|Contraception at midlife||What's the right contraceptive for me?|
|When is it safe to stop contraception?||Further resources|
|Contraceptive option to prevent pregnancy|
Until Menopause is reached women are not totally protected from pregnancy despite the decline in fertility during perimenopause.
Effective, safe and appropriate contraception is available if a woman does not want a pregnancy. See Contraceptive options for preventing pregnancy.
The risk of Sexually Transmissible Infections (STIs), including HIV, remains a lifelong concern and knowledge of safe sex practices, including the use of condoms and dental dams, is important. More on Safer Sex.
Menstrual changes at the time of menopause often prompt women to ask; ‘How long should I use contraception?’ Most women are aware that fertility naturally declines with age. The possibility of pregnancy in women 45-49 years is estimated to be two to three per cent per year. After age 50, it is less than one per cent. While this is minimal, the fertility of individual women is extremely variable, so contraception remains an important consideration in midlife.
Contraception is recommended until at least one year after menopause for women 50 years and above, or two years for women younger than 50. In early post-menopausal women, there is a small chance of spontaneous ovulation. Some women may wish to continue to use barrier methods like condoms or diaphragms after this time if they want to take as little risk as possible.
It’s important to carefully consider your options in consultation with your doctor.
Combined Oral Contraceptive pill (COCP); ‘The Pill’
This type of pill contains two hormones; progestogen and oestrogen. It prevents pregnancy by thickening the mucus at the entrance of your cervix (preventing sperm entry), preventing the release of an egg and altering the lining of the uterus. Healthy women who are non-smokers, have normal blood pressure, are not diabetic and have no increased risk of blood clots can continue on the COCP. There is no absolute rule on the age that it should be ceased, but keep in mind that it may mask the onset of menopause. The COCP can regulate the menstrual cycle and improve Pre-Menstrual Syndrome (PMS) and some menopausal symptoms. Evidence also suggests a decreased risk of endometrial and ovarian cancer. Breast cancer risk is still being investigated. Disadvantages of the COCP include a small risk of clotting, heart attack, stroke and non-cancerous liver tumour. Smokers over 35 years should not use the COCP as there is a greater risk of heart attack and blood clots in the legs or lungs.
Contraceptive hormonal vaginal ring (Nuva Ring)
This is a small, soft, silastic (pliable plastic) ring containing low dose oestrogen and progestogen. It is self-inserted into the vagina and remains for three weeks (including during intercourse) then removed. A new ring is inserted one week later, at the end of the four week-cycle. As well as its ‘set and forget’ convenience, there may also be less hormonal side effects than the oral contraceptive pill. The method of action and the disadvantages of the NuvaRing are the same as the COCP.
Progestogen-only pill – the ‘mini-pill’
This is highly effective in women older than 40 due to their naturally declining fertility. It contains a very small dose of progestogen hormone and works by thickening the mucus in the cervix to prevent sperm entering the uterus. Because it doesn’t contain oestrogen, the mini-pill doesn’t carry the same risks as the combined pill - especially for smokers. However, it must be taken at the same time every day (within three hours of your normal time) and may result in irregular periods.
Three-year contraceptive implant containing etonogestrel (Implanon) – ‘the rod’.
This has the advantage of being progestogen only, inexpensive and lasts for three years. The implant stops the production and release of eggs by releasing the hormone slowly and continuously. It also thickens the mucus around the cervix to stop sperm from entering the uterus. The matchstick-sized plastic rod is inserted by a doctor under the skin of your inner upper arm after a local anaesthetic. It can be felt under the skin but is unlikely to be seen. Menstrual irregularities can occur, particularly in the first three months with subsequent cessation of periods in many women. However, 20 per cent of women experience enough bleeding abnormalities to have the implant removed. Some women may also experience acne, breast tenderness or mood changes.
