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Birth control in perimenopause: Do you still need it?
Understanding fertility in perimenopause and how birth control can help you manage perimenopause symptoms
Top things to know about birth control and perimenopause:
Fertility declines during perimenopause, but pregnancy is still possible
If you want to avoid pregnancy, keep using birth control during vaginal sex
Some birth control can also help with perimenopause symptoms
Track any changes you experience during this time with Clue Perimenopause mode
What is perimenopause?
Perimenopause is the transitional period leading up to menopause (1). It typically begins in your 40s, though it can start earlier or later (1). Perimenopause ends once you have gone 12 months without a menstrual period (2). At this point, menopause begins (1,2).
Perimenopause happens in two stages. In the early stage, periods are still fairly regular, with only slight changes (3). In the later stage, the gaps between periods become longer until the final menstrual period marks the transition into menopause (3).
Most people enter perimenopause between the ages of 45 and 55, and the transition to menopause typically lasts between 4–8 years (2,4). The timing varies for each individual, but on average, menopause happens around age 51 to 52 (1,4).
For some, perimenopause can stretch on for longer than average (2). If perimenopause starts earlier, the transition often lasts longer; if it starts later, the transition is usually shorter (5).
Premature and early menopause
While most people reach menopause in their early 50s, about 5% experience it after age 55, and another 5% between ages 40–45 (6).
Menopause before age 40 is called premature menopause, and before age 45 it’s called early menopause (7). In both cases, the ovaries stop making hormones, and menstrual periods end sooner than they typically would (7). This can happen naturally, but it may also be linked to genetics, smoking, cancer treatments, surgery to remove the ovaries, certain health conditions, or other medical factors (7).
Typical perimenopause experiences
Perimenopause happens because the ovaries gradually produce less estrogen (1). The first sign is often a change to your period and cycle. Menstrual cycles may come closer together or further apart, flow may feel heavier or lighter, and some periods may be skipped altogether (1).
Perimenopause looks different for everyone. While some people barely notice any changes, others can experience many.
Some common perimenopause experiences include:
Vasomotor symptoms like hot flashes and night sweats that disturb sleep
Trouble falling or staying asleep
Changes in the vagina or urinary tract, such as dryness, discomfort during sex, or more frequent urination (1)
Most people experience hot flashes, and about 1 in 3 experience them severely (3). They usually last 1 or 2 years, but in some cases may continue for longer. A small number of people never stop having them completely (3).
How fertility changes with age
For people born with ovaries and a uterus, fertility decreases with age (8). They are born with a limited number of eggs in their ovaries, and these deplete over a lifetime (8,9). There is a slow and steady decline between the ages of 20 and 35 (8). This is followed by a faster decline over the next 10 years. For people older than 45 years, becoming pregnant without medical assistance is rare (8).
Out of every 10 people aged 40–44, about one will become pregnant. Out of every 100 people aged 45–49, only about two will become pregnant. (10). At age 50 or older, the chance of becoming pregnant is very low, but not zero (10).
Studies around the world show a similar pattern. At age 25, only a small number of people have trouble becoming pregnant. By age 40, about 1 in 3 can’t conceive, and by age 45, most can’t (8). On average, the last birth happens around age 42–43 (8).
In a study of 105,000 births, only 0.2% were in people over the age of 45 (8). This shows that pregnancy at this age is very rare, but not impossible. After age 45, fertility is very low, and many people are already in perimenopause (8).
Can you still get pregnant during perimenopause?
Many people in perimenopause think they can’t become pregnant anymore, but that’s not true. One study from Korea showed that unintended pregnancies were actually more common in people aged 40 years or older than in younger groups (11).
During perimenopause, ovulation can still happen, but it’s harder to predict. Cycles are often unpredictable, making it tricky to predict the fertile days. Research shows ovulation happens in about 9 out of 10 cycles up to 5 years before menopause and in about 2 out of 10 cycles within 1 year of menopause (12).
