Oral contraceptive use and depression among adolescents

A bitter pill to swallow: adjustments to oral contraceptive pill use in polycystic ovary syndrome

INTRODUCTION

This Special Report aims to highlight the importance of tailored therapies in women with Polycystic Ovary Syndrome (PCOS), avoiding prescribing generalized or unsuitable therapies based on oral contraceptive pills (OCPs).

AREAS COVERED

This article discusses benefits and risks of OCP-based therapy, highlighting the possible undesirable effects, especially in those patients exhibiting risk factors as women with PCOS, and the importance of carefully evaluated tailored therapeutic approaches. Literature searches were performed with the use of PubMed, Google Scholar, and Web of Science between January and February 2024.

EXPERT OPINION

Considering the recent re-analysis of PCOS Rotterdam Criteria by the Expert Group on Inositol in Basic and Clinical Research, and on PCOS (EGOI-PCOS), the traditional Rotterdam phenotypes can be reclassified to achieve more efficacious therapy choices. Using personalized therapies that consider the specific clinical characteristics of the patient, allows to improve the management of the syndrome, thus avoiding the generalized use of OCPs, which treat only symptoms of PCOS rather than the underlying cause. In cases when contraceptive purpose is desired, patients may benefit from combined therapy with diet or insulin-sensitizer agents, as inositol, to rebalance the metabolic profile, thus reducing the risk of developing future complications.

Chinese college students' mental health during the first three months of the COVID-19 pandemic: the protective role of family functioning

Background

Various psychological theories suggest that a supportive family environment protects the mental health of young adults during stressful life events. However, evidence is limited regarding the protective role of family support during a major public health crisis.

Objective

To examine the role of family functioning on mental health among Chinese college students during first stage of the COVID-19 pandemic.

Methods

Between January-March 2020, 1,555 college students (44% female, on average 19 years old) from five Chinese universities participated. Participants rated their family functioning on the Family APGAR Index and their mental health on the Psychological Questionnaires for Emergent Events of Public Health, measuring depression, neurasthenia, fear, obsessive-anxiety and hypochondriasis.

Results

Better family functioning was associated with having fewer psychological symptoms. In addition, we identified three mental health profiles related to the severity across the psychological symptoms: Low-level, medium-level and high-level symptom clusters. Latent profile analysis showed that as family function improved, students were, respectively, 16 to 24% more likely to be in the low-level symptom group, compared to being in the medium symptom group or the high-level symptom group.

Conclusion

These results support the notion that family support may act as a psychological buffer for young adults during a large-scale public health crisis like the COVID-19 pandemic.

Mental health conditions and contraception: current landscape, reproductive health and obstetric outcomes, and clinical guidance

PURPOSE OF REVIEW

This review presents the epidemiology of mental health conditions among reproductive aged people, common adverse reproductive outcomes, the hormonal profile of contraception and its relationship with psychiatric outcomes, and updated information for clinicians providing contraceptive counselling for this population.

RECENT FINDINGS

There is variability among contraceptive behaviours and patterns across those who have mental health conditions, impacting reproductive, psychiatric, and perinatal outcomes. The endocrinology of hormonal contraceptives is well understood, however, the impacts of steroidal hormones on mental health outcomes continue to be less understood. Overall, hormonal contraceptives are safe to use among those with mental health conditions, and among those using selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. Additional considerations are needed when prescribing contraception among people who may be at risk of poor adherence, who use certain classes of antidepressants, antipsychotics, antiepileptics, and who are <6 weeks postpartum.

SUMMARY

Barriers to effective contraceptive use should be addressed and myths on negative psychiatric impacts of hormonal contraceptives should be dispelled. Healthcare clinicians should seek out opportunities to become proficient in contraception counselling to improve health outcomes among people with mental health conditions.

