Oral contraceptives and depression: impact, prevalence and cause

Prevalence of anxiety and depression among Lebanese women using oral contraceptives: a cross-sectional study

BACKGROUND

Oral contraceptives (OCs) are used worldwide, including Lebanese women. However, the association between OCs use and anxiety or depression remains unclear. This study aims to assess the prevalence of anxiety and depression among Lebanese women using oral contraceptive pills and investigate the differential impact of combined oral contraceptives (COCs) versus progestogen-only pills (POPs) on mental health outcomes.

METHODS

A cross-sectional study was conducted among a sample of Lebanese women using OCs between January and March 2023. Nine hundred nighty seven out of the 2051 women who took part in the survey met our criteria and were included in this study. Data on anxiety and depression were collected using validated and reliable scales, the Arabic versions of the Generalized Anxiety Disorder-7 Questionnaire (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9). Statistical analyses, including multivariate analysis, were performed to assess the association between OCs type (COC vs. POP) and anxiety/depression.

RESULTS

The prevalence of anxiety and depression among Lebanese women taking OCs was found to be 39.9% and 64.3%, respectively. Furthermore, the study revealed that POP users had 2.8 times higher odds of developing anxiety (adjusted odds ratio ORadj = 2.8 with 95% confidence interval CI of 1.770 to 4.435) p-value < 0.001 and 9.2 times higher odds of developing depression (adjusted odds ratio ORadj = 9.2 with 95% confidence interval CI of 5.790 to 14.506) p-value < 0.001 compared to COC users.

CONCLUSION

The results of this study shed light on the elevated prevalence of anxiety and depression among Lebanese women using OCs and emphasized the varying effects of COCs and POPs on their mental health outcomes. Further research is needed to comprehensively understand this association, considering both the dosage and specific type of oral contraceptive to improve the overall well-being of women using these contraceptives.

Progesterone, reproduction, and psychiatric illness

Mood and anxiety disorders are vastly overrepresented in women, and one important contributor to these differences is the fluctuation in sex steroids in women during the reproductive years. Considerable evidence supports a role for abnormal sensitivity to these hormonal fluctuations for some women, who develop mood symptoms associated with reproductive transitions. This chapter presents evidence of the role of endogenous progesterone and its metabolites in such mood symptoms, and then goes on to cover the evidence concerning exogenous progesterone's effects on mood. Overall, the literature does not support an association between exogenous progesterone and negative mood in the general population, but does indicate that subset of women may be vulnerable to such effects. Research is lacking on women with psychiatric illness.

Psychiatric side effects of medications prescribed in internal medicine

Several pharmacological treatments used in internal medicine can induce psychiatric side effects (PSEs) that mimic diagnoses seen in psychiatry. PSEs may occur upon withdrawal or intoxication, and also at usual therapeutic doses. Drugs that may lead to depressive, anxious, or psychotic syndromes include corticosteroids, isotretinoin, levo-dopar mefloquine, interferon-a, and anabolic steroids, as well as some over-the-counter medications. PSEs are often difficult to diagnose and can be very harmful to patients. PSEs are discussed in this review, as well as diagnostic clues to facilitate their identification.

Management of female sexual problems: perceived barriers, practice patterns, and confidence among primary care physicians and gynecologists

INTRODUCTION

Although approximately 40% of women report female sexual problems--and particularly sexual desire disorders, there are numerous practical, professional, and personal barriers to their diagnosis and management by treating clinicians.

AIM

To identify practice patterns, perceptions, and barriers to the diagnosis and management of female sexual problems among U.S. practicing primary care physicians (PCPs) and obstetrician/gynecologists (OB/GYNs).

METHODS

A random sample of practicing U.S. PCPs and OB/GYNs were sent a case-vignette survey by e-mail and fax. Response to the survey was considered consent. A regression model was analyzed to assess predictors of confidence.

MAIN OUTCOME MEASURE

Frequency and variability in diagnostic tests ordered and treatment recommendations provided for a patient with diminished sexual desire. Percent of physicians who reported they were confident in treating hypoactive sexual desire disorder (HSDD) and percent who reported significant barriers to initiating a dialogue about sexual health with female patients.

