Perimenopausal contraception

https://www.racgp.org.au/afp/2017/june/perimenopausal-contraception-a-practice-based-appr

Definitions

Menopause

• Menopause is the final menstrual period.
• It is diagnosed retrospectively after 12 months of amenorrhoea.
• Average age of menopause in Australian women is approximately 51 years.
• Usual age range is approximately 45–55 years.

Postmenopause

• Begins 12 months after the final menstrual period.
• Continues for the rest of life.

Menopausal transition

• The transition phase leading up to the final menstrual period.
• Ends with the final menstrual period.
• Characterised by:
  • Irregular menstrual cycles
  • Fluctuating ovarian hormone levels
  • Possible vasomotor symptoms

Perimenopause

• Includes the menopausal transition and the first 12 months after the final menstrual period.
• Therefore, perimenopause ends once postmenopause begins.

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Menstrual cycle changes during the menopausal transition

Early transition

• Variable cycle length.
• Cycles may vary by more than 7 days compared with the woman’s usual pattern.
• Ovulation may still occur.

Late transition

• Longer gaps between periods.
• Amenorrhoea episodes of >60 days may occur.
• Vasomotor symptoms may become more common.

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Hormonal changes

• FSH, oestradiol and progesterone levels are highly variable.
• Levels vary:
  • Between women
  • Between cycles
  • Within the same cycle
  • Even from day to day
• Because of this, hormone testing is often unreliable in women over 45 with typical symptoms.

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Symptoms

Common symptoms may include:

• Hot flushes
• Night sweats
• Sleep disturbance
• Mood changes
• Breast tenderness
• Heavy or irregular bleeding
• Vaginal dryness
• Dyspareunia
• Urinary symptoms

Vasomotor symptoms commonly occur in the years before and after the final menstrual period.

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Types of menopause

Spontaneous / natural menopause

• Natural cessation of ovarian function.
• Usually occurs between 45–55 years.

Early menopause

• Menopause between 40–45 years.

Premature menopause / premature ovarian insufficiency

• Menopause before 40 years.
• Requires assessment for premature ovarian insufficiency.

Surgical menopause

• Occurs after removal of both ovaries before natural menopause.
• May be due to:
  • Benign pathology
  • Malignancy
  • Risk-reducing surgery, such as BRCA1/BRCA2 mutation carriers

Iatrogenic menopause

May occur after:

• Chemotherapy
• Pelvic radiotherapy
• Ovarian suppression therapy, such as goserelin

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When to measure hormones

Women over 45 with typical symptoms

Do not routinely measure FSH, LH, oestradiol or progesterone.

Reason:

• Hormone levels fluctuate significantly.
• Results are unlikely to change management.
• Diagnosis is usually clinical.

Consider FSH ± oestradiol if

• Symptoms occur before age 45 years
• Suspected premature ovarian insufficiency
• Hysterectomy has occurred and there are no periods to assess
• Secondary amenorrhoea is being investigated
• Woman aged ≥50 is using a progestogen-only method and wants to stop contraception before age 55

When to measure hormones

Clinical situation	Measure FSH/oestradiol?	Reason
Woman >45 with typical menopausal symptoms	No, usually not needed	Diagnosis is clinical; hormone levels fluctuate and rarely change management
Woman <45 with menopausal symptoms	Yes, consider FSH ± oestradiol	Need to assess early menopause or premature ovarian insufficiency
Woman <40 with menopausal symptoms / amenorrhoea	Yes	Need to assess for premature ovarian insufficiency
Hysterectomy but ovaries retained	Consider FSH ± oestradiol	No periods available to assess menopausal status
Secondary amenorrhoea	Yes, as part of workup	Need to exclude pregnancy, thyroid disease, hyperprolactinaemia, PCOS, POI, etc.
Using COCP / vaginal ring	No, FSH is unreliable	Combined hormonal contraception suppresses FSH
Age ≥50, using POP / implant / LNG-IUD, amenorrhoeic	Yes, may use FSH to guide stopping contraception	Bleeding pattern is unreliable, but FSH can help guide cessation

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Contraception in perimenopause

Key points

• Women can still ovulate during perimenopause.
• Irregular periods do not mean infertility.
• MHT is not contraception.
• Amenorrhoea while using hormonal contraception does not reliably confirm menopause.
• Contraception is required until menopause is confirmed, or until an age where fertility is extremely unlikely.

