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FHI's Quarterly Health Bulletin Network

As Menopause Approaches, Needs Change

But contraception is still important for sexually active older women.

Network: 2002, Vol. 22, No. 1

NetworkCopyright Family Health International, 2002. 
Network is reprinted with permission from Family Health International.

Between peak childbearing years and menopause, a woman’s fertility gradually declines, reducing her risk of an unplanned pregnancy. Yet, a risk still exists.
An older couple from Pakistan. Until a woman reaches menopause, she and her partner need to use effective contraception to prevent an unplanned pregnancy if they are sexually active.

Not only is contraception important for a sexually active older woman, since pregnancy late in life presents increased risks to her health and that of her fetus, but also careful consideration should be given to providing a contraceptive method that is appropriate to the changing needs of her body. Furthermore, sexually active older women and men — just like younger individuals — may need to protect themselves against sexually transmitted infections (STIs), including HIV. Those at risk of infection should be counseled to use condoms consistently and correctly and to reduce the number of their sexual partners.

The need for contraception to prevent pregnancy ends only at menopause when menses permanently end, signaling that the ovaries are no longer producing eggs that could be fertilized. Menopause is considered to have occurred only after a woman has not menstruated for one year. However, for a period of about four years before menopause — during perimenopause — a woman’s ovaries may intermittently produce eggs, and she may become pregnant if she remains sexually active and does not use contraception. Meanwhile, about 50 percent of a woman’s reproductive life occurs between the time she has achieved her desired family size and the time she has reached menopause. During that extended period, a sexually active woman needs effective contraception.1

Patterns of contraceptive use differ throughout the world, but sexually active women older than 35 tend to be particularly likely not to use contraception. Some erroneously believe that they cannot become pregnant so late in life. Many women also abandon contraception as they approach menopause because they mistakenly believe that use of contraception — particularly hormonal methods — grows more risky with advancing age, even among healthy women.2

The consequences of abandoning contraception before menopause, however, may be serious if not life threatening. At this stage of a woman’s reproductive life, the medical risks of pregnancy to both mother and child are greatest and include pregnancy-induced hypertension, hemorrhage, increased risk of maternal death, spontaneous abortion, premature delivery, fetal abnormalities, and fetal and infant death. An unplanned pregnancy late in life can be emotionally stressful and even socially undesirable in some settings. Women older than 35 years also are particularly likely to abort unplanned pregnancies and to suffer complications and death associated with abortion.3

Selecting an appropriate contraceptive

A number of factors must be considered when helping a woman approaching menopause to select an appropriate contraceptive. Her physical condition is unique in that she may be experiencing and seeking relief from menopausal-like symptoms, or may desire protection against bone loss and various reproductive tract cancers.4 Her reproductive priorities and sexual behavior also may differ from those of a younger woman. She may be less concerned about preserving her fertility. Divorce, separation, or widowhood may have ended a stable relationship with one sexual partner, and she may now have new and even multiple sexual partners, putting her at increased risk for an STI. However, she is likely to have sex less frequently and, when she does have sex, she may anticipate the event and be better prepared to protect herself against both pregnancy and STIs. Her likelihood of becoming pregnant may be further reduced if her sexual partner is an older man.5 Recent research involving 782 healthy European couples indicates that men’s fertility begins to drop as early as age 35, resulting in delayed conception. (The study found, for example, that a 35-year-old woman with a 35-year-old partner had a 29 percent chance of getting pregnant in one month. But a 35-year-old woman with a 40-year-old partner had only an 18 percent chance of doing so.)6

Little is known about patterns of contraceptive use by older women, especially those in developing countries. But, in general, sterilization is the most common choice of older women and men. According to U.S. data from the 1995 National Survey of Family Growth, two-thirds of married 40- to 44-year-old men and women chose sterilization as a contraceptive method, compared with one-third of married 30- to 34-year-olds and 7 percent of married 20- to 24-year olds.7 In a study in New Delhi, India, of the contraceptive use and sexual behavior of 500 women — half of whom were 35 years old or older — over 40 percent of the older women had been sterilized. In this setting, where it is common to marry and then bear children early in life, many older women apparently chose to be sterilized because they considered their reproductive careers to be over. Only 1.2 percent of older women used oral contraceptives (OCs), compared with 10 percent of younger women. And while both younger and older women preferred the use of an intrauterine device (IUD) over OC use, IUD use fell markedly from 23 percent to 5 percent after the age of 35.8

Female sterilization is a safe and highly effective irreversible form of contraception for healthy older women. Moreover, a growing body of evidence — including a large, prospective cohort study — suggests that it may reduce the risk of ovarian cancer.9 "How this important protection might occur is unknown," says Dr. David Grimes, FHI vice president of biomedical affairs and author of a published editorial on the subject.10 "Altered blood supply to the ovary is one possibility. Another is that sterilization prevents importation into the abdomen of cancer-causing substances."

Nevertheless, some older women may be uncomfortable with the irreversibility of the method,11 and may more readily accept the reversible sterilization that an IUD provides. "IUDs can be safely used by healthy women of any age," note Dr. Grimes and FHI senior epidemiologist Dr. David Hubacher, who recently published a systematic review of evidence of the noncontraceptive health benefits of IUD use.12 "Inserted when a woman is 40 years old, it can remain in place through menopause and thus may be the last contraceptive a woman needs." Furthermore, case-control studies offer fair evidence that copper-bearing and nonmedicated IUDs provide the noncontraceptive health benefit of protecting against endometrial cancer.13

When the Copper-T 380A IUD was introduced as an alternative to female sterilization in Rajasthan, India, researchers observed that the IUD was preferred by older women and women who had achieved their desired family size, especially tribal women. Only 30 of 216 IUDs inserted over three years were removed. IUD use gave women the freedom to change their minds about further childbearing, while reducing their dependence on doctors and on the expensive equipment needed for female sterilization.14

Before fitting an older woman with an IUD, providers should take into account her pre-existing menstrual pattern. If she already has dysfunctional uterine bleeding, heavy bleeding, or painful menstruation, any increased menstrual blood loss or pain associated with an IUD may be unacceptable.15 Because an older woman is more likely to have a tight cervical canal than a younger woman, IUD insertion may be more difficult. "If a difficult insertion is anticipated," advises Dr. Grimes, "the woman can be given 400 µg of misoprostol, a widely available and inexpensive drug, by mouth or vagina the night before or four hours in advance of the procedure. This will dilate the cervix. A paracervical block also can make the insertion more comfortable." An IUD should be removed after menopause since it may complicate the evaluation of any postmenopausal bleeding that may occur. Menopause will be obvious because the copper IUD does not mask the end of menses.

