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.
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