RESULTS

A total of 505 responses were analyzed (8.8% response rate). Of respondents, 21% of OB/GYNs and 38% of PCPs stated they were not at all confident in treating HSDD. The majority of physicians would order a thyroid panel (PCP = 63%, OB/GYN = 53%) to assess a patient's diminished desire and recommended counseling and stress management to treat a patient with sexual complaints (PCP = 48%, OB/GYN = 54%). Regression results identified time constraints, the perceived lack of effective therapies, perceptions regarding patient-physician gender discordance, years in practice, number of patients seen per week, and perceptions regarding continuing medical education and practice experience as significant and independent predictors of confidence in treating HSDD patients.

The influence of hormonal contraception on mood and sexual interest among adolescents

Mood and sexual interest changes are commonly cited reasons for discontinuing hormonal contraceptives. Data, however, are inconsistent and limited to adult users. We examined associations of hormonal contraceptive use with mood and sexual interest among adolescents. We recruited 14-17-year-old women from primary care clinics and followed them longitudinally for up to 41 months. Participants completed face-to-face interviews quarterly and two 12-week periods of daily diary collection per year. On daily diaries, participants recorded positive mood, negative mood, and sexual interest. We classified 12-week diary periods as "stable OCP use," "non-use," "initiated use," "stopped use," and "DMPA use" based on self-report of oral contraceptive pill (OCP) use and depot medroxyprogesterone acetate (DMPA) use from medical charts. Diary periods were the unit of analysis. Participants could contribute more than one diary period. We analyzed data using linear models with a random intercept and slope across weeks in a diary period, an effect for contraceptive group, and an adjustment for age at the start of a diary period. Mean weekly positive mood was higher in diary periods characterized by stable OCP use, compared to other groups. Mean weekly negative mood was lower in diary periods characterized by stable OCP use and higher in periods characterized by DMPA use. Periods characterized by stable OCP use additionally showed less mood variation than other groups. Changes in mood among adolescent hormonal contraceptive users differed from those anticipated for adult users. Attention to adolescent-specific changes in mood and sexual interest may improve contraceptive adherence.

The effects of estradiol on central serotonergic systems and its relationship to mood in women

Lifetime prevalence rates of depression are higher in women than men. Because this gender disparity appears after the onset of puberty and declines after menopause, gonadal hormones may play a role in women's increased vulnerability to dysphoric states. Estrogens have powerful effects beyond their role in reproduction. Fluctuations in estrogen occur naturally throughout the reproductive years and can be associated with disruptions in mood. Treatment for depression with exogenous estrogen has produced equivocal results. To shed light on the complex interactions among estrogens, serotonin, and mood, we briefly examine (a) central serotonin systems and their relationship to mood and mood disorders, (b) nonreproductive effects of estrogens on those systems, (c) potential points of intersection between serotonin systems and estrogens, and (d) research into the use of exogenous estrogen in depression in women. In conclusion, we reiterate the call for carefully controlled research into the etiology and treatment of depression in women.

ORIGINAL RESEARCH—WOMEN’S SEXUAL HEALTH: Comparison of Androgens in Women with Hypoactive Sexual Desire Disorder: Those on Combined Oral Contraceptives (COCs) vs. Those not on COCs

INTRODUCTION

Approximately one out of four sexually active women in the United States uses some form of hormonal contraceptive method because they provide the most effective reversible method of birth control available. However, little attention has been paid to possible adverse effects of combined oral contraceptives (COCs) on sexual functioning.

AIM

The aim of this study was to examine the potential effects of COCs on women with hypoactive sexual desire disorder (HSDD). It was hypothesized that female patients with generalized, acquired HSDD on COCs have lower androgen levels than those not on COCs.

METHODS

The patients were healthy premenopausal women with HSDD, aged 22-50 years. Subjects had a history of adequate sexual desire, interest, and functioning. Participants were required to be in a stable, monogamous, heterosexual relationship and were screened for any medication or medical or psychiatric disorders that impact desire. The patients met operational criteria for global, acquired HSDD. The 106 patients were divided into two groups: those on COCs (N = 43) and those not on COCs (N = 63). A two-tailed t-test comparison was made between the two groups comparing free and total testosterone and sex hormone-binding globulin (SHBG).

