By Maya Palit
Like many women around the world, Radha D, a 27-year-old Mumbai-based editor, has a complicated relationship with the contraceptive pill. And it’s not even a relationship that began with the need for contraception.
“I first started taking the combined oral contraceptive pill when I was in class 12. I had been misdiagnosed with PCOS and had extremely heavy periods, but from the very beginning I faced all the symptoms that are listed on the ridiculously small piece of paper that comes with the pill. Nausea, bloating, headaches, period cramps, and bad mood swings,” she says. Living with the birth control pill is a constant battle, but Radha has since then been correctly diagnosed with endometriosis and has been told that she can’t do without it.
The pill occupies this ‘frenemy’ status in the lives of a significant number of its users, besides Radha’s. From the time of the birth control pill’s approval in 1960 to now, the pill has simultaneously been vociferously marketed as the ‘key to the temple of liberty’ for women, while being dogged by speculation about its side-effects. When first created, it was tested with less-than-informed consent on women in an institution for the mentally ill in Massachusetts and working class women of colour in Puerto Rico and Haiti. The side-effects the women experienced included blood clots, nausea, bloating, dizziness, and immense mood swings. Although the reduction in estrogen dosages of hormones lessened some of these impacts, and the pill now comes in a range of formulations, the question of what the pill does to women’s mental health is still being debated today, over 50 years later.
Over the years, there have been ominous mutterings about its repercussions, right from 1969 when health activist Barbara Seaman’s book The Doctors’ Case Against the Pill prompted hearings that investigated the safety of the combined contraceptive pill. Supposed consequences like weight gain (which have been disproved by the scarce studies that address it) to those bordering on the surreal, like women finding partners’ faces less attractive once they’re off the pill, have been discussed.
For a pill being used by 100 million women around the globe, there is still astoundingly scanty information on the subject of its side-effects, although it appears that we are finally making some headway.
In April, a major new study led by Angelica Linden Hirschberg, a professor at the Department of Women and Children’s Health at the Karolinska Institutet in Sweden, confirmed for the first time that the combined contraceptive pill (a pill that combines the hormones oestrogen and progestogen) has a negative impact on a woman’s well-being.
In the study, 340 healthy women between the ages of 18 and 35 were treated for three months, and approximately half of them were given placebo pills. The other half was given a combined pill (containing the chemicals etinylestradiol and levonorgestrel), which is apparently one of the most widely recommended pills in several countries, including India. They were then asked questions that were constructed according to global scales like the psychological general well-being index (PGWBI) and self-report ratings like the 21-item Beck Depression Inventory (BDI).
The women in the study who were given the combined pill experienced dips in their moods, self-control, energy levels, and ‘quality of life’. It is important to note that there is no indication that the oral contraceptive increases depressive symptoms or puts women at the risk of developing depression.
This study, being randomised and placebo-controlled, is ostensibly more reliable than a previous study published by researchers at the University of Copenhagen last year, which suggested an association between combined contraceptives and depression.
Although previous research hadn’t found depression to be a frequent consequence of using the pill, the 2016 Danish study created ripples by claiming that women using the combined oral contraceptive were 23 percent more likely to use anti-depressants. While many women at the time felt vindicated that they had proof that the pill messed with their moods, experts also jumped to point out several limitations of the Danish study.
One, that it was a cohort study (medical research that answers a hypothesis, and establishes links between risks and outcomes) rather than a case-controlled one (a comparative study which examines patients who have a disease with those who do not). Two, that an association between the pill and depression can’t be taken to mean a direct causal relationship. Three, that anti-depressant prescriptions and similar secondary data aren’t necessarily the best indicators of depression.
The new Swedish study doesn’t have these limitations, but scientists themselves pointed out that the results should be “interpreted with a certain amount of caution”. In fact, one of the leaders of the studies suggested that a contributing cause for lower well-being could be that women were taking the pills in an irregular or erratic way.
So where does that leave us?
Bangalore-based psychiatrist Sabina Rao said that from her understanding of the study, evidence pointed to the fact that women were not staying compliant on the pill. “The study does not make a direct co-relation that says oral contraceptives are causing depression. So at no level should we be telling our patients to not take oral contraceptives because it might worsen their depression, but I do mention that contraceptives could impact your mood.”
Bangalore-based gynaecologist Shaibya Saldanha, said that she tends to advise her patients to decide based on their family history. “I often tell patients if they’ve had depression previously, or a history of breast cancer in the family, to avoid the pill. The same goes for patients who feel symptoms like migraine. The pill can, in rare cases, cause deep vein thrombosis or other complications, in the way that even medicines like paracetamol have caused kidney failure for some people. So it’s best to ask patients to look at family history and symptoms.”
Unfortunately, informed choice is not the hallmark of reproductive healthcare in India. In our country, where some families even insist their daughters pop the pill to temporarily delay their periods because they aren’t allowed to visit temples while menstruating, there are a range of factors that impact women’s choices to take the pill. It’s not clear how many of these categories of users know that mood swings or fatigue may be coming their way.
Women we spoke to, who are regular users of the pill, sounded far from alarmed. Two told us with resignation that the benefits of the pill outweighed its risks and inconveniences: they’d rather use it than other bothersome contraceptive measures.
Some women we spoke to say they haven’t experienced mood swings at all. Sixteen-year-old Deepti, who had been using the pill for contraceptive purposes for over a year, had felt nothing besides the standard pre-menstrual mood fluctuations. Anasua, a London-based academic, hadn’t faced any mood swings either but said the study gave her pause because of the apparent links between the pill and low-energy levels and fatigue.
For some women, their indifference to the study was simply due to them being stuck with the next best alternative to period pain or dysmenorrhea. Radha, for instance, has noticed very extreme mood swings and crippling bouts of depression, amongst other troubling side-effects. But with her endometriosis she has been advised not to get off it by her doctors.
For others, the pill had introduced different complications into their lives, and had subsequently been abandoned. Twenty-nine-year old Anahita Muthuswamy said she took the combined contraceptive for PCOS: “I initially thought it was the best thing that happened to me because I normally have a very heavy, very messy period and dysmenorrhea to boot. On the pill, I was not only bleeding less, but also experiencing significantly less pain. The flip side was that I was losing a lot of hair, so I decided to look for other alternatives.”
The vote, then, seems to be in favour of waiting for further evidence before signing off the pill. Should we be resigned to the pill, in the same way that millennia before the human race was resigned to no easy, scientific method of contraception for women?
As Anahita says, “I’m still gobsmacked that this is 2017, and we still haven’t reached an effective method of birth control that doesn’t compromise women’s health and well-being in some way or the other.”
While we await more information about the pill and its relationship with depression and mood swings, we have cause enough to be depressed that we still only have this pill.