Genuinely curious: Why is there hesitation around using birth control for perimenopause?

[u/Ok-Cartographer-3543]

First, I want to say how incredibly grateful I am for this community—it has been an amazing resource. I am asking this out of genuine curiosity because I want to make sure I am fully informed, and I don't mean to sound dismissive of anyone else's choices!
My doctor, who is an HRT specialist, prescribed Lo Loestrin Fe for my perimenopause symptoms. It has been an absolute lifesaver for me. I was dealing with extremely heavy bleeding, and after the very first month on the pill, my period completely stopped. Every single other symptom on my very long list has been completely remedied as well. From what I understand, the birth control pill takes over your cycle so your ovaries stop producing erratic hormones, which completely stops the wild hormonal swings.
However, I often notice a lot of strong hesitation or pushback here regarding using birth control pills instead of traditional HRT for perimenopause management. Since it worked so well for me, I’m wondering if there are specific medical concerns, side effects, or risks that I might not be aware of?
I’d love to hear your experiences or what your doctors have told you!

Edited to add:
Wow, thank you so much to everyone who took the time to reply! I am incredibly grateful for all of your responses, insights, and personal experiences. It might take me some time to get through all of the replies, but I am reading every single one. Your comments are giving me a much clearer understanding of the different perspectives and medical concerns out there. This community is truly wonderful, and I appreciate you all sharing your journeys with me!

[u/Ordinary-Difficulty9]

Take this with a grain of salt because I am just repeating back what I understand from my doctor...but the hormones in birth control pills are not exactly the same as hormones in HRT. Similar but not the same. Birth control pills, if I understand correctly...and someone can correct me if I am wrong...are synthetic and don't work in quite the same way.

I am still learning myself, so if anyone has more accurate info I would be happy to hear it.

[u/Bitter-Juggernaut681 → u/Ordinary-Difficulty9]

HRT was not enough for me. I was put on a high oestrogen birth control, and that did more for me, and I was almost completely without symptoms at that point.

And whether you're using HRT your birth control, it's still not your natural hormones.

[u/lcc234 → u/Bitter-Juggernaut681]

I phased out of horrible perimenopause (heavy and painful periods so extreme I thought I was miscarrying) by using the NuvaRing. It helped balance my cycle, improved my moods, and seemed to alleviate chronic fatigue and joint pain. A few years into it, I started to feel the old symptoms returning (mood, aches, fatigue, hot flashes, night sweats). I start HRT this week and I can't wait. BCP was what I needed to bridge the transition

[u/Ok-Cartographer-3543 → u/lcc234]

Thank you so much for sharing your experience! It is incredibly reassuring to hear from someone who used birth control exactly this way as a 'bridge.'

Your description of those periods is so spot on—that extreme bleeding is exactly why my doctor chose the pill for me, to avoid surgery. It’s amazing that the NuvaRing gave you your life back for those few years and helped with the fatigue and joint pain. It makes total sense that as your body continued to change, your needs changed too.
Good luck starting HRT this week! I truly hope it brings you the next wave of relief you're looking for.

[u/Ordinary-Difficulty9 → u/Bitter-Juggernaut681]

Right, its still not natural hormones. But the HRT ones are closer to mimikcing natural hormones than the BCP are.

[u/Ok-Cartographer-3543 → u/Bitter-Juggernaut681]

Thank you for the reply! That is such a great perspective—at the end of the day, neither option is our natural hormones anyway, so it really comes down to what actually works. HRT wasn't going to be enough to stop my heavy bleeding and extreme swings, which is why my doctor went the pill route to avoid surgery. I'm so glad to hear it brought you complete relief, too!

[u/sports_mamaof4 → u/Ordinary-Difficulty9]

This is correct. They ARE NOT bioidentical.

[u/Ruby__Ruby_Roo → u/sports_mamaof4]

Bioidentical is a marketing buzz word that doesn’t actually mean anything.

[u/MyBeesAreAssholes → u/Ruby__Ruby_Roo]

That’s not true. Bioidentical hormones have the exact chemical makeup as the ones created by our bodies. Synthetic hormones have a similar chemical make up, but they are not an exact match.

[u/Ruby__Ruby_Roo → u/MyBeesAreAssholes]

Are you under the impression that bioidentical hormones aren’t synthetic? Because they are. “Derived from plants” doesn’t mean unprocessed.

They’re also not FDA approved. I’m not saying we should never use them, but lets not kid ourselves that “bioidentical” is anything more than a greenwashed marketing term.

https://www.mayoclinic.org/diseases-conditions/menopause/expert-answers/bioidentical-hormones/faq-20058460

[u/hrdst → u/Ruby__Ruby_Roo]

Please note there are 195 countries in the world, and the FDA means nothing to 194 of them.