In contrast to copper-bearing or nonmedicated IUDs, the levonorgestrel-intrauterine system (LNg-IUS) that continuously releases progestin into the uterus controls the dysfunctional menstrual bleeding that older women commonly experience. It also reduces menstrual bleeding and thus may be a good alternative to hysterectomy, which is often considered when menstrual blood loss is unacceptably heavy. Two randomized, controlled trials of the LNg-IUS as an alternative to hysterectomy showed that women offered this method were far more likely to cancel their planned hysterectomy than women assigned to continue their current, conservative medical treatments. Eighty percent and 64 percent of women in the LNg-IUS arms of the two trials canceled their surgery compared with 9 percent and 14 percent of women assigned to conservative medical treatments in the two trials.16

The LNg-IUS can protect the uterine lining, or endometrium, of older women receiving estrogen replacement therapy to control menopausal symptoms.17 And its sustained release of levonorgestrel directly into the uterus may result in fewer systemic side effects than the release of progestins via pills or implants.18

Combined hormonal methods

When used consistently and correctly, the low-dose combined oral contraceptives (COCs) available today are highly effective. So, too, are combined injectable contraceptives (CICs). Regardless of their age, women who use these contraceptive methods face very little danger of adverse cardiovascular events — including thromboembolism (blockage of a blood vessel), stroke, and heart attack — as long as they have no history of cardiovascular disease and have no risk factors for cardiovascular disease, such as hypertension, diabetes, or a habit of smoking cigarettes. (COCs are contraindicated for women 35 or older who smoke 15 cigarettes or more daily, and are not recommended for women 35 years or older who smoke even fewer cigarettes. CICs are not recommended for women 35 years or older who smoke 15 cigarettes or more daily.)19

As a woman ages, her risk of thromboembolism and hemorrhagic stroke attributable to COC use rises. However, the incidence and mortality rates of all cardiovascular events (stroke, heart attack, and venous thromboembolic disease) in women of reproductive age are very low. The annual risk of death from cardiovascular disease attributable to COCs among users who do not have risk factors for such disease is about two deaths per million users at 20 to 24 years of age, two to five deaths per million users at 30 to 34 years of age, and approximately 20 to 25 deaths per million users at 40 to 44 years of age.20

COCs provide important noncontraceptive benefits. Their use by women of any age nearly halves the risk of ovarian and endometrial cancer, with protection continuing for 10 to 15 years after discontinuation and longer duration of use offering greater protection.21 (Whether CICs offer similar protection remains unknown.) Whether COC use increases the risk of breast cancer has been the subject of two recent studies. The first, a meta-analysis, showed a small increase in risk with recent use but a significantly lower risk of metastatic disease.22 The second, a population-based, case-control study among more than 9,000 women 35 to 64 years of age, showed that current or former COC use was not associated with increased risk of breast cancer, even among women who have close relatives with the disease.23 Conducted by scientists at the U.S. Centers for Disease Control and Prevention and the National Institutes of Health, this is the largest study ever to examine the possible risks of breast cancer among COC users.

Meanwhile, numerous studies indicate that perimenopausal women who use COCs can preserve bone mineral density (in contrast to nonusers, who experience bone loss). This suggests that perimenopausal women who use COCs may enter menopause with stronger bones.24

"Another advantage of COC use is that it makes menstrual bleeding regular, like clockwork, and thus may reduce the need for invasive procedures or gynecologic surgery to diagnose or treat the irregular menstrual bleeding so common among older women," says Dr. Grimes. "While often benign, irregular bleeding in older women must be investigated to rule out the possibility of endometrial cancer."

Finally, COCs are highly effective in controlling hot flushes and other bothersome menopausal symptoms as women approach menopause. Hormone replacement therapy (HRT) can also do so at lower doses of hormones than those contained in COCs. But HRT cannot be used as a contraceptive, and growing evidence indicates that HRT’s risks must be carefully balanced against its benefits. Providers should discuss those risks and benefits with women taking HRT or those planning to do so.

Five-year data from a recent large U.S. study of the major health benefits and risks of HRT use by healthy postmenopausal women showed that use of combined estrogen/progestin HRT raised the risk of stroke by 41 percent and the risk of heart attack by 29 percent, compared with placebo.25 Other studies had indicated a short-term, increased risk of adverse cardiovascular events among postmenopausal women with established heart disease receiving combined HRT, although that risk declined over time.26

The large U.S. study — the Women’s Health Initiative — also found that combined HRT reduced the risk of colorectal cancer and hip fractures, but raised the risk of breast cancer by 26 percent. (This increased risk led to the premature termination of the part of the study comparing estrogen/progestin HRT with placebo.) Other studies have also indicated that current or recent use of HRT for five years or longer is associated with an increased risk of breast cancer.27 However, several epidemiological studies indicate that HRT users have a significantly lower risk of metastatic breast cancer than nonusers,28 and use of HRT by postmenopausal women is associated with a reduced risk of death from breast cancer, according to a recent review by FHI researchers of published observational evidence on the subject.29

A disadvantage of COC or CIC use late in a woman’s reproductive life is that prolonged use masks the onset of menopause. (A woman will continue to bleed each month as long as she uses these estrogen-containing methods.) In settings where expensive laboratory testing of fertility is not feasible or available, there are a couple of ways to ensure that menopause has occurred and that COC use can be permanently abandoned without risking an unplanned pregnancy. First, a woman can stop COC use and use a barrier method for six months. If she does not menstruate for six months, contraception can be stopped. If regular menstruation returns, she can restart the COC. After another year, she can repeat the procedure: stop COC use and use a barrier method for six months.30 Or, a healthy nonsmoker can continue COCs until age 53 or older, when permanent cessation of ovulation is nearly certain.

