Menopause & perimenopause

Birth control pills in perimenopause

by Marcy Holmes, NP, Certified Menopause Clinician

Topics covered in this article:

• First — are birth control pills really safe?
• Birth control pills and women’s health
• The conventional approach to getting off birth control pills
• Your menstrual cycle on the Pill
• If I’m in perimenopause, can I still get pregnant?
• Taking the Pill during perimenopause
• Going off the Pill during perimenopause
• Getting your period again, once off the Pill
• Debunking the stigma of the IUD
• Other nonhormonal options for women
• The choice to use birth control is yours

Many women in my practice have been on the Pill for decades and can’t make heads or tails of what’s going on when they begin to feel perimenopause symptoms (“Is it me or the Pill?”). Others are concerned about the synthetic hormones in birth control pills (BCP’s) as they approach menopause, but feel hesitant to change what’s familiar. And then there are women who’ve been counseled to start the Pill in their 30’s or 40’s to help manage their symptoms of hormonal imbalance — a practice of conventional medicine that I question, given that there are so many natural alternatives.

The truth is that every woman who uses the Pill has to stop someday. Since it is a form of hormone therapy (even the low-dose pills have more hormones than HRT), there are safety and other health issues everyone should consider. And getting off the Pill involves a withdrawal process, just like getting off HRT.

So — should you be thinking about getting off the Pill? And how best do you go about it? When should you stop worrying about birth control at all? Are there good alternatives to the Pill, especially at this stage of your life? Let’s clear up the confusion and help you make the choices that are best for you.

First — are birth control pills really safe?

Women have become much more savvy about artificial hormones since the WHI study on the risks of hormone replacement therapy (HRT). What many women don’t realize is that the Pill actually has higher amounts of synthetic hormones than HRT — up to twice as much, depending on the brand. Even the low-dose pills have 35 mcg of estrogen combined with a progestin (a synthetic form of progesterone), slightly higher than an average HRT prescription.

There’s good news and bad news about the safety of BCP’s. The good news is that we know more about the Pill than we knew about HRT — at least, more than we knew before the WHI studies. The bad news is that our regulatory system isn’t really set up to track long-term health effects of prescription drugs, so we don’t know as much as we’d like to about the Pill in long-term use. On balance, the Pill has a better safety record than many prescription drugs. But all drugs have risks, especially for some groups. The hard part is determining which group you’re in.

Unlike with HRT, there is little data showing a connection between birth control pills and breast cancer risk. However, it is proven that a subset of the population has difficulty metabolizing estrogen. Risk of long-term use of birth control pills has not been studied for these women as a group. Perhaps genetic mapping will provide more insight in the future, but until then we should be cautious when it comes to assuming that BCP’s are absolutely safe for all women.

Birth control pills also offer some positives, like lower rates of endometrial and ovarian cancer and more regular cycles. This can be very desirable for some women in their 40’s, particularly those who would otherwise suffer the heavy periods that can accompany perimenopause. But in other women, the Pill may increase the risk or severity of other health issues (including blood clotting) and can create a host of symptoms: fluid retention, headaches, loss of sexual desire, more severe PMS, fibroid growth, and hair loss. I’d also like to emphasize one little-discussed problem — the connection between the Pill and digestive and nutritional issues.

Birth control pills and women’s health

Birth control pills have significant effects on nutrient absorption. Studies indicate BCP’s also change the pH balance in the blood, which may influence on other health factors such as bone health. A woman’s metabolism is also affected by the natural ebb and flow of estrogen and progesterone, so being on the Pill can worsen conditions like insulin resistance.

Progestin use has a definite link with yeast overgrowth, which may result in systemic candidiasis and its accompanying health concerns (weight gain, toxicity, GI issues, mental fuzziness, joint and muscle aches, fatigue). The Pill also chews up B vitamins, including folic acid, and many other nutrients, leaving the body at serious risk for nutritional deficiency. (For more, please see our articles on digestive health.)

Some women suffer from weight gain right after going on the Pill, but it’s harder to see the immediate effects of absorption issues. The weight gain is usually the result of a mismatch between a particular pill and your metabolism — a problem that usually goes away when you find a pill better suited to you. The absorption issues only show up years later, and the connection to BCP’s is rarely made. That’s why I insist that every patient on the Pill take a medical-grade nutritional supplement — but more on that in a moment.

The fact is that birth control pills may be a great choice for one woman and a poor choice for another — and what was right for you in your 30’s may not be appropriate in your 40’s. But conventional doctors rarely go into these issues for patients on the Pill. The modern medical system pushes them to move you from one pill to another.