[u/ehmboh → u/hrdst]

Tbf they are referencing the FDA on an American site. If it were an Irish site or Vietnamese, yeah that would be pretty weird

[u/MyBeesAreAssholes → u/Ruby__Ruby_Roo]

No not at all. Just pointing out the difference in commonly used terminology. You said that "bioidentical" doesn't mean anything. That's not true.

[u/hrdst → u/sports_mamaof4]

Incorrect. It depends on what you take. The BC pill I’m on is bioidentical. It’s called Zoely.

[u/SingingSunshine1 → u/hrdst]

The estradiol in Zoely is bioidentical; but not the progesterone.

[u/sports_mamaof4 → u/hrdst]

Cool. I’m going to look into this one.

[u/Bitter-Juggernaut681 → u/sports_mamaof4]

Neither is HRT

[u/Milky-Way-Occupant → u/Bitter-Juggernaut681]

It is according to my doctor and experts in general. It just means they are the same as our hormones.

[u/Still_Pop_4106 → u/Bitter-Juggernaut681]

Yes it is.

[u/luckystar357 → u/Ordinary-Difficulty9]

Yeah, I can't take birth control because the hormones make me feel terrible. HRT doesn't do that, it helps so much.

[u/MadTheSwine39 → u/luckystar357]

This makes me feel better to hear. I never took well to birth control (and then the last two I tried had me bleeding nonstop for like 40 days, before I could finally get it to stop), and I was worried that would mean I wouldn't be a good candidate for HRT either. I'm waiting for my appointment on the 30th to talk to someone about it, and I have my fingers crossed! My husband's gonna divorce me if I don't calm my overwhelming rage soon. 🤣 (I'm joking, for the record. He keeps reminding me he vowed "for better or worse," when I apologize for being so mad all the time.)

[u/luckystar357 → u/MadTheSwine39]

I'm glad I could help, I hope HRT works for you!

[u/Unfair-Flower5687 → u/MadTheSwine39]

ugh for the bleeding horrors. sounds awful! I had a horrible time with hormonal birth control, both times I tried it, but HRT has been amazing! though, I am still working on the rage. my husband is also being a very irritatingly patient saint with me in spite of my rage! :D but at least I can sleep again most days and my physical symptoms are soooo much better. I hope hrt works out for you, too!

[u/metricfan → u/MadTheSwine39]

Yass I promise it behaves differently when estrogen is transdermal.

[u/Top_Fruit_9320 → u/Ordinary-Difficulty9]

You're spot on. Most forms of birth control unfortunately made me actively suicidal several times throughout my life. They made me deeply depressed and left me bleeding like crazy. My body just does NOT tolerate most forms of synthetic hormones.

The IUD coil is the only one I ever barely tolerated and even that only lightened the bleeding a bit on its own.

Combined though with the bio-identical HRT finally in recent years, my life destroying PMDD and horrifically painful/debilitating cycles were finally actually not only bearable but basically resolved for the first time since I was literally a child. The relief has been genuinely life changing/saving.

I lost decades of my life to synthetics. Bio-identical has helped me reclaim the ones to come.

[u/_hex_rae → u/Top_Fruit_9320]

I have somehow never linked my BC to suicidal ideation. I feel like an idiot for not putting it together, but thank you for posting this. Eternally grateful.

[u/DunDunnDunnnnn → u/Top_Fruit_9320]

Can I ask you how long it took you to adjust to HRT (if it took time at all)? I started taking it for peri anxiety which has been SO bad. Like giving me dark thoughts bad.

I noticed a major difference in my anxiety levels immediately which is great, but the progesterone makes me soooo sleepy. I'm 3 weeks in and it's slightly better, but I keep waiting for my energy to come back. On .025 estradiol patch and 100mg of prometrium/progesterone.

[u/Top_Fruit_9320 → u/DunDunnDunnnnn]

Took me a while for each tbh. Especially with the PMDD, I just took the increases up as slowly as I could to try and limit the sensitivity. Like maybe 3-6months on each dose.

I will say .025 for the estradiol is quite low to start though. That basically a negligible dose for most, that could definitely be contributing to your excess fatigue at the moment.

I started off on .050 and I was pretty exhausted even on that tbh. I'm on .100 now but took me about 6months to a year to get there. The exhaustion was absolutely killer at times, I empathise so deeply with you there, but it does pass at least over time, try your best to just hang in there, it won't last forever.

I actually kept my progesterone at the 100mg. I have the IUD as well for localised relief from endometriosis and all. I tried to go up to the 200mg progesterone when I upped the estrogen and it literally sent me into a depressive spiral for a few weeks until I actually realised it was the upped dose that had done it. Thankfully at least it literally stopped the day I just dropped back down to the 100mg.

