Women aged 15 to 33 years who begin to use birth-control pills, contraceptive vaginal rings or hormone-based IUDs have an increased risk of committing suicide or attempting suicide, compared with women of the same age who do not use hormonal contraceptives.
This is the result of a new study from Rigshospitalet in which researchers followed half a million Danish women from the age of 15 in the period from 1996 to 2013. Researchers have calculated the frequency of suicide attempts and suicides among women who use different types of birth-control pills, contraceptive vaginal rings and hormone-based IUDs, known as combined hormonal contraception, CHC, and compared this frequency with women of the same age who have never used CHC. The study has just been published in the American Journal of Psychiatry.
Research shows that women who begin using a CHC are three times as likely to commit suicide and have double as many suicide attempts as women of the same age who do not use any type of CHC.
Compared to women who did not use CHC, the frequency of suicide attempts among users of CHC (i.e. the relative risk) was 2.1 among women aged 15 to 19 and 1.6 among women aged 20 to 33.
Women included in the study had not previously used CHC, been on antidepressants or been diagnosed with mental illness, cancer or blood clots. The women were therefore all psychologically healthy.
Greatest risk at the outset
The 475,802 women who took part in the study were followed for an average of 8.3 years. During the follow-up period, 54% used a type of CHC. Researchers registered 6,999 first-time suicide attempts and 71 suicides among women included in the study.
There was a close chronological correlation between the considerably increased risk of attempting suicide and the initial period after starting to use CHC (see Figure 1).
"It should be stressed that there are significant individual variations," explained Professor Øjvind Lidegaard from the Department of Gynaecology and head of the research project.
Women with a tendency towards depression should not use hormonal contraception
"Some women are more sensitive to these artificial hormones and many women do well with birth-control pills, contraceptive implants and IUDs. However, these findings underline that some women are so dramatically affected that they become depressed and attempt to commit suicide," explained Professor Lidegaard.
*) Hormonal contraception includes birth-control pills, the contraceptive patch, the vaginal ring, contraceptive implants, the mini pill and IUDs.
Together with the rest of the research team, he therefore encourages that these women be informed of the discovery of this correlation so the woman, her family and the physician involved can suspend the use of the contraceptive if these side effects appear.
Professor Lidegaard also encourages physicians to be cautious about prescribing hormonal contraception to women who have previously attempted suicide or who have a tendency towards depression.
The results of this new study are consistent with the increased risk of developing depression that has been discovered among women who use CHC and they therefore reinforce previously demonstrated correlations.
"It is well-known that oestrogen in women has a tendency to affect their moods, while progesterone has the opposite effect," explained Professor Lidegaard. He further explained that because hormonal contraception is generally dominated by progestin (artificial progesterone), it does not come as a surprise that these products generally have a negative effect on women's moods and increases the risk of depression and thereby also the risk of suicide or attempted suicide.
The factors taken into account during the study are the woman's age, the calendar year, length of education, the presence of polycystic ovarian syndrome and endometriosis. Pregnant women were excluded during pregnancy and for 6 months after giving birth.
Researchers did not discover any significant difference between the risk of attempted suicide between women who used different types of combination birth-control pills. However, contraceptive patches and vaginal rings carried a higher risk than combination birth-control pills.
Women who used pure progestin products, such as mini pills and IUDs, also had a slightly increased risk of attempted suicide compared to women who used combination birth-control pills (Figure 2).
Figure 1: Trends in suicide attempts after starting hormonal contraception compared to other users. Figure 2: Relative risk of attempted suicide among women using different types of hormonal contraception compared to other users.
The study was carried out by Charlotte Wessel Skovlund, PhD; Lina Steinrud Mørch, senior researcher; Professor of Psychiatry Lars Vedel Kessing; Theis Lange, PhD; and Professor of Gynaecological Obstetrics Øjvind Lidegaard from Rigshospitalet and Copenhagen University.
The study was funded by the Lundbeck Foundation and published in the American Journal of Psychiatry on 17 November 2017.
1) Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of hormonal contraception with depression. JAMA Psychiatry. 2016; 73: 1154-1162.
2) Skovlund CW, Mørch LS, Kesing LV, Lange T, Lidegaard Ø. Association of hormonal contraception with suicide attempts and suicides. Am J Psychiatry 2017; in press.