Many changes during perimenopause are normal and natural. They usually start when a woman is in her 40s, sometimes even in her 30s. As a rule, most will not continue far beyond menopause, and will stop without treatment. Some changes are problematic and need treatment. All changes, however, signal the need for a medical evaluation because it cannot be assumed that hot flashes and other changes are caused by approaching menopause. Some changes can be signals of disease or can be caused by other ailments, such as a thyroid disorder. Therefore, it is advisable to report any changes to a healthcare provider.
A woman's response to the physical changes of the perimenopausal years, while not genetically determined, can often be predicted by her mother's response. Women whose mothers describe their menopause as terrible may become conditioned to have a similar experience. Hot flashes or other discomforts of menopause are very real, yet the level of distress that a woman experiences is partly based on her expectations.
For some women, menopause just means the end of menstrual periods. To others, it means uncertainty about what to expect and an unwelcome reminder that they are aging. But women who embrace the changes, rather than dreading them, are the ones who find menopause to be an event that brings about better relationships and greater personal fulfillment, and they are more likely to make lifestyle changes that will improve their health for the rest of their lives. Women today are living in an era when menopause is better understood than ever before, and they have the advantage of being able to talk openly about it.

Beginning late in their 30s, women's fertility typically begins to wane significantly, primarily due to aging eggs in the ovaries. While there are many fertility-enhancing techniques available for midlife women, they are expensive, have some risks, and are
not always successful. At the same time, the risk of spontaneous miscarriage begins to rise, reaching about 50% by age 45. Also at this age, the risk of a genetic abnormality in a fetus is 1 in 40, and there is an increased chance of pregnancy complications, such as gestational diabetes, stillbirth, and the need for cesarean section.

Information about birth control in a menopause booklet may seem surprising. But, despite a decline in fertility during perimenopause, women are not totally protected from an unplanned pregnancy until menopause is reached. If pregnancy is not desired, it is important to choose an effective, safe, and appropriate method of birth control, particularly in midlife when pregnancy can have an impact on health far beyond the reproductive years.

Midlife women have a wide range of effective birth control options. A healthcare provider can help determine the best birth control choice based on a woman's medical history, lifestyle, and sexual habits. It should be noted that only one method - condom use - provides protection from HIV and other sexually transmitted infections (STDs). Options include the following:

Sterilization methods include tubal ligation (for women) and vasectomy (for men).
Pros: These methods are safe and have a very low failure rate of about 4 to 8 in 1,000. Tubal ligation (having tubes "tied") does not cause menopause.
Cons: They are surgical procedures and have to be considered permanent.

Barrier methods include the diaphragm, cervical cap, spermicides, and the male and female condom.

Pros: These methods are highly effective if used during every act of vaginal sex, although spermicide alone is less effective. A condom is the only method proven effective as protection against both pregnancy and STDs when used during vaginal, oral, and anal sex. Condoms can be used in combination with other birth control methods, and they are available without a prescription.

Cons: A few women and men are allergic to latex condoms or certain spermicides. These methods must be used during every act of sex, and condoms may break, leak, or spill when removed.

Oral contraceptives, sometimes called birth control pills, contain either one hormone (progestin) or two  (progestin plus estrogen) for contraception.

Pros: These prescription products provide effective contraception; after discontinuing use, there is a rapid return of fertility. Modern low-dose pills that combine estrogen and progestin are safe for healthy, nonsmoking, midlife women, and are highly effective when taken as directed. Noncontraceptive benefits include reduced risk of ovarian and endometrial cancer, fewer fibrocystic breast changes, and reduced rates of postmenopausal bone density loss. They may also help regulate periods and reduce hot flashes during perimenopause. Long-term use will not significantly increase cardiovascular risk in healthy nonsmokers. Most studies do not show a significant relationship between use of birth control pills and risk of breast cancer.

