• The usual (non age-related) UK Medical Eligibility Criteria apply, but if there are no other contraindications to use:
• Methods that can be used without restriction by perimenopausal women include:
• Copper intrauterine devices (IUDs), the levonorgestrel-releasing intrauterine system (IUS), progestogen-only pill, progestogen-only implants, barrier methods, and sterilization.
• Progestogen-only injectables can be used without restriction up to the age of 45 years. In women over the age of 45 years, the benefits generally outweigh the risks.
• Natural family planning is not generally recommended because irregular menstrual cycles in the menopause make this method difficult to learn and use.
• Combined hormonal contraception (the combined contraceptive pill, patch, or vaginal ring) is not contraindicated by age alone in perimenopausal women, however:
• It should not be used (unacceptable health risk) by women 35 years of age or older who smoke 15 or more cigarettes a day, or who develop migraine without aura while using combined hormonal contraception.
• It is not usually recommended (risks usually outweigh the advantages) for women 35 years of age or older who smoke less than 15 cigarettes a day, or who quit smoking less than 1 year ago, or for women 35 years of age or older who have a history of migraine without aura.
• Where the combined oral contraceptive (COC) pill is suitable, a pill containing 20 micrograms ethinylestradiol is a reasonable first choice.
• Non-contraceptive benefits can influence the choice of contraceptive for women with:
• Vasomotor symptoms (hot flushes): combined hormonal contraception may reduce symptoms.
• Women experiencing menopausal symptoms while using combined hormonal contraception may wish to try an extended regimen.
• Osteoporosis: combined hormonal contraception may increase bone mineral density; depot medroxyprogesterone acetate may reduce bone mineral density.
• Menstrual pain, bleeding, and irregularity: combined hormonal contraception may reduce symptoms.
• Menstrual pain: progestogen-only methods may reduce symptoms.
• Heavy menstrual bleeding: the levonorgestrel-releasing IUS reduces menstrual bleeding and can cause amenorrhoea.
• Hormone replacement therapy (HRT):
• Women using combined HRT should not rely on this as contraception.
• A progestogen-only pill can be used with combined sequential HRT to provide effective contraception and adequate endometrial protection (a progestogen-only pill used with oestrogen-only HRT will not provide an adequate level of endometrial protection; combined continuous HRT regimens are not appropriate in this age group due to bleeding).
• The levonorgestrel–releasing IUS can be used as the progestogenic component for HRT for 5 years (the licence states 4 years), and provide concurrent contraception.

In depth

• The copper intrauterine device (IUD) and the levonorgestrel-releasing intrauterine system (IUS) can be retained longer during the perimenopause.
• Women who have an IUD inserted at age 40 years or older may retain the device until they no longer require contraception.
• Women who have an IUS inserted at age 45 years or older may retain the device until they no longer require contraception.
• Stopping non-hormonal contraception (copper intrauterine device, condoms) at the menopause
• Women less than 50 years of age should continue contraception for 2 years after the last period.
• Women aged 50 years or more should continue contraception for 1 year after the last period.
• Stopping hormonal contraception at the menopause
• Menstrual bleeding patterns are unhelpful in determining menopause when a woman is using hormonal contraception. Amenorrhoea may be due to contraceptive hormones (progestogen-only pills, progestogen-only injectables and implants, or the levonorgestrel-releasing IUS). Regular bleeding may be due to use of combined oral contraceptives.
• Combined hormonal contraception (pill, patch or vaginal ring) or a progestogen-only injectable
• Switch to another suitable contraceptive method at 50 years of age (amenorrhoea may not indicate the menopause).
• Condoms or another method should be used for 2 years after stopping progestogen-only injectables (return of ovulation can be delayed).
• The follicle-stimulating hormone (FSH) level is not a reliable indicator of ovarian failure in women using combined hormones, even if measured during the hormone-free interval.
• Progestogen-only pills, progestogen-only implants, or levonorgestrel-releasing IUS
• Continue use to age 55 years, when natural loss of fertility can be assumed for most women (96%), or
• For women over the age of 50 years who are amenorrhoeic, check FSH on two occasions, with an interval of 6 weeks between tests. If both levels are more than 30 IU/L, this is highly suggestive of ovarian failure, and contraception may be stopped after 1 more year.

In depth