Leaning towards particular forms of contraception for certain age groups prevents medical professionals from thinking outside of the box. For example, younger women are typically offered options such as condoms, the combined pills/patches/rings, the subdermal implant (Implanon NXT) and the intramuscular (IM) depot progestogen injection (Depo-Provera). 

Women who are spacing children frequently opt for intrauterine devices such as the copper coil or the levonorgestrel intrauterine system (IUS), (Mirena and more recently Jaydess). Older women or couples whose family is finished may contemplate sterilisation but often carry on with intra-uterine contraception. It is striking how many women over 45 years of age believe their fertility has so diminished that they no longer use contraception of any kind. The spike in unplanned pregnancy rates among this age group confirms how inaccurate that belief may be. 

Importance of breaking traditional methods of prescribing

In recent times we are being urged to take a modern approach to contraception choices for all demographics. Younger women are much more likely to experience failures with the combined oral contraceptive pill (COCP) because it requires daily compliance. One forgotten pill – particularly near the pill-free interval – may result in an unintended pregnancy. 

For this reason, GPs and nurses are being advised to offer long-acting reversible contraceptive methods (LARC) to younger, more vulnerable patients. That is, of course, assuming the young woman involved is interested in the product. Concordance is key for compliance and continuation. 

The three-month IM depot progestogen-contraceptive injection conveys almost foolproof contraception for women of any age. As it can be associated with transient loss of bone mineral density (BMD) it is classified as UK Medical Eligibility Criteria (UKMEC) category 2 (benefits outweigh risks) for girls under 18 years but from 18-45 years it is category 1 (unrestricted use).

To encourage LARC use in younger women, there have been several initiatives internationally – UK, Canada, the US, Australia and other countries. These projects include the offer of intrauterine and subdermal contraceptives to adolescents who are sexually active.

The UKMEC for intrauterine device placement (Mirena, Jaydess and copper coils) is category 2 (benefits outweigh risks) for girls from menarche to 20 years and category 1 (unrestricted) for women over 20 years. Of the copper coils typically used in Ireland, the TT380 Slimline (10 years) and its smaller sister version the Mini TT 380 Slimline (five years) are the most popular. 

They not only provide years of very reliable contraception to a young woman but they can also be used as a superior form of emergency or postcoital contraception and are considered better than the over-the-counter NorLevo and even the prescription-only selective progesterone receptor modulator (ellaOne) tablets.

The main drawback of offering an intrauterine device (IUD) to sexually active teenagers is that these young women are at the age where the risk for sexually transmitted infections (STIs) is very high. There is a slight increase in pelvic inflammatory disease (PID) rates for 20 days or so after placement of an IUD. This has been shown in multiple studies. The increase appears to result from unidentified, pre-existing infections being accelerated by the instrumentation of the uterus and the arrival of a foreign body. 

Thereafter, the risk of PID returns to background. We can say with confidence that IUD-wearing women are no more exposed to PID than any other woman in that age group after the initial three weeks. So, if we are vigilant with pre-placement screening then we can safely offer IUDs to teenage patients.

All sexually active patients should be reminded that STIs are best prevented by the use of condoms.

The Contraceptive CHOICE Project 

An initiative from the US known as the Contraceptive CHOICE Project was a prospective cohort study of 10,000 women aged 14-45 who wanted to avoid pregnancy for at least one year and were initiating a new form of reversible contraception. They were read a script regarding LARC to increase awareness of LARC options. The participants were offered Mirena, copper coils, implants and Depo- Provera as first-line options, regardless of age. They were then given their chosen method free of charge and followed for three years. Results showed that 67% of women enrolled chose long-acting methods, 56% selected intrauterine contraception and 11% selected the subdermal implant. 

The project concluded that: once financial barriers were removed and LARC methods were introduced to all eligible women (including young women, nulliparous women and women with a history of an STI) then two-thirds chose LARC.

On a similar note, the American College of Obstetrics and Gynaecologists issued a committee opinion paper in October 2012 on adolescents and LARC (implants and IUDs). It advised that as adolescents were at higher risk of unintended pregnancy, they would benefit from increased access to LARC methods.

What about the other end of the spectrum? 

Women over 35 years who smoke or are overweight or who have any other significant cardiovascular (CV) risk factor must discontinue oestrogen-containing methods, that is the pill, patch and ring. But what about slim, non-smoking healthy women in their 30s and 40s and beyond? 

The use of oestrogen methods as listed above are all UKMEC 1 (unrestricted) up to 40 years (in the absence of any CV risk factors) and UKMEC 2 (benefits outweigh risks) from 40-50 years. Over 50 years of age increasing CV risks outweigh the benefits. Besides, there are many non-oestrogen methods available for patients over the age of 50.

Another factor in decision-making may be that many women in their 40s enjoy relief from their perimenopausal symptoms when using an oestrogen-based contraceptive method. 

Some women feel more comfortable using the COCP as opposed to hormone replacement therapy (HRT) which unfortunately may hold negative connotations for them. Additionally using the COCP at this time delivers both contraception and menopause relief. 

Prof John Guillebaud suggests that one of the newer, non-ethinyloestradiol COCPs like Qlaira or Zoely might be preferable but there have been no trials as yet to show safety advantages from these newer pills. 

Summary

Contraception is only as reliable as the patients’ willingness to use it. The more convenient a product is to use, the more attractive it is for the patient.  Healthy women may be offered any reversible method of contraception including LARC as long as they don’t have any category 4 (absolutely contraindicated) risk factors. Age alone is never a category 4 risk.  

References

1. FSRH: Combined Hormonal Contraception Clinical Effectiveness Unit October 2011 (Updated August 2012) & Intrauterine Contraception Clinical Effectiveness Unit November 2007
2. Guillebaud J. Contraception Today (seventh edition)
3. Secura GM, Allsworth JE, Madden T, Mullersman JL, Peipert JF The Contraceptive CHOICE Project: Reducing Barriers to Long-Acting Reversible Contraception. Am J Obstet Gynecol. 2010; 203(2): 115.e1–115.e7. doi:10.1016/j.ajog.2010.04.017
4. The American College of Obstetrics & Gynaecology Committee Opinion No 539 Oct 2012. Adolescents and Long-Acting Reversible Contraception: Implants & Intrauterine Devices