Cons: Contraindications include history of blood clots or coronary artery disease, breast cancer, jaundice during previous birth control pill use, pregnancy or suspected pregnancy, uncontrolled hypertension, and cigarette smoking in women over age 35. Possible side effects include nausea, breast tenderness, new or worsening headaches, and spotting between periods. Using birth control pills can mask changes in a woman's period, and thereby mute her natural signal of approaching menopause. Birth control pills also invalidate the FSH test that is often used to confirm menopause. Because of the difficulty in knowing when menopause is reached, most clinicians advise women to stop birth control pills at age 51, the average age of menopause. Heart attack and stroke are rare but serious side effects, especially in smokers and with the use of older high-dose pills. The mini-pill, which contains only a progestin, may be better for women at risk for blood clots in the legs (phlebitis). However, the mini-pill is slightly less effective in preventing pregnancy than the combination pills and may not offer the same noncontraceptive health benefits.

Progestin injections. An injectable birth control option is available: Depo-Provera. It contains progestin for effectiveness, and a healthcare provider needs to give the injection into a large muscle (typically the buttocks). 

Pros: A single injection of one of these products provides more than 99% contraceptive effectiveness for several weeks (up to one month for Lunelle and up to three months for Depo-Provera). Long-term use is associated with lower uterine cancer risk. After discontinuing use, fertility returns  within 10-18 months for Depo-Provera.

Cons: Contraindications include pregnancy, vaginal bleeding of unknown cause, breast cancer, liver disease, and blood clotting disorders. Common side effects include weight gain, hair loss, and changes in menstrual cycle, especially during the first few months of use. Other possible effects are fatigue, headaches, nervousness, and dizziness. They also require regular visits to the healthcare provider for injections.

Intrauterine devices (IUDs) can be placed inside the uterus by a clinician. Different devices use different materials for effectiveness, such as copper or a progestogen.

Pros: IUDs are highly effective for long-term pregnancy protection (up to five years for one progestogen device, 10 years for copper). Today's IUDs are much safer and more effective than older devices, and there is no evidence of increased risk of pelvic inflammatory disease or cancer. When removed, contraception is reversed and fertility rapidly restored.

Cons: Contraindications include pregnancy or suspicion of pregnancy, history of pelvic inflammatory disease, not being in a mutually monogamous relationship, abnormality of the reproductive system (which includes an unresolved abnormal Pap test), abnormal genital bleeding, anemia, and infection of the fallopian tubes or ovaries. Possible side effects of cramping or spotting may occur initially after insertion. In addition, menstrual periods may be heavier and last longer while the IUD is in place, although one of the progestogen-containing IUDs has been found to reduce bleeding by up to 90%. The office procedure for insertion may be uncomfortable, and cramping or spotting may occur initially. The user must periodically check the string that remains outside the uterus in the vagina to ensure the IUD is in place. The string is sometimes felt by the partner. IUD use requires at least an annual exam by a clinician.

Progestin implant system. One implant system,Implanon, is available for birth control and consists of one progestin-releasing capsule  surgically implanted by a clinician under the skin of the inner, upper arm.

Pros: The implants, which can be removed by the clinician at any time, offer 98% contraceptive effectiveness. When removed, fertility returns rapidly.

Cons: Contraindications include pregnancy, history of blood clots, unexplained vaginal bleeding, breast cancer, or liver disease. Side effects include headaches, nausea, weight change, acne, increased vaginal dryness, and irregular uterine bleeding, typically in the first 9 to 12 months after insertion. Some medications used for epilepsy may make the implants less effective. The system's costs include purchasing the product plus the office surgery to insert and remove the capsule. Implants must be removed after five years, and there is a possibility of permanent scarring at the insertion site.

Methods that use no drugs, devices, or surgery include natural family planning, such as rhythm or periodic abstinence.

Pros: There is no cost, no need to take drugs or use devices, and no need for surgery. There are no contraindications or side effects.

Cons: When using the rhythm method, it is especially difficult to predict unsafe days during perimenopause when periods are irregular.

“Emergency contraception" can be effective if used within 72 hours of unexpected, unprotected sex or a condom accident. These "morning-after" pills should not be used as regular birth control.

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