Is HRT or The Pill Better for Perimenopause Symptoms?

Like it or not, perimenopause is a natural part of aging for most women. Also called the menopausal transition, perimenopause is the time period leading up to menopause.

Researchers estimate that about two million women in the United States enter perimenopause every year. Most of us start perimenopause between the ages of 45 and 55 — and it can last for several years.

Along with perimenopause come the symptoms that many of us have heard about: hot flashes, night sweats, vaginal dryness, mood swings (we could go on). These are caused by the natural drop in hormone levels.

Fortunately, there are treatments for many of the bothersome symptoms that crop up during perimenopause. For example, you may have heard of using hormone replacement therapy (HRT) or the Pill to manage them.

But which one is better for symptoms of perimenopause? Don’t worry – we’re here to answer your questions. Keep reading as we break down HRT vs. birth control pills for perimenopause symptoms.

Oral contraceptives like the Pill are used primarily for pregnancy prevention. The most common type of birth control pill is the combined oral contraceptive pill, which contains synthetic versions of both estrogen and progestin.

There’s also a progestin-only contraceptive pill, which you may see referred to as the mini-pill.

During perimenopause, the amount of estrogen and progesterone made by your ovaries starts to drop. This leads to the symptoms we often link with menopause. Adding in extra estrogen and progestin using The Pill can help to manage these.

The Pill also has another added benefit: It may be used during perimenopause to both manage perimenopause symptoms and prevent pregnancy.

This dual approach is important because perimenopausal women can continue to ovulate up until their final period. That means you can still get pregnant even if you’re in perimenopause.

That’s why a healthcare provider may recommend that you continue to take the Pill while you’re in perimenopause. You may then switch over to HRT when you’ve entered menopause – typically when you’re over the age of 50 and haven’t had a period in at least a year.

In addition to The Pill, hormone-containing IUDs, the vaginal ring, or the birth control patch may also be used during perimenopause to manage symptoms and prevent pregnancy.

HRT supplements in estrogen and progestin, helping to alleviate many of the symptoms of perimenopause, especially things like hot flashes and night sweats.

There are two general types of HRT:

• Estrogen-only HRT

• Estrogen plus progestin, also referred to as combined HRT

HRT may be given as a pill, a patch, or a gel. There are also creams and vaginal rings containing a low dose of estrogen, which can be used to address vaginal dryness specifically.

While there’s no set amount of time for which to use HRT, the Menopause Society notes that many women take it for four to five years before stopping it entirely, using lower doses, or switching to a non-pill form.

Since HRT also contains estrogen and progestin, you may be asking Is HRT the same as birth control?

HRT isn’t a form of birth control. Researchers have long known that ovulation still happens in women using HRT, even if you already had irregular periods prior to starting on it. That means you can still get pregnant while using HRT.

If you’re already using HRT for symptoms of perimenopause, you’ll need to use an effective form of non-hormonal contraception as well. That’s because combined oral contraceptives contain a higher dose of estrogen than HRT, meaning that doubling up can boost your risk of health issues.

Some examples of nonhormonal contraceptive methods to explore include copper IUDs or barrier methods like condoms or diaphragms.

Now let’s dive into the various benefits and risks of using HRT vs. the Pill for perimenopause.

Benefits and Risks of HRT

HRT can be very effective at reducing symptoms like hot flashes and night sweats, collectively referred to as vasomotor symptoms. In fact, researchers estimate that HRT can reduce the frequency of these symptoms by up to 75%.

In addition to vasomotor symptoms, the hormonal fluctuations that happen during perimenopause can have other effects, too. Vaginal dryness can affect sexual function and pleasure. Perimenopausal women are also at an increased risk for anxiety, depression, and sleep issues.

The good news is that HRT can help with these things as well. For example, using HRT can reduce vaginal dryness. Further, some evidence suggests that it can boost mood and improve sleep quality.

Another benefit of HRT is that it slows bone loss related to menopause. This can reduce the risk of osteoporosis, a condition that impacts one in five women over age 50, and lower the risk of bone breaks.

For all of its benefits, there are also several health risks associated with HRT to be aware of.

