DOI: 10.1111/tog.

12416
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: Shagaf.bakour@nhs.net

Accepted on 31 January 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; 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 1

 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

2 ª 2017 Royal College of Obstetricians and Gynaecologists

 Bakour et al.

Table 1. Advantages, disadvantages and failure rates for all available contraceptive methods in perimenopausal women14,15

Risk of failure
in first year of
typical nonperfect
Method Advantages Disadvantages use57 (%)

Combined hormonal Regular bleeding pattern Increased risk of thrombosis, and breast and 9.0
contraception Reduction in menstrual bleeding and cervical cancer
flushes Daily dosing required
Progesterone-only pills Very few medical contraindications Irregular bleeding 9.0
Daily dosing required
Progesterone-only Long-acting method Masks menopause 6.0
injectable Often induces amenorrhoea Bone mineral density concerns
Unable to remove after injection
Progesterone-only Very few contraindications Irregular bleeding 0.05
implant Easily reversible Requires trained operative
Copper intrauterine Hormone-free Heavy menstrual bleeding and pelvic cramps 0.8
device Does not mask menopause Unsuitable if woman has a distorted uterine
Long-acting method cavity
Levonorgestrel-releasing Long-acting method Irregular bleeding 0.2
device Treatment for heavy menstrual bleeding Unsuitable if woman has a distorted uterine
Endometrial protection with hormone cavity
replacement therapy

Table 2. Contraceptive methods chosen by UK women aged 40–44

and 44–49 years (adapted from Lader D. Opinions survey report No. Box 1. Criteria for excluding pregnancy (adapted from Faculty of
41: contraception and sexual health 2008/09. Richmond: Office for Sexual and Reproductive Healthcare [FSRH])15
National Statistics; 2009)16
Health professionals can be ‘reasonably certain’ that a woman is not
Method Age 40–44 (%) Age 45–49 (%) currently pregnant if:
 there are no symptoms or signs of pregnancy
None 25 28  there has been no intercourse since last normal menses
Pill 10 13  a reliable contraception method has been correctly and consistently
Male condom 21 11 used
Withdrawal 6 4  miscarriage or termination occurs within the first 7 days of the onset
Intrauterine system 9 11 of normal menstruation
Injection 2 4 A negative pregnancy test adds weight only if ≥3 weeks has passed
Implant 0 1 since the last unprotected sexual intercourse.
Patch 1 0
Natural method 4 5
Other 0 1
Female sterilisation 18 19 the first few months after commencing CHC; incidence
Vasectomy 28 30 then decreases over the first year of use. VTE risk rises
again when restarting CHC after a break as short as
1 month, and therefore continuing CHC rather than
CHC users have a small increased risk of developing breast stopping and starting is the safer option.18
cancer (odds ratio [OR] 1.5) compared with non-users,19 but Well-researched published exclusions to the use of CHC
risks decrease after cessation. A first-degree relative with are detailed in the UK Medical Eligibility Criteria (UKMEC),
breast cancer does not preclude the use of combined including smoking over the age of 35 years.15
hormonal methods. CHC use does not increase overall
cancer risks and does not increase cancer mortality risk.20 Progestogen-only pills
In non-hormonal contraception users, the risk of venous Many women find oral contraception most acceptable.
thromboembolism (VTE) is 2 per 10 000 women per year. Progesterone-only pills (POPs) are an effective alternative
Use of CHC increases that risk up to six-fold, depending to CHC in women with comorbidities: the low progestogen
on the progestogen chosen, with pills containing dose has very few contraindications and POPs can be
levonorgestrel, norethisterone and norgestimate having the continued safely until natural fertility is lost.
lowest risk.21 VTE risk increases with age, rising POPs do not cause blood pressure to increase,22 their effect
exponentially over the age of 50 years. Risk is highest in on lipid profiles and diabetes is minimal and VTE risk is not

