Contraception Choices During Perimenopause
As women approach menopause, contraceptive needs may shift, but it remains essential to continue using contraception until certain age milestones are reached. Even while exploring hormone replacement therapy (HRT), women have a variety of contraceptive options that can either be used alongside HRT or as alternatives.
When to Stop Contraception
Contraception should be continued until the age of 55 if you are still menstruating. Alternatively, it should be used for:
One year after menopause (no periods for 12 months) if you are over 50.
Two years after menopause if you are under 50.
Women over 50 may stop contraception after two blood tests six weeks apart show a follicle-stimulating hormone (FSH) level greater than 30, provided there’s another reason their periods have stopped, such as using progesterone-only contraception.
Combined Oral Contraceptive Pill
For many women, the combined oral contraceptive pill (COC) can be used safely until the age of 50, provided they:
Don’t smoke
Have a BMI under 35
Are free of cardiovascular disease and don’t have a high risk of blood clots.
There are two types of COC that contain estradiol, the same form of estrogen used in HRT: Zoely and Qlaira.
Zoely
Zoely contains a synthetic progestin called nomegestrol, structurally similar to natural progesterone and thought to be safer and better tolerated. It can be taken continuously to avoid withdrawal bleeding, making it especially useful for women with heavy or painful periods. As both hormones in Zoely (estradiol and nomegestrol) are used in HRT, this pill can serve as both contraception and HRT. However, in some regions, such as Wiltshire, it is only prescribed after trying two other COCs.
Qlaira
Qlaira is a phasic pill, meaning hormone levels vary throughout the cycle, aiming to mimic natural hormone fluctuations. It may reduce the mood-related side effects that some experience with other pills, though there’s no strong clinical evidence supporting its superiority over other COCs.
Contraceptive Vaginal Ring (Nuvaring)
The Nuvaring is inserted into the vagina for three weeks, with the option to remove it for a week (leading to a withdrawal bleed) or insert a new ring to prevent bleeding. As it delivers estrogen locally, this method is helpful for women experiencing vaginal dryness, itching, or recurrent urinary tract infections, which are symptoms of genitourinary syndrome of menopause. However, it’s only suitable for women who don’t have contraindications to COCs.
Intrauterine System (IUS), e.g. Mirena
The IUS, or coil, can be inserted at any age and remains effective for five years in women using HRT (or eight years for those not on HRT). It offers excellent endometrial protection and is compatible with high-dose estrogen regimens used to manage perimenopausal symptoms. It’s a particularly good option for women with PCOS, diabetes, or a BMI over 35, as these conditions increase the risk of endometrial cancer. Additionally, it is an effective treatment for heavy periods, which can be a common concern during perimenopause.
Injectable Progesterone and Bone Health
Injectable progesterones are not recommended during menopause, as they can reduce bone mineral density. Continuing these injections beyond age 50 may increase the risk of osteoporosis, so switching to an alternative form of contraception is advised.
Other Contraceptive Options
Most other forms of contraception remain available during perimenopause. However, if menopause symptoms develop, additional estrogen and progesterone may be needed for relief.
This range of contraceptive options allows women to balance perimenopausal symptom management with their contraceptive needs, making this a time to reassess and tailor healthcare decisions.