Menopause & perimenopause
Birth control pills in perimenopause
by Marcy Holmes, NP, Certified Menopause Clinician
Topics covered in this article:
“Is it me, or is it the Pill?” Many women I see 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 notice perimenopause symptoms. Others worry about the synthetic hormones in their birth control pills as they approach menopause. And then there are many women who’ve been counseled to start the Pill in their 30’s or 40’s to manage their symptoms of hormonal imbalance.
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 best possible choices for you.
First — are birth control pills really safe?
While I fully support any woman who chooses to use hormonal birth control, I want to nurture the idea that our changing hormones are nothing to be afraid of in perimenopause. I also want to encourage women to explore all their options and birth control methods, including those nonhormonal methods available. In the end, I hope that whatever you decide is part of a larger plan that allows you to treasure this time in your life and take the very best care of yourself that you can.
Women have become much savvier about artificial hormones since the Women’s Health Initiative (WHI) shed light on the risks of synthetic hormone replacement therapy (HRT). What many women don’t realize is that the Pill has higher amounts of synthetic hormones than HRT — up to twice as much, depending on the brand.
On balance, the Pill has a better safety record than many prescription drugs. But there are inherent risks with all drugs. While there is little data showing a connection between birth control pills and breast cancer risk, some women metabolize hormones differently. Risk of long-term use of birth control pills is unclear for these women. There may also be an increased risk of cervical and liver cancer. For some women over 35, the Pill may increase risk factors for blood clotting, cardiovascular disease, and liver, kidney or adrenal disease. It can also cause or worsen symptoms of hormonal imbalance: fluid retention, headaches, loss of sexual desire, breast tenderness, PMS, irregular bleeding, depression, and hair loss.
Birth control pills also offer some positives, like lower rates of endometrial and ovarian cancer, more regular cycles, and — let’s face it — preventing unwanted pregnancies. This can be very desirable for menstruating women in their 40’s and 50’s, particularly those who suffer the heavy periods that can accompany perimenopause.
Getting off birth control pills — Reconsider the conventional approach
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 naturally from one stage to the next, finding its own 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 — reclaiming your life and your health.
It’s true that dropping BCP’s “cold turkey” after many years of use, for some women, can result in some very unpleasant “withdrawal” symptoms. Your body has been trained to depend on the synthetic hormones and may be making fewer of its own. And despite the kind of muzzle the Pill puts on your endocrine system, it’s still trying to make the transition into menopause.
But that’s no reason to jump from the Pill to HRT! In fact, it’s a more compelling reason to find natural alternatives like our Personal Program for Hormone Imbalance, which allow your entire body to transition off the Pill more gracefully.
The bottom line is that BCP’s can be a great choice for one woman and a poor choice for another — and what was right for you in your 20’s or 30’s may not be appropriate in your 40’s or 50’s. The same caveat applies to HRT in menopause. Some conventional doctors brush over these issues for patients on the Pill. You don’t have to be pushed from one pill to the next!
I’d also like to highlight one little-discussed concern — the connection between the Pill and a woman’s nutritional status. We do know that in many women, birth control pills affect nutrient absorption and utilization — B vitamins, zinc, and beta-carotene, among other key nutrients. And because a woman’s metabolism is influenced by the natural ebb and flow of her hormones, being on the Pill can alter her glucose tolerance, insulin sensitivity, and liver function.
Your periods on the Pill — understanding how BCP’s affect your menstrual cycle in perimenopause
One nice benefit of the Pill is predictability: periods that run like clockwork and are usually much lighter. For some, periods may even disappear — a feature enjoyed by some but anxiety-producing for others. What most women recognize as their menses while on the Pill is not a real period but a “withdrawal bleed” that’s orchestrated by the Pill hormones, not your own. Back when the Pill was new and contained much higher amounts of hormones, its creators and the women who took it were reassured by the message a withdrawal bleed seemed to imply: they weren’t pregnant now but could become so later, when and if desired.
While you are actively taking the Pill, the synthetic estrogen component stimulates the lining of your uterus somewhat, as your own hormones would normally do on their own, while at the same time the synthetic progestin agent counteracts, or “opposes” that proliferation to control the lining’s thickness. Meanwhile, the hormones in the Pill curtail ovarian function and the release of an egg. At the end of the pack, when you stop taking the active pills for several days or use placebo pills, the drop-off in both hormones stimulates a withdrawal bleed, resembling what you would experience at the end of a natural cycle. Use of a continuous-cycle or extended-cycle Pill simply suppresses this process of creating a ”pseudo period.”
Having this semblance of control over your cycle can be welcome for many women, especially for women with irregular cycles and bleeding patterns. However, perimenopause is an opportune time to tune in to your body, and the Pill is a way of pushing the “mute” button. Using the Pill may make sense if you are intent on preventing unwanted pregnancy at any age, until another method can be utilized more effectively. Relying on the Pill may make less sense if you are in a stage of your life that allows for other forms of birth control, and you are instead motivated to balance your hormones naturally and nutritionally.
If I’m in perimenopause, can I still get pregnant?
Yes! We’ve all heard about those wondrous menopausal babies!
Long-term use of the Pill effectively takes over your hormonal cycles. And when you stop taking your BCP’s, it could be months before your body clears the hormones. When or if you’ll ovulate again can be unpredictable at best. We usually counsel women in perimenopause not to consider themselves safe from conception until they’ve gone 18 months without a period after stopping the Pill.
