Pregnancy after 40

  • Health
  • Wednesday, 10 May 2006

AS LONG AS a woman has a menstrual period, there is the possibility of pregnancy although the chances are increasingly remote as one approaches the menopause. Even if a woman has perimenopausal symptoms, it does not mean that she cannot get pregnant. About 75% of pregnancies in women above the age of 40 years are unplanned.  

A woman is considered to have reached the menopause if she has not had a period for 12 consecutive months. This is a retrospective diagnosis. The average age of the menopause is 50-51 years. It is generally thought that contraception 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 of age. 

Hormone replacement therapy (HRT) does not provide contraception as it does not suppress ovulation. Many women commence HRT before they reach the menopause. It is difficult to know when the menopause occurs and how long contraception is needed. Stopping the HRT medication for six to eight weeks and then checking the blood hormone levels can confirm the menopause. 

Some women use a fertility awareness method by abstaining from sexual intercourse at certain times in the menstrual cycle. This method cannot be depended upon if the menstrual cycle is the least bit irregular; irregular cycles are common during the perimenopause. 

There are various birth control options (contraception) available. The doctor can help a couple choose an appropriate method depending on the medical history, sexual habits, lifestyle and preferences. The methods are described below: 

  • Oral contraceptives containing one hormone (progestogen) or two hormones (estrogen and progestogen) provide effective birth control. Fertility is restored rapidly on discontinuation of the Pill. The use of the Pill may make it difficult to know when the menopause is reached. Most doctors advised that the Pill be stopped at 50-51 years, which is the average age of the menopause. 

  • The low dose combined Pill (COC) is safe and effective for perimenopausal women who are non-smokers. The progestogen-only Pill is preferred for women at risk of blood clots. However, it is less effective than the combined Pill in preventing pregnancy.  

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

    The benefits of the Pill include a reduced risk of endometrial and breast cancer, less fibrocystic disease of the breast changes, 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 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 are few and may include nausea, bleeding between periods, breast tenderness, fluid retention and new or worsening headaches. 

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

    An IUCD cannot be inserted in pregnancy, suspected pregnancy, those who have a history of pelvic inflammatory disease, sexually transmitted infections, 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. 

  • Depot contraceptives contain a progestogen. A single injection in the buttocks provide effective birth control 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. 

  • Barrier methods, which include the male and female condom, diaphragm, cervical caps and spermicides, must be used during every act of sexual intercourse for it to be effective.  

    The condom is the only effective method that prevents pregnancy and protects against sexually transmitted infections. Condoms can be used in combination with other birth control methods. The condom may leak, spill when being removed or even break. 

  • Progestogen implant system contains six releasing capsules, each about the size of a match, that are inserted under the skin of the inner aspect of the upper arm by making a small incision. The method 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. 

  • Sterilisation includes vasectomy for men and tubal ligation for women. The methods are safe and have a very low failure rate of about 5 per 1,000. As they are surgical procedures, they are to be considered only as a permanent method. 

  • Emergency contraception 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.  

    There is no perfect contraceptive method. All methods have a failure rate.  

    However, the methods with no user failure are progestogen injections and implants, intra-uterine contraceptive device and sterilisation.  



  • Dr Milton Lum is chairperson of the Commonwealth Medical Trust. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. 

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