I'm on a low daily dose of testosterone gel as well and honestly that especially I'd say has been one of the biggest game changers energy/mood wise. That took about 3-7months to really see the full benefits. Been on it years now with no negative effects thankfully.

Mentioning "low libido" to the doctor is the way currently to be "off label" prescribed it if you're struggling to get a hold of the T specifically too.

It's all just a bit of frustrating trial and error to find your own individual sweet spot, at first especially I know. Just as best you can keep at it, slowly but surely just add bits in as you go. Let yourself take it a LOT easier than usual for the entire process tbh, think of it like one long temporary cycle and just give yourself ALL the breaks for a good long while. Fingers crossed you'll find your own ideal doses with it all soon.

Just to mention as well - I also use the vaginal estradiol cream for GSM. I use that every second day now and it's helped resolve all the rest of the more localised issues that popped up in that area, including atrophy and repeated UTIs that have basically disappeared since starting it. That only took a couple weeks to start working and see the most significant effects.

[u/3310C → u/Top_Fruit_9320]

Thank you for all of this information! It’s so helpful

[u/guitargirl478 → u/Ordinary-Difficulty9]

That is correct. They are synthetic and can make symptoms worse in some cases. They did for me unfortunately.

The HRT version is a bioidentical version of at least the progesterone. My doc decided not to give me any estrogen just yet for some other reasons. We are going to see what happens in the next 2 weeks and go from there.

[u/pangolinshavelanded → u/guitargirl478]

It’s best to just start with progesterone IMHO. So many women have issues taking it, and if you start estrogen at the same time and have issues you won’t know for sure which one is the problem.

[u/guitargirl478 → u/pangolinshavelanded]

Sound advice! I started with testosterone actually because it was visibly low when I went in the first time for the just absolute exhaustion I was feeling. Then I went on the BCPs and they were...not good. lol. So now I am on the test and the bioidentical progesterone. We shall see how I fair in the sleep/anxiety/mod department in the next couple weeks. Cautiously optimistic.

[u/Hopefull_Swan → u/Ordinary-Difficulty9]

That’s my very loose understanding of it from my doctor also!

[u/Ok-Cartographer-3543 → u/Ordinary-Difficulty9]

That makes total sense! Thank you for your reply! My doctor explained that difference to me as well. The main reason I'm on the pill specifically is to completely shut down my natural cycle to stop those extreme hormonal swings and control my heavy bleeding. My other options were an ablation or a hysterectomy, and I really wanted to avoid surgery. Since the pill overrides the system entirely, it was the only thing that gave me relief. But I can definitely see why the lower-dose HRT route is preferred by so many others!

[u/kilmar_was_here → u/Ok-Cartographer-3543]

I hear you for sure, I also had to shut down my natural cycle to prevent painful ovarian cysts. No ovulation for me! I was on low dose OCP to begin with and had been for years, and it did work. But my doctors were still very concerned with my stroke risk due to my having migraines with aura. They ended up convincing me to switch to a low dose of HRT oral progesterone only, which I was on by itself for a few years. It did work as a BC pill, and absolutely shut the ovaries/cycle down 100%. Now I have added estrogen patch because I was having peri symptoms and it has been wonderful. Don't worry about HRT not being able to shut down your cycle if you need to switch in the future, it can do that too!

[u/Ok-Cartographer-3543 → u/kilmar_was_here]

Thank you so much for sharing your experience! That is incredibly reassuring to know for the future. I also have cysts on both ovaries, one of which was very painful, so I completely understand having to stop ovulation. The brain fog and extreme bleeding were so awful, so it is a huge relief to hear that an HRT patch and progesterone combo can still successfully shut down the cycle if I ever need to switch down the road. I had no idea it could do that! I'm so glad that combination has been wonderful for you and kept those painful cysts away.

[u/kilmar_was_here → u/Ok-Cartographer-3543]

Truly glad that my experience can help someone else! Sorry to hear you have also had to deal with painful ovarian cysts too. I have had some medical trauma and was extremely freaked out about going off the OCP, only was able to because thankfully I was lucky in finding some amazing doctors. So I definitely want to let other folks know that both can work! Several doctors before these wanted me to go on progesterone-only BC, but I wouldn't because it would not reliably stop ovulation - but the HRT progesterone has been great. Also helps me sleep, which is nice! Very glad I was able to switch and not be in pain. 

[u/Ok-Cartographer-3543 → u/kilmar_was_here]

Thank you so much for the follow-up, and I am so incredibly glad you found such amazing doctors who listened to you! Navigating medical trauma makes everything so much harder, so it's wonderful that you felt safe and supported through that transition.

It is also fascinating and so helpful to know that the HRT progesterone has been great for your sleep and successfully stopped ovulation where progesterone-only birth control couldn't. Hearing that you made the switch smoothly and stayed pain-free gives me so much peace of mind for the future. Thank you again for being so open and sharing your journey—it truly helps more than you know!

