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Special Topic:  Birth Control Pills vs. HRT

BCPS OR HRT?: What’s the Difference?

Some of us going through early menopause or premature ovarian failure are put on birth control pills; others on hormone replacement therapy. Both act as hormone replacement; in other words, in both cases, you’re taking them to replace the hormones your body used to make. But there are significant differences between the two.

So, inevitably, questions come up: What are the differences? Is one better than the other? Why am on one and not the other? As you’d expect, there are really no simple answers! (Isn’t that always the case....)

That said, though, here’s an attempt at explaining this issue, the pros and cons of each...and the reasons your doctor may have prescribed one of these for you.

BIRTH CONTROL PILLS

Let’s start with a look at Birth Control Pills: First, and most importantly, it’s important to realize that birth control pills aren’t for contraception only! Yes, you might have used them in the past to prevent pregnancy, but if you’re prescribed them due to early menopause, POF, or perimenopause, you’re not taking them for the contraceptive reasons as much as you are taking them to boost your hormone levels.

When They’re Usually Prescribed....and Why

Most often, your doctor will suggest birth control pills for you if you’re perimenopausal -- that is, you’re still getting your periods, you’re not testing at post-menopausal levels, and you haven’t been diagnosed with POF or early menopause. In this case, it’s likely that your doctor has suggested bcps as a way of helping you cope with symptoms. This is becoming a fairly common treatment, because, although you’re getting menopausal symptoms (like hot flashes, night sweats, and so forth), you’re still producing a fair level of hormones on your own. And, unlike typical HRT which supplements hormones in your body, birth control pills literally take over.

They override your own hormonal production -- in effect, signaling your ovaries to take a breather and stop producing estrogen and progesterone -- and supplant it with the hormones in the pills themselves. In other words, you get just what is in the bcp. You’re not adding hormones on top of what you’re producing on your own, but literally replacing them.

This is a key reason bcps are often prescribed if you’re perimenopausal and going crazy with symptoms: In perimenopause, you’re still producing non-menopausal (that is, higher) levels of estrogen and progesterone on your own, so adding more hormones (as you would if you went on standard HRT) might actually make you feel worse. Your hormone levels are usually fluctuating a great deal in perimenopause, so there could be days when HRT would provide you with too much....and wind up causing symptoms from excess estrogen or progesterone. In addition, since irregular bleeding is often one of the mostly widely experienced symptom of perimenopause, bcps will regulate your bleeding.

All in all, you’ll get a set, steady amount of hormones that won’t fluctuate according to your own ovarian production.

If you’ve been diagnosed with early menopause (EM) or premature ovarian failure POF), though, it’s a somewhat different story. In this case, the issue isn’t simply helping with symptoms, but also making sure your hormonal levels are high enough to prevent consequences like osteoporosis. Many doctors feel that younger women with low estrogen levels need higher dosages of estrogen than that in standard HRT -- and the estrogen in birth control pills is more potent than that in regular HRT. This is one of the key reasons doctors may suggest going on birth control pills for women with EM or POF.

The estrogen in birth control pills is a synthetic form called ethinyl estradiol. It’s a potent form of estrogen that is roughly four to ten times stronger than that used in different types of HRT. Because it’s so much stronger, a number of doctors feel it’s a wise choice for younger women going through POF or EM, as young women’s hormonal needs are often far higher than those of older women in menopause.

Pros: If you’re perimenopausal, the big plus with bcps is, as stated before, the fact that you’re not adding hormones on top of what you’re producing on your own -- so you wind up with a very steady level of estrogen and progesterone, helping you stop the hormonal roller coaster -- and the irregular bleeding -- that’s so very common in perimeno.

If you have POF or EM: here too the notion of having your hormones set at a stable level can be a big plus. In addition, the strength of the pill as compared to HRT might be needed, since often younger women find that they don’t necessarily do as well on standard dosages of HRT.

