The discovery of the modern day birth control pill has been lauded as one of the Seven Wonders of the Modern World by The Economist and is listed as an "essential medicine" by the World Health Organization. Today over 100 million women worldwide use the pill as a means to assert some control over their own bodies and reproduction. Yet research on the pill's potential side effects have been contested since its first research trials in Puerto Rico in the 1950's. Women who expressed concerns at that time about side effects such as nausea, headaches, breast tenderness and mood swings were dismissed as mere hypochondriacs—a historically familiar refrain when women speak up and complain. Since then the pill has been modified and various formulations approved, yet one of the the most common reasons for discontinuation remains depression and mood lability.
Until recently, sparse literature has examined the connection between hormonal contraception and depression. Last year a nationwide prospective study was published in JAMA Psychiatry that followed over one million girls and women ages 15 to 34 over a period of 14 years. They found that the use of all hormonal contraception options were associated with a 20 to 30 percent increased risk for depression. 15 to19 year old girls, however, experienced the greatest risk, especially during the first year of use. For this already high risk group the use of combined oral contraceptives, with estrogen and progestin, increased the risk of depression by 80% compared to those not on the medication. Those using progestin-only pills doubled their risk of depression, while those on the patch or vaginal ring had triple the risk compared to non-users.
A follow-up to this study, now online but not yet published in the American Journal of Psychiatry, used the same extensive Danish database to assess the risk of suicide attempts in users of hormonal contraception compared to non-users. This time they followed an entire national cohort of girls from the time they turned 15 over a period of 8 years. Shockingly, the users of hormonal contraception showed double the risk of a suicide attempt and triple the risk of a completed suicide. This risk rose rapidly within the first month after starting contraception and remained doubled for the first year. After that the risk remained about 30% higher than non-users. In this study all of the oral products showed the same increased risk. The risk of the patch, however, was more than tripled and the users of the Depot injection showed a 6.5 fold increased risk! Once again those at highest risk were the adolescents. It is unclear whether aging and time decreases the risk or if those most at risk have already discontinued use due to significant mood issues.
So what is one to do with all this information? Like most things in life there is not a tidy one-size-fits-all answer. What the data from these studies suggests to me is not that we should panic and never prescribe or use hormonal contraception again. Pregnancy obviously carries even more risks, especially unplanned ones. It is critical though to take the time to have a conversation with your doctor and carefully assess your individual risk factors against potential benefits. I have seen way too many teenagers in my office, or worse, adult women who have been on antidepressants since they were started on birth control decades ago, who complain of depression after being started on the pill to manage acne, irregular bleeding or painful periods. From my perspective, the potential benefits of prescribing a pill to alleviate these symptoms to a non-sexually active adolescent, are difficult to rationalize against the possible risk of depression or suicide.There are many other options for those issues including dietary changes, exercise, supplements and stress management that will likely help with minimal to no risk. Too often modern medicine is quick to use medications for a quick solution without considering other healthier options first.
For sexually active adolescents and adults the calculations become more difficult and each women's particular life circumstances must be evaluated. It would be helpful to know if your mother or other female relatives had issues with the pill since research shows that women with certain genetic predispositions are at increased risk. Another group at higher risk of side effects are those with a history of childhood trauma. In fact research published in Nature this year, suggests that many of the long term physiological consequences of taking the pill resemble chronic stress, which at least partially explains the increased risk for depression. Obviously health risks like smoking and obesity must be considered as these factors combined with the pill further increase the risks for blood clots, strokes and breast cancer. Although to be fair, these must be weighed against the possible reduction in risks for ovarian and endometrial cancer.
If you choose to go the route of hormonal contraception the data suggests oral forms appear to be significantly safer with fewer side effects than the patch or injection. Most importantly during the first few months on the pill be mindful of any mood changes. If your mood darkens don't let your doctor tell you it is "all in your head" or "let's just try another brand" or add an antidepressant, but know that it is likely the medication and that other non-hormonal options like condoms, cervical caps or the diaphragm may be better alternatives for you.
Sometimes it's helpful and entertaining just to put it all in historical perspective and recognize that although there are undoubtedly safer options yet to be discovered attempts to control reproduction have existed throughout history. As far back as 3000 BC condoms of fish bladders and animal intestines were used. Around 1500 BC women made pastes of honey, sodium bicarbonate and crocodile dung. Chinese concubines drank lead and mercury. This combination did indeed render many of them sterile, but at the risk of death. In the Middle Ages women tied weasel testicles to their thighs.
Throughout the world, herbs and foods have been used for contraceptive purposes. Even in Greek mythology Persephone, the Goddess of Spring, ate only pomegranates to avoid conception, after being abducted and raped by Hades, the God of the Underworld. In the 1200's Pope John XXI, when he was still known only as Peter of Spain, wrote a comprehensive book on herbal methods of contraception. Many of his treatments modern science have shown to be at least somewhat effective. It's a good thing he was not a woman or instead of becoming Pope he might have been burned for such heresy! In Libya the plant Silphium was so effective and so sought after for its contraceptive effectiveness it became extinct. Egyptians used an acai paste. Women in Sri Lanka and India ate papaya. Aztecs and Native American women ate wild yams. In fact, the modern day pill was created by extracting diosgenin from the wild yam to formulate the hormone progestin.
Perhaps the birth control pill isn't really all that "modern" and ancient herbalists, "witches", and even former Popes, offered wisdom we might be wise to heed and learn from to find safer alternatives for the future. If nothing else these attempts at reproductive health are all reminders of the timeless dilemmas women have shared throughout history. Although we may have come a long way from crocodile dung and mercury, we clearly have a long way to go in finding safer alternatives for the many women who either cannot tolerate hormonal contraception or who find the possible increased risk of breast cancer, stroke, blood clots, depression and suicide unacceptable.