Contraception and menopause

Even if a woman has menopausal symptoms, it does not mean that she cannot get pregnant.

A WOMAN is considered to have reached menopause if she has not had a period for 12 consecutive months. This is a retrospective diagnosis. Although the average age of the menopause is 50-51 years, the time at which the menopause is reached varies between women.

The menstrual periods become irregular before they stop altogether. As long as a woman has a period, the ovary will still produce some eggs (ovulate). As such, the possibility of pregnancy exists, although the chances get increasingly remote nearer to the menopause.

Even if a woman has menopausal symptoms, it does not mean that she cannot get pregnant. About 75% of pregnancies in women above the age of 40 years are unplanned. It has been reported that 93% of women aged 40 to 55 years with regular menstrual cycles appear to ovulate each cycle.
As such, although there is a natural decline in fertility after the age of 37 years, effective contraception is still necessary to prevent an unplanned pregnancy.

There are various birth control options (contraception) available. Contraceptives are either hormonal (e.g. the Pill) or non-hormonal (e.g. condoms).

Hormonal contraceptives are often featured disproportionately in the media, usually with frightening headlines. Mature women are more likely to be sensitive to these negative messages, and therefore, often abandon effective contraceptive methods.

The reality is that the contraceptive methods available are very safe. In addition, many methods have significant non-contraceptive benefits to the user.

The doctor can help a couple choose an appropriate method depending on medical history, sexual habits, the method’s effectiveness and possible side effects, lifestyle and preferences.

Contraceptive pill
Hormonal oral contraceptives (the Pill) containing one hormone (progestogen) or two hormones (oestrogen and progestogen), provide effective birth control. Fertility is restored rapidly on discontinuation.

In general, the Pill is not prescribed in pregnancy, suspected pregnancy, smokers above 35 years, or those with a history of uncontrolled high blood pressure, blood clots, coronary artery disease or breast cancer.

The low-dose combined Pill (COC) is safe and effective for perimenopausal women who have no medical conditions. It is not prescribed for women above 35 years who are smokers, or those above 40 years with cardiovascular disease like angina, or those with a history of stroke or migraine.

The progestogen-only Pill (POP) is safe for women at risk of blood clots, or who have had a heart attack or stroke. However, it is less effective than the COC in preventing pregnancy.

The added benefits of the Pill include a reduced risk of endometrial and breast cancer, with the reduced risk persisting for 15 years or more after stopping. There is also less fibrocystic changes in the breasts, better regulation of periods, and reduced postmenopausal bone loss.

There is a very slight increase in the relative risk of breast cancer in all current users of the COC. As the incidence of breast cancer increases with age, this may become more significant in those above 40 years of age.

The side effects of the Pill are few, and may include nausea, bleeding between periods, breast tenderness, fluid retention, and new or worsening headaches.
The use of the Pill may make it difficult to know when menopause is reached.

Contraceptive patch and vaginal ring
The contraceptive patch and ring are like the COC, except that the hormones are delivered continuously through a patch stuck on the skin or through a ring inserted into the vagina.
They are effective and easy to use. There is no need to consume a tablet daily. The periods are lighter, more regular and less painful. However, some users may complain of skin irritation.
The conditions for use are the same as the COC.

Intra-uterine contraceptive device
An intrauterine contraceptive device (IUCD) is inserted into the uterine cavity by the doctor. Most devices contain copper and are effective for three to five years. Fertility is rapidly restored on removal.
The IUCD string must be checked periodically to confirm that it is in place by placing a finger into the vagina. The doctor will usually arrange a pelvic examination at least once annually.

An IUCD cannot be inserted in pregnancy, suspected pregnancy, those who have a history of pelvic inflammatory disease, sexually-transmitted infections (STI), anaemia or abnormal vaginal bleeding, or those in a polygamous relationship.

The side effects may include spotting, irregular, prolonged or heavier periods, or uterine cramps. These usually occur soon after insertion, which may be uncomfortable.

