Is it appropriate to initiate Combined Oral Contraceptive Pills (COCP) at the age of 50?

From the Guidelines

Starting combined oral contraceptive pills (COCPs) at age 50 is generally not recommended as a first-line contraceptive option. Women at this age are approaching menopause, and COCPs are typically discontinued at age 50 due to increasing risks that outweigh benefits, as suggested by the most recent guidelines 1. The risks of COCPs increase with age, particularly for cardiovascular events like blood clots, stroke, and heart attack, especially in women who smoke or have other risk factors such as hypertension or diabetes.

Alternative Contraceptive Methods

Instead, consider alternative contraceptive methods like:

• Progesterone-only pills (POPs)
• Hormonal IUDs
• Copper IUDs
• Barrier methods

These alternatives may offer a better risk-benefit profile for women at this age. If a woman at age 50 has no contraindications and strongly prefers COCPs, a low-dose formulation (containing 20-30 mcg of ethinyl estradiol) might be considered after thorough risk assessment by a healthcare provider, as indicated by previous studies 1. However, this should be a short-term solution with transition planning to a more appropriate method.

Perimenopausal Symptoms Management

Women at this age should also discuss perimenopausal symptoms management and when to safely discontinue contraception, which is typically recommended until one year after the last menstrual period, usually around age 51-52, according to the latest guidelines 1. The median age of menopause is approximately 51 years in North America, but can vary from 40 to 60 years, highlighting the need for individualized care 1.

Key Considerations

Key considerations in the decision to initiate COCPs at age 50 include:

• The increased risk of cardiovascular events with age
• The potential for interactions between hormonal contraception and chronic conditions
• The importance of thorough risk assessment and transition planning to a more appropriate method
• The need for individualized care and consideration of perimenopausal symptoms management, as emphasized by recent studies 1.

From the FDA Drug Label

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 Committee concluded that the benefits of low-dose oral contraceptive use by healthy non-smoking women over 40 may outweigh the possible risks.

The FDA drug label does not provide sufficient information to directly support the initiation of Combined Oral Contraceptive Pills (COCP) at the age of 50. Initiation of COCP at 50 is not explicitly recommended or discussed in the provided drug labels. However, the labels discuss the use of COCP in women over 40, and the potential risks and benefits associated with it. It is essential to consider individual patient factors and consult with a healthcare provider to determine the best course of action for a woman aged 50 who is considering initiating COCP. 2 2

From the Research

Initiation of Combined Oral Contraceptive Pills (COCP) at Age 50

• There are no studies that directly address the initiation of COCP at the age of 50, as the studies provided focus on women over 35 or in the reproductive age group (18 to 50 years) 3, 4, 5, 6, 7.
• However, the studies suggest that the risks associated with COCP use, such as cardiovascular disease and venous thromboembolism, increase with age and are higher in women over 35 years old 5, 6.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that women over 35 years old who want to use COCP should be assessed for cardiovascular risk factors and monitored regularly 5.
• Some studies suggest that the benefits of COCP use may outweigh the risks for most women, but the decision to initiate COCP should be made on an individual basis, taking into account the woman's medical history, lifestyle, and other risk factors 3, 4, 7.
• It is essential to consult with a healthcare provider to discuss the potential risks and benefits of initiating COCP at age 50 and to determine the best course of action for individual women.

Cardiovascular Risks Associated with COCP Use

• The risk of cardiovascular disease, including myocardial infarction and ischemic stroke, is increased in COCP users, particularly those over 35 years old 5, 6, 7.
• The risk of venous thromboembolism is also increased in COCP users, especially during the first year of use 5.
• Smoking and other cardiovascular risk factors, such as hypertension, can further increase the risk of cardiovascular disease in COCP users 5, 6.

Considerations for COCP Use in Women Over 50

• While there are no studies that directly address COCP use in women over 50, the available evidence suggests that the risks associated with COCP use increase with age 5, 6.
• Women over 50 who are considering COCP use should be aware of the potential risks and benefits and should discuss their individual situation with a healthcare provider 3, 4, 7.