Perimenopause symptoms like hot flashes, mood swings, heavy periods, and brain fog can make midlife feel like one long uphill climb. If you’re exploring your options to feel better, you’ve probably heard about hormone replacement therapy (HRT), also called menopause hormone therapy (MHT). But if you’ve asked your doctor about it, they may have suggested something you thought you left behind in your 30s: the birth control pill.
For many women navigating perimenopause, the pill can smooth out hormone fluctuations and ease frustrating symptoms. But is HRT the better option? Both treatments have pros and cons, and the best choice depends on your symptoms, health history, and personal preferences, say OB-GYNs.
About the Experts
Margaret Baum, M.D., FACOG, is a women’s health specialist and OB-GYN. She is also the medical director for Planned Parenthood Great Rivers.
Monica Christmas, M.D., is a NAMS-certified menopause practitioner. She’s also the associate professor of obstetrics and gynecology and the Menopause Program Director at the University of Chicago Medicine.
Robin Noble, M.D., is a NAMS-certified menopause practitioner and gynecologist with over 20 years of experience. She’s also the chief medical advisor for Let’s Talk Menopause.
Birth Control During Menopause
If you broke up with the pill years ago, it may be time to give it a second chance as you navigate the rollercoaster of perimenopause. “Managing perimenopause is often more challenging than managing menopause,” says gynecologist Robin Noble, M.D.
“Contraception is really great for preventing pregnancy, but it’s really good for other things, too,” says menopause specialist Margaret Baum, M.D.
One big perk: It helps regulate heavy and irregular periods, which are common in perimenopause. “[In perimenopause] your ovaries are still functioning and producing a lot of hormones, sometimes at erratic times and levels,” says Noble.
As you approach menopause, your body experiences fluctuating levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which trigger ovulation and regulate your menstrual cycle (1). These shifts in FSH and LH can lead to irregular ovulation—or no ovulation at all. When your body goes long stretches without releasing an egg, the uterine lining builds up and can eventually result in heavy flows.
Birth control helps here in the same way it prevents pregnancy: it prevents ovulation. It delivers a steady, level dose of estrogen and progesterone, suppressing LH and FSH production—essentially overriding your body’s erratic signals and regulating your cycle.
The big difference between contraception and HRT is the type and dose of hormone. Birth control’s mission is to suppress ovulation, which requires a heftier dose of estrogen and progesterone. That’s important, given the dose has to be strong and potent enough to overpower hormone fluctuations in perimenopause so that they balance out. With HRT, the goal is to replenish declining hormone levels to manage symptoms and protect your health, the experts explain.
Does the pill delay menopause?
Birth control pills won’t delay menopause, but they can mask its arrival, Noble says. Since the pill suppresses your cycle, you won’t know when your ovaries stop working (aka, your period stops forever). However, your doctor can clue you in on when might be the best time to stop birth control based on when your perimenopause symptoms began. (However, this gets a bit more complicated if you’ve already been on the pill, as it can also mask perimenopause symptoms.)
Most women will arrive at menopause in their early 50s, but some experience it earlier and others later (2). “You [may] start to experience symptoms related to hormonal fluctuations up to seven to 10 years before your period actually stops, and often that’s the most symptomatic timeframe for people,” says Christmas.
During perimenopause, HRT won’t stop heavy bleeding like hormonal contraception can. In addition to reducing heavy bleeding, the experts say certain types of hormonal contraception can help ease other perimenopause symptoms. Some may also protect you from ovarian and uterine cancers and prevent bone loss (3, 4).
HRT also preserves bone mineral density. Research has shown HRT may slightly increase your risk of ovarian cancer, but that’s only true for combined therapies consisting of estrogen and synthetic progesterone (progestin) (5, 6, 7).
Combined Oral Contraceptive (COC)
Combined oral contraceptives, or COCs, contain synthetic estrogen (ethinyl estradiol) and progestin, which stop ovulation. By stabilizing your hormones, COCs help regulate your menstrual cycle and mood. They may even dial down the frequency and intensity of hot flashes.
Like COCs, HRT can contain synthetic hormones, too. Though HRT can also consist of bioidentical hormones, which are lab-made hormones from plants that mimic the ones your ovaries produce. (For context, ethinyl estradiol is much more potent than bioidentical estrogen, or estradiol.)
