Oral contraceptive use changes brain activity and mood in women with previous negative affect on the pill--a double-blinded, placebo-controlled randomized trial of a levonorgestrel-containing combined oral contraceptive

Assessing the impact of contraceptive use on mental health among women of reproductive age - a systematic review

BACKGROUND

Contraceptive use is the principal method by which women avoid unintended pregnancy. An unintended pregnancy can induce long-term distress related to the medical, emotional, and social consequences of carrying that pregnancy to term.

OBJECTIVES

This review investigates the effects of modern contraception techniques such as birth control pills, long-acting reversible contraceptives (e.g., intrauterine devices, implants), and condoms on mental health status.

METHODS

We searched multiple databases from inception until February 2022, with no geographical boundaries. RCTs underwent a quality assessment using the GRADE approach while the quality of observational studies was assessed using the Downs and Black scoring system. Data were analyzed through meta-analysis and relative risk and mean difference were calculated and forest plots were created for each outcome when two or more data points were eligible for analysis.

MAIN RESULTS

The total number of included studies was 43. In women without previous mental disorders, both RCTs (3 studies, SMD 0.18, 95% CI [0.02, 0.34], high quality of evidence) and cohort studies (RR 1.04 95% CI [1.03, 1.04]) detected a slight increase in the risk of depression development. In women with previous mental disorders, both RCTs (9 studies, SMD - 0.15, 95% CI [-0.30, -0.00], high quality of evidence) and cohort studies (SMD - 0.26, 95% CI [-0.37, -0.15]) detected slight protective effects of depression development. It was also noticed that HC demonstrated protective effects for anxiety in both groups (SMD - 0.20, 95% CI [-0.40, -0.01]).

CONCLUSIONS

Among women with pre-existing mental disorders who use hormonal contraceptives, we reported protective association with decreased depressive symptoms. However, the study also draws attention to some potential negative effects, including an increase in the risk of depression and antidepressant use among contraceptive users, a risk that is higher among women who use the hormonal IUD, implant, or patch/ring methods. Providers should select contraceptive methods taking individual aspects into account to maximize benefits and minimize risks.

The levonorgestrel-releasing intrauterine device is related to early emotional reactivity: An ERP study

Despite the evidence of altered emotion processing in oral contraceptive (OC) users, the impact of hormonal intrauterine devices (IUD) on emotional processing remains unexplored. Our study aimed to investigate how behavioural performance and event-related potentials (ERPs) linked with emotion reactivity and its regulation are associated with hormonal profiles of women using different types of hormonal contraception and naturally cycling women. Women using OCs (n = 25), hormonal IUDs (n = 33), and naturally cycling women in their early follicular (NCF, n = 33) or mid-luteal (NCL, n = 28) phase of the menstrual cycle were instructed to view emotional pictures (neutral, low and high negativity) and use cognitive reappraisal to up- or down-regulate negative emotions, while their electroencephalogram was recorded. Participants rated perceived negativity after each picture and their emotional arousal throughout the task. Saliva samples were collected to assess levels of 17β-estradiol, progesterone, and testosterone. As expected, emotional arousal increased throughout the task and correlated positively with perceived negativity. Perceived negativity and the amplitudes of the middle (N2/P3) and later (LPP) latency ERP components increased with increasing stimuli negativity. Emotion regulation modulated perceived negativity and the amplitudes of very late ERP components (parietal and frontal LPP). Moreover, IUD-users showed a higher negative amplitude of the frontal N2 in comparison to all three other groups, with the most consistent differences during up-regulation. Finally, testosterone correlated positively with the N2 peak in IUD-users and NCL women. Overall, our findings suggest that IUD-use and testosterone might be related to altered preconscious processing during the emotion regulation task requiring attention to the stimulus. The study underscores the need for additional research into how different hormonal contraceptives are linked to socio-emotional functioning.

Prevalence of anxiety and depression among Lebanese women using oral contraceptives: a cross-sectional study

BACKGROUND

Oral contraceptives (OCs) are used worldwide, including Lebanese women. However, the association between OCs use and anxiety or depression remains unclear. This study aims to assess the prevalence of anxiety and depression among Lebanese women using oral contraceptive pills and investigate the differential impact of combined oral contraceptives (COCs) versus progestogen-only pills (POPs) on mental health outcomes.

METHODS

A cross-sectional study was conducted among a sample of Lebanese women using OCs between January and March 2023. Nine hundred nighty seven out of the 2051 women who took part in the survey met our criteria and were included in this study. Data on anxiety and depression were collected using validated and reliable scales, the Arabic versions of the Generalized Anxiety Disorder-7 Questionnaire (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9). Statistical analyses, including multivariate analysis, were performed to assess the association between OCs type (COC vs. POP) and anxiety/depression.

RESULTS

The prevalence of anxiety and depression among Lebanese women taking OCs was found to be 39.9% and 64.3%, respectively. Furthermore, the study revealed that POP users had 2.8 times higher odds of developing anxiety (adjusted odds ratio ORadj = 2.8 with 95% confidence interval CI of 1.770 to 4.435) p-value < 0.001 and 9.2 times higher odds of developing depression (adjusted odds ratio ORadj = 9.2 with 95% confidence interval CI of 5.790 to 14.506) p-value < 0.001 compared to COC users.

CONCLUSION

The results of this study shed light on the elevated prevalence of anxiety and depression among Lebanese women using OCs and emphasized the varying effects of COCs and POPs on their mental health outcomes. Further research is needed to comprehensively understand this association, considering both the dosage and specific type of oral contraceptive to improve the overall well-being of women using these contraceptives.

Reversible female contraceptives: historical, current, and future perspectives†

Contraception is a practice with extensive and complicated social and scientific histories. From cycle tracking, to the very first prescription contraceptive pill, to now having over-the-counter contraceptives on demand, family planning is an aspect of healthcare that has undergone and will continue to undergo several transformations through time. This review provides a comprehensive overview of current reversible hormonal and non-hormonal birth control methods as well as their mechanism of action, safety, and effectiveness specifically for individuals who can become pregnant. Additionally, we discuss the latest Food and Drug Administration (FDA)-approved hormonal method containing estetrol and drospirenone that has not yet been used worldwide as well as the first FDA-approved hormonal over-the-counter progestin-only pills. We also review available data on novel hormonal delivery through microchip, microneedle, and the latest FDA-approved non-hormonal methods such as vaginal pH regulators. Finally, this review will assist in advancing female contraceptive method development by underlining constructive directions for future pursuits. Information was gathered from the NCBI and Google Scholars databases using English and included publications from 1900 to present. Search terms included contraceptive names as well as efficacy, safety, and mechanism of action. In summary, we suggest that investigators consider the side effects and acceptability together with the efficacy of contraceptive candidate towards their development.

Association of oral contraceptive pill use and depression among US women

BACKGROUND

The link between oral contraceptive pill (OCP) and depression is still unclear. This work analyses the prevalence and correlates of major depression in US women using OCP.

METHODS

This study used the National Health and Nutrition Examination Survey (NHANES) 2005-2012 data to provide the prevalence and correlates of major depression in women using OCP. Major depression was defined as a score of ≥10 using the Patient Health Questionnaire-9 (PHQ-9).

RESULTS

A total of 6239 women aged 18-55 years were included in the present analysis. Current OCP users had a lower prevalence of major depression (4.6 %; 95 % CI, 3.2 to 6.6) compared to former users of OCP (11.4 %; 95 % CI, 10.1 to 12.9) and never users of OCP (10 %; 95 % CI, 8.3 to 12.1). Current users of OCP were significantly less likely to report major depression compared to former users of OCP (OR 0.59; 95CI%, 0.39 to 0.90) after adjusting for potential confounders. The prevalence of major depression was higher in women who were: black or Hispanic, widowed/divorced/separated, those with a low and middle income, current smokers, current users of antidepressants, and with history of cancer and thyroid problems.

