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

Sex Differences in Stress Susceptibility as a Key Mechanism Underlying Depression Risk

PURPOSE OF REVIEW

Although females are at relatively greater risk for a variety of disorders, including depression, the biological mechanisms underlying this striking health disparity remain unclear. To address this issue, we highlight sex differences in stress susceptibility as a key mechanism potentially driving this effect and describe the interacting inflammatory, hormonal, epigenomic, and social-environmental mechanisms involved.

RECENT FINDINGS

Using the Social Signal Transduction Theory of Depression as a theoretical framework, women's elevated risk for depression may stem from a tight link between life stress, inflammation, and depression in women. Further, research finds hormonal contraceptive use alters cortisol and inflammatory reactivity to acute stress in ways that may increase depression risk in females. Finally, beyond established epigenetic mechanisms, mothers may transfer risk for depression to their female offspring through stressful family environments, which influence stress generation and stress-related gene expression. Together, these findings provide initial, biologically plausible clues that may help explain the relatively greater risk for depression in females vs. males. Looking forward, much more research is needed to address the longstanding underrepresentation of females in biomedical research on the biology of stress and depression.

Polycystic Ovary Syndrome and Irritable Bowel Syndrome: Is There a Common Pathway?

OBJECTIVE

Little is known about how polycystic ovary syndrome (PCOS) is linked to irritable bowel syndrome (IBS). This study aimed to review the existing literature regarding the association between PCOS or its symptoms and complications with IBS.

METHODS

In this review, studies that investigated the proposed cross-link between features of PCOS and IBS were included. This review collectively focused on recent findings on the mechanism and novel insight regarding the association between IBS and PCOS in future clinical practice. An electronic search of PubMed, Scopus, Epistemonikos, Cochrane Library and Google Scholar was performed. We did not restrict the study setting and publication date.

RESULTS

The existing evidence has not completely answered the question of whether there is an association between PCOS and IBS and vice versa. Six case-control studies (793 women with PCOS and 547 women in the control group) directly assessed the association between PCOS and IBS. The prevalence of IBS among women with PCOS in these studies has ranged from 10% to 52% compared with 5%-50% in control groups. Evidence suggested the common pathways may have contributed to the interaction between IBS and PCOS, including metabolic syndrome, sex hormone fluctuation, dysregulation of neurotransmitters, psychological problems and environmental and lifestyle factors. To date, it is still ambiguous which of the mentioned components largely contributes to the pathogenesis of both.

CONCLUSION

Although limited evidence has shown a higher prevalence of IBS in women with PCOS, there are several potential, direct and common indirect pathways contributing to the development of both IBS and PCOS.

A Perspective on Hormonal Contraception Usage in Central Nervous System Injury

Naturally occurring life stages in women are associated with changes in the milieu of endogenous ovarian hormones. Women of childbearing age may be exposed to exogenous ovarian hormone(s) because of their use of varying combinations of estrogen and progesterone hormones-containing oral contraceptives (OC; also known as "the pill"). If women have central nervous system (CNS) injury such as spinal cord injury (SCI) and traumatic brain injury (TBI) during their childbearing age, they are likely to retain their reproductive capabilities and may use OC. Many deleterious side effects of long-term OC use have been reported, such as aberrant blood clotting and endothelial dysfunction that consequently increase the risk of myocardial infarction, venous thromboembolism, and ischemic brain injury. Although controversial, studies have suggested that OC use is associated with neuropsychiatric ramifications, including uncontrollable mood swings and poorer cognitive performance. Our understanding about how the combination of endogenous hormones and OC-conferred exogenous hormones affect outcomes after CNS injuries remains limited. Therefore, understanding the impact of OC use on CNS injury outcomes needs further investigation to reveal underlying mechanisms, promote reporting in clinical or epidemiological studies, and raise awareness of possible compounded consequences. The goal of the current review is to discuss the impacts of CNS injury on endogenous ovarian hormones and vice-versa, as well as the putative consequences of exogenous ovarian hormones (OC) on the CNS to identify potential gaps in our knowledge to consider for future laboratory, epidemiological, and clinical studies.

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.

Associations of adolescent substance use and depressive symptoms with adult major depressive disorder in the United States: NSDUH 2016-2019

BACKGROUND

Few studies have focused on the associations of adolescent substance use and depressive symptoms with adult major depressive disorder (MDD).

METHODS

Data from 168,859 adults, among which, 15,959 had experienced MDD in the past year, as indicated by a major depressive episode (MDE) marked by MDD symptoms, were from the 2016-2019 National Surveys on Drug Use and Health. Weighted multivariable logistic regression (MLR) analyses were used to determine the associations.

RESULTS

The overall MDD prevalence was 7.2 %, whereas the prevalence for adults without early onset depressive symptoms prior to age 18 was 4.6 %. Variable cluster analysis revealed that adolescent use of alcohol, cigarettes, marijuana, cocaine, hallucinogen use, and inhalants prior to age 18 were in one cluster. MLR analyses showed that the presence of depressive symptoms prior to age 18 was the major risk factor for MDD, while adolescent use of alcohol, marijuana, and inhalants prior to age 18 were associated with increased odds of MDD (p < 0.05) both in the whole data and the subset of adults without depressive symptoms prior to age 18. Adolescent use of cocaine prior to age 18 were associated with MDD only in the whole data, whereas adolescent smokeless tobacco use was associated with MDD only in those without depressive symptoms prior to age 18.

CONCLUSIONS

These findings highlight the comorbid early substance use and depressive symptoms during adolescence with adult MDD. Intervention strategies should simultaneously address early-onset substance use and depressive symptoms prior to age 18.

What Do Social Media Influencers Say About Birth Control? A Content Analysis of YouTube Vlogs About Birth Control

Youth get their sexual health information from social media, often from social media influencers (SMIs) or microcelebrities with large followings. Previous research suggests that SMIs have powerful persuasive effects on attitudes and behaviors. Thus, it is important to examine the ways in which sexual health information, such as birth control, is conveyed by SMIs. Using framing theory as a theoretical framework, this study examines characteristics of SMIs and their shared experiences pertaining to birth control. A content analysis of YouTube vlogs (n = 50) posted from December 2019-2021 was conducted on SMIs who talk about their experiences using hormonal and non-hormonal birth control. SMI status was determined based on the number of people subscribed to the YouTube channels. Results suggest that SMI YouTube videos are primarily about the discontinuation of hormonal birth control and may provide inaccurate sexual health information. Reasons for discontinuation of hormonal birth control provided by the SMIs are discussed. Future research should explore the effects of influencer sexual health messaging on beliefs, attitudes, and behaviors.

