This is a very common question and many of you have been offered the pill instead of HRT. Are they really that different, I mean, taking hormones is taking hormones, right?
While both oral birth control pills (and progestin-secreting IUDs, more on those below) and the medications used as part of HRT are all “hormones”, they are very different. These various formulations contain different hormones, they are metabolized differently (which means their effects and side effects are vary widely) and they have very different goals.
The goals of HRT (hormone replacement therapy), also referred to MHT (menopause hormone therapy, see this article for the differences in these terms), is to alleviate the symptoms of perimenopause like brain fog, hot flashes and insomnia and/or replenish low hormone levels for protection of brain, bones, heart, etc. The goal of birth control pills is contraception. Because of this, the dosing and types of hormones used are different and although the pill and the hormone IUDs (i.e. progestin secreting IUDs like Merina) can alleviate some symptoms of perimenopause and can help avoid an unwanted pregnancy, they do not help with all symptoms and do not provide the same protection or longevity benefits as HRT.
There are times when some women might want to explore options such as the pill or an IUD but it’s important to know what’s what as birth control is often offered up at the first sign of perimenopause to “level things out”.
This article will help you understand the differences between these varying types of hormone medications and in which situations birth control options might be right for you as well as clearing up any misunderstanding that the pill and HRT are in any way the same thing. This is important because many women wanting to get more information on HRT and explore that path are often told by their doc that taking the pill is the same thing. This is likely due to the doctor’s comfort in prescribing the pill over HRT, but nevertheless this is false information and they are absolutely not the same.
How Birth Control Pills Differ From HRT
There are two main differences between the hormones used for birth control and the hormones used in HRT. First, the dose of hormones is very different. It takes three to four times more estrogen to stop ovulation than the dose needed to stop most perimenopause and menopause symptoms, such as hot flashes.
The second key difference is the types of hormones used. Unlike bioidentical hormone used in hormone replacement (more on bioidentical vs. synthetic HRT in this article), the hormones used in birth control pills are all synthetic. There are no bioidentical birth control medications available.
Types Of Hormones Found In Birth Control
Birth control pills are a combined synthetic estrogen and synthetic progestin or they are a progestin only, known as a mini pill. The goal of these pills is to stop ovulation, thus preventing pregnancy. They can also be used to slow heavy bleeding, to create a predictable bleed if your cycle is irregular (though this is a withdrawal bleed and not a real period) or for various symptoms of PMS like cramping or headaches.
Estrogen Found In Contraceptives
The estrogen used in birth control pills is a synthetic estrogen called ethinyl estradiol. The estrogen your body makes and what is used in HRT is 17 beta estradiol, commonly just referred to as estradiol.
This matters because in our bodies we have three different estrogens:
- Estrone is made in body fat and from the adrenal glands mostly and can convert to estradiol. It will rise during perimenopause because the body will try to make more estradiol as it starts to wane. It is known to be inflammatory and increases risk for blood clots.
- Estradiol or 17 beta estradiol, is our main and strongest estrogen. Estradiol is known to be immune modulatory and anti-inflammatory, protects against osteoporosis, heart disease and dementia. It is 10X more potent than estrone and 100X more potent than estriol.
- Estriol the weakest of the three estrogen forms, produced in greater amounts by the placenta during pregnancy and commonly found in recently popularized estrogen face creams. As well, it is as occasionally found as part of an HRT compounded forulation called BiEst (which is estradiol and estriol combined).
Ethinyl estradiol in birth control pills will make some estradiol in your body, but it is mainly converted into estrone. Thing brings an increased risk of clotting and inflammation and does not offer the heart or brain protection of estradiol – in fact it is completely the opposite, as it increases risk in this case. Estrone also primarily binds alpha type receptors (vs. beta estrogen receptors) which generally promotes growth and proliferation impacting risk for cancer growths, fat gain, etc.
All of our estrogen forms (estrone, estradiol, estriol) have their role, as do the different types of estrogen receptors. Also, where those receptors are located and the balance of these various estrogens with other hormones, etc. is importnat. Context matters and we dont’t need to totally demonize estrone, however it’s important not to push our physiology into this pro-inflammatory, stimulating, estrone heavy environment in a middle aged woman that already feels inflammed (shwoing up as brain fog, joine pain, water retention, fatigue, etc.) or that wants to focus on prevention, longevity and not gaining more body fat – many want the opposite.
These inflammatory risk factors are well known for oral contraceptives which is why they should be avoided or used with caution in women that have heart disease, a history of blood clots, hypertension, metabolic diseases, inflammatory diseases (such as autoimmunity) and those that smoke.
So while birth control pills do temper the ups and downs of hormones during perimenopause (HRT does as well), the type of synthetic estrogen in them creates a variety of increased risks that women in midlife are actively trying to minimize, and in many ways, it works completely opposite the goals most women have for wanting to utilize HRT.
This is all true of other ethinyl estradiol contraceptive options such as the ring, patches, etc. It’s the same synthetic form of estrogen, just a different delivery system.