So while fertility is low during perimenopause, pregnancy is still possible. If pregnancy is not desired, then birth control is needed (12).
What are my birth control options during perimenopause?
Choosing the right birth control for you is a personal choice. There’s a wide range of options available, and discussing them with a healthcare provider can help identify what suits you best. Some methods may also have the benefit of easing perimenopause symptoms (13).
Age alone does not exclude the majority of contraceptive methods (14). Both hormonal birth control and non-hormonal birth control methods can be used during perimenopause. Hormonal methods, including those containing estrogen, can be a safe choice during perimenopause, but it’s important to consider individual health conditions, which become more common with age.
After the age of 50, combined oral contraceptives are no longer recommended; the same applies for progestin injections after the age of 45 (14,15). Sterilization and barrier methods (such as condoms) are possible choices, although they don’t help with perimenopause symptoms.
If you’ve previously been using fertility awareness-based methods (FABMs or FAMs), it’s important to know that they become less reliable during perimenopause. This is because ovulation and cycles become unpredictable, making it difficult to identify fertile days (12,13).
Let’s take a closer look at the birth control options.
The IUD
The IUD is a small T-shaped device placed in the uterus for long-term contraception. There are two kinds: the hormonal IUD, which releases progestin, and the non-hormonal copper IUD (16). The copper IUD is coated with copper and contains no hormones. This makes it suitable for people who cannot or choose not to take hormones. It’s effective for up to 10 years and works by stopping sperm from fertilising an egg or an egg from implanting (15). It’s important to note that for some people, their period may become heavier, longer, or more painful when using the copper IUD (15,16).
The hormonal IUD releases progestin into the uterus. It prevents pregnancy by thinning the uterine lining and thickening cervical mucus (16). Hormonal IUDs are very effective and suitable for people who cannot use estrogen-containing methods. Different types are available, with varying hormone doses, and last between 3 and 8 years (15,16). It’s common to experience spotting and/or unpredictable bleeding in the first few months of use, and some people may experience side effects such as acne or mood changes (16). The Mirena IUD can be especially helpful during perimenopause for people with heavy or unpredictable periods. It also protects the uterine lining for those using hormone replacement therapy (HRT) (15,16).
The implant
The birth control implant is a small, flexible, plastic rod about the size of a matchstick that is placed just under the skin of the upper arm. It releases progestin and is approved for up to 3 years of use (16). The implant works mainly by stopping ovulation. It also thickens the mucus in the cervix, making it harder for sperm to reach the egg, and thins the lining of the uterus (15,16).
Birth control pills
The combined oral contraceptive pill contains both estrogen and progestin. It mainly works by stopping ovulation and is a very effective method of contraception. The combined pill may help reduce menstrual bleeding and pain, which can be especially useful for people experiencing perimenopause.
The combined pill isn’t recommended for people with certain health conditions, where taking estrogen is unsafe, such as a history of breast cancer or blood clots. It’s also not recommended after age 50 (14,15).
The progestin-only pill contains progestin but no estrogen. It works by thickening cervical mucus. It’s suitable for people who can’t use estrogen but prefer an oral method, and it doesn’t increase the risk of blood clots (15). Most types must be taken within a 3-hour window each day, although the drospirenone pill allows a 24-hour window (15).
Vaginal ring
The vaginal ring is a flexible device that contains estrogen and progestin. It’s placed in the vagina for 3 weeks, and then removed for 1 week before inserting a new ring (15). Like the combined oral contraceptive pill, it prevents ovulation, but it doesn’t need to be taken daily.
The vaginal ring isn’t suitable for people who need to avoid estrogen (15). There are two options for vaginal ring contraception: a monthly disposable ring and a reusable ring used for up to 13 cycles (15,17).
The shot
The shot is a progestin injection given every 3 months into the arm or buttock, and it works by preventing ovulation (15). It often stops periods, which can be helpful for people dealing with heavy bleeding (15). Because the shot also lowers estrogen, long-term use may reduce bone density, so it’s not usually recommended for people over 45 (15).