For example, clinical trials like those conducted as part of the Women’s Health Initiative (WHI) have suggested that menopausal hormone therapy is associated with an increased risk of:

• Breast cancer with combined HRT

• High breast density with combined HRT, which can make breast cancer harder to detect with a mammogram

• Endometrial cancer, a type of uterine cancer, with estrogen-only HRT

• Blood clots, stroke, and heart attack with both estrogen-only and combined HRT

• Dementia in older women using either type of HRT

The American College of Obstetricians and Gynecologists (ACOG) also notes that there’s a small risk of gallbladder disease associated with both estrogen-only and combined HRT.

Benefits and Risks of The Pill for Perimenopause

A 2018 research review notes that perimenopausal women often experience irregular periods, heavy periods, and vasomotor symptoms like hot flashes and night sweats.

The authors of this review note that using combined oral contraceptives like the Pill can help to manage these symptoms while reducing the risk of certain cancers.

Indeed, researchers have found that oral contraceptives are associated with a reduced risk of ovarian cancer, endometrial cancer, and colorectal cancer.

When it comes to birth control pills for perimenopause anxiety, in addition to alleviating vasomotor symptoms, some research suggests that using combined oral contraceptives may also decrease perimenopausal anxiety and depression as well as improve sexual function.

Hormonal contraceptives like The Pill are also associated with a variety of side effects, including:

• Breakthrough bleeding

• Headaches

• Nausea

• Breast tenderness

• Mood changes

• Weight gain

• Acne

Like HRT, the Pill is also linked to a slightly higher risk of breast cancer. According to the American Cancer Society, this risk decreases back to normal levels within 10 years of stopping oral contraceptives.

ACOG also notes that combined oral contraceptives lead to a small increased risk of blood clots, stroke, and heart attack.

HRT and the Pill aren’t for everyone. While some people may simply choose to explore non-hormonal treatment options, others shouldn’t use HRT or the Pill based on their medical history.

According to the Menopause Society, HRT isn’t recommended for women with a history of:

• Blood clots

• Breast cancer

• Uterine cancer or unexplained uterine bleeding

• Liver disease

• Cardiovascular disease

Meanwhile, ACOG notes that the Pill and other combined hormonal contraceptives can increase the risk of blood clots, stroke, and heart attack in women who:

• Have several risk factors for heart disease, including high blood pressure, high cholesterol, and diabetes

• Have a previous medical history of blood clots, stroke, or heart attack

• Experience migraine headaches with aura

• Smoke cigarettes

So if you can’t take or choose not to take either of these treatments, are there alternative treatment options available? The answer to this question is absolutely yes!

First off, there are four FDA-approved nonhormonal treatments for various symptoms of menopause:

• Brisdelle^® (paroxetine), a selective serotonin reuptake inhibitor (SSRI), for moderate to severe vasomotor symptoms

• Evista (raloxifene hydrochloride) for reducing the risk of osteoporosis and breast cancer in postmenopausal women

• Osphena ^® (ospemifene) for vaginal dryness that causes painful sex

• Veozah^TM (fezolinetant) for moderate to severe vasomotor symptoms

Other treatment options that may help include:

• Cognitive behavioral therapy for mood changes and sleep problems

• Off-label medications like gabapentin and oxybutynin for vasomotor symptoms

• Over-the-counter vaginal lubricants for vaginal dryness

When it comes to managing perimenopause symptoms, a good rule of thumb is to stick to evidence-based methods. According to the North American Menopause Society, there’s currently not enough evidence to support using things like yoga, supplements, or dietary changes to address vasomotor symptoms.

Check out the table below for a comparison of all of the things we’ve covered on HRT and the Pill for perimenopause.

Both HRT and the Pill can help to reduce many symptoms and improve quality of life during perimenopause. Everyone’s perimenopause journey is different, so what’s right for you depends on many factors, including your age, symptoms, and medical history.

If you’re interested in ways to manage perimenopause symptoms, make an appointment with a healthcare provider, such as your OB-GYN. They can inform you about the different options available to you, including non-hormonal ones, as well as the risks and benefits associated with each to help you make an informed decision.