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Ovarian conservation at the time of hysterectomy for benign disease: where is the pendulum now?
18 August 2014: Ovarian conservation at the time of hysterectomy for benign disease has certainly become more common, mainly as the result of the landmark paper of Parker and colleagues. This was a focal point in the beginning of a turnaround in the thinking of many clinicians. Now a new body of work examining a portion of this argument comes from the Cancer Prevention Study-II Nutrition Cohort published in Obstetrics & Gynecology by Gaudet and colleagues. Log in to read more...

Fertility naturally declines with age, so when you are heading towards the end of your fertile years, you have a lower chance of becoming pregnant. However, you do still need to think about using contraceptives because you can still become pregnant. And remember, condoms are the only contraceptive choice to protect against sexually transmissible infections - worth remembering by women of all ages.

pdf Contraception For Women Approaching Menopause 129.60 Kb

When is it safe to stop contraception?

It is estimated that the possibility of pregnancy in women between 45-49 years is two to three per cent. The risk of pregnancy without contraception after the age of 50 years is minimal - less than one per cent.

Current advice is, continued use of contraception until a woman has had no periods for two years if the woman is under 50; and that women aged over 50 should continue to use contraception for 12 months after menopause (their last period).

If a woman is using the oral contraceptive pill we use 51 years (the average age of menopause) as the age by which a woman should stop taking the pill. Some women may elect to continue to use barrier methods (condoms/diaphragms) after this time if they want to take as little risk as possible.

Women need to carefully consider their options in consultation with their Doctor, including the possible risks of continuing the oral contraceptive pill such as DVT.

Contraceptive options for preventing pregnancy:

Combined oral contraceptive pill - ‘the Pill'

This type of pill contains two hormones: progestogen and oestrogen.

It prevents pregnancy by:

  1. Stopping sperm reaching your uterus by thickening the mucus at the entrance of your cervix.
  2. Preventing the release of an egg.
  3. Altering the lining of the uterus to prevent a pregnancy settling in.

If you are healthy, are not currently a smoker, and do not have uncontrolled high blood pressure, diabetes or an increased risk of blood clots in the legs or lungs, you can use the combined Pill up until 51 years of age - but health risks increase with age so the lowest dose is recommended. Always discuss this with your doctor.

Advantages

  • Most women find they have more regular periods with less blood loss during their periods.
  • Period pain is often less severe.
  • The Pill reduces your risk of ovarian and endometrial cancer.

Disadvantages

  1. There is a small risk of clotting, heart attack, stroke and non-cancerous liver tumour. The risk of breast cancer from taking the Pill is still being investigated and no clear answer has been found.
  2. If you get migraines, especially ‘focal migraines', the Pill may not be suitable.
  3. The pill may mask the onset of menopause and make it hard to know when to stop taking it.
  4. If you are a smoker and are over 35 years of age, you should not use the combined Pill as you have a greater risk of heart attack and blood clots in the legs or lungs.

 

Contraceptive hormonal vaginal ring (Nuva Ring)

This is a small, soft, silastic (pliable plastic) ring containing low dose oestrogen and progestogen. A woman inserts the ring into her vagina. It is left in for three weeks out of the four week cycle, including during intercourse. A new ring is then inserted one week later. The ring prevents pregnancy by stopping the release of eggs and increasing the thickness of mucous at the entrance to the cervix, preventing sperm from entering the uterus. 

Advantages

  1. Smaller dose of hormone.
  2. Set and forget - use only once a month.
  3. Possibly less hormonal side effects than the oral contraceptive pill.

Disadvantages

  1. You have to remember to insert it and take it out again three weeks later.
  2. There is a small risk of clotting, heart attack, stroke and non-cancerous liver tumour. The risk of breast cancer is still being investigated and no clear answer has been found.
  3. If you get migraines, especially ‘focal migraines', the ring may not be suitable.
  4. May mask the onset of menopause and make it hard to know when to stop taking it.
  5. If you are a smoker and are over 35 years of age, the ring should not be used as you have a greater risk of heart attack and blood clots in the legs or lungs.

