Contraception,
Conception,
and
Change of Life


Highlights from the
ALSWH Reproductive Health Report

From her first period to menopause, reproductive health is an ever-present feature through the first half of a women’s life. Even post-menopause, the timing and symptoms of periods and menopause influence health outcomes in our later years.

Reproductive health issues have a ripple effect with direct and indirect impacts that are both human and economic. Issues surrounding contraception, unwanted pregnancy, miscarriage, endometriosis, PCOS, fertility problems, pregnancy difficulties, and the menopause transition have an impact on service provision, economic productivity, and at the personal level - women’s physical and mental health, and their quality of life.

The Australian Longitudinal Study on Women’s Health has investigated the interrelated biological, behavioural, and social factors that influence women’s health and wellbeing and their use of healthcare services for 25 years. We know that good reproductive health is not just the absence of disease. It incorporates physical, mental and social wellbeing at all stages of women’s reproductive lives. Achieving this requires women and their health care practitioners to be equipped with knowledge, skills, and access to services that empower them to make healthy and safe reproductive choices across their life-course.

The ALSWH Reproductive Health Report was developed for the Australian Government Department of Health in consultation with other key stakeholders. It is designed to provide policymakers and women’s health advocates with detailed insight into reproductive health trends, at-risk populations, and the socio-demographic and health behaviour characteristics that could be targeted for support or intervention programs.

The Reproductive Health Report is far-ranging and detailed. It can be read from beginning to end; however, we recommend using the highlights in this summary as a starting point and delving into stand-alone chapters for detailed analysis.

The Reproductive Health Report investigates:

  • women’s use of contraceptives across their reproductive years, with a focus on the oral contraceptive pill and long acting reversible contraception (LARC)
  • women’s family planning experiences including fertility problems, pregnancy, and perinatal mental health
  • the menopause transition and the impact of menopausal symptoms on health outcomes in later life
  • the impact of COVID-19 on family planning and contraceptive choices in 2020.

The Report examines both cross-sectional and longitudinal data, and reports on trends observed across three of the four ALSWH cohorts born 1989-95, 1973-78, and 1946-51. Data from the 1921-26 cohort has not been used in this Report. ALSWH collects data on women’s physical and mental health, as well as demographics, health behaviours, lifestyle factors, social circumstances, and use of health services. In addition, ALSWH data are linked with national and state-based administrative health datasets, such as the MBS, PBS, hospital admission, perinatal, and cancer registry datasets.

This is a data-heavy report. We are mindful that behind each data point is a very real woman, and we are grateful for her contribution. We would also like to take this opportunity to thank Professor Deborah Bateson, Medical Director, Family Planning NSW; Arabella Gibson, CEO, Gidget Foundation Australia; and Professor Martha Hickey, Professor of Obstetrics and Gynaecology, The University of Melbourne for their advice. 

Yours in health,

Professor Gita Mishra – ALSWH Director, The University of Queensland
Professor Julie Byles – ALSWH Director, The University of Newcastle

Trends in women's use of

Long Acting Reversible Contraception

Compared to European countries, the uptake of implants and IUDs in Australia remains low. Chapter 5 of the ALSWH Reproductive Health Report investigates long acting reversible contraception (LARC) trends among ALSWH's 1989-95 cohort (the millennials) and the 1973-78 cohort (Generation X).  The Report also closely examines the personal and socioeconomic factors influencing women's use of LARCs.

Trends in LARC use

We first asked the 1973-78 cohort about their use of LARCs in 2009, when they were 31-36 years old. However, LARCs were widely available by the time women from the 1989-95 cohort first started to use contraceptives. The data reflect a tendency for them to be more open to these methods. The younger cohort has already reached a similar number of LARC uses to their much older counterparts. They also started using LARCs much earlier and are more likely to have tried both an IUD and an implant.

First implant (median age) 1989-95 cohort 20 years old vs. 1973-78 cohort 31 years

First IUD (median age) 1989-95 cohort 24 years old vs. 1973-78 cohort 37 years

half of LARC users had only one MBS or PBS record indicating LARC use. One in four had two records, and one in four had three or more records.

Across both cohorts, approximately half of LARC users had only one MBS or PBS record indicating LARC use. One in four had two records, and one in four had three or more records.

Across both cohorts, approximately half of LARC users had only one MBS or PBS record indicating LARC use. One in four had two records, and one in four had three or more records.


Switching LARC: 14% of the 1973 cohort and 19% of the 1989-95 cohort  have used an IUD and an implant.

Life stage trends

Trends in LARC use over time are different between the two generations. Against the context of changing availability, awareness, and attitudes towards LARCs, the differences also reflect the women’s different life stages and family planning goals. 

Among 1989-95 cohort women, LARC use decreased with age, as women moved into the stage where they intended to become pregnant and start their families. Women in this cohort were also less likely to use implants as they aged and more likely to use IUDs.

In contrast, the use of LARCs increased over time in the 1973-78 cohorts, most likely reflecting that these women had finished having children or wished to delay further pregnancies. Among these women, the use of IUDs was more common than the use of implants.

