Contraceptives: The Effects on Emotional and Physical Well-Being

A review of the effects of the pill on women's well-being.

This was originally made for something else. Thus, the format is radically different than my articles — no graphs, pictures, etc. Again, was not made for this blog. However, since I believe that the original project is DOA, I am releasing my research on Substack. Thanks.

• 1.1: History of Contraceptives

• 2.1: Sex Bias in Women’s Health Research

• 3.1: Declining Female Happiness

• 4.1: On The Effects of Contraceptives

  • 4.2: Psychological Well-Being

  • 4.3: Suicidality

  • 4.4: Substance Abuse

  • 4.5: Attraction and Sexuality

• 5.1: Physical Effects

  • 5.2: Weight

  • 5.3: Fertility

  • 5.4: Risk of Blood Clots

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1.1: History of Contraceptives

All the following information comes from Planned Parenthood (2012), the Wikipedia article on the Birth Control Movement and Maragaret Sanger, unless otherwise stated.

For centuries, societies and individuals have attempted to control fertility through different means, but it wasn’t until recently that most biological mechanisms for how fertility works were understood. For example, scientists didn’t discover sperm until 1678 and did not fully understand its function until 100 years later (Bullogh and Bullogh 1990; in Planned Parenthood 2012). Although the science of reproduction was roughly understood at that time, methods of contraception remained largely unchanged for years.

According to Planned Parenthood (2012), the Voluntary Motherhood Movement in the 1870s believed in abstinence within marriages, and some suffragists believed that men and women should altogether abstain from sex to control family size. However, promoting abstinence for birth control among married women led to an increase in reliance on prostitution by men and a rise in sexually transmitted infections. In addition to abstaining from sexual encounters, other forms of birth control include refraining from masturbation, engaging in non-penetrative sexual activities such as kissing instead of intercourse, practicing withdrawal (the modern "pull-out game"), and using condoms. While some of these methods are still used today, many have a rich history in the science of sexual health.

Modern methods of contraception, such as condoms, have been used throughout human history. Ancient illustrations from France and ancient Egypt depict figures engaged in sexual intercourse while using condoms, though it's unclear whether they were used for sexual or ritualistic purposes, or both. The oldest condoms, made from animal guts, date back to 1640. However, similar to the challenges faced with promoting abstinence, the use of condoms also encountered opposition. For example, the American Social Hygiene Association fought to restrict condom use in the early 18th century because they believed individuals who engaged in sexual intercourse deserved the risks they faced, and military leaders opposed condom use on religious grounds. As attitudes shifted, condoms became more accepted for personal and even military use, though they were not used to prevent pregnancy in married women. Thus, while women's sexual autonomy was controlled in various aspects, including the promotion of abstinence within families, men faced fewer restrictions, and their barriers were easily overcome.

It was not until the mid-20th century that the pill, one of the most widely used forms of contraception, was developed by Margaret Sanger. Sanger closely followed research on birth control while simultaneously funding and working on her own oral contraceptive pill. However, it was not until her friend, Katharine Dexter McCormick, started donating significant funds towards Sanger's work on an oral contraceptive that Sanger's research and clinical trials received financial support. In 1956, the FDA approved Sanger's contraceptive pill for distribution.

Though Sanger's story seems straightforward, it is not without misrepresentation given its place in political and socio-political history. Before addressing such controversies, it's important to understand Sanger's history. For most of her life, Margaret Sanger was a sex educator and contraceptive activist. She even imported contraceptives from Europe into the United States when they were banned in 1915. It's essential to remember that contraceptives were not always banned in the United States. In the 1870s, following a growing puritan social movement, contraceptives were banned, though shops still sold contraceptive products under different names. Thus, Sanger had to reintroduce sexual education through birth control due to the puritan laws in the U.S. at the time. True to her activism, she was the first to open a birth control clinic in the U.S. Despite facing arrest shortly after its opening, she continued to see women seeking reproductive help, distributed contraceptives with her sister, Ethel Byrne, and advocated for sexual health education.

Due to such actions, Byrne and Sanger were arrested and sentenced to work in a workhouse. After a failed hunger strike and conviction, the trial judge noted that women did not have "the right to copulate with a feeling of security that there will be no resulting conception." Sanger's actions, while not supported by the law at the time of her arrest, garnered support and new avenues of funding for birth control activism. It was not until World War I that many U.S. soldiers started contracting sexually transmitted infections (STIs), leading the U.S. government to promote abstinence and provide guidance on contraceptives, though they were unable to provide condoms due to pressure from puritans. While soldiers in Europe could access condoms, they continued to use them upon returning to the states. As the U.S. government began discussing sexual health, the topic shifted from a moral panic to a public health discussion.

During this time, contraceptives started gaining mainstream acceptance, with the creation of the American Birth Control League, the opening of a second birth control clinic by Sanger in New York, and favorable descriptions of contraceptives in American magazines. However, legislative opposition from the Catholic Church and religious lobbying continued to hinder legal acceptance of contraceptives, despite their growing mainstream acceptance. It's important to note that such opposition was primarily moralistic, guided by religious teachings, particularly Catholic beliefs. This opposition led to pressure on news agencies not to cover stories on birth control, lobbying against contraceptives, banning Sanger's speaking events in city councils, and spreading the belief that contraceptives are unnatural and harmful to keep them banned.

In the 1930s, two important legal acts furthered the birth control movement, leading to both mainstream and legal acceptance. In 1930, it was ruled that contraceptive production was a legitimate business, and the law prohibiting the mailing of condoms was overturned. In 1932, Sanger imported a diaphragm from Japan, which was confiscated by the U.S. government because diaphragms were still illegal at the time. However, Sanger anticipated this provocation causing legal issues, leading to a legal challenge that ultimately overturned the anti-contraception law restricting physicians' abilities to access contraceptives. This decision prompted the American Medical Association to accept contraceptives as a valid form of medical services and integrate them into medical school curricula. Despite these advancements, the medical community was slow to fully accept contraceptives, resulting in women continuing to use unsafe and ineffective contraceptive methods until the 1960s.