Progestin-only methods

Perimenopausal women for whom estrogen is contraindicated, such as smokers and women with cardiovascular risk factors, who still wish to use a hormonal contraceptive method can safely use progestin-only injectables, pills, or implants.

However, unpredictable bleeding patterns associated with such methods — ranging from normal cycles to erratic short or long cycles, nuisance spotting, and amenorrhea — may prove unacceptable for some women. In a two-year, prospective study among 60 women older than 35 years in Bangkok, Thailand, irregular bleeding due to the use of the progestin-only, three-month injectable depot-medroxyprogesterone acetate (DMPA) was the main reason why four of every five women discontinued the method.31 Because older women tend to have gynecological problems that cause menstrual bleeding irregularities, care must be taken to evaluate those irregularities before progestin-only methods are begun. Also, if frequent or prolonged bleeding develops during use, a gynecological cause must be ruled out. Because the return to regular menstrual cycles is long and unpredictable after DMPA use is discontinued, quick identification of meno-pause may be difficult.

DMPA offers the noncontraceptive health benefit of protecting against uterine fibroids32 and may protect against endometrial cancer.33 Its use has been associated with reduced bone density in premenopausal women, but bone density increases after the drug is discontinued. Residual effects of DMPA use on postmenopausal bone density are small and unlikely to have a substantial impact on fracture risk.34

For older women, levonorgestrel implants may be a better contraceptive option than progestin-only injections because they continuously release hormones in lower doses and for longer periods of time. (The six-rod Norplant implant provides safe and effective contraceptive protection for seven years;35 the two-rod Jadelle implant, for five years.36) Use of the six-rod Norplant implant among 100 women ages 35 to 47 years was found to be safe and effective in a recent, one-year prospective study in Thailand.37 "Studies of levonorgestrel implants in various countries indicate that effects on bone density, if any, are small," says Irving Sivin, a senior scientist at the New York-based Population Council who has extensively studied and helped to develop progestin-only contraceptives. "In terms of fibroids and reproductive system cancers, these implants appear neither to benefit nor harm users."

Progestin-only pills (POPs) are somewhat less effective than COCs. However, older women’s reduced fertility coupled with their better adherence to the regimen of taking a POP at the same time each day offsets this lower efficacy. Two doses of POPs (providing at least 0.75 mg levonorgestrel per dose) can also be used by older women as emergency contraception to prevent pregnancy after unprotected intercourse, method failure, or incorrect method use.

When can contraception stop?

"A woman may still have some menstrual bleeding in her late reproductive years, but many of her menstrual cycles will be anovulatory," says Dr. Grimes. "And, by the time she is in her 50s, her fertility is nearly zero." Indeed, some experts suggest that women be advised to abandon contraception at the age of 50, while others recommend waiting six to 12 months after a woman’s last menstrual cycle. Women who use hormonal methods that mask the cessation of menses should be advised to continue using the methods until age 53, Dr. Grimes adds.

But, regardless of an individual’s age, one reproductive health consideration does not change: Consistent and correct condom use remains essential for sexually active women at risk of contracting an STI, including HIV.

