Although pregnancy is less likely around the menopause, over the age of 40 years it is still important to use contraception. There are various different types of contraception available. Most need to be used until you have gone through the menopause or are aged 55 years. An overview of all the different types is given here.
The time of menopause varies tremendously between women. Before your periods stop altogether, it is likely that your periods will become irregular and unpredictable. Although you are less likely to ovulate (produce an egg) every month, your ovaries will still be producing some eggs and, for this reason, it is important that you consider using contraception. So, although there is a natural decline in your fertility after the age of about 37, effective contraception is still required to prevent an unplanned pregnancy.
If you are using contraception other than hormone-based contraceptives (such as the pill), you will be able to stop using contraception one year after your periods stop if you are aged over 50 years, or two years after your periods stop if you are aged under 50 years.
However, if you are using hormone-based contraception, then your periods (withdrawal bleeds) are not a reliable way of knowing if you are fertile or not. Some women who take hormone-based contraceptives will have irregular or no periods, but will still be fertile if they stop using their contraceptive. The age for stopping the different hormone-based contraceptives are detailed below.
All the methods of contraception listed below are effective. However, no method is absolutely 100% reliable. The reliability for each method is given in percentages. For example, between 2 and 60 women in 1000 using the contraceptive injection for one year will become pregnant. When no contraception is used, more than 80 in 100 sexually active women who have not gone through the menopause become pregnant within one year.
The effectiveness of some methods depends on how you use them. You have to use them properly or they may lose their effect. For example, around 3 women in 1000 using the combined oral contraceptive pill perfectly will become pregnant. If it is not taken correctly (for example, if you miss a pill or have vomiting) closer to 90 women in 1000 become pregnant. Other user-dependent methods include barrier methods, the progestogen-only pill and natural family planning.
Some methods are not so user-dependent and need to be renewed only infrequently or never. These methods include the contraceptive injection, implant, intrauterine contraceptive devices (coils) and sterilisation.
Your choice of contraception when you are over the age of 40 years may be influenced by:
The types of contraceptives can be divided into short-acting, long-acting and permanent. (See also separate leaflets on the various methods of contraception for more details.)
The combined oral contraceptive pill (COCP) is often just called the pill. It contains oestrogen and progestogen and works mainly by stopping ovulation. It is very popular. Different brands suit different people.
The COCP can safely be taken by women over the age of 40 with no other medical problems. However, you should not take it if you are aged over 35 years and a smoker, or are aged over 40 years and have a cardiovascular disease (for example, angina), or a history of a stroke or migraine.
Many women over 40 take a COCP with a lower amount of oestrogen in it. However, taking the COCP may actually improve any menopausal symptoms that you may have. There is also some evidence that taking the COCP when you are aged over 40 years may increase the density of your bones. This means your bones are stronger and may be less likely to fracture when you have gone through the menopause.
There is a reduction in your risk of developing ovarian and endometrial cancer if you take the COCP. This reduced risk actually continues for 15 years or more after stopping the pill. There may be a very small additional risk of breast cancer, which actually reduces to no risk after 10 years after stopping the COCP. There is actually a reduction in the risk of colorectal cancer in women who take the COCP.
You should stop taking the COCP and use another form of contraception when you reach the age of 50 years.
The progestogen-only pill (POP) used to be called the mini-pill. It contains just a progestogen hormone. Between 3 and 90 women in 1000 using the POP will become pregnant. It is commonly taken if the COCP is not suitable - for example: breast-feeding women, smokers over the age of 35 and some women with migraine. It works mainly by causing a plug of mucus in the cervix that blocks sperm and also by thinning the lining of the uterus. It may also stop ovulation.
You need to remember to take it at the same time every day because if you take a pill more than three hours later than usual (12 hours for a POP called Cerazette®), you lose protection.
The POP is safe if you have had a stroke, heart attack or suffered with a clot in the past. There is no increased risk of developing breast cancer if you take the POP.
The POP can be continued until you reach the age of 55 years, after which time you will no longer need to use contraception.
A combined hormone form of contraception, containing oestrogen and progestogen hormones. It is essentially the same type of contraception as the COCP but it is used in a patch form. The contraceptive patch is stuck on to the skin so that the two hormones are continuously delivered to the body. There is one combined contraceptive patch available in the UK, called Evra®.
