Contraceptive options open for 40-somethings

[Editor’s note: Women in perimenopause still eed a reliable form of birth control. Contraceptive Technology Update helps you review all the options with this special two-part series. Oral contraceptives and intrauterine devices (IUDs) were reviewed in the December 1996 issue. This article focuses on progestins, barrier contraceptives, and natural family planning.]

Looking for contraception options to offer your "40-something" patients? While choices such as pills, Norplant, and Depo-Provera may lose some of their allure due to complications, other barrier methods pick up speed, with their efficacy suited for the decline in fertility.

Norplant, Depo-Provera and the progestin-only mini-pill are effective forms of birth control, but the bleeding changes associated with them may pose contraindications for older women.

The risks for endometrial cancer rise as women age, says Joyce King, CNM, PhD, assistant professor at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta. Detecting the difference between bleeding problems caused by contraceptives and the early signs of cancer may prove challenging for clinicians.

Norplant and mini-pill users may display irregular bleeding, and those on Depo-Provera can become amenorrheic, King notes. For older women with irregular cycles, any changes may prompt clinicians to increase the number of endometrial samplings to monitor for endometrial hyperplasia.

"I do think you need to think seriously about using any progestin-only contraception, because whether you’re talking about Depo-Provera, the mini-pill, or Norplant, you have irregular bleeding," King notes. "You will always be in that dilemma about what is causing this irregular bleeding in this perimenopausal woman."

Felicia Stewart, MD, director of reproductive health programs at Kaiser Family Foundation in Menlo Park, CA, agrees with this assessment.

"The progesterone and irregular period problem certainly might be a consideration for women who are getting to the point where their periods were disrupted in the first place," she says. "And with older women, it becomes doubly hard to tell, because if you have abnormal bleeding and you’re close to 50, then some kind of evaluation is needed to make sure it’s not uterine cancer. So that is one slightly less attractive feature."

With women who are still having regular menstrual cycles and want long-term birth control, Depo-Provera and Norplant shouldn’t be ruled out, the clinicians agree. The two offer long-lasting effectiveness for many patients, they note.

For progestin-only mini-pills, the message is mixed. For women who don’t do well with estrogen products, mini-pills may offer a viable option, says Stewart. But as cycles become more unpredictable in the later years, the mini-pills may further aggravate the problem and therefore become less desirable as a contraception option.

Barrier methods meet waning fertility rates

As a woman’s fertility wanes, barrier contraceptives such as the diaphragm, condom, or cervical cap, all used in tandem with spermicide, may prove to be very effective choices.

"As women enter the perimenopausal time, their likelihood of ovulating each month goes down, so these methods actually become more effective as we age," notes King. "I probably fit more diaphragms in women in their 40s than other groups."

It’s important that women who use barrier methods understand the need for using them correctly and consistently, says Kirtly Parker Jones, MD, associate professor in and chief of the division of the reproductive endocrinology at the University of Utah in Salt Lake City. This may be no problem for those in a long-term relationship, but women who are changing partners may find negotiation challenging with multiple partners.

Be sure to point out to patients that barrier methods also provide added protection against sexually transmitted diseases, say clinicians.

"We cannot assume that women in their 40s are not having more than one partner," King says. "I always talk about [STD protection with] every woman patient who comes into my office — I don’t care if she’s been married for 25 years. I don’t assume. I don’t judge. I just say, ‘This is something you need to keep in mind, that if you should be at risk for a sexually transmitted infection, you need to use a barrier method of contraception to protect yourself.’"

Spermicide and condoms offer nearly foolproof protection against disease, says Stewart. "If you’re in the situation of divorce, or resuming a relationship after a long period of time, then you need STD protection," she says. "It’s an issue even for women who are married, if their husbands are not monogamous, or if they’re not."

NFP fans can plan, too

Women who choose natural family planning (NFP) can continue to use the method through the later years, but must be "perfect users" in the truest sense of the word, note clinicians.

"We very seldom rely just on the menstrual cycle when we’re talking about natural family planning, so even if you’re having irregular cycles, you should still be able to practice natural family planning," says King. "You still should be able to check for the basal body temperature rise. If ovulation should occur, you should still be able to check for cervical mucus changes that would indicate ovulation, and you would follow the same rules you have always followed, even if you’re having irregular menses."

Although patients who have been long-time NFP users may not need to be reminded, it’s important to note that the rules of the contraceptive game definitely cannot be altered with NFP, says Jones.

"If you miss a couple of pills, you probably aren’t going to get pregnant," she says. "If you break the rules with this method, though, it’s very unforgiving. Having said that, if you break the rules with natural family planning, emergency contraceptive pills are an excellent backup for women of any age. So if a woman finds she’s using natural family planning and she may have misjudged, emergency contraceptive pills are perfectly appropriate for women of this age."