Many women assume contraception during perimenopause becomes unnecessary as fertility declines. Around 27% of conceptions in women over 40 end in termination. This shows the ongoing risk of unplanned pregnancy6. Pregnancy rates in this age group are increasing19. Women can remain fertile until menopause is confirmed, which requires one to two years without periods depending on age. This piece covers everything about birth control perimenopause and available options for women over 40 in the UK. It also explains when to stop contraception menopause and how contraception during menopause works among other HRT.
Why You Still Need Contraception During Perimenopause
Fertility decline doesn't mean zero pregnancy risk
Perimenopause brings irregular cycles, but ovulation still occurs. The unpredictability is what makes this challenging. Hormonal fluctuations can trigger multiple ovulations within a short span, which explains why twin pregnancy chances double by age 35 and triple by 4028.
Women in their early 40s have a monthly conception probability of roughly 10%. This drops to 2-3% by the late 40s and falls below 1% at age 5028. These percentages may seem small. They represent pregnancy risk that's very much there. Evidence shows ovulation activity in 87.9% of cycles up to five years before menopause and still appears in 22.8% of cycles within one year of the final period2.
Age raises the stakes. Pregnancy complications become more common, including gestational diabetes and high blood pressure28. Miscarriage risk exceeds 50% for pregnancies between ages 40-44 and rises above 90% after age 452. Chromosomal abnormalities also increase, with Trisomy 21 odds climbing from 1:85 at age 40 to 1:35 at age 452.
Unexpected pregnancy rates in women aged 45-50
Women in their 40s experience some of the highest rates of unplanned pregnancy in any age group. One-third of pregnancies in the 40-45 age range are unintended29. About 17% of women aged 45-50 who face pregnancy risk report not using birth control perimenopause30.
The unplanned pregnancy rate in women over 40 can reach up to 75%15. Termination rates for this age group mirror those of under-16s31. Birth rates among women aged 45-50 have been climbing since the early 1990s. The US birth rate for women 45 and older reached 0.8 births per 1,000 women in 2013, up from 0.3 in the early 1990s30. England saw a 15% rise in births to women over 50 between 2016-18 and 2019-2132.
Many women receive incorrect information. Some patients have been told by providers that they were too old to conceive, only to face unexpected pregnancies later28. The misconception that irregular periods equal infertility contributes to inconsistent contraceptive use2.
When you can stop using contraception
NHS guidelines provide timeframes that are clear. Women over 50 can stop contraception during menopause one year after their last natural period. Those under 50 should wait two years after periods stop19. These rules only apply when not using hormonal medication.
Contraception can cease at age 55, whatever the period status, as natural conception becomes rare19. Women can stop at this age even if still experiencing menstrual bleeding31.
Hormonal contraception and HRT complicate matters. The combined pill produces monthly withdrawal bleeds that aren't true periods. Progestogen-only methods may stop periods and make it impossible to track the final menstrual period11. Women over 50 using progestogen-only contraception who want to stop before 55 can have FSH levels tested. Contraception can stop one year later if FSH falls within the menopausal range31. NHS menopause services can help determine [what age menopause starts](https://goldmanlaboratories.com/blogs/blog/what-age-does-menopause-start) for individual circumstances.
Contraception Options for Women Over 40 in the UK
No single method suits everyone during perimenopause. Age alone doesn't rule out any contraceptive method for women in their 40s1. Health status, lifestyle factors and personal priorities determine the best choice.
Combined pill over 40: benefits and risks
The combined pill remains an option for healthy, non-smoking women until age 501. First-line formulations should contain 30 µg or less ethinylestradiol with levonorgestrel or norethisterone due to lower VTE risk15. These formulations reduce risks of cardiovascular disease and stroke compared to higher-dose options1.
Benefits extend beyond pregnancy prevention. The combined pill reduces menstrual bleeding and pain, which proves especially relevant during perimenopause when irregular periods become common1[152]. Protection against ovarian and endometrial cancer lasts for several decades after stopping1[152]. The pill also helps maintain bone mineral density compared to non-use of hormones1[152].
Risks increase with age. Women who smoke must stop the combined pill at age 351[152]. All women should switch to safer alternatives after 501. Meta-analyzes show a slight increased breast cancer risk during use, but no risk persists 10 years after stopping1.
Progestogen-only pill (mini pill)
The progestogen-only pill offers a safer profile for women with cardiovascular risk factors. It carries no association with VTE, stroke or myocardial infarction1[152]. Bone mineral density remains unaffected1[152].
Nearly half of users experience altered bleeding patterns1. Women over 45 with excessive bleeding require endometrial assessment6. The mini pill can be used until age 55, when pregnancy risk becomes very low1[152].
