Between the ages of 30 and 40, most women's fertility will decline by about 50 per cent (1). However, as pregnancy can still occur up to menopause, it is important to be well informed on contraception options to reduce the risk of an unplanned pregnancy.
This decline in fertility can impact on a woman's views on contraceptive options. Lower fertility levels, for example, could mean contraception previously considered less reliable may now be a viable option.
If you are over 40, it may be time to re-evaluate your contraceptive options. Women who do not wish to have children or who have finished having children may also like to consider longer-acting or more permanent methods of contraception.
Another issue to consider is that some contraceptives offer added non-contraceptive benefits which can be useful at this stage in life. Some contraception, for example, helps regulate the menstrual bleeding pattern and relieve associated pain and discomfort. This could be especially beneficial for women who are experiencing shorter intervals between periods and heavier and/or irregular bleeding due to decreasing ovarian function in the lead-up to menopause.
A range of factors can influence a woman's contraceptive choices over the age of 40. This could include the need for added non-contraceptive benefits such as a reduction in heavy bleeding; a change in relationship status (i.e. separation, divorce, a new relationship, bereavement); the importance of effectiveness (i.e. potential for failure); possible side effects; the need for protection from sexually transmissible infections; the impact of other health issues; and tolerance (i.e. what people are familiar with or comfortable using).
The combined oral contraceptive pill is commonly referred to as the pill and consists of a combination of the hormones oestrogen and progestogen. Women who have no risk factors for cardiovascular disease and are non- smokers can continue taking this form of contraception until menopause or they reach the age of 51.
The pill can provide women with a number of benefits in addition to effective contraception. Irregular cycles and heavy or painful periods commonly experienced in the time leading up to menopause (called perimenopause) may be controlled with the pill. The use of the pill is also associated with a reduced incidence of gynaecological disorders such as pelvic infection, ovarian cysts and cancer of the ovaries and uterus (2). Perimenopausal symptoms such as hot flushes and vaginal dryness may also be reduced with the pill. Women should take the lowest effective dose.
Side effects may include breast enlargement and tenderness, nausea, bloating, loss of libido and a slightly increased risk of breast cancer. Migraines may improve, worsen or occur for the first time while on the pill.
The use of combined oral contraceptives is associated with an increased risk of cardiovascular complications in women who smoke, suffer from hypertension, diabetes, high blood cholesterol, migraines with aura, have a family history of cardiovascular disease or are obese. The risks are compounded if a number of these factors are present (3). The benefits of taking oral contraceptives, however, generally outweigh the risks for non- smoking women aged between 40 and menopause with no additional risk of cardiovascular disease.
The progestogen only pill consists of low doses of the synthetic hormone progestogen. Women unable to take the combined pill (i.e. are breastfeeding, smokers or have cardiovascular risks) or who experience unpleasant side effects from its oestrogen component may be able to take the POP. This pill is often a suitable choice for older women as its effectiveness is comparable to that of the pill for younger women i.e. women over 40 taking the POP have the same risk of pregnancy as a younger, more fertile woman on the pill (4).
The POP must be taken at the same time every day to ensure effectiveness. A pill is considered 'missed' if it is more than three hours late. Side effects can include irregular menstrual bleeding, sometimes with nuisance spotting. Irregular periods, headaches and breast tenderness are less common side effects. The POP also does not provide additional non-contraceptive benefits like the combined pill.
Condoms offer effective contraception if used correctly and consistently. Condoms are a particularly good choice for those entering into a new relationship as they provide contraception as well as reduce the risk of sexually transmissible infections. Both male and female condoms are available.
Lubricated condoms or the use of an additional lubricant can be helpful for women who are experiencing vaginal dryness. Only water-based lubricants should be used with male condoms as petroleum or oil-based lubricants such as Vaseline or baby oil can damage the latex, causing it to break.
Female condoms are non-latex (polyurethane) so an oil-based lubricant can be used. Polyurethane male condoms are also available for people with latex allergies.
Condoms may not be acceptable to women who have not regularly used them in the past. Some couples feel there is a reduction in sensation when using male condoms and women may experience allergies to the latex in the male or female condom or to the lubricants used.