Which factors are related to LARC use?

icon - woman making heart over her tummy
icon - house with a fist
icon - two hearts ina broken eternity symbol
icon - point on a map
icon - graduation cap and books
icon - globe
icon - scales
icon cigarette
icon -two glasses and a wine bottle

Number of children

The number of children a woman had had was the factor most strongly associated with her use of LARCs. A woman's odds of using a LARC increased in line with the number of children she had borne.

Miscarriage

1989-95 cohort women were less likely to use a LARC if they had a history of miscarriage.

Termination

1989-95 cohort women’s odds of using a LARC increased in line with the number of pregnancies they had terminated.

Domestic violence

1989-95 cohort women who had been in a violent relationship were more likely to use LARCs than women who had not been in a violent relationship.

Relationship status

Across both cohorts, un-partnered women were more likely to LARCS than women with partners.

Area of residence

In both cohorts, women in regional areas were more likely to use implants than women in major cities.

Education

1989-95 cohort women with post-school level qualifications were more likely to use LARCS than those with lower levels of education. However, level of education was not a factor affecting LARC use in the older 1973-78 cohort.

Country of birth

Members of the 1989-95 cohort who were born in non-English speaking countries were less likely to use IUDs, compared to those born in Australia or other English-speaking countries.

In comparison, women who were born outside Australia were less likely to use implants. In this cohort there was no association between country of birth and women’s use of IUDs.

Weight

Obesity was associated with higher use of LARC in both generations. In contrast, women who were underweight were less likely to use LARCs.

Smoking

Current smokers in the 1989-95 cohort had increased odds of LARC use compared to non-smokers.

Alcohol

Higher use of alcohol was associated with LARC use in the 1973-78 cohort.

For more information

Chapter 5: Trends in women's use of LARC methods
Authors: Julie Byles, Nicholas Egan, Isabelle Barnes, Melissa Harris

Contact: Prof Julie Byles

Short and long term use of the

Oral Contraceptive Pill

In Chapter 6 of the Reproductive Health Report, we examine how long women remained on the oral contraceptive pill and which factors were associated with its long-term use. To do this, we compared usage trends for the 1989-95 and 1973-78 cohorts. We determined women’s use of oral contraceptives from claims made to the PBS. However, these data may underestimate use of the pill if women used medications that did not attract a PBS benefit.

How did we define short term use of the pill?

More than 99% of the OCP scripts supplied to women from 1 July 2012 to 30 June 2019 contained 112 pills (four 28 pill packs), which is sufficient supply for 80% of 140 days. Therefore, we defined short-term OCP use as 150 days or less, or equivalent to less than 6-months of use, and this usually represented a single script.

Around 50% of all OCP use periods involved a single script.

Women may have switched to another OCP not listed on the PBS or may have transitioned to another form of contraception (e.g., LARC), or stop using contraception.

35% of the 1989-85 cohort only used the OCP for short periods. 38% of the 1973-78 cohort only used the OCP for short periods.
35% of the 1989-85 cohort only used the OCP for short periods. 38% of the 1973-78 cohort only used the OCP for short periods.

What differentiates short term and long term users of the OCP?

In the 1973-78 cohort, we did not find any statistically significant differences in demographic and health risk factors between women who used an OCP for a short term and those who used it for a more extended period.

Compared to long-term users, millennials who used the pill for less than 150 days were more likely to:

  • have a certificate/diploma (although similar numbers had a university degree)
  • be partnered
  • have previously been in a violent relationship
  • be psychologically distressed
  • have poor to fair general health
  • report a chronic condition
  • have had a previous miscarriage or termination.
  • smoke tobacco
  • be non-drinkers
  • have a slightly higher BMI.

Which factors are related to time spent on the OCP?

Periods of short-term use of the OCP (less than 150 days) were common in both cohorts. As noted in the summary of contraceptive trends, women frequently transition from one contraceptive to another, so the same woman might have multiple short and long-term periods using oral contraceptives.

In the 1989-95 cohort, four factors significantly affected the duration of use amongst long-term OCP users. Women with shorter durations of OCP use were:

  • older
  • had a higher BMI
  • smoked
  • used illicit drugs.

In the 1973-78 cohort, the factors related to discontinuation of OCP use in the long term were very different. In this group, the duration of OCP use was shorter for women who had:

  • poorer mental health
  • did not live in outer regional or remote areas
  • had been in a violent relationship
  • had endometriosis or PCOS.

For more information

Chapter 6: Short and long term use of the OCP
Authors: Julie Byles, Dominic Cavenagh, Isabelle Barnes, Melissa Harris

Contact: Prof. Julie Byles

Pregnancy and
Assisted Reproductive Technology (ART)

Are birth rates changing?

In Chapter 7 of the Reproductive Health Report, we examine pregnancy patterns, fertility issues and women’s use of assisted reproductive technologies in the 1989-95 and 1973-78 cohorts.

