Perimenopause on the pill or a hormonal coil

The NHS page on menopause symptoms spells out the problem: hormonal contraception can make it harder to tell if you have reached perimenopause or menopause, because it affects your periods. For most women the first clue is a change in their cycle. If your method has already made your bleeding irregular, light or absent, that clue is gone, and you have to read the other signs instead.

This page goes through what each method hides, the signs that still come through, how doctors assess it, and how long you need contraception. It does not tell you which method to use. That depends on your age and health, and is a conversation for a GP or sexual health clinic.

What each method hides

The methods hide different things, so it helps to know which one you are on.

• The combined pill (or patch or ring) gives you a monthly bleed for as long as you take it, according to the NHS. That bleed comes from the week without hormones, so it stays regular whatever your ovaries are doing. The pill also contains oestrogen and suppresses ovulation, which can smooth over the hormone swings of perimenopause. A GP quoted by Patient.info describes it as more likely than other methods to conceal the process altogether.
• The progestogen-only pill, the hormonal coil (IUS), the implant and the injection can make periods irregular or stop them completely, the NHS says. Any bleeding you have is shaped by the method, so a gap of three months or a run of spotting tells you little about the transition. None of these methods contains oestrogen.

A copper coil holds no hormones and leaves your natural cycle in place, so the period changes of perimenopause show as they would without contraception.

How do you know if you are in perimenopause on the pill?

Look at everything except bleeding. The NHS list of perimenopause symptoms runs well beyond periods, and most of it can come through hormonal contraception:

• hot flashes and night sweats
• trouble getting to sleep or staying asleep
• low mood, mood swings, and problems with memory or concentration (brain fog)
• vaginal dryness, itching or pain during sex, and more UTIs or UTI-like symptoms
• aching joints and muscles
• headaches or migraines that are worse than usual
• palpitations
• dry, itchy skin, thinning hair and a lower sex drive

If you take a pill with oestrogen in it, timing is a useful clue. Patient.info notes that some women first get symptoms in the pill-free break or after a missed dose, when the hormones from the pill dip. A run of night sweats that arrives in the same week of every pack is worth writing down with the pack day next to it.

The harder part is that several of these overlap with side effects of hormonal contraception: mood changes, headaches, breast tenderness, acne and weight change. The useful question is whether something is new. A symptom that started years after you began the method, with nothing else changed, points more towards perimenopause than one you have had since the first month. If your symptoms could fit other causes, our pages on perimenopause or thyroid and the symptom checklist help sort them.

Perimenopause with a Mirena coil

The hormonal coil releases a progestogen, levonorgestrel, mostly into the womb, where it keeps the lining thin. Bleeding often becomes light or stops, which is why it masks the cycle so well. According to The Femedic, citing NICE, about 75% of people with a Mirena still ovulate. The coil holds no oestrogen, so it does not make up for what the ovaries stop producing. In practice that means hot flashes, sweats, sleep problems and vaginal dryness can appear just as they would without it.

One point specific to the coil: UK sexual health guidance (FSRH), as summarised by GPnotebook, says a Mirena fitted at 45 or older can stay in for contraception until menopause. If yours went in before 45, it follows the usual replacement date. The NHS notes that an IUS used as part of HRT is replaced every 5 years whatever your age.

Bleeding on a coil is easy to dismiss as the coil. If you have had settled, light bleeding for a long time and it becomes heavier or more frequent, raise it, since the NHS advises seeing a GP when your bleeding pattern changes and you are bleeding more, not less. Our bleeding checker sorts which kinds of bleeding need a call and how soon.

Perimenopause on the implant or injection

The implant often brings unpredictable bleeding in its own right, so perimenopause implant symptoms are best judged by the non-bleeding list above. The injection more often stops bleeding altogether. It also has a quirk that matters for testing: GPnotebook notes that the injection can partly suppress FSH, so a woman on it could be menopausal and still show a normal level. A raised FSH on the injection, on the other hand, can be put down to perimenopause with some confidence.

How doctors assess perimenopause on contraception

Mostly from your age and symptoms. The NICE menopause guideline tells doctors to identify perimenopause in people over 45 without blood tests, and warns that it is harder to diagnose in anyone taking hormonal treatment. It also says FSH should not be used to judge menopause in people on combined contraception or a high-dose progestogen, because those hormones change the result.

The one place FSH has a defined role is deciding when contraception can stop. FSRH guidance, as GPnotebook summarises it, limits the test to women over 50 on a progestogen-only method other than the injection who have no bleeding. A level above 30 IU/L suggests the ovaries are winding down, and contraception can then stop after one more year. Our page Is there a test for perimenopause? covers what FSH and other tests can and cannot show.

When to stop contraception in perimenopause

The NHS rule is to keep using contraception for 2 years after your last period if you are 40 to 49, and for 1 year if you are 50 or over. That rule assumes you can see your periods, which hormonal contraception prevents. So the guidance works by age and method instead:

• Combined pill, patch or ring: the NHS says this pill is not recommended from 50, as the risks generally outweigh the benefits, and a GP may suggest a progestogen-only method instead.
• Progestogen-only pill, implant or hormonal coil: FSRH guidance allows these to continue until 55. A test at 50 or over, as above, can sometimes let you stop sooner.
• At 55: FSRH guidance says most women can stop all contraception, because pregnancy after that age is exceptionally rare even if bleeding continues.

Two practical points. HRT is not contraception, as Patient.info reminds readers, so starting HRT does not replace your method. And a coil or implant left in after you no longer need it should be taken out, which is easy to forget once it has stopped being a daily thought. Our article Can you get pregnant during perimenopause? covers how likely pregnancy is in your 40s and how to tell early pregnancy from a perimenopause cycle.

What to write down before an appointment

A record makes this conversation shorter. Note:

• which method you use, when you started it, and what your bleeding has been like on it
• each symptom, when it began, how often it comes and whether it is mild, moderate or severe
• if you take a pill in packs, the pack day each symptom appears on
• any bleeding that is new for you on this method: heavier, more often, or after sex

You can keep these notes in our printable symptom diary, which also lists questions to bring to the appointment.

My take

If you are in your mid-40s on hormonal contraception and wondering whether this is it, I'd stop waiting for your periods to tell you and judge it by the other signs. I'd start with two or three months of notes on sleep, sweats and mood, with how often each one comes. A GP can do far more with that record than with a hormone result they have been told not to rely on. I'd skip asking to have a coil removed just to see what your periods do, since you lose your contraception for an answer your age and symptoms usually give anyway. And I'd book a contraception review around 50, whatever method you use, because that is when the advice on oestrogen-containing methods changes and when an FSH test starts to be useful on progestogen-only ones.

Related reading

Our section Is it perimenopause? gathers the pages on telling the transition apart from other causes. For the full list of changes the NHS describes, start with perimenopause symptoms and how to track them.