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The 'Pause
The menopause podcast with unfiltered conversations about the symptoms you hate, the changes you didn’t see coming, and the hilarious moments midlife can bring. You've got questions and we've got the experts to answer them.
The 'Pause
The Birth Control vs. HRT Dilemma
Perimenopause symptoms are often mismanaged with birth control pills instead of appropriate hormone replacement therapy (HRT) because many practitioners lack knowledge about the menopausal transition.
• Birth control pills contain synthetic hormones at doses approximately 120 times higher than HRT
• Birth control is designed to prevent pregnancy and control bleeding, while HRT addresses menopause symptoms
• Unlike birth control, HRT does not prevent pregnancy during perimenopause
• Combining methods like a hormonal IUD with bioidentical hormones can provide both contraception and symptom relief
• Transitioning off birth control should be gradual to avoid the "12,000-foot cliff" of hormone withdrawal
• Continuous birth control (skipping the placebo week) is acceptable and was originally designed by men
• Women deserve practitioners who listen, educate, and offer personalized options
• Virtual appointments have increased access to specialized menopause care
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Welcome to the Pause, the menopause podcast, with unfiltered conversations about the symptoms you hate, the changes you didn't see coming and the hilarious moments midlife can bring. I'm your host, val Leggo, and I've been a dedicated health reporter for 25 years and I wanted to normalize something that every woman goes through menopause. So together we're going to talk about it the Perry, the Menno and the Post. Welcome to the Pause. Hi friends, welcome back to the Pause. I'm your host, val Leggo, and I'm a nationally accredited health reporter with 25 years of experience, and when I started on my perimenopause journey, I had some subtle and then some not so subtle symptoms. But I also had lots of questions, but finding the answers to them just was not easy. That's why I started this podcast.
Speaker 1:One question that's come up a lot lately with both my friends and women in our private Facebook group, the Pause Diaries, is can you really use birth control pills instead of hormone replacement therapy for perimenopause symptoms? So in this episode we are breaking down the difference between birth control and HRT and what the options are for women in their 40s. If you're still getting your period but you're feeling off, this one is for you. I'm joined by my friend and co-host and nationally certified menopause provider, nisha McKenzie. She's a trusted voice in women's health and the off. This one is for you.
Speaker 1:I'm joined by my friend and co-host and nationally certified menopause provider, nisha McKenzie. She's a trusted voice in women's health and the menopause space and one of my favorite straight talkers when it comes to the truth about hormones. Nisha, a lot of women in their 30s and 40s are being prescribed and this just kills me birth control pills to manage their perimenopause symptoms, and I love the eye roll you just gave me from across the table because that was really great. So I feel like you really want to tell women why birth control pills are not interchangeable with HRT. My girlfriends be like well, it does have estrogen in it.
Speaker 2:It does do this, and I'm like they are meant to do two different things. They are meant to do two different things. Here's the thing is like. Sometimes, birth control pills are great during perimenopause. The problem is is, more often than not, what I see is the people that are being given birth control pills are being given that because their practitioner doesn't know about perimenopause and menopause and they don't have other options for them. Talked about it before on this show. If your practitioner gives you one option, that's probably not the most comprehensive visit that you'll have.
Speaker 1:So let's talk about what birth control pills are designed to do.
Speaker 2:Okay, Generally what they'll do is they will shut down ovulation. They'll change the cervical mucus. Ovulation is the release of the egg from your ovary. So they suppress that so that you don't get pregnant. But we use them off-label most of the time, meaning the FDA hasn't approved them for these indications. But we'll use them for acne. Sometimes we use it for heavy menstrual bleeding. We use it for painful cramping with periods and perimenopausal women unfortunately not all of them just get like lighter and farther apart with their periods. Some people get closer, closer together, heavier, more painful periods. Some people need that bleeding control.
