The Combined Oral Contraceptive Pill and Perimenopause
What’s Really Happening With Your Hormones?
Hello and welcome to Menopause & Me.
I’m Jenna, Nurse Practitioner and menopause educator.
Many women in perimenopause still require reliable contraception or support with cycle control. For this reason, the combined oral contraceptive pill (COCP) is commonly prescribed during midlife.
As women move through perimenopause, however, hormonal needs can change — and the combined pill works very differently from menopause hormone therapy (MHT). Understanding this difference can help explain why some women notice unexpected or new symptoms during this stage of life.
This article explores how the combined pill works, how it differs from menopause hormone therapy, and why a review can be helpful as needs evolve.
How the combined pill works
The combined oral contraceptive pill contains:
A synthetic progestogen (progestin)
A synthetic oestrogen (most commonly ethinylestradiol)
Its primary actions are to:
Suppress ovulation
Reduce the ovaries’ natural production of oestradiol, progesterone, and testosterone
This creates a steady, non-cyclical hormonal environment. Although a monthly withdrawal bleed may occur, this does not reflect a natural ovulatory cycle.
Why the combined pill is not menopause hormone therapy
Menopause hormone therapy aims to support symptoms associated with hormonal decline by replacing oestradiol (and progesterone when required) using body-identical hormones at physiological doses.
In contrast, most combined oral contraceptive pills:
Contain synthetic hormones rather than body-identical forms
Suppress ovarian hormone production rather than replacing it
Are designed for contraception and cycle control, not menopausal symptom management
For these reasons, the combined pill is not considered a form of menopause hormone therapy.
Effects on oestrogen levels
Despite containing oestrogen, many combined pills result in relatively low circulating oestradiol levels compared with typical physiological midlife requirements.
For some women, this may be associated with symptoms such as:
Hot flushes or night sweats
Vaginal dryness or discomfort
Changes in sleep quality
Individual responses vary, and not all women experience these effects. Symptoms are influenced by many factors beyond oestrogen alone.
Effects on progesterone and mood
Because ovulation is suppressed while taking the combined pill, the body produces little natural progesterone.
Progesterone plays a role in:
Sleep regulation
Mood stability
Nervous system calming
Lower endogenous progesterone levels may be associated with sleep disturbance, anxiety, or low mood in some women, though these symptoms are always multifactorial and individual.
Effects on testosterone and sexual wellbeing
The combined pill may:
Reduce ovarian testosterone production
Increase sex hormone-binding globulin (SHBG), which lowers free testosterone levels
For some women, this can influence sexual desire, energy, motivation, or overall wellbeing. These effects are variable and not universal.
When the combined pill may still be appropriate
The combined pill can remain an appropriate option for some women who need:
Reliable contraception
Management of heavy or irregular bleeding
Hormonal support in premature ovarian insufficiency or early menopause
Newer formulations containing estradiol or estetrol may be better tolerated for some women. These options remain contraceptive treatments rather than menopause hormone therapy.
As with all hormonal options, the benefits and risks should be reviewed in the context of age, medical history, and personal priorities. A personalised review is essential.
Journal Club: Placing the evidence in context
As part of our commitment to evidence-based menopause care, we also share selected research through Journal Club at Menopause & Me.
For this topic, we’ve highlighted a recent 2025 peer-reviewed review examining the use of hormonal contraception, including the combined oral contraceptive pill, in perimenopausal women. The paper is important because it helps explain why advice about the combined pill can differ between clinicians and why guidance has changed over time.
The review shows that evidence in this area is still evolving, particularly for women in later reproductive years, and that many recommendations are based on expert consensus rather than definitive trial data. It reinforces that the combined pill may still be appropriate for some women, but it is not menopause hormone therapy and does not suit everyone.
Importantly, this research supports current practice moving away from blanket rules and towards regular review, individual risk assessment, and shared decision-making as women’s needs change through perimenopause.
You don’t need to read research papers yourself — Journal Club is simply a way of translating evidence into clear, relevant context to support informed conversations about care.
A simple 3-step check-in
If you’re using the combined pill during perimenopause, it may be helpful to:
Notice any changes in symptoms (bleeding, mood, sleep, flushes, libido)
Book a consultation with a menopause-trained healthcare provider
Ask:
“Is the combined pill still the best option for my contraceptive and symptom needs at this stage of life?”
You’re not alone on this journey — and understanding how different treatments work can support more informed, confident decisions.
If you’d like support or a personalised review, you’re welcome to reach me at: hello@menopauseandme.com.au www.menopauseandme.com.au
Warmly,JennaNurse Practitioner & Menopause Educator
Sources
Australasian Menopause Society – Contraception and Perimenopause | Faculty of Sexual & Reproductive Healthcare – Combined Hormonal Contraception Guidelines | British Menopause Society – Midlife Hormone Guidance | Prior JC et al. – Progesterone physiology and perimenopause | Panay N et al. – Hormonal contraception in midlife women
Journal Club feature:
Whitburn, S., McNamee, K., Boerma, C., & Bateson, D. (2025). Hormonal contraception in perimenopausal women. Best Practice & Research Clinical Obstetrics & Gynaecology, 103, 102655. https://doi.org/10.1016/j.bpobgyn.2025.102655
Important Disclaimer: The information in this blog/newsletter is general in nature and intended for educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your Nurse Practitioner, doctor, or another qualified health practitioner with any questions you may have regarding a medical condition or before commencing any new treatment, exercise program, changing your diet, or taking supplements – particularly if you have existing health conditions, are on medication, or have had fractures or falls in the past. Individual needs and responses vary.
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