Menopausal Hormone Therapy vs. Estrogen-Containing Contraception: Understanding the Difference

A Practical Guide to the Hormone Menoverse

Since launching my guide on menopausal hormone therapy (MHT), I’ve been asked about the birth control pill, specifically, is the pill MHT?

Whenever a several people ask a variation of a question, I know I need to address it because I’m sure many others are wondering the exact same thing. That’s one reason I love your questions, because they encourage me to take on topics I hadn’t considered or tell me I need to expand on something. 

And with that preamble…on to the pill…and here that means an estrogen containing birth control pill (or ring or patch)

I understand why someone might think the estrogen-containing birth control pill is menopausal hormone therapy, after all, they both have estrogen. However, there are some important distinctions.

Menopausal Hormone Therapy vs. Estrogen-Containing Contraception: The Basics

MHT is taking a dose of estrogen that may be the same, although is typically less than the body makes, to treat symptoms related to lower levels of estrogen in menopause and the menopause transition. 

In a typical ovulatory cycle, estradiol, the body’s main estrogen is made by the ovary and it is at its lowest at the beginning of the cycle, then rises to a peak right before ovulation (see the chart below from my book, The Menopause Manifesto). Levels range from as low as 20 pg/ml to as high as 400 pg/ml. This averages out to approximately 100 pg/ml.

The goal with MHT is to replace enough estradiol to treat the symptoms that can be treated with estrogen (not all of them can). The fact that the average level of estradiol over the cycle is 100 pg/ml forms the basis for the upper limit of MHT. This is because a 100 mcg estradiol patch results in an approximate blood level about 100 pg/ml, a 50 mcg patch about 50 pg/ml and so on (a 100 mcg patch is equivalent to 2 mg of oral estradiol taken daily). There may be occasions with people with primary ovarian insufficiency or who have their ovaries removed under the age of 40 where a slightly higher dose is needed. We’ll discuss starting doses in a future post, and no, you should not be checking estradiol levels to see if you are absorbing enough (we’ll get to that later as well).

The estrogen in the pill is typically ethinyl estradiol, although there are newer pills with different estrogens. Ethinyl estradiol is much more potent than the estradiol made by the ovaries or found in MHT. A direct conversion is hard for a variety of biochemical reasons, but depending on which assay you use oral ethinyl estradiol is anywhere from 100 to 250 times more potent than oral estradiol. Meaning 20 mcg birth control pill (which is the dose in an ultra low dose pill), is roughy equivalent to 2-5 mg of oral estradiol. And if we convert that to an estradiol patch, it’s about 100 mcg-250 mcg. While there are ways to quibble about how to convert ethinyl estradiol to estradiol, the bottom line is with a 20 mcg pill the dose of estrogen at least as much as the body makes, but possibly more. And of course there are many pills with higher doses of ethinyl estradiol.

This higher dose/more potent ethinyl estradiol in the birth control pill helps suppress ovulation and limit bothersome bleeding from the progestin (the other hormone in the pill). Essentially all the risks of the pill are related to this higher dose of estrogen, so we don’t use the pill for women after menopause as A) that dose isn’t needed B) the risks of cardiovascular disease increase with age, and the dose of estrogen that is safe at 40 is no longer safe at 60.

So Why Do People Take the Pill in Menopause if it’s not for MHT?

The pill isn’t prescribed for hot flashes or night sweats. However, it can treat those symptoms when it is prescribed for other reasons, which are:

• Bleeding issues: These are common in the menopause transition, I often call this menstrual mayhem. The pill is an effective way to control this bleeding. If someone is also having hot flashes or night sweats, then that might factor in to the decision making here as the pill can treat hot flashes and night sweats.

• Needing contraception: This is obviously reason enough to start the pill. However, if you need contraception and are having symptoms, like hot flashes and night sweats, or heavy and/or irregular bleeding that might affect your decision making.

• Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD): These conditions can sometimes get worse during the menopause transition. This can be because the cycles initially are getting closer together which primarily affects the first part of the cycle, meaning percentage wise you are spending more time each cycle with PMS/PMDD. The other reason symptoms may worsen is because hormone levels can be chaotic. Because the pill suppresses ovulation and produces a steady levels of hormones it can be very effective for PMS/PMDD. Basically, it stops the hormonal chaos.

Do You Have to Start with a Birth Control Pill in the Menopause Transition? 

No.

If you are having symptoms that are typical of menopause, have a uterus, and don’t have a reason described above to consider the pill, you can absolutely start with MHT. There are three basic “new start” options:

• Transdermal estradiol and oral progesterone. 

• Transdermal estradiol and a progestin IUD.

• Transdermal estradiol and an oral or transdermal progestin.

There are advantages and disadvantages to each of these three regimens, and we will take a deeper dive into each one when we discuss how to select a progestin. But in a nutshell, sometimes when we give the oral progesterone or progestin to someone who is still having periods it can create chaotic menstrual bleeding, but not always. We can’t really predict what is going to happen because everyone’s hormonal situation and uterus is unique. However, it is fine to start with MHT in the menopause transition and then switch to the pill (or the progestin IUD) if needed.

Is the Pill Safe for Bones in the Menopause Transition?

Yes, read more about that here.

Is the Pill Otherwise Safe in the Menopause Transition?

If you have high blood pressure, smoke and are over the age of 35, or have migraines with aura, oral contraceptive pill with estrogen is not safe for you. Other reasons you may not be able to take the pill can be found here. 

Basically, the biggest risk with the pill is cardiovascular, and cardiovascular risks increase with age, so it’s always important to consider these when reviewing options.

In Summary

The pill is not MHT, but it can be used in the menopause transition to control a variety of symptoms related to the menopause transition. When we talk about risks of MHT, that means the risks of MHT, not the risks of the pill. 

When you are reasonably considered to be in menopause, we switch from the higher dose of estrogen in the pill to the lower dose in MHT.

Coming Up Next

The next installment in this guide will delve into the osteoporosis discussion, as I promised previously. I felt this information on the pill was important background, so wanted to get it in before moving on.  

And as always, if you have questions, leave them below. I try to reply to the easier ones directly in the comments (obviously, nothing is individual medical advice), and those that are more complex, I tuck away to try to incorporate in future posts. And sometimes, as in the case here, I get to them sooner rather than later. 

References

1. Kirk JM, Wickramasuriya N, Shaw NJ. Estradiol: micrograms or milligrams. Endocrinol Diabetes Metab Case Rep. 2016;2016:150096. doi: 10.1530/EDM-15-0096. Epub 2016 Jan 6. PMID: 26843960; PMCID: PMC4738193.

2. Stuenkel CA, Gompel A. Primary Ovarian Insufficiency. N Engl J Med. 2023;388:154-63.

3. NAMS Position Statement. The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022;29:767-794.

4. Cynthia A. Stuenkel et. al. Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 100, Issue 11, 1 November 2015, Pages 3975–4011, https://doi.org/10.1210/jc.2015-2236.