So over Contraception? Think Again.

Yeah, I know. You’ve been doing the contraception shuffle for, oh, decades now. Isn’t it “safe” yet? After all, you’re past 40. Maybe you’ve even missed a couple periods.

Not so fast.

You’re in the midst of a very hazardous crossing—those uncertain years between fertility and menopause during which you are less likely to get pregnant, but, make no mistake, you still can!

While women are indeed less fertile after 40, they absolutely can get pregnant. In fact, women can conceive even during perimenopause, when the menstrual cycle is beginning to become irregular.

For some reason, however, women seem to become more casual as they near the goalposts. How else to account for the fact that women over 40 are the least likely to use birth control of any age group, and that their abortion rates are as high those of adolescents, according to a 2008 USA Today article.

In Great Britain, women in their 40s are now called “the Sex and the City generation,” and they, too, have grown careless. In the UK, abortions within the over-40 age group have risen by one-third in the past decade. In the US, 38 percent of pregnancies in women age 40 and older are unplanned. Of those, 56 percent end in abortion, according to this article in HealthyWomen.org.

By the time they reach 40, women are generally old hands at birth control. But at this point in life some reevaluation may be in order. Levels of fertility are decreasing, and hormonal levels are (or soon will be) in flux. Some women may not want to have children; others may want to keep the option open. In any case, an unplanned surprise complicates life really fast.

This is a good time for a conversation about birth control with your healthcare provider, and you may have to initiate it. While you have more options than ever, the best one for you might be different than what worked for you in your 20s.

And just so you know, current guidelines advise that you remain on birth control until one year after your last period, the official definition of menopause. Complicating the picture is the fact that with hormonal forms of birth control, such as the pill, your cycles may be irregular or may stop completely, which masks the onset of menopause. And the withdrawal bleed during the week off the pill isn’t considered a true period.

Birth control after 40 falls into several categories: permanent, long-term or short, hormonal or barrier method. They vary in levels of effectiveness and in the side effects you may experience. And remember that condoms are the only type of birth control that protects against sexually transmitted infections.

Probably your most immediate decision is whether to end childbearing permanently. Tubal ligation is a laparoscopic procedure that happens under general anesthetic in a hospital. There’s also a new, non-surgical option that a doctor can do with a local anesthetic right in the office.  Or, of course, your partner could have permanent sterilization as an outpatient office procedure.

Hormonal types of birth control are very effective, but can have both side effects (bloating, risk of stroke for some women) as well as protective benefits (against bone loss and some forms of cancer, for example).  It is very important to carefully review your health history with your health care provider to select the best option for you.

Short-term hormonal options include

  • Combined estrogen-progestogen pill (COCP). This is “the pill” you are probably familiar with. Since it now has very low estrogen levels, it’s considered safe for women who have no risk factors until age 55.
  • Progestogen-only pill (POP), which is a good option for older women. It must be taken regularly at the same time of day, however.
Long-term hormonal options include
  • Progestogen shot, which is a once-every-8-12-week option.
  • Progestogen implant, in which a tiny rod is inserted in the upper arm. It lasts for three years.
  • Vaginal rings release low dosages of estrogen. The ring is kept in the vagina for three weeks, then removed for a week.
  • A patch, which also releases low dosages of estrogen and progestogen.
  • An IUD impregnated with progestogen, which is highly effective and lasts for years.
The old non-hormonal standbys still include
  • Condom. Again, the only birth control that also protects against STIs.
  • Non-hormonal IUD. Also highly effective and long-lasting.
  • Diaphragm with spermicide, cervical cap, or spermicidal sponge.

Your choice of birth control at this point should be informed and careful. You need a plan to carry you through menopause, and you need to begin the dialog with your healthcare provider.

Since the consequences of ignoring the issue are so life-changing, this conversation ought to begin now!

Q: What non-hormonal birth control can I use when I go off the pill?

There are two principle non-surgical options for birth control: hormonal and barrier methods. Sounds like you've already decided to steer clear of hormones, at least for a time.

The most common barrier options include condoms (male or female) or diaphragms, in combination with a vaginal spermicide. (Vaginal spermicides, available as film, foam, and suppositories, have a slightly higher failure rate than other methods when used alone.) We haven't yet found a female condom that is easy to use and reliable--let us know if you have a recommendation! Don't count on condoms that have been rattling around in a drawer while you've been on the pill: Freshness does count so the condoms aren't brittle.

You'll need to talk to your health care provider about a diaphragm, since it needs to fit you well.

And, of course, there are surgical options for your partner (vasectomy) or for you (tubal interruption). Again, a discussion with your health care provider will help you weigh those options.

You're smart to be thinking ahead about this!

Q: What birth control should I consider at 49?

This is an important issue. At 49 you are ‘subfertile,’ but not infertile. You also can’t rely on rhythm, as there is no rhythm!

Barrier methods--condoms or a diaphragm--can work well, although they take some anticipation and planning. (If you're in a new relationship, you might also consider the protection condoms provide against STIs, too.) If you choose that route, intravaginal spermicides in combination with the barrier will give you some additional coverage. The birth control pill, which is approved for use until age 55 or menopause, can still be an option. If you did well on it in the past, you would likely do well on it again; a careful health history would help make sure you are a good candidate. Now pills can be given in such a way that you menstruate much less often, or not at all. And one more option: There is an IUD on the market that lasts 5 years--likely to get you to menopause.

What you choose depends on your health history and your personal preferences. I'm glad you're both enjoying your sexuality again and paying attention to this issue!