— Kim Best

References

  1. Forrest JD. Timing of reproductive life stages. Obstet Gynecol 1993;82(1):105-11.
  2. Agarwal N, Deka D, Takkar D. Contraceptive status and sexual behavior in women over 35 years of age in India. Adv Contracept 1999;15(3):235-44; Oddens BJ, Visser AP, Vermer HM, et al. Contraceptive use and attitudes in Great Britain. Contraception 1994;49(1):73-86; Riphagen FE, Fortney JA, Koelb S. Contraception in women over forty. J Biosoc Sci 1988;20(2):127-42.
  3. Glasier A, Gebbie A. Contraception for the older woman. Baillieres Clin Obstet Gynaecol 1996;10(1):121-38; Westhoff C. Contraception at age 35 years and older. Clin Obstet Gynecol 1998;41(4):951-57.
  4. Upton GV, Corbin A. Contraception for the transitional years of women older than 40 years of age. Clin Obstet Gynecol 1992;35(4):855-64.
  5. Ford WC, North K, Taylor H, et al. Increasing paternal age is associated with delayed conception in a large population of fertile couples: evidence for declining fecundity in older men. The ALSPAC Study Team (Avon Longitudinal Study of Pregnancy and Childhood). Hum Reprod 2000;15(8):1703-8.
  6. Dunson D, Colombo B, Baird D. Changes with age in the level and duration of fertility in the menstrual cycle. Hum Reprod 2002;17(5):1399-1403.
  7. Abma J, Chandra A, Mosher W, et al. Fertility, family planning, and women’s health: new data from the 1995 National Survey of Family Growth. National Center for Health Statistics. Vital Health Stat 1997;23(19):63. Available: http://www.cdc.gov/nchs/data/series/sr_23/sr_23019.pdf#table%2041.
  8. Agarwal.
  9. Hankinson SE, Hunter DJ, Colditz GA, et al. Tubal ligation, hysterectomy, and risk of ovarian cancer. A prospective study. JAMA 1993;270(23):2813-38.
  10. Grimes DA. Primary prevention of ovarian cancer. JAMA 1993;270(23):2855-56.
  11. Upton.
  12. Hubacher D, Grimes D. Noncontraceptive health benefits of intrauterine devices: a systemic review. Obstet Gynecol Surv 2002;57(2):120-28.
  13. Salazar-Martínez E, Lazcano-Ponce EC, González Lira-Lira G, et al. Reproductive factors of ovarian and endometrial cancer risk in a high fertility population in Mexico. Cancer Res 1999;59(15):3658-62; Sturgeon SR, Brinton LA, Berman ML, et al. Intrauterine device use and endometrial cancer risk. Int J Epidemiol 1997;26(3):496-500; Hill DA, Weiss NS, Voigt LF, et al. Endometrial cancer in relation to intra-uterine device use. Int J Cancer 1997;70(2):278-81; Rosenblatt KA, Thomas DB. Intrauterine devices and endometrial cancer. The WHO Collaborative Study of Neoplasia and Steroid Contraceptives. Contraception 1996;54(6):329-32; Parazzini F, La Vecchia C, Moroni S. Intrauterine device use and risk of endometrial cancer. Br J Cancer 1994;70(4):672-73; Castellsague X, Thompson WD, Dubrow R. Intra-uterine contraception and the risk of endometrial cancer. Int J Cancer 1993;54(6):911-16; Shu XO, Brinton LA, Zheng W, et al. A population-based case-control study of endometrial cancer in Shanghai, China. Int J Cancer 1991;49(1):38-43.
  14. Iyengar K, Iyengar S. The copper-T 380A IUD: a ten-year alternative to female sterilization in India. Reprod Health Matters 2000;8(16):125-33.
  15. Glaiser.
  16. Lahteenmaki P, Haukkamaa M, Puolakka J, et al. Open randomised study of use of levonorgestrel releasing intrauterine system as alternative to hysterectomy. BMJ 1998;316(7138):1122-26; Hurskainen R, Teperi J, Rissanen P, et al. Quality of life and cost-effectiveness of levonorgestrel-releasing intrauterine system versus hysterectomy for treatment of menorrhagia: a randomized trial. Lancet 2001;357(9252):273-77.
  17. Wollter-Svensson LO, Stadberg E, Andersson K, et al. Intrauterine administration of levonorgestrel 5 and 10 microg/24 hours in perimenopausal hormone replacement therapy. A randomized clinical study during one year. Acta Obstet Gynecol Scand 1997;76(5):449-54; Suhonen SP, Holmström T, Allonen HO, et al. Intrauterine and subdermal progestin administration in postmenopausal hormone replacement therapy. Fertil Steril 1995;63(2):336-42.
  18. Wollter-Svensson.
  19. World Health Organization. Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use, Second Edition. Geneva: World Health Organization, 2000; Schwingl PJ, Ory HW, Visness CM. Estimates of the risk of cardiovascular death attributable to low-dose oral contraceptives in the United States. Am J Obstet Gynecol 1999;180(1 Pt 1):241-49.
  20. World Health Organization. Cardiovascular Disease and Steroid Hormone Contraception: Report of a WHO Scientific Group. WHO Technical Report Series 877. Geneva: World Health Organization, 1998.
  21. World Health Organization. Oral Contraceptives and Neoplasia. Report of a WHO Scientific Committee. (Geneva: World Health Organization, 1992)16-21; Walker GR, Schlesselman JJ, Ness RB. Family history of cancer, oral contraceptive use, and ovarian cancer risk. Am J Obstet Gynecol 2002;186(1):8-14; Ness RB, Grisso JA, Klapper J, et al. Risk of ovarian cancer in relation to estrogen and progestin dose and use characteristics of oral contraceptives. Am J Epidemiol 2000;152(3):233-41.
  22. Familial breast cancer: collaborative reanalysis of individual data from 52 epidemiologic studies including 58,209 women with breast cancer and 101,986 women without the disease. Lancet 2001;358(9291):1389-99.
  23. Marchbanks PA, McDonald JA, Wilson HG, et al. Oral contraceptives and the risk of breast cancer. N Engl J Med 2002;346(26):2025-32.
  24. DeCherney A. Bone-sparing properties of oral contraceptives. Am J Obstet Gynecol 1996;174(1 Pt 1):15-20; Shargil AA. Hormone replacement therapy in perimenopausal women with a triphasic contraceptive compound: a three-year prospective study. Int J Fertil 1985;30(1):15-28; Gambacciani M, Spinetti A, Cappagli B, et al. Hormone replacement therapy in perimenopausal women with a low dose oral contraceptive preparation: effects on bone mineral density and metabolism. Maturitas 1994;19(2):125-31; Michäelsson K, Baron JA, Farahmand BY, et al. Oral-contraceptive use and risk of hip fracture: a case-control study. Lancet 1999;353(9163):1481-84.
  25. Writing Group for the Women’s Health Initiative. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA 2002;288(3):321-33.
  26. Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA 1998;280(7):605-13; Heckbert SR, Kaplan RC, Weiss NS, et al. Risk of recurrent coronary events in relation to use and recent initiation of postmenopausal hormone therapy. Arch Intern Med 2001;161(14):1709-13.
  27. Chen CL, Weiss NS, Newcomb P, et al. Hormone replacement therapy in relation to breast cancer. JAMA 2002;287(6):734-41; Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormone replacement therapy: collaborative reanalysis of data from 51 epidemiological studies for 52,705 women with breast cancer and 108,411 women without breast cancer. Lancet 1997;350(9084):1047-59.
  28. Collaborative Group on Hormonal Factors in Breast Cancer; Longnecker MP, Bernstein L, Paganini-Hill A, et al. Risk factors for in situ breast cancer. Cancer Epidemiol Biomarkers Prev 1996;5(12):961-65; Gapstur SM, Morrow M, Sellers TA. Hormone replacement therapy and risk of breast cancer with a favorable histology: results of the Iowa Women’s Health Study. JAMA 1999;281(22):2091-97.
  29. Nanda K, Bastian L, Schulz K. Hormone replacement therapy and the risk of death from breast cancer: a systematic review. Am J Obstet Gynecol 2002;186(2):325-34.
  30. Weisberg E. Contraception after age 35. IPPF Med Bull 2001;35(6):2-3.
  31. Taneepanichskul S, Reinprayoon D, Phaosavadi S. DMPA use above the age of 35 in Thai women. Contraception 2000;61(4):281-82.
  32. Lumbiganon P, Rugpao S, Phandhu-fung S, et al. Protective effect of depot-medroxy-progesterone acetate on surgically treated uterine leiomyomas: a multicentre case-control study. Br J Obstet Gynaecol 1996;103(9):909-14.
  33. WHO Collaborative Study of Neoplasia and Steroid Contraceptives. Depot-medroxyprogesterone acetate (DMPA) and risk of endometrial cancer. Int J Cancer 1991;49(2):186-90.
  34. Orr-Walker BJ, Evans MC, Ames RW, et al. The effect of past use of the injectable contraceptive depot medroxyprogesterone acetate on bone mineral density in normal post-menopausal women. Clin Endocrinol 1998;49(5):615-18; Merki-Feld GS, Neff M, Keller PJ. A prospective study on the effects of depot medroxyprogesterone acetate on trabecular and cortical bone after attainment of peak bone mass. Br J Obstet Gynaecol 2000;107(7):863-69.
  35. Sivin I, Mishell DR, Diaz S, et al. Prolonged effectiveness of Norplant® capsule implants: a 7-year study. Contraception 2000;61(3):187-94.
  36. Sivin I, Moo-Young A. Recent developments in contraceptive implants at the Population Council. Contraception 2002;65(1):113-19.
  37. Taneepanichskul S, Intharasakda P. Efficacy and side effects of Norplant use in Thai women above the age of 35 years. Contraception 2001;64(5):305-7.
Contraceptive Considerations for Older Women
Click on the image to see a larger version.

