WHY DID MY DOCTOR PRESCRIBE LOW DOSE BIRTH CONTROL FOR PERIMENOPAUSE?

You’re in peri. You’ve done the research and you decide you’d like treatment for the litany of shit your body and mind is going through. You talk to your primary care doctor or OB-GYN and they prescribe low dose birth control. 

Um, what? Why did my doctor prescribe low dose birth control for perimenopause?

Birth control has been the go-to perimenopause treatment for doctors in the U.S. for a long time since it can help with some issues related to peri. However, plenty of women don’t like taking the birth control pill, especially after 40 when it poses an increased risk of blood clots and breast cancer, as well as potentially lowering libido.

In the UK and Ireland, for example, a woman is often prescribed HRT to manage peri symptoms, so why on earth are peri women in the US being prescribed the pill instead?

“I think it stems from a lack of experience and lack of knowledge”

“I think it stems from a lack of experience and lack of knowledge,” says Dr. Heather Hirsch, who prescribes HRT to 5-6 patients every day. “They think it will stop the symptoms, but estradiol and Prometrium (a.k.a. the estrogen and progesterone in HRT) fare a lot better for symptoms than ethynol estradiol and norethindrone, [the hormones] in birth control pills.”

"The birth control pill does not allow you to personalize [treatment] and does not allow you to go by symptoms”

Besides, says Dr. Hirsh, the risk of unintended pregnancy for women over 40 is low, so those patients don’t get the intended usual benefits of taking the pill. “Women are knowledgeable, they can use back-ups like condoms. It’s such a disservice to women. The birth control pill does not allow you to personalize [treatment] and does not allow you to go by symptoms.”

“HRT is usually safer, more effective, and allows for personalization. Some women do okay on birth control pills, but the fact that some doctors will say HRT is off the table doesn’t make any logical sense. 99.9% of my patients do amazing on FDA-approved, commercially available HRT. Patients come back and say I feel amazing! My libido is better because I’m sleeping and I’ve lost 5lbs and I feel sexy and great. And then about a quarter of my patients will say I feel really good, but my libido is still in the tubes, and then I prescribe testosterone.”

Since both the birth control pill and HRT are often a combination of estrogen and progesterone, it begs the question, Is the birth control pill just HT dressed in different clothes? 

“The pill can technically be considered HRT”

“The pill can technically be considered HRT,” says Dr. Anna Barbieri “It is just one version of hormone therapy. I think people are very liberal with starting a birth control pill that may carry actually higher risk, in terms of cardiovascular risk, or breast risk, because of the type of hormones that has, and how it gets delivered compared to HRT.”

"HRT is a lower dose of hormones"

OB-GYN and Chief Medical Officer of Alloy Women’s Health Dr. Sharon Malone says calling birth control hormone therapy is “a matter of semantics.” “Both birth control pills and HRT estrogen and progestin (a synthetic form of progesterone) are the same classes of medications,” she says “ There's estrogen in them and there's progestin in them. However, HRT is a lower dose of hormones. We can use HRT in peri, with the caveat that it will not provide birth control or control cycles.” 

So how does the pill differ from HRT? They are different in terms of formulation. Hormones used in birth control are “synthetic” and differ from the body's natural estrogen and progesterone, whereas hormones used in HRT can be made to be bioidentical, meaning they mimic the hormones your own body makes.

To clarify, progestogens in birth control pills (progestins) are not the same as the body’s own progesterone, and the estrogen used in birth control (ethinyl estradiol) is not the same as the bioidentical estrogen (estradiol) used in HRT.

In addition, the combined estrogen/progesterone birth control pill is taken orally, which is what causes the clotting risk. Estrogen in HRT can be absorbed through the skin, which mitigates the clot risk. There is no known risk of clotting with oral progesterone.

So, is birth control HRT? Yes, but it seems it’s generally not a substitute for personalized HRT and if your doctor is prescribing it to use for peri, feel free to get a second opinion.

The Perisphere is not medical advice. The information provided should not be used for diagnosing or treating a health problem. Always seek the advice of your doctor or other qualified health provider.