What is perimenopause?

Perimenopause is the phase in a woman’s life that leads up to menopause. It involves fluctuating levels of hormones such as oestrogen and progesterone, and can cause symptoms such as changes in menstrual patterns, hot flushes, mood changes, heavy periods and difficulty sleeping.

“Perimenopause can start several years before menopause, often in the early to mid-40s, although it can begin earlier for some women,” said Dr Zara Haider, the president of the College of Sexual and Reproductive Healthcare.

Why are experts concerned?

The worry is that while social media has helped break down stigma around menopause, women are also encountering misinformation.

“We are seeing people turn to supplements or alternative treatments marketed online, sometimes instead of established, effective options – often at significant personal cost,” said Haider.

Misinformation can have serious consequences.

“We are seeing some women in their late 30s and early 40s questioning whether they’re perimenopausal based on what they’ve seen online, and in some cases assuming they can stop contraception,” Haider said.

Haider added that perimenopause symptoms can overlap with a range of other conditions, including primary ovarian insufficiency.

“If there are concerns, women should speak to their GP to explore what’s going on and make sure they’re still protected against unintended pregnancy if needed,” she said.

What sort of contraception is best for women in perimenopause?

“There’s no single ‘best’ method, it’s about finding what works for the individual,” said Haider.

There are many forms available, including condoms – which also protect against sexually transmitted infections – and the hormone-free coil (IUD), although this may not be suitable for women with heavy periods.

However, Dr Paula Briggs, a consultant in sexual and reproductive health, said hormonal contraception offers many benefits.

“One [benefit is] prevention of unplanned pregnancy, but there are other non-contraceptive benefits: reduction in bleeding, pain, fibroids, improvement in endometriosis, acne, so loads of other things,” she said.

And while some forms of hormonal contraception have been associated with a slight increased risk of breast cancer, there can be benefits for reducing the risk of other types of cancer.

Progestogen-only contraceptives – which contain synthetic progesterone-like substances – include patches, the mini-pill, injections, implants and intrauterine systems (IUS), some of which last for years. And while progestogen-only contraceptives can help reduce heavy bleeding, HRT can be used alongside to ease other symptoms of perimenopause.

What about the combined pill?

Traditional combined pills contain ethinyl estradiol – a synthetic, non-natural form of oestrogen – and a progestogen. While they are effective contraceptives, there are drawbacks.

“[Ethinyl estradiol is] actually an incredibly strong steroid with some oestrogen-like properties,” said Prof Channa Jayasena, an expert in reproductive endocrinology at Imperial College London. “And that increases chances of blood clotting.”

Such risks are greater for people with certain health conditions, such as obesity, and among people who smoke. And they increase with age.

However, Briggs said the idea that older women cannot have the combined pill is erroneous.

“Age alone is not a contraindication [as to whether contraception is needed]. It’s about assessing for risk factors, which include migraine with aura, being overweight, hypertension – but if it’s treated, then the patient might still be able to access the combined pill,” said Briggs.

Crucially, a newer type of combined pill has been developed.

“It contains your natural oestrogen, which doesn’t confer that same blood clot risk,” said Jayasena.

“These are really good modern, next-generation contraceptive pills, which have a safety advantage and could be much more suitable for women in their 40s in particular, or even their 50s,” he said. “It’s basically a mini-pill with natural oestrogen.”

Do women need contraception if they are also using HRT?

If women have not yet reached menopause, are under the age of 55 and do not wish to become pregnant, then yes.

While HRT contains oestrogen – and progestogen if a woman’s womb is intact – the doses are thought to be too low and the substances not potent enough to prevent the ovaries from releasing an egg.

What are body-identical hormones?

Body-identical hormones are natural forms of oestrogen and progesterone that are the same as those found in the body, although they are made in the laboratory.

But experts say whether these are better than non-natural versions depends on the situation.

Body-identical hormones are already used in some forms of HRT, with early research suggesting there can be some benefits.

However, Jayasena noted that only non-natural forms of oestrogen and progesterone are strong enough to act as contraceptives.

In addition, Jayasena noted that some non-natural progestogens for HRT have a greater testosterone action, which can boost libido, whereas other non-natural progestogens have an anti-testosterone action and can be useful for women who have acne or excess hair.

“So actually, there are advantages sometimes to deviating from nature,” he said.