Ready to talk to your doctor about hormones? Read this first.

How to address symptoms of perimenopause or menopause.

I was recently at a social gathering where a friend shared something with the group in shock. She was 43 and thus sure she ought to be on menopause hormone therapy. After all, that was what everything she read seemed to tell her. A good self-advocate, she went to her doctor to inquire about this. That’s where she received the surprising news that she already was on hormone therapy: She was on birth control pills.

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OK so maybe it shouldn’t be surprising that hormones are hormones — but it still kind of is, right? Given the way they’re discussed, you may be wondering what they do and when you need them. You’re not alone.

I knew who I had to call.

Cue the expert

Dr. Wen Shen is the director of the Women’s Wellness and Healthy Aging program at Johns Hopkins University in Baltimore, the clinical director of their Menopause Consultation service, and a renowned expert on the whole range of treatments and complementary therapies that can help a patient manage symptoms as they navigate midlife.

Shen said that starting in perimenopause, many people will begin to experience symptoms that impact quality of life. Significantly, many of these symptoms can impact your ability to sleep, which can lead to fatigue and brain fog and mood changes — not to mention increased risk of heart disease and early-onset dementia, Shen said.

“It’s not just ‘Hahaha — hot flashes!’ It is actual medical risks. So for women who are having severe night sweats, severe hot flashes — those need to be addressed because they can carry severe medical complications later in life,” said Shen.

Which brings us to birth control and hormone therapy, which are both medications that could be good solutions for many people.

Birth control

The primary difference between hormonal birth control and menopause hormone therapy is that the former can prevent pregnancy, by delivering higher doses of hormones, and the latter cannot. And for many people, contraception is a really important part of navigating midlife health.

People who conceive after the age of 35 are considered to have high-risk pregnancies; the risks of diabetes, preeclampsia and chromosomal abnormalities increase with age. There’s also the reality that after the age of 45, 50 percent of all pregnancies will end in miscarriage.

It’s why hormonal birth control can be such a good option for so many people throughout perimenopause. Not only does it prevent pregnancy, but the higher level of hormones designed to stop ovulation can also help provide relief for people experiencing severe symptoms.

Shen said she often prescribes birth control to her patients who are perimenopausal — people who still have ovarian function, if not regular ovarian function. Because birth control pills have higher doses of hormones in them than menopause hormone therapy does, they can be better at helping stabilize the big hormonal swings that are a defining part of perimenopause. The form of estrogen in birth control pills is also better at protecting against bone loss than that found in transdermal menopause hormone therapy products.

“Birth control pills are very good options, and there are such a huge range of birth control pills out there now,” Shen said.

But they’re still not a perfect fit for all people, since they may increase a person’s risk for blood clots, which in turn increases the risk of stroke and heart attack. This rare side effect is caused by estrogen being metabolized by the liver. Further complicating this is that the rates of high blood pressure, Type 2 diabetes and high cholesterol — all things that can increase the risk of blood clots — also increase with age.

“You need to be able to weigh the risks,” Shen said. And a conversation with your own provider about your medical history and symptoms is a crucial first step in determining whether birth control pills might be a good option for managing your perimenopause symptoms.

Menopause hormone therapy

Menopause hormone therapy doesn’t have the same risks for blood clots that hormonal birth control does, though, which can make it a good option for those who don’t need contraception or are at higher risk for developing clots.

Most estrogen used in menopause hormone therapy prescribed today comes in a transdermal 17β-estradiol format. These are the estrogen patches, gels, sprays and rings you have heard about — all products that do not have to be metabolized by the liver, and thus are lower risk than birth control pills.

If a patient doesn’t need contraception, Shen said she’ll suggest they try menopause hormone therapy first.

The transdermal products have lower doses of hormones than birth control pills since they aren’t aimed at suppressing ovulation.

And if you’re already on birth control and experiencing perimenopause symptoms? It’s time to talk to your provider about what else could work. Shen said that this might mean a different birth control, with a different hormone dosage. It might be an alternate form of contraception combined with menopause hormone therapy. It’s all about finding a provider who wants to work with you and is willing to stick with you to find the best way to help address your symptoms.

Shen stressed that there’s no one-size-fits-all solution that magically works for all people, so working with a skilled provider who knows the options and can think dynamically about potential combinations is critical.

What if hormones aren’t right for you?

Can’t take estrogen in any form because of your medical history but looking to manage your perimenopause symptoms? Great news — you still have non-hormonal medication options.

Shen points out that there are a few new medications known as KNDY agonists, Veozah and Lynkuet, that are approved by the Food and Drug Administration and are very effective for treating moderate to severe vasomotor symptoms like hot flashes and night sweats.

She also adds that a number of older medications have off-label applications for night sweats and sleep: SSRIs, gabapentin and Oxybutynin.

The real takeaway: Talk to your doctor, review your medical history and find the right medications for you. If your symptoms are impacting your quality of life, you deserve some relief.

How to figure out what you need and when

And if you are experiencing symptoms — recurrent urinary tract infections, sleep disruption, night sweats, mood changes — that are impacting your quality of life, don’t feel like you need to wait to be a certain age to discuss options with your doctor.

Shen recommends staying on hormonal birth control until you are 50 or 51, then stopping them for seven days to then get your hormone levels checked. If two months in a row, labs show that someone’s hormones are in the post-menopause range, they can stop the pills and see how they feel.

If they’re still having some symptoms, then they can evaluate what kind of menopause hormone therapy might help them.

No symptoms? Then you don’t necessarily need hormone therapy!

Yes, there’s a lot of talk about menopause hormone therapy and its benefits, but Shen reminds that it’s really intended for symptom management.

“Menopause hormone therapy is not meant to be a magic bullet to keep you forever young,” Shen said.