An IUCD inserted before reaching the menopause has to be kept in place for one year in women aged above 50 years, or two years if the periods stop below 50 years of age.

Contraceptive injections
A single injection of a depot progestogen provides effective contraception for one to three months, depending on the brand. Fertility returns within a year after discontinuation.
It is not prescribed in pregnancy, vaginal bleeding of undetermined origin, liver disease, blood clotting conditions and breast cancer.

The side effects may include menstrual cycle changes and weight gain. Regular visits to the doctor’s clinic for the injections are required.
The conditions for use are the same as the POP.

Contraceptive implants
The progestogen implant system contains capsules, each about the size of a match, which are inserted under the skin of the inner aspect of the upper arm. It is effective and fertility is rapidly restored on removal. The implants must be removed after five years of use.
It is not prescribed in pregnancy, undetermined vaginal bleeding, liver disease, breast cancer or blood clots.

The side effects may include nausea, weight change, acne, vaginal dryness, irregular uterine bleeding and headaches, especially in the first year after insertion.
The conditions for use are the same as the POP.

Barrier methods
Barrier methods, which include the male and female condom, diaphragm, cervical caps and spermicides, must be used during every act of sexual intercourse to be effective.
The condom is the only effective method that prevents pregnancy and protects against STI. Condoms can be used in combination with other contraceptive methods.

Fertility awareness
Some women use fertility awareness methods by abstaining from sexual intercourse at certain times in the menstrual cycle. These methods cannot be depended upon if the menstrual cycle is irregular, and indeed, irregular cycles are common during the menopausal years.

Emergency contraception
Emergency contraception (EC) is effective if used within 72 to 120 hours after unprotected sexual intercourse or condom accidents. The “morning-after Pill” must be taken within 72 hours.
An IUCD can be inserted within 120 hours. They should not be used as regular birth control methods.
Mature women need not be shy or embarrassed about asking for EC.

Double protection
A woman is exposed to STIs, including HIV/AIDS, if she has more than one sexual partner, or the sexual partner has more than one sexual partner.

In such situations, there is an additional need to prevent transmission of STIs.
Whenever there is a possibility of transmission of STI, doctors will strongly recommend dual protection, either through the simultaneous use of condoms with other contraceptive methods, or through the consistent use of condoms alone for the prevention of pregnancy and the transmission of STI.

Stopping contraception
If one is using non-hormonal contraception, it should be continued for two years after the last menstrual period in women under 50 years of age, and for a year after the last menstrual period in women more than 50 years.

If one is using hormonal contraception, one cannot depend on the periods, which are hormone withdrawal bleeds, to know if one is fertile or not.
Some women on hormonal contraceptives have irregular or no periods, but are still fertile if they stop using their contraceptives.

The COC, contraceptive patch, vaginal ring and injection should be stopped at the age of 50 years and another contraceptive method used instead.

The POP, contraceptive implant, IUCD and barrier methods can be used until the age of 55 years, after which, contraception will not be needed any more. This is because no spontaneous pregnancy has been reported after that age.

Women with premature menopause because of medical conditions, e.g. undergoing chemotherapy, may have protracted fluctuating ovarian function. This would require special attention from the attending doctor.

Hormone therapy is not a contraceptive
Hormone therapy (HT) prescribed for menopausal symptoms like hot flushes, do not provide contraception, as it does not suppress ovulation due to its low levels of hormones.
Many women commence HT before they reach the menopause. It is difficult to know when the menopause occurs and how long contraception is needed in HT users.
If one has reached the menopause (had no period for one year if aged over 50 years, or for two years if under 50 years) before commencing HT, then contraception should be used until the age of 55 years.

A method of confirming if the menopause has been reached is to stop the HT medication for six to eight weeks, and then check blood hormone levels.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. The views expressed do not represent that of any organisation the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

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