Hormonal Contraceptive Mood and Sexual Side Effects (Episode 516)

Full Transcript: Episode 516

Lisa Hendrickson-Jack:

Today I have an interesting study to share with you. I’ve spoken about this study many times. I wrote about this study in The Fifth Vital Sign. And so I thought it would be a perfect follow-up to last week’s rant about the Washington Post article. So in today’s research series episode, I’m sharing a study with you in a new episode of the FAM Research Series. And the name of the study is “Characteristics of Women Who Experience Mood and Sexual Side Effects With Use of Hormonal Contraception.” So without further ado, let’s go ahead and jump right in.

All right, so I’m actually going to read a short excerpt from The Fifth Vital Sign. And so this was in Chapter 7, the pill chapter. In a study published in the Journal of Obstetrics and Gynecology Canada, the objective is listed as follows: “To describe the characteristics of women who experience sexual and mood side effects associated with use of hormonal contraception and to compare them with women who do not.” End quote.

So this is essentially the heart of what I want to talk about today. I found the study to be really interesting because of what the researchers have deemed important — because of what they’ve chosen to study. So they’ve identified a problem. And the problem is that a high percentage of women are discontinuing their use of hormonal birth control. In fact, the statistics are around 50%.

So in this particular study, they recruited 1,300 women — a little over 1,300 women — average age was 28. And of these women who had previously used contraception, they said 978 of them had previously used hormonal contraception. And of these women, 51% said that they had at least one mood-related side effect, and 38% said they had at least one sexual side effect.

So this study was a survey study and they had these women report on what they had experienced on birth control. So 51% had at least one mood side effect. Now in the body of the study, they cite other research and this is important as well. So I’m going to share some of these stats with you and then get back to the point.

In the general population of women of reproductive age who have ever used contraception, 29% say they had discontinued oral contraceptives because of dissatisfaction with the method. In the 2002 Canadian Contraception Study, 59% of women had changed their method of contraception and 20% of these women had switched because of the side effects. A study of 79 women in stable committed relationships found that only 38% had continued oral contraceptive use one year later. 47% had discontinued and 14% had switched to another preparation.

So literally they’re telling you that when they look at women who have started a new oral contraceptive, one year later only 38% are still using it. They’re saying 47% had stopped entirely and 14% had switched to a different option. They go on to say that emotional side effects, worsening of premenstrual syndrome, decreased frequency of sexual thoughts, and decreased psychosexual arousability accounted for 87% of cases.

So just this is how they start — this is the background that they’re providing. And this is similar to some of the information I shared in The Fifth Vital Sign, which is that when you actually look at the statistics of women who are taking contraceptives and how satisfied they are with their experience, what you find is that a high percentage of women are actually not satisfied. They are experiencing a variety of side effects — particularly mood and sexual side effects. I mean, there are other side effects, but those are some of the extremely common ones. And another extremely common side effect that women experience would be unscheduled bleeding. Particularly the IUD is more prone to this side effect, and that would represent another reason why many women are unsatisfied with their experience on hormonal contraceptives.

And so with that in mind, when you hear that, you would think, okay, this is a problem. Look at how many women are experiencing a negative experience on contraceptives — it’s like 50%. And look how few women, compared to who started on the contraceptives, are still taking it. Yes, there are different reasons why someone is going to stop taking contraceptives. A percentage of those women are probably wanting to conceive. But in the one study that they quoted here, it was 87% of those women who reported that they had stopped because of side effects specifically. So even though you have many women discontinuing for other reasons, this represents a significant issue.

So from my perspective, when I’m thinking about empowering women and having positive experiences and wanting to improve the health and overall experience of women as a whole, I see this and I think to myself, okay, well, if I produced a product that caused this high degree of dissatisfaction and this significant side effect profile, then at some point I would think to myself — what can I do to improve the product? What could I do to improve the experience of women? Is there anything that we could do to change the formulation? Is there a different approach we could take? What are our options here? I feel like that’s a reasonable possibility for how we would be looking at the situation.