Progestogen-only pill - the ‘mini-pill'

This type of pill contains a very small dose of progestogen hormone. It works by thickening the mucus in the cervix to prevent the sperm getting into your uterus. It doesn't contain any oestrogen.

Advantages

  • Because it doesn't contain oestrogen, it doesn't carry the same risks as the combined pill -  especially for smokers.

Disadvantages

  • To work well, you must take the mini-pill at the same time every day (within three hours of your normal time).
  • Your period might be irregular and you will need to talk to your doctor.

Three-year contraceptive implant containing etonogestrel (Implanon), also known as ‘the rod'.

This implant is a matchstick-sized plastic rod, inserted by a doctor under the skin of your inner upper arm after a local anaesthetic. It releases the hormone etonogestrel which is a progestogen. You will be able to feel it under your skin but will probably not be able to see it.

The implant stops you producing and releasing an egg. It also thickens the mucus around the cervix to stop sperm entering the uterus.

Advantages

  • The hormone is released slowly and continuously so you don't need to remember to take the Pill every day.
  • It is cheap and only needs to be replaced every three years.
  • You are likely to have less bleeding than you would with a normal period.

Disadvantages

  • Bleeding may be irregular. About 20 per cent of women will have no periods, 40 per cent will have regular periods and 40 per cent will have irregular, annoying bleeding and may request the implant be removed.
  • Some women experience acne, breast tenderness, irritability and a lower sex drive.

Copper intra-uterine device (IUD)

A copper-containing IUD is inserted into your uterus through the vagina. It can be fitted while you are awake, with or without anaesthetic. Once inserted, you need to check once a month to make sure it is still in place, by feeling for a string coming out of your cervix.

Both copper and progestogen IUDs are toxic to sperm and stop fertilisation of the egg. The IUD also stops a fertilised egg from settling in the uterus.

Advantages

  1. The IUD is very effective as a medium-term contraceptive.
  2. You don't need to take any tablets.
  3. It lasts five years and is easily removed.
  4. It's a good alternative if you suffer problems from the Pill.

Disadvantages

  1. Your period might be heavier and more painful.

May not be suitable if:

  1. Your periods are heavy and painful.
  2. You have more than one sexual partner.
  3. Your partner has sex with someone else.
  4. You have had an ectopic pregnancy.
  5. You have not had a child.

Progestogen IUD (Mirena)

This IUD contains a slowly releasing, progestogen, levonorgestrel, which stops pregnancy by thinning the lining of the uterus making it unfavourable for implantation and preventing sperm from getting into the uterus by thickening cervical mucous. It is fitted the same way as the copper IUD.

Advantages

  1. It lasts five years and is easily removed.
  2. You are likely to have less blood loss and discomfort when you have your period.
  3. After 12 months or so, you may not have a period at all.
  4. If you find you are entering menopause and have symptoms from low levels of oestrogen, you can take oestrogen alone rather than combined hormone therapy. Your doctor will be able to advise you.

Disadvantages

  • Most women have some irregular spotting and bleeding for the first few months after insertion and this can continue indefinitely in a small number of women.
  • Some women get progestogen-related side effects, especially initially e.g. bloating, sore breasts and weight gain. These usually settle with time.

May not be suitable if:

  1. You have more than one sexual partner.
  2. Your partner has sex with someone else.
  3. You have had an ectopic pregnancy.
  4. You have not had a child.

Diaphragms and caps

The diaphragm and cap are barrier methods, placed inside the vagina to cover the entrance to the uterus. A diaphragm is a shallow dome of thin rubber and is held in place by the pelvic muscles. A cap is a firm, cup-shaped device which fits over the cervix by suction.

The diaphragm and cap stop sperm reaching the uterus and prevent pregnancy. You leave the product inside for six hours or longer after sex so the sperm die without reaching their target. It is more effective if used with a spermicide cream/gel. Spermicides kill or disable sperm so that the sperm cannot cause a pregnancy.

Advantages

  1. They offer a drug-free alternative.
  2. They can be used with short notice, unlike the Pill which requires forward planning and consistent use.

