Welsh Baccalaureate Individual investigation Hormonal birth control

Welsh Baccalaureate Individual investigation
Hormonal birth control: Does it cause depression?
For my investigation I will be exploring the role of hormonal birth control on depression. It is a topic that can no longer be ignored as an increasing number of females are reporting showing symptoms of depression after taking the contraceptive pill over a duration of time. A recent study in Denmark by Øjvind Lidegaard showed that 15-18 year olds are 80% more likely to develop symptoms of depression whilst on the pill. I have decided to research this topic as I wish to become a mental health nurse in the future therefore find it necessary to have an understanding of possible ways in which depression can develop.
Mental illness is currently a key issue in the UK due to the stigma that surrounds it. The Welsh government brought out a 3-year plan as part of their ‘Together for Mental Health’ in 2016 in order to improve the services available for young people suffering from Mental Health issues, showing that there is a lot to be done before the stigma surrounding mental illness comes to an end.
Aims and Objectives:
Aim 1: Discover how hormonal birth control works
1a. Specify what hormones are and what role they play in the body.

1b. Differentiate between different types of birth controls.

1c.Research side effects and the benefits of different methods of birth control.

Aim 2: Establish the effect of hormonal birth control on mental wellbeing.

2a.Analyse the data of the Denmark study.

2b.Research how effects differ with age.

2c. Collect people’s personal experiences whilst on birth control.

Aim 3: Establish how synthetic hormones, such as birth control, have an effect on the brain.

3a. Research the
3b. Discover possible tests which could be done before prescribing hormonal birth control e.g hormonal panel tests.

Research methods
Aim 1: I will be using the NHS official website, as it will give me relevant data to suit my aim. For example, an extensive list of the side effects of birth control is easily accessible from the brand’s website or on the NHS website. By using the NHS official website it ensures that all information I find is valid as it is an official website designed by National Health Service staff to give information to people regarding their health. I will also be using the oxford dictionary in order to find the official definition of a hormone.

Aim 2- To establish the effect of hormonal birth control on the brain I will be using a study that was published in 2016 in Denmark It consisted of over 1 million women on birth control who had no prior history of mental illness and was done over the duration of 10 years. I therefore believe that its current, valid and representative. Furthermore, I will analyse the data graphs showing the rate ratio of first use of anti-depressants by contraceptive type to decipher which type has a greater effect on mental health. I will also be using an article from ‘Hormone’s matter’, a website that specifies in Women’s health because it contains records and information from the 1970 Nelson Pill Trials, which are relevant to my research. I believe these records to be accurate as they are documents from the original testimony of the trials.

Aim 3- To establish what procedures are in place before prescribing birth control I will be using an NHS Border sexual health document written by Dr A Wylie in 2010 (adapted in 2011) which contains the guidelines for prescribing hormonal birth control. *****
Main Body
Aim 1
According to an article titled ‘Our bodies, Ourselves’ , birth control is the use of synthetic hormones to prevent pregnancy. In 1960 the first birth control was developed but they caused serious side effects such as severe headaches and high blood pressure as they contained a very high dose of oestrogen. Nowadays, birth control pills contain much lower doses of oestrogen and progesterone, with some only containing progesterone. However, there are still many severe side effects of the combined and progestin only pills as you are putting an unknown amount of hormone into your body without knowing your current hormone levels. According to an article written for a website called ‘Hormones and Balance’ the pill can interfere with a body’s methylation process by reducing methyl donors, leaving the woman deficient in hormones like serotonin (improves or worsens mood, dependant on level) and melatonin which improves sleep. On average, 20% of people are estimated to be slow methylators anyway so the pill could leave them edgy and anxious all day long and then prevent them from getting a good night’s sleep. The reliability of this website could be questioned as, although a holistic health coach wrote it, she claims to be a drugless practitioner so she could be bias towards birth control. This article was published in early 2017, therefore it is recent and has considered evidence , such as the study done in Denmark, to come to their conclusion.

