Contraception in Perimenopause

Perimenopause is the 3 to 5 years around menopause, when cycles become irregular but ovulation and pregnancy remain possible. Menopause is confirmed after 12 consecutive months of amenorrhoea, or an FSH over 30 mIU/mL. Most women reach menopause between 45 and 55 years, half by 50 and about 96% by 55. Contraception continues until menopause is confirmed.

Assessment. Age, smoking, blood pressure, BMI, lipid and glucose risk, migraine, past thrombosis, breast and gynaecological history, menstrual pattern, vasomotor symptoms, bleeding patterns that need evaluation, medicines and plans for hormone therapy.

Bleeding evaluation. Heavy, intermenstrual or postcoital bleeding at this age needs pregnancy testing, cervical screening, and consideration of endometrial assessment when risk factors or persistent bleeding exist; it is not assumed to be a perimenopausal change.

Diagnosis of menopause on hormonal methods. Hormonal methods mask the bleeding pattern, so FSH cannot be interpreted reliably on combined methods and amenorrhoea is not evidence of menopause. After stopping a hormonal method, use a non-hormonal method until 12 months of amenorrhoea has passed.

Effectiveness. Pregnancy risk falls with age but is not zero; methods with the lowest failure remain preferred.

Eligibility.

• Combined oral contraceptives: category 1 from menarche to 40 years; category 2 at 40 years or more. Smokers aged 35 years or more are category 3 at under 15 cigarettes daily and category 4 at more than 15 cigarettes daily. Blood pressure 140/90 to 159/99 is category 3 and 160/100 or more is category 4.

• Progestin-only pills and implants: category 1 for age; check cardiovascular risk.

• DMPA: category 2 after 45 years; bone density concern, with no age or time limit on use.

• Copper intrauterine device and levonorgestrel 52 mg device: suitable; the copper device can remain until menopause and is removed 12 months after the last period.

• Condoms, diaphragm: suitable for occasional intercourse.

• Fertility awareness methods: poor choice because cycles are irregular.

• Sterilisation: suitable when no further children are wanted; cardiac disease, complicated diabetes and hypertension may require delay or referral.

Method comparison. The levonorgestrel 52 mg device is attractive because it reduces heavy bleeding, gives endometrial protection with oestrogen therapy where used, and lasts 5 years. Implants suit those without oestrogen eligibility. Combined pills help vasomotor symptoms and bleeding but carry rising thrombotic and cardiovascular risk.

Special groups. Obesity, diabetes, hypertension and smoking are common and shift the choice to progestin-only methods or an intrauterine device. Women living with HIV or on enzyme inducers follow the same interaction rules as at other ages.

Regimen lines.

• Levonorgestrel 52 mg intrauterine device: inserted within 12 days of the start of bleeding or at any time if reasonably not pregnant; 5 years; backup 7 days if inserted after day 7 of bleeding.

• Copper T 380A: up to 12 years; may remain until menopause; remove 12 months after the last menses.

• Etonogestrel 68 mg rod (3 years) or levonorgestrel two 75 mg rods (5 years or 3 years by system): insert within 7 days of bleeding or with backup 7 days.

• DMPA 150 mg intramuscularly every 13 weeks, up to 4 weeks late, or 104 mg subcutaneously every 13 weeks; start within 7 days of bleeding or with backup 7 days.

• Combined pill with ethinylestradiol 30 micrograms: only if category 1 or 2 for age and risk, and non-smoking; daily with a 7-day break.

When to stop. Continue the method until 12 months without periods. If on a hormonal method, stop it and use condoms or a copper device for 12 months. On a levonorgestrel 52 mg device, an FSH over 30 mIU/mL supports menopause, but amenorrhoea on the device is not evidence of menopause.

Follow up. Annual review of blood pressure, weight, smoking, breast and cervical screening, and bleeding pattern; earlier for new symptoms.

Bleeding. Persistent heavy or irregular bleeding is evaluated before being attributed to the method. Levonorgestrel 52 mg devices commonly produce amenorrhoea; copper devices may increase bleeding and are managed with ibuprofen 800 mg three times daily for 5 days or tranexamic acid 500 mg three times daily for 5 days.

Cardiovascular and thrombotic events. Stroke, ischaemic heart disease and venous thromboembolism warrant immediate stop of combined methods.

Breast and gynaecological cancer. Any new breast lump, postcoital or postmenopausal bleeding requires diagnosis.

Red flags. Leg swelling, chest pain, focal neurological symptoms, new migraine with aura, postcoital bleeding.

Referral and escalation. Refer abnormal uterine bleeding with risk factors, breast masses, suspected cancer and cardiovascular events urgently.