The Pill Is Good. Why Isn’t It Better?

When Samantha Pines* was in her early 30s, she decided to quit the birth control pill. She’d been on it for several years, and was experiencing weight gain and depression. She had since been prescribed antidepressants, but she still wasn’t feeling good. At that point, she wasn’t sure that being on birth control was worth it anymore. “I felt like birth control was contributing to my depression, and it just wasn’t making me feel great,” she explains. After getting off the pill, Pines says she “felt less low, and knew it was the right decision.”

Now, Pines is 49 and she’s back on the pill, this time to help with heavy, erratic periods, hot flashes and night sweats. Despite her prior experience, Pines was willing to try the pill again because her perimenopause symptoms were so disruptive. On top of her physical symptoms, Pines’s mental health was declining, too. Plus, she remembers how awful menopause was for her mom. “That was my biggest fear. I was like, I can’t go through that. She was such a terrible person to be around.”

Pines’s doctor prescribed her a low-dose birth control pill. But after just six months, Pines was feeling extremely anxious—and wasn’t getting much relief from her other symptoms. So, she did what many people with a health problem do: She turned to Google. “I had a really hard time finding anything about [anxiety and the pill], but some people on Reddit said they were also experiencing anxiety,” she recalls. She went back to her doctor and got on a different brand. And while the new pill is now providing some relief, she finds herself experiencing breakthrough bleeding and severe migraines every six weeks. The anxiety hasn’t let up. She plans to ask her doctor for a non-pill alternative soon.

Unfortunately, Pines’s experience isn’t uncommon. Mood-related issues like anxiety and depression are all too familiar to people on the pill. The thing is, it’s extremely safe and, when taken correctly, spectacularly effective at preventing pregnancy—factors that might help to explain why mood changes are brushed off as unimportant or not real.

“The pill has been around now for so long, it’s one of the most researched medications,” says Cynthia Graham, a professor of sexual and reproductive health at the University of Southampton in the U.K. “It’s the behavioural effects, how people feel, that we’re lacking research in.” More extensive research is imperative: Several recent studies have shown that hormonal contraceptive users have higher rates of depression, anxiety, fatigue, sexual disturbances and anger. They confirm what Pines and many other women experience. But compared to the efficacy and physical safety of the pill, cognitive and sexual side effects often aren’t taken seriously, says Graham, even though they’re one of the biggest predictors of quitting the pill.

Since the pill was first made legal, we’ve witnessed how much better the world is when people have access to safe and effective birth control. And yet, despite its long history, we still don’t know much about the pill’s effects on mental health, mood and libido. How, more than 60 years on, is that possible—and how can we make the pill even better?

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The pill is the most popular form of hormonal contraceptive in Canada: About three-quarters of Canadian women have taken it at some point in their life and, globally, 151 million people are on the pill. Its popularity can be attributed to its effectiveness: When used perfectly, it’s 99 percent effective, and even with imperfect use, efficacy still hovers around 91 percent. And despite the rise of newer hormonal contraceptive options like IUDs, the patch and the implant, which are also highly effective, the pill is still very popular, especially for young people. In Canada, about 30 percent of teens between the ages of 15 to 19 are on the pill.

It’s called birth control, but many people are prescribed the pill for non-contraceptive reasons. A 2011 study found that more than half (58 percent) of pill users don’t use it exclusively to prevent pregnancy. The same study found that the most common non-contraceptive reasons for going on the pill are menstrual regulation, reducing cramps or menstrual pain, alleviating acne and treating endometriosis. And there are more benefits—the pill can even reduce the risk of uterine and ovarian cancers and prevent the development of breast cysts.

Of course, there are downsides. Nuisance side effects like breast tenderness (which makes running even more painful) and spotting (RIP cute underwear) are quite common, especially when you first get on the pill. And then there are the rare and potentially fatal side effects, like blood clots: 10 in 10,000 people will develop them as a result of being on the pill.

In the ’60s, when the first pills were being developed, they contained high doses of estrogen, which is associated with ischemic stroke and heart disease, explains Ashley Waddington, an associate professor of obstetrics and gynecology at Queen’s University in Kingston, Ontario. The first brand on the market had 10,000 micrograms of progestin and 150 micrograms of estrogen; today, all the pills available in Canada are considered “low-dose,” meaning they contain 35 micrograms or less of estrogen—and even lower doses are being experimented with right now. “Adjusting doses and getting into these really ultra-low-dose estrogen pills is a trend we’re seeing,” says Waddington.

