[Co-written with Margherita Caissotti di Chiusano]
Hormonal contraception is available worldwide in many different forms. Fear of side effects and health concerns are among the main reasons for not using contraceptives or discontinuing their use. Although the safety and efficacy of contraceptives have been extensively examined, little is known about their impact on mental health and sexual functioning, and the evidence on the topic is controversial.
This article will focus on:
- What are different types of hormonal contraceptives?
- Effects on Mental Health
- Estrogens and the Sexual Response
- Nuvaring and author’s personal note
- What does the European Society of Sexual Medicine have to say? [6]
What are different types of hormonal contraceptives?
- Birth Control Injections - injected into a muscle e.g. in the buttock or upper arm, or injected subcutaneously (under the skin). No matter the type of injection, this contraceptive is given every three months. [7]
- Hormonal Intrauterine Device IUD - implant that releases progestin that can be left inside the uterus from three to six years depending on the brand. Some types of IUD inhibit bleeding during the period but not all.
- Vaginal Ring - a flexible plastic fibre containing progestin and estrogen which is inserted in the vagina and kept inside for three weeks and removed during the period.
- Birth Control Pills - oral contraceptive that contains progestin and estrogen (or only progestin also known as mini pill) It is the most common hormonal contraceptive.
- Implant - a small rod containing progestin. Inserted under the skin of the upper and inner part of the arm by a healthcare professional. It is effective for at least three years.
- Skin patches - these are like plasters containing estrogen and progestin, similar to the pill. Some choose patches as they do not require you to remember the pill every day; however, some do not want a visible patch on their skin either. [7]
*Note: Advantages and disadvantages of these methods vary and are very personal. There is no such thing as the best contraceptive for everyone. Make sure you visit a professional for recommendations on the type of contraceptives you can take.
Effects on Mental Health
The fact that hormonal contraceptives may influence a person’s mental health is well-known among professionals. The side effects like: change in mood and irritability are listed on most package leaflets and warning labels. Yet, when asking around a lot of women state they have not been properly warned of these side effects.Additionally they have been asked to monitor them as much as other physical symptoms. This may be perhaps because research on the relationship between contraceptives and mental health decline at a population level and are still very mixed.[8]
Indeed, one of the biggest studies on the matter failed to support a negative relationship between the two. Overall, they found that hormonal contraception was well tolerated by the participants. Surprisingly, their results suggested that oral contraceptives (the pill) had a modest to favourable effect on mental health. The length of the use of the pill was inversely related to some Beck Depression Inventory (a questionnaire to measure depression) items (namely: dissatisfaction, irritability, lost interest in people, earlier waking and lost interest in sex). This means that people who were on the pill for longer started noticing improvements on these domains compared to people who had just started and to people who were not on the pill. [8]
However, the same study indicated that people who took the pill scored higher on ‘worries about one's health’ (BDI) and reported more diagnoses of ‘alcohol dependence’ (CIDI). [8]
These results are in line with other studies which show a slight negative relationship between Beck Depression Inventory and the use of the pill; especially in items of dissatisfaction, feelings of uselessness, irritability, lost interest in people and lost appetite. However, this finding only underlines improvements in the short term and not in long-term use.[9]
Interestingly, however, a study in Denmark of over 1 million women found a positive association in the use of hormonal contraceptives and the risk of being prescribed antidepressants or getting a first diagnosis in depression. The highest rates for these increased risks were seen amongst adolescents. [11]
Results from a European sample in 2018, indicated that use of hormonal contraception was positively related to suicidal behaviour, again especially in adolescents. [10]
We can conclude that these results are quite inconclusive and that the amount of research on the field is quite disappointing. The studies are very few and mostly focus on oral contraceptives leaving doubts on whether other contraceptives could be more helpful in terms of mental health effects.
