A number of women report the onset of depressive symptoms after starting oral contraceptives. So why are many doctors failing to warn them it’s a side effect?
This article contains frank discussion of anxiety and depression.
The pill: banisher of unwanted pregnancies, boon for women’s health, harbinger of the sexual revolution. Its small colourful blister-packs are a familiar sight on the nightstands of around 202,000 New Zealand women.
But for a number of those women, the pill can have significant mental health side effects that they aren’t warned about by their doctors. We spoke to a barista, a doctor, a public servant, a cafe manager, a stay-at-home mum. They all had two things in common: first, they experienced a serious onset of depression or anxiety after beginning on hormonal contraceptives. Second, none of their doctors had ever warned them that changes to mood or mental health were a possible side effect.
Two different women echoed each other almost exactly, saying they sunk into a depressive fog so completely that they barely remember the entire period they were on the medication.
Possible links between the pill and depression jumped into the headlines this month, when a new study found the women on the pill had a higher likelihood of being diagnosed with depression.
The study evaluated contraception use of the entire female population of Denmark aged 15 to 35 - more than one million women in total. It found women using the combined pill were 23 percent more likely to be prescribed antidepressants and women on progestin-only pills 34 percent more likely. Teen girls appeared to be at highest risk, with those on combined pills 80 percent more likely to be described an antidepressant and those on progestin-only more than twice as likely than their peers who were not on any kind of hormonal contraceptive.
The figures sound alarming enough, but study is by no means proof the pill causes depression - nor does it claim to be. The researchers acknowledge more research is needed and other factors that could be at play: women prescribed the pill are already in contact with a doctor, so may be more likely to be prescribed other medication - including antidepressants. There are other strange trends in the data - like for women using the pill for seven years or more, the trend reverses and they are less likely to receive a depression diagnosis.
Dr Helen Roberts, from Auckland University’s Department of Obstetrics and Gynaecology, said there had been only two randomised studies on the pill - considered the gold standard of research evidence. One did not find a correlation between the pill and depression. The other studied women in Manila and Edinburgh, and found a correlation between pill use and depression for the woman in Edinburgh, but not Manila.
But while larger scale trends are inconclusive, there’s strong evidence that doses of hormone can impact some women’s mood, and mood changes are listed as one of the contraceptive pill’s side effects. A study of menopausal women given doses of estrogen and progestogen found it increased negative moods and other psychological symptoms, with women on higher doses reporting stronger effects. A review of the body of research by the International Review of Psychiatry found “accumulating evidence” that hormonal changes and fluctuations could increase the risk of or trigger depressive symptoms in some women. Another study of 500 women in Iran found 400 of them reported side effects. Of those, 37.7 percent reported mood changes.
Leanne* sits curled in her lounge-chair. She’s a stay-at home mum these days and Thomas the tank engine sits derailed on the carpet at her feet. Paper lanterns are strung above the door. Family photos in plastic sheaths on wall.
I couldn’t trust my own thoughts and my anxiety just went through the roof.
Several years ago, Leanne went to the doctor before she got married, and said she’d need a long-term contraception option. The pill seemed like the easiest and most drama-free. She was prescribed the most common combined pill.
“It wasn’t a fun time,” she laughs. “That’s for sure.”
“Within two weeks, I just felt like I was going completely nuts. I just felt really crazy, really up and down, quite paranoid. I couldn’t trust my own thoughts and my anxiety just went through the roof.”
Feeling constantly on edge, she stopped eating, felt deeply depressed and struggled with thoughts of suicide.
“I was almost suicidal within just over a week,” she says.
“I’d never experienced mental health like that before, so I was very much like, what’s wrong with me?”
Leanne had a history of mild anxiety, but she didn’t know mood changes were a possible side-effect of hormonal contraceptives and says her doctor didn’t tell her when it was prescribed.
“I made the connection because it happened so suddenly and because I’d never taken it before - it was such a huge change in my mental state.”
She now wishes her doctor had told her to monitor her mood from the start.
“What say I hadn’t put it down to being on the pill and I’d just kept taking the pill? That could have had terrible results. Or if it had happened more gradually and I didn’t correlate the two. I think the only reason I put it together was because it was so sudden.”
She remembers around a week after she’d stopped taking it, standing in the kitchen and doing the dishes with her husband. The fog had lifted.
“We just looked at each other, like, wow. That was something.”
While mood changes are a listed side effect of oral contraceptives, it’s not a requirement for GPs to tell women that the pill could affect their mental health.
Mood changes are listed as a side effect, but are not common, so they may be discussed by some doctors, but not necessarily all.
The Royal New Zealand College for General Practitioners trains GPs, and is the professional body for those practicing. College medical director Dr Richard Medlicott says while it is normal practice for GPs to discuss side effects when prescribing, they tend to stick to the more common ones.
Medsafe’s documentation of the Ava 30 pill - the most common combined pill - does list “depression, mood change” under “common” side effects: those with more than a 1 in 100 chance of occurring. But Medlicott says its not among those most commonly discussed.
