Hysterical Women: Why Is Hormonal Contraception Still Failing Us?

Illustrated by Erin Aniker
Reproductive autonomy as we know it today began on 15th October 1951 with a Mexican wild yam root. Dr Carl Djerassi (also known as the father of the pill) was one of two chemists working with a student assistant in a small pharmaceutical laboratory in Mexico City when they synthesised a hormone – a progestin called norethindrone – from the yam. It would go on to become a key ingredient in and chemical base for hormonal contraception
From the late 1930s, experiments on animals had demonstrated that high doses of progestins (synthetic versions of the naturally occurring hormone progesterone) could pause ovulation, effectively putting the female reproductive system to sleep temporarily. The idea of doing the same in human women became a reality when Djerassi and his small team successfully managed to get the hormone from that yam. Eventually hormonal contraception or birth control was born. In 1961 the pill became available in Britain (although only to married women) and today it is taken by more than 3.1 million women in this country according to the latest figures, though its use has fallen in recent decades as long-acting reversible contraceptives (LARCs) like the coil or the implant have become more popular. 
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Hormonal contraception, which now includes not only the pill but the injection, the implant and the Mirena coil, has been hailed by some as the greatest scientific invention of the 20th century. It’s not perfect, as we will shortly discuss, but before we do, we must not forget how revolutionary it was nor what it has done for women and people with wombs, for things were very different before the invention of the contraceptive pill. Women had little or no control over when we got pregnant or how many children we had. We married early and, on the whole, stayed at home and raised children while men worked. When we did work, it was rarely outside of the domestic sphere. Now we have choices, options. We enter higher education in unprecedented numbers and there are more of us in work than ever before. When taken correctly, the pill is more than 99% effective at preventing pregnancy, which is never something we should overlook. 

Today the pill is taken by more than 3.1 million women in this country, though its use has fallen in recent decades as long-acting reversible contraceptives (LARCs) like the coil or the implant have become more popular. 