By 1942, there was general mainstream and legal acceptance of contraceptives, and anti-contraceptive laws were rarely enforced. During this time, Sanger closely followed research on birth control and received funding from McCormick. Shortly after, in the 1960s, the birth control pill was developed.

So, what are the controversies surrounding Margaret Sanger? One of the most important and often repeated pieces of misinformation relates to the supposed racism of Sanger and Planned Parenthood. According to commentators like Dinesh D’Souza in "The End of Racism" (1995), Harriet Washington in "Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present" (2007), and Conley (2020) writing in "America: The Jesuit Review," among others, Sanger and Planned Parenthood have been accused of racism, alleging that Sanger attempted to depopulate the black population through the use of contraceptives, largely because Sanger was, like others at the time, a eugenicist.

According to D’Souza and others, evidence of Sanger’s racism comes from her comment in "The Negro Project" documents, where she stated, "We do not want the word to go out that we want to exterminate the Negro population." Others like Washington go a step further, accusing Sanger of being a racist because of her discussions related to African American reproduction in the context of eugenics and breeding, citing her husband's favorable review of the infamous racialist book "The Rising Tide." However, there is little direct evidence showing that Sanger had racialist views aligned with her eugenic views. Such evidence is interpreted to suggest that Sanger’s push for contraceptives within the black community aimed at limiting the total black population.

Such revisionist accounts have been rebutted for years. In 1985, Valenza (1985) remarked that many accusations of racism toward Sanger stem from secondary sources, but an analysis of her publications demonstrates something different. First, Valenza notes that the eugenic view at the time was largely not racial, but after its use by the Nazis, the public viewed eugenics as inherently racial. Some, like Washington, criticize Sanger because of her terminology when discussing the "fit" and "unfit," with the "unfit" tending to be poor and having worse life outcomes, which she alleges included black individuals. However, as Valenza notes, such terms were subjective and biased towards the middle class, and Sanger "was arguing for a complete environment that nurtures human excellence," not one based on race. Second, Valenza indirectly responds to Washington’s argument that Sanger is a racist because her journal published works from other eugenicists. However, Sanger’s journal covered a wide variety of opinions and research, and inclusion required contributions to the discourse surrounding contraception. Passages written by racial eugenicists were published after Sanger had left her review, not during her time – a fact omitted by Washington.

Third, it’s essential to remember that Sanger was not attempting forced population control on any race or social class. As Sanger herself said, “Margaret Sanger has not advocated larger families for the rich. Rather, she has emphasized the necessity of leaving the decision as to the number of children and the time of their arrival to the mother, whether she be rich or poor.” Though she believed individuals with severe mental retardation and other issues should not reproduce, she did not view these issues along racial lines, contrary to critics like D’Souza and Washington.

However, what are we to make of Sanger’s comment that “we want to exterminate the Negro population” in the context of the nefariously worded "The Negro Project"? Nothing, largely because such quotations from "The Negro Project" document lack further context. Though the quote offered by D’Souza seems damning, the full context provides a radically different picture. According to the full quote: “The minister's work is also important and he should be trained, perhaps by the Federation as to our ideals and the goal that we hope to reach. We do not want word to go out that we want to exterminate the Negro population and the minister is the man who can straighten out that idea if it ever occurs to any of their more rebellious members.” The context was about Sanger opening a birth control clinic in the South, knowing it would be challenging given the opposition from black nationalists, described in Washington’s work regarding “the survival of the black race” and how it was perceived to be under threat by birth control. When the full context is considered, quotes like those shared by D’Souza lose the power they once had regarding the history of contraceptives.

The history of contraceptives has a long and rich intersection with race and sex, though this history is often overlooked in discussions regarding contraceptives. Indeed, most discussions surrounding sexual health are plagued by misinformation presented as truth, particularly concerning the history and science of human sexuality. For example, in the now infamous "What is a Woman?" film featuring conservative commentator Matt Walsh, it is asserted that much of modern “gender ideology” was created by Alfred Kinsey, along with claims that he sought to undermine Judeo-Christian values regarding sexuality. This research was deemed fraudulent since it was conducted by pedophiles, convicted sex offenders, and child molesters. Along with Walsh, Miriam Grossman, M.D., an adolescent and adult psychiatrist, notes that John Money’s experiment on the Reimer siblings was the inception of “gender theory.”

Though unrelated to contraceptives, this example highlights the bias in discussions surrounding human sexuality and health. Though Walsh and Grossman present the claims related to Kinsey with background music and a sense of authority, such authority is misplaced. For example, though Walsh claims the research was fraudulent because it was based on data collected by sex offenders and presented as nationally representative, this is not entirely accurate. Though this sampling bias was noted prior to Walsh and Grossman’s claims, Kinsey and his successor, Paul Gebhard, cleaned the data by removing information from sex offenders. Gebhard and Johnson (1998) found that none of Kinsey’s original estimates regarding human sexual behavior were significantly altered. Though not mentioned by Walsh or Grossman, Kinsey attempted to obtain a representative sample, which was challenging at the time due to the difficulty of conducting sex studies with a probability sample.

Though Money's experiment on the Reimer twins is referenced, the full story suggests a more complex narrative regarding gender theory. In the original experiment, David Reimer was raised as a girl after a botched circumcision during infancy. Despite initially considering the experiment a success in demonstrating that gender can be learned, David ultimately did not identify as female and tragically ended his life in his 20s. Thus, even a thorough examination of the story indicates that gender may not be solely a social construct.