ª 2017 Royal College of Obstetricians and Gynaecologists 3

 Contraception and the menopause

increased.23 They are safe for use in women suffering from at 12-week intervals), Noristerat (Bayer plc, Newbury, UK)
migraine with aura.24 The limited evidence available does not (norethisterone enantate 200 mg, given intramuscularly at 8-
support a causal link between POP use and breast cancer. week intervals) and the recently licensed Sayana Press
However, there is a small increased risk of breast cancer in (Pfizer Limited, Sandwich, UK) (medroxyprogesterone
women who take POPs, but this risk is reduced when the user acetate 104 mg, given subcutaneously at 13-week intervals).
stops taking these pills.25 Another advantage of POPs is they All are reliable long-acting methods of contraception, with
can be used in smokers over the age of 35 years.24 very low user failure rates. Although Depo Provera is
Traditional POPs contain norethisterone or levonorgestrel, licensed for 12 weeks, there is evidence that pregnancy rates
and newer POPs contain desogestrel. Both can be used until remain low for up to 14 weeks after administration.31
the age at which natural loss of fertility is assumed.26 POPs Depo Provera is the most commonly used injectable
help to reduce HMB and dysmenorrhea27 and there is no method of contraception. Sayana Press has equivalent
delay in return of fertility when POPs are stopped. efficacy and an almost identical side effect profile, and is
Disadvantages of POPs include an irregular bleeding pattern licensed for self-administration in the UK.32 More than 50%
and narrow window of safety for missed pills. A missed pill is of women become amenorrhoeic after 1 year of use and
one that is taken more than 3 hours late, or with desogestrel nearly 70% after 2 years of use.33 This is very desirable for
pills, more than 12 hours late. Although some older studies some women and can be a way to manage irregular bleeding
suggest that they may be of use, POPs do not improve in the perimenopause.
menopausal hot flushes8 like the combined contraceptive pill. The main concern with injectable methods is bone health:
approximately 5% of bone is lost within the first 2 years of
Implants use.34 Longer-term use causes no further loss of bone, but
The only contraceptive implant available in the UK and the research suggests that bones take longer to recover when this
USA is the etonorgestrel-containing Nexplanon (Merck method is stopped.35 It is unknown whether or not bones
Sharp & Dohme Limited, Hoddesdon, UK), a 4 cm x 2 mm make a full recovery. In a small study, there was no difference
rod that is implanted in the inner aspect of the upper arm, in bone mineral density after 3 years between women who
usually on the non-dominant side. It has similar indications became postmenopausal while using Depo Provera and
and a similar side effect profile to the desogestrel-containing those who never used this method.36 Another trial found that
POPs. This implant should be fitted and removed by an Depo Provera users have a higher fracture risk than non-
operator trained to Faculty of Sexual and Reproductive users prior to starting, but Depo Provera does not increase
Healthcare (FSRH) safety standards.28 the subsequent risk of fractures.37 Bone loss after 2 years of
Nexplanon is the most effective reversible method of Depo Provera use is equivalent to bone lost during
contraception and can be used for up to 3 years with pregnancy and breastfeeding for 6 months. The FSRH
immediate return of fertility on removal. There is no user recommends that women consider stopping injectable
failure rate, but additional contraceptive protection is advised contraceptives at the age of 50 years, but add that
if not fitted within the first 5 days of menstruation. It can be continuing beyond this age is unlikely to result in
used safely by nearly all women throughout their unacceptable adverse outcomes.
reproductive years to menopause, even in women with Another disadvantage of Depo Provera is that the
comorbidities. Unlike injectable contraceptive methods, this injection cannot be removed if side effects or health
implant has no effect on bone mineral density. There is no concerns arise. The FSRH’s position is that the risks of the
evidence to suggest an increased failure rate in women method outweigh the benefits in women with multiple risk
weighing up to 149 kg,28 and no limit to the number of times factors for cardiovascular disease.8
the implant can be replaced at 3-yearly intervals.
About 20% of women with this implant have amenorrhoea; a Intrauterine device
desirable side effect for some women, for example, those with The intrauterine device (IUD) is an effective and safe form of
irregular perimenopausal bleeding after exclusion of pathology. long-term contraception in women over 40 years of age.
However, 1 in 5 women have the device removed within the IUDs should contain at least 300 mm of copper8 wound onto
first year because of persistent or irregular bleeding.29 This can a plastic frame, with bands of copper on the horizontal arms
mask other causes of irregular bleeding such as endometrial as well as the stem (Figure 1). The TT380 slimline (Durbin
cancer, although this diagnosis remains rare in perimenopausal PLC, South Harrow, UK) and Cu T 380 A (Pregna
women using hormonal contraception.30 International Ltd, Mumbai, India) are examples of gold-
standard 10-year IUDs. Also available is Gynefix (Contrel
Injectable contraception Europe NV, Gent, Belgium), a frameless device with copper
Three injectable contraceptives are available: Depo Provera bands mounted onto a monofilament thread (Figure 2). The
(medroxprogesterone acetate 150 mg, given intramuscularly expected reduction in IUD-associated dysmenorrhoea with a

4 ª 2017 Royal College of Obstetricians and Gynaecologists

 Bakour et al.