Elevated lipid class concentrations in females with anorexia nervosa before and after intensive weight restoration treatment-A lipidomics study

OBJECTIVE

To study the plasma lipidome of patients with anorexia nervosa (AN) before and after weight restoration treatment and report associations with AN subtypes and oral contraceptive pill (OCP) usage.

METHODS

Quantitative shotgun lipidomics analysis was used to study plasma lipids of 50 female patients with AN before and after weight restoration treatment and 50 healthy female controls (HC). The AN group was assessed with blood samples and questionnaires before and after weight restoration.

RESULTS

In total we quantified 260 lipid species representing 26 lipid classes of which 13 lipid class concentrations were elevated in patients with AN at admission compared with HC. Lipid classes remained elevated after weight restoration treatment of 84 days (median; interquartile range 28), and only the concentration of the ceramide lipid class increased between pre- and post-treatment (p = .03), whereas lysophosphatidylcholine (LPC, p = .02), ether-linked Phosphatidylcholine (LPCO, p = .02), and lysophosphatidylethanolamine (LPE, p = .009) decreased.

CONCLUSION

In AN, 13 out of 26 lipid class concentrations were elevated at admission and remained elevated post-treatment. Ceramides increased further between pre- and post-weight restoration treatment, which could be related to the rapid weight gain during re-nutrition. Further research is needed to elucidate the effects of weight restoration treatment on short- and long-term lipid profiles in individuals with AN.

PUBLIC SIGNIFICANCE STATEMENT

Lipidomics research can increase the understanding of AN, a complex and potentially life-threatening eating disorder. By analyzing lipids, or fats, in the body, we can identify biological markers that may inform diagnosis and develop more effective treatments. This research can also shed light on the underlying mechanisms of the disorder, leading to a better understanding of the processes involved in eating behavior.

The Relationship Between Mood and Sleep in Different Female Reproductive States

Mood and sleep are tightly interrelated. Mood and sleep symptoms and disorders are more common in women than in men and often associated with reproductive events. This article reviews the current literature on the reciprocal relationships between mood and sleep across reproductive phases in women, such as menstrual cycle and related disorders, pregnancy, climacteric, and use of hormonal contraception and hormone replacement therapy. Mood and sleep symptoms seem to covary in relation to physiologic and pathologic reproductive conditions, although the relationship seems more clear for subjective than objective sleep.

Morphologic alterations of the fear circuitry: the role of sex hormones and oral contraceptives

Background

Endogenous sex hormones and oral contraceptives (OCs) have been shown to influence key regions implicated in fear processing. While OC use has been found to impact brain morphology, methodological challenges remain to be addressed, such as avoiding selection bias between OC users and non-users, as well as examining potential lasting effects of OC intake.

Objective

We investigated the current and lasting effects of OC use, as well as the interplay between the current hormonal milieu and history of hormonal contraception use on structural correlates of the fear circuitry. We also examined the role of endogenous and exogenous sex hormones within this network.

Methods

We recruited healthy adults aged 23-35 who identified as women currently using (n = 62) or having used (n = 37) solely combined OCs, women who never used any hormonal contraceptives (n = 40), or men (n = 41). Salivary endogenous sex hormones and current users' salivary ethinyl estradiol (EE) were assessed using liquid chromatography - tandem mass spectrometry. Using structural magnetic resonance imaging, we extracted surface-based gray matter volumes (GMVs) and cortical thickness (CT) for regions of interest of the fear circuitry. Exploratory whole-brain analyses were conducted with surface-based and voxel-based morphometry methods.

Results

Compared to men, all three groups of women exhibited a larger GMV of the dorsal anterior cingulate cortex, while only current users showed a thinner ventromedial prefrontal cortex. Irrespective of the menstrual cycle phase, never users exhibited a thicker right anterior insular cortex than past users. While associations with endogenous sex hormones remain unclear, we showed that EE dosage in current users had a greater influence on brain anatomy compared to salivary EE levels and progestin androgenicity, with lower doses being associated with smaller cortical GMVs.

Discussion

Our results highlight a sex difference for the dorsal anterior cingulate cortex GMV (a fear-promoting region), as well as a reduced CT of the ventromedial prefrontal cortex (a fear-inhibiting region) specific to current OC use. Precisely, this finding was driven by lower EE doses. These findings may represent structural vulnerabilities to anxiety and stress-related disorders. We showed little evidence of durable anatomical effects, suggesting that OC intake can (reversibly) affect fear-related brain morphology.

Physician Ownership for the Virtuous Practice of Medicine

The shift from physicians as owners or shareholders of practices to being employees of corporations is now a widespread trend with over 50% of physicians now considered employees. If continued, this trend will have profound effects on the medical profession and on physicians' personal lifestyles and sense of agency. However, ownership is not a morally neutral consideration but is important for safeguarding the traditions of virtue in the medical profession. Virtue develops within localized communities of practice and thrives in settings that embody principles such as solidarity, subsidiarity, and participation found in Catholic social teaching. Ownership increases physicians' investment in moral communities where they practice, affording physicians greater agency to benefit these communities according to their best judgment. This ownership can vary by type of organization and degree of shareholding. Because moral communities are the settings in which physicians form virtue, and ownership increases physicians' commitment and investment in communities, I make a principled argument that physicians who value developing virtue should consider having ownership of their practices when planning their careers. Ownership will be an important aspect of any medical ethics based on virtue rather than on principlism.

Bone health and prevalent fractures in women with polycystic ovary syndrome: a meta-analysis and endocrine-context pathophysiology review

INTRODUCTION

Bone health in those with Polycystic Ovary Syndrome (PCOS) is complex, but the general consensus is that cortical areal bone mineral density (aBMD) sites will be higher in PCOS than in age- and BMI-similar controls. However, spine aBMD sites may be lower, especially in non-obese PCOS. Whether or not incident fracture risk is increased in PCOS is currently controversial; no meta-analysis has yet assessed prevalent fractures.

AREAS COVERED

We assessed the bone effects of PCOS-related ovarian hormone alterations, e.g. androgen excess, tonically normal/higher estradiol, and lower-than-normal progesterone levels. We also highlighted evidence that common PCOS medications (e.g. combined hormonal contraceptives [CHC], metformin, and spironolactone) have important bone effects. In adolescents, meta-analysis of CHC showed significant negative aBMD changes. Inflammation has negative PCOS bone effects and is linked with CHC use.

EXPERT OPINION

Is fracture risk altered by PCOS? Our meta-analysis showed a 25% increased risk of prevalent fracture in PCOS versus controls; this did not reach statistical significance. Future prospective research needs to collect and evaluate ovulation characteristics, progesterone exposure, and adolescent CHC use, in addition to the complex variables that may influence risks for prevalent or incident fragility fractures and/or for cortical and cancellous aBMD values in PCOS.

