What’s the best contraceptive pill in perimenopause?

In this article:

• Navigating perimenopause
• Does birth control help perimenopause?
• Best birth control for perimenopause
• Alternative therapies
• The bottom line

In this article

• Navigating perimenopause
• Does birth control help perimenopause?
• Best birth control for perimenopause
• Alternative therapies
• The bottom line

If you’re a woman in your late 40s experiencing irregular periods, weight gain, or sleep and mood disturbances, there’s a good chance you’re in perimenopause. Defined as the transition into menopause, perimenopause can be confusing because hormone fluctuations cause different symptoms at different times. The good news is that birth control pills protect against pregnancy and often help alleviate some of the symptoms.

Here’s what you need to know about hormonal birth control as you approach menopause, including the best contraceptive pill in perimenopause.

Understanding perimenopause

Perimenopause, also known as the menopausal transition, refers to the time leading up to menopause. It is a years-long, gradual on-ramp toward menopause—a milestone clinically defined as 12 months after a woman’s last menstrual period. Perimenopause typically occurs between the ages of 45 and 54 and lasts an average of four years.

During perimenopause, changing hormone levels cause a host of seemingly unrelated symptoms, including hot flashes, weight gain, vaginal dryness, mood changes, sleep problems, lower sex drive, joint pains, and irregular periods. Research shows that at least 20% of women experience this collection of symptoms to a degree that affects their quality of life.

Why birth control matters during perimenopause

Birth control is still important during perimenopause. Many women who have not yet reached menopause still need an effective way to prevent pregnancy, manage their cycles, control vasomotor symptoms of perimenopause caused by hormone fluctuations (hot flashes and night sweats), and more.

Pregnancy prevention

It’s a myth that contraception isn’t necessary for perimenopausal women with irregular periods during perimenopause. If ovulation happens, so can pregnancy. Any female who has had a menstrual cycle within the last year, is sexually active with a male partner, and does not want to get pregnant should use some form of birth control. 

Hormonal contraceptives aren’t the only way to prevent pregnancy, but birth control pills are popular for a reason. Contraceptives are available in a daily pill (either with estrogen and progestin or progestin-only pills), weekly patch, monthly vaginal ring, injection every 12 weeks, arm implant every 3 years, or intrauterine device changed every 3 to 10 years. There are contraindications to estrogen-containing contraceptive methods, such as hypertension, migraines with visual aura, or nicotine use. These hormonal birth control options have been widely studied for safety and effectiveness, cause limited side effects and notable health benefits, and tend to be widely available. 

Addressing irregular periods

About 9 in 10 women experience irregular periods in the years leading up to menopause. Unpredictable periods can be frustrating from a practical standpoint, but they can also make it challenging to track your cycle for birth control purposes or to track ovarian function.

Fortunately, birth control pills can help. “I’ve had many patients tell me that their biggest relief is not having an annoying period showing up at inconvenient times,” says Rachel Miller, MD, FACOG, a board-certified gynecologist and clinical consultant. Placebo birth control pills can also be skipped, and therefore, a menstrual period can be skipped that month. After having menstrual periods for decades, many women like this function of the combination oral contraceptive pills. 

Perimenopause symptom relief

“Birth control pills can be really helpful for smoothing out a lot of the ups and downs of perimenopause,” says Barbara Sparacino, MD, a triple board-certified healthcare provider. 

Research shows that taking hormonal birth control—combination pills, specifically—can relieve hot flashes and night sweats. Dr. Sparacino says combination birth control also eases mood swings and irritability caused by fluctuating estrogen, while Dr. Miller reports that some patients even notice improvements in hormonal acne.

Reduced risk of certain cancers

Whether a woman is in perimenopause or not, taking birth control can reduce her risk of certain cancers. One meta-analysis found that women on combination birth control have a reduced risk of endometrial cancer and ovarian cancer, and that the protective effects last up to 30 years after the pill has been discontinued. Oral contraception can also lower the risk of colorectal cancer by about 20%. However, oral birth control has been linked to a slightly increased risk of breast cancer and venous thromboembolism (blood clots in the legs and/or lungs).

In other words, it’s not too late for someone in perimenopause to start taking birth control pills or change to a different pill. There’s no right or wrong time to ask your healthcare provider about taking the pill for perimenopause. Unlike hormone replacement therapy, which is intended to treat menopause, hormonal birth control can be prescribed to younger and middle-aged women. Statistics show that in the United States, 14% of women ages 15 to 49 use the pill.