 

The Benefit of Experience

Older women tend to have more contraceptive experience than do younger women. As a result, they may more responsibly use and maximize the effectiveness of periodic abstinence and barrier methods. Their lower fertility and generally reduced frequency of sexual intercourse also may offset the lower effectiveness of these methods.

However, in an older woman whose menses have become irregular, the effectiveness of periodic abstinence may decrease if it is based only on a calendar approach or on signs of fertility. Measurements of basal body temperature or cervical mucus can increase effectiveness in such cases, although the number of permissible days for intercourse may be further limited using these approaches.1

The relatively high failure rate of condoms and such methods as diaphragms, cervical caps, and spermicides decreases as fertility declines with age. If an older woman’s vaginal walls sag, securely fitting and retaining a diaphragm may be difficult. A cervical cap that fits directly onto the cervix may be a better option. Vaginal dryness, often a problem for older women, can be relieved by the use of lubricating spermicidal preparations that are recommended for use with these methods.2

— Kim Best

References
  1. Westhoff C. Contraception at age 35 years and older. Clin Obstet Gynecol 1998;41(4):951-57.
  2. Glasier A, Gebbie A. Contraception for the older woman. Baillieres Clin Obstet Gynaecol 1996;10(1):121-38.

 

HIV/AIDS Does Not Spare Older People

A common perception is that AIDS afflicts only young people. In HIV/AIDS prevention campaigns, wrinkled faces are seldom featured. Global reporting of HIV/AIDS prevalence tends to refer only to children and individuals of reproductive age (ages 15 to 49 years), as if persons 50 years and older could not be infected with HIV or develop AIDS.1 Many older people themselves believe their risk of HIV infection is low.2 Often unfamiliar with methods to prevent sexually transmitted infections (STIs), including HIV, and no longer needing contraception, they are unlikely to use condoms consistently during sex for either pregnancy or disease prevention.3

Furthermore, believing themselves to be at low risk of HIV/AIDS, many older people do not seek testing for HIV infection.4 If they become sick with AIDS, they may dismiss their symptoms as part of the aging process. Not receiving or delaying diagnosis and treatment of AIDS decreases the likelihood of survival. In fact, older people often do not survive as long as younger people because of delays in diagnosis and treatment5 and because age appears to accelerate the progress of HIV infection to AIDS.6

Despite the impression that AIDS is a younger person’s disease, older people are not spared. Older, sexually active men and women at risk of infection should adopt safe sexual behaviors, such as using condoms correctly and consistently.

In the United States, about 11 percent of AIDS cases occur among people ages 50 years and older, with that number reaching 15 percent in some parts of the country. Heterosexual sex is increasingly a source of these infections.7 Trends are similar in other developed countries. In Western Europe, about 10 percent of new HIV infections reported between January 1997 and June 2000 were among people older than 50 years.8

"The share of total AIDS cases among people ages 50 years and older in developing countries is generally lower than that in developed countries, probably because there are relatively fewer older people in these populations," notes Dr. John Knodel, a professor at the University of Michigan’s Population Studies Center and principal author of a recent report about the global impact of AIDS on persons 50 years or older.9 "The percentages of cases occurring in men or women ages 50 years or older are approximately 5 percent in Asia, 6 percent in Africa, and 7 percent in Latin America. In Africa and Asia, where heterosexual intercourse is the main mode of HIV transmission, older men tend to have higher rates of HIV infection than older women. This likely reflects the fact that sexual relations typically occur between couples in which the man is older than the woman."

In view of these statistics, reproductive health care providers should keep in mind that:

  • Many older people are sexually active. A 1999 survey by the U.S.-based American Association of Retired Persons (AARP) of a nationally representative sample of 1,384 people 45 years and older found that approximately two-thirds of men and women ages 45 to 59 years who had sexual partners said they had sexual intercourse at least once a week. (Over a quarter of those 75 years and older reported doing so.)10 And a study of sexual activity among persons ages 50 years and older in Thailand, based on a large nationally representative survey conducted in 1995, found that substantial proportions of older married Thais remain sexually active, although at lower levels than older persons in Western countries.11
Older Persons as Percentages of AIDS Cases
Click on the image to see a larger version.

