Contraception from 40 to the Menopause
Although pregnancy is less likely around the menopause, over the age of 40 years it is still important to use contraception. There are various different types of contraception available. Most need to be used until you have gone through the menopause or are aged 55 years. An overview of all the different types is given here.
At what age will I stop being fertile?
The time of menopause varies tremendously between women. Before your periods stop altogether, it is likely that your periods will become irregular and unpredictable. Although you are less likely to produce an egg (ovulate) every month, your ovaries will still be producing some eggs and, for this reason, it is important that you consider using contraception. So, although there is a natural decline in your fertility after the age of about 37 years, effective contraception is still required to prevent an unplanned pregnancy. Most women will no longer be fertile by the age of 55 years. However, a few women will still be having periods at this age and may need contraception. The average age at which women get to their menopause in the UK is 51 years.
When can contraception be safely stopped?
If you are using contraception that does not contain hormones, you will be able to stop using contraception one year after your periods stop if you are aged over 50 years. If you are aged under 50 years, you should use contraception until two years after your periods stop.
However, if you are using hormone-based contraception, then your periods (withdrawal bleeds) are not a reliable way of knowing if you are fertile or not. Some women who take hormone-based contraceptives will have irregular or no periods but they will still be fertile if they stop using their contraceptive. The ages for stopping the different hormone-based contraceptives are detailed below.
How effective is contraception?
All the methods of contraception listed below are effective. However, no method is absolutely 100% reliable. An idea of reliability for each method is given in the sections below. When no contraception is used, more than 800 in 1,000 sexually active women who have not gone through the menopause become pregnant within one year. Different contraceptive methods can be compared to this. The number of women out of 1,000 who become pregnant whilst using contraception count as "contraceptive failures". In other words, their method of contraception has failed or not worked.
The effectiveness of some methods depends on how you use them. In other words they are "user-dependent". You have to remember to use them, or you have to use them properly or they may not work. For example, around 3 women in 1,000 using the combined oral contraceptive (COC) pill perfectly will become pregnant. If it is not taken correctly - for example, missing taking a pill or being sick (vomiting) - closer to 90 women in 1,000 become pregnant. Other user-dependent methods include barrier methods, the progestogen-only pill (POP) and natural family planning.
Some methods are not so user-dependent and do not need to be remembered or renewed as often. These methods include the contraceptive injection, contraceptive implant, intrauterine contraceptive device or system (IUCD and IUS) and sterilisation.
What are the different methods of contraception?
Your choice of contraception when you are over the age of 40 years may be influenced by:
- How effective it is.
- Possible risks and side-effects.
- Your natural decline in fertility.
- Personal preference.
- If you have a medical condition that needs to be considered.
The types of contraceptives can be divided into short-acting, long-acting and permanent. (See also separate leaflets, linked in the sections below, for more details on the various methods of contraception.)
The combined oral contraceptive (COC) pill is often just called the pill. It contains oestrogen and progestogen and works mainly by stopping egg production (ovulation). It is very popular. Different brands suit different people.
- Some advantages - it is very effective. Side-effects are uncommon. It helps to ease painful and heavy periods. It reduces the chance of some cancers. Taking the COC pill may improve any menopausal symptoms that you may have. There is also some evidence that taking the COC pill when you are aged over 40 years may increase the density of your bones. This means your bones are stronger and may be less likely to fracture when you have gone through the menopause.
- Some disadvantages - there is a small risk of serious problems (such as thrombosis). Some women get side-effects. You have to remember to take it. It can't be used by women with certain medical conditions.
The COC pill can safely be taken by women over the age of 40 years with no other medical problems. However, you should not take it if you are aged over 35 years and a smoker. You should not take it if you are aged over 35 years and have migraine. You also should not take it if you have a history of stroke or heart disease, or if you are very overweight. Women who have complications from diabetes (including problems with eyes, blood vessels or kidneys) should not take the COC pill. These are just a few of the conditions which make it unsafe to take the COC pill. Your doctor or healthcare professional will go through your medical history with you to decide if it is safe for you personally. If you have no medical problems or risk factors for medical problems, the COC pill can be taken until the age of 50 years.
You should stop taking the COC pill and use another form of contraception when you reach the age of 50 years.
The progestogen-only pill (POP) used to be called the mini-pill. It contains just a progestogen hormone. Between 3 and 90 women in 1,000 using the POP will become pregnant. It is commonly taken if the COC pill is not suitable - for example, breast-feeding women, smokers over the age of 35 years and some women with migraine.
- Some advantages - there is less risk of serious problems than there is with the COC pill.
- Some disadvantages - periods often become irregular. Some women have side-effects. It is not quite as reliable as the COC pill.
You need to remember to take it at the same time every day because if you take a pill more than three to twelve hours later than usual you lose protection. There are different brands, which suit different people. This timescale may vary depending on which brand you take.
