I am 49 and have PCOS. My doctor suggested the Mirena IUD as a birth control method, but it resulted in autoimmune progesterone dermatitis that took me over two years to get under control. I am currently not on any birth control and am experiencing all kinds of perimenopausal symptoms. Is there anything that would work for me for birth control, HRT, and/or to keep my PCOS symptoms in check?
—Anna
This is a tricky situation! Autoimmune progesterone dermatitis (AIPD) is a rare condition in which progesterone or progestins cause skin rash, asthma, or even anaphylaxis. Many women with AIPD spend months or even years getting their symptoms under control. Because both progesterone and progestin can trigger symptoms, I think what you are really asking is how to manage your symptoms without progesterone.
Remember that the main role of progesterone in treating both polycystic ovary syndrome (PCOS) and perimenopause is to protect the uterine lining from overgrowth. Estrogen is the hormone that is most effective at managing perimenopausal symptoms and helps reduce PCOS symptoms related to high levels of male hormones, such as body hair growth and acne. The challenge is that without progesterone, estrogen can cause the lining of the uterus to become too thick, increasing the risk for endometrial cancer.
The most obvious answer, then, is to use non-hormonal treatments for both your PCOS and perimenopause symptoms. Metformin has been shown to help normalize irregular periods in women with PCOS and can improve symptoms like irritability if those symptoms are caused by a difficulty processing carbohydrates — something that is common in women with PCOS. Symptoms like body hair growth, scalp hair loss, and acne can be treated with medications like spironolactone, which blocks testosterone from acting on hair follicles and oil-producing glands in the skin.
Currently, the best non-hormonal option for perimenopausal hot flushes and night sweats is Veozah (fezolinetant), which acts like estrogen just at the temperature-sensing centers in the brain. It was developed as an alternative for women who cannot take estrogen, but it would be a reasonable choice for women who cannot take progesterone as well.
However, if you are having urinary symptoms related to perimenopause, vaginal estrogen would be a safe and effective option. Because estrogen given vaginally doesn’t circulate in significant levels in the bloodstream, it does not have significant effects on the uterine lining. As a result, it doesn’t need to be taken with progesterone.
Ultimately, it is possible to treat both PCOS and perimenopausal symptoms without using progesterone. Non-hormonal treatments like metformin and Veozah, as well as vaginal estrogen, can all be safe and effective options.
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Anecdotally, I had a great experience with spironolactone for my PCOS-related acne and to a lesser extent excess hair growth, though I have had to go off it for pregnancy and breastfeeding. I definitely intend to start taking it again once my baby is weaned. The one downside is that you do have to monitor your potassium and sodium levels regularly. In my case, I had to seriously limit my banana intake and for the first time getting enough salt in my diet became a real concern, particularly when it was hot out.