The two cohorts are at different stages of their reproductive lives. However, both started participating in ALSWH surveys at the age of 18-23. Comparing the two cohorts at equivalent ages provides insight into generational differences in pregnancy intentions and birth patterns.

Pregnancy intentions

One in ten women from the 1989-95 cohort were pregnant or trying to conceive at age 24-30 (their most recent survey).
Among women from the 1973-78 cohort, one in five women reported being pregnant or trying to conceive at age 28-33 years.
By age 40-45 (at their most recent survey in 2018), just under one in twenty (4%) of this cohort were pregnant or trying to conceive.

Reproductive outcomes

among women born 1973-78 (aged up to 45 years) who completed one of the two most recent surveys: •	81% have reported giving birth •	36% have reported a miscarriage •	The average birth rate was 2.3.
Among women born 1989-95 (aged up to 30 years) who completed one of the two most recent surveys: •	14% reported giving birth •	7% reported a miscarriage •	The average birth rate was 1.5.

When we compare the two cohorts at similar ages, the differences in birth rate become apparent.

At 18-23 years, a higher percentage of women born 1973-78 reported giving birth than women born 1989-95. Results were similar when women were aged 22-27 years.

At 18-23 years, a higher percentage of women born 1973-78 reported giving birth than women born 1989-95. Results were similar when women were aged 22-27 years.

At 18-23 years, a higher percentage of women born 1973-78 reported giving birth than women born 1989-95. Results were similar when women were aged 22-27 years.

Implications for policy and practice
Almost 20% of the 1973-78 cohort had not reported any births by age 45. Policy initiatives for women’s health need to account for this by not assuming all women will bear children, and by ensuring health professionals are aware of the health issues that pertain to women who do not have children.

How prevalent are PCOS and endometriosis?

In our analysis of fertility issues and assisted reproductive technologies (ART), we have included two key reproductive conditions that can impact fertility: endometriosis and polycystic ovary syndrome (PCOS).

Prevalence of Endometriosis and PCOS

Prevalence of Endo and PCOS in women trying to conceive

Women who were trying to conceive had the highest prevalence of reproductive health problems in comparison to women who were already pregnant or not trying to conceive.

It may be that women with reproductive problems have a heightened awareness of the potential difficulties, so they try to conceive earlier than those without these conditions. Alternatively, it may be that the women's health problems were identified during fertility investigations.

In the 1973-78 cohort, when the women were 37-42 years old,  22% of women trying to become pregnant had endometriosis compared to only 12% of those already pregnant and 12% who were not trying. The figures for PCOS reveal a comparable situation; 19% of those trying to conceive had PCOS, compared to 11% who were already pregnant and 9% who were not trying.

In the 1973-78 cohort, when the women were 37-42 years old, 22% of women trying to become pregnant had endometriosis compared to only 12% of those already pregnant and 12% who were not trying. The figures for PCOS reveal a comparable situation; 19% of those trying to conceive had PCOS, compared to 11% who were already pregnant and 9% who were not trying.

In the 1973-78 cohort, when the women were 37-42 years old, 22% of women trying to become pregnant had endometriosis compared to only 12% of those already pregnant and 12% who were not trying. The figures for PCOS reveal a comparable situation; 19% of those trying to conceive had PCOS, compared to 11% who were already pregnant and 9% who were not trying.

When the 1989-95 cohort were 24-30 years old, 27% of women trying to become pregnant had PCOS compared to 21% who were already pregnant and 14% who were not trying. The prevalence of endometriosis was similar for pregnant women (14%) and those who were trying to conceive (13%). Both these groups were slightly more likely to report endometriosis than women not trying to conceive (9%).

When the 1989-95 cohort were 24-30 years old, 27% of women trying to become pregnant had PCOS compared to 21% who were already pregnant and 14% who were not trying. The prevalence of endometriosis was similar for pregnant women (14%) and those who were trying to conceive (13%). Both these groups were slightly more likely to report endometriosis than women not trying to conceive (9%).

When the 1989-95 cohort were 24-30 years old, 27% of women trying to become pregnant had PCOS compared to 21% who were already pregnant and 14% who were not trying. The prevalence of endometriosis was similar for pregnant women (14%) and those who were trying to conceive (13%). Both these groups were slightly more likely to report endometriosis than women not trying to conceive (9%).

How prevalent are fertility issues?
And are women seeking help?

ALSWH investigated the prevalence of fertility issues in the 1989-95 and 1973-78 cohorts and explored whether or not women sought help through assisted reproductive technologies (ART). Chapter 7 of the Reproductive Health Report defines fertility issues as occurring when a woman couldn’t fall pregnant after 12 months of regular unprotected intercourse.

The prevalence of fertility issues was similar at equivalent ages for women born 1989-95 and 1973-78.

We found that while it was more common for women in the 1973-78 cohort to seek help, the younger generation of women in the 1989-95 cohort actually started using assisted reproductive technologies earlier and more frequently.

In the 1989-95 cohort, 6% of women reported fertility issues at age 24-30. For women born 1973-78, fertility issues increased from 4% at age 22-27 to 24% by age 40-45.

