unless clinical concerns exist.
Canadian Contraceptive Study found that 25 percent of married women using reversible methods were using condoms. Advantages in this age group are the absence of risk, low cost, STD protection and availability without prescription. The higher failure rate generally quoted for this method is offset by increased compliance and lower fecundity in the mature woman. One disadvantage in this age group is the potential exacerbation of male impotence or ejaculatory difficulty associated with increasing age. 25 ,26 The female condom appears to offer promise of good efficacy for both birth control and STD prevention as it is made from polyurethane as opposed to latex. This may be a good option for the mature woman, but currently there is inadequate information about this specific group. The diaphragm was reportedly used by nine to 13 percent of women aged 40 to 44 in the previously mentioned study referring to women using reversible methods. 24 The diaphragm offers some similar benefits to the condom, though initial fitting and instruction regarding insertion are required by a trained professional. Vaginal laxity may reduce the effectiveness of the diaphragm in older women. The cervical cap avoids problems with vaginal wall laxity, though fewer personnel have been trained to fit caps. This skill is more difficult to acquire than diaphragm fitting, and in addition only about 60 percent of women can be fitted successfully with a cervical cap. The Lea's Shield is a silicone device somewhat similar in principle to the cervical cap, in that it attaches to the cervix by suction. As there is only one size, it is easier to fit than the cervical cap. It has a one-way valve which allows the escape of secretions and menstrual blood. Like the cap, it can be left in place for up to 48 hours and is used in conjunction with spermicidal cream. Pregnancy rates were reported between 5.6 and 8.7 per 100 women users at six months, and these failures tended to be in parous women as has been noted in previous studies on barrier contraceptives. 27 A vaginal sponge, containing benzalkonium chloride, sodium cholate and nonoxyno19, has recently become available to Canadian women and is another option for the mature woman.
I NJ ECTABLES/I M PLANTS
Until its recent approval for contraceptive use by the HPB, medroxyprogesterone acetate (Depo-Provera) was often requested by women immigrants who had previously used this method of birth control successfully. The major disadvantage as a woman approaches menopause is that the changes in bleeding pattern-either frequent episodes or amenorrhoea-may be difficult to distinguish from pathological causes of genital tract bleeding or physiological menopause. The delayed return of fertility with Depo-Provera may be up to 20 months, making this a concern for older women using this method for pregnancy spacing. A more positive aspect is the beneficial progestin effect on the endometrium, which is more likely to show the effects of unopposed estrogen in this age group. With Norplant, the return to fertility appears to be fairly rapid and the rods can be withdrawn if the method is unsuitable, making this more popular with the mature woman. The cost (around $450) may also be less of a deterrent than it is for young women. Irregular bleeding patterns would again be a potential concern, as prolonged or frequent bleeding occurs in 27.6 percent of women and spotting in 17.1 percent. 23 Amenorrhoea is much less frequent than with depo-medroxyprogesterone acetate. Norplant is highly effective, and the continuation rates are 80 percent or higher for the first four years. Removal difficulties have been reported to occur in about 13.2 percent of cases. This method has been less popular than anticipated in Canada, as a result of litigation in the United States, mostly related to improper insertion and removal. BARRIER METHODS/SPERMICIDES
NATURAL METHODS
It is of interest that a study of American women
Natural methods include periodic abstinence alone or in conjunction with basal body temperature charting or examination of cervical mucus changes, or a combination
showed condoms to be the most popular contraceptive in the 40- to 44-year-old age group, being employed by 30 to 40 percent of those using reversible methods.24 The
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, , , of techniques as in the symptothermal method. Theoretically, those couples wishing touse these methods should find compliance easier as sexual intercourse generally occurs less frequently in the fourth and fifrh decades than in the second and third. Fertility decreases in older women. However, the cycle irregularities associated with impending menopause make natural methods less reliable.
2.
3.
4.
5.
CONCLUSION
In conclusion, many factors sh ould be considered when counselling any woman or c ouple about their contraceptive options. In the case of the mature woman, health considerations and physiological changes assume more relevance. It is important at any age to encourage women to return should the method chosen prove unsatisfactory in practice, so that an laternate may be found. It is also mandatory to discuss protection from STDs concurrently with birth control in order to promote optimal reproductive health care.