Progestins Found in Contraceptives
Progestins can be part of a combination pill with ethinyl estradiol or alone in both mini-pills and hormone secreting IUDs, i.e. Merina, Skyla, etc. It’s used often interchangeably with the term “progesterone” but molecularly they are not the same and have some important differences.
Progestins are not only synthetic but are chemically more similar to androgens (i.e. testosterone) than to the progesterone our body makes. Because of this it can have unwanted androgen effects such as acne, hair loss and weight gain. As well, it will not give the same anxiety calming, sleep soothing benefits that bioidentical progesterone will. Progestins also carry a risk for increased clotting and certain cancers.
The most common side effects of progestins include depression, weight gain, breast tenderness and acne. There are a host of different types of progestins and each one carries a slightly different side effect profile and potential for androgenic effects as well as if periods will stop, become more irregular, etc.
Progestins will protect your uterus from estrogen’s stimulation so it can be used as part of an estrogen containing HRT regimen to protect the uterine lining, however it will not help with sleep or mood the way bioidential progesterone does. Progestins may also be helpful with irregular bleeding, though combination pills are typically better in this case. Bleeding with progestin only pills can be very erratic ranging from no period, irregular periods to spotting so that can be very confusing for women in midlife who are often already experiencing cycle irregularities.
Because there is no estrogen in progestin-only pills, they are also not usually helpful for symptoms such as hot flashes, night sweats, brain fog, weight gain, depression or sleep issues.
Advantages of HRT Over Contraceptives For Perimenopause
While it may seem like these two options are simply estrogen or progesterone in various forms, the bioidentical estradiol used in HRT increases nitric oxide and lowers inflammatory peptides like endothelin 1, actually leading to a lowered risk of heart disease, clotting, elevated cholesterol, arterial lining damage, arterial plaque oxidation as well as mitochondrial support of all cells including heart muscle. HRT actually provides protection against much of the risks associated with the ethinyl estradiol in birth control.
When it comes to cancer, estradiol is anti-inflammatory and promotes a healthier metabolism as well as supporting the clearing out of seolytic cells and being neuroprotective, thus offering a reduction in risk in cancer overall. Estrogen in contraceptives have a slight increase risk of breast and cervical cancer while lowering the risk of endometrial cancer.
And while we can use progestin or progesterone to protect our uterus from estrogen’s stimulation, most women in midlife again do not need the added risk of clotting and cancer that comes with a progestin and many want to have an improved mood, less anxiety and more restful sleep, making bioidentical progesterone a better option.
Again, the goals of these two forms of hormonal medications are simply very different.
When Birth Control Is The Right Option In Perimenopause
If a woman is experiencing irregular bleeding and has contraindications for estrogen as part of HRT or a combination birth control pill such as liver disease, smoking, clotting issues or history of heart disease, a progestin only pill might be a good option. Bioidentical progesterone is also a good option in this case.
If a woman wants to avoid pregnancy during perimenopause as ovulation is perhaps irregular, fertile months are still certainly possible (perhaps increased actually if you have PCOS, see this article for more info), birth control pills or an IUD can be used. However, there are other options that women can explore including their partners getting a vasectomy if they are in a long term relationship, as well as barrier options like a diaphragm or fertility awareness method (admittedly trickier in perimenopause).
The Vasectomy Option
There is so much misinformation and fear around this procedure leading many men to be very wary of getting a vasectomy. Fearing it will make them less of a man or impact their virility, sexual performance and vitality. All of that is simply untrue and it’s a very viable, non hormonal option to allow for a fulfilling sex life without the fear of getting pregnant. And let’s be honest: it’s time that men share the contraception burden, it’s been carried alone by women for far too long.
Here’s the gist:
A vasectomy is simply a cutting and blocking of the vas deferens, the small tubes that carry sperm to the urethra for ejaculation. Local anesthesia is all that is typically used and nothing is removed and nothing is outwardly noticeable after the stitches are gone. And there are even no needle, no stitches options available here in the 2020s so it’s even easier and has an even faster recovery. The procedure lasts on average only about 20 minutes.
After this procedure, ejaculated semen no longer contains sperm. That’s it! Nothing else changes.
A vasectomy does not lower a man’s testosterone, it simply removes the sperm from the semen. It’s also highly reversible with success rates up to 95%. While age of the vasectomy is a factor, reversals have been successful even up to 30 years later. It is much less invasive than a tubal ligation for women (cutting of the fallopian tubes to prevent the egg from reaching the uterus) and much more easily reversed if there’s a change in desire for more kids. And no one has to take synthetic hormones, so win, win.
As always here at BetterByDrBrooke, there is no judgement for using whatever methods feel right for you during all phase of life and if you support women, you support their right to make choices about their reproductive health.
The point of this post was to help women better understand not only the risks of using birth control pills or intrauterine contraceptives during midlife but also how they differ from the hormones used in HRT. Most women exploring HRT want not only symptoms reduction but improved wellness and increased longevity, which is simply a different approach than contraception although both can alleviate some symptoms of perimenopause and protect the uterine lining from hyperplasia.
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