IUDs have minimal systemic effects so can be safely used in

women with comorbidities that are more common in
perimenopausal women,39 such as diabetes, hypertension,
cardiovascular, cerebrovascular and thrombotic diseases.
IUDs are associated with intermenstrual bleeding,
spotting and prolonged bleeding, especially within the
first 3–6 months.8 These bleeding patterns are usually
harmless and self-limiting, but counselling is necessary to
prevent early discontinuation in perimenopausal women.
If they persist, it is essential to exclude STIs
and gynaecological pathologies.
Figure 1. Example of a banded intrauterine device.
STIs are not increased with IUDs, but fitting in the
presence of STIs can increase the risk of pelvic inflammatory
disease (PID) within the first 3 weeks of use.

Intrauterine system
An IUS is a reliable, cost-effective contraceptive option for
women, which releases very low systemic levels of
levonorgestrel locally into the endometrium. Approximately
4% of UK perimenopausal women40 use an
IUS for contraception.
Two IUS devices are currently available; Mirena or
Levosert (Gedeon Richter Plc., Budapest, Hungary), both of
which contain 52 mg of levonorgestrel (52 mg IUS), and
Jaydess (Bayer plc, Newbury, UK) which contains 13.5 mg
of levonorgestrel (13.5 mg IUS). Mirena is licensed for
contraceptive use for 5 years; Levosert and Jaydess for
3 years. However, the FSRH evidence-based guidance
supports the use of Mirena in women older than 45 years
of age for up to 7 years, or to menopause if the woman
remains amenorrhoeic.39
Mirena is licensed for the treatment of HMB, and to give
endometrial protection when used with estrogen-only
HRT.41 Neither Jaydess or Levosert are licensed for these
indications. The newer and lower dose-containing Jaydess
has an insertion diameter smaller than the 52 mg IUS, so can
be used in smaller uteri, nulliparous women and older
women in the later years of reproduction.42
Figure 2. Example of a frameless intrauterine device. For women of perimenopausal age, the most important
health benefit of the 52 mg IUS is its effect on menstrual
bleeding. Within 3 months of insertion this IUS reduced
frameless device has not been shown in practice, but it might blood loss by over 80% in women with HMB. A Cochrane
be useful for women with distorted cavities; for example review42 showed that using an IUS is more effective than
women with small fibroids where a framed device may be norethisterone for the management of HMB. IUS devices are
harder to fit. equal to ablation and hysterectomy for improving women’s
IUDs can be used both as emergency and continuing quality of life. IUSs are also effective for reducing fibroid-
contraception for a period of 5–10 years. They prevent associated bleeding, and improve endometriosis-associated
fertilisation when inserted precoitally, and when inserted pain. Guidelines published by the National Institute for
postcoitally, they prevent implantation after fertilisation.38 Health and Care Excellence (NICE) should be followed if the
When inserted in women older than 40 years they can be IUS is fitted to manage HMB. A 52-mg IUS can also been used
used until menopause,8 although this use is outside of the for endometrial protection during tamoxifen treatment.43
manufacturer’s license. IUDs must be removed after There is no evidence to support a link between breast
menopause or when no longer required. cancer and IUS use. IUSs have minimal systemic side effects,

