DOI: 10.1111/tog.12416 2017;19:289–97
The Obstetrician & Gynaecologist
Review
http://onlinetog.org
Contraceptive methods and issues around the menopause:
an evidence update
a,b, c d
Shagaf H Bakour MD FRCOG, * Archana Hatti MRCOG, Susan Whalen DFSRH MRCOG
a
Senior Lecturer and Consultant Obstetrician and Gynaecologist, City Hospital, Dudley Road, Birmingham B18 7QH, UK
b
Director of Medical Education, Aston Medical Research Institute (AMRI), Aston Medical School, Aston University, Birmingham B4 7ET, UK
c
Specialist Trainee (ST4), Obstetrics and Gynaecology, City Hospital, Dudley Road, Birmingham B18 7QH, UK
d
Consultant in Sexual Health, Sexual Health Department, Lyng Centre, Frank Fisher Way, West Bromwich B70 7AW, UK
*Correspondence: Shagaf Bakour. Email:
Accepted on 31 January 2017. Published Online 26 September 2017
Key content Be aware that the risks of fetal chromosomal abnormalities,
There have been a number of recent advances and an increase in miscarriage, pregnancy complications and maternal morbidity and
the number of contraceptive methods available to mortality increase for women aged 40 years and over.
perimenopausal women. No contraceptive method is contraindicated on the basis of
Other relevant issues, including transition to and diagnosis age alone.
of menopause, the use of hormone replacement therapy Clinicians must carefully consider comorbidities when prescribing
with contraception, and when to stop contraception, are women the most suitable contraception.
discussed.
Ethical issues
Some hormonal contraceptives have added benefits in the
Return of fertility can be delayed for up to 1 year after
management of common perimenopausal
discontinuing progestogen-only injectable contraceptives;
gynaecological problems.
Research and development into intrauterine contraception,
therefore, these contraceptives are not suitable for perimenopausal
women considering future pregnancies.
microchip drug release technology, progesterone receptor Contraceptive methods with a recognised post-fertilisation,
modulators, male contraception and vaccines is
pre-implantation effect may not be acceptable to some
currently underway.
women.
Learning objectives Women should be given information about all suitable
Understand that, although women’s natural fertility declines after contraceptive methods to make an informed choice.
their mid-30s, effective contraception is required until menopause
Keywords: combined hormonal contraception / contraception /
to prevent unintended pregnancies.
contraceptive device / menopause / progestogen-only contraception
Please cite this paper as: Bakour SH, Hatti A, Whalen S. Contraceptive methods and issues around the menopause: an evidence update. The Obstetrician &
Gynaecologist 2017;19:289–97. DOI: 10.1111/tog.12416.
Introduction Conception and demographics in
older women
The World Health Organization (WHO) defines the
menopause as permanent cessation of menstruation During the perimenopause, menstrual irregularities can
caused by the loss of ovarian follicular activity;1 a occur with both prolonged or shorter anovulatory cycles
retrospective diagnosis that is clinically confirmed after and sometimes heavy menstrual bleeding (HMB). Hot
12 months of amenorrhoea. Diagnosis is difficult when flushes often begin at this time. Women’s fecundity
women use methods of contraception that interrupt the declines when they reach their mid-30s, with an associated
natural menstrual cycle. No accurate biological marker increase in pregnancy loss secondary to oocyte ageing.
