Hot Flashes and a Surprise Perimenopause Pregnancy?

When to stop birth control and how to know you’re in menopause

As Generation X reaches perimenopause and menopause, more are opening up online and in pop culture about their symptoms. In November, Gen X music icon Tori Amos went viral after botching the chords of her song during a concert and blaming it on menopausal brain fog. “It was bound to happen in my menopausal mind, but at least I can laugh this time,” she impromptu sang on stage.

Still, few are talking about the possibility of becoming pregnant at this life stage. “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,” says Jacqueline Sanchez, M.D., a gynecologist with the University of Miami Health System.

Most women who speak to Dr. Sanchez about perimenopause focus more on hot flashes, disturbed sleep and mood swings than getting pregnant. But that doesn’t mean you can’t simultaneously experience all of the above. “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,” says Dr. Sanchez.

Natural pregnancies after age 45 are rare, constituting only 0.2% of total deliveries –– but they do happen.

What is perimenopause?

Perimenopause is the natural transition leading up to menopause, when your hormone levels begin to fluctuate, and menstrual cycles are irregular. It can start years before menopause, in your late 30s to late 40s, and end once you reach menopause.

Some women don’t have any symptoms from hormonal fluctuations in perimenopause. Others experience symptoms like hot flashes, brain fog and mood swings.

The key difference between perimenopause and menopause:

• Perimenopause: You’re still having periods, which may be irregular. You can still get pregnant.
• Menopause: You’ve gone 12 consecutive months without a period. At this point, fertility has ended.

This distinction matters, especially when considering birth control, hormone therapy and symptom management.

Many women don’t realize they’re still fertile in perimenopause.

Women seeking treatment for perimenopausal symptoms can mistakenly think their older age and hot flashes mean they’re no longer fertile. It’s a risky misunderstanding. Ovulation becomes unpredictable in perimenopause and can be even more active, with more than one egg released in a cycle. Spontaneous pregnancies can still happen, even in the late 40s.

“​​Hormone therapy is not a contraceptive. If you’re still having periods — even irregular ones — pregnancy is still possible,” says Dr. Sanchez.

She recommends discussing contraception with your provider until you’ve missed 12 periods and are sure you’re in menopause.

Can you stay on birth control into your 40s and 50s?

For many healthy women, the answer is yes. “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,” Dr. Sanchez says.

That includes:

• Combined oral contraceptive pills
• Progestin-only pills (POP)
• Hormonal IUDs

Discuss your options with your provider, especially if you have a history of stroke, breast cancer, blood clots or migraine with aura.

How do you know you’re in menopause if you’re on birth control?

Menopause is defined as 12 consecutive months without a period, but birth control can make that harder to track, especially if you don’t menstruate.

If you’re under age 55 and birth control stops your periods (known as amenorrhea), menopause symptoms are the only way to know you’re in perimenopause or menopause. “By 55, nearly everyone is menopausal,” says Dr. Sanchez.

For some, birth control can make perimenopause harder to recognize because it can partially treat or mask menopause symptoms. Hormonal birth control delivers steady doses of hormones that can:

• Regulate periods that would otherwise become irregular
• Reduce hot flashes and night sweats
• Reduce mood swings

If you still have a period, even an irregular one, on birth control, then you haven’t reached menopause. To know for sure, you can ask your provider about hormone testing — but only after stopping birth control briefly.

Do you have to stop birth control to “check” for menopause?

Not necessarily, says Dr. Sanchez, but it’s worth revisiting as you age to determine whether you still need birth control. “If you’re happy with your method, I don’t see why you’d need to come off it right away,” Dr. Sanchez says.

When birth control is no longer necessary to prevent pregnancy, continuing it may offer no benefit while slightly increasing health risks, such as blood clots or stroke.

An effective transition option for birth control during perimenopause

For women who need symptom relief from perimenopause but still require pregnancy prevention, Dr. Sanchez often uses a specific combination:

• Estradiol (for menopause symptom relief)
• Levonorgestrel intrauterine devices (IUDs) for contraception

This approach helps manage perimenopausal symptoms and prevents pregnancy. It also protects the uterine lining from thickening due to unchecked estrogen. When estrogen is taken alone, the uterine lining can continue to thicken, raising the risk of:

• Endometrial hyperplasia (abnormally thick uterine lining)
• Endometrial cancer

This specific use case of the IUD is off-label in the U.S., meaning it’s FDA-approved for contraception but not specifically for perimenopausal symptoms. Still, Dr. Sanchez says it’s effective, and she commonly recommends it in menopause care.

Be cautious about “alternative” menopause treatments.

As menopause conversations among friends and celebrities become more mainstream, more products are pitched as perfect solutions to relieve symptoms. Many come with hefty prices, and not all options are safe.

Dr. Sanchez advises women to be especially cautious about:

• Hormone pellets, which are popular on social media
• Compounded hormones
• Cash-only menopause clinics
• Vaginal rejuvenation lasers

“These aren’t FDA-approved and can even be dangerous with inconsistent dosing and underexplained risks,” says Dr. Sanchez.

Instead, speak to your provider about symptom relief or consider seeking a clinician trained through The Menopause Society, which maintains a directory of menopause-trained providers. “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,” says Dr. Sanchez.

What to know for women in perimenopause

For every woman in her late 40s, Dr. Sanchez emphasizes two 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.”

Know there are options, both hormonal and non-hormonal, to ease perimenopause symptoms along this life-cycle journey. “No one should feel dismissed or alone,” says Dr. Sanchez.

Written by Wendy Margolin. Medically reviewed by Jacqueline Sanchez, M.D.

Tags: Dr. Jacqueline Sanchez, Fertility after 40, geriatric pregnancy, Hormonal fluctuations, Menstrual cycle irregularities