A few years ago, one of my gynaecologist colleagues, who was not closely involved in menopausal medicine, told his wife that she could safely come off the Pill as he declared that she was now menopausal at the age of 50. They now have three children aged 20, 18 and 3 years of age. His wife was not amused. The words “trust me, I’m a doctor” don’t work in that household anymore and she still tells everyone what a lousy gynaecologist he is (even if the baby is the most loved and spoiled child I have ever seen).
So, can you still get pregnant while you are going through the menopausal process? The answer is ……unlikely but maybe.
When talking with women in their perimenopause, usually in their 40s to 50s and still having irregular or occasional periods, I am commonly asked whether they can still get pregnant.
The question is asked for one of two reasons.
Firstly, there are some who still want to have a baby, wondering if time is running out and what they should do. The nature of the perimenopausal state means that ovulation, ie egg production, is irregular and infrequent. The egg quality is not as good as it once was and fertilisation is less successful. T
his is the natural process. Fertility declines rapidly from the age of about 37 onwards and even using IVF in the best hands, the success rates fall significantly once a woman enters her 40s. The bioidentical hormones we use to treat the symptoms of the perimenopause will reduce the symptoms of the hormonal disruption but will not improve the conception rate.
When managing these women, we may ask for blood tests to identify if ovulation is still occurring as well as other tests to determine the number of eggs that still remain. Two of the tests that may be done are pelvic ultrasound and a blood test for what is called anti-Mullerian hormone both of which are aimed at measuring the remaining eggs ……what is called the ovarian reserve. Once that is done the couple must make a sometimes difficult decision, whether to treat the perimenopause or be treated as a fertility problem. In that case referral for appropriate treatment may be advised.
The second reason for asking the question is that the woman does not want to find herself pregnant, like the Gynaecologist’s wife, and is seeking advice on how to avoid this. The first and most important thing to understand is that hormone replacement of any sort is not contraceptive. If egg production is still occurring then pregnancy may still occur.
In the workup of the perimenopause, you should ask the question “am I still ovulating”. Often we will ask you to have a series of blood tests a week apart looking for a rise in hormone levels which would indicate ovulation. This is the hormone progesterone which is only produced when an egg has been produced. As many of you, who are ovulating infrequently know, low levels of progesterone produce symptoms such as overheating and night sweats, poor sleep, irritability and mood swings and even poor concentration and memory. That’s when you can’t remember where you left the car in the carpark at Woolworths. The symptoms respond well to replacement with bioidentical progesterone. But this is not a contraceptive.
Sometimes, your GP will have prescribed the contraceptive pill. The Pill works by taking over your cycle so everything is artificial, even the periods. It works great to prevent pregnancy but still may not control the perimenopausal symptoms and very often we need to add progesterone even in women on the Pill. The Pill contains very high levels of hormones and generally your doctor will not prescribe it beyond the late 40s or early 50s because of the danger of causing clots.
Pregnancy rates in the perimenopause are small due to the infrequent egg production and the poor quality of the eggs. Nonetheless, if there is real concern about conceiving then you should discuss this when talking with the doctor at the Menopause Centre or with your own doctor as there are many still options available.
We will not discuss these in detail here, but they fall into several categories:
- Condoms; not always popular but effective at this stage of the menopausal process
- Intrauterine devices, these days generally as a Merina (which has the added advantage of reducing the amount of bleeding with periods) though other forms of intrauterine devices are available
- Tubal interruption can be performed; either a standard tubal ligation or even as insertion of small devices into the tubes. Both can be done as day only procedures.
- This is a relatively minor procedure which can be done under local anaesthetic. All you need do is convince your partner, particularly reminding him that it does not affect his sex drive or performance.
Don’t forget to ask the doctor about the potential for pregnancy in the perimenopause or the menopause. We’ve all heard of menopausal babies that have come as a complete surprise to all concerned.
AND DON’T BE SHY.
Written by Dr David Woodhouse