But the reason that I’m talking about this study today, and the reason that I believe that it’s a good follow-up to the Washington Post article, is because that’s not the angle the researchers are taking. Actually, they’re taking the angle that they want to describe the characteristics of women who experience sexual and mood side effects and compare them to women who do not. And the reason that they want to do that is because they want to find out what is wrong with the women who are experiencing the side effect.

And this — this could be how I’m reading it. I mean, I was already irritated when I saw the title. So obviously, you know, maybe not objective here. But what I’m saying though is that the question that they’re asking — when you read the study, what they’re getting at is that we want to figure out what are the particular qualities and characteristics of women who complain about side effects. Is there something about them that we can learn? Because I feel like this invalidates their experience to some degree, because they’re not asking what’s wrong with this contraceptive. They’re saying, well, some women are experiencing these side effects — so what’s wrong with them?

There’s got to be some differences between the women who are complaining about the side effects and the women who aren’t. And if we could find out what that is, then we could kind of better market this. There’s no thought process with this particular study of making any changes at all to the medication. It’s almost like the bottom baseline assumption is that the medication is perfect and it’s just the women. There’s just something wrong with these ones who are complaining. Let’s figure that out — let’s figure out if they are from a certain ethnic group, if they’re a certain age and economic status, what is their education level — because if we can figure that out then maybe we can better market this.

Again, in the interest of scientific study, I’m not saying that there’s anything inherently wrong with doing that. I’m just saying that I am a little bit put off by the fact that that’s what they’re doing.

And if we go back to the Washington Post article and essentially what that individual was saying — they’re saying that anybody who talks against birth control who isn’t a doctor basically isn’t allowed to do it. If you don’t have a medical degree you should just shut up and just not even talk about it because you’re clearly not qualified. And all these crazy women who are going to all these uneducated influencers who are telling all this stuff about the side effects — they were acting in that article as if the side effects weren’t real. But because the side effects are real, when you read the article you see that it’s very difficult for them to pretend like all of these side effects aren’t real. They’re not citing any research, they’re not talking to women about their experiences, they’re essentially invalidating the experiences of the women themselves and criticizing anybody who talks about the pill as if it’s just hocus pocus crazy stuff.

People wouldn’t be talking about the pill critically if there wasn’t a reason. And all you have to do, if you’re ever in a group of like three or more women, is ask them about the pill. It’s just so crazy to me that this is controversial — talking about side effects — because this research that I’ve just shared with you already shows you that a high percentage of women experience side effects.

So anyway, moving on so I don’t get lost in that particular section. So they went ahead, they did the study, they surveyed all these women who had previously used hormonal contraceptives, and what they did was they gathered as much information and data about these women as possible so that they could try to identify any potential trends of the women in particular who did have an issue with contraception. They took the ethnicity of the women, their socioeconomic status, education level — just trying to determine some of the characteristics of these women and see if there’s any trends.

So here’s one little excerpt from the study: “Women who complained of sexual side effects were more likely to also complain of mood and physical side effects. Women who complained of mood side effects were more likely to be younger, unmarried, never had children before, Caucasian or South Asian, and presenting for IUD insertion rather than for primary care or abortion.”

So that’s just a little excerpt, but basically they’re identifying, okay, what is similar about these women? And then they go on to discuss what they feel the findings mean, and they say women who complain of mood or sexual side effects with use of hormonal contraception may have different physiological reactions to hormones. In a previous study, East Asian women had a lower rate of mood and sexual side effects than Caucasian and South Asian women. So they’re saying, okay, so we’re seeing a bit of a difference in different populations. And so maybe it’s related to ethnic differences between groups — like maybe certain ethnic groups have a higher sensitivity to hormones, maybe they process the hormones a little differently.

Another thing that they suggest is, our finding that women who were more educated and unmarried complained more of sexual side effects may be related to higher expectations related to sexual pleasure. So they’re kind of like, they don’t really know, but they’re like, okay, we saw that the women who had higher levels of education and who weren’t married, they tended to complain more about these sexual side effects, so maybe that’s related to their expectations.

