Basics of Contraception and Safe Sex are to protect against pregnancy and protect against STDs. But beyond that your health and periods can be improved if you just pick the right one for you. That means you and your gyno have to discuss on an annual basis. Make a reproductive life plan and review it at your yearly check up.
At Women’s Health Practice we want to help you be healthy and we take contraceptive and STD advice in the context of your whole health. We want to understand your goals for future pregnancy, any family history of hormonal problems, any special considerations such as travel and if you are an athlete, have you a tendency to depression? Your weight is important as most methods have not been studied in those women who are obese. All of these factors can make getting contraceptive advice from us a bit unique.
1. Use contraception if you don’t intend to get pregnant, it’s important as you get closer to menopause. I do remind women that by age 40, only 3 percent of women are attempting to conceive. By age 50, very few are trying to conceive. Therefore, for the average woman even during perimenopause prevention of pregnancy and prevention of sexually transmitted infections are still concerns. You may need testing for the age of your ovaries and you may need evaluation of your bones, your muscle strength, your heart, and your calcium levels before deciding whether hormones are right for you or not.
2. It is our goal to make every pregnancy planned. Unintended pregnancies in the young and the older fertile age group are still a frequent problem. Planning helps you review family risks and understand what new genetic testing you may need. It helps you become pregnant when not drinking too much smoking too much. There is not much known about marijuana use in pregnancy, so please stop that as well. Even with changed menstrual cycles, ovulation can occur. Conceptions that are planned in the perimenopause are more complex and percent of pregnant women over age 40 will have a greater risk of spontaneous miscarriage. In a recent study almost 25% of women in their 40s did not use contraception, most believing it is not necessary. This chapter will emphasize the importance of contraception for the woman in early menopause. A comfortable, safe method is necessary to enhance your sense of well-being. Generally your gynecologist will try to estimate your ‘ovarian age’ or how close to menopause you are, and use that fact to assist you in making informed decisions regarding contraception. If you think you are pregnant, make an appointment with us right away, we want to help you get a healthy start to your pregnancy!
3. There are ways to make Non-Hormonal Barrier Methods easier to use. Women nearing the end of their fertile years might consider barrier methods as a first choice. A third of all couples using contraception after the age of 35 opt for sterilization, and approximately one in four use barrier methods. Barrier methods tend to have high failure rates (15-20%) when used by younger age groups for pregnancy prevention. For women in their 40s or 50s, the failure rates are much lower, although effectiveness rates vary widely. Compared to the over 95% effectiveness of the pill, or the over >99% effectiveness or sterilization with tubal ligation, and almost the same rates of protection from IUD, barrier methods do not offer as secure protection against pregnancy, but after the age of 40 they work more effectively when we look at statistics.
4. Contraception makes you more fertile, not less! Couples who have used a barrier method successfully for more than 1 year will show success rates of preventing pregnancy getting closer to that of the pill. The exceptions to be concerned about are the sponge and the cervical cap, which may dislodge more easily for women who have had children.
5. We recommend non-hormonal treatments of vaginal dryness even as a way to make it more comfortable to use barrier contraception. For perimenopausal women who have early onset atrophy, barrier methods may be much more uncomfortable than hormonal methods such as oral contraception which may actually treat the early atrophy at the same time as providing contraception.
6. Get STD testing when you should. Sexually transmitted infections (STIs) continue to be a concern throughout the sexually active years. If you have a new partner, if you are under 25, if you have new symptoms of pain or discharge, don’t put off getting tested. Testing can be very non-invasive, and at Women’s Health Practice we often have walk-in appointments for the symptoms of an STD or a UTI. Older women with more advanced urogenital atrophy can actually be infected with the AIDS virus more easily than younger women, because vaginal dryness may lead to microscopic tears in the vaginal wall. These tears are ideal paths for viruses to enter the blood stream. For women with more than 1 partner, or for couples who have been together sexually for less than 2 years, we advocate barrier methods in conjunction with hormonal methods, or sterilization, because of the combined effectiveness against sexually transmitted infections and unplanned pregnancy. This is why we recommend ongoing vaginal health and a preventative MonaLisaTouch laser therapy treatment for women as they transition to lower hormone levels after pregnancy, towards perimenopause, during times of stress and at other times.