Newer forms of estrogen that may be safer for blood clotting risks, like estradiol and estradiol valerate, are also hitting the market. “It’s an interesting and exciting development in birth control,” Waddington says. “For the last 60 years, the pills that were available all contained some dose of the same estrogen, and now we’re seeing different types of estrogen, which may bring in different side effect profiles.”

Waddington also points to improved progestin-only pills (also called the “mini-pill”) as another innovation. Without the estrogen, there’s less risk of clotting or cardiovascular problems, but they need to be taken within the same, precise three-hour window every day to be effective. A new progestin-only pill now available in Canada, Slynd, offers a different progestin and dosage than the mini-pill, which makes it safe but more forgiving (if you miss it by a couple of hours, it’ll still be effective). “I think we might see a shift towards more people going directly to a progesterone-only pill and not taking the risks associated with estrogen,” Waddington says.

Image: Vicky Lam

There’s been great innovation to improve the physiological side effects of the pill, so why hasn’t there been more action to address the mood-related ones? Given the long history of reproductive injustice and the struggle for accessible birth control, some might argue that looking for problems with the pill could come off as anti-pill, anti-feminist or anti-choice. Especially when the problems are, well, not fatal.

Contraceptives (and, in turn, reproductive choices) don’t improve if no one thinks they need to be better, says Rebecca Sullivan, a professor at the University of Calgary who specializes in gender and sexual politics and culture. But arguing that there’s something “wrong” with the pill feels fraught, especially as the U.S. strips away federal protections for abortions and puts access to contraceptives on the line. “The thought of losing access to the pill is terrifying,” says Sullivan, “and rightly so.”

According to Tory Eisenlohr-Moul, an assistant professor of psychiatry at the University of Illinois at Chicago who studies sensitivities to hormonal shifts, another reason why there’s a lack of research in mood and libido effects from oral contraceptives is the separation between gynecology and psychiatry as medical practices. “The people who develop the pills are usually gynecologists and researchers focused on physical health outcomes like blood clots or cholesterol problems,” she says. “To my knowledge, there’s no scientific group working on a new birth control method that’s better for mood.”

And when it comes to the sexual side effects of the pill, there’s been even less work done. In an editorial written for BMJ, Graham notes that “sexual side effects have been deemed ‘extremely difficult to assess’ and described in the literature as ‘trivial’ or a ‘nuisance.’” Later in the article, Graham writes that one of the most consistent findings has been how varied people’s experiences on the pill are—some show increased libido, some show a decrease and others show no change. “It will not be easy to establish whether, how and in whom the pill produces adverse sexual effects; carefully planned, adequately funded research is needed,” she concludes. “But as the ultimate value of a contraceptive method depends on its acceptability and usage, it is important that it is done.”

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When the pill was first legalized in the ’60s, it underwent a small number of randomized, placebo-controlled trials (the gold standard for medical research) on its effects on mood and sexuality. These allowed researchers to rule out the “placebo effect” (thinking that a medication is affecting you even if you’re taking a sugar pill), which can skew the results of a trial—especially when researching something as hard to quantify as mood and libido. However, according to Graham, most of the pill research conducted now is in the form of cross-sectional studies. These compare those who are on the pill to those who aren’t, but don’t account for the fact that established, long-time pill-users are generally happy on it, which can skew the results in a positive direction. Plus, funding in this area is woefully lacking, says Graham, who has done research on the pill and how it affects users’ libido and mood. Long studies that follow users are expensive and difficult to conduct. And no one seems to want to invest the time or money.

People who do take the pill, however, are deeply invested in the matter. According to Graham, finding willing study participants has never been a challenge. “I remember some women saying that they didn’t want [to be paid]. They wanted the money to be put back into research,” she says. “They said they wanted their daughters to have more options.”

Of course, the lack of funding and support for this kind of research is symptomatic of a health-care system that overlooks anyone who isn’t cis, white, straight and male. For decades, women were excluded from clinical trials. The FDA in the U.S. even issued a guideline in 1977 that recommended excluding most women of “childbearing potential” from participating in phase I and early phase II drug research trials. There’s far less representation in clinical trials if you’re not white—even today.

