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Case History

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Image not available. A 40-year-old lady requests contraceptive advice. She has recently started a relationship with a new partner of the same age. She has two children from a previous relationship and she is very sure that she does not wish to have any more children. During her previous relationship she took the combined oral contraceptive (COC) pill and this suited her well.

What are the important points to record in the history?

What are the choices available and which methods are most appropriate?

How long does she need to continue with contraception?

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Background

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Image not available. Contraceptive choices for women over the age of 35 years differ from those of teenagers and younger women for a number of reasons. With increasing age, concurrent medical conditions are more likely to exist and risk–benefit ratios of the different methods often change. Frequency of intercourse, sexual function, menstrual irregularities and hormonal changes all impact on contraceptive choice.

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Although there is a natural decline in fertility with age, pregnancy in older women is associated with a higher risk of miscarriage, congenital and chromosomal abnormalities, pregnancy complications and maternal morbidity and mortality.1 Unwanted pregnancy leading to termination is often particularly distressing in this group of patients. It is therefore essential to offer an acceptable method which also provides effective contraceptive cover.

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What are the important points to record in the history?

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It is essential to take a careful medical history, with particular emphasis on cardiovascular risk factors, malignant disease and medication. Family history remains of importance, as does smoking status, and a brief obstetric and gynaecological history should be recorded, including date of the last cervical smear.

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Often overlooked in this age group, but of particular importance, is the need to record a sexual history. The importance of using barrier contraception is often not appreciated in relationships in later life. Sterilization is more common, and having more often been in long-term relationships previously, the risk of sexually transmitted infection (STI) is often not considered seriously enough. As a result, the prevalence of STIs in this age group is increasing.2

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What are the choices available and which methods are most appropriate?
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The World Health Organization Medical Eligibility Criteria for Contraceptive Use (WHOMEC)3 offers guidance on the safety of use of 19 different methods of contraception for women or men with specific characteristics or known medical conditions. The recommendations are based on systematic reviews of available clinical and epidemiological research. Categories include circumstances where generally the benefits of using a particular method outweigh the risks (WHO category 1: unrestricted use; and WHO category 2: benefits outweigh risks) and circumstances where the reverse is true (WHO category 3: risks outweigh the benefits, use with caution; and WHO category 4: use of the method poses an unacceptable health risk).

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Combined hormonal contraception
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