Walsh and Grossman claim that Kinsey was responsible for societal decay, but such claims are subjective, lacking evidence of the societal impact of Kinsey and his work. Furthermore, there is no evidence that Kinsey himself abused or encouraged the sexual abuse of children, a claim refuted by the Institute itself.

In conclusion, the history of contraceptives is rich and complex, but it has also been subject to misinformation. However, such misinformation is not uncommon in discussions about human sexuality and health. While some may argue that contraceptives are under researched, this is far from the truth given their extensive history of research. As early as 1995, the FDA noted: “… more studies have been done on the pill to look for serious side effects than have been done on any other medicine in history” (Asbell 1995). Given this extensive research history, it's crucial to distinguish between factual information and misinformation in discussions surrounding contraceptives and sexual health.

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2.1: Sex Bias in Women’s Health Research

The following chapters are better understood if readers understand the issues of sex bias in health research, particularly the lack of focus on sex differences that impact women’s health.  In this chapter, the lack of research surrounding women’s health will be discussed, along with its potential impact on the effects of contraceptives. 

As would be noted in a later chapter, Roberts et al. found that women rarely received comprehensive information surrounding contraceptives from their healthcare providers. Given this, women relied on information given to them from their relationships, like from friends and family, for example, who often provided misinformation. Contraceptive counseling that lacks accurate information is associated with discontinued hormonal contraceptives among women (HC, henceforth), but not when the information given is comprehensive. Such information surrounding contraceptives can impact weight gain perception, the effectiveness of the contraception, satisfaction in one’s chosen contraception method, trust in health providers, and awareness and knowledge of different HC methods and their effects. 

This lack of comprehensive information surrounding women’s health is not simply restricted to information surrounding contraceptives, though. Mirin (2021) found that when analyzing diseases that primarily affect one gender, the funding patterns to study such diseases favored males. Diseases that primarily affected women were underfunded, while those that affected men were overfunded. Stranges (2023) notes that from 2009 to 2020, there was no change in the number of paper abstracts mentioning female-specific health research. Lack of focus on sex differences within the health field sometimes leads women to face more severe health consequences compared to males (Westergaard et al. 2019; Zucker and Prendergast 2020; Golden and Voskuhl 2017; Yakerson 2019). Such lack of research regarding sex differences in the health field and the underrepresentation of women in health studies (Merone et al. 2021) led Dr. Janine Austin, associate Director of the NIH, to say “We literally know less about every aspect of female biology compared to male biology” (in Rabin 2014).

Given the lack of research into women’s health, it’s no surprise that the following information related to contraceptives may come as a surprise to some readers. Indeed, when women and health care providers aren’t aware of the effects surrounding contraceptives, it may lead to false beliefs about the effects of contraceptives and even a lack of knowledge about information related to contraceptives. For example, Craig (2014) found that Latina and Black women were less likely to have heard of the IUD than White women, and were less likely to know that a woman experiencing adverse effects could switch to COC. They may also tend to overestimate or underestimate the effectiveness of hormonal contraceptives (Edwards et al. 2000). 

Such lack of proper information regarding women’s health and bodies is not exclusive to health research and information regarding contraceptives, but also in the academic textbooks that influence the next generation of health practitioners. In a review of Dutch medical textbooks by Dijksta, Verdonk, and Lagro-Janssen (2008), they found that gender-specific information was scarce or absent, with such information missing applying to reproductive items and epidemiological data. Parker, Larkin, and Cockburn (2017) found that in anatomy textbooks, the representation of gender is largely male, except within sex-specific specifications. Even medical professionals themselves may be biased, especially since, for example, physicians are more likely to focus on the emotions of women than men and focus more on the science and diagnoses of men compared to women (Markowitz 2022). Samulowitz et al. (2018) found that medical professionals are more likely to dismiss women patients as too sensitive, hysterical, or as time-wasters. Women are less likely to receive  pain medication, effective pain medication, more antidepressant prescriptions, more referrals to mental health services. Women are believed to  be “used to internal pain” because of periods and the ability to bear a child.

In conclusion, the proceeding chapters shed light on the surprising gap in research and information regarding women's health, particularly in the context of contraceptives. Despite society's presumed pro-female stance, the underrepresentation of women's health in medical research is evident, leading to a lack of comprehensive information. The discussion on contraceptive counseling underscores the reliance on personal relationships for information, perpetuating potential misinformation. The consequences of inadequate information extend beyond contraceptives, influencing various aspects of women's health, including funding disparities in diseases affecting different genders and biased representation in academic textbooks. The profound lack of knowledge about female biology, as expressed by Dr. Janine Austin, further emphasizes the urgent need for more inclusive and gender-focused research. The repercussions of this knowledge gap are far-reaching, affecting not only individual beliefs about contraceptives but also perpetuating biases in medical education and practice. Addressing these shortcomings is crucial to fostering a more informed, equitable, and gender-sensitive approach to women's health.

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3.1: Declining Female Happiness

In the original Stevenson and Wolfers (2009) study, the researchers found that despite the lives of women getting better, subjective well-being has declined both absolutely and relative to men in different industrialized societies. Such a decline has been noted in Finnish adolescents (Uusitalo-Malmivaara 2014), but not in other places like Japan, for example (Mitsuyama and Shimizutani 2018). In an updated paper by Blanchflower and Bryson (2022) which touches upon the COVID pandemic, lower female happiness continued to be observed. While men’s happiness has also been decreasing, it has not been to the same extent it has been for women. The decrease is also not consistent across time, as Blanchford and Bryson note. Herbst (2010) found that between 1985 and 2005, men’s happiness declined more than women's during that period, while for women the decline slowed down. In the statistical tests Herbst ran between 1985 and 2005, there were no statistically significant differences in happiness between men and women. In a more recent paper by Blanchard and Flower (2024), they find that women score higher than men on items assessing negative emotions, are less satisfied with different aspects of their lives – like democracy, the economy, education, etc, and score lower on current emotional well-being. 

