You may have heard about the recent study, published in the medical journal JAMA Psychiatry (Journal of the American Medical Association), that found a link between use of hormonal contraception and the development of future depression. Many patients and clinicians have asked about the significance of these results and about the link between mood and hormonal contraception. Understandably, given that hormonal contraception is the primary form of birth control, this is an important topic. In fact, over 80% of women in the US use hormonal contraceptives during their reproductive years.
The strengths of this new study include the fact that it is quite large (with over a million women in a Danish database) and the fact it followed women over time. They found that there was an increased risk in the diagnosis of depression for women (and a higher risk for younger women/adolescents) taking hormonal contraception, and the risk was highest for non-oral forms of hormonal contraception (like patch, ring, depot, and implant). Interestingly, their results were most significant at about six months after starting the contraceptive medication, and tapered off afterwards.
In contract, a different, US-based study from 2013 found that women taking hormonal contraception were in fact less likely to have depression. And this effect was most significant for those taking progesterone types of contraception, such as the depot injection. Is this result due in part to the fact that women with depression are less likely to be compliant with medications, including contraceptives?
Older studies, from before the 1980s, notably associated combined hormonal contraception (medications with both estrogen and progesterone) with mood changes. This was thought to be related to the fact that back then, the doses of these hormones in the medications were much higher than today.
An investigation out of Harvard back in 2003 found that the majority of women do not experience premenstrual mood changes with hormonal contraception, but a significant minority do: 16% reporting mood deterioration and 12% reporting mood improvement.
While most women do not experience significant mood changes with hormonal contraceptives, there is a significant minority that do – some positive and others negative. It can be most helpful to try to figure out what particular risk factors a woman might have to fall into that group
#1 – Type of Medication Formulation
Some studies suggest that contraceptives with more steady dosing (not the triphasic formulations) and the use of these medications continuously is associated with fewer mood changes. Others suggest the important consideration is the type of progestin in the medication makes the most difference. There is a trend towards the medications with progestins of lower androgenicity (like drospirenone) have more positive psychological effects.
#2 – Physical symptoms with menses
Those who have improvements in physical symptoms – like pain, bleeding, and headaches – usually report an improvement mood. Understandably, when you are feeling better physically, that will affect your mood in a positive way.
#3 – Age
Age is a factor. Younger women are more likely to report mood side effects with hormonal contraceptive use.
#4 – History of Depression
There has been mixed data on the impact of hormonal contraception for women with a history of depression. Some report improvement in symptoms, while others report mood deterioration.
Why Does Hormonal Contraception Affect Mood?
It makes sense that hormonal contraception would have an effect on mood. There are estrogen receptors throughout the brain – in the hypothalamus, amygdala, prefrontal cortex to name a few – and research shows that estrogen affects many different neurotransmitters and neurochemicals and other hormones such as cortisol. Many of these same molecules are known to play a role in mood disorders and depression.
Some research has also shown that progesterone in particular has adverse mood effects in women. One of the metabolites of progesterone is known to have inhibitory impacts on the central nervous system. Additional, external progestins are known to influence the system that changes serotonin levels. Serotonin is a neurotransmitter implicated in depression and is a primary target of antidepressant medication treatment.
So What Should I Consider if I’m Taking Hormonal Contraceptives?
First, I recommend against making any treatment decision without having a thorough discussion with your prescribing physician. As you can see above, the studies are mixed and many of them have confounders, so the answer is not crystal clear and requires a thorough conversation about risks, benefits, and your specific history.
Be sure to discuss significant elements of your history with your doctor – do you have a history of depression? Do you have a family history of depression? Do you have monthly mood changes? Do you have significant physical symptoms pre-menstrually? All of these will impact the decision about hormonal contraception.
Next, consider the possibility of pregnancy. Yes, in one major study the result was greater risk of depression with long-term birth control. However, pregnancy itself is not without its complications. In fact, 15-20% of pregnant and postpartum women experience depression. And long-term birth control is one of the most effective ways of preventing pregnancy, especially in adolescents. There is good data on this out of an initiative in Colorado, in fact.
Finally, keep in mind that the illness of depression is quite complex and there may be many influencing factors. Please seek the guidance of a mental health professional if you are experiencing symptoms of depression in order to obtain an accurate diagnosis, prognosis, and treatment plan.
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Keyes, K.M. et al. (2013) Association of hormonal contraceptive use with reduced levels of depressive symptoms: A national study of sexually active women. American Journal of Epidemiology, 178(9): 1378-1388.
Schaffir, J., Worly, B.L., & Gur, T.L. (2016) Combined hormonal contraception and its effect on mood: a critical review. European Journal of Contraception and Reproductive Health Care, 21(5): 347-355.
Joffe, H., Cohen, L.S. & Harlow, B.L. (2003) Impact of oral contraceptive pill use on premenstrual mood: Predictors of improvement and deterioration. American Journal of Obstetrics & Gynecology, 189: 1523-30.
Skovlund, C.W. et al. (2016) Association of hormonal contraception with depressioin. JAMA Psychiatry, published online 9/28/16.