Many women take the pill, have the injection, the implant or the Mirena coil and experience no significant side effects. Some even enjoy the positive benefits beyond preventing unwanted pregnancy such as fewer PMS symptoms, better skin and improved moods. As 26-year-old mental health campaigner Aimee-Louise Carton tells me, the combined pill has regulated her depression, anxiety and suicidal thoughts which she experienced as a result of borderline personality disorder. "It was always much worse around my period," she explains. "Since being on the pill I’ve really seen the benefits of contraception."
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However, many more also report serious experiences of its known side effects such as loss of libido, depression, anxiety and even suicidal ideation and attempts. Hormonal contraception might remain the most commonly prescribed form of contraception in England but it is not perfect. Ask any woman and if she can’t tell you herself, she will tell you a story about someone who feels like they were "a different person" on the pill. For years we have discussed the ways in which we feel that hormonal contraception makes us sad, bad and mad while weighing up the freedom it gives us to have sex without fear of pregnancy. But in recent years studies have emerged confirming our stories, verifying links to poor mental health and, perhaps most importantly, revealing the extent of the need for more research into the negative and potential long-term effects of these potent medications which healthy women take every single day during their fertile years.
A lot has changed since the 1960s. Back then, radio car phones were cutting-edge; today you likely carry a phone in your pocket which is thought to have more than 100,000 times the processing power of the computer that landed man on the moon 50 years ago. It follows that medical technology dating back to the same period might not quite hold up to modern scrutiny. There is, it turns out, a lot we don’t know and are only just finding out about hormonal contraception. 
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At the end of 2019, a small study was presented at the annual meeting of the Radiological Society of North America. It was conducted by Dr Michael Lipton, professor of radiology at the Albert Einstein College of Medicine in New York and found that hormonal contraception might be "altering the structure of women’s brains". 
In Dr Lipton’s study, women taking the combined oral contraceptive pill (which provides a dose of synthetic oestrogen and progestin) were found on average to have a 6% smaller hypothalamus than those not taking it. The hypothalamus is a small but crucial part of the brain which serves as a link to the nervous system and regulates pretty much all of the hormones in our bodies. Dr Lipton and his team of researchers used MRI scans of 50 women, 21 of whom were taking a combination pill. 
"The hypothalamus sends signals to the pituitary gland through which most all hormones are regulated," Dr Lipton tells me when I ask him about his findings. "Hypothalamic functions are very diverse and regulate, among other things, growth, sleep, appetite, sex and reproduction, mood, bone health and brain function such as cognition."
Crucially, the study shows that women taking the combined pill do not have smaller brains overall and that their mental abilities are not affected. However, Dr Lipton’s team did note that a smaller hypothalamus is associated with increased anger and symptoms of depression
When I press Dr Lipton on why this could be, he is clear that his research "did not address the functional implications [of a decrease in the size of the hypothalamus in combined pill users], which require further study." However, when I ask why the combined pill could be altering the size of this crucial part of the brain, he says that it could be because the synthetic hormones in the combined pill "inhibit" what he calls "trophic or growth-promoting" sex hormones. This – the suppression of sex hormones – is a known potential side effect of some hormonal contraception, which is why some women experience decreased libido when taking it. 
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Significant as Dr Lipton’s findings are, he is keen to make it clear that he regards them as "preliminary" and an indicator that more research and "further investigation" is needed into how hormonal contraception affects women’s brain structure and potentially impacts brain function. 
My own experiences of zero sex drive plus poor mental health in the form of relentless panic attacks, anxiety, depression and suicidal thoughts which I believe were connected to hormonal contraception have led me to investigate this area intensely over the last decade. I have spoken to leading NHS experts and consultants and travelled to Denmark while filming an episode of BBC Two’s science programme Horizon, The Contraceptive Pill: How Safe Is It? where I interviewed the man behind two studies which have confirmed a link between hormonal contraception and mental health problems, Professor Øjvind Lidegaard. From the very first article I wrote on this subject to the one you’re reading now, there is one recurring theme: more research is needed to confirm exactly how women’s mental health is affected. While it’s fair to say that the pill has changed a bit since it first became available – the doses of synthetic hormones it contains are lower and therefore safer, for instance – there has been no great scientific innovation since its inception beyond the refining of the hormonal coil and implant.

It is much more difficult to get support to study the negative reactions and demonstrate the adverse effects. Many more studies have been conducted to prove that [the pill] protects against ovarian cancer than that it can increase the risk of depression.

