combined oral contraceptive (COC) in the perimenopause

Last edited 02/2020

Combined Hormonal Contraception in women aged over 40 years

• may be given if no contraindications to women up to the age of 50 years
  • at aged 50 years switch to an alternative method of contraception (progestogen only pill or barrier). Subsequently follow advice on stopping contraception as per method used
    
    
• meta-analyses have found a slight increased risk of breast cancer among women using COC, but with no significant risk of breast cancer by 10 years after cessation
  
  
• women who smoke should be advised to stop CHC at 35 as this is the age at which excess risk of mortality associated with smoking starts to become clinically significant
  
  
• combined hormonal contraception (CHC) use in the perimenopause may help to maintain bone mineral density
  
  
• use of CHC may help to reduce menstrual pain and bleeding
  
  
• CHC may reduce menopausal symptoms
  
  
• however women experiencing menopausal symptoms while using CHC may wish to try an extended regimen
  
  
• CHC use provides a protective effect against ovarian and endometrial cancer - lasts for several decades after cessation of the method
  
  
• cervical cancer - appears to be a small increased risk of cervical cancer associated with COC use (former or current)
  
  
• there may be a reduction in the incidence of benign breast disease with CHC use (1)
  
  
• there is a reduction in the risk of colorectal cancer with CHC use
  
  
• there may be a small additional risk of breast cancer with CHC use, which reduces to no risk 10 years after stopping CHC use
  
  
• women who are aged 35 years or over and smoke should be advised that the risks of using CHC usually outweigh the benefits
  
  
• clinicians should be aware that there may be a very small increased risk of ischaemic stroke with CHC use
  
  
• women with cardiovascular disease, stroke or migraine with aura should be advised against the use of CHC
  
  
• practitioners who are prescribing CHC to women aged over 40 years may wish to consider a pill with <30 µg ethinylestradiol as a suitable first choice
  
  
• hypertension may increase the risk of stroke and myocardial infarction (MI) in those using CHC
  
  
• blood pressure should be checked before and at least 6 months after initiating a woman aged over 40 years on CHC and monitored at least annually thereafter

Reference:

• 1) FSRH (2010). Contraception for Women Aged Over 40 Years.
• 2) FSRH (2019). Contraception for Women Aged Over 40 Years.