  • If older clients are sexually active, they may be at risk for HIV. Many persons diagnosed with AIDS at 50 years or older were probably infected as younger adults, but many infections are newly acquired — often through heterosexual sex. (Specific risks associated with heterosexual sex include unprotected sex, multiple sexual partners, and infection with other STIs.) That older persons often face these risks was demonstrated in a six-year, retrospective study of 239 new patients, 60 years and older, receiving genitourinary medical care at a hospital in the United Kingdom. Over half (121) of the 239 patients were single, divorced, separated, or widow/widowers. They were "on their own," the researchers noted, "resulting in sex with casual partners and even with prostitutes. On the other hand, protective sex was performed by only a minority of this group, probably because they link protection with contraception only."12

  • Discussing sexuality or asking questions about sexual activity may be appropriate with aging clients. Older people are less likely than younger people to talk about such matters with a doctor, and doctors tend not to ask their older patients about sexual behavior.13

  • Providers should be prepared to discuss HIV/AIDS, its risk factors, and safe sex practices with older people. Older people, in both developed and developing world settings, often know less than younger people about HIV/AIDS.14

  • Counseling older, sexually active, at-risk clients to use condoms is important. A 1994 U.S. study, based on data from two large cross-sectional national surveys, found that at-risk persons 50 years or older were one-sixth as likely to use condoms during sex as at-risk persons in their 20s.15 Another U.S. study conducted in 12 state and local health department clinics among 556 women with AIDS attributed to heterosexual contact (11 percent of whom were 50 years or older) showed that older women were less likely than younger women to have used a condom before their HIV diagnosis.16

  • Physical changes associated with menopause (such as a decrease in vaginal lubrication, vaginal shortening and narrowing, and thinning of vaginal walls) can increase a woman’s risk of STI/HIV infection if she has unprotected sexual intercourse.

  • Suggesting that an older, at-risk client be tested for HIV infection, particularly if that person reports feeling sick, may be appropriate. A study in New York City among 78 HIV-infected men and women ages 50 years and older indicated that asymptomatic individuals often waited to get HIV testing or medical care, even if they knew they were at risk for the infection. Even those with symptoms often delayed seeking HIV testing or medical care, attributing those symptoms to other illnesses, normal aging, or menopause.17

Meanwhile, many health care providers are not well aware of older persons’ risk for HIV infection18 and may be less likely to suspect it among older clients than among younger ones. About two-thirds of 330 U.S. primary-care physicians surveyed in 1996 reported that they rarely or never discussed HIV/AIDS or HIV infection risk reduction with patients older than 50 years. They were also less likely to counsel older patients to seek HIV testing than younger patients.19 This failure to consider the possibility of HIV infection among older persons is due in part to the fact that AIDS-related opportunistic infections that commonly occur among persons ages 50 years or older (HIV encephalopathy and wasting syndrome) often have symptoms similar to those of other diseases associated with aging (Alzheimer’s disease, depression, and cancer).20 These symptoms include memory problems, fatigue, and weight loss. Health professionals also may make the mistake of assuming that night sweats and depression are only symptoms of menopause, when they may be symptoms of AIDS. Such confusion often results in older people with AIDS not having their disease diagnosed.21

  • Postponing testing and treatment increases the chance that HIV-infected people will transmit the virus and may result in life-threatening delays in treatment, if available. The length of time between HIV infection and the development of AIDS — as well as total survival time — is shorter among HIV-infected older people.22 As of 1996 in the United States, persons 50 years and older with AIDS were twice as likely as younger persons to die within a month of their diagnoses.23 In a 1998 U.S. study of 321 AIDS patients ages 60 years and older and 7,511 AIDS patients 20 to 39 years old, older patients’ median life span from time of diagnosis was nine months compared to 22 months for younger patients.24
Sexual Activity among Married Older Thais
Click on the image to see a larger version.

  • Even when antiretroviral drugs are available, an older person with HIV/AIDS is more difficult to treat than a younger person. Older individuals are more likely than the young to have chronic medical problems — such as high blood pressure, diabetes, peripheral vascular disease, and coronary artery disease — and the drugs they take for these conditions may adversely interact with drugs used to control HIV/AIDS. However, a recent U.S. study among 101 patients ages 50 and older and 202 patients ages 18 to 39 years, all of whom received antiretroviral therapy from 1993 through 1999, found that older patients were more likely than younger patients to achieve blood levels of HIV below detectable limits, perhaps because they were less likely to stop taking their medications.25

— Kim Best

References
  1. Joint United Nations Programme on HIV/AIDS. Report on the Global HIV/AIDS Epidemic, June 2000. Geneva: UNAIDS, 2000; Joint United Nations Programme on HIV/AIDS, World Health Organization. AIDS Epidemic Update: December 2000. Geneva: UNAIDS and WHO, 2000.
  2. Rose MA. Knowledge of human immunodeficiency virus and acquired immunodeficiency syndrome, perception of risk, and behaviors among older adults. Holist Nurs Pract 1995;10(1);10-17.
  3. Gordon SM, Thompson S. The changing epidemiology of HIV in older persons. J Am Geriatr Soc 1995;43(1):7-9.
  4. National Institute on Aging. AgePage. HIV, AIDS, and Older People. 1999. Available: http://www.nia.nih.gov/health/agepages/aids.htm; U.S. Centers for Disease Control and Prevention. AIDS among persons aged >50 years. United States, 1991-1996. MMWR 1998;47(2):21-27. Also available: http://www.cdc.gov/mmwr/preview/mmwrhtml/00050856.htm.
  5. U.S. Centers for Disease Control and Prevention.
  6. Skiest DJ, Rubinstein E, Carley N, et al. The importance of comorbidity in HIV-infected patients over 55: a retrospective case-control study. Am J Med 1996;101(6):605-11; Adler WH, Baskar PV, Chrest FJ, et al. HIV infection and aging: mechanisms to explain the accelerated rate of progression in the older patient. Mech Ageing Dev 1997;96(1-3):137-55; Phillips AN, Lee CA, Elford J, et al. More rapid progression to AIDS in older HIV-infected people: the role of CD4 T-cell counts. J Acquir Immun Deficien Syndr 1991;4(10):970-75.
  7. U.S. Centers for Disease Control and Prevention.
  8. Joint United Nations Programme on HIV/AIDS. Impact of HIV/AIDS on Older Populations. Geneva: UNAIDS, 2002. Available: http://www.unaids.org 
  9. Knodel J, Watkins S, VanLandingham M. AIDS and Older Persons: An International Perspective. PSC Research Report No. 02-495. Ann Arbor, MI: Population Studies Center, 2002.
  10. American Association of Retired Persons. Modern Maturity Sexuality Survey: Summary of Findings. Washington: AARP, 1999. Available: http://www.research.aarp.org/health/mmsexsurvey_1.html.
  11. Knodel J, Chayovan N. Sexual activity among the older population in Thailand: evidence from a nationally representative survey. J Cross-Cult Gerontol 2000;16(2):173-200.
  12. Jaleel H, Allan PS, Wade AA. Sexually transmitted infections in elderly people. Sex Transm Infect 1999;75(6):449.
  13. LeBlanc AJ. Examining HIV-related knowledge among adults in the U.S. J Health Soc Behav 1993;34(March):23-36; National Institute on Aging.
  14. National Institute on Aging; Im-em Wassana, VanLandingham M, Knodel J, et al. Knowledge and Attitudes of Older People about HIV/AIDS in Thailand: A Comparison with Young Adults. PSC Research Report No. 01-464. Ann Arbor, MI: Population Studies Center, 2000.
  15. Stall R, Catania J. AIDS risk behaviors among later middle-aged and elderly Americans: the National AIDS Behavioral Surveys. Arch Intern Med 1994;154(1):57-63.
  16. Schable B, Chu SY, Diaz T. Characteristics of women 50 years of age or older with heterosexually acquired AIDS. Am J Public Health 1996;86(11):1616-68.
  17. Siegel K, Schrimshaw E, Dean L. Symptom interpretation: implications for delay in HIV testing and care among HIV-infected late middle-aged and older adults. AIDS Care 1999;11(5):525-35.
  18. High KP. AIDS: a disease of the young? Infect Med 1998;15(12):832, 835.
  19. Skiest DJ, Keiser P. Human immuno-deficiency virus infection in patients older than 50 years: a survey of primary care physicians’ beliefs, practices, and knowledge. Arch Fam Med 1997;6(3):89-94.
  20. U.S. Centers for Disease Control and Prevention.
  21. Johnson M, Haight BK, Benedict S. AIDS in older people: a literature review for clinical nursing research and practice. J Gerontol Nurs 1998;24(4):8-13.
  22. Skiest, 1996; Adler; Phillips.
  23. U.S. Centers for Disease Control and Prevention.
  24. Chen HX, Ryan PA, Ferguson RP, et al. Characteristics of acquired immunodeficiency syndrome in older adults. J Am Geriatr Soc 1998;46(2):153-56.
  25. Wellons MF, Sanders L, Edwards LJ, et al. HIV infection: treatment outcomes in older and younger adults. J Am Geriatr Soc 2002;50(4):603-7.

