Over the last couple of years birth control and it’s affect on mood, most commonly depression, has been in the news. Many are left wondering if birth control is safe for women. I’ve assessed a couple of studies, looking at various groups of women to get a better idea of what the research is saying. 

What is depression?

Like most conditions, a person must experience a certain number of symptoms to be diagnosed with a major depressive episode. 

 Five or more of the following symptoms must be present on most days for at least 2 weeks

• Depressed mood*

• Diminished interest or pleasure*

• Significant weight loss or weight gain

• Insomnia or hypersomnia

• Psychomotor agitation or impairment

• Fatigue or loss of energy

• Feelings of worthlessness or excessive guilt

• Decreased ability to think, concentrate, or ability to be decisive

• Recurrent thoughts of death/suicide, or a suicide attempt

*One of these symptoms MUST be present

Select Populations & Birth Control

Adult Women 

A study conducted in Sweden (Zethraeus, 2017), looked at the effects of a combined pill (150 mg of levonorgestrel and 30 mg of ethinylestradiol) on general well being and depression in women aged 18-35. Compared to the placebo group, there was no difference in anxiety, depressed mood, general health. However, there WAS a significant reduction in in general well-being in women who used a levonorgestrel-containing OC, compared to women taking the placebo. 

Postpartum Women

A study by Horibe analyzed the connection between postpartum depression, drugs, and reported adverse events. They found that levonorgestrel was the top drug reported in connection with postpartum depression. This was followed by other progestins: etonogrestrol and drospirenone (further down in the list). The authors concluded that contraceptives or intrauterine devices with progestin might convey risk for postpartum depression.

With this in mind, I believe that postpartum women should be aware of the risk of depression with many of the pharmaceuticals they may taking during that first postpartum year. Moreover, it’s important to have these conversations with their doctors of what may happen, and what the next steps would be. Currently progestin-only contraception is considered first-line therapy for breastfeeding women. Estrogen-containing contraceptives are not started until breastfeeding is stopped as it may decrease milk supply. 

Adolescents

A groundbreaking study (looking at over a million women!) in 2016 by Skovlund, looked to investigate if hormonal contraception is associated with antidepressant use and a depression diagnosis. They ended up finding that adolescents (15 to 19 years) using hormonal contraception are more sensitive than older women (20 to 34 years old). when it came to getting a diagnosis of depression or using antidepressants. This effect was seen in both the combination pill as well as progestin-only pills (which was more predominant). The study also indicated that the incidence of depression and use of antidepressants decreased with age. 

For teens considering taking birth control, I would ask yourself why this might be. What is the outcome you are hoping to achieve? There are two conditions in which girls are given birth control as a treatment: endometriosis and acne (usually resulting from PCOS).

If you are experiencing heavy and painful periods (where you are unable on some days to go to school), talk to your medical doctor about endometriosis and if it’s a possibility. If you are experiencing acne, hair growth in places usually seen in males, and even irregular periods, talk to your doctor about PCOS as a possible explanation.  

Women with Bipolar Disorder and Depression

The study by Pagano aimed to look at the safety of contraception in women with depression and/or bipolar disorder. This was a meta analysis which looked at 6 studies that met their specific inclusion criteria. They found that oral contraception, levonorgestrel-releasing IUD and the depo shot, were not associated with worse clinical outcomes of depression or bipolar disorder in women who already had this condition. 

A couple things to note about this review: there was no standard definition or assessment of depressive and bipolar disorders or symptoms across studies, and the use of depression medication was unknown in three of the six studies. 

Final Thoughts on Birth Control and Depression

Overall, while there’s no clear cut answer on whether birth control causes depression – these studies still give you an idea of what the risk might be. Here are a couple of questions to think about if you’re considering taking birth control:

• Why do you want to take birth control?

• Are you considering birth control because of painful periods or ‘regulating’ your cycle?

• Are you considering birth control because you want to prevent a pregnancy?

• Are you willing to live with side effects (ie. a decreased quality of life)?

• Are you an adolescent?

• Have you given birth within the past year? 