exists that truly defines the moment when fertility ceases. However, a decrease in the ability to conceive does not
The period of time immediately before menopause is called occur until women are in their mid-40s.2 The 2013 National
perimenopause, and is when endocrinological, biological Survey of Sexual Attitudes and Lifestyles (NATSAL) research
and clinical features of the approaching menopause project showed that 1 in 5 pregnancies conceived when the
commence. Perimenopause includes the first year after the mother is aged 40 years or older are unplanned and 28% of
last natural menstrual period.1 these pregnancies end in termination.3 In Western society,
ª 2017 Royal College of Obstetricians and Gynaecologists 289
, Contraception and the menopause
relationship breakdown and re-partnering is increasing, and progestogen in most hormonal contraception methods
sexual intercourse occurs more frequently in new provides endometrial protection. The exception is the
relationships.4 Sexually transmitted infection (STI) rates are Mirena (Bayer plc, Newbury, UK) levonorgestrel-releasing
increasing most rapidly in women over the age of 40 years.5 intrauterine system (IUS) (52 mg IUS), which is licensed for
Only condoms protect against STI transmission, including HIV. this indication for 4 years but evidence supports its use for
5 years.8
Women using combined methods of contraception can use
Stopping contraception
regimens with shorter pill-free intervals to reduce the risk of
During the perimenopause, follicle stimulating hormone menopausal symptoms.12
(FSH) levels can fluctuate considerably.6 Neither a single FSH
measurement nor the presence or absence of menopausal
Choice of methods of contraception
symptoms can reliably predict loss of fertility. For women
over the age of 50 years who do not use hormonal methods, Women must be advised on all available methods of
contraception can be stopped after 1 year of amenorrhoea as contraception, including long-acting reversible methods
fertility is unlikely to return. In women under 50 years of age, (LARC), so they can make an informed choice.13 No
contraception should be continued for 2 years, as the return method of contraception is contraindicated based on age
of fertile ovulation is more likely to occur.7 alone, up to the age of 50 years.8 Table 1 summarises the
Hormonal contraception can affect bleeding patterns main advantages, risks and reliability of contraceptive
making it difficult for clinicians to advise when methods for perimenopausal women.14,15 Table 2 shows the
contraception can safely be stopped. For women over the age contraceptive methods chosen by UK women in
of 50 years using oral progestogen-only methods, subdermal this age group.16
implants and intrauterine systems, the Faculty of Sexual and It is essential to acquire a personal, sexual and family
Reproductive Healthcare (FSRH) recommends that history, and pregnancy should be excluded (see Box 1).17
contraception should be continued for 1 year after recording Body mass index and blood pressure should be checked and
two FSH levels at >30 IU/l, taken at least 6 weeks apart.8 STI screening offered, particularly before an IUC device is
Combined hormonal contraception (CHC) affects FSH inserted. Pelvic examination is only required prior to fitting
levels so should be stopped for at least 2 weeks prior to testing, an IUC. Cervical cytology should be offered in line with the
although evidence is limited.9 Return of ovulation is delayed National Cervical Screening Programme.
when injectable methods such as medroxyprogesterone acetate
(Depo Provera [Pfizer Ltd., Sandwich, UK]) are stopped, so Combined hormonal contraception
these should be stopped at least 1 year before The use of CHC beyond the age of 50 years is not
taking FSH levels.10 recommended, although a lack of safety evidence in this age
Alternatively, women can consider stopping their method group means it cannot be completely ruled out.18 Combined
of contraception at the age of 55 years when most will have methods can be given orally, transdermally (Evra [Janssen-
reached natural infertility.8 Very few women continue to have Cilag International NV, Beerse, Belgium]) and vaginally
fertile ovulation beyond this age. Despite this guidance, it is (NuvaRing [Merck & Co., Inc. NJ, USA]), but less data are
impossible to completely guarantee infertility after stopping available on the patch and the vaginal ring. Combined
contraception, so careful counselling is essential to balance monthly injections (Cyclofem and Mesigyna) are available
the consequences of unplanned pregnancy with the potential in many countries, but not in the USA or Europe.
health risks of continuing contraception. Most combined pills contain the synthetic estrogen ethinyl
estradiol. Newer methods (Zoely [Merck Sharp & Dohme
Limited, Hoddesdon, UK] and Qlaira [Bayer plc, Newbury,
Hormone replacement therapy and
UK]) contain estradiol but there is no established difference
contraception
in their safety profiles. Estradiol formulations have shorter
Although very little data are available to inform practice in hormone-free intervals, so may reduce the occurrence of hot
this area, sequential hormone replacement therapy (HRT), flushes during the pill-free week in standard regimens.
