Contraception after 40

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A woman's fertility declines slowly from about 30 years of age, dropping by approximately 50%, by age 40 (1). For those requiring contraception, a reliable method is still important, however, as pregnancy at this age poses greater risks for both mother and baby.

The drop in fertility also means that contraceptives previously considered unsuitable due to an unacceptable failure rate may now be a good option. In addition, women who have decided not to have children or further children may choose longer acting or permanent methods.

Some contraceptives also have non-contraceptive benefits that can be useful at this stage in life. In the years leading up to the menopause (the perimenopause), women commonly experience changes in their menstrual cycle, including shorter intervals between periods and heavier and/or irregular bleeding due to decreasing ovarian function. As some contraceptives can address these symptoms this can be an opportune time to re-evaluate one's choice of contraception.

Contraceptive options

A number of factors will influence a woman's contraceptive choice in her 40s including: the importance she places on effectiveness (ie. potential for failure); the need for added non-contraceptive benefits (eg. reduction in heavy bleeding); potential side effects; the need for protection from sexually transmitted infections; the impact of other health issues; and tolerance (ie. what a woman and her partner are familiar with or comfortable using).

Sterilisation
For Australian women over the age of 40, sterilisation is the most popular method of contraception (2). Many women welcome the reassurance that a permanent contraceptive method brings. As reversal can be complicated and/or unsuccessful, sterilisation should always be considered a permanent method.

Male sterilisation or vasectomy involves cutting and tying or blocking the tubes (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. Vasectomy has no effect on sexual drive, erections or ejaculation. Side effects include bruising and discomfort for a few days after the procedure. A small percentage of men develop chronic pain which reduces over time. Vasectomy is a very popular option in Australia with the rate five times higher than that of tubal ligation (3).

Female sterilisation or tubal ligation involves the blocking of the Fallopian tubes by cutting or burning or by the use of clips, clamps or rings. Tubal ligation is most commonly performed as a laparoscopic procedure under general anaesthetic. The laparoscopy involves 1-3 small incisions near the navel. The abdomen is filled with gas and a laparoscope, an instrument that allows the interior of the abdomen to be viewed, is inserted through one of the incisions. Tubal ligation has no effect on sexual drive or on the menstrual cycle. It usually takes about a week after surgery for the abdominal discomfort caused by the gas to subside.

A new female sterilisation procedure, Essure, is now available. It involves the insertion of a small flexible device called a 'micro-insert' into each of the Fallopian tubes causing scar tissue to form, blocking the tubes. The Essure procedure requires no incisions (instead, access is via the vagina/cervix) and can usually be performed under local anaesthetic.

Considerations - Tubal ligation carries the risks associated with surgery and anaesthesia. Both vasectomy and the Essure procedure are not effective immediately, so another form of contraception must be used in the interim for 3 months. If a woman does become pregnant after female sterilisation there is a higher risk the pregnancy will be ectopic (in the Fallopian tube). There are now reversible methods of contraception available which have failure rates as low as sterilisation (ie. Implanon, IUS). These may provide a suitable alternative to permanent methods for some women.

Combined oral contraceptive pill
The combined oral contraceptive pill, commonly referred to as the Pill, consists of a combination of the hormones oestrogen and progestogen. In the past, it was often recommended that women only take the Pill until the age of 35. The lower dosages used today, however, allow women who have no risk factors for heart disease and are non-smokers to continue on this form of contraception until menopause.

The Pill can provide women with a number of benefits in addition to effective contraception. Irregular cycles, commonly experienced in the perimenopause may be controlled with the Pill, as can heavy or painful periods. 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 (4). Perimenopausal symptoms such as hot flushes and vaginal dryness may also be reduced with the Pill. Women should be given the lowest effective dose.

Considerations - 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 during Pill use.

Progestogen only pill (POP) or mini pill
The progestogen only pill consists of low doses of the synthetic hormone progestogen. Women unable to take the Pill (breastfeeding, smokers, family history of blood clots) or who experience unpleasant side effects from its oestrogen component, may be able to take POP. POP is a good choice for older women as its effectiveness is comparable to that of the Pill in young women (ie. women aged over 40 taking POP have the same risk of pregnancy as a 25 year old on the Pill) (5).

