Mental Health and
Contraception
Robin C. Kopelman, M.D., M.P.H.
Clinical Assistant Professor, University of Iowa
Department of Psychiatry
Co-Director, Women’s Wellness and Counseling Service
Iowa Depression and Clinical Research Center
September 17, 2013
Overview
 Epidemiology of mood disorders in women
 Reproductive hormones and mood in
women
 Mood effects of hormone-based
contraception
 Mood symptoms and contraceptive use
 Contraception and preconception
counseling
Major Depressive Episode:
Diagnostic Criteria
 5 of 9 symptoms, including 1 or 3
(SIGECAPS)
1
2
3
4
5
6
7
8
9
depressed mood
thoughts of death, Suicidal ideation
anhedonia or diminished Interest
worthless or Guilty
fatigue, loss of Energy
poor Concentration, indecisiveness
change in Appetite
Psychomotor retardation or agitation
change in Sleep (insomnia or hypersomnia)
Depression: A “women’s issue”
Overall rates: 12% per year, 20%
lifetime
Compared to men: 2 – 3 times more
common
Difference starts in adolescence
Depression Across the
Female Reproductive Cycle
Depression
during pregnancy
Depression associated
with infertility,
miscarriage, or perinatal
loss
Menarche
Pregnancy
Premenstrual
depression/anxiety
Menopause
Depression/anxiety
during the
perimenopausal period
Depression during
the postpartum period
CONTRACEPTION
Not just hormones…
Reproductive hormones are
neuroactive
Progesterone and metabolites
GABA
Estrogen and progesterone
MAO
Opioid, serotonergic, cholinergic NTs
Not simple relationship to mood
U shaped dose-response
Fluctuations, not absolute levels
What do we see clinically?
Premenstrual Dysphoric Disorder
Depressive symptoms
confined to luteal phase
3 – 8 % of women of
reproductive age
Etiology
PMS ≠ PMDD
Decreased luteal phase serotonin activity
related to hormone shifts (progesterone)
Antenatal Depression
 10 – 20% of women
during pregnancy
Select group - role for
hormones
O'Hara, 1986; O'Hara & Swain, 1986; Hobfoll et
al., 1995; Seguin et al., 1999
Untreated Antenatal Depression
 Inadequate prenatal care
 Low birthweight, preterm delivery, spontaneous AB,
bleeding, preeclampsia/gestational hypertension, fetal death
 Behavior issues
in neonate
 Developmental effects
in children
 Increased use of
alcohol, drugs,
and cigarettes
Bonari et al 2004;Kelly et al., 1999; Kelly et al.,
2002;Deave et al., 2008
Postpartum Blues
Common (70 – 80% of women)
Linked to hormone shifts
10 days to 2 weeks
Peaking at 5 days
Associated factors
PMDD
Depression
Postpartum Depression (PPD)
 10-20%
of Childbearing Women
Select PPD Risk Factors
Family history
4 – 8 weeks postpartum
History of PMDD
Implication: hormone
shifts play a role
Untreated PPD
 Inconsistent birth control use*
 Less likely to engage in healthy
parenting practices
 Negative impact on Family
 Developmental, behavioral, and
emotional problems in children
 Personal suffering of the mother
 Suicide – a leading cause of maternal death
Why do women not use
contraception?
Affective symptoms cited as a major
reason for contraceptive
discontinuation
Historically change in mood “one of
the most common reasons”
Study of 79 women – 47% discontinued
oral contraceptives within 6 months, 1/3
due to mood changes
Oinonen & Mazmanian 2002; Sanders et al.
2001
Are mood symptoms a reason to
avoid hormonal contraception?
Bottom line:
Results conflicting
Randomized controlled trials on mood
effects limited
Mood effect profile may be largely favorable
for most women
Tori
27 yo female seen in gyn for painful
menses, contraception
Has a history of depression
Currently without mood symptoms
Reports that oral contraceptives make
mood symptoms worse and bouts
more frequent
“What’s my best option?”
Depot medroxyprogesterone
acetate
Label warns against use in pts w/
depr hx
1.5% of 4200 users reported depression,
0.5% d/c’d use because of depr
16,000 women, 5.4% users vs. 2.3%
non-users had mood disorders
Rapkin & Sonalkar 2011; Meirik et al. 2001
Depot medroxyprogesterone
acetate
Studies limited and conflicting
393 women, 56% d/c’d by 1 year, no
increase in depr among cont or d/cers
63 adolesc (dmpa & controls) – no depr
Role of choice - profile of depot users
Rapkin & Sonalkar 2011;Gupta et al. 2001
Levonorgestrel
910 women with LNG implant – 93 dropouts had higher depr scores, continuers no increase depression scores at 6 months
Oral LNG = 2 studies, used in combo with
EE, no evidence of mood sx
Intrauterine
3100 women, 212 IU users, no assoc with
scores or depr dx
Lower serum level
Maybe good option
Westhoff 1998;O’Connell et al 2007;Rapkin &
Sonalkar 2011; Toffol 2011
Lisa
36 yo woman, recently hospitalized for
anxiety and new episode severe
depression, now partially remitted
No history of premenstrual mood
symptoms
Considering pregnancy, but not for a
few months
“Would using hormonal contraception
make my depression worse?”
