Transcription
If you want to understand how many young women end up on psychiatric medications, you have to look at where it often starts. Not with trauma, not with mental illness, but with hormonal birth control and a side effect that no one was ever warned about. Birth control medications are one of the most common gateway drugs into the psychiatric system for young women. And I see this pattern over and over again. A young woman starts the pill or the IUD and then months later she becomes anxious, irritable, or depressed, and neither she or her doctor recognize the real cause. Instead, she's misdiagnosed with a mental disorder and placed on an unnecessary psych med. All the while, the hormonal contraceptive continues to destabilize her mood. Now, this is how a medication cascade begins. And so, today we're going to talk about the research describing the mental health side effects of hormonal contraception and how to recognize them.
And for those of you who don't know me, I'm Dr. Yseph Wurring, a board-certified psychiatrist who used to study side effects at the FDA. Now, to start with some context, hormonal contraception is one of the most commonly prescribed classes of medications in the US, and around 80% of women will use it at some point in their lives. Also, increasingly, it's not being prescribed just for pregnancy prevention, but it's also being used for things like painful periods or acne, sometimes in young girls as old as 12. But the worst thing about all of this is that often at the point of prescribing, women are warned about only the physical side effects, things like nausea and headaches. And few of them are told that hormonal contraception can affect mood, anxiety, libido, or even overall mental well-being. Or sometimes it's even worse than that. They're told that there's no link between these medications and depression, or they're told incorrect things like the IUD, which is an implantable contraception that sits in the uterus, has no mood effects because it's just acting locally in the uterus. Unfortunately, this is all wrong and it can lead women to developing serious mood effects which go unrecognized, sometimes for years, which is exactly what happened to Katie Russell, who was put on hormonal contraceptives for painful periods as a teen, only to become emotionally volatile to the point that she alienated all of her friends and her boyfriend, as this headline crudely put it, started calling her a 24/7. Thankfully, she was able to recognize this problem and she recovered when she came off.
Now, because there's some people out there who still like to deny this link between hormonal contraception and mood problems, I want to start off this presentation by talking about what we already know, and that is that depression and mood changes are already recognized side effects in the labels of the most commonly prescribed contraceptives in the US. This means that both the FDA and drug companies already recognize this as side effects. For example, the Marina, which is the intrauterine device, which is extremely common in the US. According to their labels, in their clinical trials that looked at over 5,000 patients, 6.4% of them experienced depression as an adverse reaction. Or if we look at the oral contraceptive pill, YAS, in the warnings and precautions, which is the section of the label which is reserved for the most serious side effects of a drug, they list depression in there.
Now, you might be thinking, well, you know, 6.4% 4% of people having problems. That doesn't seem like that much. But I want you to know that these trials are often underestimating how frequently these problems are occurring because they're excluding the very group that is actually the most sensitive to these mood effects and that is adolescents. So I want to shift focus to another study now that looked at how these drugs performed in real world populations that also included teens. Now this study was a Danish study by Scolland and colleagues and was published in 2016 and the Danes I just have to tell you they have excellent data. All of the healthcare goes through one unified system. So they they know the diagnosis and they also know the prescriptions that are given and they used their excellent uh administrative reporting on this to follow over 1 million girls and women aged 15 to 34 for 14 years using this national registry. And these researchers tracked when hormonal contraception was started, when anti-depressants were prescribed, and when depression diagnoses were given. And they were also able to collect data like their age, their education, their weight, and also their prior psychiatric history. And that last one's really important because when you're looking at population level data like this, you need to look at whether they already had psychiatric problems because you want to rule out the idea that maybe people who have psychiatric problems are just they just take the pill more often and we want to make sure that we don't miss that confounding variable. So they collected all of that so they could control for that as well and they found three very surprising findings.
