If you think that going through the menopause means you don’t have to worry about contraception any longer, think again. Here Dr Kate Burns, a GP with an interest in menopause, explains why…
Amongst the many challenges faced by women going through the perimenopause or menopause, having to worry about contraception and not getting pregnant is not normally high on the agenda. However, it remains possible to fall pregnant during perimenopause (the phase leading up to the menopause) and for some women, contraception may be needed up until the age of 55 years. What complicates things slightly is that if you are using hormonal contraception or Hormone replacement therapy (HRT) (see below) it can be tricky to clearly determine where you are on your menopause journey and when it is safe for you to stop contraception. So, before you bin your birth control here’s what is useful to know.
What is hormonal contraception?
In short, any contraception that relies on the use of hormones to stop you getting pregnant. The two main groups are progesterone only contraception (POC) which, as its name suggests, contains progestogen alone and combined hormonal contraception (CHC) which contains both progestogen and estrogen. Examples of progestogen only contraception include progestogen- only pills (POPs, sometimes known as the mini pill), the contraceptive injections Depo Provera® and Sayana Press®, the contraceptive implant Nexplanon® and various hormone-releasing coils including the Mirena coil®. Forms of combined hormonal contraception include combined oral contraceptive pills, the contraceptive patch (Evra®) and the contraceptive ring (NuvaRing®) – a small plastic ring placed inside the vagina which releases .
How does use of hormonal contraception affect menopause?
Taking or using any form of hormonal contraception will not affect when your menopause occurs – it won’t delay it, make it start earlier or influence how long it will last.
How do you know if you’re in menopause when on the pill?
However, recognizing the perimenopause or menopause can be more challenging when using hormonal contraception, for a number of different reasons. This is mainly because all forms of hormonal contraception can – and commonly do – change or even stop your usual menstrual (period) cycle. Why this is relevant is that one of the key symptoms/signs clinicians look for to indicate perimenopause or menopause is changes to your usual periods (i.e. changes in the length of time between them or how heavy or light your bleeds are plus missing periods and/or periods stopping). Therefore, if your hormonal contraception is altering or stopping your natural period cycle and bleeding pattern, we can no longer rely on this symptom/sign. Another consideration here is that using CHC will cause a hormone withdrawal or ‘false’ monthly bleed when used in certain ways (with breaks). Such bleeds may therefore continue to happen even if your natural period cycle is changing or stopping in the background. However, none of this means you should stop or change your contraception in order to work out whether you are perimenopausal or menopausal, as clinicians are very used to carefully considering all of your symptoms, without relying on your bleeding pattern, to recognize whether you are in perimenopause or menopause.
As well as changes to bleeding patterns, there are also some other factors related to use of hormonal contraception that may impact on recognizing perimenopause/menopause. For example:
- If you are taking combined hormonal contraception (CHC) – this can potentially help manage or prevent various menopause-related symptoms like hot flushes and night sweats.[i] This is because such symptoms are thought to be largely due to declining estrogen levels that begin during perimenopause/menopause (when the ovaries begin to slow down and release less of this). CHC contains estrogen so will help boost and improve estrogen levels. In addition, some possible side effects related to use of CHC are very similar to typical perimenopause and menopause symptoms. For example, mood swings, and lack of libido.
- If you are using progestogen only contraception– Similarly to CHC, some possible side effects related to use of POC are similar to typical perimenopause and menopause symptoms, e.g. mood swings or mood changes). However, as POC does not contain estrogen (and it is the drop in estrogen levels that seems to cause most menopausal symptoms; although progestogen levels do also drop at this time), its use does not generally notably help with (or “mask” ) menopausal symptoms.
Can I take a blood test to diagnose if I am in menopause?
Generally, use of any hormonal blood tests to diagnose menopause or perimenopause is neither necessary nor helpful for women 45 years or older (although the advice may be different for women younger than this). Therefore, this is not recommended; and this approach is supported by both the British Menopause Society (BMS) and the National Institute for Health and Care Excellence (NICE) in their guidelines on menopause.
The reason for this is because firstly we can generally recognize the perimenopause/menopause after carefully considering symptoms and if possible period changes in the context of age; plus hormone levels are very changeable in the perimenopause and normal levels do NOT therefore exclude or rule it out. Hormone levels will generally be in the menopausal range after periods have stopped for 12 months or more. However, this may not tell us anything more than we already know and also does NOT affect either whether or not we advise HRT or what type or dose of HRT we use (instead we have a standard approach to this).
In contrast, sometimes non-hormonal blood tests may be used to help safely exclude any other non menopausal causes of symptoms.
Can I take a blood test to work out whether or not I still need contraception?
Potentially yes, but this depends on your age and your recent bleeding pattern! We sometimes use a blood test called FSH (follicle stimulating hormone) to help us here.
FSH is a hormone produced by the brain that controls the ovaries. When the ovaries begin to slow down as you go into perimenopause and eventually transition to the menopause FSH levels begin to rise in an attempt to keep the ovaries going. It is generally accepted that if FSH is elevated to >30 IU/L or above, this indicates a degree of “ovarian insufficiency” i.e. your ovaries have notably slowed down, although it does NOT necessarily mean that you definitely can no longer become pregnant. However, generally accepted advice is that if you are over 50 years and your FSH level is >30 IU/L, this should be enough to confirm you can safely stop contraception 12 full months after this blood test was taken. If your FSH level is below >30IU/L however, you will generally be advised to continue with contraception and can, if you want to, take another FSH test a year later to check again on this.
Can hormonal contraception affect FSH levels?
Yes. If you are using combined hormonal contraception (and/or estrogen-based HRT) the results of the FSH test will not be reliable. FSH levels may also be affected if you use the contraceptive injection, although checking levels when on the contraceptive injection may still be helpful (whereas this would not be recommended if using combined hormonal contraception or estrogen-based HRT).
