A recent study in JAMA Network Open found that long-term birth control pill users experienced noticeably worse mental health during the four to seven day phase of placebo pills, also known as a ‘pill pause,’ each month [1]. (This ‘pause’ causes a woman on birth control to bleed each month, and is often mistakenly called a ‘period.’). Researchers speculated that, from a mental health perspective, perhaps the pill pause should be eliminated altogether (i.e., that the placebo pills should be eliminated from monthly pill packs).
But that’s not the only possible takeaway from the data, which we’ll delve into in this article. What’s more, the idea of taking continuous hormonal contraception doesn’t take into account the potential total impact of other birth control side effects or the known health benefits of ovulation, the latter of which are inaccessible to women on the Pill, which primarily prevents pregnancy by preventing ovulation.
Oral contraceptive users who took a pill pause had similar dips in mental health as naturally cycling women
In the study, conducted in Salzburg, Austria, between April 2021 and June 2022, Danish and Austrian researchers tracked mental health data from 180 women. The women were split into three even groups. Two different oral contraceptive (OC) groups were studied to see if the type of birth control mattered for mental health symptoms. All users had been on their birth control pill for 6 months or more. The third group, the control group, was made up of naturally cycling women (i.e., women not on any form of contraception).
Negative affect (a sense of seeing the world negatively), positive affect (a sense of seeing the world positively), anxiety symptoms, and other mental health symptoms were measured twice in each participant, once during the active pill phase of OC users and once during the pill pause week of placebo pills. Naturally cycling women were measured midway through the luteal phase (the second half of the cycle, following ovulation, when progesterone is highest) and then again during menstruation.
During the hormonal withdrawal phase, when OC users took the placebo pills, users in both the birth control groups reported increases in mental health symptoms and anxiety. Interestingly, they experienced about the same amount of symptoms as naturally cycling women experienced around the time of menstruation. The researchers observed that withdrawal from synthetic hormones in the Pill appeared to mimic the natural withdrawal from endogenous hormones experienced by naturally cycling women during their periods. Additionally, OC users with mental health symptoms unrelated to their periods reported worse symptoms during the pill pause than OC users who didn’t have mental health issues at baseline.
Does this mean that a birth control ‘pill pause’ should be eliminated?
The researchers reported:
“Our data suggest a significant increase in negative affect, anxiety, and mental health symptoms during the pill pause in long-term COC users, which was (1) irrespective of COC type, (2) moderated by baseline depression scores, and (3) comparable with mood changes observed along the [natural cycle].”
“Our data suggest a significant increase in negative affect, anxiety, and mental health symptoms during the pill pause in long-term COC users, which was (1) irrespective of COC type, (2) moderated by baseline depression scores, and (3) comparable with mood changes observed along the [natural cycle].”
The researchers commented, “These results question the use of the pill pause from a mental health perspective.” They then speculated that “Long-term COC users may benefit more from the mood-stabilizing effects of COCs in cases of continuous intake.” But this isn’t the only possible way to read the data!
It’s true, as we’ve covered previously, that the withdrawal bleed women experience during the pill pause serves no physiological purpose. That’s because a withdrawal bleed isn’t a true period since it doesn’t follow ovulation. Ovulation has real benefits for brain, breast, bone, heart, and immune health, and preps the woman’s body for healthy future pregnancies. Women who are on oral contraceptives, i.e. not cycling naturally, miss out on the benefits of ovulation.
Potential benefits of the birth control pill pause
Keep in mind, too, that some of the many side effects of hormonal birth control use, including increased risk of certain cancers, are likely dose-dependent. The more synthetic hormones you consume and the longer you consume them, the higher your risk. The monthly pill pause may mitigate some of this risk. Research is needed to confirm or disprove this theory.
Should women take oral contraceptives continuously for mood stabilization?
The researchers referenced the presumed ‘mood-stabilizing’ effects of specifically long-term (longer than 6 months) OC use. At the same time, they simultaneously acknowledged the significant negative mental health effects associated with oral contraceptive use in many other studies, especially for teen users. How can both these things be true? Does birth control stabilize mood if you take it for long enough?