Older men may find it harder to maintain their erection when using a male condom.
'Typical use' failure rate for this method of contraception is 85 per cent, which is relatively high compared to other contraceptive methods (5). This factor needs to be seriously considered for women with medical conditions which make the risk of pregnancy unacceptably high.
Female condoms can also be more expensive than male condoms and are not as widely available. Some couples also find the use of a female condom can result in a slight noise during intercourse which can be distracting.
A copper intra-uterine device (IUD) is a small, flexible device made of plastic and copper which provides highly effective contraception. It is inserted into the uterus via the cervix, which is the opening to the womb. Some IUDs can be left in place for up to ten years.An IUD fitted when a woman is over 40 can remain in place until menopause (6). In some cases, menopause may even be over by the time the device is due to be removed.
A hormonal IUD is a small flexible device made of plastic which provides highly effective contraception. Its failure rate of 1 in 1000 is the same as that for female sterilisation. It is inserted into the uterus via the cervix and releases a steady, low dose of progestogen over five years. The only type currently available in Australia is called Mirena. As well as providing contraception, Mirena also significantly reduces a woman's menstrual flow by making the lining of the uterus (called the endometrium) very thin. This feature makes Mirena ideal for women who experience menstrual problems like heavy bleeding. Many women have little or no periods at all with a Mirena. Other typical progestogen-related side effects such as breast tenderness, headaches, acne and mood changes are rare with a Mirena as the small amount of progestogen used is delivered directly into the uterus within the pelvic cavity and not the into bloodstream like other hormonal methods of contraception.
An IUD is not recommended for women at high risk of sexually transmitted infections. This includes women with more than one sexual partner or those who may have a partner who has more than one sexual partner.
Some women, particularly those who have not had children, can find it uncomfortable to have an IUD inserted, although 50 per cent of women experience little or no pain during the procedure (7) . A local anaesthetic or a light sedation called a twilight anaesthetic can be used to minimise pain or discomfort.
Not all GPs cater for women who require the insertion of an IUD. Women can call the Women's Health Information Line on 3839 9988 or 1800 017 676 ( for calls outside Brisbane) to obtain contact details of Queensland practitioners who insert IUDs.
Side effects of copper IUDs can include heavier, longer or more painful periods. Side effects of hormonal IUDs can include irregular bleeding in the first few months after insertion or missed periods, which many women see as an added benefit.
Tubal ligation is a form of female sterilisation and a popular method of contraception for Australian women over the age of 40 (8). Many women welcome the reassurance that a permanent contraceptive method can offer.
Female sterilisation is conducted by a doctor specially trained in this procedure. It involves blocking the fallopian tubes by cutting, burning or using clips, clamps or rings to prevent the ovum from passing down the fallopian tube so the sperm cannot reach it.
The procedure is most commonly performed as a laparoscopic procedure under general anaesthetic. A laparoscopy involves making a number of small incisions near the navel. The abdomen is filled with gas and a laparoscope, which is an instrument used to view the interior of the abdomen, is inserted through one of the incisions. It usually takes about a week after surgery for abdominal discomfort caused by the gas to subside.
Tubal ligation has no effect on sexual drive and most women do not experience menstrual disturbances as a result of this procedure (9). Some women stopping hormonal contraception may experience heavier menstrual bleeding or more irregular cycles due to the effect of increasing age or pre-existing gyneacological conditions (10) .
The Essure female sterilisation procedure is also available in Australia. It involves inserting a small flexible device called a 'micro-insert' into each of the fallopian tubes. This causes scar tissue to form which blocks the tubes. This procedure can usually be performed under local anaesthetic and requires no incisions as access is through the vagina into the womb. It is important to be aware the Essure method of contraception is completely irreversible.
Sterilisation should always be considered a permanent method of contraception as reversal of this procedure can be complicated and at times unsuccessful. Female sterilisation carries the risks normally associated with surgery and anaesthesia.
The Essure procedure is not effective immediately, so another form of contraception must be used for three months after the operation.