6.
7.
8.
REFERENCES 1.
Boroditsky R, Fisher W, Sand M. The Canadian Contraceptive Study. J Soc Obstet Gynaecol Can (Suppl), July 1995.
9.
Mann JI, Inman WH, Thor0900d M. Oral contraceptive use in older women and fatal myocardial infarction. BMJ 1976;2:445-7. Mann JI, Doll R, Thorogood M, Vessey MP, Waters WE. Risk factors for myocardial infarction in young women. Br J Prev Soc Med 1976;30:94-100. Royal College of General Practitioners Oral Contraceptive Study. Further analysis of mortality in oral contraceptive users. Lancet 1981 ; 1541-3. : Ramcharan S,Peliegrin FA, Ray RM et al. The Walnut Creek Contraceptive Drug Study: a prospective study of the side effects of oral contraceptives. Vol. 3. Bethesda, Maryland: National Institutes of Health: 1981; NIH publication no. 81-564. Adams MR, Clarkson TB, Koritnik DR et a/. Contraceptive steroids and coronary artery atherosclerosis in cynomologous macaques. Fertil Steril1987;47 :1010-8. Meade TW, Greenberg G, Thompson SG. Progestogens and cardiovascular reactions associated with oral contraceptive use and a comparison of the safety of 50- and 30-119 oestrogen preparations. BMJ 1980;280:1157-61 . Mann JI. Progestogens in cardiovascular disease: an introduction to the epidemiological data. Am J Obstet GynecoI1982;142:752-7 . Fruzzetti F, Cabiria R, Fioretti P. Haemostasis profile in smoking and non-smoking women taking low-dose oral contraceptives. Contraception 1994;49:579-92.
WHO EVER THOUGHT YAMS COULD BE SO GOOD.
Organ ieally- Sou reed Estrogen.
Pharmacia &Upjohn OntariO, Canada
Please consult Product Monograph before prescrib ing.
CE 2447
I PAAB I
, , , 10. Lewis MA, Heinemann LAJ, MacRae KD, Bruppacher R, Spitzer WO. The increased risk of venous thromboembolism and the use of third generation progestagens: role of bias in observational research. Contraception 1996;54:5-13. 11. Robinson GE. Older women taking modern pilis. Br J Fam Plann 1989;15:11-3. 12. Lindsay J, Tohme J, Kanders P. The effect of oral contraceptive use on vertebral bone mass in pre-menopausal and post-menopausal women. Contraception 1986;34:333-40. 13. Vessey MP, Lawless M, Yeates D, McPherson K. Progestin-only oral contraception: findings in a large prospective study with special reference to effectiveness. BrJ Fam Plann 1985;10:117-21. 14. Reinhart W. Minipill: a limited alternative for certain women. Popul Rep 1975;A(3):53-67. 15. Westrom L. Incidence, prevalence and trends of acute pelvic inflammatory disease and its consequences in industrialized countries. Am J Obstet Gynecol 1980; 138:880. 16. Burkman RT. The Women's Health Study. Association between intrauterine device and pelvic inflammatory disease. Obstet GynecoI1981;57:269. 17. Lapido OA, Farr G, Otolorin E et a/. Prevention of IUDrelated infection: the efficacy of prophylactic doxycycline at IUD insertion. Adv Contracept 1991;7(1):43-54. 18. Sinei SKA, Schulz KF, Lamptey PR et a/. Preventing IUDrelated pelvic infection: the efficacy of prophylactic doxycycline use at insertion. Br J Obstet Gynaecol 1990;97(5):412-9. 19. Population Reports. Intrauterine Devices. Series B, No.5, March 1988; XVI, No.1. 20. The Population Council. US FDA extends effective use of the Copper-T IUD from six to eight years (news release). New York: The Population Council, October 7,1991. 21. Sivin I, Stern J. Long-acting, more effective Copper T IUDs: a summary of U.S. experience, 1970-75. Stud Fam Plann 1979;10(10):263-81. 22. Kozuh NM, Andolsek L, Balogh SA, Waszak CS. Long term use of intrauterine devices. IPPF Med Bull 1988;22(1 ):1-3. 23. Special report: NORPLANT. Contraceptive Technology Update Jan 1990;11(1):1-20. 24. Riphagen FE, Fortney JA, Koelb S. Contraception in women overforty. J Biosoc Sci 1988:127-42. 25. Beard RJ. Diseases affecting contraceptive practice in middle age. J Biosoc Sci 1979;SuppI.6:143. 26. Bowen-Simpkins P.Contraception for the older woman. Br J Obstet Gynaeco11984;91 :513. 27. Mauck C, Glover LH, Miller E et a/. Lea's Shield: a study of the safety and efficacy of a new vaginal barrier contraceptive used with and without spermicide. Contraception 1996:53(6):329-35.
