By Karla Cloete
Edited by Humairaa Mayet & Imaan Moosa
Anyone with a uterus knows PMS sucks, but when should you be concerned? Is your birth control making you depressed? Anxious? We spoke to an OBGYN specialising in women’s reproductive issues to find out.
Trigger Warning: Mentions of sexual violence, suicide and depression.
This information is intended only to educate and shouldn't be used to diagnose, treat or replace the advice of a registered medical professional.
You may have seen this viral TikTok of two boyfriends reading the rather extensive lists of their girlfriend’s birth control medications. Iterations of this trend have been highlighting the seldom discussed and poorly understood effects of hormonal contraceptives on our bodies and mental health. So naturally, you may be wondering: Is it really that bad? Should I be worried?
Image sourced from the greatist.
But, first things first:
All jokes aside, the invention of birth control played a massive role in the hard road towards equality for women, as explained in this Bloomberg video. The ability to delay pregnancy allowed women to further their education and career, and almost doubled their earning potential. It gave women more autonomy over their own bodies and provided financial independence. Access to birth control is essential to women’s rights and safety, especially in an era where the Supreme Court of the USA has banned abortions and South Korea is considering doing the same.
Secondly, there are a lot of reasons women may take birth control – such as managing acne, PMS, and endometriosis – not only for preventing unwanted pregnancies, which they have every right to do.
Complaints about mood changes while being on ‘the pill’ have been around since the 1960s, although today’s pills use far lower hormone dosages. Yet 21 percent of women still cite mood symptoms as the reason they stop using hormonal birth control.
Image sourced from Healthline.
There are a lot of contradictions in the literature. Let’s begin with the naysayers:
A 2018 review of 26 studies could not find a link between progesterone-only contraceptives and depression. Another study found that hormonal contraception helped stabilise mood problems in women with mental health problems. A different study showed the pill lessened PMS-related mood swings and women who used them had fewer depressive symptoms and fewer suicide attempts.
An Archives of Gynaecology and Obstetrics study didn’t find a link between the use of the pill and depression, and found that subjects were prone to an “inconsistent use of the word depression”. Women taking placebo pills reported similar mood effects.
One study found that women with mental health conditions had heightened awareness of their physical symptoms and were more likely to internalise negative information about their contraception and therefore be more concerned about risks and side effects.
There are research gaps when it comes to women's health and contraceptives. A Harvard review found that many studies use small sample sizes, fail to control variables or tap biassed populations or simply use self-reporting measures which aren’t always so reliable. The Harvard critical review found that there was a small but real risk for depression, especially with methods like the IUD. The risk is quite small: 2.2 out of 100 women.
So some people are more prone to developing depression, to begin with, and therefore they may also be more susceptible to these side effects.
Image sourced from Zikoko.
The risk is small, but for a subset of the population who have certain risk factors, there may be a link.
Sarah E. Hill is an evolutionary psychologist and the author of ‘This is your brain on birth control’. She had become the foremost thought leader on the matter.
Hill says that it would be impossible for something like hormonal contraceptives to have no side effects. Men and women are both affected by their sex hormones, so of course, any interventions to adjust them will affect us.
Hill says for some women the pill amplifies existing depression or anxiety issues:
“If these things happen to you, it doesn’t mean you’re crazy; it just means you’re on the wrong pill!” Hill said in her TedTalk.
Almost half of women will stop using hormonal birth control within the first year because of intolerable effects like changes in mood.
A rather notorious study was conducted in Denmark of over a million Danish women aged 15-35 who were prescribed hormonal birth control and were followed for 8 years. 50 percent of whom were diagnosed with depression or prescribed an anti-depressant within 6 months, suggesting an increase in depression after controlling for other variables- history of depression, pregnancy and previous use of psychiatric medications or hormonal forms of birth control.
It was noted that women aged 15-19 were the most at risk for these effects, as well as increased risk for suicide attempts since their brains were still in the process of developing. A 2018 Swedish study of 800,000 confirmed this risk when they found that adolescents were more likely to be prescribed antidepressants or anti-anxiety medications after they began taking hormonal birth control.
But correlation isn’t causation, as Hill is quick to point out: “For instance, women who seek medical interventions to prevent pregnancy might be more likely to seek medical interventions for depression. Or, getting into a new sexual relationship (which can prompt a pill prescription) could be what’s increasing women’s depression risk.”
