My gyn has indicated that, since I'm still getting periods, I am not a candidate for any hormone treatment. I have the mirena IUD for bc. BUT, I think I'm in "menstrual mayhem" as you call it. I know this is not a place for individual advice, per se, so to make the question general... if one is having VERY irregular cycles (16 days? 45 days?) for going on two years and PMS symptoms alongside these irregular cycles (2 weeks of bloating and irritability say), is there a treatment for this aside from "wait it out"? TIA!
Question about hormonal birth control for a future post: I'm 41 and early in peri (I think). Started with anxiety, mood swings, night sweats and subtle changes in length of period and number of days bleeding. I know you don't answer direct medical questions but would love to hear more specifically about the combination pill for peri. I didn't do well on it when I was a teenager and generally "run a little anxious". I re-started low-dose BC a few weeks ago. Wondering if it's possible for my moodiness to get worse before it gets better, as It feels more magnified right now. I want to stick it out incase regulating my hormones does make a difference, especially on mood but there is SO much out there about the opposite being true and having worse mood symptoms.
Thank you for this! I am 49 and have been on the pill for several years now. I went off for a few years in my late 30s, but had terrible mood swings and heavy bleeding, so went back on the pill. I take 3 months in a row and then one week off and haven’t had a real period in years (some spotting now and then.) At what point do you recommend going off the pill to see where a person is in their transition? I’m very nervous to go off of it. I’m reconnecting with my OB/GYN in October after having everything managed through my GP for the past 10 years or so. Thank you for all you do!!
So if I have been on a low dose bcp for years (due to heavy bleeding and pms symptoms), and am now experiencing perimenopause symptoms (hot flashes, night sweats, vaginal issues, etc) does that mean I cannot do MHT? Would it not be possible to get a prescription for vaginal estrogen if I am on the pill? I've been trying to get help for the menopause symptoms for awhile, and have gotten nowhere with my doctor, but I'm wondering if it is because the pill is already doing more than MHT would do.
Questions for when you address the subject of progestogens:
1. How is the dosage of a progestogen prescribed relative to the dosage of estrogen? Is there a ratio that is typically followed?
I know a progestogen is necessary in someone with a uterus who is also taking estrogen, but I have PMDD & mood issues that I believe are connected to progesterone. Wondering how low the dose can safely be while still protecting the uterus.
2. Are there particular forms/doses of MHT that, in your experience, seem to be safer/less disruptive for patients with autoimmune disorders? (I know everyone’s situation & body vary hugely.)
I will be addressing the dose of progestogens in future posts.
The best first line MHT for someone with autoimmune conditions is the best first line therapy, transdermal estradiol and either oral progesterone or a hormonal IUD.
Great article! Would love future article on premature BSO and hormone therapy vs OCP, risks of OCP. Dosing if still symptomatic on 0.1 patch. Also any nuanced thoughts about these for BRCA, CHEK2, PALB2 and Lynch carriers :)
We think transdermal estrogen is best for those who had a premature BSO. Oral estrogen, especially ethinyl estradiol, can have a negative effect on the bone. If you are in the menopause transition and have ovaries, you are still making some estrogen so that compensates. Obviously not if your ovaries are removed.
For those who have hypothalamic amenorrhea (think anorexia or excessive exercise) we know that transdermal estradiol is better for bones than ethinyl estradiol as EE increases IGF-1 interfering with bone development (it may because it's oral or because it's EE or both). I would apply this scenario to a BSO under age 40, because in both situations there no estradiol make by the ovary to compensate. With POI the data is conflicting, some studies suggest estradiol may build more bone than ethinyl estradiol, but there is also data that refutes that. For someone in the menopause transition or someone who is just using the estrogen containing contraception the effect isn't seen. Probably because the follicles are still developing to day 3 and so there is still estradiol, although truthfully we don't know.
Someone who had a BSO doesn't need the doses of estrogen in the pill, and they don't need ethinyl estradiol, which is likely more thrombogenic. So there are several reasons to go with transdermal estradiol
Thank you for this series and your hard work on this.
