As they pass the age of 40, women and men continue to be fertile and sexually active, and up to half of women are able to become pregnant until well into their fifth decade.1 But pregnancy-related risks rise as much as 50-fold for this age group compared with women in their twenties.2
"The risk of hemorrhage is higher during and after delivery" for women over 40, says Dr. Judith Fortney, an FHI research scientist who studies maternal health. "And some women this age have chronic underlying conditions, such as hypertension, diabetes and heart disease" that make their pregnancies riskier. Late pregnancy can be dangerous for the fetus and infant as well. Women over 40 are more likely to miscarry or to bear children with birth defects, including Down's syndrome (a form of mental retardation), and infants born to older women have a higher perinatal mortality rate. The risk of birth defects in an infant also increases with the age of the father, and with an older woman it is more likely that her partner will be older.
Women typically reach menopause -- the end of their menstrual periods and childbearing capacity -- between the ages of 45 and 55. While their fecundity declines after age 35, "plenty of women do get pregnant," Dr. Fortney says. "There is a huge variability in individual fertility" among women.
Although there is a trend in developing countries toward postponing childbearing, an unexpected pregnancy late in life is an unwelcome event for many women. Women over 40 are more inclined to choose abortion when they find they are pregnant than those in their twenties and thirties. In 1992, more than a third of pregnant U.S. women between the ages of 40 and 44 chose induced abortion, a higher rate than any other age group except for pregnant women 19 and under, says Dr. Stanley Henshaw, deputy director of research at the New York-based Alan Guttmacher Institute.
"Women over 40 are still in need of effective contraception," says Dr. Carlos Huezo, medical director of the International Planned Parenthood Federation (IPPF), based in London. "Providers should be prepared to assist these women in making an appropriate method choice according to their circumstances and needs." Men can also play a vital role, he says, by supporting their partners in choosing good options or by practicing contraception themselves. For men, fertility continues through most of their adult lives. While they can keep using the four contraceptive methods available to them -- condoms, vasectomy, periodic abstinence and withdrawal -- they face different issues as they grow older.
The risk of birth defects in an infant also increases with the age of the father, Dr. Huezo says. "And with an older man, it is more likely that his partner will be older" so the couple must take into account the health restrictions on certain contraceptives, he says.
Providers must screen carefully for health conditions that may increase the risk of using a contraceptive method, Dr. Huezo says. For example, high blood pressure, diabetes, smoking and a history of cardiovascular disorders increase the risk of using hormonal contraceptives containing estrogen (combined oral contraceptives and certain injectables). Unexplained bleeding is particularly important, because it could be a symptom of endometrial or ovarian cancer, which become more common as women approach menopause.
In addition to looking at health factors, family planning providers should address other issues. What is the couple's preference for a contraceptive method? Have they finished adding to their family? Are they interested in a permanent or temporary method of contraception? How sexually active are they? What contraceptives have they used in the past, and what has been their experience? What is their risk of sexually transmitted diseases (STDs)?
"People make assumptions about older couples -- that women quit having sex at 40, or that women over 40 are at no risk of STDs -- but that is not true," Dr. Fortney says. "Providers should always ask."
Methods for older couples
In general, perimenopausal women -- those approaching menopause -- have a broader range of contraceptive methods available to them than younger women, Dr. Fortney says. First, they are more likely to consider permanent methods, such as surgical sterilization. Second, methods that might not be appealing in youth because of their higher failure rate -- barrier methods, for example -- become more suitable because of older women's low fecundity. But because of the physical changes associated with menopause, certain contraceptive methods have specific advantages and disadvantages.
In the perimenopause, a woman's ovaries slow estrogen production, leading to widespread physical changes. Her menstrual periods may become irregular -- either lengthening or shortening, and increasing or decreasing in blood loss. Even with irregular periods, a woman can still become pregnant. And such irregularity makes natural family planning difficult to use.
A woman may also experience other symptoms as menopause approaches. Her vagina may lose lubrication, she may find that intercourse becomes painful, and she may begin to experience urinary incontinence, hot flashes or other symptoms. In addition, the loss of estrogen causes less obvious internal shifts. The bones may begin to thin, and heart disease becomes more prevalent. Quitting smoking, getting regular exercise and eating a nutritious diet can help a woman prepare for menopause.3
For older men or women who have completed their families, surgical sterilization is an excellent contraceptive method. In the United States, about 47 percent of women at risk of pregnancy between 40 and 44 choose it.4 It is very effective for all age groups, and the failure rates are lowest for older women, according to a recent study of more than 10,000 women by the U.S. Centers for Disease Control and Prevention and Princeton University.5 Women sterilized at age 34 or older were less likely to become pregnant than those who were sterilized between 28 and 33, even after adjusting for sterilization method, race and study site, the researchers found. However, if sterilization fails, a woman and her provider need to be aware of the possibility of ectopic pregnancy.