While there isn’t a naturopathic alternative to birth control (I’m talking about supplements, not the fertility awareness method), it’s necessary to dive deeper into why you may be considering this option. This may also have you wondering what’s going on in your body and if you can help support it in other ways – perhaps with the assistance of Naturopathic Doctor as well!

References

Zethraeus N, Dreber A, Ranehill E et al. A first-choice combined oral contraceptive influences general well-being in healthy women: a double-blind, randomized, placebo-controlled trial. Fertil Steril. 2017;107(5):1238-1245. doi:10.1016/j.fertnstert.2017.02.120.

Horibe M, Hane Y, Abe J et al. Contraceptives as possible risk factors for postpartum depression: A retrospective study of the food and drug administration adverse event reporting system, 2004-2015. Nurs Open. 2018;5(2):131-138. doi:10.1002/nop2.121.

Pagano H, Zapata L, Berry-Bibee E, Nanda K, Curtis K. Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review. Contraception. 2016;94(6):641-649. doi:10.1016/j.contraception.2016.06.012.

Worly B, Gur T, Schaffir J. The relationship between progestin hormonal contraception and depression: a systematic review. Contraception. 2018. doi:10.1016/j.contraception.2018.01.010.

Skovlund C, Mørch L, Kessing L, Lidegaard Ø. Association of Hormonal Contraception With Depression. JAMA Psychiatry. 2016;73(11):1154. doi:10.1001/jamapsychiatry.2016.2387.

Ask Alexsia: Can menstrual cups cause toxic shock syndrome?

Since switching to a menstrual cup years ago, I commonly get asked if toxic shock syndrome (TSS) is still a concern (spoiler alert: yes!).

How does toxic shock syndrome happen?

TSS is a rare, but severe disease. It commonly happens when tampons or menstrual cups cause the vaginal canal to colonized by Staph aureus, which produce a toxin called TSST-1. Toxic shock was first seen in women who used tampons made of high-absorbency fibres favouring the growth of Staph aureus and TSST-1 production 

Symptoms of TSS include: fever, hypotension (low blood pressure), a skin rash with subsequent peeling, and multiple organ dysfunctions.

Research on Menstrual Cups

Three reasons have been suggested to explain why bacteria grows:

1. Accumulation of blood

2. Increase of vaginal pH during menstruation from 4.2 to 7.4

3. Oxygen and carbon dioxide are both present in the vagina during menstruation 

Few studies exist in relation to menstrual cups and TSS, but they have all come to the same conclusion that while menstrual cups do not absorb blood, they still put women at risk for TSS.

Many cups are made with medical-grade silicone. While silicone does not support bacterial growth, because of blood accumulation, menstrual cups provide a medium for bacterial growth. 

According to one study, because Staph aureus can form a biofilm (bacteria sticking to the surface of the cup), bacteria may be resistant to water. Therefore, it has been recommended to have 2 cups on hand during the menstrual cycle, and to boil them in water in between uses. 

Final Thoughts

At the end of the day, I’m still sticking with my beloved menstrual cup. I like using them because I can keep track of my monthly blood loss, I always forget to buy pads and tampons, and I don’t like the waste associated with the disposable options!

Therefore, you still want to be cautious when using a cup. As mentioned above, think about purchasing 2, boiling between use, and most importantly – not forgetting about it! 

References

Nonfoux L, Chiaruzzi M, Badiou C et al. Impact of currently marketed tampons and menstrual cups on Staphylococcus aureus growth and TSST-1 production in vitro. Appl Environ Microbiol. 2018:AEM.00351-18. doi:10.1128/aem.00351-18.

Juma J, Nyothach E, Laserson K et al. Examining the safety of menstrual cups among rural primary school girls in western Kenya: observational studies nested in a randomised controlled feasibility study. BMJ Open. 2017;7(4):e015429. doi:10.1136/bmjopen-2016-015429.

Mitchell M, Bisch S, Arntfield S, Hosseini-Moghaddam S. A Confirmed Case of Toxic Shock Syndrome Associated with the Use of a Menstrual Cup. Canadian Journal of Infectious Diseases and Medical Microbiology. 2015;26(4):218-220. doi:10.1155/2015/560959.

