The Birth Control Pill is Safe for Bones in Perimenopause

The business of hating the pill comes to menopause

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There can be a wide range of bothersome symptoms during the menopause transition, also known as perimenopause, and one of the big ones is irregular and/or heavy bleeding. Some people also suffer from a worsening of premenstrual syndrome (PMS) and menstrual migraines, and of course hot flashes can start before the final period (which is what officially marks menopause).

To manage these symptoms, many turn to hormonal contraception, specifically the estrogen-containing oral contraceptive pill. It’s a great option here. It’s fantastic for controlling bleeding, is evidence-based therapy for PMS, and can also help menstrual migraines when taken continuously so there is no menstruation. In addition, the estrogen dose is higher than what is found in menopausal hormone therapy, so it’s excellent for hot flashes and other symptoms. And of course, it provides contraception for those who need it.

The specific advantage of the pill here over menopausal hormone therapy is that the dose and type of hormones suppresses ovulation, keeping the follicles suspended at day 3 of the cycle. This provides superior control of bleeding and a steady level of hormones as opposed to the chaos of the menopause transition. For many people it’s the fluctuations in hormones in  menopause or the hormonal chaos that causes symptoms, not the actual levels of hormones. The pill controls the chaos.   

The levonorgestrel IUD is certainly a great option for controlling bleeding and for providing contraception and a standard dose of estrogen for menopausal therapy can be added in for hot flashes, but it won’t suppress ovulation and it’s the erratic ovulation that causes issues for many people. Also, not everyone wants an IUD. \

Recently, I've heard about people afraid to take the pill in the menopause transition because naturopaths and functional nutritionists are warning them that it is bad for bone health. So yes, the business of hating on birth control, which has become bigger than a cottage industry, is now coming to menopause.

I’m going to pause here and heave a sigh that I hope you can feel through the ether and the ethernet. We have data from actual studies here, so the people who are doing the fear mongering are either woefully uneducated or simply don’t care about the data or think their personal (and biased) opinion is somehow better than a researcher doing an actual high quality study. Or all of the above. Who am I kidding, it’s usually all of the above. 

Where does this idea that estrogen is bad for bone health in the menopause transition come from? It’s always hard to know the origin story of pseudoscience, because sometimes it’s simply something pulled out of someone’s asshole. There is some data to suggest that with primary ovarian insufficiency that estradiol (the hormone most commonly used in menopausal hormone therapy) may build more bone than ethinyl estradiol (the estrogen in estrogen containing oral contraception), but there is also data that refutes that. A systematic review of the literature was not able to reach a firm conclusion about estrogen containing contraceptives being inferior to estradiol for bone health in this population.

But this isn’t a post about primary ovarian insufficiency, it’s a post about the menopause transition and they are different. And we have data on estrogen-containing contraception for people who don’t have POI, meaning we don’t need to look at data from POI for guidance. 

There are at least two large cohort studies, which looked at data from people taking estrogen-containing contraceptives and compared them against those who did not take these medications, and no increased risk of fractures with oral contraceptives was seen. One study looked at women with a mean age of 37.8 years and the other specific specifically looked at women between the ages of 45 and 59. The study with the mean age of 37.8 years actually showed a reduced risk of fracture when oral contraceptives with estrogen were taken for 5 or more years versus not taking these medications. Now it’s true this kind of observational data can’t account for every factor that could impact risk of osteoporosis. For example, people who take oral contraceptives may have other factors associated with better bone health, but the fact that we have data from two different studies in two different countries showing no negative effect on bone health is reassuring as is the fact that together these studies comprise over 14,000 women. 

There are also a few prospective studies, meaning women who were taking oral contraceptives were followed and periodically evaluated. While these studies have smaller numbers of participants, they provide excellent quality data because people are followed in real time. In addition, these studies looked at bone density as well as blood markers of bone health. Meaning if there were a negative effect, but one that isn’t significant enough to lead to a fracture, these studies should identify that safety signal. The results? In the menopause transition estrogen-containing contraceptives protected bone health. 