ª 2017 Royal College of Obstetricians and Gynaecologists 5

 Contraception and the menopause

no risk of venous thromboembolism or other systemic happened without using the method.41 With lower fertility
diseases, and no evidence of weight gain, hence they are a safe rates in the perimenopause, withdrawal can be used as an
option for perimenopausal women, especially those adjunct to other methods, like NFP.
with HMB.
IUSs should be removed after menopause. Actinomyces- Sterilisation
like organisms (ALOs) can be found in IUD and IUS users. In Female sterilisation is a permanent and highly successful
the absence of pain, pyrexia or unscheduled bleeding the form of contraception used by about 18% of UK women over
device can be left in situ as the risk of actinomyces-related the age of 40 years.40 All women considering sterilisation
PID is very low.44 must be counselled regarding LARC methods, as these are as
reliable as sterilisation. A woman who is approaching
Barrier contraception menopause and will shortly reach natural sterility should
Both men and women have barrier methods of contraception consider LARC rather than pursue a surgical method of
available to them. Condoms account for 10% of time-limited value.
contraceptive use in the perimenopausal age group40. Use Sterilisation involves occluding the fallopian tubes and can
of diaphragms and caps with spermicides are used by <1% of be done laparoscopically, via mini-laparotomy, during
UK women. Barrier contraception is safe to use until caesarean section, or hysteroscopically. Hysteroscopic
menopause is confirmed. techniques can be done under local anaesthetic; however,
Condoms are 98% effective and women’s barrier methods another form of contraception must be used until tubal
are up to 95% effective; however, effectiveness of both occlusion is confirmed after 3 months.
methods is user-dependent.45 Erectile dysfunction can Vasectomy has a lower failure rate after proven
prevent condom use for some men. Diaphragms and caps azoospermia (1 in 2000)47 and lower complication rates,
must be used with spermicide, correctly inserted, and remain although chronic postvasectomy pain occurs in up to 14% of
in place for 6 hours after intercourse.45 Condoms have the men.47 Female sterilisation has a failure rate of 1:200.47 Other
advantage of protecting against STIs, rates of which are than preventing pregnancy, sterilisation confers none of the
known to be increasing in perimenopausal women. other benefits of hormonal contraceptives, and is associated
Oil-based lubricants and estrogen-containing vaginal with surgical risks.
creams and pessaries should not be used with condoms or
latex diaphragms.45 They can weaken latex and most non- Emergency contraception
latex condoms, thereby increasing the risk of failure caused There are three methods of emergency contraception (EC)
by breakage. They do not affect silicone diaphragms and available in the UK: levonorgestrel (LNG; Levonelle [Bayer
female condoms. Non-oil-based lubricants should be used plc, Newbury, UK]), an oral progestogen; ulipristalacetate
and these can also improve sexual difficulties secondary to (UPA; ellaOne [Laboratoire HRA Pharma, Paris, France]),
vaginal dryness. Non-latex diaphragms and condoms should an oral selective progestogen receptor modulator; and the
be offered to those with latex allergy. copper IUD. All are safe for use during the perimenopause.
LNG and UPA inhibit or delay ovulation for up to 7 days,
Natural family planning methods which is beyond the natural span of sperm within the genital
Fertility awareness methods, also called ‘natural methods’, are tract, and can both be used more than once in the
used by 4% of older women in the UK.40 These methods same menstrual cycle.15
include monitoring body temperature, cervical mucus and the Levonorgestrel can be used up to 72 hours after
length of the menstrual cycle, and plotting the values on a unprotected sexual intercourse (UPSI) but becomes less
chart to predict the fertile time. Devices such as Persona effective as time passes.49 UPA remains effective for up to
(Swiss Precision Diagnostics, Bedford, UK) are also available 120 hours after UPSI.49 Although levonorgestrel works only
to buy, which monitor urine hormone levels.46 Natural family up until the start of the pre-ovulatory LH surge,50 UPA works
planning (NFP) methods become less reliable in the up to just before the LH peak.51
perimenopause because ovulation becomes more difficult to Copper IUDs are the most effective form of EC and should
predict as cycles become less regular and ovulation markers are always be offered when EC is requested. IUDs effectively
difficult to interpret. Both the woman and her partner must be prevent implantation after fertilisation as soon as they are
motivated to use this method consistently and correctly. fitted. This mechanism of action should be explained because
methods that act after fertilisation are not acceptable to some
Withdrawal method women. IUS devices are not licenced for use as EC and
Withdrawal is natural form of contraception used by should therefore not be used.
approximately by 5% of UK perimenopausal couples.40 It Following EC with levonorgestrel, reliable continuing
prevents approximately 50% of pregnancies that would have contraception should be started as soon as possible –

6 ª 2017 Royal College of Obstetricians and Gynaecologists

 Bakour et al.

ideally straight away – along with an additional barrier

method until the hormonal method becomes effective.
Commencing progestogen hormonal contraception
immediately after UPA increases the risk of breakthrough
ovulation so should not be commenced for at least 5 days
after UPA is given.52 Abstinence or a barrier method of
contraception should be used instead.
There is no evidence that failed EC results in increased fetal
abnormality rates,48 so a request for EC should rarely be
refused, even where menstrual cycles have become irregular.

Future developments Figure 4. Magnified view of a a progestogen-releasing microchip.