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.

Hormonal contraception & face processing: Examining face gender, androgenicity & treatment duration

Previous cross-sectional studies observed differences between users and non-users of combined oral contraceptives (COCs) in both the structure and function of the fusiform face area (FFA) related to face processing. For the present study 120 female participants performed high-resolution structural, as well as functional scans at rest, during face encoding and face recognition. Participants were either never-users of COCs (26), current first-time users of androgenic (29) or anti-androgenic COCs (23) or previous users of androgenic (21) or anti-androgenic COCs (21). Results suggest that associations between COC-use and face processing are modulated by androgenicity, but do not persist beyond the duration of COC use. The majority of findings concern the connectivity of the left FFA to the left supramarginal gyrus (SMG), which is a key region in cognitive empathy. While connectivity in anti-androgenic COC users differs from never users irrespective of the duration of COC use already at rest, connectivity in androgenic COC users decreases with longer duration of use during face recognition. Furthermore, longer duration of androgenic COC use was related to reduced identification accuracy, as well as increased connectivity of the left FFA to the right orbitofrontal cortex. Accordingly, the FFA and SMG emerge as promising ROIs for future randomized controlled trials on the effects of COC use on face processing.

Prepubertal ovariectomy confers resilience to stress-induced anxiety in adult female mice

The increased vulnerability to stress-induced neuropsychiatric disorders in women, including anxiety disorders, does not emerge until pubertal onset, suggesting a role for ovarian hormones in organizing sex-specific vulnerability to anxiety. Parvalbumin (PV) interneurons in the prefrontal cortex are a potential target for these ovarian hormones. PV+ interneurons undergo maturation during the adolescent period and have been shown to be sensitive to stress and to mediate stress-induced anxiety in female mice. To test the idea that ovarian hormones at puberty are necessary for the acquisition of sensitivity to stress, hypothetically driving the response of PV+ interneurons to stress, we performed ovariectomy or sham surgery before pubertal onset in female mice. These mice then were exposed to four weeks of unpredictable chronic mild stress in adulthood. We then assessed anxiety-like behavior and PV/FosB colocalization in the medial PFC. Additionally, we assessed stress-induced anxiety-like behavior in female mice following ovariectomy in adulthood to determine if puberty is a sensitive period for ovarian hormones in mediating vulnerability to stress. We found that prepubertal ovariectomy protects against the development of anxiety-like behavior in adulthood, an effect not found following ovariectomy in adulthood. This effect may be independent of ovarian hormones on prefrontal PV+ interneurons response to stress.

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).

Combined oral contraceptives and mental health: Are adolescence and the gut-brain axis the missing links?

Combined oral contraceptives (containing synthetic forms of estradiol and progestins) are one of the most commonly used drugs among females. However, their effects on the gut-brain axis have not been investigated to a great extent despite clear evidence that suggest bi-directional interactions between the gut microbiome and endogenous sex hormones. Moreover, oral contraceptives are prescribed during adolescence, a critical period of development during which several brain structures and systems, such as hypothalamic-pituitary-gonadal axis, undergo maturation. Considering that oral contraceptives could impact the developing adolescent brain and that these effects may be mediated by the gut-brain axis, further research investigating the effects of oral contraceptives on the gut-brain axis is imperative. This article briefly reviews evidence from animal and human studies on the effects of combined oral contraceptives on the brain and the gut microbiota particularly during adolescence.

"I hardly have a problem […] I have my period quite rarely too": Female football players' and their coaches' perceptions of barriers to communication on menstrual cycle

Introduction

Symptoms related to the menstrual cycle (MC) affect the performance level and health of female athletes in various ways. Previous research has reported MC symptoms such as pain, mood disturbance, reduced coordination and competition distraction as well as diminished performance levels and an increased injury risk among female elite athletes. Despite this, the coach-athlete communication related to the female hormonal cycle is limited. The aim of the present study was to explore the perceptions of MC communication in a group of junior elite football players and their male coaches in a case study of one youth football team in a specific club in Norway.

Methods

The study used a qualitative approach with semi-structured interviews. In total, 8 female junior elite players (aged 16-20) from a Norwegian football team and 2 of their male coaches participated in the study.

Results

The data analysis revealed two main communication barriers: 1. interpersonal barriers (e.g., false assumptions about the coach/athletes and social discomfort) and 2. knowledge barriers (e.g., unaware/perceptions of insufficient knowledge levels).

Discussion

As the players seemed to be unaware of their insufficient MC knowledge (e.g., failed to see a connection between the MC and their health and performance level), the coaches perceived their knowledge as insufficient and coped mainly by outsourcing MC communication to female staff and apps. Hence, the MC communication was hindered by both the athletes and the coaches (e.g., mutual avoidance). In line with previous research, this study supports that there is a need for developing effective strategies to overcome the interpersonal barriers and knowledge gaps.

Moving beyond the mean: Promising research pathways to support a precision medicine approach to hormonal contraception

Women's psychological and behavioral responses to hormonal contraceptive (HC) treatment can be highly variable. One of the great challenges to researchers seeking to improve the experiences of women who use HCs is to identify the sources of this variability to minimize unpleasant psychobehavioral side-effects. In the following, we provide recommendations for programs of research aimed at identifying sources of heterogeneity in women's experiences with HC. First, we review research demonstrating person- and prescription- based heterogeneity in women's psychobehavioral responses to HCs. Next, we identify several promising person- and prescription- based sources of this heterogeneity that warrant future research. We close with a discussion of research approaches that are particularly well-suited to address the research questions raised in article. Together, this review provides researchers with several promising research pathways to help support the development of a precision medicine approach to HC treatment.

Hormonal contraceptives, stress, and the brain: The critical need for animal models

Hormonal contraceptives are among the most important health and economic developments in the 20thCentury, providing unprecedented reproductive control and a range of health benefits including decreased premenstrual symptoms and protections against various cancers. Hormonal contraceptives modulate neural function and stress responsivity. These changes are usually innocuous or even beneficial, including their effects onmood. However, in approximately 4-10% of users, or up to 30 million people at any given time, hormonal contraceptives trigger depression or anxiety symptoms. How hormonal contraceptives contribute to these responses and who is at risk for adverse outcomes remain unknown. In this paper, we discussstudies of hormonal contraceptive use in humans and describe the ways in which laboratory animal models of contraceptive hormone exposure will be an essential tool for expanding findings to understand the precise mechanisms by which hormonal contraceptives influence the brain, stress responses, and depression risk.

