“In your 40s it is important to continue using effective contraception”
There is no doubt that at 40, most women are done and dusted when it comes to having children, so it is easy to become blasé about contraception. dr. Polly Weston discusses the different contraceptive choices for women over 40.
As the average age at separation and divorce in Australia is now 42 for females and 45 for males this means that many individuals in their 40s are entering new relationships. Starting at age 32, a woman’s chance of conceiving decreases gradually but significantly. From age 35 the fertility decline speeds up and by age 40, fertility has fallen by half. There is however still a 10% chance of conception per cycle. Any pregnancy that does occur may well continue successfully but carries greater risks to both mother and baby due to the advancing age of both parties at conception.
Plenty of myths exist regarding contraception for those over 40. No contraceptive method is actually contraindicated by age alone. Choice of method must be determined by frequency of sexual intercourse, sexual interest, non-contraceptive benefits and menstrual issues. Incidental medical conditions may also have an impact. While condoms reduce the risk of sexually transmitted infections (STIs) at any age, there has been a notable increase in STIs in the over 40s, with the number of cases of chlamydia and gonorrhoea doubling in the 40-64 years age group between 2004 and 2010. In 2010, men in the 30-39 years age group had the highest rates of new HIV and syphilis diagnoses and the greatest prevalence of new genital herpes infection. Reluctance of older women to practice safe sex has been attributed variously to having missed out on the safe sex campaigns aimed at the young, assumption of minimal risk and occasions of erectile dysfunction preventing successful condom use.
Menopause is defined as the last menstrual period so can only be diagnosed retrospectively after a year of amenorrhoea (no periods). Irregular periods as ovarian function fails and menopause approaches may cause increased concerns regarding possible pregnancy. No single independent marker for the menopause exists. Blood tests for hormone levels (FSH, oestrogen, progesterone) are often taken but are unreliable as hormone levels fluctuate so much around this time. It is important to remember that even when the menopause has occurred and pregnancy is no longer a concern, there is still a risk of acquiring an STI with any unprotected sex.
What are the Contraceptive Choices?
UK data from the Office of National Statistics 2008/9 indicated that for women aged over 40, the most commonly used methods of contraception were sterilisation, Combined Oral Contraceptive Pills (COCP), condoms and intrauterine devices (copper coil or Mirena). Only condoms can provide true protection against STIs. Female condoms exist but seem rarely used in practice, male type condoms are
98% effective. Non-oil based lubricant can be used safely with them.
The COCP contains both oestrogen and progesterone. Amounts and proportions vary with different brands. It is taken for three weeks, with either no pills or sugar pills during the fourth week when a bleed will occur. Benefits of the COCP include a reduction in menstrual pain and bleeding and regulating of bleeding pattern for a predictable period. The hormones in the COCP will boost natural levels causing relief of menopausal symptoms and maintenance of bone density if used in perimenopause. The COCP reduces risks of ovarian, endometrial and colorectal cancers. Data shows a small increase in risk of breast cancer and ischaemic stroke, so blood pressure should be checked yearly while taking the COCP. It is not suitable for smokers or those who suffer focal migraine.
The progesterone only pill (POP) contains no oestrogen. It is taken every day at same time. It works by creating a hostile environment for sperm, fertilisation and implantation. Menstrual periods occur as they would normally, though the POP may slightly disrupt the cycle to cause erratic bleeding. There are no beneficial oestrogen effects on menopausal symptoms or bones, though the lack of oestrogen also means this method is suitable for smokers or those with previous deep vein thrombosis, stroke, heart attack or liver diseases. There may be a benefit for sufferers of endometriosis.
The Mirena is a T shaped device impregnated with progesterone hormone. It is inserted into the womb by a doctor and can be left there for five years. People are sometimes suspicious that the Mirena is like the copper coil. Aside from the shape and fitting location of the two devices, there are no similarities. The Mirena protects the womb lining by thinning it down with progesterone hormone. This causes a gradual reduction in bleeding with most women having no periods (amenorrhoea) by one year after insertion. Women that don’t like taking hormones will often find that the Mirena suits them as the hormone levels released are so low and directly where their effect is required. The Mirena may cause a reduction in endometriosis pain, will cause lighter, less painful periods and is more effective than sterilisation. The Mirena may be recommended to treat abnormalities of the womb lining or even early forms of cancer in these cells. There is no link with breast cancer. As the Mirena is likely to result in amenorrhoea it can make it difficult to establish the timing of true menopause. The Copper IUCD (coil) is inserted into the womb by a doctor and also lasts five years. It works by releasing copper ions into the womb creating a hostile environment for sperm, fertilisation and implantation. It can increase heavy bleeding and painful periods. The benefit of this method is that it contains no hormones. If inserted after 40 years old, it can be kept until after menopause.
The Depo injection consists of an intra muscular injection of progesterone hormone given every 3 months. It is a very effective contraceptive but may reduce bone mineral density (recovers when stopped) and affects lipid metabolism so should be avoided by those with high cholesterol or over 50. There is often a delay in return of fertility when the injections cease, so is best avoided if future fertility is desired.
Natural family planning, also known as the rhythm method, involves restriction of sexual intercourse to times of the menstrual cycle when ovulation is least likely to occur. This can be effective but may become harder to rely upon as the woman approaches menopause if her menstrual
cycle starts to become less regular.
Female sterilisation is done as a day case procedure under anaesthetic. Using keyhole techniques two small cuts are made in the abdomen and instruments are used under camera guidance to apply Filshie clips to each of the fallopian tubes. This is considered to be an irreversible permanent procedure and carries the attendant risks of surgery and anaesthetic procedures. As there is now growing evidence that ovarian cancers may originate in the fallopian tubes, women may choose to have the tubes removed completely, rather than clips applied. Removal of tubes does not impact on ovarian function or increase surgical complications. In fact there is no benefit for retaining fallopian tubes after your family is completed.
Non-hormonal contraception can be stopped after one year of amenorrhoea once you are over 50, or after two years of amenorrhoea if under 50. If using hormonal contraception this can be stopped after a year of amenorrhoea once aged over 50, with two separate blood test results of FSH over 30 IUl. It is important to know that Hormone Replacement Therapy on its own is not contraceptive. Only a combination of HRT plus either IUCD (copper coil or Mirena) or condoms is reliable.
The most important message is to talk things through with your partner and your GP to arrive at the best possible contraceptive choice for your specific needs.