40+ CON­TRA­CEP­TION

“In your 40s it is im­por­tant to con­tinue us­ing ef­fec­tive con­tra­cep­tion”

Australian Health Today - - Contents -

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.

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