LIMITATIONS

This is a cross-sectional study.

CONCLUSION

The prevalence of major depression among women using OCP may be lower than in former users of OCP, however, the burden of depression remains high. Further research with longitudinal follow-up for depression in women using OCP is needed to understand real world effect of the OCP on depression.

Sex steroids and the female brain across the lifespan: insights into risk of depression and Alzheimer's disease

Despite widespread sex differences in prevalence and presentation of numerous illnesses affecting the human brain, there has been little focus on the effect of endocrine ageing. Most preclinical studies have focused on males only, and clinical studies often analyse data by covarying for sex, ignoring relevant differences between the sexes. This sex- (and gender)-neutral approach is biased and contributes to the absence of targeted treatments and services for all sexes (and genders). Female health has been historically understudied, with grave consequences for their wellbeing and health equity. In this Review, we spotlight female brain health across the lifespan by informing on the role of sex steroids, particularly oestradiol, on the female brain and on risk for diseases more prevalent in females, such as depression and Alzheimer's disease.

Mental Health Symptoms in Oral Contraceptive Users During Short-Term Hormone Withdrawal

Importance

Hormonal contraception has been linked to mood symptoms and the ability to recognize emotions after short periods of treatment, whereas the mental health of users of long-term hormonal contraceptives has had limited investigation.

Objective

To evaluate whether short-term hormonal withdrawal, which users of combined oral contraceptives (COCs) undergo once a month (pill pause), was associated with altered mood and emotional recognition in long-term users of COCs.

Design, Setting, and Participants

This case-control study included a community sample of individuals assigned female sex at birth who identified as women and used COC for 6 months or longer. The control group included women with natural menstrual cycles who otherwise fulfilled the same inclusion criteria. The study was conducted between April 2021 and June 2022 in Salzburg, Austria.

Exposure

COC users and women with natural menstrual cycles were tested twice within a month, once during their active pill phase or luteal phase and once during their pill pause or menses.

Main Outcomes and Measures

Negative affect, anxiety, and mental health problems were assessed during each session. The percentage increase in mental health symptoms was calculated during the pill pause compared with that during the active intake phase in COC users. How this change compared with mood fluctuations along the menstrual cycle in women with natural menstrual cycles was assessed.

Results

A total of 181 women aged 18 to 35 years (mean [SD] age, 22.7 [3.5] years) were included in the analysis (61 women with androgenic COC use, 59 with antiandrogenic COC use, 60 women with a menstrual cycle not taking COCs). COC users showed a 12.67% increase in negative affect (95% CI, 6.94%-18.39%), 7.42% increase in anxiety (95% CI, 3.43%-11.40%), and 23.61% increase in mental health symptoms (95% CI, 16.49%-30.73%; P < .001) during the pill pause compared with the active intake phase. The effect size of this change did not differ depending on progestin type (negative affect: F1,117 = 0.30, P = .59; state anxiety: F1,117 = 2.15, P = .15; mental health: F1,117 = .16, P = .69) or ethinylestradiol dose (negative affect: F1,57 = .99, P = .32; state anxiety: F1,57 = 2.30, P = .13; mental health: F1,57 = .14, P = .71) was comparable with mood changes along the menstrual cycle in women with natural cycles (negative affect: F2,175 = 0.13, P = .87; state anxiety: F2,175 = 0.14, P = .32; mental health: F2,175 = 0.65, P = .52). Mood worsening during the pill pause was more pronounced in women with higher baseline depression scores (negative affect increase of 17.95% [95% CI, 7.80%-28.10%] in COC users with higher trait depression [BDI >8]). Emotion recognition performance did not differ between active pill phase and pill pause.

Conclusions and Relevance

In this case-control study of long-term COC users, withdrawal from contraceptive steroids during the pill pause was associated with adverse mental health symptoms similar to those experienced by women during menses with withdrawal from endogenous steroids. These results question the use of the pill pause from a mental health perspective. Long-term COC users may benefit more from the mood-stabilizing effects of COCs in cases of continuous intake.

Women's health, hormonal balance, and personal autonomy

Hormone-based contraception disrupts hormonal balance, creating artificial states of anovulation and threatening women's health. We reviewed its main adverse effects and mechanisms on accelerated ovarian aging, mental health (emotional disruptions, depression, and suicide), sexuality (reduced libido), cardiovascular (brain stroke, myocardial infarction, hypertension, and thrombosis), and oncological (breast, cervical, and endometrial cancers). Other "collateral damage" includes negative effects on communication, scientific mistrust, poor physician-patient relationships, increased patient burden, economic drain on the healthcare system, and environmental pollution. Hormone-sensitive tumors present a dilemma owing to their potential dual effects: preventing some cancers vs. higher risk for others remains controversial, with denial or dismissal as non-relevant adverse effects, information avoidance, and modification of scientific criteria. This lack of clinical assessment poses challenges to women's health and their right to autonomy. Overcoming these challenges requires an anthropological integration of sexuality, as the focus on genital bodily union alone fails to encompass the intimate relational expression of individuals, complete sexual satisfaction, and the intertwined feelings of trust, safety, tenderness, and endorsement of women's femininity.

Triple network model of brain connectivity changes related to adverse mood effects in an oral contraceptive placebo-controlled trial

Combined oral contraceptives (COC) are among the most commonly used contraceptive methods worldwide, and mood side effects are the major reason for discontinuation of treatment. We here investigate the directed connectivity patterns associated with the mood side effects of an androgenic COC in a double-blind randomized, placebo-controlled trial in women with a history of affective COC side effects (n = 34). We used spectral dynamic causal modeling on a triple network model consisting of the default mode network (DMN), salience network (SN) and executive control network (ECN). Within this framework, we assessed the treatment-related changes in directed connectivity associated with adverse mood side effects. Overall, during COC use, we found a pattern of enhanced connectivity within the DMN and decreased connectivity within the ECN. The dorsal anterior cingulate cortex (SN) mediates an increased recruitment of the DMN by the ECN during treatment. Mood lability was the most prominent COC-induced symptom and also arose as the side effect most consistently related to connectivity changes. Connections that were related to increased mood lability showed increased connectivity during COC treatment, while connections that were related to decreased mood lability showed decreased connectivity during COC treatment. Among these, the connections with the highest effect size could also predict the participants' treatment group above chance.

Hormonal contraception & face processing: Examining face gender, androgenicity & treatment duration

Previous cross-sectional studies observed differences between users and non-users of combined oral contraceptives (COCs) in both the structure and function of the fusiform face area (FFA) related to face processing. For the present study 120 female participants performed high-resolution structural, as well as functional scans at rest, during face encoding and face recognition. Participants were either never-users of COCs (26), current first-time users of androgenic (29) or anti-androgenic COCs (23) or previous users of androgenic (21) or anti-androgenic COCs (21). Results suggest that associations between COC-use and face processing are modulated by androgenicity, but do not persist beyond the duration of COC use. The majority of findings concern the connectivity of the left FFA to the left supramarginal gyrus (SMG), which is a key region in cognitive empathy. While connectivity in anti-androgenic COC users differs from never users irrespective of the duration of COC use already at rest, connectivity in androgenic COC users decreases with longer duration of use during face recognition. Furthermore, longer duration of androgenic COC use was related to reduced identification accuracy, as well as increased connectivity of the left FFA to the right orbitofrontal cortex. Accordingly, the FFA and SMG emerge as promising ROIs for future randomized controlled trials on the effects of COC use on face processing.

