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.
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 factsheet 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 website.
With rates of divorce and separation increasing, many women are ‘back on the scene’ and should use a barrier method of contraception to prevent sexually transmitted infections (STIs) 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.
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. Vaginal lubricants can be helpful, but care should be taken as any oil-based lubricant can cause condoms to split, leading to a risk of pregnancy and infection.
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 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 and these will provide additional lubrication. Women who have previously used a diaphragm or cap usually have no problem with these methods and can continue with their use right up until the menopause.
The combined pill
The combined pill can safely be used until the age of 50, so long as there are no health risks such as smoking, obesity, high blood pressure etc that could lead to heart, stroke or blood clotting problems. Your doctor or nurse will be able to advise on this.
The pill 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.
The contraceptive patch and vaginal ring
The efficacy, benefits, risks and side-effects are similar to the combined pill and again can be safely prescribed until 50 years old to those with no health risks.
All progestogen-only methods may cause irregular bleeding or even no bleeding at all. The absence of bleeding doesn’t necessarily mean that the menopause has been reached – 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 suitable for older women and can safely be used up until the age of 55.
The contraceptive injection
Use of this method may continue until the age of 50. There has been some concern that the injection may reduce bone mineral density and increase the risk of osteoporosis. Women who have lifestyle or risk factors for osteoporosis (smokers, previous fractures, steroid use, family history etc) may wish to consider another method of contraception.
The implant is suitable until the age of 50 and there are no anxieties about loss of bone mineral density with this method.
Intrauterine system (IUS)
The hormone-releasing IUS is not only a highly effective method of contraception but it also significantly reduces the amount of bleeding and period pain. 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 could remain in place for 7 years after discussion with your doctor or nurse. It is only licensed for 4 years if used for HRT but is known to be effective for this purpose for 5 years.
Other contraceptive methods
Intrauterine devices (IUD)
An IUD is a suitable method but may cause periods to become heavier or more painful, so may not be a good idea 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 the menopause. It should be removed one year after periods stop if this is over the age of 50 or two years after periods stop if this is under the age of 50.
Male and female sterilisation
Sterilisation (both male and female) is the most commonly used method for couples in their 40s. However, sterilisation is a surgical procedure and it may not be justified for a woman with low fertility to undergo such a procedure when there are so many other highly effective options available.
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 manage to continue to do so until the perimenopause. However this can be more difficult to teach to beginners at this stage in life due to variable cycle lengths and erratic ovulation.
Emergency contraception can be used if a woman has had unprotected sex or if a form of contraception has failed (a split condom or missed pills). There are two forms: the emergency contraceptive pill or the emergency intrauterine device (IUD).
There is no age limit for using emergency contraceptive pills (levonorgestrel or ulipristal) and they can be easily obtained from your doctor or in pharmacies without a prescription. The emergency IUD has the advantage that it can remain in place and is an effective method of ongoing contraception.
When to stop contraception
Contraception should be continued for at least one year after your last period if the periods stop 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.
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. These methods can be safely used until the age of 50 (55 years for the progestogen-only pill or the IUS). Your doctor may recommend a blood test which would give some guidance as to whether you are menopausal.
If using combined hormonal contraception you will experience regular periods or withdrawal bleeds which again would mask one of the signs of the menopause. Blood tests are not reliable and not recommended if you are using combined hormonal methods.
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. 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 as the vast majority of women will be menopausal by then.