Estrogens and the Sexual Response
Why may contraceptives influence our sexual response? Well, several organs are vital to a normal sexual response: the brain, however, is the centre of the sexual universe. The five senses (smell, sight, sound, taste, touch) help to relay sexual images, fantasies and ideas to the brain. The brain on its side accepts the signals and translates them into messages the body can understand. These messages include signals to increase blood flow and release sex hormones, such as estrogen, testosterone and vasoactive substances. For example, estrogens increase blood flow to the brain and the vagina, increase peripheral vibratory sensation, and have a positive effect on nerve growth and nerve transmission.
It is conceivable therefore that hormonal contraceptives might modify the neuroendocrine pattern (hormonal homeostasis) in women, affecting their sexuality. Available data refer to oral hormonal contraceptives, and can be interpreted in different ways. Indeed, some studies report more frequent sexual intercourse and orgasms, together with their intensity, in women who take oral contraceptives compared to controls and to other contraceptive methods.
From a psychological point of view, the fact that hormonal contraceptives are extremely efficacious in preventing pregnancies (efficacy ranging from 95% to 99%) may bring a psychological sense of safety as it reduces the fear of an unwanted pregnancy. This may in turn therefore increase desire and sexual satisfaction. These positive effects on sexual function may originate from the ability to separate sexual activity for procreation purposes from that of pleasure, which bring reassurance.
Still, it must be noted that available review articles suggest chronic birth-control pill use as commonly associated with female sexual dysfunction. Indeed, authors of a recent study recommend the discontinuation of oral contraception to treat sexual dysfunction, given an improvement in sexual desire scores among women who discontinued their medication. Reports of lower sexual desire and it’s maladaptive effects on sexual wellbeing and relationship quality pose reasons for interrupting hormonal contraception among women.
Let’s keep in mind however, that research is still little. This means that no holistic conclusion exists in determining one pattern of relationship among womens population. Especially there is no clarity on whether these complaints stem from the hormonal nature of the contraceptives.
Author’s Note: Following personal experiences I have decided to start a hormonal contraception treatment very soon, more specifically the hormonal intrauterine device. I felt obliged to read about all the possible methods and effects, even the negative ones just to be sure that I am making the right choice. I decided to report some of the findings I encountered but this is not in any way trying to place this type of contraceptive above others. In any case, you should extensively talk with your gynecologist for what suits you best and for further information as well.
The vaginal ring (NuvaRing) for contraception
A new intravaginal hormonal contraceptive ring (Nuvaring) was recently introduced. This contraceptive device consists of a flexible ring made of ethylene vinyl-acetate copolymers and magnesium stearate. In plain words it is made mostly from plastic.
Because of the position of the ring in the vagina during sexual intercourse, an influence on sexual activity of the users and their partners was observed.
In a study, they observed a significant reduction in anxiety relating to sexual activity, both in the women and their partners, in both groups using contraception compared to the control group. Also, a significant increase in the frequency of sexual intercourse, pleasure and satisfaction, complicity, sexual interest and intensity of orgasm was observed in both groups. There was also improvement in sexual function in the partners of the two groups using contraception. The positive effects are similar to previous studies, stressing the strong effect of psychological reassurance resulting from use of very effective contraception methods. That is the reason why sexual function among women and their partners has increased as well.
Note: The NuvaRing® does not protect against STI.
In general user satisfaction and preferences vary, with women following the use of the ring to being very satisfied, and at the same time women using the oral method claiming that they prefer it over the ring. In general, young women prefer the ring rather than the patch or the oral contraceptives but that is a recent finding. The ring is a relatively new method of hormonal contraception and therefore not many young women knew about it nor was it chosen by families very frequently.
What does the European Society of Sexual Medicine have to say?
The effects of hormonal contraceptives on sexual function have not been well studied and remain controversial [5,6]. Evidence that exists indicates that a minority of women experience a change in sexual functioning with regard to general sexual response, desire, lubrication, orgasm, and relationship satisfaction. The pathophysiological mechanisms leading to reported sexual difficulties such as reduced desire and vulvovaginal atrophy remain unclear. Insufficient evidence is available on the correlation between hormonal contraceptives and pelvic floor function and urological symptoms. In general, a whole lot more research is needed to conclude on topics concerning contraceptive methods, whichever are these. Mostly we can conclude that contraceptive methods improve sexual function because of the reassurance they offer to women that make them feel more pleasure, instead of anxiety.