Progesterone and contraceptive progestin actions on the brain: A systematic review of animal studies and comparison to human neuroimaging studies

In this review we systematically summarize the effects of progesterone and synthetic progestins on neurogenesis, synaptogenesis, myelination and six neurotransmitter systems. Several parallels between progesterone and older generation progestin actions emerged, suggesting actions via progesterone receptors. However, existing results suggest a general lack of knowledge regarding the effects of currently used progestins in hormonal contraception regarding these cellular and molecular brain parameters. Human neuroimaging studies were reviewed with a focus on randomized placebo-controlled trials and cross-sectional studies controlling for progestin type. The prefrontal cortex, amygdala, salience network and hippocampus were identified as regions of interest for future preclinical studies. This review proposes a series of experiments to elucidate the cellular and molecular actions of contraceptive progestins in these areas and link these actions to behavioral markers of emotional and cognitive functioning. Emotional effects of contraceptive progestins appear to be related to 1) alterations in the serotonergic system, 2) direct/indirect modulations of inhibitory GABA-ergic signalling via effects on the allopregnanolone content of the brain, which differ between androgenic and anti-androgenic progestins. Cognitive effects of combined oral contraceptives appear to depend on the ethinylestradiol dose.

Impact of Premenstrual Syndrome Symptoms on Sport Routines in Nonelite Athlete Participants of Summer Olympic Sports

PURPOSE

Most women during their lifetime experience a combination of premenstrual syndrome (PMS) symptoms (eg, menstrual cramps) before and often to the end of menstruation. However, the impact of these symptoms on sport routines (eg, performance, training absence) during phases around menstruation is still unclear. Therefore, we investigated the impact of PMS symptoms on sport routines among nonelite athletes over 3 phases related to menstruation.

METHODS

An online questionnaire was developed to recruit nonelite female athletes who participate in summer Olympic sports. Participants were allocated into 2 groups: those who experienced mild to moderate PMS symptoms (no-PMS) and those with severe PMS symptoms (p-PMS). Two hundred thirty-four responses from eumenorrheic women (p-PMS = 78%) were considered valid. An unpaired Student t test was conducted to compare demographic characteristics between groups and chi-square test to evaluate the impact of PMS status on sport routines between groups.

RESULTS

A significant (P < .05) proportion of women in the p-PMS group changed their training schedule because of menstrual (55%) and premenstrual (61%) symptoms compared with the no-PMS group. Overall, all participants indicated that training (P = .01) and competitive (P < .01) performance are impacted during menstruation, followed by a greater impact (P < .05) in the p-PMS group before menstruation.

CONCLUSION

The presence of PMS symptoms reduces training and competitive performance, primarily during and before menstruation, respectively. Severity of PMS symptoms was significantly associated with alterations in training schedule but not with competitive schedule.

Mental rotation, episodic memory, and executive control: Possible effects of biological sex and oral contraceptive use

Oral contraceptives (OCs) are one of the most common forms of hormonal birth control. A small literature suggests that OC use may affect visuospatial ability, episodic memory, and executive control. However, previous studies have been criticized for small sample sizes and the use of different, single cognitive tests. We investigated the degree to which biological sex and OC use might affect individual mental rotation, episodic memory, and executive control in a large sample of healthy, young adults (N = 155, including 52 OC users, 53 naturally cycling females, and 50 males) tested individually over videoconference. To measure cognition, we used a set of neuropsychological tasks inspired by Glisky and colleagues' two-factor episodic memory and executive control battery, from which two composite scores (based on principal component analysis) were derived for each participant. Our pre-registered analysis revealed a clear female advantage in episodic memory, independent of OC use. In an exploratory analysis, gist memory was elevated in OC users. Interestingly, we found no significant sex-related differences nor effects of OC use on mental rotation or executive control. Duration of OC use was also not related to any of our cognitive measures. These results suggest that the use of combined, monophasic OCs does not lead to many significant changes in cognition in young adults, although young females overall may have better episodic memory than young males. Additional studies, including longitudinal designs and looking in more detail at the menstrual cycle and OC use history, will further clarify the effects of different types of OCs and their duration of use on different aspects of cognition.

No decrease in perseverance and performance on cognitive tasks in Danish cohort of hormonal contraceptive users

Cognitive consequences of hormonal contraceptives (HCs) are largely underexplored, despite the popularity of use. This study investigates the association between perseverance during cognitively challenging tasks and the use of HCs among Danish women. We hypothesised that women using HCs show decreased perseverance across tasks compared to their naturally cycling counterparts. We further hypothesised that HC using women would show decreased performance as a measure of accuracy (i.e. more incorrect answers) compared to naturally cycling women. The study used a cross-sectional repeated measures design, consisting of a Danish version of the Anagram Persistence Task and the Hagen Matrices Test, followed by an extensive survey documenting menstrual and HC history for each participant. The study was conducted online. Data processing was conducted on data from 129 participants. The former hypothesis was analysed through multilevel regression with a nested random effects structure on log-transformed data. The latter hypothesis was analysed through a multilevel generalised linear model with a nested random effects structure using the binomial family. No support was found for either of the hypotheses.

Oral contraceptives in the central nervous system: Basic pharmacology, methodological considerations, and current state of the field

Millions of women around the world use combined oral contraceptives (OCs), yet surprisingly little is known about their central nervous system (CNS) effects. This article provides a short overview of the basic pharmacology of OCs, emphasizing features that may be relevant to understanding their effects in the CNS. Historical and recent findings from studies of cognitive function, mood, and negative affect (depressive changes under OC use) are then reviewed. We also present data from an archival dataset from our own laboratory in which we explore dysphoric changes in women using four generations of contraceptive progestins. Current data in the field are consistent with a modest effect of OC use on CNS variables, but conclusions based on current findings must be made very cautiously because of multiple methodological issues in many published studies to date, and inconsistencies in the findings. Directions for future research over the next 10 years are suggested. (150 words).

The Impacts of Sex Differences and Sex Hormones on Fear Extinction

Fear extinction memories are strongly modulated by sex and hormonal status, but the exact mechanisms are still being discovered. In humans, there are some basal and task-related features in which male and female individuals differ in fear conditioning paradigms. However, analyses considering the effects of sex hormones demonstrate a role for estradiol in fear extinction memory consolidation. Translational studies are taking advantage of the convergent findings between species to understand the brain structures implicated. Nevertheless, the human brain is complex and the transfer of these findings into the clinics remains a challenge. The promising advances in the field together with the standardization of fear extinction methodologies in humans will benefit the design of new personalized therapies.

Hormonal contraceptives and the brain: A systematic review on 60 years of neuroimaging, EEG, and biochemical studies in humans and animals

Hormonal contraception has been widely prescribed for decades. Although safety and efficacy are well-established, much uncertainty remains regarding brain effects of hormonal contraception. We systematically review human and animal studies on the brain effects of hormonal contraception which employed neuroimaging techniques such as MRI, PET and EEG, as well as animal studies which reported on neurotransmitter and other brain biochemical effects. We screened 1001 articles and ultimately extracted data from 70, comprising 51 human and 19 animal studies. Of note, there were no animal studies which employed structural or functional MRI, MRS or PET. In summary, our review shows hormonal contraceptive associations with changes in the brain have been documented. Many questions remain and more studies are needed to describe the effects of hormonal contraception on the brain.

