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Contraception for the Mature Woman
Her needs aren't necessarily the same
Contraception, also known as birth control, is one of the most common reasons a woman sees her family doctor. As women age, contraception is still important but different factors come into play. If you are a mature woman in the age range called perimenopausal (between the age of 40 and menopause) this article may answer some of your birth control questions. We will explore the available options, and points to keep in mind when discussing these options with your doctor.
Types of contraception
Combined estrogen and progesterone oral contraceptive (COC) pill
Many women have heard that the COC pill is not suitable for women over age 35 who smoke. Indeed, there was a fear that the COC pill was dangerous for any woman over the age of 35 whether she smoked or not. However, this information was based on older COC pills. Newer estrogen and progesterone compounds are safe in women over age 35 who do not smoke and have no other risk factors. Women with cardiovascular disease, unexplained vaginal bleeding, tumours that grow in response to estrogen, and certain liver problems should avoid the COC pill.
Some women fear the COC pill increases their risk of breast cancer. However, many studies have shown there is no increased risk with use of the COC pill, regardless of age. As well, the COC pill helps protect against ovarian and uterine cancer.
Perimenopausal women may have an added benefit from this pill with regular, predictable and often lighter cycles. The COC pill masks the onset of menopause as withdrawal bleeds continue. In addition, menopausal symptoms such as hot flashes and irritability tend to be reduced.
Along with the benefits from using the COC pill during perimenopause, there are advantages for any age group. These include reducing dysmenorrhea, endometriosis, uterine fibroids, ovarian cysts, anemia and pelvic infections. Your doctor can explain these conditions in relation to your own situation.
Progesterone-only methods
These methods are more appropriate for the mature woman who smokes or has cardiovascular disease. It is the estrogen component of the COC that increases the risk for these women of heart attacks and stroke. A safer alternative is a progesterone-only method. The progesterone-only pill (mini-pill) has one disadvantage because it must be taken exactly on schedule to offer birth control but it is effective in very committed users. It is not unusual to experience irregular bleeding with its use.
Depo-Provera™ is a progesterone-only contraceptive given by injection at 12-week intervals. It is an easy, safe and reliable form of birth control. The effectiveness is similar to the COC pill (approximately 99.5 per cent). In contrast to the COC pill, Depo-Provera™ requires little commitment. The woman does not have to think about it during the 12 weeks until her next injection. Side effects are similar to the COC pill and include weight changes (usually weight gain), headache, abdominal discomfort, fatigue, nervousness and irritability. Many women will not have periods while on Depo-Provera™ and some will have unpredictable vaginal bleeding. There is really no way of predicting how a woman will respond.
In women who do not have a period using Depo-Provera™, there has been concern that bone density may be affected. Decreased bone density is the main factor in osteoporosis in women after menopause. Research thus far indicates there is no significant cause for concern. However, women who choose Depo-Provera™ should discuss the risks with their doctors.
Intrauterine devices (IUD)
IUDs are highly effective and pose fewer problems for the mature woman than for a younger woman. However, if there is already a problem with irregular bleeding, an IUD may make the problem worse. An appealing aspect of the IUD is that it can be inserted at age 40 and removed one year after the last menstrual cycle. This provides a form of contraception into menopause.
Barrier methods
With the natural decline in fertility as a woman ages, barrier methods of contraception may be more reliable than they are for younger women. The diaphragm or a condom, combined with a spermicide, give extra lubrication if vaginal dryness is a problem. As a bonus, the condom provides protection against sexually transmitted diseases. Another less commonly used barrier form of contraception is spermicidal foam.
Sterilization
Sterilization is the permanent way to avoid pregnancy once child-bearing has been completed. This surgical procedure involves cauterizing, clipping or cutting the woman’s fallopian tubes under general anesthetic. This is usually done through a laparoscope with two small incisions and it has a rapid healing time.
Natural family planning
Calendar calculations, charting basal body temperature and assessing cervical mucus (Billings method) are considered forms of natural family planning. As fertility declines with age, this may be a suitable form of contraception. On the other hand, menstrual cycles tend to become irregular with age as ovulation becomes less frequent. Since these forms of natural family planning rely on identification of ovulation, the method becomes less reliable in the perimenopause.
Special considerations for the mature woman
During perimenopause, a woman may have symptoms of menopause such as hot flashes, vaginal dryness and irritability. In addition, menstrual cycles tend to become more irregular and heavy.
If a woman becomes pregnant in the perimenopause, the risks to both mother and unborn child increase significantly. Women in this age group are at an increased risk of complications of pregnancy and delivery. One such complication includes postpartum hemorrhage. There is a higher rate of miscarriage, fetal abnormality, premature delivery, and resulting low birth weight babies. Women in this age group are also more at risk of psychological problems such as postpartum depression.
When can contraception be stopped?
A woman who is not using hormone contraception should continue protection until one year after menstruation stops. While on COC pills, a woman will continue to have withdrawal bleeds. While on Depo-Provera™, a woman may have already stopped bleeding. In these cases, a reasonable option would be to stop the hormone contraception at age 50, and continue with another form of birth control until one year after the last menstrual period.
A second option is to measure a hormone in the blood called follicle-stimulating hormone (FSH). This hormone is increased in women who have reached menopause. If a woman is on a progesterone-only contraception, a blood test to measure FSH can be performed. The test is done on two separate occasions. If a woman is on the COC pill, the estrogen component of the pill can mask the results and it should be stopped six weeks before the blood test.
How do I decide what form of contraception is right for me?
Deciding the contraceptive method that will suit you best is not easy. Many factors are involved. Discuss the options with both your partner and your doctor before making any decision.
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