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CONTRACEPTION: SPECIAL CONSIDERATIONS IN THE MATURE WOMAN Dorothy Shaw, MB, ChB, FRCSC, Clinical Professor, Departments of Obstetrics and Gynaecology and Medical Genetics, University of British Columbia ABSTRACT
Unplanned pregnancy at the upper end of the reproductive age range may have more potential risk both medically and psychosocially, yet the contraceptive methods available w these women, or chosen by them, are more limited than those for women in the middle of the reproductive years. It is important w consider the complex factors involved in contraceptive decision-making for the mature woman, including the changing physiology that characterizes the climacteric. In the 1990s, consideration must be given both to the provision of a birth control method and the prevention of sexually transmitted diseases, though this is often forgotten when counselling mature women. An assessment of the medical and personal his wries will guide discussion as w which methods might be appropriate and which are contra-indicated. Sterilization is the most common method used by this group, with no method and barriers the next most common, yet few are planning w become pregnant. As with couples at any age, the method of birth control which works best is the one they will use, and efficacy is optimized by identifying potential barriers w effective use as part of the decision-making process. RESUME
Pendant les dernieres annees OU une femme est en age de procn:er, une grossesse imprevue peut se traduire par un risque potentiel accru pour des motifs d' ordre medical et psychologique; les femmes de cet age disposent pourtant de methodes ou de choix contraceptifs plus limites que celles dont I' age se situe au milieu de cette periode. II importe de tenir compte des facteurs complexes qui entrent en jeu dans la prise de decisions relatives ala contraception chez la femme d' age mur, notamment les modifications physiologiques qui caracterisent le climatere. A notre epoque (les annees 1990), il faut prevoir une methode ala fois de contraception et de prevention des maladies sexueUement transmissibles, meme si on I' oubUe souvent au moment de conseiUer les femmes d' age mur. Une evaluation des antecedents medicaux et personnels orientera la discussion des methodes appropriees ou contre-indiquees. La steriUsation est la methode contraceptive a laquelle les femmes de ce groupe ont le plus frequemment recours, viennent ensuite l'absence de methode et les obturateurs. Pourtant, peu de femmes prevoient une grossesse. Comme les couples de tout age, elles utiliseront la methode contraceptive qui donne les meilleurs resultats et on optimisera I' efficacite de celle-ci en identifiant les obstacles eventuels ason utilisation efficace dans le cadre du processus decisionnel. J soc OBSTET GYNAECOL CAN 1998;20:133-38 KEY WORDS
Contraception, mature, sexually transmitted diseases Received on May 17th, 1997. Revised and accepted on July 14th, 1997.
JOURNAL SOGe
133
FEBRUARY 1998
, , , INTRODUCTION
STDs, but how often is this issue raised with individuals who have chosen this method of birth control?