MAIN OUTCOME MEASURES

The main outcome measures are the differences between the two groups comparing free testosterone, total testosterone, and SHBG.

RESULTS

These patients with HSDD on COCs had significantly lower free and total testosterone levels compared with those who were not on COCs. The SHBG was significantly higher in the group on COCs compared with those who were not on COCs.

CONCLUSION

The result of this study suggests that COCs in premenopausal women with HSDD are associated with lower androgen levels than those not on COCs. Further research is required to determine if low androgen levels secondary to COCs impact female sexual desire.

Decreased neuroactive steroids induced by combined oral contraceptive pills are not associated with mood changes

OBJECTIVE

To evaluate the effects of a low-dose combined oral contraceptive pill (OCP) on peripheral neuroactive steroid concentrations, precursors for neuroactive steroid synthesis, and mood in healthy women desiring contraception. These neuroactive steroids are gamma-aminobutyric acid receptor agonists and are important in the modulation of affect and adaptation to stress.

DESIGN

Prospective observational study.

SETTING

Human ambulatory patient study.

PATIENT(S)

Healthy OCP-naive women without current or history of affective disorder.

INTERVENTION(S)

A 0.020-mg ethinyl E2-0.1-mg levonorgestrel containing OCP for 3 months.

MAIN OUTCOME MEASURE(S)

Serum neuroactive steroids allopregnanolone, allotetrahydrodeoxycorticosterone, and DHEA; neuroactive steroid precursors P and pregnenolone; E2; and mood and anxiety as assessed by the Premenstrual Syndrome Daily Ratings Form, Beck Depression Inventory, Spielberger State-Trait Anxiety Inventory, and Profile of Mood States.

RESULT(S)

The combined OCP resulted in a decrease in neuroactive steroids and neuroactive steroid precursors as well as in E2. However, this decline was not associated with adverse mood changes on any of the well-validated assessment tools.

CONCLUSION(S)

Healthy women without underlying mood or anxiety disorder who were given a low-dose OCP did not experience adverse psychological symptoms despite a significant reduction in neuroactive steroids.

Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder

OBJECTIVE

To compare the efficacy of a new low-dose oral contraceptive pill (OCP) formulation with placebo in reducing symptoms of premenstrual dysphoric disorder.

METHODS

This multicenter, double-blind, randomized clinical trial consisted of 2 run-in and 3 treatment cycles with daily symptom charting; 450 women with symptoms of premenstrual dysphoric disorder were randomized to either placebo or an OCP formulation containing drospirenone 3 mg and ethinyl estradiol 20 microg. Hormones were administered for 24 days, followed by 4 days of inactive pills (24/4).

RESULTS

Scores on the total Daily Record of Severity of Problems decreased by -37.49 in the drospirenone/ethinyl estradiol group and by -29.99 in the placebo group (adjusted mean difference -7.5, 95% confidence interval [CI] -11.2 to -3.8; P < .001 by rank analysis of covariance). Mood symptom scores were reduced by -19.2 and -15.3 in active-treatment and placebo groups, respectively (adjusted mean difference -3.9, 95% CI -5.84 to -2.01; P = .003); physical symptom scores were reduced by -10.7 and -8.6 in active-treatment and placebo groups, respectively (adjusted mean difference -2.1, 95% CI -3.3 to -0.95; P < .001); and behavioral symptom scores were reduced by -7.7 and -6.2 in active-treatment and placebo groups, respectively (adjusted mean difference -1.5, 95% CI -2.251 to -0.727; P < .001). Response, defined as a 50% decrease in daily symptom scores, occurred in 48% of the active-treatment group and 36% of the placebo group (relative risk 1.7, 95% CI 1.1 to 2.6; P = .015) and corresponds to a number-needed-to-treat of 8 patients.