7. Used alone, barrier methods help protect against STIs. Spermicidal agents, combined with a barrier method, are the safest option. In addition to its ability to kill sperm, the spermicide nonoxynol-9 can kill many organisms responsible for STIs. This capacity is retained regardless of the vehicle of delivery: vaginal films, suppositories, foams, creams, jellies, in sponges or in the cavity of a diaphragm. Although each delivery system affords a slightly different level of protection from infection, they are all effective for this purpose. Their use should be encouraged regardless of efficacy of other contraceptive methods practiced.
8. Keep Condoms handy! The fear of Herpes, Chlamydia, HPV, and HIV, as well as awareness of the benefits of condom use has increased the popularity of condoms. Nevertheless, consumers need to be aware that there are no federal regulations for condom manufacture. Consequently, many novelty condoms are available that do not successfully prevent pregnancy and STIs. Only 1% of condoms sold nationally are made of latex rubber tested to prevent STIs. All countries have national standards for thickness and tensile strength for quality control purposes, but successful condom use really depends on adhering to proper usage techniques. Condoms are designed to be airtight and water tight. The herpes virus, for example, is 1000 times larger than air or water molecules. Therefore, as the condom is a barrier to the relatively small air and water molecules, it should easily prevent the larger virus particles from passing through the pores of the latex.
Condoms are designed to fit over the erect penis to act as a barrier to semen. Most condoms are designed with a tip than can contain some spermicide to prevent pregnancy and STIs if the condom tears. They come in various shapes, colors, and textures, with and without lubrication. Although the length of condoms does not vary, they do vary in width, and are available in small, standard and large sizes. Latex has become such a ubiquitous substance that many people have become allergic to it. For those with a latex allergy, there are now condoms available made of polyurethane, natural membranes and other types of rubber products. Polyurethane condoms are reported to allow greater sensitivity and sensation of body heat than latex condoms. They are more expensive than latex condoms, and are associated with a higher pregnancy rate than latex. Natural membranes, also known as lambskins, were one of the first types of condoms produced. They have a natural feeling and are an effective form of birth control. However, bacteria and viruses, which carry STIs and AIDS, can pass through the porous walls of the natural membrane. Regardless of the type of condom used, the addition of a spermicide is uniformly recommended for maximum protection. At Women’s Health Practice we can discuss what you have been using, and make suggestions of condoms that may be better for you.
9. You can almost always benefit from back up, especially with condom use also use spermicides Spermicides act by killing sperm in the vagina before the sperm reach the cervical canal and the upper genital tract. Spermicides come in creams, gels, foams, films, tablets and suppositories and can act as both a physical and chemical barrier to sperm. Most commercially available preparations contain nonoxynol-9, which is a mixture of several detergents. Creams and foams are usually thicker than gels and have slightly greater potency and lasting power. Vaginal film is a small sheet that releases the spermicidal agent upon dissolving in the vagina. The film must be in place for at least 15 minutes prior to intercourse. Foaming tablets and suppositories also release carbon dioxide bubbles that help disperse spermicide into the upper vagina. Recent studies suggest that the use of nonoxynol-9 alone (without a condom or diaphragm) is not effective in preventing some STIs such as gonorrhea, chlamydia and HIV infections. Vaginal therapy, with MonaLisaTouch, for atrophy can make spermicide use more comfortable and allow menopausal women to additionally be protected against STD. Frequent use of nonoxynol-9 spermicides, paradoxically, may cause irritation in the genital tract potentially increasing the risk of STD and HIV acquisition and transmission. If irritation develops with spermicide use see your health care provider to try to resolve any issues.
10. Don’t forge that Diaphragms are still available! Diaphragms are shallow, rubber saucers designed to act as a mechanical barrier to sperm, and as a cup for retention of spermicide. Three different types of spring rims are available, ranging in size from 45 to 105 millimeters. Diaphragms require a prescription and special fitting by your doctor initially. Any prior surgeries, including vaginal meshes, can affect the fit but your health care provider can make sure you are fit correctly. At Women’s Health Practice we have extensive experience in helping to determine if you have a healthy pelvic floor and whether a diaphragm would be comfortable and effective for you to use. If you have pelvic floor weakness that might be a problem, we can help design a program to strengthen your muscles.
