From the Guidelines
Oral contraceptive pills can be a good long-term option for many women, but individual suitability varies and should be determined based on the latest guidelines and a thorough assessment of the patient's medical history and risk factors. According to the most recent study 1, the age at which a person is no longer at risk for becoming pregnant is not known, and spontaneous pregnancies can occur among persons aged >44 years.
Key Considerations
- The American College of Obstetricians and Gynecologists and the North American Menopause Society recommend that women continue contraceptive use until menopause or age 50–55 years 1.
- The median age of menopause is approximately 51 years in North America, but can vary from 40 to 60 years 1.
- No reliable laboratory tests are available to confirm definitive loss of fertility in a woman, and the assessment of follicle-stimulating hormone levels to determine when a woman is no longer fertile might not be accurate 1.
Risks and Benefits
- Pregnancies among women of advanced reproductive age are at higher risk for maternal complications, such as hemorrhage, venous thromboembolism, and death, and fetal complications, such as spontaneous abortion, stillbirth, and congenital anomalies 1.
- Risks associated with continuing contraception, in particular risks for acute cardiovascular events or breast cancer, also are important to consider 1.
- The incidence of venous thromboembolism was higher among oral contraceptive users aged 45–49 years compared with younger oral contraceptive users, but an interaction between hormonal contraception and increased age compared with baseline risk was not demonstrated 1.
Recommendations
- Healthcare providers should consider the risks for becoming pregnant in a patient of advanced reproductive age, as well as any risks of continuing contraception until menopause, and use the U.S. MEC to guide the safe use of contraceptives in these patients 1.
- Patients of advanced reproductive age might have chronic conditions or other risk factors that might render use of hormonal contraceptive methods unsafe, and individualized assessment is necessary 1.
From the FDA Drug Label
The activity and amount of both hormones should be considered in the choice of an oral contraceptive. Minimizing exposure to estrogen and progestogen is in keeping with good principles of therapeutics For any particular estrogen/progestogen combination, the dosage regimen prescribed should be one which contains the least amount of estrogen and progestogen that is compatible with a low failure rate and the needs of the individual patient
In 1989, the Fertility and Maternal Health Drugs Advisory Committee was asked to review the use of oral contraceptives in women 40 years of age and over The Committee concluded that although cardiovascular disease risks may be increased with oral contraceptive use after age 40 in healthy non-smoking women (even with the newer low-dose formulations), there are also greater potential health risks associated with pregnancy in older women and with the alternative surgical and medical procedures which may be necessary if such women do not have access to effective and acceptable means of contraception.
The benefits of low-dose oral contraceptive use by healthy non-smoking women over 40 may outweigh the possible risks Of course, older women, as all women, who take oral contraceptives, should take an oral contraceptive which contains the least amount of estrogen and progestogen that is compatible with a low failure rate and individual patient needs
Oral Contraceptive (OC) Pill as a Long-Term Option: The decision to use oral contraceptives as a long-term option should be made on an individual basis, taking into account the woman's age, health status, and risk factors.
- Key Considerations:
- Minimizing exposure to estrogen and progestogen
- Choosing the lowest effective dose
- Weighing the benefits and risks for each individual patient
- Special Considerations for Women Over 40:
From the Research
Effectiveness and Risks of Oral Contraceptives
- Oral contraceptive pills are a reliable and convenient method of birth control, with pregnancy rates of 4% to 7% per year 3.
- The effectiveness of oral contraceptives is determined by a combination of drug or device efficacy, individual fecundability, coital frequency, and user adherence and continuation 3.
- Long-acting methods, such as intrauterine devices and subdermal implants, have higher effectiveness, with failure rates of less than 1% per year 3.
Safety Concerns
- Estrogen-containing oral contraceptives increase the risk of venous thrombosis, with 7 to 10 venous thrombotic events per 10 000 women-years 3.
- Progestin-only pills are associated with lower risks, including rare serious risks, and are a safer option for patients with a history of hypertension or thrombosis 4.
- Oral contraceptive pills have been linked to an increased risk of myocardial infarction, stroke, and venous thromboembolism, although these risks are minimal in low-risk women 5.
Considerations for Long-Term Use
- Well-designed studies have shown that the incidence of thromboembolic disease is related to the estrogen dose, and the risk of thromboembolism is highest in women who smoke 6.
- Oral contraceptives have been shown to protect against endometrial and ovarian cancer, and the risk of breast cancer appears to be increased only minimally among current oral contraceptive users 6.
- The medical eligibility criteria for contraceptive use, summarized by the Centers for Disease Control and Prevention, provide recommendations for contraception use by patients with preexisting conditions or risk factors 4.
Alternatives and Patient Considerations
- Estrogen-free progestin-only pills are a valuable option for women who prefer to take an oral hormonal contraceptive but are ineligible for, or choose not to use, combined oral contraceptives 7.
- Optimal contraceptive selection requires patient and clinician discussion of the patient's tolerance for risk of pregnancy, menstrual bleeding changes, other risks, and personal values and preferences 3.