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It seems as though every week another celebrity is talking about her quest to have a baby. There's so much focus on infertility in the media these days that it's easy to forget you can get pregnant right up until menopause. In fact, women over the age of 40 have a slightly higher proportion of unintended pregnancies than women in their 30s. One possible reason for that? They might be skipping contraception.
"Many perimenopausal women think they can't conceive," says ob-gyn Andrew M. Kaunitz, MD, of the University of Florida College of Medicine, in Jacksonville. "That's not true." And even if you're not done having kids, you may not be using the best birth-control method for you. Unless you have a medical issue, the smartest way to choose contraception is by considering where you are in life right now.
You need to be prepared for all romantic possibilities. On the other hand, you may not want to expend too much effort and expense on contraception if you're just dating.
Your best choice "For spontaneity, it's best to use a contraceptive that's highly effective with minimum advance planning," says Beth Jordan, MD, medical director of the Association of Reproductive Health Professionals. If you're having sex infrequently, you might not want the hassle of taking a pill every day. An IUD is much less trouble. The copper T type has no hormones and works for up to 12 years; the progestin IUD needs replacement every five. An IUD is also a good choice if you're having sex regularly because it has one of the lowest failure rates (less than 1 percent) and, like the pill, won't affect your future fertility. Or get as much protection as you do from the pill by using the vaginal ring (insert a new one each month) or the patch (apply weekly for three weeks, then take a break the fourth week).
What to avoid Having sex without a condom, since condoms are the only way to protect yourself against sexually transmitted diseases. But use them with another method -- the failure rate can be as high as 15 percent.
Talk to your doctor if you prefer a barrier method. The sponge is back on the market and is convenient but may have as high as a 32 percent failure rate. A diaphragm is a good option but it still has a 16 percent failure rate.
Special considerations The copper T IUD can make your period heavier; methods with estrogen (pill, ring, patch) may increase the risk of blood clots.
You want to use something that will allow you to get pregnant quickly when you're ready.
Your best choice The IUD -- you can get pregnant within a month of having it removed. Most hormone-based methods (the pill, ring, and patch) may restore fertility more slowly; sometimes it takes several months for your body's natural hormones to get back on schedule so you can get pregnant. On the other hand, you don't need to see a doctor to stop taking the pill or using a patch or ring.
What to avoid The progestin shot, known by its brand name, Depo-Provera. Although the shot is given in 12-week intervals, it can take you as long as a year to get pregnant after stopping the shots.
Talk to your doctor if you have trouble conceiving six months after suspending birth control.
Special considerations When you stop using a hormonal method that shuts down ovulation, such as the pill, it's good to have a "real" period before trying to get pregnant. The doctor uses the date you last ovulated to calculate your baby's due date.
Yes, you need to use birth control. It's possible to get pregnant as soon as a month after the baby is born, especially if you're not breastfeeding.
Your best choice You should use condoms plus spermicide in the first month while your body is recovering and your hormones are settling down. Then the mini-pill, implant, or IUD if you're breastfeeding because they don't have estrogen. If you don't breastfeed or you've stopped doing so, you can use any birth-control method you want as long as your doctor has given you the go-ahead.
What to avoid Estrogen-based methods (such as the pill, ring, or patch) for the first month, because they increase the chance of blood clots -- and new mothers are already at higher risk, says Dr. Kaunitz. Continue to stay off estrogen-based methods if you breastfeed, because the hormone may reduce the amount of breast milk you make. It can also cause growth problems for the baby, Dr. Jordan says. The sponge is a poor choice now, too: It doesn't work as well after pregnancy because it won't fit as tightly.
Talk to your doctor if you'd been using a diaphragm and want to return to it. You'll need to be refitted.
Special considerations If you've been thinking about trying an IUD, it may be most convenient to have the device inserted during one of your postpartum checkups. IUDs got a bad rap in the 1970s because of a flawed type called the Dalkon Shield. Newer research shows that the risk of pelvic inflammatory disease is small.