Some women undoubtedly suffer mental health problems from OCs
As summarized in a Contemporary OBGYN commentary on the study:
“Approximately 407 million women worldwide use hormonal contraceptives, and data has indicated a 1.8-fold increased risk of a first depression diagnosis or antidepressant use in the first few months of [combined oral contraceptive] use, as well as a 2-fold increased risk of a suicide attempt.”
“Approximately 407 million women worldwide use hormonal contraceptives, and data has indicated a 1.8-fold increased risk of a first depression diagnosis or antidepressant use in the first few months of [combined oral contraceptive] use, as well as a 2-fold increased risk of a suicide attempt.”
The researchers believed that some women are more hormonally sensitive than others (this has similarly been speculated in research into the connection between hormonal birth control use and postpartum depression), and these women are more prone to worsening mental health on OCs. As a result, they’re likely to stop using OCs in the first few months of use. It’s also possible that prolonged OC use gradually makes women more sensitive to hormone withdrawal periods, such as during the postpartum period.
Some women don’t seem to suffer mental health problems from OCs
The researchers argued that women who aren’t hormonally sensitive are more likely to continue taking their OCs long-term, and these are the women who could end up in a study of long-term OC users. This phenomenon is called the survivor effect. It may be, then, that OCs don’t so much stabilize mood if you take them for long enough. What may actually be happening is that women who weren’t as hormonally sensitive in the first place don’t experience worsening mood from their OCs.
What we don’t yet know
Is the withdrawal phase or the active phase of birth control to blame for its negative mental health effects?
The researchers observed:
“Although it has been reported that women with a history of depression are more susceptible to negative mood symptoms during short-term COC use, 13,14, 52 to the best of our knowledge, this was the first study demonstrating a similar effect in long-term COC users.”
Because the researchers found that the women reported mental health symptoms during their pill pause, this might mean that the hormone withdrawal (rather than the active ingredients in OCs) is at least part of the problem. For this reason, long-term OC use might stabilize mood to some degree, particularly if there is no pill pause and therefore no hormone withdrawal.
What are the health effects of steady reproductive hormone levels on the female body?
But more research on the long-term mental health effects of OCs is needed because steady-state reproductive hormone levels in the body (as maintained by OC use if there is no pill pause) don’t naturally occur in the body. Qualitative evidence, such as the research evolutionary psychologist Sarah E. Hill shared in her book This is your brain on birth control, suggests that after years of OC use, many women reported feeling as though they were “seeing the world in color again” or as if they were emerging from a fog when they stopped taking their pills. Further high-quality studies are needed to assess what years of OC use, especially continuous use, do to mental health in the long run.
The researchers wrote that they couldn’t determine whether the mental health symptoms were related to the synthetic estrogens or the synthetic progestins in OCs, or the ratios of one to another or to both. This too is an area for future research.
Debilitating PMS or other mental health symptoms aren’t normal and need to be addressed
During the birth control pill pause, OC users reported comparable mood symptoms to naturally cycling women during their periods. For most women, PMS symptoms are annoying, not debilitating. Women who chart their cycles using evidence-based fertility awareness methods can practice cycle syncing, particularly when ‘that time of the month’ is approaching, to lean into their bodies’ natural hormonal rhythms for optimal physical and mental health. PMS or premenstrual dysphoric disorder (PMDD) symptoms that impact a woman’s ability to live her daily life should be investigated and addressed, not Band-Aided with birth control. It’s clear from this study that birth control can’t solve a mental health problem, though it may mute the symptoms for a time.
References:
[1] Noachtar IA, Frokjaer VG, Pletzer B. Mental Health Symptoms in Oral Contraceptive Users During Short-Term Hormone Withdrawal. JAMA Netw Open. 2023;6(9):e2335957. doi:10.1001/jamanetworkopen.2023.35957Additional Reading:
Cycle Syncing: How to hack the natural hormonal shifts of your menstrual cycle