Speaker 1:It definitely happened to me, which I was really surprised about, like just really super heavy. Like when I had my first gusher, I was like, oh my gosh, some people, this was their entire life. It really gave me a lot of sympathy. I was also glad it only happened like twice to me and I was like, ok, great, now I'm done. That's awesome. You just called it a gusher, a gusher.
Speaker 2:I mean, it's literally what happens to you. You stand up and you laugh and all of a mean. There's a lot of terms for it, but it's all very visual. You can see it.
Speaker 1:Yes, absolutely see it. So would you say in the early phase of perimenopause, if you're on birth control pills, that it may help a little bit with symptoms, if your symptoms are?
Speaker 2:mild. Yeah, it can help. I mean, it can help more than a little bit with symptoms. They are synthetic estrogens and synthetic progestogens versus hormone therapy or menopausal hormone therapy, which generally will use bioidentical, but they can help. Sometimes people will have their menopausal symptoms supersede the birth control pill and then they'll still have that. The interesting thing is you can still use hormone therapy often certain types of it on top of your birth control regimen, because they're different. Yes, they're both estrogens, yes, they're both progestogens, but they're different and so you can, without overdosing, you can sometimes use them together. So I think this is a good time to talk about exactly what hormone replacement therapy does.
Speaker 1:That's different than birth control.
Speaker 2:First of all, it's like a fraction of the dose. The birth control, the potency of the synthetic estrogen in birth control is. I mean, if we're going to talk numbers, we're talking like 12,000, for that it's ethanol, estradiol and birth control pills versus hormone therapy, menopausal hormone therapy we're talking like 100. Wow, right, so it's a fraction of the dose, which is also why we're somewhat getting away from calling it hormone replacement therapy, because we're not replacing all of the estrogen you used to have when you were 20. Sure not. We're giving you just enough that the data has shown us can help prevent some chronic diseases, can help with your symptoms and just make us less tire slashing.
Speaker 1:Right, I mean you know the hot flashes, the brain fog, the bone health, like all of that is what it can help with at such a tiny, tiny dose. You know we did a podcast recently about bioidentical. It's interesting to me that you mentioned that birth control pills are the bioidentical.
Speaker 2:Oh, I'm sorry, I hope I didn't say that they're not. You mentioned that birth control pills are the bioidentical. Oh, I'm sorry, I hope I didn't say that they're not. Okay, the birth control pills are the synthetic. There are two birth control pills now that have a bioidentical estrogen in them. Okay, one is a little bit older, one is relatively new, but that's two. I don't even know how many birth control pill varieties out there. There are hundreds and hundreds, maybe even thousands, because all the generics but they're almost all the pill, the patch and the ring for birth control are almost all synthetic. It's the hormone therapy. That's bioidentical Gotcha, all right.
Speaker 1:So we want to make sure that people understand that they're not interchangeable, Like if you go on hormone replacement therapy you can still get pregnant if you still have your period. Yeah so that's the thing we need to talk about, right? Maybe that's where the surprise babies come from. I don't know, but let's just make sure everybody realizes that.
Speaker 2:People feel like, oh, I only have a period every, you know, six weeks, every three months, because I'm going through perimenopause, so I can't get pregnant. And I will tell people like, unless you want to be on the cover of Time magazine as a 51-year-old pregnant person, like maybe we need to use if you've got sperm in your life, we need to use birth control, we need to use something. For, unless you want to get pregnant, we need to use something for contraception. Your likelihood of getting pregnant is lower, but there's still a possibility. So, if you want to prevent that possibility, hormone therapy, menopausal hormone therapy is not going to prevent that possibility of pregnancy.
Speaker 1:I do like talking about how you can use both.
Speaker 2:Yeah.
Speaker 1:So how does that work?