I will be 53 in 2 months. I was on continual BCP for many years to deal with PMS symptoms - mood swings, painful periods and non-aura menstrual migraine. When I turned 50, my healthcare provider switched me to a progestin only BCP on the advice that after 50 a person should not be taking high levels of estrogen. At 51, I had some UTIs out of the blue, vaginal discomfort, and decreasing libido. I have been using vaginal estrogen cream for 1.5 years and that makes me more comfortable - no more UTIs, but I have arousal challenges. I haven't been having hot flashes or night sweats. Some joint pain, sleeplessness and extra-phlegmyness which I understand can be connected to menopause?
I saw a GP with a menopause practice (in BC) who recommended Effexor for mood and transition off BCP. I started that a few months ago and am now at 75mg. I stopped taking the BCP about 3 weeks ago and no withdraw bleed yet, so that's interesting. I've been stressing over when to stop BCP to find out what's going on with my body and decided with the Effexor to help manage mood, I'd bite the bullet and see what happens.
Side rant: My sexual desire and arousal have plummeted and I only recently found out Effexor can cause sexual dysfunction. I'm pissed off because the menopause doctor knew I already had decreased libido and did not talk to me at all about potential sexual side effects of Effexor. Neither did my NP for that matter. Also, no one counselled me on the risks of drinking alcohol while on Effexor, including exacerbating effects of alcohol and increasing risks of alcohol abuse. I have noticed a shift in my relationship with alcohol and it isn't good. I have an appointment next week to transition off of Effexor and ask for MHT.
So that's the background and here are the questions on my mind I'm hoping you can address in future articles:
- can MHT help with mood management? I feel like it helped me a lot with PMS mood swings. Am I just resisting taking an antidepressant for mood management or can MHT help?
- if I take MHT do I also continue vaginal estrogen or do I stop that for a while and see how I feel?
- the menopause doctor I mentioned above says MHT is not indicated for libido problems. But my gut tells me that my libido started dropping about a year after I went off estrogen-containing-BCP, which was maybe when my own body dropped its estrogen production and I started having genital urinary symptoms. Can MHT be a yellow light for GSM and libido where I don't have other risk factors? What do we say to healthcare providers who don't to prescribe MHT to a person who does not have hot flashes?
- Might MHT help with the extra phlegmyness and hoarseness I experience? I realize that might be a whole separate topic.
Thanks for any guidance you're able to offer in future writing.
What about those of us who would benefit from OCP, but are contraindicated? Is progesterone w/ transdermal estradiol helpful for AUB at all? Hoping that will be covered when the options are discussed in the other post.
42, post bi-salp, mental/emotional symptoms of peri, and AUB. Other potential causes ruled out. Neurologist has advised against estrogens due to migraine. Progesterone alone is not cutting it.
I just turned 50 and still menstruating regularly. I was on low dose bcp (Alysena) from 48-49 for heart palpitations after checking out my heart- the bcp was miraculous- no more palpitations, hot flashes, anxiety or joint pain- but went off it about 6 months ago due to galactorrhea (tested and determined to be benign). My heart palpitations and panic attacks returned with a vengeance and i’m now on 75mcg estradiol patch and micronized progesterone pill. I was feeling ok until I had a horrible flu last month and since then it’s like everything stopped working. Now I get tingling in my mouth, limbs and torso (moves around constantly); occasional palpitations and hot flashes that wake me in the night, and panic attacks. My gp is wonderful but says he’s unfamiliar with perimenopause. I’m running and doing yoga daily (not a lot but at least 20mins/day) and otherwise healthy but the tingling is really stressful. I’d read that it can be caused both by too high progesterone OR too low estrogen… would it be too risky to restart the bcp at 50 with no breast cancer/cardiovascular disease family history? Or should I try a higher patch dose than 75mcg? please advise if you can?
