Avoiding fertility
There are a few ways to try and avoid fertility… Personally (not a medical professional), I believe if you understand your cycle deep enough, you can avoid pregnancy hormone suppressants like The Pill.
Why use non-hormonal birth control? Let’s ask the experts:
Despite its popularity, hormonal birth control has some undesirable side effects and risks. It's associated with a higher incidence of breast cancer, blood clots, and stroke. Hormonal birth control with estrogen is also off-limits during breastfeeding.
People also report changes to mood, possible decreased libido, and increased risk of sexual pain problems when using the pill, though studies don't agree as to whether the pill increases these issues. These side effects have prompted some people to look for hormone-free alternatives. - Clue
Should I use a Fertility Awareness Method (FAM)?
If any of the following applies to you, you are not a good candidate for FAMs:
You have recently started having periods
You are close to menopause
You have just gone off hormonal birth control
You have recently been pregnant
You aren’t willing to track fertility indicators daily
You may want to consider other forms of birth control, as these life events can make it harder to read fertility signs.
Different types of non-hormonal birth control:
Outercourse
Barrier methods
Fertility Awareness Methods / natural family planning
Withdrawal
Copper IUDs (intrauterine devices)
Sterilisation
Breastfeeding (lactational amenorrhea)
Learn more about this at Clue and remember that nothing is 100% full proof, even the pill.
A recent study had the objective to improve awareness of the natural age-related decline in female and male fertility with respect to natural fertility and assisted reproductive technologies (ART) and provide recommendations for their management and to review investigations in the assessment of ovarian aging.
What they discovered in order to recommend the below is pretty fascinating:
Women in their 20s and 30s should be counselled about the age-related risk of infertility when other reproductive health issues, such as sexual health or contraception, are addressed as part of their primary well-woman care. Reproductive-age women should be aware that natural fertility and assisted reproductive technology success (except with egg donation) is significantly lower for women in their late 30s and 40s.
Menstruation in girls and adolescents: using the menstrual cycle as a vital sign
Young patients and their parents often are unsure about what represents normal menstrual patterns, and clinicians also may be unsure about normal ranges for menstrual cycle length and amount and duration of flow through adolescence. It is important to be able to educate young patients and their parents regarding what to expect of a first period and about the range for normal cycle length of subsequent menses. It is equally important for clinicians to have an understanding of bleeding patterns in girls and adolescents, the ability to differentiate between normal and abnormal menstruation, and the skill to know how to evaluate young patients' conditions appropriately. Using the menstrual cycle as an additional vital sign adds a powerful tool to the assessment of normal development and the exclusion of pathological conditions. - Pubmed
Hormonal birth control
Hormonal birth control can affect many elements including your wellbeing. If you are properly educated and understand your cycle, you can avoid fertility without having to take any hormone suppressors ie the Pill.
Here’s what the research tells us about each birth control type:
Implant
The implant is a progestin-only method of birth control. There is a single-rod implant containing the progestin etonogestrel, and a two-rod implant containing levonorgestrel.
In the large Danish study mentioned previously, current users of the implant were more likely to be prescribed antidepressants for the first time than people who weren’t currently using it, but the rate of depression diagnosis among implant users was not reported in the study. This study does not specify which implant people were using.
People using the etonogestrel implant in a large Swedish study were more likely to be prescribed an antidepressant, particularly for adolescents. The same study showed an increased risk for antidepressant prescription among people using levonorgestrel-only methods, which included both the hormonal IUD and implant.
In a study of people using the etonogestrel implant for up to two years, 14% reported mood swings and 7% reported depression that was attributed to the implant.
The key takeaway: The implant may increase the chance of being treated for depression, but more studies are needed to understand if implant users report mood changes during use.
Hormonal IUD
The hormonal IUD is a progestin-only method containing levonorgestrel.
In the Danish study, current users of the hormonal IUD were more likely to be diagnosed with depression and prescribed antidepressants for the first time than people who weren't currently using it. The risk for being diagnosed with depression and prescribed an antidepressant was higher for adolescent hormonal IUD users than adults in the study.
The Swedish study showed an increased risk of being prescribed an antidepressant among people using a levonorgestrel-only birth control method, which included both the hormonal IUD and implant.
Conversely, a large Finnish study showed that people using the hormonal IUD were just as likely to have symptoms of depression or anxiety as people not using this method.
Two studies of people who received the hormonal IUD to treat heavy periods, showed scores on depression surveys either remained the same or improved, but this could be due to an improvement in quality of life when heavy periods become more manageable.