More women are delaying their childbearing into their thirties and even forties; yet scant attention is paid to their need for reliable, reversible methods of birth control either before or between pregnancies. The population of women in the age range from 35 to 44 has increased by about 60 percent in the last 15 years, and this growth is expected to continue over the next 10 to 20 years. The recent Canadian Contraceptive Study surveyed Canadian women and examined the prevalence of various contraceptive methods. 1 Sterilization was the most commonly used method, accounting for 65 percent of married women and 38 percent of unmarried women over age 35. This leaves a group of women wishing to preserve their fertility or not wanting permanent contraception. The average age of menopause is 50 and although fertility declines with age, especially over age 35, unplanned pregnancy in this age group may be extremely stressful, particularly when a couple has older children and a completed family. Thus, less reliable methods of birth control may be unacceptable to some older women. In the later reproductive years, there is a decline in cyclic ovulatory function and accompanying steroidogenesis. Anovulatory perimenopausal cycles may result in abnormal bleeding patterns due to unopposed estrogen which can be addressed by hormonal methods of contraception, however, only two percent of married and ten percent of unmarried women over age 35 use oral contraceptives (OCS).l
ORAL CONTRACEPTIVES
The Directions for Use of Estrogen-Progestin Combination Oral Contraceptives published by the Health Protection Branch (HPB) of Health Canada in 1994 stated: "Cigarette smoking increases the risk of serious adverse effects on the heart and blood vessels. This risk increases with age and becomes significant in OC users older than 35 years of age. Women should be counselled not to smoke." These directions are more consistent with the FDA guidelines in place since 1989 which removed the labelling requirement to stop OCs at age 40 in healthy, non-smoking women. Previous recommendations to discontinue OC use over the age of 35 years were based mostly on the use of pills containing 100 mcg or more of estrogen, as well as higher progestin doses. In addition, women with risk factors for cardiovascular disease were given OCs during the period of study and this was not corrected for in the original analysis of the data. When Mann et al. re-analysed their data, they found no significant difference between OC users and controls in the incidence of myocardial infarction in women over 40 years of age, providing no other risk factors were presentY Smoking was the most important risk factor, with hypertension, hyperlipidaemia and diabetes being the other risk factors for cardiovascular disease. The Royal College of General Practitioners study4 confirmed that the only significant increase in circulatory disease mortality rates was in women over 35 years who smoked. The Walnut Creek Contraceptive Drug studyS found no increased risk for myocardial infarction in past or current users. The risk of cerebrovascular disease was only significantly increased in OC users who smoked. Although certain OC fonnulations have been shown to lower HDL-cholesterollevels, an interesting study using these preparations in cynomologous monkeys suggested that the estrogen component (ethinyl estradiol) appeared to protect against atherosclerosis. 6 Meade et al. and Mann have observed that the incidence of arterial and venous thrombosis is lower than expected in women taking 30mcg estrogen preparations as opposed to 50mcg of estrogen. 7,8 Furthermore, there is some evidence suggesting that the induced coagulation changes in smoking OC users are decreased by a reduction in estrogen dose from 35 to 20 mcg. 9
SEXUALLY TRANSMITTED DISEASE PREVENTION
While prevention of sexually transmitted diseases (STDs) may seem less of an issue for the mature woman, a consideration of our society today shows this not to be the case. Women in this age group may be single, divorced, or in a relationship which is not mutually monogamous whether within the confines of marriage or not. It requires a sensitive approach to detennine the risk of STD and, even when a woman appears to be in a monogamous married relationship, she should be cautioned to protect herself and her partner should she ever have a sexual encounter outside the primary relationship. This applies equally to the male partner who should receive similar counsel. Sterilization is no protection from
JOURNAL SOGC
134
FEBRUARY 1998
