Contraception in the perimenopause
What is the perimenopause?
The perimenopause is the name given to the time of hormonal changes leading up to and shortly following the menopause. These changes span several years, often beginning around the age of 40. The menopause itself is marked by your last menstrual period. The age at the menopause has remained remarkably consistent over the centuries: occurring any time between the ages of 48 and 55, with the average age being 51. A few women have an early menopause, under the age of 45, although less than 1% experiences the menopause before the age of 40. For many, women the first sign of the perimenopause are a change in the pattern of menstruation. Initially, periods become far more frequent and then more irregular, often longer with heavier bleeding. Many of these cycles are anovulatory, meaning that the egg that is usually released from the ovaries each month fails to develop. Because this upsets the usual hormone balance, erratic bleeding can result. Levels of oestrogen fluctuate resulting of symptoms of hot flushes, night sweats, tiredness, depression, and joint pains.
Fertility and the perimenopause
Many women approaching the menopause mistakenly believe that they are unlikely to become pregnant. It is certainly true that a woman in her 40s is about half as fertile as women in her 20s. In addition, her eggs are of poorer quality, and ovulation (the release of an egg from the ovaries each menstrual cycle) occurs less regularly. For many women intercourse also becomes less frequent than when they were younger.
Despite this, pregnancy can occur. Although this may delight a couple who have been unsuccessfully trying for a baby for many years, it can be a shock for others. Although many babies born to older mothers are very healthy, genetic abnormalities can occur such as Down’s syndrome become more common. The risk of miscarriage and risks to mother and baby are also increased in older women. Therefore effective contraception can be as important for a woman in her late 40s as it is for women in her 20s.
When can contraception be stopped?
Knowing when to stop is not always easy. Blood tests to check hormone levels are unreliable and particularly difficult to interpret in women using the pill. Because most women’s natural periods stop around the age 50, it is generally advisable to stop using the pill at around the age of 50 and change to an alternative contraception until menopause status can be determined. Ideally, blood tests should be taken about 6 weeks after stopping the pill and repeated 1-2 months later. If your periods have stopped and the blood tests suggest the menopause, contraception can be stopped after one year (if over the age 50) and two years (if under 50), provided your periods do not return in that time. Barrier methods, spermicides alone, or the contraceptive sponge are sufficient since fertility is low.
The progesterone-only ‘mini’pill and IUS can be continued without interfering with the blood test. Menopause status cannot easily be determined in women using implants or injectables unless they are discontinued.
HRT and contraception
Although HRT does not restore fertility, neither is it an effective contraceptive. Therefore, if you start HRT before your periods have naturally finished, there is a risk of pregnancy. Most standard HRT methods are not contraceptive so additional non-hormonal contraception is usually recommended. However, the IUS is often used in conjunction with natural oestrogens acting as the progesterone component of HRT as well as providing contraception.
Withdrawal bleeds associated with some types of HRT can make it difficult to assess the timing if the natural menopause. Blood tests taken in the oestrogen only phase of the HRT cycle. If the result suggests the menopause, this can be confirmed by a repeat blood test taken a few weeks later. Otherwise contraception should be continued to age 55 at which time loss of natural fertility can be assumed.
Seeking further advice
This leaflet is not intended to provide full information about all the different methods of contraception available- its purpose is to high light aspects of each method that are of particular relevance to women approaching the menopause.
For further advice on any of these methods contact your GP or local FAMILY PLANNIG /WELL WOMAN CLINIC.
The family planning association provides comprehensive and objective information to the public and professional on all aspects of contraception, abortion and sexual health through its contraceptive education services (CES) helpline and enquiry service
UK helpline 020 7837 4044 open Monday-Friday 9am –7pm
The national helpline offers advice on individual contraception and sexual health needs as well as details of the nearest clinic, abortion or contraceptive services.
Further information is available on their website www.fpa.org.uk
The Amarant trust: 80 Lambeth Road, London, SE1 7PW
Telephone 01293 41300
The Amarant trust is an independent medical charity set up to promote greater understanding of the menopause and HRT and to support and extend research into this area of medicine. The trust provides a series of leaflets and other information to improve the knowledge of women and health care professionals. The trust also has a 24 hour help line providing a range of facts and advice about the menopause.
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