According to the Oxford dictionary, a sex hormone is defined as 1- a regulatory substance produced in an organism and transported in tissue fluids such as blood or sap to stimulate specific cells or tissues into action 2.A person’s sex hormones as held to influence behaviour or mood.’ This definition is valid as it has come from a pristine and respected brand which is frequently updated. The 2 main hormones in a female are Oestrogen and Progesterone. Oestrogen is responsible for growth and development. Within the body, it can be found in 3 different forms: estradiol, estrone and estriol. A deficiency in Oestrogen can lead to a variety of health problems such as fatigue, hair loss and mood swings. However, in excessive amounts it can also lead to mood swings, proving vital to regulate the amount of Oestrogen in a female body. Progesterone and Oestrogen work together to strengthen bones, support libido and sustain cholesterol levels. Both hormones are essential as they regulate many reactions in the body. Oestrogen and Progesterone are the two main hormones found in birth control. Birth control works in a way that inhibits the production of FSH (Follicle stimulating hormone) so no eggs mature in the ovaries. Without mature eggs, women cannot get pregnant.

There are many different types of birth control. There is the combined oral contraceptive, progestin only contraceptive, patch, vaginal ring and the IUS (intrauterine system/hormonal coil). The NHS website is the accredited database for the National Health Service in Wales, it contains valid information written by doctors, nurses, professors and the NMC therefore one can assume that the information posted on the NHS website is valid medical information.

The combined oral contraceptive
The combined oral contraceptive contains both oestrogen and Progesterone. It is 99% effective against pregnancy therefore understandably the most common form of hormonal birth control. In addition, it is difficult to find a pill that is right for your body. Prescribing a birth control, specifically the contraceptive pill, that is right for your body can be described as ‘hit and miss’, someone may try over 10 different pills before finding one that suits them- according to Dr Harries, a qualified GP in New Quay surgery when questioned about the popular method of birth control.

The Progestin only oral contraceptive
The progestin only pill contains only progesterone; it is an alternative for women who cannot take the combined pill. Typically, the progestin only pill is only 92% effective against pregnancy, as it has to be taken every 24 hours within 3 hours of the time you last took it.

The patch
The hormonal patch is a patch that releases the hormones progesterone and oestrogen through the skin into the blood stream on a daily basis, which prevents pregnancy in the same way as the combined pill, by preventing the release of an egg each month. The patch also thickens the cervical mucus, making it more difficult for sperm to travel to the egg.

Vaginal ring
The vaginal ring (NuvaRing) is a small soft ring that you place inside your vagina. It releases the hormones Oestrogen and progesterone into the blood stream to prevent the release of an egg each month. Like the patch, it thickens cervical mucus to prevent sperm moving through the cervix. The vaginal ring also thins the lining of the womb so a fertilised egg cannot implant itself.

IUS (intrauterine system/hormonal coil)
The IUS is very similar to the IUD (intrauterine device) but it releases a progesterone hormone instead of copper. The progesterone hormone is very similar to the progesterone released in a woman’s ovaries. The progesterone causes the mucus from the cervix to thicken and causes the womb lining to become thinner and less likely to accept a fertilized egg. In a small amount of women, the IUS will stop them from ovulating, but most women will continue to ovulate normally.

According to WebMD , there are many benefits to hormonal birth control, for example, they will lower your chances of getting accidently pregnant by around 99%. Many women take hormonal birth control for a variety of reasons, such as;To regulate their periods
To help minimize the symptoms from illnesses like PCOS (Polycystic Ovary Syndrome) and endometriosis.

To improve their skin
To help with period pain
Menorrhagia (heavy periods)
Dysmenorrhea (painful periods)
These are just a few of the reasons why women take birth control; they can be prescribed for many different reasons. Just like there is an extensive list of benefits, there is also an extensive list of disadvantages and side effects. According to ‘Medical News Today’ the most common side effects of birth control are:
Intermenstrual spotting
Nausea
Breast tenderness
Headaches
Weight gain
Mood changes
Missed periods
Decreased libido
Vaginal discharge
I surveyed 100 women at random using Survey Monkey, an online anonymous survey website, to ask them if they had had any side effects from their birth control. 52.08% said yes to having side effects, the remaining said no or were unsure. I asked the women surveyed to specify what side effects they had while on hormonal birth control. I have compiled the results into the graph below.