The vaginal microbiome is becoming increasingly popular nowadays, and so I wanted to explore the relationship between it and hormonal birth control. I wanted to investigate if being on a form of hormonal contraception increased the risk of getting a vaginal infection. All the studies that I looked at ranged between 2014 and 2018, and looked at a variety of birth control options including combined oral contraceptive pills, progestin-only pills, the depo shot, copper IUD, and mirena IUS.  

Types of Birth Control

Combined Oral Contraceptives 

In one study, there were more hydrogen peroxide producing lactobacilli, and less BV-associated bacteria compared to condom users. 

Progestin-Only Pills

Women taking progestin-only pills, in one study, seemed to readily develop aerobic vaginitis (aka. abnormal flora) and vaginal atrophy (aka. thinning, drying, and inflammation of the vaginal walls). However, compared to Mirena users, women taking Mirena has a less likelihood of getting a candida infection. In fact, another study showed that women with a recurrence of vulvovaginal candidiasis should take progestin-only pills instead of intrauterine contraception. 

Depo Provera Shot

One study showed that a proportion of women with the Depo provera shot, had more Lactobacillus-dominated vagitypes than compared to condom users.

Copper IUD

According to a few studies, there was an asymptomatic prevalence of bacterial vaginosis in women with the copper IUD. One study looked at the time in which women began using this form of contraception, and BV prevalence continued to increase 6 months after the IUD was inserted. Moreover, another study showed that in women with the copper IUD, there was a trend towards BV, abnormal flora, increased pH (remember vaginal pH is about 3.8-4.5) and candida infections. 

Mirena IUS

There are mixed accounts of how Mirena affects the vaginal microbiome. In one study compared to the combined contraceptive pill, there were greater amounts of BV-associated bacteria in women with the Mirena device. This study indicated that Mirena may have a negative effect on the vaginal microbiome. With respect to Candida, women using Mirena has a higher risk of Candida compared to women not using any form of contraception.

Two other studies said that compared to copper IUD users, long-term Mirena users had a lower risk of abnormal microflora,  and that the vaginal microbiome changes very little in response to Mirena. 

Lastly a final study found a found a temporary worsening in lactobacilli and increased rates of BV after 3 months of Mirena use (compared to pre-insertion). However, after 1 and 5 years, the flora changes were reversed. Ultimately, there was a complete restoration to pre-insertion levels. However, candida increased significantly after long-term Mirena (when compared to pre-insertion).

Final Thoughts

Depending on the type of birth control you’re using, it’s important to be aware of any potential effects it may have on your vaginal microbiome. Moreover, if you find yourself getting constant infections – one of the causes may be the type of birth control you’re using! In that case, it may be best to start taking a vaginal probiotic and immune support, all under the supervision of a Naturopathic Doctor. 

References

Brooks J, Edwards D, Blithe D et al. Effects of combined oral contraceptives, depot medroxyprogesterone acetate and the levonorgestrel-releasing intrauterine system on the vaginal microbiome. Contraception. 2017;95(4):405-413. doi:10.1016/j.contraception.2016.11.006.

Achilles S, Austin M, Meyn L, Mhlanga F, Chirenje Z, Hillier S. Impact of contraceptive initiation on vaginal microbiota. Am J Obstet Gynecol. 2018. doi:10.1016/j.ajog.2018.02.017.

Donders G, Bellen G, Janssens D, Van Bulck B, Hinoul P, Verguts J. Influence of contraceptive choice on vaginal bacterial and fungal microflora. European Journal of Clinical Microbiology & Infectious Diseases. 2017;36(1):43-48. doi:10.1007/s10096-016-2768-8.

Jacobson J, Turok D, Dermish A, Nygaard I, Settles M. Vaginal microbiome changes with levonorgestrel intrauterine system placement. Contraception. 2014;90(2):130-135. doi:10.1016/j.contraception.2014.04.006.

Donders G, Bellen G, Ruban K, Van Bulck B. Short- and long-term influence of the levonorgestrel-releasing intrauterine system (Mirena®) on vaginal microbiota and Candida. J Med Microbiol. 2018;67(3):308-313. doi:10.1099/jmm.0.000657.