Hormonal contraceptive influences on cognition and psychopathology: Past methods, present inferences, and future directions

In the last decade, there has been a remarkable surge in research on the neural and behavioral correlates of hormonal contraceptive use, particularly oral contraceptive use. Questions have evolved swiftly and notably, with studies no longer revealing if hormonal contraceptives matter for the brain and behavior, but rather how, when, and for whom they matter most. Paralleling this shift, the goal of this review is to move beyond an average synthesis of hormonal contraceptive influences on human cognition and psychopathology (and their neural substrates) in order to consider the nature and specificity of effects. Accompanied by an evaluation of study methods and informed by findings from animal models, this consideration uncovers promising areas of research in the next ten years, including potential activational and organizational effects of hormonal contraceptive use, individual differences in effects that matter for the wellbeing of unique individuals, and correlates of intrauterine device use.

The Allopregnanolone Response to Acute Stress in Females: Preclinical and Clinical Studies

The neuroactive steroid allopregnanolone ((3α,5α)-3-hydroxypregnan-20-one or 3α,5α-THP) plays a key role in the response to stress, by normalizing hypothalamic-pituitary-adrenal (HPA) axis function to restore homeostasis. Most studies have been conducted on male rats, and little is known about the allopregnanolone response to stress in females, despite that women are more susceptible than men to develop emotional and stress-related disorders. Here, we provide an overview of animal and human studies examining the allopregnanolone responses to acute stress in females in the context of stress-related neuropsychiatric diseases and under the different conditions that characterize the female lifespan associated with the reproductive function. The blunted allopregnanolone response to acute stress, often observed in female rats and women, may represent one of the mechanisms that contribute to the increased vulnerability to stress and affective disorders in women under the different hormonal fluctuations that occur throughout their lifespan. These studies highlight the importance of targeting neuroactive steroids as a therapeutic approach for stress-related disorders in women.

Methods and considerations for the use of hormonal contraceptives in rat models of neurobehavior

Hormonal contraceptives (HCs), prescribed to millions of women around the world, alter the ovarian hormonal cycle resulting in neurobehavioral changes in HC users. Human epidemiological and experimental data has characterized some of these effects with oftentimes conflicting or irreproducible results, reflecting a dearth of research considering different compositions, routes of administration, or time-courses of HC use. Non-human animal research can model these effects and help elucidate the underlying mechanisms by which different HCs modulate neurobehavioral outcomes. Still, animal models using HCs are not well-established. This may be because the pharmacological profile of HCs - including the metabolism, receptor binding affinity, and neuromodulatory effects - is dynamic and not always clearly translatable between animals and humans. The current review addresses these issues and provides basic methods and considerations for the use of HCs in animal models of neurobehavior to help advance the field of behavioral neuroendocrinology and inform decisions regarding to women's health.

How hormonal contraceptives shape brain and behavior: A review of preclinical studies

Steroid hormones influence different aspects of brain function, including development, neurogenesis, neuronal excitability, and plasticity, thus affecting emotional states, cognition, sociality, and reward. In women, their levels fluctuate across the lifespan and through the reproductive stages but are also altered by exogenous administration of hormonal contraceptives (HC). HC are widely used by women throughout their fertile life both for contraceptive and therapeutic benefits. However, awareness of their effects on brain function and behavior is still poorly appreciated, despite the emerging evidence of their action at the level of the central nervous system. Here, we summarize results obtained in preclinical studies, mostly conducted in intact female rodents, aimed at investigating the neurobiological effects of HC. HC can alter neuroactive hormones, neurotransmitters, neuropeptides, as well as emotional states, cognition, social and sexual behaviors. Animal studies provide insights into the neurobiological effects of HC with the aim to improve women's health and well-being.

Effects of an Oral Contraceptive on Dynamic Brain States and Network Modularity in a Serial Single-Subject Study

Hormonal contraceptive drugs are used by adolescent and adult women worldwide. Increasing evidence from human neuroimaging research indicates that oral contraceptives can alter regional functional brain connectivity and brain chemistry. However, questions remain regarding static whole-brain and dynamic network-wise functional connectivity changes. A healthy woman (23 years old) was scanned every day over 30 consecutive days during a naturally occurring menstrual cycle and again a year later while using a combined hormonal contraceptive. Here we calculated graph theory-derived, whole-brain, network-level measures (modularity and system segregation) and global brain connectivity (characteristic path length) as well as dynamic functional brain connectivity using Leading Eigenvector Dynamic Analysis and diametrical clustering. These metrics were calculated for each scan session during the serial sampling periods to compare metrics between the subject’s natural and contraceptive cycles. Modularity, system segregation, and characteristic path length were statistically significantly higher across the natural compared to contraceptive cycle scans. We also observed a shift in the prevalence of two discrete brain states when using the contraceptive. Our results suggest a more network-structured brain connectivity architecture during the natural cycle, whereas oral contraceptive use is associated with a generally increased connectivity structure evidenced by lower characteristic path length. The results of this repeated, single-subject analysis allude to the possible effects of oral contraceptives on brain-wide connectivity, which should be evaluated in a cohort to resolve the extent to which these effects generalize across the population and the possible impact of a year-long period between conditions.

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.

Associations between use of psychotropic medications and use of hormonal contraception among girls and women aged 15-49 years in Finland: a nationwide, register-based, matched case-control study

OBJECTIVES

The relationship between the use of contraception and of psychiatric medications is understudied. We examined whether the current and past use of psychotropic medications is associated with the use and type of hormonal contraception (HC).

DESIGN

Nationwide register-based matched case-control study.

SETTINGS

All fertile-aged (15-49 years) girls and women living in Finland in 2017; data from several national registers.

PARTICIPANTS

294 356 girls and women with a redeemed prescription of HC in 2017, and their same-sized control group of non-users (n=294 356) identified through the Prescription Centre.

MAIN OUTCOME MEASURES

Associations between the use of psychotropic medications and the use of HC, and the type of HC tested in logistic regression models.

RESULTS

Altogether 19.5% of the HC users, and 18% of the HC non-users received at least one prescription for a psychotropic medication in 2017. Among HC users, the proportions of occasional and regular users of psychotropic medications in 2013-2016 were 4.5% and 14.8%, while among HC non-users the respective figures were 4.3% and 14.6%, respectively. In multivariable logistic regression models both the use of psychotropic medications in 2017, and their occasional or regular use between 2013-2016 were associated with higher odds of HC use, although with small to very small effect sizes (ORs between 1.37 and 1.06 and 95% CIs 1.22 to 1.53, and 1.03 to 1.09, respectively). After adjustment for covariates, when fixed combinations of progestogens and oestrogens for systemic use was the reference category, women using almost any class of psychotropic medications had higher odds of using other types of HC.