Now, the first thing that they found was that the problems weren't associated with just the oral contraceptive pill. In fact, all hormonal birth control methods increase the risks of getting on an anti-depressant or becoming depressed. And that's what we're seeing in this graphic here. So, on the y-axis here, you have the risk ratio. This is the number of times more likely it was to end up on anti-depressants. For instance, this 2.0 means a doubling risk here. And then on the y-axis you have the age. And this shows how this effect changed over um depending on what age cohort you are. Just off the top you can see 15 to 19%. The risk here. Gosh, it's it's pretty much double compared to someone who is age 25 to 29. So there's a doubling of risk in this younger cohort compared to these older cohorts here. And what I want to bring your attention to is what the worst hormonal contraceptives were. Now, this top line here is actually the IUD that uses progesterone. And so, this is the device like the Marina, which is the most common IUD used in the US. And so, this has the highest risk here. Now, the second highest risk is actually the patch. And so, this is a patch that you wear on your skin and it secretes both um synthetic estrogens and progesterones. And then the third highest risk was the vaginal ring, which is a implantable ring that kind of sits near the cervix in the vagina that also has synthetic progesterones and estrogen. And then next we had the synthetic progesterone, oral contraceptive. And the lowest the lowest risk out of all of them was the combined oral contraceptive pill that has synthetic estrogen and progesterone.
Now, why might it be this way? Now, there's a couple theories. So firstly, it is quite widely recognized that it is the synthetic progesterones which appear to have more mood effects and that's because they act on the GABA system and when you mess with the GABA system you end up having more anxiety and more insomnia. And so this is a common thread that you'll see with um hormonal birth control that progesterone containing compounds tend to be worse. And so firstly, so the IUD, as I mentioned, this is progesterone. Uh, this is a synthetic progesterone only. But the other thing about the IUD is you don't cycle on and off this. They they put it into the uterus and then it stays there. And so you are constantly being hit with this hormonal effect, which is different from some of these other ones. The other thing that many people believe about the IUD because it is local there, they think that there's no systemic exposure. That is simply not true. We find systemic exposure with these hormonal contraceptives that aren't taken orally because they go straight into the bloodstream. And we're going to talk a little bit more about why that's important in a moment.
Now, the second one with the patch and also the implanted ring, you might think, why would that be so high? Well, it's actually high because they bypass the liver. So, when you orally consume a medication, the blood from the gut actually goes straight into the liver. They call it first pass metabolism and you start to already break down some of the drug. If you are absorbing the drug either through the uterine wall or through your skin or in the vagina, it goes straight into systemic circulation. And so that might be why you're having more side effects to these types of uh medications. And then finally with the bottom two, the uh combined oral contraceptive and the uh progesterine one, the progesterone one is higher because it's thought that the synthetic estrogens in there actually balance things out and it's it's never great to just be on a progesterone only pill.
So that was the first finding. The next finding was, you know, what we kind of talked about and that was that the risks were much higher in younger individuals. And this table over here shows by how much. And I'm just going to focus here on the IUD, which is the marina. So the relative risk overall for the entire population was 1.4. So that's a 40% increase in getting anti-depressants if you were on the IUD. Now, if we go over here to what happened in teenagers, that risk more than doubled. And this held true for all of them, whether it was the combined oral contraceptive, the progesterone only pill, the vaginal ring, or the transdermal patch. Why might this be the case? Well, in humans, our neurological system, our brains continue to adapt up into our mid to late 20s. And so, what that means is that drugs that cause neurological side effects, they generally tend to hit younger people more because we don't have a fully matured nervous system yet. And so, that's why we're seeing this.