Assisted Reproductive Technologies

Chapter 7 of the Report details the 1973-78 cohort's self-reported use of IVF, ovulation induction, and fertility hormones. We use MBS data to investigate women's use of ART according to demographic characteristics, age, treatment types, and their number of cycles, and costs.

ART from 1996-2020. Average cycyles 4.6. Ranging from 1 to 36 cycles. Average time on ART - 2 years. Ranging from 1 to 18 years. Average out of pocket expense $7536. Average MBS paid $12,296

Number of ART cycles

Overall, the 1989-95 cohort started ART sooner and have used it at higher rates when compared to the 1973-78 cohort. Across both cohorts so far, women have undertaken 1 to 36 cycles, with an average of 4.6 cycles per woman. Most women (72%) had only accessed IVF, rather than intra-uterine insemination (IUI).

Women who undertook more ART cycles tended:

  • to have endometriosis
  • had not given birth before starting ART treatment
  • reported one rather than two or more births across all surveys (note that we cannot tie births to ART).

Age at treatment

Women in the 1989-95 cohort who engaged with ART services early (aged 17-24) were less likely to have a partner compared to women who engaged ART services later in life. Conversely, women born 1973-78 who engaged with ART services later (aged 40-45) were less likely to have a partner than women who engaged ART services earlier in life.

Women who engaged with ART services late in their reproductive life (aged 40 45; 1973-78 cohort) tended to report that they had not given birth by 40-45 years.

Reproductive health problems and ART

The prevalence of reproductive health problems was high among women accessing ART services:

  • 25% of women born 1989-95 and 1973-78 reporting endometriosis,
  • 20% of women born 1973-78 reporting PCOS
  • 42% of women born 1989-95 reporting PCOS.

Slightly more women with endometriosis used both IVF and IUI, and more women with PCOS used IUI.

Implications for policy and practice
Overall, 9-15% of women reported reproductive health problems (endometriosis and PCOS). In the linked MBS data for ART treatment, this rose to 20-42%. Women with endometriosis had undertaken a higher number of ART cycles on average. This suggests reproductive health problems are prevalent, and that more women with reproductive health problems are likely to seek ART treatment.

For more information

Chapter 7: Patterns of pregnancy and ART
Authors: Katrina M Moss, Richard Hockey, Emma Byrnes & Gita D Mishra

Contact: Dr Katrina Moss

Perinatal Mental Health

Studies using data from ALSWH participants in the 1973-78 cohort have contributed to the body of research on perinatal mental health in Australia. Previous analyses contributing to the evidence base for policy development have identified risk factors for perinatal mental health disorders, examined health care costs and the optimal timing of mental health interventions and evaluated aspects of perinatal mental health screening. Chapter 8 of the Reproductive Health Report highlights these findings. It also provides an update on perinatal mental health screening and prevalence in the 1973-78 cohort and the younger 1989-95 cohort who are entering their peak childbearing years. These findings provide a basis for policy development to improve the identification and treatment of perinatal health disorders among Australian women.

Screening for perinatal depression and anxiety

Rates of screening for perinatal mental health have increased, with 85% of women born 1973-78 reporting being screened in 2009, compared to 91% of women in 2018.

Women in the 1989-95 cohort with no formal qualifications were less likely to report being screened for perinatal mental health issues than those women with higher qualifications.

Previous research based on ALSWH data has shown that routine mental health assessment is positively associated with help-seeking during the perinatal period. However, clinicians need to provide referral pathways (Reilly et al., 2014). A separate analysis (Reilly et. al., 2013) found that when clinicians inquired into women’s past and current mental health, they increased initiation of referrals for additional support in the perinatal period.

Screening may not pick up the women who are most in need of support:
- 20% of women did not always respond honestly when asked about their emotional wellbeing.
- 40% were not comfortable being questioned about their emotional wellbeing by a health practitioner.

Women who were uncomfortable with mental health screening were four times more likely to report perinatal anxiety and twice as likely to report perinatal depression as those who did feel comfortable (Forder et al., 2020).

Implications for policy and practice
The approach to perinatal mental health screening needs to be improved to increase women’s comfort with their clinicians and encourage honesty. Screening should investigate women’s past and current mental health experiences and provide a clear referral pathway.

Prevalence of perinatal depression and anxiety

Women born 1989-95 have higher perinatal depression and anxiety rates than women born 1973-78. For women born 1989-95 and 1973-78, postnatal diagnoses for depression and anxiety were more common than antenatal diagnoses.

Antenatal anxiety and postnatal anxiety over time for women born 1989-95 and 1973-78.

graph showing increasing rates of Antenatal anxiety and postnatal anxiety over time for women born 1989-95 and 1973-78.

Antenatal depression and postnatal depression over time for women born 1989-95 and 1973-78.

Graph showing Antenatal depression and postnatal depression over time for women born 1989-95 and 1973-78.

