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Mood symptoms (irritability, moodiness, anxiety) in people with PMS and PMDD (premenstrual dysphoric disorder) are thought to be caused by changes in hormone levels
Some people find that hormonal birth control helps their mood, others find it makes their mood worse
Yaz is the only hormonal birth control that has been FDA-approved specifically for preventing pregnancy and treating PMS and PMDD
The difference between PMS and PMDD
In both PMS and PMDD (premenstrual dysphoric disorder), people experience mood and/or physical symptoms in the luteal (premenstrual) phase of the menstrual cycle, i.e. the few days before bleeding begins (1). The symptoms go away once bleeding starts. People with PMS have fewer, milder symptoms, while those with PMDD have severe symptoms that impact their day to day activities. The mood symptoms—such as irritability, moodiness, or anxiety—are thought to be due to changing hormone levels in the luteal phase of the menstrual cycle, the time after ovulation and before the period starts (2).
Hormonal fluctuations can affect mood
People who have been diagnosed with PMS or PMDD seem to be sensitive to fluctuations in hormones like progesterone and estrogen, which are produced by the ovaries and are also present in synthetic form in hormonal birth control (2,3).
These ovarian hormones are called “neuroactive steroids” because they affect the brain and therefore can affect mood (4,5).
No ovulation = no cyclical mood symptoms
People with PMDD have mood symptoms during normal menstrual cycles, but during an anovulatory cycle (when ovulation does not occur) levels of hormones do not fluctuate, and the PMDD symptoms disappear (3).
Most hormonal birth control prevents ovulation
Hormonal birth control pills prevent ovulation, so in theory, they can improve PMS/PMDD symptoms by preventing ovulation-related hormone changes.
Sugar pills cause a sudden drop in hormones—which sometimes means a drop in mood
Most people who take the pill have a hormone-free interval (a week or so of “sugar pills”). This causes a sudden drop in hormones from the active pill weeks to the sugar pill week. People who are sensitive to sudden fluctuations in hormone levels may experience worse symptoms during the sugar pill week.
Hormonal birth control can affect mood
Some people report relief from mood symptoms when they take hormonal birth control, but others report that hormonal birth control makes their symptoms worse (6). In fact, mood side effects are sometimes cited as a reason why people stop using it (7,8).
In one study, 16.3% of women reported that the birth control pill worsened their mood premenstrually, compared to 12.3% of women who said that the pill improved their mood (9).
A study in 2016 made news when it reported that hormonal birth control use is associated with depression (10). The study used data from patient medical charts, and found that women who filled prescriptions for hormonal birth control were more likely to later fill prescriptions for antidepressants or have a diagnosis of depression recorded in their medical charts. However, because it was a correlational study based on medical chart data, it doesn’t establish that the birth control necessarily caused the antidepressant use or depression diagnosis.
Another study of women with severe PMS found that the women who used hormonal birth control had less severe premenstrual depression, anger and irritability, compared with those who were not using hormonal birth control (11).
Do birth control pills help with PMS/PMDD, or make it worse?
Which birth control pill is best for people with PMS or PMDD?
Here’s how different types of hormonal contraception affect mood, in people with PMS or PMDD.
How Yaz affects people with PMS or PMDD
Yaz is the only hormonal birth control pill that’s FDA approved to treat PMDD.
Yaz follows a 24/4 dosing scheme, so there are 24 active hormone pills and 4 hormone-free “sugar pills.” Yaz is monophasic, meaning that the hormone dose stays the same across the 24 days of active pills.
Here’s what the research says about Yaz and mood:
Yaz worked better than a placebo in improving PMDD mood symptoms (12).
In women with PMDD, Yaz reduced premenstrual negative emotions and food cravings (13, 14).
Yaz improved premenstrual symptoms affecting work, relationships, and social activities in women with PMDD, compared to a placebo (15).
One review of Yaz studies found that although Yaz reduced premenstrual symptoms in women with PMDD, a high number of women who took a placebo pill also reported an improvement in their symptoms (16).
Out of all of the hormonal birth control methods, Yaz has the most evidence supporting its use for improving PMS / PMDD symptoms.
