Woman Around Town’s Editor Charlene Giannetti and writers for the website talk with the women and men making news in New York, Washington, D.C., and other cities around the world. Thanks to Ian Herman for his wonderful piano introduction.

Denise Howard

Contraception over 40: Four Questions You Should Ask 


Are you over 40 and in need of contraception? There are four important questions you need to consider when deciding on a method. You should expect your health care provider to counsel you on the usual topics such as contraindications to the method or medical risks such as venous thromboembolism which is a serious complication of hormonal contraception where clots form in the blood vessels causing life-threatening problems. They should also describe the expected side effects and effectiveness of each method. There are however, some other benefits to contraception that are not commonly discussed. The questions below can help you assess your contraceptive needs and explore other benefits you may not have considered. 

1. What is my risk of pregnancy? 

Contraceptive choices, like all life choices, should be driven by an assessment of the risks and benefits. In this case what are the risks of getting pregnant and what are the risks if you conceive? Fecundability is the probability of obtaining a clinically recognized pregnancy in a single menstrual cycle. In women over 40, the cycle fecundity is 6 percent vs 12 percent in women 35 to 40 years old and 20 percent in those under 35.

Women who become pregnant over 40 are at increased risk of complications. They are almost 2.5 times more likely to have a miscarriage and nearly 10 times more likely to have a pregnancy with a chromosomal abnormality. Women 40 years and older have a more than two-fold risk of developing gestational diabetes, having a placenta previa (placenta implanting over the cervical opening) and needing a cesarean section for delivery. This increased risk also extends to other serious complications such as delivering an infant who is larger than average, having a preterm delivery and experiencing a perinatal death. 

While this information may seem scary, most women deliver without any major problems. It is, however, important to understand the risks you face if you decide to become pregnant after 40. For those who have completed their childbearing or don’t want to have children, this information should reinforce the importance of effective contraception.

2. Which contraception will help with my menstrual problems? 

Menstrual related problems are one of the most common reasons women seek the care of a gynecologist. Women of any age can experience these problems, however the percentage of women affected increases with age. Hormonally based contraception will typically help with many of the menstrual related complaints. There are two types used: combination hormonal contraception (CHC) which contains estrogen and progestin and comes in a pill, patch or intravaginal ring, and the progestin only contraception which is delivered via a pill, injection, implant or intrauterine device. 

The CHC which includes the traditional oral contraceptive pill has been shown to decrease dysmenorrhea (pain with menses) in 70-80% of women who suffer and reduces menorrhagia (heavy bleeding with menses) by 40-50%. The progestin methods can lead to amenorrhea (elimination of the menses) in 40% of implant users and 80% of those with the levonorgestrel intrauterine device (LNG-IUD). Irregular cycles can be managed by regulating them with CHC or eliminating them with one of the progestin only methods.

Other conditions that can be improved with hormonal contraception include premenstrual syndrome, premenstrual dysphoric disorder, acne and new facial hair growth. Any CHC can be used to address premenstrual symptoms, however, select brands containing the progestin, drospirenone, have been specifically studied to prove its effectiveness in treating these problems. 

3. Will contraception increase my risk of cancer? 

Many women express concern over using a hormonal contraception for years at a time. The main questions relate to its safety and if it contributes to the development of cancer. Hormonal contraception has been on the market for over fifty years, providing enough time to do outcome studies. The hormonal effect varies depending on which organ is studied, but data has been consistent in showing that hormonal contraception reduces the risk of endometrial cancer by 50%. The relatively recent and amazing finding is the reduction in ovarian cancer by 27% in anyone who’s ever used CHC and an additional 20% reduction in risk for every 5 years of use of the CHC.  A recent study examining over 46,000 women also confirmed a reduction in colorectal cancer by 18% in recent or current users of the oral combination hormonal pill. A reduction in epithelial ovarian cancer can also be found with tubal sterilization. Women who have had a tubal ligation or have had their tubes removed are significantly less likely to develop ovarian cancer than women who haven’t undergone these procedures. The studies related to breast cancer have not been consistent, with some showing no increase in risk while others showing a slight increase in risk. 

4.  Which contraception will fit my lifestyle? 

Long-acting reversible contraception (LARC) and permanent sterilization are the most convenient methods as you don’t need to remember to take a pill, place or remove an insert or put on a patch. You can live your life without giving much thought to contraception. 

LARC includes methods like the contraceptive implant which lasts three years and the intrauterine devices (IUD) which last from 3-10 years depending on the product chosen. These products are inserted in the office by a trained physician. The advantage is that once in place you don’t have to remember to take any action for the life of the product. This contributes to the high effectiveness of these methods as most failures are related to improper use.  Some of the products use progestin resulting in light, irregular menstruation and many women enjoy not having a period at all. If you prefer non-hormonal methods, then the copper IUD is available worldwide and is effective from 5-10 years depending on the selected brand. 

If you are not in a long term monogamous relationship, then condoms should always be worn. The female and male condoms are readily available and reasonably priced. This method will protect against sexually transmitted infections. 

