You may have grown accustomed to your period over the years, but at some point, things can begin to change. Perimenopause is not a one-size-fits-all experience by any means, so you might start to have irregular, painful or unusually heavy periods some months in the lead-up to the menopausal transition.
In fact, 32% of perimenopausal women report heavy bleeding, and 80% of women in perimenopause report that one or more of their symptoms disrupt their quality of life. Or you could be having some of the traditional “menopause” symptoms before your period actually stops, like sudden hot flashes, brutal sleep disturbances or uncomfortable vaginal dryness.
Either way, you shouldn’t have to deal with any of these symptoms.
There are treatment options to end your heavy period, pre-menopausal misery.
It’s just a matter of working with your OB-GYN to figure out which one is best,and getting started with the treatment as fast as possible.
So, is hormonal birth control the answer your perimenopause symptoms (and pregnancy prevention, along the way), or should you go straight to using menopause hormone therapy (MHT)? Flow Space reached out to expert OB-GYNs to get the answers to your burning questions about perimenopause treatments, as well as the HRT vs. birth control debate.
Why Is There Confusion Around Perimenopause Symptoms and Treatments?
Some of the ambiguity of perimenopause, compared to the full-on menopausal transition, is the timeline, which can differ for every person.
“When you go through menopause, which is constituted as one year without periods, people have expectations of symptoms,” explains Dr. Mindy Goldman, an OB-GYN and chief clinical officer at Midi Health. “Perimenopause, which can take place months or years before menopause, is typically between four and six years, but can last as long as 10 years.”
For some people, periods might be regular, or they may have some classic menopause-like symptoms or other confusing symptoms that are actually related to menopause, like joint pain or heart palpitations.
For others, periods are irregular but heavy and painful when they do pop up.
Some doctors may be quick to put you on a birth control prescription to help with these symptoms and get your period back on track. But that may not always be the right treatment—especially, if you don’t experience irregular periods and are more concerned with other uncomfortable menopause symptoms, says Goldman.
How to Know If Hormonal Birth Control Is the Right Choice for You
If you’re having heavy, irregular periods during perimenopause, hormonal birth control is likely going to be helpful in this scenario.
But first, before putting you on a birth control pill or other form of contraception, your doctor will do a full workup to make sure that irregular bleeding is not caused by any other serious conditions, like endometrial cancer, explains Goldman. Some of the criteria they may ask for is your history of periods in terms of regularity and heaviness, other medical history like migraines or family health history with blood clots, and any contraceptive or fertility goals you may have, adds Dr. Asima Ahmad, co-founder and chief medical officer of Carrot Fertility.
After you’re cleared of any health issues or pre-cancerous risks, you will most likely get a prescription for hormonal birth control to regulate your periods, which is a form of hormone therapy, Ahmad points out.
Many forms of hormonal birth control, including the oral contraceptive pill, have a combination of hormones: estrogen and progestin (a form of progesterone).
“The pills inhibit ovulation, and then, it is with the withdrawal of the hormones that a bleed is induced,” explains Ahmad. Because they suppress ovulation, you can also use hormonal birth control to prevent pregnancy—yes, that’s right, you can still get pregnant during perimenopause.
For symptoms beyond irregular and heavy bleeding, like sleep and mood changes, you might try birth control first to see if it helps with all symptoms, but it may end up that hormone replacement therapy (HRT), like the estrogen patch, could be the best move for you, explains Goldman.
How to Know If HRT Is the Better Choice
If irregular bleeding is not your experience, but you have other menopause symptoms, such as hot flashes, mood swings and sleep disturbances, hormone replacement therapy (HRT) with estrogen may be a more effective solution for you.
“Estrogen therapy addresses the hormonal fluctuations responsible for these symptoms by supplementing the body’s declining estrogen levels,” says Dr. Thaïs Aliabadi, an OB-GYN, co-host of the SHE MD podcast and co-founder of PCOS supplement Ovii.
This is a very much individualized process.
For patients who do not feel they need contraception, have their periods spaced out and are more bothered by brain fog or night sweats, Goldman takes that into consideration and prioritizes their primary concerns.
The hormone therapy dose will depend on your symptoms, menopause status and any risks to your health. Your doctor may prescribe low-dose estrogen to start or a combination of estrogen and progestin, and the prescription can be adjusted based on how you’re feeling, as well as any side effects you may have, says Aliabadi.
In Some Cases, You May Benefit From Both Birth Control and HRT
For anyone with all of the above symptoms, there are still options.
Sometimes, to treat both abnormal bleeding and menopause symptoms, doctors may prescribe a hormonal IUD like Mirena to regulate periods along with HRT to treat the symptoms of estrogen deficiency. The IUD contains progestin, which often makes periods very light, and can be used as off-label uterine protection for taking HRT (progestin is needed whenever you take estrogen hormone therapy to protect against uterine cancer), explains Goldman.
That way, you have contraception for a couple of years if you need it, control of irregular bleeding and uterine protection to go along with the hormone therapy treatment.
What Should You Do If You Can’t Take Any Hormonal Treatments?
Some people who have certain health histories are likely not going to be able to take any form of hormone therapy for their perimenopause symptoms.
According to Ahmad and Aliabadi, this includes anyone who has a personal or family history of blood clots, is a heavy smoker, has a heart disease or stroke history, or has had hormone-sensitive sensitive breast cancer, liver tumors, or liver disease.
If you have certain autoimmune conditions, high blood pressure, migraines, diabetes or are breastfeeding, you should check with your doctor before starting any kind of hormone therapy.
Experts emphasize that even if systemic estrogen therapy, like the birth control pill or an estrogen patch, won’t be an option for you based on prior health history, you may still be able to use topical estrogen for symptoms like vaginal dryness, since that doesn’t get absorbed by your whole system.
For Goldman, who specializes in cancer survivorship, it’s important for people to know that hormone-sensitive breast cancer is the most common type of breast cancer, making hormone therapy, as well as birth control, unavailable for most people with a history of breast cancer.
However, it is not a reason that you need to just “deal with” any uncomfortable, disruptive perimenopause symptoms.
In that case, a menopause specialist will look into treating individual symptoms, such as poor sleep. The right move might be alternatives for sleep disturbances caused by menopause-related symptoms, like night sweats or an overactive bladder—or your doctor might send you for a sleep study referral, if the potential diagnosis is something like sleep apnea or restless leg syndrome.
“No one should feel that they need to suffer because they have a health condition and can’t take hormones,” says Goldman.