How 21/7 monophasic and triphasic pills (Ortho-Cept, Nordette, Yasmin, Ocella) affect people with PMS and PMDD
Many monophasic pills (hormone levels stay the same throughout the cycle) are used on a 21/7 schedule—21 days of hormone pills, followed by 7 days of sugar pills.
Here’s what the research says about 21/7 pills and mood:
Several open-label studies (participants knew they were receiving Yasmin and not a placebo) found Yasmin to be effective for minor PMS symptoms (17,18).
Women who took Yasmin for three months had significant improvement in PMS symptoms compared to calcium (which slightly improved symptoms) and placebo pills (which improved symptoms very little) (19).
For women with more severe PMDD, Yasmin provided a greater improvement in mood swings, anger, irritability, sensitivity, crying, anxiety, and depressed mood, than a placebo pill (20). At the same time, 43% of women in this study who took a placebo pill also experienced symptom improvement.
One study in women with PMS compared monophasic (Ortho-Cept, Levlen) and a triphasic pill (Trivora), finding that the monophasic Ortho-Cept significantly decreased tension and irritability symptoms compared with Levlen or Trivora (21).
Among the 21/7 pills, research suggests that Yasmin may improve PMS / PMDD symptoms.
How extended-cycle pills (Amethyst, Lybrel, Seasonique, LoSeasonique) affect people with PMS or PMDD
With extended-cycle oral contraceptives like Amethyst or Lybrel, active hormone pills are taken daily, with a hormone-free interval (and therefore a withdrawal bleed) only 1-4 times per year.
Here’s what the research says about extended-cycle birth control pills and mood:
A review of four studies of Amethyst/Lybrel taken continuously for at least three months suggests that extended-cycle oral contraceptives of this type may reduce symptoms of PMDD and PMS (22).
Women with PMDD who took this type of pill for four cycles (four 28 day pill packs, with no hormone-free interval) had an improvement in premenstrual depressive symptoms, anger, irritability, and physical symptoms (such as headaches, breast tenderness, bloating, and joint pain) compared to women in the same study who took a placebo (23).
While more research is needed, the existing studies suggest that extended-cycle pills may be effective in reducing PMS/PMDD symptoms.
What causes mood changes: the hormones in birth control, or the length of time that placebo pills are taken?
It is difficult to disentangle the effects of the different hormones versus the length of the time when sugar or placebo pills are taken.
One study explored the role of hormone-free interval in premenstrual mood changes, by keeping the hormone types and amounts constant while varying the time without hormones l (24).
The researchers tested Yaz taken in a 21/7 schedule or a continuous schedule (no hormone-free break) compared with a placebo pill. They found no difference in effect on mood symptoms between the different options.
This shows that the benefits of hormonal birth control on mood in PMS or PMDD are complex, and may vary considerably from one person to another.
How hormonal IUDs (Mirena) affect people with PMS or PMDD
There have been very few studies on hormonal IUD impact on premenstrual mood symptoms, and none examining use of hormonal IUDs specifically in women with PMS / PMDD. More research is needed.
Here’s what the research says about the Mirena IUD and mood:
There have also been reports of women discontinuing the levonorgestrel IUD due to mood-related side effects (25)
Studies generally do not suggest associations between the levonorgestrel IUD and depression in healthy women (26).
In one study, women using the levonorgestrel IUD were found to be more physically responsive to stress, compared to people taking birth control pills or no hormonal birth control (27). This doesn’t mean they found things to be more stressful or had a greater experience of stress. While the study did not focus on women with PMS/PMDD, it suggests that the hormonal IUD may make women more physiologically responsive to stress, both in the moment and long term.
Placebo-controlled studies of hormonal IUD impact on mood are needed, particularly in women with PMS/PMDD.
How the birth control shot (Depo-Provera) affects people with PMS or PMDD
Depo Provera is a shot administered every three months, which prevents ovulation and thickens cervical mucus to prevent pregnancy.
Here’s what the research says about Depo-Provera and mood:
There have been mixed reports of mood worsening or remaining unchanged with Depo-Provera, but these studies did not focus specifically on women with PMS/PMDD (28,29).