I am not sure if you come back to earlier posts to track questions for future posts/your book, but just in case: I am still really unclear on whether MHT is really a good option for someone in the middle of "menstrual mayhem" (e.g., a 46-year-old like moi). From what I understand, MHT doesn't suppress cycles so all those wacky up and downs will still be there even if the hot flashes are possibly reduced. So wouldn't the pill be THE best option until periods cease, unless contraindicated? I was going to try the estradiol + IUD combo bc I wanted to avoid systemic progestin but upon learning this regimen will not suppress ovulation or change my hormones aside from supplementing estrogen, I feel far less enthused. Some clarification on this in a future post would be great.
The Mirena IUD is great at controlling bleeding issues. So, if the major concern is bleeding, either the IUD and an estradiol patch or an estrogen-containing pill would be a good option. If PMS-like symptoms are a major part of the issue, then the estrogen-containing pill is the better option. This is something that is hard to tackle in a post because you really need to know what the individual concerns are if people have taken hormones before, how they have done it, and the ease and expense of an IUD insertion. For some people, this is painful and/or expensive. For others, it is not. The easiest try is the pill because if it doesn't help after 3 months, you have your answer and can switch. But that doesn't mean it's the best option for everyone. Medicine is sometimes trying something and seeing if it's the best fit, and we take the best therapy to start with.
Thank you so much! I guess it might be useful for others to know that MHT/iud combo before periods cease may not change the cyclic craziness aside from bleeding and low est issues. I am still confused about whether MHT-level doses of transdermal estradiol during perimenopause are less effective at controlling peri symptoms than would be the case later. I would think so given that the symptoms aren't due to low estrogen per se but rather the fluctuations in estrogen, but I don't know if there are empirical data to back this up. I have noticed in myself that lower doses of estradiol (in low est bc pills for example) don't seem to do anything for my peri symptoms.
Any thoughts on taking MHT for someone with a familial history of breast and ovarian (aunts and cousins; not parents). I'm definitely experiencing perimenopausal symptoms (hot flushes, sweats, mood, vaginal stuff) but worried about increasing my risk of cancer with the exposure to estrogen. Thank you for your amazing work, Dr. Gunther!
I am particularly worried about the switch from a combination birth control pill to MHT because of the dramatically lower dose of estrogen. I am relatively early (I think) the menopause transition and already have been experiencing significant problems with mood (I have a disposition towards anxiety/depression and the transition seems to be exacerbating it). I tried very low dose estrogen and they didn't seem to help as much as more moderate doses. I wish there was more research on this. I know estrogen has risks but those risks are likely moderated by a woman's specific risk factors and there are also risks to mental health of not taking estrogen that need to be taken into account. I look forward to you clarifying these issues in future posts or in a future book on HRT!
I thought part of the hormonal chaos of the menopause transition is proportionally more days in the luteal phase in which progesterone is up, which can cause mood symptoms...if so, the pill doesn't necessarily address the chaos because one has to take progestin throughout the cycle. Also, wondering if the low, low dose pills also are less likely to help with menopause transition because estrogen dose is relatively low in these pills (e.g., Lo Lo Estrin Fe has 10 mcg) and progestin higher than in other pills (I think, although I know it's hard to compare across progestins). Mood is a big issue for me in the transition so I'm trying to find the option that addresses that best (in addition to other annoying symptoms). Thanks!!!
I’m currently 52 and was switched to progestin BCP in my late 40s when my blood pressure started getting too high. If my doctor agrees I’m a candidate to start using an estrogen transdermal patch to help with perimenopause symptoms, would I likely just continue the progestin BCP? Is that standard? I believe you wrote that using progestin BCP should likely continue to 55 because not having periods is not uncommon while on it.
I had a pretty serious DVT in my late 30s and it was concluded it was due to the vaginal ring. (I don’t have any other risk factors - eg Leiden Factor 8). Is HRT an option for me now that I’m in my 50s? I am hearing conflicting info.
This is a decision that you need to make with your specialists. Most guidelines list a previous clot as a contraindication. So it would depend on your other risk factors as well as how bad your symptoms are and if they have not responded to other therapy.