Implications for policy and practice
The higher prevalence of mental health issues in women born 1989-95 needs to be investigated further as a matter of urgency. The already high rates of perinatal mental health issues in the 1989-95 cohort are likely to increase as more women in this age group start families, and those who have children continue to grow their families.

What are the impacts of poor mental health before conception?

Pre-conception mental health

Longitudinal data collected from mothers participating in ALSWH have shown that having a prior history of mental health issues increases the risk of perinatal mental health issues.

Women who were diagnosed or treated for depression three or six years before pregnancy were more than twice as likely to experience postnatal depression as those had not reported depression. (Chojenta et al., 2012).

Similarly, a 2020 study provided evidence for the link between pre-conception maternal depression and poorer maternal mental health and parenting post-birth. This study highlighted pre-conception as the optimal time for depression interventions (Moss et al., 2020).

Health care costs

Women with a history of poor mental health faced higher health care costs in the perinatal period, compared to those without such a history (Chojenta et al.,2019).

Those with a history of poor mental health averaged 11% higher costs per birth, regardless of birth type (i.e. vaginal, instrumental, caesarean) and private health insurance status.

Implications for policy and practice
ALSWH research and data underscores the urgent need to investigate the factors contributing to poor mental health in young women. Improvements in mental health in the pre-conception period will help to reduce the cost of childbirth and improve women’s quality of life, their parenting styles – and related child outcomes.

Are traumatic birth experiences affecting women's mental health?

For the purposes of the Reproductive Health Report, traumatic birth experiences include emergency caesarean, labour lasting more than 36 hours, emotional distress during labour, or stillbirth.

46% of the 1989-95 cohort and 37% of the 1973‑78 cohort experienced a traumatic first birth.

Traumatic birth experiences among first births for Australian women born 1989-95 and 1973-78

Traumatic birth experiences among first births for Australian women born 1989-95 and 1973-78

Traumatic birth experiences were associated with an increase in the risk of perinatal depression or anxiety, even after controlling for selected socioeconomic and demographic factors and history of mental health issues.

Women in the 1989-95 cohort who had experienced a traumatic birth had 74% higher chance of being diagnosed with postnatal depression and anxiety, compared with women who did not experience a traumatic birth.

Similarly, women from the 1973-78 cohort who had experienced a traumatic birth had 63% higher odds of being diagnosed with postnatal depression and anxiety, compared with women who did not experience a traumatic birth.

Implications for policy and practice
The high prevalence of traumatic births and the association between traumatic births and poor perinatal mental health underscore the need to enquire about past traumatic birth experiences as part of perinatal mental health screening in subsequent pregnancies.

For more information

Chapter 8: Perinatal mental health
Authors: Deborah Loxton, Natalie Townsend, Peta Forder, Isabelle Barnes

Contact: Prof Deb Loxton

Menopause

Menopause marks the end of a woman's reproductive years when the ovaries no longer release an egg every month, and menstruation stops. The time before menopause, known as the menopause transition, may last for ten years or more and is marked by a range of symptoms. Menopausal Hormone Therapy (MHT) is the most effective treatment to manage vasomotor symptoms (VMS) such as hot flushes and night sweats.

Menopause usually occurs between 45 and 55 years of age. Menopause before age 45 is called early menopause. Early menopause may occur naturally or following chemoradiation or removal of both ovaries (oophorectomy).

Chapter 9 of the Reproductive Health Report includes new analyses and previous research findings on four main topics: natural menopause, hysterectomy/oophorectomy, VMS, and MHT.

How do age at menopause and type of menopause red-flag future health issues?

Age at menopause

Premature and early menopause are risk factors for chronic disease in later life. In the 1946-51 cohort, 90% of women reached natural menopause by age 55, with an average age at 50.9 years. However, 1.3% experienced premature menopause (earlier than 40 years), and 5.8% experienced early menopause (40-44 years).

Women from the 1946-51 cohort who were less educated; separated, divorced, or single; or who were financially stressed all the time were more likely to have a slightly earlier age at menopause.

Menopausal status of the 1973-78 cohort at age 40-45 years

Menopausal status of the 1973-78 cohort

The 1973-78 cohort are approaching the menopause transition. At age 40-45, almost 10% have already reached menopause. This is similar to the prevalence of menopause in other studies. Based on women’s survey responses about their periods and menstrual regularity we know that about 20% had entered perimenopause and half were still premenopausal. We couldn’t determine a menopausal status for 13% of women who were on the pill.

Early menopause

Risk factors for early menopause

Research from ALSWH and the InterLACE consortium has shown that certain socio-economic, demographic, lifestyle, reproductive and social and environmental factors are associated with premature menopause (earlier than 40 years) and early menopause (40-44 years). The International collaboration for a Life course Approach to reproductive health and Chronic disease Events (InterLACE) combines data from 26 women’s health studies, including ALSWH.

Cigarette smoking icon
scales icon
Menstrual pad icon
Icon of a baby sleeping on its stomach

Smoking

Women who currently smoked were at twice the risk of premature menopause (earlier than 40 years), while the risk was considerably lower for women who no longer smoked (only 15% increased risk), compared with women who had never smoked.