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When contraception can be stopped

Step 1 — Is the woman using hormonal contraception?

Situation	Approach
Not using hormonal contraception	Use the spontaneous amenorrhoea rule
Using hormonal contraception	Bleeding pattern may be unreliable; use method-specific guidance

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If NOT using hormonal contraception

Age ≥50 years

• Contraception can usually be stopped after:
  • 12 months of spontaneous amenorrhoea

Age <50 years

• Ovarian activity may still resume intermittently.
• Continue contraception until:
  • 24 months of spontaneous amenorrhoea

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If using hormonal contraception

Important point

Hormonal contraception may:

• Suppress bleeding completely
• Cause irregular bleeding
• Produce artificial withdrawal bleeding

Therefore:

• Amenorrhoea on hormonal contraception does not reliably confirm menopause.

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Using POP, implant or LNG-IUD

Includes

• Progestogen-only pill (POP)
• Etonogestrel implant
• Levonorgestrel IUD (e.g. Mirena)

Key points

• These methods can usually be continued until menopause.
• Bleeding pattern is unreliable.
• FSH testing may help guide when contraception can stop.

If age ≥50 years and amenorrhoeic for ≥12 months

Option 1 — FSH-guided approach

• Check:
  • 2 FSH levels
  • At least 6 weeks apart
• If both FSH levels are:
  • ≥30 IU/L
• Then:
  • Continue contraception for another 12 months
  • Then stop contraception

Option 2 — Age-based approach

• Continue contraception until:
  • 55 years of age

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Using combined hormonal contraception

Includes

• Combined oral contraceptive pill (COCP)
• Vaginal ring

Key points

• Bleeding pattern is unreliable.
• FSH testing is not useful because combined hormonal contraception suppresses FSH levels.
• Combined hormonal contraception is generally not recommended beyond age 50 years.

Practical approach

At around age 50 years:

• Switch to:
  • Non-hormonal contraception, or
  • Progestogen-only contraception

Then follow the stopping rules for the new method.

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Using DMPA

Example

• Depot medroxyprogesterone acetate injection

Key points

• Amenorrhoea is unreliable.
• DMPA is generally not recommended beyond age 50 years because of bone density and cardiovascular considerations.

Practical approach

At around age 50 years:

• Switch to:
  • Non-hormonal contraception, or
  • POP / implant / LNG-IUD

Then follow the stopping rules for the new method.

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summary table

Situation	When contraception can stop
No hormonal contraception, age ≥50	After 12 months spontaneous amenorrhoea
No hormonal contraception, age <50	After 24 months spontaneous amenorrhoea
POP / implant / LNG-IUD, age ≥50 and amenorrhoeic	2 FSH levels ≥30 IU/L at least 6 weeks apart, then continue contraception 12 more months
POP / implant / LNG-IUD	Alternative: continue until age 55
COCP / vaginal ring	Switch around age 50 to another method first
DMPA	Usually switch around age 50 to another method
Any method, age 55	Contraception can usually be stopped

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Practical contraception options

Method	Advantages	Limitations / cautions	Menopause-related note
LNG-IUD	Highly effective; reduces heavy bleeding; few interactions; can be used with oestrogen as endometrial protection within licensed duration	Avoid/current breast cancer; investigate abnormal bleeding before insertion	Amenorrhoea does not confirm menopause
Copper IUD	Highly effective; hormone-free; can be emergency contraception	May worsen heavy bleeding; not PBS-listed	If inserted ≥40, may be retained until menopause
Etonogestrel implant	Highly effective; few contraindications; minimal metabolic effects	Irregular/prolonged bleeding; avoid/current breast cancer	Does not provide endometrial protection for MHT
POP	Useful when oestrogen contraindicated; minimal metabolic effects	Strict timing required depending on type; irregular bleeding	Does not provide endometrial protection for MHT
COCP / vaginal ring	Cycle control; may improve heavy bleeding and vasomotor symptoms; bone benefit	Avoid with smoking >35, hypertension, migraine with aura, VTE/IHD/stroke, multiple CV risk factors	Generally not recommended after 50
DMPA	Effective; may reduce bleeding	Bone density, lipid and CV considerations	Not first-line after 45; generally avoid after 50
Barrier methods	No hormones; condoms protect against STIs	Less effective than LARC; may be affected by vaginal dryness/ED	Can stop based on spontaneous amenorrhoea rule
Vasectomy	Highly effective permanent option	Requires partner procedure and semen clearance confirmation	Useful if female hormonal methods contraindicated