Diaphragms are safe and easy to use. As with all barrier methods, there is some interference with spontaneity, and some discomfort due to the messiness of the spermicide. Diaphragms should be inserted no more than 6 hours before intercourse, and removed 6 to 8 hours after intercourse. If left in place for more than 24 hours, there is an increased likelihood of unpleasant vaginal odor, urinary tract infections, and vaginitis. Dislodgment, tearing of the vaginal vault due to poor fit and vaginal discharge are possible disadvantages of this device. A diaphragm compresses the urethra and can cause urethral irritation. Some retention of urine in the bladder after voiding with the diaphragm in place does occur. This explains reports of increased urinary tract infections in diaphragm users. Diaphragm users practice a greater amount of genital manipulation (insertion and removal of the diaphragm) and this may predispose them to increased vaginal bacteria. It is recommend that women with recurrent urinary tract infections switch to the cervical cap if they prefer a barrier, or hormonal methods. The diaphragm shape is not so different than a ring pessary, but it doesn’t sit specifically under the pubic bone and won’t help with incontinence the way pessaries do. The diaphragm prevents contact of the sperm with the cervix, and affords protection against cervical and tubal infections. Thus, the benefits of this method, with regard to STI protection, are still felt to significantly outweigh any risks. However, pregnancy rates may be up to 20% with typical use.
11. The Vaginal Sponge works with spermacide.
The vaginal sponge will block passage of sperm. It can be used for a full 24 hours. There is actually a sponge that can be purchased on line that has 3 spermacides called Protectaid. You have to wet the sponge with water before insertion, but it can be inserted right before intercourse, or up to 24 hours before you actually have sex.
The sponge has a nylon cord attached to facilitate removal and disposal. It is available without a prescription and requires no special fitting. It is 5.5 cm in diameter and 2 cm thick. The one-size-fits-all sponge is easily inserted by women, although some users report difficulty with insertion, retention, and removal. Women who use the sponge report unplanned pregnancy, odor, vaginal irritation, infection and dryness as reasons for discontinuing sponge use. The failure rate (pregnancy rate) for the sponge is 20% in women who have never had children and 40% in those who have.
13. Cervical Caps can be difficult to find and get fitted for, but they still do exist. Cervical caps are similar to diaphragms in terms of their use and effectiveness. They are made of latex rubber and are thimble shaped. The only cervical cap approved for use in the US is the Prentif Cavity-Rim and it comes in four different sizes with diameters ranging from 22 to 31 millimeters. Use of the cervical cap requires a prescription and an initial fitting by a health care provider. The cap fits snugly with mild suction over the base of the cervix where the vaginal fornix and cervix intersect. It is designed to hold spermicidal cream or jelly. Cervical caps may be left in place for 48 hours and that may aid in improving spontaneity for the couple. When caps are left in place longer than 48 hours, some women report increased vaginal odor. This seems to resolve after removing the cap and does not usually require treatment. The cervical cap tends to lose suction if inserted during your menstrual period and, theoretically, may also increase the prevalence of endometriosis if used at this time. The failure rate of cervical caps is 20% for women that have never given birth and 40% for those who have.
14.Female Condom A new female condom was released in 1993 to reduce the risk of STDs including HIV and offer an alternative barrier method for women. The female condom is a double-ringed device with a tube of tough polyurethane material, and is an option for those allergic to latex. The ring at the closed end fits snugly over the cervix like a diaphragm and the other extends beyond the vagina and covers part of the vulva. It is disposable and should be used only once. The female condom costs approximately $3 and this makes it a very expensive method. It is comfortable, however, and we suggest our patients give it a try.
10. There are Intrauterine Devices of several sizes and does now. IUDs work by being spermacidal in the ueterine cavity. IUDs do not prevent ovulation, they prevent conception. The intrauterine device (IUD) is an excellent method for women over 40 and is effective for many years. In one fitting, it may satisfy the rest of your contraceptive needs from perimenopause through menopause. IUDs were introduced many years ago and four devices are currently available in the USA, three of which do contain hormone. While they do not have protection against uterine cancer, all devices lower a woman’s chance of endometrial uterine lining cancer. These devices are recommended for all age women without cervical or uterine abnormalities and who do not pelvic inflammatory disease (PID). Contraindications to the use of IUDs are really very few, and don’t significantly differ from medicated to unmedicated and include undiagnosed vaginal bleeding, impaired response to infections (e.g., in diabetics, cancer patients), and acute genital tract infections. Risks are expulsion of the device, perforation, or infection. Hormonal IUDs do leak some hormone and side effects may include acne, breast tenderness, mood changes, and in rare cases libido changes.