This whole study, as I read through it, I feel like my blood was just boiling little by little. Again, there’s nothing wrong with scientific inquiry. But I find this whole premise of trying to figure out what is wrong with the women who are complaining about this stuff — what are their characteristics and traits? — so offensive. I think it’s really important to understand that this is peer-reviewed published research. So there’s nothing in this kind of line of inquiry that is out of the ordinary. This is what we’re dealing with as women. When we go to try to seek support from health professionals, this is the level of their inquiry. When we complain about the side effects, they’re kind of just like, “Here we go again,” because they don’t seem to think that the complaint is valid.

And again, this ties directly to the Washington Post article. They’re not even concerned about the fact that millions of women all over the world are complaining about the side effects. They’re not concerned that women have tried to go to their healthcare providers who don’t listen to them, and then they seek support anywhere else, anyone who will listen to them. And women form groups all over the place. Sometimes it’s only those online communities where women can actually get information and referrals for medical providers who will listen to them.

All right, I will continue. So to kind of wrap up my line of discussion here — IUD users reported the highest rate of hormone-related side effects, and it is likely that the choice to use an IUD may often be related to previous problems with other contraceptive methods. So this is a useful finding. When you have women who have a negative experience with hormonal contraceptives, women still need birth control. So if you try X brand and you don’t have a good experience, many women will then try Y, try A, B, C, whatever. And then eventually they try the hormonal IUD. So I do think that it is possible that women who tend toward the IUD — maybe there’s a higher proportion of them who did have negative side effects with other hormonal contraceptives, and this is kind of like one of their last-ditch attempts at trying to make it work.

The formulation for the pill, although there have been changes throughout the years and there are different generations of these estrogen-containing hormones, largely the formulations are very, very similar. Although they’ve made slight tweaks to the different specific synthetic hormone formulation, the premise is the same. And so 60-plus years later, we’re still looking at a very similar contraceptive option. And I would argue that given the high volume of women who are not satisfied with the contraceptives and their side effects, we should be looking for another alternative. But that doesn’t seem to happen. We just put the same type of formulation in a different outfit. We administer it in a patch, we stick it in an IUD, we put it in an implant, we put it in a ring that can be inserted in the vagina.

So in The Fifth Vital Sign, I did put an extended quote because I wanted the readers to see the conclusion of this study. So I’m going to read the whole conclusion: “Understanding more about which women report mood and sexual side effects with hormonal contraception may be useful when counseling women about contraception. It is likely that both physiological susceptibility and psychosocial and cultural issues affect which women complain of these side effects. It is important that women choose contraception that is not only effective, but also does not complicate their emotional and sexual lives.”

They go on to say — and this is my favorite part — “It is a major challenge for clinicians to provide the information women need to make choices without unduly discouraging them from using the most effective methods. More research is needed to determine the best way to inform women about potential risks and benefits of hormonal contraception.”

This is the whole reason that this study irritates me. The conclusion — after all of this discussion, these researchers surveyed over a thousand women — they conclude that it is difficult for clinicians to provide information to women about contraceptives without also discouraging them about using the most effective methods. The biggest problem here is that it’s hard for clinicians because if they come out and tell women about the side effects, then oh my gosh, they might discourage them from using it. And we don’t want that because the pill is infallible, there’s nothing wrong with the pill, obviously.

Are you kidding me? The biggest problem isn’t the millions of women who experience anxiety and depression and low libido and sexual dysfunction and clitoral shrinkage and vulvodynia. The pill profoundly decreases free testosterone and therefore it has this negative effect on libido for many women. Obviously all women don’t have the same effect. What I will say is all women do experience a profound decrease in testosterone when they take oral contraception. So if you were to do a blood draw across the board, all women are going to have a significantly decreased amount of free testosterone. That’s due to the influx of synthetic estrogen when you’re taking this hormone cocktail — that large influx of synthetic estrogen causes the sex hormone binding globulin, SHBG, to essentially attract and bind a significant amount of the free testosterone, and there’s also a reduction in the amount of testosterone that we produce. So across the board this effect is there, but then how it plays out — what you’re specifically going to experience — is going to be different from woman to woman.

