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These are activities that require reflection on feedback about your work.
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While fertility declines in perimenopause, an unplanned pregnancy at this time of life can have serious consequences—physically, emotionally and personally. Appropriate contraception can not only reduce this risk, but also help with other perimenopausal symptoms.
Perimenopause is often a “tumultuous time both for the patient and their doctor,” says Sexual Health Physician and lecturer at the School of Women’s and Children’s Health, UNSW, Dr Terri Foran.
Fluctuating estrogen levels can cause symptoms ranging from headaches and bloating one month to hot flushes and brain fog the next — and also complicate family planning.
“There will be some months where some of these women will ovulate twice in a month, and it makes it completely impossible to work out what are your likely fertile times or non-fertile times,” Dr Foran says.
Women aged 40 to 44 who have unprotected sex over a year have a 10-20% chance of pregnancy, the Faculty of Sexual and Reproductive Healthcare’s Clinical Guideline: Contraception for Women Aged over 40 Years points out. This drops to approximately 12% in women aged 45 to 49, while spontaneous pregnancy in women aged over 50 is rare, the guideline notes.
It’s therefore important women know they can still fall pregnant during perimenopause.
“Many women think of their late 40s as a time of decreasing fertility, and it certainly is,” Dr Foran says. “It’s also a time when unintended pregnancy is not all that uncommon either. And for most of us, a pregnancy in your late 40s is not something we would have been planning and it can be a difficult thing to deal with, manage, and make decisions about.”
For most women, natural loss of fertility occurs by age 55 and contraception can be stopped.
Otherwise, it depends on cessation of periods, Dr Foran says.
“We would recommend that they continue to use a reliable method of contraception until 12 months after their last period if their menopause is 50, or two years after that last period if they come to menopause at an earlier age.”
However, “a lot of the contraceptive methods we use actually make it really hard to work out when that last period is,” Dr Foran says.
“If you’re on the pill it gives you a bleed. If you’re on a hormonal IUD, you might not have any bleeds at all, so it can be tricky.”
If in doubt, you can measure FSH levels in women over 50 who aren’t taking combined oral contraceptives (COCP), notes GP and medical educator Dr Sara Whitburn, Medical Director of Sexual Health Victoria and chair of the RACGP’s Sexual Health Specific Interest Group.
“If that is above 30 international units, you recommend contraception for one more year. They still need it because of those double ovulations or spontaneous ovulations. You can stop the contraception 12 months later. You don’t have to repeat the blood test.”
If FSH is equal to or less than 30 international units, they need to continue contraception and have another blood test in 12 months, she explains.
“And you repeat the process. And they may choose to instead just use their contraception up to 55.”
Importantly, the contraceptive injection (DMPA) can suppress FSH and it’s best to measure it just before giving another injection.
FSH levels are very suppressed in women using combined hormonal contraception, so it’s not a suitable measure of menopausal status for them.
All methods of contraception are suitable options at any age and “it’s really a question of looking at what that particular woman needs,” Dr Foran says, noting this can change as people are in or out of relationships or develop medical problems.
Many women in their 40s have comorbidities that may mean combined hormonal methods are not suitable, Dr Foran points out. The Australasian Menopause Society cautions against using estrogen-based methods in women over the age of 50 because of the cardiovascular risks.
Progestogen-only methods are safer in women with cardiovascular risk factors, Dr Foran says.
However, the perimenopausal years are also the final opportunity to maintain bone health, Dr Foran notes, and the contraceptive injection tends to stall bone deposition.
“If a woman’s been happily on it, I certainly wouldn’t suggest she needs to stop it, but it’s probably not top of my list of choices for this particular age group.”
Dr Whitburn points out that “conception in the 40s and 50s comes with its own health risks,” so it’s important to support people in this age group to manage their fertility if they don’t want to get pregnant.
With contraceptive methods falling on an efficacy spectrum, one consideration is the trade-off with side effects.
“There are ones that are least likely to cause side effects, but they’re also the least effective, all the way up to the ones that are most effective but more likely to cause side effects and problems,” Dr Foran says.
Women tend to fall into two camps on this matter, she adds.
“You get people who say, ‘there’s no way in the world I want to fall pregnant right now, it would be an absolute disaster, and therefore I want to look at the most effective method I possibly can.’ That’s one group.”
“Then there’s the other group who says, ‘What are my actual chances of pregnancy?’ And they’re certainly lower than she would have had at, say, age 20. And they might say, ‘I’d rather not use something hormonal if my chances of pregnancy are less. I might go for something that’s non-hormonal and perhaps not as effective, like a female barrier or condoms, and if I get pregnant, I will deal with that.’”