“The list of possible side effects for any medication can be very long,” Medlicott says. “For oral contraceptives, the more common side effects would be weight gain, skin changes, and period changes. We would also tell patients about the increased risk of blood clots.”
For the progestogen only “mini-pill”, the common side effects GPs discuss are irregular periods, acne, oily skin and weight gain.
“Mood changes are listed as a side effect, but are not common, so they may be discussed by some doctors, but not necessarily all,” Medlicott says.
He added that there are many things that need discussing at consultations for contraception - so if mood changes were discussed at all by GPs, it was likely to be brief.
“I definitely think it kind of feels like you’re rushed out of the room,” says Lara, a barista in Wellington.
“For the individual women who are trying to find a contraception - you kind of want it explained to you well, side effects and different options. But instead it’s like ‘oh yep sweet, we’ll put you on this one, off you go, here’s your prescription.”
Lara switched pills to the Ava 30 on the recommendation of her doctor, after finding her previous pills had a high risk of blood clotting.
It took her some time to realise how the new medication was affecting her mood: heightened anxiety at work, low mood and depression, outbursts of anger.
“I just became super emotionally unstable” she says.
“It took a while for me to realise it was the pill - but it was from the period I started taking it to when I stopped.”
She went back to her doctor, switched to a different pill and the symptoms stopped. But her doctor had never told her there was a possibility of mental health side-effects, and she said it took her months to join the dots.
“A lot of the time it’s hard to recognise that [the pill] is why you’re feeling that way - because if you’re down or stressed, you think it’s just you. You don’t associate that with your contraception,” she says.
“They should definitely make the women aware of the possible side effects of these experiences. And they should book in a follow-up appointment.”
Part of the danger if side effects aren’t properly discussed is that women can abandon their contraception method altogether, using a less reliable method or no contraception at all.
In the United States, a study of 1657 women starting a new oral contraceptive found around one third discontinued after six months. Of those stopping, 46 per cent did so because of unexpected side effects.
The researchers concluded that “counseling is vital, particularly in presenting the possibility of side effects, stressing of the facts, and the need to identify a backup method, with follow-up visits after 1-2 months after receiving prescription.”
New Zealand’s Medical Classifications Committee is currently considering recommendations to make the pill available over-the-counter, so many women would no longer require a consult to access repeat prescriptions.
Other studies have found around half of women stopped taking the pill a year after starting, and the most common predictor of women stopping or switching method were emotional side effects.
Many women will never experience side effects from their pill. But for those who do, there are plenty of effective contraception options to look at: different pills, the mirena, or copper IUD.
“I would say to any woman using the pill – if you think it is affecting your mood – discuss this with your GP or Family Planning clinic,” Dr Helen Roberts says. “There are good non-hormonal options; which have a lower contraceptive failure rate than the pill and can be used by young women also.”
There is also some evidence hormonal doses can, for some women, work in the opposite direction - relieving symptoms of depression and anxiety.
For years, Sapphire*, 28, used to fall into cyclical depressive episodes before her period.
“Some days I would have trouble with cognition: I couldn't understand essays that I had been working on fine the day before,” she says.
“Some days I would be very teary, like tripping up or hearing a loud noise would make me want to cry. Some days I would wake up suicidal, but in a very abstract way because I would be aware I felt fine a day or two ago and that I had no reason to want to die.”
Because her symptoms didn’t appear like clockwork each month, it took some time to identify a pattern. Eventually, she was diagnosed with premenstrual dysphoric disorder (PMDD) - a condition formally recognised by the Diagnostic and Statistical Manual of Mental Disorders in 2012. She was prescribed a combined pill alongside a dose of testosterone to stabilise her hormone levels, and says it’s worked for her.
“Obviously mental disorders aren't fully understood,” she says, “but for me there was a clear link between the physical levels of hormones and my mental state. I know the whole medical community doesn’t agree on how to treat PMDD. But for me, taking hormones works.”
Dr Roberts says some doctors do use a specific type of combined pill “to help a particular severe type of premenstrual syndrome which can include depression - and randomised evidence shows that it can help.”
The manager of a popular cafe in Christchurch, Kimberlea had been experiencing extreme period pain, to the point where she couldn’t work or move.
I talked to my GP and said I feel really low, I have no energy to hang out with people, I can’t function, I just can’t handle life.
“I really didn’t want to be on the pill because I didn’t see it as very natural,” she says, “but it was my only option at the time, to be able to go to work and stuff.
She was prescribed the Ava 30. It didn’t stop her periods, but she experienced an onset of other symptoms: terrible bad mood swings, emotional slumps, social anxiety.
After six months, she tried the progestogen-only minipill, to see if it would help with her periods. Her symptoms worsened: Days spent crying, unable to face social contact, cancelling plans and overwhelmed by social anxiety.
In April this year, things reached a tipping point.