Combined oral contraceptives and mental health: Are adolescence and the gut-brain axis the missing links?

Combined oral contraceptives (containing synthetic forms of estradiol and progestins) are one of the most commonly used drugs among females. However, their effects on the gut-brain axis have not been investigated to a great extent despite clear evidence that suggest bi-directional interactions between the gut microbiome and endogenous sex hormones. Moreover, oral contraceptives are prescribed during adolescence, a critical period of development during which several brain structures and systems, such as hypothalamic-pituitary-gonadal axis, undergo maturation. Considering that oral contraceptives could impact the developing adolescent brain and that these effects may be mediated by the gut-brain axis, further research investigating the effects of oral contraceptives on the gut-brain axis is imperative. This article briefly reviews evidence from animal and human studies on the effects of combined oral contraceptives on the brain and the gut microbiota particularly during adolescence.

Moving beyond the mean: Promising research pathways to support a precision medicine approach to hormonal contraception

Women's psychological and behavioral responses to hormonal contraceptive (HC) treatment can be highly variable. One of the great challenges to researchers seeking to improve the experiences of women who use HCs is to identify the sources of this variability to minimize unpleasant psychobehavioral side-effects. In the following, we provide recommendations for programs of research aimed at identifying sources of heterogeneity in women's experiences with HC. First, we review research demonstrating person- and prescription- based heterogeneity in women's psychobehavioral responses to HCs. Next, we identify several promising person- and prescription- based sources of this heterogeneity that warrant future research. We close with a discussion of research approaches that are particularly well-suited to address the research questions raised in article. Together, this review provides researchers with several promising research pathways to help support the development of a precision medicine approach to HC treatment.

Hormonal Contraceptive Use and Risk of Depression Among Young Women With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Women with attention-deficit/hyperactivity disorder (ADHD) have an increased risk of becoming teenage mothers. Adverse effects of hormonal contraception (HC), including depression, may affect adherence to user-dependent contraception and increase the risk for unplanned pregnancies and teenage births in women with ADHD. The current study analyzed whether girls and young women with ADHD are at increased risk for depression during HC use compared with non-ADHD women.

METHOD

A linkage of Swedish national registers covering 29,767 girls and young women with ADHD aged 15 to 24 years and 763,146 without ADHD provided measures of ADHD and depression diagnoses (International Classification of Diseases [ICD] code) and prescription of stimulant medication, HC, and antidepressant medication (Anatomical Therapeutic Chemical [ATC] code). Cox regression models applying an interaction term (ADHD diagnosis × HC use) evaluated the excess risk of HC-induced depression in women with ADHD.

RESULTS

Women with ADHD had a 3-fold higher risk of developing depression, irrespective of HC use (adjusted hazard ratio [aHR] = 3.69, 95% CI = 3.60-3.78). Oral combined HC users with ADHD had a 5 times higher risk of depression compared with non-ADHD women who were not using oral combined HC (aHR = 5.19, 95% CI = 4.94-5.47), and a 6 times higher risk in comparison with non-ADHD women who were on oral combined HC (aHR = 6.10 (95% CI = 5.79-6.43). The corresponding risk of depression in women with AHDH who used a progestogen-only pill (aHR = 5.00, 95% CI = 4.56-5.49). The risk of developing depression when using non-oral HC was similarly moderately increased in both groups.

CONCLUSION

Girls and young women with ADHD have an increased risk of developing depression when using oral HC compared with their unaffected peers. Information on risks with HCs as well as potential benefits with long-acting reversible contraceptives needs to be an integrated part of the shared decision making and contraception counseling for young women with ADHD.

The impact of hormonal contraceptives on anxiety treatments: From preclinical models to clinical settings

Exposure therapy is a central component of the first-line treatment for anxiety disorders, a common mental health condition that is twice as prevalent in women relative to men. A key underlying mechanism of exposure therapy is fear extinction, which is an active learning process supported by a neural circuitry that is highly regulated by ovarian hormones. This review synthesises research examining the impact of hormonal contraceptives on laboratory fear extinction tasks in female rats and women, and on exposure therapy in women with anxiety disorders. The evidence indicates that hormonal contraceptives have a detrimental impact on fear extinction and exposure therapy that is consistent across species, and from laboratory to clinical settings. Candidate pathways by which hormonal contraceptives impede fear extinction and exposure therapy include suppression of endogenous ovarian hormones and glucocorticoids, and downregulation of signalling pathways that support extinction learning. Key areas of focus for future research are discussed.

Hormonal contraceptives, stress, and the brain: The critical need for animal models

Hormonal contraceptives are among the most important health and economic developments in the 20thCentury, providing unprecedented reproductive control and a range of health benefits including decreased premenstrual symptoms and protections against various cancers. Hormonal contraceptives modulate neural function and stress responsivity. These changes are usually innocuous or even beneficial, including their effects onmood. However, in approximately 4-10% of users, or up to 30 million people at any given time, hormonal contraceptives trigger depression or anxiety symptoms. How hormonal contraceptives contribute to these responses and who is at risk for adverse outcomes remain unknown. In this paper, we discussstudies of hormonal contraceptive use in humans and describe the ways in which laboratory animal models of contraceptive hormone exposure will be an essential tool for expanding findings to understand the precise mechanisms by which hormonal contraceptives influence the brain, stress responses, and depression risk.

Hormone-based models for comparing menstrual cycle and hormonal contraceptive effects on human resting-state functional connectivity

Oral contraceptives (OCs) are widely used yet understudied given their potential for public health consequences. Emerging investigations scaling from single-subject, dense-sampling neuroimaging studies to population-level metrics have linked OCs to altered brain structure and function. Modeling the hypogonadal, hypergonadal, or mixed state effects of OCs in terms of their impact on hormone action in the brain is a valuable approach to synthesizing results across neuroimaging studies and comparing OC effects to companion findings from research on menstrual cycle phase effects on brain anatomy and function. Resting-state functional connectivity studies provide a powerful tool to evaluate the role of OCs on the intrinsic network connectivity that underlies multiple behavioral domains. The preponderance (but not consensus) of the current literature indicates that (1) as the menstrual cycle proceeds from a low to high progesterone state, prefrontal connectivity increases and parietal connectivity decreases; (2) OCs tend to mimic this connectivity pattern; therefore (3) OCs may produce a hyperprogestogenic state in the brain, in spite of overall reductions in endogenous steroid hormone levels. Alternative models are also considered.

Pharmaceutical Side Effects and the Sex Differences in Depression and Distress

INTRODUCTION

Women suffer from depression at higher rates than men. This difference is well established, although a consolidated explanation remains elusive. This study examines the role played by medications with depression or suicidality as a potential side effect in explaining the sex difference in depression.

METHODS

Data were analyzed for 224,810 U.S. adults aged ≥18 years from the 2008-2018 Medical Expenditure Panel Survey. Linear and logistic regressions were used to assess the sex differences in distress and depression while controlling for sociodemographic characteristics, healthcare access, health conditions, and the use of medications with depression or suicidality as a side effect.

RESULTS

41% and 28% of women used ≥1 medication with depression and suicidality as a side effect compared with 27% and 17% of men, respectively. When controlling for sociodemographic characteristics, healthcare access, and health conditions, women were more likely to report significant distress (OR=1.16, 95% CI=1.10, 1.24) and major depression (OR=1.12, 95% CI=1.07, 1.18) than men. In models that further adjusted for the use of medications with depression or suicidality as a side effect, the sex differences became statistically nonsignificant for both distress (OR=0.97, 95% CI=0.91, 1.03) and depression (OR=0.97, 95% CI=0.92, 1.02). Nonhormone medications (rather than hormone medications) with such side effects helped explain the sex differences in distress and depression.