Copper intra-uterine device (IUD)
A copper-containing IUD is very effective as a medium-term, non-hormonal contraceptive. It’s inserted into the uterus through the vagina (with or without anaesthetic). Once inserted, you need to check once a month to make sure it is still in place by feeling for a string coming out of your cervix. The IUD is toxic to sperm and also stops a fertilised egg from settling in the uterus. It lasts up to five years (but the IUD lifespan doubles if it is inserted after the age of 40) and is easily removed. Heavy painful bleeding can be a side-effect. It can also be used as an emergency contraceptive if inserted within 72 hours of intercourse.
Progestogen IUS (Mirena®)
The Mirena® contains a slowly releasing progestogen, levonorgestrel, which stops pregnancy in the same way as the copper IUD and also by thinning the lining of the uterus, making it unfavourable for implantation. It does not stop ovulation. It is fitted the same way as the copper IUD, lasts up to five-seven years and is easily removed. Periods are likely to involve less blood loss and discomfort and after approximately 12 months, you may not have a period at all. However, irregular spotting and bleeding can continue indefinitely in a very small number of women. Some women may also get progestogen-related side effects e.g. bloating, sore breasts and weight gain.
Diaphragms and caps
Diaphragms and caps offer drug-free contraception and can be used with short notice. They are called ‘barrier methods’ as they are placed inside the vagina to cover the entrance to the uterus (stopping sperm from reaching the uterus). A diaphragm is a shallow dome of thin rubber which is held in place by the pelvic muscles. A cap is a firm, cup-shaped device which fits over the cervix by suction. These products are left inside the vagina for six hours or longer after sex (so the sperm die without reaching their target). They are more effective if used with a spermicide cream/gel, which kill or disable sperm. Unfortunately, they are not as reliable as some other contraceptive methods. Some women find them difficult to insert and therefore risk incorrect placement. Insertion and removal may also increase the risk of urinary tract infection.
Condoms are very relevant for women in new relationships, as they are the only contraception that protects against sexually transmissible infections. The fine rubber or plastic sheath is worn on an erect penis, catches sperm and stops it reaching the egg. Condoms have a five to 10 per cent failure rate, and vaginal dryness and erectile dysfunction may cause difficulties.
Emergency contraception (Postinor)
Often called the ‘morning after pill’, Postinor reduces the chance of pregnancy after unprotected sex. The sooner it is taken (within 24 hours of unprotected sex), the more effective it will be, and it must be taken within five days. It works by delaying the release of an egg from your ovary or may stop a fertilised egg from settling in the uterus. If it fails to work, it is not harmful to the pregnancy and embryo. After use, it is important to keep using other contraception until your next period. If your period is late, visit your doctor or call Family Planning Australia for advice.
Permanent contraception (surgical); ‘sterilisation’
Tubal ligation (for women) is a popular but invasive procedure known as ‘having your tubes tied’. Surgery can be done through ‘keyhole’ surgery in your lower abdomen and requires a general anaesthetic. It’s immediately effective however there are low risks of injury to blood vessels and bowel damage.
Blocking fallopian tubes with coils (Essure device) (for women): these tiny metallic coils are inserted into the fallopian tubes through a hysteroscope (a telescope inserted into the uterus via the vagina) by a specially-trained gynaecologist under a local or general anaesthetic. The device stops pregnancy by scarring and blocking the tubes. Other contraception isn’t necessary once the device is confirmed to be in place - this occurs when an X-Ray is done three months after insertion.
Vasectomy (for men): This method is very popular in Australia, particularly if family size has been completed. A vasectomy is a permanent option for men where the tubes carrying sperm to the penis are cut with no effect on other functions. It is usually done under local or general anaesthetic. It is not immediately effective - a follow-up semen analysis at three months is required to check for effectiveness. There is also a very small risk of injury to the testicles and long-term testicular pain.
Finding an ideal contraceptive in midlife is often complicated by health conditions as well as social and relationship issues. Fortunately, waning fertility allows the consideration of options not suitable for younger, more fertile women. Choosing the contraceptive that best works for you requires careful thought and consultation with your doctor.
Contraception across your lifespan - Jean Hailes Magazine, Vol.2/2012
Content update November 30, 2009