Managing Hormonal Contraception and Depression

Introduction to Hormonal Contraception and Depression

Progesterone can cause depression through several mechanisms, including disrupting serotonergic receptors 1
Individual sensitivity to hormonal fluctuations varies significantly, and women with a history of depression may be more vulnerable to progesterone-induced mood changes 1

17β-estradiol based combined contraceptives are preferred over ethinylestradiol formulations, and recommended formulations include 17β-estradiol + acetate nomegestrol and 17β-estradiol + dienogest 2
Low-dose combined oral contraceptives (COCs) containing 35 μg or less of ethinyl estradiol are considered a first-line option 3
The American Academy of Pediatrics recommends low-dose combined oral contraceptives as a first-line option, as the estrogen component may be beneficial for mood 3
Combined hormonal contraceptives are classified as Category 1 for women with depressive disorders, indicating they are safe to use and may help alleviate depressive symptoms in some women, according to the U.S. Medical Eligibility Criteria for Contraceptive Use 4
Progestin-only contraceptives are also classified as Category 1 for women with depressive disorders, meaning there are no restrictions on their use 4

Micronized progesterone may have fewer mood effects than synthetic progestins, although the evidence is not cited here, it is generally considered in clinical practice
Consider transdermal estrogen patches (50-100 μg/24h) if oral administration is contraindicated 2
Avoid progestins with anti-androgenic effects in women with symptoms of hypoandrogenism 2
The American College of Obstetricians and Gynecologists suggests considering bioidentical progesterone rather than synthetic progestins for perimenopausal women, but this is not directly cited in the article

Evidence shows that hormonal contraceptive use does not increase depressive symptoms in women with depression compared to baseline or to non-users with depression 4
Assess mood symptoms after starting hormonal contraception, and if depressive symptoms worsen, consider changing to a different formulation or method 4
For women with pre-existing depression, monitor closely for changes in symptoms, and some antidepressant medications may interact with hormonal contraceptives, according to the U.S. Medical Eligibility Criteria for Contraceptive Use 4

Sudden discontinuation of hormonal contraception can lead to unintended pregnancy and hormone fluctuations
Correlation doesn't always mean causation when attributing mood changes to contraception
Always assess mood symptoms before starting contraception to establish a baseline
For women with severe depression, ensure adequate treatment of the underlying depression and consider close monitoring when initiating hormonal contraception
If mood worsens with CHCs, consider switching to a different progestin formulation or non-hormonal methods if mood effects persist
For women with depression and no contraindications, start with a low-dose combined oral contraceptive (≤35 μg ethinyl estradiol), consider formulations with less androgenic progestins, and use cyclical rather than continuous regimens initially