Friday Q&A: birth control pills & menopause; fish oil & atrial fib; health anxiety; and Parkinson's disease
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The following questions have been lightly edited for length and clarity.
QUESTION #1: BIRTH CONTROL PILLS & MENOPAUSE
Hi Dr. McBride, I’m 49 and have been on birth control pills for almost 30 years. At this point I haven’t had a period in over a year because I deliberately space out my pills to avoid periods. My mom was finished with menopause by the time she was may age, but I was still having periods when I started spacing out my pills. How will I ever know if I’m in peri- or menopause?
-Angela
Hi Angela,
This is one of the more common questions I hear from women on long-term hormonal contraception. Here’s the deal: the birth control pill is essentially “hormone replacement,” delivering your body a steady dose of synthetic estrogen and progesterone to suppress ovulation. Which means that the symptoms of menopause will not be as obvious. You could say menopause symptoms are being “masked” by the pill, but they also are being prevented/treated.
The most reliable way to get a real read on where you are is to take a break from the pill for a few months and pay attention to what happens—to your cycle, your symptoms, and how you feel. I often suggest doing this in the early 50s for women in your situation. If periods don’t return or you develop classic perimenopausal symptoms during the break, that suggests you’re in menopause. If your period resumes normally, you may not be.
Hormone testing isn’t particularly helpful here. FSH and estrogen levels fluctuate so dramatically during perimenopause (sometimes hour to hour!) that a single blood test, especially while on the pill, tells you very little about what your ovaries are doing.
The other important thing to know: the pill itself provides meaningful benefits during perimenopause. It smooths out the hormonal fluctuations that drive symptoms like hot flashes, mood changes, and irregular bleeding. So if you’re feeling well on it, great. The question of when to stop and what to transition to—continued contraception, HRT, or neither —is worth a dedicated conversation with your doctor as you get closer to 50.
QUESTION #2: FISH OIL, AFIB, AND STROKE
My cardiologist recommended fish oil for my heart - I have atrial fib and high cholesterol. But my sister’s cardiologist (my sister also has atrial fib) said that fish oil doesn’t do anything good - and it may even make atrial fib WORSE and increase the risk of a stroke. Do you have any advice on this?
- Paula
Dear Paula,
Great question. Fish oil is one of the more popular supplements out there, despite the lack of compelling evidence as to its benefit to cardiovascular health. The American Heart Association (AHA) and other medical organizations don’t strongly recommend fish oil supplements for preventing cardiovascular disease either.
In the last few years, some large clinical trials and meta-analyses have found that high doses of omega-3 supplements may be associated with an increased risk of developing atrial fibrillation. A study published in BMJ Medicine in 2024 found that people without cardiovascular disease who regularly take fish oil supplements have a 13% higher risk of developing atrial fibrillation.
However, the relationship between fish oil supplements, afib, and stroke is more complex. If you want to nerd out with me, note that there are two types of strokes: ischemic (caused by blood clots) and hemorrhagic (caused by bleeding). Fish oil is thought to have protective effects against ischemic stroke due to its anti-inflammatory and anti-clotting properties. However, some concerns have been raised about the potential for fish oil to increase the risk of hemorrhagic stroke because of its blood-thinning effects. Which is probably why the evidence on fish oil and stroke risk is mixed. Some studies suggest a potential increase in the risk of hemorrhagic stroke (like the BMJ Medicine study above), while others (like this study published in JAMA) do not show a significant increase.
Given these mixed findings, I suggest two things: 1) moderation and 2) medical advice. It is generally better to get omega-3s through food (think: fatty fish such as salmon, mackerel, and sardines; flaxseeds; chia seeds; walnuts; and certain oils like flaxseed oil and canola oil). And check with your doctor, always!
QUESTION #3: HEALTH-RELATED ANXIETY
Dr. McBride, I recently went through two months of follow-up testing (an aborted biopsy, additonal imaging, etc) after something showed up on my mammogram that turned out to be nothing. Even though it turned out okay, the waiting, the procedures, and the fear completely took over my life. My relationships and work suffered, and I was a wreck the whole time. If this happens again, how do I get through it without falling apart?
- Jana
Hi Jana,
I am sorry to hear. That kind of medical experience is incredibly scary and emotionally destabilizing. Here’s what I tell my patients: the anxiety you felt wasn’t a failure to cope. It was your nervous system responding appropriately to a genuine threat.
