November 17, 2016 by Alison Contreras, PhD, FCP Last month an article in JAMA Psychiatry caused waves when it revealed what many users of hormonal birth control have long suspected: a link between hormonal contraception use and depression [1,2]. This news has reopened the conversation about how physicians should counsel patients about their reproductive health options. 
Increased depression risk across birth control methods
The first of its kind, this prospective cohort study of more than 1 million Danish women between the ages of 15 and 34, showed an increased risk for first use of an antidepressant in users of hormonal birth control. This finding was consistent no matter what type of hormonal method was used, including the combined pill (23% increase), progestin-only pill (34% increase), the patch (100% increase), the ring (60% increase), and intrauterine system (IUS) (40% increase). Additionally, the risk of depression generally decreased with age, so the highest rates of increased risk occurred among adolescents, with an 80% increase in depression when taking a combined pill and 120% increase when taking a progestin-only pill [2]. Most hormonal methods include a warning for users to inform their physicians if they have a history of depression, but this is the first prospective study to indicate a link between the onset of hormonal birth control and an increased risk of first antidepressant use. Now women must add an increase in depression to that already long, fine print list of side-effects that they must consent to when they are seeking out an effective birth control option, including stroke, blood clots, heart attacks, liver disease, and many others [3].
Side effects of birth control result in high discontinuation rates
So, how should a physician respond when confronted with a woman who is experiencing these side effects? In an article responding to the study, Kaiser Health News reported that Dr. Cora Breuner, a Seattle pediatrician and chair of the committee on adolescents for the American Academy of Pediatrics cautioned against over-reaction to the news. “An unintended and unwanted pregnancy far outweighs all the other side effects that could occur from a contraceptive,” she said [4]. Meanwhile Holly Grigg-Spall, author of Sweetening the Pill or How we got hooked on hormonal birth control calls this response “pillsplaining” and sees it in any every discussion of research into the side-effects of birth control. “If that’s true, why bother researching the side-effects at all?” Griggs-Spall asks [5].
“If [unintended and unwanted pregnancy far outweighs all the other side effects that could occur from a contraceptive is] true, why bother researching the side-effects at all?”
The ultimate answer is: because side effects matter to women. “Depression and anxiety from hormonal contraceptives may not be the experience of every woman, but that doesn’t mean it’s not the experience of your friend, your daughter or your partner, and of many women out there, who, in reading about this could have their lives changed for the better” explains Grigg-Spall. While methods of hormonal birth control may work for some women, high discontinuation rates due to side effects abound (as high as 65% discontinuation rate with the pill [6,7] and up to 40% discontinuation rates for the IUD [8].) This is proof that for many women, the equation that leads to a birth control method that is acceptable to them has more variables in it than just the effectiveness rate.
Whether or not an unintended or unwanted pregnancy would be worse than the potential myriad of side effects associated with birth control is a decision a woman needs to make based on fully informed choice, including both effectiveness rates and real risk of side effects.
These include more common side effects such as bleeding irregularities, breast tenderness and depression and more serious ones, such as blood clots, increase risk of breast cancer and even death [9,10,11].
Equipping patients to make informed decisions
Physicians can’t make this decision for women. As with all medical choices, what they can do is give women the information necessary so that women can make informed choices for their own health. There are several articles on shared decision making that can be used as it relates to birth control counseling [11,12] 
While effectiveness of birth control is a very important factor to consider, many women also have other priorities and may express greater preference for methods with minimal side effects. Therefore, when a woman expresses interest in other options, consider providing evidence-based information on fertility awareness based methods (FABMs). Most FABMs are as effective as the pill and are the only methods of family planning that have no medical side effects [13, 14]. FACTS is currently doing a study on the use of an FABM specific shared decision making tool to supplement existing hormonal birth control tools, and hopes to publish these results in the near future.
Yes, every method has benefits and obstacles. Some require a greater time commitment to learn to use and others involve surgery and the associated risks of surgery. It is a physician’s responsibility to provide accurate information about all of the risks and side-effects of different methods and leave the decision to their patients.
Resources
[1] Hall, et al. Contraception and Mental Health: A Commentary on the Evidence and Principles for Practice. Am J Obstet Gynecol. 2015 Jun; 212(6): 740–746. [PubMed]
[2] Skovlund, et al. Association of Hormonal Contraception with Depression. JAMA Psychiatry. 2016;73(11):1154-1162. [JAMA]
[3] Side Effect Information on Ortho Tri-Cyclen. Accessed 11/15/16. https://www.drugs.com/pro/ortho-tri-cyclen.html
[4] C. Rodriguez. Large Danish Study Links Contraceptive Use To Risk of Depression. Accessed 11/10/16. https://khn.org/news/large-danish-study-links-contraceptive-use-to-risk-of-depression/
[5] Holly Grigg-Spall. The pill is linked to depression – and doctors can no longer ignore it. The Guardian. Accessed 11/01/16. https://www.theguardian.com/commentisfree/2016/oct/03/pill-linked-depression-doctors-hormonal-contraceptives
[6] C. Moreau, et al. Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception. 2007;76(4):267–272. [PubMed]
[7] N.G. Barr. Managing Adverse Effects of Hormonal Contraceptives. Am Fam Physician. 2010 Dec 15;82(12):1499-1506. [PubMed]
[8] M.M. Ali, et al. Long-term contraceptive protection, discontinuation and switching behaviour: intrauterine device (IUD) use dynamics in 14 developing countries. London: World Health Organization and Marie Stopes International, 2011. [PDF]
[9]C. Kahlenborn, et al. 2006. Oral contraceptive use as a risk factor for premenopausal breast cancer: A meta-analysis. Mayo Clinic Proceedings 81: 1290–302 [PubMed]
[10] V. Cogliano, et al. and World Health Organization International Agency for Research on Cancer. 2005. Carcinogenicity of combined oestrogen-progestogen contraceptives and menopausal treatment. Lancet Oncology 6: 552–3. [PubMed]
[11] G. Elwyn, et al. Option Grids: Shared decision making made easier. Patient Education and Counseling. 90 (2013) 207–212. [PubMed]
[12] F. Le ́gare ́ and P. Thompson-Leduc. Twelve myths about shared decision making. Patient Education and Counseling. 96 (2014) 281–286. [PubMed]
[13] M. Manhart, et al. Fertility awareness-based methods of family planning: a review of effectiveness for avoiding pregnancy using SORT. Osteopathic Fam Physician. 2013;5(1):2-8. [PDF]
[14] BA Smoley and CM Robinson. Natural family planning. Am Fam Physician. 2012;86(10):924–928. [PubMed]