What to know about birth control and depression

First off 

Birth control has revolutionized the lives of women, offering them the power to plan and control their fertility. It has paved the way for extended education, fulfilling careers, and financial independence, granting women the freedom to shape their lives and reproductive choices. However, like any medical intervention, hormonal birth control comes with considerations, and one significant aspect is its potential impact on mental health.

Sometimes when we highlight side effects from a medication or a treatment that almost assumes that we don't still recommend that treatment. But that's not how this works. Just because there are side effects to things doesn't mean that they are not helpful. The goal of this is to be INFORMED. When deciding about a treatment or a therapy it's always about weighing the advantages and disadvantages and it almost always depends on how it fits into your own health and life circumstances. 

Obviously birth control has many benefits, can decrease acne, painful periods and importantly prevent pregnancy. But amidst the benefits, there are still many reasons why people discontinue their birth control, one of these being regarding their mental and emotional being on birth control.

Do hormones impact your mood? (Read more here) 

Depression and anxiety are twice as prevalent in women than men. This gender difference does not occur until puberty. The connection between hormones and mood is complex, as explored in another blog. mental health is profoundly multifaceted, influenced by genetics, environment, and other variables. Addressing concerns about the impact of birth control on mood requires a nuanced understanding.

OK… so what about birth control? (Let’s talk through the evidence)

Some show yes, some show no, some show no effect. We have seen inconsistent results in different types of studies. Most of the studies we do have are observational making it challenging to establish causation and leaves open the possibility that the outcomes of the study are not related to birth control itself, but to other factors. So some studies looked at if they were diagnosed with depression or if they started an antidepressant. Other studies used surveys to ask questions about their mental health symptoms. This just means that most of the studies used different outcomes so it makes it difficult to compare studies and come to a definitive conclusion. 

The other thing is that randomized controlled trials (RCTs) are the reference standard for studying casual relationships (meaning does X causes X) and unfortunately with birth control and depression the RCT for this subject are limited. 

There are two large observational cohort studies that are often included in the discussion around the evidence of birth control and mood. 

1. One large Danish study involving more than 1 million women found that there was an increased risk of use of an antidepressant and first diagnosis of depression among all birth control users (oral contraceptive, patches, vaginal rings, IUDs). The highest incidence was among adolescents (15-19yo) compared to adults. Read here

2. Another large study involved 800,000 women aged 12-30yo and looked at the association between hormonal contraception and subsequent use of psychotropic drugs for women of reproductive age. The strongest association was found in adolescents (12-14yo), while non significant for adult women. Which was consistent with the finding in the Danish study of 1 million women. Read here

One randomized control trial (gold standard for science) of 1010 adolescents (age 16-25yo) found that users of the oral contraceptives showed worsening symptoms of depression - more crying, sleeping, issues with eating however did not meet the criteria for a diagnosis of depression (sadness and lack of pleasure). Meaning there were side effects that were mood related, but the use of oral contraception did not increase the likelihood of developing a mood disorder (depression). Read here

Another RCT of 202 women (age 18-35yo), showed that combined oral contraceptive use increased anxiety, irritability and mood swings during the intermenstrual phase, but a significant improvement in premenstrual depression. Said another way these symptoms were worse during most of the month, however improved depressive symptoms in the PMS phase of the month. Read here

Age Matters: Sensitivity in Adolescents

There seems to be an age of vulnerability, where the effects of birth control causing mood related side effects worsen in adolescents compared to adults. Adolescents may be more sensitive to external hormones, contributing to potential mood effects. However, we still do not have a cause and effect, and we do need to remember that there are many external contributors and factors influencing adolescents' mental health - social factors (pressure from others, school, identity), starting new relationships, initiation of sexual activity, etc. While studies show an association, establishing causation remains elusive.

Does it matter which type of birth control? Is there one thats better than the other for mood?

Examining different forms of birth control, including combined oral contraceptives, progestin-only pills, patches, vaginal rings, IUDs, and implants, reveals an increased risk of depression across the board. The data underscores a notable correlation, particularly in the adolescent age group. There seems to be a higher incidence in progestin only compared to oral contraceptives - from highest incidence to lowest (depovera shot, patch, IUD, progestin only pill). There sems to be a notably higher difference with birth control of all kinds in adolescents specifically with progestin only comparatively to oral contraception. 

OK, so what do we do with this information? This information should not be a reason to not start or continue birth control but I think its important in making informed decisions and worth having a conversation with your healthcare provider. 

Here are big takeaways and things to really consider and questions to ask yourself 

• There may be an association with worsening mood - but it is not that simple. 

• There seems to be an age related vulnerability specifically with adolescents 

• Confirming the reason to take hormonal birth control - if it is for contraception then It likely has a globally more benefit than risk of getting pregnant on your mental health than taking it. 

• Are there other benefits you are getting or going to get with taking birth control? Ie acne, PMS, PMDD, headaches

• Do you have a history of depression or struggle with mood swings already? Making sure you have additional support set in place is important. 

Remember that this is not medical advice and it is to inform and educate you about the potential association between hormonal birth control and mood. As you can see, it's not that simple and this is something that would be really really difficult to do in a 5-10 minute appointment. If you are curious about birth control and want to go discuss the risks and benefits and the use of birth control in the context of your OWN life - let’s chat! There is a lot of misinformation out there, talking to your health care provider who is well informed is the first step in feeling confident about your health!