contraception during perimenopause

Last edited 02/2020 and last reviewed 12/2022

Although there is reduced fertility in the perimenopausal period, pregnancy is still possible. Maternal mortality is increased in older women and there is a higher incidence of pregnancy associated morbidity e.g. pre-eclampsia. There is also a higher incidence of congenital abnormality with increasing maternal age (1).

• no method is contraindicated by age alone for women in their 40s (2)
• however, once women reach 50, they should no longer use combined hormonal contraception (CHC) as there are greater risks compared to estrogen-free methods which are at least as effective for contraception at this stage
• women over 50 should also be encouraged to choose an alternative to the progestogen-only injectable (depot medroxyprogesterone acetate, DMPA) due to concerns around bone health

Contraceptive methods available include:

• intrauterine progesterone-only system
• progestogen-only pill (POP) - many women over 40 years of age develop amenorrhoea with this form of contraception
• progestogen implants
• depot progestogen injections
• combined oral contraceptive pill - FDA permit the use of the combined oral contraceptive pill to women at low-risk (non-smokers, no cardiovascular risk factors) up to the age of 50
• barrier methods
• conventional intrauterine devices
• natural methods

Summary points from FSRH guidance state (2):

• Copper intrauterine devices

  • the FSRH supports extended use of the copper intrauterine device until menopause when inserted at age 40 or over
  • the Cu-IUDs currently available in the UK are licensed for either 5 or 10 years of use
  • FSRH supports extended use of the Cu-IUD when inserted at age 40 or over. A Cu-IUD containing ≥300 mm2 copper inserted at or after age 40 can remain in situ until 1 year after the LMP if it occurs when the woman is 50 or older. If a woman is under 50, the Cu-IUD can remain in situ for 2 years after the LMP
    
    
• Levonorgestrel intrauterine system
• women using a Mirena® levonorgestrel intrauterine system (LNG-IUS) for endometrial protection as part of a HRT combination must have the device changed every 5 years
• women who have undergone endometrial ablation should be advised about the potential risk of complications if intrauterine contraception (IUC) is used
• FSRH supports extended use of a Mirena® levonorgestrel intrauterine system (LNG-IUS) for contraception until the age of 55 if inserted at age 45 or over, provided it is not being used as the progestogen component of hormone replacement therapy (HRT) for endometrial protection
• endometrial protection
• Mirena 52 mg LNG-IUS has been shown to provide endometrial protection from the stimulatory effects of exogenous estrogen, and the FSRH supports use of Mirena 52 mg LNG-IUS for up to 5 years (outside product licence) for this purpose
  
  
• Progestogen-only implant
• women can be informed that the progestogen-only implant (IMP) is not associated with increased risks of venous thromboembolism (VTE), stroke or myocardial infarction (MI) and has not been shown to affect bone mineral density (BMD)
• as the risk of pregnancy is extremely low once a woman reaches age 55, contraception can be stopped at that age
  
  
• Progestogen-only injectable

• women over 40 using depot medroxyprogesterone acetate (DMPA) should be reviewed regularly to assess the benefits and risks of use. Women over 50 should be counselled on alternative methods of contraception
• compared to non-DMPA users, women using DMPA experience initial loss of bone density due to the hypoestrogenic effects of DMPA but the evidence suggests that this initial bone loss is not repeated or worsened by onset of menopause
• after age 45, DMPA moves from UKMEC Category 1 to Category 2 - women of all ages using DMPA should be reviewed every 2 years to assess the benefits and risks of use. Women over 50 should be counselled on alternative methods of contraception as there are safer methods that are equally effective. If a woman over 50 does not wish to stop using DMPA, consideration should be given to continuation providing the benefits and risks for her as an individual have been assessed and discussed with her. The decision to continue above age 50 should be regularly reassessed at review visits
  
  
• Progestogen-only pills

• women can be informed that the progestogen-only pill (POP) is not associated with increased risks of VTE, stroke or MI and has not been shown to affect BMD
• one consideration regarding POP use for women over 40 is the potential for altered bleeding patterns, which affect nearly half of women using POP
• as the risk of pregnancy is extremely low once a woman reaches age 55, contraception can be stopped at that age. For personal reasons, an individual woman may wish to continue POP beyond this age for reasons relating to perceived non-contraceptive benefits
  
