Contraception during menopause and perimenopause

How to choose the type of contraception that best suits you

In general, women can stop using contraception aged 55 but the age you are menopausal has an influence
There are lots of contraception methods but each one has its pros and cons
HRT contains very low levels of hormones so does not usually work as a contraceptive

Although pregnancy is less likely during perimenopause and menopause, it’s still important to use contraception to prevent an unplanned pregnancy. This is because it is possible to ovulate (produce an egg) when you are having periods, even if they are irregular.

The rate of women getting pregnant in their 40s is increasing. While most women in their 40s will have healthy pregnancies and babies, statistically there is an increase in complications. Contraception is especially important in this age group to prevent an unplanned pregnancy.

What is the best type of contraception?

There are various types of contraception available:

Barrier methods include male condoms, female condoms, diaphragms and cervical caps, all of which can be used at any age. Male and female condoms are crucial for women in newer relationships and/or where there is any risk of a sexually transmitted infection.

The combined oral contraceptive pill (COCP) is a popular choice in younger women but usually needs careful consideration in women over the age of 40. It should be avoided over the age of 35 if you smoke or are overweight.

Although some clinicians prescribe the combined oral contraceptive pill as an alternative to HRT for perimenopausal women, there are more risks associated with it than natural body identical hormones.

RELATED: Body identical hormones

The progestogen-only pill (POP, also known as the ‘minipill’) contains a synthetic type of progesterone that is associated with more side effects and risks than natural progesterone. Although it can help with heavy, painful periods, natural body identical progesterone is often preferable.

The contraceptive injection (Depo Provera and Sayana Press) is a three-monthly injection. It is an option for some women as it can be a useful treatment for heavy periods. However, it contains synthetic progesterone and is associated with more risks and side effects compared to natural progesterone.

The contraceptive implant is a small plastic rod that is inserted under the skin of your upper arm and lasts for three years. Bleeding with this can be very variable – periods may become irregular, stop altogether or last for longer. The implant may help with heavy, painful periods. However, it contains synthetic progesterone and is associated with more risks and side effects compared to natural progesterone.

The progestogen-onIy pill, contraceptive injection and contraceptive implant can all be used alongside HRT, if needed.

Coils

There are several types of coil:

The copper coil is hormone free. If it is inserted after the age of 40, it can usually be left in place until after the menopause.

The Mirena coil is one of several hormone-containing coils. The Mirena contains a small amount of a progestogen (a synthetic type of progesterone) hormone, which is released gradually. During perimenopause it has three potential uses: as a contraceptive; a treatment for heavy periods (it can reduce blood loss by more than 90% over six months for most women with heavy menstrual bleeding periods [2]); and it can be used with oestrogen as part of HRT to protect the lining of the womb. If being used as part of HRT, it needs changing after five years. If being used solely for contraception, then it can be used for eight years. If solely for heavy periods, then it lasts for five years.

Levosert and Benilexa are hormonal coils that also contain the hormone progestogen at the same dose as the Mirena coil, 52 mg of Levonorgestrel. Like the Mirena, they can be used as contraception, as a part of HRT or for heavy periods, the only difference being that if used for heavy periods then they have only been shown to be effective for up to three years rather than the five years seen with the Mirena.

The Kyleena coil contains the hormone progestogen and is used for contraception alone. It is slightly smaller than the Mirena and needs changing every five years.

The Jaydess coil also contains progestogen, is available for contraception and needs changing every three years.

Other options

Sterilisation can be undertaken for men and women. For men, it is safe and usually quick and easy to perform. In comparison, female sterilisation is associated with more risks. Female sterilisation does not usually alter or eliminate periods.

When can contraception be safely stopped?

The current guidelines are that if you are under 50 years old, then you should use contraception for at least two years, following your last menstrual period. If you are over 50, then you should use contraception for at least one year following your last menstrual period [2].

However, if you are taking the combined contraceptive pill, your periods are happening because of the hormones (withdrawal bleeds), rather than due to your own menstrual cycle. If you’re using a progestogen-only contraception such as the POP, implant, injection or hormone-containing coil, you might not have any periods, which can make it difficult to know when your menopause occurs.

If you are uncertain when your last period was, you can have a blood test to check your follicle stimulating hormone (FSH) level. If this hormone is elevated, you will need to continue using contraception for two years if you are under 50 years old, or one year if you are over 50 years old.

You will need to stop taking the combined contraceptive pill at least six weeks before this blood test is taken in order to get an accurate result, so use adequate protection in the meantime. However, if you are using the Mirena coil or POP, there is no need to remove/stop these. High doses of progestogens, such as those seen in the contraceptive injection, may affect the FSH result.

In general, all women can stop contraception when they are 55 as natural conception after this age is exceptionally rare, even in women still having some periods.

Can HRT be used for contraception?

As HRT contains very low levels of hormones, it does not usually work as a contraceptive. If you are taking HRT, you can also take the progesterone only pill, or have a coil inserted, or use other methods of contraception, if you require contraception. However, if you are taking a type of HRT that does not lead to periods then contraception is usually not necessary.

References

FSRH (2023): Contraception for women aged over 40 years

2. Cho MK. (2018), ‘Use of Combined Oral Contraceptives in Perimenopausal Women’, Chonnam Med J. Sep;54(3):153-158. doi: 10.4068/cmj.2018.54.3.153

3. Creinin MD, Barnhart KT, Gawron LM, Eisenberg D, Mabey RG Jr, Jensen JT. Heavy Menstrual Bleeding Treatment With a Levonorgestrel 52-mg Intrauterine Device. Obstet Gynecol. 2023 May 1;141(5):971-978. doi: 10.1097/AOG.0000000000005137