My gyn has indicated that, since I'm still getting periods, I am not a candidate for any hormone treatment. I have the mirena IUD for bc. BUT, I think I'm in "menstrual mayhem" as you call it. I know this is not a place for individual advice, per se, so to make the question general... if one is having VERY irregular cycles (16 days? 45 days?) for going on two years and PMS symptoms alongside these irregular cycles (2 weeks of bloating and irritability say), is there a treatment for this aside from "wait it out"? TIA!
Question about hormonal birth control for a future post: I'm 41 and early in peri (I think). Started with anxiety, mood swings, night sweats and subtle changes in length of period and number of days bleeding. I know you don't answer direct medical questions but would love to hear more specifically about the combination pill for peri. I didn't do well on it when I was a teenager and generally "run a little anxious". I re-started low-dose BC a few weeks ago. Wondering if it's possible for my moodiness to get worse before it gets better, as It feels more magnified right now. I want to stick it out incase regulating my hormones does make a difference, especially on mood but there is SO much out there about the opposite being true and having worse mood symptoms.
Thank you for this! I am 49 and have been on the pill for several years now. I went off for a few years in my late 30s, but had terrible mood swings and heavy bleeding, so went back on the pill. I take 3 months in a row and then one week off and haven’t had a real period in years (some spotting now and then.) At what point do you recommend going off the pill to see where a person is in their transition? I’m very nervous to go off of it. I’m reconnecting with my OB/GYN in October after having everything managed through my GP for the past 10 years or so. Thank you for all you do!!
So if I have been on a low dose bcp for years (due to heavy bleeding and pms symptoms), and am now experiencing perimenopause symptoms (hot flashes, night sweats, vaginal issues, etc) does that mean I cannot do MHT? Would it not be possible to get a prescription for vaginal estrogen if I am on the pill? I've been trying to get help for the menopause symptoms for awhile, and have gotten nowhere with my doctor, but I'm wondering if it is because the pill is already doing more than MHT would do.
Questions for when you address the subject of progestogens:
1. How is the dosage of a progestogen prescribed relative to the dosage of estrogen? Is there a ratio that is typically followed?
I know a progestogen is necessary in someone with a uterus who is also taking estrogen, but I have PMDD & mood issues that I believe are connected to progesterone. Wondering how low the dose can safely be while still protecting the uterus.
2. Are there particular forms/doses of MHT that, in your experience, seem to be safer/less disruptive for patients with autoimmune disorders? (I know everyone’s situation & body vary hugely.)
Many thanks in advance!!
I will be addressing the dose of progestogens in future posts.
The best first line MHT for someone with autoimmune conditions is the best first line therapy, transdermal estradiol and either oral progesterone or a hormonal IUD.
Duavee is an option for those people who can take oral estrogen and can't tolerate a progestogen. https://vajenda.substack.com/p/duavee-is-back-on-the-market
Thanks for replying. Very grateful for you 💜
Great article! Would love future article on premature BSO and hormone therapy vs OCP, risks of OCP. Dosing if still symptomatic on 0.1 patch. Also any nuanced thoughts about these for BRCA, CHEK2, PALB2 and Lynch carriers :)
We think transdermal estrogen is best for those who had a premature BSO. Oral estrogen, especially ethinyl estradiol, can have a negative effect on the bone. If you are in the menopause transition and have ovaries, you are still making some estrogen so that compensates. Obviously not if your ovaries are removed.
Will be getting to your other questions.
EE has a neg. effect on bone?! Please explain.
For those who have hypothalamic amenorrhea (think anorexia or excessive exercise) we know that transdermal estradiol is better for bones than ethinyl estradiol as EE increases IGF-1 interfering with bone development (it may because it's oral or because it's EE or both). I would apply this scenario to a BSO under age 40, because in both situations there no estradiol make by the ovary to compensate. With POI the data is conflicting, some studies suggest estradiol may build more bone than ethinyl estradiol, but there is also data that refutes that. For someone in the menopause transition or someone who is just using the estrogen containing contraception the effect isn't seen. Probably because the follicles are still developing to day 3 and so there is still estradiol, although truthfully we don't know.
Someone who had a BSO doesn't need the doses of estrogen in the pill, and they don't need ethinyl estradiol, which is likely more thrombogenic. So there are several reasons to go with transdermal estradiol
Thank you for this series and your hard work on this.