If a woman does become pregnant after female sterilisation, there is a higher risk the pregnancy will be ectopic. This is when a pregnancy develops outside the uterus, most commonly in the fallopian tube.
There are now reversible methods of contraception available which have failure rates as low as sterilisation (see section on intra-uterine devices for more information). These may provide a suitable alternative to permanent methods for some women.
Male sterilisation (or vasectomy) is a very popular option in Australia with the rate five times higher than that of female sterilisation (11). The procedure involves cutting and tying or blocking the tubes (called the vas deferens) that carry sperm from the testicles to the penis. The procedure is performed through either small incisions in the scrotum or a 'no-scalpel' method, and usually only requires a local anaesthetic. It can be done as day surgery or in a medical specialist's office . A vasectomy does not affect the appearance or function of the penis or testicles in any way. Erections, orgasms and ejaculations will be the same as before the operation (12).
Side effects of male sterilisation include bruising and discomfort for a few days after the procedure.
A vasectomy is not effective immediately so another form of contraception must be used for three months after the operation. After three months, semen samples must be tested three times to confirm the vas deferens is no longer carrying sperm and the vasectomy has been successful.
The combined vaginal ring is a combined hormonal contraceptive that is inserted in the vagina for three weeks and removed for one week each month. It is made of plastic and releases a steady low dose of oestrogen and progestogen. The vaginal ring available in Australia is called NuvaRing and acts to inhibit ovulation, thicken cervical mucus and possibly to inhibit implantation. A vaginal ring may be preferred by some women because it only needs to be used once a month.
The vaginal ring is a consideration for older women until menopause as it has a low dose of oestrogen and provides good cycle control. It should be noted, however, that evidence for this age group is currently limited.
Women using the vaginal ring may experience the usual possible side effects of the combined pill such as breast enlargement and tenderness, nausea, bloating, loss of libido, the possibility migraines may improve, worsen or occur for the first time and a slightly increased risk of breast cancer. Expulsion of the ring may occur in women with poor pelvic tone, obesity or utero-vaginal prolapse.
A diaphragm is a soft, dome-shaped rubber cap which fits across the cervix, blocking sperm. It is fitted prior to intercourse and must remain in place for a minimum of six hours after the last time vaginal sex occurred. Diaphragms are often used in conjunction with a spermicide, which is a sperm-killing foam, gel or cream inserted into the vagina prior to intercourse to prevent pregnancy.
Diaphragms must initially be fitted by an experienced health practitioner. They also require refitting after pelvic surgery and after any weight gain or loss of five kilograms or more. New users may find them difficult to fit at first and some women may experience an allergic reaction to rubber or spermicide.
Diaphragms are also associated with a slightly increased risk of urinary tract infections and are unsuitable for women with pelvic floor weakness and/or genital prolapse (13).
Medroxyprogesterone acetate or DMPA is a progestogen-based contraceptive injection given to women every 12 weeks. In Australia, DMPA is sold as Depo Provera and Depo Ralovera.
DMPA is long-acting and in some women is broken down slowly. Any side effects may be present for up to three months or longer in some cases.
Return of normal fertility is delayed on average for eight months after the last injection but can take up to 18 months (14). For women still considering pregnancy, DMPA may not be an appropriate choice because of a possible delay in return to fertility.
DMPA is associated with a small loss of bone density and may be associated with osteoporosis and fractures after long-term use. This is usually reversible after injections are stopped (15).
All progestogen-only methods produce changes in the menstrual cycle. 50 per cent of women who use DMPA experience amenorrhea (the permanent or ongoing absence of menstruation) after using it for one year (16). Other side effects of DMPA include small weight gain, decreased libido and mood changes.
A progestogen implant is a small rod, approximately 4cm long by 2mm wide, which is inserted under the skin in the upper arm by a medical practitioner trained in the procedure. It provides highly effective contraception for three years. Its failure rate of one in 1000 is the same as for female sterilisation. The rod releases a slow dose of progestogen and lasts for three years. Implanon is the only progestogen implant available in Australia.