Considerations - POP must be taken at the same time every day, with a pill being considered 'missed' if it is more than three hours late. Side effects include irregular menstrual bleeding, sometimes with nuisance spotting. Less commonly, amenorrhoea, headaches and breast tenderness may occur. It does not provide additional non-contraceptive benefits like the Pill.

Condoms
Condoms offer effective contraception if used properly and consistently. They are a particularly good choice for those entering into a new relationship as they provide both contraception and protection from sexually transmitted 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 (eg. Vaseline, baby oil) can damage the latex causing it to break. Female condoms are non-latex (polyurethane) so an oil-based lubricant can be used. For people with latex allergies, polyurethane male condoms are available.

Considerations - Condoms may not be acceptable to women who have not regularly used them in the past. Some couples feel that there is a reduction in sensation when using condoms and women may also experience allergies to the latex in the male condom or to the lubricants used. Older men may find it harder to maintain their erection when using a male condom. The female condom is not as widely available as the male condom, is more expensive and has a tendency to make 'rustling' noises.

Intra-uterine device (IUD) and intra-uterine system (IUS)
The intra-uterine device (IUD) is a small, flexible device, made from plastic and copper, which is inserted into the uterus via the cervix (opening to the womb). IUDs can be left in for long periods of time (5-8 years). An IUD fitted when a woman is over 40 can actually remain in place until menopause (6). The risk of expulsion, where the IUD is completely or partially pushed out of the uterus, is lower in older women.

The intrauterine system (IUS), called Mirena, differs from conventional IUDs in that it has a stem which releases a steady low dose of progestogen. As well as providing contraception, Mirena has the added benefit of greatly reducing a woman's menstrual flow by making the lining of the uterus (endometrium) very thin. This feature makes Mirena ideal for women who experience menstrual problems like heavy bleeding. It lasts for five years.

Considerations - An IUD or IUS is not recommended for a woman who is at high risk of sexually transmitted infections (ie. has more than one sexual partner or has a partner that has more than one sexual partner). Side effects of IUDs (but not Mirena) may include heavier, longer or more painful periods. Side effects of Mirena may include irregular bleeding or amenorrhoea. Other typical progestogen-related side effects (breast tenderness, headaches, acne and mood changes) are less common with Mirena as the amount of progestogen is small.

Diaphragm
The diaphragm is a soft, dome shaped rubber cap which fits across the vagina, covering the cervix to block the sperm. It is fitted prior to intercourse and needs to stay in place for longer than six hours after the last time vaginal sex occurred. Diaphragms are often used in conjunction with spermicide.

Considerations - Diaphragms must initially be fitted by an experienced health practitioner and require refitting with any significant weight gain or loss (5kg or more) and after pelvic surgery. New users may find them difficult to fit at first and some women may experience an allergic reaction to the rubber or spermicide. They are associated with a slightly increased risk of urinary tract infections and are unsuitable for women with pelvic floor weakness and/or genital prolapse (7).

Progestogen injections and implants
Medroxyprogesterone acetate or DMPA is a progestogen based contraceptive given to women as an injection every 12 weeks. In Australia, DMPA is sold as Depo Provera and Depo Ralovera.

The progestogen implant, Implanon, is a small rod approximately 4cm long and 2mm wide. It is inserted under the skin in the upper arm by a medical practitioner with special training in the procedure. It releases a low steady dose of progestogen and lasts for three years.

Considerations - DMPA is long-acting and in some women broken down slowly and so any side effects experienced may by present for up to 12 weeks or longer. Return of normal fertility is delayed on average for 10 weeks after the last injection. DMPA is associated with a small loss of bone density. This is usually reversible after the injections are stopped and there is currently no evidence that long term DMPA users have an increased risk of osteoporosis or fractures after menopause. All progestogen-only methods produce changes in the menstrual cycle. Fifty percent of women using DMPA have amenorrhoea after using it for 1 year. Most women using Implanon have little or no bleeding but 30% may have frequent or prolonged bleeding. Other side effects of both DMPA and Implanon include weight gain, loss of libido and mood changes.

