What are the recommended contraceptive options for women over 35?

Contraceptive Options for Women Over 35

For women over 35, long-acting reversible contraceptives (LARCs) such as IUDs and implants are the most recommended options due to their high efficacy and safety profile, while combined hormonal contraceptives should be used with caution, particularly in women with cardiovascular risk factors. 1

Safety Considerations for Women Over 35

Age-related contraceptive considerations are important as women approach their late reproductive years:

• Pregnancy risks increase with advanced maternal age, including higher rates of:

  • Hemorrhage
  • Venous thromboembolism
  • Maternal mortality
  • Spontaneous abortion
  • Stillbirth
  • Congenital anomalies 1

• Cardiovascular risks must be balanced against pregnancy risks:

  • Venous thromboembolism incidence is higher in oral contraceptive users ≥45 years compared to younger users
  • Myocardial infarction risk is elevated in all oral contraceptive users compared to non-users
  • Smoking significantly compounds these risks 1, 2, 3

Recommended Contraceptive Methods by Category

First-Line Options (U.S. MEC Category 1)

1. Progestin-only methods:

   • Levonorgestrel IUD (LNG-IUD): 0.1-0.2% failure rate
   • Copper IUD (Cu-IUD): 0.8% failure rate
   • Contraceptive implant: 0.05% failure rate
   • Progestin-only pills (POPs) 1, 4

2. Benefits of LARCs for women >35:

   • Highest efficacy (>99%)
   • No daily adherence required
   • LNG-IUD provides up to 8 years of protection with favorable bleeding profile 5
   • Cu-IUD is hormone-free, ideal for those with concerns about hormonal side effects 4

Second-Line Options (U.S. MEC Category 2)

1. Combined hormonal contraceptives (CHCs) for women 40-45 without risk factors:

   • Pills, patches, rings
   • Require careful screening for cardiovascular risk factors
   • 5-9% typical failure rate 1, 4

2. Injectable contraception (DMPA):

   • 0.3-6% failure rate
   • U.S. MEC Category 2 for women >45 years 1, 4

Contraindicated or Use with Caution

1. Combined hormonal contraceptives in women with:
   • Age ≥35 who smoke (<15 cigarettes/day: Category 3; ≥15 cigarettes/day: Category 4)
   • Hypertension
   • History of venous thromboembolism
   • Migraine with aura 1, 2, 3

Mortality Risk Considerations

The FDA drug label for hormonal contraceptives provides important mortality data:

Method of control	35-39 years	40-44 years
No contraception*	25.7	28.2
Oral contraceptives (non-smoker)†	13.8	31.6
Oral contraceptives (smoker)†	51.1	117.2
IUD†	1.4	1.4

*Deaths are birth-related †Deaths are method-related 2

This data clearly demonstrates that:

• IUDs have the lowest mortality risk across all age groups
• Smoking dramatically increases mortality risk with oral contraceptives
• For non-smoking women over 40, pregnancy-related mortality exceeds contraceptive-related mortality 2

Practical Algorithm for Contraceptive Selection in Women >35

1. Assess cardiovascular risk factors:

   • Smoking status
   • Hypertension
   • Diabetes
   • Migraine with aura
   • Previous VTE or stroke
   • Obesity

2. For women with NO cardiovascular risk factors:

   • First choice: LARCs (IUDs or implants)
   • Second choice: Progestin-only pills
   • Third choice: Combined hormonal methods (if <40 years)
   • Fourth choice: Barrier methods

3. For women WITH cardiovascular risk factors:

   • First choice: Copper IUD (non-hormonal)
   • Second choice: LNG-IUD or implant
   • Third choice: Progestin-only pills
   • Avoid: Combined hormonal contraceptives

Common Pitfalls to Avoid

1. Assuming fertility has ended prematurely:

   • No reliable laboratory tests can confirm definitive loss of fertility
   • Spontaneous pregnancies can occur until menopause (median age 51)
   • Continue contraception until menopause or age 50-55 1

2. Overestimating risks of hormonal methods:

   • For healthy, non-smoking women over 40, the benefits of low-dose hormonal contraceptives may outweigh risks
   • The risks of pregnancy at advanced maternal age often exceed contraceptive risks 1, 2

3. Underutilizing LARCs:

   • Despite having the highest efficacy and lowest risk profile, LARCs are still underutilized
   • Recent evidence supports extended use of LNG-IUD for up to 8 years 5

4. Unnecessary medical barriers:

   • Pelvic examinations are not required before initiating most contraceptive methods
   • Most women can start most contraceptive methods at any time 1

Remember that women approaching menopause should continue effective contraception until fertility has definitively ended, as unintended pregnancy in this age group carries significant health risks.