The conventional approach to getting off birth control pills

It’s difficult for any practitioner to assess what’s really happening to your hormones while you’re on the Pill. So a conventional practitioner may simply pick an age (typically 50) and move you then from BCP’s directly to HRT.

This is a convenient way of keeping your appointment time to a minimum, but I don’t think it’s good medicine. The major problem is that this denies your body the chance to progress from one stage to the next, finding its own natural balance. The second problem is that you aren’t given full information about your choices and their consequences. And the third problem is that you’re missing the great purpose of menopause — taking control of your life and your health.

It is true that just dropping BCP’s “cold turkey” will usually result in some very unpleasant symptoms. Your body has been trained to depend on the synthetic hormones; in fact, it may no longer make as many of its own. And despite the kind of muzzle that the Pill puts on your endocrine system, it’s still trying to make the transition into menopause.

But that’s no reason to go from the Pill to HRT! In fact, it’s a stronger argument to find natural alternatives. Before we do that, let’s gain a deeper understanding of how BCP’s affect our menstrual cycle.

Your menstrual cycle on the Pill

One nice benefit of the Pill is a period that runs like clockwork. Every 28 days or once every three months (depending on the brand of pill), your uterus sheds its lining and you have a period. This is not a real period — it’s actually a “withdrawal bleed” that’s orchestrated by the Pill, not by ovulation.

While you are actively taking the Pill, the lining of your uterus thickens as it would in preparation for ovulation. But the hormones in the Pill curtail ovarian function and interrupt the mechanism that leads to ovulation. There are no follicles, no egg and no follicle rupture with a hormone method like the Pill — so ovulation, fertilization, implantation and pregnancy cannot occur. When you stop taking the Pill for a week, the withdrawal from the hormones simulates the drop in progesterone at the end of a cycle — and you bleed.

This sense of control over your cycle can be very nice, particularly for women who would otherwise have heavy bleeding or irregular periods — a common symptom of perimenopause. But I question how wise this interference is, the closer a woman gets to her natural menopause, especially when there are equally effective forms of non-hormonal contraception and her symptoms can be brought under control through natural methods.

The point is that perimenopause is an opportune time to tune into your body, and the Pill is a way of pushing the “mute” button. Although this may make sense if you are concerned about an unwanted pregnancy, find the Pill really easy, and are disinclined to consider alternatives, it makes less sense if you are in your 40’s, open to other forms of birth control and really want to balance your hormones.

It all comes down to your preferences and symptoms. If you don’t know whether or not you’re in perimenopause, please read our perimenopause article and take our health assessment. Then talk to your practitioner. If you decide that the Pill is still the best option for you, there’s a lot you can do to support your body while you’re on it. And if you’re on the Pill, the more support you provide, the easier it will be to transition off — something every woman eventually has to do. But don’t make a decision until you’ve thought about what kind of birth control might work best for you.

If I’m in perimenopause, can I still get pregnant?

So many women in their 40’s find themselves wondering about perimenopause and pregnancy and thinking, I doubt I can still get pregnant — why do I need to worry about birth control? The truth is that if you are getting off BCP’s in your 40’s, it could be years before it becomes clear that you will not resume ovulation — and we’ve all heard of those wondrous menopausal babies!

The problem is that long-term use of the Pill has effectively taken over your hormonal cycles. When you stop taking your BCP’s, it may take months for your body to clear the hormones. At any point, a natural ovulatory cycle could resume, but months more have to pass before you can be sure. We usually counsel women not to consider themselves safe from conception until they’ve gone 18 months without a period after stopping the Pill.

The Pill even masks the FSH tests (for follicle-stimulating hormone) given women to determine if they’re menopausal. (FSH tests — in particular the over-the-counter variety — are not a perfect measure of where you stand in the transition to menopause. See our article on menopause test kits.) If you are on the Pill, your practitioner will do a blood test of your FSH and estradiol levels while you are having your “period” — at the end of a pill package — to get the most accurate result. (If you aren’t on the Pill, your practitioner will time your test around day 3 of your cycle.)

If a test reveals that your FSH is high and your estradiol is low, chances are, you are in menopausal range. If the FSH is high but you are still getting a period — even if it’s just one period a year — you can get pregnant. I’ve seen cases where perimenopausal women get surges of hormones and a few random instances of ovulation at unexpected times. So while elevated FSH levels make pregnancy less likely, they are no guarantee against it.

Even if it seems like a stretch, until you are officially a year past your last menstrual cycle (i.e., “menopausal” by definition), you need to think about birth control. But birth control does not automatically mean the Pill.

