Birth Control Pills Vs. Hormone Replacement Therapy

Answering your questions about the difference between birth control pills and HRT, perimenopausal insomnia, and iron infusions

Time for a Q&A to answer your questions about:

· The difference between birth control pills and hormone replacement therapy

· Treating insomnia with hormones

· Can iron infusions cause irregular periods?

Enjoy! And remember to e-mail your questions to gillian@thesavvypatient.com or leave them in the chat

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Q: Hi! I am 46 years old and went through a grueling three-month period of perimenopausal insomnia and anxiety a year and a half ago. Prior to this, I had no sleep or anxiety issues. Fortunately, going on a low-estrogen birth control pill did the trick and resolved my symptoms. However, of late I’m noticing the sleep issues (mainly just simply not feeling tired) returning. At what point do I consider going on a higher-dose estrogen pill (or another form of HRT)? And what are the potential risks of doing this? —No sleep ’til Jersey

A: There is nothing worse than lying in bed, staring at the ceiling, and willing yourself to sleep, but sleep issues in the perimenopausal years are common. In a review of sleep disturbance in perimenopause, researchers found 40% to 60% of women report difficulty with sleep during the perimenopausal transition. Your sleep disruption might come in one of a few flavors including difficulty falling asleep, difficulty staying asleep, or waking up too early. Different problems may need to be treated with different solutions.

When it comes to hormone therapy and sleep, the information we have is not complete. Let’s break down what we do know. There is data regarding estrogen reducing night sweats. Night sweats have been shown to wake women up in the middle of the night. So, when you treat night sweats you reduce the number of times women wake during the night. It is not clear whether estrogen actually helps you fall asleep. As a result, we don’t know if increasing the dose of estrogen will help when you close your eyes.

Progesterone in high doses taken at bedtime has been shown to improve sleep. Your pill contains a progestin (a synthetic progesterone-like substance), not progesterone. It is unclear if progestins improve sleep. You could consider switching to an estrogen patch, plus a progesterone capsule at bedtime. But, before you do this, you should know that the dose of progesterone studied for sleep is three times the dose of progesterone typically used for hormone therapy. That higher dose can cause a lot of side effects including bloating, constipation, and breast pain. Plus, this combination does not provide reliable contraception.

One option would be to try some evidence-based nonhormonal sleep options. Progressive muscle relaxation has been shown to improve sleep in perimenopausal and menopausal women. It is simple to do, and you can try it tonight. A specific type of cognitive behavioral therapy called CBT-I has also been shown to significantly improve sleep. Unfortunately, for this you need to find a certified practitioner, but if you are really struggling it may be worth the effort.

The Savvy Short: Problems with sleep are common in midlife. Progesterone (not progestin) has been shown to be helpful for sleep, but the role of estrogen is less clear.

Q: I am 39 and after my first iron infusion my body had a strong immediate response (mental clarity, hair and nails growing, etc.). I also started having irregular periods but they would regulate after a few months. My periods had very little bleeding and happened with 17 to 23 days in between. My PCP was concerned, and I started taking better notes since I have several other medical problems recently. After my third iron infusion a couple of months ago, I noticed between-period spotting and then missed a period. Could the iron infusions cause this menstrual irregularity? —Ferritin and Menstruation

A: Iron infusions can give women with severe iron deficiency and anemia significant and immediate symptom relief. The most common cause of iron deficiency in women during the reproductive years is heavy menstrual periods. In some cases, it is nearly impossible for a woman to get enough iron from her diet to make up for the iron lost with a heavy period. The iron deficiency and anemia that results can cause fatigue, hair loss, palpitations, and lightheadedness. In short, not having enough iron can make you feel pretty awful.

Despite how terrible iron deficiency anemia can make you feel, iron supplements taken orally can be a tough sell, too. Iron supplements, even those claiming to be “gentle,” can cause stomach aches and constipation. As result, intravenous (IV) iron infusions can be an excellent option.

There is no evidence that taking IV iron causes irregular periods. However, that’s partly because it’s difficult to study. Many of the women who are getting IV iron are doing so because they have heavy periods, and they may also have irregular periods. It isn’t safe to give people without iron deficiency these iron infusions, so designing a randomized-controlled trial to answer this question would be pretty challenging. (A randomized-controlled trial is the best type of study to show that one thing causes another.)

All that said, I also can’t think of a mechanism through which the iron would affect the hormones that regulate your menstrual cycle. There is no point in the feedback loop between the hypothalamus in the brain, the pituitary gland just below the brain, and the ovaries, in which iron is involved. Plus, it sounds like you have some other physical stresses right now and the feedback loop between the hypothalamus, pituitary gland, and ovaries is particularly sensitive to stress hormones. So, physical stressors like illness or surgery, and emotional stressors like work or family can disrupt the menstrual cycle. In your case this sounds like the more likely culprit.

The Savvy Short: Iron infusions can be a great treatment for severe iron deficiency. There is no evidence that they cause menstrual cycle changes.

Q: You talk about using birth control pills as hormone therapy. What is the difference between a birth control pill and HRT? Why do we make a distinction? —Anonymous

A: There are a few things that make birth control pills and hormone replacement therapy different. Those differences make them better suited to help manage different situations. Let’s start with birth control pills, and specifically combination birth control pills (as opposed to progestin only pills).

All combination birth control pills contain a type of estrogen called ethinyl estradiol and a progestin. Ethinyl estradiol is very similar to the estrogen our body makes. It has a single chemical modification that keeps it from getting metabolized too quickly so it can be taken by mouth. Different pills have different amounts of ethinyl estradiol (anywhere from 10 mcg to 35 mcg in modern pills), and different types of progestin.

The combination of estrogen and progesterone in birth control pills tells the pituitary gland not to make the hormones that drive ovulation. If you don’t ovulate you can’t get pregnant. But the estrogen in birth control pills also keeps the estrogen levels in your body stable which can help treat symptoms like hot flushes and mood changes. As a result, they can be an excellent form of hormone therapy especially for women in the late-reproductive stage and early perimenopause.

Usually when we talk about hormone therapy, we are also talking about estrogen plus progesterone. But, in this case, we will typically give the estrogen in the form of a patch or gel and it is identical to the estrogen that our bodies make. Progesterone can be taken as a pill or given in a combination patch with the estrogen. A progestin-eluting IUD (Mirena or Kyleena, are examples) can also get the job done and has the added advantage of providing contraception. There are also combination pills that contain estrogen and progesterone that are designed as hormone therapy, not birth control, but we use them less often these days.

It is hard to compare doses of estrogen taken as a pill to those of estrogen taking as a patch or gel, but in general hormone therapy provides less estrogen than birth control pills. The goal of hormone therapy is to provide a stable dose of estrogen, not to replace the estrogen the ovaries made during the peak reproductive years. Importantly, these lower doses of estrogen and progesterone aren’t high enough to suppress ovulation, so hormone therapy doesn’t provide reliable contraception (except when an IUD is used as the progesterone component).

In terms of risks, the biggest distinction is between estrogen in pill form and estrogen that is given through the skin (patches and gels). Oral estrogen in any dose is associated with an increased risk of blood clots. This risk is dose related, so the bigger the estrogen dose, the higher the risk. However, there is no increased risk of blood clots with estrogen given through the skin as a gel or patch.

The Savvy Short: Combination birth control pills contain estrogen and progesterone in doses high enough to suppress ovulation and prevent pregnancy. Hormone therapy is generally given in lower doses that do not provide contraception. Estrogen in pill form increases the risk for blood clots, but estrogen in a gel or patch does not.