Review reinforces link between contraceptive pill and depression

Progestin based hormonal contraceptive pills can tip vulnerable
women into depression, review shows

by Anne Crawford

For some time, Monash Central Clinical School psychiatrist Professor Jayashri Kulkarni has treated women telling her they had developed depression since being prescribed certain oral contraception or that their existing depression had become out of control.

“It was a very common story, repeated over and over again,” said Professor Kulkarni, who heads the Women’s Mental Health Clinic at Monash University’s MAPrc (Monash Alfred Psychiatry Research Centre). “We needed to get more information,” she said.

To this end Professor Kulkarni and MAPrc Research Fellow Dr Eveline Mu, conducted a review, published last month in ‘Australian Prescriber’. It looks at hormonal contraceptive pills and other forms of contraception such as the IUD (intrauterine device) and subdermal implant.

The review, which also draws on research conducted at MAPrc, found that there were few oral contraceptive pills on the market that didn’t cause depression in vulnerable women, (vulnerability described by Professional Kulkarni as being “emotionally sensitive to their hormonal milieu”). 

“It seems to be that the progestin, the synthetic progesterone pill or hormonal contraceptive, is the culprit in terms of creating worse depression or depression for the first time whereas the estrogen component by and large seems to be good for mental health,” she said. “That’s been backed by animal research and our own work in the field. So put bluntly, estrogen is good for mental health, progestin is not good except for a very few types of progestin.

“There’s only one pill on the market that has a ‘good’ progestin, which we often prescribe, that is a nomegestrol - estradiol combination.”

The paper ranks hormonal contraceptives from best to worst in terms of mental health for vulnerable women.

It concludes that general community education and better information about the relationship between oral contraceptive pills and depression is urgently needed for primary healthcare practitioners. “The global rate of depression is climbing, especially in young women; we need to get on top of this. 

“If a general practitioner or other practitioner is starting to write a prescription for a woman it would be important to consider whether she has a history of depression on a hormonal contraceptive, whether she has premenstrual depression or whether she has a strong family history of depression and then in those cases we would urge people to prescribe the mood-neutral pill that’s on the market, nomegestrol plus estradiol,” she said. 

“I’m not by any means saying that this is the only factor that women of reproductive age are facing but it could be the tipping point factor for someone who is already facing work or relationship challenges and other stresses. If we could get rid of the hormone contraceptive that might be the ‘tipping point’ factor, that can really help the woman with depression.”

Professor Kulkarni said health professionals should consider the huge impact that the hormones in the pill have in the brain and on women’s mental health. 

“While I’d be the first to say that good contraception is absolutely critical for women, hormone contraception is developed to focus on stopping ovulation and the implantation of the fertilised ovum and preventing those two processes – all below the waist considerations!” she said. “However, these hormones are also potent brain steroids, and their actions in the brain are multiple. New hormone contraceptives being developed must also include depression and other mental health measures as part of the clinical trials being done ”

Professor Kulkarni said that not all women were sensitive to the effects of hormonal contraception and that more research needed to be done into why some women have mental health changes due to hormone contraception and others do not.

Reference

Mu E, Kulkarni J. Hormonal contraception and mood disorders. Aust Prescr. 2022 Jun;45(3):75-79. doi: 10.18773/austprescr.2022.025. Epub 2022 Jun 1. PMID: 35755988; PMCID: PMC9218393.