Shaaban M M
Department of Obstetrics and Gynecology, School of Medicine, Assiut University, Egypt.
Maturitas. 1996 Mar;23(2):181-92. doi: 10.1016/0378-5122(96)83915-6.
To review the implications of pregnancy in women in their forties and the contraceptive options open to them.
Medline and popline reviews of the literature.
Women in their forties are still potentially fertile, and pregnancy in this age group is attended with increased maternal mortality, spontaneous abortion, fetal anomalies and perinatal mortality. In developing countries, these risks are compounded by high parity and poor medical care. Contraception for women in this age group has special risks and benefits, both should be balanced to choose between the different options available. Recent epidemiological and clinical pharmacology studies have indicated the safety of extending the use of combined oral contraceptives (COCs) beyond the age of 35 years and up to menopause. The improved picture of COCs has largely resulted from the use of low-dose-formulations, and avoidance of their use in women with risk factors for developing cardiovascular diseases. Besides their high reliability, which is desirable at this age, COCs will prevent the occurrence of climacteric symptoms and menstrual irregularities which are frequently complained of in the premenopausal years. Moreover, the use of COCs has a substantial protective effect against ovarian and endometrial cancers. Women who have reasons for avoiding COCs can use progestogen-only contraceptives like pills, depot injectables and implants. Norplant combines high efficacy and the long-term effect. Both copper-releasing and levonorgestrel-releasing IUDs (LNG-IUD) combine the advantages of high efficacy and long term effect. The reduced fecundity above the age of forty can allow extending the use beyond the accepted term, and up to one or two years beyond the menopause without the need for replacement. The levonorgestrel IUD has the advantage of reducing the amount of menstrual bleeding. The extent of use of barrier methods will depend upon the availability of a back-up by abortion service in case of failure. The condom has the added benefit of protection against STDs. Male or female sterilization is an excellent contraceptive option, provided that this approach is culturally acceptable and available at reasonable cost and low risk.
Increasing the number of contraceptive options available to premenopausal women will improve proper counseling and enhance compliance.
探讨40多岁女性怀孕的影响因素以及她们可选择的避孕方法。
对医学文献数据库（Medline）和大众健康文献数据库（Popline）进行文献综述。
40多岁的女性仍有生育能力，该年龄段女性怀孕会导致孕产妇死亡率、自然流产率、胎儿畸形率和围产期死亡率上升。在发展中国家，高生育次数和医疗条件差使这些风险更加复杂。这个年龄段女性避孕有特殊的风险和益处，选择不同避孕方法时需权衡利弊。近期流行病学和临床药理学研究表明，复方口服避孕药（COCs）在35岁以上直至绝经后使用是安全的。COCs安全性提高主要得益于低剂量配方的使用，以及避免在有心血管疾病风险因素的女性中使用。除了这个年龄段所需的高可靠性外，COCs还能预防更年期症状和绝经前常见的月经不调。此外，使用COCs对卵巢癌和子宫内膜癌有显著的保护作用。有理由避免使用COCs的女性可以使用仅含孕激素的避孕药，如口服避孕药、长效注射剂和皮下埋植剂。Norplant（左炔诺孕酮皮下埋植剂）兼具高效和长效的特点。含铜宫内节育器和左炔诺孕酮宫内节育器（LNG-IUD）都有高效和长效的优点。40岁以上女性生育能力下降，可延长宫内节育器的使用时间，甚至在绝经后一到两年内无需更换。左炔诺孕酮宫内节育器有减少月经量的优点。屏障避孕法的使用程度取决于万一失败时堕胎服务作为后备措施的可及性。避孕套还有预防性传播疾病的额外好处。男性或女性绝育是很好的避孕选择，前提是这种方法在文化上可接受，成本合理且风险低。
增加绝经前女性可用的避孕方法数量将改善适当的咨询并提高依从性。
