Birth control in perimenopause & beyond
Updated: Apr 4
I’m recently divorced and I find myself researching birth control methods for the first time in decades. I’m 48, in perimenopause and my periods are still fairly regular. How long will I continue to need birth control? What are my options? And where is the course for birth control for the midlife woman?
Here's my reply:
Great questions, Melanie! There is definitely a gap in quality birth control education for women of all ages—so I do love your idea for a course! There is a tendency to focus birth control messaging on younger women, leaving those of us who are navigating perimenopause-to-menopause (& beyond!) with many of the same questions you have.
You are not alone.
How long you require birth control
Ask any woman about the benefits of post-menopause, and you are most likely going to hear: no more worries about becoming pregnant.
But what about women in perimenopause? There is quite a bit of confusion around contraception for women who have passed the family planning stage of life, but not yet reached menopause.
Let’s begin with a few definitions:
Menopause is one day. It is the 12-month anniversary of the final menstrual period.
Post-menopause is every day after the menopause milestone, for the rest of your life.
And perimenopause is the phase of life leading up to the menopause anniversary. It spans over a number of years (anywhere from five-to-fifteen) and is defined as a phase of life that includes fluctuating hormones. These fluctuating hormones can lead to changes in your period such as heavier bleeding, lighter bleeding, more frequent or less frequent periods, or no changes at all; everyone is unique.
One of the most common experiences of perimenopause is for women to skip one or more periods, and then have it show up again a few months later. That is why the agreed definition of reaching menopause is 12 months period-free.
I frequently receive questions such as “How do I know if I have reached menopause?” and the answer is: it doesn’t really matter UNLESS you are making decisions about birth control! Every woman needs to know she can still become pregnant in perimenopause, and birth control is necessary.
What the experts recommend
To be clear, when it comes to preventing pregnancy, you are the expert on your own body. Few women 45 and up are interested in becoming pregnant. And their doctors are especially wary of dealing with unplanned pregnancies.
For that reason, at the 2018 World Congress on Menopause, doctors recommended women who reach menopause (12 months period-free) and are under the age of 50, should continue to use birth control for two additional years. And women who reach menopause after age 50 should continue birth control for one more year.
Birth control options: some old; some new
There have not been that many new developments in birth control options for women since the pill made its debut in 1960. To answer your question, here is an overview of some of your current options (best discussed with your health care professional so you can choose the option that is best for you):
Non-hormone birth control:
Vasectomy: This is my personal favourite, and I realize it is not an option for everyone, especially women starting new relationships. Con: Doesn’t protect from sexually transmitted infections (STIs).
Condom: Covers the STI concern and can be used in combination with other methods. When using a lubricant, choose water-based as oil-based may cause latex condoms to break.
Non-hormonal vaginal gel: Evofem BioSciences recently a new “on-demand” form of birth control in the USA called phexxi. It’s a hormone-free, prescription gel known as a vaginal pH modulator. And it prevents pregnancy by maintaining a woman’s natural vaginal pH within the normal range of 3.5 - 4.5 which is an acidic environment that is not hospitable to sperm. Similar to condoms, it is designed to be used in-the-moment, but can be administered up to one hour before intercourse.
Hormone birth control:
Birth-control pill: Probably the most common choice, the birth control pill is a form of hormone therapy used by three-quarters of Canadian women at some point in their lives between ages 15 and 49 to prevent pregnancy. Advice as to whether the pill is right for you if you are over 49 is going to vary depending on your overall health, if you are a smoker/non-smoker and best left to an individualized conversation between you and your health care provider.
IUD: Stands for “intauterine device.” It’s a “T-shaped” copper wire that fits inside your uterus and prevents sperm from reaching any egg. An IUD can contain hormones or be hormone-free. Some women find that a hormone-based IUD in perimenopause (the Mirena is popular) helps manage heavy bleeding.
How to decide what’s right for you
It’s a personal decision. Make a checklist before discussing with your health care team. It’s important to first decide where your personal values and preferences lie so you are prepared to either ask for what you want, or to say “no thanks, that won’t work for me.” For example:
· Am I at risk of getting pregnant?
· Do I need protection from STIs?
· Have I reached menopause?
· Am I under 50 or over 50?
· Am I seeking short-term protection or a longer-term strategy?
· What is best for me at this point in my life—hormone-based or hormone-free?
It’s important to note that some practitioners look to the hormone birth control options as ways to manage hormone imbalance during perimenopause, regulate periods, or manage acne. Personally, I’m not a fan of this approach—especially if you don’t need birth control protection or the pill is not already your preferred contraception method.
The pill, for example, is a uniform dose of hormones—whereas a woman’s natural hormones are fluctuating (sometimes wildly!) in perimenopause. It’s rarely a perfect or personalized match. Women should also be sure to weigh all the pros and cons of their decision and be aware that the birth control pill is known to cause vaginal dryness (how ironic!) and deplete women’s bodies of essential nutrients, especially vitamin B.
What is your preferred method of birth control?