In summary, we have no data linking estrogen-containing oral contraceptives with worse bone health in the menopause transition. So if this is your therapy of choice, be it to control bleeding, migraines, PMS, or for contraception, don’t worry about your bones. In fact, the data tells us you can probably worry a little less about your bones.  

Why do some people say otherwise? Perhaps they aren’t real experts or can’t be bothered to look at the data? Some also profit financially when people don’t take the pill, so it’s important to follow the money.

How do people profit by scaring people about the pill? Well, they can’t order all the unnecessary hormone tests to “track” or “advise” you when you are taking the pill, and useless hormone tests and the analysis of those useless tests is the business model, along with untested supplements to “fix” the issues uncovered by this testing. Untested supplements that these pill demonizers almost always sell. Shocker, I know.

So the next time you see someone writing negative things about the birth control pill and the menopause transition, a.k.a perimenopause, look to see if they promote hormone testing or the “DUTCH” test (you can read more about that scam here). In fact, advertising as being certified in “DUTCH” testing is one of my red flags that you are being scammed!

Real experts don’t manage hormone therapy in the menopause transition or menopause with hormone levels because these tests are useless at best and misleading at worst. They also don’t do testing to see if you are a “poor absorber,” which is another red flag that you are seeing a non-expert. Remember, hormone testing equals cash, not care. 

And real experts know that the estrogen-containing birth control pill is one of many good options for managing symptoms in the menopause transition.

References

Shannon D. Sullivan, MD, Philip M. Sarrel, MD, and Lawrence M. Nelson, M.D. Hormone replacement therapy in young women with primary ovarian insufficiency and early menopause. Fertil Steril. 2016 Dec; 106(7): 1588–1599.

Cartwright B, Robinson J, Seed PT, et. al. Hormone Replacement Therapy Versus the Combined Oral Contraceptive Pill in Premature Ovarian Failure: A Randomized Controlled Trial of the Effects on Bone Mineral Density The Journal of Clinical Endocrinology & Metabolism, Volume 101, September 2016, Pages 3497–3505. 

Gazarra, Lívia B. Carvalho, Bonacordi, Camila L., Yela, Daniela A. et. al. Bone mass in women with premature ovarian insufficiency: a comparative study between hormone therapy and combined oral contraceptives. Menopause 27(10):p 1110-1116, October 2020. 

Fine, Alexa, Busza, Alicja, Allen, Lisa M. et. al. Comparing estrogen-based hormonal contraceptives and hormone therapy on bone mineral density in women with premature ovarian insufficiency: a systematic review. Menopause 29(3):p 351-359, March 2022.

Delia Scholes, Andrea Z. LaCroix, Rebecca A. Hubbard, et. al. Oral Contraceptive Use and Fracture Risk around the Menopausal Transition. Menopause. 2016 February ; 23(2): 166–174.

Dombrowski S, Jacob L, Hadji P, Kostev K. Oral contraceptive use and fracture risk-a retrospective study of 12,970 women in the UK. Osteoporos Int. 2017;28:2349–2355. 

Gambacciani M, Ciaponi M, Cappagli B, Benussi C, Genazzani AR. Longitudinal evaluation of perimenopausal femoral bone loss: effects of a low-dose oral contraceptive preparation on bone mineral density and metabolism. Osteoporos Int. 2000;11:544–548. 

Gambacciani M, Cappagli B, Lazzarini V, Ciaponi M, Fruzzetti F, Genazzani AR. Longitudinal evaluation of perimenopausal bone loss: effects of different low dose oral contraceptive preparations on bone mineral density. Maturitas. 2006;54:176–180. 

Soo Min Kim,1 Whan Shin,2 Hyo Jeong Kim,1 Ji Soo Lee,3 Yong-Ki Min,4 and Byung-Koo Yoon. Effects of Combination Oral Contraceptives on Bone Mineral Density and Metabolism in Perimenopausal Korean Women. J Menopausal Med. 2022 Apr; 28(1): 25–32.