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.
How long will I be fertile for?
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, effective contraception is still required to prevent an unplanned pregnancy. Most women will no longer be fertile by the age of 55. However, a few women will still be having periods at this age, and may need contraception.
When can contraception be safely stopped?
If you are using contraception other than hormone-based contraceptives (such as the pill), you will be able to stop using contraception 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.
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 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. The reliability for each method is given, in the sections below, in percentages. For example, between 2 and 60 women in 1,000 using the contraceptive injection for one year will become pregnant. When no contraception is used, more than 80 in 100 sexually active women who have not gone through the menopause become pregnant within one year.
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 pill (COCP) 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 contraceptive pill (POCP) 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 devices (IUCDs, or coils) 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 on the various methods of contraception for more details.)
The combined oral contraceptive pill (COCP) 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 COCP may improve any menopausal symptoms that you may have. There is also some evidence that taking the COCP 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 COCP can safely be taken by women over the age of 40 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 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.
There is a reduction in your risk of developing ovarian and endometrial cancer if you take the COCP. This reduced risk actually continues for 15 years or more after stopping the pill. There may be a very small additional risk of breast cancer. This reduces to no extra risk (the normal risk for your age) after 10 years after stopping the COCP. There is actually a reduction in the risk of cancer of the bowel (colorectal cancer) in women who take the COCP.
You should stop taking the COCP and use another form of contraception when you reach the age of 50 years.
The progestogen-only contraceptive pill (POCP) used to be called the mini-pill. It contains just a progestogen hormone. Between 3 and 90 women in 1,000 using the POCP will become pregnant. It is commonly taken if the COCP is not suitable - for example, breast-feeding women, smokers over the age of 35 and some women with migraine.
- Some advantages - there is less risk of serious problems than there is with the COCP.
- Some disadvantages - periods often become irregular. Some women have side-effects. It is not quite as reliable as the COCP.
You need to remember to take it at the same time every day because if you take a pill more than three 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 POCP is safe if you have had a stroke, heart attack or suffered with a clot in the past. There is no increased risk of developing breast cancer if you take the POCP. However, women who have had breast cancer cannot usually take a POCP.
The POCP 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 hormone form of contraception, containing oestrogen and progestogen hormones. It is essentially the same type of contraception as the COCP 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 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.
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. This means that it is almost as effective as sterilisation. It works by preventing egg production (ovulation) and also has similar actions as the POCP. 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 is safe if you have had a stroke, heart attack or suffered with a clot in the past. There is no increased risk of developing breast cancer if you use the contraceptive injection.
Long-term use of 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.
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 is safe if you have had a stroke, heart attack or suffered with a clot in the past.
The implant can be continued until you reach the age of 55 years, after which time you will no longer need to use contraception.
Intrauterine contraceptive device
The intrauterine contraceptive device (IUCD) is a plastic and copper device which is put into the womb (uterus). It lasts five or more 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 uterus. 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.
- Some disadvantages - periods may get 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 uterus in a similar way to an IUCD. The progestogen is released at a slow but constant rate. Two women per 1,000 using the IUS for a year will become pregnant. It works by making the lining of your uterus 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 POCP, implant and injection. However, they are much less likely, as the hormone is mostly in the uterus, and not much gets into your bloodstream.
The IUS is safe if you have had a stroke, heart attack or suffered with a clot in the past.
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.
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. Male sterilisation (vasectomy) stops sperm travelling from the testicles (testes). Female sterilisation prevents the egg from travelling along the Fallopian tubes to meet a sperm. Vasectomy is easier 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 72 hours 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).
- 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 or for two years if aged under 50) before you started HRT, you should use contraception until you are aged 55.
If you are taking HRT then you can take the POCP or have an IUCD or IUS inserted. Alternatively, many women choose to use barrier methods of contraception.
Further help & information
Dr Tim Kenny
Dr Mary Harding
Prof Cathy Jackson