, , , Venous thrombo-embolism (VTE) is a rare condition which is increased three-to four-fold in low-dose oral contraceptive users and has been reported to be increased approximately six-fold with OCs containing new progestins.lO However, concern exists over bias in the user population who may have had additional risk factors. Women at high risk of VTE, including Protein C or S deficiency should not use OCs. The newer progestins-desogestrel, gestodene and norgestimate-are reported to have fewer potentially negative metabolic effects and may prove to be particularly useful in mature women. 11 The metabolic effects include no influence on blood pressure by cycle six, and no negative consequences for lipid and lipoprotein biosynthesis-indeed there may be a possible improvement in the LDL/HDL ratio. As the new progestins are more specific for the progesterone receptor, and have lower affinity for the androgen receptor, the effects on lipids would be expected to be more favourable than currently available products, though the clinical significance of these changes remains to be clarified. Another interesting finding was that OC use in women aged 40 to 44 increased both axial and peripheral bone density, though this effect only persisted for one to two years postmenopause. 12 In summary, low-dose combined 0Cs are a safe option for women over age 35 who have no risk factors and particularly non-smokers. Prior to prescribing OCs for members of this group, full personal and family histories are necessary as are physical assessments, including pelvic examinations. The provision of an effective, reversible method of contraception is, of course, a major benefit. Progestin-only pills may be chosen by women with estrogen-related side effects from combined OCs. While the theoretical risk might be expected to be lower than those of a combined OC, research data are unavailable to confirm this. The failure rate is reported as 0.5 to 2.5 per 100 woman years, though in older women it is lower--
monogamous relationship. Unfortunately, the experience with the Dalkon shield has contributed to widespread paranoia regarding pelvic inflammatory disease (PID) which is mostly undeserved with the current copper IUDs. It is important to understand that many studies purporting to show an association between IUD use and subsequent PID or tubal infertility are fraught with methodological flaws. Because the use of any other method offers some protection from STDs, the IUD user can only reasonably be compared with a non-contraceptor. Whether or not this is a fair comparison is also open to question. Furthermore, the diagnosis of PID is often subjective, and more likely to be made when an IUD is present in the uterus. A study of laparoscopically diagnosed PID in young women by Westrom, found IUD users to have a relative risk 1.5 times that of sexually active women using no contraception. IS The Women's Health Study found no significantly increased risk of PID in married monogamous IUD users compared with non-contraceptors. 16 These and other recent studies with copper-bearing IUDs appear to show that any associated increased risk for PID occurs within the first four months after insertion. This underlines the need for cervical cultures (especially for chlamydia and gonorrhoea) prior to insertion and careful aseptic technique during insertion. The use of prophylactic antibiotics at the time of insertion is controversial and, based on information in the two reported studies, currently cannot be recommended routinelyy,18 Pelvic inflammatory disease occurring after a few months is probably due to an STD, and the problem with the IUD is that it offers no protection in this situation. Three IUDs are currently available in Canada-the Nova-T, the Gyne-T and the GyneT 380 slimline. At present, copper IUDs in Canada are required to be changed every 30 months, although clinical trials have shown the lifespan of current copper IUDs to be at least five years. 19 This clearly makes no sense when the insertion time carries a recognized (albeit small) risk for PID. The US Food and Drug Administration (FDA) has approved the GynT 380A for six to eight years. zo Pregnancy rates with current copper IUDs are very low-less than one per 100 women per year. After six years use of the TCu 380A, the cumulative pregnancy rate was 1.4 per 100 women per year in a WHO international study.19 Studies also suggest a lower pregnancy rate for the older woman. Older women and women with children are reported to have lower rates of removal because of pain
THE INTRA-UTERINE DEVICE
The intra-uterine device (IUD) is a highly effective method of birth control and well-suited to the mature woman, with the proviso that she is in a mutually
JOURNAL SOGC
135
FEBRUARY 1998
, , , and bleeding. 21 ,22 Although fibroids and menstrual problems are more common in the mature woman and may be contra-indications to IUD use, in general this is a good method for the older woman in a mutually faithful sexual relationship. The IUD may be particularly suitable for the smoker, the breastfeeding mother and those undecided about further pregnancies. If an IUD is inserted after the age of 40, it is unnecessary to change it or remove it prior to menopause, unless clinical concerns exist.
