Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review

Abstract

Background

Women with depressive or bipolar disorders are at an increased risk for unintended pregnancy.

Objective

To examine the safety of hormonal contraception among women with depressive and bipolar disorders.

Methods

We searched for articles published through January 2016 on the safety of using any hormonal contraceptive method among women with depressive or bipolar disorders, including those who had been diagnosed clinically or scored above threshold levels on a validated screening instrument. Outcomes included changes in symptoms, hospitalization, suicide and modifications in medication regimens such as increase or decrease in dosage or changes in type of drug.

Results

Of 2376 articles, 6 met the inclusion criteria. Of three studies that examined women clinically diagnosed with depressive or bipolar disorder, one found that oral contraceptives (OCs) did not significantly change mood across the menstrual cycle among women with bipolar disorder, whereas mood did significantly change across the menstrual cycle among women not using OCs; one found no significant differences in the frequency of psychiatric hospitalizations among women with bipolar disorder who used depot medroxyprogesterone acetate (DMPA), intrauterine devices (IUDs) or sterilization; and one found no increase in depression scale scores among women with depression using and not using OCs, for both those treated with fluoxetine and those receiving placebo. Of three studies that examined women who met a threshold for depression on a screening instrument, one found that adolescent girls using combined OCs (COCs) had significantly improved depression scores after 3 months compared with placebo, one found that OC users had similar odds of no longer being depressed at follow-up compared with nonusers, and one found that COC users were less frequently classified as depressed over 11 months than IUD users.

Conclusions

Limited evidence from six studies found that OC, levonorgestrel-releasing IUD and DMPA use among women with depressive or bipolar disorders was not associated with worse clinical course of disease compared with no hormonal method use.

Introduction

Mental health disorders are debilitating illnesses that affect both men and women. The most common mental health disorders that affect mood are depression with a lifetime prevalence of 16.6% and bipolar disorder with a lifetime prevalence of 3.9% in the United States [1]. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, depression is a disorder that may make a person feel sad, empty or in an irritable mood, which may in turn affect the person's ability to function in normal activities [2]. The prevalence of depression in women of reproductive age has been reported to be about 14% [3], and it is almost twice as common in women as in men [4]. Bipolar disorder is characterized by depressive and manic or hypomanic episodes [5] in which patients may experience unusual and abnormal patterns in mood, energy, activity levels and sleep [5]. Bipolar disorder has an early age of onset [6], with the highest prevalence in the 18- to 29-year age group [1]. The prevalence of bipolar disorder in women is between 1% and 2%, with the mean age of onset at approximately 20 years [7].

Depressive and bipolar disorders have been associated with unintended pregnancy, risky sexual behaviors and lack of consistent and effective contraceptive use [8], [9], [10], [11]. Moreover, depression symptoms during pregnancy may lead to adverse obstetric, fetal and neonatal outcomes [3], [12], [13]. Women with depressive or bipolar disorders may experience risks during pregnancy, such as teratogenic effects to the fetus from the medications for the disorder or worsening of symptoms during pregnancy [14]. An unintended pregnancy may also lead to or worsen depressive symptoms [15].

Little is known about the safety of contraceptive use among women with these disorders. Studies that have linked hormonal contraceptive use to mood changes and subsequent discontinuation of oral contraceptive (OC) use in healthy women have raised the possibility that these methods may worsen symptoms in women with diagnosed disorders [16], [17], [18]. Proposed biological theories for mood changes in normal women using hormonal contraceptives include estrogen-induced pyridoxine deficiency or estrogen or progestin interaction with the serotonergic system or noradrenergic systems [19]. Given the high prevalence of depressive and bipolar disorders among women of reproductive age and the public health importance of preventing unintended pregnancies, the objective of this review was to examine the safety of hormonal contraception among women with depressive and bipolar disorders.