As more members of Generation X approach perimenopause and menopause, public conversations about symptoms such as hot flashes and mood swings are becoming more common. However, the possibility of pregnancy during perimenopause is less frequently discussed.
“Pregnancy in perimenopause is a conversation I have to initiate instead of the other way around because it doesn’t dawn on most women that we’re still fertile until we actually reach menopause,” said Jacqueline Sanchez, M.D., a gynecologist with the University of Miami Health System.
Dr. Sanchez noted that while most patients are concerned about typical symptoms like disturbed sleep or mood changes, unexpected pregnancies can still occur. “We mainly see pregnancies among women in perimenopause in the setting of assisted reproductive technology, but just the other day, we saw a spontaneous pregnancy at 47,” she said.
Although natural pregnancies after age 45 are rare—accounting for only 0.2% of total deliveries—they remain possible.
Perimenopause refers to the transitional period before menopause when hormone levels fluctuate and menstrual cycles become irregular. This phase can begin in a woman’s late 30s or 40s and ends once menopause is reached, which is defined as going 12 consecutive months without a period. During perimenopause, women may continue to experience periods—even if they are irregular—and therefore can still become pregnant.
Dr. Sanchez explained that many women mistakenly believe that symptoms like hot flashes mean fertility has ended. Ovulation during this time can be unpredictable and sometimes even more active than before, increasing the chance of an unplanned pregnancy. “​​Hormone therapy is not a contraceptive. If you’re still having periods — even irregular ones — pregnancy is still possible,” she said.
She recommends discussing contraception options with healthcare providers until menopause is confirmed by missing 12 consecutive periods.
For healthy women in their 40s and 50s, Dr. Sanchez said continuing birth control is generally safe: “You can be on almost any form of birth control until you’re menopausal, or until you decide you don’t want to be on it anymore.” Options include combined oral contraceptive pills, progestin-only pills (POP), and hormonal IUDs. However, women with certain medical histories should consult their providers about risks.
Determining whether someone has reached menopause while using birth control can be challenging since some methods suppress menstruation altogether. According to Dr. Sanchez: “By 55, nearly everyone is menopausal.” For those whose periods stop due to birth control before age 55, monitoring for menopause symptoms becomes important.
Hormonal birth control may also mask or partially treat symptoms associated with perimenopause by regulating cycles and reducing hot flashes or mood swings. If any bleeding occurs—even if irregular—menopause has not yet been reached; hormone testing may help clarify status after stopping contraception temporarily.
Dr. Sanchez emphasized there’s no need to discontinue birth control solely to check for menopause unless otherwise advised: “If you’re happy with your method, I don’t see why you’d need to come off it right away.” She cautioned that unnecessary continuation could increase health risks such as blood clots or stroke when contraception is no longer needed.
For symptom relief alongside pregnancy prevention during perimenopause, Dr. Sanchez often recommends combining estradiol for symptom management with a levonorgestrel intrauterine device (IUD) for contraception—a strategy that also protects against endometrial hyperplasia and cancer caused by unchecked estrogen exposure from hormone therapy alone. While this use of IUDs is considered off-label in the U.S., Dr. Sanchez finds it effective in practice.
With increased attention on menopause in popular culture and social media, Dr. Sanchez warned against unregulated treatments such as hormone pellets, compounded hormones, cash-only clinics, or vaginal rejuvenation lasers: “These aren’t FDA-approved and can even be dangerous with inconsistent dosing and underexplained risks.”
She encouraged patients seeking reliable care to consult clinicians trained through The Menopause Society: “Physicians are notoriously underprepared to deal with menopause and women’s aging, so it’s incredibly important to go to the Menopause Society list in your region to find someone who has intentionally trained to offer you the most up-to-date, FDA-approved medications.”
For women approaching their late 40s experiencing perimenopausal symptoms or concerns about fertility status, Dr. Sanchez highlighted two key points: “Until you’ve gone a full year without a period, you’re fertile, and symptoms of perimenopause are not something women have to just live with.” She added: “No one should feel dismissed or alone.”
