Safe Contraceptive Options for Perimenopausal Women in 2025

Despite declining fertility in their midlife, many women remain at risk for unintended pregnancy during perimenopause—a stage when cardiovascular risk, metabolic disease, and pregnancy-related complications rise sharply. Yet, contraceptive counseling for these women is often overlooked, leaving clinicians uncertain about how long to continue hormonal contraception and which options remain safest as menopause nears.

At The Menopause Society 2025 Annual Meeting, Andrew Kaunitz, MD, MSCP, FACOG, professor and associate chair of obstetrics and gynecology at the University of Florida, outlined updated, evidence-based recommendations for managing contraceptive care in older reproductive-age women.1 His presentation reviewed safety considerations, breast cancer risk data, and noncontraceptive benefits of hormonal methods for women transitioning to menopause.

Balancing Fertility and Risk in the Perimenopausal Years

Although women’s fertility declines steadily through their 40s, many women remain at risk of unintended pregnancy well into their 50s. Andrew Kaunitz, MD, MSCP, FACOG, professor and associate chair of obstetrics and gynecology at the University of Florida, explained that about 83% of women at age 40, 45% at age 45, and 10% at age 50 remain fertile. The maternal mortality rate in this group is 7 times higher than in younger women, underscoring the importance of continuing contraception until menopause is confirmed.

“It’s not only important to recognize that perimenopausal women can conceive,” Kaunitz said. “It’s also critically important to recognize that if they conceive, the likelihood of morbidity or even mortality is greater.”

Guidance from the CDC, the American College of Obstetricians and Gynecologists (ACOG), and The Menopause Society (TMS) remains aligned on this issue, with Kaunitz saying these recommendations are evidence-based. The CDC’s medical eligibility criteria app—CDC US MEC SPR—continues to provide detailed contraceptive guidance. However, Kaunitz noted, “there are no plans for the federal government to continue contraceptive guidance,” raising concerns about future updates.

Are Combination Hormonal Contraceptives Safe?

Hormonal contraceptives can offer therapeutic benefits in perimenopause. | Image credit: RFBSIP – stock.adobe.com

Healthy, lean, nonsmoking women can safely use combined oral contraceptives, patches, or rings until their early to mid-50s, Kaunitz said, noting there are no contraindications based on age alone. For these women, CDC classifies combination hormonal contraceptives (CHCs) as category 2, meaning the benefits generally outweigh any risks and the treatment is greenlit.

However, clinicians should exercise caution in patients with cardiovascular risk factors such as obesity, diabetes, hypertension, smoking, or migraine with aura, especially as cardiovascular risk increases with age. When these factors are present, CHCs fall into CDC categories 3 or 4, suggesting risks outweigh benefits.

In such cases, progestin-only and intrauterine options offer safer alternatives, including continuous norethindrone 0.35 mg, drospirenone 4 mg in a 24/4 regimen, or continuous norgestrel 0.075 mg as an over-the-counter option. Long-acting methods like the depot medroxyprogesterone acetate injection, etonogestrel implant, and 52 mg levonorgestrel intrauterine device (IUD) are also suitable for older reproductive-age women. These all fall under categories 1 and 2, according to the CDC. According to Kaunitz, these methods “are all appropriate when cardiovascular risk factors are present, making combination methods inappropriate.”

Does Hormonal Contraception Increase Breast Cancer Risk?

In the session, Kaunitz reviewed a few major studies examining hormonal contraception and breast cancer risk. He noted that 2 of the most rigorous investigations, published by Marchbanks et al and Iversen et al, found no significant increase in breast cancer risk among users of oral CHCs or hormonal IUDs.2,3

In contrast, a highly publicized Danish cohort study published in the New England Journal of Medicine suggested a small, modest elevation of risk.4 Kaunitz noted that observational data should be interpreted with caution given confounding factors and relatively low absolute risk.

Noncontraceptive Benefits of Hormonal Contraceptives

Beyond pregnancy prevention, hormonal contraceptives offer therapeutic benefits that make them particularly valuable in perimenopause.1 Randomized trials and cohort studies have shown that combination pills can reduce hot flashes, stabilize irregular bleeding, and treat heavy menstrual bleeding, including bleeding due to fibroids or adenomyosis. Adjusting regimens—such as switching from 21/7 to 24/4 or continuous dosing—can minimize hormone-free intervals and improve vasomotor control, Kauntiz explained.

Combination contraceptives can also lower the lifetime risk of endometrial and ovarian cancers, with protective effects persisting for up to 4 decades after discontinuation. Evidence suggests these benefits extend to both average- and high-risk women, including those with BRCA mutations.

Additionally, oral CHC use has been linked to increased bone mineral density and a lower risk of postmenopausal hip fractures, helping mitigate bone loss that often accelerates during perimenopause.

When Can Women Safely Stop Contraception?

The median age of menopause among nonsmoking women is 52 years, but about half of women at this age have not yet reached menopause. By age 55, roughly 90% have transitioned into menopause, Kaunitz explained. Therefore, women who remain at risk for pregnancy and are appropriate candidates may continue hormonal contraception into their mid-50s without follicle-stimulating hormone (FSH) testing.

For those transitioning to menopausal hormone therapy, Kaunitz noted that the shift can occur seamlessly without any hormone-free days. Levonorgestrel-releasing IUDs remain a particularly useful option, offering endometrial protection, reduced bleeding, and compatibility with systemic estrogen therapy for symptom control.

References

1. Kaunitz A. Addressing contraceptive needs of perimenopausal women. Presented at: The Menopause Society 2025 Annual Meeting; October 22, 2025; Orlando, FL.
2. Marchbanks PA, McDonald JA, Wilson HG, et al. Oral contraceptives and the risk of breast cancer. N Engl J Med. 2002;346(26):2025-2032. doi:10.1056/NEJMoa013202
3. Iversen L, Sivasubramaniam S, Lee AJ, Fielding S, Hannaford PC. Lifetime cancer risk and combined oral contraceptives: the Royal College of General Practitioners' oral contraception study. Am J Obstet Gynecol. 2017;216(6):580.e1-580.e9. doi:10.1016/j.ajog.2017.02.002
4. Mørch LS, Skovlund CW, Hannaford PC, Iversen L, Fielding S, Lidegaard Ø. Contemporary hormonal contraception and the risk of breast cancer. N Engl J Med. 2017;377(23):2228-2239. doi:10.1056/NEJMoa1700732