Symptoms of mental disorders and oral contraception use: A systematic review and meta-analysis

Worldwide, over 150 million adolescent and adult women use oral contraceptives (OC). An association between OC-use and the emergence of symptoms of mental disorders has been suggested. This systematic review and meta-analysis provide an overview of published research regarding symptoms of mental disorders in association with OC-use, factoring the influence of OC types, age of first-use, duration of OC-intake, and previous diagnoses of mental disorders. A systematic literature search was conducted between June-July 2022. 22 studies were included. While most found no significant OC-use effects on mental symptoms, some hinted at OCs as a potential risk. The existing evidence regarding the potential link between progestin-only OC-use and an elevated risk of mental symptoms in comparison to combined OC-use remains inconclusive. However, due to emerging indications suggesting that the formulation of OC might play a role in mental health outcomes, this topic warrants further investigation. Moreover, indications of an increased risk for depressive symptoms in adolescent OC-users should be noted. Hence, while general population effects seem unlikely, they cannot be completely disregarded. The decision on OC-use should depend on the patient's medical history and should be re-evaluated regularly.

The Mind Body Connection in Dermatologic Conditions: A Literature Review

Psychodermatology pertains to the relationship between the skin and brain. This review aims to summarize the evidence of the mind body connection in four psychophysiological conditions: rosacea, atopic dermatitis (AD), acne vulgaris (AV), and psoriasis. A literature search was conducted using several English language databases. All four conditions share similar psychiatric co-morbidities, including but not limited to anxiety, depression, and suicidality. In rosacea, the upregulation of transient receptor potential vanilloid type 1, Toll like receptor 2, and Th17 cells releases downstream products that are simultaneously implicated in mood disorders. Stress exacerbates AV through the hypothalamic-pituitary-adrenal (HPA) system, which alters functioning of sebocytes and Cutibacterium acnes. In AD and psoriasis, the HPA axis influences Th1, Th2, Th22, and Th1, Th17 immune mediated responses, respectively. This leads to the secretion of pro-inflammatory cytokines which are also involved in the pathogenesis of anxiety and depression. Neurotransmitters implicated in mental illness, such as gamma-aminobutyric acid and serotonin, may also play a role in the development of AD and psoriasis. The management of cutaneous disease may mitigate psychological distress, and future research may show the corollary to also be true.

Serotonergic multilocus genetic variation moderates the association between interpersonal relationship and adolescent depressive symptoms

BACKGROUND

Research suggests that genetic variants linked to serotonin functioning moderate the association between environmental stressors and depressive symptoms, but examining gene-environment interactions with single polymorphisms limits power.

METHODS

A multilocus genetic profile score (MGPS) approach to measuring serotonergic multilocus genetic variation and examined interactions with interpersonal relationship, insomnia with depressive symptoms as outcomes in an adolescent sample (average age = 14.15 ± 0.63 years since first measurement; range: 13 to 15).

RESULTS

(1) interpersonal relationship predicted adolescent depressive symptoms; (2) insomnia mediated the effect of interpersonal relationships on adolescent depressive symptoms; (3) the THP2 gene rs4570625 polymorphism G allele was a key risk factor for depressive symptom, and the MGPS moderated the effects of teacher-student relationship and insomnia on adolescent depressive symptom. Specifically, as the MGPS increased, the effects of insomnia on adolescent depressive symptom were enhanced; further, when the MGPS score increased, the effect of teacher-student relationship on depression showed a similar phenomenon with an increased slope and enhanced prediction; and (4) the results of sensitivity analysis showed that multilocus genetic interaction with the environment had a better explanatory power and stability for depression than single polymorphism studies.

CONCLUSION

MGPS provides substantial power to examine gene-environmental interactions linked to affective outcomes among adolescents.

Population-based cohort study of oral contraceptive use and risk of depression

AIM

Research on the effect of oral contraceptive (OC) use on the risk of depression shows inconsistent findings, especially in adult OC users. One possible reason for this inconsistency is the omission of women who discontinue OCs due to adverse mood effects, leading to healthy user bias. To address this issue, we aim to estimate the risk of depression that is associated with the initiation of OCs as well as the effect of OC use on lifetime risk of depression.

