Hormonal Contraception And Mental Health: How Worried Should You Be?

The NHS still isn't looking into how many women experience the mental health side effects of contraception

Contraceptive pill and mental health

by Vicky Spratt |

In 1961, the contraceptive pill became available in Britain. The story of what happened next is well known: a social and economic revolution which saw women have sex solely for pleasure without fear of pregnancy as they took control of their bodies’ ability to bring human life into the world and enter the workforce in unprecedented numbers.

The fact that there was outrage about what this would do to our country’s morals at the time is a testament to just how emancipating hormonal contraception was. It’s no coincidence that early advertisements for the pill’s early incarnation – Enovid – bore the image of the Greek goddess Andromeda as a symbol for all women being freed from their biological chains.

Today, its benefits are still great. So great, in fact, that it’s easy to forget that it was first tested on women living in a public housing project in Puerto Rico. However, it’s not only the pill’s shady history that casts a shadow over this game-changing medical intervention.

But hormonal contraception – which includes the pill, the injection, the hormonal coil, the implant and the Nuva ring – is not without side effects. How could any drug which, quite literally, intends to change the course of nature, not be?

In 2017 I undertook an investigation called ‘Mad About The Pill’ for The Debrief, looking at the mental health side effects of hormonal contraception. Thousands of women reached out, sharing their stories. That investigation is being continued at Grazia and forms the subject of an episode of the BBC’s Horizon which is due to air this week.

Much of the conversation surrounding the impact that hormonal contraception can have on our mental health has been stoked by studies which have come out of the University of Copenhagen from teams overseen by Professor Øjvind Lidegaard. I interviewed him at his office in Copenhagen’s Rigshospitalet for Horizon.

In Denmark, Professor Lidegaard has access to a unique database of medical records because every single person’s data is logged in a central system. This allowed him to look at the records of more than one million Danish women aged 15-34 over a sixteen-year period. As a result, he has produced two studies. One found that women taking the pill - either the combined pill or the progestogen-only pill - were more likely to be prescribed an antidepressant than those not on hormonal contraception. The difference was particularly noticeable for young women aged between 15 and 19 on the combined pill. Another found a link between hormonal contraception, suicide attempts and suicide.

These findings seemed to be confirmed by a separate Swedish study published earlier this year.

In 2017, when I found out that Professor Lidegaard had been able to conduct this research by looking at women’s records to see if there was a correlation between experiencing mental health issues and using hormonal contraception, I asked the NHS whether this is something they had ever look at in England. After all, there is an established link between hormones and mental health (both positive and negative), it’s listed in the small print inside every tiny booklet that comes alongside your monthly blister pack.

This is what the NHS’s Business Services Authority (NHSBA) told me then:

‘Further to discussions with a colleague, they have confirmed that data will be available dating back to April 2015, as this was when we started to capture NHS Numbers, giving us the opportunity to count the number of unique patients. This will not be possible until our data warehouse is introduced. This is still some way off, however. It is hoped that it will be ready next year, however, I am at pains to make promises of when exactly this will be.’

I followed up with them last week to find out whether they’d found a way to collect that data yet. This is the reply I received:

'NHSBSA does not have access to a centralised database of medical records nor does it receive any information about a patient's medical condition or diagnosis'.

Following this response, I decided to try NHS digital. They told me that they 'don’t hold any demographic data'.

Why does this matter? Well, put simply, it means that the NHS is not monitoring women who are concurrently talking hormonal contraception and being treated for mental health issues in the way that a country like Denmark is. It matters because it means that we don’t know exactly how many women are experiencing negative mental health side effects as a result of their contraception.

While some women not only report experiencing no issues with hormonal contraception, some report positive side effects such as easing of PMS and clearer skin, others say it makes them feel anxious and depressed.

Dr Michael Craig, clinical lead and consultant psychiatrist at the National Female Hormone Clinic, recently explained to me that ‘there is no doubt that there is a subgroup of women who are more vulnerable to both their own hormones and the synthetic ones contained in the pill’. However, he added, 'what we don’t know is how big this group of women is or what’s different about them – it’s still controversial, even though there is a general acceptance now that some women will get more depressed pre-menstrually, post-natally and perimenopausally than other women'.

