Perimenopause and Pregnancy: Fertility, Contraception, and Reproductive Decisions in Your 40s

Perimenopause Does Not Mean Your Fertility Has Ended

Your periods are irregular. You are having hot flashes. You are wondering whether perimenopause means your reproductive years are behind you.

Here is what many people do not know: perimenopause and fertility overlap far more than most expect. You can get pregnant during perimenopause. Irregular periods are not the same as no ovulation. The fertility decline is gradual, not a switch that flips.

If you are not planning a pregnancy, you still need reliable contraception. If you are hoping to conceive, the picture is complex but not hopeless. And if you are navigating both at once, your feelings make complete sense. This transition asks a lot of you emotionally.

Why Ovulation Still Happens in Perimenopause

During perimenopause, your ovaries are producing less estrogen and progesterone, but they have not stopped releasing eggs entirely. Your cycles become irregular because ovulation is unpredictable, not because it has ceased.

You may skip ovulation some months and ovulate in others with no clear pattern. A cycle that arrives after two or three months of nothing does not tell you whether ovulation occurred. It tells you that your uterine lining built up and shed. Ovulation is a separate event that precedes this, and it can happen without a predictable cycle to signal it.

Ovulation predictor tests (OPKs) detect the LH surge that precedes ovulation. They work during perimenopause, though results can be harder to interpret because LH levels are more variable. If you are actively trying to conceive, working with a reproductive endocrinologist gives you much more precise information than home tests alone.

Pregnancy After 40: What the Risks Look Like

Choosing to conceive in your forties is increasingly common, and the medical landscape for supporting it has expanded. But a fully informed decision includes understanding the elevated risks.

Chromosomal abnormalities in the fetus are more common with older eggs. The risk of conditions like Down syndrome rises meaningfully through the forties. Prenatal genetic testing (including NIPT, chorionic villus sampling, and amniocentesis) is typically recommended and gives you important information early.

Miscarriage rates are higher. Approximately 40 to 50 percent of pregnancies in women over 40 end in miscarriage, most due to chromosomal issues. This is not your body failing. It is a biological reality about egg quality and chromosomal stability at this stage.

Pregnancy complications including gestational diabetes, preeclampsia, and placenta previa occur at higher rates in pregnancies over 40. These are manageable with appropriate monitoring, but they mean your pregnancy will typically be treated as higher risk and followed more closely.

If You Want to Conceive

Natural conception becomes less likely but is not impossible during perimenopause. Women in their early forties have a roughly 10 to 20 percent chance per cycle with unassisted conception. By the mid-to-late forties this drops considerably, though the exact numbers vary by individual.

If egg freezing is something you are considering, earlier is better. Eggs frozen at 38 or 39 have meaningfully better outcomes than eggs frozen at 43. If this path is on your radar at all, early conversation with a reproductive endocrinologist gives you the most options.

IVF with donor eggs is often the most reliable path to pregnancy after 44 or 45. Using eggs from a younger donor largely removes the age-related egg quality barrier, and IVF with donor eggs has relatively consistent success rates well into the mid-forties and beyond.

Preconception health matters more at this stage. Optimize sleep, nutrition (especially folate), protein intake, and blood sugar regulation before trying. Thyroid function should be checked, as it can be disrupted by perimenopause. Your provider can assess any other factors relevant to your individual history.

Contraception During Perimenopause: What Works and What to Consider

If pregnancy is not your intention, you need reliable contraception throughout perimenopause, up until you have been confirmed postmenopausal for 12 consecutive months. Symptoms alone cannot tell you when you have reached that point.

Combined hormonal contraceptives (pill, patch, ring) are highly effective and have the added benefit of regulating irregular periods and reducing hot flashes for some women. However, combined estrogen-progestogen contraceptives carry increased cardiovascular risk with age, particularly for women who smoke, have high blood pressure, or migraines with aura. Many providers recommend switching to progestogen-only or non-hormonal options after 40.

Hormonal IUDs (such as Mirena) are among the most convenient options during perimenopause. They provide continuous contraception, often reduce or eliminate periods, and the hormonal effect is primarily local. A Mirena inserted in your forties may provide contraception through menopause without needing replacement.

Copper IUD provides highly effective non-hormonal contraception for up to 10 years. It suits those who want to avoid any hormonal effect, though it can increase menstrual bleeding.

Barrier methods are appropriate at any age but depend more heavily on consistent use for effectiveness.

Hormone Therapy and Contraception: These Are Not the Same Thing

One of the most important things to understand about perimenopause is this: hormone replacement therapy (HRT) is not a contraceptive.

HRT is prescribed at doses designed to relieve symptoms. These doses are lower than those in hormonal contraceptives and are not calibrated to suppress ovulation. Taking HRT does not protect you from pregnancy.

If you are using HRT and have not yet reached confirmed menopause, you need a separate contraceptive method. Non-hormonal options like a copper IUD or barrier methods work well alongside most HRT regimens. Some providers also use a low-dose progestogen-only pill alongside HRT.

When you start HRT, bring up contraception explicitly in the same conversation. Many women are not proactively counseled on this. Ask directly: what contraceptive method is compatible with the HRT you are recommending for me?

The Emotional Complexity of This Moment

Being perimenopausal and navigating reproductive decisions at the same time is a lot to hold. Some women grieve the end of their fertile years even if they did not want more children. Some feel relief. Some feel both at once.

If you are trying to conceive during perimenopause, you may be managing hope, anxiety, medical appointments, and hormonal symptoms simultaneously. The emotional weight of that is real.

If you are winding down your reproductive chapter and managing perimenopause at the same time, that transition deserves acknowledgment too. Your experience does not have to fit a simple narrative.

There is no right way to feel about this. What matters is that you have accurate information, a provider who takes your situation seriously, and support for whatever you are navigating. PeriPlan can help you track your cycle and symptoms during this time, so you are not doing it all from memory.

When Can You Stop Using Contraception?

This is one of the most commonly asked questions about perimenopause, and the answer is more specific than most people expect.

The standard medical guidance: stop contraception after 12 consecutive months without a period if you are over 50, or after 24 consecutive months without a period if you are under 50. These thresholds reflect the time it takes to confidently confirm that ovulation has stopped.

Going six or nine months without a period does not mean you are done. Until you hit the threshold that applies to your age, with no period in between, the guidance holds.

FSH blood tests are sometimes used to assess menopausal status, but they are not reliable for contraception decisions in women using hormonal contraception. Hormonal methods suppress FSH, so a low result on the pill does not confirm you are still fertile. Stopping hormonal contraception to test a baseline FSH requires a gap of several weeks, during which alternative contraception should be used.

Do not use symptom pattern alone to decide you no longer need contraception. Talk to your provider, tell them your cycle history, and let them help you identify the right moment to stop.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.