CONCLUSION

A 24/4 regimen of drospirenone 3 mg and ethinyl estradiol 20 mug improves symptoms associated with premenstrual dysphoric disorder.

LEVEL OF EVIDENCE

I.

Impact of common contraceptive methods on quality of life and sexual function in Hong Kong Chinese women

The combined oral contraceptive (COC) pills, injectables, intrauterine contraceptive device (IUCD) and female sterilization are the most common contraceptive methods used by women. Women's choice, compliance and satisfaction with specific contraceptive methods are influenced by any impact of the method on their quality of life and sexual function. Anxiety regarding possible adverse effects of the contraceptive methods on their quality of life and sexual function is one of the common concerns. The aim of this prospective observational study was to determine the impact of the abovementioned contraceptive methods on the quality of life and sexual function of the users. A sample of 361 Hong Kong Chinese women who were first-time users of the following contraceptive methods completed the study: COC pills (n=87), injectables (n=67), IUCD (n=96) and female sterilization (n=111). Quality of life and sexual function of the subjects were assessed before and 3-4 months after use of the method by a standardized questionnaire. The questions were adopted from the validated Chinese versions of the World Health Organization Quality of Life (WHOQOL) questionnaire and the Derogatis Sexual Functioning Inventory (DSFI). In the female sterilization group, we found a significantly higher score for sexual satisfaction (p=.004) and sexual drive (p=.003) 3-4 months after sterilization, as well as an improved WHOQOL social domain score (p=.009). However, the other DSFI subscale scores and WHOQOL domain scores were not significantly different (p>.05). No significant difference was demonstrated in all the WHOQOL domain scores and DSFI subscale scores after use of COC pills, injectables and IUCD (p>.05). We conclude that the COC pills, injectables, IUCD and female sterilization all do not have significant adverse impact on quality of life and sexual function. After female sterilization, there is a significant improvement in sexual satisfaction and sexual drive.

Triphasic oral contraceptive treatment alters the behavior and neurobiology of female cynomolgus monkeys

Oral contraceptives (OCs) are the most widely prescribed and effective of the reversible contraceptive methods. In addition to inhibiting ovulation, OCs alter central nervous system function in women; however, methodological problems have prevented clear human studies. Thus, in this experiment we investigated the effects of OC treatment on behavior, hypothalamic- pituitary-adrenal axis function and the central nervous system in 75 adult female cynomolgus monkeys (Macaca fascicularis) housed in social groups of four to five monkeys per pen. Monkey social groups were randomly divided into either a control or an OC treatment group which was administered a clinically prescribed OC (Triphasil(R), levonorgestrel and ethinyl estradiol tablets) for 2 years. OC treatment increased the frequency of contact aggression received, time spent in locomotion, and sitting close to another animal, and decreased time spent fearfully scanning. OC treatment decreased heart rate, increased activity levels, and increased baseline cortisol concentrations and the cortisol response to adrenocorticotropin compared to control animals. OC treatment decreased the prolactin response to fenfluramine suggesting decreased serotonergic activity. These results suggest that this triphasic OC disrupts social behavior, hypothalamic-pituitary-adrenal axis regulation and the underlying central nervous system function.

Reproductive life events and sexual functioning in women: case reports

Are reproductive life events in women associated with an increased risk of sexual dysfunction? Female sexual dysfunction effects up to 40% of women in the United States between 18 and 59 years of age. Sexual dysfunction may be accompanied by fluctuations in gonadal hormone secretion, making women more vulnerable to sexual symptoms, especially during times of reproductive life events. Reproductive life events, such as the use of birth control pills, various phases of the menstrual cycles, postpartum and lactation states, and perimenopause, are highly correlated with changes in sex steroids. As an understanding of the role of sex steroids on sexual functioning is elucidated, clinicians will be able to offer more specific and effective treatment options for women during various phases of reproductive life. Several case studies are presented to illustrate the unique clinical considerations that a clinician must consider when treating the biologic component of female sexual dysfunction.

To what extent do oral contraceptives influence mood and affect?

BACKGROUND

Studies examining the effects of oral contraceptives (OCs) on mood, affect, and affect variability are reviewed.

