Contracepting at Midlife: Not Done Yet
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Post written by guest blogger Amy Alspaugh, CNM, MSN, Clinical Instructor, School of Nursing, Duke University & University of North Carolina at Chapel Hill
The pregnancy rate in the United States has steadily declined during the last three decades, hitting subsequent lows in 2016 and 2017. However, for women over 40, the birth rate has steadily increased every year since 1985. The National Survey for Family Growth does not yet record national statistics on unplanned pregnancy rates of women over 45, but current national data for women aged 35-44 show an unintended pregnancy rate similar to that of the general population, around 48%. Of those unintended pregnancies, 46% of them will end in abortion, the highest percentage of any age group. Moreover, two small studies identified that 15-17% of women over 40 were not using any contraceptive method despite being at risk for pregnancy. And, when midlife women do use contraception, dissatisfaction is common.
A clinical update is published every few years in medical journals that addresses the contraceptive needs of perimenopausal women. Usually, the update rehashes the same general principles: there is an unmet need for contraception in women over 35, no method is contraindicated by age alone, comorbidities must be considered, and certain contraceptives can lessen hormonal fluctuations and bothersome side effects associated with perimenopause. Very few of these updates, however, incorporate qualitative findings from women about what they desire in contraception. One study investigated women over 35’s perspectives of contraception and identified some age-specific findings. For example, women involved in the study who had not had an unplanned pregnancy after the age of 35 were more likely to use contraceptive methods that helped treat a medical condition, considered pregnancy to be dangerous, or expressed concerns about the responsibilities of motherhood. Women over 35 who did have an unplanned pregnancy were more likely to report unstable partnerships, perceived themselves at lower risk of pregnancy, or reported past experiences with unwanted contraceptive side effects.
Certainly, midlife women are not immune to the phenomenon of unintended pregnancies, nor are these pregnancies necessarily seen as a welcomed surprise when they do occur. As menopause approaches, changes in menstrual cycle length and irregular bleeding may make women believe they can no longer get pregnant. Many older women find themselves in new relationships or unable to use their preferred method of contraception when comorbidities like hypertension occur. After decades of using contraception, many women are tired of the burden of birth control. While much of the focus of contraceptive research is on adolescents and young women, ignoring the unique desires and concerns of women approaching menopause is a disservice to all women. Contraceptive researchers, product developers, marketers, and providers can all play a role in meeting the needs of women across their reproductive life span.
Product developers can help meet the needs of perimenopausal women in much the same way they meet the needs of younger women–by creating safe, effective, and affordable contraception that provides non-contraceptive benefits specifically with these women in mind. Some older women could be better served by hormonal methods that are specifically formulated to minimize the perimenopausal symptomology, including, hot flashes, mood changes, night sweats, vaginal dryness, and fatigue. The contraceptive vaginal rings, for example, has been shown to alleviate vaginal dryness and could be prescribed more frequently for older women if knowledge of this specific side effect (or side benefit) was widely known. As pills like Yaz have been tested and approved for treatment of premenstrual dysmorphic disorder, formulations could also be targeted toward the depressive symptoms that effect 45% to 68% of perimenopausal women. While both hormonal and nonhormonal long-term reversible contraception is a good option for many women, no research has been done specifically on intrauterine device (IUD) use in this age-group to identify possible areas for improvement. For example, the hormonal intrauterine system (IUS) has the potential to confer long-term contraception while also treating many perimenopausal symptoms such as irregular bleeding, which may be appealing to many midlife women.
As women approach menopause, they continue to need and desire contraception that is effective, safe, and fits into their way of life. Researchers and developers should embrace this growing age-group of women who desire effective contraception that might also provide non-contraceptive benefits and better address their evolving needs and priorities.