The POP is safe if you have previously had a stroke or a heart attack, or if you have developed a clot in the past. There is no increased risk of developing breast cancer if you take the POP. However, women who have had breast cancer cannot usually take a POP.
The POP can be continued until you reach the age of 55 years, after which time you will probably no longer need to use contraception. Blood tests can be done if you are not sure if you have gone through your menopause.
The contraceptive patch (Evra®) is a combined hormonal form of contraception, containing oestrogen and progestogen hormones. It is essentially the same type of contraception as the COC pill but it is used in a patch form. The contraceptive patch is stuck on to the skin so that the two hormones are continuously delivered to the body.
- Some advantages - it is very effective and easy to use. You do not have to remember to take a pill every day. Your periods are often lighter, less painful and more regular. If you have been being sick (vomiting) or have had diarrhoea, the contraceptive patch is still effective.
- Some disadvantages - some women have skin irritation. Despite its discreet design, some women still feel that the contraceptive patch can be seen.
The patch can safely be used by women over the age of 40 years with no other medical problems. However, you should not use it if you are aged over 35 years and a smoker, or are aged over 40 years and have cardiovascular disease, or a history of a stroke or migraine. You should stop using the patch and use another form of contraception when you reach the age of 50 years.
Contraceptive vaginal ring
The contraceptive vaginal ring is another combined hormonal contraceptive, with similar hormones to the COC pill and the patch above. It is a flexible, see-through ring which is just over 5 cm in diameter. It is inserted into the vagina, where it stays for three weeks. You have exactly one ring-free week before you put a new ring in place. Between 3-90 women in 1,000 will become pregnant using this form of contraception for a year. Generally, if for medical reasons you are unable to use the COC pill or the patch, the ring will not be right for you either.
The ring has some advantages over the pill. Because you leave the ring in place for three weeks, you do not need to remember to take a pill every day. You only need to remember to take it out after three weeks and put in a new ring one week later. Your contraception is still effective even if you have an upset stomach - being sick (vomiting) or runny stools (diarrhoea).
Disadvantages include the following. Your partner may feel the ring during sex. You may be aware of the ring and feel it to be uncomfortable. It may fall out. Common side-effects are headaches, a sore vagina and vaginal discharge.
These include male condoms, the female condom, diaphragms and caps. They prevent sperm entering the womb (uterus). 20 women in 1,000 having sex with male partners using male condoms perfectly will become pregnant. Nearer 160 women in 1,000 become pregnant with normal (not perfect) usage. Other barrier methods are slightly less effective than this.
- Some advantages - there are no serious medical risks or side-effects. Condoms help to protect from sexually transmitted infections. Condoms are widely available.
- Some disadvantages - they are not quite as reliable as other methods. They need to be used properly every time you have sex. Male condoms sometimes split.
Natural methods of contraception involve being able to predict your fertile time - effective if done correctly. It requires commitment and regular checking of fertility indicators such as body temperature and cervical secretions. This is less likely to be an effective method around the time of menopause if your periods have become irregular and unpredictable.
- Some advantages - there are no side-effects or medical risks.
- Some disadvantages - they may not be as reliable as other methods. Fertility awareness needs proper instruction and takes 3-6 menstrual cycles to learn properly.
Contraceptive injections contain a progestogen hormone which slowly releases into the body. 2-60 in 1,000 women using the injection for one year become pregnant. It works by preventing egg production (ovulation) and also has similar actions to the POP. An injection is needed every 8-12 weeks.
- Some advantages - it is very effective. You do not have to remember to take pills.
- Some disadvantages - periods may become irregular (but often lighter or stop altogether). Some women have side-effects. The injection cannot be undone, so if side-effects occur, they may persist for longer than 8-12 weeks.
The injection can be used if you have had a blood clot (thrombosis) in the past.
Long-term use of the progestogen-only injection can be associated with a reduction in the strength (density) of your bones. However, this returns to normal after stopping using the injection. Bones become thinner after the menopause, so this may be a factor for you and your healthcare professional to consider when choosing your contraception.
The contraceptive injection is usually stopped when you reach the age of 50 years and another method of contraception should then be used.
A contraceptive implant (Nexplanon®) is a small device placed under the skin. It contains a progestogen hormone which slowly releases into the body. 1 woman in 2,000 using the implant for a year will become pregnant. This means it is as effective as sterilisation. It works in a similar way to the contraceptive injection. It involves a small minor operation using local anaesthetic. Each one lasts three years.
- Some advantages - it is very effective. You do not have to remember to take pills.
- Some disadvantages - periods may become irregular (but often lighter or stop altogether). Some women develop side-effects but these tend to settle after the first few months. The implant can be removed if the side-effects do not settle and it does not suit you.
The implant can be continued until you reach the age of 55 years, after which time you will no longer need to use contraception. If you think you have had your menopause before this, some blood tests may help to confirm this. If you have become menopausal then the implant can be removed one year after if you are over 50 years, and two years after if not.
