Menopause Transition: When to take the pill and when to start menopausal hormone therapy?

Ask Dr. Jen

I’m perimenopausal and want to start hormones, but my doctor says I need to take the birth control pill, but I want to just take hormones for menopause. Is my doctor out of date?

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Short Take

It depends

Go On…

It depends on a few things, and without knowing what is bothering you–meaning why you want to take hormones–and more about your health, it’s hard to answer. So I will discuss when we think the pill is a better option, some information about what menopausal hormone therapy (MHT) can and can’t do, and some tips on how to proceed. 

Perimenopause is known medically as the menopause transition, and during this time women often experience their worst symptoms, such as hot flashes, night sweats, brain fog, and changes in mood. Unfortunately, women don’t always get treatment when they are suffering as they are told because they are not yet menopausal, meaning a year from their last period, that they can’t be having symptoms.

Sigh.

The advantage of the birth control pill (and here we are talking about the pill with estrogen) is that it suppresses ovulation and thins the endometrium (lining of the uterus). This means the pill provides contraception and menopausal hormone therapy (MHT) does not AND that the pill provides superior control of menstrual cycles when compared with MHT. The pill also the better option for treating PMS symptoms, which can often worsen during the menopause transition (read more about that here). As it has estrogen, the pill it can also treat hot flashes and night sweats and it also protects against osteoporosis.

The disadvantage of the pill is that the doses of hormones, estrogen in particular, are higher than MHT, and so there is the rare risk of blood clots. Also, not everyone can safely take the pill. For example, if you are over 35 and are a smoker or have migraines with aura. And some people just don’t like how they feel on the pill.

MHT is excellent therapy for hot flushes, night sweats, for mild depression in the early menopause transition and for protection against osteoporosis. Vaginal estrogen is excellent for treating any vaginal changes and protecting against urinary tract infections, and typically isn’t considered part of MHT because it doesn’t get into the bloodstream).

So, the three initial questions to ask yourself are the following:

• Do I need contraception?

• Do I have irregular/heavy periods?

• Do I have PMS that needs treatment?

If the answer to the first two is “yes” then the pill is your best option, with a couple of caveats. You can get a levonorgestrel (hormonal) IUD, which can provide contraception and control periods, and then try the lower estrogen of MHT. Also, you can certainly start MHT and if your bleeding gets worse, switch from progesterone (the recommended starting hormone to protect your uterus) to a progestin, like medroxyprogesterone acetate. Progestins are superior for controlling bleeding as they have a stronger effect on the lining of the uterus than progesterone, so this switch can sometimes make a real difference.

If PMS is the issue, the pill is superior, no caveats. You will know it’s PMS if each cycle the symptoms go away within a day or two or your period starting.

It’s also important to ask yourself why you want to go on MHT, as I often see it oversold by many providers. If you are worried that without that you are going to crumble up, get dementia, and die, then you have been led astray. Like any medications, you only want to take MHT if you need it. We have good data to support the use of MHT for hot flashes, night sweats, mild depression in the early menopause transition, and for prevention of osteoporosis. It is not recommended for treatment of brain fog or for prevention of dementia, prevention of Alzheimer’s, prevention of diabetes, or prevention of cardiovascular disease and providers saying otherwise are not following the guidelines laid out by professional organizations. While fewer women are getting MHT than could benefit, and that is an issue and is one of the reason I wrote The Menopause Manifesto and started this blog, the answer is not to scare everyone into taking it. The answer is to give women the evidence so they can make informed decisions about their health and advocate for themselves.