A woman's fertility declines with age. Women trying to conceive in their twenties have an 80-90% chance of becoming pregnant within a year. After the age of 50, women who have not had the menopause (last ever period) have a 0-5% chance of becoming pregnant. What this means is that, although pregnancy is much less likely, it is not impossible and some form of contraception needs to be considered if pregnancy is to be avoided. However, because the intrinsic fertility is lower, it is possible to use methods of contraception which would have an unacceptably high failure rate in younger, more fertile, women. We would also recommend that women in their 50's continue using for contraception for a year after their last period, since it possible that their ovaries may contain a few eggs which have the potential to be released and fertilised and this cannot be accurately predicted.

The combined oral contraceptive containing ethinyloestradiol and a progestogen is very effective. These provide good cycle control, and reduce the likelihood of other gynaecological problems such as ovarian cysts and cancer of the ovary and lining of the womb. However, the combined oral contraceptive also carries associated risks of clots in veins and arteries and can affect cholesterol in an unfavourable way. Women in their 50's are approaching the age at which heart disease becomes an increasing possibility and for this reason, it may be unreasonable to use such potent contraceptives. They do, however, provide oestrogen type hormone at a time when a woman's ovary may be failing to do so and this may help to control peri-menopausal symptoms such as hot flushes. Breast cancer also increases with age, is often aggravated by oestrogens and this is a worry. Therefore, in non-smoking women without risk factors for blood vessel disease or clotting, a low dose combined pill (e.g. Mercilon or Loestrin 20) may offer some advantage although the attendant risks mentioned make it difficult to recommend.

It is possible to supply oestrogen hormone as hormone replacement therapy (HRT). The type of hormone is different (natural oestrogens do not have such a long half-life in the body as ethinyloestradiol) and the dose is much lower. Therefore, the risks of clotting and changes in cholesterol mentioned above are not as great with HRT doses of oestrogens. In fact there may be beneficial effects in terms of a woman's overall risk of heart and blood vessel disease. Unfortunately, HRT dose oestrogens will not suppress ovulation in a reliable way and cannot be used for contraception. One way around this would be to use HRT to control symptoms such as hot flushes, to maintain a healthy bone density and help prevent heart disease and use another method for contraception itself. HRT combined with the progesterone only pill (the "minipill") will provide the desired effect. The progesterone only pill is taken every day, within the same 3 hours every day (since the contraceptive effect on the mucus at the neck of the womb lasts about 27 hours only) and can have a variable effect on the menstrual cycle. It will provide protection to the lining of the womb, though, which is important when taking oestrogen HRT. Breakthrough bleeding or spotting may occur and this may be controlled by increasing the dose of the progestogen given. Remember, HRT alone is not a contraceptive!

Other methods of delivering progestogen include implants and injections (e.g. Depo-Provera). They carry the same problem as the progesterone only pill (namely, breakthrough bleeding or the lack of periods altogether which makes it more difficult to determine when the menopause occurs). A further option is the progestogen releasing intra-uterine device (Mirena). This releases tiny amounts of hormone into the womb which suppresses the lining. As a result, there are no periods, the coil provides very effective contraception and you can add on oestrogen HRT without fear of over stimulating the lining of the womb when peri-menopausal symptoms such as hot flushes start. There is no significant absorption of progestogen into the blood stream so women who are vulnerable to PMT like symptoms with progesterones can use this method when the progesterone only pill, implants or injections would cause unpleasant side effects.

Other methods of contraception that would be suitable include the use of a high concentration spermicidal foam (e.g. Delfen foam). This is inserted into the vagina before intercourse, is unobtrusive and easy to use. Use of Delfen foam does not preclude the use of HRT should this be desirable for other reasons. Other vaginal methods of contraception such as the diaphragm or cap offer an alternative that can be inserted at any convenient time before intercourse (e.g. before going out). The diaphragm is a thin rubber hemisphere, held in place over the cervix by a gentle spring action and the cap is held in place by suction. They prevent sperm getting to the cervix where they can survive in the alkaline mucus for up to 6 days. Use of a spermicide is recommended and if this has been put in more than 3 hours before intercourse, should be topped up by an application over diaphragm/cap. There is no evidence, however, that spermicide use makes the method more reliable; the clinical trials have never been done. The diaphragm or cap is left in at least 6 hours after intercourse so that all the sperm have died in the acidic vaginal mucus. Diaphragms and caps need to be removed and cleaned daily, and of course needn't be kept in if you are not anticipating having sex. The practice nurse will be happy to help you to decide whether the diaphragm or cap would be a method that works for you. Don't forget, condoms are another option that is readily available. A copper coated intrauterine coil, such as the Copper T 375 will provide effective contraception and can then be left in until after the menopause.

Fertility awareness methods such as Persona are less suitable in this age group because the ovaries do not release an egg reliably every cycle and using these methods would require long periods of unnecessary abstinence. Male or female sterilization provide a permanent solution (there is a very low failure rate) but with the menopause imminent and a woman's intrinsic low fertility at this age it seems less appropriate to submit to an operation when other simple contraception will be effective over the time required.