Contraception during the menopause and perimenopause

How to choose the type that best suits you

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

Although pregnancy is less likely during the 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. They can be used at any age and 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 years if you smoke or are overweight. In women who are fit and healthy, such as those without cardiovascular risk factors or migraines, taking the pill can have considerable benefits in regulating periods and reducing the heaviness of flow. It can also be used in place of hormone replacement therapy (HRT) to treat menopausal symptoms and prevent osteoporosis in women under the age of 50 years [1].

The progestogen-only pill (POP, also known as the ‘minipill’) has fewer risks associated with it and can be taken safely at any age, for as long as contraception is required. On the progestogen-only pill, periods can become irregular, stop altogether or last for longer. It can help with heavy, painful periods.

The contraceptive injection (Depo Provera and Sayana Press) is a three-monthly injection. It is a good option for some women as it can be a useful treatment for heavy periods. It is also helpful for those who might forget to take a daily pill. Alternative options should generally be considered if a woman has other risk factors for osteoporosis or once she reaches 50, and consideration should be given to switching to lower dose methods such as the POP or implant.

The contraceptive implant is a small plastic rod which is inserted under the skin of the 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.

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

Coils

There are several types of coil:

The copper coil is hormone free. If it is inserted after the age of 40, it can 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 hormone, which is released gradually. During the perimenopause it has three potential uses: as a contraceptive; a treatment for heavy periods – about half of women stop having periods with it – and it provides the progestogen component of HRT. If being used for the latter, it needs changing after five years.

Levosert is another coil containing the hormone progestogen. It has two potential uses: working both as a contraceptive and as a treatment for heavy periods. It cannot be used as HRT. Levosert needs changing every six years for contraception and every five years if used for the management of heavy periods.

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 alter or eliminate periods therefore most women opt for long acting contraceptive options, such as coils, implants or depo injections as they provide additional benefits to your 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, and 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. It is therefore best to switch to another contraceptive method when you are 50.

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

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Can HRT be used for contraception?

As HRT contains very low levels of hormones, it does not work as a contraceptive. If you are taking HRT, you can also take the progesterone only pill, or have a coil inserted, 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

1. 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

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