Perimenopause & Birth Control
Oral Contraceptive Pill or Hormone Therapy? How do we think about hormone use in perimenopause & menopause.
Written by Dr. Madeleine Clark, ND
The perimenopause transition involves hormonal fluctuations and changes that can bring about a variety of different symptoms that may include:
Vasomotor Symptoms (hot flashes)
Anxiety
Low Energy
Genitourinary Symptoms of Menopause
Increased urinary tract infections, vaginal atrophy, irritation of the vagina
Insomnia
Decreased libido
Reduced bone density
Brain Fog
Body composition changes & weight gain
During this time, there is a decline in natural fertility related to hormonal changes, egg quality, and age. Despite patients sometimes experiencing regular cycles in their 40s, the likelihood of falling pregnant naturally is 1 in 1000 at 45 years of age. We think that this is due to the quality of eggs, as many patients in their 40s can carry to term using donor eggs. While the likelihood of falling pregnant is low, it is not impossible, and contraception needs to be considered for any woman who has not fully entered menopause (1 year without a menstrual cycle) or who is older than 55.
Should I be using oral contraceptives (birth control) or hormone therapy?
This question has a bit of nuance to it because we don't have set guidelines that help us decide what hormonal prescription we should use during this time.
For many patients, oral contraceptive pills (OCP) provide relief from symptoms related to hormonal changes, and contraception. However, oral contraceptives use a much higher dose of hormones, and carry with them higher risks related to blood clots and cardiovascular concerns.
Even when we prescribe hormone therapy (HT), contraception is a part of the conversation. Though the risk of pregnancy is low during this time, it is not impossible, and we need to be using something to prevent pregnancy (condoms, vasectomy, IUD etc.).
How do I know I’m in Perimenopause or Menopause if I’m taking hormones?
If you are taking an oral contraception, we won’t have the typical information that lets us understand if you are in perimenopause or menopause (symptoms listed above, and irregular or absent periods). What we can do to confirm this is test Follicle Stimulating Hormone (FSH) in the blood after a pill free time of 6 weeks, or discontinue OCP and watch for a period free year. Either way we won’t know for sure when changes started or when you would have experienced menopause.
Why do we want to switch to Hormone Therapy at some point?
Most guidelines suggest switching over to hormone therapy from oral contraceptives at the age of 50. We have this age cut off of switching to HT due to the of blood clots increasing significantly past 50 years of age (in general and on OCP).
OCP is also higher dose hormones than HT, which we likely don't need for contraceptive purposes in this time frame (although we don't consider ourselves "in the clear" on not needing contraception until age 55, or until you have had a year without a period).
In some cases we want to maintain the hormone prescription for the benefits it might be providing that individual. This may include preventing vasomotor symptoms "hot flashes", preserving bone density, persevering body composition & lean muscle mass, mood support and blood sugar regulation. Not everyone needs, wants or suits HT, therefore it is important to discuss your options with your health care provider.
What are other potential options?
A hormonal IUD (Mirena) can be a good contraceptive option during this time. Hormonal IUDs are progesterone based, prevent pregnancy, and provide endometrial protection.
If the decision to begin HT is made, transdermal estrogen (patch, gel, cream) is easily added to a hormonal IUD.
When we use estrogen containing medications, we need some element of progesterone to offset it. Unopposed estrogen (say if we just had patch and nothing else) we risk being in a situation where the endometrial lining in the uterus builds up, which can increase our risk for endometrial hyperplasia (the lining of our uterus being thickened, which can cause bleeding, but also is considered pre-cancerous).
How we prevent this situation is using a progesterone medication along side the estrogen. This is typically either oral (micronized progesterone) or the hormonal IUD.
Most birth control pills are combined oral contraceptives or progestin containing pills, meaning they either have estrogen and progesterone, or just progesterone components to mitigate these risks.
What about breast cancer risks?
The risk of breast cancer is slightly increased in most hormonal contraceptive users. We often aren’t concerned about this because users of OCP are typically younger patients in which the risk of breast cancer is typically low in OCP users due to age.
This is similar to breast cancer risk with HT; unless someone has elevated risk factors associated with breast cancer risk, (a history of previous breast cancer, hodgkins lymphoma, BRCA gene, first degree relatives with breast cancer history, previous history of breast biopsy), the risk depending on the individual is often similar to that of drinking alcohol.
In order to feel our best and understand these risks to make informed decisions, we will often complete breast cancer risk calculators with patients, along side cardiovascular risk calculators and osteoporosis calculators so that patients can fully understand where their individual health history places them, and can make informed decisions. As health status and medications status changes, we continue to revisit these risks to ensure we feel fully informed about the choices we are making for our health.
How can I get more support?
If you have more questions about what hormonal options make sense for you, please book a complimentary meet and greet with Dr. Madeleine Clark, ND to discuss your options further. She can address questions you have about your medication options, provide information regarding lifestyle, naturopathic solutions and write prescriptions for hormone therapy for those who require it.