Speaker 2:I mean, what I'll often do in my practice is people will come in with heavy bleeding and we'll talk about maybe a levonorgestrel IUD, something like a. There's four of them there's a Mirena, a Lylata, a Kylena and a Skyla. So of those four we kind of figure out what's most appropriate for the person. But that can help control bleeding and prevent pregnancy. Those synthetic progestins are great for that. It is such a low dose of progestin that remember, like the 12,100 that we talked about. This is more like 150 to 300-ish, so a little bit more than what's in hormone replacement therapy, but also different because it's synthetic. The synthetics are good at birth control and at bleeding control. The bioidentical, that's the stuff that's better at menopausal symptom control and potentially disease prevention. So if I've got them on a levonorgestrel IUD then we could add, say, for example, they're not sleeping. That tends to be one of the first things that goes in perimenopause is we just can't sleep.
Speaker 1:We're tossing and turning and we write it off for all these different reasons, but not realizing that's a humongous and probably the first symptom that comes along.
Speaker 2:Yeah, lots of reasons or excuses. The dogs sleep in the bed with me and they're hot boxes. My partner is a hot box. I've got angsty teenagers that are coming in and out late, you know, all hours of the night. I'm at my aging parents really late at night and I'm stressed about that and so I'm waking up. For those reasons those can be part of it. But perimenopause and this fluctuation or this decrease in progesterone can also be part of it. So if you're on a levonorgestrel IUD, I could potentially in theory add a bioidentical progesterone at night to help you sleep. And if you're on the levonorgestrel IUD and say you're having hot flashes or night sweats, we can add an estradiol. I mean for estrogen we've got pills, patches, rings, trochies, pellets, injections, gummies. Oh no not yet.
Speaker 2:Sorry, we should do that there's a gummy for everything, but we don't have a gummy for estrogen. Okay, we're going to take a pause on the podcast and we're going to start making an estrogen gummy, yes, yes.
Speaker 1:So do you have to have the IUD, though, in order to add in the hormone replacement therapy?
Speaker 2:No, no, it's just if that person needs bleeding control and or birth control, okay, then they could use. So the IUD is a great one because you can transition through you kind of skate through perimenopause a little bit. I don't want to say easier, because perimenopause isn't easy.
Speaker 1:Those two words don't really go together. They sure don't.
Speaker 2:But a little less difficult because you almost kind of narrow the window of opportunity for fluctuation if you've got a little bit of that hormone on board. Okay so, and then if we remove the IUD, you also don't have. Imagine the 12,000, imagine that's a 12,000 foot cliff. Imagine that Now, if I stop your hormones and you're in a birth control pill and you're 51 or 52, and I say you're probably menopausal, post-menopausal, we can probably come off your birth control pill, that's a big cliff to fall off of right. You got 12,000 feet to fall down.
Speaker 2:And your hormone that we've talked about it numerous times. It's that change in hormone that makes us feel ick, and so that's a big change. So people don't feel good with that. It can be pretty miserable. Actually, Some people do fine with it. Yeah, some people don't feel good with that. It can be pretty miserable. Actually, Some people do fine with it. Yeah, Some people don't. So if I've got them on and leave an adjuster IUD and I remove that at the time that it you know, if it's served its sentence, if it's served its lifespan, and we remove it, there's, it's like a blip in the radar.
Speaker 1:It's not as big of a change in the system as far as hormone levels as what the like, stopping a birth control pill or a patch or a ring would be. So if you were just on regular birth control pills, is there a moment in time where you should transition, and how does that transition to hormone replacement therapy look?
Speaker 2:It's going to be different for everybody. This is the individualized approach. And so if you go into someone again and they say you're this age, you need to do this, that's just not that individual approach. What I would say is, if someone comes in and they're on a birth control pill and they're open to saying, let me get to something, lower dose, but I still need birth control, I still got sperm in my life and I still don't want to be pregnant, then I'll say are you open to trying an IUD? We could potentially. Maybe they're really nervous about I had really bad bleeding previously to this birth control pill. I don't want to bleed like that again. I don't have time for that. I don't have space for the gushers in my life, right? And so I'll say well, maybe we could consider putting in the IUD, staying on your birth control pill until that's in, giving it like a month or so to kind of settle in, and then we can come off your birth control pill. If we can get people off their pills during perimenopause, before they're, you know, 45-ish and up, then they're going to have a slightly easier time coming off of it. One other note is after we hit around age 35-ish our clot risk starts to go up our stroke risk just generally in humans and so we do have a slightly higher clot and stroke risk when we're taking birth control pills or something with that high of a hormone dose. So if they're also a smoker, then we really got a higher clot risk and it's probably worth saying okay, let's have a really, really informed discussion or decision making process on what's the best option for you going forward. So it just depends.
