Helping perimenopausal women make informed contraceptive choices, with Andrew Kaunitz, MD

Andrew Kaunitz, MD, professor and associate chair of obstetrics and gynecology at the University of Florida College of Medicine in Jacksonville, discussed contraceptive counseling for perimenopausal women during a presentation at The Menopause Society Annual Meeting 2025.¹

Contraceptive relevance in later reproductive age

Kaunitz emphasized that although fertility declines with age, pregnancy risk persists well into the late reproductive years.

“Many women, as they get into their mid and late 40s, assume they no longer need contraception. And although it's true that fertility declines as women approach menopause, for instance, at age 50, about 10% of women remain fertile.”²

He noted that most patients in their 40s or early 50s would not welcome an unintended pregnancy, underscoring the need for continued contraceptive use.

Guidance from national organizations

Kaunitz highlighted that guidance from the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), and The Menopause Society align on recommendations for contraceptive use among older reproductive-age women.

“For healthy, lean, older reproductive age women, it is safe and appropriate to continue combination estrogen-progestin contraceptives until menopause.”

He cautioned against using laboratory markers such as FSH or estradiol levels to determine menopausal status in women using hormonal contraception.
“Checking FSH or estradiol levels ends up not being useful, and if anything, can be misleading.”

Balancing benefits and risks

Kaunitz explained that cardiovascular risk is a key determinant when selecting a contraceptive method for perimenopausal women.

“For women not at elevated risk for cardiovascular disease who are lean and non-smoking, all contraceptive options, including combination methods such as pills, patches, and rings, are available to them.”

However, as women age and the likelihood of comorbidities such as obesity, hypertension, and type 2 diabetes increases, clinicians should avoid combination methods.

“If cardiovascular risk factors are present in older reproductive-age women, we counsel women not to use combination methods, but they can safely use progestin-only or non-hormonal methods.”

He added that progestin-only pills, injectables, implants, and intrauterine devices (IUDs)—both progestin-releasing and copper—are appropriate alternatives.

Discontinuing contraception and transitioning to hormone therapy

Regarding when contraception can safely be discontinued, Kaunitz noted that age-based guidance is more reliable than laboratory testing.

“FSH is not a reliable guide. It can vary. It can be elevated one month, suggesting menopause, and it can be lower when checked at another time.”
Instead, he follows the consensus from CDC, ACOG, and The Menopause Society.

“Continuing their method until mid-50s, such as age 55, is appropriate because the likelihood that a 55-year-old is still capable of conceiving ends up being very low.”

He added that women using hormonal contraception may transition directly to systemic hormone therapy to address menopausal symptoms or bone health concerns.

“Women using hormonal contraception can transition without any hormone-free days or weeks and without any specific laboratory testing to systemic hormone therapy, for instance, an estradiol patch and progestational agent or oral estrogen.”

References

1. Kaunitz A. Addressing Contraceptive Needs of Perimenopausal Women. Presentation. Presented at: The Menopause Society’s 2025 Annual Meeting. October 21–25, 2025. Orlando, Florida.
2. Towner MC, Nenko I, Walton SE. Why do women stop reproducing before menopause? A life-history approach to age at last birth. Philos Trans R Soc Lond B Biol Sci. 2016;371(1692):20150147. doi:10.1098/rstb.2015.0147