Friday, July 20, 2018
Health

There is an array of contraceptive choices for the over-40 crowd

Almost one-fourth of women in the United States between ages 15 and 44 use the birth control pill to prevent pregnancy. Some doctors advise against continuing its use after age 40, but women need to protect themselves against unwanted pregnancy until one year after menopause, which on average occurs at the age of 51-52.

JoAnn Pinkerton, executive director of the North American Menopause Society, said the second highest rate of unintended pregnancy is for women 40 to 50 who are sexually active. Many can continue to safely take the pill, but some should think about other options.

A gynecologist and contraceptive expert at the Mayo Clinic, Dr. Petra Casey said a woman younger than 40 can safely take the pill unless she has a history of strokes, blood clots, heart attacks, hypertension, migraines or other serious health conditions. After age 40, for healthy women who don't smoke, the benefits still usually outweigh the risks.

"For women approaching menopause," Casey said, "the pill can enable a smooth transition through hormonal changes and symptoms such as hot flashes."

Dr. Gillian Dean, director of the fellowship in family planning at the Icahn School of Medicine at Mount Sinai in New York, said women have more options than ever when reassessing their birth control choices.

"The methods I discuss most are the most effective and easiest to use: the IUD and the implant. But if I have a healthy nonsmoking patient who wants to stay on pills, I counsel her that it's a safe and effective option all the way until menopause," she said.

Dean said the combination estrogen-progestin pill that works by thickening the cervical mucus and thinning the lining of the uterus to prevent sperm from reaching an egg is safe for middle-aged women with no health problems. The progestin-only pill or the "minipill" is safe even for those who have health problems or smoke, because it doesn't contain the hormone estrogen, which can be associated with increased risk of blood clots and sometimes heart attack or stroke.

Here are other contraceptive choices for women over 40:

LARCS (long-acting reversible contraceptives): LARCs provide birth control for long periods of time and include intrauterine devices (IUDs) and implants. "The American College of Obstetricians and Gynecologists highly recommends LARCs for women of all ages who don't want to think about taking a pill every day," Casey said. It's what's known as the forgettable option that works (except the copper IUD) by thickening cervical mucus and keeping the lining of the uterus thin, so it's less likely that an egg can be fertilized by sperm.

IUDs: IUDs are small, long-acting, T-shaped plastic devices that are inserted into the uterus to prevent pregnancy and can remain in place for several years. In the United States, two kinds are available: the copper IUD that contains no hormones and hormonal IUDs. The World Health Organization cites the failure rate of the IUD at less than 1 percent.

Implants: The implant is a plastic tube about the size of a small matchstick that's inserted into the skin of a woman's upper arm and can remain in place for up to three years. It releases the hormone progestin into the body to prevent egg fertilization and is safe, effective and convenient. "Implants work well for women needing contraception during the menopause transition," Casey said.

The patch and the ring: The estrogen and progestin hormones in the patch and the ring prevent eggs from leaving the ovaries and thicken cervical mucus to block sperm from reaching an egg. A patch has to be affixed to the skin once a week for three weeks and removed for the fourth week. A ring has to be inserted in the vagina for three weeks and also removed for the fourth. "Both alternatives have similar advantages and disadvantages as the pill, though the patch has been linked to a slightly higher risk of blood clots and is generally not a top choice for menopausal women," Casey said.

Shot/injection: The birth control shot is an injection of progestin into the arm or buttocks. To prevent pregnancy, it requires a new injection every three months to stop ovaries from releasing an egg and to thicken cervical mucus to block sperm. The shot, Dean said, is effective and safe and can be used even by women who smoke or have health issues.

Barrier methods: The diaphragm, cervical cap, male and female condoms, and spermicidal foams and sponges are all barrier methods that must be put in place before sexual intercourse and remain there for specified amounts of time to block the opening of the uterus and prevent sperm from fertilizing an egg. "Methods that require a lot of attention on the part of the user, like barrier methods, have the highest failure rates, because it's hard to be motivated to use them with every act of intercourse," Dean said.

In the 1970s, the U.S. Food and Drug Administration recommended that women over 35 stop taking the birth control pill. It was widely believed that the pill increased the risk of heart disease. But now we've learned that the risk is mostly for women who smoke. Additionally, the amount of estrogen used in the pill has dropped significantly, and so has the risk of health complications.

For menopausal women, the pill can help with controlling irregular bleeding, lessening hot flashes, maintaining bone density and lowering the risks of uterine and ovarian cancers.

"When perimenopausal women make birth control decisions, I encourage them to think about whether or not they wish to get pregnant, how disruptive an unplanned pregnancy would be and to discuss with their health care provider any health issues that affect contraceptive choices," Casey said. "The best option for each woman is an individual choice."

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