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Birth Control and Depression

birth control and depression, toronto naturopath, naturopathic doctor toronto

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.

The Microbiome and Birth Control

April 30, 2018
microbiome and birth control, toronto naturopath, naturopathic doctor toronto, yeast infections, UTI, candida, bacterial vaginosis

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.

    Understanding the Birth Control Pill

    October 30, 2017
    birth control pill, naturopathic doctor toronto

    The first time I heard about the birth control pill was in high school when my friend started taking it for her severe cramps. Back then, I thought that it could just be used for pregnancy prevention! Today I’m breaking down the two types of birth control pills – how they work, side effects, contraindications and potential drug interactions. 

    Combination Pills

    This pill contains two types of synthetic hormones: ethinylestradiol and progestin. They can either have a ‘fixed’ dose of both synthetic hormones, or different doses in each pill to mimic the natural phases of the menstrual cycle.

    Ethinylestradiol content ranges between 20-40ug, higher doses are given when there are drug interactions causing liver enzyme induction. Whereas lower doses are usually given when a woman’s natural fertility is declining.  

    There are different types of progestins used such as levonorgestrel, desogestrel, drospirenone and gestodene. Some forms of progestin have been associated with an increased risk of venous thromboembolism. 

    How does it work?

    The combined pills prevent pregnancy in a couple of different ways:

    • Suppressing ovulation, by preventing LH surge

    • Preventing follicles from maturing, thus suppressing FSH and LH

    • Thickening cervical mucus, thereby preventing sperm movement

    • Thinning the endometrial lining, thereby preventing implantation of the egg

    Most of these products are available in 21 or 28 (21 days of active medication and 7 days hormone-free) day cycles. This method of contraception has a failure rate of 9%, and with perfect use has a failure rate of 0.3%.

    With the combined pill you may notice a decrease in your flow, less period pain, regular periods and fewer PMS symptoms. This is because your true hormones – estrogen and progesterone – are not in charge of your cycle anymore. So, if you went on the combined pill to stop the above symptoms, they’ll stop until you stop using the pill. Once you go off the birth control, they may come back! Studies are controversial, but the pills can actually increase breast cancer risk. 

    The combined pill has shown a reduction in ovarian and endometrial cancer. 

    What are some side effects?

    Some side effects to pay attention to are: abdominal pain, chest pain, headaches, eye problems and severe leg pain. Consult your medical doctor if you begin to experience these symptoms.

    A 2016 study by the University of Copenhagen studied over 1 MILLION Danish women and investigated the effects of depression and hormonal birth control use. They found that compared to non-users, women taking the combined pill were at a 23% higher risk for depression. Teens (15-19 years old) taking the combined pill had a 80% higher risk for depression.  

    A 2013 study, was a review that looked at combined pills and nutritional deficiencies. Folate status may be implicated with the use of the pill, however evidence indicated that levels return to normal after 3 months of pill discontinuation. If a woman plans to become pregnant right after discontinuation, supplementation may be warranted. A decrease in vitamins B2, B6 and B12 was associated with pill use. In addition, Vitamin C levels were lowered in those taking the birth control pill, especially the combined pill as the estrogen may increase Vitamin C metabolism. Vitamin E levels also decreased with combined-pill use. 

    Mineral deficiencies were also seen with birth control use. Plasma zinc levels were lower in women taking the combined pill. The pill can also interfere with selenium absorption. Lastly, magnesium can be affected by the pill as it can result in depletion. 

    What are their absolute contraindications?

    From the Compendium of Therapeutic Choices (2014):

    • Breast cancer or hormone-dependent cancer

    • Cerebrovascular disease

    • Complicated valvular heart disease

    • Current or past history of venousthromboembolism or pulmonary embolism

    • Diabetes with microvascular complications

    • History of, or current myocardial infarction (heart attack) or ischemic heart disease

    • Less than 6 weeks postpartum, if breastfeeding

    • Migraines with aura at any age

    • Hypertension (over 160/100 mmHg)

    • Severe cirrhosis or liver tumour

    • Smoker over 35 years old

    Drug interactions to be aware of

    It’s not advised that you take St. Johns Wort while taking the pill. You may also experience contraceptive failure if you are concurrently taking certain antibiotic medications. Either refrain from sex at this time, or pair the pill with a condom. Lastly, the combination pill does not protect against STIs, so you may also want to use a condom. 

    Mini-pills

    These pills contain progestin only, and are an alternative if a woman cannot take exogenous estrogens. 

    How does it work?

    Progestin-only pills reduce or prevent ovulation (in 60-80% of cycles), prevent sperm from entering the cervix, and thins the endometrial lining, thereby preventing implantation of the egg. Progestin-only pills need to be taking regularly and consistently because their effects can decrease after 22 hours. Manufacturers, recommend a backup method (ie. condom) during their first month of use. 

    For postpartum women who are breastfeeding, the Canadian Contraception Consensus guidelines recommend progestin-only methods because there is a decreased risk of blood clots. They also have a neutral effect on milk supply.

    This method of contraception has a failure rate of 9%, and with perfect use has a failure rate of 0.3%. 

    What are some side effects?

    They have a higher incidence of ectopic pregnancy (fertilized egg implants somewhere other than the uterus) and irregular bleeding. A 2016 study by the University of Copenhagen studied over 1 MILLION Danish women and investigated the effects of depression and hormonal birth control use. They found that compared to non-users, women taking the progestin-only pill were at a 34% higher risk for depression. Teens (15-19 years old) taking progestin-only pills had a 120% higher risk for depression.  

    What are their absolute contraindications?

    From the Compendium of Therapeutic Choices (2014):

    • Pregnancy

    • Current diagnosis of breast cancer

    Drug interactions to be aware of 

    Skip taking St. John’s Wort, even if if you are experiencing depressive symptoms. For the progestin-only pill, antibiotics don’t seem to have an effect on the efficacy. That said, a backup method may be warranted if you are taking them. 

    Final Thoughts

    Birth control pills can have significant effects on the body, aside from preventing pregnancy. If you’re on either a combined or progestin-only pill you may want to speak to your Medical or Naturopathic Doctor about nutrient deficiencies as well as the risk of depression

    If you love learning about your hormones and period, be sure to sign up for my monthly newsletter called The Flow for great and informative content like this!

    References

    Palmerley, M., Saraceno, A., Vaiarelli A, Carlomagno G. (2013). Oral contraceptives and changes in nutritional requirements. Eur Rev Med Pharmacol Sci. Jul;17(13):1804-13.

    Scholes, D., Ichikawa, L., LaCroix, A., Spangler, L., Beasley, J., Reed, S. and Ott, S. (2010). Oral contraceptive use and bone density in adolescent and young adult women. Contraception, 81(1), pp.35-40.

    Skovlund, C., Mørch, L., Kessing, L. and Lidegaard, Ø. (2016). Association of Hormonal Contraception With Depression. 
    JAMA Psychiatry, 73(11), p.1154.

    Webberley, H. and Mann, M. (2006). Oral Contraception. Women’s Health Medicine, 3(6), pp.262-268.