 

‘No One Thinks Older Persons Are at Risk’

"I learned the hard way that you do not have to be young to be become infected with HIV," says 67-year-old Jane Fowler.

More than 10 years ago, at the age of 55, the retired career journalist from Kansas City, Missouri, USA, found out that she was HIV-positive. Although her diagnosis was devastating, she feels lucky to have learned of her HIV status when she was still healthy. "Often, HIV infection is not diagnosed in older people until an AIDS-defining illness develops," she says. "That’s largely because no one thinks older persons are at risk."

Fowler, herself, did not think she was at risk. She had been married to one man for over two decades before divorcing in 1983. Three years later, at the age of 50, she had unprotected sex with a friend she had known her entire adult life. She never considering using a condom because "condoms for people of my generation were for birth control and I had had in my 40s a surgical procedure to prevent pregnancy."

"You think there is no need to be concerned about unprotected sex. But you must be concerned, because no one ever knows anyone else’s true sexual history."

Also, Fowler never expected her friend to be infected. She believed she knew him well, and she trusted him. "Older people often think that HIV won’t happen to them," she says. "Also, you may think you know a person well . . . perhaps he has the same background, the same education, and so on. He may seem healthy. So you think there is no need to be concerned about unprotected sex. But you must always be concerned, because no one ever knows anyone else’s true sexual history."

Fowler was diagnosed with HIV at a time when antiretroviral drugs had become available and her use of those drugs has helped prevent her infection from developing into AIDS. "I am blessed," she says. Yet, during the first years after her diagnosis, "I withdrew and lived quietly. I withdrew because I lacked the courage to face possible discrimination, rejection, intolerance," she says. During this period, Fowler shared what was happening to her with her family and a small group of friends whom she could trust.

Such a reaction, especially among older HIV-infected persons, is not unusual. "Not only does one experience the stigma of aging, but there is the stigma of having a disease caused by drug use or sex," Fowler says. "I did not use drugs and I lived a conventional lifestyle. I was not promiscuous. But if you are HIV-positive, people tend to think you have been promiscuous and, worse, cannot understand how an older person could be sexually active, let alone promiscuous."

Despite the stigma associated with her infection, Fowler ultimately concluded that her self-imposed semi-isolation was a mistake. "I decided to publicly acknowledge my predicament and bring a prevention message to noninfected people, particularly those my own age," she says. "Suddenly, I became determined to make a difference. I decided to stand up and say: ‘Look at this wrinkled face. This is another face of HIV.’"

In the spring of 1995, Fowler became what she calls an "HIV/AIDS activist." She has now given about 500 speeches to audiences of all ages and helped found the National Association on HIV Over Fifty, for which she served as board cochairperson for five years. She now directs the national HIV Wisdom for Older Women program (Web site: http://www.hivwisdom.org) based in Kansas City, and is actively involved in numerous other HIV/AIDS-related organizations.

Among the many messages she shares is the need "to dispel the myth among health care providers that older people are not sexually active and are not engaging in behaviors that put them at risk for HIV. I have spoken to numerous acquaintances and none have had their sexual history taken by their health care providers. An older person’s sexual behavior is not something that providers want to talk about."

That is not surprising. "Imagine a health care provider in his or her late 30s or 40s sitting across the desk from a woman 60 or 65 years old," Fowler says. "It’s like talking to ‘Mom’ about sex. That’s uncomfortable, and so it is not often done. Also, in some cultural contexts, providers who are younger than their clients would never ask such questions, out of honest respect for their elders."

Older HIV-infected persons often sink into depression and isolation because "they are probably not as good at participating in support groups as younger people," Fowler says. "And, because of the stigma of the disease, many older women may not be able to tell members of their families."