Canadian Contraceptive Study found that 25 percent of married women using reversible methods were using condoms. Advantages in this age group are the absence of risk, low cost, STD protection and availability without prescription. The higher failure rate generally quoted for this method is offset by increased compliance and lower fecundity in the mature woman. One disadvantage in this age group is the potential exacerbation of male impotence or ejaculatory difficulty associated with increasing age. 25 ,26 The female condom appears to offer promise of good efficacy for both birth control and STD prevention as it is made from polyurethane as opposed to latex. This may be a good option for the mature woman, but currently there is inadequate information about this specific group. The diaphragm was reportedly used by nine to 13 percent of women aged 40 to 44 in the previously mentioned study referring to women using reversible methods. 24 The diaphragm offers some similar benefits to the condom, though initial fitting and instruction regarding insertion are required by a trained professional. Vaginal laxity may reduce the effectiveness of the diaphragm in older women. The cervical cap avoids problems with vaginal wall laxity, though fewer personnel have been trained to fit caps. This skill is more difficult to acquire than diaphragm fitting, and in addition only about 60 percent of women can be fitted successfully with a cervical cap. The Lea's Shield is a silicone device somewhat similar in principle to the cervical cap, in that it attaches to the cervix by suction. As there is only one size, it is easier to fit than the cervical cap. It has a one-way valve which allows the escape of secretions and menstrual blood. Like the cap, it can be left in place for up to 48 hours and is used in conjunction with spermicidal cream. Pregnancy rates were reported between 5.6 and 8.7 per 100 women users at six months, and these failures tended to be in parous women as has been noted in previous studies on barrier contraceptives. 27 A vaginal sponge, containing benzalkonium chloride, sodium cholate and nonoxyno19, has recently become available to Canadian women and is another option for the mature woman.
I NJ ECTABLES/I M PLANTS
Until its recent approval for contraceptive use by the HPB, medroxyprogesterone acetate (Depo-Provera) was often requested by women immigrants who had previously used this method of birth control successfully. The major disadvantage as a woman approaches menopause is that the changes in bleeding pattern-either frequent episodes or amenorrhoea-may be difficult to distinguish from pathological causes of genital tract bleeding or physiological menopause. The delayed return of fertility with Depo-Provera may be up to 20 months, making this a concern for older women using this method for pregnancy spacing. A more positive aspect is the beneficial progestin effect on the endometrium, which is more likely to show the effects of unopposed estrogen in this age group. With Norplant, the return to fertility appears to be fairly rapid and the rods can be withdrawn if the method is unsuitable, making this more popular with the mature woman. The cost (around $450) may also be less of a deterrent than it is for young women. Irregular bleeding patterns would again be a potential concern, as prolonged or frequent bleeding occurs in 27.6 percent of women and spotting in 17.1 percent. 23 Amenorrhoea is much less frequent than with depo-medroxyprogesterone acetate. Norplant is highly effective, and the continuation rates are 80 percent or higher for the first four years. Removal difficulties have been reported to occur in about 13.2 percent of cases. This method has been less popular than anticipated in Canada, as a result of litigation in the United States, mostly related to improper insertion and removal. BARRIER METHODS/SPERMICIDES
NATURAL METHODS
It is of interest that a study of American women
Natural methods include periodic abstinence alone or in conjunction with basal body temperature charting or examination of cervical mucus changes, or a combination
showed condoms to be the most popular contraceptive in the 40- to 44-year-old age group, being employed by 30 to 40 percent of those using reversible methods.24 The
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, , , of techniques as in the symptothermal method. Theoretically, those couples wishing touse these methods should find compliance easier as sexual intercourse generally occurs less frequently in the fourth and fifrh decades than in the second and third. Fertility decreases in older women. However, the cycle irregularities associated with impending menopause make natural methods less reliable.
2.
3.
4.
5.
CONCLUSION
In conclusion, many factors sh ould be considered when counselling any woman or c ouple about their contraceptive options. In the case of the mature woman, health considerations and physiological changes assume more relevance. It is important at any age to encourage women to return should the method chosen prove unsatisfactory in practice, so that an laternate may be found. It is also mandatory to discuss protection from STDs concurrently with birth control in order to promote optimal reproductive health care.
6.
7.
8.
REFERENCES 1.
Boroditsky R, Fisher W, Sand M. The Canadian Contraceptive Study. J Soc Obstet Gynaecol Can (Suppl), July 1995.
9.