And the third finding that was interesting was that the risk of getting diagnosed with depression or starting an anti-depressant seemed to peak within the first year. And so the first table up here we have the risk ratio for getting put on an anti-depressant. As you can see by uh months 2 to 3 up to 6 to 12, you're already up here at this 1.4. So 40% increase. And then things sort of taper down. On this next graphic you're seeing the time to first diagnosis. As you can see, it sort of steadily rises up to 3 to six months. Still quite high up to six to 12 months and then it starts to steadily go down. Now, I know these graphs are sort of peaking at around 3 to 6 monthsish, but that doesn't mean it takes that long for the mood effects to kick in because often times people may get depressed in the first month. They try and push through it for a couple of months and then they eventually decide to get on a medication or they get this diagnosis. But generally most people are impaired enough that by about 6 months and 6 to 12 months they are seeking help for this. Now you might be looking at this graph sort of tapering off at the end for both of them and think oh wow you know this means that if I get through the first you know 6 to 12 months I will be fine. No, what is probably happening based on other data that I've seen is that most of the people who have problems with the pill, they actually stop within the first year. And so that means that later on the risk of having problems looks lower. But that's just because all of people who would have had negative effects to it have already stopped it. And so that kind of pushes uh the the risk ratios down. And so if you were someone who never recognized that the drug was causing a problem and you've been on the pill for several years and you might be on several psychiatric medications, you shouldn't assume just because you've been on it for, you know, several years now that it's not causing a problem. It could be the actual reason why you're still having many psychiatric symptoms.
Okay. So now that we've gotten a sense of how these pills affect young girls and older women more, let's have a look at another study that examines what proportion of women stopped the pill and what were their reasons. Now this study was done by Sanders in 2001 in women who were over 18 and they followed 79 women who' started the oral combined contraceptive and they tracked what happened over time. Now remember the oral combined contraceptive was the one that was found to be the most tolerable in terms of like depression and starting a a anti-depressant. And here's what they found. They found that by one year only 38% of women were still taking the pill. 47% had discontinued it. That's essentially half of them and 14% had switched to another pill. And when researchers compared the women who continued versus the women who stopped, the strongest predictors of discontinuing the pill were number one emotional side effects. This was the number one reason that women decided to stop this pill. Now the second one was decreased sexual desire and the third was decreased sexual arousal. This is also underrecognized and a very common reason why women want to come off this. And the fourth thing was worsening PMS symptoms. It turns out that physical side effects like headaches, nausea, or weight gain were much weaker predictors of whether women wanted to stop this medication. Despite these being the side effects that most women are told about by their doctors while all of the mood and the sexual stuff is ignored probably because they don't have enough time in the visits and no one wants to talk about sexual side effects with like a 16, 17, 18year-old girl. So that stuff is ignored even though that's the stuff that women find the most impactful. And obviously this study tells us something really important because if a side effect is causing nearly half of the users to abandon a medication within a year, this is not a minor effect. This is a major effect of the drug.
Now you might be asking yourself, okay, this is really interesting. But why is this happening? What is it about the pills that is doing this? And we actually have a really cool study that looks at what's happening in the brains of women who are having these side effects. So in 2013, Gingell and colleagues recruited 34 women who believed they had experienced a negative mood side effect to the oral contraceptive pill. And then they randomized them into a double blind study. So half of them got oral contraceptive pill again and the other half got placebo again. And they did this for one cycle. Now neither the participants or the researchers knew who received what. And after the researchers started the study, they tracked the mood effects at the end of the first cycle. And what they found was that women who were on the pill had much more mood swings and fatigue compared to those on placebo. Now that's hardly, you know, a dramatic finding because, you know, this was already a selected population for women who had had bad side effects, bad mood side effects from this before. But the next thing they did was really interesting. They actually performed functional MRI scans on all of the women in the study to look at their brain and the physiological changes that happened in there while they were on the medication or placebo. Now, this is really unusual. We we never get this data. In fact, I've been looking at uh SSRI side effects for a really long time. No one has ever done a brain scan study like this where we could say, "Oh, the people who are becoming more suicidal on the SSRIs, it's because of this brain region." So we we don't have that and but they have it for this and here is what they found. They found significant changes in brain activation in the pill group specifically in the anterior insula and the prefrontal cortex. Now both of these regions are deeply involved in emotional regulation. And what was even more compelling than that was that the magnitude of the changes in brain activity in these region actually correlated with the severity of the mood symptoms. So this essentially strongly supports the idea that hormonal altering medications are brain active drugs that can induce depression by directly altering brain activity in key emotional control regions. And to add to this, when I look at the broader research on this, many researchers believe that also the synthetic progesterones interact differently with brain receptors. And there is evidence to suggest that they impact GABA signaling, which I already discussed, but also the serotonin system, and that they may cause a whole range of different effects in the brain. And while we've been focusing just on depression, I want to go a little bit broader because we actually have case reports linking oral contraceptives to a whole host of different psychiatric problems. For instance, we have this case report that linked hormonal contraceptive to a woman experiencing mania. Or this case report that linked psychosis to an 11year-old girl who was put on oral contraceptive. Or even this case report here that linked the IUD uh placement with the onset of an eating disorder, which was bulimia. So this suggests when these mood altering effects hit genetically vulnerable women, it may extend beyond depression and moodiness, but also into a whole host of other psychiatric problems.
