Pick your poison: The serious side effects of The Pill we're not talking about.

In 1961, the contraceptive pill first came out in Australia. It was a huge deal. Massive. For the first time, women had control over their sexual and reproductive health. We had options and a sense of freedom that we had never experienced before. 

We entered the workforce. We extended our education. We got degrees. We made money. The introduction of oral contraception was revolutionary. 

It had a powerful impact on social and economic benefits for women, and has been hailed as one of the greatest scientific innovations of the 20th century.

Watch: Did you know there are different types of birth control pills? Here's some advice on how to find which one is right for you. Post continues below.

These days, around 922 million women of reproductive age (or their partners) are contraceptive users.

When taken correctly, the pill is more than 99 per cent effective at preventing pregnancy, and many women who take it enjoy positive side effects such as clearer skin, fewer PMS symptoms, regular periods and improved moods.

However, while we can't forget how groundbreaking it was or what it did for women, the pill isn't perfect. In fact, we're only now beginning to learn that it's far from it. 

While we usually focus on the physical side effects of the pill, you might not be aware that the most common reason women stop taking the pill is not because they're ready to start a family — but due to mental health issues.

There are women who experience little to no negative side effects taking the pill, but there are also many more who report things like a serious loss of libido, depression, anxiety and even suicidal thoughts.

To put this into perspective, these side effects are coming from one of the most commonly prescribed forms of contraception in Australia. Something that one in four Australian women between the ages of 18 and 49 use.

Pretty scary, huh?

But it's not completely surprising. For a long time we've been aware of how the pill can make us feel sad, angry, or just a bit 'off' — ask any woman and if she hasn't experienced some negative side effects, chances are she'll know of someone who has. The problem is, no one has been told why.

While some of these people will decide to go off the pill, many of us will stay on it — or not even be acutely aware of these side effects. So more often than not, these issues just get pushed into the back corner.

But did you know there's actually a proven link between the pill and poor mental health? A big fat link that no one really talks about? We didn't. In fact, we had to write an entire article on it before we found out how the pill impacts our brain.

In recent years new studies have not only verified this link, but revealed so many other side effects most of us are completely unaware of. Negative and potentially long-term effects of something healthy women, like you and I, take every day. 

That's pretty terrifying.

So, why are we tiptoeing around the suggestion the birth control pill could be problematic? Why is it so explosive if we're talking about our health? 

Well, it's an incredibly delicate subject for good reason. The stakes aren't just high for anyone who has ovaries, but the possibility of scaremongering and unwanted pregnancies is a very real risk.

So now we've found ourselves trapped in this weird limbo where we don't want to be ungrateful, but we know we deserve better. 

Let's break down what we know.

Does the pill really cause depression and anxiety?

Okay. We're not going to dance around it — the research behind this paints a pretty bleak picture.

Professor and author of This Is Your Brain On Birth Control, Sarah Hill, wrote an entire book that validates what generations of women have suspected since the introduction of the pill — that it is doing a whole lot more than simply preventing pregnancy.

She told us that oral contraceptives are affecting women’s thinking, emotions and behaviour. And we need to have a conversation about it.

"There has been a growing body of research that suggests that women who are on hormonal contraception are at greater risk of developing depression and anxiety than women who are not," said Professor Hill. "Research suggests that these differences stem from differences in hormonal and neurotransmitter activity in the brains of hormonal contraception."

In Australia, Jayashri Kulkarni, a Professor of Psychiatry at Monash University, led research into the effects of oral contraception on mood and anxiety. Her study found that woman taking the oral contraceptive pill were more likely to be depressed than non-pill users. 

It was discovered that women taking the pills with low amounts of oestrogen had more depression than those taking higher oestrogen dose pills. (FYI: Typically, combined oral contraceptive pills contain a form of estrogen and a form of progesterone).

Overall, the study found that the progesterone-only contraceptives were the most depressive of all the contraceptives. 