“I had been in bed and couldn’t move for five days. I was really really low. I talked to my GP and said I feel really low, I have no energy to hang out with people, I can’t function, I just can’t handle life. Am I depressed, what’s going on?”
Her GP said it was possible the pill could be part of the cause, but told her to try for another three months and see how it went. Instead, Brown used made her own appointment with a gynecologist. She was diagnosed with endometriosis, and booked for surgery where they inserted a Mirena contraceptive implant.
Since switching to the Mirena, she’s stopped experiencing anxiety attacks, and her mood has risen.
“Before surgery I would spend days at home crying, really low, having anxiety attacks. But since surgery, the Mirena has been really really great. I haven’t had anxiety. I just feel so so different.”
Emma Harcourt is studying science communication and anatomy, and currently writing her thesis on the morning after pill.
She’s sceptical of the Danish study that initially caused a stir on the subject, saying the lack of a control group on non-hormonal contraception makes the results less convincing.
“I would hate for people to see the headlines about this and start using a birth control method that isn’t very effective or feel like they have to give up birth control that’s working for them,” she says.
But Harcourt does believe that there needs to be better communication from doctors.
“It’s definitely a side effect people should be told about: if you start to feel depressed, come back, and we can try something else.
“There is a problem with doctors not taking people seriously … Women overwhelmingly have the largest burden of preventing conception, and there are definitely problems in the way women are treated in health care, particularly with contraception.”
The medical world hasn’t had a historically pristine record in dealing with women’s health concerns. In 2001, a study titled The Girl Who Cried Pain attempted to map out why women were less likely than men to get medication when reporting pain to their doctors.
The report found that women actually felt pain more acutely - but they were less likely to be treated urgently, and prescribed less pain medication overall. It discusses one study which found women were more likely to be given sedatives for their pain and men to be given pain medication - suggesting the pain women reported was more likely to be interpreted as psychosomatic or anxiety-related.
The researchers concluded that while women had a higher prevalence of chronic pain syndromes and “are biologically more sensitive to pain ... they are more likely to have their pain reports discounted as “emotional” or “psychogenic” and, therefore, “not real”.
All this doesn’t precisely explain women’s less-than-perfect experiences of contraception, but it does help paint some of the details of our backdrop: a medical system still vulnerable to underestimating, under-treating and misinterpreting women’s health concerns.
Conditions like endometriosis and hormone-related depression sit at the intersection of women’s physical, mental and reproductive health, and have remained something of a battleground for women who feel many doctors are still failing to hear them.
Rachael* says she still feels like her doctor didn’t take her concerns seriously. She started on the pill after experiencing extreme period pain. Her doctor told her he suspected endometriosis, and the simplest way to address the symptoms was for her to simply stop having periods.
The first pill didn’t work for her - she still had periods, pain, and began experiencing major mood swings. So she switched to the Depo Provera - a three-monthly injection of progesterone.
On the injection, her mood dropped severely. “I was very low, but also in a complete fog so I wasn't really aware that I was feeling depressed,” she says. “It’s really hard to try and remember how I was feeling.”
For Rachael, dropping the Depo didn’t seem like an option - her period pain was so crippling she was unable to work or function.
Eventually, she returned to her doctor seeking treatment for depression. Agreeing the hormones could be contributing to her low mood, he put her on a second dose of hormonal therapy designed for menopausal women, and prescribed her an antidepressant.
Now, Rachael remains taking all three. But she wishes her doctor had initially told her that she should monitor her mood for changes, so she knew what to look for.
“Now I feel like I’m fairly balanced,” she says, “but yeah I’m pretty angry to be honest. I get so mad when I think about it.”
Dr. Grace* works as GP herself, and has spent much of her career prescribing contraception to young woman. She remembers, though, being on the other side of the exchange. Grace started on the combined pill when she was about to go travelling, and wanted to run packs together to avoid periods.
I remember when my boyfriend rang me and said ‘my sister thinks it could be the pill’ I kind of went - oh of course it is!
The impact on her mood, she says, was immediate and dramatic.
“I wouldn't have called it depression - because the medical definition involves it lasting for months - but I did go nuts on first combined pill I took, ie would have met definition for depression if I hadn't stopped taking it,” she said. She felt constantly irritable, and down.
“I remember when my boyfriend rang me and said ‘my sister thinks it could be the pill’ I kind of went - oh of course it is! It was this amazing relief of, oh there’s something causing this and I can do something about it.”
These days, she tries to remember to warn patients that mood changes are a possibility, and give written information about all the potential side effects to women taking the pill for the first time.
“What I try to tell people most of all is there are a lot of contraceptive options and if this one doesn’t agree with you, just come back.”
*Some women’s names have been changed due to their concerns of stigma around mental illness.
Where to get support:
Lifeline: 0800 543 354
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO
Depression Helpline: 0800 111 757
Samaritans: 0800 726 666
Youthline: 0800 376 633 or email firstname.lastname@example.org
Healthline: 0800 611 116
If it is an emergency and you feel like you or someone else is at risk, call 111.