Women who had quit smoking for more than ten years had a similar risk as those who had never smoked, suggesting women should quit smoking early, preferably before the age of 30 years (Zhu et al., 2018).

Weight

Underweight women (BMI less than 18.5 kg/m2) had over twice the risk of early menopause (<45 years). In contrast, women in the overweight or obese BMI category had a 50% increased risk of late menopause (≥56 years).

These findings highlight the role of optimal weight in reducing the risk of early or late menopause (Inter et al., 2019).

Early first period

Women who had their first period before age 11 had an 80% increased risk of premature menopause compared with those who got their periods at age 13 (Mishra et al., 2017).

Number of children

The combination of having an early first period and never having children resulted in a five-fold increased risk of premature menopause, compared with women who got their first period at age 12 or older and women who had two or more children (Mishra et al., 2017).

Early menopause and cardiovascular disease

Research using ALSWH data has shown that women who enter menopause before age 40 (premature menopause) have 1.5 times higher risk of cardiovascular disease (CVD). They also have twice the risk of having a CVD event before 60 (Zhu et al., 2019).

Supporting evidence also shows that women with a very short reproductive lifespan (less than 30 years) were at 1.7 times higher risk of CVD than those with a reproductive lifespan of 36-38 years (Mishra et al., 2020).

Implications for policy and practice
Women who experience premature or early menopause need early screening tests (e.g., blood pressure, lipids, blood glucose) to monitor their cardiovascular health before age 60.

Hysterectomy and oophorectomy

Hysterectomy is one of the most common gynaecological procedures performed in developed countries. In the past, bilateral oophorectomy (removal of both ovaries) was commonly performed during hysterectomy for benign diseases to prevent ovarian cancer. Removal of normal ovaries is no longer recommended apart from women at high inherited risk of ovarian cancer.

Prevalence

In the 1946-51 cohort:

  • 37.9% of women had had a hysterectomy and/or oophorectomy by age 68-73 years
  • 12.6% reported a hysterectomy with bilateral oophorectomy (surgical menopause)
  • The average age at hysterectomy was 46.3 years, with one third occurring before age 45.

In the 1973-78 cohort:

  • 5.7% of women had undergone a hysterectomy and/or oophorectomy by age 40-45 years
  • 0.8% reported a hysterectomy with bilateral oophorectomy. 

Health risks related to having a hysterectomy or oophorectomy

Research from ALSWH and InterLACE have looked at the health risks related to hysterectomy and oophorectomy.

Surgical menopause before age 45 was associated with an additional risk of cardiovascular disease, compared with natural menopause at the same age (Zhu et al., 2020a).

Women with a hysterectomy and/or oophorectomy were at a higher risk of type 2 diabetes than pre and perimenopausal women (Pandeya et al., 2018).

Having a hysterectomy with ovarian conservation before the age of 50 did not increase women's risk of death (all-cause mortality) compared to women without a hysterectomy. However, women who had a hysterectomy and bilateral oophorectomy before age 50 and who did not take MHT had an increased risk of premature mortality (Wilson et al., 2019).

Implications for policy and practice
These findings on chronic diseases lend support to the position that normal ovaries should not be removed at the time of hysterectomy before age 50, except in women at high inherited risk of ovarian cancer.

Do menopausal symptoms red-flag future health issues?

Vasomotor Symptoms – hot flushes and night sweats

Vasomotor symptoms can be incredibly disruptive to women's lives and are linked to sleeping difficulties and depressed mood. They are also an important indicator of future chronic health conditions. Previous ALSWH research has shown that hot flushes and night sweats are associated with an increased risk of cardiovascular disease. Women who experience both are at greater risk of CVD than women who only experience hot flushes or only experience night sweats.

Prevalence and experience of VMS

In the 1946-51 cohort, the prevalence of hot flushes peaked, with almost 25% of women experiencing hot flushes 'often' at age 50-58 years. Only 6% still experienced hot flushes 'often' at age 68-73. Similarly, the prevalence of night sweats peaked at age 50-58 years, but it was lower than that of hot flushes (16.9% vs 24.2%).

6% of women still experienced hot flushes 'often' at age 68-73.

ALSWH has profiled the 1946-51 cohort's experiences with hot flushes. We identified five symptom profiles over a 20-year period which show the progression of symptoms. Women's experiences with night sweats fit a similar profile.

icon - move phone to landscape orientation

Best viewed in landscape.

Best viewed in landscape.

Nearly two thirds of the cohort (62.2%) only experienced minimal hot flushes across this period of their lives.

Over 20% of women experienced later onset of hot flushes. This group was characterised by a peak in the prevalence of hot flushes at age 53-58 years or after.

About 6% of women were still experiencing hot flushes at age 68-73 years (Later onset, not resolved).

The majority of women who experienced later onset of hot flushes (17.4%) reported that their hot flushes had ceased by age 62-67 years (Later onset resolved).

About 3% of women experienced hot flushes throughout the survey period (Persistent group).

