Mood Swings, Depression, and CHCs

There is a common belief that CHCs adversely impact mood, but the published evidence is significantly flawed, [1] 1 and recent publications have been conflicting, either demonstrating a protective effect [2] or not, [3] report Shaalini Ramanadhan and Alison Edelman. [4] It is important to note that the study reporting an increased risk of depression in COC users had a risk estimate well below 2, which is considered by epidemiologists to be not significant. In those with existing depression, CHC use does not appear to worsen the condition. [5]

If patients do report an increase in depressive symptoms, moodiness, and other emotional states when on CHCs, respond with empathy. Discuss options with the patient like considering an empiric change to a lower dose formulation or CHC cessation. However, it is also important to identify when in a patient’s cycle these symptoms develop. If the symptoms appear just before the menses, then extended use of active pills may help to suppress or prevent cycle-related mood changes. [6]

For those who suffer from PMDD, all CHCs likely have the ability to suppress or reduce symptoms, and consideration should be given to extended dosing (eliminating the scheduled withdrawal week). The COC containing drospirenone/EE has an FDA indication for treatment of PMDD. A systematic review of drospirenone-containing pills for PMDD demonstrates that in the first 3 months of use, participants experienced less severe symptoms, but data were insufficient to determine a longer impact. [7] In addition, the use of placebo had a significant beneficial impact on symptoms. If you have any concern about your patient suffering from an underlying depressive or anxiety disorder, perform or refer for an explicit evaluation and treatment. Stopping CHC use is not adequate therapy and may not even be indicated. Suicidal patients need emergency treatment by specialists.

Mental health problems tend to become more symptomatic with menses writes Anita Nelson. [8] Patients with anxiety disorders tend to experience more anxiety and panic attacks as well as higher rates of suicide attempts and psychiatric hospitalizations during menses. Symptoms of obsessive-compulsive disorders have been found to increase before menstruation, and patients with psychotic disorders, including schizophrenia, also tend to suffer more intense symptoms during menses. [9, 10] There is some evidence that women with bulimia may experience increased food cravings premenstrually. [11]

Eliminating menses by controlling the endometrium alone (i.e., LNG-IUD use) will be sufficient therapy for some, but may not be adequate for those whose medical conditions fluctuate in response to hormonal cycling. However, it is possible to suppress ovulation with the ENG implant, DMPA, or extended COC use and prevent practically all hormonal fluctuations as well as menstrual-related symptoms. Selection of the appropriate method depends upon the patient’s preferences, underlying health problems, and specific presentation of symptoms.

References

1. Schaffir J, Worly BL, Gur TL. Combined hormonal contraception and its effects on mood: a critical review. Eur J Contracept Reprod Health Care. 2016;21:347-55.
2. Keyes KM, Cheslack-Postava K, Westhoff C, et al. Association of hormonal contraceptive use with reduced levels of depressive symptoms: a national study of sexually active women in the United States. Am J Epidemiol. 2013;178:1378-88.
3. Skovlund CW, Morch LS, Kessing LV, Lidegaard O. Association of hormonal contraception with depression. JAMA Psychiatry. 2016;73:1154-62.
4. Ramanadhan S, Edelman A. Combined hormonal contraceptives (CHCs). In: Cason P, Cwiak C, Edelman A, et al. (Eds) Contraceptive technology, 22nd edition. Burlington MA: Jones-Bartlett Learning, 2023.
5. Pagano HP, Zapata LB, Berry-Bibee EN, Nanda K, Curtis KM. Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review. Contraception. 2016;94:641-9.
6. Sulak PJ, Kuehl TJ, Ortiz M, Shull BL. Acceptance of altering the standard 21-day/7-day oral contraceptive regimen to delay menses and reduce hormone withdrawal symptoms. Am J Obstet Gynecol. 2002;186:1142-9.
7. Lopez LM, Kaptein AA, Helmerhorst FM. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD006586.
8. Nelson A. Menstrual disorders. In: Cason P, Cwiak C, Edelman A, et al. (Eds) Contraceptive technology, 22nd edition. Burlington MA: Jones-Bartlett Learning, 2023.
9. Reilly TJ, Sagnay de la Bastida VC, Joyce DW, Cullen AE, McGuire P. Exacerbation of psychosis during the perimenstrual phase of the menstrual cycle: Systematic review and meta-analysis. Schizophr Bull. 2020;46:78-90.
10. Sönmez I, Kös ‚ger F. Menstrual cycle in schizophrenic patients: Review with a case. Noro Psikiyatr Ars. 2015;52:417-9.
11. Gladis MM, Walsh BT. Premenstrual exacerbation of binge eating in bulimia. Am J Psychiatry. 1987;144:1592-5.