Disparities in Contraceptive Access and Provision
Contraceptive nonuse again increases in the latter portion of the reproductive age spectrum. In the age group of 40 to 44, contraceptive nonuse has been found more likely among black or Hispanic women, those who are not married or not cohabitating, who have less than a high school diploma or GED and have an income which is 100 to 249% of Federal Poverty Level. Factors associated with contraceptive nonuse among women 35 years and older, such as low SES, contraceptive knowledge, attitudes, and cost are similar to factors described in other age groups. However, the burden of medical comorbidities and maternal fetal complications are more common in women with advanced maternal age. Although women age 40 and older have a low rate of abortion overall, rates among this age group are increasing compared with younger women. Although providers and patients may assume that ovulation is rare in older women, ovulation has been observed even with elevated follicle-stimulating hormone (FSH) levels (> 20 IU/L). Eighty percent of women ages 40 to 43 are capable of conception, although their pregnancy rates are lower. Based on clinical experience, some experts recommend:
Contraceptive options for older women require consideration of associated medical comorbidities. Despite this, hormonal contraception is an option for appropriately selected patients. Birth control methods for older reproductive age women can include combined hormonal contraception after evaluation for cardiovascular risk factors and longer acting methods including the implant and IUC. These methods provide safe, removable alternatives for women of older reproductive age who wish to stop childbearing but do not desire sterilization. Benefits of levonorgestrel IUC, in addition to contraception, include improvements in menorrhagia, dysmenorrhea, and anemia (reducing requirements for hysterectomies), and counteraction of unopposed estrogen for women taking hormone replacement therapy or as adjuvant therapy with tamoxifen.
Women in Perimenopause
Contraceptive nonuse again increases in the latter portion of the reproductive age spectrum. In the age group of 40 to 44, contraceptive nonuse has been found more likely among black or Hispanic women, those who are not married or not cohabitating, who have less than a high school diploma or GED and have an income which is 100 to 249% of Federal Poverty Level. Factors associated with contraceptive nonuse among women 35 years and older, such as low SES, contraceptive knowledge, attitudes, and cost are similar to factors described in other age groups. However, the burden of medical comorbidities and maternal fetal complications are more common in women with advanced maternal age. Although women age 40 and older have a low rate of abortion overall, rates among this age group are increasing compared with younger women. Although providers and patients may assume that ovulation is rare in older women, ovulation has been observed even with elevated follicle-stimulating hormone (FSH) levels (> 20 IU/L). Eighty percent of women ages 40 to 43 are capable of conception, although their pregnancy rates are lower. Based on clinical experience, some experts recommend:
Restricting use of FSH to diagnose menopause to women older than 50 years who are using no or progesterone-only contraception.
Women older than 50 years waiting for 1 year of amenorrhea before stopping non-hormonal contraception.
Women younger than 50 years waiting for 2 years of amenorrhea before stopping non-hormonal contraception.
Contraceptive options for older women require consideration of associated medical comorbidities. Despite this, hormonal contraception is an option for appropriately selected patients. Birth control methods for older reproductive age women can include combined hormonal contraception after evaluation for cardiovascular risk factors and longer acting methods including the implant and IUC. These methods provide safe, removable alternatives for women of older reproductive age who wish to stop childbearing but do not desire sterilization. Benefits of levonorgestrel IUC, in addition to contraception, include improvements in menorrhagia, dysmenorrhea, and anemia (reducing requirements for hysterectomies), and counteraction of unopposed estrogen for women taking hormone replacement therapy or as adjuvant therapy with tamoxifen.
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