The hormones in the Pill even cloud results of the FSH tests (for follicle-stimulating hormone) women are given to determine if they’re menopausal. FSH tests can still be used, however, if the practitioner times it right. I prefer to schedule the blood draw for the day the woman is to start her new pill pack, because she won’t have taken any active pills for 7 or 8 days at that point.
If your FSH is high but you’re still getting a period — even if it’s just one period a year — you can get pregnant. I’ve seen cases where perimenopausal women experience 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.
Going off the birth control pill — healthy hormonal support at any age
At Women to Women, we think less is more when it comes to synthetic (non-bioidentical) hormones. So, taking individual needs and health history into account, we encourage women at any age who have been on the Pill for a number of years to think about discontinuing it — with support. It is easier than you think with the following steps:
- Choose another birth control method.
- For women already on a 30–35-mcg estrogen birth control pill formula, ask your healthcare practitioner to drop you down to an ultra-low-dose 20-mcg estrogen pill formula like LoEstrin 1/20 or the Nuvaring for 1–3 months, in preparation for stopping the Pill.
- Take a medical-grade multivitamin/mineral supplement every day (We offer our own doctor-formulated Essential Nutrients in our Personal Program for Hormone Imbalance.)
- Consider starting a multibotanical formula such as our Herbal Equilibrium to ameliorate the dual effects of Pill “withdrawal” and fluctuations in your body’s own hormones in perimenopause.
- Do not smoke. Limit your alcohol intake. Honor your healthy habits instead.
- Follow a nutrient-dense, low-glycemic diet of whole foods, with adequate lean protein, healthy fats, ample fiber, complex carbohydrates, and phytonutrients — with every meal and snack.
- Drink plenty of filtered water.
- Minimize toxins. Being on the Pill puts additional demands on your detoxification pathways, so pay special attention to your environment and any dietary sensitivities or digestive concerns.
- Exercise regularly and practice gentle stress management techniques such as yoga, or deep-breathing.
- After at least one month of consistent support, stop your Pill at the end of a package and continue the daily nutrient and herbal support you have started.
- For at least the first month off the Pill be patient and especially good to yourself, with positive daily affirmation, continued self-nourishment, and consistent nutrient and herbal support.
The few women who experience more severe symptoms when they go off the Pill can layer additional support, such as a higher intake of phytonutrient-rich foods, including soy. If appropriate, we sometimes suggest low-dose over-the-counter progesterone cream to patients at our clinic, or prescribe bioidentical hormone replacement (bHRT) on a limited basis.
Getting your period again, once off the Pill
Every woman going off the Pill should consider her cycle when she makes decisions about other birth control methods. Importantly, the bleeding pattern you had while on the Pill does not predict what will occur when you go off.
If you stop taking birth control hormones and do not get a period, don’t just assume you’ve entered menopause — or that you’re pregnant (though it could be wise to test for pregnancy if there’s any question)! As I mentioned above, a woman can sometimes take several months to settle back into her natural hormonal rhythm.
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, again, if you do not want to become pregnant, you should practice some form of birth control or abstinence.
Taking the Pill during perimenopause — what’s good to know should you choose the Pill
For a woman in her 40’s starting or continuing on the Pill, we have three basic recommendations.
- First, ask for the lowest-dose birth control pill options available today when talking to your healthcare provider.
- Second, apply the basic healthy hormonal support guidelines detailed above to the extent you can.
- Third, keep track of how you feel on the Pill.
By following these health measures while you remain on the Pill, you are providing valuable support for your body that will serve you very well when you do come off — and someday you will have to come off.
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 or Loestrin 24 pills — they are low-dose, regulate periods nicely, and contain the least anti-androgenic progestin — all of which minimizes any decrease in libido and seems to have the fewest side effects overall. It’s also available in several generic forms at lower cost.
Other women have excess androgen concerns, from abundant testosterone or DHEA levels — acne, oily skin/hair, PCOS, severe PMS. They may want to choose a pill whose progestin component offers the most antiandrogenic effects. The pills Yaz and Yasmin are comparatively antiandrogenic and approved for use in PMDD — though they do not agree with, or work well for every woman! They are also available in generic forms. These pills have recently been updated to include a form of folic acid, and renamed as BeYaz and Ocella. Ideally, all women of reproductive age should have folic acid stores to prevent neural tube birth defects in case they conceive.
Another recently arrived pill called Natazia uses the “more natural” form of estrogen called estradiol valerate, as well as an antiandrogenic progestin called dienogest. It may mimic a woman’s physiology a little better, or work well in women who do not do well on other pill formulations tried in the past — but we’ll wait to see more patients using it and get their feedback before saying much more about it!
While there’s no perfect solution for every situation, we’re fortunate nowadays to have a range of birth control options for women. These include not just oral contraceptives but other options that can be very attractive for women in perimenopause. (See our information on IUDs and nonhormonal alternatives.)
The choice to use birth control is yours
At Women to Women, we want our patients to have the best, most up-to-date information so they can make decisions that work well for them.
Whether you choose to stay on the Pill or to come off it, supporting your body through optimal nutrition and lifestyle should be high on your list. The better you treat yourself while on the Pill, the easier your transition will be when you do inevitably come off it. Plus, you will already have the positive health measures in place to help you sail through perimenopause and beyond.
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