METHODS

This is a population-based cohort study based on data from 264,557 women from the UK Biobank. Incidence of depression was addressed via interviews, inpatient hospital or primary care data. The hazard ratio (HR) between OC use and incident depression was estimated by multivariable Cox regression with OC use as a time-varying exposure. To validate causality, we examined familial confounding in 7,354 sibling pairs.

RESULTS

We observed that the first 2 years of OC use were associated with a higher rate of depression compared to never users (HR = 1.71, 95% confidence interval [CI]: 1.55-1.88). Although the risk was not as pronounced beyond the first 2 years, ever OC use was still associated with an increased lifetime risk of depression (HR = 1.05, 95% CI: 1.01-1.09). Previous OC use were associated with a higher rate of depression compared to never users, with adolescent OC users driving the increased hazard (HR = 1.18, 95% CI: 1.12-1.25). No significant association were observed among adult OC users who had previously used OCs (HR = 1.00, 95% CI: 0.95-1.04). Notably, the sibling analysis provided further evidence for a causal effect of OC use on the risk of depression.

CONCLUSIONS

Our findings suggest that the use of OCs, particularly during the first 2 years, increases the risk of depression. Additionally, OC use during adolescence might increase the risk of depression later in life. Our results are consistent with a causal relationship between OC use and depression, as supported by the sibling analysis. This study highlights the importance of considering the healthy user bias as well as family-level confounding in studies of OC use and mental health outcomes. Physicians and patients should be aware of this potential risk when considering OCs, and individualized risk-benefit assessments should be conducted.

Oral contraceptives in the central nervous system: Basic pharmacology, methodological considerations, and current state of the field

Millions of women around the world use combined oral contraceptives (OCs), yet surprisingly little is known about their central nervous system (CNS) effects. This article provides a short overview of the basic pharmacology of OCs, emphasizing features that may be relevant to understanding their effects in the CNS. Historical and recent findings from studies of cognitive function, mood, and negative affect (depressive changes under OC use) are then reviewed. We also present data from an archival dataset from our own laboratory in which we explore dysphoric changes in women using four generations of contraceptive progestins. Current data in the field are consistent with a modest effect of OC use on CNS variables, but conclusions based on current findings must be made very cautiously because of multiple methodological issues in many published studies to date, and inconsistencies in the findings. Directions for future research over the next 10 years are suggested. (150 words).

EFFECT OF HORMONAL CONTRACEPTION ON DEPRESSION IN WOMEN

Oral contraceptives are the most frequently chosen method of preventing pregnancy in Poland. Mood changes are one of the most common reasons why young women quit therapy. Depression is a severe disorder that affects millions of people around the world. Some long-term studies suggest an increased relative risk of antidepressant use during contraceptive use compared to non-users. Scientists note an increased risk of suicide as well. Other researchers suggest that there is insufficient evidence to support these findings. Some indicate strong correlation between most hormonal contraceptives and following usage of antidepressant drugs in female adolescents. There is still no consensus in the scientific community. Analyzes of many studies provide ambiguous information. Large-scale studies with properly selected test groups and particular therapies taken into consideration are required in order to accurately assess the risk of depression and mood disorders. In this article, we try to present different approaches to the subject of effects of various types of hormonal contraception methods on depression in women.