professor Øjvind Lidegaard
This is an incredibly delicate subject, for good reason. The stakes are high not only for women and people with wombs but for medical professionals who want to avoid scaremongering and a spike in unwanted pregnancies. When a complex study such as Dr Lipton’s is released, media hysteria ensues and girl gang WhatsApp groups are set alight. Anyone who, like me, has ever experienced negative side effects as a result of taking hormonal contraception feels vindicated while medical experts seek to downplay the findings while panicking that women – even those for whom it works well – will throw away their contraception and take reproductive risks. From speculation about when or if the male pill will ever arrive to article after article about a "backlash" against the pill and reports that some women are looking to tracker apps and digital forms of birth control such as Natural Cycles to provide an alternative, which in some cases has led to unwanted pregnancies because – guess what – an app can’t stop sperm fertilising an egg, as the author Olivia Sudjic found out, recent headlines about hormonal contraception have been distressing and confusing. 
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We find ourselves in a bemusing bind, walking a thin line of being grateful for what we have and knowing that it’s not good enough. We are at once aware that hormonal contraception has been our great emancipator, that it prevents unwanted and problematic pregnancies and gives women control, while knowing that it just won't do because no two women are the same and for many, the side effects are too much to bear.
I first met Øjvind Lidegaard in his office at Copenhagen’s sprawling concrete Rigshospitalet back in 2018. He cut an imposing figure, which is befitting of his status as an unpopular disruptor within the medical community. Lidegaard is the lead author of the 2016 study which looked at the medical records of more than 1 million Danish women and national registers of prescriptions over 16 years and found a link between hormonal contraception and depression. Women taking the combined oral contraceptive pill were 23% more likely to be diagnosed with depression, while those using progestin-only pills were 34% more likely.
Professor Lidegaard and his team were able to do this work for one simple reason: Denmark collects patient and prescription data. While writing this article, I caught up with him. Reliable data on women’s health, Lidegaard explains, is everything. "We had a reliable population-based study where over 1 million women were followed," he tells me. "Several studies have been conducted before ours but the main limitation in previous studies has been the inclusion of only long-term users of hormonal contraception, thus already by design excluding the possibility of assessing depression development shortly after starting use of hormonal contraception." Depression and anxiety are known potential side effects of hormonal contraception for some women (though the NHS tends to describe this as "mood swings") and if you develop them within the first few months of starting a new pill, coil, implant or injection, it’s more likely that the two are related. This is why being able to see whether women were prescribed anti-anxiety medication or antidepressants shortly after hormonal contraception, as Lidegaard did, is so important. The NHS currently isn’t looking at data in this way, as I have previously reported. 
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The problem, Lidegaard explains, is that while we know some women experience severe mental health side effects when taking hormonal contraception, beyond his study we don’t know exactly how many are affected. "There has been a lot of research in hormonal contraception," he explains. "On mental health, the quality of the studies have been poor and the results consequently unreliable. Those studies, for example, had not followed women from their first use of hormonal contraception in the way we did."
Another issue according to Lidegaard is who funds the research – many studies are, he says, ​"sponsored by the marketing holders" i.e. drug companies. When we first met, he explained to me that it is very difficult to secure funding for research which looks at the negative effects of hormonal contraception. "I think it’s true that the companies who produce these pills are very willing to support proving that there are benefits to taking hormonal contraception," he said. "It is much more difficult to get support to study the negative reactions and demonstrate the adverse effects. Many more studies have been conducted to prove that [the pill] protects against ovarian cancer than that it can increase the risk of depression."

We find ourselves in a bemusing bind, walking a thin line of being grateful for what we have and knowing that it's not good enough.

Since Lidegaard’s research, another study has been published in the peer-reviewed medical journal, Plos. It was conducted by Swedish scientists who, in a similar way to Professor Lidegaard in Denmark, were able to look at a large sample size of 800,000 Swedish women. They found that women (particularly teenagers) taking hormonal contraception were more likely to also be taking psychotropic drugs. "Psychotropic" describes any medicine which is used to treat someone’s mental health. Of the women the study recorded who were taking hormonal contraception, 3.7% were also taking medication for their mental health. Among the women not taking hormonal contraception, only 2.5% were taking medication for their mental health.
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Yet despite Lidegaard’s work, the Swedish study and the more recent findings of researchers like Dr Lipton, it strikes me that little has changed. There is no new miracle, side effect-free contraception on the market and women and people with wombs of childbearing age still face a trade-off if we want to have sex and not get pregnant: take hormonal contraception and risk not wanting to have sex while on it and not knowing whether your moods are actually your own, or rely exclusively on condoms or riskier and less reliable methods. 
Beyond more reliable large-scale data, what’s really needed now, says Dr Sarah E. Hill, a professor of social psychology at Texas Christian University in Fort Worth, Texas and author of How the Pill Changes Everything: Your Brain on Birth Control, is medical innovation. Hill tells me that it was also her own experience which prompted her to start investigating this issue. "I was on the pill for more than a decade and when I went off it, I felt like I woke up," she explains via video call. 
As she sees it, when it comes to the mental health side effects of hormonal contraception, the current confusion, conflicting messaging and lack of concrete research which can be accepted across the board is down to several things. "Firstly, women and 'women's issues' have been under-studied in science. This started out with rampant sexism, with people thinking we weren’t worth studying. But now, as we've gotten an increasing number of women in the sciences, women are being studied more frequently but still not as frequently as men because we're more difficult to study because of our hormones. And because science is super competitive, a lot of times what ends up happening is that researchers gravitate toward things that are easy to study, meaning women and 'women's issues' tend to get the short shrift."
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The result, Hill adds, is that "funding agencies will still fund research that doesn't include females or includes very few females. And then research journals will publish articles that include male-only samples or majority males."
Another aspect to this, she confirms, is that criticising hormonal contraception in both the US and the UK is a "political hot potato". Hormonal contraception is, she says, "the single biggest tool for women's liberation that we've had in the last 100 years," which means "we should be wary of people who don’t have our best interests in mind who criticise the thing that has allowed us to become economically and politically independent from men, while also making sure we have thoughtful conversations about its flaws. There are scientists who are like, ‘Oh, I’m not touching that because it can be a hot button issue’ and the last thing that scientists want to do is end up in a situation where their work is being used to argue against women having access to contraception. Sometimes, researchers even do the work in this arena but don’t want to talk about it because they don’t want to be assailed."