The key takeaway: The hormonal IUD may increase the chance of being diagnosed with or treated for depression, but does not appear to have a negative effect on mood when hormonal IUD users are asked to report symptoms.
The shot
There are several types of birth control shots available. All the studies mentioned in this section involve the progestin-only shot containing medroxyprogesterone acetate.
The Danish study showed current users of the shot were more likely to be prescribed antidepressants for the first time than people who weren’t currently using it, but the rate of depression diagnosis among shot users was not reported in the study. In the Swedish study, shot users were more likely to be prescribed an antidepressant.
A study of 183 people using the shot for up to three years showed that they were more likely to report depressive symptoms compared to people using another method of birth control or no method. People who stopped using the shot during the study reported depressive symptoms at higher rates, which subsided after stopping. It’s worth noting, however, that shot users in this study were also more likely to report depressive symptoms before starting the shot.
One study followed almost 400 users of the shot for a year. Among the 170 people who continued using the shot for a year, there was a decrease in depressive symptoms from the time they started it. Among the 218 people who stopped using depo during the year-long study, there was no change in depressive symptoms.
Adolescents using the shot do not appear to be at increased risk for depression based on three small studies.
In one two-year study, shot users were less likely to report mood swings compared to people not using hormonal contraception.
The key takeaway: The shot may increase the chance of being treated for depression, but results are mixed when people report mood symptoms while taking it—some people may have improved mood while others have worsened mood.
Pills
Combined oral contraceptives (COCs) are pills that contain both synthetic estrogen—usually in the form of ethinyl estradiol—and a progestin.
In the Danish study, current users of COCs were more likely to be diagnosed with depression and prescribed antidepressants for the first time than people who weren't currently using them.
The large Swedish study looked at the likelihood of being prescribed an antidepressant medication while taking different formulations of the birth control pill. It found that users aged 16-31 were more likely to be prescribed an antidepressant when taking birth control pills containing the combination ethinyl estradiol/lynestrenol and ethinyl estradiol/drospirenone. People using pills containing ethinyl estradiol/norethindrone, ethinyl estradiol/levonorgestrel, and ethinyl estradiol/desogestrel were less likely to be prescribed an antidepressant. People taking ethinyl estradiol/norgestimate were just as likely as non-users of hormonal birth control to be prescribed an antidepressant.
Several studies have found that birth control pills users are not more likely to report symptoms of depression, although one of these studies did show a decrease in general well-being among pill users. Another showed that people using birth control pills for reasons other than for birth control were more likely to experience depression.
One study found that COC users tracking daily mood had small increases in anxiety, irritability, and mood swings in the intermenstrual phase (roughly cycle days 5-22 of a 28-day cycle), but improvement in depression in the premenstrual phase (the seven days leading up to the start of the next period) compared to people on a placebo pill. At the end of the three-month study, there was no difference in depression scores between the birth control pill and placebo groups.
Some people may experience improvement in nervousness and mood swings while taking COCs, but people who have experienced negative mood effects while on birth control pills in the past may be more likely to experience depressed mood and mood swings.
Adolescents and the pill
Adolescents using COCs in the Danish study had a higher risk for being diagnosed with depression and prescribed an antidepressant than adults in the study.
Adolescents (age 16-19) in the study Finnish study were more likely than people not using hormonal birth control to be prescribed an antidepressant for every COC formulation they studied.
A study of adolescents in the U.S. who were currently or had ever used the pill showed an increased risk for ever having experienced depression, but no increased risk for current depression. But when other factors such as age, smoking, BMI, family socioeconomic status, and whether the adolescents were sexually active were considered along with the use of birth control pills, there was no increased risk for depression.
A small study where adolescents were randomly assigned to use COCs containing ethinyl estradiol/levonorgestrel or placebo for three months showed no difference in depression scores between the two groups at the end of the study.
The key takeaway: The pill may increase the chance of being diagnosed with or treated for depression, but the specific pill formulation may make a difference. Overall, it appears as though COCs do not have a harmful effect on mood reported by users, but this may vary between individuals.
Patch
The patch is a combined hormonal birth control containing ethinyl estradiol/norelgestromin. Very few studies on birth control and mental health specifically include the patch.
In the Danish study, current users of the patch were more likely to be diagnosed with depression and prescribed antidepressants for the first time than people who weren't currently using them. The risk for being diagnosed with depression and prescribed an antidepressant was higher for adolescent patch users than adults in the study.