The Impact of Nicotine along with Oral Contraceptive Exposure on Brain Fatty Acid Metabolism in Female Rats

Smoking-derived nicotine (N) and oral contraceptive (OC) synergistically exacerbate ischemic brain damage in females, and the underlying mechanisms remain elusive. In a previous study, we showed that N + OC exposure altered brain glucose metabolism in females. Since lipid metabolism complements glycolysis, the current study aims to examine the metabolic fingerprint of fatty acids in the brain of female rats exposed to N+/-OC. Adolescent and adult Sprague-Dawley female rats were randomly (n = 8 per group) exposed to either saline or N (4.5 mg/kg) +/-OC (combined OC or placebo delivered via oral gavage) for 16-21 days. Following exposure, brain tissue was harvested for unbiased metabolomic analysis (performed by Metabolon Inc., Morrisville, NC, USA) and the metabolomic profile changes were complemented with Western blot analysis of key enzymes in the lipid pathway. Metabolomic data showed significant accumulation of fatty acids and phosphatidylcholine (PC) metabolites in the brain. Adolescent, more so than adult females, exposed to N + OC showed significant increases in carnitine-conjugated fatty acid metabolites compared to saline control animals. These changes in fatty acyl carnitines were accompanied by an increase in a subset of free fatty acids, suggesting elevated fatty acid β-oxidation in the mitochondria to meet energy demand. In support, β-hydroxybutyrate was significantly lower in N + OC exposure groups in adolescent animals, implying a complete shunting of acetyl CoA for energy production via the TCA cycle. The reported changes in fatty acids and PC metabolism due to N + OC could inhibit post-translational palmitoylation of membrane proteins and synaptic vesicle formation, respectively, thus exacerbating ischemic brain damage in female rats.

Hormonal Contraceptive Use and Risk of Depression Among Young Women With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Women with attention-deficit/hyperactivity disorder (ADHD) have an increased risk of becoming teenage mothers. Adverse effects of hormonal contraception (HC), including depression, may affect adherence to user-dependent contraception and increase the risk for unplanned pregnancies and teenage births in women with ADHD. The current study analyzed whether girls and young women with ADHD are at increased risk for depression during HC use compared with non-ADHD women.

METHOD

A linkage of Swedish national registers covering 29,767 girls and young women with ADHD aged 15 to 24 years and 763,146 without ADHD provided measures of ADHD and depression diagnoses (International Classification of Diseases [ICD] code) and prescription of stimulant medication, HC, and antidepressant medication (Anatomical Therapeutic Chemical [ATC] code). Cox regression models applying an interaction term (ADHD diagnosis × HC use) evaluated the excess risk of HC-induced depression in women with ADHD.

RESULTS

Women with ADHD had a 3-fold higher risk of developing depression, irrespective of HC use (adjusted hazard ratio [aHR] = 3.69, 95% CI = 3.60-3.78). Oral combined HC users with ADHD had a 5 times higher risk of depression compared with non-ADHD women who were not using oral combined HC (aHR = 5.19, 95% CI = 4.94-5.47), and a 6 times higher risk in comparison with non-ADHD women who were on oral combined HC (aHR = 6.10 (95% CI = 5.79-6.43). The corresponding risk of depression in women with AHDH who used a progestogen-only pill (aHR = 5.00, 95% CI = 4.56-5.49). The risk of developing depression when using non-oral HC was similarly moderately increased in both groups.

CONCLUSION

Girls and young women with ADHD have an increased risk of developing depression when using oral HC compared with their unaffected peers. Information on risks with HCs as well as potential benefits with long-acting reversible contraceptives needs to be an integrated part of the shared decision making and contraception counseling for young women with ADHD.

Association between adolescent oral contraceptive use and future major depressive disorder: a prospective cohort study

BACKGROUND

Because of the widespread use of oral contraceptives (OCs) and the devastating effects of depression both on an individual and a societal level, it is crucial to understand the nature of the previously reported relationship between OC use and depression risk. Insight into the impact of analytical choices on the association is important when interpreting available evidence. Hence, we examined the association between adolescent OC use and subsequent depression risk in early adulthood analyzing all theoretically justifiable models.