Such findings can be taken to be interpreted in multiple ways. One way would be to question the impact social movements like feminism have had on the well-being of women, despite the progress made through feminism. If women are supposed to be made happy through equality, why has their happiness decreased? Such questions, especially when paired with the data, lend credence to the idea that feminism may have, indeed, been a failed social movement.

An alternative to ibid., it’s also possible that there might not be any gender differences or smaller gender differences in happiness than previously hypothesized. As Klein (2013) remarks when discussing Stevenson and Wolfers, the way men socialize might lead them to be less accurate when reporting on their well-being. In multiple references from Klein, it was found that men and boys often do not report lower well-being in typical assessments (see page 24). As Klein further notes, women scored lower than men both relatively and absolutely in only one barometer: lower satisfaction regarding family financial situations. Klein further argues that some of the gender differences are aligned with how males report their well-being: they tend to do so in some aspects of well-being but not others. While female happiness may have declined, this does not mean that men may truly be fairing any better than women or not given reporting issues. There might be some gender differences in different aspects related to well-being, none in others, or somewhere men or women are scoring higher than their counterparts. It’s hard to tell, but current evidence does not provide much information on such causes or whether feminism and the like are truly to blame. 

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4.1: On The Effects of Contraceptives

4.2: Mental Health

4.3: Psychological Well-Being

Concerns surrounding the effects of contraception use and a woman’s mental health has been a long area of debate. However, there exists a mismatch between what articles tend to say and what the abundance of research and reviews indicates. In this review, it’s argued that the effects of contraception use on mental health differ by the type of contraception use, but generally, there seems to be no effect in which contraception use is associated with decreases in psychological well-being.

One of the more blatant examples of bad science comes from Johansson et al. (2013), in which they found that contraception use increased the risk of depression by 71%. However, such an effect was attenuated and decreased to 5% as time passed. Such findings have indeed caused some to claim that contraception use is a net negative for a woman’s mental health through the use of Johansson et al. (e.g, Lallanilla 2023). However, the fact that such data is often not applicable to contemporary times is not mentioned. In a critical commentary by Kendall and Lazorwitz (2024),  they note that the author's data from the 1970s and 1980s, when dosage levels and preparation methods were different, along with potential “nocebo” effects . Such science communication where incorrect findings, or findings that are no longer applicable to modern times, go unchecked is not uncommon. However, others do often leave a caveat noting that their findings don’t apply to modern times (e.g. Charlton et al. 2014 serves as a good example). 

Indeed, the propensity and quality of the evidence display that contraception use tends to have largely positive or neutral effects on psychological well-being. A meta-analysis (K = 16, N = 10,642,840 ) by Kraft et al. (2024), found a RR between oral contraception use and mental health at 1.44. In other words, the use of oral contraception increased mental health issues by 44%. However, when a random effects model was used – a statistical model that considers the variability between different groups or levels of a categorical predictor as random, allowing for the generalization of findings to a broader population from which the observed groups are considered a random sample – there was no association as the RR was 1.00 with a confidence interval containing 0. Akin, Worly, Gur, and Schaffir (2018) conducted a systemic review and found that multiple studies with varying levels of quality found no association between progestin use and mental health. In a review and meta-analysis of 12 randomized control trials, oral contraception use was not associated with depressive symptoms among users when compared to those on a placebo (De Wit et al. 2021). A systemic review did not find depression to be a common hormonal contraception side-effect (Bottcher et al. 2012). 

Non-reviews of the literature have also suggested similar findings. In a population-based study featuring 30 to 54-year-olds and some analyses lowering the minimum to 18, Toffol et al. (2011) found that oral contraceptive use on women’s mental health was mostly positive and modest, such as decreases in Beck’s Depression Inventory questions. Similarly, Newman (2022) found reductions in depression symptoms following hormonal birth control use. When comparing current users to never users, those on the pill had a lower prevalence of depression compared to former and non-users, with also being less likely to report major depression (Gawronska et al. 2024). Robakis et al. (2019) found that oral contraception use was not associated with mental health among the general population, but may affect a subset of women with other pre-existing comorbidities. Looking at 25-34-year-olds, Keyes et al. (2013) found a lower odd of concurrent depressive symptoms among hormonal contraceptive users when compared to women on nonhormonal contraception or no contraception. Lundin et al. (2021) did not find a relationship between combined oral contraceptive use and progestin-only and increased risk of depression.

De Witt et al. (2020) noted that contraception use was not significantly associated with insomnia, loss of energy, self-harm, anhedonia, suicidal ideation, sadness, worthlessness, and inappropriate guilt. However, it was associated with eating problems, hypersomnia, and crying. Though, age and user status explained a small portion of the variance (2%), other stuff besides contraception might be the cause. In a longitudinal data set among adolescents, when compared to oral contraception users, never-users showed an increase in depressive and anxiety symptoms in late adolescence but OC users showed stable trajections. Results were held after adjustments for romantic relationships, sexual debut, educational level, smoking, drinking, and drug use (Doornweerd et al. 2022). In a large representative sample of German adolescents, exogenous contraceptive hormones were associated with “higher arterial blood pressure and serum 25(OH)D concentration, whereas hormonal contraception was not linked to health-related quality of life or mental well-being” (Lewanoski et al. 2022). A similar lack of results among adolescents has also been noted in a sample from the National Comorbidity Survey-Adolescent Supplement between oral contraceptive pills and depression (McKetta and Keyes 2019).

