April 4, 2008

Greater Birth Control Options Available For Women

Birth control options for women over 40 are now wider than ever, with improvements in medical technology making the pill, the IUD and even a nonsurgical method of tube-tying viable alternatives for those whose options were previously limited to condoms and surgical tube-tying.  

Experts say this variety of methods has long been needed, as women in their 40s and 50s are a complex group. Many have had several children and are willing to have sterilization surgery, while others may want to keep their options open for having children in the future.

Women in this age group are the least likely to use birth control, and along with adolescents have the highest abortion rates.  

Dr. Vanessa Cullins, vice president for medical affairs of the Planned Parenthood Federation of America, said that when it comes to contraceptives for women 40 and older, "one size definitely does not fit all".

Dr. Andrew Kaunitz, a gynecologist with the University of Florida, recently authored a report after reviewing the current science of contraception for women over 40. He wrote that the risk of serious blood clots rises sharply at age 40 for women who take birth control pills containing estrogen, and is even greater for overweight women, who more often have high blood pressure and diabetes.

But as a result of the dramatic reduction in the dosage of estrogen in current birth control pills, it is now considered a safe alternative for lean, healthy, older women, according to Kaunitz and other experts.

"It may not be well known that the current low-dose formulations are a reasonable option for healthy women in their 40s," Dr. JoAnn Manson, a Harvard endocrinologist who authored a book on menopausal hormone therapy, told the Associated Press.

Kaunitz said the pill may be preferable for some women, since it can help control irregular menstrual bleeding and hot flashes and has also been shown to reduce hip fractures and ovarian cancer. But experts say middle-aged women who smoke, have migraines, are obese or have certain other risk factors should continue to be steered toward IUDs or progestin-only treatments like "mini-pills."

Although higher breast cancer rates have been reported in older women who took estrogen-progestin pills for menopause, the studies failed to find an increased breast cancer risk in women 35 and older who took oral contraceptives.

Sterilization, which includes both tubal ligations (tube-tying) and vasectomies in male partners, continues to be the most common form of contraception for women over 40.   

Gynecologists are increasingly performing a new type of tubal ligation that is nonsurgical. Approved in 2002, the new procedure, called Essure, uses a thin tube to thread small devices into each fallopian tube, causing scarring that after three months plugs the tubes and keeps eggs from the ovaries from reaching the uterus. The traditional tubal ligation procedure cut through the abdomen to sever and tie the fallopian tubes.  

Another relatively new product is Implanon, in which a matchstick-sized plastic rod is placed under the skin of the upper arm. Approved in 2006, the product lasts about three years, and can be seen as an updated cousin of Norplant.

"Things have definitely changed. There are a lot more options for older women than there used to be," Dr. Erika Banks, director of gynecology at New York City's Montefiore Medical Center, told the Associated Press.

Lisa Riley, a 44-year-old who works in Banks' medical practice, recently got a new IUD. She said choosing the right contraception can be a bit of an odyssey.

She took the pill when she was younger, but discontinued its use to have kids - twins - in 1993. She was wary about returning to the pill because of worries about a possible cancer risk. She and her husband used condoms for about a year, but he got tired of that, Riley said.  She had friends on IUDs and chose that option instead, which worked well for several years until it began to cause heavy menstrual bleeding. She then chose Mirena, a version that releases hormones for about five years, after Banks advised her to get a new one.    

For now, Riley doesn't plan any more children, but wasn't ready for sterilization.

"It's too permanent for me," she said.

Dr. Kaunitz's  review of the current science of contraception and women 40 and older was published recently in the New England Journal of Medicine. An extract of the report can be viewed at http://content.nejm.org/cgi/content/extract/358/12/1262. Kaunitz has received fees or grants from several companies that make oral contraceptives.


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