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Contraception during perimenopause

Women can still get pregnant during peri-menopause. Whilst your still having periods, and releasing eggs you need to use contraception if you don't want to have a child. This explains how contraception works alongside hormone therapy for your menopause symptoms.

How long do I need to be on contraception?

If you are still having periods, even if they are not regular, you should assume that your ovaries are still working. This means you could get pregnant. So if you are not looking to have a child you should use contraception.

Perimenopause is the years before your periods stop completely. You may experience some menopausal symptoms and your periods might become more irregular. During this time your ovaries are still releasing eggs and so you could still get pregnant. Your periods might get closer together at first, and then you can go several months without a period, and then restart.

Menopause is a year without periods and it happens because your ovaries stop producing eggs. If there's no other medical reason for your periods stopping (including medication) you can assume a year without periods means you're postmenopausal. You do still need to use contraception for at least 1 year after your last period to avoid pregnancy if you are over 50, or 2 years if you are under 50.

What is the difference between hormone replacement therapy (HRT) and a combined contraceptive pill?

HRT works by topping up your hormones oestrogen and progesterone to avoid the natural drop in their levels at the menopause, which causes symptoms.

The combined contraceptive pill (COCP) uses much higher doses of those hormones to stop your body producing eggs (ovulating). This is a popular method of contraception, but women need to consider this form carefully once they are over 40. This is because it can increase your cardiovascular disease risk. If you want to keep taking this pill over the age of 40, you should be making sure to get regular blood pressure checks and seeing your doctor as advised. It can't be used with HRT. If you are a fit and healthy COCP user this medication does provide some of the same benefits as HRT like protecting your bones from weakening. If you do continue to take this pill in your 40s, you should stop as you approach your 50s. The COCP often masks or reduces menopausal symptoms, but as the dose of hormones is higher than the ‘natural’ levels it should not be taken over the age of 50. The higher hormone levels can cause an increased risk of blood clots, and if you are a smoker you should not take it above the age of 35 years, as it is associated with increased cardiovascular risk.

Is HRT a contraceptive?

No! Hormone replacement therapy is one way to reduce your menopause symptoms. It works by topping up the hormones oestrogen and progesterone (only needed if you have a womb). Although HRT and some contraceptives work by increasing these hormones the dose of hormones in HRT is much lower.

The lower dose of hormones in HRT does not stop your ovaries releasing eggs. So it does not provide protection from getting pregnant.

Can I use the combined contraceptive pill for HRT?

The COCP will often improve symptoms. It can be used in different ways on the advice of your doctor For example if you suffer from bad PMT, mood swings or have headaches around the time of your withdrawal bleed (period) you might be able to take it continuously, rather than stopping every 21 days. You should discuss this with your doctor or family planning clinic.

The COCP is not suitable for everyone. You will need to switch to HRT aged 50, as the lower dose of hormones in HRT is safer at that age.

Will using contraceptives like the pill delay my menopause?

No. There's very little evidence to suggest any forms of contraception impact the timing or onset of menopause. Taking the COCP may mask your symptoms, so you may not be aware you are perimenopausal.

What types of contraception can I take during perimenopause?

All types of contraception that are safe for you personally are safe during perimenopause. Your doctor or family planning clinic can advise on your personal risk. Or look at the family planning association sexwise website https://www.sexwise.fpa.org.uk/

But if you want to take HRT to reduce your symptoms only some forms of contraception are recommended.

  • Progesterone only pill (mini-pill): This pill has fewer risks than the COCP and can be used safely alongside HRT.

  • Implant: The implant is sometimes used to help with painful or heavy periods. It's inserted under the skin and last for 3 years. It works by releasing the hormone progesterone. Like with the mini-pill it can be used safely with HRT.

  • Injection: The injection is a 3-monthly progesterone based contraceptive. It can work well for women who can't easily remember to take a pill, and can also help with heavy, painful periods. Like with the implant and mini-pill this contraceptive can safely be with HRT.However it is associated with some thinning of the bones, so may not be suitable for people at higher risk of osteoporosis (thinning of bones).It is not used over the age of 50 years.