METHODS

Data from the prospective cohort study TRacking Adolescents' Individual Lives Survey, among women aged 13-25 years were used. Adolescent OC use (ages 16-19 years) was used as a predictor and major depressive disorder (MDD) in early adulthood (ages 20-25 years), as assessed by the Diagnostic and Statistical Manual of Mental Disorders-IV oriented Lifetime Depression Assessment Self-Report and the Composite International Diagnostic Interview, was used as an outcome. A total of 818 analytical models were analyzed using Specification Curve Analysis in 534 adolescent OC users and 191 nonusers.

RESULTS

Overall, there was an association of adolescent OC use and an episode of MDD in early adulthood [median odds ratio (OR)_median  = 1.41; OR_min  = 1.08; OR_max  = 2.18, p < .001], which was driven by the group of young women with no history of MDD (OR_median  = 1.72; OR_min  = 1.21; OR_max  = 2.18, p < .001).

CONCLUSIONS

In summary, adolescent OC use was associated with a small but robust increased risk for experiencing an episode of MDD, especially among women with no history of MDD in adolescence. Understanding the potential side effects of OCs will help women and their doctors to make informed choices when deciding among possible methods of birth control.

Assessing the role of adolescent hormonal contraceptive use on risk for depression: a 3-year longitudinal study protocol

BACKGROUND

The incidence of depression in human females rises steadily throughout adolescence, a critical period of pubertal maturation marked by increasing levels of gonadal hormones including estrogens and progesterone. These gonadal hormones play a central role in social and emotional development and may also contribute to the increased occurrence of depression in females that begins in early adolescence. In this study, we examine whether and how introducing synthetic estrogen and progestin derivatives through the use of combined hormonal contraceptives (CHC), affects adolescent females' risk for developing depression. We further assess potential links between CHC use and alterations in stress responses and social-emotional functioning.

METHODS

Using a longitudinal cohort design, we will follow a sample of adolescent females over the span of three years. Participants will be assessed at three time points: once when they are between 13 and 15 years of age, and at approximately 18 and 36 months after their initial assessment. Each time point will consist of two online sessions during which participants will complete a clinical interview that screens for key symptoms of mental health disorders, along with a series of questionnaires assessing their level of depressive symptoms and history of contraceptive use. They will also complete a standardized social-evaluative stress test and an emotion recognition task, as well as provide saliva samples to allow for assessment of their circulating free cortisol levels.

DISCUSSION

In this study we will assess the effect of CHC use during adolescence on development of Major Depressive Disorder (MDD). We will control for variables previously found to or proposed to partially account for the observed relationship between CHC use and MDD, including socioeconomic status, age of sexual debut, and CHC-related variables including age of first use, reasons for use, and its duration. In particular, we will discover whether CHC use increases depressive symptoms and/or MDD, whether elevated depressive symptoms and/or MDD predict a higher likelihood of starting CHC, or both. Furthermore, this study will allow us to clarify whether alterations in stress reactivity and social-emotional functioning serve as pathways through which CHC use may result in increased risk of depressive symptoms and/or MDD.

Stable Anxiety and Depression Trajectories in Late Adolescence for Oral Contraceptive Users

BACKGROUND

The use of oral contraceptives (OCs) has been associated with increased incidences of anxiety and depression, for which adolescents seem to be particularly vulnerable. Rather than looking at singular outcomes, we examined whether OC use is associated with depressive and anxiety symptom trajectories from early adolescence into early adulthood.

MATERIALS AND METHODS

Data from 178 girls were drawn from the Research on Adolescent Development and Relationships (RADAR-Y) younger cohort study. We used assessments on 9 waves from age 13 until 24. Developmental trajectories of ratings on the Reynolds Adolescent Depression Scale (RADS-2) and the Screen for Child Anxiety Related Emotional Disorders (SCARED) were compared between never and ever users of OCs.

RESULTS

Never users showed increases in depressive and anxiety symptoms in late adolescence, whereas OC users showed a stable level of symptoms throughout adolescence. This effect remained after adjusting for baseline differences between groups in romantic relationships, sexual debut, educational level, smoking, drinking, and drug use. Age of OC use onset did not significantly predict symptom development.

