The midlife guide to contraception

The so-called Sandwich Generation – midlifers who are dealing with the twin stresses of growing children and elderly parents, along with work and money – have enough to worry about, but surely contraception isn’t one of them?

Apparently so, according to the Office for National Statistics (ONS) who, in November 2023, published figures that found a growing number of older women are becoming pregnant. Between 2016-2018 and 2019-2021, there was a 15 per cent rise in the number of women giving birth in England aged over 50. 

When can women stop using contraception?

“Although fertility does naturally decline in your 40s and 50s, the rate this happens is different for everyone,” says Bekki Burbidge, an information specialist at the Family Planning Association (FPA). “To avoid an unintended pregnancy, effective contraception is needed until after the menopause when periods stop. And it’s important to keep on using contraception for a while, even after you’ve had your final period. If you’re aged over 50, you’re advised to use contraception one year after your final natural period. If you’re under 50 you should keep using contraception for two years after.”

What are the chances of getting pregnant over 40?

“To give you an idea of numbers, the chance of pregnancy for women aged 40-44 years having regular unprotected sex for one year is about 10 to 20 per cent, and about 12 per cent for women aged 45 to 49,” says Dr Anita Mitra, a gynaecologist. “Therefore if you don’t want to get pregnant in midlife you still need to use contraception.”

“Everyone’s different so there’s no one type of contraception that’s recommended for women in midlife,” says Burbidge. “However, age does increase the risk of certain health conditions such as heart disease, osteoporosis, and some types of cancer, so this needs to be considered when choosing a contraceptive method. Your healthcare professional should discuss any additional risks with you, and you may need a regular review.”

What are the different types of contraception?

The combined pill

This contains synthetic progesterone and oestrogen, which prevents your ovaries from releasing an egg each month, along with thickening the mucus in the neck of the womb making it harder for sperm to reach an egg, and thinning the womb’s lining. It’s over 99 per cent effective, but isn’t advised for older women. “Once you reach 50, you’re usually advised not to use the combined pill,” says Burbidge. “This is because an increased risk of blood clots and other health conditions means the risks generally outweigh the contraceptive benefits.”  

Research has found the combined pill is associated with a small rise in breast cancer risk, however last March, data collected by the Clinical Practice Research Datalink (CPRD) found women may face an increased breast cancer risk of up to 20 to 30 per cent from taking any kind of hormonal contraception, including the progesterone-only pill and injections. Experts also point out the benefits of hormonal contraceptives, such as protection from ovarian cancer.

Dr Aziza Sesay, a GP specialising in women’s health, says that the combined pill may also impact on blood pressure and cholesterol levels, which can increase with age. “Similarly the risks of blood clots can be higher among women in midlife. We also need to consider the fact that older women may be on other medications, which may interact with the combined pill.”  

Progesterone-only pill

Known as the mini pill, or POP, this contains progesterone which can be taken by over-35s and works by thickening the mucus in the cervix to stop sperm reaching an egg. The GP Dr Jane Leonard says: “Women in their 40s are more likely to be put on the mini pill rather than combined, because there is a lower risk of blood clots, which you’re more at risk of when you’re older.”

Implants

The most commonly used is the Nexplanon implant, which is a small plastic rod that’s placed under the skin in your upper arm using local anaesthetic. It slowly releases progestogen into your bloodstream, which prevents pregnancy, and it lasts for three years.

“The implant is the most effective form of contraception with a 0.05 per cent failure rate, and it can be used up until 55 years of age,” says Dr Mitra. Implants are also a LARC – a long-acting reversible contraceptive – so they require little patient input (in other words, remembering to take a pill every day) and have the added benefit of improving problems such as heavy bleeding or painful periods which can occur in midlife.

Injectible hormones

Usually a brand like Depo-Provera, Sayana Press, or Noristerat, a contraceptive injection works by releasing the hormone progesterone, which stops ovulation, thickens the cervical mucus, which prevents sperm getting to an egg, and thins the lining of the womb. The Depo-Provera injection, which is one of the most common, lasts for 13 weeks. “However,” says Burbidge, “you’ll also usually be advised not to use the injection after the age of 50.”  

Hormonal IUD

An IUD (intrauterine device) is a small T-shape device that’s placed in your uterus by a nurse, and releases synthetic progesterone to stop you getting pregnant for up to five years. Also known as a coil, the Mirena is one of the most commonly used, and it can be taken out at any time.