  • 52mg Levonorgesterol IUS or Mirena coil: This intrauterine system (IUS) or ‘ coil’ slowly releases progesterone into the womb. It can be a great choice for women in their 30s and 40s because it's long acting (doesn't need regular appointments or renewals); it thins the lining of the womb and reduces heavy periods; and can act as the progesterone part of HRT. So you'll only need the oestrogen part of the HRT. It does need to be changed every 5 years if used for both HRT and contraception.

  • Copper coil: This is the non-hormonal coil. It's safe to use in your 40s and 50s, and can be used alongside HRT. You'll need both the progesterone and oestrogen parts if you use the copper coil.

  • Condoms, female condoms, diaphragms and cervical caps ('Barrier Methods'): These methods are safe and effective at any age. You need to be discplined about using them during sex to protect yourself from pregnancy. They're safe to use with HRT. The barrier methods are also the only form of contraception that protect against STIs. So if you're in a new relationship, or have multiple partners barrier methods are recommended. Also make sure that if you are changing partners you also have a routine STI check.

  • Emergency contraception: If your usual method fails, or you have sex without contraception don’t forget you can get emergency contraception from your GP, some pharmacies, and family planning clinics. It is important to contact them as soon as possible after sex, as the earlier you take the treatment, the better the chance of not getting pregnant. There are both pills, or emergency coils that can be used.

  • Male vasectomy or female sterilisation ‘getting your tubes tied': Both forms of sterilisation are effective if you know that you no longer want to have children. The operation to have your tubes tied as a women is slightly higher risk than a male vasectomy. It is worth knowing that a Mirena IUS is about as effective as sterilsation, and easier, safer and can be used as part of HRT.Your doctor should explain the risks and benefits to your as a heterosexual couple.

Are all the progesterone forms of contraception an alternative to the progesterone part of HRT?

No. Only the mirena coil can be used instead of the progesterone part of HRT. The other progesterone contraceptives (POP, implant and injection) are safe to use with HRT but you do need the micronised progesterone part of HRT in addition.

When should I come off my contraception?

If you're under 50 then in the UK it's advised that you should use contraception for 2 years after your last period. If you're over 50, this is shortened to 1 year. In general, it's advised that women can stop contraception after the age of 55 even if you're still having periods. This is because the chance of conceiving is so much lower at this age.

Can I tell by my pattern of bleeding if I am menopausal?

Irregular periods, with hot flushes, and other symptoms suggest that you are menopausal. Irregular periods are common during menopause but other changes in bleeding patterns like inbetween periods, bleeding after sex, or very heavy periods should be discussed with a doctor in case these are symptoms of different medical problems.

How do I know if I have gone through the menopause?

It can be hard to know when your menopause is if your contraception gives you monthly bleeds (e.g. the 'withdrawal bleeds' from the combined contraceptive pill). Other progesterone only forms of contraception like the IUS, POP, implant or injection can stop your periods all together. This does not mean you have reached natural menopause. The average age of menopause in the UK is 51 years.

If you are on the progesterone only pill you can take a blood test whilst taking it to see if you are menopausal.. You may have to do this privately. This blood test will measure your follicle stimulating hormone (FSH) level. If the FSH level is high you'll need to keep taking contraception for 2 years after your last period if under 50, and one more year if over 50. If it's normal, you need to stay on contraception. This is not useful if you are on the COCP, and high doses of progestogens, such as those seen in the contraceptive injection or the implant can impact the blood test.

Usually you should review your contraception at the age of 50, as you may need to change methods depending on your personal health. This time is a good opportunity to consider HRT for any menopausal symptoms if you have not already done so.

References:

  1. FSRH Clinical Effectiveness Unit, 2019. FSRH Clinical Guideline: Contraception For Women Aged Over 40 Years (August 2017, Amended September 2019) - Faculty Of Sexual And Reproductive Healthcare. [online] Fsrh.org.
    Available at: http://www.fsrh.org/pdfs/ContraceptionOver40July10.pdf [Accessed 26 March 2020].

  2. Brotherston, J., 2015. Contraception meets HRT: seeking optimal management of the perimenopause. British Journal of General Practice, [online] 65(638), pp.e630-e632.
    Available at: https://bjgp.org/content/65/638/e630.

  3. nhs.uk. n.d. Menopause. [online]
    Available at: https://www.nhs.uk/conditions/menopause/ [Accessed 27 March 2020].