There are other benefits from the pill as well that apply to both situations: Studies have shown that it helps prevent osteoporosis (a definite plus for young women going through POF or EM, since bone loss due to low estrogen levels tends to be rapid and can be severe, and reduces your risk of ovarian and endometrial cancer, as well as benign breast disease (fibrocystic breasts). Some studies also have suggested that bcps may help protect you against colorectal cancer, uterine fibroids and rheumatoid arthritis, but, in these cases, the jury is still out.

Cons: The synthetic estrogen in birth control pills also has its drawbacks. It is less easily metabolized -- which makes your liver work harder. There have been studies linking use of birth control pills with an increase in strokes and blood clots -- one reason why doctors will tell you not to go on the pill if you’re over age 35 and smoke, have untreated hypertension, or a history of stroke, and other blood clot related disorders (such as thrombosis or pulmonary embolisms). Bcps also may cause breast tenderness or nausea.

In addition, there seems to be some debate where pregnancy is concerned. Some doctors hold that the pill won’t act as a contraceptive for women with POF; others feel that, if you’re hoping for a pregnancy, the pill isn’t your best choice. Finally, while there are a number of different bcps available, there isn’t the wide range of options that there is in HRT. Birth control pills always consist of synthetic estrogen and progestin; there’s no patch form; and while you can get different doses, there aren’t as many as with HRT.

 

HORMONE REPLACEMENT THERAPY

Now for a quick look at Hormone Replacement Therapy (HRT). This is the standard type of hormone replacement given to women who have low hormone levels. Unlike bcps, HRT doesn’t suppress the production of our own hormones, but adds hormones to our bodies. Even after menopause your ovaries produce hormone -- although at much lower levels than in the past. But since the levels are so low and don’t fluctuate the degree that they might in perimenopause, adding hormones via HRT typically doesn’t cause the same problems they might if you’re still producing pre-menopausal levels of hormones.

When They’re Prescribed and Why

Usually, hormone replacement therapy is prescribed once you’ve tested at post-menopausal levels (that is, your FSH is high and your estradiol -- the primary human estrogen -- low. For specific hormone levels, see Hormone Testing). Because women going through POF or EM still get their periods sometimes -- even though their hormone tests come in as post-menopausal -- the typical menopause rule of thumb of "wait until your periods are done for one year before HRT" doesn’t really apply. In the case of us younger women, the numbers tend to be the crucial factor.....and the impetus for a doctor to suggest HRT.

The theory behind this is simple: Low estrogen levels -- particularly in a young woman who is exposed to low estrogen long before the "normal" age -- can lead to serious consequences, such as osteoporosis and cardiovascular problems. So replacing the hormones helps prevent these problems and, at the same time, can help us cope with symptoms ranging from hot flashes to mood swings to vaginal dryness. In addition, on the quality of life side of things, often replacing hormones can make us feel better again.....like our own ages.

There has been -- and probably will continue to be -- a great deal of debate about the use of HRT; its risks and benefits, and so forth. But on the whole, there seems to be little debate about its use for younger women, that is, women with POF or EM who are not producing the usual levels of hormones for their age.

But what about perimenopause? What if you haven’t been diagnosed with either POF or EM, but have been getting symptoms.....and are either considering HRT or have had your doctor suggest it? Well, in some cases, doctors do prescribe regular HRT for women going through perimenopause. It’s still not as common as being prescribed bcps, but it appears to be done more often than in the past, perhaps because of the introduction of more very low-dose estrogens. Usually, if you’re perimenopausal, HRT is prescribed to help you deal with symptoms, since the risk of osteoporosis

Pros: Flexibility -- there are a wide range of options open to you where HRT is concerned, not only different dosages, but also different forms -- i.e. patches vs. pills.

Cons: If you’re perimenopausal: Because regular HRT doesn’t suppress your own hormone production, you might experience heavier bleeding and other side effects....due to excess hormones. Doctors sometimes suggest that perimenopausal women on HRT get regular ultrasounds and/or uterine biopsies to keep track of the uterine lining.

The bottom line? There are clearly are differences between bcps and HRT....but either can work well depending upon your specific situation. As always, the only thing that matters is YOU -- how you feel, what you’re comfortable with, and what makes you feel best.