And so to bring this video to a close, I want to give you a few takeaways which are important. Firstly, these medications can cause serious mood effects and quite commonly remember the Sanders study before 50% of women stopped within a year and the number one reason was mood effects. So do not let anyone tell you otherwise or tell you that you're just moody or you're just an adolescent, you're going through a phase where you just developed some mental illness out of nowhere. If you developed new mental health symptoms starting within a year of the oral contraceptive medication and it is not in proportion to stressful things in your life, you should consider stopping this medication. No taper is required for these. You can just stop them and you should just see how you feel. But give it at least 3 months for things to normalize before you judge whether the intervention has helped or not.
Second thing I want you to know is the groups at the highest risk of side effects from these meds are teenagers, those with pre-existing mental health conditions, and those who are using continuous delivery methods of um these synthetic hormones. So that's the IUD that essentially just sits in your uterus the whole time. Other medications that are worse are implants or the vaginal ring because that bypasses your liver because you're not taking it orally and so it's hitting your systemic circulation directly. And then finally, those who are on progesterone only medications, remember progesterine only without the synthetic estrogen to balance it out seems to be more mood destabilizing. Uh the good news is that older women, I'm going to say over 30, um typically those who may be using uh hormones for menopause and HRT, they appear to be at lower risk for this.
Now, let's talk quickly about alternatives because, you know, it's one thing just to bash a medication where people are looking for help. So, let's see if we can give you something else. So, if you're taking um hormonal contraceptives for painful periods, make sure you've tried other approaches first. For instance, we have good randomized control studies like this one right here, showing that dietary modification, particularly targeting high sugar and unhealthy highfat foods and sugar sweetened beverages, like if you remove those, you can drastically improve your symptoms. We also have randomized control trials showing that exercise can reduce pain likely through its anti-inflammatory effects. Again, this is not speculative and theories or based on a patient or two that I've seen. These are randomized control trials that have good evidence behind it. So, please try those approaches.
Now, if you're using it for acne, I'm going to say just just don't try try something else first. And I'm and also do not try other acne medications like isotininoonean or Accutane. This is a dermatology drug that's commonly given for this. You should try dietary interventions. Again, for this condition, we have randomized control trials that show that dietary modification, particularly lowering sugar consumption, can lead to great clinical improvement. And finally, if you're using it for contraception, there are other options out there. For instance, there's things like condoms, or if you don't want to use condoms, you can use the copper IUD, which is non hormonal. Finally, there are things like the fertility awareness or the calendarbased method which may not be as foolproof if you do not do it consistently and track your cycle carefully. And so there's always a risk with that. But the copper IUD is a great option if you want a set it and forget it option.
Anyway, that's it for me today. If you like what I do, please consider supporting me by subscribing to my channel and sharing my content. And you know, just a moment ago, I did mention isotininoan. I said it was worse than this drug and that's true. And so if you want to understand more about how a medication like this can completely derail your life, you're not going to want to miss this next video where I do an interview with a man who lost his son because of this.