Hormonal contraception is the single biggest tool for women's liberation that we've had in the last 100 years. We should be wary of people who don't have our best interests in mind who criticise the thing that has allowed us to become economically and politically independent from men, while also making sure we have thoughtful conversations about its flaws.

DR SARAH E. HILL
Ultimately Hill wrote her book because she feels we have a "blind spot" when it comes to hormonal contraception. "Of course changing women’s sex hormones – which is how hormonal contraception works – influences women’s brains. That’s why women experience mental health side effects. The problem is that for too long, nobody has been telling them why. We have to talk about it so that women can make informed decisions as opposed to walking away and growing distrustful of doctors."
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"The pervasiveness of the effects of hormonal contraception on the brain is shocking in and of itself," Hill continues, "but for me, the thing that really stopped me in my tracks was learning about what the pill does to women’s stress response." She cites a study which found that women taking oral contraceptives had "smaller hippocampal volumes" than women not taking them. The hippocampus is located near the hypothalamus; it plays an important role in the limbic system and is associated with learning and emotions. 
"In that study," Hill explains, "they found that women who were taking oral contraceptives didn’t exhibit a cortisol change in response to stress. Cortisol is a stress hormone. Even though it gets a bad rap, it actually helps our bodies cope with stress. So when I saw that research showing that women have a blunted stress response, it highlighted that the effects of the birth control pill go far beyond sex hormones, right? Because sex hormones have a domino effect on all these other systems in the body. But the other thing about it that was alarming was twofold. One, the pattern that we see in women who are on the pill looks just like the pattern that you see in people with PTSD and people who've experienced chronic trauma. And essentially what it looks like is that women's stress response is actually turning itself off when they are taking hormonal oral contraceptives. They have all of these different indicators that – like in someone who has experienced severe trauma – the stress response system went totally haywire and then got shut down, which could potentially be associated with some of the potential negative mental health side effects of hormonal contraception. The pill doesn’t just affect a woman’s ovaries." 
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My friend and colleague, the poet and writer Bridget Minamore, once joked to me that we "know more about Mars than we do about women’s bodies". I think about this a lot. If we can explore space, surely we can come up with a method of contraception that prevents pregnancy without adversely impacting women and people with wombs in other ways. I put this to Dr Hill, who sighs before saying: "I am just hoping, hoping, hoping that there is somebody who creates something. The copper coil was a step in the right direction but not everybody handles that well. However, it’s something that's not hormonal and is very effective. Why can’t we come up with something that changes the microbiome of the vagina (this basically means bacterial environment) in a way that's not unpleasant to women but makes it inhospitable for sperm?"
We've come a long way from Carl Djerassi's yams but what will it take for this to happen, I ask? "A lot of pressure from women," Dr Hill says affirmatively. "Pressure on drug companies, on the people who are funding research and development to start investing in this. As things stand, around only 2% of the revenue from contraception is going towards research and development of new methods. With other drugs, it’s more like 50%." 
When you put it like that, it sounds so simple, doesn’t it?
If you are concerned about the effect your contraception is having on your mental health, please contact your GP immediately. 

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