Levonorgestrel IUD

• Highly effective contraception.
• Reduces menstrual bleeding.
• Few drug interactions.
• Useful for heavy menstrual bleeding once pathology has been excluded.
• Can provide endometrial protection as part of MHT for the licensed duration.
• If inserted at age ≥45, may be used for contraception until menopause or age 55 depending on guidance and device type.

Copper IUD

• Highly effective non-hormonal contraception.
• Useful when hormonal methods are contraindicated.
• May worsen heavy menstrual bleeding.
• Can be used as emergency contraception.
• If inserted at age ≥40, may be retained until menopause.

Etonogestrel implant

• Effective progestogen-only contraception.
• Can generally be used until menopause.
• May cause irregular bleeding.
• Does not provide endometrial protection as part of MHT.
• Not recommended beyond its licensed duration.

Progestogen-only pill

• Suitable for many women in perimenopause.
• May cause irregular bleeding.
• Does not provide endometrial protection as part of MHT.
• Amenorrhoea does not confirm menopause.

Combined hormonal contraception

• May help with:
  • Cycle control
  • Heavy menstrual bleeding
  • Vasomotor symptoms
  • Bone health
• Use cautiously in women over 40.
• Generally avoid if:
  • Smoker over 35
  • Hypertension
  • Migraine with aura
  • VTE history
  • IHD/stroke/TIA history
  • Multiple cardiovascular risk factors
  • BMI ≥35

DMPA

• Not first-line after age 45.
• Generally avoid beyond age 50.
• Consider bone density and cardiovascular risk factors.

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Red flags requiring assessment

Symptom/sign	Why it matters	Consider
Postcoital bleeding	Cervical pathology must be excluded	Cervical screening status, speculum exam, referral if indicated
Intermenstrual bleeding	May indicate endometrial/cervical pathology	Pelvic exam, pregnancy test, STI testing, TVUS ± endometrial sampling
Heavy menstrual bleeding after 40	Endometrial pathology risk increases with age	FBC/ferritin, TVUS, consider gynae referral
Postmenopausal bleeding	Endometrial cancer must be excluded	Urgent assessment, TVUS/endometrial sampling pathway
New or changed bleeding on hormonal contraception	Not always benign in this age group	Lower threshold for investigation
Bleeding risk factors	Obesity, PCOS, tamoxifen, diabetes, unopposed oestrogen increase endometrial cancer risk	Investigate appro

Do not assume bleeding is due to perimenopause or contraception if there is:

• Postcoital bleeding
• Intermenstrual bleeding
• Heavy menstrual bleeding
• New bleeding pattern after age 40
• Postmenopausal bleeding
• Risk factors for endometrial cancer, such as obesity, PCOS or tamoxifen use

Consider:

• Cervical screening status
• Pregnancy test if relevant
• FBC/ferritin if heavy bleeding
• Pelvic examination
• Transvaginal ultrasound
• Endometrial assessment or gynaecology referral if indicated

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Bottom line

Contraception can usually be stopped at 55 years, as spontaneous conception is extremely unlikely.

Menopause is usually a clinical diagnosis.

In women over 45 with typical symptoms, routine hormone testing is usually unnecessary.

Contraception is still needed during perimenopause because ovulation can still occur.

Hormonal contraception can mask menopause.

For women ≥50 using POP, implant or LNG-IUD, FSH can help guide when contraception can stop.