Gillian Dean, MD, MPH
Associate Professor of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai
The Mount Sinai Hospital
Birth Control Options for Women Over 40
Many women believe, once they pass 40, that they are no longer fertile. In fact, a woman can get pregnant, intentionally or not, into her late 40s and beyond. And pregnancy after age 40 may carry greater risks. For this reason, contraception until menopause is important for women who are at risk for pregnancy and don't want to be pregnant.
Because of misconceptions about the health risks of different birth control methods, some health care providers discourage perimenopausal women (those transitioning toward menopause) in their 40s and 50s from using contraceptive methods, such as birth control pills, that they previously relied on in their 20s and 30s. The truth is that a healthy, nonsmoking woman can safely use almost any contraceptive method, including the pill, all the way through menopause.
Many contraceptive methods are available, and each has its own advantages and disadvantages. The main thing to consider (after health issues for women choosing certain contraceptives) is what method you are most motivated to use. By choosing a method that appeals to you, you will be more likely to use it correctly and stick with it.
Forgettable Contraception
When I talk with patients about contraception, I begin by discussing the methods that are most effective, safest, and easiest to use. These are called LARC, for long-acting reversible contraception, or HERC, for highly effective reversible contraception. I also like the term "forgettable contraception" because once you start one of these methods, you can typically forget about it for three or more years.
LARC includes contraceptive implants and intrauterine devices (IUDs). These are two of the safest birth control methods available. They not only have the lowest failure rates, but are also extremely easy to use, can be used by almost all women, and women tend to like and stick with them. For women in their 40s and 50s, who are often busy with careers, childrearing, and care of elderly parents, IUDs and implants fit well into their busy lifestyles. Moreover, these methods are safe for most women all the way through menopause.
Implants and IUDs are completely reversible and do not require surgical procedures. Because they lack estrogen, they can be used by women who smoke or have a history of blood clots, migraines, or high blood pressure. However, women who have had breast cancer within the past five years should not use methods that contain progestin.
Implants. Placed just beneath the skin of the inner upper arm, an implant is a small, flexible, synthetic rod, about the size of a matchstick. Lasting three years, it releases a small amount of progestin (a synthetic version of the female hormone progesterone) continuously into the bloodstream, like a slow-release capsule. This stops eggs from leaving the ovaries (ovulation), thereby preventing pregnancy.
IUDs. An IUD is a small T-shaped device placed inside the uterus. There, the IUD creates a sterile inflammatory reaction that works like a spermicide to prevent sperm from reaching the egg. Medication in the IUD enhances this contraceptive effect.
There are four types of IUD available in the United States. Three of these release a low dose of the hormone progestin; the progestin dose is low enough that it does not block ovulation, but rather works locally on the uterus and cervix to prevent fertilization. The hormone IUDs are approved for 3 or 5 years of use, depending on the model. Hormone-releasing IUDs decrease menstrual blood flow and cramps, which can be a benefit to perimenopausal women experiencing heavy periods. The other IUD available in the U.S.is a non-hormone IUD containing copper; this IUD lasts 10 years.
Other Hormonal Methods
Other hormonal birth control methods include injections, pills, patches, and vaginal rings, all of which prevent ovulation and are highly effective if used correctly. However, these methods require more attention on the part of the user, and thus are more prone to error.
Injection. Commonly known by the brand name Depo-Provera®, the depot medroxyprogesterone acetate (DMPA) injection is a progestin given every three months. Women using DMPA may experience a decrease in bone mineral density (a measure of fracture risk), which may be a concern for women approaching menopause. However, there is no strong evidence that women using DMPA have more fractures than women who use other contraceptive methods. For this reason, the Centers for Disease Control and Prevention (CDC) says that the advantages of DMPA outweigh the risks in healthy women even over age 45. Because DMPA contains no estrogen, women who smoke or with health conditions such as a history of blood clots, migraines, or high blood pressure may safely use it.
The pill, patch, and ring. These methods are all just different ways of delivering the hormones estrogen and progestin into the bloodstream, either through the gastrointestinal tract, skin, or vaginal mucosa, respectively. The ring has to be changed monthly, the patch weekly, and the pill taken daily. They are essentially equivalent in terms of health risks. A healthy, nonsmoking woman can safely use these birth control methods all the way through menopause. According to the CDC, however, the risks may outweigh the benefits if you are a smoker or have a medical condition for which estrogen use is contraindicated, such as cardiovascular disease, migraines, or high blood pressure (even if it is well controlled). And any hormone-based method is contraindicated in a woman who has had breast cancer within the last five years.
Barrier Methods
A barrier method can be effective, but takes a high degree of user motivation and, in the case of condoms, male involvement. Condoms are great for preventing sexually transmitted diseases. Many women in their late 40s are in longer-term, committed relationships and don't want to use a method that requires interrupting the sex act. Other barrier methods include diaphragms and cervical caps, but these are rarely used anymore.
Sterilization
A surgical procedure to permanently prevent pregnancy is an excellent option for women who are certain their family life is complete and need to avoid unintended pregnancy for many more years. But women near menopause must weigh the benefits of sterilization--freedom from worrying about unintended pregnancies and not needing to use other contraceptive methods--against the risks, though minor, of undergoing surgery. Women who need birth control for only a few more years might prefer to use something like an IUD or implant instead.
Additional Health Benefits
Beyond contraception, some birth control methods offer additional health benefits for many women in this age group. For instance, because they contain estrogen, pills, patches, and rings can treat hot flashes, as well as control irregular bleeding. Estrogen can also help increase bone mineral density. And any method that contains progestin lowers the risk of uterine cancer.
It is important for older women who are still at risk for unintended pregnancy to understand that birth control methods they might have thought risky may actually be safe, effective, and beneficial to their overall health. Women will find the best form of birth control to be the one they are motivated to use, whether it is one that requires attention like the pill or patch, or a "set it and forget it" method like an IUD. Choosing the birth control method that suits them best can help perimenopausal women enjoy a healthy, worry-free sex life.