Intrauterine contraception
Like the frameless IUD, Gynefix, a frameless levonorgestrel- made the development of an acceptable method difficult. The
releasing IUS, has also been developed but is not yet licensed.53 ethics of contraception for men should be considered as it
However, the intrauterine ball (IUB) (Figure 3) has recently prevents pregnancy in women but might be associated with
been licensed in Austria and will likely be marketed elsewhere risks or side effects for the man. Contraceptives for men
in Europe and North America. It is a frameless IUD consisting might be suitable for some couples in the perimenopause,
of a shaped memory alloy (Nitinol) thread that holds 20 tiny especially if there are medical problems precluding the use of
copper spheres. The device becomes spherical once delivered other methods, but it is unlikely that these will be marketed
into the uterus and might have greater potential for use in in the near future.
non-uniform endometrial cavities.54 As a hormone-free
method, there will be no contraindications to its use in Progesterone receptor modulators
perimenopausal women. Work continues to develop a vaginal ring releasing UPA, a
selective progesterone receptor modulator (PRM) currently
Microchip drug-release technology licensed as an EC, which will provide effective estrogen-free
Microchip drug-release technology, currently in development, contraception.56 Benign endometrial thickening and
will allow a progestogen-releasing microchip (Figure 4) to be glandular cystic dilation can occur with this method, as
implanted for up to 16 years of use, which can be switched on well as unscheduled heavy bleeding.56 Research is currently
and off with a remote control.55 This would allow planned exploring the safety of this method of contraception,
pregnancy followed by immediate reactivation. Although this especially given that endometrial changes in
may be the future of LARC, there is potential for malicious perimenopausal women could be misdiagnosed if bleeding
control of the device. irregularities require investigation.
Research into the contraceptive effects of mifepristone, a
Male contraception selective PRM that effectively causes endometrial atrophy, is
Contraception for men has been widely studied but so far the unlikely to continue because of its use in early medical
only available licensed methods are condoms and abortion, and resulting licensing restrictions and
sterilisation. The drop in testosterone levels associated with methodical concerns.
azoospermia, and the time taken to achieve azoospermia, has
Vaccines
Vaccines against gametes have been a promising avenue of
research in the past, but unpredictable response to
vaccination and then early loss of immunity have meant
their promise has not been fulfilled.57

Conclusion
In the absence of accurate evidence-based advice on fertility,
contraception and HRT, perimenopausal women remain at
risk of an unplanned pregnancy. There is no method of
contraception that is contraindicated for women under the age
Figure 3. Example of an intrauterine ball. of 50 years on the basis of age alone. HRT does not provide