Overall, the evidence seems to indicate that contraception use does not tend to have big negative effects on women’s psychological well-being. Despite this, there are significant issues with the literature that require acknowledgment. First, as Kraft et al. noted, there seems to be an effect between contraception use and lower mental health among adolescents, but such findings have been inconsistent, as noted in other studies on adolescents. Furthermore, the question that should also be asked is how important is age. If the findings from De Witt et al. are common, then age seems to not be a big explanation if age is truly important. Lundin also notes that “Age-stratified analyses demonstrated that COC use in adolescents conferred no increase in risk.” Then, it’s hard to say that adolescents are at a unique risk given the mixed findings and the importance of the effect when effect sizes are analyzed. 

Second, the evidence has significant issues when it comes to their methodology. As Bottcher et al. remark, in many studies, it’s not clear what classification of  “depression” is being used. Major depression, like those measured by the DSM and ICD, is different from negative mood changes – yet some of these terms related to negative mood changes are used interchangeably to refer to depression rather than simple mood changes. Some of these mood changes are also symptoms associated with premenstrual syndrome, with the two (premenstrual syndrome and major depression) sometimes not being separated. Classifications have also changed over the years, so the results of some studies looking at older cohorts might not be the same for studies looking at modern cohorts, along with the composition and preparation of contraceptives – an issue perfectly demonstrated by the Johansson et al. study. Such issues should be taken into account when examining the literature and in future studies.

Third, not all contraception methods are equal in their effects. As was displayed here, the type of contraceptive method analyzed was made clear when describing a specific study. However, meta-analysis and systemic reviews often do not make clear what method is being analyzed, so emphasis was placed on this report. However, this does not mean this issue is not present in other papers. As Lundin and colleagues showed, “use of progestogen-only pills (RR 1.13, 95% CI 1.07–1.19), contraceptive patch/vaginal ring (RR 1.43, 95% CI 1.30–1.58), implant (RR 1.38, 95% CI 1.30–1.45) or a levonorgestrel intrauterine device (RR 1.59, 95% CI 1.46–1.73) were associated with increased risks [of depression]”. Indeed, Worly and colleagues argued that most women using combined contraceptives suffer no adverse effects, that contraceptives containing less androgenic progestins may have fewer effects on one’s mood, and that non-oral doses might have fewer side effects, according to their review. However, even in their reviews studies “group together hormonal contraceptives with different formulations and different routes of administration, making it difficult to interpret the effect of a particular regimen.” Regardless, their review indicated no effect. Furthermore, their review is in contrast to studies like Lundin and their findings on the effect of other forms of contraception. As Worly and colleagues note, a randomized control trial found no effect of patch and vaginal rings on well-being, levonorgestrel displayed fewer positive effects or no differences when compared to other groups with other methods. Thus, not all methods will have similar effects and some may not have negative effects. However, inconsistent methods and lack of uniform assessments still cast a shadow over some aspects of this area of study.

Suicidality

Similar to mental health, suicide can also be used as a potential proxy to measure one’s well-being, as compared to self-reported questionnaires which might be influenced by social desirability bias. Though studies do show a relationship between contraception use and the risk of suicide ideation and suicide attempts, other studies do not find such a relationship.

Perez-Lopez et al. (2020) found a 36% increased risk of suicide from hormonal contraception. Akin to this finding, Weakley et al. (2022) in the American Family Physician argue that hormonal contraceptives increase the risk of suicide ideation and suicide attempts. In one cited paper from Weakley and colleagues, Edwards et al. found an increased risk of suicide in users of COC and progestin-only pills at 36% and 75% respectively. Another cited paper from the AFP found an increased risk of suicide attempts at 97% for hormonal contraceptive users and a 3-fold increase in suicide completion, according to Skovlund and colleagues. Similar findings were noted for the progestin-only OCs. Amarasekera et al. (2020)’s review of the literature found a relationship between contraceptive use and suicide ideation and attempts, with contraceptive use during adolescence also increasing the risk of suicidality – but not for older women.

Other studies have not found an association. Once adjusting for marital status, socioeconomic status, education, chronic diseases and recent delivery, and hormonal contraception, Toffol et al. (2022) found a lower off odd of a past-year suicide attempt among contraceptive users. In a critical commentary on Skovlund et al., Berlin et al. (2018) note that Skovlund and colleagues own data showed that when compared to women using less effective hormonal contraceptions or non-users, women on hormonal contraceptives had lower odds of a past-year suicide attempt and a lower odd of depressive symptoms. Gallagher and Pazderka (2020) offer a less skeptical view, saying that the direction of the relationship is unknown. 

Overall, the evidence on contraceptives and their link with suicides is mixed. While some studies show an effect, others do not find one. A general issue with these studies is measuring causality: Is the increased risk due to contraceptives themselves or some other factor? If another factor is involved, then the relationship would not be causal directly and linearly. Robinson et al. (2004) argue that data from randomized control trials showing no relationship display evidence against a causal relationship. Amarasekera et al. echoes similar concerns in the literature, saying that studies have not adjusted for confounding variables or investigated potential moderators. 

4.4: Substance Abuse

Strzelecki et al. (2023) found that for women using OCs, altercations in ovarian hormone levels are associated with increases in substance use. When compared to non-OC users, OC users are more likely to report an increase in alcohol consumption (Warrens et al. 2021). Toffol et al. (2011) found that the duration of current OC use was positively correlated with alcohol dependence. Newman (2022) also found an increase in alcohol and cannabis dependence. Strzelecki et al. (2023) remark that ethinyl estradiol from OC pills is associated with excessive alcohol consumption. 

Little evidence exists documenting the relationship between contraceptive use and alcohol and cannabis use. Due to such scant evidence, it’s unknown where causality runs. Could individuals who use contraceptives be more risk-taking and thus more likely to take drugs? Or might contraceptives themselves, as argued by Strzelecki et al. and Warrens et al., lead to substance use due to the chemicals used in contraceptives? Future research is needed to answer this question or to provide clarity.

