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Contraceptive Pearl: Considerations in Contraception During Perimenopause

By Natalie Cheung-Jones, DO

During perimenopause, some people have inconsistent ovulation and irregular menses. Despite these changes, pregnancy occurs for 30% of pregnancy-capable people ages 40-44, decreasing to 10% by ages 45-50.¹ Though menstrual cycles may be unpredictable, studies indicate that ovulation occurs in 87% of cycles up to five years before menopause and 22% of cycles within one year.² Thus, if pregnancy is not desired, it is important to discuss the use of contraceptive options that are aligned with patients’ goals.

No contraceptive option is contraindicated due to age alone. Permanent sterilization or non-hormonal barrier methods can be used but do not treat perimenopause symptoms (e.g., hot flashes, heavy and/or irregular menses). The fertility awareness method may be less effective due to irregular ovulation and cycles, making menstrual tracking unpredictable. Hormonal methods, including estrogen-containing methods, are safe during perimenopause, but it is important to review the CDC Medical Eligibility Criteria (MEC) given the increasing prevalence of medical comorbidities.³

Hormonal contraceptives can ameliorate vasomotor symptoms that occur in perimenopause. Birth control pills containing drospirenone have anti-mineralocorticoid properties that can help reduce fluid retention and bloating.² For those with a uterus on estrogen therapy, progestin is required to provide endometrial protection. Progestin-only methods such as progestin-only pills and hormonal IUDs can be used for this purpose.

The North American Menopause Society states that 90% of pregnancy-capable people will reach menopause by age 55 and recommends continued use of contraception until then or menopause is confirmed.⁴ FSH serum tests may be used to confirm menopause for patients using hormonal contraception. This testing is optional and may not lead to changes in treatment. A combination of FSH serum tests can be utilized to help guide recommendations (Table 1).

Table 1. Confirming Menopause while using hormonal contraception²

Progestin-only pills, Nexplanon implant, Hormonal IUD
  1. Test FSH while using method, if FSH > 30 iu/l
  2. Then, continue method for one additional year before discontinuing
Combined Hormonal Contraception (pill, patch, ring)
  1. Discontinue use for 6 weeks,
  2. If no menses, then test FSH twice 1-2 months apart
  3. If both levels > 30 iu/l, then menopause is confirmed


  1. After age 50, discontinue use for 7-14 days
  2. Test FSH and if > 30 iu/l, 
  3. Repeat FSH level in 6-8 weeks
  4. Menopause is confirmed with two elevated FSH levels
Depo-Provera Injection
  1. Test FSH on first day of injection, then again 90 days apart before next injection
  2. If both levels > 30 iu/l, then menopause is confirmed

RHAP Resources:

Your Birth Control Choices Fact Sheet

Medically Complex Contraceptive Care

Medical Eligibility Criteria for Initiating Contraception


1.Baldwin MK, Jensen JT. Contraception during the perimenopause. Maturitas. 2013;76(3):235-242. doi:10.1016/j.maturitas.2013.07.009

2. Voedisch AJ, Ariel D. Perimenopausal contraception. Curr Opin Obstet Gynecol. 2020;32(6):399-407. doi:10.1097/GCO.0000000000000667

3. CDC – Summary – USMEC – Reproductive Health. Published 2019.

4. Allen RH, Cwiak CA. Contraception for midlife women. Menopause. 2016;23(1):111-113.

5. Kaunitz AM. Clinical practice. Hormonal contraception in women of older reproductive age. N Engl J Med. 2008;358(12):1262-1270. doi:10.1056/NEJMcp0708481

6. “The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. doi:10.1097/GME.0000000000002028


The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or contraception. The information in the Contraceptive Pearls is unbiased, based on science alone.

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