ª 2017 Royal College of Obstetricians and Gynaecologists 7

 Contraception and the menopause

adequate contraception. After taking a comprehensive medical 6 Burger HG. Diagnostic role of follicle-stimulating hormone (FSH)
measurements during the menopausal transition – an analysis of FSH,
history, all women should be given information on all suitable oestradiol and inhibin. Eur J Endocrinol 1994;130:38–42.
methods of contraception so that they can make an informed 7 World Health Organization. Progress in Reproductive Health. Contraception
choice. When giving contraceptive advice to perimenopausal and the Late Perimenopause. 40(2). 1996.
8 Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit.
women with multiple comorbidities, clinicians should FSRH clinical guidance: contraception for women over 40. London: FSRH;
carefully consider the associated risks. New research and 2010 [http://www.fsrh.org/pdfs/ContraceptionOver40July10.pdf].
product developments will widen the contraceptive choice for 9 Castracane VD, Gimpel T, Goldzieher JW. When is it safe to switch from oral
contraceptives to hormonal replacement therapy? Contraception
women in this age group. 1995;52:371–6.
10 Jain J, Dutton C, Nicosia A, Wajszczuk C, Bode FR, Mishell DR Jr.
Pharmacokinetics, ovulation suppression and return to ovulation following
Disclosure of interests a lower dose subcutaneous formulation of Depo-Provera. Contraception
2004;70:11–8.
SB is a TOG Editorial Board member, a member of the 11 Gebbie AE, Glasier A, Sweeting V. Incidence of ovulation in perimenopausal
MRCOG Membership Exam Part III Committee, an women before and during hormone replacement therapy. Contraception
1995;52:221–2.
MRCOG Membership Exam Part II Standard Setter, a 12 Casper RF, Dodin S, Reid RL. The effect of 20 lg ethinyl estradiol/1 mg
reviewer for StratOG and BJOG and a former member of norethinderone acetate (MinestrinTM), a low-dose oral contraceptive, on
the Royal College of Obstetricians and Gynaecologists’ vaginal bleeding patterns, hot flashes and quality of life in symptomatic
perimenopausal women. Menopause 1997;4:139–47.
Education Quality Assurance Committee. 13 National Collaborating Centre for Women’s and Children’s Health, National
SW is a member of the British Menopause Society, Chair of Institute for Health and Care Excellence. Long-acting reversible
the West Midlands Association for Contraception and Sexual contraception: the effective and appropriate use of long-acting reversible
contraception (CG30). London: RCOG Press; 2013 [http://www.nice.org.uk/
Health, and a Faculty of Sexual and Reproductive Health- guidance/cg30/evidence/full-guideline-194840605].
registered trainer for the diploma and letters of competence 14 Association of Reproductive Health Professionals. Choosing a birth control
in contraceptive techniques. method. Contraceptive failure rates: table. Washington, DC: ARHP; 2014
[https://www.arhp.org/Publications-and-Resources/Quick-Reference-Guide-
for-Clinicians/choosing/failure-rates-table].
Contribution to authorship 15 Faculty of Sexual and Reproductive Healthcare of the Royal College of
This paper was the sole work of SB, AH and SW. All authors Obstetricians and Gynaecologists. UK medical eligibility criteria for
contraceptive use. London: FSRH; 2016 [https://www.fsrh.org/standards-
approved the final version. and-guidance/external/ukmec-2016-digital-version/].
16 Lader D. Opinions survey report No. 41: contraception and sexual health
Acknowledgements 2008/09. Richmond: Office for National Statistics; 2009.
17 Faculty of Family Planning and Reproductive Healthcare of the Royal College
Thanks to Claire Bailey, Specialist Trainee, for her comments of Obstetricians and Gynaecologists. UK Selected practice
on the manuscript. Recommendations for Contraceptive Use. London: Faculty of Sexual Family
Planning and Reproductive Healthcare; 2002.
18 Faculty of Sexual and Reproductive Healthcare of the Royal College of
Supporting Information Obstetricians and Gynaecologists. FSRH clinical guidance: combined
hormonal contraception – August 2012. London: FSRH; 2012 [http://
Additional supporting information may be found in the www.fsrh.org/pdfs/CEUGuidanceCombinedHormonalContraception.pdf].
19 Beaber E, Buist DS, Barlow WE, Malone KE, Reed SD, Li CL. Recent oral
online version of this article at http://wileyonlinelibrary. contraceptive use by formulation and breast cancer risk among women 20
com/journal/tog to 49 years of age. Cancer Res 2014;74:4078–89.
20 Hannaford PC, Selvaraj S, Elliot AM, Angus V, Iversen L, Lee AJ. Cancer
Infographic S1: Contraceptive methods and issues risk among users of oral contraceptive: cohort data from the Royal
around the menopause. College of General Practitioner’s oral contraceptive study. BMJ 2007;
335:651.
21 Stegeman B, de Bastos M, Rosendaal FR, van Hylckama Vileg A,
Helmerhorst FM, Stijnen T, et al. Different combined oral contraceptives
References and the risk of venous thrombosis: systematic review and network meta-
analysis. BMJ 2013;347:f5298.
1 World Health Organization. Research on the menopause in the 1990s:
22 Duijkers IJ, Heger-Mahn D, Drouin D, Skouby S. A randomised study
report of a WHO Scientific Group. Geneva: World Health Organization;
comparing the effect on ovarian activity of a progestogen-only pill (POP)
1996. p. 12–4.
containing desogestrel and a new POP containing drospirenone in a 24/4
2 O’Connor KA, Holman DJ, Wood JW. Declining fecundity and ovarian
regimen. Eur J Contracept Reprod Health Care 2015;16:1–9.
ageing in natural fertility populations. Maturitas 1998;30:127–36.
23 Mantha S, Karp R, Raghavan V, Terrin N, Bauer KA, Zwicker JI. Assessing the
3 Wellings K, Jones KG, Mercer CH, Tanton C, Clifton S, Datta J, et al. The
risk of venous thromboembolic events in women taking progestin-only
prevalence of unplanned pregnancy and associated factors in Britain:
contraception: a meta-analysis. BMJ 2012;345:e4944.
findings from the third National Survey of Sexual Attitudes and Lifestyles
24 Nappi RE, Merki-Feld GS, Terreno E, Pellegrinelli A, Viana MJ. Hormonal
(Natsal-3). Lancet 2013;382:1807–16.
contraception in women with migraine: is progestogen-only contraception
4 Rao K, Demaris A. Coital frequency among married and cohabiting couples
a better choice? J Headache Pain 2013;14:66.
in the United States. J Biosoc Sci 1995;27:135–50.
25 Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer
5 Public Health England. National STI surveillance data tables 2015 – Table 8.
and hormonal contraceptives: collaborative reanalysis of individual data on
London: Public Health England; 2015 [https://www.gov.uk/government/
53 297 women with breast cancer and 100 239 women without breast
uploads/system/uploads/attachment_data/file/534564/2015_Table_8_Atte
cancer from 54 epidemiological studies. Lancet 1996;347:1713–27.
ndances_by_gender__sexual_risk___age_group__2011-2015.pdf].