Sterilisation is an option for women looking for highly effective contraception, Dr Foran notes.
“I think many women would agree with me that vasectomy is the very best method any perimenopausal woman could consider,” she says.
“Sterilisation for women is harder to organise unless you’ve got private health insurance because you can be waiting forever in the public hospital system.”
It’s also less attractive the closer you get to menopause, she adds.
“If you’re 48 and expecting to not have any periods in two years, do you go and have an abdominal procedure in hospital? I think from that perspective, unless there’s another good reason to have surgery, then most women would probably look to use something like a hormonal IUD or even a copper IUD until they don’t require contraception at all.”
The choice might provide added benefits for the woman, Dr Foran notes.
For example, using a method that contains estrogen can “kill two birds with one stone” by helping control symptoms such as hot flushes and muscle aches and pains.
On the COCP, however, symptoms can creep back during the week on placebo pills, “in which case you need to manipulate that cycle so she’s getting estrogen every day.”
You can achieve this by running packs together to skip scheduled withdrawal bleeds, planning a shorter break of two to four days every three months (which will generally be followed by a bleed). Other women continue taking active pills until they have three days of spotty bleeding before taking a four-day break from the pills and allowing the uterine lining to shed completely, Dr Foran explains.
“Some women can do it continuously, other women can’t, and it depends a little bit on the pill.”
“The other thing you can do is use a hormone patch during the week that people have off. Other people find that if they reduce the usual pill-free time to two to four days every month, that’s enough to prevent vasomotor symptoms from kicking in,” Dr Foran says.
The two oestradiol pills (Clara and Zoely) that contain the same estrogen used in MHT “actually have very short placebo breaks, so in many ways they’re a good choice for this particular group if there are no obvious risk factors,” she says.
The new drospirenone progestogen-only pill and the contraceptive implant effectively prevent ovulation (though not always bleeding), and “you can safely add combined MHT to the mix to combat any menopausal symptoms,” she notes. “The use of combined MHT is suggested here, because we don’t have any safety data on adding back estrogen alone.”
Many women in their 40s start getting heavier bleeding that can be harder to manage. In this case, you can look at contraceptive methods that reduce bleeding—such as the combined pill, a progestogen-only method or a hormonal IUD, Dr Foran says.
The Mirena can be used for contraception and menstrual control for up to eight years when inserted before the age of 45, and for ten years when put in after 45, Dr Whitburn explains. This drops to five years if you start using it as the progestogen component of MHT.
The Kyleena is another option but is not licensed for use as the progestogen component of MHT, so you can’t just add estrogen back like you can with Mirena, Dr Foran explains.
“So if I’m talking perimenopause … the Mirena is probably the better choice. It gives you effective contraception, it’ll take you right through to menopause and if you do start to get symptoms like hot flushes, you can add back some estrogen really easily.”
A copper IUD tends to make menstrual bleeding heavier and longer, so may not be the best choice for women with this symptom.
For PMS-type symptoms, you can look for “a method of contraception that will actually suspend the natural cycle and that will occur with the use of a combined pill or a contraceptive implant, but that won’t happen on a hormonal IUD,” Dr Foran says.
That’s because hormonal IUDs do not stop ovulation, she explains.
“The hormonal production throughout the cycle still occurs even though there may not be any regular bleeding. And this of course can be even more of an issue at perimenopause.”
The decision is also a personal one, Dr Foran adds.
“Some women won’t turn a hair when you suggest that they have an IUD inserted, for example, whereas others will go pale. I’ve had women who are very happy to have an IUD inserted but hate the idea of having anything under their skin.”
Prior experience may play into the decision, although you can challenge certain things, she adds.
“You get people who say things like, ‘I tried the pill when I was 20 and the doctor put me on the lowest pill that was around and I still got side effects so, no, I won’t try that again.’ And the reality is that there is no such thing as the ‘lowest pill available’, there are different ingredients and different doses. And what suits some people doesn’t suit others.”
“If after that discussion the woman says, ‘I hear what you’re saying but I still don’t like the idea of the pill,’ then you can look somewhere else. There are plenty of other options.”
Another consideration is the balance between efficacy and side effects: the most effective methods tend to have the most side effects and vice-versa.
Look for a method that will also help to manage any menopausal symptoms.
Sexual Health Victoria | Contraception for users over 40 years: Health practitioner FAQs
Faculty of Sexual and Reproductive Healthcare | FSRH Clinical Guideline: Contraception for Women Aged over 40 Years
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