The Swedish study showed the people using the patch containing were more likely to be prescribed an antidepressant than people not using hormonal birth control.
The key takeaway: The patch may increase the chance of being diagnosed with or treated for depression, but studies are needed to determine if patch users report mood changes during use.
Ring
The ring is a combined hormonal birth control containing ethinyl estradiol/etonogestrel. Few studies on birth control and mental health specifically include the ring.
In the Danish study, current users of the ring were more likely to be diagnosed with depression and prescribed antidepressants for the first time than people who weren't currently using them. The risk for being diagnosed with depression and prescribed an antidepressant was higher for adolescent ring users than adults in the study.
Studies have shown that ring users may be less likely than pill users to report depression, irritability, and mood swings as side effects.
The key takeaway: The ring may increase the chance of being diagnosed with or treated for depression, but more studies are needed to see if ring users report mood changes during use.
Mini-pills
Mini-pills are progestin-only birth control pills. They may contain norethindrone, desogestrel, drospirenone, lynestrenol, or other forms of progestin.
In the Danish study, current users of the mini-pill were more likely to be diagnosed with depression and prescribed antidepressants for the first time than people who weren't currently using them. The risk for being diagnosed with depression and prescribed an antidepressant was higher for adolescent mini-pill users than adults in the study.
In the Swedish study, people age 16-31 taking norethindrone or lynestrenol mini-pills were just as likely as people not taking hormonal birth control to be prescribed an antidepressant, although adolescents (age 16-19) taking norethindrone mini-pills were more likely to be prescribed antidepressants. People taking the progestin-only pill containing desogestrel were more likely to be prescribed an antidepressant.
The key takeaway: The mini-pill may increase the chance of being diagnosed with or treated for depression, but the specific formulation may make a difference. Studies are needed to see if mini-pill users experience changes in their mood while using it.
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The pill has a diverse benefit on conditions such as polycystic ovary syndrome (PCOS), endometriosis, pelvic inflammatory diseases, anaemia and dysmenorrhea (menstrual cramps) to name a few. Women usually start the pill early in teens for both cycle control and contraception.
Women usually discontinue pills for conception and sometimes when there is a delay in conceiving, it starts the unnecessary debate on whether the pill is possibly the culprit. It might be a misconception perpetuated by blogs and magazines and leads to women avoid taking the pill and risking unwanted pregnancies, stress and terminations. We asked fertility expert Dr Virochana Kaul to review data to provide clarity and guidance for supporting the safety of pills.
How does the pill work?
To understand how the effects of the pill reverse themselves once you’ve stopped taking it, first it’s important to understand how the pill works in the first place.
Essentially, the combined oral contraceptive (COC) works by ‘switching off’ a woman’s natural production of two hormones called ovarian oestrogen and progesterone and replacing them with a synthetic version.
It works to prevent pregnancy in three ways: inhibiting egg release (ovulation), changing the thickness of cervical mucus, and altering the lining of the womb so that implantation of a fertilised egg is less likely.
Having a thin lining and less bleeding makes periods more controllable, relieves dysmenorrhea (period pain), treats endometriosis and the thick mucus prevents infection.
Fertility after the contraceptive pill
Data reviewed for women on the pill shows that:
57.9% of all first cycles after discontinuing oral contraceptives were ovulatory (you released an egg)
Only 10.24% of all first cycles after discontinuing oral contraceptives were not ovulatory
Cycle disturbances after discontinuing oral contraceptives were reversible but regulation took up to nine months or longer
It’s important to remember that the late return of cycles was associated with older age groups and previous impaired fertility. The data is quite reassuring for women who want to conceive and start trying soon after discontinuing the pill. Tracking ovulation is an easy way to start.
Knowing when to seek help on conception
It’s normal for cycles to resume anywhere from a few weeks to a few months following taking a contraceptive pill. If you’re under 35 and have been trying for a year, it might be time to start thinking about seeking some fertility help. If you’re over 35, you might want to seek help after six months of trying. Until then, make sure you’re getting the timing right and keeping healthy.
About the author
Dr Virochana Kaul is a Consultant Obstetrician and Gynaecologist experienced in general obstetrics and gynaecology, and has a special interest in laparoscopic surgery, and reproductive endocrinology and infertility. She has more than 15 years’ of experience in obstetrics and gynaecology.
Dr Virochana Kaul
Monash IVF Fertility Specialist
FRANZCOG MRCOG MD DNB