M. Short

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“Contraception should be used on every conceivable occasion”
       Spike Milligan



       In general decline in fertility is associated with increasing age,  most notably for women. Women are born with a fixed number of oocytes  which diminish with age leaving few if any capable of fertilization in  the peri menopause.

       Non the less women continue to have a sexual life long after their  desire to have children and there is probably a no more compliant group  than these women, who are all well aware of the inherent problem of  pregnancy at this age, both for themselves and for the       foetus.





       There is a high degree of foetal abnormality, especially in older  women due in part to the increasing frequency of trisomies as one gets  older. Clinically recognised abortion occurs in only 12% of women  younger than the age of twenty but the incidence more than doubles in  women over 40 years and the overall abortion risk (recognised and  unrecognised) in women over 40 years is 75% and more than two thirds or  70% of these are due to chromosomal abnormalities. 25% of pregnancies in  theory at least, in this age group go to term - the potential for a  chromosomal abnormality of which downs Syndrome is the most noted, is  very high.

       As with ageing of the ovaries ageing of the testes influences both  the individual and the progeny. From around the age of thirty the  number and quality of the spermatozoa begin to decline with endocrine  function diminishing some ten years later. Paternal ageing may therefore  be responsible for chromosomal abnormalities; it may also be the source  of dominant and recessive mutations which will manifest themselves in  the descendants. Chromosomal abnormalities are not the only problem; in a  study from the Rotunda Hospital, Milner et al found a significant  increase of gestational diabetes, ante partum haemorrhage, foetal  distress, pre-maturity low birth weight and peri-natal mortality. With  statistics like this contraception for both men and women in their 40’s  becomes a public health issue.





       Progesterone only pills become more efficacious with age but there  are the attendant problems of poor cycle control with irregular  bleeding or no bleeding at all Irregular cycles at this time may only  serve to create more tension and anxiety in the relationship when fear  of pregnancy becomes more real due to the increased risk of foetal  abnormality. Amennorhea may also pose a problem.

       Good counselling might reassure the woman that she is not pregnant  but there is the anxiety regarding osteoporosis after 5 years of  amenorrhea. The same applies to Depo Provera and Norplant. Added to this  is the local problem of the progestagenic effects on the cervix leading  to thickened cervical mucus thus making intercourse more difficult than  it need be. On a more positive note progestagen only pills have a less  suppressive effect on gonadotrophins. Raised FSH levels on two separate  occasions in a woman using P.O.P. usually indicates ovarian failure  hence the biochemical diagnosis of the menopause is not interfered with.  On the other hand the effect of the long term use of progestagens on  lipids and on bone mass have yet to be fully evaluated.

       IUCD’s may well be another option but IUCD’s are not without their  problem relating to insertion and subsequent sequelae like spotting and  cramps and menorrhagia. However, they are a good way to receive  progestagens at the time of the peri-menopause and after without the  nuisance side effects, especially in women with menorrhagia.

       Barrier methods, particularly condoms, are an oft suggested method  of contraception for peri-menopausal couples. However when couples have  been used to more aesthetically pleasing contraception condoms and  diaphragms may not only prove difficult to use but can be off-putting as  well. Indeed regular users of diaphragms often experience difficulty  with insertion due to an increase in vaginal dryness and concomitant  cystitis. What would be the benefits of using a combined oral  contraceptive for the pre-menopausal women? Advantages of Combined Oral  Contraception

       Apart from the primary advantage of effective contraception in a  very compliant population major advantage would be cycle control. There  would be fewer hospital admissions for curettage and perhaps fewer  hysterectomies. It is reasonable to assume that oral combined  contraceptives protect against hot flushes. They may also protect  against osteoporosis. Other benefits of oral contraceptives, like  protection against ovarian cysts, endometrial and ovarian cancer are the  same in the age group above 40 as among younger women.





       It is known that 9% of women over the age of 45 years with a  history of 6 months amenorrhea will resume menstruation and that  ovulation can occur right up o the menopause in spite of post menopausal  hormone profiles.

       In 1988 the New Zealand study of Metcalf suggested that as long as  menstruation remains regular, women over the age of 40 years continue  to ovulate in 98% of cycles.