Further to this, a 2016 study conducted in Denmark by Professor Øjvind Lidegaard, showed women taking the combined oral contraceptive pill were 23 per cent more likely to be diagnosed with depression, while those using progestin-only pills were 34 per cent more likely. 

In an interview with Refinery29, Lidegaard explained that while we know some women experience severe mental health side effects when taking hormonal contraception — the problem was that beyond his study we don’t know exactly how many are affected. Professor Lidegaard and his team were only able to run this study because Denmark collects patient and prescription data.

"There has been a lot of research in hormonal contraception," he told Refinery29. "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."

Image: Getty 

Since Professor Lidegaard's research, a study was conducted in late 2019. It was led by Dr Michael Lipton, Professor of Radiology at the Albert Einstein College of Medicine in New York, and it found that hormonal contraception might be "altering the structure of women’s brains". 

It was noted that the pill had an effect on a part of the brain (called the hypothalamus) which regulates pretty much all of our hormones. However, it was concluded that further investigation is needed into how hormonal contraception potentially impacts a woman's brain function.   

Yet, despite the significance of these studies and the overwhelming evidence produced, it is surprising that nothing has really changed.

"This is something that has been found in research studies since the 1990s. It's crazy to me that a bigger deal hasn't been made of this," said Professor Hill. 

So, why hasn't there been more noise made around these studies? Why are we all being left in the dark?

Well, the fact is that until very recently, there has been little research surrounding hormonal contraceptions and mental health. And the research that is out there isn’t being published in medical journals, but rather in psychology and neuroscience journals. Meaning? Doctors often aren’t aware of these side effects.

Professor Kulkarni, who led the Australian study, also said it's still a taboo topic in society.

"While the data shows a link between certain types of pill (eg: progesterone-only pills, subcutaneous and intra-uterine devices — are associated with higher levels of depression), there is still confusion because many women using hormone contraception do NOT experience depression. Their experience throws doubt on the experience of those who do."

Professor Kulkarni also says that often the type of depression experienced on the pill is not always the easily recognised major depressive disorder with characterised, described symptoms. "I also think there is reluctance to believe that gonadal hormones impact mental health – although there is ample neuroscientific evidence for this," she adds.

According to Professor Hill, more research and medical intervention is the only way forward.

"The stress response of pill-takers looks very similar to that of people who have PTSD or have experienced trauma. This is also something that is linked with depression and anxiety. There isn't a clear answer, yet, for why this happens and there is critical need for new research on this," she explains.

When we spoke to Associate Professor Caroline Gurvich, Clinical Neuropsychologist and Deputy Director of Monash Alfred Psychiatry research centre, she said there is a crucial need to learn more about which women are vulnerable to the adverse mood effects. 

"Research suggests somewhere between 32 per cent and 60 per cent of women discontinue oral contraceptive use within six months for a variety of reasons — but one of those reasons is mood changes."

As 22-year-old Melinda tell us: "I tried four different versions of the pill across a year and a bit, and my god it was chaotic. I was extremely moody and on edge. I was constantly eating and my head always felt a mess, to the point my boyfriend was concerned for my health. It also triggered my anxiety and depression. I already had this but the pill just amplified it and I ended up needing to see a doctor. Never again."

While the statistics speak for themselves, for some reason it is still surprising and scary to find out how common it is for Australian women to experience a wealth of side effects on their mental health.

After being on the pill for nine years due to polycystic ovary syndrome, 24-year-old Emily recently went off it only to experience dramatic changes in her body and mental heath. 

She said, "I suffer from sporadic depression episodes and I haven’t had one since. My scalp has gotten so much oiler, my skin, which used to be oily is now dry.

"I lost 2kg the minute I got off it, I eat heaps less, my mood is so much brighter and I feel like I’m in control with my feelings."

One 26-year-old woman said, "I have been on the pill for 11 years, and one time the doctor messed up one of my scripts and gave me a different dosage (I went from Microgynon 25 to Microgynon 30) and I literally slipped into a black hole. I felt like everything was hazy and I cried pretty much for two weeks straight. It was terrifying. I realised then that the dosage was different and switched back ASAP."