CONCLUSIONS

Findings suggest a significant sex difference in pharmaceutical treatment and the potential consequences of pharmaceutical side effects on distress and depression. These results highlight the importance of pharmaceutical side effects in understanding health and health disparities.

Hormone contraceptive use in young women: Altered mood states, neuroendocrine and inflammatory biomarkers

Oral contraceptives are used by millions of women worldwide, yet there are questions regarding the psychological and biological consequences of these medications. Considering that sex steroid hormones can regulate neuroendocrine and behavioral responses to stress, the current study examined mood and stress symptomatologies, as well as circulating levels of cortisol and inflammatory biomarkers among young women (N = 388), of whom, 47.0 % (n = 182) were using a form of hormonal contraception. Women using hormone contraceptives displayed significantly higher depressive and stress scores compared to non-users, whereas no differences were found for anxiety symptoms. Moreover, contraceptive users had markedly elevated plasma cortisol and C-reactive protein levels in comparison to non-users. Upon assessing women at different phases of their menstrual cycle, hormone contraceptive users displayed higher levels of cortisol compared to women in the follicular and luteal phases, in addition to higher levels of CRP levels compared to women in the luteal phase. Together, these findings suggest that hormone contraceptive use is linked to exaggerated basal neuroendocrine and inflammatory profiles, which could potentially increase sensitivity to the impacts of stressors and mood disturbances.

How hormonal contraceptives shape brain and behavior: A review of preclinical studies

Steroid hormones influence different aspects of brain function, including development, neurogenesis, neuronal excitability, and plasticity, thus affecting emotional states, cognition, sociality, and reward. In women, their levels fluctuate across the lifespan and through the reproductive stages but are also altered by exogenous administration of hormonal contraceptives (HC). HC are widely used by women throughout their fertile life both for contraceptive and therapeutic benefits. However, awareness of their effects on brain function and behavior is still poorly appreciated, despite the emerging evidence of their action at the level of the central nervous system. Here, we summarize results obtained in preclinical studies, mostly conducted in intact female rodents, aimed at investigating the neurobiological effects of HC. HC can alter neuroactive hormones, neurotransmitters, neuropeptides, as well as emotional states, cognition, social and sexual behaviors. Animal studies provide insights into the neurobiological effects of HC with the aim to improve women's health and well-being.

A Reciprocal Link Between Gut Microbiota, Inflammation and Depression: A Place for Probiotics?

Depression is a severe mental disorder that places a significant economic burden on public health. The reciprocal link between the trillions of bacteria in the gut, the microbiota, and depression is a controversial topic in neuroscience research and has drawn the attention of public interest and press coverage in recent years. Mounting pieces of evidence shed light on the role of the gut microbiota in depression, which is suggested to involve immune, endocrine, and neural pathways that are the main components of the microbiota-gut-brain axis. The gut microbiota play major roles in brain development and physiology and ultimately behavior. The bidirectional communication between the gut microbiota and brain function has been extensively explored in animal models of depression and clinical research in humans. Certain gut microbiota strains have been associated with the pathophysiology of depression. Therefore, oral intake of probiotics, the beneficial living bacteria and yeast, may represent a therapeutic approach for depression treatment. In this review, we summarize the findings describing the possible links between the gut microbiota and depression, focusing mainly on the inflammatory markers and sex hormones. By discussing preclinical and clinical studies on probiotics as a supplementary therapy for depression, we suggest that probiotics may be beneficial in alleviating depressive symptoms, possibly through immune modulation. Still, further comprehensive studies are required to draw a more solid conclusion regarding the efficacy of probiotics and their mechanisms of action.

Prolactin mediates the relationship between regional gray matter volume and postpartum depression symptoms

BACKGROUND

Pospartum Depression (PPD) causes significant adverse effects on mothers and their offspring. The condition is considered to have multiple pathogenic factors. However, the underlying neural basis of these factors keeps unclear.

METHODS

A group of 86 patients with PPD and 74 Healthy Postnatal Women (HPW) were enrolled in this structural Magnetic Resonance Imaging (MRI) study. Between-groups differences in regional gray matter volume (rGMV) were measured and association and mediation analyses were performed to investigate the relationship between rGMV, PPD severity and a range of demographic/clinical factors which could contribute to PPD.

RESULTS

Relative to HPW, PPD patients had higher scores indicating adverse effects on most questionnaires and higher prolactin levels, as well as increased rGMV in left dorsolateral prefrontal cortex (DLPFC) and right anterior insular (anI). In PPD patients, rGMV in right anI was positively correlated with prolactin level, PPD severity, and the number of children raised, whereas rGMV in left DLPFC was negatively correlated with education and age. Besides, prolactin level was found to mediate the association between rGMV in anI and PPD symptoms.

LIMITATIONS

Potentially factors such as fertility or delivery pattern were not studied.

CONCLUSION

Our results provide information on the risk and protective factors, and rGMV abnormalities, associated with PPD. The finding that prolactin level mediated the impact of rGMV in right anI on PPD symptoms is a potential mechanism for explaining the association between brain structure and PPD symptoms. Increased understanding of the neuro-pathophysiology of PPD is important for early diagnosis and treatment.

Discontinuation of hormonal contraception due to changes in mood and decreases in sexual desire: the role of adverse childhood experiences

PURPOSE

To evaluate if adverse childhood experiences are associated with hormonal contraception discontinuation due to mood and sexual side effects.

MATERIALS AND METHODS

Women, ages 18-40 (N = 826), with current and/or previous hormonal contraceptive use completed surveys on demographics, contraceptive history, and the Adverse Childhood Experiences Questionnaire. We characterised women into high (≥2 adverse experiences) and low (0 or 1) adverse childhood experience groups. We calculated risk ratios for associations between adverse childhood experiences and outcomes of interest using log binomial generalised linear models, and adjusted for relevant demographic variables.

RESULTS

Women in the high adverse childhood experiences group (n = 355) were more likely to report having discontinued hormonal contraception due to decreases in sexual desire (adjusted risk ratio 1.44, 1.03-2.00, p = .030). Covariates included age, current hormonal contraception use, and various demographic variables associated with discontinuation. Adverse childhood experiences were not associated with mood or sexual side effects among current (n = 541) hormonal contraceptive users.

CONCLUSIONS

Self-reported adverse childhood experiences were associated with greater likelihood of discontinuing hormonal contraception due to behavioural side effects, particularly decreases in sexual desire. Identification of risk factors for behavioural side effects can assist patients and clinicians in making informed choices on contraception that minimise risk of early discontinuation.

Event-Related Potentials in Women on the Pill: Neural Correlates of Positive and Erotic Stimulus Processing in Oral Contraceptive Users

Background/Aims: Exposure toward positive emotional cues with - and without - reproductive significance plays a crucial role in daily life and regarding well-being as well as mental health. While possible adverse effects of oral contraceptive (OC) use on female mental and sexual health are widely discussed, neural processing of positive emotional stimuli has not been systematically investigated in association with OC use. Considering reported effects on mood, well-being and sexual function, and proposed associations with depression, it was hypothesized that OC users showed reduced neural reactivity toward positive and erotic emotional stimuli during early as well as later stages of emotional processing and also rated these stimuli as less pleasant and less arousing compared to naturally cycling (NC) women. Method: Sixty-two female subjects (29 NC and 33 OC) were assessed at three time points across the natural menstrual cycle and corresponding time points of the OC regimen. Early (early posterior negativity, EPN) and late (late positive potential, LPP) event-related potentials in reaction to positive, erotic and neutral stimuli were collected during an Emotional Picture Stroop Paradigm (EPSP). At each appointment, subjects provided saliva samples for analysis of gonadal steroid concentration. Valence and arousal ratings were collected at the last appointment. Results: Oral contraceptive users had significantly lower endogenous estradiol and progesterone concentrations compared to NC women. No significant group differences in either subjective stimulus evaluations or neural reactivity toward positive and erotic emotional stimuli were observed. For the OC group, LPP amplitudes in reaction to erotic vs. neutral pictures differed significantly between measurement times across the OC regimen. Discussion: In this study, no evidence regarding alterations of neural reactivity toward positive and erotic stimuli in OC users compared to NC was found. Possible confounding factors and lines for future research are elaborated and discussed.