Around 10% of women experienced early onset of hot flushes at age 45-50. The prevalence peaking at age 47-52 years, followed by a steady decline in frequency as the women aged (Early onset group).

Predictors of hot flushes and night sweats

Although menopause-related hormonal changes are associated primarily with VMS, previous ALSWH and InterLACE studies have shown that certain lifestyle factors and diet were also associated with the frequency and severity of VMS.

Higher risk of VMS was associated with:

  • cigarette smoking
  • having a BMI in the overweight/obese range
  • high fat-sugar diet.

Lower risk of VMS was associated with:

  • high intakes of soy products (but not soy milk)
  • eating fruit, and the Mediterranean diet
  • quitting smoking – women who quit before age 40 had a similar level of risk as never smokers.

Implications for policy and practice
Age and type of menopause should be considered as an important factor when assessing CVD risk for women. Women with early menopause, having had a hysterectomy and/or oophorectomy, and experiencing frequent/severe vasomotor symptoms need early screening tests (e.g., blood pressure, lipids, blood glucose) for monitoring cardiovascular health before age 60.

Seeking help for symptoms

Three in four women from the 1946-51 cohort who often experienced hot flushes sought help at age 45-50. By age 59-64 only one in four women who often experienced hot flushes sought help.

Around 20-25% of women who sought help for hot flushes reported that they were not satisfied with the support given.

The proportion of women seeking help for night sweats was similar to those with hot flushes, as was their satisfaction with the support given.

In the 1973-78 cohort, less than 3% of women reported that they often experienced hot flushes or night sweats at age 37-45 years. Thirty-one per cent of these women sought help. By age 40-45, 41% of women with night sweats sought help.

Menopausal Hormone Therapy

In the 1946-51 cohort, the use of MHT peaked at age 50-55 years (33%). About 7% of women were still taking MHT at age 68-73 years. Among women taking MHT at age 45-50, 52.4% reported a hysterectomy and/or bilateral oophorectomy.

In the 1973-78 cohort, 1% reported currently taking MHT at age 40-45 years. Of these, 40% reported a hysterectomy and/or bilateral oophorectomy.

For more information

Chapter 9: Menopause
Authors: Hsin-Fang Chung, Katrina Moss, Gita D Mishra.

Contact: Dr Hsin-Fang Chung

Family planning and use of contraceptives during the

COVID-19 pandemic

Chapter 10 of the Reproductive Health Report illustrates women’s lived experiences during the COVID-19 pandemic. To capture the impact of the COVID-19 pandemic on women’s health and wellbeing, ALSWH deployed a series of short, online surveys. Each fortnight, the same questions were asked concerning COVID-19 symptoms, testing, general health, and stress. Brief questions on specific topics were also included, with the topics changing each fortnight.

At the 10th COVID-19 survey (2‑15 September 2020), women from the two youngest cohorts (aged 25-31 years and 42-47 years) were asked about the impact of the pandemic on their plans for pregnancy and about contraceptive use during the pandemic.

We also invited survey participants to elaborate on their experiences through free text comments. Qualitative analysis of the women’s comments revealed several themes, including reproductive and sexual health service use, contraceptive practices, sexual activity, fertility issues, attitudes towards having children, and pregnancy and birth.

Changes to sexual activity

Women described changes to sexual activity during the pandemic, such as having limited opportunities for sexual activity or reduced interest in sex. The impact of the COVID-19 crisis on single women’s sexual activity was apparent.

"Single. Stage 4 lockdown. No sexual prospects possible."
(1989-95 cohort participant)

"I’m single and not currently sexually active and that’s unlikely to change while socially distancing is still recommended."
(1989-95 cohort participant)

"I have not been intimate with my husband during covid, I think we are just too stressed and too tired"
(1973-78 cohort participant)

Changes to contraception during the pandemic

14% of women aged 25-31 years and 3% of women aged 42-47 years indicated that their contraception use had changed since the pandemic began.

Compared to data collected at the last main ALSWH survey of women born 1989-95 (2019), women during the pandemic were less likely to use condoms, more likely to use LARC, and more likely to use no contraception. Overall, the differences were minimal and reflected changes that occurred both within the context of the pandemic and those changes in use that ordinarily occur as time passes.

During the COVID-19 pandemic, women from the 1973-78 cohort were less likely to report using condoms (9% versus 15%), and more likely to use no contraception (49% versus 46%), compared to contraceptive methods reported before the pandemic (reported at the last main ALSWH survey in 2018).

6% of women aged 25-31 had difficulty accessing contraceptives. 2% of women aged 42-47 had difficulty accessing contraceptives.

Most women indicated that they could access their usual contraception during the pandemic. Among women aged 25-31, 6% reported difficulty accessing contraception, most commonly the OCP (4%) and the progesterone IUD (1%). Of women aged 42-47, 2% reported difficulty accessing contraception, most commonly the OCP (1%).

The qualitative data suggest that difficulty with accessing contraception was distressing. For some women, limited access to reproductive and sexual health services created unintentional consequences, including additional stress and costs, and prolonged pain or side effects.