Progestin-only options
If estrogen isn’t a good fit for you due to health risks like blood clots or stroke, progestin-only options are available and can tame heavy bleeding. These include the progesterone-only pill (POP) and hormonal IUDs.
Research published in 2020 suggests that progestin-releasing IUDs may be more effective in reducing heavy menstrual bleeding and improving quality of life than other treatments (8).
Vaginal ring
The circular, insertable device delivers synthetic estrogen and progestin, which can help regulate your menstrual cycle, improve vaginal lubrication, and reduce night sweats.
Potential side effects and risks
The most common side effects of birth control (at any age) are similar to those of HRT: breast tenderness, spotting or bleeding, and headaches. These usually subside within two to three months of starting the pill (9).
However, birth control—especially options with estrogen—can carry additional risks as you age. After 35, some women aren’t good candidates for COCs in particular because their risk for other health complications (such as blood clots) increases, Noble says. Since your liver metabolizes the hormones in COC pills, women with an increased risk of blood clots (like smokers in particular) should avoid them (10). If you’re a smoker or you have hypertension, oral contraceptives can increase your risk of cardiovascular disease (11).
COCs can also cause vaginal dryness, but using vaginal estrogen can help offset those symptoms. Noble suggests nonhormonal birth control is an option for people in perimenopause, it just depends on your symptoms. Consider asking your doctor which option is best for you.
Perimenopause Symptoms
Birth Control
HRT
Heavy Bleeding
Yes
Somewhat
Osteoporosis
Yes
Yes
Vaginal dryness
Only vaginal ring
Yes; especially topical/local treatment. Systemic may provide some relief, too
UTIs
No
Yes; only topical/local therapy, not systemic.
HRT During Perimenopause
As you move closer to menopause, estrogen and progesterone fluctuations start to peter out and eventually naturally stabilize at a steady low level. If you’re on birth control, switching to a low-dose HRT when you reach menopause can help combat symptoms safely.
Instead of overriding your body’s natural hormone fluctuations, HRT replenishes declining estrogen and progesterone. The goal isn’t to suppress ovulation; it’s to alleviate and improve symptoms like hot flashes, brain fog, and vaginal dryness.
Most women will reach menopause by the time they hit 55, which is when many switch from the pill to HRT, says NAMS-certified menopause practitioner Monica Christmas, M.D.
However, there are several instances where it makes more sense to start with HRT and forgo the pill altogether. HRT, specifically vaginal estrogen, can be especially effective at targeting symptoms like vaginal dryness and pain during sex in perimenopause, Noble explains. Another instance where HRT is the right choice from the get-go? If you have high blood pressure or high blood clot risk, HRT—particularly estradiol patches—is a better option than estrogen pills or combined birth control because the hormone dose is lower, Christmas says. Also, if you’re prone to UTIs, vaginal estrogen can help lower your risk (12).
Finding the right dose of and delivery of HRT is a personalized process. It’s all about customization, says Noble. A knowledgeable provider or menopause specialist can tinker with formulations and delivery methods until you find what’s best. Christmas concurs: “If one treatment doesn’t work, we will pick another. If it works, we’ll stay with it. If not, we can add to it, tweak it, or choose something different.”
How long can you stay on HRT?
How long you stay on HRT depends on your health, symptoms, and preferences. “There’s not a right answer,” says Noble. Some women stay on HRT for the long haul. Experts have differing opinions on long-term HRT, so it’s important to talk to your doctor about your unique risks.
“[The decision] needs to be individualized,” Noble says, adding that your doctor will consider your quality of life, weighing the benefits of HRT against any potential risks. Regular check-ins with your doctor will help make sure your treatment stays safe and effective as your body’s needs evolve.
Potential side effects and risks of HRT
A few common side effects of HRT include mood swings, irregular bleeding, and breast tenderness (13). There are also risks to consider: HRT may amplify your health risks if you have a history of breast cancer, coronary heart disease, or stroke (14, 15, 16).
The Bottom Line
Both HRT and birth control pills help treat perimenopause symptoms. Birth control delivers a steady dose of estrogen and progestin to stabilize fluctuating hormones, which helps control heavy and irregular bleeding. HRT replenishes estrogen and progesterone to ease symptoms like hot flashes and vaginal dryness. Your doctor may start you on birth control when you begin to experience perimenopause symptoms, then switch you to HRT once you’re closer to or at menopause. Weigh the pros and cons of each with your doctor so you know which route is right for you.