We’ll talk about the many hormonal and nonhormonal birth control options available and the advice I give women who are choosing a form of contraception in a moment. But first, let’s talk about what you should know if you do choose the Pill, and what you should know about coming off it.

Taking the Pill during perimenopause

If a perimenopausal woman really wants to continue to use the Pill or start the Pill and it seems right for her, we try to use the lower–dose pills now available. The most common birth control pill we prescribe for these patients tends to be the Loestrin 1/20 and Loestrin 1/5/30 pills — they seem to have the fewest side effects, especially in terms of lost libido.

It is possible to use the Evra patch, but recently there has been concern that its sustained-release transdermal delivery system provides higher levels of circulating estrogen than traditional oral pills. Your total synthetic estrogen exposure is estimated to be up to 60% higher when using the Evra patch than it would be if taking a 35-mcg birth control pill. Not surprisingly, there is an attendant increase in risk of adverse events such as blood clots and stroke, which makes the Evra patch less attractive for some groups of women, including women in perimenopause.

We also use the NuvaRing 21–day vaginal insert to deliver a consistent low dose of birth control hormones. Another plus is that the NuvaRing seems to promote good vaginal moisture compared to oral pills.

Your body may need a few months to settle in to a new or different pill or contraceptive product, so you may want to give yourself some time before making adjustments.

It is very important for women of all ages on the Pill and other hormonal methods to take a medical-grade multivitamin. Studies have shown (and our own patient monitoring backs this up) that women on the Pill are deficient in B vitamins, particularly folic acid, as well as many other nutrients. This is especially worrisome for women who drink, because alcohol also disrupts absorption of folic acid. Smoking and the Pill after age 35 are contraindicated, but if you do smoke and use hormones for contraception you need to be very diligent about nutrition — you’re making a lot of demands on your body.

Our best recommendations for a woman in her 40’s starting or continuing on the Pill are:

• Take a medical-grade vitamin supplement every day that’s rich in essential fatty acids, calcium, magnesium and a full roster of other important vitamins and minerals to fill in any nutritional gaps. (In our Personal Program we offer such a supplement called Essential Nutrients.)


• Do not smoke. Limit your alcohol intake.


• Follow a balanced diet of whole foods that includes the right amount of protein, fat, fiber and complex carbohydrates — at every meal.


• Drink plenty of filtered water.


• Be aware of toxins. Being on the Pill puts additional demands on your body, so pay special attention to any dietary sensitivities or digestive concerns.


• Exercise regularly and practice stress management techniques like yoga, meditation, or deep breathing exercises.

By following these health measures while you’re on the Pill, you are providing valuable support for your body that will serve you well when you come off — and someday you will have to come off.

Going off the Pill during perimenopause

At Women to Women, we think less is more when it comes to synthetic (non-bioidentical) hormones. So, taking your individual needs and health history into account, we encourage women in their late 40’s who have been on the Pill for a number of years to think about discontinuing. Some of our patients have been taking the Pill for 30 or more years — it seems inconceivable to them to do anything else! But going off the Pill is easier than you think, and can be done with minimal symptoms if you start supporting your body before you go off.

We suggest that a woman in perimenopause who’s on BCP’s continue taking the Pill for a month while she establishes a healthy foundation of nutrition, supplements, and exercise.

Natural progesterone at this time is also a good idea because it helps jump-start your natural hormonal synthesis (progesterone is a building block for all three forms of estrogen, among other hormones) and supports hormonal balance. There is also some indication that the synthetic progestins in birth control pills actually lower levels of natural progesterone (the body resists making its own when an easy substitute is at hand), so having a bioidentical supplement can be helpful while weaning off the Pill.

We suggest using a low-dose topical progesterone cream on days 7–21 of the pill package (days 14–28 of your cycle), when your body would naturally be high in progesterone, or during the second and third week of the NuvaRing or Evra patch. At the end of that pill package, patch, or insert time span, stop taking the Pill or remove the hormonal devices and continue the rest of your routine, which should include another, nonhormonal birth control method as back-up.

The few women who experience more severe symptoms when they go off the Pill can layer additional support onto this foundation. We recommend extra dietary changes and adding soy to the diet. If necessary, we’ll use bioidentical hormone replacement (bHRT) on a limited basis.

This approach may seem like a little more work than just moving directly from BCP’s to synthetic HRT, but like menopause itself, getting off the Pill can be a wonderful turning point in your life. In my experience, it only takes a little work and a little time before most women feel better than ever.