4.5: Attraction and Sexuality

The discourse surrounding the impact of contraceptives on mate choice and relationship outcomes has brought attention to the assumption that contraceptive use impacts attraction and sexuality. This hypothesis posits that women's preferences change over time due to hormonal shifts induced by contraceptive use, thereby influencing partner selection and relationship dynamics. Noteworthy findings suggest that contraceptive users may report lower sexual satisfaction and partner attraction, exhibit preferences for less masculine faces, and even experience alterations in their sense of smell.

For instance, Roberts et al. (2011) observed lower sexual satisfaction and partner attraction in women using contraceptives, while Little et al. (2013) found a preference shift toward less masculine faces. Birnbaum (2019) even suggests a potential impact on olfactory perceptions. Further complexity is introduced by Russet al. (2014), who discovered that wives discontinuing hormonal contraceptive use reported lower relationship satisfaction, particularly if their husbands had less attractive faces during the relationship's formation.

However, the evidence is not entirely unequivocal. Lassila (2022) found no significant differences in relationship satisfaction and sexual satisfaction between hormonal contraception users and non-users. Taggart et al. (2018) reported higher levels of relationship satisfaction among oral contraceptive users, and Taggart et al. (2016) identified an increase in romantic relationship satisfaction associated with oral contraceptive use.

Critiques of the existing literature, such as Larson's (2014) review, highlight methodological limitations. Most studies lack true experimental designs, relying on cross-sectional or longitudinal approaches with small sample sizes, insufficient control for confounding variables, and a lack of consideration for variations in contraceptive types. Jones et al. (2018) and Arthur and Blake (2022) contribute additional skepticism, suggesting that hormonal status might not be directly linked to preferences for facial masculinity or mate-seeking interest.

The question arises: are the observed relationships between contraceptive use and relationship outcomes causal, or do they result from selection effects? Botzet et al. (2021) investigated perceived partner attractiveness, relationship satisfaction, sexual satisfaction, libido, and sexual activity frequency in relation to contraceptive use. While they found little support for contraceptive impact on most variables, they did observe a positive relationship with vaginal intercourse and a negative relationship with masturbation frequency, with age, relationship duration, and congruent contraceptive use explaining these associations.

In summary, while the cyclical preference shift hypothesis offers intriguing insights into the potential effects of contraceptives on relationships, the existing evidence is nuanced and subject to methodological considerations. The complexity of hormonal influences, coupled with limitations in study designs, calls for a more comprehensive understanding before drawing definitive conclusions.

Summary

This review navigates the debate surrounding contraception use and its impact on women's mental health, emphasizing the importance of considering different contraceptive methods. While early studies suggested a heightened risk of depression with contraception use, critical commentaries and recent research highlight contextual factors and societal changes. Meta-analyses, such as Kraft et al. (2024), indicate diminished associations when employing robust statistical models. Non-review studies present diverse findings, indicating positive, neutral, or context-specific effects on mental health. The relationship with suicide remains inconclusive, with conflicting evidence and challenges in establishing causality. Methodological issues, evolving depression classifications, and variations in contraceptive methods call for caution in drawing definitive conclusions. Despite a general trend suggesting no major negative effects, addressing these challenges is crucial for a nuanced understanding of the complex relationship between contraception use and women's psychological well-being.

In contrast to self-reported measurements, we also investigate  the complex relationship between contraceptive use and the risk of suicide, considering suicide as a potential proxy for measuring well-being in contrast to self-reported questionnaires. Conflicting findings emerge from studies on this topic, with some suggesting an increased risk associated with hormonal contraceptives. Perez-Lopez et al. (2020) and Weakley et al. (2022) report heightened risks, with specific percentages attributed to hormonal contraception use. Conversely, Toffol et al. (2022) and Berlin et al. (2018) found no association between contraceptive use and suicide attempts after adjusting for various confounding factors. Gallagher and Pazderka (2020) express uncertainty about the direction of this relationship. The challenge of establishing causality is a recurrent theme in the literature, with concerns raised about potential confounders and moderators not being adequately addressed in many studies. Robinson et al. (2004) and Amarasekera et al. argue against a direct and linear causal relationship, emphasizing the need for more robust study designs, including randomized control trials. In summary, the evidence regarding the link between contraceptives and suicides remains inconclusive, warranting further research to unravel the complexities and potential confounding factors involved.

Individuals on OCs are also reported to exhibit greater alcohol consumption compared to non-users, with positive correlations found between the duration of OC use and alcohol dependence. Despite these associations, limited evidence exists to determine the direction of causality. The question remains: are individuals using contraceptives more predisposed to risk-taking behavior and substance use, or do contraceptives themselves contribute to substance consumption through their chemical composition? Further research is crucial to unravel these complexities and provide clarity on the relationship between contraceptive use and substance dependence.

The discourse on contraceptives' influence on mate choice and relationship outcomes posits that hormonal shifts induced by contraceptive use may impact attraction and sexuality, leading to changes in partner preferences and relationship dynamics. Studies by Roberts et al. (2011) and Little et al. (2013) indicate lower sexual satisfaction, altered partner attraction, and preferences for less masculine faces among contraceptive users. Birnbaum (2019) even suggests potential impacts on olfactory perceptions. However, conflicting findings, such as Lassila's (2022) discovery of no significant differences in satisfaction between hormonal contraception users and non-users, and Taggart et al.'s (2018) report of higher relationship satisfaction among oral contraceptive users, create complexity. Critiques, including Larson's (2014) review, highlight methodological limitations, emphasizing the need for true experimental designs and consideration of contraceptive variations. The question of causality versus selection effects arises, with Botzet et al. (2021) finding limited support for contraceptive impacts on various variables but observing associations with sexual activity and masturbation frequency. In conclusion, the cyclical preference shift hypothesis provides intriguing insights into contraceptive effects on relationships, yet nuanced evidence and methodological considerations demand a more comprehensive understanding before definitive conclusions can be drawn.