These studies and experiences not only verify very obvious links to poor mental health, but they also highlight the need for more research into the negative and potential long-term effects of the oral contraception pill.

"Learning more about why some women are particularly vulnerable to adverse mood effects is needed. Developing a biomarker (e.g. a marker that could be picked up in a blood test) that could identify which women are vulnerable to adverse mood effects would be a significant step forward," said Gurvich.

However, this need for further research then ties us into another issue — the funding of clinical trials. It's obviously very expensive to secure research funding, and the main sponsors are often drug companies — which makes things incredibly difficult when you're trying to prove the negative effects of a medication.

What other side effects have been associated with the pill?

Yep. There's more. Beyond the link between depression and anxiety, Professor Hill said there are other, lesser-known side effects you might not be aware of. The fact is that sex hormones have a domino effect on other parts of our body — the pill doesn't just affect your ovaries.

Listen: More of a podcast person? That's cool. Here's what no one tells you about the pill and men. Post continues below.

"In addition to impacting mood and the stress response, hormonal contraceptions can impact sexual functioning and who we are attracted to, the way our brain processes rewards, the structure of the hippocampus and hypothalamus, how hungry we feel, our ability to persevere on difficult tasks, and certain aspects of our memories," said Hill. "The effects are pervasive because there are sex hormone receptors on cells in almost all key areas of the brain."

Just on the fact that pill can alter WHO YOU ARE ATTRACTED TO: Apparently oestrogen is known to shape a woman's preferences when it comes to partners. The hormone steers us to favour qualities associated with masculinity and higher testosterone, like square jaws and broad shoulders, for example. 

But research suggests women who are taking the pill are lacking this cyclical oestrogen urge (thanks to the artificial progesterone dominance), meaning their preferences towards who they are attracted to are different. 

Why is this important? Well, it could lead to dissatisfaction. If a woman chooses her partner when she's on the pill and then goes off it, she may no longer find that she is attracted to the person.

When it comes to sexual functioning, for many years it has been suspected that the oral contraceptive pill may influence libido and sex drive. And there is now significant evidence to prove this. 

A study recently completed in Sweden, found that sexual desire, arousal and pleasure were significantly diminished in the women using the contraceptive pill compared with women using a placebo pill.

As 30-year-old Lisa tells us, going on the pill not only resulted in feelings of depression and anxiety but also sexual dissatisfaction. "I was also SO moody and depressed, my libido was non-existent (like what is the point?) and I felt as though my emotions were almost borderline psychotic. I'd start fights with my boyfriend and take every little comment so badly, it was hell. For me and everyone around me. I went off the pill and have never touched it again."

But stay with us — it's not all bad news. In terms of memory function, Professor Gurvich and Professor Kulkarni published a study that found that the combined contraceptive pill may improve 'verbal memory' or memory for words and language.

"The 'exogenous' hormones that make up the contraceptive pill are understood to have an impact on our brain and behaviour. Studies on oral contraceptives and cognition so far suggest that some areas of cognition may improve with the contraceptive pill – for example verbal memory has been shown to improve with contraceptive pill use and this has been attributed to the estrogen component in the pill," explains Professor Gurvich.

The recent study involved 35 oral contraceptive users who had their cognitive (thinking) skills assessed during days seven to 10 of active hormonal pill phase, and days three to five of the inactive or 'sugar' pill phase (coinciding with the withdrawal bleed resembling menstruation). 

According to Professor Gurvich, "Approximately half the women were taking oral contraceptives with older 'androgenic' progestins and half were taking oral contraceptives that contained a newer generation of progestin ('anti-androgenic'). We found that the older androgenic pill types were associated with better visual-spatial skills, as well as better facial emotion recognition."

However, women using newer contraceptives (like Dianne and Yaz), which use anti-androgenic progestins, had impaired visual-spatial performance.

So, how big are the effects we're talking about? Professor Gurvich said the cognitive effects are likely to be subtle. But at an individual level, some women are going to experience changes while others are going to have absolutely none.