To put it back to the point — this is the problem. The problem is that women are using this contraception and they’re having negative experiences. And although not all women have negative experiences, a high percentage do. So much so that half of the women are coming off of it within a year because they just don’t like how they feel. And instead of having a medical system that’s actually concerned about what these women are experiencing and validating it — saying, “This is a problem, we should actually try to improve the delivery of this, we should try to improve the formulation, is there anything we can do?” — they’re saying basically that this method is effective and these women have to take it. So how do we present them with the information about it without discouraging them? Because at the end of the day, we need them to take the medication.

So for anyone who isn’t aware of why it’s so difficult to go to your medical doctor and express that you’ve had side effects and have this person take you seriously — as opposed to just telling you, “Oh, let’s just get you on another one,” or “That’s normal, don’t worry about it, just keep taking it, in a few months it’ll get better” — now you can kind of see that this is the underlying assumption of our healthcare system. This is why it is the way it is. Basically, this is the pill. The pill is great. The side effects are minor, according to them. And so just take it. And if you don’t like this one, just take this other one. And then if you say, “Okay, but I’m not having a good experience, I don’t respond well to the hormones, I want to do a non-hormonal method” — they tell you, oh, those don’t work. Those are totally ineffective, and it’s irresponsible for you to even consider that. And anybody who talks about it is an uneducated blah blah blah.

Anyways, I wanted to share this study because I just feel like it shows you what we’re up against. It shows you what we’re dealing with. It sheds a lot of light on why women have the experiences that they do in medical offices. And I think one of the challenges as well is that since not all women experience negative side effects, there’s a lot of women out there who get really upset when people talk about the side effects because they personally haven’t experienced it. A lot of women out there will say, okay, well, you’re trying to take away my birth control and this is about reproductive rights. And by me talking about these things, it’s not me trying to take away birth control. I took birth control and hundreds of millions of women take birth control around the world. So it’s not about that. For me, it’s about education. We just have the right to know. We have the right to know — because since half of women who are going on contraceptives are dissatisfied enough that they’re coming off of it within a year, we need to be educated about the side effects so that at least we can know what to expect. At least we can know if we’re experiencing panic attacks or low mood, depression, low libido, painful sex — some of the common side effects women experience — at least we know it could be related to the pill.

When we don’t talk about the side effects, women experience this stuff and they internalize it. They think it’s them. They think there’s something wrong with them. I’ve spoken to so many women who experienced mood side effects on the pill. They didn’t feel like themselves. They felt depressed. They felt even just like having a low, flat emotion — no affect, no ups and downs, feeling numb. And especially women who go on the pill at a young age, in their teens — they tend to then think that okay, this is just me, this is how I am, I just don’t have a happy personality, I’m just a depressed person. And if no one tells you that these are common side effects of the pill, then you just take that on and continue to have this negative experience.

I think it’s unfortunate that there’s such a pro-pill bias in the medical community that they’re not really willing to talk honestly and frankly about the side effects because they’re concerned that they’re going to discourage women from using it. I think that that is a terrible way to go, because women — we should be thought of as smart individuals who can make informed choices for ourselves. We shouldn’t be pushed into using something because our health professionals feel this fatherly desire to tell us that it’s the right thing for us. At the end of the day, I have the right to identify the positives and negatives about anything that I’m thinking about doing and making that decision for myself. I shouldn’t have this paternalistic medical system telling me that this is what I should be doing because they feel it’s right for me and there’s something wrong with me and that’s why I’m complaining about my side effects.

So if you enjoyed today’s episode and you want to share the link, it is fertilityfriday.com/516. I hope that you have a wonderful week — whenever you’re tuning into the show — and of course, as always, until next time, be well and happy charting.