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J Obstet Gynaecol (Lahore). 1985 Jan;5 Suppl 2:S70-7.

Contraception for the older woman.



In this discussion of contraception for the older woman, attention is directed to declining fertility with age as well as the various available contraceptive methods--combinations of estrogen and progestagen oral contraceptives (OCs), the progestagen only pill, injectable progestagens, IUDs, the levonorgestrel releasing IUD, barrier methods, other reversible methods, natural family planning methods, postcoital contraception, and male and female sterilization. According to a review of the literature pertaining to declining fertility with age by Gray (1979), the likelihood of permanent sterility at age 40 is about 40% and at age 45 is about 80%. For the remainder, above age 40 the monthly risk of pregnancy declines as ovulation becomes less frequent. A most important consequence of this declining fertility is that the efficacy of various methods "catches up" with that for the combined pill. Carefully used, all the contraceptive methods are nearly 100% effective. At this time, there is good agreement that modern lowest dose combined OCs may be used up to age 45 if no risk factors exist, but they should be discontinued at age 35 in the presence of risk factors such as smoking. It appears that combination preparations for treatment of climacteric symptoms give more progestagen than is either necessary or desirable and do not provide the progestagen for long enough in each monthly cycle to be reliably contraceptive. A better choice is a daily dose of 1 of the natural estrogens with the addition of 1-3 progestagen only pills daily, the dose of the latter being titrated against the uterine bleeding response. If the woman will accept amenorrhea, a continuous regimen appears more likely to avoid the problem of breakthrough bleeding or spotting. For women without climacteric symptoms who want contraceptives above the accepted maximum age for the combined OC, most doctors would welcome a combination preparation administered by any approved route. Pending the availability of this, prescribers may be prepared to give selected women a combination of tablets each day. For contraception alone, a new option should be the levonorgestrel releasing IUD, without or with estrogen supplementation orally, according to symptoms. Barrier methods are highly appropriate. The use of spermicides alone is not recommended in older women unless they already are experiencing prolonged cycles and vasomotor symptoms and accept a small conception risk. Natural family planning normally cannot be recommended in this age group who may have menstrual irregularity. Postcoital contraception may be indicated on the same criteria as at younger ages. Finally, for many couples sterilization of the appropriate partner is the answer.

[Indexed for MEDLINE]

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