The pill helps my depression. How do I transition to menopausal hormone therapy?

Ask Dr. Jen

I am on the pill as one of my two antidepressants as well as for pregnancy prevention at age 49. I’m concerned about losing the stability of mood fluctuations that the pill provides me. It’s critical for managing my treatment resistant major depressive disorder (onset at puberty). I have no other antidepressants to try. How can I transition to MHT (menopausal hormone therapy)  in a way that won’t disrupt mood fluctuations?

• Via The Vajenda

Short Take

By age 55 almost every woman is in menopause and the cycle-to-cycle hormone fluctuations that can be part of MDD simply won’t exist. How to get there is the question, and if there are no contraindications to being on the pill, the strategy of taking it until age 55 and then deciding the next best steps is one approach I’ve found successful. 

Go On…

Many medical conditions fluctuate with the menstrual cycle, and depression can be one of them. Painful periods, menstrual migraines, premenstrual syndrome (PMS) and premenstrual mood dysphoric disorder (PMDD, a more severe version of PMS), and endometriosis are just a few. Many people with these conditions use the estrogen-containing birth control pill to manage symptoms. 

For many people with these conditions menopause will bring improvement. But we don’t have blood work to predict when menopause will happen or to reliably diagnose it and anyway, hormone levels are useless on the pill. So the real question is how do you get from the pill to menopause in the least onerous way possible?

One strategy is to stay on the pill until age 55, the age where we consider essentially everyone to be in menopause. If you don’t have high blood pressure, have a normal lipid profile, and no history of blood clots or heart disease, in general the benefits of the pill outweigh the risks. Your health care provider who knows you best can help you determine if there are other risks to consider and you can also look up information at the CDC on the medical eligibility criteria for contraception here and read more about being on the pill (or the patch or the ring after 50 here).

If someone were sitting in my office and they were taking a pill with 35 mcg of ethinyl estradiol, I would want to discuss the pros and cons of reducing the dose of estrogen in their early fifties. This is because estrogen is associated with all of the rare but serious side effects of the pill (such as blood clots). There are 20 mcg and even 10 mcg pills. In addition, to go from 35 mcg of ethinyl estradiol to menopausal hormone therapy or to menopause (should you decide against hormones) is a pretty big drop in estrogen. This could trigger symptoms, like hot flashes, and potentially be an issue for someone whose depression is hormonally sensitive (likely to be less of an issue for some of the other conditions listed earlier). So reducing the dose of estrogen in the pill is one strategy to gradually slide into menopause. If I were recommending a pill switch for someone with depression I’d look for a pill with the same progestin (if available) to minimize the change in hormones (i.e. so only the dose of estrogen changes). This obviously requires a lot of shared decision making and is beyond our discussion here.

Whether you should consider MHT at age 55 depends on many factors, but the estrogen in MHT has only been shown to help depression in the early menopause transition, so we wouldn’t recommend starting estrogen for depression at age 55. At this age it really comes down to hot flashes, night sweats, and your personal risk for osteoporosis.

People with hormonally mediated depression just don’t know how they are going to do in menopause until they are in menopause. If a patient of mine stopped the pill and found she was struggling with depression, I would consider a trial of MHT. But I also have people who tell me they feel better than ever without hormones. One thing to keep in mind with MHT is the progesterone/progestin needed to protect the uterus can negatively affect mood for some women at risk for depression. The good news is there are also non hormonal medications for menopausal symptoms and osteoporosis prevention to consider. Like every therapy, starting MHT requires a review of the benefits and risks and shared decision making.

At age 55 with depression managed by the pill, or any medical condition improved by the pill, the options are three fold:

• Simply stop the birth control pill and see how you do. You may or may not have hot flashes and night sweats. If you have stepped down to a 20 mcg or 10 mcg pill it’s possible the change in hormones will feel less dramatic. You can decide to start MHT later if the symptoms are bothersome. 

• Transition from the birth control pill to MHT with the goal of staying on MHT. I try to make the decrease in estrogen from pill to MHT more gradual for someone with hormonally dependent depression. For reference, 10 mcg of ethinyl estradiol is about equivalent to 0.1 mg of transdermal estradiol. If someone were taking a 10-20 mcg pill, I’d start with a 0.05 mg estradiol patch and if they were taking a 35 mcg pill I’d probably consider a 0.1 mg patch for 3 months then switch to a 0.05 mg patch. I prefer an estrogen patch over the lotions and creams for someone with depression as it produces less fluctuations in hormone levels. This assumes the appropriate progesterone/progestin would also be prescribed to protect the uterus (for people with a uterus). One option instead of taking an oral progesterone/progestin is to consider a hormonal IUD to protect the uterus, as this produces very low levels of hormone in the blood and they don’t fluctuate. 

• Transition from the birth control pill to MHT, with the plan of gradually reducing the MHT and stopping it (for those who don’t want to be on hormones long term). Just as described above, but after 3-6 months, reducing the MHT dose even further and then eventually stopping. I often do this for people who want to stop the pill, but are unsure if they want MHT. I admit there is no data to support this approach over just stopping the pill, but I’ve had great success tapering the hormones over 6 months. I recommend vaginal estrogen as the hormones are being tapered to prevent genitourinary syndrome of menopause. 

This is a lot of information, but hopefully it helps in your discussion with your own health care provider.