Hormonal birth control (HBC), containing estrogen, which can be delivered through pills, patches, or vaginal rings, can play a role in managing the menopause transition (peri-menopause) for women under the age of 55.
To understand how HBCs work, let's review the menstrual cycle and the role of hormones. During a normal menstrual cycle, two hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), both released by the pituitary gland in the brain, manage the development of the egg, ovulation, and preparation of the uterus for implantation. HBCs containing estrogen and a progestin suppress FSH and LH, disrupting the process so that ovulation does not occur. Progestin also thins the uterine lining, decreasing monthly bleeding.
During peri-menopause, hormonal fluctuations can be erratic, making it challenging to manage symptoms. By suppressing FSH and LH, HBCs prevent ovulation and stabilize estrogen levels, effectively managing symptoms associated with peri-menopause. In addition to stabilizing estrogen levels, HBCs can address other menopausal symptoms:
Contraception: Although the chances of getting pregnant decrease significantly after age 45, contraception is recommended until age 55 or one year after the final period, whichever comes first.
Mood Disorders: HBCs can help manage mood disorders, which may appear or worsen during the menopause transition.
Bleeding Issues: HBCs also are effective in managing irregular or heavy periods common during peri-menopause by suppressing ovulation and thinning the endometrium.
If the primary symptom of peri-menopause is irregular and/or heavy bleeding, a levonorgestrel IUD may be a good option. However, an IUD may not be suitable for everyone, (e.g., women with large fibroids.) Women who have been taking HBC for years prior to peri-menopause who have no new symptoms can continue using it until the average age of menopause (~52 years old). By age 55, women should transition to MHT or discontinue hormone use altogether if they no longer have unwanted symptoms. Talk with your doctor about whether MHT or other invention can best help with your menopause symptoms.
I get a lot of questions about why I prescribe HBCs during peri-menopause but switch to MHT once menopause has commenced. I get the confusion - both contain estrogen and a progestin. Here's the short answer: the progestins in MHT and HBCs are not the same, and, the estrogens also are different. The primary purpose of HBC is to prevent pregnancy. The HBCs are developed and tested for that purpose, using reproductive age women as the target audience. The primary purpose of MHT is to reduce symptoms of menopause, specifically hot flashes and genitourinary symptoms. MHT is developed and tested for those purposes using menopausal age women as the target audience. It is true that using MHT during peri-menopause may help in some ways, but the real goal of treatment during peri-menopause is to level out the hormonal chaos, and HBCs are often the better choice. Hormones stabilize at low levels during menopause, so the treatment goals change. The goal of MHT is to replace hormones in a state of hormone deficiency.
Sometimes, I also get pushback from women about using HBCs during peri-menopause because they had unwanted side effects using them when they were younger. In great news, HBCs have evolved significantly in the past 30 years. Virtually all older HBCs used an estrogen called ethinyl estradiol (EE). Now, a few contain EE but many do not, and the ones that do utilize doses much lower than previously. Today, HBCs may contain estetrol, estradiol valerate (EV), or micronized 17-beta-estradiol instead of EE. EV and micronized 17-beta-estradiol mimic the estradiol produced by the ovary. Estetrol is only present normally in women during pregnancy, but it has significant efficacy as a contraceptive and may be a safer option for women with higher risk for breast cancer. Common progestins used in HBC include levonorgestrel, norethindrone, drospirinone, desogestrel, and norgestimate; whereas, micronized progesterone is typically used for MHT. Unfortunately, it may take some trial and error to find the HBC that works best for you to minimize unwanted side effects and reduce your symptoms of peri-menopause. A good working relationship with your doctor will facilitate the best results.
HBCs are a convenient and effective option for managing the menopause transition. They offer relief from symptoms, regulate bleeding, and provide contraception for women under 55. Additionally, there are other non-hormone treatment options available for women who are not appropriate candidates for HBCs. Talk with your doctor about what will work best for your circumstances.
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