Inadequate support: Studies evaluating a potential link between hormonal contraception and risk of depression produced conflicting results and are inconclusive due to conflicting results.
FULL CLAIM: “An entire generation of women was prescribed birth control from the age of 14 for acne and irregular periods and now that same generation is dealing with PCOS [polycystic ovarian syndrome], hormonal imbalances, depression, and infertility”
REVIEW
Birth control (contraception) refers to any method, medicine, or device used to prevent pregnancy. Common methods include permanent male and female sterilization, barrier methods that block the sperm like condoms and diaphragms, and hormonal methods.
All hormonal contraceptives contain a synthetic form of the female hormone progesterone, alone or in combination with another female hormone called estrogen. These hormones prevent pregnancy by inhibiting the release of an egg (ovulation), thickening the mucus around the mouth of the womb to prevent sperm from entering and fertilizing the egg, and/or thinning the lining of the uterus’ wall to prevent a fertilized egg from attaching to it.
However, hormonal contraceptives also have other uses that are unrelated to birth control. For example, they can help control irregular periods, excessive menstrual bleeding, and acne. They can also alleviate premenstrual syndrome, a combination of physical and emotional symptoms of different intensity that most women experience one or two weeks before their periods and can be temporarily disabling in some cases.
In April 2022, a Facebook post suggesting that these non-contraceptive uses of birth control have harmful effects went viral on the platform, receiving more than 86,000 shares. The post reproduced a tweet by a video blogger who goes by the handle Reallygraceful that specifically linked the use of hormonal contraceptives during adolescence to the development of polycystic ovarian syndrome (PCOS), hormonal imbalances, depression, and infertility later in life.
The tweet went viral in February 2022, prompting some gynecologists to refute the claims on social media, stating that birth control pills don’t cause or contribute to PCOS or infertility. This was documented (timestamp 5:31) in a podcast that Reallygraceful published on her YouTube channel, which has accumulated over 360,000 subscribers, supposedly providing evidence in support of her claims.
However, the podcast didn’t cite any scientific studies but instead compiled anecdotal accounts from a few women, including Reallygraceful herself, about the alleged harmful effects of birth control. Given that anecdotal evidence tends to be biased for various reasons, such as the fallibility of human memory and confirmation bias, they are unreliable without systematically collected and analyzed scientific data to support it.
Multiple studies show that long-term use of hormonal contraceptives doesn’t reduce fertility
The claim that contraception causes infertility is a pervasive myth that is unsupported by scientific evidence, as the gynecologist Jennifer Gunter explained in her blog The Vajenda. Research shows that hormonal contraception doesn’t reduce fertility. About 20% of women get pregnant within their first cycle after discontinuing hormonal contraception, and most of them can become pregnant within the first year[1,2].
A 2018 systematic review and analysis of 22 earlier studies found no difference in fertility rate between women who discontinued contraception after having used intrauterine devices (IUDs) and those who had used hormonal contraceptives, including implants, injections, and pills[2].
Another study published in the British Medical Journal in 2020 evaluated the ability to conceive in almost 18,000 women from Denmark, Canada, and the U.S. after discontinuing hormonal contraception, IUDs, and barrier or natural contraceptive methods between 2007 and 2019[3]. While the authors found that some hormonal contraceptive methods caused a slight delay in return to fertility compared to barrier and natural methods, the rate of conception by one year was the same among the different groups. The authors concluded that long-term use of these methods had “little or no lasting effect” on fertility.
Hormonal contraceptives aren’t associated with PCOS but are instead part of the treatment
PCOS is a hormonal disorder that affects the function of women’s ovaries. Symptoms include irregular menstrual periods and unusually high levels of male sex hormones (androgens), which in women are usually only present in small amounts. Sometimes ovaries’ also enlarge due to the accumulation of unreleased eggs in the form of multiple small fluid-filled follicles.