The ParaGard IUD, is a copper-containing device that is approved for use for 10 years, but there are studies that show effectiveness for 12. The IUDs that contain hormone are sometimes called Intrauterine System (IUS) has a T-shaped frame that contains the hormone levonorgestrel, that is also found in some birth control pills. The 52 mg dosages are called the Mirena and the Liletta device which are very similar in shape and size. This hormone is released at a much lower level than that in the pill and the first approved Mirena is approved for both heavy menstrual bleeding and contraception, use up to 5 years in the U.S. and 7 years in Europe. The identical Liletta is now approved for 6 years of use. The Skyla device is smaller, and approved for 3 years of use. Kyleena has less hormone than Mirena or Liletta and is used for 5 years. This combination device is over 99% effective in preventing pregnancy. Outside the USA Mirena has also been approved for hormone therapy. Because the Skyla is smaller and would fit in to a smaller uterus, like the size a menopausal woman would have, it may be an even better choice for menopausal women. Unlike the copper ParaGard device IUDs, use of hormonal IUDs results in lighter menstrual periods, and one-third of women using Mirena do not have a period at all. For this reason, Mirena is also approved for use in the treatment of heavy periods. The medications in these IUDs can also treat uterine lining thickening called hyperplasia.The contraindications for use of Mirena are the same as for other IUDs.
Intrauterine Devices and Pelvic inflammatory Disease
Older research indicated that the incidence of Pelvic Inflammatory Disease (PID) was 5 times higher in IUD users than in non-users. Recent data from the World Health Organization Scientific Group (WHO) indicate that the incidence was greatly overestimated. The WHO study asserted that the highest risk of PID occurs in the first month after IUD insertion. The PID risk returns to that of nonusers in women who have been using their current IUD for more than 4 months. IUD insertion cannot be performed without introducing the normal vaginal bacteria into the mostly sterile uterine cavity, but by 30 days after insertion, the uterine cavity is usually once again (mostly) sterile. PID is less likely in perimenopausal women overall, and thus any infection risk is extremely small. PID in a woman with an IUD is treated the same way as with nonusers. A reasonable approach is to remove the device once broad spectrum antibiotics have been given, although there is debate as to whether the IUD need be removed at all. Using an IUD may put you at risk for other types of genital tract infections.
Intrauterine Devices and Pregnancy
Women who become pregnant with an IUD in place are at greater risk for spontaneous miscarriage following infection. This was the case for users of the Dalkon Shield. This device had a thin multifilament string that allowed bacteria to cross the normally sterile barrier of cervical mucus. For women who become pregnant while using an IUD, the risk of spontaneous miscarriage without infection is approximately 50%, and greater if an infection occurs. Clearly this number would be higher for the perimenopausal women.The recommendation is to remove the IUD as soon as possible after the diagnosis of pregnancy is made. If the device is removed in the first trimester, the risk of miscarriage is reduced from 50% to 25%.
No specific causal relationship between the IUD and ectopic pregnancies has ever been established. It is known that IUDs prevent intrauterine pregnancies more effectively than they prevent extrauterine (ectopic) pregnancies. Perimenopausal women are more at risk of ectopic pregnancy than a younger woman any way. In an IUD user with a positive pregnancy test, the diagnosis of ectopic pregnancy must be thoroughly excluded by ultrasonography, serial beta-HCG determinations and clinical evaluation.
11. Oral Contraceptive Methods are varied and have health and contraceptive benefits In 1990, the Food and Drug Administration (FDA) formally approved the use of oral contraceptive pills for healthy pre- and perimenopausal women. I am a strong advocate of the pill because of its many benefits beyond pregnancy prevention. Women who take the pill have the following non contraceptive benefits :
• less pelvic inflammatory disease,
• fewer menstrual cramps,
• lighter menstrual bleeding,
• less anemia,
• fewer uterine fibroids,
• less rheumatoid arthritis,
• fewer ovarian cysts,
• less uterine and ovarian cancer
• greater bone density.