the type recommended in the perimenopause, is not Combined pills cause shorter withdrawal bleeds and more
contraceptive as it inhibits ovulation in only 40% of amenorrhoea than standard pills, but more unscheduled
women.11 Contraception must be used alongside HRT to bleeding; this may be unacceptable to perimenopausal
avoid unplanned conception. Progestogen-only methods and women. With all ethinyl estradiol pills, if less frequent
intrauterine contraception (IUC) are suitable. bleeds are desirable or hot flushes occur during the pill-free
Combined progestogen and estrogen HRT must be used in week, tailored regimens with prolonged pill-taking or shorter
women with an intact uterus as there is no evidence that the pill-free intervals are effective, reliable and safe.18
290 ª 2017 Royal College of Obstetricians and Gynaecologists
The Obstetrician & Gynaecologist
Review
http://onlinetog.org
Contraceptive methods and issues around the menopause:
an evidence update
a,b, c d
Shagaf H Bakour MD FRCOG, * Archana Hatti MRCOG, Susan Whalen DFSRH MRCOG
a
Senior Lecturer and Consultant Obstetrician and Gynaecologist, City Hospital, Dudley Road, Birmingham B18 7QH, UK
b
Director of Medical Education, Aston Medical Research Institute (AMRI), Aston Medical School, Aston University, Birmingham B4 7ET, UK
c
Specialist Trainee (ST4), Obstetrics and Gynaecology, City Hospital, Dudley Road, Birmingham B18 7QH, UK
d
Consultant in Sexual Health, Sexual Health Department, Lyng Centre, Frank Fisher Way, West Bromwich B70 7AW, UK
*Correspondence: Shagaf Bakour. Email:
Accepted on 31 January 2017. Published Online 26 September 2017
Key content Be aware that the risks of fetal chromosomal abnormalities,
There have been a number of recent advances and an increase in miscarriage, pregnancy complications and maternal morbidity and
the number of contraceptive methods available to mortality increase for women aged 40 years and over.
perimenopausal women. No contraceptive method is contraindicated on the basis of
Other relevant issues, including transition to and diagnosis age alone.
of menopause, the use of hormone replacement therapy Clinicians must carefully consider comorbidities when prescribing
with contraception, and when to stop contraception, are women the most suitable contraception.
discussed.
Ethical issues
Some hormonal contraceptives have added benefits in the
Return of fertility can be delayed for up to 1 year after
management of common perimenopausal
discontinuing progestogen-only injectable contraceptives;
gynaecological problems.
Research and development into intrauterine contraception,
therefore, these contraceptives are not suitable for perimenopausal
women considering future pregnancies.
microchip drug release technology, progesterone receptor Contraceptive methods with a recognised post-fertilisation,
modulators, male contraception and vaccines is
pre-implantation effect may not be acceptable to some
currently underway.
women.
Learning objectives Women should be given information about all suitable
Understand that, although women’s natural fertility declines after contraceptive methods to make an informed choice.
their mid-30s, effective contraception is required until menopause
Keywords: combined hormonal contraception / contraception /
to prevent unintended pregnancies.
contraceptive device / menopause / progestogen-only contraception
Please cite this paper as: Bakour SH, Hatti A, Whalen S. Contraceptive methods and issues around the menopause: an evidence update. The Obstetrician &
Gynaecologist 2017;19:289–97. DOI: 10.1111/tog.12416.
Introduction Conception and demographics in
older women
The World Health Organization (WHO) defines the
menopause as permanent cessation of menstruation During the perimenopause, menstrual irregularities can
caused by the loss of ovarian follicular activity;1 a occur with both prolonged or shorter anovulatory cycles
retrospective diagnosis that is clinically confirmed after and sometimes heavy menstrual bleeding (HMB). Hot
12 months of amenorrhoea. Diagnosis is difficult when flushes often begin at this time. Women’s fecundity
women use methods of contraception that interrupt the declines when they reach their mid-30s, with an associated
natural menstrual cycle. No accurate biological marker increase in pregnancy loss secondary to oocyte ageing.