48% of the women surveyed claimed to have mood related side effects to their birth control, a figure that can no longer be ignored. In this pie chart, mood related symptoms are considered to be depression, anxiety, mood swings and elevated mood. However, only 3 people out of the 100 surveyed claimed to have an elevated mood as a side effect, the majority claimed to have negative psychological side effects.
-723900100711000For my investigation, I will be focusing in on what is really meant by ‘mood changes’ which is listed as a side effect to all hormonal birth controls. According to a survey done by the BBC news magazine ‘The Debrief’ , which surveyed 1022 of their readers aged 18-30, 58% of the people surveyed claimed that the pill had a negative impact on their mental health, 4% believed it had a positive impact and the remaining 38% were not sure or had never taken birth control. ‘The Debrief’ is a popular magazine written
2533650102235This is an example of the leaflet that comes with contraceptive pills listing the possible side effects. Here you can see clearly that low mood and depression are reported side effects of the combined pill ‘Loestrin’. Many contraceptives list mood swings as a side effect but only a handful list depression.

0This is an example of the leaflet that comes with contraceptive pills listing the possible side effects. Here you can see clearly that low mood and depression are reported side effects of the combined pill ‘Loestrin’. Many contraceptives list mood swings as a side effect but only a handful list depression.

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Aim 2: Establish the effect of hormonal birth control on mental wellbeing
Objective 1- Analyse the results of the Danish study published in 2016 which links the use of hormonal birth control to anti-depressants.

In 2016, a study was published in Denmark that shows a positive correlation between the use of anti-depressants and hormonal birth control. The study’s aim was to show that birth control does play a role in the development of depression. The study combined data from the National Prescription Register and the Psychiatric Central Research Register in Denmark in order to control the use of birth control used and register the date that the person first received a prescription for anti-depressants. This study consisted of over one million women aged 14 to 34 living in Denmark; they started collecting data in 1995 and started following up on them from the 1st of January 2000 to December 2013. In order to make this study more accurate, women with prior diagnosis of depression, cancer , endometriosis, venous thrombosis, a different major psychiatric diagnosis and women receiving infertility treatments were excluded. The data collected was analysed from the 1st of January 2015 through to the 1st of April 2016. In order to have data to compare to, they followed up with women not on any form of birth control. The study showed that 1.7% of women, not on any form of birth control, began taking anti-depressants in a given year whilst 2.2% of women on birth control began taking anti-depressants within a given year.
The results of the study showed that users of the combined oral contraceptive are 23% more likely to be diagnosed with depression; users of the progestin only oral contraceptive (mini pill) are 34% more likely to be diagnosed with depression and users of the hormonal IUS are 40% more likely to be diagnosed with depression compared with non-users.
The conclusion written by Øjvind Lidegaard states “Use of hormonal contraception, especially among adolescents, was associated with subsequent use of antidepressants and a first diagnosis of depression, suggesting depression as a potential adverse effect of hormonal contraceptive use.” From reading this conclusion, I interpreted that hormonal birth control doesn’t cause depression fully, but there is most definitely a link between depression and birth control that needs to be researched further.
An article titled It’s Not All In Your Head: Mental Health and Hormonal Birth Control contains evidence from the 1970s which shows yet another link between depression and birth control. During the Nelson Pill Hearings of 1970, a doctor pointed out that there had been a suicide during the original pill trials in Puerto Rico, neither the suicide or the three sudden deaths were investigated. Below is Doctor Edmond Kassouf’s testimony answering questions from Mr James Duffy, minority counsel at the hearings (Page 6112 of the testimony)
Mr. Duffy:  One of the five deaths was suicide.

Dr. Kassouf:  Yes.

Mr. Duffy:  So what I would like to understand is how does one take a suicide and link the cause of death to the pill?
Dr. Kassouf:  Very simply. It has been of current concern. Many physicians and psychiatrists are concerned about depression and the pill. If this is true, suicide may well be the end result of that combination and, therefore, a reasonable suspect, a reasonable link.

Although there are no records on this person’s medical history prior to the pill trials, there’s room to assume that they thought the hormonal birth control was responsible as it was covered up.