Surgical sterilization protects against ovarian cancer, a concern for older women. Poststerilization regret is also less likely for these women, says Dr. Sangeeta Pati of AVSC International.
Still, surgery carries a slight risk, which should be balanced against the number of years a woman will benefit from the procedure. For example, if she is in her late forties, another method might be more suitable. "Long-term non-surgical methods like the IUD are also good options for the extremely obese, those with respiratory problems and others who are not good surgical candidates," Dr. Pati says. But women with these characteristics should not be ruled out automatically as candidates for surgery, she says, because unintended pregnancy may carry even higher risks than surgery for them.
Vasectomy is even safer and easier, and recovery is quicker, than with female surgical sterilization. Vasectomy can be done in an office setting with a local anesthetic and without an incision. "Surgical male and female sterilization should be considered permanent procedures and are not good options for those who are unsure, in unstable relationships or in a midlife crisis. Assessing this should be part of standard counseling," Dr. Pati says.
IUD
For an older woman who wants a long-term method but doesn't want to undergo surgery, an IUD may serve well, as long as she faces no risk of STDs. IUDs have few systemic effects, and some Copper T IUDs work for up to 10 years. A woman who chooses this method past age 40 can consider it permanent because it likely will carry her through menopause.
One drawback of the IUD, however, is that it can increase bleeding. Such bleeding must be examined, especially in older women, because it can indicate a reproductive tract cancer or other disorder. For women who risk anemia and who have increased bleeding not due to cancer, iron supplements are an important adjunct to IUD use. Providers also must screen IUD users to be sure they do not have uterine fibroids -- benign growths that can distort the shape of the uterus and prevent proper IUD placement.
IUDs that release levonorgestrel can decrease bleeding. These IUDs also appear to reduce uterine fibroids and the risk of hysterectomy when compared with copper IUD use, says Irving Sivin, a Population Council senior scientist.6
Barrier methods
Women who have not completed their childbearing, or who have sexual intercourse infrequently and want a coitus-dependent method, might find barrier methods a good option. "Barrier methods have few medical contraindications," says Dr. Paul Feldblum, an FHI researcher who studies these methods. Diaphragms and condoms are about twice as effective for women over 35 as for younger ones, he says. Still, barrier methods do have a higher failure rate than most other contraceptives.
Besides their safety, barrier methods have non-contraceptive benefits. The spermicides used with diaphragms, and on some lubricated condoms, can substitute for the vaginal lubrication that diminishes as women age. Barrier methods also protect against STDs, which may be a concern for some older men and women.
One drawback with diaphragms is that if women have borne many children or are beginning to lose vaginal muscle tone because of perimenopausal changes, diaphragms do not fit as well and may dislodge. Women who have urethral problems due to estrogen loss can develop infections when using a diaphragm.
As men age, they sometimes have a more difficult time attaining and maintaining an erection, so they may not use a condom as effectively. A condom must be placed on an erect penis and the erection must be maintained, otherwise the condom can slip off. Another difficulty for older men is that condoms can decrease penile sensitivity, which also declines with age.
Hormonal methods
Combined pills and injectables are highly effective for older women. In addition, they offer many non-contraceptive benefits. They prevent endometrial and ovarian cancer, pelvic infection and ectopic pregnancy; reduce benign growths in the breasts, ovaries and uterus; and cut back on bleeding and pain during menstruation. Combined pills prevent bone loss.7
Women with existing cardiovascular disorders, high blood pressure, long-term diabetes and some other conditions should not use methods containing estrogen.8 In the past, all older women were discouraged from using combined hormonal methods because of an increased risk of cardiovascular disease.
More recent studies have shown that, while such problems become more frequent as women age, the greatest increase is among heavy smokers and those with pre-existing cardiovascular disorders. "However, if [women over 35] do not smoke and have no other risk factors for cardiovascular disease, such as hypertension and diabetes, the increased risk is very small," according to an IPPF statement on contraception for women over 35.9 While there are no large-scale studies looking at combined injectables and cardiovascular disease risk, laboratory studies indicate they have little effect on metabolism or coagulation factors, the IPPF statement says.
Another question about combined hormonal methods is whether they increase the risk of breast cancer. A recent analysis of 54 studies including 153,536 women from around the world indicated that those who use combined hormonal contraceptives have a slightly increased risk of breast cancer during use and for up to 10 years after they stop.10
This finding is of particular concern to older women, because they have an increased absolute risk of breast cancer due to age. However, for younger women, the added risk from hormones is relatively small. For all women, these concerns must be balanced against the higher risks of unwanted pregnancy. Also, tumors in oral contraceptive users are more likely to be confined to the breast, and so are less dangerous than those that have spread elsewhere in the body.11
One advantage of combined pills for perimenopausal women is that they contain similar combinations, although greater amounts, of hormones given to women after menopause to prevent osteoporosis, reduce the risk of heart disease and treat menopausal symptoms. Some companies and nonprofit organizations are working to develop combined hormonal pills that could be used for contraception during perimenopause and continued for hormone replacement after the last menstrual period, says Dr. Michael Edwin Kafrissen, vice-president of Ortho-McNeil Pharmaceutical, based in New Jersey.