Progestin-only birth control (Depo-Provera shot, Mirena IUD) have been linked with increased risk of depression in the press, but the research does not show a clear link between progestin-only methods and depressive symptoms in healthy women (26).
There have not been studies on how the Depo shot affects premenstrual mood symptoms in people with PMS/PMDD. More research is needed.
How the patch (Ortho Evra, Xulane) affects mood in people with PMS or PMDD
The contraceptive patch releases hormones through the skin for three weeks, followed by a hormone-free week in which a withdrawal bleed occurs. The synthetic hormones in the patch prevent ovulation.
Here’s what the research says about the patch and mood:
Adolescent women reported improvement of premenstrual mood symptoms on the patch, but this study was open-label, meaning that participants knew that they were receiving an active patch and not a placebo (30).
There are no studies on the patch and mood symptoms specifically in women with PMS/PMDD.
There have not been any studies on how the birth control patch affects premenstrual mood symptoms in people with PMS/PMDD. More research is needed.
How the ring (NuvaRing) affects mood in people with PMS or PMDD
The NuvaRing is a hormonal vaginal ring that is inserted for three weeks and removed for one week, to prevent ovulation and pregnancy.
Here’s what the research says about the ring and mood:
In one study, women who were starting the ring experienced a reduction in PMS symptoms, but these women did not have severe or diagnosed PMS (31).
There are no studies specifically on the contraceptive vaginal ring’s effect on premenstrual symptoms in women with PMS or PMDD.
There haven’t been sufficient studies to determine how the ring affects mood in women with PMS or PMDD. More research is needed.
What to do if you have PMS or PMDD and are considering hormonal birth control
1. Communicate with your healthcare provider
Let your provider know that you experience PMS or PMDD symptoms. A record of your symptoms can be helpful—tracking in Clue is an option.
The only hormonal birth control method that has been FDA-approved specifically for preventing pregnancy and treating PMS or PMDD is Yaz. That means your healthcare provider may prescribe this pill first.
2. If symptoms worsen, let your provider know
Evidence suggests that triphasic (Ortho Tri-Cyclen, Tri Sprintec) or biphasic pills (Mircette, Azurette) may be more likely to affect mood symptoms than monophasic pills (Ortho Cyclen, Sprintec). This is due to the hormonal fluctuations that occur with the tri- and biphasic preparations.
If you try a tri or biphasic pill and notice after several cycles that your premenstrual symptoms are worsening, let your healthcare provider know.
3. Track your symptoms daily
If you have PMS or PMDD, professionals recommend tracking your symptoms daily using a tool such as the Daily Record of Severity of Problems (32, 33).
Symptom tracking is especially important when you are starting or stopping a new medication.
Tracking gives you and your healthcare providers clear data on patterns in your symptoms. Maybe you start taking the pill, and in the following two menstrual cycles you track a significant worsening of your mood symptoms. That’s important for you and your provider to know.
4. Be aware of interactions with other medications
Treatment options may also be influenced by what other medications you are taking, or your mental health history. If you’re taking an antidepressant to manage your PMS or PMDD symptoms, this could influence what your provider prescribes.
If you’ve had major depression in the past (whether you currently have PMS or PMDD or not) you may be more at risk for contraceptive-induced mood changes (9).
5. Seek help if you experience thoughts of self-harm or suicide
If you are experiencing severe symptoms such as suicidal ideation or thoughts of self-harm when starting or stopping a hormonal birth control method, let your healthcare provider know right away.
Remember, every body is different
There is relatively little high-quality research on how hormonal birth control affects premenstrual mood symptoms in women with PMS or PMDD.
Some people may be more sensitive to hormonal medications, or hormone fluctuations, than others. Even though studies have found a particular result, it doesn’t mean that it will reflect your own experience. This is why it's important to track your symptoms and stay in regular communication with your healthcare provider.
Above all, trust yourself
If you suspect a symptom may be related to your birth control method, get it checked out.
(The research cited in this article was done on cisgender women, but it should also be relevant for binary and nonbinary transgender people who were assigned female at birth, who have not had any gender-affirming hormone therapy).
Originally published July 31, 2019.
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