exists that truly defines the moment when fertility ceases. However, a decrease in the ability to conceive does not
The period of time immediately before menopause is called occur until women are in their mid-40s.2 The 2013 National
perimenopause, and is when endocrinological, biological Survey of Sexual Attitudes and Lifestyles (NATSAL) research
and clinical features of the approaching menopause project showed that 1 in 5 pregnancies conceived when the
commence. Perimenopause includes the first year after the mother is aged 40 years or older are unplanned and 28% of
last natural menstrual period.1 these pregnancies end in termination.3 In Western society,
ª 2017 Royal College of Obstetricians and Gynaecologists 289
, Contraception and the menopause
relationship breakdown and re-partnering is increasing, and progestogen in most hormonal contraception methods
sexual intercourse occurs more frequently in new provides endometrial protection. The exception is the
relationships.4 Sexually transmitted infection (STI) rates are Mirena (Bayer plc, Newbury, UK) levonorgestrel-releasing
increasing most rapidly in women over the age of 40 years.5 intrauterine system (IUS) (52 mg IUS), which is licensed for
Only condoms protect against STI transmission, including HIV. this indication for 4 years but evidence supports its use for
5 years.8
Women using combined methods of contraception can use
Stopping contraception
regimens with shorter pill-free intervals to reduce the risk of
During the perimenopause, follicle stimulating hormone menopausal symptoms.12
(FSH) levels can fluctuate considerably.6 Neither a single FSH
measurement nor the presence or absence of menopausal
Choice of methods of contraception
symptoms can reliably predict loss of fertility. For women
over the age of 50 years who do not use hormonal methods, Women must be advised on all available methods of
contraception can be stopped after 1 year of amenorrhoea as contraception, including long-acting reversible methods
fertility is unlikely to return. In women under 50 years of age, (LARC), so they can make an informed choice.13 No
contraception should be continued for 2 years, as the return method of contraception is contraindicated based on age
of fertile ovulation is more likely to occur.7 alone, up to the age of 50 years.8 Table 1 summarises the
Hormonal contraception can affect bleeding patterns main advantages, risks and reliability of contraceptive
making it difficult for clinicians to advise when methods for perimenopausal women.14,15 Table 2 shows the
contraception can safely be stopped. For women over the age contraceptive methods chosen by UK women in
of 50 years using oral progestogen-only methods, subdermal this age group.16
implants and intrauterine systems, the Faculty of Sexual and It is essential to acquire a personal, sexual and family
Reproductive Healthcare (FSRH) recommends that history, and pregnancy should be excluded (see Box 1).17
contraception should be continued for 1 year after recording Body mass index and blood pressure should be checked and
two FSH levels at >30 IU/l, taken at least 6 weeks apart.8 STI screening offered, particularly before an IUC device is
Combined hormonal contraception (CHC) affects FSH inserted. Pelvic examination is only required prior to fitting
levels so should be stopped for at least 2 weeks prior to testing, an IUC. Cervical cytology should be offered in line with the
although evidence is limited.9 Return of ovulation is delayed National Cervical Screening Programme.
when injectable methods such as medroxyprogesterone acetate
(Depo Provera [Pfizer Ltd., Sandwich, UK]) are stopped, so Combined hormonal contraception
these should be stopped at least 1 year before The use of CHC beyond the age of 50 years is not
taking FSH levels.10 recommended, although a lack of safety evidence in this age
Alternatively, women can consider stopping their method group means it cannot be completely ruled out.18 Combined
of contraception at the age of 55 years when most will have methods can be given orally, transdermally (Evra [Janssen-
reached natural infertility.8 Very few women continue to have Cilag International NV, Beerse, Belgium]) and vaginally
fertile ovulation beyond this age. Despite this guidance, it is (NuvaRing [Merck & Co., Inc. NJ, USA]), but less data are
impossible to completely guarantee infertility after stopping available on the patch and the vaginal ring. Combined
contraception, so careful counselling is essential to balance monthly injections (Cyclofem and Mesigyna) are available
the consequences of unplanned pregnancy with the potential in many countries, but not in the USA or Europe.
health risks of continuing contraception. Most combined pills contain the synthetic estrogen ethinyl
estradiol. Newer methods (Zoely [Merck Sharp & Dohme
Limited, Hoddesdon, UK] and Qlaira [Bayer plc, Newbury,
Hormone replacement therapy and
UK]) contain estradiol but there is no established difference
contraception
in their safety profiles. Estradiol formulations have shorter
Although very little data are available to inform practice in hormone-free intervals, so may reduce the occurrence of hot
this area, sequential hormone replacement therapy (HRT), flushes during the pill-free week in standard regimens.
the type recommended in the perimenopause, is not Combined pills cause shorter withdrawal bleeds and more
contraceptive as it inhibits ovulation in only 40% of amenorrhoea than standard pills, but more unscheduled
women.11 Contraception must be used alongside HRT to bleeding; this may be unacceptable to perimenopausal
avoid unplanned conception. Progestogen-only methods and women. With all ethinyl estradiol pills, if less frequent
intrauterine contraception (IUC) are suitable. bleeds are desirable or hot flushes occur during the pill-free
Combined progestogen and estrogen HRT must be used in week, tailored regimens with prolonged pill-taking or shorter
women with an intact uterus as there is no evidence that the pill-free intervals are effective, reliable and safe.18
290 ª 2017 Royal College of Obstetricians and Gynaecologists