There’s also the lack of women in the pharmaceutical and medical fields. “We continue to have a largely male-dominated industry and government where this just isn’t a priority,” says Sullivan. “There are a whole bunch of factors that make it difficult to impossible to have a sustainable, flourishing research career coming up with a contraceptive that is safer and even more effective.”

Laura Symul, a postdoctoral fellow who studies cycle-related symptoms at Stanford University’s department of statistics—often using data from cycle tracking apps—points to a lack of female lab directors, hospital CEOs and heads of clinical research as factors behind the lack of data. Those who are guiding the research, she says, “don’t have first-hand experience with [birth control].”

Structural issues within medical research circles also move careers in particular directions. For researchers to gain promotions and salary raises and to continue to have a thriving career, they need to bring in their own funding—leading to acute pressure to secure that funding. Often, this means going after designated grants even if they’re not totally interested in the topic. Then, once a researcher does gets their foot in the door, they can fall into a pattern of pursuing similar research topics to secure more funding, sending them down a particular research and career route while their interests fall to the wayside. So, topics that aren’t popular, or for which there isn’t express interest from others higher up, don’t get investigated.

Then there are the social mores around birth control. People are still uncomfortable, says Waddington, with the idea that women can have total control over their fertility. “Many still believe that it should be left up to fate or left up to God,” she explains. And such moralizing about fertility can mean that advances in reproductive health become subject to questions of ethics—rather than of medicine. “It just doesn’t exist in other disciplines,” Waddington says. “Like, when somebody sees their endocrinologist about diabetes, they don’t have a whole discussion about whether or not it’s ethical to treat it.”

Image: Vicky Lam

Lately, there’s been more scientific attention paid to the ways that hormones affect mental health. A randomized study out of Sweden used brain imaging to study the hormone levels and depressive symptoms of healthy women who had previously experienced negative effects related to oral contraceptives. The researchers found a causal link between the administration of synthetic hormones and connectivity in the salience network (as in, the parts of our brain that detect significant stimuli and the integration of sensory, emotional and cognitive processes). There’s also a study out of Denmark that looked at more than 1 million Danish women and found that being on the pill was associated with a diagnosis of depression. At the University of British Columbia, Frances Chen is researching how being on the pill as a teenager might lead to a higher risk of developing MDD (major depressive disorder). While this research is still preliminary, studying the links between hormones and mental health generally will lay the groundwork for a pill designed to avoid detrimental mental health side effects.

The recent growth of personalized medications, especially customized hormone therapy to treat menopause symptoms, might also point to developments for contraceptives.Another major gap in contraceptive research is the inability to figure out how someone will react to the pill: Finding the right pill for you comes down to the imperfect science of trial and error. It’s common for people to try two or three brands before settling on one that works. “The big problem that we have is that we can’t predict which women are going to respond in which way [to the pill],” says Graham. “That to me is striking after 60 years.”

However, Waddington notes, there are already so many formulations and brands out there that compounded and customized birth control pills won’t likely be coming to a pharmacy near you. Eisenkohr-Moul in Chicago reiterates that “the companies working on [birth controls] tend to focus more on secondary health effects like blood clots and lipids—not on mood.”

Stanford’s Symul says that research and development on new birth control pills and formulations is underway, but it’s been slow going. There are start-ups working on very innovative birth controls that aren’t hormonal, but research takes a long time, she explains. “There hasn’t been as much money or top-down approaches or a consortium working on this,” says Symul. “It’s a lot of people trying to make their own research move forward.”

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While scientists are working to develop better birth control pills, especially ones that have fewer negative effects on mood and mental health, there’s still a long way to go. In the meantime, the pill continues to be popular, both as a contraceptive and as a therapeutic for a number of painful ailments. It’s still an important pillar of reproductive health.

Now, more than ever, the conversation around reproductive justice and increasing safe options is vital. We don’t just need a pill that’s safe and effective—that should be the bare minimum. We need a pill that makes us feel good. Or, at least, makes us feel like ourselves.

“Yes, pills are used to prevent pregnancy, but they’re also used because people want to have sex,” says Graham. “So if you have really bad side effects from the pill, including a loss of libido…well, as a patient once said to me, it defeats the entire purpose.”

Next: What’s the Best Way to Switch Birth Control Pills?