I'm 51, can I still use the NuvaRing?

Ask Dr. Jen

I’m 51 and about to fill my last NuvaRing prescription. My PCP is reluctant to fill it this last time, but I still get periods and I’m worried about having a positive pregnancy test without the birth control. Are the tests they use reliable to say if you’re no longer likely to get pregnant? I didn’t get my first period until I was 15. 

Via Instagram

Short Take

Taking estrogen-containing contraception, like the NuvaRing, until age 55 is generally considered low risk for women without cardiovascular risk factors. The period that you get with the NuvaRing is due to the hormones in the ring, so it isn’t a marker of whether you are ovulating or not. Unfortunately, hormone testing doesn’t reliably tell us when people can stop using contraception. 

Tell Me More…

While the pregnancy rate drops considerably for women over the age of 45, it isn’t zero until you are menopausal. The current guidelines for when you can stop contraception and not worry about pregnancy are 2 years with no menstrual bleeding if you are under age 50, and one year if you are 50 years old or older. By age 55, the consensus is contraception is no longer needed, but I’ll add the caveat that if by some chance you are having regular periods and are 55 years old, I’d talk with your health provider before going contraception-free. 

It’s true that when people are a few years into their menopause (defined as the last period) that estradiol levels are low and follicle stimulating hormone (FSH) levels are high. And so some providers test these hormones and if they get a low estradiol/high FSH they say, great, you are in menopause. You can give up contraception. However, we have no studies to support this approach.

There are 4 basic hormonal profiles in the menopause transition, and the hormone tests can’t tell us which profile is yours. Look at the image below, which is from the SWAN study. The top graph is levels of estradiol and the bottom is FSH, and each one has 4 lines that represent the 4 different hormone profiles.

You can see that for some women estradiol levels are lower before their final period and for some it takes 2-3 years to reach that level. In addition, within these lines are cycle to cycle variability during the menopause transition, so during some cycles, estradiol may be low and FSH high, and look just like menopause, and then the very next cycle you could ovulate. And, the reverse is true. You could have a cycle with very high estradiol levels and low FSH and think, wow, my hormones look like I’m 25, and that could literally be your last cycle.

Hormone tests can either falsely tell you that you are in menopause, increasing your risk of pregnancy and they can falsely tell you that you are years away, when in fact you may be closer than you think. This all sucks, I’m not denying that, but the facts are the facts. In addition, you can’t have these tests done while using hormonal contraception.

The period that you get with the NuvaRing, pill, or the patch, can’t be used to see if you are menopausal or not. It is due to the withdrawal of the hormones in the medication, not your cycle. 

So, then, what do you do?

One option is to stop the hormonal contraception and have an IUD inserted, use condoms, or use surgical sterilization. If you choose condoms and your period restarts within a month or so, then you have your answer. If you are 51 and select an IUD, you are covered until menopause. 

The other option is to stay on hormonal contraception until age 55. A product with estrogen, like the NuvaRing, will prevent many symptoms that may be experienced in the menopause transition, such as irregular bleeding and hot flashes. Estrogen seems to also help with mood issues in the early menopause transition. So you get double the benefit, contraception and a smoother menopause transition. But is it safe?

It depends. There is no hard age cut-off. However, it’s also true that the serious health risks related to the ring, pill, and patch, including blood clots, heart attacks and stroke, are all estrogen-related and those risks increase with age. So at age 51 your risks are a little higher than they were at age 31.

To know if it's safe to stay on the NuvaRing (or the estrogen-containing birth control pill or the patch) until age 55 you need to consider your risk factors for cardiovascular disease. Some are hard stops, but others require more nuance in the discussion. To assess your risk level you need to know your blood pressure, be screened for diabetes, and also have your lipid levels checked.

It helps to know how we classify patients based on their risk factors.  We use of the following four categories for contraceptive safety:

Category 1: No restriction for the use of the contraceptive method

Category 2: The advantages of using the contraceptive method generally outweigh the theoretical or proven risks.

Category 3: The theoretical or proven risks of using the contraceptive method usually outweigh the advantages. There may be individual circumstances that, after extensive informed consent, the method may be continued, but in general it’s not recommended. 

Category 4: An unacceptable health risk if the contraceptive method is used.

Now let’s take a look at the risk factors we consider in placing people into their appropriate risk classification:

High blood pressure: As blood pressure increases with age, you should have this documented once a year. If your blood pressure is over 160 mmHg systolic (upper number) or over 100 mmHg diastolic (lower number, you shouldn’t be on an estrogen-containing contraceptive regardless of your age, meaning category 4. If you have high-blood pressure that is well-controlled using medications or your systolic blood pressure is 140–159 mm Hg or diastolic 90–99 mm Hg, then the risks usually outweigh the benefits and we try to avoid estrogen products (category 3). This also applies regardless of your age. The estrogen in the pill can also raise blood pressure, so if you are newly diagnosed with high blood pressure, when you stop the pill, your blood pressure may improve. 

Smoker: If you are 35 and older and smoke 15 or more cigarettes a day, absolutely avoid estrogen containing birth control (category 4). If you smoke fewer than 15 cigarettes a day, the risks of estrogen-containing birth control usually outweigh the benefits (category 3). 

History of cardiovascular disease, such as a stroke or a heart attack: estrogen containing contraception is not recommended. Category 4. 

Multiple level 2 risk factors: there are several conditions that increase the risk of cardiovascular disease (meaning blood clots, stroke, and heart attacks) that by themselves are not significant enough to recommend against birth control pills with estrogen, but they slightly raise the risk so they fall into the level 2 category. The main ones are age, a low HDL, a high LDL, high triglycerides, diabetes (without vascular disease), migraines without aura and obesity. Anyone who has migraines with aura or diabetes with vascular disease shouldn’t take estrogen-containing birth control (category 4). 

This is the situation where you have to sit down with your medical provider and look at the number of level 2 risk factors and decide what is best for you. You can look up medical conditions and their safety vis-a-vis contraceptive methods here. 

Ok that was a lot…

Age by itself is not a reason to stop estrogen-containing contraception. However, risks do increase with age, and so discussing other non-estrogen options is always good so you can make an informed choice.

If you are 51 and otherwise healthy with no risk factors we think it is medically fine to stay on estrogen-containing contraception until age 55, this is a level 2 situation, meaning the advantages of using the contraceptive method generally outweigh the theoretical or proven risks. You do need to look at your health holistically and consider all of the factors that support the ring (pill or patch) being safe or unsafe for you.

There are also excellent non-estrogen options if you can’t take an estrogen-containing contraceptive, but you still want a hormonal option.

References

1. US Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016

2. Contraception inWomen With Cardiovascular Disease. Kathryn J. Lindley, MD; Stephanie B. Teal, MD, MPH. JAMA. July 22, 2022.

3. US Selected Practice Recommendations for Contraceptive Use https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/stop_using_contraceptives.html