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Contraception for the Transitional Years of Women Older than 40 Years of Age


 Many women older than 40 years of age require both contraceptive protection and hormonal replacement therapy for climacteric symptoms. Combination therapy is advisable but progestins should be added to estrogen to prevent endometrial hyperplasia, decrease the risk of breast cancer, and prevent bone loss. Since the mid-1970s oral contraceptives (OCs) have been limited to women under 35 years of age because of risks of myocardial infarction and thromboembolic disease. The new low-dose OCs used in the 1980s and 1990s have minimized these risks, however, older women who smoke are advised against using estrogen-containing OCs. Natural estrogens are often preferred to the synthetic estrogenic hormones in hormone-replacement products including conjugated equine estrogens, 17 beta estradiol, estradiol valerate, estrone sulfate, and combinations. New progestational agents, 19-nortestosterone derivatives, include norgestimate, gestodene, and desogestrel. RU-486 has potential applications in abortion, once-a-north treatment to induce menses, postcoital therapy, and in breast cancer. Reversible nonhormonal methods such as rhythm, abstinence and withdrawal are used frequently. Barrier methods (diaphragms, cervical caps, and condoms) and spermicides alone or with barrier methods (e.g., vaginal sponges) are increasingly used by older women. IUDs have enjoyed wide acceptance. Sterilization is a nonreversible method but clips (e.g., Filshie clip) have provided reversibility. Progestin-only contraceptives are supplied as oral tablets, injectable solution, silastic implants, medicated IUDs and vaginal rings. Combination estrogen and progestin contraceptives are available as oral tablets and as vaginal rings. A variety of doses and alternate products are necessary for older women.