CONCLUSIONS

Fertile-aged girls and women with current and past use of psychotropic medications have higher odds of using HC, with a specific pattern in the type of contraceptives used. Further research is warranted to examine whether our observations indicate a reduction of unwanted pregnancies in women with psychiatric disorders.

Event-Related Potentials in Women on the Pill: Neural Correlates of Positive and Erotic Stimulus Processing in Oral Contraceptive Users

Background/Aims: Exposure toward positive emotional cues with - and without - reproductive significance plays a crucial role in daily life and regarding well-being as well as mental health. While possible adverse effects of oral contraceptive (OC) use on female mental and sexual health are widely discussed, neural processing of positive emotional stimuli has not been systematically investigated in association with OC use. Considering reported effects on mood, well-being and sexual function, and proposed associations with depression, it was hypothesized that OC users showed reduced neural reactivity toward positive and erotic emotional stimuli during early as well as later stages of emotional processing and also rated these stimuli as less pleasant and less arousing compared to naturally cycling (NC) women. Method: Sixty-two female subjects (29 NC and 33 OC) were assessed at three time points across the natural menstrual cycle and corresponding time points of the OC regimen. Early (early posterior negativity, EPN) and late (late positive potential, LPP) event-related potentials in reaction to positive, erotic and neutral stimuli were collected during an Emotional Picture Stroop Paradigm (EPSP). At each appointment, subjects provided saliva samples for analysis of gonadal steroid concentration. Valence and arousal ratings were collected at the last appointment. Results: Oral contraceptive users had significantly lower endogenous estradiol and progesterone concentrations compared to NC women. No significant group differences in either subjective stimulus evaluations or neural reactivity toward positive and erotic emotional stimuli were observed. For the OC group, LPP amplitudes in reaction to erotic vs. neutral pictures differed significantly between measurement times across the OC regimen. Discussion: In this study, no evidence regarding alterations of neural reactivity toward positive and erotic stimuli in OC users compared to NC was found. Possible confounding factors and lines for future research are elaborated and discussed.

A Year Through the COVID-19 Pandemic: Deleterious Impact of Hormonal Contraception on Psychological Distress in Women

BACKGROUND

Women are more at risk than men of suffering from psychological distress during disease outbreaks. Interestingly, no biological factors have been studied to explain this disparity in such contexts. Sex hormone variations induced by hormonal contraceptives (HC) have been associated with mental health vulnerabilities. However, most studies have examined current effects of HC without considering whether a chronic modulation of sex hormone levels could induce long-lasting effects that persist after HC cessation.

OBJECTIVES

To date, the role of HC on psychological health in women during a disease outbreak is still unknown. We aimed to investigate both current and long-term effects of HC on psychological distress throughout the COVID-19 pandemic.

METHOD

At four time points during the COVID-19 pandemic (June 2020, September 2020, December 2020, March 2021), we collected self-reported data on psychological distress, assessing symptoms of post-traumatic stress [via the Impact of Event Scale-Revised (IES-R)], symptoms of depression, anxiety, and stress [via the Depression Anxiety Stress Scales (DASS-21)]. Linear mixed models were first used to compare men (n = 49), naturally cycling women (n = 73), and women using HC (n = 32) across time. To examine long-lasting effects of HC, exploratory analyses were restricted to women, comparing current HC users (n = 32), past users (n = 56), and never users (n = 17).

RESULTS

The first model revealed that women taking HC reported stable post-traumatic stress symptoms across time, compared to naturally cycling women and men who showed a significant decrease from T1 to T2. HC users also reported greater DASS-21 total scores over time. Moreover, HC users reported higher stress and anxiety symptoms than men. In the second model, results showed that past HC users had similar anxiety levels as current HC users. These two groups reported significantly more anxiety symptoms than never users.

CONCLUSION

HC users report increased distress during the pandemic relative to naturally cycling women and men. Our results also suggest a long-lasting effect of HC intake, highlighting the importance of considering both the current use of HC and its history. This could provide some insight into potential avenues for explaining why some women are prone to higher psychological distress than men.

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.

The Impact of Hormonal Contraceptive Use on Serotonergic Neurotransmission and Antidepressant Treatment Response: Results From the NeuroPharm 1 Study

BACKGROUND

Hormonal contraceptive (HC) use has been associated with an increased risk of developing a depressive episode. This might be related to HC's effect on the serotonergic brain system as suggested by recent cross-sectional data from our group, which show that healthy oral contraceptive (OC) users relative to non-users have lower cerebral serotonin 4 receptor (5-HT4R) levels. Here, we determine if cerebral 5-HT4R binding differs between HC non-users, OC users, and hormonal intrauterine device (HIUD) users among women with an untreated depressive episode. Also, we test if antidepressant drug treatment response and its association with pre-treatment 5-HT4R binding depends on HC status.

METHODS

[¹¹C]-SB207145 Positron Emission Tomography imaging data from the NeuroPharm-NP1 Study (NCT02869035) were available from 59 depressed premenopausal women, of which 26 used OCs and 10 used HIUDs. The participants were treated with escitalopram. Treatment response was measured as the relative change in the Hamilton Depression Rating Scale 6 items (rΔHAMD₆) from baseline to week eight. Latent variable models were used to evaluate the association between global 5-HT4R binding and OC and HIUD use as well as rΔHAMD₆.

RESULTS

We found no evidence of a difference in global 5-HT4R binding between depressed HC users and non-users (p≥0.51). A significant crossover interaction (p=0.02) was observed between non-users and OC users in the association between baseline global 5-HT4R binding and week eight rΔHAMD₆; OC users had 3-4% lower binding compared to non-users for every 10% percent less improvement in HAMD₆. Within the groups, we observed a trend towards a positive association in non-users (p_adj=0.10) and a negative association in OC users (p_adj=0.07). We found no strong evidence of a difference in treatment response between the groups (p=0.13).

CONCLUSIONS

We found no difference in 5-HT4R binding between HC users vs. non-users in depressed women, however, it seemed that 5-HT4R settings differed qualitatively in their relation to antidepressant drug treatment response between OC users and non-users. From this we speculate that depressed OC users constitutes a special serotonin subtype of depression, which might have implications for antidepressant drug treatment response.

Effect of the Monthly Injectable Combined Contraceptives versus Oral Contraceptive Pills on Mood

Background

Contraceptive agents are widely used by women of reproductive age, and resulting depression is the most common side effect of this usage. This study aimed to study the effect of monthly injectable combined contraceptives versus that of combined oral contraceptive pills (COC) on patients’ mood.