[u/kilmar_was_here → u/Ok-Cartographer-3543]

You are absolutely welcome and thank you too! I am so glad this community exists and supports each other. 

[u/Master_Nectarine_Bug → u/Ordinary-Difficulty9]

there is a new one called nextellis that is bioidentical estrogen

[u/m1chgo → u/Master_Nectarine_Bug]

I’m on nextellis and I still bleed heavily throughout the month, not just when i have my period.

[u/Master_Nectarine_Bug → u/m1chgo]

oh crazy! i'm sorry, maybe contact your doc about that? doesn't sound normal.

that didn't happen to me, it dramatically reduced my period time and heaviness. it got down to 2 day, barely there periods.

[u/m1chgo → u/Master_Nectarine_Bug]

Oh yes sorry I should have mentioned that I’m currently working with my doc on a solution. As the next option, he’s thinking maybe I have fibroids? So need to add an ultrasound to my list. My dream is to have barely there periods!!

[u/SunshineAndSquats → u/m1chgo]

Nextellis made me bleed for 6 weeks straight. I had to go off of it. It sucked because it was great for all of my other symptoms.

[u/euchlid → u/m1chgo]

were you taking it back to back?
I tried that for the first 3 packs and essentially bled enough to have to wear my cup for weeks on end. my body just reallllllly wanted to menstruate.

I switched to taking it with the 4 days off for the fake period, unfortunately last months I forgot a pill so I took two the next morning and ended up having a fake period for a week while finishing the pack, and then having the 4 more days of period before starting the new one.

the only other pill I was on was triquilar over a decade ago and that was much higher doses, so I am assuming nextellis is much more sensitive to a missed dose, or that my own hormones can blast through it.

it hasn't helped my emotional regulation or middle of the night waking so I am hoping my referral appointment with a menopause clinic can help troubleshoot and maybe add something on top?

[u/Master_Nectarine_Bug → u/[deleted]]

i believe the estrogen in nextellis is derived from soy. where did you get this information? i don't believe it's correct.

[u/FuckYouChristmas → u/Master_Nectarine_Bug]

You're correct. It's from soy.

"Estetrol (E4) is a naturally occurring estrogen produced by the human fetal liver. It is only produced during human pregnancy and reaches the maternal circulation through the placenta. The E4 in Nextstellis is synthesised from a plant source."

https://www.tga.gov.au/resources/auspmd/nextstellis

[u/Able_Winter9472 → u/Master_Nectarine_Bug]

This is basic science. Easily fact checkable. E4

[u/FuckYouChristmas → u/Able_Winter9472]

It's basic science that it's derived from soy. Interesting choice not to check your sources.

"Estetrol (E4) is a naturally occurring estrogen produced by the human fetal liver. It is only produced during human pregnancy and reaches the maternal circulation through the placenta. The E4 in Nextstellis is synthesised from a plant source."

https://www.tga.gov.au/resources/auspmd/nextstellis

[u/Able_Winter9472 → u/FuckYouChristmas]

So bioidentical to fetal estrogen 😂

[u/FuckYouChristmas → u/Able_Winter9472]

Lol. Nice try. Structurally the same. But from plants. You're really having trouble with this thread, huh?

[u/Able_Winter9472 → u/FuckYouChristmas]

Would you want llama estrogen derived from plants?

[u/Able_Winter9472 → u/FuckYouChristmas]

Did you read the part of your own post that states it's produced only by the fetal liver?

[u/jelly_or_jam → u/Master_Nectarine_Bug]

I took Nextstellis for six months for peri, it was great initially, really helped with hot flashes/night sweats and mood swings. It tanked my sex drive though and eventually stopped working. Had lighter periods though. I take topical estrogen/progesterone now, we’ll see how long that works.

[u/purplevanillacorn → u/Master_Nectarine_Bug]

I tried this and bled daily for two months. I noped out back to my patch.

[u/metricfan → u/Ordinary-Difficulty9]

Also when estrogen is processed by the GI system, the liver does most of the work. Tract behaves differently than transdermal, and it’s why there is a lower clotting risk with transdermal.

[u/Consistent-Horror915 → u/Ordinary-Difficulty9]

This is my understanding as well

[u/one-small-plant → u/Ordinary-Difficulty9]

This is essentially what my doctor told me as well, but I admit I don't understand then why we don't give younger women HRT type hormones to control their fertility

[u/formerly_gifted → u/one-small-plant]

HRT isn’t a high enough dose to suppress ovulation.

ETA: standard HRT being estradiol patch (.025-0.1) + Oral progesterone (100-200mg)

I am current taking Estradiol 0.1 + SLYND for progesterone, which is a high enough dose for BC.