Mental Health Impacts of Contraceptives
Mental Health Impacts of Contraceptives
Hormonal contraception is available in a variety of methods, whether that be oral pills, patches, vaginal rings, or subcutaneous implants. There are many mental health effects and mood issues reported while using hormonal contraceptives, and even in the years afterwards. In this blog I will cover some of what we know about these issues.
Even with all these choices, the combined oral contraceptive pill continues to be the most commonly used method. This is an oral contraceptive pill that contains both estrogen and progestin in it. The first generation of birth control pills had astronomically high amounts of these steroid drugs, and the modern COC (combined oral contraceptive) contains much lower amounts, which have been reported as causing significant improvements in premenstrual mood and depression scores compared to earlier generations.
There are also monophasic vs multiphasic pills. With a monophasic pill, the same dose is given every day, and with a multiphasic pill, you have varying dosages throughout the 3 week hormonal cycle, plus the 7 days of fortified sugar pills.
Another thing to consider in regards to mental health effects is the route of administration. Hormonal contraceptives can be taken orally or delivered via IUD, ring, patch, or implant. At first, the delivery system of the inserted objects seemed to give a much more stable amount of these drugs over the course of 24 hours, and it was thought that this improved their ability to stabilize mood. However, the data is conflicting, and as time has gone on we are less inclined to believe there is a meaningful statistical difference between these delivery method in regards to mental health.
Even though we must consider all the variables: the constituents, the dosage, the pattern of dosage, the ratio of progesterone to estrogen, and the method of delivery, there is a consensus that hormonal contraceptives increase negative moods, mood swings, anxiety, doom, rage, depression, and suicide risk.
Hormonal contraceptives are specifically designed to hack the feedback loop system in the menstrual cycle.
The steroid drugs are pretty efficient at inhibiting the secretion of follicle stimulating hormone and luteinizing hormone, and thus they prevent the brain from triggering the necessary steps that lead to ovulation. Because there is no egg released, there is no possibility of pregnancy. However, the birth control pill is also able to influence every other cell in the body that has receptors for progesterone and estrogen.
Contrary to what your gynecologist may tell you, hormone cycling is really important to the longevity of your full body health. Ovarian hormones perform key mechanisms of action in the brain. Let's go over them briefly.
Estrogen receptors ERa and ERb are widely distributed in the brain, including ERa in the hippocampus, hypothalamus, amygdala, and brain stem.
Estrogen facilitates glutamate transmission (a neurotransmitter that sends signals between nerve cells) and suppresses GABA inhibitory input (GABA is a neurotransmitter that decreases the likelihood that a neuron will fire, in other words, it calms the nervous system).
When estrogen is present at glutamate NMDA receptors you have increased plasticity, learning and memory. Progesterone is responsible for suppressing the glutamate response and facilitates GABAergic neurotransmission (This is why progesterone is known for its calming effects on the mind).
Estrogen increases serotonin levels and decreases 5-HT (serotonin) reuptake. Reuptake means that serotonin is reabsorbed by the nerve cells after transmitting a message.
Progesterone increases serotonin neurotransmission via regulation of expression of serotonin related genes and proteins. Estrogen and progesterone also modify serotonin responsivity to SSRI administration.
Estrogen increases dopamine release in the striatum by reducing the GABAergic inhibitory tone.
In short, these hormones are doing A LOT to your brain on a constant basis. It's affecting everything about you, including your personality, the way you solve problems, the way you socialize, and more. Because the steroid drugs in contraceptives are binding to these same hormone receptors, it's simply just a fact that there are effects on the brain.
Oral Contraceptives and the Brain
Oral contraceptives are not bio-identical to your homemade hormones. They are synthetic sex steroids which are associated with functional and structural changes in the brain that affect cognitive performance, behavior, personality, and emotion.
These effects can be understood through several mechanisms.
Synthetic hormones act on estrogen and progesterone receptors all over the body, which has many downstream effects on mental health.
Hormonal contraceptives reduce your homemade testosterone by increasing sex hormone binding globulin (SHBG), which reduces the availability of testosterone and increases estrogen in ratio to it.
