Contraception Around the Menopause

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 ovulate (produce an egg) 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 37 years, effective contraception is still required to prevent an unplanned pregnancy.

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 over 50 years, or two years after your periods stop if you are under 50 years.

However, if you are using hormone based contraception, then your periods (or '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 age 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 percentages. For example, the contraceptive injection is more than 99% effective. This means that less than 1 woman in 100 will become pregnant each year using this method of contraception. 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. You have to use them properly or they may lose their effect. For example, the 'pill' is more than 99% effective if taken correctly. If it is not taken correctly (for example, if you miss a pill or have vomiting) then it becomes less effective. Other 'user-dependent' methods include barrier methods, the progestogen-only pill and natural family planning.

Some methods are not so 'user-dependent' and need to be renewed only infrequently or never. These methods include the contraceptive injection, implant, intrauterine devices (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
• Your sexual function
• 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.)

Short-acting contraceptives

Combined pill

The combined oral contraceptive (COC) pill is often just called 'the pill'. It is more than 99% effective if used properly. It contains oestrogen and progestogen and works mainly by stopping ovulation. It is very popular. Different brands suit different people.

• Some advantages - very effective. Side-effects uncommon. Helps ease painful and heavy periods. Reduces the chance of some cancers.
• Some disadvantages - small risk of serious problems (such as thrombosis). Some women get side-effects. Have to remember to take 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 with no other medical problems. However, you should not take it if you are over 35 years and a smoker, or are over 40 years and have a cardiovascular disease (for example, angina), or a history of a stroke or migraine. Many women over 40 years are prescribed a COC pill with a lower amount of oestrogen in it.

There is some evidence that taking the COC pill when you are 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.

There is a reduction in your risk of developing ovarian and endometrial cancer if you take the COC pill. This reduced risk actually continues for 15 years after stopping the pill.

You should stop taking the COC pill and use another form of contraception when you reach the age of 50 years.

Progestogen-only pill

The progestogen-only pill (POP) used to be called the 'mini-pill'. It contains just a progestogen hormone. It is more than 99% effective if used properly. It is commonly taken if the COC pill is not suitable. For example: breastfeeding women, smokers over the age of 35 and some women with migraine. It works mainly by causing a plug of mucus in the cervix that blocks sperm and also by thinning the lining of the uterus. It may also stop ovulation.

• Some advantages - less risk of serious problems than the COC pill.
• Some disadvantages - periods often become irregular. Some women have side-effects. 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 hours later than usual (12 hours for a POP called Cerazette®), you lose protection.

The POP 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 POP.

The POP can be continued until you reach the age of 55 years, after which time you will no longer need to use contraception.

Contraceptive patch

A combined hormone 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. There is one combined contraceptive patch available in the UK called Evra®.

• 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 vomiting or 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 taken by women over the age of 40 with no other medical problems. However, you should not use it if you are over 35 years and a smoker, or are 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.

Barrier methods

These include male condoms, the female condom, diaphragms and caps. They prevent sperm entering the uterus. Male condoms are about 98% effective if used properly. Other barrier methods are slightly less effective than this.

• Some advantages - no serious medical risks or side-effects. Condoms help protect from sexually transmitted infections. Condoms are widely available.
• Some disadvantages - not quite as reliable as other methods. Need to be used properly every time you have sex. Male condoms occasionally split or come off.

Natural methods

This involves fertility awareness. Effective if done correctly. Requires commitment and regular checking of fertility indicators such as body temperature and cervical secretions.

• Some advantages - no side-effects or medical risks.
• Some disadvantages - may not be as reliable as other methods. Fertility awareness needs proper instruction and takes 3-6 menstrual cycles to learn properly.

Long-acting contraceptives

Contraceptive injection (such as Depo-provera® and Noristerat®)

This contains a progestogen hormone which slowly releases into the body. It is more than 99% effective. It works by preventing ovulation and also has similar actions as the POP. An injection is needed every 8-12 weeks.

• Some advantages - very effective. Do not have to remember to take pills.
• Some disadvantages - periods may become irregular (but often lighter or stop all together). Some women have side-effects. Cannot undo the injection, 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 density (strength) 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.

Contraceptive implants (such as Implanon®)

An implant is a small device placed under the skin. It contains a progestogen hormone which slowly releases into the body. Is more than 99% effective. 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 - very effective. Do not have to remember to take pills.
• Some disadvantages - periods may become irregular (but often lighter or stop all together). Some women develop side-effects but these tend to settle after the first few months.

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 device

An intrauterine device (IUD) is a plastic and copper device which is put into the 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 has a spermicidal effect (kills sperm).

• Some advantages - very effective. Do not have to remember to take pills.
• Some disadvantages - periods may get heavier or more painful. Small risk of serious problems.

It can be common to have spotting, light bleeding, heavy or longer periods in the first 3-6 months after having an IUD inserted.

If you have an IUD inserted when you are 40 years or over, then 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 over 50 years, or two years after your periods stop if you are under 50 years

Intrauterine system

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 IUD. The progestogen is released at a slow but constant rate. It is more than 99% effective. 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 your cervix. It is also used to treat heavy periods.

• Some advantages - very effective. Do not have to remember to take pills. Periods become light or stop altogether.
• Some disadvantages - side-effects may occur as with other progestogen methods such as the POP, implant and injection. However, they are much less likely, as the hormone is mainly confined to the uterus (little gets into the 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 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. Vasectomy (male sterilisation) stops sperm travelling from the 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 - very effective. Do not have to think further about contraception.
• Some disadvantages - 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, 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. Can be bought at pharmacies or prescribed by a doctor. They work either by preventing or postponing ovulation or by preventing the fertilised egg from settling in the uterus (womb).
• An IUD - 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, then you should use contraception until you are 55 years old.

If you are taking HRT then you can take the POP or have an IUD or intrauterine system (IUS) inserted. Alternatively, many women choose to use barrier methods of contraception.

Further information

This leaflet is just a brief account of the available methods of contraception around the menopause. Ask your practice nurse, doctor or pharmacist if you want more detailed information about any of these methods.

The fpa (formerly the family planning association) also provides information and advice.
fpa's helpline: 0845 310 1334 or visit their website www.fpa.org.uk