Speaker 2:Some people will come in If you're on a birth control pill through perimenopause and then you come in and you're I've had people come in their 60s, early 60s. They're still on their birth control pill and they're like, nish, I'm not in menopause yet and I'm like, okay, well, so here's the problem is that birth control pill you know how generally they have a week off. You get your seven days of placebo or four days maybe you take that you're not actually having a period on birth control pills. You're having a withdrawal bleed. So you get that seven days of no hormone. You have a withdrawal bleed. That's all it means.
Speaker 2:That person might very well actually most likely will be that 62-year-old, will most likely be postmenopausal, but she's still having withdrawal bleed because we're giving her the hormone and then we're withdrawing it and we're causing her uterus to bleed. So she's like I got to stay on this birth control pill because I don't want to get knocked up. I'm 62. Okay, maybe, but so you know, if she's got a male partner and partner has not had a vasectomy can get a little trickier, right, like I may say. Because generally what I'll do is I'll tell people, if you're menopausal age, let's wean off your birth control pills so that you don't drop off that 12,000 foot cliff, right? So we'll wean by maybe a pill a week. So it takes six or seven weeks to come off of your pill and then people start to do a little better. But the problem is is if they are not postmenop, well, you might get pregnant during that week, yes, so then you've got to either use condoms maybe, like you know, man up and go get the vest.
Speaker 1:Right. Why does it always have to be the woman taking care of all the things, right? One other question I had you know how it got really popular about 10 years ago to just continue your birth control pill, so you never got a period. Especially, it's like oh, I'm going on vacation, I don't want my period, it's going to come out.
Speaker 2:And so women found that convenient and just kept doing it. Is there a concern or something people who women who have chosen to do this need to be aware of? No, I love this. You do. You know who invented the idea that we have to have a period once a week on birth control pills?
Speaker 1:Men Dude.
Speaker 2:Right, we don't. It's men, dude, right, like we don't it's. And again, it's not a period, it's a withdrawal bleed and so, no, don't ever bleed. I always see like it's like if you don't water your grass, you don't have to mow it. It's that kind of idea.
Speaker 2:If you're not building up the lining of your, your endometrium or your uterus, it doesn't have to shed. So if you're on hormones, like a birth control pill, and you're not having a period, great, maybe don't brag to your friends, they'll be super jealous. But if you're not on hormones and you're not having a bleed about once a month, that can be a red flag. Then we got to look at why aren't you having these bleeds? Are there other things that could cause longer-term health consequences for you?
Speaker 2:But if you're on hormones, it's not building up, so it doesn't need to shed. That could cause longer-term health consequences for you. But if you're on hormones, it's not building up, so it doesn't need to shed. Some people on that continual birth control pill, their body just kind of like supersedes the pill and eventually they'll start to eep out just a little bit of bleeding or spotting and then I'll say you know what your body just said. Hey, I'm stronger than the pill. I'm going to bleed a little bit. I need to bleed. Then you stop your pill for four or five days, you allow the bleed and then you go back on.
Speaker 1:So if somebody stayed on the continuous pill from, let's just say, 40 through 57, what does that transition look like for them getting to do? They need the hormone replacement therapy, the transition. And then also, when you put them on birth control or on hormone replacement therapy, excuse me, are they going to expect to have to bleed a little because you took the birth control pills away and will it be a lot because they haven't had a period in 17 years? Possibly, possibly, and possibly, okay, yeah.