The pill may be able to affect your mood via your body’s HPA axis or the systems in charge of your stress response.
“The type of blunting of the HPA axis we tend to see in pill-taking women is a known contributor to mental health problems,” Hill said. This disruption in our stress response can impede our coping ability thus increasing the risk of anxiety and depression.
Hills says furthermore that since the pill keeps estrogen levels low, this can cause a dampening of the brain's reward system and just a sense of lowered positive emotions in some women.
Hormonal contraceptives can lead to higher rates of anxiety, this proved especially true if you had a preexisting anxiety problem as those feelings of anxiety can become more intense. But if your anxiety is only a problem when you’re experiencing PMS- then birth control can really help to relieve that.
A 2015 study found that oral contraceptives were linked to thinning in two regions of the brain. Firstly in the posterior cingulate cortex- the part interprets our internal emotional state. The second is the orbitofrontal cortex – the part that responds emotionally and behaviourally to external stimuli. Thus, “these changes suggest that hormonal contraceptives not only affect how [users] view external circumstances, but may also affect their view of themselves.”
To further compound our conundrum, a 2014 study consistently found that mental health issues influenced not only what contraceptives women chose, but if they used them and how they used them. We spoke with Dr. Colin Marias, an obstetrician and gynecologist from Cape Town, to help us make sense of these contradictory findings.
Image sourced from SheKnows.
So what does it all mean?
When should you be concerned?
If you've currently been using a hormonal contraceptive for a few months with none of these effects there’s no need to be alarmed – it’s highly unlikely you’ll start to experience any problems.
Dr. Marias says that if your PMS or pain during your period is intense enough to keep you from work or school or if they are negatively affecting your relationships or your ability to cope there is cause for concern. Disorders like endometriosis or Premenstrual Dysphoric disorder will interfere with your quality of life and you should consult an expert.
He also says that hormonal contraceptives don’t work overnight – they take time. He suggests waiting at least 3 months with a new medication and then having a follow-up appointment with your practitioner. If you’re still having intensely negative side effects after this period then it may be time to try a different dosage or type of contraceptive.
What should I do if I have a concern about my hormonal contraceptive?
You can speak to your general practitioner, but Dr. Marias advises for issues relating to hormonal contraceptives it’s best to make an appointment with a gynecologist.
As many women’s concerns are often brushed off and dismissed, he advises choosing someone who takes time to listen to you and takes you seriously. Advocating for yourself and finding a practitioner you trust is very important to your health and well-being.
Your doctor should take not only your medical history but consider any mental health problems, family psychiatric history and traumas like sexual violence into account when advising you about what methods are best for you. Ideally, practitioners should take a holistic approach to women’s health considering multiple factors, and most importantly taking their symptoms seriously.
What else can be done about PMS?
This article isn't meant to scare you off hormonal birth control- we mean to inform and empower you so you can advocate for your own health and well-being. Dr. Marias says that birth control is a tool- it can be used correctly or incorrectly and since our hormones don’t play by one-size-fits-all rules it may take time to figure out the right tool for you.
Still, there are some things you can do to help manage PMS symptoms without birth control or along with it. Exercise, vitamin B6 and calcium have been known to have some benefits in managing PMS symptoms and evening primrose oil can specifically help with breast tenderness. SSRI’s can be used to treat PMS if you’re interested in a pharmacological route. Therapeutic interventions like CBT have also been found to be helpful.
Dr. Marias says that these might not work for someone with severe PMS or those experiencing disorders. “It helps but very seldom cures,” he says. The Royal College of Obstetricians and Gynaecologists advises that you should see a gynecologist if you’ve already exhausted these methods and did not see a difference.
The takeaways
For most of the population, hormonal contraceptives are safe and effective and there is little cause for concern.
However, you’re at risk if:
-You have a family history of mood-related side effects on birth control
-You have a history of depressive episodes
-You use progesterone-only pills or a non-oral product
-You’re 19 or younger.
If you have any of these factors you should discuss them with your practitioner when choosing a method that’s right for you. Most importantly, don’t diagnose yourself or make rash decisions, be patient and trust the process and be vocal about your needs and concerns in the doctor's office.
More about Dr. Colin Marias:
Dr. Colin did his MBChB at the University of Pretoria in 2008. He later completed a Fellowship in Obstetrics and Gynecology at the College of Medicine. He works at MediClinic in Cape Town and has been specialising in reproductive issues for 14 years.
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