I will be 53 in 2 months. I was on continual BCP for many years to deal with PMS symptoms - mood swings, painful periods and non-aura menstrual migraine. When I turned 50, my healthcare provider switched me to a progestin only BCP on the advice that after 50 a person should not be taking high levels of estrogen. At 51, I had some UTIs out of the blue, vaginal discomfort, and decreasing libido. I have been using vaginal estrogen cream for 1.5 years and that makes me more comfortable - no more UTIs, but I have arousal challenges. I haven't been having hot flashes or night sweats. Some joint pain, sleeplessness and extra-phlegmyness which I understand can be connected to menopause?
I saw a GP with a menopause practice (in BC) who recommended Effexor for mood and transition off BCP. I started that a few months ago and am now at 75mg. I stopped taking the BCP about 3 weeks ago and no withdraw bleed yet, so that's interesting. I've been stressing over when to stop BCP to find out what's going on with my body and decided with the Effexor to help manage mood, I'd bite the bullet and see what happens.
Side rant: My sexual desire and arousal have plummeted and I only recently found out Effexor can cause sexual dysfunction. I'm pissed off because the menopause doctor knew I already had decreased libido and did not talk to me at all about potential sexual side effects of Effexor. Neither did my NP for that matter. Also, no one counselled me on the risks of drinking alcohol while on Effexor, including exacerbating effects of alcohol and increasing risks of alcohol abuse. I have noticed a shift in my relationship with alcohol and it isn't good. I have an appointment next week to transition off of Effexor and ask for MHT.
So that's the background and here are the questions on my mind I'm hoping you can address in future articles:
- can MHT help with mood management? I feel like it helped me a lot with PMS mood swings. Am I just resisting taking an antidepressant for mood management or can MHT help?
- if I take MHT do I also continue vaginal estrogen or do I stop that for a while and see how I feel?
- the menopause doctor I mentioned above says MHT is not indicated for libido problems. But my gut tells me that my libido started dropping about a year after I went off estrogen-containing-BCP, which was maybe when my own body dropped its estrogen production and I started having genital urinary symptoms. Can MHT be a yellow light for GSM and libido where I don't have other risk factors? What do we say to healthcare providers who don't to prescribe MHT to a person who does not have hot flashes?
- Might MHT help with the extra phlegmyness and hoarseness I experience? I realize that might be a whole separate topic.
Thanks for any guidance you're able to offer in future writing.
What about those of us who would benefit from OCP, but are contraindicated? Is progesterone w/ transdermal estradiol helpful for AUB at all? Hoping that will be covered when the options are discussed in the other post.
42, post bi-salp, mental/emotional symptoms of peri, and AUB. Other potential causes ruled out. Neurologist has advised against estrogens due to migraine. Progesterone alone is not cutting it.
Thank you!
I just turned 50 and still menstruating regularly. I was on low dose bcp (Alysena) from 48-49 for heart palpitations after checking out my heart- the bcp was miraculous- no more palpitations, hot flashes, anxiety or joint pain- but went off it about 6 months ago due to galactorrhea (tested and determined to be benign). My heart palpitations and panic attacks returned with a vengeance and i’m now on 75mcg estradiol patch and micronized progesterone pill. I was feeling ok until I had a horrible flu last month and since then it’s like everything stopped working. Now I get tingling in my mouth, limbs and torso (moves around constantly); occasional palpitations and hot flashes that wake me in the night, and panic attacks. My gp is wonderful but says he’s unfamiliar with perimenopause. I’m running and doing yoga daily (not a lot but at least 20mins/day) and otherwise healthy but the tingling is really stressful. I’d read that it can be caused both by too high progesterone OR too low estrogen… would it be too risky to restart the bcp at 50 with no breast cancer/cardiovascular disease family history? Or should I try a higher patch dose than 75mcg? please advise if you can?