METHODS

MEDLINE and PsycLIT data bases were examined to identify studies that compared OC users with nonusers using daily ratings of mood, affect, or affect variability.

RESULTS

Compared to non-users, OC users experience less variability in affect across the entire menstrual cycle, and less negative affect during menstruation (i.e. withdrawal bleeding). In women with OC-related negative mood and affect change, potential mediators of the relation between OCs and mood or affect were identified: a history of depression, psychiatric symptoms, dysmenorrhea, and premenstrual mood symptoms prior to OC use; a history of pregnancy-related mood symptoms; a family history of OC-related mood complaints; being in the postpartum period; and age. Furthermore, a lower ratio of progesterone to estrogen is associated with more negative mood change in women with a history of premenstrual emotional symptoms, higher progesterone to estrogen ratios are associated with increased negative mood effects in women without such a history, and monophasic OCs have a greater stabilizing effect on mood than triphasic OCs.

LIMITATIONS

The 'survivor effect', psychological factors, and indirect pharmacological effects (e.g. weight gain) have not yet been systematically investigated. Furthermore, most studies have examined only negative mood or affect, as opposed to both positive and negative affect and affect variability; and few affect studies have assessed potential mediators of OC-related affect change.

CONCLUSIONS

While the only consistent OC-related mood effects experienced by most women are beneficial, a subgroup of women do experience negative mood change. Future research must focus on expounding the individual difference and OC-related risk factors for negative mood change.

Effects of oral contraceptives on daily self-ratings of positive and negative affect

OBJECTIVES

The relationship between affect and duration of oral contraceptive (OC) use was investigated.

METHOD

Ninety-six women (17 first-time OC users, 34 long-time users, and 45 never-users) completed the Positive and Negative Affect Schedule (PANAS) and the Menstrual Distress Questionnaire (MDQ) daily for 35 days. This study was the first to examine positive affect variability; and personal family psychiatric history; and to compare early-, late-, and never-users of OCs.

RESULTS

Triphasic users experienced greater variability in positive affect across the cycle, likely due to the variable hormone levels. Withdrawal of a constant level of hormones (monophasics) during early use was associated with greater variability in positive affect than withdrawal of changing hormonal levels (triphasics). Furthermore, personal and family psychiatric history may mediate an effect of OCs on negative affect variability.

CONCLUSIONS

OCs and, therefore, hormones can alter day-to-day affect variability. Four variables are associated with this effect: duration of use, OC type, personal psychiatric history, and family psychiatric history.

Low dose oral contraceptives and quality of life

This study investigated the effects of a low dose oral contraceptive (OC) (Mercilon) on women's satisfaction and quality of life based on a detailed questionnaire. A total of 614 first-time users of oral contraceptives were enrolled by 102 gynecologists for a treatment period of > or = 4 months. The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) was filled in both before and during pill intake. The total quality of life score was significantly increased under OC intake. In contrast to older preparations, modern low dose OCs appear to act favorably on a number of psychological parameters, thus increasing satisfaction with various aspects of daily life and, consequently, improving quality of life.

Effects of estradiol, progesterone, and norethisterone on regional concentrations of galanin in the rat brain

Concentrations of immunoreactive galanin were compared in eight gross brain regions of ovariectomized female rats treated with either estradiol, estradiol + progesterone, estradiol + norethisterone, or placebo. Higher concentrations with estradiol treatment compared with placebo were found in the pituitary (357%), frontal cortex (162%), occipital cortex (174%), hippocampus (170%), and median eminence (202%). A more profound difference with addition of progesterone or norethisterone was seen in the pituitary (529% and 467%, respectively). Sex steroids, particularly estradiol, modulate galanin concentrations not only in reproductive, but also in nonreproductive, brain regions.