Can hormonal contraception improve my menopause symptoms?
Potentially, yes. As explained above, any form of CHC (which contains estrogen and progestogen) will likely help to control perimenopausal symptoms because these are largely thought to be triggered by declining estrogen levels. In fact, using combined hormonal contraception is an accepted alternative to HRT (which also works by providing estrogen) for some women under the age of 50, as continued use of this type of contraception can keep potentially troublesome perimenopausal or menopausal side effects at bay. However, use of CHC for women aged 50y or older is generally not recommended, and CHC may also not be suitable for a number women under the age of 50y as their medical history, weight, or smoking history may mean that its use is too risky. This is because use of all CHC is associated with a slightly increased risk of DVT and stroke (and the likelihood of DVT and stroke increases with age). In contrast, use of transdermal (through the skin) estrogen as part of a HRT regimen is not associated with any increased risk of DVT or stroke.
Does HRT provide contraception?
Hormone Replacement Therapy (HRT) does not protect against unwanted pregnancy (unless a Mirena hormonal coil forms part of the HRT regimen). This is because HRT uses different forms of estrogen in different doses to those used in hormonal contraception and these are not enough to reliably prevent ovulation (egg release) and therefore pregnancy. It is, however, generally seen as the gold-standard treatment for often debilitating menopausal symptoms like hot flushes, night sweats, mood swings, joint problems, insomnia and more. However, many methods of hormonal contraception can be safely used alongside HRT (the main exception is the combined hormonal contraceptive – as both HRT and CHC contain estrogen and doubling up on it is deemed unsafe). The Mirena coil might be particularly helpful here in that it provides not just birth control but also the womb lining protection part of HRT (which is always needed alongside estrogen use unless a woman has had a hysterectomy); plus it can also reduce and improve problematic periods.
What if I am not using hormonal contraception?
The generally accepted advice is If your periods stop when you are under 50, contraception can safely be stopped two years after your final period. For women aged 50 and over (ie. if your periods stop when you are 50 or above) it is advised that you can safely stop contraception one year after the date of your final period.
Will the pill make my menopause worse?
In a short answer – no. However, there are potential short and long-term side effects associated with both the progestogen-only and combined pill, such as headaches, breast tenderness, weight gain, alongside more serious risks such as deep vein thrombosis and blood clots. These risks are more significant with use of the combined pill.
It is important to be aware of these side effects before taking hormonal contraceptives, however, it is also pertinent to note that for women experiencing menopause the pill provides no additional or increased risk, nor is there any evidence to suggest it exacerbates symptoms. In fact, hormonal contraception can be prescribed as an effective alternative to HRT in helping to manage difficult menopausal symptoms in women under fifty.
Menopause contraception key facts
- The average age for a woman to go through menopause in the UK is 51 years and it is considered typical to experience menopause between 45 and 55. [iii]
- If you use hormonal contraception your vaginal bleeding pattern is not necessarily a clear signifier of what is happening with your natural menstrual cycle and will not reliably indicate how your ovaries are functioning and whether you are entering perimenopause or menopause. Bleeds caused by taking the combined contraceptive pill are false withdrawal bleeds and shouldn’t be confused with natural spontaneous periods and many women using progestogen-based contraception (mini pill, Mirena coil, injection or implant) may bleed only very infrequently or not at all. However, this is due to hormone use and should not be confused as a sign of perimenopause/menopause.
- If you are aged 50 or over and using hormonal contraception it may be possible to check your Follicle Stimulating Hormone (FSH) levels via a blood test in order to help you decide whether you can safely stop contraception before 55.
- Many forms of hormonal contraception can be safely used until 55 including the progestogen only pill (POP, or mini pill), the contraceptive implant (Nexplanon®) and hormonal coils (including Mirena).
- It is generally not advisable however to use any form of combined hormonal contraception (which contains progestogen and estrogen) like the combined oral contraceptive pill, the contraceptive ring (Nuvaring®) or patch (Evra®) from the age of 50 onwards, as it can put you at an increased risk of Deep Vein Thrombosis (DVT)[iv] and stroke. [v] Plus, it is not usually advisable to go on using Depo Provera over 50 – as it may affect your bone density[vi] (something that becomes particularly important around the time of the menopause as estrogen, which helps to maintain bone density, decreases.) [vii]
- All forms of progestogen-only contraception can generally safely be used alongside HRT, although Depo Provera is not generally recommended as it contains a higher dose of progestogen than other forms of progestogen-only contraception.
- All women should safely be able to stop contraception at the age of 55, (without needing any blood test to confirm they are menopausal), as it is extremely rare to get pregnant at this age (even if periods continue).
- Whilst is safe to stop using contraception after 55 without the worry of getting pregnant, using a barrier method such as condoms is still recommended to protect / guard against sexually transmitted disease.
- If you are worried or confused about using contraception during your perimenopause and menopause, please do talk to your GP or a knowledgeable menopause expert.
Resources and sources
[i] https://www.nhs.uk/conditions/contraception/menopause-contraceptive-pill/#:~:text=The%20combined%20pill%20may%20also,and%20therefore%20no%20longer%20fertile.
[ii] https://www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception/
[iii] https://www.nhs.uk/conditions/menopause/
[iv] https://www.nhs.uk/conditions/deep-vein-thrombosis-dvt/
[v] https://www.nhs.uk/conditions/stroke/
[vi] https://www.nhs.uk/conditions/contraception/contraceptive-injection/#:~:text=Using%20Depo%2DProvera%20affects%20your,cause%20any%20long%2Dterm%20problems.
[vii] https://www.themenopausecharity.org/2021/05/26/lets-talk-about-bone-health/