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5.1: Physical Effects

5.2: Weight 

In The Echo Trials, a randomized control trial conducted by Beksinska et al. (2021), the impact of contraception on weight gain was explored. The trial involved three groups of women receiving different contraceptives: depot medroxyprogesterone acetate (DMPA-IM), levonorgestrel (LNG) implant, or a copper intrauterine device (IUD). The study revealed varying weight increases across the groups: 7.7 lbs for DMPA-IM, 5.3 lbs for LNG, and 3.3 lbs for the IUD. Berenson and Rahman (2009) conducted a study comparing DPMA with other non-hormonal contraceptives, showing that DPMA was associated with increased weight gain (11.25 lbs), body fat (9 lbs), and body fat percentage (3.4%) after 36 months. The impact on weight gain was higher for DPMA users compared to those on oral contraception or non-hormonal contraceptives. Beksinska, Smit, and Guidozzi (2011) pointed out that while combined oral contraceptives (COC) were not associated with weight gain, DPMA might induce weight gain in adolescent users, particularly those already overweight or obese at the start of DPMA use, as suggested by Nicoletti et al. (2010).

Warholm, Peterson, and Ravn (2012) highlighted limited data on the effects of COC on adolescent weight but found no indication of weight gain among those younger than 18, irrespective of their obesity status. This observation aligns with a longitudinal study by Lindh, Andersson, and Milson (2011), indicating that age predicts weight gain rather than the use or duration of COC. Additionally, Firrahmawati, Wahyuni, and Silvitasari (2022) found no association between the duration of hormonal contraceptive use and weight gain. Oral contraceptives were not associated with gains in weight among both 

Turning to contraceptive implants, Bahamondes et al. (2018) studied women with etonogestrel (ENG) or levonorgestrel (LNG) implants and a non-randomized sample using copper intrauterine (IUD). ENG and LNG users experienced similar weight increases of 6.6 lbs and 6.4 lbs, respectively, after 36 months, while IUD users had a mean weight increase of 2.4 lbs. Although not clinically significant, the weight gain was statistically significant. Contrary to concerns about long-acting reversible contraceptives (LARC), Brito (2017) found no evidence of weight gain association, with mixed evidence on increased body fat percentage.

Lopez et al. (2011) cautioned that lower-quality studies might suggest an association between progestin-only contraceptives and weight gain, while higher-quality studies showed no such link. Kusumaningtiyas, Tamtomo, and Murti's (2021) meta-analysis found a non-significant increase in weight gain with hormonal contraceptives among women of reproductive age, emphasizing the need for cautious interpretation due to methodological limitations in some studies. 

As can be seen, the effects of different contraceptives on weight gain seem to be dependent on other factors, along with the contraceptive being used. In the case of DPMA, the association seems to be dependent on an individual's prior-existing weight issues. While ENG, LNG, and IUD were associated with increases in weight gain, these increases are not clinically significant as they are low levels of weight gain. COC and OC do not seem to be associated with weight increases.

It may also not be colloquial body weight that women are seeing an increase in when it comes to contraceptives but rather water retention and bloating, and other factors related to life development and psychology. As Hassan et al. (2003) remark, for example, IUDs were associated with weight gain among the women who got them, but this increase in weight was due to factors independent of the IUD itself. Psychology speaking, some women also perceive an increase in weight rather than experiencing an actual change in their weight. Gallo et al. (2016) found that while women with progestin implants reported greater perceived weight gain when compared to the controls, there was no difference in actual weight between the implant and control group. Indeed, a review from Roberts et al. (2022) provides strong evidence that individuals who know others with bad experiences regarding hormonal contraceptives influence their hormonal contraception method, which also influences their adherence and the influence of the contraceptive. Weight gain was a large reason many women stopped taking hormonal contraceptives, despite evidence on how the weight changes aren’t directly related to hormonal contraceptives themselves. 

In conclusion, the diverse array of studies discussed sheds light on the nuanced relationship between contraceptive methods and weight gain. The findings from The Echo Trials underscore the differential impacts of depot medroxyprogesterone acetate (DMPA-IM), levonorgestrel (LNG) implants, and copper intrauterine devices (IUDs) on weight, revealing variations in weight gain among these contraceptive choices. While DPMA stands out for its association with increased weight, body fat, and body fat percentage for certain users, other studies, including those on combined oral contraceptives (COCs) and contraceptive implants, contribute valuable insights. Notably, the absence of weight gain associated with COCs, OCs and the nuanced impacts of long-acting reversible contraceptives (LARCs) underscore the importance of considering individual factors and methodological rigor in interpreting study outcomes.

5.3: Fertility

Though contraceptives do hinder a woman’s ability to become pregnant, this effect is not long-lasting. Rather, users of contraceptives are still found to be fertile after discontinuation of contraceptives, but it might take a while for the users' fertility level to go back to normal following discontinuation. 

A 3-year study found that women who took oral contraceptives found that long-term use of OCs did not affect their ability to have children in the future; participants who took COCs more often were more fertile than participants who used them less often (Mikkelson et al. 2013). Echoing similar results, Mansour et al. (2011) found that discontinuation of oral contraceptives, LNG-IUS, or IUDs did not lead to issues with fertility. Typical one-year pregnancy rates ranged from 79% and 96% following cessation of levonorgestrel-releasing intrauterine system (LNG-IUS ), and 71% to 91% for IUDs. The range following cessation of implants ranged from 50% to 86%, though this lower bound of 50% comes from one study and rises to 77% when removed. Similar results were seen for injectable contraceptives, with no evidence of adverse effects on the fetus following cessation from any method. Girum and Wasie (2018) found a pooled pregnancy rate of 83.1% following cessation of contraceptive discontinuation. Yland et al. (2020) did not find OC use during adolescence to harm one's ability to become fertile. 