Clinical Implications of Hormonal Contraceptives from Professionals: A careful baseline psychological, sexual, and relational assessment is necessary for the health care provider to evaluate eventual effects of hormonal contraceptives at follow-up.
Strengths & Limitations that can be Drawn: All studies have been evaluated by a panel of experts who have provided recommendations for clinical practice.
Additional Sources:
- The Pill : Combined Pill / Oral Contraceptive Pill https://www.fpv.org.au/for-you/contraception/daily-contraceptive-pills/contraceptive-pill
- Contraceptive Vaginal Ring https://www.brook.org.uk/your-life/contraceptive-vaginal-ring/
References
[1] Current issues and available options in combined hormonal contraception Johannes Bitzera,⁎, James A. Simonb
[2] Maurizio Guida, Attilio Di Spiezio Sardo, Silvia Bramante, Stefania Sparice, Giuseppe Acunzo, Giovanni Antonio Tommaselli, Costantino Di Carlo, Massimiliano Pellicano, Elena Greco, Carmine Nappi, Effects of two types of hormonal contraception—oral versus intravaginal—on the sexual life of women and their partners, Human Reproduction, Volume 20, Issue 4, April 2005, Pages 1100–1106, https://doi-org.eur.idm.oclc.org/10.1093/humrep/deh686
[3] Johannes Bitzer (2012) The vaginal ring (NuvaRing®) for contraception in adolescent women, Gynecological Endocrinology, 28:2, 125-129, DOI: 10.3109/09513590.2011.579665
[4] Intravaginal oestrogen and progestin administration: advantages and disadvantages Ettore Cicinelli* MD Professor 4th Department of Obstetrics and Gynecology, University of Bari, Policlinico, Piazza Giulio Cesare, 70124 Bari, Italy
[5] Lew-Starowicz M, Luria M, et al. Hormonal Contraception and Female Sexuality: Position Statements from the European Society of Sexual Medicine (ESSM). J Sex Med 2019;16:1681e1695.
[6] Hormonal Contraception and Female Sexuality: Position Statements from the European Society of Sexual Medicine (ESSM) Stephanie Both, PhD,1 Michal Lew-Starowicz, MD, PhD,2 Mijal Luria, MD,3 Gideon Sartorius, MD,4,5 Elisa Maseroli, MD,6 Francesca Tripodi, PsyD,7 Lior Lowenstein, MD,8,9 Rossella E. Nappi, MD, PhD,10 Giovanni Corona, MD, PhD,11 Yacov Reisman, MD, PhD,12 and Linda Vignozzi, MD, PhD6
[7] Kaunitz, A. M. (2016). Patient education: Hormonal methods of birth control (beyond the basics). Beschikbaar op https://www. uptodate. com/contents/hormonal-methods-of-birth-control-beyondthe-basics.
[8]]Toffol, E., Heikinheimo, O., Koponen, P., Luoto, R., & Partonen, T. A. (2011). Hormonal contraception and mental health: results of a population-based study. Human reproduction, 26(11), 3085-3093.
[9]Toffol, E., Heikinheimo, O., Koponen, P., Luoto, R., & Partonen, T. (2012). Further evidence for lack of negative associations between hormonal contraception and mental health. Contraception, 86(5), 470-480.
[10] Skovlund, C. W., Mørch, L. S., Kessing, L. V., Lange, T., & Lidegaard, Ø. (2018). Association of hormonal contraception with suicide attempts and suicides. American Journal of Psychiatry, 175(4), 336-342.
[11] Skovlund, C. W., Mørch, L. S., Kessing, L. V., & Lidegaard, Ø. (2016). Association of hormonal contraception with depression. JAMA psychiatry, 73(11), 1154-1162.