"I was still able to access a contraceptive implant but the supplier did change as well as the cost. My appointment with Family Planning was cancelled with no replacement appointment offered. Fortunately my local health centre offered to put in for me instead. The cost difference was about $150…"
(1973-78 cohort participant)

"…The pill I was [supposed] to get is out of stock Australia wide and will take a few weeks to get shipped in so am without for a few weeks."
(1989-95 cohort participant)

"Changing contraception due to lack of availability of the pill I was on before has had a massive negative impact. I tried a number of pills before settling on a pill. The pills I initially tried had massive side effects on my mental health. Having to move to another pill thus caused a large amount of stress and anxiety and the new pill has again caused negative side effects and severe anxiety."
(1989-95 cohort participant)

Changes to pregnancy plans

10% of women aged 25-31 changed their pregnancy plans. 1% of women aged 42-47 changed plans

Younger women were more likely to change their pregnancy plans than older women. In their free-text comments, women wrote of limited maternal health service use, economic instability, additional stress, and uncertainty as reasons contributing to their change of mind on pregnancy and having children.

“My partner wants to begin the process of IUI and then IVF if unsuccessful but she wants to carry the baby. However due to IVF being an elective surgery that has been cancelled, it has been postponed.”
(1989-95 cohort participant)

“My plans have not changed around pregnancy (I am still unsure about ever having children) and in fact this crisis has given me further reason not to become a mother. It seems very counterintuitive to bring another person I love into a world like this one.”
(1989-95 cohort participant)

The qualitative data revealed the depth of feeling evoked by the pandemic with regard to having children. Women's responses were not all negative. For some, the COVID-19 crisis has been a catalyst confirming the desire to have children.

“This year has been intense in so many ways and I think just seeing how our relationship has held strong, and we’ve survived what has happened personally, and throughout the world, that has helped confirm the decision to have kids.”
(1989-95 cohort participant)

“I’m actually doing IVF as a single person because I’ve had a frozen embryo in storage for several years. There seemed like no better time than to give this one last go.”
(1973-78 cohort participant)

Pregnancy and birth during the pandemic

One of the most prominent themes drawn from the comments concerned the difficulties associated with being pregnant and giving birth during the COVID-19 crisis. This included the multifaceted struggle of many women from the 1989-95 cohort experiencing pregnancy and the postpartum period while living through a pandemic.

"I gave birth in March 2020 to my first baby. So I’ve been navigating COVID alongside navigating post-partum, often it’s hard to tell which major event has affected me more."
(1989-95 cohort participant)

Women wrote about the challenges of restrictions on travel and social gatherings how difficult it was to access emotional and practical support.

"My baby was born at the start of the pandemic. It really impacted my mental health as I was isolated and only had my partner and baby."
(1989-95 cohort participant)

"There was a time when I was pregnant since covid began and covid made keeping the baby impossible as my family are in NSW and I’m Victoria and I couldn’t see there being any support to do it on my own."
(1989-95 cohort participant)

An overwhelming number of comments were also made about shortfalls of perinatal health care during the COVID-19 crisis.

"Covid caused me to have less prenatal visits throughout my pregnancy. My birth class was also cancelled so I felt I didn’t receive the knowledge people normally would for birth."
(1989-95 cohort participant)

"Partner hasn’t been allowed to attend appointments. I was admitted to hospital this week due to reduced movement of baby and my partner was not allowed to enter the hospital with me. This was extremely stressful and difficult for us both."
(1989-95 cohort participant)

For more information

Chapter 10: Family planning and the use of contraceptives during the COVID-19 pandemic
Authors: Natalie Townsend, Peta Forder, Emma Byrnes, Isabelle Barnes, Deborah Loxton

Contact: Ms Natalie Townsend

Reproductive health: Contraception, conception, and change of life – Findings from the Australian Longitudinal Study on Women’s Health
Loxton D, Byles J, Tooth L, Barnes I, Byrnes E, Cavenagh D, Chung H-F, Egan N, Forder P, Harris M, Hockey R, Moss K, Townsend N & Mishra GD.
Report prepared for the Australian Government Department of Health, May 2021.

ISBN: 978-1-76007-460-9        


Stay informed


Acknowledgments

The research on which this report is based was conducted as part of the Australian Longitudinal Study on Women’s Health by researchers from the University of Queensland and the University of Newcastle. We are grateful to the Australian Government Department of Health for funding and to the women who provided the data. The authors also acknowledge the The Australian Government Department of Health, Department of Veterans’ Affairs (DVA), and Medicare Australia, for the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme linked health records used.

We would like to thank the University of Newcastle and the Hunter Medical Research Institute for providing funding for the COVID-19 surveys.

The authors would like to thank the following stakeholders for their advice and expertise regarding the content of this report:

  • Professor Deborah Bateson, Medical Director, Family Planning NSW
  • Arabella Gibson, CEO, Gidget Foundation Australia
  • Professor Martha Hickey, Professor of Obstetrics and Gynaecology, The University of Melbourne