By: Dr. Jackie Piasta, DNP, WHNP-BC, MSCP

Here’s a question I hear often in the Monarch Health clinic: “I’m in my 40s, my periods are irregular, and I think I’m in perimenopause, do I still need to worry about getting pregnant?”

The Short Answer: Yes.

Perimenopause is defined as the transitional period before menopause when ovarian hormone production becomes erratic. Cycles may become shorter, longer, or skipped, but ovulation can still occur albeit sporadically.

Why? Follicle-stimulating hormone (FSH) rises as ovarian reserve declines, but some follicles remain responsive. This means ovulation, while less frequent, can still surprise you.

Fertility in the 40s

Natural fertility declines significantly after age 40 due to diminished ovarian reserve and egg quality.
However, pregnancy is still possible until menopause is confirmed (12 consecutive months without a period).
Unplanned pregnancy rates in perimenopausal women are not negligible. In fact, nearly half of pregnancies in women 40+ are unintended, often due to the mistaken belief that contraception is no longer needed.

Risks of Pregnancy in Perimenopause

Pregnancy at this stage carries higher risks for both mother and baby, including:

Miscarriage (up to 50% at age 45+)
Gestational diabetes and hypertension
Higher rates of cesarean delivery
Preterm birth and low birth weight
Chromosomal abnormalities (e.g., trisomy 21)

While many women have healthy pregnancies in their 40s, these risks highlight why planning and preconception counseling are essential.

Contraception in Perimenopause

Hormonal contraception:

Combined oral contraceptives, patches, or rings can regulate cycles, reduce heavy bleeding, and protect bone health. They may also alleviate vasomotor symptoms.
Progestin-only options (IUD, implant, mini-pill) are excellent for women who cannot use estrogen.

Non-hormonal contraception:

Copper IUDs, condoms, or permanent sterilization.

Important note: Menopause hormone therapy (MHT) is not contraceptive. A woman using estrogen therapy in perimenopause still needs additional contraception if pregnancy is not desired.

When Can Contraception Be Stopped?

If <50 years old: Continue contraception until 24 months after your last period.
If ≥50 years old: Continue contraception until 12 months after your last period.
FSH levels are not reliable for confirming menopause if you are using hormonal contraception.

Practical Guidance for Patients

If you’re sexually active with a male partner and not seeking pregnancy, contraception is recommended until menopause is confirmed.
If contraception is not desired but pregnancy would be high risk or unwelcome, discussion of sterilization or long-acting reversible contraception is appropriate.
If pregnancy is desired, fertility counseling and preconception planning (including genetic counseling) should be considered.

Key takeaway: Perimenopause is a time of uncertainty, cycles are irregular, hormones fluctuate, but pregnancy is still possible. The safest approach is to assume fertility until proven otherwise and use contraception tailored to your health and preferences.

Do I Need to Worry About Pregnancy in Perimenopause?