Contraceptives result in a reduction and flatlining of homemade estrogen and progesterone, which conversely leads to more active testosterone and testosterone like side effects.
Contraceptives suppress vitamins b6 and b12 causing a decrease in serotonin and GABA levels in the brain.
Oral contraceptives reduce the levels of serotonin through increasing MAO activity. MAO is involved in removing neurotransmitters from the brain, essentially cleaning them up once they've done their job. With oral contraceptives this activity is increased beyond normal levels, and the effect is lower than normal amounts of serotonin.
Contraceptives and Mental Health
You've probably heard conflicting stories about contraceptives. Some people take one pill and start sobbing uncontrollably in public, other people take the same pill and feel fine. The way your body will respond to the concoction of drugs is in some ways, unique to you, like your genes or your neurotransmitter profile. But there are some overarching trends that are worth understanding.
[Sidebar: personal note
My partner realized that something was WRONG when I had had a birth control induced episode (from what? I have not even the slightest recollection now, lol) and I came home with a bottle of whiskey to apologize. He said he was completely freaked out... because years earlier, his ex girlfriend had also gotten him this exact same apology gift, a bottle of whiskey... and she too was on the same birth control pill as I was. Freaky, eh? ]
Because hormonal contraceptives have other life threatening effects such as blood clots and strokes, mental health investigation has taken a back burner in research. However, it bears repeating that depression, anxiety, and suicide risk ARE life threatening.
There is no better study than "the Denmark study" on the mental health effects of contraceptives, because Danish citizens have a unique identification number that follows them throughout their lives for social services, including health services. Through the health registries database, researchers found that those using hormonal contraceptives were 50% more likely to be diagnosed with depression six months later. They were 40% more likely to be prescribed an antidepressant than were those who were not prescribed hormonal contraceptives. You can check out a full breakdown below.
The results are obvious. Hormonal contraception increases risk of depression, and particularly, non-oral products seemed to be the most risky. Also, younger people and particularly teenagers are more impacted by the mood changes brought on by using hormonal contraceptives.
The same research team decided to look at suicide risk, too. Oral contraceptive users were twice as likely to have attempted suicide than those not using the drugs. The risk of successful suicide was triple that of those not using contraceptives. The largest risks were the same as the depression study, with the biggest impact being non-oral products and younger people.
A 2016 study from JAMA psychiatry investigated whether hormonal contraception was associated with future use of antidepressants that included over one million women. Researchers found that contraceptive users were 23% more likely to be prescribed antidepressants at a later date.
A 2019 study examined 1,236 women in the United States who used oral contraceptives as a teenager to those who had not, and found a long term association between adolescent oral contraceptive use and depression risk regardless of current contraceptive use. This means that adolescence may be a particularly sensitive time to expose someone to these drugs and may have long lasting mental health effects even if the contraceptives are discontinued.
This is not OK.
So we know it's happening, and we only kind-of know why. But here's what's known so far...
We think that the shut down of communication between the hypothalamus/pituitary and the ovaries is having much bigger impacts than doctors are letting on. The blunting of the HPA axis is known for mental health problems and mood disturbances. This is because stress hormones actually help our body deal with stress, and so if you are missing the tools necessary to deal with stress, you can't cope with it, and thus this broken stress response may be a major contributor to why the pill is harming us mentally.
This same issue can also cause us to not really be able to feel the same joy that we normally would from happy events in our lives. The low estrogen levels that you experience on the pill makes pleasure, less pleasurable. Combined, we have a recipe for depression.
The other area to look at is the role of neurotransmitter systems, especially those GABA receptors, which, when stimulated, are a major source of anti-anxiety in the brain, making you feel calm and chilled out. Those people who are using the pill have lower levels of these naturally occurring sedative neurotransmitters. When GABA receptors aren't activated, you'll feel anxious, overwhelmed, and depressed. This causes a number of mental health issues like panic disorders, depression, bipolar, and PMS.
Lastly, there are observed changes in the GABAergic system which dysregulates dopamine and serotonin signaling. These changes in neurotransmitter patterns certainly cause problems for mental health.