“The Mirena coil is great in midlife because it acts as contraception, but can also make periods lighter (heavy periods are quite common leading up to the menopause) and can be used as part of your HRT regime, if required,” says Dr Mitra. “The majority of menopausal symptoms are due to lack of oestrogen, which can be supplemented using pills, patches or a gel. If you’ve never had a hysterectomy, you need to use it with progesterone to protect the endometrium (the lining of the uterus) because oestrogen alone can cause the lining to thicken and potentially develop into a precancerous or cancerous abnormality. The Mirena can therefore provide this progesterone protection.”

However, some people find the insertion uncomfortable. Your periods may become irregular, and you may also experience headaches, mood changes, and breast tenderness. They also don’t protect you against STIs.

Non-hormonal IUD

This is a small T-shaped plastic and copper device that, rather than releasing hormones, releases copper to alter the cervical mucus, which stops you getting pregnant. It lasts between five and 10 years, and it’s sometimes called a copper coil.

“The copper coil is a non-hormonal form of contraception,” says Dr Mitra. “If you have it inserted over the age of 40 years it can be left in place until the menopause, but it’s important to make sure you get it removed at some point because it can become a source of infection if left in and forgotten about. Some people don’t like it during the perimenopause because it has a tendency to make periods heavy, which is a common problem during this time.”

Emergency contraception

As the ONS figures show, you can become pregnant in your 40s and 50s. “However, if you do have sex without contraception you can use emergency contraception at any age,” says Burbridge. “Emergency contraception can be used up to five days after sex, but the earlier it’s used the better the chances of it preventing pregnancy.”

 There are two types of emergency contraception, the emergency contraceptive pill (known as the morning after pill), which is usually Levonelle or ellaOne. Then there’s also the emergency IUD or coil. The Levonelle pill needs to be taken three days after unprotected sex, and the ellaOne up to five days after. If you use an emergency IUD it can be left in and used as your regular contraception if you wish.

Condoms

The condom, which is usually made of stretchy latex, acts as a barrier to stop men’s sperm coming into contact with his partner’s body. This prevents pregnancy, but also sexually transmitted diseases (STIs). “Even after the menopause, don’t forget to consider using condoms to help protect yourself from STIs in new or casual relationships,” says Burbidge, who says that STIs are becoming more commonly diagnosed in people aged 40 and over. 

 However, unlike LARCs, condoms leave room for human error, such as putting them on wrong or snagging them with fingernails, and some couples find them to be a mood killer.

Withdrawal

Whatever your age, the NHS states that the withdrawal method – where a man withdraws before ejaculating – is not a reliable method of contraception because fluid with sperm in it leaks from the penis before ejaculation. If used regularly, your chances of becoming pregnant increase by up to 22 per cent. 

Sterilisation

“If your family is now complete, or you don’t want children at all, then sterilisation may be an option to consider in midlife,” says Burbidge.

Female sterilisation is an operation that involves blocking or sealing the fallopian tubes to prevent the egg reaching the sperm, which is usually done under either general or local anaesthetic. It’s designed to be permanent, which makes it very hard to reverse. Female sterilisation doesn’t affect your hormone levels, you’ll still have periods, and you’ll need to use contraception up to three months after the operation.

Male sterilisation, more commonly known as a vasectomy, involves cutting or sealing the tubes that carry a man’s sperm. It’s usually carried out under local anaesthetic. It’s considered permanent and can be difficult to reverse, and it doesn’t affect a man’s sex life or enjoyment of sex.

Contraceptives and the menopause

How does contraception affect menopause?

“Contraception doesn’t affect when you go through perimenopause and menopause or how long it lasts,” says Burbidge. “If you’re using non-hormonal contraception, then you’ll have the same signs and symptoms of menopause that you would if you weren’t using any contraception. However, if you’re using hormonal contraception this can often reduce or mask some of the signs and symptoms of menopause. So you may not know that you’re going through menopause until you stop using contraception.”

Burbidge says it’s also important to know that using hormonal replacement therapy (HRT) is not the same as using contraception: “HRT won’t stop you from getting pregnant. However, the exception to this is the hormonal IUD, some types of which can be used as the progestogen part of HRT and as a contraception.”

 When can you stop using contraception?

“In general, all women can stop using contraception at the age of 55 as you’re extremely unlikely to get pregnant at this age even if you’re still having periods,” says Burbidge.