by Bethany Ao, The Philadelphia Inquirer

Credit: CC0 Public Domain

When Sophia DuRose was 19, her primary physician prescribed her a birth control pill to help regulate her periods.

But soon after DuRose, now a junior at the University of Pennsylvania, began taking the pill, she noticed that her mood changed drastically.

"I just felt this crushing apathy," she said. "I felt like I wasn't enjoying the things I normally enjoy as much as I used to. And I felt like the things that should've made me sad, I was just too drained to care about."

Like many other women who experience side effects from oral contraceptives—which may include decreased libido, nausea, migraines, weight gain and mood changes—DuRose began wondering whether there was a better option for her.

According to the U.S. Centers for Disease Control and Prevention, nearly 6 million women in the United States use oral contraceptives, making it one of the most popular birth control methods. But oral contraceptive use among women ages 15-44 dropped from 15.9% between 2011 and 2015 to 13.9% between 2015 and 2017, while other methods of birth control, such as female sterilization, intrauterine devices (IUDs) and contraceptive implants became more widespread. Male sterilization, equally effective and less invasive, is used as a contraceptive by only about a third of married or in-union women ages 15 to 45, according to the United Nations.

In a 2013 National Health Statistics Report published by the CDC, 62.9% of women who stopped using oral contraceptives did so because of side effects.

It is common to hear about the pill's negative mood effects on social media websites such as Reddit and in Facebook groups. But studies actually point to the opposite: Most women on hormonal birth control experience no effect or a beneficial effect on mood.

However, a 2016 review of existing scientific literature on hormonal birth control and mood pointed out there is a lack of research in this area, and that negative mood effects are measured differently in every study. Often, researchers lump different types of contraceptives together in studies, when each contain different levels of hormones.

What's perhaps more concerning is that this lack of knowledge extends to how birth control affects developing adolescent brains.

One of the largest studies to date on birth control's effects on mental health was conducted by researchers at the University of Copenhagen in 2016. Scientists found that among more than 1 million Danish women, those using hormonal contraception were more likely to be prescribed antidepressants for the first time in subsequent months and years. But experts have pointed out that the study does not account for life changes, making it impossible to know whether it's hormonal contraception driving that risk.

"It's somewhat remarkable that the pill has been on the market for half a century, but its effects on the brain are poorly studied and not understood," said Michael Lipton, a neuroradiologist at Albert Einstein College of Medicine in New York. Lipton studies how oral contraceptives affect the hypothalamus, a region of the brain that is key to controlling body temperature, emotions, sex drive, sleep cycles, and appetite.

In a study presented at the 2019 annual meeting of the Radiological Society of North America, Lipton found that women who take a combination pill containing both progestin and estrogen have a smaller hypothalamus volume.

"We haven't shown or proven that the pill causes this," Lipton said. "But the finding is significant. However, it's not necessarily harmful or surprising."

Lipton said that the hypothalamus difference is about 6% between women who take oral contraceptives and women who do not, a noticeable contrast in the small brain structure.

Lipton also found that smaller hypothalamus volume was associated with feelings of anger and depressive symptoms, but stressed that this finding was preliminary.

"Neurons in the brain can grow or develop more complexity due to things like progesterone," he said. "If you have something that's interfering with those hormones, you might see an effect on tissue volume."

Rachael Polis, a pediatric and adolescent gynecologist for Crozer-Keystone Health System, said that she screens all her patients for depression before prescribing birth control. It's part of "sorting out what is safe for a patient to take," she said. When a patient has preexisting mental health issues, Polis often works with their psychiatrist to pick a contraceptive method that works best for them. For example, a patient looking for a hormone-free option can get the Paragard, a copper IUD that lasts for as long as 12 years.

"I always tell patients that birth control is not one size fits all," she said. "But we will find something that works for her. Sometimes it's a little bit of trial and error."

Polis said that depressive moods are a potential side effect for all hormonal birth control methods. She tells patients to pay attention to how they're feeling, and assesses whether there are other events going on in their lives that can affect their mood, such as a move or a divorce. And she always stresses that what doesn't work for one patient may be great for someone else.

"Sometimes, moms will interject and say that their daughter can't use a certain birth control because they had a negative experience with it," Polis said. "But I just explain that everyone is different."

C.W. Kennedy has tried 15 types of birth control pills over the years through various studies in the area. Kennedy began working with researchers when she first moved to Philadelphia 14 years ago because she didn't have health insurance.

In 2017, Kennedy, 35, stopped taking the pill when she started trying to conceive with her husband. After she finished breastfeeding her daughter, Kennedy started taking the pill she was on before her pregnancy, only to find that her hair fell out in clumps and her mood changed.

"I was severely depressed within a week," Kennedy said. "It was weird because there were two parts of my brain—one that was really sad and depressed, and the other was like, 'That's not really you.'"

She dealt with the side effects for a few months until her insurance switched her prescription without explanation. Her depression and hair loss stopped soon afterward.

"I learned that some birth controls are right for some people, some are not," Kennedy said. "I'd notice minor things from doing each study, like this one definitely made me feel different than that other one. If you're willing to try a bunch of different ones, you might find one that works with your body chemistry."

When DuRose was taking birth control pills, her mood shift was noticeable to those around her; her former roommate even pulled her aside to express concern. Eventually, DuRose went online to search for information. She studied the product pages of the pills she was taking, reading the long list of side effects.

"I wanted to know whether the pill was making me feel this way," said DuRose, who wrote an op-ed for the Daily Pennsylvanian about her experience with birth control. "I wanted to feel better about this necessary part of my life, and I was also angry that I didn't have enough information about this necessary part of my life."

DuRose tried two more brands of pills before switching over to a hormonal IUD—which releases progestin that is localized to the uterus, instead of throughout the body—after hearing about it from a friend at work. She said that although she experienced pain right after the insertion process, she felt much better mentally in the weeks following.

DuRose appreciates how open women have become about their experiences with birth control.

"It's good that it's not viewed as uncomfortable as before," DuRose said. "When I told my mom that it was my co-worker who told me about her copper IUD, my mom was like, 'When I was 20, I never would have talked about that in my work space.'"

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