Choosing contraception during the menopause transition

Does contraception affect the menopause?

Contraception does not affect the timing or duration of menopause, but it may mask the symptoms that indicate the start of menopause transition. This is because many women do not have periods when using some types of contraception. Other types of contraception give a regular ‘artificial’ bleed. You are therefore unable to use your bleeding pattern ‘know where you are’ in the menopause transition, or whether your periods have stopped.

Some methods of contraception may actually help you to manage symptoms – for example, progesterone-only contraception can help manage heavy and irregular bleeding of the perimenopause, and the combined oral contraceptive pill contains an oestrogen that may help manage hot flushes and other symptoms.

Fertility

Fertility decreases as you get older (starting around the mid-30s), and it drops significantly as you approach the menopause. However, your fertility doesn’t decrease to zero in the perimenopause – some women get pregnant naturally in their late 40s and even in their 50s – so it’s important to use contraception if you don’t want to get pregnant.

Pregnancy in your 40s and 50s can be more complicated. The risk of miscarriage and ectopic pregnancy increases with age, as do pregnancy and birth complications. Discussing your plans with a healthcare professional may be helpful if you’re trying to conceive.

You can read more about fertility in menopause here.

Types of contraception

The different types of contraception fall into categories of:

• Contraception with no hormones, 
• Progestogen-only hormonal contraception and 
• Combined hormonal contraception.

Contraception with no hormones

This form of contraception can be used alongside hormone replacement therapy (HRT).

Copper coil

What is it?

The copper coil, or intrauterine device (Cu-IUD) is a small T shaped copper-containing device that sits in the cavity of the womb. It lasts either 5 or 10 years depending on the type of fit. However, because fertility declines in your 40s, you can keep it for longer if it is fit at, or after, the age of 40. A Cu-IUD inserted at, or after, age 40 can remain in place until 1 year after the last menstrual period if it occurs when the woman is 50 years or older. If a woman is aged under 50, the Cu-IUD can remain in place for 2 years after the last menstrual period. They are fitted by specially trained doctors and nurses.

Pros

• The copper coil is an effective method of contraception
• It doesn’t contain hormones so you will know when your periods are changing and when your periods finally stop
• You won’t experience hormone side effects

Cons

• The Cu-IUD can cause longer, heavier and more painful periods so it’s not the best option if this is already an issue for you

Condoms

Male and female condoms prevent pregnancy by acting as a physical barrier to male sperm coming into contact with the female egg. They are made from very thin latex (rubber), polyisoprene or polyurethane. They are effective as a method of contraception if you use them correctly.

Pros

• You don’t have to take hormones and so there is no change to your natural bleeding pattern
• No risk of hormone side effects
• They reduce the risk of sexually transmitted infections (the only method listed here to do this)

Cons

• You have to remember to use one – or ask your partner to use one
• Do not use condoms with oil-based lubricants as this can make them less effective
• Do not use latex-containing condoms if you are allergic to latex
• Condoms can slip off during sex
• Condoms can break (a large survey from the US showed around 5% of condoms break)
• The failure rate for make and female condoms increases if you use them incorrectly

Progesterone-only hormonal contraception

Progesterone only contraception can be used alongside hormone replacement therapy (HRT).

Progesterone-only pill

What is it?

The progesterone-only pill (POP) is sometimes also known as the mini pill. It’s a tablet you take every single day. You can take the POP until the age of 55 – there are no specific age-related concerns.

Pros

• You can take the POP even if you have medical conditions which rule out the combined oral contraceptive pill for you
• It’s easy to stop if you want to
• Your periods can become lighter or stop

Cons

• You have to remember to take a pill every day
• You may get progestogen side effects when you start taking it – headaches, nausea, worsening of acne, breast tenderness and mood swings – but they usually settle
• The effect on your bleeding is unpredictable – some have no bleeding, some have regular bleeding and some have unpredictable erratic bleeding
• You cannot use this method of contraception as part of HRT as the dose of progestogen has not been shown to be adequate in protecting the womb lining against the oestrogen part of HRT

Mirena™ intrauterine system

What is it?

The Mirena™ intrauterine system (IUS) is a small T shaped plastic device that releases a tiny amount of hormone – levonorgestrel. It sits in the cavity of the womb and is fit by specially trained doctors and nurses.

