For most people, perimenopause typically begins in your late 30s or mid-40s and can last for several years, leading up to menopause.
Certain influences may affect when perimenopause starts and how you experience it. These can include genetics, lifestyle, medical history, and whether or not you’ve given birth.
You might find yourself going through perimenopause while your friends haven’t started yet – or they may be further along than you, without you even realising it. That’s because everyone’s journey is different, and there’s no single way to move through perimenopause.
One often-overlooked aspect that can shape how and when you notice perimenopausal symptoms, however, is whether or not you use birth control.
Perimenopausal symptoms can be influenced by whether you’re taking medication to manage or control your hormone levels.
For some people entering perimenopause, hormone replacement therapy (HRT) is designed to ease certain symptoms and can be a helpful option when navigating this stage of life.
For others, taking hormonal birth control, the experience can be a little different.
Dr Opel Baker, a General Practitioner at Mayfield Clinic in Brighton and Hove, UK, explains that combined oral contraceptives contain synthetic oestrogen – typically ethinylestradiol – alongside a progestogen. These hormones work together to suppress ovulation and prevent pregnancy, creating a steady, controlled hormonal environment that overrides your body’s natural cycle.
“HRT works differently,” he says. “It uses body-identical oestradiol at significantly lower, replacement-level doses, paired with progesterone or a progestogen if needed. Rather than suppressing ovarian function, it aims to restore declining hormone levels during the menopause transition.”
Baker emphasises that this distinction is critical. The combined pill suppresses hormonal fluctuations and can mask early signs of perimenopause, whereas HRT replaces declining hormones without fully suppressing the ovaries.
If you’re using birth control, you could be at the same stage of perimenopause as someone experiencing classic symptoms, but it may be completely concealing the signs.
Dr Opel Baker
Perimenopause can look quite different from person to person, and whether you’re taking hormonal contraception can play a part in how obvious those changes are. If you’re not taking the pill, you may notice symptoms more clearly as they appear, as there’s no hormonal contraception influencing your natural cycle. This can make changes easier to spot and may lead you to seek advice about options such as HRT.
If you’re taking hormonal birth control – whether a combined pill that suppresses your cycle or a progestogen-only option such the mini-pill or Mirena IUD that lightens periods or stops periods – those changes may not be as pronounced.
“The pill is more likely to conceal the process altogether because it suppresses ovarian cycling,” says Baker. “This means that changes in your menstrual pattern, one of the earliest indicators of perimenopause, are no longer visible.
“Symptom presentation can appear more noticeable in those not using hormonal contraception.”
Baker explains that without the pill, your natural cycle continues, although it may become increasingly irregular. As oestrogen and progesterone levels fluctuate during perimenopause, you may feel these changes more directly – with symptoms such as irregular periods, hot flushes, mood changes, and disrupted sleep becoming more apparent.
“In contrast, people on the pill may experience a smoother hormonal background and therefore only recognise changes once contraception is stopped,” he notes. “So it is less a question of intensity or timing and more about how visible the transition is.”
Both birth control and HRT can make perimenopausal symptoms less noticeable, but they work in different ways.
HRT can ease symptoms such as hot flushes, disrupted sleep, and mood changes, while some of the subtler hormonal effects may remain.
Baker says you might still notice changes such as feeling more emotionally sensitive, having disrupted sleep despite being on treatment, or shifts in your libido and energy levels.
If you’re taking the pill, you may also experience symptoms during the pill-free break or if you miss a dose. For some people, these changes can offer early clues that their hormones are beginning to fluctuate.
“For those who no longer require contraception, transitioning from the pill to HRT can offer a more targeted approach to symptom management,” Baker explains. “HRT uses lower, physiological doses of oestrogen, which are designed to replace what your body is no longer producing rather than suppressing ovarian function.”
He emphasises that many people find HRT helps with symptoms such as hot flushes and night sweats, while also improving sleep and helping to keep your mood more stable.
HRT can also be tailored to suit your individual needs, with different ways of taking it and doses that can be adjusted over time. In some cases, this may mean using a lower overall dose of hormones than you would with the contraceptive pill.
Ultimately, when you stop using birth control and whether you consider switching to HRT is a personal choice. It’s still possible to become pregnant during perimenopause, so you may decide to stay on the pill for contraception even as you start noticing other symptoms.
You may also feel that neither option is right for you. Whatever you choose, it’s a good idea to speak to a healthcare professional before stopping or changing any medication, so you can make an informed decision.
Baker says there’s no one set age when you need to stop using contraception. However, it’s often worth reviewing your options from your mid-to-late 40s. This is particularly important if you’re starting to notice symptoms despite being on the pill, or if it’s becoming difficult to tell whether they’re linked to perimenopause or your medication.
“It’s worth noting that cardiovascular risk factors – such as migraine with aura, smoking history, or rising blood pressure – may make continued use of combined oral contraceptives less suitable,” he adds.
“In many cases, a planned transition to HRT is considered rather than an abrupt stop.”
If you’ve been taking the pill during the years when perimenopause typically begins, you may notice symptoms appearing more clearly once you stop. Because the pill suppresses ovarian hormone activity, coming off it can reveal some of the hormonal fluctuations that are happening naturally during perimenopause.
Baker says this can lead to symptoms such as hot flushes, disrupted sleep, mood changes, or irregular bleeding appearing within weeks of stopping the pill.
“However, this does not happen for everyone,” he notes. “The severity depends on how advanced the perimenopausal transition already is. In some people, symptoms develop gradually, while in others there is a more abrupt ‘unmasking’ effect once hormonal suppression is removed.”
Is HRT a safer option than the pill in midlife?
Both birth control and HRT come with health risks. However, those risks differ and should be weighed against the potential benefits for your overall wellbeing.
Baker explains that the main differences in risk come down to the type and amount of hormones used – as well as how each treatment works.
These include:
-
Combined oral contraceptives – contain higher doses of synthetic oestrogen and suppress ovarian function, which can increase your chance of blood clots. This is particularly relevant for people over 40 and those with additional risk factors, such as smoking, migraine with aura, or cardiovascular disease.
-
Modern HRT – generally uses lower doses of hormones that are chemically identical to those naturally produced by your body. When delivered through the skin, such as with patches or gels, this can offer a significantly lower blood clot risk than the combined pill.
If you do switch from the pill to HRT, remember that HRT is designed to manage symptoms – it is not a contraceptive. You will still need barrier methods or an option such as the Mirena IUD if you wish to prevent pregnancy.
Baker concludes that the choice between the pill and HRT ultimately comes down to what you need it for – contraception, managing symptoms, or both. The right option will be different for everyone and should take into account your overall health, individual needs, and any potential risks.