CONCLUSIONS

OC use in adolescence was related to an altered developmental trajectory of internalizing symptoms, in which OC users did not show an increase in depressive and anxiety symptoms in late adolescence, whereas never users did. The question remains whether this altered symptom trajectory can be considered a protective effect of OC use on psychopathology. Additional research is needed to improve our understanding of the long-term consequences of OC use on mental health.

There is no association between combined oral hormonal contraceptives and depression: a Swedish register-based cohort study

OBJECTIVE

To investigate whether users of hormonal contraceptives (HCs) are at increased risk of depression compared with non-users.

DESIGN

Register-based cohort study.

SETTING

Sweden.

SAMPLE

Women aged 15-25 years between 2010 and 2017 with no prior antidepressant treatment, psychiatric diagnose or contraindication for HCs (n = 739 585).

METHODS

Women with a prescription of HC were identified via the Swedish Prescribed Drug Register (SPDR). Relative risks (RRs) for first depression diagnosis in current HC-users compared with non-users were modelled by Poisson regression. Adjustments included age, medical indication for HC-use and parental history of mental disorders, among others.

MAIN OUTCOME MEASURES

Depression, captured by a redeemed prescription of antidepressant treatment, or a first depression diagnosis in the SPDR and the National Patient Register.

RESULTS

Compared with non-users, women on combined oral contraceptives (COCs) and oral progestogen-only products had lower or no increased risk of depression, relative risk (RR) 0.89 (95% CI 0.87-0.91) and 1.03 (95% CI 0.99-1.06) after adjustments, respectively. Age-stratified analyses demonstrated that COC use in adolescents conferred no increase in risk (RR 0.96, 95% CI 0.93-0.98), whereas use of progestogen-only pills (RR 1.13, 95% CI 1.07-1.19), contraceptive patch/vaginal ring (RR 1.43, 95% CI 1.30-1.58), implant (RR 1.38, 95% CI 1.30-1.45) or a levonorgestrel intrauterine device (RR 1.59, 95% CI 1.46-1.73) were associated with increased risks.

CONCLUSIONS

This study did not find any association between use of COCs, which is the dominating HC in first time users, and depression. Non-oral products were associated with increased risks. Residual confounding must be addressed in the interpretation of the results.

TWEETABLE ABSTRACT

There is no association between combined hormonal contraceptives and depression.

An Exploratory Cohort Study of the Association between the Level of Testosterone and Suicidal Ideation in Hospitalized Adolescent Females with Depression in China

BACKGROUND

To date, around 4 per 100,000 adolescents committed suicide within the 29 OECD countries. The suicidal behavior is related to psychological factors, genetics, neurobiology, and other biomarkers. The aim of this study was to examine risk factors for the development of suicidal ideation in adolescent females with depression, focusing on the relationship between different testosterone levels and suicidal ideation, in order to help develop strategies to intervene in suicidal behavior in female adolescents with depression.

METHOD

In this single-center prospective cohort study, we enrolled adolescent females with depression. We collected information on their baseline data, testosterone levels, symptom self-rating scale scores, suicidal ideation, non-suicidal self-injurious (NSSI) behaviours, and suicide attempts. We used multivariate logistic regression to identify risk factors for the development of suicidal ideation in adolescent females with depression.

RESULTS

A total of 113 hospitalized adolescent females were enrolled with a mean age of 13.5 (1.20). Among these patients, there were 86 (76.11%) subjects who suffered from suicidal ideation, 59 (52.21%) had NSSI and 23 (20.35%) had suicide attempt behavior. In the final model, higher level of testosterone (p=0.04) and higher age (p=0.02) were associated with the higher odds of having suicidal ideation.