All progestogen-only methods produce changes in the menstrual cycle. Most women using Implanon experience little or no bleeding but 30 per cent may have frequent or prolonged bleeding.
Other side effects of Implanon include small weight gain, decreased libido and mood changes.
The Implanon method is reversible and can be removed by a medical practitioner trained in this procedure if a woman decides it is unsuitable. Call our Health Information Line on (07) 3839 9988 or 1800 017 676 (calls outside Brisbane) to obtain the contact details of these practitioners in Queensland.
This method involves the withdrawal of the penis from the vagina before ejaculation. It is important to be aware that even if the penis is withdrawn in time, there is often pre-ejaculate fluid present and this can contain some sperm. The effectiveness of this method in the wider population ranges from 81 to 96 per cent (17). If used perfectly, the withdrawal method is 96 per cent effective, however, typical use shows it is only 73 per cent effective. By way of comparison, if used perfectly the pill is 99.7 per cent effective and with typical use is 92 per cent effective.
While some couples find the failure rate of the withdrawal method unacceptable, others may be comfortable with this level of risk given reduced fertility associated with ageing.
These methods involve determining fertile and non-fertile days and abstaining from vaginal sex at 'unsafe' times. While natural methods can be effective for motivated, younger women with regular cycles, they can be problematic in women over 40. Irregular cycles and hormonal fluctuations in women this age can make calculating the 'safe' days more difficult (18). It is important to consult an experienced practitioner to ensure you are well informed about this method of contraception.
If contraception fails or is overlooked, emergency contraception can be used as a back-up method. There are two forms of emergency contraception available – the copper IUD and the emergency contraceptive pill also known as the 'morning after pill'.
When inserted within five days of unprotected sex, a copper IUD will prevent pregnancy and provide ongoing contraception for suitable women . The emergency contraceptive pill available in Australia is called Postinor, Norlevo or Levonelle and can be taken within 120 hours of unprotected sex. It can be obtained without a prescription at pharmacies. The sooner these drugs are taken after unprotected sex, the more effective they are as an emergency contraceptive.
Hormone replacement therapy alone is not a form of contraception as the oestrogen dosage is too low to stop ovulation from occurring.
Women approaching menopause are often unsure about when it is safe to stop using contraception. It is generally recommended that if the woman is 50 or younger she should continue using contraception for at least two years following her last period. If she is older than 50, contraception should be used for one year following the last period (19).
While these guidelines are relevant to women using non-hormonal contraception such as condoms, diaphragms and IUDs, other women will find that the hormones in their contraception will mask the end of their menstruation. For example, the bleed that a pill user has during the non-active pill week is not a true menstrual period and will continue even after menopause. Similarly, POP, Implanon and Mirena users may experience missed or irregular periods or an absence of menstruation which may disguise the true end of their menstruation.
Women using these forms of contraception can continue to do so until they reach an age where the natural loss of fertility is likely to have occurred. As a point of reference, 95.9 per cent of women will have reached menopause by the age of 55 (20).
Women using the pill can switch to a form of non-hormonal contraception to see if menstruation returns. If menstruation does not return, they could then follow the general guidelines for stopping contraception. That is, two years after the last period for women under 50 and one year after the last period for women aged 50 and over. If menstruation does return, women can either switch back to their hormonal contraceptive and repeat the process at a later date or continue using non-hormonal contraception.
Women on the pill are advised to discuss options with their practitioner with a view to switching to another method of contraception around the age of 50-51, as the benefits of the pill as an effective contraceptive are generally outweighed by potential risks such as blood clots or cardiovascular disease at an age when fertility is very low anyway.
For help understanding this fact sheet or further information on contraception call the Health Information Line on 3839 9988 (within Brisbane) or 1800 017 676 (toll free outside Brisbane)
Last updated: 8 June 2010
© Women's Health Queensland Wide Inc. This factsheet was originally published by Women's Health Queensland Wide (Women's Health) in June 2006. It was revised and updated by the Editorial Committee in June 2010. We would like to thank Family Planning Queensland and FPA Health for their assistance in producing this fact sheet.