Duration of oral contraceptive use relates to cognitive performance and brain activation in current and past users

Previous studies indicate effects of oral contraceptive (OC) use on spatial and verbal cognition. However, a better understanding of the OC effects is still needed, including the differential effects of androgenic or anti-androgenic OC use and whether the possible impact persists beyond the OC use. We aim to investigate the associations of OC use duration with spatial and verbal cognition, differentiating between androgenic and anti-androgenic OC. Using functional magnetic resonance imaging (MRI), we scanned a group of 94 past and current OC-users in a single session. We grouped current OC users (N=53) and past OC users with a natural cycle (N=41) into androgenic and anti-androgenic user. Effects of OC use duration were observed for current use and after discontinuation. Duration of OC use was reflected only in verbal fluency performance but not navigation: The longer the current OC use, the less words were produced in the verbal fluency task. During navigation, deactivation in the caudate and postcentral gyrus was duration-dependent in current androgenic OC users. Only during the verbal fluency task, duration of previous OC use affects several brain parameters, including activation of the left putamen and connectivity between right-hemispheric language areas (i.e., right inferior frontal gyrus and right angular gyrus). The results regarding performance and brain activation point towards stronger organizational effects of OCs on verbal rather than spatial processing. Irrespective of the task, a duration-dependent connectivity between the hippocampus and various occipital areas was observed. This could suggest a shift in strategy or processing style with long-term contraceptive use during navigation/verbal fluency. The current findings suggest a key role of the progestogenic component of OCs in both tasks. The influence of OC use on verbal fluency remains even after discontinuation which further points out the importance of future studies on OC effects and their reversibility.

Oral contraceptives, depressive and insomnia symptoms in adult women with and without depression

BACKGROUND

Worldwide, oral contraceptive (OC) use is a very common form of birth control, although it has been associated with symptoms of depression and insomnia. Insomnia is a risk factor for major depressive disorder (MDD) but may also be a symptom of the disorder. Despite the large number of women who use OC, it is yet unknown whether women with previous or current diagnosis of depression are more likely to experience more severe depressive and insomnia symptoms during concurrent OC use than women without diagnosis of depression.

AIM

This study examined associations between OC use and concurrent symptoms of depression (including atypical depression) and insomnia as well as between OC and prevalences of concurrent dysthymia and MDD. Participants were adult women with and without a history of MDD or dysthymia. We hypothesized that OC use is associated with concurrent increased severity of depressive symptoms and insomnia symptoms, as well as with an increased prevalence of concurrent diagnoses of dysthymia and MDD. We also hypothesized that a history of MDD or dysthymia moderates the relationship between OC use and depressive and insomnia symptoms.

METHODS

Measurements from premenopausal adult women from the Netherlands Study of Depression and Anxiety (NESDA) were grouped, based on whether participants were using OC or naturally cycling (NC). OC use, timing and regularity of the menstrual cycle were assessed with a structured interview, self-reported symptoms of depression (including atypical depression), insomnia with validated questionnaires, and MDD and dysthymia with structured diagnostic interviews.

RESULTS

We included a total of 1301 measurements in women who reported OC use and 1913 measurements in NC women (mean age 35.6, 49.8% and 28.9% of measurements in women with a previous depression or current depression, respectively). Linear mixed models showed that overall, OC use was neither associated with more severe depressive symptoms (including atypical depressive symptoms), nor with higher prevalence of diagnoses of MDD or dysthymia. However, by disentangling the amalgamated overall effect, within-person estimates indicated increased depressive symptoms and depressive disorder prevalence during OC use, whereas between-person estimated indicated lower depressive symptoms and prevalence of depressive disorders. OC use was consistently associated with more severe concurrent insomnia symptoms, in the overall estimates as well as in the within-person and between-person estimates. Presence of current or previous MDD or dysthymia did not moderate the associations between OC use and depressive or insomnia symptoms.

DISCUSSION

The study findings showed consistent associations between OC use and more severe insomnia symptoms, but no consistent associations between OC and depressive symptoms or diagnoses. Instead, post-hoc analyses showed that associations between OC and depression differed between within- and between person-estimates. This indicates that, although OC shows no associations on the overall level, some individuals might experience OC-associated mood symptoms. Our findings underscore the importance of accounting for individual differences in experiences during OC use. Furthermore, it raises new questions about mechanisms underlying associations between OC, depression and insomnia.

Little evidence for sex or ovarian hormone influences on affective variability

Women were historically excluded from research participation partly due to the assumption that ovarian hormone fluctuations lead to variation, especially in emotion, that could not be experimentally controlled. Although challenged in principle and practice, relevant empirical data are limited by single measurement occasions. The current paper fills this knowledge gap using data from a 75-day intensive longitudinal study. Three indices of daily affective variability-volatility, emotional inertia, and cyclicity-were evaluated using Bayesian inferential methods in 142 men, naturally cycling women, and women using three different oral contraceptive formulations (that "stabilize" hormone fluctuations). Results provided more evidence for similarities between men and women-and between naturally cycling women and oral contraceptive users-than for differences. Even if differences exist, effects are likely small. Thus, there is little indication that ovarian hormones influence affective variability in women to a greater extent than the biopsychosocial factors that influence daily emotion in men.

Association of levonorgestrel intrauterine devices with stress reactivity, mental health, quality of life and sexual functioning: A systematic review

Levonorgestrel-intrauterine-devices (LNG-IUD) are one of the most used contraceptive methods worldwide. While several reviews exist on how LNG-IUDs impact physiology and gynaecological functions, this systematic review focuses on stress, mental health, quality of life, sexual functioning, and effects on brain architecture. While data on stress is scarce, results on mental health are ambiguous. More consistently, LNG-IUD use seems to improve quality of life and sexual functioning. No studies highlighting the consequences of LNG-IUD use on the brain were found. The reviewed studies are characterized by a substantial variation in approaches, participant groups, and study quality. More high-quality research assessing the effects of LNG-IUD on mental health, including response to stressors and brain function and structure, is needed to identify women vulnerable to adverse effects of LNG-IUD, also in comparison to oral contraceptives, and to empower women to make more informed choices concerning hormonal contraception.

Population heterogeneity in associations between hormonal contraception and antidepressant use in Sweden: a prospective cohort study applying intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA)

OBJECTIVES

From a reproductive justice framework, we aimed to investigate how a possible association between hormonal contraceptive (HC) and antidepressants use (as a proxy for depression) is distributed across intersectional strata in the population. We aimed to visualise how intersecting power dynamics may operate in combination with HC use to increase or decrease subsequent use of antidepressants. Our main hypothesis was that the previously observed association between HC and antidepressants use would vary between strata, being more pronounced in more oppressed intersectional contexts. For this purpose, we applied an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy approach.