Pros

• It is an effective form of contraception
• It lasts for 5 years for contraception but if it is fit at or over the age of 45, you can keep it till you are 55 if you are using it for contraception alone. It must be changed after 5 years if you are using it as part of HRT
• It is also an effective treatment for heavy periods
• You can use it as the progestogen part of HRT for 5 years
• Only a tiny amount of hormone is released into the body, so the risk of hormone side effects is low
• You don’t need to remember to take a pill every day

Cons

• When it is first fit, some women have frequent spotting and bleeding for the first 3-6 months which can be a nuisance.
• You may get some hormonal side effects in the first few weeks – headaches, nausea, worsening of acne, breast tenderness and mood swings – but they usually settle.

Other intrauterine systems – eg Levosert™, Jaydess™ and Kyleena™

What are they?

These are other intrauterine systems that also release tiny amounts of levonorgestrel. They are licenced for contraception only. Jaydess™ is licenced for 3 years for contraception, Kyleena™ is licenced for 5 years.

Pros

• You don’t have to remember to take a tablet
• They may also make periods lighter
• The dose of hormone is tiny so you are less likely to experience hormone side effects – headaches, nausea, worsening of acne, breast tenderness and mood swings – and they usually settle

Cons

• You may get some irregular bleeding
• You cannot use these intrauterine systems for HRT (which you can if you have a Mirena™ fit)

Progesterone-only contraceptive implant (eg Nexplanon™)

What is it?

The progesterone-only contraceptive implant is a small flexible plastic-based rod that is fit by a doctor or nurse just beneath the surface of the skin in your upper arm. They provide effective contraception for up to 3 years.

Pros

• You don’t have to take a tablet
• Your period can become lighter, less painful or even stop

Cons

• A small number of women have more frequent bleeding
• You may get hormone side effects such as headaches, nausea, breast tenderness, worsening acne and mood swings though side effects generally settle in the first few months
• You can’t use this method of contraception as part of HRT

Progestogen-only injectable contraception (eg depot Provera™)

What is it?

The progestogen-only injectable contraception or ‘depot’ is a 3 monthly injection. You may be able to use this method of contraception up till the age of 50. However, if you are over 40 and you have risk factors for osteoporosis (thinning of the bones) – for example, you smoke, are underweight or have a medical condition which means you do not absorb nutrients well from your gut – the depot would not be the first choice for you. You should discuss this with a doctor if it applies to you.

Pros

• The depot can reduce periods – many women have no periods while they are using it
• You don’t have to remember to take a pill

Cons

• There is a risk of osteoporosis – thinning of the bones
• Once the injection has been given you cannot reverse the effects – it will last for 3 months
• You can’t use this method of contraception as part of HRT
• You may get some hormonal side effects in the first few weeks – headaches, nausea, worsening of acne, breast tenderness and mood swings – but they usually settle

Combined hormonal contraception (CHC)

You can’t take CHC alongside HRT.

What is it?

The combined hormonal contraceptive (CHC) pill or patch is the only method of contraception to contain an oestrogen and a progestogen. There are health risks associated with this specific method of contraception, so if you are aged 50 and over and still taking CHC, it is advised that you stop and switch to a safer alternative. If you are 40 and taking CHC, you will need a discussion with a doctor to make sure that it is safe for you to continue to use CHC in your 40s.

Pros

• Combined contraception can reduce some of the symptoms of the perimenopause – irregular, heavy bleeding and hot flushes and night sweats
• If you are under the age of 50 and are eligible to take CHC (you will need to discuss this with a doctor), CHC can be used instead of HRT

Cons

• The risk of blood clots, stroke and heart disease increases with CHC. This is why you shouldn’t take the pill if you smoke over the age of 35, if you suffer migraine or if you have other risk factors for heart disease (for example raised blood pressure or if your weight is high in relation to your height)
• CHC is associated with a slightly increased risk of breast cancer, the incidence of which also increases with age. There is no apparent increased risk 10 years after cessation of CHC
• You have to remember to take a pill

Stopping contraception

You can stop using contraception if you are over the age of 50, and your periods have naturally stopped for more than 12 consecutive months (that is, you are through the menopause and are now postmenopausal). This advice applies only if you are not taking hormones or using the hormone intrauterine system.

If you are between 40 and 50, you can stop using contraception if you have been postmenopausal for 2 years (i.e. your periods have stopped naturally for 24 consecutive months). Again, this advice applies only if you are not taking hormones or using the hormone intrauterine system.

At the age of 55, you can stop using contraception even if you’re still bleeding.

If you are not bleeding because you are using a progestogen only hormone contraception (such as the progesterone-only ‘mini pill,’ the Nexplanon™ implant, the depot injection or the Mirena™ intrauterine system), an FSH (follicle stimulating hormone) blood test can be useful in helping you work out when to stop using contraception. Speak to a doctor to arrange this, and for advice on how to interpret the results.