CONCLUSION

In this exploratory cohort study, the emergence of suicidal ideation was common among adolescent females with depression. This study is consistent with the other studies. It shows that the age is a potential predictor for suicidal ideation in hospitalized adolescent females with depression.

Contraception for Women With Psychiatric Disorders

OBJECTIVE

Mental health care for women includes decision support to prepare for major life events, including preconception planning for treatment during pregnancy and the postpartum period. The authors discuss contraceptive choices and their effectiveness, side effects, and impact on psychiatric symptoms. The Centers for Disease Control and Prevention's recommendations, Medical Eligibility Criteria for Contraceptive Use, provided the structure for review of contraceptive choices.

METHODS

A search of PsycINFO, PubMed, Embase, and Scopus was conducted for publications on the management of contraception for women with mental illness. Publications were selected if they included, based on the authors' consensus, data supporting evidence-based care important for psychiatrists who treat women desiring contraceptives.

RESULTS

The majority of women choose combined oral contraceptives. Although long-acting reversible contraceptives (implants, intrauterine devices) are associated with low failure rates, favorable safety profiles, rapid return to fertility after removal, and few contraindications, they are chosen by only 14% of women. All methods are acceptable for women with depression, although medical comorbidities may dictate a specific type. The impact of hormonal contraceptives on the risk for depression is controversial; however, clinical studies and randomized placebo-controlled trials of women with psychiatric disorders have generally reported similar or lower rates of mood symptoms in hormonal contraceptive users compared with nonusers. Although interactions between psychotropic drugs and contraceptives are rare, clozapine, anticonvulsants, and St. John's Wort are exceptions.

CONCLUSIONS

Proactive management of mental illness, contraception, and pregnancy improves a woman's capacity to function and optimizes her mental and reproductive health.

Hormonal Contraception and Depression: Updated Evidence and Implications in Clinical Practice

Hormonal contraceptives are used worldwide by more than 100 million women. Some studies have been published about the possible appearance of depressive symptoms when using hormonal contraceptives, but this link is still a matter of debate. The purpose of this review is to provide an update of the literature on this issue, and to investigate the possible explanations of this problem based on animal and human studies. The main pathway responsible for menstrual cycle-related mood changes is the γ-aminobutyric acid pathway, which is sensitive to changes in the levels of progesterone and of its metabolites, the neurosteroids. In particular, allopregnanolone is a potentiating neurosteroid with anxiolytic and anti-convulsant effects whose levels change during a normal menstrual cycle together with progesterone levels. Progestins have different effects on allopregnanolone, mainly owing to their diverse androgenicity. Moreover, they might affect brain structure and function, even though the meaning of these changes has yet to be clarified. It is important to define the groups of women in which negative mood disorders are more likely to occur. Adolescence is a critical period and this age-specific vulnerability is complex and likely bidirectional. Moreover, women with a history of mood affective disorders or premenstrual dysphoric syndrome are at a higher risk when taking contraceptives. In this review, we aim to provide clinicians with advice on how to approach these difficult situations.

Hormonal contraceptives and the risk of suicide: a systematic review and meta-analysis

OBJECTIVE

To assess the effect of hormonal contraceptive use over the risk of suicide.

METHOD

Systematic review and meta-analysis of observational studies retrieved from five search engines until September 2019, comparing the use of any hormonal contraceptive versus non-hormonal contraceptive use or no use. Primary outcome was consumed suicide, and secondary outcomes were suicidal attempt and ideation. Random effects meta-analyses with the inverse variance method were used to evaluate the effects of exposure over outcomes. Effect was calculated as risk ratio (RR) with their corresponding 95% confidence interval (CI). Risk of bias was assessed with the Newcastle-Otawa Scale.

RESULTS

There were no randomized controlled trials concerning suicide and hormonal contraceptive use. Only three cohort studies (n = 184,721 women), that evaluated the primary outcome (consumed suicide), were included in the meta-analysis. Hormonal contraceptive use was associated to a higher risk of consumed suicide (RR = 1.36, 95% CI 1.06 to 1.75, P =  0.015, I² = 0%). There were no secondary outcomes in at least two cohorts.