IUD and Mirena coil: dual benefit for contraception and HRT
Intrauterine devices provide long-acting protection. The copper IUD inserted at age 40 or over can remain until menopause56. The Mirena coil has unique advantages. When inserted at 45 or older for contraception alone, it can stay in place until age 551[152].
The Mirena serves dual purposes for HRT menopause use. It provides endometrial protection when combined with estrogen therapy and prevents pregnancy2533. Replacement occurs every five years in this capacity1[152]. The device reduces blood loss by over 90% within six months for most women with heavy bleeding25.
Contraceptive injection and implant
The contraceptive injection requires careful thought after 40. Women using DMPA experience original bone density loss due to hypoestrogenic effects1[152]. DMPA moves from Category 1 to Category 2 in UK Medical Eligibility Criteria after age 451. Regular reviews every two years assess individual benefits and risks1[152].
The progestogen implant has fewer concerns. It shows no association with VTE, stroke or MI and doesn't affect bone density5. The implant lasts three years and can be used until 55.
Barrier methods and condoms
Barrier methods carry no age restrictions1[152]. Male condoms, female condoms and diaphragms often achieve high effectiveness in women over 40 due to declining fertility and more consistent use1[152].
Sterilization: what to think about
Female sterilization provides permanent contraception but requires surgical intervention3. The procedure doesn't alter or eliminate periods5[153]. Women switching from another contraceptive method may notice bleeding pattern changes after sterilization because they've stopped hormonal contraception5[153]. Male vasectomy offers a safer, simpler alternative with fewer complications3.
When to Stop Contraception: NHS Guidelines
The 1 year rule if you're over 50
Women aged 50 and above can stop using contraception during menopause one year after their final natural period8910. This guideline applies only when not taking additional hormones or using hormonal intrauterine systems. Natural conception after 55 becomes rare, even among women still experiencing menstrual bleeding11[181].
The 2 years rule if you're under 50
Women under 50 who reach menopause and fertility must wait two years after their last period before stopping birth control perimenopause8[222][181]. Periods may restart even after several months without bleeding. This explains the extended timeframe12. This precaution will give assurance that ovulation has stopped.
How to know if you've reached menopause
Menopause occurs after 12 consecutive months without a menstrual period131415. Most women reach this stage by age 5416. At 55, all women can discontinue contraception whatever their bleeding patterns11[181]6. The age threshold reflects that 90% of women reach menopause by this point17.
Women over 45 don't need hormone testing to diagnose menopause9. Hormone levels fluctuate wildly during perimenopause, and normal levels don't rule out the transition9. Then, NHS menopause services rely on symptom assessment and [irregular periods menopause](https://goldmanlaboratories.com/blogs/blog/irregular-periods-menopause) patterns rather than blood tests.
What to do if you're using hormonal contraception
Hormonal contraception masks menopause signs. The combined pill produces withdrawal bleeds that resemble periods but aren't natural cycles1118. Combined pill users cannot determine menopause status through bleeding patterns8. Women must stop the combined pill six weeks before FSH testing to get accurate results19.
Progestogen-only methods include the mini pill, implant, injection and Mirena coil. These often eliminate periods11[191]. FSH levels menopause testing helps women over 50 using these methods determine when to stop before 5510[231]. FSH above 30 IU/L indicates ovarian insufficiency, though it doesn't guarantee infertility9. Women with elevated FSH should continue contraception for one additional year after the test20[222]. FSH below 30 IU/L requires continuing contraception, with retesting possible after another year9. High-dose progesterone menopause contraception like injections may affect FSH accuracy19.
Using HRT and Contraception Together
Why HRT alone doesn't prevent pregnancy
HRT menopause contains hormone levels far too low to act as contraception19. The estrogen and progestogen in HRT cannot prevent ovulation8. Research from 1995 showed ovulation occurred unpredictably in women taking HRT, with one participant who had elevated FSH levels menopause still ovulating despite markers suggesting low ovarian function21. Women using HRT who remain sexually active during perimenopause require separate contraception if they wish to avoid pregnancy.
Which contraception methods work with HRT
Women cannot take the combined pill with HRT22. Women aged 50 or older using the combined pill should switch to HRT instead, as the pill isn't recommended past this age22. The NHS suggests continuing the combined pill until 50, then transitioning to HRT22.
Progestogen-only methods work safely with HRT. Women can use the progestogen-only pill, contraceptive injection and implant with HRT if contraception is needed19. Barrier methods and condoms present another compatible option. Contraception becomes unnecessary on condition that HRT produces no periods19.
Blood clot risks: what you need to know
Oral HRT carries a higher blood clot risk compared to transdermal options23. Transdermal HRT delivered through patches, gels or sprays doesn't increase clot risk24. The oestradiol bypasses the liver, which produces clotting factors24. Women with obesity, smoking history or previous clots face elevated risks24.