Methods

A prospective cohort study was conducted on 124 females aged 18–45 years attending the Kom-Ashfeen Family Medicine Unit, El-Kalyubia, Egypt. Participants were divided into three groups according to their choice: group A included 44 participants who received monthly combined injectable contraceptives (CIC); group B included 40 participants who took COC; and group C included 40 participants who used the copper intrauterine device (IUD). The Patient Health Questionnaire-9 (PHQ-9) score was assessed at the beginning of the study and after 6 months of follow-up.

Results

After 6 months of follow-up, there were mild but statistically significant increases in the PHQ-9 score in groups A and B, with group A (CIC users) showing the highest increase. Approximately 34.1%, 27.5%, and 15% of CIC, COC, and IUD users, respectively, moved from the non-depression stage to mild depression after 6 months; this change was statistically significant in groups A and B only.

Conclusion

Monthly injectable combined contraceptives and oral contraceptive pills were associated with an increased risk of developing mild depression; this risk was higher in users of CICs, although the difference was not statistically significant. Thus, it is crucial to counsel patients about this possible risk and to follow them up. However, further studies are required to confirm our results.

Mitochondria as the target for disease related hormonal dysregulation

Mitochondria play an important role in the synthesis of steroid hormones, including the sex hormone estrogen. Sex-specific regulation of these hormones is important for phenotypic development and downstream, sex-specific activational effects in both brain and behavior. First, mitochondrial contribution to the synthesis of estrogen, followed by a discussion of the signaling interactions between estrogen and the mitochondria will be reviewed. Next, disorders with an established sex difference related to aging, mood, and cognition will be examined. Finally, review of mitochondria as a biomarker of disease and data supporting efforts in targeting mitochondria as a therapeutic target for the amelioration of these disorders will be discussed. Taken together, this review aims to assess the influence of E2 on mitochondrial function within the brain via exploration of E2-ER interactions within neural mitochondria and how they may act to influence the development and presentation of neurodegenerative and neurocognitive diseases with known sex differences.

"Do Elite Sport First, Get Your Period Back Later." Are Barriers to Communication Hindering Female Athletes?

Competitive female athletes perceive their hormonal cycles to affect their training, competition performance and overall well-being. Despite this, athletes rarely discuss hormonal-cycle-related issues with others. The aim of this study was to gain an in-depth understanding of the perceptions and experiences of endurance athletes and their coaches in relation to barriers to athlete-coach communication about female hormonal cycles. Thirteen Swedish national-/international-level female cross-country skiers (age 25.8 ± 3.6 y) and eight of their coaches (two women and six men; age 47.8 ± 7.5 y) completed an online survey relating to their educational background, prior knowledge about female hormonal cycles and a coach-athlete relationship questionnaire (CART-Q). They then participated in an online education session about female hormonal cycles and athletic performance before participating in semi-structured focus-group interviews. Thematic analyses revealed three main barriers to communication: knowledge, interpersonal, and structural. In addition, the results suggested that a good coach-athlete relationship may facilitate open communication about female hormonal cycles, while low levels of knowledge may hinder communication. To overcome the perceived barriers to communication, a model is proposed to improve knowledge, develop interpersonal relationships and strengthen structural systems through educational exchanges and forums for open discussion.

Oral contraceptives, depressive and insomnia symptoms in adult women with and without depression

BACKGROUND

Worldwide, oral contraceptive (OC) use is a very common form of birth control, although it has been associated with symptoms of depression and insomnia. Insomnia is a risk factor for major depressive disorder (MDD) but may also be a symptom of the disorder. Despite the large number of women who use OC, it is yet unknown whether women with previous or current diagnosis of depression are more likely to experience more severe depressive and insomnia symptoms during concurrent OC use than women without diagnosis of depression.

AIM

This study examined associations between OC use and concurrent symptoms of depression (including atypical depression) and insomnia as well as between OC and prevalences of concurrent dysthymia and MDD. Participants were adult women with and without a history of MDD or dysthymia. We hypothesized that OC use is associated with concurrent increased severity of depressive symptoms and insomnia symptoms, as well as with an increased prevalence of concurrent diagnoses of dysthymia and MDD. We also hypothesized that a history of MDD or dysthymia moderates the relationship between OC use and depressive and insomnia symptoms.

METHODS

Measurements from premenopausal adult women from the Netherlands Study of Depression and Anxiety (NESDA) were grouped, based on whether participants were using OC or naturally cycling (NC). OC use, timing and regularity of the menstrual cycle were assessed with a structured interview, self-reported symptoms of depression (including atypical depression), insomnia with validated questionnaires, and MDD and dysthymia with structured diagnostic interviews.

RESULTS

We included a total of 1301 measurements in women who reported OC use and 1913 measurements in NC women (mean age 35.6, 49.8% and 28.9% of measurements in women with a previous depression or current depression, respectively). Linear mixed models showed that overall, OC use was neither associated with more severe depressive symptoms (including atypical depressive symptoms), nor with higher prevalence of diagnoses of MDD or dysthymia. However, by disentangling the amalgamated overall effect, within-person estimates indicated increased depressive symptoms and depressive disorder prevalence during OC use, whereas between-person estimated indicated lower depressive symptoms and prevalence of depressive disorders. OC use was consistently associated with more severe concurrent insomnia symptoms, in the overall estimates as well as in the within-person and between-person estimates. Presence of current or previous MDD or dysthymia did not moderate the associations between OC use and depressive or insomnia symptoms.

DISCUSSION

The study findings showed consistent associations between OC use and more severe insomnia symptoms, but no consistent associations between OC and depressive symptoms or diagnoses. Instead, post-hoc analyses showed that associations between OC and depression differed between within- and between person-estimates. This indicates that, although OC shows no associations on the overall level, some individuals might experience OC-associated mood symptoms. Our findings underscore the importance of accounting for individual differences in experiences during OC use. Furthermore, it raises new questions about mechanisms underlying associations between OC, depression and insomnia.

Acute LPS exposure increases synaptosomal metabolism during estrus but not diestrus

The hormones estrogen and progesterone alter physiological functions, including the estrus cycle and relevant neurological and synaptic activity. Here, we determined the extent to which estrus cycle stage interacts with an inflammatory stimulus, lipopolysaccharide (LPS), to alter synaptic mitochondrial respiration in female rats. LPS elevated synaptic mitochondrial respiration of rats in estrus, but not diestrus. Likewise, estrogen concentration correlated with multiple respiratory metrics in LPS treated females in estrus. These data suggest estrogen likely modulates synaptic mitochondrial respiration in a high progesterone environment.