• fewer tubal pregnancies
• fewer tubal infections
• less fibrocystic breast disease, and
• possibly protection against atherosclerosis and heart disese
The pill is an excellent treatment for hot flashes in perimenopausal women. Hot flashes are reduced in frequency, as well as severity, by oral contraceptive pills. Physicians believe that oral contraception helps to osteoporosis as women on the pill will have increased bone mineral density (BMD). There are also studies that indicate that estrogen treatment improves bone structure. Healthier bone structure reduces fracture risk. There are not specific studies that show oral contraceptive pills prevent fractures, but many studies show better and reduces the risk of fractures.
Cancer prevention is complex, and depends upon your personal family history and risks. At Women’s Health Practice we can offer genetic screening that will help you determine personal risks and how proper contraception can help lower your personal risks. Oral contraception reduces your risk of cancer. Long term oral contraception protects against ovarian cancer and endometrial (uterine lining) cancer. Patients have a 12% lower risk of getting any cancer, and a 29% lower risk of any gynecologic cancer including uterine or ovarian Ovarian cancer is the fourth leading cause of cancer death in women with 20,000 cases diagnosed in the U.S. each year. Survival rates from this type of cancer are poor as it usually far advanced by the time of diagnosis. After the first 6 months of taking the pill, a woman has reduced her risk of ovarian cancer, with additional benefit if she remains on the pill over time. Eight out of 10 ovarian cancers could be prevented if women took the pill for at least 12 years. Despite these benefits, oral contraceptives may not be the best option for everyone. We recommend Gail Scale screening for breast cancer risk, it is simple and yet many women are not offered this test from their health care providers. Come into Women’s Health Practice to get a consultation as individual consultation with your doctor is essential.
Not For Everyone
Many medical conditions are contraindications to pill use, others are just relative concerns that can be monitored by your If you have breast, uterine or ovarian cancer, liver disease, heart disease, blood clots, severe migraines or severe hypertension you should not take the pill. The pill is not recommended for smokers at any age and should never be prescribed to smokers over the age of 35 because of the risk of heart attack. For additional contraindications please see the next table, and always consult your personal physician
Smoking over the age of 35
Uncontrolled or severe hypertension
Blood clotting tendencies or History of Stroke
Heart disease, prior Stroke
Active Liver Disease including Hepatitis
Estrogen dependent cancer
Although proper monitoring, treatments, and nutrition can prevent many of these complications there are conditions that potentially can worsen with pill use are chronic yeast infections, uterine fibroids with irregular bleeding (oddly some studies show less fibroids with oral contraception!), seizure disorders and migraine headaches. Minor side effects of the pill may include headaches, nausea, weight gain or loss, breast pain, hair loss, premenstrual syndrome, mood changes, hirsutism, vaginitis, acne, sex drive changes, vomiting, breakthrough bleeding, and loss of menstrual periods. An increase in blood fats, including cholesterol and triglycerides, may also be seen, but usually the cholesterol elevations for the most part are of the good, high-density lipoproteins. Hypertension may occur but is reversible after discontinuing pill use. A word about hirsutism and acne, in menopause women may have new onset of acne or abnormal male pattern health.
At Women’s Health Practice we remind women that medications and food can cause drug interactions and we even offer genetic testing to help you see how your personal genetics can affect medications including contraception. Very few drugs adversely interact with the contraceptive pill. In most cases, you can remain on your other medications while taking the pill, but a dosing of medications may have to be adjusted. Consult with your doctor or pharmacist when taking antibiotics or any medication because you may need a backup method of contraception.
12. Contraceptive Patch won’t stick to everyone but very convenient A contraceptive patch, marketed under the name Ortho-Evra, was recently approved by the FDA. This patch contains the same kinds of hormones as oral contraceptive pills. A new patch is applied once a week for 3 weeks (21 days). The patch is taken off in week 4 and you will have a menstrual period, or withdrawal bleed. After week 4, the patch cycle begins again. The patch may be worn anywhere on the buttocks or abdomen (not on the breasts) and can be worn while bathing and swimming. This method is thought to be slightly more effective than the pill because there is a lower chance that a dose is forgotten. It is associated with side effects similar to that of the pill. Women who weigh more than 196 pounds may not get high enough hormone levels while wearing the patch and may be at risk for unwanted pregnancy.