Combined oral contraceptives increase clot risk when used with HRT. Natural estrogen-based contraceptives show a 33% reduction in venous thromboembolism risk compared to synthetic versions19. Women over 50 should avoid combined methods as they heighten blood clot risk8.
The Mirena coil as both contraception and HRT
The Mirena coil serves three purposes during perimenopause: contraception, heavy period treatment and progesterone menopause protection when combined with estrogen19. Blood loss reduces by more than 90% over six months for most women with heavy bleeding19.
Replacement timeframes vary by use. The Mirena requires changing after five years for HRT endometrial protection19. It lasts eight years for contraception alone19. The device provides over 99% contraceptive effectiveness25. Women using the Mirena as part of HRT only need to take estrogen separately, simplifying their hormone regimen8.
What to Discuss With Your GP
Your current health conditions and risk factors
Scheduling a contraception review with your GP addresses age-related health considerations. Women over 40 face increased background risks of cardiovascular disease, obesity, breast and gynecological cancers6. These factors influence contraception during perimenopause safety.
Your smoking status matters. The combined pill should be avoided after 35 for smokers or those who are overweight19. History of blood clots, high blood pressure, migraine with aura or diabetes limits options12. Osteoporosis risk factors make the contraceptive injection unsuitable for women over 40. These include previous fractures, steroid use or family history12.
Your GP should ask about urogenital symptoms and sexual health concerns6. These discussions help arrange menopause and fertility management with contraceptive needs.
Choosing the right contraception for your situation
No single approach works for everyone. Three considerations guide the choice: symptoms requiring treatment, desired non-contraceptive benefits, and existing health conditions that may limit options26. Discussing whether you plan to use HRT menopause treatment affects which methods work together8.
Complete counseling addresses efficacy, side effects and potential implications of each method26. Your priorities matter alongside medical factors.
Signs that you may need to change methods
Women over 40 with substantial bleeding pattern changes need gynecological assessment, whatever their birth control perimenopause method6. Regular reviews apply to those using the contraceptive injection, after age 45 when it moves to Category 2 in UK guidelines27.
At 50, women using combined contraception should switch to safer alternatives27. Those uncertain about when to stop contraception menopause can request FSH levels menopause testing through NHS menopause services.
Emergency contraception options
Emergency contraception remains available for women over 40 who experience unprotected sex or contraceptive failure6. No upper age limit exists if menopause hasn't been confirmed7.
Two emergency pill types operate within specific timeframes. Levonorgestrel must be taken within 72 hours after sex4. Ulipristal acetate extends this window to 120 hours4. Both are available free from sexual health clinics, GP surgeries and some pharmacies4.
The copper IUD provides the most effective emergency option when fitted within 5 days4. It can remain as ongoing contraception afterward12.
Conclusion
Contraception remains essential throughout perimenopause until menopause is confirmed. Fertility decline doesn't eliminate pregnancy risk, as shown above, and unplanned pregnancies occur often in women over 40. Multiple safe contraceptive options exist for this age group, from the Mirena coil to progestogen-only methods. Many of these work together with HRT.
You should consult your GP to discuss your health profile and when to stop contraception before making any decisions. The right guidance helps you choose a method that protects against pregnancy and manages perimenopausal symptoms.
Key Takeaways
Understanding contraception during perimenopause is crucial for preventing unplanned pregnancies while managing hormonal changes effectively.
• Pregnancy risk persists throughout perimenopause - Women over 40 have up to 75% unplanned pregnancy rates, with ovulation occurring in 87.9% of cycles up to 5 years before menopause.
• Follow NHS timing guidelines for stopping contraception - Wait 1 year after final period if over 50, or 2 years if under 50; all women can stop at age 55 regardless of bleeding patterns.
• Multiple safe options exist for women over 40 - Progestogen-only pills, Mirena coil, and barrier methods offer effective protection without age-related cardiovascular risks.
• HRT alone doesn't prevent pregnancy - Hormone replacement therapy contains insufficient hormone levels to suppress ovulation, requiring separate contraception during perimenopause.
• The Mirena coil provides dual benefits - Acts as both contraception and HRT endometrial protection, reducing bleeding by 90% while preventing pregnancy for up to 8 years.
Regular GP consultations ensure your contraceptive choice aligns with your health profile, symptoms, and whether you're using HRT, helping you navigate this transitional period safely.
FAQs
Q1. Which contraceptive methods are most suitable during perimenopause? Several options work well during perimenopause. The progestogen-only pill (mini pill) is often recommended for women over 40 as it carries no cardiovascular risks. The Mirena coil offers dual benefits—providing contraception whilst also helping manage heavy bleeding and working alongside HRT. For healthy non-smokers, the combined pill remains an option until age 50. Your choice should depend on your individual health profile, symptoms, and whether you're using HRT.