Mann JI, Inman WH, Thor0900d M. Oral contraceptive use in older women and fatal myocardial infarction. BMJ 1976;2:445-7. Mann JI, Doll R, Thorogood M, Vessey MP, Waters WE. Risk factors for myocardial infarction in young women. Br J Prev Soc Med 1976;30:94-100. Royal College of General Practitioners Oral Contraceptive Study. Further analysis of mortality in oral contraceptive users. Lancet 1981 ; 1541-3. : Ramcharan S,Peliegrin FA, Ray RM et al. The Walnut Creek Contraceptive Drug Study: a prospective study of the side effects of oral contraceptives. Vol. 3. Bethesda, Maryland: National Institutes of Health: 1981; NIH publication no. 81-564. Adams MR, Clarkson TB, Koritnik DR et a/. Contraceptive steroids and coronary artery atherosclerosis in cynomologous macaques. Fertil Steril1987;47 :1010-8. Meade TW, Greenberg G, Thompson SG. Progestogens and cardiovascular reactions associated with oral contraceptive use and a comparison of the safety of 50- and 30-119 oestrogen preparations. BMJ 1980;280:1157-61 . Mann JI. Progestogens in cardiovascular disease: an introduction to the epidemiological data. Am J Obstet GynecoI1982;142:752-7 . Fruzzetti F, Cabiria R, Fioretti P. Haemostasis profile in smoking and non-smoking women taking low-dose oral contraceptives. Contraception 1994;49:579-92.
WHO EVER THOUGHT YAMS COULD BE SO GOOD.
Organ ieally- Sou reed Estrogen.
Pharmacia &Upjohn OntariO, Canada
Please consult Product Monograph before prescrib ing.
CE 2447
I PAAB I
, , , 10. Lewis MA, Heinemann LAJ, MacRae KD, Bruppacher R, Spitzer WO. The increased risk of venous thromboembolism and the use of third generation progestagens: role of bias in observational research. Contraception 1996;54:5-13. 11. Robinson GE. Older women taking modern pilis. Br J Fam Plann 1989;15:11-3. 12. Lindsay J, Tohme J, Kanders P. The effect of oral contraceptive use on vertebral bone mass in pre-menopausal and post-menopausal women. Contraception 1986;34:333-40. 13. Vessey MP, Lawless M, Yeates D, McPherson K. Progestin-only oral contraception: findings in a large prospective study with special reference to effectiveness. BrJ Fam Plann 1985;10:117-21. 14. Reinhart W. Minipill: a limited alternative for certain women. Popul Rep 1975;A(3):53-67. 15. Westrom L. Incidence, prevalence and trends of acute pelvic inflammatory disease and its consequences in industrialized countries. Am J Obstet Gynecol 1980; 138:880. 16. Burkman RT. The Women's Health Study. Association between intrauterine device and pelvic inflammatory disease. Obstet GynecoI1981;57:269. 17. Lapido OA, Farr G, Otolorin E et a/. Prevention of IUDrelated infection: the efficacy of prophylactic doxycycline at IUD insertion. Adv Contracept 1991;7(1):43-54. 18. Sinei SKA, Schulz KF, Lamptey PR et a/. Preventing IUDrelated pelvic infection: the efficacy of prophylactic doxycycline use at insertion. Br J Obstet Gynaecol 1990;97(5):412-9. 19. Population Reports. Intrauterine Devices. Series B, No.5, March 1988; XVI, No.1. 20. The Population Council. US FDA extends effective use of the Copper-T IUD from six to eight years (news release). New York: The Population Council, October 7,1991. 21. Sivin I, Stern J. Long-acting, more effective Copper T IUDs: a summary of U.S. experience, 1970-75. Stud Fam Plann 1979;10(10):263-81. 22. Kozuh NM, Andolsek L, Balogh SA, Waszak CS. Long term use of intrauterine devices. IPPF Med Bull 1988;22(1 ):1-3. 23. Special report: NORPLANT. Contraceptive Technology Update Jan 1990;11(1):1-20. 24. Riphagen FE, Fortney JA, Koelb S. Contraception in women overforty. J Biosoc Sci 1988:127-42. 25. Beard RJ. Diseases affecting contraceptive practice in middle age. J Biosoc Sci 1979;SuppI.6:143. 26. Bowen-Simpkins P.Contraception for the older woman. Br J Obstet Gynaeco11984;91 :513. 27. Mauck C, Glover LH, Miller E et a/. Lea's Shield: a study of the safety and efficacy of a new vaginal barrier contraceptive used with and without spermicide. Contraception 1996:53(6):329-35.
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