As middle years near, women may need to rethink contraceptive choices
If you’re approaching the middle years of your life, it might be time to review your choice of contraceptives. But don’t be too hasty in putting them away for good.
Middle-age women and teenagers have the highest rates of unintended pregnancy and abortion in the United States, says physician Michele Curtis, an associate professor of obstetrics and gynecology at the University of Texas-Houston Medical School.
“Teenagers think they’re bulletproof,” she says. “Middle-age women think it’s too late. They say, ‘I’m 45, my fertility is dropping and I’m having hot flashes. What do you mean, I’m pregnant?’ ”
Misconceptions about the safety of birth-control methods contribute to the incidence of later-than-desired pregnancies, says physician Andrew Kaunitz, who reviewed contraceptive choices and their risks for women 35 and older for a study published in the March 20 issue of the New England Journal of Medicine.”Many women assume it becomes unsafe for them to use oral contraceptives or other hormonal contraceptives as they get older,” Kaunitz, a gynecologist at the University of Florida College of Medicine-Jacksonville, says by phone. “And that is true for women in their mid-30s and older if they’re smokers or grossly overweight or have high blood pressure, diabetes or migraines.”For them, the cardiovascular risks associated with combination estrogen-progestin oral contraceptives outweigh the benefits, he says.”But for healthy, non-smoking, lean women,” he says, “the pill remains safe for as long as they need birth control, up until the time of menopause.”The dangers associated with pregnancy when a woman is in her 40s are “considerably higher” than those linked to oral-contraceptive use, says Kaunitz, who reports receiving fees from contraceptive makers.
Denise Hanson, 45, of Mesa, in good health and a non-smoker, falls into the category of women for whom oral contraceptives usually are safe. But when she turned 40, she considered alternatives.
“I was a little concerned about still being on birth-control pills at that age,” she says.
Around the same time, her husband, Mark, was on a health kick, encouraging his family to choose unprocessed foods and vitamins over medicine when possible.
Denise went off the pill, and the couple began using condoms. Without the regulating effect of the pill, however, her menstrual periods became heavy and she needed an endometrial ablation to control the bleeding.
Because the Hansons’ family is complete – they have two kids, Alec, 16, and Haley, 10 – she underwent a non-surgical tubal ligation called Essure at the same time as the ablation, which destroys a thin layer of the uterine lining.
“It had taken me a long time to get pregnant with both my kids,” Denise says, “so I thought I might not even need birth control any longer.”
But she decided that wasn’t a chance she wanted to take in the years until menopause, which begins for many women at about 50.
In the Essure procedure she chose, doctors thread tiny springlike coils through the woman’s cervix and into her fallopian tubes, where scar tissue forms and blocks sperm from reaching the egg.
Approved by the federal Food and Drug Administration in 2002, Essure is one of the contraception choices boomers didn’t have when they began using birth control. Other contraceptives have since been improved.
“The pill certainly is safer than it was,” the University of Florida’s Kaunitz says, “and women who use it experience less nausea and breast tenderness than they used to.”
The oral contraceptives prescribed routinely today are low-dose, containing 20 to 35 micrograms of estrogen compared with 80 to 150 mcg when they became available in the early 1960s, he says.
Kaunitz says his review found that pill use does not increase risk for breast cancer, heart attack or stroke in healthy older women, and it may provide benefits beyond preventing pregnancy. These appear to include reductions in bone fractures and in ovarian, endometrial and colorectal cancers, he says.
However, using the pill contributes to the formation of blood clots, even in younger women, Kaunitz says. The likelihood of developing a clot remains small, he says, but being overweight or older than 35 multiplies the odds. Women with those risk factors should consider non-estrogen contraception, such as injections, in-arm implants or intrauterine devices.
Curtis, the Houston doctor, recommends the low-dose pill as the best choice for healthy women who want to prevent both pregnancy and the abnormal bleeding that often accompanies their premenopausal years.
But for those who can’t or don’t want to use the pill, an IUD that releases the hormone progestin in the uterus offers similar hormonal control over inconvenient and unpredictable menstrual periods, she says. It doesn’t get into the bloodstream and affect the rest of the body as oral contraceptives do.
Women who have had a blood clot, have a family history of a blood disorder or have a breast mass that has not been checked out are not good candidates for oral contraceptives, Curtis says. If they have well-controlled high blood pressure or diabetes, they should talk with their doctor about whether the low-dose pill would be safe for them.
The one thing a sexually active woman should do is use condoms, unless she’s in a long-term, monogamous relationship.
“Every woman, I don’t care if she’s 75, has to be aware of sexually transmitted infections and the need to use a condom,” Curtis says. “And as far as birth control goes, if a condom is used every time and used properly, particularly with a spermicide, it’s pretty effective.
“The problem is people assume men are born knowing how to use a condom.”
Medical guidelines for age, contraceptive use
If you’re 35 or older and have any of the following risk factors, combination estrogen-progestin contraceptives may not be safe for you. Guidelines are from the American College of Obstetricians and Gynecologists and the World Health Organization.
OBESITY
ACOG guidelines: Progestin-only or intrauterine contraception may be safer than combination estrogen-progestin contraception.*
WHO guidelines: Benefit usually outweighs risks.**
SMOKING
ACOG guidelines: Progestin-only or intrauterine contraception should be used.*
WHO guidelines: Risk unacceptable.
HIGH BLOOD PRESSURE
ACOG guidelines: Progestin-only or intrauterine contraception should be used.*
WHO guidelines: Risk unacceptable.
DIABETES
ACOG guidelines: Progestin-only or intrauterine contraception should be used.*
WHO guidelines: Risk unacceptable.
MIGRAINES
ACOG guidelines: Progestin-only or intrauterine contraception should be used.*
WHO guidelines: Risk unacceptable.
NONE OF THE ABOVE RISKS
ACOG guidelines: Healthy women who are non-smokers and doing well with combination contraceptive can continue this method until 50 to 55, after weighing risks and benefits.
WHO guidelines: For women 40 or older, risk of cardiovascular disease increases with age and may also increase with combined hormonal contraceptive use; in absence of other adverse clinical conditions, combined hormonal contraceptives can be used until menopause.
*This category includes progestin-only oral contraceptives, depot medroxyprogesterone acetate, contraceptive implants, and copper and progestin-releasing intrauterine devices.
**Obesity in women 35 and older not specifically addressed.
Common contraceptives for women in later years
Next to tubal ligations (or their partners’ vasectomies), these are common birth-control choices for women 35 and older, says gynecologist Andrew Kaunitz of the University of Florida College of Medicine-Jacksonville.
ESTROGEN-CONTAINING
• Low-dose oral contraceptives (“the pill”).
• Transdermal patch (Ortho Evra).
• Vaginal ring (NuvaRing).
NON-ESTROGEN
• Intrauterine devices, progestin-releasing (Mirena) or copper (ParaGard).
• Injectable progestin (Depo-Provera).
• Implant (Implanon).
Source: Connie Midey – The Arizona Republic