Fowler says she is fortunate that her 38-year-old son, with whom she was always candid about sex, "was and remains my best support. Without his support and that of his fiancée, I could not do what I am doing these days." The drugs Fowler once took restricted her life, but her current drug regimen is simple and interferes little with her activities. "With each year, I become busier, going wherever I am invited — crisscrossing the country, even traveling abroad," she says.

Meanwhile, Fowler is encouraged that many other older people will avoid her fate. "Many people in their 50s who are in new relationships are now demanding that their partners be tested for HIV infection before beginning a sexual relationship," she says. "And my advice is to always talk about protected sex before you are in the heat of passion. If your partner refuses to use protection, find another partner. Having unprotected sex — even with someone you think you know well — is not worth risking your life."

— Kim Best

 

The Many Meanings of Menopause
 

To best serve women approaching menopause, providers need to identify and keep in mind various values, beliefs, and practices associated with the end of a woman’s reproductive life.

In some cultural settings, menopause brings women unprecedented freedom and even power. Yet, in others, it is associated with loss, poor health, and lowered self-esteem. Where menstrual bleeding is highly valued as a sign of health and youth, menopausal women may welcome even abnormal bleeding as a sign of continued fertility and thus fail to seek necessary medical care.

For many women who have had little access to contraception and have been unable to control their fertility, menopause is a welcome end to the fear of unplanned pregnancy. For the first time, they may actually enjoy sexual intercourse.

Women in some settings may also find that menopause confers special privileges.1 For example, various tribes in the northwestern parts of Cameroon believe that women become wise when menstruation ends and thereafter can rise in social stature and even assume leadership positions.2 In Nigeria, postmenopausal women often are given more power both within and outside of the home.3 Among the Hausas of northern Nigeria, menopausal women even win physical freedom, being released from confinement (a practice imposed when they are married) when menstruation ceases. However, menopause also can strip women of their identity and bring sexual prohibitions. Among the Hausas, postmenopausal individuals are no longer considered to be women and are denied the right to have sexual intercourse.4

For childless women in many settings, menopause signals a loss of hope for motherhood and can result in depression. Even women who have children may suffer a drop in self-esteem in response to the loss of reproductive capacity. The importance of maintaining the appearance of continuing fertility is such that many menopausal women from Côte d’Ivoire adopt hormonal contraception to induce monthly bleeding.5

Commonly, women report ambivalence about menopause. In a 1997 survey conducted by FHI in El Alto and La Paz, Bolivia, among 816 menopausal and postmenopausal women ages 45 and older (from the original nationally representative sample for the 1993-1994 Demographic and Health Survey), most women described either positive or neutral feelings about menopause. They were relieved not to be menstruating and not to be at risk of an unplanned pregnancy. However, about a third of the women reported negative feelings, primarily due to fears of aging and of related health problems. And, when the 83 menopausal women in the survey were asked what they considered to be appropriate sexual activity for women who had gone through menopause, about two-thirds said that they thought they should have sex less frequently or not at all. A third reported that their relationships with their partners had deteriorated since menopause.6

Three-quarters of 456 women ages 45 to 60 years queried in a population-based survey, based on the 1991 Demographic Census of the Brazilian Institute of Geography and Statistics, reported a lack of sexual desire. A third of the sample reported sexual abstinence, although the main reason for forgoing sexual relations was lack of a sexual partner or a medical problem afflicting their regular sexual partner. Among the older women, maintenance of sexual activity was associated with greater earning power, being in a stable relationship (especially marriage), and current use of hormone replacement therapy. Also, better-educated women reported greater enjoyment of sex.7

In settings where menstruation is seen as a cleansing process and evidence of a healthy uterus, its absence may be viewed as a sign of poor health.8 As a result, older women who experience bleeding or develop abdominal masses due to cancer may welcome these events as signs of continued fertility or pregnancy and thus fail to seek medical care. Cancers of the reproductive tract — including cervical, endometrial, and ovarian tumors — usually occur between 35 and 65 years of age and, because they are often reported and diagnosed late in the developing world, kill many women there. For this reason, it is imperative that health care providers educate older women about normal changes related to menopause and encourage early reporting and evaluation of abnormal changes.9

— Kim Best

References
  1. Zurayk H, Sholkamy H, Younis N, et al. Women’s health problems in the Arab World: a holistic policy perspective. Int J Gynaecol Obstet 1997;58(1):13-21.
  2. The Cameroon Medical Women Association. Traditional Practices Affecting the Reproductive Health of Women in Cameroon. Nairobi: African Medical and Research Foundation (AMREF), 1995.
  3. Osakue G, Martin-Hilber A. Women’s sexuality and fertility in Nigeria. In Petchesky R, Judd K, eds. Negotiating Reproductive Rights: Women’s Perspectives across Countries and Cultures. Atlantic Highlands, NJ: Zed Books, 1998.
  4. Johnson BC. Traditional practices affecting the health of women in Nigeria. In Baasher T, Bannersman RH, Rushwan H, et al., eds. Traditional Practices Affecting the Health of Women and Children. Alexandria, Egypt: World Health Organization, 1982.
  5. Wambua LT. African perceptions and myths about menopause. East Afr Med J 1997;74(10):645-46.
  6. Bailey P, Najera T, Trottier D. Menopause in Bolivia: perceptions and experiences of women in El Alto and La Paz. The Second International Interdisciplinary Conference on Women and Health. Edinburgh, July 12-14, 1999.
  7. Tadini V, Pinto-Neto AM, Pedro AO, et al. Sexualidade no climatério. Reproducão & Climatério 2001;16(suppl 1):104-5.
  8. Snowden R, Christian B, eds. Patterns and Perceptions of Menstruation, a World Health Organization International Collaborative Study in Egypt, India, Indonesia, Jamaica, Mexico, Pakistan, Philippines, Republic of Korea, United Kingdom and Yugoslavia. New York: Croom Helm, Long and Canberra, and St. Martin’s Press, 1983; Scott CS. The relationship between beliefs about the menstrual cycle and choice of fertility regulating methods within five ethnic groups. Int J Gynaecol Obstet 1975;13(3):105-9.
  9. Wambua.

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