Withdrawal method
This involves the withdrawal of the penis completely from the vagina before ejaculation. Even if the penis is withdrawn in time, there is often pre-ejaculate fluid and this can contain some sperm. The effectiveness of this method in the general population (not specifically women over 40), ranges from 81-96%, which is greater than not using any contraceptive method (8). While some couples will find the failure rate unacceptable, others may be comfortable with this level of risk.

Natural family planning methods
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 are problematic in women over 40. Irregular cycles and hormonal fluctuations in women this age make calculating the 'safe' days more difficult (9).

Emergency 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 IUD and the emergency contraceptive pill. When inserted within five days of unprotected sex an IUD will prevent pregnancy and provide ongoing contraception for suitable women. The emergency contraceptive pill (Postinor-2) can be taken within 72 hours of unprotected sex. It consists of two higher dose progestogen tablets, taken 12 hours apart. Postinor-2 can now be obtained without a prescription (over the counter) from a pharmacy.

Hormone replacement therapy
Hormone replacement therapy alone is not a form of contraception as the dosage of oestrogen is not great enough to stop ovulation from occurring.

When to stop contraception

Women approaching menopause are often unsure of when it is safe to stop the use of contraception. Generally, it is recommended that if a woman is 50 or younger she should continue using contraception for two years following the last menstruation. If she is older than 50, contraception should be used for one year following the last menstruation (10).

While these guidelines are relevant to women using non-hormonal contraception (condom, diaphragm, IUD), 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 amenorrhoea which will disguise the true end of their menstruation.

For women using hormonal contraceptives, options include:

POP and Implanon users : Can continue using the contraception until they reach an age where the natural loss of fertility is very likely to have occurred (for example, 95.9% of women will have reached menopause at age 55) (11).

Pill users : Can switch to a form of non-hormonal contraception to see if menstruation returns. If menstruation does not return they can then follow the general guidelines for stopping contraception (two years after last menstruation for those 50 and under and one year after last menstruation for over 50s). If menstruation does return they could either switch back to their hormonal contraceptive and repeat the process at a later date, or continue using the non-hormonal contraception. Women on the Pill are advised to switch to another method of contraception at age 51, as the Pill is stronger than necessary at this age (12).

References

1. Frank O, Bianchi PG, Campana A. The end of fertility: age, fecundity and fecundability in women. J Biosoc Sci 1994; 26:3:349-68.
   
2. Yusuf F & Siedlecky S. Contraceptive use in Australia : Evidence from the 1995 National Health Survey Australian and New Zealand Journal of Obstetrics & Gynaecology 1999; 30:1:58-62
   
3. AMA Queensland . Australian men carry the load for contraception [media release] October 27 2004
   
4. Szarewski, A & Guillebaud J. Contraception: A User's Handbook Oxford University Press 1998; 36-41
   
5. Guillebaud, J. Contraception: Your Questions Answered . Edinburgh : Churchill Livingstone 2004
   
6. Guillebaud, J. Ibid; 431
   
7. Guillebaud, J. Ibid; 68
   
8. Guillebaud J. Ibid; 14
   
9. Szarewski, A & Guillebaud J. Ibid;161
   
10. Guillebaud J. Ibid; 515
    
11. Patientplus. Contraception and the Mature Woman http://www.patient.co.uk/showdoc/40024661 [website] date accessed: 10 January 2006
    
12. Guillebaud J. Ibid; 521

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Further information

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This factsheet was originally published as "Sexuality and contraception when apporaching menopause". This contraception-only version was written by Kirsten Braun and reviewed by the Editorial Committee in June 2006. We would like to thank Family Planning Queensland and FPA Health for their assistance in producing this factsheet.

Last Modified: June 13, 2006