Does the pill make sense when you are 35+?
It wasn’t all that long ago that doctors used to discourage all women – regardless of their health or lifestyle – to go off of the birth control pill once they were 35 or older. However, times have changed. Not only have birth control pills, themselves, become safer (they contain much lower doses of hormones than they used to, minimizing the risk of cardiovascular events); the science now tells us that, for healthy, nonsmoking women who are older than 35, the mortality risk associated with pill use differs little from the risk to much younger women.
Although doctors continue to recommend that women 35 and older use a pill with the lowest hormone dosage possible, it is now understood that most commercially available birth control pills can be safely used by healthy, nonsmoking women until menopause (which is typically assumed at age 55).
Given the relaxing of restrictions that used to prevent women in their midlife from using hormonal forms of contraception, a growing number of women in their mid-30s, 40s, and 50s are finding themselves on the birth control pill. For some women, this reflects their first foray into the word of hormonal contraceptives. However, for many others, this is simply a matter of habit. They were on the pill throughout their teens, twenties, and thirties (with some taking breaks to have children). Now, they’re continuing to use it because their doctor never told them that it was time to stop or consider alternatives. This has led many women to begin wondering to themselves about whether using the pill for so long is safe and what it might be like for them once they eventually go off of it.
First, let’s talk about the benefits of midlife pill use. And there are quite a few of them. The big one is, of course, pregnancy prevention. Although the idea of a pregnancy scare can feel almost absurd to women in their 40s, unplanned pregnancies are not altogether uncommon in this age group. The reason for this is that a lot of women in this age group feel totally invulnerable to their own fertility. Somehow, the idea of getting pregnant at a time we are confronted with nearly daily reminders of our aging seems too cruel to be possible. Unfortunately, it’s not. Although women’s fertility declines as they approach middle-age, pregnancy is still possible. And the risk of complications from pregnancy and childbirth increase as women get older, women in their 40s can have a lot more to lose when it comes to unexpected pregnancies than women in their 20s. So, the pill’s pregnancy prevention effects are a huge benefit to women in midlife who are hoping to avoid the complications of an unwanted pregnancy at a time in their lives when the risks of such a pregnancy are particularly high.
There are also other perks that come from being on the pill during midlife. For example, many women find that pill use can help relieve some of the symptoms associated with perimenopause, such as cycle irregularity and hot flashes. Combination pills containing both estrogen and progestin seem to offer women the greatest symptom relief. These symptoms occur because of hormonal imbalances that can occur across the cycle as women age. The pill – because it keeps women’s own levels of sex hormones low and replaces them with a consistent daily dose of synthetic hormones – can help manage these symptoms. Although the pill does not address the cause of these symptoms (it does not address any of the underlying issues that create the hormonal imbalances at the root of these symptoms), it can provide women relief from them.
The pill has also been found to offer symptom relief to women who experience severe PMS or PMDD (premenstrual dysphoric disorder – a more serious form of PMS). PMS and PMDD symptoms – which manifest themselves as a combination of physical and psychological effects, such as mood changes, irritability, and physical discomfort – are believed to be caused by abnormal physiological responses to changing levels of hormones across the cycle. By ironing out the hormonal fluctuations that occur across the cycle and lifespan, the pill can take the edge off PMS for women whose brains and bodies don’t respond well to hormonal ups and downs. This is particularly true of brands that use the same dose of hormones throughout the cycle (monophasic treatments) or those that keep you on a steady dose of hormones for three months before you have your week of placebo pills.
Estrogen containing pills are also known to reduce women’s risk of endometrial and ovarian cancer, and may even offer some protection against colon cancer.
Now, for the drawbacks. Although research consensus tells us that midlife pill use is perfectly safe for most healthy, nonsmoking women 35 and older, it’s not for everyone. It can still be associated with an increased risk of serious cardiovascular events (like strokes and heart attacks) in women who smoke, are obese, or have a personal health history that is known be associated with an increased risk of cardiovascular events (e.g., migraine with aura or diabetes). It is generally recommended that these higher-risk women avoid estrogen containing products, since estrogen use is linked with an increased risk of cardiovascular events; however, progestin only formulation can often be safely. You will need to talk with your doctor about whether it makes sense for you, given your unique personal and health history.
It’s also worth noting that we don’t yet know a whole lot about what it means for women to be on a more-or-less steady dose of hormonal contraceptives for decades at a time.
How does this change women’s bodies? And brains?
There is a growing body of research in psychology and neuroscience that finds that the birth control pill can number of effects of the activities of the brain. For example, research indicates that the pill can influence the psychological processes involved in sexual attraction and partner preferences, the desire for sex, the nature of the stress response, learning and memory, mood, suicide risk, and learning and memory.
Accordingly, women of all ages on the birth control pill will want to keep track of how they are feeling, psychologically, as well as physically to determine whether the birth control pill is the right choice for them. Keeping a journal of your physical, as well as psychological, symptoms before and after starting hormonal contraception can be a useful tool to help determine whether birth control pill use is right for you.
Although birth control use is a safe and effective means of regulating fertility for healthy women 35 and over, it is important to understand that there are questions that still remain. For example, we don’t know whether women 35 and over need the same doses of hormones needed by younger women to regulate fertility. We also don’t know what doses of estrogens and progestins are least likely to cause cardiovascular or metabolic issues, which tend to be of greater concern to women 35 and over.
Women in midlife need to be proactive about regulating their fertility up until they have stopped having menstrual cycles for two years or reach age 55, when natural sterility is assumed. If you are a healthy non-smoking woman, the birth control pill can be part of this strategy until birth control is no longer needed.
Written by Dr. Sarah E. Hill
Psychologist at the forefront of research on women, health, and sexual psychology.