Birth control pills or HRT? What’s the Difference? Why are they prescribed? And which one is right for me?
This helpsheet provides the best in-depth comparison of birth control pills and hormone replacement therapy (HRT), answering these questions and more.
Some of us going through early menopause or premature ovarian failure (POF) 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 I on one and not the other? As you’d expect, there are really no simple answers.
That said, though, we’ve set about explaining this issue, the pros and cons of each — and the reasons your doctor may have prescribed one or the other of these for you.
Birth Control Pills
Let’s start with a look at Birth Control Pills: first, and most importantly, 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 likely not taking them for the contraceptive reasons as much as you are taking them to boost your hormone levels.
When They’re 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, your hormones aren’t 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 birth control pills 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 pill. You’re not adding hormones on top of what you’re producing on your own, but literally replacing them.
This can be a welcome relief in stabilizing your hormones during perimenopause — a time when fluctuating hormones can be the source of problems.
It’s also a key reason why birth control pills are often prescribed if you’re perimenopausal and suffering 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.
All in all, you’ll get a set, steady amount of hormones that won’t fluctuate according to your own ovarian production.
In addition, birth control pills can regulate your bleeding. This can be a great help since irregular bleeding is one of the mostly widely experienced symptoms of perimenopause.
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 most commonly 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, most doctors feel it’s a wise choice for younger women going through POF or early menopause, as young women in menopause are lacking the hormone production of their peers of a similar age.
Pros
If you’re perimenopausal: the big plus with birth control pills 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.
This helps stop the hormonal roller coaster — and the irregular bleeding — that’s unfortunately so very common in perimenopause.
If you have POF or EM: here too the possibility 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 suggest that contraceptive pills may help prevent osteoporosis. This is 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 (1).
It may also reduce your risk of ovarian and endometrial cancer, as well as benign breast disease (fibrocystic breasts) (2).
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 may 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) (3).
Birth control pills also may cause breast tenderness or nausea. While these side effects are highly subjective, they have been reported by some women.
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. This is something that requires close examination with your doctor.
Finally, while there are a number of different birth control pills 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 birth control pills, HRT doesn’t suppress the production of our own hormones, but adds hormones to our bodies on top of what we do (or don’t) already have.
Even after menopause your ovaries produce hormones — although at much lower levels than in the past. But since the levels are so low and don’t fluctuate to 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 follicle stimulating hormone (FSH) is high, and your estradiol — the primary human estrogen — is low). For specific hormone levels, see our Hormone Testing helpsheet.
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, our hormone level test results tend to be the crucial factor and the impetus for a doctor to suggest HRT.
The theory behind this is simple: Low estrogen levels can lead to serious consequences (such as osteoporosis and cardiovascular problems), particularly in a young woman who is exposed to low estrogen long before the “normal” age of menopause (4).
So replacing the hormones may help 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, an emotional sense like we’re “back” at our own age.
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 premature ovarian failure (POF) or early menopause (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 birth control pills, 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 and you’ve been prescribed HRT, it’s intended to help you deal with your immediate symptoms. In the specific sub-population of EM and POF sufferers, HRT may be used to lower the already elevated risk of osteoporosis. However, if you’re going through perimenopause at the “normal” age, your risk of osteoporosis is not as dramatically elevated as it is in these women.
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.
These can be explored with your doctor to identify the one that is best suited to your needs.
Cons
If you’re perimenopausal: Because regular HRT doesn’t take the place of your own ovarian hormone production (like birth control), you might experience heavier bleeding and other side effects due to excess hormones.
Doctors will sometimes suggest that perimenopausal women on HRT get regular ultrasounds and/or uterine biopsies to keep track of the uterine lining.
Finally, the highly publicized Women’s Health Initiative (WHI) study generated significant fear regarding the health risks linked with HRT use.
Although this study did not follow women going through early menopause specifically, the entirety of the evidence in favor and against is still worth bearing in mind while discussing HRT with your doctor.
Summary
There are clearly significant differences between birth control pills and HRT in the way they’re used, and the way they affect your body. Nevertheless, both can be very effective. The one that is best suited to you will depend upon your specific situation. As always, the only thing that matters is you — how you feel, what you’re comfortable with, and what is best for your health and wellbeing. These are the issues we encourage you to explore with your doctor to identify a regimen that meets your needs, whether this is with or without hormone replacement.
