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Oral Contraceptive Pill Pause & Withdrawal Linked to Depression & Anxiety in Young Women (Study)

A recent study has shed new light on the mental health implications of hormonal contraceptives, particularly focusing on the period known as the ‘pill pause.’

Research indicates that temporarily stopping synthetic hormone intake during this break can lead to increased negative emotions and anxiety among long-term contraceptive pill users.

This finding challenges the conventional approach to contraceptive pill cycles and underscores the importance of considering mental health effects in contraceptive practices.

Key facts:

  • Short-term withdrawal from synthetic hormones during the contraceptive pill pause was associated with increased negative affect, anxiety, and mental health symptoms in long-term pill users.
  • The mood worsening during the pill pause was comparable to mood changes seen during the menstrual cycle in non-pill users.
  • The mood changes during the pill pause were not influenced by progestin type or estrogen dose but were more pronounced in women with higher baseline depression.
  • These findings question the mental health benefits of having a pill pause. Continuous use may provide more mood stabilization.

Source: JAMA Network Open (2023)

Hormonal Contraceptive Use Increasing Globally

Hormonal contraceptives remain one of the most popular birth control options worldwide, with over 400 million women currently using some formulation.

Use is estimated to be adopted by millions more each year, especially in lower-income countries, as access to family planning resources improves.

While hormonal contraceptives provide an effective way to prevent unwanted pregnancy, their effects on mental health have been heavily debated.

Concerns emerged after some studies found associations between depression diagnoses or antidepressant use and contraceptive initiation.

However, subsequent research has produced mixed findings, hinting that individual differences and study methodology play a key role.

Overall, mental health implications remain unclear, especially surrounding the common pill pause in combined oral contraceptive (COC) users.

Combined Oral Contraceptives (COCs) Mimic Menstrual Cycle Hormone Levels

Most COCs are designed to artificially mimic shifts in hormones across the menstrual cycle.

Pills containing synthetic estrogens and progestins are taken daily for 21-24 days.

This elevates circulating hormone levels to correspond with the follicular and luteal phases.

Then a 4-7 day pill pause induces withdrawal bleeding meant to mimic menstruation.

Some formulations replace active pills with placebo pills during this time.

These monthly fluctuations in exogenous hormones parallel changes in endogenous ovarian hormones across the menstrual cycle.

This regimen emerged to assure users of regular bleeding and provide a monthly confirmation of non-pregnancy.

However, from a mental health perspective, these monthly hormone fluctuations may be disadvantageous.

Phases of hormone withdrawal are linked to mood symptoms in relation to menstruation or menopause.

Studies find women are most susceptible to depression diagnoses postpartum when hormones precipitously drop after delivery.

This suggests acute hormone withdrawal could also impact mood in COC users.

Contraceptive Pause (Short-Term Hormone Withdrawal) & Mental Health

A new case-control study published in JAMA Network Open provides the first systematic look at potential mood changes during the pill pause.

Researchers at the University of Salzburg recruited 181 healthy women aged 18-35 years.

Of these, 120 were long-term COC users (on their current pill for over 6 months) and 61 had natural menstrual cycles without exogenous hormones.

The COC users were divided based on pill formulation – 61 took pills with androgenic progestins while 59 took pills with anti-androgenic progestins.

Participants completed validated mood questionnaires during an active pill phase and again during their pill pause or menstrual period depending on group.

Trait depression was also assessed at baseline.

Significant Increase in Depression & Anxiety During Pill Pause

Results showed COC users experienced a significant worsening of mood from active pill phase to pill pause.

Measures of negative mood (depression) increased 12.7%, anxiety increased 7.4%, and mental health symptoms increased 23.6% during the pill pause compared to active pill use.

The mood changes were not influenced by progestin type or estrogen dose.

Notably, the increase in symptoms during the pill pause was comparable to the worsening seen in non-users during their menstrual period versus the luteal phase.

This suggests endogenous and exogenous hormone withdrawal impacts mood similarly.

Women with higher baseline depression scores also showed greater mood worsening during the pill pause compared to less depressed women.

This hints some women may be more susceptible to changes induced by hormone fluctuations.

Continuous Use of Oral Contraceptives May Provide Mental Health Benefits

These findings provide evidence that acute withdrawal from synthetic ovarian hormones, whether exogenous as during the pill pause or endogenous as occurs during menstruation, is associated with adverse effects on mood and mental health.

Therefore, the data calls into question whether monthly pill pauses are useful from a psychiatric perspective.

Prior research indicates OC use beyond 6 months is associated with mood stabilization and mental health benefits compared to non-users.

However, these studies did not account for monthly hormone withdrawal during pill pauses.

The current results suggest extended OC use without regular pill pauses could enhance mood by eliminating acute hormone withdrawal.

Future studies should explore trends in women who opt for continuous OC use rather than monthly withdrawal.

Comparing extended use to traditional OC cycles may clarify ideal regimens for mood stabilization.

It will also be important to identify predictors of sensitivity to hormone withdrawal, like baseline depression, to personalize contraceptive recommendations.

In summary, this well-powered case-control study provides evidence of worsened mood during OC pill pauses, likely due to acute hormone withdrawal.

The mood changes were comparable to natural menstrual cycles.

The data questions the mental health advantage of monthly pill pauses.

Future work should explore the feasibility of extended OC use to minimize hormone fluctuations for optimal psychiatric outcomes.


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