CONCLUSION

This meta-analysis found a positive association between hormonal contraceptive use and consumed suicides. Prior to their use, populations at suicidal risk should be properly evaluated.

[Physician's obligations to inform about complications based on a recent warning from drug authorities]

BACKGROUND

Based on a recent warning from the drug authorities about increased suicidality among users of hormonal contraceptives, this article discusses the legal consequences of translating novel findings from clinical trials into altered contents of gaining informed consent during the medical consultation.

METHODS AND RESULTS

Comprehensive information in accordance with § 630e German Civil Code (BGB) requires that rare drug reactions be mentioned by the prescribing physician, when they are associated with serious sequelae. This act regulates the treating physician's obligations to inform about complications for both preventive and curative treatment options. In this paper, we refer to the scientific evidence level of data from clinical trials as the key feature for implementing altered medical information in the proper conduct of acquiring the consent of the patient in line with § 630e BGB. The article discusses how additions and amendments to the package leaflet and the expert information will impact on the obligations for the treating party to provide information for the patient in order to obtain informed consent. In particular, we focus on the relationship between the obligations for the physician prescribing oral contraceptives on an individual case and the generalized information conditions according to § 11 and § 11a German Medicinal Products Act.

DISCUSSION

Current warnings of the drug authorities in the form of red-hand letters do not necessarily have legal consequences for gaining informed consent during the medical consultation.

Oral contraceptive use in adolescence predicts lasting vulnerability to depression in adulthood

BACKGROUND

Previous evidence suggests that use of oral contraceptives (OCs), especially during adolescence, may increase women's vulnerability to depression in the short term. Here, we investigate whether women who had first used OC in adolescence show an increased prevalence of depression in the long term.

METHODS

We examined 1,236 women in the United States National Health and Nutrition Examination Survey for whom information on depression and age at first OC use was publicly available. We compared women who reported first use of OCs in adolescence to women who had never used OCs and women who had first used OCs in adulthood on 1-year prevalence of major depressive disorder (MDD) assessed by trained interviewers.

RESULTS

Compared with women who had used OCs during adolescence, women who had never used OCs were less likely to meet the criteria for MDD within the past year in adulthood [odds ratio (OR) = 0.31, 95% CI = 0.16-0.60], and so were women who only started using OCs in adulthood (OR = 0.54, 95% CI = 0.30-0.95). Third factors that have previously been proposed to explain the relationship between OC use and depression risk such as age at sexual debut, and, importantly, current OC use, did not account for the results in propensity score analyses.

CONCLUSIONS

We show a long-term association between adolescent OC use and depression risk in adulthood regardless of current OC use. Our findings suggest that adolescence may be a sensitive period during which OC use could increase women's risk for depression, years after first exposure.

The brain as a target of hormonal contraceptives: Evidence from animal studies

Hormonal contraceptives are frequently prescribed drugs among women, mainly for their reversible contraceptive purposes but also for beneficial effects in some gynecological pathologies. Despite extensive studies aimed at elucidating the physical effects of hormonal contraceptives and ameliorating some unwanted outcomes, little is known yet about the effects of these drugs on brain function and related behavior, which are known to be modulated by endogenous steroid hormones. We describe the current literature on preclinical studies in animals undertaken to investigate effects of hormonal contraceptives on brain function and behavior. These studies suggest that hormonal contraceptives influence neurohormones, neurotransmitters, neuropeptides, and emotional, cognitive, social and sexual behaviors. Animals allow examination of the basic biological mechanisms of these drugs, devoid of the psychological aspect often associated to hormonal contraceptives' use in women. Understanding the neurobiological effects of these drugs may improve women's health and may help women making informed choices on hormonal contraception.