8 ª 2017 Royal College of Obstetricians and Gynaecologists

 Bakour et al.

26 Faculty of Sexual and Reproductive Healthcare of the Royal College of 41 Hardman S, Gebbie AS. The contraception needs of perimenopuausal
Obstetricians and Gynaecologists. Progestogen-only pills. London: FSRH; women. Best Pract Res Clin Obstet Gynaecol 2014;28:903–15.
2015 [https://www.fsrh.org/standards-and-guidance/documents/cec-ceu- 42 Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing
guidance-pop-mar-2015/] intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst
27 Ahrendt HJ, Karckt U, Pichi T, Mueller T, Ernst U. The effects of an oestrogen- Rev 2005;(4):CD002126.
free, desogestrel-containing oral contraceptive in women with cyclical 43 Dominick S, Hickey M, Chin J, Su HI. Levonorgestrel intrauterine system for
symptoms: results from two studies on oestrogen-related symptoms endometrial protection in women with breast cancer on adjuvant
and dysmenorrhoea. Eur J Contracept Reprod Health Care 2007;12: tamoxifen. Cochrane Database Syst Rev 2015;(12):CD007245.
354–61. 44 Westhoff C. IUDs and colonization or infection with Actinomyces.
28 Faculty of Sexual and Reproductive Healthcare of the Royal College of Contraception 2007;75:S48–50.
Obstetricians and Gynaecologists. FSRH clinical guidance: progestogen-only 45 Faculty of Sexual and Reproductive Healthcare of the Royal College of
implants – February 2014. London: FSRH; 2014 [http://www.fsrh.org/pdfs/ Obstetricians and Gynaecologists. FSRH clinical guidance: barrier methods
CEUGuidanceProgestogenOnlyImplants.pdf]. for contraception and STI prevention – August 2012. London: FSRH; 2012
29 Lakha F, Glasier AF. Continuation rates of implanon in the UK: data from [https://www.fsrh.org/standards-and-guidance/documents/ceuguidanceba
an observational study in a clinical setting. Contraception 2006;74: rriermethodscontraceptionsdi/].
287–9. 46 Bouchard T, Genuis S. Personal fertility monitors for contraception. CMAJ
30 Cancer Research UK. Uterine cancer (C54–C55), average number of new 2004;183:73–6.
cases per year and age-specific incidence rates per 100 000 population, 47 Faculty of Sexual and Reproductive Healthcare of the Royal College of
females, UK 2012–2014. London: Cancer Research UK; 2016 [http:// Obstetricians and Gynaecologists. FSRH clinical guidance: male and female
www.cancerresearchuk.org/health-professional/cancer-statistics/statistics- sterilisation – September 2014. London: FSRH; 2014 [http://www.fsrh.org/
by-cancer-type/uterine-cancer/incidence#heading-One]. pdfs/MaleFemaleSterilisation.pdf].
31 Paulen M, Curtis K. When can a woman have repeat progestogen-only 48 Faculty of Sexual and Reproductive Healthcare of the Royal College of
injectables depot medroxyprogesterone acetate or norethisterone Obstetricians and Gynaecologists. CEU clinical guidance: emergency
enantate? Contraception 2009;80:391–408. contraception – March 2017. London: FSRH; 2017 [https://www.fsrh.org/sta
32 Pfizer Ltd. Sayana Press 104 mg/0.65 ml suspension for injection. ndards-and-guidance/current-clinical-guidance/emergency-contraception/].
Leatherhead: Electronic Medicines Compendium, Datapharm; 2017 49 Glasier A, Cameron ST, Fine PM, Logan SJ, Casale W, Van Horn J, et al. Ulipristal
[https://www.medicines.org.uk/emc/medicine/27798/SPC/SAYANA+ acetate versus levonorgestrel for emergency contraception: a randomised
PRESS+104+mg+0.65+ml+suspension+for+injection/]. non-inferiority trial and meta-analysis. Lancet 2010;375:555–62.
