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!

STDs for Grownups: What You Don’t Know Can Hurt You. A Lot

Sit down, Girlfriend. We need to talk.

Remember those uncomfortable discussions you had with your kids back in the day? You know, the birds-and-bees and how-not-to-get-pregnant talks?

Well, now it’s your turn to listen. This is your middle-age sex talk.

At some point in life, you’ll probably be alone, demographics and life expectancies being what they are. Maybe you already are. Maybe you’re newly divorced. Or widowed.

And maybe, after being married for many years you’re not ready to write off a relationship—or sex—for the rest of your life.

That’s great! We’ve already discussed the health benefits of sex. And we’ve talked about the research that shows that older women really like sex and are good at it.

But the singles scene is now a completely different ball game from those long-ago days when you were a player. “When I was younger we only worried about getting pregnant or getting crabs. Now that I’m divorced, I realize it’s a whole new world!” said a woman on one health website.

“In my practice I see a lot of older single women who don’t know the rules of dating,” says Mary Jo Rapini, psychotherapist and MiddlesexMD advisor. “They’re looking for someone to desire them again, and they’re much too easy with letting sex happen. They aren’t comfortable with demanding that the guy wear a condom.”

You may not need protection against pregnancy any more, but you sure need protection against a cornucopia of STDs that has flourished since your first date.

STDs affect every age group, but rates of infection are growing fastest among older people. According to the Centers for Disease Control, 15 percent of new HIV infections are in those over 50—and death rates are rising, too. In 2008, the journal Sexually Transmitted Infections noted that infection rates among those over 45 had doubled in less than 10 years. Research at Indiana University in 2010 indicated that condom use was lowest in that age group. Maybe there’s some connection there?

Besides general lack of awareness, a few physiological factors make it easier for older women to become infected. The thin, dry vaginal walls that accompany loss of estrogen create small tears and microscopic vaginal bleeding during sex, thus offering a warm welcome to invading nasties. Further, our pH balance tends to be less acidic after menopause, creating a friendly environment for bacterial infection.

So what’s a newly single older gal to do?

Empower yourself, says Rapini. Take a page from your kids’ playbook and insist on safe sex. This isn’t about being difficult or demanding, it’s about your health, and you have every right to safeguard it. Here are the safe sex rules:

  • Wait to have sex. Isn’t this the advice you give your kids? What’s the rush? Date for a while and get to know the person. A lusty first date could fizzle on the second or third. And then you might be stuck with an unpleasant reminder of a fleeting passion.
  • Get tested. And insist that your partner does as well. How can I ask that? you’re thinking. Girlfriend, this is how you empower yourself. You don’t take chances. “If the guy has nothing to hide, he shouldn’t resist.” says Rapini.
Once you’ve decided that sex is on the horizon, you could say something like, “I’m getting tested for STDs, and I think it’s a good idea for you as well.” That creates a level playing field and opens the door to discussion later.
  • Share the results of your screening. This gently opens the door to honest talk about sex. If you’ve never talked openly about sex before, it’s time to change. “If you stay passive you’re less likely to have good sex.” says Rapini.
  • Continue to use condoms for at least six months after a screening. Some infections, such as HIV, don’t show up immediately. Always keep latex condoms with you, just in case. If a condom is used correctly, it provides 90 percent protection. It’s less effective against the genital herpes virus or the HPV virus because those viruses are more widespread on the genital area.
  • Take care of your vagina. We’ve talked (and talked) about good vaginal hygiene. In addition to the infection-fighting properties of a healthy vagina, the sex will be better and more comfortable, too.
  • Keep communicating. This may be uncomfortable at first because our generation didn’t talk about sex, but this is the time of life for discovery. Learn what you like, and learn to ask for it.

Empowerment, remember? Respect yourself enough to insist on safe sex.

Let us know how it goes.

When Was the Last Time You Used a Condom?

It's a personal question, I know, but one I'm trying to be sure to ask my midlife and older patients who are newly single and sexually active.

Among women our age, sexually transmitted infections (STIs, sometimes called STDs for sexually transmitted diseases) are up and condom use is down. There's a direct correlation.

Those of us who have spent the last 30 to 40 years in long-term monogamous relationships may not have even seen a condom in that time, let alone bought and used one. When contraception was the goal and a steady partner was the norm, we tended to choose less intrusive methods of protection--like the pill or IUDs.

Now, though, if you're single and entertaining the possibility of a new sexual relationship, it's time to get acquainted or reacquainted with the most effective means of preventing transmission of STIs like gonorrhea, HPV, herpes, chlamydia, and HIV: the venerable condom. Because it's an actual physical barrier, and because it's the easiest barrier to use, it's the most effective option we've seen.

Of course you can buy condoms at your local drugstore or grocery store, but if you don't want your kid's best friend waiting on you, you may want to consider an online source. And if you've never bought or used latex protection before, don't worry. We've sought out the right combination of function, fun, and discreet packaging so you can purchase from the comfort (and privacy) of your laptop, and our website offers basic instructions for using condoms.

(A parenthetical note: We know there are female condoms, which work just fine as a barrier for protection. But when we actually tested them as part of our product selection, we found them too clunky for us to be comfortable. We wouldn't recommend them to our friends. But we'll keep an eye on the options and let you know when something better comes along--or let us know if you've found a brand or a method that makes them your preference.)

A few more tips to help build your condom confidence:

-- Keep a ready supply on hand--in a zippered pocket of your purse, in a drawer of your nightstand, or in nifty bedside storage like this tissue box we found with a private drawer. Scrambling around for that little packet in the heat of passion can cool things down in a hurry.

-- Talk with your partner about condom use as soon as it seems clear that sexual intimacy is a definite possibility for the two of you. Agreeing that protection is essential--and deciding who's in charge of making sure it's there when the time is right--will ease anxiety and embarrassment for both of you.

-- Incorporate condoms into your sex play and lovemaking. Application can be quite exciting in itself!

Finally, remember that not even your friendly condom offers 100-percent protection. In addition to insisting on a latex condom, NAMS (North American Menopause Society) guidelines for safer sex include choosing partners wisely and discussing sexual histories, getting an annual exam that includes testing for STIs, and making sure that your Hepatitis B vaccine is up to date.