Columns

Papendorp ’17: Birth control — it’s complicated

By
Staff Columnist
Monday, October 17, 2016

Sept. 28, 1965, Brown’s director of Health Services Roswell Johnson ignited a nationwide controversy by prescribing birth control pills to two Pembroke students. Because both women were engaged to be married, Johnson was confident that he was “not contributing to” the “unmitigated promiscuity” that oral contraceptives were feared to instigate. Fifty-one years later, hormonal birth control is ubiquitous — especially on college campuses. About 10 million U.S. women are on the pill, and 80 percent of women will take oral contraceptives in their lifetimes. And oral contraceptives are just one form of hormonal birth control: the patch, the ring, the shot, implants and some intra-uterine devices all use synthetic female sex hormones to prevent pregnancy.

Three weeks ago, almost on the anniversary of Johnson’s radical prescription, the New York Times ran an article entitled “Contraceptives Tied to Depression Risk.” Despite this article’s clear importance for the more than 10 million American women who use hormonal contraceptives, it was buried on page D4 in the middle of the newspaper. The article also wasn’t shared on the New York Times Well Facebook page, apparently overshadowed by more universally relevant headlines like “Homeopathic Teething Gels May Pose Risks.”

The article summarized the findings of a Danish study published in the Journal of the American Medical Association: Psychiatry.

Spanning 14 years and citing over a million women as subjects, the study found that oral contraceptives increase the relative risk of antidepressant use by 40 percent. The effect was even greater among adolescents: Taking the birth control pill made 15- to 19-year-old girls 1.8 times more likely to be prescribed antidepressants.

Of course, correlation is not the same as causation, and there could be other factors affecting why women who opt to use hormonal contraceptives may also be more susceptible to depression. But since a randomized controlled trial — the only way to definitively prove causation — involving birth control would be impossible, this prospective cohort study represents the next-best thing. And a sample size of over a million women is nothing to shrug at.

More critics of the study argued that, though the increases in relative risk of depression seem dramatic, the increase in absolute risk (from 1.7 percent to 2.2 percent, for antidepressant use) is miniscule. But given that over 80 percent of U.S. women will use the pill in their lifetimes, even a tiny increase in absolute risk affects millions of women. Moreover, using antidepressant use and a diagnosis of depression as proxies for depression may underestimate the effects that hormonal birth control has on mood, as some women experience depression but do not seek help. Most studies find that less than half of those suffering from depressive symptoms seek treatment.

When I was taking hormonal birth control, my primary care doctor warned me to watch out for ACHES: abdominal pain, chest pain, headaches, eye problems and severe leg pain. These are the symptoms of blood clots, which have an incidence in birth control users of about 0.005 percent: in other words, out of 100,000 women taking birth control for a year, five would experience a blood clot. By contrast, according to this new data, 350 of these women would be diagnosed with depression. If doctors take the time to counsel their patients about blood clots, why not include a warning about depression as well? Both blood clots and depression represent serious health risks, and depression is much more likely to occur.

I started taking oral contraceptives at 17. At the time, I was fully convinced that hormonal birth control should be available over the counter, like condoms, emergency contraception and spermicide. And the country seems to be slowly moving in that direction: This summer, California became the third state to pass a law allowing women to get birth control pills from a pharmacy without a prescription. These laws expanding access to hormonal contraceptives are necessary and good: Everyone should have access to the birth control method of her choice. But I wonder if making hormonal birth control so freely available, outside of the supervision of medical personnel, will allow us to further trivialize the side effects that some experience.

Taking hormonal birth control made it difficult not only for me to be happy, but also for me to even imagine how others could be happy. Often I would cry uncontrollably without being able to explain why. Whereas the smallest negative development could send me into a rage or a spiral of despair, very few things made me smile or laugh. I never saw a physician for these symptoms, so I don’t know if I was clinically depressed. But I wasn’t myself. Because I was unwilling or unable to recognize the connection between these changes in my mood and my birth control medication, I spent several years of my life in emotional limbo.

If I had realized how hormonal birth control was changing my mood, I would have stopped taking it a lot sooner. But reading the dismissive comments on the New York Times article makes me realize why it took me so long. For example, one of the most popular comments reads, “You think contraception causes depression? Try unintended pregnancy.” Why are we so quick to dismiss and ignore women’s well-being? And why did it take 50 years of anecdotal evidence about the emotional harms of hormonal contraception for there to be a methodical, large-scale study of this kind?

To be sure, oral contraceptives were one of the most important inventions of the 20th century. And just because a medication has psychological and emotional side effects does not mean that it is not valuable. Hormonal contraception is extremely effective, inexpensive and convenient — but it’s not perfect. Instead of accepting it for what it is, we need to keep pushing pharmaceutical companies to develop better, non-hormonal contraceptive options with fewer side effects for both men and women.

Carin Papendorp ’17 can be reached at carin_papendorp@brown.edu.

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