       Kaufert in interviews with peri-menopausal women over a 3 year  period provided evidence that there is no steady progress from pre- to  post menopause. Indeed women appeared to oscillate between the peri- and  the pre-menopausal state. Hence post menopausal bio-chemical parameters  were no guarantee of a post menopausal state. The most sensitive marker  for declining ovarian function in women with regular cycles is an  elevated FSH in the follicular phase. Lenton et al found that FSH levels  rise dramatically from 40 - 41 years such that by the age of 46 - 47  concentrations had almost doubled with a further increase in the 48 - 49  age group. On the other hand mean concentrations of LH remain static  until the 49 - 49 age band when they are doubled. The oestrogen  containing oral contraceptive prevents ovulation by the suppression of  gondotrophin secretion and will mask the symptoms of ovarian failure as  the progestagen component of the combined pill will ensure regular  monthly withdrawal bleeds irrespective of menopausal status. In the  pre-menopause LH and FSH are suppressed by at least 50% and may be  undetectable by current assays. In post menopausal women an 80-%  suppression of FSH has been reported for women given 50 micrograms of  Ethinyl oestradiol. The question of menopause therefore arises in women  who have become amenorrheic on stopping the pill.

       FSH levels are of value here providing sufficient time has elapsed  since stopping the pill to allow for recovery of the endogenous  gonadotrophins, There are data to show that gonadotrophin levels return  to normal after 1 week. However the women is not likely to present for 6  - 8 weeks after stopping the pill when the FSH levels should no longer  be affected.

       Use of oral contraception masks the menopause and the correct time  for transition from contraception to HRT may be difficult.

       Since standard HRT is not a contraceptive there are two approaches  to contraception currently available Clinically contraception should be  advised up to the age of 55 years while women are taking HRT.  Alternatively while off all hormonal preparations two FSH levels 4 - 8  weeks apart, together with amennhorea are taken to mean significant loss  of ovarian function. Current recommendations then are that in the over  50’s contraception be used for 1 year following one year of amenorrhea  and for two years in younger women. Very little is mentioned in the  literature regarding oral contraception at this transient time, although  the FDA have no upper limit on the use of oral contraception at this  time.

       It is estimated that approximately 9% of women taking HRT and  fewer still take it for any significant length of time. Most stop after  three months perhaps then we should be advocating combined oral  contraception preparations not only for their contraceptive effects but  for the very real beneficial side effects that are not diminished in  this age group.





       The benefits of combined oral contraception are not in doubt  regardless of age. However, we must weigh up the benefits of effective  contraception which alleviates menopausal symptoms and perhaps has bone  sparing properties against the cardio-vascular risks in women over the  age of 45 years. The risk of pregnancy, delivery or abortion should not  be underestimated. Contrary to popular belief women over a certain age  do have intercourse. Maybe they don’t get pregnant so easily but they  need more effective contraception not less for the sake of their health,  if not their sanity.

1) Kruitwagen R.F.P.M, Poels, L.G. Willemsen, W.N.P., Jap, P.H.K., Thomas, C.M.G. and Roland, R. (1991) Endometrial epitheleal cells in peritoneal fluid during the early follicular phase. Fertil. Steril.,55, 297.

2) Jenkins, S.,Olive, D.L. and Haney, A.F. (1986) Endometriosis: pathogenic implications of the anatomic distribution. Obstet. Gynecol., 67, 335

3) Milner, M., Barry-Kinsella C., Unwin, A. and harrison, R.F (1992). The impact of maternal ageing on pregnancy and it’s outcome. Int. J.Gynaecol. Obstet., 38, 281-6 

4) Auroux M. (1995) Fertility and Sterility: A current Overview, pp. 321-2. (Carnforth, U.K; Parthenon Publishing.) 

5) Guillebaud, J. (1993). Contraception: Your questions Answered, 2nd edn., pp 228-34 (London: Churchill Livingston)

6) Whitehead M.I. and Godfree, V. (1992) Hormone Replacement Therapy: Your Questioned Answered, pp. 217-18 (Edinburgh: Churchill Livingstone)

7) Nesheim, B.I. (1994) Contraception towards the menopause. Lake-medelsverket, Sweden, 2 177-83 

8) Volpe, A., Silfieri, M., Genazzani, A.D and Genazzani, A.R. (1993) Contraception in older women. Contraception, 47, 29-39 

Articles

In general decline in fertility is associated with increasing age, most notably for women. Women are born with a fixed number of oocytes which diminish with age leaving few if any capable of fertilization in the peri menopause.

M. Short

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