Disadvantages

  1. It is not as reliable as some other methods and is difficult to measure. If 100 women used a diaphragm as their regular method of contraception for a year, between four and 20 would have an unexpected pregnancy.
  2. Some women are allergic to rubber and/or spermicide.
  3. Some women find it difficult to insert with a risk of it being placed incorrectly.
  4. Putting it in and taking it out can increase your risk of having a urinary tract infection.
  5. You may have difficulty finding a spermicide.

Condoms

The male condom is a fine rubber or plastic sheath, worn on an erect penis. It catches sperm, stopping it reaching the egg. There is also a female condom, Femidom, which sits in the vagina.

Advantages

  1. Drug-free alternative.
  2. Condoms can protect you from sexually transmissible infections - no other method of contraception can.
  3. They can be used with short notice, unlike the Pill which requires forward planning and consistent use.

Disadvantages

  1. Condoms have a five to 10 per cent failure rate.
  2. A water-based lubricant should be used and the condom needs to be put on carefully - sometimes difficult in the heat of the moment!

Emergency contraception (Postinor)

Often called the ‘morning after pill', this is a special dose of a contraceptive pill. You take it to reduce the chance of pregnancy after unprotected sex. Perhaps you didn't use contraception or a condom broke.

The sooner you take it after unprotected sex, the more effective it will be - definitely within five days. It works by delaying the release of an egg from your ovary or may stop a fertilised egg from settling in the uterus. If it fails to work, it is not harmful to the pregnancy and embryo. After use, it is important to keep using other contraception until your next period or you may become pregnant.

Advantages

  • A last chance option to prevent pregnancy occurring.
  • Available from a pharmacy, over the counter.
  • Relatively easy to take: two tablets taken together.
  • Your period will probably come at the expected time. If it is late, visit your doctor or call Family Planning Australia for advice.

Disadvantages

  1. Should not be used frequently as a contraceptive.
  2. More likely to work if taken within 24 hours after unprotected sex.
  3. May cause some nausea and vomiting (uncommon).

Permanent contraception (surgical)

Tubal ligation (for women)

This is well known as ‘having your tubes tied'. These days surgery can be done through a ‘keyhole' in your lower abdomen, and requires a general anaesthetic.

Advantages

  1. It works straight away.

Disadvantages

  1. There are low risks of injury to blood vessels and bowel damage.
  2. Requires a day in hospital and a general anaesthetic.
Blocking fallopian tubes with coils (Essure device) (for women)

These tiny metallic coils are inserted into the fallopian tubes through a hysteroscope by a specially trained gynaecologist. It stops pregnancy by scarring and blocking the tubes. It can be done under local anaesthetic but some women need a general anaesthetic.

Advantages

  • You don't need to use other contraception once the device is confirmed to be in place. This occurs when an X-Ray is done three months after insertion.
  • You may not need a general anaesthetic.

Disadvantages

  • It is an uncomfortable procedure to have if done under local anaesthetic.
  • Requires day surgery.
  • Only some gynaecologists are able to do it.
Vasectomy (for men)

This is a permanent option for men when the tubes taking sperm to the penis are cut. It is usually done under local or general anaesthetic. The man will need to have a check at three months to make sure sperm is no longer getting through.

Advantages

  1. Frees his partner from worrying about contraception.

Disadvantages

  1. There is a small risk of injury to the testicles and long-term testicular pain.
  2. It is not immediately effective. There needs to be a follow-up semen analysis to check for effectiveness.

This fact sheet has been developed by the Australasian Menopause Society
in partnership with The Jean Hailes Foundation for Women's Health
Updated April 2008

 

This fact sheet is designed to be informative and educational.

 It is not intended to provide specific medical advice or replace advice from your health practitioner.

 

AMS New directions in women's health

Note: Medical and scientific information provided and endorsed by the Australasian Menopause Society might not be relevant to a particular person's circumstances and should always be discussed with that person's own healthcare provider.

This Information Sheet may contain copyright or otherwise protected material. Reproduction of this Information Sheet by Australasian Menopause Society Members and other health professionals for clinical practice is permissible. Any other use of this information (hardcopy and electronic versions) must be agreed to and approved by the Australasian Menopause Society.

Content Updated April 2008 

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