Gurvich said research exploring the impact of the oral contraceptive pill on cognitive performance is still in its infancy, and there is a strong case for further studies.

"If the current studies are replicated and extended to help us understand how different hormonal therapies (including oral contraception) influence cognitive and emotion processes, this may have implications for women's choices about oral contraceptions and the impact on their daily life," said Professor Gurvich.

Why is there such a lack of research?

While there is some research and development, the mental health aspect of hormonal contraception remains far behind. But why?

Professor Hill said this current confusion, conflicting messaging and lack of research that has just been accepted, comes down to several things.

"Much of the research is cross-sectional because doing randomised experiments is difficult to do with the pill (for obvious ethical reasons). This leaves a window open for criticism, for people to say, 'You can't show causation for this research', despite the fact that new statistical methods allow researchers to do a really thoughtful job of removing confounds from such research," said Professor Hill.

"We are all motivated to believe that the pill doesn't impact anything other than our ovaries, so we are quick to accept dismissive statements about this research. We have a blind spot with the pill. The idea that changing women's hormones won't impact their brains is nothing short of magical thinking."

Professor Kulkarni said that contraception is seen as a choice, an option — not a necessity — so the development in research and alternatives is at a lower priority than life saving cancer drugs, for example. 

"I think there is still considerable coyness/prudery or even acknowledging that women have the right to enjoy sex without having to get pregnant. And then there are the traditional religious bans on contraception that are still with us today, which may exert subtle restrictions on further developments," she said.

Should we seek alternatives to the pill?

Every woman is different, and while we don't want to make recommendations surrounding whether the pill is right for you, it's worth understanding the psychological trade-offs before deciding if you should use it.

"The contraceptive pill as a class of drug is safer than the early versions produced in the 1960s. BUT — there are still many unacceptable side effects. This includes life-threatening ones (blood clots), major depression in some women, and a more insidious subclinical depression in others, decreased libido, weight gain, dark skin patches on the face and for some women, increased thrush and migraines," said Professor Kulkarni. 

"The 'safety' depends on the woman’s age, other health issues and whether she smokes," she adds.

Professor Gurvich said if women, particularly younger adolescent women, are experiencing depression or other mood symptoms, it is important to question whether they are taking oral contraception and the type of oral contraception they are taking.

"It is important for women who have started a type of pill or changed it and then felt 'not quite right' or other non-specific mental changes, to recognise that it could be the pill causing this," adds Professor Kulkarni. "Your doctors need to work with you on this — and not dismiss your observations. It is important in this instance to change the type of pill — as they are all different — to find one that suits."

So, where does this leave us?

Ideally, we need a better contraception option that’s really safe and effective — we need something that prevents pregnancy without negatively impacting women's bodies in other ways. The fact is that there has been no scientific innovation since the pill — beyond the hormonal coil and implant. 

"We need 'real world' clinical trials (expensive to do!), we need women to come forward and talk about their experiences and collect this type of qualitative data, we need for general media to do more stories on this topic — so that women in the community are better informed. Ultimately — we need for the pharmaceutical industry to develop newer pills that do not contain depressogenic progesterone, and do not cause other adverse effects like weight gain," said Professor Kulkarni.

But don't hold your breath. Professor Gurvich said, "Studies have reported on the slow rate of development in the area of male contraceptive research — one barrier cited is the limited support from major pharmaceutical sponsors of male hormonal contraceptive research."

As Professor Hill sees it, it all comes down to education and creating awareness of the potential negative mental health side effects of hormonal contraception. It's getting women to know that the pill isn't just something that affects your ovaries — it's so much more.

"We need to teach women about their bodies, brains and cycles in school," said Professor Hill. "This should be part of basic education curriculum. It's absurd to me that I had to be in a PhD program to learn how my cycle worked and the critical role that my sex hormones play in coordinating the activities in my brain and behaviour. Without this information, we are at the mercy of doctors to make decisions for us."

What is your experience with taking the pill? Share with us in the comment section below.

Feature image: Getty