Despite the ability to still conceive, this does not mean it comes without consequences. For women on oral contraceptives, there might be a short-term fertility delay of about 2-6 months on the ability to conceive (Mikkleson et al. 2013).  IUDs, rings, and patches may have a delay of  2-4 months (Yland et al. 2020). The DPMA shot, however, lasts longer – with fertility going back to normal 10 months after one receives the shot (Pfizer n.d.). Therefore, the type of contraception one is using can impact how long it would take their fertility levels to get to normal, with some allowing faster returns than others. 

In conclusion, contraceptives do not impact a woman’s ability to become fertile. The use of contraceptives does not affect one’s ability to become fertile later in life, but it does take a while for one’s fertility levels to reach the levels it was before the contraceptives. OCs, IUDs, rings, and patches have a shorter delay and the DPMA shot has a longer delay. The effects of contraceptives on fertility, then, seem to be temporary.

5.4: Risk of Blood Clots

Voelker (2011) remarks that the risk of blood clots is higher for oral contraceptions that make use of newer progestins may double the risk of getting thromboembolism and may increase the risk of venous thromboembolism by 7-folds when compared to women who did not take the pill. Middeldorp (2005) found that certain 3rd-generation progestins in low-estrogen preparations increased the risk of venous thromboembolism pulmonary embolism. The risk associated with newer COCs containing estradiol is unclear. Progestin-only contraception, except for depot medroxyprogesterone acetate, is not significantly linked to increased VTE risk. Emergency contraceptives with levonorgestrel or ulipristal acetate do not raise VTE risk (Rott 2015). Thrombotic and vascular compilations have been associated with oral contraceptives (Windisch and Frishman 2024). 

A systemic review of hormonal contraception found that “Users of HC have a significant increased risk of VT compared to nonusers. Current risks would project at least 300–400 healthy young women dying yearly in the United States due to HC” (Keenan et al. 2018). Third and fourth-generation COC pills increase the risk of blood clots by 3 to 4 times (Baratloo et al. 2014), second generation is slightly lower at 3 (Stegeman et al. 2013). Compared to hormonal contraceptives, vaginal rings increase the risk by 6.5 times (Lidegaard et al. 2012). The patch by 8 times (Lidegaard et al.), and shots by 3.6 (Vlieg, Helmerhorst, and Rosendaal 2010). Progestin-only contraceptives and IUDs have not been found to increase the risk of blood clots.

After cessation of combined hormonal contraceptives, it is followed by a decrease in estrogen-related thrombotic biomarkers after 2-4 weeks (Hugon-Rodin et al. 2024). However, such fears of the risks of blood clots require knowing the difference between an absolute risk and a relative risk. As Hugon-Rodin et al. note, “The relative risk of thrombosis on combined oral contraception is three- to fivefold, whereas the absolute risk for a healthy adolescent on this therapy is only 0.05% per year.” The former tells you the actual chances of something happening in a group, and the latter compares the risk between two groups. Therefore, these risks have to be viewed in full contexts – where the data is not as scary as the statistics make them out to be.

Summary

This review highlights diverse findings on the impact of contraceptives on weight gain. Depot medroxyprogesterone acetate (DMPA-IM) resulted in higher weight gain than other methods, with significant associations to increased body fat and percentage. Combined oral contraceptives (COCs) showed no weight gain, and similar weight increases were observed for contraceptive implants. Concerns about long-acting reversible contraceptives (LARCs) and progestin-only contraceptives varied in evidence quality, with some studies suggesting an association with weight gain. The relationship between contraceptives and weight gain appears nuanced, influenced by individual factors, and perceptions that may affect adherence. In conclusion, these findings underscore the importance of considering individual variability when interpreting the impact of contraceptives on weight gain.

Contrary to common misconceptions, contraceptives do not hinder long-term fertility. Research indicates that women using oral contraceptives (OCs), levonorgestrel-releasing intrauterine systems (LNG-IUS), intrauterine devices (IUDs), rings, and patches generally maintain their fertility after discontinuation. While short-term delays are observed, ranging from 2-6 months for OCs to 10 months for the depot medroxyprogesterone acetate (DPMA) shot, the effects are temporary. Notably, the type of contraceptive used influences the duration of fertility recovery. Despite potential short-term delays, contraceptives do not adversely affect fertility in the long run. This abstract provides a concise and informative overview of the temporary nature of contraceptive impacts on fertility, contributing to a better understanding of family planning choices.

Recent research has highlighted the varying risks associated with different forms of hormonal contraceptives. Oral contraceptives utilizing newer progestins may elevate the risk of thromboembolism, doubling the overall risk and potentially increasing venous thromboembolism by sevenfold. Third-generation progestins in low-estrogen preparations have been linked to increased risks of venous thromboembolism and pulmonary embolism. However, uncertainties surround the risks posed by newer contraceptives containing estradiol. Progestin-only contraceptives, excluding depot medroxyprogesterone acetate, and emergency contraceptives with levonorgestrel or ulipristal acetate do not significantly heighten venous thromboembolism risk. Various studies emphasize the thrombotic and vascular complications associated with oral contraceptives, with third and fourth-generation pills elevating blood clot risks three to four times. Vaginal rings, patches, and shots also exhibit increased risks, with progestin-only contraceptives and intrauterine devices demonstrating no such association. Upon discontinuation of combined hormonal contraceptives, a reduction in estrogen-related thrombotic biomarkers occurs within 2-4 weeks. However, it is crucial to discern between absolute and relative risks.