Some data suggest - maybe…
Individual characteristics may play a
role
History of depression
Possible premenstrual worsening
History of premenstrual mood symptoms
History of perinatal depression
History of dysmenorrhea
Psychological distress level
Oinonen & Mazmanian 2002
Oral contraceptives –
Evidence for no association
 20,000 women no differences in depressive
symptoms users vs. non-users
 3100 women, 181 users, no association
with mood symptoms
 151 women, combo/progestinonly/placebo, no between group differences
 76 women, OCP/Placebo, no difference
between groups
Duke et al. 2007; Toffol et al 2011;Graham et al.
1995;O’Connell 2007
Oral contraceptives – evidence for
mood benefits
Adolescent girls, placebo vs. OC,
depression scores improved
Combo (estr/prog) may improve mood
in women with MDD
1238 women - combo vs. progestin-only vs.
none
Combo had lower depression severity
Attributed to ethinyl estradiol
O'Connell et al. 2007;Young et al. 2007
Erin
20 yo woman, followed for depression
in pregnancy. Now 1 week
postpartum.
Mild depressive symptoms.
Does not want to use intrauterine,
injectable, or barrier methods.
“Will mini-pill make my depression
worse?”
Oral contraceptives –
Composition
Higher progestin more mood
symptoms
Data mixed, but overall studies of
progestin-only or higher progestin = greater
# and severity depression symptoms
Lower progestin/estrogen ratio may be
better
Postpartum depression &
progestin-only contraception
Long-acting norethistherone
enanthate (progestogen only, non-US)
Increased depressive symptoms
compared to placebo 6 wks
postpartum
No difference at 12 wks
Caution warranted?
Angie
History of premenstrual mood
symptoms, dysmenorrhea
Referred to gyn for symptom
management
Reported worsening of mood with
OCPs, self-harm ideation escalating
Charting data indicated an independent
major depressive episode
“What should we do next?”
Premenstrual Dysphoric
Disorder Treatment
 SSRIs
Dosing
 Continuous
 Luteal
 Depression - both
fluoxetine 20 mg
fluoxetine 40 mg
Follicular
 Hormonal treatment
Luteal
GNRH agonists, SubQ or transdermal estrogen
Oral Contraceptives (Yaz)
 Drosperinone/Ethinyl Estradiol vs. placebo
 Contraception Considerations
May be at increased risk for mood sx
Depression & use of
contraception
“Survivor” effects
Psychological symptoms predict:
contraceptive nonuse
use of less effective methods
Depression impacts perceptions of
provider communication
Limits self-efficacy
Barnet et al. 2008; Carvajal et al 2012;Hall et. al
2013
Perinatal depression & use of
contraception
 Perinatal depression may affect:
Contraception use
Birth spacing
Adolescents and women with loweducation levels may be particularly
vulnerable
Patchen & Lanzy 2013; Faisal-Cury et al
2013;Barnet et al. 2008; Bennett et al. 2005
Counseling our patients
Acknowledge hormones play a role in
mood symptoms
Most women will not develop mood
symptoms related to contraception
Counseling women with
depression
Many reasons to avoid unanticipated
pregnancy
Depression impacts pregnancy intervals
and outcomes, child outcomes
Risks of contraceptives for women
with depression, as well as benefits,
may direct to specific options
Depression affects:
Health behaviors, like contraception
use
Choice of contraception
Perceptions of provider
communication
Screen for and treat depression in
women
Other common disorders
Schizophrenia
Estrogen may be beneficial
Bipolar disorder
As many as 40% not using contraception
Perinatal period = high risk – relapse,
psychosis
Several BPAD treatments -- known
teratogens
Adherence an important issue
What if we need help?
Clinical Resource
University of Iowa Women’s Wellness
and Counseling Service –
UIHC, Iowa River Landing
Referrals to the WWC
Perinatal and reproductive psychiatry
referrals
Phone 319-335-2464
http://www.uihealthcare.org/womenswellness/
Consultation and Support Resource
Iowa Perinatal
Mental Health
Consultation
Service
Patient & Provider Resource
Summary
Hormones influence mood
Contributor to common disorder in women
Guiding data is limited
Depression influences contraceptive
choices and related behaviors
Mood symptoms should be always be
evaluated and treated
Resources available