Essays

May 1, 2024

 Should You Still Take Birth Control During Perimenopause?

Image via Stocksy.

By Ines Bellina

By the time women hit their 50s, more than 80 percent will have been on birth control pills for an average of five years. Many use birth control pills or long-acting reversible contraceptives like IUDs for much longer — 10 or even 20 years. When I got my first prescription for birth control pills at 19, it didn’t even occur to me to ask about perimenopause, an experience that felt as far away as writing a will. At 41, though, I wondered: What kind of effects have all those hormones had on my body? Do I need to “detox” from them? Or should I stay on them to buffer the hormonal up-and-down of middle age?

When I tell Dr. Lisa Larkin, a board-certified internist, women’s health expert, and the current president of The Menopause Society, that some women are afraid of contraceptives adding an “excess of hormones” to their bodies, she says that’s a misconception. “When you’re taking birth control pills, you’re not adding hormones to your body,” she explains. “You are evening them out by suppressing your ovarian estrogen functions.” 

While TikTok fearmongering about birth control pills typically targets young women, older generations have had to deal with the consequences of the Women’s Health Initiative, a study with significant design flaws that made patients suspicious of the benefits of hormone replacement therapy during menopause. “We have scared an entire generation of women away from hormones because of a study that is 22 years old, even women who would benefit greatly from them,” says Dr. Larkin. 

I spoke with her to find out more about how long-term use of hormonal birth control impacts perimenopause. 

Many Gen X and Millennial women have been taking birth control pills or other contraceptives continuously for decades. What kind of impact does this have on our bodies?

We don’t believe that any of the forms of contraception significantly impact the natural history of reproductive aging. The quality of your eggs, even if you’ve been on oral contraceptives or long-acting reversible contraceptives, will still be of a regular 41-year-old. Fertility drops significantly in most women after age 45, and menopause marks the time of no additional fertility at all, but contraceptives don’t impact that. 

Contraception [use] does have [some potential impacts], like vaginal dryness or weight gain, but there are benefits to contraceptives beyond preventing pregnancy, like a reduction in ovarian cancer risk. I use their benefits a lot in perimenopause when women are often having a hard time with heavy menstrual bleeding, premenstrual dysphoric disorder, and mood disturbances related to hormone changes.

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Are the benefits and risks of IUDs the same as the pill?

They’re a little different. There are hormone-containing IUDs and copper IUDs, which do not have any hormones. I’m a huge fan of both. IUDs containing progestin decrease bleeding dramatically and sometimes make it go away. Occasionally migraines will worsen and sometimes IUDs don’t do as great a job controlling premenstrual dysphoric disorder and mood swings. Taking oral contraceptives continuously is more effective. It depends on what your major symptoms are. 

Barring wanting to get pregnant, is there any reason to take a break from birth control? Does “detoxing” do anything?

It doesn’t. On social media, there are lots of anti-birth control pill people saying [that contraception is] causing all kinds of problems. In most women, there are huge benefits to both oral contraceptives and the IUD. Some people have side effects, like sexual dysfunction, and I will stop them for that reason. In general, if you have been on birth control for 15 years and still need contraception, I do not tell you to take a break.

In fact, if they’ve been doing well on oral contraceptives, people are often miserable when they stop. Suddenly, they’re having terrible PMS, breast tenderness, heavy bleeding, and cramps. A typical patient [of mine] is a 37-year-old who is finished childbearing, whose husband had a vasectomy, and decided that they didn’t want to be on birth control pills because they don’t want to take hormones. At 42, they’re having horrible bleeding and mood disturbance. I put them on oral contraceptives for that reason, and they do great. 

Some studies show a negative effect of birth control pills on breast cancer risk or a very slight increase in breast cancer risk. In general, though, there is no increased breast cancer risk with oral contraceptives in premenopausal women, and ovarian cancer risk is significantly reduced with them. That’s a different discussion than one I’m having with a 52-year-old, post-menopausal woman about the pros and cons of hormone therapy and whether data suggests any impact on breast cancer risk – because that woman is no longer making her own estrogen. 

What are some of the signs we can look out for to see if we are entering perimenopause if we have “fake” periods or missing periods because of birth control? 

Age is the biggest predictor, though it’s variable. The average age of menopause is 51. Usually, perimenopause starts four to six years before that. Typically, if you are in your early 40s and doing well on birth control pills, we leave you on birth control pills until 50 or 51. Then I would try stopping them to see whether you were menopausal and having symptoms, and we’d have a conversation about hormone therapy. If you started having terrible hot flashes and bleeding again off the birth control pill, I might put you back on it for another year. You don’t have to go off them to see where you are until 50. We want you to have estrogen around until then because it protects your bone, brain, and heart health. 

For people on IUDs or who have an implant, would the process be the same?

It would be the same. If you’re in your late 40s, and you need to have your progestin IUD replaced, we love putting in an IUD because a progestin IUD around the time of perimenopause is great for bleeding. Then we can safely give a low-dose menopausal hormone therapy of estrogen, like estradiol or conjugated equine estrogen, without having to give another systemic oral progestin or progesterone. 

Are there any other factors we should consider when choosing birth control or switching birth control once we’re in perimenopause? 

Obesity, cardiovascular risk factors like smoking or diabetes, a family history of cardiovascular disease, high cholesterol, hereditary cancer mutations like a BRCA gene, an elevated breast cancer risk because of family history and breast density, and prior blood clots post-surgery. All kinds of things would make it a very individual discussion for a patient. 

What signs should we look out for if we’re worried that our go-to birth control is suddenly having a negative impact on our body? 

Some of the questions about that are related to the dose of pills you are on and whether you skip the placebo pills in your pill pack. For patients in their forties, I’m prescribing a 20 or 10-microgram birth control pill, which contains a lower dose of estrogen than standard birth control pills. Sometimes women have more vaginal dryness, breakthrough bleeding, migraines or mood issues during the week they take the placebo pills. That’s when it’s great for women to skip the placebos and continue taking the active pills.

Sometimes women are more sensitive to one type of progestin than the other, which also varies between birth control pills. If the pill you were on in your twenties and thirties is suddenly giving you acne, or you are noticing weight gain and mood swings, we’ll switch you to a different type of pill.

Do you have any final thoughts on birth control and perimenopause?

A healthy 42-year-old going through menopause early should be on oral contraceptives or hormone therapy at appropriate doses, at least until age 50. Earlier menopause that’s not given estrogen is associated with earlier cardiovascular disease, bone loss, sexual dysfunction, and cognitive changes. If you go through menopause early, you should be on hormones at least until age 50, unless you’ve had breast cancer or prior clots. 

For more information about The Menopause Society, please visit their website

**This interview has been edited for length and clarity.**

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