Intrauterine contraceptive device
The intrauterine contraceptive device (IUCD) is a plastic and copper device which is put into the womb (uterus). It lasts for up to ten years. It works mainly by stopping the egg and sperm from meeting. It may also prevent the fertilised egg from attaching to the lining of the womb. The copper also works by killing sperm (it has a spermicidal effect).
- Some advantages - it is very effective. You do not have to remember to take pills. It can easily be removed if it does not suit you. It does not contain any hormones, so there are no hormonal side-effects.
- Some disadvantages - periods may become heavier or more painful.
It can be common to have spotting, light bleeding and heavy or longer periods in the first 3-6 months after having an IUCD inserted.
If you have an IUCD inserted when you are aged 40 years or over, this can remain in place until you have gone through the menopause and no longer require contraception. That is, for one year after your periods stop if you are aged over 50 years, or two years after your periods stop if you are aged under 50 years.
A hormone-releasing intrauterine device called an intrauterine system (IUS) is a plastic device that contains a progestogen hormone. It is put into the womb in a similar way to an IUCD. It should be renewed every five years. The progestogen is released at a slow but constant rate. 2 women per 1,000 using the IUS for a year will become pregnant. It works by making the lining of your womb thinner so it is less likely to accept a fertilised egg. It also thickens the mucus from the neck of the womb (your cervix).
- Some advantages - it is very effective. You do not have to remember to take pills. Periods become light or stop altogether. It can easily be removed if it does not suit you.
- Some disadvantages - side-effects may occur as with other progestogen methods such as the POP, the implant and the injection. However, they are much less likely, as the hormone is mostly in the womb and not much gets into your bloodstream.
The IUS is safe if you have had a blood clot in the past or currently.
The IUS can be continued until you reach the age of 55 years, after which time you will probably no longer need to use contraception. If you have an IUS put in at the age of 45 years or older, you may be able to keep it longer than the usual five years before removing it.
Sterilisation - a permanent method of contraception
You and your partner may have decided that you would like a more permanent method of contraception. Sterilisation involves an operation. It is more than 99% effective; however, even sterilisation can fail.
Male sterilisation (vasectomy) stops sperm travelling from the testicles (testes). In about 1 in 2,000 cases, it fails, and a pregnancy occurs. Female sterilisation prevents the egg from travelling along the Fallopian tubes to meet a sperm. It is about ten times less effective, as a pregnancy occurs in 1 in 200 women. This is still very effective contraception, but nothing is absolutely perfect. Vasectomy is easier, safer and more effective than female sterilisation.
- Some advantages - it is very effective. You do not have to think further about contraception.
- Some disadvantages - it is very difficult to reverse. Female sterilisation usually needs a general anaesthetic.
Can I still use emergency contraception?
Emergency contraception can be used at any time if you had sex without using contraception. Also, it can be used if you had sex but there was a mistake with contraception. For example, a split condom or if you missed taking your usual contraceptive pills.
- Emergency contraception pills - are usually effective if started within 120 hours (five days) of unprotected sex. They can be bought at pharmacies or prescribed by a doctor. They work either by preventing or postponing egg production (ovulation) or by preventing the fertilised egg from settling in the womb (uterus). One type works if used within 72 hours; another type can work up to 120 hours. The sooner the tablet is taken, the better.
- An IUCD - inserted by a doctor or nurse - can be used for emergency contraception up to five days after unprotected sex.
Can hormone replacement therapy be used for contraception?
As hormone replacement therapy (HRT) contains very low levels of hormones, it does not work as a contraceptive. Unless you went through the menopause (had no period for one year if aged over 50 years or for two years if aged under 50 years) before you started HRT, you should use contraception until you are aged 55 years.
If you are taking HRT then you can take the POP or have an IUCD or IUS inserted. Alternatively, many women choose to use barrier methods of contraception.
Further help & information
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Further reading & references
- Contraception for Women Aged Over 40 Years; Faculty of Sexual and Reproductive Healthcare (2010)
- UK Medical Eligibility Criteria for Contraceptive Use; Faculty of Sexual and Reproductive Healthcare (2016)
- Contraception - assessment; NICE CKS, August 2016 (UK access only)
- Long-acting reversible contraception; NICE Clinical Guideline (September 2014)
- Barrier methods for contraception and STI prevention; Faculty of Sexual and Reproductive Healthcare (August 2012 - updated October 2015)
- Fertility Awareness Methods; Faculty of Sexual and Reproductive Healthcare (June 2015 - updated November 2015)
- Male and female sterilisation; Faculty of Sexual and Reproductive Healthcare (September 2014)
- PRAC confirms that benefits of all combined hormonal contraceptives continue to outweigh risks; European Medicines Agency, October 2013
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Mary Harding
Dr Jacqueline Payne