Does birth control affect you differently at different ages?
-22943265317400The Denmark study shows that, on average, the relative risks of depression generally decreased with increasing age. The graph below shows the RR (Rate Ratio) of first use of anti-depressants based on what contraceptive type and age of the participants.

When looking at the graph, the overall trend shows that the average RR (rate ratio) of first use of anti-depressants is relatively higher for all females aged 15-19. Firstly, for the combined oral contraceptive, the RR for a 15-19 year old is 1.8 while the RR for a 30-34 year old is 1.1 showing a 0.7 difference. However, the graph shows that the rate ratio of first use of anti-depressants, in 15-19 year olds, increases significantly with non-oral forms of birth control such as the Levonorgestrel-IUS (Intrauterine system) with a rate ratio of 3.1. Primarily, the rate ratios of first use of anti-depressants decrease with age as all the rate ratios of first use of anti-depressants for adolescents are above 1.5 for all types of birth control and for women between the age ranges 25-29 and 30-34, the rate ratio is below 1.5 for all types of birth control. This shows that the relative risk of developing depression as a side effect of birth control decreases with age.

In a survey I created, I asked 100 women if they had suffered any psychological side effects to their hormonal birth control. 23% of the 100 surveyed were 18 and under, 10 said yes to having psychological side effects, 2 were not sure and 4 claimed to not have any psychological side effects at all. The remaining females 18 and under had never taken any form of hormonal birth control. The results for 19-25 year olds were similar. 37% of the women surveyed were between the ages of 19-25, 21 said yes , 3 were not sure and 11 said no to having any psychological side effects. The results received from the 38% of women aged 33 and over contrast with these results with only 11 saying yes. 23 claimed to have never had any psychological side effects to their hormonal birth control. The results from my survey show a higher rate of mood altering symptoms in women between the age groups 18 and under and 19-25 compared with women aged 33 and over. However, unlike the Denmark study, I did not ask if they had any symptoms of depression before they started taking their hormonal birth control nor did I ask at what age they started taking their birth control pills. This decreases the validity of my survey slightly; however, it does not mean that the results received are not valid.
2c. Collect people’s personal experiences whilst on birth control.

In order to collect people’s personal opinions I created a survey using Survey Monkey. Using this website, I was able to reach out to 100 females at random to collect and analyse data. Out of the 100 women I surveyed, 90% of them had taken a form of birth control at one point in their lives, with over half being on birth control for more than 2 years. As I stated earlier, 52.08% of the women surveyed stated that they had side effects to birth control and 42.86% of the women surveyed said yes to having psychological side effects to birth control and 13.27% were unsure. The evidence I found from my survey is similar to many stories I have read online regarding hormonal birth control and mental health. Many women were told, by their doctor, that the deterioration of their mental health was in no way related to their hormonal birth control. After the study linking depression to hormonal birth control was published in Denmark, women took to Twitter to share their personal stories on whilst on birth control. Below are a few of the tweets used in an article titled Women have emotional response on Twitter after birth control linked to depression.

Thousands of women expressed their concern on twitter, which lead to a chain reaction of tweets regarding the stigma surrounding reproductive and mental health. The reason the link between hormonal birth control and depression has gone undetected for so long is that women are ashamed to talk about their side effects to their birth control.

Aim 3: Establish what procedures are in place before prescribing birth control.

3a. Research what questions should be asked before prescribing birth control.

3b. Discover possible tests which could be done before prescribing hormonal birth control e.g hormonal panel tests.

Moreover, external progestins, probably more than natural progesterone, increase levels of monoamine oxidase, which degrades serotonin concentrations and thus potentially produces depression and irritability.

https://www.ncbi.nlm.nih.gov/pubmed/23219471 — Worsening depression study
https://www.popsci.com/science/article/2010-09/birth-control-pills-shown-alter-structure-womens-brainshttp://www.refinery29.com/2013/07/50279/birth-control-side-effects#page-2https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4139599/https://www.youtube.com/watch?v=hUqODNzgxdohttps://www.hormonesbalance.com/articles/pill-can-seriously-affect-womans-health/

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