As a Naturopathic Doctor, who commonly treats mental health concerns, I am always looking for the underlying cause of depressive and anxiety symptoms and looking for obstacles which prevent symptom resolution. One of my first questions to women who suffer from mood and emotional symptoms is “are you on ‘the pill’?”
Oral contraceptives (OCs), or birth control pills, have been prescribed to women since the 1950’s and today over 100 million women use OCs (9). They allow women the freedom of reproductive choice however it isn’t without its downside, which, since their introduction almost seventy years ago, is often not fully disclosed to women by their prescribing doctor.
Doctors prescribe OC for virtually any and all menstrual or hormonal related symptoms – acne, menstrual pain, irregular cycles, etc. in addition to contraception. It is reported that over half of OC users aged twenty and older use OC’s for non-contraceptive reasons (2). What some, many or all of these women may not realize is that OC’s will suppress hormone-related symptoms, however they do not address the underlying cause, therefore once a woman stops taking OC’s her symptoms will likely return. Furthermore, they are not without their own metabolic, neurological, and other physiological adverse side effects.
How Birth Control Works
The most common birth control pills contain two synthetic hormones, ethinylestradiol, a synthetic estrogen, and progestin, a synthetic form of progesterone. The ‘mini-pill’ contains only progestins. It should be noted that these are not the same as the hormones estrogen and progesterone that our bodies produce. These synthetic hormones prevent the release of the hormone messengers in the hypothalamus and pituitary that signal the ovaries to ovulate (thus preventing pregnancy). Subsequently, this prevents the production of estrogen, progesterone, and testosterone by the body. OC’s essential shut down the cyclical hormonal cycle. Typically women take hormone-containing pills for the first twenty-one days, then take sugar pills for the remaining week, where they will bleed, giving the illusion of a period. To be very clear – this is not a period, it is a pill bleed caused by the sudden withdrawal of the synthetic hormones.
How Oral Contraceptives Create Side Effects
Hormonal birth control has an array of side effects, from increased risk of blood clots to headaches to weight gain, to mood changes (5). The side effects are due to the two synthetic hormones – ethinylestradiol and progestins. The dosage of the constituents, as well as the route of delivery, can influence the type and magnitude of side effects. While birth control pills are consumed orally, hormonal birth control is also available as a vaginal ring or injection. OCs create side effects for two reasons.
1 – The impact of the synthetic hormones themselves
2 – The deprivation of natural estrogen, progesterone, testosterone, and DHEA
Neurotransmitters are chemical messengers which affect mood, behavior, memory, reward, pleasure, sleep, appetite, libido, etc. GABA is our inhibitory neurotransmitter, which signals a feeling of calm promotes relaxation. Progesterone and it’s metabolite allopregnanolone increase GABA transmission and therefore promote calm and prevent anxiety. Progesterone is also neuroprotective, as it supports myelination, which is the fatty coating around neurons which allow transmission of signals. It protects against glutamate, which is a stimulating neurotransmitter, and when left unchecked can lead to damage of cells through a process called excitotoxicity (1,7,8). Progesterone affects an area of the brain called the amygdala, modulating pain, anxiety, and fear (3,4). Progestins, the synthetic progesterone in birth control pills do not possess any of these qualities, leaving the brain vulnerable to excess glutamate, unchecked neuronal damage, and feelings of anxiety and fear (1,3,4,7,8).
Estrogen increases both serotonin and dopamine synthesis and transmission. Both of these neurotransmitters impact positive mood, reward, motivation and emotional well-being. Optimal levels and transmission of these two neurotransmitters protect against depression (1). A 2016 JAMA Psychiatry study with over a million participants found that women who used OCP were 23% more likely to receive an anti-depressant prescription later in life and concluded that depression is a potential adverse effect of OCP use (8).
A 2017 study reported an alarming association between suicidality and OC use. It concluded that women between the ages of fifteen and thirty-three who took OC’s had increased rates of suicide ideation and suicide attempts. It was noted that adolescents were at the greatest risk (9).
Estrogen and progesterone increase a messenger called brain-derived neurotrophic factor (BDNF) which protects the brain from injury, induces repair mechanisms and regeneration. Given that OC’s prevent the natural production of estrogen and progesterone, they too limit the amount of BDNF in the brain ultimately reducing the amount of regeneration in the brain (1).
One of the most concerning findings of birth control pills is the permanent changing to the brain they induce. A 2015 Human Brain Mapping study found that women who take OC’s have significantly lower cortical thickness in areas of their frontal cortex and posterior cingulate cortex (6). These areas of the brain are required for sensory input, emotion, learning, and memory.
Birth control causes an increase in sex hormone binding globulin (SHBG) and thyroid binding globulin (TBG) which binds up active testosterone and thyroid hormones, making them less bioavailable and therefore active in the body. Even after the discontinuation of OC’s, SHBG and TBG remain elevated and therefore create long-term changes in hormone function (PANZER). Elevated TBG can lead to symptoms of under-active thyroid, known as hypothyroidism, which itself is known to produce depression therefore potentially compounding the adverse effect on mood that OCPs have. Elevated SHBG can result in symptoms of low testosterone, such as low libido and sexual dysfunction (5).
Birth control pills have been widely prescribed to women for almost seventy years, providing them with reproductive freedom however an open and honest conversation about the short term as well as long-term risk and adverse effects on mood, neurology, and hormones should take place.
1. Barth, C., Villringer, A., & Sacher, J. (2015). Sex hormones affect neurotransmitters and shape the adult female brain during hormonal transition periods. Frontiers in neuroscience, 9, 37.
2. Jones, R. K. (2011). Beyond birth control: the overlooked benefits of oral contraceptive pills. Alan Guttmacher Institute.
3. Merz, C. J., Tabbert, K., Schweckendiek, J., Klucken, T., Vaitl, D., Stark, R., & Wolf, O. T. (2012). Oral contraceptive usage alters the effects of cortisol on implicit fear learning. Hormones and Behavior, 62(4), 531-538.
4. Montoya, E. R., & Bos, P. A. (2017). How oral contraceptives impact social-emotional behavior and brain function. Trends in cognitive sciences, 21(2), 125-136.
5. Panzer, C., Wise, S., Fantini, G., Kang, D., Munarriz, R., Guay, A., & Goldstein, I. (2006). Impact of oral contraceptives on sex hormone-binding globulin and androgen levels: a retrospective study in women with sexual dysfunction. The journal of sexual medicine, 3(1), 104-113.
6. Petersen, N., Touroutoglou, A., Andreano, J. M., & Cahill, L. (2015). Oral contraceptive pill use is associated with localized decreases in cortical thickness. Human brain mapping, 36(7), 2644-2654.
7. Pluchino, N., Luisi, M., Lenzi, E., Centofanti, M., Begliuomini, S., Freschi, L., … & Genazzani, A. R. (2006). Progesterone and progestins: Effects on brain, allopregnanolone and β-endorphin. The Journal of steroid biochemistry and molecular biology, 102(1-5), 205-213.
8. Skovlund, C. W., Mørch, L. S., Kessing, L. V., & Lidegaard, Ø. (2016). Association of hormonal contraception with depression. JAMA psychiatry, 73(11), 1154-1162.
9. Skovlund, C. W., Mørch, L. S., Kessing, L. V., Lange, T., & Lidegaard, Ø. (2017). Association of hormonal contraception with suicide attempts and suicides. American journal of psychiatry, 175(4), 336-342.