DESIGN

Observational prospective cohort study using record linkage of national Swedish registers.

SETTING

The population of Sweden.

PARTICIPANTS

All 915 954 women aged 12-30 residing in Sweden 2010, without a recent pregnancy and alive during the individual 1-year follow-up.

PRIMARY OUTCOME MEASURE

Use of any antidepressant, meaning being dispensed at least one antidepressant (ATC: N06A) during follow-up.

RESULTS

Previously mentally healthy HC users had an OR of 1.79 for use of antidepressants compared with non-users, whereas this number was 1.28 for women with previous mental health issues. The highest antidepressant use were uniformly found in strata with previous mental health issues, with highest usage in women aged 24-30 with no immigrant background, low income and HC use (51.4%). The largest difference in antidepressant use between HC users and non-users was found in teenagers, and in adult women of immigrant background with low income. Of the total individual variance in the latent propensity of using antidepressant 9.01% (healthy) and 8.16% (with previous mental health issues) was found at the intersectional stratum level.

CONCLUSIONS

Our study suggests teenagers and women with immigrant background and low income could be more sensitive to mood effects of HC, a heterogeneity important to consider moving forward.

Prevalence of contraceptive use and its association with depression among women in the Jazan province of Saudi Arabia

Background:

Hormonal contraceptives (HC) are used for birth control and the treatment of premenopausal syndrome. Mood changes represent the leading reported cause of discontinuation of HC. Changes in mood vary from mild disturbances to severe clinical depression.

Objectives:

This study aims to estimate the prevalence of depression among HC users who visit primary health care centers in the Jazan Province of Saudi Arabia and to identify psycho-social factors that may predispose HC users to depression.

Methods:

A self-administered questionnaire was distributed among women who visited five primary health care centers in the Jazan Province. The survey included questions about socio-demographic information and an Arabic adaptation of the Beck Depression Inventory.

Results:

Among the 904 women surveyed, the prevalence of HC use was 57.3%. Mood disturbances were observed in approximately one-third of these women. There is was a significant correlation between higher depression scores and a history of depression therapy (P-value < 0.001), as moderate, severe, and extreme depression was more common in those with a history of taking depression therapy. The type of contraception used was also found to be a significant factor (P-value = 0.01) in the degree of depression.

Conclusion:

Approximately one-third of women using HC were shown to exhibit symptoms of mood disturbance. Working, limited social support, asked whether or not they experienced living problems in the past 2 months, and having an uncomfortable or somewhat comfortable marital relationship increased the likelihood of mood disturbances. Primary health care physicians should be aware of the relatively high prevalence of mood disturbances in women using HC, to provide support and care to patients.

Ethinyl Estadiol/Progestin Oral Contraceptives Depress Spatial Learning and Dysregulate Hippocampal CA3 Microstructure: Implications for Behavioral-Cognitive Effects of Chronic Contraceptive Use?

Combined oral contraceptive pill contains ethinyl estradiol and a synthetic progestin, which prevent ovulation by suppressing the release of the gonadotropins resulting in the inhibition of ovarian follicles’ development. Although advantageous in birth control, the impact on learning and memory is limited necessitating this study on its effect on spatial learning, and hippocampal CA3 microstructure. Thirty two female Wistar rats of average body weight 200 g were equally divided (n = 8) into four groups; 0.002 mg/kg levonorgestrel plus 0.00043 mg/kg ethinyl estradiol (COCP) were administered orally for 21, 42 and 63 days. 24 hours after the last administration the rats underwent Morris water maze test and were sacrificed by transcardial perfusion-fixation. Their hippocampal regions were processed for histological study, and immunolabelled with anti-neuron specific enolase (NSE) and glial fibrillary acidic protein (GFAP). Results showed that the COCP test groups had shorter escape latencies (p ≤ 0.05) in the visible and hidden platform trials. The COCP test groups showed no difference in neuronal population, although some of the hippocampal CA3 pyramidal neurons were either atrophic and/or karyorrhectic, with shrunken and dense nuclei. NSE expression was lower (p ≤ 0.05) in the 21, 42 and 63 days COCP groups, while GFAP expression was lower in the 21 days COCP group, but not different in the 42 and 63 days COCP groups compared with the control. These preliminary results show that COCP influence spatial learning, and may also reduce neuronal metabolic activity, while increasing astrocytic activity in the hippocampal CA3.

Hormonal Contraception and Violent Death: The Physiological and Psychological Links

In the past decade, two large prospective cohort studies of British and American women have been conducted which found a statistically significant increase in the risk of violent death in ever-users of hormonal contraceptives. Research on the effects of hormonal contraceptives upon the behaviors of intimate partners and on the physiology of women using hormonal contraceptives has provided insight into the possible basis for the resulting increase in violent death. This review examines the changes that are potential contributors to the reported increase.

Contraception for Women With Psychiatric Disorders

OBJECTIVE

Mental health care for women includes decision support to prepare for major life events, including preconception planning for treatment during pregnancy and the postpartum period. The authors discuss contraceptive choices and their effectiveness, side effects, and impact on psychiatric symptoms. The Centers for Disease Control and Prevention's recommendations, Medical Eligibility Criteria for Contraceptive Use, provided the structure for review of contraceptive choices.

METHODS

A search of PsycINFO, PubMed, Embase, and Scopus was conducted for publications on the management of contraception for women with mental illness. Publications were selected if they included, based on the authors' consensus, data supporting evidence-based care important for psychiatrists who treat women desiring contraceptives.

RESULTS

The majority of women choose combined oral contraceptives. Although long-acting reversible contraceptives (implants, intrauterine devices) are associated with low failure rates, favorable safety profiles, rapid return to fertility after removal, and few contraindications, they are chosen by only 14% of women. All methods are acceptable for women with depression, although medical comorbidities may dictate a specific type. The impact of hormonal contraceptives on the risk for depression is controversial; however, clinical studies and randomized placebo-controlled trials of women with psychiatric disorders have generally reported similar or lower rates of mood symptoms in hormonal contraceptive users compared with nonusers. Although interactions between psychotropic drugs and contraceptives are rare, clozapine, anticonvulsants, and St. John's Wort are exceptions.

CONCLUSIONS

Proactive management of mental illness, contraception, and pregnancy improves a woman's capacity to function and optimizes her mental and reproductive health.

Shaping of the Female Human Brain by Sex Hormones: A Review

Traditionally sex hormones have been associated with reproductive and developmental processes only. Since the 1950s we know that hormones can have organizational effects on the developing brain and initiate hormonal transition periods such as puberty. However, recent evidence shows that sex hormones additionally structure the brain during important hormonal transition periods across a woman's life including short-term fluctuations during the menstrual cycle. However, a comprehensive review focusing on structural changes during all hormonal transition phases of women is still missing. Therefore, in this review structural changes across hormonal transition periods (i.e., puberty, menstrual cycle, oral contraceptive intake, pregnancy and menopause) were investigated in a structured way and correlations with sex hormones evaluated. Results show an overall reduction in grey matter and region-specific decreases in prefrontal, parietal and middle temporal areas during puberty. Across the menstrual cycle grey matter plasticity in the hippocampus, the amygdala as well as temporal and parietal regions were most consistently reported. Studies reporting on pre- and post-pregnancy measurements revealed volume reductions in midline structures as well as prefrontal and temporal cortices. During perimenopause, the decline in sex hormones was paralleled with a reduction in hippocampal and parietal cortex volume. Brain volume changes were significantly correlated with estradiol, testosterone and progesterone levels in some studies, but directionality remains inconclusive between studies. These results indicate that sex hormones play an important role in shaping women's brain structure during different transition periods and are not restricted to specific developmental periods.