A few things that might actually help you next time: First, identify someone in your life who can sit in the uncertainty with you, not so much to reassure you that it will be fine (sometimes it’s not), but to just be present with you in the discomfort of not knowing. Second, set limits on how much time you spend researching your specific finding online. The information is almost never calibrated to your individual situation and tends to amplify fear rather than resolve it. Third, and most importantly, talk with your medical team about the anxiety itself. You can ask for more frequent check-ins, a clearer timeline of what to expect, and a named person to call when the waiting becomes unbearable.
The experience you had, including the aborted biopsy, was also objectively difficult on a logistical level, and it’s worth debriefing that with your doctor so the process goes more smoothly if it’s ever needed again. I’m sorry this process was so difficult, and I hope this helps you feel more prepared if you find yourself in a similar position in the future. Fingers crossed you don’t.
QUESTION #4: EARLY PARKINSON’S DISEASE
I just got a diagnosis of mild Parkinson's aka PD. What does that mean? And what can I do right now?
-John
Hello John,
A Parkinson’s diagnosis, even a mild one, is a lot to absorb. That said, there is good reason for hope here, particularly at this stage. Parkinson’s disease is a progressive neurological condition caused by the gradual loss of dopamine-producing cells in the brain. Dopamine is essential for coordinating smooth, controlled movement, which is why Parkinson’s is associated with tremor, slowed movement, stiffness, and balance changes. “Mild” means you’re at the early end of the spectrum, where symptoms are present but not yet significantly limiting daily function.
Here’s where the evidence is clear: exercise is the single most powerful tool available to you right now (and in general). Not as an adjunct to treatment, but as the treatment. Studies consistently show that regular aerobic exercise (such as cycling, swimming, brisk walking) slows disease progression and improves motor function in ways that no medication currently matches. Strength training helps preserve muscle mass and protect against falls. There is also growing evidence for specific programs like boxing and dance, which challenge balance and coordination in ways that have measurable neurological benefits.
On the medical side, your neurologist will discuss whether medication makes sense now or whether watchful waiting is appropriate. That decision depends on how much your symptoms are affecting your quality of life, and it’s a conversation, not a foregone conclusion.
The other things worth prioritizing: sleep, which supports brain health broadly; social engagement, which matters more than most people realize; and getting connected with a movement specialist or physical therapist who has experience with Parkinson’s specifically. This is not a diagnosis to manage passively.
The trajectory is highly individual. Many people live well with Parkinson’s for decades. I hope this offers you some clarity, and I wish you well.
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🎉 An invitation — the official Beyond the Prescription Book Club!
For five years, I’ve been sitting at this desk writing Beyond the Prescription, and it finally hits shelves on August 11. I couldn’t have done it without this community. Your questions, your curiosity, your authenticity, AND your frustrations with the medical system—you are the reason I wrote the book.
Join me this summer for the official Beyond the Prescription Book Club. It’s open exclusively to Substack readers and gives you early access to the book. Sign-ups are open in May only.
Hi Dr. McBride. I continue to get so much out of the different topics you explore with us! I have a question on a different topic, and although you recently discussed bone meds - I'm wondering if this might be one for a future post. Evenity seems to be such a good drug for so many of us at higher risk of fracture who have already taken a bisphosphonate, and yet there is the black box warning regarding cardiovascular events. Although not listed as a specific contraindication, I'm wondering if having a genetic prothrombin factor (mine is one copy of the G20210A mutation) is a reason not to take Evenity. All the best to you!!
I was on birth control (Ortho-Tri-Cyclen and its generics) for over twenty years without problems, but have had three failed tries with different forms/strengths of HRT with increasing allergic reactions. I'm able to use vaginal estradiol without problem, but it appears that higher strength estradiol goes straight into my sinuses and makes my tongue irritated and then swollen (the combo pill with synthetic progesterone needed due to my peanut allergy) caused a near anaphylactic response within less than an hour.
Are there any fully synthetic HRT options? I know bioidentical is supposed to cause less reactions, but not for me. My doctor is at a loss and, even though my menopause symptoms over the last two years without hormone supplementation has become unsustainable, I'm fearful to try anything else.