Menopause is the date a year after your last period. The menopause occurs when your ovaries stop producing eggs and, as a result, the levels of your hormones called oestrogen and progesterone fall. The term perimenopause is often used as this is the time in which you experience menopausal symptoms but are still having periods. These periods are often more irregular and scanty than they used to be. For some women they can actually be closer together and heavier.
Contraception does not affect the onset or duration of any menopausal symptoms but it may mask the signs and symptoms of menopause.
How important is contraception?
Although pregnancy is less likely during the perimenopause and menopause, it is still important to use contraception. This is because it is still possible to ovulate (produce an egg) when you are having periods, even when they are irregular. Effective contraception is still required to prevent an unplanned pregnancy until your menopause.
Contraception is especially important as pregnancy and childbirth after the age of 40 years are associated with a greater risk of adverse maternal and neonatal outcomes than in women under the age of 40 years.
It is important to note that HRT contains low levels of hormones and therefore it does not work as a contraceptive.
What is the best type of contraception?
There are various different types of contraception available:
Barrier methods include male condoms, female condoms, diaphragms and cervical caps. There are no age restrictions to the use of barrier methods. Barrier methods are also crucial in those women in newer relationships and/or where this is any risk of a sexually transmitted infection.
Sterilisation can be undertaken for men and women. For men it is safe and usually quick and easy to perform. This is in comparison to female sterilisation which is associated with more risks. Female sterilisation does not alter or eliminate periods and long acting contraceptive options should be considered instead eg coils, implants or depo injections.
The Combined Oral Contraceptive Pill (COCP) is a popular choice in younger women but usually needs very careful consideration in women over the age of 40. It should be avoided in smokers over the age of 35 and those women who are obese. In women who are fit and healthy (ie those without cardiovascular risk factors or migraines) it can usually have considerable benefits in regulating periods and reducing the heaviness of periods and can be used in place of HRT to treat menopausal symptoms and prevent bone loss in those women under the age of 50 years.
The Progestogen-Only Pill (POP, also known as the ‘mini-pill’) has fewer risks associated with it and can be taken safely at any age for as long as contraception is required. It can be associated with irregular bleeding in some women. Periods may become irregular, stop or last longer. The POP may help with heavy, painful periods.
The Contraceptive Injection (Depo Provera® and Sayana Press®) is a 3-monthly injection. It is a good option for some women as it can be a useful treatment for heavy periods. It is also useful for those women that may forget a daily pill. Alternative options should generally be considered if a woman has other risk factors for osteoporosis or once she reaches 50; and consideration should be given to switching to lower dose methods eg POP or implant.
The Contraceptive Implant is a small plastic rod which is inserted under the skin of the upper arm and lasts for three years. Bleeding with this can be very variable. Periods may become irregular, stop or last longer. The implant may help with heavy, painful periods.
The Progestogen-Only Pill, contraceptive injection and contraceptive implant can all be used safely alongside HRT.
There are two types of coil:
The IUCD (copper coil) is hormone-free. It if is inserted after the age of 40 if can be left in place until after the menopause.
The IUS (Mirena®️ coil) contains a small amount of a progestogen hormone which is gradually released. It can be a very useful device during the perimenopause as it has three potential uses - as a contraceptive, a treatment for heavy periods (half of women stop having periods with it) and it provides the progestogen component of HRT. If being used for the latter it needs changing after 5 years.
When can contraception be safely stopped?
The current guidelines are that if you are under 50 years of age then you should use contraception for at least two years following your last menstrual period. If you are over 50 years, then you should use contraception for at least one year following your last menstrual period.
However, if you are taking the combined contraceptive pill, then your periods are related to the hormones (withdrawal bleeds) rather than due to your own menstrual cycle. If you are using a progestogen only contraception (such as the progesterone-only pill, implant, injection or Mirena® coil) then you might not have any periods which can then be difficult to know when your menopause occurs.
If you are uncertain when your last period was then you can have a blood test taken to check your follicle stimulating hormone (FSH) level. If this is elevated, then you will need to continue using contraception for two years if you are under 50 years old and one year if you are over 50 years old. It is important to note that you will need to stop taking the combined contraceptive pill at least 6 weeks before this blood test in order to get an accurate result (and use adequate protection in the meantime). However, if you are using the Mirena® coil or progesterone only pill there is no need to remove/stop these. High-doses of progestogens, such as those seen in the contraceptive injection, may affect the FSH result, so in general it is best to switch to another contraceptive method when you are 50 years old.
In general, all women can stop contraception at age 55 years as spontaneous conception after this age is exceptionally rare, even in women still having some periods.
Can HRT be used for contraception?
As HRT contains very low levels of hormones, it does not work as a contraceptive.
If you are taking HRT then you can also take the progesterone only pill or have an IUCD or IUS inserted if you require contraception.
However, if you are taking a type of HRT that does not lead to periods then contraception is usually not necessary.
Last updated: March 2019