Contraception during the menopause and perimenopause Factsheet

Menopause is medically determined if it has been a year since your last period. The menopause occurs when your ovaries stop producing eggs and, as a result, the levels of your hormones called estrogen and progesterone fall.

The term ‘perimenopause’ is often used, as this is the time in which you experience menopausal symptoms but are still having periods. These periods are often scanty and more irregular than they used to be, but for some women they can occur closer together and be heavier.

Contraception does not affect the onset or duration of any menopausal symptoms, but it may mask the signs and symptoms of menopause.

How important is contraception?

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

Contraception is especially important as pregnancy and childbirth after the age of 40 years is associated with a higher chance of poorer outcomes for both the mother and baby, than in women under 40 years.

It is important to note that HRT contains only low levels of hormones and therefore it does not work as a contraceptive.

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. There are no age restrictions to the use of barrier methods. Barrier methods are also crucial for women in newer relationships and/or where there is any risk of a sexually transmitted infection.

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, e.g. coils, implants or depo injections as they provide additional benefits to your periods.

The Combined Oral Contraceptive Pill (COCP) is a popular choice in younger women but usually needs very 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 (i.e. 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 HRT to treat menopausal symptoms and prevent weakening of the bones (osteoporosis) in women under the age of 50 years.

The Progestogen­Only 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 progestogen­only 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 3­monthly injection. It is a good option for some women as it can be a useful treatment for heavy periods. It is also useful for those women 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 e.g. 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 Progestogen­OnIy Pill, contraceptive injection and contraceptive implant can all be safely used alongside HRT.

There are two types of coil:

The IUCD (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 IUS (Mirena® coil) contains a small amount of a progestogen hormone which is released gradually. It can be a very useful device during the perimenopause as it has three potential uses ­ as a contraceptive, a treatment for heavy periods (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 5 years.

When can contraception be safely stopped?

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

However, if you are taking the combined contraceptive pill, then your periods are happening because of the hormones (withdrawal bleeds), rather than due to your own menstrual cycle. If you are using a progestogen only contraception (such as the POP, implant, injection or Mirena coil) you might not have any periods, which can then be 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. It is important to note that you will need to stop taking the combined contraceptive pill at least 6 weeks before this blood test in order to get an accurate result (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 years old.

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.

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.