The patch can safely be taken by women over the age of 40 with no other medical problems. However, you should not use it if you are aged over 35 years and a smoker, or are aged over 40 years and have cardiovascular disease, or a history of a stroke or migraine. You should stop using the patch and use another form of contraception when you reach the age of 50 years.
These include male condoms, the female condom, diaphragms and caps. They prevent sperm entering the uterus. 20 women in 100 using male condoms will become pregnant if used perfectly. Nearer 160 women in 100 become pregnant with normal (not perfect) usage. Other barrier methods are slightly less effective than this.
This involves fertility awareness - effective if done correctly. It requires commitment and regular checking of fertility indicators such as body temperature and cervical secretions.
This contains a progestogen hormone which slowly releases into the body. 2-60 women in 1000 women using the injection for one year become pregnant. This means that it is almost as effective as sterilisation. It works by preventing ovulation and also has similar actions as the POP. An injection is needed every 8-12 weeks.
The injection is safe if you have had a stroke, heart attack or suffered with a clot in the past. There is no increased risk of developing breast cancer if you use the contraceptive injection.
Long-term use of progestogen-only injection can be associated with a reduction in the density (strength) of your bones. However, this returns to normal after stopping using the injection.
The contraceptive injection is usually stopped when you reach the age of 50 years and another method of contraception should then be used.
An implant is a small device placed under the skin. It contains a progestogen hormone which slowly releases into the body. 1 women in 2000 using the implant for a year will become pregnant. This means it is as effective as sterilisation. It works in a similar way to the contraceptive injection. It involves a small minor operation using local anaesthetic. Each one lasts three years.
The implant is safe if you have had a stroke, heart attack or suffered with a clot in the past.
The implant can be continued until you reach the age of 55 years, after which time you will no longer need to use contraception.
An intrauterine contraceptive device (IUCD) is a plastic and copper device which is put into the uterus. It lasts five or more years. It works mainly by stopping the egg and sperm from meeting. It may also prevent the fertilised egg from attaching to the lining of the uterus. The copper also has a spermicidal effect (kills sperm).
It can be common to have spotting, light bleeding, heavy or longer periods in the first 3-6 months after having an IUCD inserted.
If you have an IUCD inserted when you are aged 40 years or over, then this can remain in place until you have gone through the menopause and no longer require contraception. That is, for one year after your periods stop if you are aged over 50 years, or two years after your periods stop if you are aged under 50 years
A hormone-releasing intrauterine device called an intrauterine system (IUS) is a plastic device that contains a progestogen hormone. It is put into the uterus in a similar way to an IUCD. The progestogen is released at a slow but constant rate. 2 women per 1000 using the IUS for a year will become pregnant. It works by making the lining of your uterus thinner so it is less likely to accept a fertilised egg. It also thickens the mucus from your cervix. It is also used to treat heavy periods.
The IUS is safe if you have had a stroke, heart attack or suffered with a clot in the past.
The IUS can be continued until you reach the age of 55 years, after which time you will no longer need to use contraception.
You and your partner may have decided that you would like a more permanent method of contraception. Sterilisation involves an operation. It is more than 99% effective. Vasectomy (male sterilisation) stops sperm travelling from the testes. Female sterilisation prevents the egg from travelling along the Fallopian tubes to meet a sperm. Vasectomy is easier and more effective than female sterilisation.
Emergency contraception can be used at any time if you had sex without using contraception. Also, if you had sex but there was a mistake with contraception. For example, a split condom or if you missed taking your usual contraceptive pills.
As hormone replacement therapy (HRT) contains very low levels of hormones, it does not work as a contraceptive. Unless you went through the menopause (had no period for one year if aged over 50 or for two years if aged under 50) before you started HRT, then you should use contraception until you are 55 years old.
If you are taking HRT then you can take the POP or have an IUCD or IUS inserted. Alternatively, many women choose to use barrier methods of contraception.
This leaflet is just a brief account of the available methods of contraception around the menopause. Ask your practice nurse, doctor or pharmacist if you want more detailed information about any of these methods.
The fpa (formerly the family planning association) also provides information and advice.
fpa's helpline: 0845 310 1334 or visit their website www.fpa.org.uk