The effects of inducing self-compassion on affective and physiological recovery from a psychosocial stressor in depression

The current study was designed to extend previous research by testing whether self-compassion acts as a protective factor that facilitates faster affective and physiological recovery from stress in people with elevated depressive symptoms. Specifically, we examined the effect of experimentally induced self-compassion on positive affect, negative affect, and respiratory sinus arrhythmia (RSA) recovery from stress. Participants (N = 59) experiencing elevated depressive symptoms completed the Trier Social Stress Test (TSST), a standardized psychosocial stressor, and then were randomly assigned to either a self-compassion induction or a no-strategy control induction before resting quietly during the 30-min recovery period. During the induction period, participants in the self-compassion condition exhibited a greater increase in positive affect and a trend towards a greater decrease in negative affect than did participants in the no-strategy control condition. However, the psychological benefits of self-compassion did not continue during the post-induction recovery period. Moreover, changes in RSA levels did not differ between participants in the self-compassion and no-strategy control condition. These results suggest that, among individuals with elevated depressive symptoms, brief self-compassion inductions have short-term beneficial psychological, but not physiological, effects. As such, our findings delineate the benefits and boundaries of single-session self-compassion inductions in depression, and in doing so, inform future experimental and applied research.

The modulation of social behavior and empathy via oral contraceptives and female sex hormones

Oral contraceptives (OC) and endogenous female sex hormones in naturally cycling women (NC) are related to a wide range of psychological variables (eg, cognition and affect). Little research on social behavior has been done. One study documented a tendency towards more prosocial behavior in NC than OC women, but the underlying neuroendocrine mechanisms remain unknown. The sex hormones progesterone and estradiol are potential candidates. We analyzed social decision-making and social behavior in 83 healthy women (38 OC and 45 NC) via the Social Value Orientation (SVO) and in real social interactions within a paradigm adapted from behavioral economics. We also measured empathy, and collected saliva samples to quantify the basal levels of estradiol and progesterone. Our analyses revealed higher levels of prosocial behavior and emotional empathy in NC than in OC women, a finding supported by higher levels of prosocial decisions in NC than OC women in the SVO. Regarding the underlying biological mechanisms, we detected lower progesterone levels in OC than NC women. Exploratory analyses revealed a negative correlation between progesterone and trust on the trend level. We found no correlations between estradiol and behavior. Our findings provide evidence that OC modulate social behavior and initial indications of a possible modulation by progesterone. Further research is needed to replicate our findings and extend them to other social behaviors.

Hormonal Contraception and Violent Death: The Physiological and Psychological Links

In the past decade, two large prospective cohort studies of British and American women have been conducted which found a statistically significant increase in the risk of violent death in ever-users of hormonal contraceptives. Research on the effects of hormonal contraceptives upon the behaviors of intimate partners and on the physiology of women using hormonal contraceptives has provided insight into the possible basis for the resulting increase in violent death. This review examines the changes that are potential contributors to the reported increase.

Hormonal contraceptive use and depressive symptoms: systematic review and network meta-analysis of randomised trials

BACKGROUND

Observational studies suggest that hormonal contraceptive use may increase depressive symptoms in women, but it is unclear whether the effect is causal.

AIMS

To quantitatively examine the evidence from randomised clinical trials for the link between hormonal contraceptive use and depressive symptoms.

METHOD

We performed a systematic review and network meta-analysis of randomised clinical trials comparing women randomised to any form of a hormonal contraceptive with women randomised to any other form of a (non-)hormonal contraceptive or placebo. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Web of Science, PsycINFO, EMCare and EMBASE, from inception to 1 May 2020. Certainty of the evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation approach. A random-effect Bayesian network meta-analysis was conducted, with change in depressive symptoms between baseline and three cycles as outcome.

RESULTS

This review identified 3492 records, of which 14 trials were eligible and 12 could be included in the network meta-analysis. These trials included 5833 participants (mean age per study range: 16.8-32.4 years) and compared 10 different interventions. Compared with placebo, hormonal contraceptive use did not cause worsening of depressive symptoms (standardised mean difference: median, -0.04; range, -0.17 [95% credible interval -0.46 to 0.13] to 0.13 [95% credible interval -0.28 to 0.56]).

CONCLUSIONS

This study suggests that hormonal contraceptive use does not lead to an increase in depressive symptoms in adult women. Future studies should include first-time users, to confirm the results in young women.

Broad Metabolome Alterations Associated with the Intake of Oral Contraceptives Are Mediated by Cortisol in Premenopausal Women

The use of oral contraceptives (OCs) has been associated with elevated blood cortisol concentrations. However, metabolic downstream effects of OC intake are not well described. Here, we aimed to determine if the blood metabolome is associated with the use of OCs and to estimate if these associations might be statistically mediated by serum cortisol concentrations. Plasma metabolites measured with the Biocrates AbsoluteIDQ p180 Kit and serum cortisol concentrations measured by an immunoassay were determined in 391 premenopausal women (116 OC users) participating in two independent cohorts of the Study of Health in Pomerania (SHIP). After correction for multiple testing, 27 metabolites were significantly associated with OC intake in SHIP-TREND (discovery cohort), of which 25 replicated in SHIP-2. Inter alia, associated metabolites included 12 out of 38 phosphatidylcholines with diacyl residue, 7 out of 14 lysophosphatidylcholines and 5 out of 21 amino acids. The associations with phosphatidylcholines were statistically mediated by cortisol, whereas lysophosphatidylcholines showed no mediation effect. The results represent a step toward a better understanding of the metabolic consequences of OC intake. Connecting cortisol with metabolic consequences of OC intake could help to understand the mechanisms underlying adverse effects. The blood metabolome may serve as a biomarker for identifying users at high risk for developing such adverse effects.

Hormonal Contraceptive Use in Football Codes in Australia

The recent launch of the new National elite women's football competitions in Australia has seen a 20-50% increase in grassroots female participation. With the growing participation across grassroots to elite competitions, understanding the health of female athletes should be prioritized. In elite level athletes, hormonal contraceptive (HC) use is common (~50%), however, little is known about the prevalence and reasons for use and disuse of HC in elite female football athletes. As such, the impact of HC use is often not considered when monitoring the health of female footballers. This study involved a subset of data collected as part of a larger questionnaire investigating menstrual cycle function, hormonal contraception use, and the interaction with training load volume and perceived performance in elite female football code athletes. A total of 177 participants completed the questionnaire across three football codes within Australia (rugby league, rugby union/sevens, Australian football). One third (n = 58) of athletes were currently using HC, predominately in the form of an oral contraceptive pill (OC, n = 47). Reasons for use included: to avoid pregnancy (71%); to control/regulate cycle (38%); and to reduce menstrual pain (36%). However, most athletes using an OC (89%) could not identify the type of pill used (e.g., mono-, bi-, or triphasic). The main reason for disuse was due to the negative side effects (n = 23), such as mood swings, weight gain, and depression/anxiety. Comparing HC users and non-users, there were no statistical differences in the number of reported menstrual symptoms, use of medication to relieve menstrual pain, or frequency for needing to adapt training due to their menstrual cycle (p > 0.05). Since most athletes were unaware of the type of OC they used, female football athletes require further education about the different types of HC, and specifically OC, available to them. Similarities in the symptoms experienced, pain management, and training adaptation requirements between groups suggests that HC use may not have the intended outcome for certain athletes. As such, greater awareness of athlete's personal experiences with the menstrual cycle, how HC may influence their experience, and acknowledgment of non-pharmacological methods to help manage menstrual cycle related symptoms are warranted.

