As fertility declines, the risk of unintended pregnancy and cardiometabolic concerns rises, making perimenopause a clinical minefield. As prescribing roles expand, pharmacists must deliver individualised contraceptive care.
Perimenopause, which usually occurs between the ages of 45 and 55, marks the beginning of the transition out of the reproductive years. As hormone levels fluctuate, women may experience a range of symptoms, including hot flushes, night sweats, weight gain, mood changes and sleep disturbances.1
Menstrual cycle changes are also common, including longer or shorter cycles, and are frequently associated with heavy menstrual bleeding.2
But while ovarian function is winding down, ovulation can occur, meaning an unintended pregnancy is still possible.
Fertility may reduce during this phase of life, but it can be unpredictable, says GP pharmacist, diabetes educator and Aged Care On-site Pharmacist Shona Oxley.
‘Menopause is not always obvious, and the consequences of unintended pregnancy are clinically more significant in this cohort,’ she says.
Pregnancies in women over 40 are associated with higher risks of fetal abnormality, miscarriage and premature delivery than in younger women.3 Women aged 35 and over also have higher risks of gestational diabetes and pre-eclampsia.4
And it’s not just unexpected pregnancy risks that women in this stage of life need to grapple with.
‘Declining oestrogen during perimenopause also contributes to increased cardiometabolic risk, including insulin resistance, central adiposity and dyslipidaemia, elevating the risk of cardiovascular disease (CVD) and type 2 diabetes,’ Ms Oxley says.
‘Contraceptive choices during perimenopause should be individualised and guided by evolving cardiometabolic risk profiles, particularly in patients with hypertension, obesity or other established CVD risk factors.’
Now that pharmacists in many states and territories are either initiating or continuing contraceptive treatments alongside dispensing them, it’s important to keep the needs of this patient cohort in mind.
AP spoke with Ms Oxley about a new women’s health assessment introduced in her clinic, and to prescribing pharmacist Emma Conway about prescribing contraceptive medicines to women in perimenopause.
Case 1Shona Oxley, MMR, ACOP, GP Pharmacist, North East Family Medicine, Wangaratta, VIC Perimenopause and menopause have historically been misdiagnosed and undertreated. Without routine screening, diagnosis can be delayed, and the window for addressing long-term health risks, including osteoporosis, cardiovascular disease and mental health, may be missed. With a Medicare item number now allowing GPs to perform dedicated menopause and perimenopause assessments, North East Family Medicine has introduced a structured health assessment for women aged 45–49, aimed at supporting early identification of chronic disease risk factors and helping women understand where they are in their menopause transition – and what contraceptive approach suits them best. |
The model is built around improving access to women’s health services through a bulk-billed, multidisciplinary approach – bringing together nurses, pharmacists and GPs to deliver care that is both individualised and evidence-based.Each consultation begins with pathology completed prior to the appointment, allowing the clinical team to review results in context. Clinical observations – including weight, height, blood pressure and waist circumference – are recorded at the visit, and a structured consultation template guides the conversation through relevant areas such as family history, symptom history and lifestyle factors. Shared decision-making between the patient and clinicians then helps determine which screening activities are appropriate for each individual.
Where screening proceeds, it may encompass cervical, breast, bowel and skin cancer screening, osteoporosis assessment (including bone mineral density testing for eligible patients), STI screening where clinically appropriate, and CVD and diabetes risk assessments. Women may also be offered self-collected cervical screening or have an appointment arranged for a clinician-collected test, depending on what their preference is.
Whole-of-person care is key to the service. Health assessments are conducted by a nurse or pharmacist in collaboration with the GP, and patients may be referred to allied health professional
– such as a dietitian, exercise physiologist or pelvic physiotherapist
– or to specialists such as a gynaecologist where indicated.
A key aim of this approach is to strengthen preventive care, particularly around osteoporosis risk and fracture prevention. Integrating cardiovascular disease and diabetes screening into perimenopause care also means emerging risk factors can be identified earlier, supporting timely preventive and therapeutic action. Screening results directly inform safe prescribing of menopausal hormone therapy (MHT), helping ensure treatment aligns with each patient’s cardiovascular and metabolic profile.
For women using combined hormonal contraception, transition to alternative methods is managed using an individualised, risk-based approach. This includes assessment of key cardiovascular risk factors – blood pressure, BMI, smoking status and lipid profile – supported by the AusCVD Risk Calculator. Education and shared decision-making are central to this process, with open discussion of the relative risks and benefits of combined contraception compared with progesterone-only or long-acting reversible contraceptive (LARC) options. Where risk factors are identified, the progesterone-only pill or a LARC is recommended.