According to the U.S. Centers for Disease Control and Prevention (CDC), PCOS affects an estimated 6 to 12% of women of reproductive age in the U.S. and is one of the most common causes of female infertility. Furthermore, this condition also increases the risk of metabolic problems like diabetes, as well as heart disease, blood clotting, and stroke. PCOS has no cure, but changes in diet and activity and medication help manage the symptoms and prevent these long-term complications.
Although the exact cause of PCOS is unknown, multiple factors such as family history, higher levels of androgens, and excess weight are suspected contributors. In a blog post, Jennifer Gunter explained that current epidemiological evidence doesn’t indicate that hormonal contraceptives are among these factors. On the contrary, combined hormonal contraceptives are often part of the long-term PCOS treatment in women who don’t wish to get pregnant, as they help regulate menstrual periods and reduce the level of androgens.
Like any medical intervention, hormonal contraceptives can cause side effects, most of them minor. Common side effects include nausea, headache, breast tenderness, and spotting or bleeding between periods. Serious side effects, including high blood pressure, blood clots, heart attacks, and strokes, have been reported but are very infrequent, as Health Feedback explained in an earlier review.
There is consistent evidence that hormonal contraceptives are also associated with a slightly higher risk of breast and cervical cancer. On the other hand, hormonal contraceptives reduce the overall risk of cancer by providing significant protection against colorectal, ovarian, and endometrial cancer[4,5]. Thus birth control pills could offer an important benefit for women with PCOS, who have a higher risk of endometrial cancer[6].
Studies linking hormonal contraception during adolescence with an increased risk of depression have produced conflicting results, making them inconclusive
Reallygraceful’s claim that hormonal contraception causes depression might be based on a study published in JAMA Psychiatry in 2016 that evaluated the risk of depression in more than one million women in Denmark[7]. The study found that female adolescents who were using hormonal contraception had about double the risk of being diagnosed with depression compared to those who never used hormonal contraception.
However, these results only showed an association between hormonal contraception and depression. This doesn’t imply that hormonal contraceptives cause depression, as association alone isn’t evidence of causation.
Overall, research evaluating the potential effect of hormonal contraceptives on the risk for depression has produced conflicting results. A recent review published in the Journal of American Psychiatry in 2021 concluded that “clinical studies and randomized placebo-controlled trials of women with psychiatric disorders have generally reported similar or lower rates of mood symptoms in hormonal contraceptive users compared with nonusers”[8]. However, more research is needed to draw more definitive conclusions.
Conclusion
Social media posts linking hormonal contraceptives with PCOS, infertility, and depression are based on anecdotal evidence that contradicts currently available scientific data. Multiple studies show that hormonal contraceptives don’t cause infertility. There is also no evidence supporting an association between the development of PCOS and previous use of hormonal contraceptives, which are, in fact, effective in alleviating PCOS symptoms. Evidence supporting an association between hormonal contraceptives and depression is inconclusive.
REFERENCES
- 1 – Cronin et al. (2009) Rate of Pregnancy After Using Drospirenone and Other Progestin-Containing Oral Contraceptives. Obstetrics and Gynecology.
- 2 – Girum et al. (2018) Return of fertility after discontinuation of contraception: a systematic review and meta-analysis. Contraception and Reproductive Medicine.
- 3 – Yland et al. (2020) Pregravid contraceptive use and fecundability: prospective cohort study. British Medical Journal.
- 4 – Gierisch et al. (2013) Oral Contraceptive Use and Risk of Breast, Cervical, Colorectal, and Endometrial Cancers: A Systematic Review. Cancer Epidemiology, Biomarkers and Prevention.
- 5 – Yin et al. (2019) Association Between Polycystic Ovary Syndrome and Cancer Risk. JAMA Oncology.
- 6 – Gottschau et al. (2015) Risk of cancer among women with polycystic ovary syndrome: A Danish cohort study. Gynecologic Oncology.
- 7 – Skovlund et al. (2016) Association of Hormonal Contraception With Depression. JAMA Psychiatry.
- 8 – McCloskey et al. (2020) Contraception for Women With Psychiatric Disorders. The American Journal of Psychiatry.
