CPD: Casebook – complicated contraception
In this case-based module, Dr Toni Hazell discusses how to manage requests for contraception in women with a relevant medical or family history. Complete the full module on Pulse 365 today
Learning objectives
This case-based module will support your knowledge and understanding of:
- The different types of progestogen-only pill available in the UK.
- Contraception for those affected by obesity and/or polycystic ovarian syndrome.
- How to manage the transition from the reproductive years to the menopausal years in terms of contraception and combining contraception and HRT.
- Safe use of hormonal contraception for those with a family history of breast cancer.
Case 1: Contraception in the perimenopause
1. Sarah has come in for her annual contraception review – she has just turned 50 and has been taking the progestogen only pill (POP) desogestrel for many years. She wonders if she can stop using contraception now. What do you tell her?
Fertility decreases with age and it’s unusual, but not unheard of, to get pregnant over the age of 50. It isn’t until 55 that all women can stop using contraception, as spontaneous conception is exceptionally rare1 after this age. The natural absence of periods can also be used to judge fertility – it is safe to stop contraception one year after the last normal period, if that is over the age of 50, or two years after the last normal period if the last period is under the age of 50. This doesn’t help Sarah though, as she has been amenorrhoeic for years on the POP, so she can’t use the lack of periods to guide questions about fertility. As you open your mouth to explain her options, she says that she has another question for you.
2. Sarah mentions that she also has some symptoms of the menopause. She wants to know if she should have a blood test for the menopause (as she can’t be guided by periods stopping) and whether she can think about starting HRT – what would you say?
The menopause is a clinical diagnosis over the age of 45, with no need for a blood test – checking a follicle-stimulating hormone (FSH) level is only needed if the menopause is suspected under 45.2 For women not using hormonal contraception, the menopause can be diagnosed after one year of not having a period, but making this diagnosis can be difficult if there is contraception associated amenorrhoea. For the purposes of starting HRT, the decision can be made on the basis of the presence of menopausal symptoms, but this doesn’t work for the purposes of a discussion about contraception in women who are amenorrhoeic due to their current method. Sarah therefore has two options. She can simply continue to take her POP until the age of 55 and then stop, or you can request a single FSH test at any point after the age of 50. If it is in the menopausal range (usually >30 IU/L but may vary slightly with different laboratories), then she should use contraception for one year from the date of the test and then stop.1 This is essentially using the date of the blood test as equivalent to the date of the last period. This can be done with any progestogen only method of contraception, but not with combined hormonal contraception (CHC), which suppresses FSH. CHC should be stopped at 50 in any case.3
3. Sarah is happy to have an FSH test, and you do a blood form for her. She clearly has symptoms of the menopause and is keen to start HRT, but wonders how she would combine it with contraception, if her FSH test isn’t in the menopausal range, and in any case for the next year. What do you tell her?
Sarah is probably in the perimenopause and it is absolutely appropriate to prescribe HRT for her symptoms. Most forms of HRT are not contraceptive, and it’s important that fertile women continue to use contraception. Any form of progestogen only contraception (pill, implant or depot injection) can be used alongside HRT, but the depot is relatively contraindicated over the age of 452 and should ideally be stopped from 50.1 So, Sarah could use a combined oral or patch HRT and continue with her POP, or she could use transdermal oestrogen with an oral progesterone for her HRT and also continue with the POP.
Her other option would be to have a levonorgestrel intrauterine device (LNG-IUD) fitted; this would do double duty as the progestogenic part of HRT and to provide her with good contraception. Only the Mirena brand has a licence for use in HRT, which is for four years, but the College of Sexual and Reproductive Health (CoSRH; formerly Faculty of Sexual Health and Reproduction, FSRH) advises that any brand of 52mg LNG-IUD can be used for up to five years as the progestogenic component of the menopause.1 This includes the brands Levosert and Benilexa but not Kyleena or Jaydess, both of which give a lower dose of progestogen. A 52mg LNG-IUD being used for both contraception and HRT must be changed at five years, rather than being left for eight years which is the duration for contraception use only.
Click here to complete the full module and log 2 CPD hours towards revalidation
Dr Toni Hazell is a portfolio GP in north London with an interest in women’s health
References
- CoSRH. Contraception for Women Aged Over 40 Years. May 2025.
- NICE. Menopause: identification and management. [NG23] 2024
- CoSRH. UK Medical Eligibility Criteria for Contraceptive Use (UKMEC). 2019
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