Many women are aware that their fertility declines from their mid 30s and think they can stop using contraception once they are in their 40s. They wrongly assume – because their fertility is lower, they have less sex and their periods may have become irregular – that contraception can be abandoned. However, women do still get pregnant in their late 40s and even into their 50s (without using assisted reproduction techniques), so contraception should continue to be used every time they have sex if pregnancy is to be avoided. Contraception should be continued until menopause, which is defined as two years after the last natural menstrual period in women under age 50 and until one year after the last natural menstrual period in women over age 50. If menopause cannot be confirmed, contraception should be continued until age 55.
An unplanned pregnancy at any age can pose problems, but particularly so for a woman in her 40s who may be beginning to enjoy more freedom as children grow up. Furthermore, a pregnancy in older women is often associated with an increased number of complications such as miscarriage, high blood pressure, diabetes and chromosomal problems with the baby, and consequently will need more careful monitoring.
In recent years there have been many advances in contraception, and new methods may have additional health benefits (such as lighter periods) as well as providing excellent contraception. Women’s needs change as they get older and a method that may not have been ideal when she was younger may become much more suitable.
This fact sheet comments on various methods of contraception and discusses how appropriate they are for women in their 40s. It should be read in conjunction with the more detailed fact sheet on contraception available from the Women’s Health Concern.
Barrier methods of contraception prevent sexually transmitted infections (STIs) so are recommended for women with new sexual partners even if they have been sterilised or are using another method of contraception. Chlamydia, gonorrhoea, HIV and other STIs are on the increase in women in their 40s and 50s, so it is a good idea to be screened for infection before starting a new relationship. There is no age restriction on barrier methods, which can be continued until contraception is no longer needed (see below).
The male condom
This is an effective method for this age group, although some men may find them difficult if they have not used them for several years and may experience erection difficulties. As hormone levels change many women experience vaginal dryness which can cause discomfort during intercourse. Condoms are lubricated to make them easier to use. You should avoid condoms with the spermicide nonoxinol-9 as this doesn’t protect against STIs and has been linked to higher risk of HIV transmission so you should avoid this if you are at risk of HIV. Vaginal lubricants can be helpful, but avoid oil-based lubricants as they can cause latex and polyisoprene condoms to split, leading to a risk of pregnancy and infection. Check with the pharmacist if you are using vaginal medication of thrush as some of these can also damage latex and polyisoprene condoms. There is no interaction with oil-based lubricants or thrush treatments and polyurethane condoms.
The female condom
Some women may find these awkward if they have not used them before. They are well lubricated, so vaginal dryness should not be a problem.
The diaphragm and cervical cap
Again, some women may find these awkward to use if they have not used them before, and if suffering from a small prolapse or stress incontinence may find them uncomfortable. Spermicides are an inherent part of using a diaphragm or cervical cap and these will provide additional lubrication. Non toxic spermicide gels that prevent sperm motility are preferred.
Combined hormonal methods
Combined hormonal contraceptive methods (pill, patch and vaginal ring) are suitable until the age of 50, so long as there are no health risks (e.g. smoking, obesity, high blood pressure) that could lead to heart, stroke or blood clotting problems. Your healthcare provider will be able to advise on this.
Combined hormonal contraception has several advantages for women in this age group as it will regulate periods, may help to maintain bone mineral density (which is reduced after the menopause), may reduce blood loss and period pains and may also relieve some troublesome menopausal symptoms such as hot flushes and night sweats.
All progestogen-only methods may cause irregular bleeding or even no bleeding at all. The absence of bleeding doesn’t necessarily mean that you have reached the menopause – it is just a side effect of the method of contraception. Medical advice should be sought if bleeding occurs after a long time with no periods.
The progestogen-only pill (POP or mini-pill)
The progestogen-only pill is a suitable method and can safely be used up until the age of 55, when contraception can be stopped.