Women who cannot use estrogen for health reasons, or who prefer not to because of certain side effects, can use progestin-only methods. These methods, including pills, injectables, and implants, are very effective for older women, and apparently do not carry the risk of heart disease due to estrogen. However, irregular bleeding caused by these methods can mimic gynecological disorders.
Progestin-only pills are a good choice for women who like using oral contraceptives but cannot use estrogen. For women ages 40 to 44, the pregnancy rate is less than one per 100 woman years of use -- about as effective as combined pills for a 25-year-old.12 POPs contain a very small amount of progestin, even less than is in the combined pills. They must be taken faithfully at about the same time every day, or a pregnancy can result.
Depot-medroxyprogesterone acetate (DMPA or Depo-Provera) is a popular method for older women in many developing countries, says Dr. Olav Meirik, chief of the World Health Organization unit of epidemiological research in reproductive health. The three-month injectable is effective, discreet and simple to use. However, at least one study indicated that DMPA may reduce bone density, an important consideration for women as they approach menopause.13 This study included largely younger women, and more research is needed to examine the relationship between DMPA use and bone density in all women, Dr. Meirik says.
Norplant may serve as a "permanent" method for some older women, because it works for five years. No studies have indicated that Norplant causes problems with loss of bone density, Dr. Meirik says.
Besides learning which methods are most suitable, clients over 40 also need to know when to stop using certain methods. Hormonal methods, for example, can mask the onset of menopause.
IPPF recommends that women stop taking combined pills at age 50 and then, when possible, receive a follicle stimulating-hormone (FSH) test three months later. Levels of FSH, a hormone that triggers a complex hormonal cascade governing the menstrual cycle, increase after menopause. POP users over 45 should continue taking pills until their menstrual bleeding stops. Then they should have an FSH test to determine whether they have reached menopause. If not, they should resume taking pills. IUDs should be removed after menopause, to keep them from being lodged in the uterine wall because of changes brought on by dropping estrogen.
Providers can help women prepare for menopause by letting them know what it involves and that it is simply a stage of life. Many providers are not accustomed to answering questions about older women's physiology, says Dr. Huezo of IPPF. "It is important to educate them so they can make the methods as safe as possible," he says. "They can assess the risks and benefits jointly with the client, and then allow the client to take the lead in deciding."
-- Carol Lynn Blaney
Carol Lynn Blaney, a former Network staff writer, is a science writer based in San Jose, CA, USA.
References
- World Health Organization. Research on the Menopause in the 1990s. WHO Technical Report Series, #866. Geneva: World Health Organization, 1996.
- Riphagen FE, Fortney JA, Koelb S. Contraception in women over forty. J Biosoc Sci 1988;20(2):127-42.
- International Planned Parenthood Federation. Statement on Health Needs of Perimenopausal Women. London: International Planned Parenthood Federation, 1997.
- Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. (New York: Irvington Publishers, 1994) 109.
- Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996;174:1161-70.
- Sivin I, Stern J. Health during prolonged use of levonorgestrel 20 µg/d in the copper TCu 380Ag intrauterine contraceptive devices: a multicenter study. Fert Steril 1994;61(1):70-77.
- DeCherney A. Bone-sparing properties of oral contraceptives. Am J Obstet Gynecol 1996;174(1):15-20.
- 8. World Health Organization. Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Initiating and Continuing Use of Contraceptive Methods. Geneva: World Health Organization, 1996.
- International Planned Parenthood Federation. IMAP Statement on Contraception for Women over 35. London: International Planned Parenthood Federation, 1997.
- Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53,297 women with breast cancer and 100,239 women without breast cancer from 54 epidemiological studies. Lancet 1996;347:1713-27; Calle EE, Heath CW Jr, Miracle-McMahill HL, et al. Breast cancer and hormonal contraceptives: further results. Contraception 1996;54(Suppl):1-106.
- Meirik O. The pill and breast cancer: new information. IPPF Med Bull 1996;30(6):1-2.
- McCann MF, Potter LS. Progestin-only oral contraception: a comprehensive review. Contraception 1994;50(6 Suppl1):S36-40.
- Cundy T, Evans M, Roberts H, et al. Bone density in women receiving depot-medroxyprogesterone acetate for contraception. BMJ 1991;303(6793):13-16 [erratum appears in BMJ 1991;303(6796):220].
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