Behavioral and neurobiological effects of estrogen replacement therapy and a history of triphasic oral contraceptive exposure

The effects of contraceptive steroids and estrogen replacement therapy on behavior and neuroendocrine function were evaluated in adult female cynomolgus monkeys. During the 'premenopausal' phase of the experiment, the animals were assigned to either treatment with a triphasic oral contraceptive (OC) for 24 months or the untreated control group. The monkeys were then ovariectomized and half of each of the premenopausal groups were randomly assigned to either treatment with conjugated equine estrogens (ERT) or the untreated control group for 12 months (the 'postmenopausal' phase). All evaluations were completed during the postmenopausal phase of the experiment. Both types of exogenous steroid treatments appeared to increase cardiovascular and hypothalamic-pituitary-adrenal responses to stress in socially dominant but not socially subordinate females. A history of triphasic OC administration increased contact aggression received, and reduced the prolactin response to fenfluramine, suggesting reduced serotonergic activity, for at least a year following the cessation of triphasic OC treatment.

The psychotherapeutic effects of estrogens

The effect of estrogens on the central nervous system, particularly mood and behavior, remains a controversial area which needs clarification, not just for understanding of depression in women but to ensure that such commonplace problems in women have efficient and appropriate therapy. There is now good evidence that estrogens are rapidly effective in the treatment of depression in many women but this information has not found its way through to those health care personnel, psychiatrists and psychologists who are principally involved in the treatment of depression. There is also strong evidence for the benefits of estrogens on cognitive functioning, not only in preventing the onset of dementia but also in improving the symptoms in the established condition. Recent work has also suggested a benefit for estrogens on mood in women diagnosed as suffering from chronic fatigue syndrome. This article reviews the effect of endogenous estrogen on the female central nervous system and the ever increasing evidence for the diverse psychotherapeutic effects of exogenous estrogens.

Oestrogens and psychological well-being

The last decade has seen increased interest in the role of hormones, including oestrogens, not only in regulating growth, sexual development and reproduction but in maintaining a sense of psychological well-being. Episodes of change in oestrogen levels, whether increasing or decreasing, are high-risk periods for the emergence of psychological symptoms in some women. This may be due to a 'kindling effect' for women with previous psychological disturbance, an effect on circadian rhythm activity and therefore altered neurovegetative functions, or an effect on central rhythmic functioning between the hypothalamus and the cerebral cortex, all mediated by effects on neurotransmitter systems. Data supporting these hypotheses come from animal studies as well as converging research in several areas including the study of psychological side-effects of oral contraceptives, the study of mood and cognitive disturbances related to the menstrual cycle, the studies of states of hormonal change such as pregnancy and the menopause and, of course, studies of women with psychiatric disorders such as major depression, seasonal affective disorder and dementia. Improvement in such symptoms via hormonal therapies or other interventions will probably lead to better quality of life for women and may actually impede the deterioration associated with ageing and certain medical illnesses. Current data support a relationship between oestrogen and psychological well-being.

Oral contraceptive side effects: where's the beef?

The initial report is reviewed, as well as the results of subsequent investigations, and the current status of the following side effects attributed to the use of oral contraceptives: subjective symptoms such as mood and libido changes, also headache; melanoma; gallbladder disease; liver tumors, sickle cell disease exacerbation; teratogenesis; "post-Pill" amenorrhea; atherogenesis; and diminished carbohydrate tolerance. In many instances a cause-and-effect relationship appears to be incorrect or highly improbable. In other instances the side effects are clinically insignificant or so rare as to be of minimal importance. Yet they continue to be listed by various authorities as validated side effects or relative contraindications to oral contraceptive use. This, in turn, limits the access of many women to a highly effective form of contraception. This re-examination of past history is intended to modernize our concepts of the safety of this modality.

Oral contraceptives, sociocultural beliefs and psychiatric symptoms

The occurrence of psychiatric symptoms as detected by the General Health Questionnaire was examined in three groups of Moslem women. Those who used oral contraceptives were compared to those who used local contraceptives and those using no contraceptives in relation to their beliefs about prohibition of contraception by the Islamic religious code and/or about possible health hazards of contraception. Those who held one or both sets of adverse beliefs had significantly more symptoms. However the fact that women on oral contraceptives had most symptoms has been attributed to the repetitive nature of pill-taking acting as a reminder of the presumed adversity and/or to the biochemical effects of oral contraceptives.