Barrier methods
Barrier methods, such as condoms, are another birth control option. But they can be less effective than other methods if not used consistently and correctly. They are the only method that also protects against sexually transmitted infections (STIs) (15).
Can birth control also help with perimenopause symptoms?
Yes. Some hormonal contraceptives can do more than prevent pregnancy—they may also ease perimenopause symptoms. These include symptoms such as heavy or unpredictable periods, hot flashes, or menstrual migraines (13,18).
Vasomotor symptoms (such as hot flashes and night sweats): The combined pill may help. In some cases, extra estrogen can be added during the placebo days (the hormone-free days in a pill pack) for more relief (13).
Migraines: The combined pill may also help with menstrual migraines without aura. If migraines with aura occur, the combined pill should be avoided, since it can increase the risk of stroke (19).
Cycle changes and heavy bleeding: The combined pill or vaginal ring may help regulate cycles and reduce heavy or unpredictable bleeding (13,14). It can be a good option for people who experience breakthrough bleeding on the pill or who prefer not to take a daily tablet (15).
Hormonal IUDs (like the Mirena): These can reduce heavy or unpredictable bleeding, protect the uterine lining when combined with hormone therapy, and may ease other perimenopausal symptoms when used with low-dose estrogen (15,18).
The shot: This can stop bleeding altogether, which can help with heavy periods. As long-term use can lower bone density, which is linked to osteoporosis (a condition where bones become fragile), this method is not recommended for people over 45 (15).
When can you safely stop using birth control?
If your final period happens after age 50, contraception should be continued for 12 months.
If your final period happens before age 50, contraception should be continued for 24 months.
By age 55, contraception can usually be stopped, as pregnancy is extremely rare, even if some bleeding continues.
If you’re 55 or older and want to stay on your method, this may be possible, but discuss it with your healthcare provider (14,15).
Keep in mind that even after the risk of pregnancy is gone, barrier methods like condoms may still be important for STI protection.
If you’re considering hormone replacement therapy (HRT) for perimenopause symptoms, talk with your healthcare provider about how to transition smoothly from birth control to HRT (13).
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The importance of tracking during perimenopause
Perimenopause is unique for everyone, and your cycles and symptoms can change along the way. Tracking with Clue’s Perimenopause mode can help you notice patterns, manage symptoms, and make informed choices about birth control.
Whether you’re considering a hormonal method, a non-hormonal option, or just want to understand your body better, tracking can give you the clarity and confidence to navigate this time on your own terms.
FAQs
Which birth control is best for perimenopause symptoms?
Contraception during perimenopause depends on your personal needs and preferences, and age alone does not limit your choice for most methods (14). Hormonal IUDs, such as the Mirena, can help with heavy or unpredictable bleeding, while combined methods like the combined birth control pill or vaginal ring may ease vasomotor symptoms and regulate cycles.
Can perimenopause cause bleeding?
Yes, perimenopause can cause changes in your bleeding pattern. As hormone levels fluctuate, periods may become unpredictable, heavier, lighter, longer, or shorter. Some people experience spotting between periods or very heavy bleeding. While these changes are typical and can be part of the perimenopausal transition, unusual or very heavy bleeding should be discussed with a healthcare provider to rule out other underlying issues (1).
Do birth control pills help with perimenopause?
The combined birth control pill, which contains estrogen and progestin, can help manage symptoms of perimenopause. It can help regulate cycles and control unpredictable or heavy bleeding. For some people, it can also help with headaches, premenstrual symptoms, and hot flashes (11).
At what age is birth control no longer needed?
After age 55, pregnancy is extremely unlikely, and contraception can usually be stopped, even if some menstrual bleeding continues (14). After menopause, contraception is needed for 12 months after the final menstrual period if it happens after age 50. If menopause happens before age 50, contraception should be continued for another 24 months (15).