Q2. Is it still possible to get pregnant during perimenopause? Yes, pregnancy remains possible throughout perimenopause until menopause is confirmed. Even with irregular periods, ovulation can still occur unpredictably. Studies show ovulation happens in nearly 88% of cycles up to five years before menopause, and in about 23% of cycles within one year of the final period. This is why contraception remains essential during this transition.
Q3. How long should I continue using contraception after my periods stop? The timing depends on your age when periods cease. If you're over 50, you should continue contraception for one year after your last natural period. If you're under 50, continue for two years after periods stop. At age 55, contraception can be discontinued regardless of whether you're still having periods, as natural conception becomes extremely rare.
Q4. Can I use HRT as contraception during perimenopause? No, HRT alone does not prevent pregnancy. The hormone levels in HRT are too low to stop ovulation, so you'll need separate contraception if you're sexually active and wish to avoid pregnancy. However, certain contraceptive methods like the Mirena coil, progestogen-only pill, or barrier methods can be safely used alongside HRT.
Q5. When should I switch from the combined pill to other contraceptive methods? Women who smoke must stop the combined pill at age 35. All women should switch from the combined pill to safer alternatives by age 50, regardless of smoking status. At this point, you can transition to progestogen-only methods, the Mirena coil, or discuss starting HRT with your GP if you're experiencing menopausal symptoms.
References
[1] - https://gpnotebook.com/en-GB/pages/gynaecology/progestogen-only-implant-in-the-perimenopause
[2] - https://contraceptivetechnology.org/perimenopause-pregnancy-risks/
[3] - https://pmc.ncbi.nlm.nih.gov/articles/PMC3626808/
[4] - https://www.nhs.uk/contraception/emergency-contraception/
[5] - https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf
[6] - https://www.nnuh.nhs.uk/publication/download/perimenopausal-contraception-g15-v6-792/
[7] - https://www.ellaone.co.uk/magazine/ask-ella/im-over-40-can-i-take-the-morning-after-pill/
[8] - https://www.brook.org.uk/your-life/contraception-during-perimenopause-and-menopause/
[9] - https://healthandher.com/blogs/expert-advice/menopause-contraception-everything-you-need-to-know-about-menopause-038-contraception
[10] - https://www.mymenopausecentre.com/gp-resources/choosing-contraception-during-the-menopause-transition/
[11] - https://www.nhs.uk/conditions/menopause/symptoms/
[12] - https://www.womens-health-concern.org/wp-content/uploads/2025/12/04-NEW-WHC-FACTSHEET-Contraception-for-women-over-the-age-of-40-DEC2025-A.pdf
[13] - https://my.clevelandclinic.org/health/diseases/21841-menopause
[14] - https://www.nhs.uk/conditions/menopause/
[15] - https://www.healthpartners.com/blog/birth-control-and-menopause/
[16] - https://themenopausecharity.org/information-and-support/could-it-be-menopause/am-i-perimenopausal-or-menopausal/
[17] - https://www.reproductiveaccess.org/resource/contraceptive-pearl-considerations-in-contraception-during-perimenopause/
[18] - https://sh24.org.uk/help-centre/when-can-i-stop-contraception
[19] - https://www.drlouisenewson.co.uk/knowledge/contraception-during-menopause-and-perimenopause
[20] - https://www.glastonburysurgery.co.uk/somerset-nhs-menopause-service/contraception-in-the-perimenopause-and-menopause/
[21] - https://www.forhers.com/blog/can-you-get-pregnant-on-hrt
[22] - https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/when-to-take-hormone-replacement-therapy-hrt/
[23] - https://www.menopausecare.co.uk/blog/hrt-perimenopause
[24] - https://www.drlouisenewson.co.uk/knowledge/blood-clot-and-hrt-what-you-need-to-know
[25] - https://www.drlouisenewson.co.uk/knowledge/the-mirena-coil-everything-you-need-to-know
[26] - https://gremjournal.com/journal/01-2024/hormonal-contraception-and-menopausal-transition-a-short-review/
[27] - https://gpnotebook.com/en-GB/pages/gynaecology/contraception-during-perimenopause
[28] - https://www.uhhospitals.org/blog/articles/2025/08/can-you-get-pregnant-during-perimenopause
[29] - https://www.theatlantic.com/health/archive/2023/11/perimenopause-vs-menopause-age-pregnancy/675998/
[30] - https://pmc.ncbi.nlm.nih.gov/articles/PMC10994517/
[31] - https://healthandhormones.co.uk/advice-for-pregnancy-risk-in-perimenopause/
[32] - https://www.theguardian.com/uk-news/2023/nov/17/ons-data-shows-15-rise-in-births-among-women-over-age-of-50-in-england
[33] - https://clarewellclinics.co.uk/family-planning/hormonal-coil-ius/mirena-coil-as-treatment-for-the-menopause/
