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Hormonal changes may be a factor in the risk for depression
Hormonal birth control may increase the risk for being diagnosed with depression, but effects on mood are mixed and vary by birth control type
For people who have depression, hormonal birth control is not associated with worsening symptoms
What you may have heard
You may hear people say hormonal birth control negatively affected their mood, making them feel depressed, anxious, or irritable. You may also hear people say that hormonal birth control improved their mood, making them feel more calm or stable. Of course each person’s body—and brain—is unique and their response to hormonal birth control can be different.
Hormonal birth control comes in several forms, including the implant, the intrauterine device (IUD), the shot, the pill, the patch, and the ring. Progestin-only hormonal birth control contains just progestin (a synthetic form of the body’s naturally-occurring hormone, progesterone). Combined-hormonal birth control contains both progestin and a form of estrogen.
Several large studies have explored whether there is a connection between different types and formulations of hormonal birth control and changes in mood or mental health with some conflicting results.
A 2016 study of more than one million women in Denmark really brought the possible connection between birth control and mental health to mainstream attention (1). This study analyzed nationwide health records and showed that hormonal birth control users were more likely to be diagnosed with or treated for depression (1).
Two large studies in the United States and Finland showed something different. In these studies, people using hormonal birth control of any type reported fewer symptoms of depression and anxiety (2,3).
What does this mean when it comes to selecting a birth control type that’s right for you? Considering the effects that birth control could have on your mood or mental health is important. We will dive into what we know and what we don’t know about different methods of birth control and the impact they have on mood and mental health.
How hormones impact your mental health
There is reason to believe that hormones play a role in depression. Women are about twice as likely as men to have depression—a difference that begins during puberty (4). One small study showed that people with depression had lower estrogen levels during the follicular phase (the time when estrogen levels normally rise between the start of a period and ovulation) (5). Changes in estrogen levels may explain why some people experience depressive symptoms more frequently in the premenstrual phase, postpartum, and in perimenopause (6).
When a person uses hormonal birth control, it can change the natural level of hormones in their body and could possibly cause changes to their mental health.
Environmental and societal factors likely affect the risk for depression as well (7). A family history of mood or psychiatric disorders, adversities in childhood, stressful life events, and social isolation all make it more likely that someone will be diagnosed with major depression (4).
Why hormonal impact on mood is hard to measure
Studies on hormonal contraception and mood effects have had inconsistent results. Some of this inconsistency is likely because studies are designed and carried out differently and have different ways of measuring mood and mental health outcomes (8).
There are few randomized controlled trials on the subject, which involve taking a group of people and randomly assigning them to either take hormonal birth control or not. Most of the studies done on mood and hormonal birth control are based on groups of people who chose for themselves what type of birth control they wanted to use. This leaves open the possibility that the outcomes of the study aren’t related to the birth control itself, but to some other factor that would lead people to choose that method (9). Some studies try to account for personal, familial, or societal factors that can increase a person’s risk for depression, but it can be hard.
Research studies vary in how they measure mood and mental health outcomes. Some studies look at medical records to see if people using hormonal birth control were more likely to be diagnosed with depression or prescribed an antidepressant. Some studies have people complete surveys asking questions about symptoms of depression or anxiety and compare scores before and after hormonal birth control or between groups of birth control users. Other studies rely on the subjective experience of users and whether symptoms such as depression or mood swings are reported as side effects. These various outcomes can make it hard to compare studies.
Study results are often reported as the average for the group of participants, and do not take into account the experience of individuals. Even in a study that concludes that hormonal birth control does not affect mood, there will be small numbers of individuals in that study that have improvement or worsening of their mood (8).
Here’s what the research tells us about each birth control type
The implant is a progestin-only method of birth control. There is a single-rod implant containing the progestin etonogestrel, and a two-rod implant containing levonorgestrel (10).
In the large Danish study mentioned previously, current users of the implant were more likely to be prescribed antidepressants for the first time than people who weren’t currently using it, but the rate of depression diagnosis among implant users was not reported in the study (1). This study does not specify which implant people were using.
People using the etonogestrel implant in a large Swedish study were more likely to be prescribed an antidepressant, particularly for adolescents (11). The same study showed an increased risk for antidepressant prescription among people using levonorgestrel-only methods, which included both the hormonal IUD and implant (11).
In a study of people using the etonogestrel implant for up to two years, 14% reported mood swings and 7% reported depression that was attributed to the implant (12).
The key takeaway: The implant may increase the chance of being treated for depression, but more studies are needed to understand if implant users report mood changes during use.
The hormonal IUD is a progestin-only method containing levonorgestrel (10).