Stress-Hormone Dynamics and Working Memory in Healthy Women Who Use Oral Contraceptives Versus Non-Users

BACKGROUND

Women who use oral contraceptives (OCs) may have a higher risk of developing a depression, which is associated with both vulnerability to stress and cognitive dysfunction. OCs disrupt the hypothalamic-pituitary-gonadal (HPG) axis by suppressing endogenous sex steroid production including estradiol. The HPG axis and the hypothalamic-pituitary-adrenal (HPA) axis are known to interact, possibly through modulations driven by estradiol. OCs may affect HPA regulation capacity, i.e., disturb cortisol dynamics such as the cortisol awakening response (CAR), and influence cognition such as working memory (WM). We hypothesize that OC use is associated with blunted cortisol dynamics and impaired WM performance relative to non-users.

METHODS

Data from 78 healthy women in the reproductive age were available from the CIMBI database. We evaluated if CAR and WM differed between OC users (n=25) and non-users (n=53) and if the level of estradiol modulated the OC use effect on CAR or WM in generalized least square models.

RESULTS

We found that OC users had a blunted CAR (p= 0.006) corresponding to a 61% reduction relative to non-users; however, no estradiol-BY-OC use interaction effect was observed on CAR. Also, OC users had higher cortisol levels at awakening compared to non-users (p = 0.03). We observed no effect of OC use or an estradiol-BY-OC use interaction effect on WM. Also, within the OC user group, neither CAR nor WM was associated with suppressed estradiol. CAR was not associated with WM.

CONCLUSION

Healthy women who use OCs have blunted cortisol dynamics relative to non-users. However, we could not detect OC use effects on working memory in our sample size. We speculate that disrupted cortisol dynamics may be important for the emergence of depressive symptoms in OC users.

Oral contraceptive use, especially during puberty, alters resting state functional connectivity

Millions of women worldwide use oral contraceptives (OCs), often starting during puberty/adolescence. It is, however, unknown how OC use during this critical period of development affects the brain. The objective of the current study was to examine resting state functional connectivity (FC) in the default mode network (DMN), central executive network (CEN), salience network (SN), reward network (RN), and subcortical limbic network of the brain using independent component analysis (ICA) between pubertal- and adult-onset OC users (n = 27) and naturally cycling women (n = 48). It was hypothesized that OC use would result in network-specific increases and decreases in FC and that pubertal-onset OC use would result in differences to the aforementioned networks compared to adult-onset OC use. Pubertal-onset OC use is related to heightened FC in the SN compared to adult-onset OC users. In general, OC use also increases connectivity in the SN, CEN, RN, and subcortical limbic network compared to NC women. No significant differences in connectivity were observed in the DMN between OC users and NC women. These findings provide a mechanistic insight for the altered executive functioning and emotion/reward processing previously seen in OC users, which may then increase their vulnerability to mental health conditions.

Oral contraceptives and the serotonin 4 receptor: a molecular brain imaging study in healthy women

OBJECTIVE

Sex steroid hormones potently shape brain functions, including those critical to maintain mental health such as serotonin signaling. Use of oral contraceptives (OCs) profoundly changes endogenous sex steroid hormone levels and dynamics. Recent register-based studies show that starting an OC is associated with increased risk of developing depression. Here, we investigate whether use of OCs in healthy women is associated with a marker of the serotonin system in terms of serotonin 4 receptor (5-HT4R) brain imaging.

METHODS

[11C]SB207145-PET imaging data on 53 healthy women, of whom 16 used OCs, were available from the Cimbi database. We evaluated global effects of OC use on 5-HT4R binding in a latent variable model based on 5-HT4R binding across cortical and subcortical regions.

RESULTS

We demonstrate that OC users have 9-12% lower global brain 5-HT4R binding potential compared to non-users. Univariate region-based analyses (pallidostriatum, caudate, hippocampus, amygdala, anterior cingulate cortex, and neocortex) supported the global effect of OC use with the largest difference present in the hippocampus (-12.8% (95% CI [-21.0; -3.9], Pcorrected = 0.03).

CONCLUSION

We show that women who use OCs have markedly lower brain 5-HT4R binding relative to non-users, which constitutes a plausible molecular link between OC use and increased risk of depressive episodes. We propose that this reflects a reduced 5-HT4R gene expression, possibly related to a blunted ovarian hormone state among OC users.

Use of the birth control pill affects stress reactivity and brain structure and function

Millions of women worldwide use oral contraceptives (i.e., birth control pill; OCs), often starting during puberty/adolescence; however, it is unknown how OC use during this critical period of development affects the brain, especially with regard to emotional working memory. Here, we examined stress reactivity, and brain structure and function in OC users using the Trier Social Stress Test and structural and functional magnetic resonance imaging (MRI). Our results show that OC use during puberty/adolescence gives rise to a blunted stress response and alters brain activation during working memory processing. OC use, in general, is also linked to increased prefrontal brain activation during working memory processing for negatively arousing stimuli. OC use is also related to significant structural changes in brain regions implicated in memory and emotional processing. Together, these findings highlight that OC use induces changes to brain structure and function and alters stress reactivity. These findings may provide a mechanistic insight for the increased vulnerability to mood-related mental illness in women after OC use.

Editorial: From risk prediction to action: leveraging electronic health records to improve pediatric population mental health

The identification of child, family, and other environmental factors that confer risk for poor developmental outcomes has long been a major theme in child and adolescent psychopathology research. Over the past 6 decades, the Journal of Child Psychology & Psychiatry has seen an exponential increase in articles that have included the search term 'risk prediction', with 17 such works appearing in the 1960s and 930 occurring in the 2010s. Indeed, the current issue of JCPP continues this trend with a number of high-quality studies that in some capacity seek to predict poor child and adolescent outcomes on the basis of variables that can be measured earlier in development.