But you're not finished with birth control. Now's when many women look for a more permanent way to protect themselves.
Your best choice "If a woman asks for a tubal ligation, we recommend first getting an IUD or Implanon, a thin plastic implant with progestin that prevents pregnancy for three years,? says Noa'a Shimoni, MD, a family physician in New Jersey and a fellow of Physicians for Reproductive Choice and Health. Both offer nearly 100 percent protection but leave your options open. If you're absolutely certain you'll never want to have children again, male vasectomy may be preferable to female sterilization, notes Lawrence B. Finer, PhD, director of domestic research at the Guttmacher Institute, a reproductive research and policy organization in New York City. It's an outpatient procedure, costs less ($350 to $1,000, compared with $1,500 to $6,000 for female procedures) and is less invasive than any type of sterilization done on women. But logic doesn't always drive birth-control decisions: Vasectomies represent only 9 percent of contraception in this country, while female sterilization is America's second-most-popular choice (27 percent) after the pill.
What to avoid A hysterectomy, which is major surgery, unless you need it for other reasons.
Talk to your doctor if you don't want your fertility to depend on your partner's decision or if he refuses to have a vasectomy. The least-invasive method of female sterilization is Essure or Adiana. Tiny inserts are placed into your fallopian tubes through the vagina (no surgery required), causing scarring that blocks them. Other options are laparoscopy (smallest incisions), mini-laparotomy (often done just after childbirth), and laparotomy. All are surgeries that allow the doctor to sever the tubes or block them (with clips, rings, or cauterization) and all require anesthesia.
Special considerations You'll need to use a supplementary birth-control method for three months after the Essure or Adiana procedures to be sure that the blockage is complete and for a similar amount of time after your partner has a vasectomy. There is a small risk of dangerous tubal (ectopic) pregnancy after female sterilization.
You can still get pregnant. "Pregnancies might be particularly unwelcome and are more likely to be high risk at this time," says Dr. Kaunitz. Stay with your current birth-control method or consider one that helps relieve perimenopausal symptoms.
Your best choice If you're having hot flashes, vaginal dryness, or other annoying symptoms, a birth-control pill with estrogen can counter them. So can the patch and ring, which also contain estrogen. Some of these may also relieve PMS (including estrogen/progestin pills that limit your period to four times a year or less).
What to avoid The mini-pill (progestin only) if your goal is relief from your perimenopausal symptoms.
Talk to your doctor if vaginal dryness is your main problem and you prefer to use an IUD or barrier method. An estrogen cream or suppository could help (though neither of them prevents pregnancy).
Special considerations The estrogen in birth-control pills may help prevent bone loss. Hormone therapy also helps your bones and perimenopause symptoms, but it doesn't contain enough hormones to act as a contraceptive and has other potential risks. Some doctors say you shouldn't use HT until you've gone through menopause, which means a full year without a period, but others do prescribe it for symptoms of perimenopause.
Tammi Collins, 40, La Vista, Nebraska
Her Method Combination pill
I've been using the same brand since I was young, except when I was having my three kids. I'm pretty athletic and at a healthy weight, plus I've never smoked, so my doctor says I can continue it. I've used it to avoid having a period during vacations. I considered trying the pills that suppress periods, but I'm going to stick with the pill I've been taking.
Sue Greenwald, 52, Kearney, Nebraska
Her Method Husband had a vasectomy
Here I was, heading toward menopause and getting a checkup for an ovarian cyst when my doctor told me I'm still fertile. I was shocked but I wasn't worried. My husband had a vasectomy after our second child was born. It's a simple office procedure that takes about five minutes; he left with two little bandages.
Karen Buscemi, 40, Royal Oak, Michigan
Her Method An IUD
I was on the pill for years but I have a busy job and was forgetting to take it. Then I used NuvaRing for five years and liked having less PMS with it. But I had a hard time remembering when to put in a new one. So I got a Mirena IUD more than a year ago. Though I know I don't want another child, I don't want to close the door completely.