33 Pfizer Ltd. Depo-Provera 150 mg/ml injection. Leatherhead: Electronic 50 Croxatto HB, Brache V, Pavez M, Cochon L, Forcelledo ML, Alvarez F, et al.
Medicines Compendium, Datapharm; 2016 [https://www.medicines.org. Pituitary-ovarian function following the standard levonorgestrel emergency
uk/emc/medicine/11121]. contraceptive dose or a single 0.75-mg dose given on the days preceding
34 Clark M, Sowers M, Levy B, Nichols S. Bone mineral density loss and ovulation. Contraception 2004;70:442–50.
recovery during 48 months in first-time users of depo 51 Brache V, Cochon L, Jesam C, Maldonado R, Salvatierra AM, Levy DP, et al.
medroxyprogesterone acetate. Fertil Steril 2006;86:1466–74. Immediate pre-ovulatory administration of 30 mg ulipristal acetate
35 Kaunitz AM, Miller PD, Rice VM, Ross D. McClung MR Bone mineral significantly delays follicular rupture. Hum Reprod 2010;25:2256–63.
density in women aged 25–35 years receiving depot 52 Brache V, Cochon L, Duijkers IJ, Levy DP, Kapp N, Monteil C, et al. A
medroxyprogesterone acetate: recovery following discontinuation. prospective, randomized, pharmacodynamic study of quick-starting a
Contraception 2006;74:90–9. desogestrel progestin-only pill following ulipristal acetate for emergency
36 Cundy T, Cornish J, Roberts H, Reid IR. Menopausal bone loss in long-term contraception. Hum Reprod 2015;30:2785–93.
users of depot medroxyprogesterone acetate contraception. Am J Obstet 53 Wildemeersch D, Jandi S, Pett A, Nolte K, Hasskamp T, Vrijens M. Use of
Gynecol 2002;186:978–83. frameless intrauterine devices and systems in young nulliparous and
37 Lanza L, McQuay LJ, Rothman KJ, Bone HG, Kauntiz AM, Harel Z, et al. Use adolescent women: results of a multicentre study. Int J Womens Health
of depot medroxyprogesterone acetate contraception and incidence of 2014;6:727–34.
bone fracture. Obstet Gynecol 2013;121:593–600. 54 OCON Medical Ltd. Safe and hormone free birth control: IUBTM copper
38 Faculty of Sexual and Reproductive Healthcare of the Royal College of pearls. Modiin: OCON Medical Ltd [http://www.oconmed.com/en/support/
Obstetricians and Gynaecologists. FSRH clinical guidance: intrauterine brochures].
contraception – April 2015. London: FSRH; 2015 [http://www.fsrh.org/pdfs/ 55 Microchips Biotech, Inc. Microchips announces clinical results for first
CEUguidanceIntrauterineContraception-1.pdf]. successful human trial of implantable, wireless microchip drug delivery
39 Newton J, Tacchi D. Long-term use of copper intrauterine devices. A device. Lexington, MA: Microchips Biotech, Inc; 2012 [http://microchipsb
statement from the Medical Advisory Committee of the Family Planning iotech.com/news-pr-item.php?news=4].
Association and the National Association of Family Planning Doctors. Lancet 56 Huang Y, Jensen JT, Brache V, Cochon L, Williams A, Miranda MJ, et al. A
1990;335:1322–3. randomized study on pharmacodynamic effects of vaginal rings delivering
40 Office for National Statistics. Statistical Bulletin: Conceptions in England the progesterone receptor modulator ulipristal acetate: research for a novel
and Wales. London: ONS; 2012 [http://webarchive.nationalarchives.gov.uk/ estrogen-free, method of contraception. Contraception 2014;90:565–74.
20160109214216/http://www.ons.gov.uk/ons/rel/vsob1/conception-sta 57 Naz RK, Gupta SK, Gupta JC, Vyas HK, Talwar AG. Recent advances in
tistics–england-and-wales/2010/2010-conceptions-statistical-bulletin.html? contraceptive vaccines development: a mini-review. Hum Reprod
format=print]. 2005;12:3271–83.

ª 2017 Royal College of Obstetricians and Gynaecologists 9