Contraception in women over forty

The choice of an acceptable effective easy and safe contraceptive method for women over 40 is not easy. The US Food and Drug Administration warns against the use of combined oral contraceptives for women over 35 because of their cardiovasular risks. Studies showing increased risks of thromboses and myocardial infarct however have examined all combined OCs as a group without differentiating dose levels or the type of progestein employed and have not controlled other possible vascular risk factors such as hypertension smoking stress or hyperlipidemia. Studies dating from 1975 and 1977 refer largely to use of high-dosed pills. Estrogens increased the triglyceride level aggravate some cases of diabetes increase blood pressure cause a modest disturbance of blood coagulation and have a negative effect on vascular endothelium. Progestins derived from norsteroids lower cholesterol levels including high density lipoprotein cholesterol levels lower triglyceride levels and have a moderate effect on blood pressure coagulation and the vascular wall. On the other hand the carcinogenic effects earlier feared have not been proven. Combined OCs have the advantages of efficacy prevention of benign breast disease secondary to hyperestrogenism after age 40 and reduction of rheumatoid arthritis. Age is not an absolute contraindication for healthy women under 45 with no vascular or metabolic risk factors as long as regular follow-up every 6 months is provided. Low-dose biphasic or continuous preparations are preferable. After 45 most patients will have anovulatory cycles. High-dosed progestin-only pills provide effective contraception and are helpful in cases of benign breast disease and endometrial hyperplasias and cysts but use on a longterm basis carries vascular and metabolic risks. Continuous low-dose progestins appear to be an ideal method for women over 40 with no effect on blood pressure lipid or glucose metabolism or the cardiovascular system. However they are poorly tolerated by some patients because of irregular bleeding patterns hyperestrogenism and other factors. The failure rate is higher than that of other OCs and the ectopic pregnancy rate is also higher because of reduced tubal motility. The IUD may be a good method for older women because the risk of expulsion is less and the consequences of a possible infection would be less serious for women whose childbearing is completed. The classic contraindications should be respected; uterine scars upper genital tract infections suspected neoplasia polycups and undiagnosed genital bleeding. Progesterone-bearing IUDswhich reduce menstrual bleeing and pain may be particularly appropriate. A new generation of spermcidal tablets and creams have relatively low failure rates but their use requires a 15-minute delay after insertion. Diaphragms used with spercides and the new contraceptive sponges may be good choices for older women in case of contraindications or refusal of other methods. Voluntary sterilization is very reliable but its legal status in France is ambiguous. Couples should be encouraged to use a less permenent method because of the possibilty of psychological sequelae. Most operators will not attempt sterilization reversals in women over 40.