CONTRACEPTION IN PERIMENOPAUSE
Why it is important.
If you are still having periods and do not want to fall pregnant, then contraception is necessary, as pregnancy is still possible. The usual contraceptive options are suitable for use with a few restrictions. As fertility declines with age, methods that are not suitable for younger women, such as withdrawal or rhythm methods, become suitable for older women because the chance of pregnancy is much lower.
Combined Oral Contraceptive Pill (COCP)
The Combined Oral Contraceptive Pill (COCP), often called ‘the pill’, contains artificial versions of oestrogen and progesterone, which are hormones normally produced by your ovaries. The pill mainly works by inhibiting ovulation, thinning the endometrium (lining of the womb), and thickening the cervical mucus to make it harder for sperm to penetrate. When used correctly, it is a reliable method of contraception (99% effective) and has other benefits, including regulation of hormone levels and reduction of cyclical symptoms. When you take the pill 'continuously', without skipping the sugar pills or the 'pill-free interval', you can completely avoid experiencing a withdrawal bleed. Additionally, because the pill regulates hormone levels, it can minimise perimenopausal symptoms such as hot flushes and vaginal dryness.
Women may not realise they are perimenopausal until they stop taking the pill, as it can mask menopausal symptoms. It is advisable to stop the pill at 50 years due to an increased risk of developing blood clots. If you are over the age of 35 and smoke, the pill is contraindicated.
Alternative Contraceptive Methods
Where oestrogen or the pill is contraindicated, the progesterone-only pill or another method of contraception, such as an IUD (progesterone-containing intrauterine system (IUS) or copper-containing IUS), is preferable.
If the progesterone-containing IUS is being used for either contraception or to treat heavy periods, oestrogen replacement therapy can be added to manage menopausal symptoms, as the progesterone will protect the endometrium.
Barrier Methods and Permanent Contraception
Barrier methods (e.g., condoms or diaphragm) are very suitable in the older age group as there are no contraindications to their use other than allergy.
Permanent methods of contraception include vasectomy, tubal ligation and removal of both fallopian tubes (bilateral salpingectomy). These options are indicated for older women or women who need to avoid hormonal contraception due to risk factors such as a clotting tendency. Permanent methods of contraception are not first-line options for younger women as the incidence of regret regarding loss of fertility is much greater in the under 35 age group. That said, it is a good option for younger women who are certain that their family is complete. Although tubal ligation is referred to as a ‘permanent’ method of contraception, the procedure can be reversed (tubal reanastomosis) with pregnancy rates of over 60%. A vasectomy is preferable to tubal ligation as it is more effective, quicker, safer, and cheaper but there is a 5% risk of chronic testicular pain.
Age Related Fertility Decline and Contraceptive Needs
Fertility generally starts to decline in your 30s. This decline is more rapid over the age of 35. A woman in her early to mid-20s has a 25–30% chance of pregnancy per cycle, while at age 40, the possibility of getting pregnant in any monthly cycle is around 5%. Unintentional pregnancy is rare in women over the age of 50, but you still need to exercise caution. Women should use contraception for 2 years after their last menstrual period if they are 50 or under, and for 1 year after their last menstrual period if they are over 50.
Menopausal Hormone Therapy (MHT)
Menopausal Hormone Therapy (MHT) does not prevent pregnancy, as the dose of oestrogen and progesterone is too low to interfere with ovulation, unlike the pill.
It is recommended that you see your doctor or gynaecologist to ensure the best treatment for you at this stage of your life.