Speaker 2:I mean, my first question would be for them is there a sperm in your life? And if there is and you don't want to be pregnant, then we've got to figure out what other method of contraception, whether it's a barrier method there's a gel, an ointment called Fexi that you can put in. That's something that is it's a prescription, but you can use it for birth control. That's non-hormonal. So there's some non-hormonal things that you can use to make sure you don't get pregnant. And then I would offer the wean. They can just stop and, like I said, many people do just fine, just stopping. But if they want to chance it, great. If they don't want to chance it, we wean, we wean off and then we give it maybe a month or so off and we see how they do, and maybe we check some labs. Maybe not, because maybe their body tells us what they are. You know what they're doing.
Speaker 1:And then they can start the hormone replacement therapy.
Speaker 2:Yep, then they can go on menopausal therapy and if they need it, if they want it, they can go on non-hormonal things. They can just watch and wait. It's you know. Menopause is supposed to be your journey, yes, and you deserve to have a practitioner who will just listen to you and work with you in what you want, but educate you. I feel like that's my goal as a practitioner is just give you the education that you deserve so that you can make a fully informed decision. So many of us make decisions out of fear or out of just. You know what our friends did, what our parents did.
Speaker 1:Or the fact that they're being told this is your option.
Speaker 2:Right, this is what it is.
Speaker 1:Right. There are few and far between. Like you, we are getting better at that, which is great. Hopefully in the next 10 years that will grow even more, so that when we tell women, find the provider that works for you, we're telling them there's actual options, because I know that is still a really big complaint and concern, like yeah, I'm trying, but I can't find anyone. So I'm thankful for the fact that this is finally changing and hopefully the pendulum is going to switch and stay in that direction.
Speaker 2:I think it will, because I think we, as women, are going in we're hearing podcasts like this, we're part of like Facebook groups, like the pause diaries, we're part of some of these things and we're going in armed and we're going in having having the questions that we wanted to ask and we're making providers pay attention, and that's that's. I think what's causing the pendulum to swing is us is women.
Speaker 2:Saying it's time, look at me. I'm putting myself in that group. I'm like, I'm the practitioner when it's good for me. I'm also the patient when they're cool.
Speaker 2:But yeah, we can drive that, as women, you can go in and you can say here's what I want. Do you know about this? If you don't, are you willing to look into it and get back to me? And if not, if you don't have time for that, I totally get it. I get that. The systems, the systems suck right and I know you're in the system. So do you have someone else that you can think of that I can go to?
Speaker 1:And sometimes that might have to be a virtual option especially for women in the rural communities.
Speaker 2:That's the one good thing I always say came out of the pandemic is telehealth. Yeah, you can do telehealth as long as the practitioner is licensed in the state you're in. Then you can do it across the state and a lot of practitioners are getting licensed in different states. There's some legislation going through now for PAs in particular, where there's a licensing compact where you know it'll be making it a little bit easier for me to be licensed in other states. So Michigan's kind of working on this compact, trying to see if we can get people licensed in other states.
Speaker 1:Yeah.
Speaker 2:So hopefully that'll increase access.
Speaker 1:That would be fantastic, for I know for a lot of women. So, I hope we answered your questions about birth control and hormone therapy and how. They're not the same, but they're different.
Speaker 2:But also a little bit the same. And also, just don't get pregnant Unless you want to, unless you want to.
Speaker 1:As usual, this has always been a really, really great conversation. Nisha, I love it when you're on the show with me. Hey, if you've got more questions or want to hear more from other women walking through this too, join the Paws Diaries that we've been talking about on this episode and other episodes. It's our private Facebook page. It is about real talk, real support, real answers. There's about 700 women in there. It continues to grow. I love each and every one of them because they are just so supportive and inquisitive, and I love that they give us a lot of ideas for the podcast. Remember, menopause is not the end of anything. It's the start of the rest of your life and we are going to talk about it.