Getting your period again, once off the Pill

Since one of the important indicators of potential fertility is a period, it’s necessary for every woman going off the Pill to get a handle on her cycle when she considers other birth control methods. Importantly, the bleeding pattern you had while on the Pill does not predict what will occur when you go off. Some women who are especially thin or athletic may skip bleeding altogether on the Pill — and perhaps when they go off.

If you stop taking birth control hormones and do not get a period, don’t assume you’ve entered menopause. As I mentioned above, a woman can sometimes take several months to settle back into her natural hormonal rhythm. Other women may need a few months of progesterone support to initiate a natural period.

If six months to a year goes by without a period, ask your practitioner for an FSH test. If 18 months go by without a period and your blood test indicates menopause, it is safe to assume that you will not get pregnant. Until then, if you do not want to become pregnant, you should practice some form of birth control or abstinence.

Although there is no perfect contraception solution for every situation, we’re fortunate nowadays to have a range of birth control options for women. But I want to discuss one in particular here, the IUD.

Debunking the stigma of the IUD

A lot of women in their 30’s and 40’s grew up hearing horror stories about the IUD (intrauterine device). In fact, the IUD these days is one of the most effective forms of birth control (only abstinence ranks higher!) and poses little to no side effects for most women.

There were two main problems with old IUD’s. First was the flawed design of the Dalkon Shield, which led to higher rates of pelvic inflammatory disease (PID). Second was that we then blamed other IUD’s for cases of PID. As I overheard recently at a medical conference, “We now know the IUD doesn’t cause PID — bad boyfriends do!”

That may seem glib, but there’s an element of truth in it. The IUD’s of 20–30 years ago were of a different design and probably given to many candidates with multiple partners. At that time, medicine did not have effective testing for Chlamydia — the infection that is the cause of most PID and infertility.

IUD’s are much better today. The new technology has made them a great option for many women, particularly mothers who don’t want more children. To get away from the stigma of the past, some manufacturers now refer to this device as an intra-uterine system, or IUS.

I think the IUD is an excellent option for a woman who is accustomed to the sexual spontaneity of the Pill. Once it’s in, a woman can forget about it. At our practice we regularly prescribe the copper ParaGard IUD.

The ideal candidate for an IUD is an infection-free woman in a monogamous relationship, who has had at least one pregnancy (for ease of insertion), and whose uterus is free of fibroids. There are other considerations, so if you are interested, talk to your practitioner. You can read more about the ParaGard IUD at their website.

Other nonhormonal options for women

Barrier methods like condoms, diaphragms and the new Today Sponge (yes, it’s back!) are other relatively reliable birth control methods that don’t use hormones. The patent for the Today Sponge was bought out, and it is now manufactured in New York State. Initially it was only approved for sale in Canada, but the Sponge is now available in the USA (FDA–approved as of April 2005). You can read more about the Today Sponge here: www.todaysponge.com.

For women who have had as many children as they wish and those who don’t want children, there is the surgical option of tubal ligation (having your tubes “tied”), or vasectomy for the male partner.

Bear in mind that none of the above options, with the exception of condoms, will protect you against STD’s. STD’s are a substantial and growing health risk to post-menopausal women, either through partner infidelities or new sexual encounters. (Read our article on safe sex in midlife for more on minimizing your risks.)

With so many things to consider when choosing a birth control method, we want to make sure that women find the option that is right for them. I have a three-step approach to choosing a birth control method that many women have found helpful. For details, read my article on choosing a birth control method.

Click here for answers to some of the most common questions about birth control that I hear at the clinic and from women in the Personal Program.

The choice to use birth control is yours

Birth control is an extremely important part of women’s health because it is women who bear the greatest burden when it comes to pregnancy. At Women to Women, we want our patients to have the best, most up-to-date information so they can make the decision that’s right for them.

Whether you choose to stay on the Pill or to come off it, supporting your body through nutrition, lifestyle and natural progesterone should be high on your list. The better you treat yourself while you are on the Pill, the easier your transition will be when you come off. Plus, you will already have the positive health measures in place to help you sail through menopause and beyond.

While I fully support and encourage any woman who wants to take hormones for birth control, I want to nurture the idea that our changing hormones are nothing to be afraid of. I also want to encourage women to explore the many other methods of nonhormonal birth control available to them. In the end, I hope that whatever you decide is part of a larger plan that will help you treasure this time in your life and take the very best care of yourself you can.

 

Original Publication Date: 11/01/2005
Last Modified Date: Last Modified: 02/16/2010
Principal Author: Marcy Holmes, NP