The scientific body of knowledge - Whose body does it serve? A spotlight on oral contraceptives and women's health factors in neuroimaging

Women constitute half of the world's population, yet neuroscience research does not serve the sexes equally. Fifty years of preclinical animal evidence documents the tightly-coupled relationship between our endocrine and nervous systems, yet human neuroimaging studies rarely consider how endocrine factors shape the structural and functional architecture of the human brain. Here, we quantify several blind spots in neuroimaging research, which overlooks aspects of the human condition that impact women's health (e.g. the menstrual cycle, hormonal contraceptives, pregnancy, menopause). Next, we illuminate potential consequences of this oversight: today over 100 million women use oral hormonal contraceptives, yet relatively few investigations have systematically examined whether disrupting endogenous hormone production impacts the brain. We close by presenting a roadmap for progress, highlighting the University of California Women's Brain Initiative which is addressing unmet needs in women's health research.

Oral contraceptive use, especially during puberty, alters resting state functional connectivity

Millions of women worldwide use oral contraceptives (OCs), often starting during puberty/adolescence. It is, however, unknown how OC use during this critical period of development affects the brain. The objective of the current study was to examine resting state functional connectivity (FC) in the default mode network (DMN), central executive network (CEN), salience network (SN), reward network (RN), and subcortical limbic network of the brain using independent component analysis (ICA) between pubertal- and adult-onset OC users (n = 27) and naturally cycling women (n = 48). It was hypothesized that OC use would result in network-specific increases and decreases in FC and that pubertal-onset OC use would result in differences to the aforementioned networks compared to adult-onset OC use. Pubertal-onset OC use is related to heightened FC in the SN compared to adult-onset OC users. In general, OC use also increases connectivity in the SN, CEN, RN, and subcortical limbic network compared to NC women. No significant differences in connectivity were observed in the DMN between OC users and NC women. These findings provide a mechanistic insight for the altered executive functioning and emotion/reward processing previously seen in OC users, which may then increase their vulnerability to mental health conditions.

The Effects of Hormonal Contraceptives on the Brain: A Systematic Review of Neuroimaging Studies

Background: Hormonal contraceptive drugs are being used by adult and adolescent women all over the world. Convergent evidence from animal research indicates that contraceptive substances can alter both structure and function of the brain, yet such effects are not part of the public discourse or clinical decision-making concerning these drugs. We thus conducted a systematic review of the neuroimaging literature to assess the current evidence of hormonal contraceptive influence on the human brain.

Methods: The review was registered in PROSPERO and conducted in accordance with the PRISMA criteria for systematic reviews. Structural and functional neuroimaging studies concerning the use of hormonal contraceptives, indexed in Embase, PubMed and/or PsycINFO until February 2020 were included, following a comprehensive and systematic search based on predetermined selection criteria.

Results: A total of 33 articles met the inclusion criteria. Ten of these were structural studies, while 23 were functional investigations. Only one study investigated effects on an adolescent sample. The quality of the articles varied as many had methodological challenges as well as partially unfounded theoretical claims. However, most of the included neuroimaging studies found functional and/or structural brain changes associated with the use of hormonal contraceptives.

Conclusion: The included studies identified structural and functional changes in areas involved in affective and cognitive processing, such as the amygdala, hippocampus, prefrontal cortex and cingulate gyrus. However, only one study reported primary research on a purely adolescent sample. Thus, there is a need for further investigation of the implications of these findings, especially with regard to adolescent girls.

Oral contraceptives and the serotonin 4 receptor: a molecular brain imaging study in healthy women

OBJECTIVE

Sex steroid hormones potently shape brain functions, including those critical to maintain mental health such as serotonin signaling. Use of oral contraceptives (OCs) profoundly changes endogenous sex steroid hormone levels and dynamics. Recent register-based studies show that starting an OC is associated with increased risk of developing depression. Here, we investigate whether use of OCs in healthy women is associated with a marker of the serotonin system in terms of serotonin 4 receptor (5-HT4R) brain imaging.

METHODS

[11C]SB207145-PET imaging data on 53 healthy women, of whom 16 used OCs, were available from the Cimbi database. We evaluated global effects of OC use on 5-HT4R binding in a latent variable model based on 5-HT4R binding across cortical and subcortical regions.

RESULTS

We demonstrate that OC users have 9-12% lower global brain 5-HT4R binding potential compared to non-users. Univariate region-based analyses (pallidostriatum, caudate, hippocampus, amygdala, anterior cingulate cortex, and neocortex) supported the global effect of OC use with the largest difference present in the hippocampus (-12.8% (95% CI [-21.0; -3.9], Pcorrected = 0.03).

CONCLUSION

We show that women who use OCs have markedly lower brain 5-HT4R binding relative to non-users, which constitutes a plausible molecular link between OC use and increased risk of depressive episodes. We propose that this reflects a reduced 5-HT4R gene expression, possibly related to a blunted ovarian hormone state among OC users.

Progesterone - Friend or foe?

Estradiol is the "prototypic" sex hormone of women. Yet, women have another sex hormone, which is often disregarded: Progesterone. The goal of this article is to provide a comprehensive review on progesterone, and its metabolite allopregnanolone, emphasizing three key areas: biological properties, main functions, and effects on mood in women. Recent years of intensive research on progesterone and allopregnanolone have paved the way for new treatment of postpartum depression. However, treatment for premenstrual syndrome and premenstrual dysphoric disorder as well as contraception that women can use without risking mental health problems are still needed. As far as progesterone is concerned, we might be dealing with a two-edged sword: while its metabolite allopregnanolone has been proven useful for treatment of PPD, it may trigger negative symptoms in women with PMS and PMDD. Overall, our current knowledge on the beneficial and harmful effects of progesterone is limited and further research is imperative.

A Systematic Review and Meta-analysis of the Adverse Effects of Levonorgestrel Emergency Oral Contraceptive

INTRODUCTION

The levonorgestrel oral emergency contraceptive is well tolerated and effective, however its use is still limited, mainly due to safety concerns.

OBJECTIVE

This systematic review and meta-analysis aimed to summarize current evidence regarding the adverse events, and their prevalence, reported during the use of oral levonorgestrel emergency contraceptives.

METHODS

Four electronic databases and the US FDA Adverse Event Reporting System (FAERS) Public Dashboard were searched. Studies that reported or investigated safety outcomes or adverse reactions during the use of levonorgestrel as an emergency oral contraceptive were included. Data on study design, demographics of levonorgestrel and the control cohort, and reported adverse effects were extracted.

RESULTS

A total of 47 articles were included in this systematic review, from which it was shown that most of the adverse reactions were common and not serious. Uncommon adverse reactions identified included anorexia, ectopic pregnancy, exanthema, chloasma, miscarriage, and weight gain. Multiple serious adverse events, including convulsion, ectopic pregnancy, febrile neutropenia, stroke, abdominal hernia, anaphylaxis, cancer, ovarian cyst rupture, serious infections, and suicidal ideation, were reported. In addition, the prevalence of adverse events after a levonorgestrel 0.75 mg two-dose regimen and a levonorgestrel 1.5 mg single-dose regimen were not statistically different (p > 0.05).

CONCLUSIONS

The most common adverse effects of levonorgestrel were not serious. This systematic review shows that data regarding the adverse reactions of repeated use of levonorgestrel are scarce. Studies on the multiple uses of levonorgestrel emergency contraception are still required to ensure its safety.