Is contraception recommended for a 44‑year‑old sexually active woman who does not wish to become pregnant and has no smoking, hypertension, venous thromboembolism, migraine with aura, or active breast or liver disease?

Contraception for a 44-Year-Old Woman

Yes, contraception is strongly recommended for a 44-year-old sexually active woman who wishes to avoid pregnancy, and she should continue using it until menopause is confirmed (12 months without menstruation) or until age 50-55 years. 1

Why Contraception Is Still Necessary

Pregnancy remains possible and carries significant risks at age 44. Although fertility declines with age, spontaneous pregnancies still occur in women over 44 years, and the exact age when fertility definitively ends cannot be reliably determined. 1

Risks of Pregnancy at Advanced Reproductive Age

Unintended pregnancy at age 44 poses substantially elevated risks compared to younger women:

• Maternal complications: Hemorrhage, venous thromboembolism, and death occur at higher rates 1
• Fetal complications: Spontaneous abortion, stillbirth, and congenital anomalies are more common 1
• High unintended pregnancy rate: A substantial proportion of pregnancies in this age group are unintended, which compounds negative maternal and infant outcomes 2

Fertility Cannot Be Reliably Confirmed

No laboratory test can definitively confirm loss of fertility—even follicle-stimulating hormone (FSH) levels are unreliable for this purpose. 1 The median age of definitive fertility loss is 41 years, but it can extend to age 51 years. 1

Recommended Contraceptive Methods

For a healthy 44-year-old woman without contraindications, the safest and most effective options are IUDs (copper or levonorgestrel) and contraceptive implants, which are classified as Category 1 (no restrictions) by the U.S. Medical Eligibility Criteria. 1, 3

First-Line Options (Category 1 - No Restrictions)

• Copper IUD (Cu-IUD): Highly effective, non-hormonal, no age-related concerns 1, 3
• Levonorgestrel IUD (LNG-IUD): Highly effective, provides additional benefits of reduced menstrual bleeding and endometrial protection 1, 3, 4
• Contraceptive implants: Highly effective, long-acting reversible contraception 1, 3
• Progestin-only pills (POPs): Safe option without estrogen-related risks 1, 3

Second-Line Options (Category 2 - Benefits Generally Outweigh Risks)

• Combined hormonal contraceptives (CHCs): Pills, patches, or vaginal rings can be used but require more careful consideration of cardiovascular risk factors 1, 3
• Depot medroxyprogesterone acetate (DMPA/Depo-Provera): Effective but has bone density concerns that are particularly relevant in perimenopausal women approaching natural bone loss 1, 5

Important Considerations for Combined Hormonal Contraceptives

While CHCs are classified as Category 2 (generally safe) based on age alone, the evidence shows nuanced risks: 1, 3

• Venous thromboembolism: Incidence is higher in women aged 45-49 years using oral contraceptives compared to younger users, though the interaction between hormonal contraception and age versus baseline risk has not been consistently demonstrated 1, 3
• Myocardial infarction: Relative risk is elevated in all oral contraceptive users versus non-users, but no clear trend of increasing risk with age has been shown 1, 3
• Stroke: No studies specifically examined stroke risk in women aged 45-49 using CHCs 1
• Breast cancer: Small, non-significant increased relative risks have been suggested in women who used oral contraceptives or DMPA when aged ≥40 years 1

The key principle: Age alone does not contraindicate any method, but individual risk factors (smoking, hypertension, VTE history, migraine with aura, breast cancer, liver disease) must be assessed using the U.S. Medical Eligibility Criteria. 1, 2, 6

Special Considerations for Depo-Provera

If considering DMPA, be aware of specific concerns for women over 44: 5

• Bone mineral density loss: While BMD losses stabilize by 5 years and are largely reversible after discontinuation, this is particularly concerning in perimenopausal women already at risk for osteoporosis 5
• Preferred alternatives: Transition to copper IUDs, levonorgestrel IUDs, or implants (all Category 1) to avoid bone density concerns while maintaining highly effective contraception 5
• If continuing DMPA: Ensure adequate calcium and vitamin D supplementation, regular weight-bearing exercise, and avoidance of smoking and alcohol 5

Duration of Contraceptive Use

Continue contraception until one of these endpoints: 1, 5, 3

• Confirmed menopause: 12 consecutive months without menstruation 5, 3
• Age 50-55 years: As recommended by both ACOG and the North American Menopause Society 1, 3

The median age of menopause in North America is approximately 51 years, but it can vary from 40 to 60 years. 1, 3

Common Pitfalls to Avoid

• Do not assume fertility has ended before confirmed menopause: Unintended pregnancy remains possible and carries higher maternal and fetal complication risks at advanced reproductive age 5, 3
• Do not rely on FSH testing: No reliable laboratory test confirms definitive loss of fertility 1, 3
• Do not continue DMPA indefinitely without reassessment: Particularly regarding cumulative bone density loss in perimenopausal women 5
• Do not overlook individual risk factors: While age alone doesn't contraindicate methods, smoking, hypertension, VTE history, migraine with aura, or breast cancer significantly alter method eligibility 1, 3

Practical Algorithm for Method Selection

1. Assess contraindications: Screen for smoking, hypertension, VTE history, migraine with aura, breast cancer, liver disease 1, 3

2. If no contraindications exist:

   • First choice: Offer IUDs (copper or levonorgestrel) or implants—these are Category 1 and provide the best safety profile with highest efficacy 1, 3
   • Alternative: Progestin-only pills if patient prefers oral method 1, 3
   • Consider CHCs: If patient specifically desires combined hormonal method and has no cardiovascular risk factors 1, 3

3. If contraindications exist: Use U.S. Medical Eligibility Criteria to guide method selection based on specific conditions 1

4. Counsel on duration: Continue until confirmed menopause (12 months amenorrhea) or age 50-55 years 1, 5, 3