Best Contraceptive for a 40-Year-Old Non-Smoking Woman with Normal BMI
For a 40-year-old non-smoking woman with normal BMI, long-acting reversible contraception (LARC) methods—specifically the levonorgestrel IUD, copper IUD, or contraceptive implants—are the optimal choices, as they carry no restrictions (U.S. MEC Category 1) and provide the highest effectiveness with minimal cardiovascular risk. 1, 2
Primary Recommendation: LARC Methods
Why LARC Methods Are Superior
Progestin-only pills (POPs), implants, the LNG-IUD, and the Cu-IUD are classified as U.S. MEC Category 1 (no restrictions) for women over 40 based on age alone. 1
These methods have failure rates of less than 1% per year, making them the most effective reversible contraceptive options available. 3
LARC methods avoid estrogen exposure entirely, eliminating concerns about age-related cardiovascular risks while maintaining superior efficacy. 2
The American College of Obstetricians and Gynecologists specifically recommends copper IUDs, levonorgestrel IUDs, contraceptive implants, and progestin-only pills as the most suitable options for women over 40 due to their favorable safety profiles. 2
Secondary Option: Combined Hormonal Contraceptives
When Combined Methods Are Acceptable
Combined hormonal contraceptives (pills, patch, ring) are classified as U.S. MEC Category 2 for women over 40 who are non-smokers, meaning advantages generally outweigh theoretical or proven risks. 1, 2
Low-dose combined oral contraceptives (containing ≤0.035 mg estrogen) can be used safely in healthy non-smoking women over 40, though careful follow-up is required. 4
Important Cardiovascular Considerations
The incidence of venous thromboembolism is higher among oral contraceptive users aged 45-49 years compared with younger users, though the interaction between hormonal contraception and increased age compared with baseline risk has not been consistently demonstrated. 1, 2
The relative risk for myocardial infarction is higher among all oral contraceptive users than non-users, though a trend of increased relative risk with increasing age has not been consistently demonstrated. 1
Small but nonsignificant increased relative risks for breast cancer have been suggested among women who used oral contraceptives when aged ≥40 years compared with never-users. 1
Critical Clinical Context
Balancing Pregnancy Risk vs. Contraceptive Risk
Pregnancies among women of advanced reproductive age carry higher risks for maternal complications (hemorrhage, venous thromboembolism, death) and fetal complications (spontaneous abortion, stillbirth, congenital anomalies). 1
The FDA Fertility and Maternal Health Drugs Advisory Committee concluded that the benefits of low-dose oral contraceptive use by healthy non-smoking women over 40 may outweigh the possible risks, given the greater health risks associated with pregnancy in older women. 4
Duration of Contraceptive Need
Contraceptive protection is still needed for women aged >44 years who want to avoid pregnancy. 1, 2
Both 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, 2
The median age of menopause is approximately 51 years in North America but can vary from 40 to 60 years, and no reliable laboratory tests are available to confirm definitive loss of fertility. 1, 2
Common Pitfalls to Avoid
Do not assume fertility has ended before confirmed menopause (12 months without menses), as spontaneous pregnancies can occur in women over 44 years. 1, 2
Do not require unnecessary screening examinations (such as pelvic exams) before prescribing oral contraceptives—hormonal contraception can be safely provided based on medical history and blood pressure measurement alone. 1
Do not overlook screening for chronic conditions or other risk factors that might render hormonal contraceptive methods unsafe in this age group, as U.S. MEC should guide safe use. 1
If combined hormonal contraceptives are chosen, prescribe the lowest effective dose formulation (≤0.035 mg estrogen) to minimize cardiovascular risk. 4