  
• Combined Hormonal Contraception

• combined oral contraception (COC) with levonorgestrel or norethisterone should be considered first-line COC preparations for women over 40 due to the potentially lower VTE risk compared to formulations containing other progestogens
• COC with ≤30 μg ethinylestradiol should be considered first-line COC preparations for women over 40 due to the potentially lower risks of VTE, cardiovascular disease and stroke compared to formulations containing higher doses of estrogen
• combined hormonal contraception (CHC) can reduce menstrual bleeding and pain, which may be particularly relevant for women over 40
• HCPs can offer an extended or continuous CHC regimen to women for contraception and also to control menstrual or menopausal symptoms
• women aged 50 and over should be advised to stop taking CHC for contraception and use an alternative, safer method
• COC is associated with a reduced risk of ovarian and endometrial cancer that lasts for several decades after cessation
• CHC may help to maintain BMD compared with non-use of hormones in the perimenopause
• meta-analyses have found a slight increased risk of breast cancer among women using COC, but with no significant risk of breast cancer by 10 years after cessation
• women who smoke should be advised to stop CHC at age 35 as this is the age at which excess risk of mortality associated with smoking starts to become clinically significant HCPs should advise women that sterilisation does not alter or eliminate menstrual periods. Women who have been using another method of contraception should be made aware that bleeding patterns may well change after sterilisation because they have stopped a contraceptive method


• Barrier methods

• barrier methods include male condoms, female condoms, diaphragms and cervical caps. There are no age restrictions to the use of barrier methods and there are few contraindications
• barrier methods often have high effectiveness in women over 40 due to declining fertility and more consistent usage

Notes (1):

• combined contraceptive pill
  • women aged over 40 years can be advised that combined hormonal contraception can be used unless there are co-existing diseases or risk factors
  • risks of using combined hormonal contraception outweigh the benefits for smokers aged >=35 years
  • women aged >=35 years with no other risk factors who have stopped smoking more than a year ago may consider using combined hormonal contraception. The excess risk of MI associated with smoking falls significantly 1 year after stopping and is gone 3-4 years later, regardless of the amount smoked
  • women aged over 40 years with cardiovascular disease, stroke or migraine (even without aura) should be advised against the use of combined hormonal contraception
  • clinicians prescribing COC to women aged over 40 years should consider a monophasic pill with <=30 µg ethinylestradiol with a low dose of norethisterone or levonorgestrel as a suitable firstline option
  • women using combined contraception should be advised to switch to another suitable contraceptive method at the age of 50 years
  • FSH is not a reliable indicator of ovarian failure in women using combined hormones, even if measured during the hormone-free or oestrogen-free interval
    
    
• progestogen only methods
  • women with current venous thromboembolism (VTE) should be advised that the risks of using progestogen-only methods outweigh the benefits. Women with previous VTE, however, can be advised that the benefits of using progestogen-only methods outweigh the risks
  • women with a history of ischaemic heart disease or stroke should be advised that the risks of initiating a progestogen-only injectable outweigh the benefits, however, the benefits of initiating POPs, implants or the intrauterine progesterone-only system outweigh the risks
  • women can be advised that a POP or implant can be continued until the age of 55 years when natural loss of fertility can be assumed. Alternatively, the woman can continue with the POP or implant and have FSH levels checked on two occasions 1 or 2 months apart, and if both levels are >30 IU/l this is suggestive of ovarian failure. In this case the woman may continue with the POP, implant or barrier contraception for another year (or 2 years if aged <50 years)
  • women should be counselled about the risks and benefits of continuing with the progestogen-only injectable at the age of 50 years and be advised to switch to a suitable alternative
  • women can be advised that a POP can be used with HRT to provide effective contraception
  • women using oestrogen replacement therapy may choose the intrauterine progesterone-only system to provide endometrial protection

Reference:

1. FFPRHC Guidance (January 2005) Contraception for women aged over 40 years Journal of Family Planning and Reproductive Health Care 2005; 31(1): 51-64
2. FSRH (September 2019). Contraception for Women Aged Over 40 Years.