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Contraception in midlife offers benefits beyond preventing pregnancy
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For many women in their 40s, contraception is generally no longer a high health care priority. Decreases in fertility during this decade, along with heavy or irregular periods, may lead these women to believe they cannot get pregnant and can discontinue birth control. However, this assumption can lead to surprising consequences in the form of unwanted midlife pregnancies.
“If you look at statistics in Canada as far as the nonuse of contraception, we actually find that it goes up in women in their later reproductive years, and with that, we also see higher abortion rates,” Amanda Black, MD, MPH, FRCSC, professor of obstetrics and gynecology at The University of Ottawa, told Endocrine Today. “Women in their later reproductive years may use contraception less consistently than younger women, possibly due to a lower perceived risk for pregnancy. However, unintended pregnancies occur at ratios similar to or even higher than younger age groups, and almost half of these pregnancies will be terminated.”
Endocrine Today spoke with Black about when hormonal contraception should be discontinued and contraception’s impact on menopausal symptoms, bleeding and the risks for certain types of cancer.
Is there a specific age at which women should discontinue oral contraception?
Black: Both the Society of Obstetricians and Gynaecologists of Canada (SOGC) and WHO state that no method of contraception is contraindicated on the basis of age alone. This means that as long as a woman is a healthy nonsmoker, she can essentially use any method of contraception up until menopause. However, we do have to remember that as we get older, we may develop medical conditions that can make some options less suitable or even contraindicated completely. For example, if someone develops high blood pressure or coronary artery disease or develops blood clots in the legs or lungs, then methods such as the pill, the patch or the ring may no longer be good contraceptive options. Still, there are other methods that could be good options.
One of the other things people tend to forget is that a lot of contraceptives have noncontraceptive benefits associated with them that can help improve quality of life. In the later reproductive years, vasomotor symptoms like hot flashes may start, and using a combined hormonal oral contraceptive pill (OCP) may help manage that. Vasomotor symptoms may be manageable for some individuals, but for others they may be really debilitating and affect quality of life. There’s nothing worse than sweating through your blouse in the middle of a board meeting.
Abnormal uterine bleeding, which includes irregular bleeding or heavy menstrual bleeding, affects many individuals approaching menopause. An OCP or a hormonal IUD can help manage those problems.
Although it is important to review contraception choices regularly, at the age of 50 years it is especially important to reevaluate options in light of an individual’s needs and current health profile. It may be time to switch to something else, or maybe even stop altogether. We take the individual with all of her specific issues into account.
If a woman is using hormonal contraception, would she know when she has reached menopause? How?
Black: Menopause is a retrospective diagnosis, meaning that you can only diagnose it after someone has gone at least a year without having a natural period, without using a hormonal contraceptive. Some people think that using contraception affects when menopause occurs — it doesn’t. Menopause will still occur at the same time, but contraception may mask the signs of menopause. Amenorrhea — no menstrual bleeding — cannot be used on its own to diagnose menopause in users of hormonal contraception. If a woman is on a pill, she might not be having the hot flashes, and she is still having regular periods; if she has a hormonal IUD, she might not be having any periods at all so she wouldn’t necessarily know when menopause has occurred.
reproductive years.
What are some options that can be used to eliminate bleeding?
Black: If a woman is in her later reproductive years and is having abnormal bleeding, using something like a pill, a patch, a ring or a hormonal IUD can help with that. Again, as long as she is healthy and no other contraindications develop during that time, she can continue that until contraception is no longer required. There are some methods, hormonal IUDs like Mirena, that can be inserted in the office and remain in place for up to 7 years. So, if patient has a Mirena inserted at age 45 years, it can stay in place until she is 52 — the average age of menopause is 51 years, so hopefully by the time she is ready for it to be taken out, she may no longer require contraception at all. We always talk about how a woman can kind of coast into menopause with that, because she is not having the irregular or heavy bleeding that often occurs during this time of an individual’s life.
What are the recommended options for contraception in midlife?
Black: Because there is no method that is contraindicated based on age alone, all options can be considered. Maybe they are looking for permanent options at this point; maybe they are just looking to improve their quality of life. In some countries, there are much higher rates of use of permanent birth control methods (tubal ligation, vasectomy) compared with reversible methods these during these years. However, there are many reversible options available that offer benefits beyond contraception. Some methods will actually decrease the risks for certain cancers, such as endometrial cancer and ovarian cancer. That’s another benefit. Basically, these women have their choice of anything that is out there: permanent birth control, pills, patches, rings, injections, IUDs and barrier methods. It’s really all on the table provided there are no contraindications. The key is to always look at the whole picture. What does an individual need — not just their contraceptive needs, but their overall needs within the context of their lives. It’s important to consider any symptoms they might be having or any health concerns that may arise, so that you can not only protect them against an unintended pregnancy, but address a number of these other health issues as well, ultimately improving their quality of life while avoiding an unintended pregnancy. Just remember that although fertility declines with increasing age, contraception should still be used consistently by individuals who wish to avoid pregnancy until menopause is confirmed. – by Jennifer Byrne
For more information:
Amanda Black, MD, can be reached through the society of Obstetricians and Gynecologists of Canada at www.sexandu.ca.
Disclosure: Black reports she has consulted for Allergan, Bayer, Merck and Pfizer.