In the Danish study, current users of the hormonal IUD were more likely to be diagnosed with depression and prescribed antidepressants for the first time than people who weren't currently using it (1). The risk for being diagnosed with depression and prescribed an antidepressant was higher for adolescent hormonal IUD users than adults in the study (1).
The Swedish study showed an increased risk of being prescribed an antidepressant among people using a levonorgestrel-only birth control method, which included both the hormonal IUD and implant (11).
Conversely, a large Finnish study showed that people using the hormonal IUD were just as likely to have symptoms of depression or anxiety as people not using this method (3).
Two studies of people who received the hormonal IUD to treat heavy periods, showed scores on depression surveys either remained the same or improved, but this could be due to an improvement in quality of life when heavy periods become more manageable (13,14).
The key takeaway: The hormonal IUD may increase the chance of being diagnosed with or treated for depression, but does not appear to have a negative effect on mood when hormonal IUD users are asked to report symptoms.
There are several types of birth control shots available. All the studies mentioned in this section involve the progestin-only shot containing medroxyprogesterone acetate (10).
The Danish study showed current users of the shot were more likely to be prescribed antidepressants for the first time than people who weren’t currently using it, but the rate of depression diagnosis among shot users was not reported in the study (1). In the Swedish study, shot users were more likely to be prescribed an antidepressant (11).
A study of 183 people using the shot for up to three years showed that they were more likely to report depressive symptoms compared to people using another method of birth control or no method (15). People who stopped using the shot during the study reported depressive symptoms at higher rates, which subsided after stopping (15). It’s worth noting, however, that shot users in this study were also more likely to report depressive symptoms before starting the shot (15).
One study followed almost 400 users of the shot for a year (16). Among the 170 people who continued using the shot for a year, there was a decrease in depressive symptoms from the time they started it (16). Among the 218 people who stopped using depo during the year-long study, there was no change in depressive symptoms (16).
Adolescents using the shot do not appear to be at increased risk for depression based on three small studies (9).
In one two-year study, shot users were less likely to report mood swings compared to people not using hormonal contraception (17).
The key takeaway: The shot may increase the chance of being treated for depression, but results are mixed when people report mood symptoms while taking it—some people may have improved mood while others have worsened mood.
Combined oral contraceptives (COCs) are pills that contain both synthetic estrogen—usually in the form of ethinyl estradiol—and a progestin (10).
In the Danish study, current users of COCs were more likely to be diagnosed with depression and prescribed antidepressants for the first time than people who weren't currently using them (1).
The large Swedish study looked at the likelihood of being prescribed an antidepressant medication while taking different formulations of the birth control pill. It found that users aged 16-31 were more likely to be prescribed an antidepressant when taking birth control pills containing the combination ethinyl estradiol/lynestrenol and ethinyl estradiol/drospirenone (11). People using pills containing ethinyl estradiol/norethindrone, ethinyl estradiol/levonorgestrel, and ethinyl estradiol/desogestrel were less likely to be prescribed an antidepressant (11). People taking ethinyl estradiol/norgestimate were just as likely as non-users of hormonal birth control to be prescribed an antidepressant(11).
Several studies have found that birth control pills users are not more likely to report symptoms of depression (3,18,19), although one of these studies did show a decrease in general well-being among pill users (18). Another showed that people using birth control pills for reasons other than for birth control were more likely to experience depression (19).
One study found that COC users tracking daily mood had small increases in anxiety, irritability, and mood swings in the intermenstrual phase (roughly cycle days 5-22 of a 28-day cycle), but improvement in depression in the premenstrual phase (the seven days leading up to the start of the next period) compared to people on a placebo pill (20). At the end of the three-month study, there was no difference in depression scores between the birth control pill and placebo groups (20).
Some people may experience improvement in nervousness and mood swings while taking COCs (17), but people who have experienced negative mood effects while on birth control pills in the past may be more likely to experience depressed mood and mood swings (21).
Adolescents and the pill
Adolescents using COCs in the Danish study had a higher risk for being diagnosed with depression and prescribed an antidepressant than adults in the study (1).
Adolescents (age 16-19) in the study Finnish study were more likely than people not using hormonal birth control to be prescribed an antidepressant for every COC formulation they studied (11).
A study of adolescents in the U.S. who were currently or had ever used the pill showed an increased risk for ever having experienced depression, but no increased risk for current depression (22). But when other factors such as age, smoking, BMI, family socioeconomic status, and whether the adolescents were sexually active were considered along with the use of birth control pills, there was no increased risk for depression (22).
A small study where adolescents were randomly assigned to use COCs containing ethinyl estradiol/levonorgestrel or placebo for three months showed no difference in depression scores between the two groups at the end of the study (23).
The key takeaway: The pill may increase the chance of being diagnosed with or treated for depression, but the specific pill formulation may make a difference. Overall, it appears as though COCs do not have a harmful effect on mood reported by users, but this may vary between individuals.