The contraceptive injection
There has been some concern that the injection may reduce bone mineral density and increase the risk of osteoporosis. If you are over 40 and have lifestyle or risk factors for osteoporosis (e.g. smoking, previous fractures, steroid use, family history), you are advised to consider a different method of contraception, many of which are just as effective at this age. Otherwise, you can choose to continue this method until the age of 55 with regular review by your healthcare provider.
The implant is a suitable method that can safely be used up until the age of 55.
Intrauterine system (IUS)
The hormone-releasing IUS is a suitable method. As well as being a highly effective method is has important non-contraceptive benefits, significantly reducing period pain and bleeding. This is particularly important as a considerable number of women complain of heavy periods and ‘flooding’ in their 40s. Additionally, if a woman decides to start HRT during the perimenopause, then the IUS can be used as the progestogen element of HRT.
The IUS is licensed for contraception for 5 years but if it is inserted over the age of 45 years it can remain in place until the age of 55, when contraception is no longer needed. However, if you are using the IUS as part of HRT, it will need to be replaced every 5 years.
Other contraceptive methods
Intrauterine devices (IUD)
An IUD is a suitable method but as it can cause periods to become heavier or more painful, it may not be suitable if periods are already causing a problem. If an IUD (of any type) is inserted over the age of 40 years then it can remain, without being changed, until menopause.
Male and female sterilisation
Sterilisation (both male and female) is a suitable method and is the most commonly used method for couples in their 40s. However, it is a non-reversible surgical procedure and is less effective than reversible methods such as the injection, implant and IUS, which have also added non-contraceptive benefits for problem periods.
Natural family planning
Women who have already been using natural methods of contraception (timing of periods, changes in cervical mucus and body temperature) can usually continue this method while they have regular periods. During perimenopause, variable cycle lengths and erratic ovulation makes this method unreliable.
Although often used by couples in their 40s, withdrawal is not a reliable method of contraception.
There is no upper age limit for emergency contraception, which is indicated for any woman who still needs contraception who has had unprotected sex or contraceptive failure (a split condom or missed pills). There are two forms: emergency contraceptive pills or the emergency intrauterine device (IUD).
Emergency contraceptive pills (levonorgestrel or ulipristal) can be obtained from your healthcare provider or from pharmacies without a prescription. The emergency IUD is the most effective method and has the advantage that it can remain in place for ongoing contraception.
When to stop contraception
Contraception should be continued for at least one year after your last menstrual period if this was after the age of 50, and for two years if your periods stop before the age of 50. This is because sometimes periods may restart even after several months with no bleeding. Otherwise contraception can be stopped at the age of 55, even if you are still having occasional periods, as the risk of pregnancy at this age is extremely low.
However, if you are using progestogen-only hormonal contraception you may well have only occasional periods or no periods at all, thus making it difficult to tell if you are menopausal. With the exception of the injection, progestogen-only methods can be safely used until the age of 55 years. Your healthcare provider may recommend a blood test which would give some guidance as to how much longer you need to continue the method.
If using combined hormonal contraception you will experience regular periods or withdrawal bleeds which mask one of the signs of the menopause. Blood tests are not reliable and not recommended if you are using combined hormonal methods, which should be stopped at the age of 50, switching to an alternative non-hormonal or progestogen-only method.
Hormone replacement therapy
The average age for the menopause in the UK is 51 years but women in their 40s may start experiencing menopausal symptoms and consider taking hormone replacement therapy (HRT).
It is important to realise that HRT is not a method of contraception. If periods have not stopped before starting HRT then a method of contraception should be used in addition to HRT. Suitable methods to consider would be barrier methods, an IUD, the progestogen-only pill or the IUS. As well as being an effective method of contraception, the IUS has the additional advantage of providing the progestogen component of HRT and so minimises bleeding problems and other side-effects that might occur from the progestogen.
Once HRT has been started, it can be difficult to know when contraception can be stopped since HRT will often produce regular monthly bleeds. It is best to continue contraception alongside HRT until the age of 55 when contraception is no longer needed.