May 2018

While most patients with depression and related disorders will do well on most types of combined oral contraceptives, some have difficulty finding a satisfactory pill. For these patients, consider progestin type, phasic dosing, and extended or continuous regimens, say Kelli Stidham Hall and Julia R. Steinberg in the upcoming 21st edition of Contraceptive Technology, available September 2018.^[1]

Family planning providers, who are often the sole source of healthcare for reproductive-aged women, are uniquely well-suited to address interrelated mental and reproductive health needs. In a brand new chapter on mental health and contraception, Hall and Steinberg write that contraception should be situated in the broader context of patients’ mental, physical, and reproductive health and wellbeing.

Most patients with depression and related disorders will do well on most types of combined oral contraceptives (COCs), and in fact research has suggested that the experi­ences of women with perceived side effects are generally similar across the many different available formulations of COCs (there are more than 90 different Food and Drug Administration (FDA)-approved COCs in the U.S. alone).^[2],[3],[4] Contraceptive counseling should emphasize this point. However, several theoretical considerations may be useful in help­ing patients select the most suitable formulation, particularly for those patients who may have difficulty finding a satisfactory pill.

Progestin type, phasic dosing, and extended or continuous regimens are other considerations for COC selection among patients with de­pression and related conditions. A recent comprehensive review found that COCs containing less androgenic progestins may be less likely to contribute to mood symptoms compared to pills with higher androgenic properties.^[5] Fourth-generation drospirenone-containing COCs have an FDA-approved indication for treatment of premenstrual dysphoric dis­order (PMDD)-related mood symptoms and thus may be beneficial for some patients with depression and anxiety disorders.⁴ Levonorgestrel- and norgestrel-containing COCs (second generation) are not known to contribute to mood symptoms, and given their widespread use, also offer suitable options.^[6],[7],[8] Many of these progestins are available in various phasic dosages, which could have rel­evance for cyclic mood symptoms due to variable circulating estrogen levels during ovulation and menses. For patients with cyclic mood con­cerns, monophasic formulations offer a steady dose (versus triphasic or 4-phasic formulations) to better stabilize hormone levels and minimize the risk of mood symptoms.^8,[9] Patients who report mood symptoms during their placebo week (i.e., estrogen withdrawal) may benefit from COCs with extended cycle regimens (e.g., 24/4) or continuous dosing (i.e. skipping inactive pills), which would reduce or eliminate the estro­gen withdrawal period.⁹

See Table 1 for strategies on counseling patients with mental health concerns.

Hall and Steinberg advise that, for the most part, a patient-provider shared deci­sion-making process should inform contraceptive method selection based upon the patient’s individual health circumstances, contraceptive preferences, and family planning needs, rather than a mental health diagnosis or treatment. Drug interactions between modern pharmaco­logic antidepressant agents and hormonal contraceptives are relatively rare, and the best available scientific evidence suggests selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) do not interact with hepatic metabolism of synthetic steroids in COCs or other locally acting hormonal contraceptives.^[10],[11]

You can read more about contraception and mental health in the 21^st edition of Contraceptive Technology, due out in September 2018. Click here for ordering information.

[1] Hall KS, Steinberg JR. Mental Health and Contraception. Hatcher RA, Nelson A, Trussell J, et al. Contraceptive Technology, 21^st edition. New York, NY: Ayer Company Publishers, Inc. In production.

[2] Moreau C, Trussell J, Gilbert F, Bajos N, Bouver J. Oral contraceptive tolerance: does the type of pill matter? Obstet Gynecol 2007;109:1277-85.

[3] Hall KS, Trussell J. Types of combined oral contraceptives used by US women. Contraception 2012:86:659-65.

[4] Hatcher RA, Trussell J, Stewart F, et al. Contraceptive technology, 20th revised edition. New York, Ardent Media, 2004.

[5] Schaffir J, Worly BL, Gur T. Combined hormonal contraception and its effects on mood: a critical review. Eur J Contraception Reprod Health Care 2016;21:347-355.

[6] Maitra NN, Kulier R, Bloemenkamp K, Helmerhorst FM, Gulmezogul AM. Progesto­gens in combined oral contraceptives for contraception. Cochrane Database Syst Rev 2004;3:CD004861.

[7] Lawrie TA, Helmerhorst FM, Maitra NN, Kulier R, Bloemenkamp K, Gulmezoglu AM. Types of progestogens in combined oral contraception: effectiveness and side-effects Cochrane Database Syst Rev 2011;5:CD004861.

[8] Van Vliet HAAM, Grimes DA, Lopez LM, Schulz KF, Helmerhorst FM. Triphasic ver­sus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev 2011;11:CD003553.

[9] Edelman A, Gallo MF, Jensen JT, Nichols MD, Grimes DA. Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception. Cochrane Database Syst Rev 2014;7:CD004695.

[10] Koke SC, Brown EB, Miner CM. Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy. Am J Obstet Gynecol 2002;187:551-5.

[11] D’Arcy PF. Drug interactions with oral contraceptives. Drug Intell Clin Pharm 1986;20:353-62.