The patch is a combined hormonal birth control containing ethinyl estradiol/norelgestromin (10). Very few studies on birth control and mental health specifically include the patch.
In the Danish study, current users of the patch were more likely to be diagnosed with depression and prescribed antidepressants for the first time than people who weren't currently using them (1). The risk for being diagnosed with depression and prescribed an antidepressant was higher for adolescent patch users than adults in the study (1).
The Swedish study showed the people using the patch containing were more likely to be prescribed an antidepressant than people not using hormonal birth control (11).
The key takeaway: The patch may increase the chance of being diagnosed with or treated for depression, but studies are needed to determine if patch users report mood changes during use.
The ring is a combined hormonal birth control containing ethinyl estradiol/etonogestrel (10). Few studies on birth control and mental health specifically include the ring.
In the Danish study, current users of the ring were more likely to be diagnosed with depression and prescribed antidepressants for the first time than people who weren't currently using them (1). The risk for being diagnosed with depression and prescribed an antidepressant was higher for adolescent ring users than adults in the study (1).
Studies have shown that ring users may be less likely than pill users to report depression, irritability, and mood swings as side effects (24).
The key takeaway: The ring may increase the chance of being diagnosed with or treated for depression, but more studies are needed to see if ring users report mood changes during use.
Mini-pills are progestin-only birth control pills. They may contain norethindrone, desogestrel, drospirenone, lynestrenol, or other forms of progestin (10).
In the Danish study, current users of the mini-pill were more likely to be diagnosed with depression and prescribed antidepressants for the first time than people who weren't currently using them (1). The risk for being diagnosed with depression and prescribed an antidepressant was higher for adolescent mini-pill users than adults in the study (1).
In the Swedish study, people age 16-31 taking norethindrone or lynestrenol mini-pills were just as likely as people not taking hormonal birth control to be prescribed an antidepressant, although adolescents (age 16-19) taking norethindrone mini-pills were more likely to be prescribed antidepressants (11). People taking the progestin-only pill containing desogestrel were more likely to be prescribed an antidepressant (11).
The key takeaway: The mini-pill may increase the chance of being diagnosed with or treated for depression, but the specific formulation may make a difference. Studies are needed to see if mini-pill users experience changes in their mood while using it.
What if you already have depression?
The U.S. Center for Disease Control (CDC) and the World Health Organization (WHO) guidelines put no restrictions on the use of any type of birth control for people who have depression (25,26). The use of combined hormonal birth control, the hormonal IUD, implant, and the shot is not associated with worsening of symptoms among people with depression or bipolar disorder (27,28). One study actually showed less depressive symptoms among combined hormonal birth control users compared to people not using hormonal methods (27).
There aren’t believed to be any interactions between SSRIs (selective serotonin reuptake inhibitors), which are commonly prescribed for depression, and hormonal contraception (29). The CDC puts no restriction on the use of any hormonal birth control for people who are taking SSRIs (25).
Other supplements and medications used for depression, such as tricyclic antidepressants, bupropion, and St. John’s Wort may interact with hormonal contraception (25,29).
It’s important to speak with your healthcare provider about what supplements and medications you are taking and whether there are possible interactions with hormonal birth control.
PMS and PMDD
COCs are a recommended treatment for premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) (30). Continuous COCs (not having any hormone-free days) may be a particularly good choice for people with PMDD to avoid fluctuations in hormones (31).
Postpartum mood disorders
More research is needed to better understand the impact of hormonal contraception on the risk for postpartum depression, postpartum anxiety, and other postpartum mood disorders. Breastfeeding may impact the type of hormonal birth control a person is prescribed, as well as their risk for postpartum depression regardless of birth control use.
A study of more than 16,000 people who had given birth two to eight months prior showed no relationship between reporting depressive symptoms and use of any birth control method (32).
One study showed no increased risk for a depression diagnosis among people who had given birth in the previous 12 months and were using the implant or ring, but these users were more likely to be prescribed an antidepressant than people not using a hormonal birth control method (33). Use of COCs did not change the risk for a depression diagnosis in the postpartum period (33). People using the mini-pill containing norethindrone and the hormonal IUD were less likely to have a postpartum depression diagnosis (33).
Two studies of people who received the shot shortly after giving birth showed no increase in depression based on self-reported surveys (34). However, these studies only followed shot users for up to three months after delivery, while postpartum depression can occur up to 12 months after delivery.
Choosing a method
Whether you are thinking about starting birth control or are already using a method, talk to your healthcare provider about any concerns you have about your mental health. Your healthcare provider can help you decide on the best birth control for you, or whether trying a new method might help.
Using Clue to track your emotions when you start a new birth control can help you identify if anything is changing.
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