Contraceptive choice is also considered alongside perimenopause symptom management, including the potential role of MHT, so that both symptom control and contraceptive needs can be safely addressed together. But before contraception is ceased, a structured decision algorithm is applied, considering the woman’s age, contraceptive method, duration of amenorrhoea and, in some cases, follicle-stimulating hormone testing – with an absolute discontinuation point at age 55. Guidance on when and how to stop contraception safely is provided in line with the RANZCOG C-Gyn 3 Contraception Clinical Guideline and recommendations from the Australasian Menopause Society.
Once a treatment or management plan is decided on, continuity of care is supported through a follow-up appointment with the GP. This could involve a brief phone consultation or a longer visit for more complex needs. Relevant clinical reminders are added to the patient’s record, such as a repeat menopause health assessment or heart health check in 12 months where indicated.
So far, early feedback from both GPs and patients has been encouraging. GPs have responded positively to the structured format and the collaborative model of care, while many patients have reported feeling better informed about their symptoms and more engaged in decisions about their health.
Case 2Emma Conway, Managing Pharmacist, LiveLife Pharmacy Group, Laidley, Queensland
Mrs D experienced regular but prolonged menstrual cycles lasting 7 days, with 1 day of significantly heavy bleeding. Improving menstrual control and overall quality of life was her primary goal. While she did not require immediate contraception following the recent death of her husband, she wished to use hormonal therapy to regulate her cycle and manage her symptoms. |
Mrs D revealed that she had no known medical conditions, took no regular medicines and had no known medicine allergies. She had three children, all via vaginal delivery. There was no family history of breast or uterine cancer, and she had no history of migraine or venous thromboembolism. She was a non-smoker and reported no alcohol intake. Pregnancy was excluded, and there were no symptoms or risk factors for sexually transmitted infections. Cervical screening was also up to date.
I conducted a cardiovascular risk assessment, which was unremarkable, with a blood pressure of 98/75 mmHg, pulse of 82 bpm and a BMI of 20.
Previous hormonal therapies included a levonorgestrel intrauterine device, which did not adequately control bleeding, as well as the etonogestrel implant and vaginal ring – both of which caused unacceptable irregular bleeding and spotting.
I explained the role of combined hormonal contraception in perimenopause, particularly its non-contraceptive benefits, including cycle regulation, reduction in menstrual blood loss and hormonal stability. Progestogen-only options were excluded due to Mrs D’s prior experiences of irregular bleeding. The risks and benefits of combined oral contraceptives were also discussed, with consideration given to age, cardiovascular risk and personal preference. Visual aids were used to explain hormonal fluctuations in perimenopause and the advantages of monophasic formulations over older triphasic preparations.
Given her low cardiovascular and thromboembolic risk, a combined oral contraceptive was considered appropriate. A 4-month supply of monophasic levonorgestrel/ethinylestradiol 150/30 microgram preparation was prescribed. The 30 microgram estrogen dose was selected to optimise cycle control while avoiding unnecessary dose escalation. A repeat was intentionally not issued to facilitate review after 3–4 cycles of treatment.
Mrs D was counselled on expected benefits, potential adverse effects and warning signs requiring medical review. Follow-up was planned after several cycles to assess bleeding control, tolerability and symptom improvement. She was also referred to her GP to discuss ongoing management of perimenopausal symptoms. Mrs D returned 3 months later with a prescription from her GP for continuation of levonorgestrel/ethinylestradiol 150/30 micrograms, indicating good tolerability and benefit.
Supporting Mrs D with hormonal contraceptive management provided an opportunity for a holistic discussion during a significant life transition.
This included her progression into perimenopause, with its associated physical and emotional changes, as well as the recent loss of her husband. Providing continuity of care during this period enabled both informed clinical decision-making and patient-centred support.
The dos and don’ts of contraceptive care in perimenopause
| Do | Don’t |
|
|
References
- Jean Hailes for Women’s Health. Menopause: symptoms, causes and management. Melbourne: Jean Hailes for Women’s Health. At: https://www.jeanhailes.org.au/health-topics/menopause/
- Australasian Menopause Society. Perimenopause or menopausal transition [information sheet]. AMS Hub. At: https://hub.menopause.org.au/Play?pId=dc385480-d0c0-4033-9e07-bc82306a84f6
- Bateson D, McNamee K. Perimenopausal contraception: a practice-based approach. Aust Fam Physician 2017;46(6):372–7.
- Women and Newborn Health Service, King Edward Memorial Hospital. Advanced maternal age [clinical guideline]. Perth: WNHS. 2023. At: https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Advanced-Maternal-Age.pdf
- National Heart Foundation of Australia; Australian Chronic Disease Prevention Alliance. Australian cardiovascular disease risk calculator (AusCVDRisk). 2023. At: https://www.cvdcheck.org.au/calculator
- Royal Australian and New Zealand College of Obstetricians and Gynaecologists; Faculty of Sexual and Reproductive Healthcare. Contraception clinical guideline (C-Gyn 3). Melbourne: RANZCOG. 2024. At: https://ranzcog.edu.au/wp-content/uploads/Contraception-Clinical-Guideline.pdf