Permanent sterilization in the form of a tubal ligation or a vasectomy is the ultimate fix if you have completed your family or are sure you don’t want any children. Once the procedure is done and your doctor confirms that all steps are complete then you don’t have to think about contraception again. The traditional tubal ligation can be done immediately postpartum or at the time of a cesarean section. There is also the laparoscopic approach which can be done anytime and involves surgery using small incisions and a lighted camera. The tubes can be clipped, banded, coagulated or even removed in less than an hour and most women are back to their usual activities in approximately two weeks. 

If you are considering contraception think about the other benefits that can be had with the proper contraceptive choice. Are you having problems with your periods? Are you concerned about developing ovarian cancer? There are methods that can resolve your menstrual related problems, dispense with the heavy blood loss, decrease your chance of developing certain gynecologic cancers and improve the quality of your life. Consider this when selecting a birth control method. 

Denise Howard, MD, MPH  is a Senior Attending Physician at Sidra Medical and Research Center and an Assistant Professor of Clinical Obstetrics and Gynecology, Weill Cornell Medicine-Qatar. Click to purchase her new book, The Essence of You: Your Guide to Gynecologic Health, published by WAT-AGE Publishing. 

Top photo from Bigstock

We Celebrate Our Women Around Town 2017


2017 is the ninth year that we have featured outstanding women on our website. We continue to be excited about telling the stories of women who are making a difference in so many disciplines. Once again, the women we spotlight are different ages, come from various areas of the country, and represent many different ethnic groups. While some work in traditional businesses, others have followed a dream and launched their own company. We are inspired by all of them and feel honored to tell their stories.

Click on a name in the tags that follow to be able to read an individual story.

In a few short days, we begin a new year, a new chance to spotlight even more women who inspire us all. Do you know someone who should be on our radar? Let us know!

Enjoy a year’s worth of fabulous women!

Happy New Year!

A Call to Action: Women, Become Engaged in Your Health


Women and girls, you can’t afford to be a passive participant in your own health. It is naïve to assume health care providers and government agencies will tell you what you need to know and what you need to do to remain healthy. In the instances when they do provide this information, so many people fail to receive it or think it isn’t relevant to them. Diligent attention is required to increase your probability of leading a long and healthy life.

After practicing medicine for nearly 20 years, I’m distressed by the number of women I still encounter who don’t undergo regular preventative screening tests and am horrified when I learn that many of them don’t even know what these tests are and why they are important. The reasons for this are complex and the blame can be placed at many doors, but for the individual there is one truth: you must become actively involved in your health if you don’t want to become victim to a preventable disease.

When I heard of the death of Gwen Ifill, a history-making journalist and newscaster, who died from endometrial cancer in 2016, I had one thought: how could this have happened? She was a highly educated, gainfully employed woman. Endometrial cancer is one of the most treatable cancers if it is caught early enough. Did she have symptoms she didn’t realize were important to act on? Did she seek care but the health care provider did not act promptly? The details of her care are not known to me and she may have received timely and appropriate care that just wasn’t effective. Her story does highlight the ongoing threat of gynecologic malignancies. The importance of early intervention can’t be over emphasized and this can only be done if you know when intervention is required.

The New York Times recently reported that death rates from cervical cancer are much higher in the U.S. than previously thought and there is a significant racial disparity in these deaths. This too is an alarming story in that cervical cancer is the most preventable gynecologic cancer. Women who develop cervical cancer are usually those who have never undergone a Pap smear or who haven’t had this test in many years. Every woman should know about and have access to the simple screening tests that can prevent this cancer but obviously, this isn’t the case.

You are just a number. Unfortunately, this is a fact for many women seeking healthcare in America. For economic reasons, physicians and other healthcare providers are expected to see a large volume of patients. It is therefore, understandable that each patient is allotted only a short amount of time per visit and the focus is usually on the most immediate concern. These rushed visits don’t lend themselves to exploring other healthcare needs or educating woman about preventative services.

All doctors are not created equal. Their training, skill and empathy level aren’t the same and they don’t have the same knowledge, motivations and perspective. Doctors are also human. Given this, it’s not surprising that each patient’s experience may be vastly different and their needs may not be met. Not all women feel empowered to demand the care they deserve.

Women can’t count on the government to ensure they receive adequate care. In fact, many government officials are attempting to limit access to certain gynecologic services. Uninsured women are in an even more precarious position. The situation has the potential to become worse under the current administration.

Women, you are on your own. If you want to receive the best health care possible, you must become actively involved in your care. You must become health literate and then work with your doctor so your healthcare needs are met.  Life is short and you don’t want to contribute to shortening it further by becoming a casualty of your own inaction. If you want to improve your chance of living a full and healthy life, then you must become engaged.

Denise Howard, MD, MPH  is a Senior Attending Physician at Sidra Medical and Research Center and an Assistant Professor of Clinical Obstetrics and Gynecology, Weill Cornell Medicine-Qatar. Her new book, The Essence of You: Your Guide to Gynecologic Health, will be published by WAT-AGE Publishing this spring.

Top photo from Bigstock