13. For very consistent hormone delivery consider the Contraceptive Ring Recently, a vaginal contraceptive ring—NuvaRing—has been made available. The flexible ring fits easily into the vagina and releases a steady stream of contraceptive hormones. The ring is worn for 3 weeks and removed for the week of your menstrual period. This method has a success rate of more than 98%. The side effects of the ring are similar to that of oral contraceptive pills. If the ring is removed from the vagina for more than 3 hours, a backup method of contraception should be used for 7 days. Most patients can use rings more continuously for fewer periods, and we at Women’s Health Practice want you to understand how to live your life better with a healthier way to manage your periods.
14. Long acting contraceptives have the highest contraception protection rates:Injectable Contraceptives In 1992 the FDA approved the injectable steroid contraceptive, medroxyprogesterone, under the brand name Depo-Provera (DMPA). DMPA had been used for contraception in other countries for almost 30 years prior to that and equally as long in this country for gynecologic disorders (e.g., endometriosis). As a contraceptive, it is essentially flawless with only 1 to 2 failures per 1,000 women if administered every 12 weeks. Its action is so long-lasting that it may take 12 to 18 months to become pregnant after discontinuing use. The most common side effect of the DMPA injection is irregular menstrual bleeding. Two-thirds of all women who take DMPA experience complete amenorrhea (no periods) after the first year of use. Weight gain, headaches, nervousness, stomach pains or cramps, dizziness, weakness, fatigue, lower bone mass, and decreased sex drive have all been reported as side effects. Many of these side effects diminish over time. Generally, women who do well on the pill will do well on DMPA. DMPA has never been shown to increase the risk of breast cancer, heart attacks, or deep venous clots (VTE)
Women with unexplained, irregular bleeding, current cancers, clotting disease. Women who may use DMPA but probably should select another method and if you have family history of breast cancer, fibrocystic breast disease, kidney disease, hypertension, migraine headaches, asthma, seizures, diabetes or a history of depression, consult your personal health care provider so as to make your best contraceptive decisions. Women at a high risk of osteoporosis may want to avoid prolonged DMPA use as it may reduce bone density. At Women’ Health Practice we can monitor your bone density with specialized testing at an affordable rate. DMPA has never been shown to increase osteoporosis or osteoporotic bone fractures. It is not clear if DMPA will treat hot flashes or not, as some studies have shown a lot of benefit for perimenopausal and menopausal women, and yet it is possible DMPA can lower the body estrogen and thus actually cause hot flashes for some women. DMPA lasts in the woman’s body for about 3 months, it can be given with estrogen in some cases, and the estrogen, while not interfering with the contraception ability, can reduce the hot flashes.
15. Whether you have children or not, Sterilization is an available method Permanent contraception can be done in three ways: interruption of the tube, occluding the tube or removing the tube. The traditional laparoscopic tubal sterilization is done with heat destroying the midsection and has been called ‘tying’ the tube. Surgery to remove the tube is called salpingectomy, and can be cancer preventing. We also offer office procedures at Women’s Health Practice to make these procedures more accessible for our patients. And a procedure to insert coils into the tube through the cervix and the uterus via a hysteroscope is called the Essure procedure. All women, regardless of their risk have about a 40% lower rate of ovarian cancer if they utilize one of the methods of sterilization of the tubes. Risks of the Essure procedure include up to 10% of only occluding one tube, and up to 3% chance of other complications such as perforation of the uterus, causing infection or endometriosis around the device, or expulsion of the device. The FDA is looking in to the device complications as they seem much greater than the initial studies seem and it’s important to discuss your personal risks and benefits of having an Essure verses a non-hormonal IUD as the risks are much lower with the IUD.
16. Final Thoughts Regarding Contraception in Menopause There are many contraceptive options currently available and more options being researched and made available every year. This discussion was not exhaustive one, but hopefully can guide you to thinking about alternatives in light of your changing perimenopausal and early menopausal status. An open discussion with your health care provider can determine the best option for you. Women should continue contraceptive practices until they are sterile. For the average woman she can use age 55 as the age of sterility. It is reasonable to consider your natural decline in fertility, the frequency you have sex, gynecologic problems such as fibroids or irregular periods, and any medical problems before making final decisions regarding what contraceptive method you would like to use. Hormonal methods can also treat vasomotor symptoms and have other health benefits such as prevention of osteoporosis. The age at which women should discontinue oral contraception has never been firmly established. Many women can safely take them into their early or mid 50s. But you should be closely followed, and take into considerations new problems such as obesity, lack of exercise, and periods of immobility.