Which type of contraceptive pill is best for perimenopause?

Drs. Miller and Sparacino say most women in perimenopause feel best on a combined estrogen-progestin birth control pill. That said, they also both emphasize that there’s no one-size-fits-all pill, since treatment depends on your body, health history, and goals.

Birth control pill types in perimenopause

Despite countless brand-name and generic birth control pills on the market, all contraceptive pills fall into three main categories:

• Combination pills: These include varied combinations of synthetic estrogen and progestin. There are many combination pills available, including (but not limited to) Apri, Loestrin, Levora, Yaz, Azurette, Velivet, and Natazia. If women take the placebo pills, they have 13 menstrual periods a year.  
• Extended or continuous cycle pills: Technically, continuous cycle pills are also combination pills. They contain estrogen and progestin, but they are specifically intended to extend the menstrual cycle to 12 or 13 weeks instead of 4 weeks. The result is that women on continuous cycle pills such as Quartette and Amethyst have only four periods per year.
• Progestin-only pills: Also dubbed the “minipill,” progestin-only pills do not contain estrogen. Camila, Errin, Heather, and Jencycla are examples of minipills. Many women who take progestin-only pills have a contraindication to taking estrogen: high blood pressure, nicotine use, migraines with visual aura or neurologic symptoms, or a history of venous thromboembolism events. 

Why combination pills are best for many

Combination pills help prevent pregnancy and reduce hormonal fluctuations, according to Dr Miller. This makes them more likely to alleviate irregular periods and perimenopause symptoms than progestin-only pills that don’t contain estrogen. With so many combination pills on the market in slightly different formulations, it might take time to find the right combination pill for your symptoms and lifestyle. Dr. Sparacino says most perimenopausal women end up feeling best on a “low-dose” combined birth control pill, which means the ethinyl estradiol dose is 20 micrograms per pill.

Why progestin-only is best for some

It’s also important to remember that what’s best for most patients isn’t always best for every patient. While combined birth control pills tend to perform best to decrease unwanted perimenopause symptoms, women with certain medical conditions—migraines with aura, high blood pressure, a history of blood clots, or current nicotine use, per Dr. Sparacin—can face complications from taking estrogen, and these reasons are absolute contraindications for starting an estrogen-containing contraceptive method. For instance, research has established a clear link between estrogen and thrombosis, the medical term for blood clots. 

Taking a progestin-only pill can lower the risk of complications from estrogen, but it’s important to understand that the minipill might not relieve mood swings, sleep issues, hot flashes, night sweats, or weight gain. Progestin-only contraception is also associated with abnormal bleeding patterns such as spotting and heavy bleeding.

What to know about estrogen-only treatments

Estrogen-only medication is not safe for women with a uterus. Estrogen alone raises the risk of uterine cancer, and adding progestin helps protect the uterus. 

Guidelines recommend against routinely checking estrogen levels as menopausal hormonal therapy is prescribed to decrease vasomotor symptoms, not to treat a lab result. “As menopause approaches, we revisit whether [birth control] is still the right option and, if not, talk about transitioning to hormone therapy if symptoms persist,” Dr. Sparacino says. The transition from combination oral contraceptives to menopausal hormonal therapy is typically considered around age 50–51, but should be tailored to the individual’s health status and preferences.

The bottom line

There is no one-size-fits-all best contraceptive method for perimenopause. That said, in most cases, a combination pill containing estrogen and progestin can effectively prevent pregnancy and improve irregular periods, mood swings, hot flashes, and more. 

It is vital to seek personalized medical advice from a women’s health professional who takes time to get a complete picture of your cycle patterns, health risk factors, symptoms, personal and family medical history, and lifestyle. For instance, some women should not take estrogen. Others with a uterus should not take estrogen without supplemental progestin. 

Finally, if you or someone you love is experiencing irregular cycles, don’t just assume that it’s perimenopause. Make an appointment with a healthcare provider. “If there’s abnormal bleeding, we don’t just mask it,” Dr Miller says. “We need to check that nothing more serious is going on.”  If you would like to see a menopause specialist, Menopause.org lists Menopause Society Certified providers by zip code.