The Menopause

Do I need contraception during menopause?

Contraception during menopause can be something of a minefield. Can pregnancy occur after menopause? And which contraceptives can be used alongside HRT?

Dr Sarah Glynne, a GP with a special interest in menopause, sets the record straight.

Contraception and menopause – what you need to know

Menopause is diagnosed when a woman has had no periods for 12 months. The average age of menopause is 51, but women often notice a change in their health and periods from their mid to late 40s – the perimenopause.

It’s worth noting that one in 100 women will have a premature menopause, under the age of 40 (premature ovarian insufficiency or ‘POI’).

Spontaneous pregnancies have been reported in women up to the age of 59, and so it’s important that all perimenopausal women use contraception if they wish to avoid becoming pregnant. Additionally, women having sex with new partners will continue to need barrier contraception after menopause to protect them from STDs.

How do I know if I need contraception?

Women can stop using contraception two years after their last period if they’re under 50 and not having periods. For women over 50, they can stop using contraception one year after their last period. For those still having periods, or if using hormonal contraception (the combined pill, the progesterone-only pill, the progesterone injection or implant, or the progesterone containing coil – Mirena), or hormone replacement therapy (HRT), they should continue to use contraception until the age of 55.

Women may wish to stop using contraception earlier. It can be difficult to know if women using hormone contraception are menopausal, as they are not having natural periods. In this case, ask your GP for a blood test (follicle stimulating hormone ‘FSH’). If the FSH is in the menopausal range, contraception only needs to be continued for one more year. If it is still in the premenopausal range, contraception should be continued and the blood test can be repeated after one year.

Note, FSH levels are unreliable in women using the combined pill or progesterone injections. These medications need to be stopped six weeks before a blood test, in which case alternative contraception should be used.

What are my options?

The combined pill contains synthetic estrogen and progesterone. It’s useful to treat menopausal symptoms and provide contraception up to age 50. It also reduces the risk of osteoporosis. Plus, it’s suitable for women with POI, who may prefer not to take HRT until they’re older.

Historically, women were advised to take the combined pill for three weeks out of four. We now know it isn’t necessary to have a bleed every month, so it’s better to take the pill continuously. This prevents menopausal symptoms in the pill-free interval, and protects against future osteoporosis and heart disease, which is especially important for women with POI.

The pill may slightly increase the risk of heart attack and stroke – it’s not suitable for women over 35 who smoke or are overweight; and it should be avoided if there is a history of migraine or risk factors for blood clots.

All other forms of hormone contraception can be used in the perimenopause, but they don’t contain estrogen, so women may notice they start to experience menopausal symptoms. If this is the case, HRT can be used to treat symptoms and reduce the risk of future diseases that are associated with the menopause (such as heart disease, stroke, diabetes, dementia, and osteoporosis) alongside contraception to prevent pregnancy.

What about HRT?

HRT that is commonly prescribed nowadays contains body-identical hormones – i.e. estrogen and progesterone that are chemically identical to the hormones produced by the ovaries. They are often better tolerated compared to the synthetic hormones in the contraceptive pill, and have a superior safety profile (for example, no increased risk of blood clots or breast cancer; reduced risk of cardiovascular disease). For these reasons, even women who can take the pill may prefer to switch to body-identical HRT with added contraception.

Women can choose to have body-identical estrogen in the form of a patch, gel or spray. Women with a uterus must additionally take progesterone to reduce the risk of bleeding and endometrial cancer.

The Mirena coil is an excellent choice because it is the only contraception that is also licensed as HRT. It is helpful to treat heavy periods, which can be problematic in the perimenopause. Although it contains synthetic progesterone, the dose is very low compared with oral progesterone, and so it is not associated with an increased risk of breast cancer and is suitable for women with a history of progesterone intolerance or sensitivity.

A Mirena coil is inserted into the womb and is effective for up to five years. There is no upper age limit, so post-menopausal women can continue to use the coil to provide the progesterone component of their HRT, even if they no longer require contraception.

If women don’t want a Mirena coil, they can take body-identical progesterone in the form of Utrogestan tablets. Utrogestan is not licensed as contraception, so extra precautions are needed.

Options include:
  • The progesterone-only pill (POP) – a daily pill.
  • The progesterone injection (Depo-Provera or Sayan Press) – an injection every three months.
  • The progesterone-only implant (Nexplanon) – a small, flexible, matchstick-shaped rod that is inserted under the skin of the upper arm for up to three years.
  • Non-hormonal methods – sterilisation, the copper coil, barrier methods (condoms, diaphragms and cervical caps), natural family planning.

The progesterone injection is only recommended up to the age of 45, as it may reduce bone density and increase the risk of osteoporosis after the menopause. All other forms listed can be used until the age of 55.

In conclusion, all perimenopausal women need contraception to avoid unwanted pregnancy until they are menopausal (no periods for one year, or two years if under the age of 50). If women start to experience menopausal symptoms, they can also have HRT to improve quality of life and safeguard their future health. The Mirena coil is ideal as it is licensed for both. Otherwise, body-identical HRT is the treatment of choice, with added contraception – there are many options and it is important to speak to your doctor about which is most suitable for you.

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