I am not sure if you come back to earlier posts to track questions for future posts/your book, but just in case: I am still really unclear on whether MHT is really a good option for someone in the middle of "menstrual mayhem" (e.g., a 46-year-old like moi). From what I understand, MHT doesn't suppress cycles so all those wacky up and downs will still be there even if the hot flashes are possibly reduced. So wouldn't the pill be THE best option until periods cease, unless contraindicated? I was going to try the estradiol + IUD combo bc I wanted to avoid systemic progestin but upon learning this regimen will not suppress ovulation or change my hormones aside from supplementing estrogen, I feel far less enthused. Some clarification on this in a future post would be great.
The Mirena IUD is great at controlling bleeding issues. So, if the major concern is bleeding, either the IUD and an estradiol patch or an estrogen-containing pill would be a good option. If PMS-like symptoms are a major part of the issue, then the estrogen-containing pill is the better option. This is something that is hard to tackle in a post because you really need to know what the individual concerns are if people have taken hormones before, how they have done it, and the ease and expense of an IUD insertion. For some people, this is painful and/or expensive. For others, it is not. The easiest try is the pill because if it doesn't help after 3 months, you have your answer and can switch. But that doesn't mean it's the best option for everyone. Medicine is sometimes trying something and seeing if it's the best fit, and we take the best therapy to start with.
Thank you so much! I guess it might be useful for others to know that MHT/iud combo before periods cease may not change the cyclic craziness aside from bleeding and low est issues. I am still confused about whether MHT-level doses of transdermal estradiol during perimenopause are less effective at controlling peri symptoms than would be the case later. I would think so given that the symptoms aren't due to low estrogen per se but rather the fluctuations in estrogen, but I don't know if there are empirical data to back this up. I have noticed in myself that lower doses of estradiol (in low est bc pills for example) don't seem to do anything for my peri symptoms.
Any thoughts on taking MHT for someone with a familial history of breast and ovarian (aunts and cousins; not parents). I'm definitely experiencing perimenopausal symptoms (hot flushes, sweats, mood, vaginal stuff) but worried about increasing my risk of cancer with the exposure to estrogen. Thank you for your amazing work, Dr. Gunther!
I am particularly worried about the switch from a combination birth control pill to MHT because of the dramatically lower dose of estrogen. I am relatively early (I think) the menopause transition and already have been experiencing significant problems with mood (I have a disposition towards anxiety/depression and the transition seems to be exacerbating it). I tried very low dose estrogen and they didn't seem to help as much as more moderate doses. I wish there was more research on this. I know estrogen has risks but those risks are likely moderated by a woman's specific risk factors and there are also risks to mental health of not taking estrogen that need to be taken into account. I look forward to you clarifying these issues in future posts or in a future book on HRT!
What about dose? Do women often need a higher dose bc pill during the menopause transition to regulate their cycle?
Nope
I thought part of the hormonal chaos of the menopause transition is proportionally more days in the luteal phase in which progesterone is up, which can cause mood symptoms...if so, the pill doesn't necessarily address the chaos because one has to take progestin throughout the cycle. Also, wondering if the low, low dose pills also are less likely to help with menopause transition because estrogen dose is relatively low in these pills (e.g., Lo Lo Estrin Fe has 10 mcg) and progestin higher than in other pills (I think, although I know it's hard to compare across progestins). Mood is a big issue for me in the transition so I'm trying to find the option that addresses that best (in addition to other annoying symptoms). Thanks!!!
I’m currently 52 and was switched to progestin BCP in my late 40s when my blood pressure started getting too high. If my doctor agrees I’m a candidate to start using an estrogen transdermal patch to help with perimenopause symptoms, would I likely just continue the progestin BCP? Is that standard? I believe you wrote that using progestin BCP should likely continue to 55 because not having periods is not uncommon while on it.
I had a pretty serious DVT in my late 30s and it was concluded it was due to the vaginal ring. (I don’t have any other risk factors - eg Leiden Factor 8). Is HRT an option for me now that I’m in my 50s? I am hearing conflicting info.
This is a decision that you need to make with your specialists. Most guidelines list a previous clot as a contraindication. So it would depend on your other risk factors as well as how bad your symptoms are and if they have not responded to other therapy.