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
contraceptive use
ALSWH has tracked the health and wellbeing of 14,247 women born between 1973 and 1978 for over 25 years. Their data reveals trends in contraceptive choices as they navigated their 20s, had children, and now, aged 40-45, enter the menopause transition. In 2013 we started to survey the next generation of young women. The 17,010 women from the 1989-95 cohort are just entering their childbearing years – they were aged 24-29 in 2019. Both cohorts started their surveys between the ages of 18-23, allowing us to compare the two generations.
Are there generational differences in women’s contraceptive choices?
The 1989-95 cohort were surveyed annually and completed five surveys from age 18-23 to 24-29. In comparison, the 1973-78 cohort were only surveyed three times during this period.
Short term contraception
The oral contraceptive pill and condoms are the most common forms of contraception used by ALSWH participants. Women’s use of short-term contraception decreases as they reach their mid to late 20s and 30s, most likely reflecting the desire to have children.
The pill
Use of the oral contraceptive pill peaked earlier in the 1989-95 cohort than the 1973-78 cohort. At age 18-23, 60% of the 1989-95 cohort were using the pill. In comparison, use of the pill didn’t peak until age 22-27, when 56% of the 1973-78 cohort used this method of contraception.
Condoms
At age 18-23, more than twice as many of the 1989-95 cohort used condoms as the 1973-78 cohort at the same age: 45% compared to 19%.
No contraception
At age 18-23, only 9% of women in the 1989-95 cohort reported not using any contraception. In comparison, 30% of the 1973-78 cohort did not use contraception.
Long Acting Reversible Contraception (LARC)
We first asked the 1973-78 cohort about their use of LARC methods in 2009. Their use of LARC increases sharply as they finish having children. Almost a quarter of women use LARCS by age 40-45.
Around 25% of the 1989-95 cohort are using a LARC before age 30. This may reflect that they are more open to LARC methods or that LARCs are more easily available.
Can we predict which contraceptives
women will choose?
Women's contraceptive choices are complex, making predicting which contraceptives will be in demand difficult. This complexity is best illustrated with the transition plot below, reproduced from the ALSWH Reproductive Health Report. The transition plot shows the contraceptive choices made by women from the 1989-95 cohort. The animation reveals which contraceptives the woman used at their first survey. From survey to survey, the categories subdivide as women transition to different methods of contraception. After several surveys, the graph reveals the tremendous amount of change in the types of contraception used by individual women.
Implications for policy and practice
It is difficult to predict which contraceptive a woman will use from year to year. Therefore it is important to have a wide range of contraceptives available so that women can affordably access the most appropriate contraceptive method to meet their needs.
What factors are associated with women's contraceptive choices?
In Chapter 3 of the ALSWH Reproductive Health Report, we break down the prevalence of use of different types of contraceptives by socioeconomic, demographic and health behaviour characteristics. In Chapter 4, we investigate women’s patterns of contraceptive use around family planning and reproductive events (i.e. births, miscarriages and terminations).
We found some generalisable trends between generations in terms of health behaviours and personal experiences. However, there were mixed associations between socioeconomic factors and contraception use between cohorts. Overall, we would urge caution before generalising these same trends to the next generation of teens and young women.
Socioeconomic status
Among the 1989-95 cohort, higher socioeconomic status (reflected by higher levels of education and less income stress) was associated with greater use of the pill and condoms and less use of the implant or no contraception.
In contrast, we did not find these associations among women from the 1973-78 cohort.
Area of residence
Women in the 1989-95 cohort living in remote or rural areas had a higher prevalence of implant use or no use of contraception.
In comparison, women born in 1973-78 who lived in rural and remote settings had higher use of the pill.
Language spoken at home
In both cohorts, women who spoke a non-English language at home had higher use of condoms and no contraception.
Health behaviours
In both cohorts, women who reported engaging in less healthy behaviours (e.g., illicit drug use, smoking, low physical activity) or had a BMI in the overweight or obese categories were more likely not to use contraception.
The one exception to this trend was among women who drank high levels of alcohol.
Alcohol
In the 1989-95 cohort, women who consumed high levels of alcohol were more likely to use the hormonal IUD and less likely to use no contraception than women who consumed less.
In contrast, women from the older 1973-78 cohort who drank high levels of alcohol were less likely to use the pill and no contraception and were more likely to use condoms than women who drank less.
Reproductive events
Never pregnant: Across both cohorts, women who had never been pregnant had the highest use of the pill and condoms.
One child: Women who had one child were more likely to use no contraception, most likely reflecting the desire to have additional children.
Two children: Once women had two children, they were just as likely to use contraception as not use contraception.
Two or more children: In the 1973-78 cohort, women with two or three children showed increased uptake of LARCs as they aged.
Miscarriage: Across both cohorts, women who experienced a miscarriage between the ages of 18 and 25 years were generally equally likely to use the pill, condoms, or no contraception. Women who had a miscarriage in their late 20s and 30s were more likely not to be using contraception – most likely reflecting the desire to have a pregnancy.
Termination: Women from the 1989-95 cohort who had a pregnancy terminated when they were 18-23 years old were more likely to go on to use LARC at age 19-24. These women had generally higher use of the pill until they were 25 years old and higher use of condoms across all surveys. In contrast, during their 20s, 1973-78 cohort women were more likely to use the pill following a termination. In their 30s, they were more likely to use a LARC and less likely to use fertility awareness methods after experiencing a termination.
For more information:
Chapter 2: The prevalence of contraceptive use across the lifespan
Authors: Leigh Tooth, Richard Hockey
Chapter 3: Socioeconomic and health behaviour variations in the use of contraceptives
Authors: Leigh Tooth, Richard Hockey
Chapter 4: The use of contraceptives following reproductive events
Authors: Leigh Tooth, Richard Hockey
Contact: A/Prof. Leigh Tooth
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.
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?
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.
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
Reproductive outcomes
When we compare the two cohorts at similar ages, the differences in birth rate become apparent.
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.
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.
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.
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 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
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.
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.
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
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).
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
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