As with so many areas of women’s health, this is one where more research is needed. Without that research, women are left to discuss the pitfalls of the pill and its counterparts amongst themselves. Only this week did someone I know post on Instagram that she had been dismissed by her GP when she said that she thought the pill was making her depressed. Over a hundred women commented on her post, saying they had had a similar experience.

So, what’s going on? And, how concerned should women be?

As with most things worth investigating, the answer here is that it’s complicated. The reason for this complexity, Dr Michael Craig explains, is reasonably simple (if surprisingly rarely openly acknowledged). He says no two women are exactly the same and, therefore, no two women will react to the synthetic hormones in contraception the same way. 'This is touching on the more general shift to personalised medicine that we’re seeing', he explains 'we are now accepting that some people will see a positive effect to a medicine while others may experience negative side effects'. When it comes to hormonal contraception, then, there is no one size fits all approach. 'I also work with autism and this is an area where we think certain treatments haven’t been developed because what might be good for one kind of autism could be bad for another', Dr Craig adds.

So, how do we figure out what will work for who? 'What we need to do is unpick groups of people and look at who is likely to have a positive and who is likely to have a negative response' Michaels explains 'it’s likely that this is all going to come down to genetics – it’s about a person’s risks and vulnerabilities based on their genetic makeup'.

We know that there is an established link between hormonal contraception and mental health side effects. What we need is more research to enable those affected to make informed choices. We don’t want women to abandon their contraception and face an unwanted pregnancy but, equally, we can’t make informed choices without information.

'The way that the Danish studies have approached this is good' Michael says 'they have looked at the medical records of large numbers of women and been able to cross reference their records for contraception prescriptions with mental health treatments.' But, we can’t do that here. Yet. As unheadline-worthy as it sounds, more research and big data is probably the only way to finally put a number on exactly how many women are being adversely affected by their hormonal contraception in England. Right now, the truth is that we don’t know.

'It’s the old thing that one man’s meat is another man’s poison' Michael adds. In this case, I say, we should probably sub the word woman in there and we laugh. Jokes aside, it’s fitting that even the phrase Michael uses to describe the problem references men. As health journalist Angela Sani has documented, for a long time women’s health has been under-researched and misunderstood.

With every study that confirms a potential link between hormonal contraception and mental health problems, the likelihood of the issue being taken more seriously increases. The general consensus is that doctors should look out for depressive symptoms in patients who are using hormonal contraception. As David Brent MD writes in the American Journal of Psychology in response to the most recent Swedish study, doctors ‘should routinely inquire [sic] about the use of hormonal contraceptives in their female patients and chart the temporal relationship of hormonal contraceptive use against depressive symptoms’.

But, as Professor McGregor Anne McGregor told The Debrief as part of the ‘Mad About The Pill’ investigation, not all GPs will be aware of the latest research. ‘Not all GPs are trained in sexual and reproductive health care’ she said ‘they have to do an extra qualification to gain very specific experience’.

We like to think that the truth is neat. That facts can be neatly packaged up and clearly explained to us by short, succinct headlines. But, when it comes to the mental health side effects of hormonal contraception the truth is paradoxical, one fact seems to contradict another.

The young woman who contacted me this week because she felt dismissed by her GP said she felt 'completely mental as soon as my doctor said the pill caused no mood swings or depression. I instantly shut up, because I felt essentially that I was in an unsafe place to share my concerns, they wouldn't be taken seriously'. Misinformation can be dangerous so it’s important to get it right.

'The really important thing is not to over egg the pudding' Michael says 'we don’t want to have loads of women coming off the pill because they assume their depression is caused by it but, equally, we should listen to what women are telling us.'

It is both true that the pill can help to stabilise some women’s moods and have a negative effect on the mental health of others. And so, the next time you read a headline which says 'the pill causes depression' or, equally, one which says 'the pill doesn’t cause depression' remember that no two women are exactly the same. When it comes to female hormones, those two statements can be and are true at the same time.

Contraception is about principal. It’s a cornerstone of women’s freedom. So is it too much to ask that we can have that and engage in a proper conversation about its potential side effects at the same time?

If you have any concerns about your contraception you should speak to your GP immediately.

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