Menopause and contraception – do you really need it?

Hi and welcome to my VLOG. So this week is a short and sweet VLOG but the contents are really really important. And
the reason I’m doing it is because it’s a question I get asked all of the time,
on both the radio show and in the Latte Lounge, where I’m the resident GP. So the
question is.. menopause or perimenopause and contraception – what’s needed and what do you do? So here we go.First of all I think some definitions will really help.
So what is perimenopause? So perimenopause can start 10 years before
you actually go through menopause and have your very last period. So menopause
itself is when your periods stop completely, but perimenopause is the 10 years leading up to that. So on average in the UK women go through menopause when they’re 51. So that’s when their periods
stop completely, forever. This means you can be perimenopausal for your
entire forties, so it’s a long time. For some women, they have periods into their
late fifties. So even though the average is 51, it varies dramatically. And it tends
to be quite genetic; so when your mum went through menopause and your sisters. So fertility, when you need contraception to stop getting pregnant, actually
declines after about the age of 37, and definitely after the age of 40. But, and
this is a massive but, even though potential declines and even if your
periods become irregular (so you don’t have one every month) as long as you’re
having a period from time to time you are still potentially fertile! And
you still can get pregnant and it does happen. So most women are considered to no longer be fertile after the age of 55. So what do we do between the ages of 40
and 55 if we don’t want to get pregnant? So that’s what I’m going to cover today.
So when can you stop using contraception? That’s the question I get asked as a
doctor much of the time. Well if you’re using a non hormonal contraception such
as condoms or diaphragm you can reliably stop using
contraception two years after your very last period (so no periods at all for two
years) if you’re under 50 and if you’re over 50 you can stop one year after your
periods have stopped completely. However if you’re already using hormonal methods; so the combined pill or the mini pill, then it’s not so clear and it’s
difficult to tell, almost impossible, when this point has been reached, because they
interfere with your periods. On the mini pill you may have no periods or irregular periods. And on the combined pill you’ll have monthly periods but you
don’t know if they’re real periods or just induced by the hormones. An isolated
blood test for follicle stimulating hormone (which is the one that we use to
indicate whether or not you’re going through perimenopause or menopause) are not reliable. They just aren’t, they can vary dramatically. So one month normal
and the next month could look like you’re menopausal. And if you’re on the
combined pill they’re not reliable at all. So you can still get pregnant if
you’ve had a blood test that suggests that you’re menopausal and if you are
having periods, however irregularly. And then it becomes even more complicated….what if you’re on HRT? and some women are of course on HRT and the mini pill, and there’s a reason for that. So HRT in any format (tablet, patch, gels)
contains very low doses of hormones and those doses are not high enough to act
like a pill, even though logically it might seem like that’s what they should
be doing they’re not! You can still get pregnant taking HRT; it is not a contraceptive. And believe me women in their early 50s, on HRT who think they’re protected do get pregnant. And if you don’t want to be
pregnant at that age, obviously that can be devastating. So if you’re on HRT and
you’ve been on it for a period of time so you don’t know whether or not your
periods have stopped for long enough to make you infertile as it were, you can
use all of the normal methods: barrier, mini pill, intrauterine
devices or systems as well as HRT. You just use them alongside. So just to break
that down a little bit better, I’m going to go into the details over that
because this is what people want to know… what do they do? So the first approach is
that whether perimenopausal or not, over 40 you still need contraception.
And for you the choice is personal. How effective is the choice? What are the
risks and the side effects? What’s your personal preference, which always has to
come into account. And are you on HRT or not? And then you start thinking about
the choices. So let’s assume you’re on HRT, (because that’s what this VLOG is
about) and you use barrier methods; so if you’re quite happy using condoms or a
diaphragm alongside your HRT no other methods are needed. You’re protected if
it’s a condom, against sexually transmitted infections and sexually
transmitted infections have gone up amongst women who are over 50 because we’re seeing marriage break downs and new partnerships and people are having sex with people other than their partner, in times when they wouldn’t have done that previously because society was different. So barrier methods give you that protection as well. Although they need some planning so again you have to decide what works for you. The mini pill is probably the choice
that most women use when they’re on HRT, because it’s safe to take up to the age
of 55, when you’re considered no longer fertile. And you can safely add it to
your HRT and it’s just one tablet a day so that’s probably one of the most
popular choices. The copper coil; so the copper coil will protect you against
pregnancy for sure. You don’t have to think about it, there’s no planning
involved and it can stay in place for up to 10 years. There’s no additional
hormones being added to your HRT so it’s quite a nice method to use. However it
does not supply you with the progesterone of other coil systems that can be used as part of HRT. So if you have the copper coil you will still need an HRT that has both progesterone and oestrogen in it. However the Mirena coil or IUS does provide you with the progesterone that you need for HRT. So if you have the Mirena coil all you need to have as part of your HRT is the oestrogen; as a gel, patch or tablet. And that actually makes it quite simple for some women. They don’t have to think about contraception, they have the progesterone element covered and it works really well for many women. So that’s another alternative and it’s licensed for four years as the progesterone side of HRT but you can actually leave it in for 5. So quite often you won’t need that changed if you have it put in at 50,
you can go through to 55 and be safe against pregnancy and have that part of
your HRT covered off. So that’s quite nice for women who don’t like to take
progesterone because of side effects. And the nice thing about that as well is
that if you start it younger, so if you’re in your forties when you start
needing HRT, you can actually just have it changed every five years and it’s
literally a take out and put back. And it keeps you covered for your HRT so the
IUS or Mirena coil is another really good choice that some women
prefer. So I’d say the two most common types of contraception that women use alongside their HRT are the mini pill, which goes on top of HRT, or the Mirena (IUS) coil which actually acts as the progesterone part of your HRT. So it’s
reasonably simple even though it quite often doesn’t appear that way. And to
summarise the whole affect; fertility definitely does decline over the age of
40 and you are much less likely to get pregnant in that age range but women do,
all of the time! And whilst you’re still having periods of any type, any
regularity, there is a chance that you might just throw out one good egg and that’s all it needs, (obviously to meet one good sperm) and you could get pregnant! You do need therefore practical safe contraception to cover you for this period if you don’t want to be pregnant (and some women do). You need contraception until you’ve been without a period for two years if
you’re under 50 or for one year if you’re over 50. But if you are taking
hormonal contraception in that period it’s very difficult to tell when you’ve
hit that point, so the safest assumption, and the one recommended by the BMS, is
that you are still fertile until the age of 55. So add contraception to your HRT.
And as I’ve said HRT is not a contraception on its own. And you can
still get pregnant on it if you haven’t added other contraception. And if your
periods were not, as I’ve said, finished for two years or one year depending on
whether you’re over or under 50 when you start HRT, then you definitely need some
contraception. so hopefully that’s a very complex subject that people really
struggle with covered in a very simple way for you today. And I hope you enjoyed
it. Please do ask me any questions after the VLOG, I’m more than happy to answer
them or in the Latte Lounge or the Menopause support network – all of those places where I operate as a doctor giving my advice, and I’m more than happy to
answer. But hopefully that’s given you the basis; So HRT is not a contraception. You do need to add something to it and the choices I’ve covered for you. Thanks
for listening as always, it’s been a pleasure, it’s always a pleasure. And let
me know if there’s any topics that you want me to cover. Take care, bye for now.

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