The scenario:
An 18-year-old (she/her) started a combined hormonal contraceptive pill (COC) three months ago, prescribed by her primary care provider. She’s been taking a pill with 0.15 mg levonorgestrel/30 mcg EE. She’s now following up with you because she’s been feeling moodier since starting the pill. She’s not totally sure if the pill is to blame, but says it’s affecting her quality of life and she’s interested in talking about other options.
Could the pill be causing her mood symptoms?
Possibly. While most people tolerate COCs well, some experience mood-related side effects, especially when starting or switching formulations. While there is limited data supporting a quantifiable impact of COCs on mood, patients frequently report experiencing mood changes, so validating their experience is key even in the absence of definitive causation.
Which of the hormones in COCs is likely responsible for mood changes, when they occur?
The progestin component of COCs is most likely to cause mood changes. Other progestin-related side effects include decreased libido and irregular periods. Estrogen in COCs is typically responsible for nausea, breast tenderness, and headaches.
If she wants to try a different birth control pill, which might you recommend?
Because she is possibly experiencing a progestin-related side effect, it makes sense to try another pill from a different progestin “family.” Levonorgestrel is in the gonane family. Some research suggests that pills with progestins from the spirolatone family, like drosperinone, may have fewer mood-related side effects. For example, 3 mg dorsperinone-30mcg EE might be appropriate to try next. Patients sometimes feel better on a different formulation, even if hormone doses are similar, due to differences in metabolism or individual sensitivity.
What are some important counseling points to share?
- Normalize her experience: “Some people feel fine on one pill and not on another. That doesn’t mean there’s something wrong; it just means we need to find a better fit.”
- Explain your reasoning for changing to a particular pill: “Since you’re wanting to stick with the pill for now, we can try a different one. I’m prescribing this new one because the hormones in it may be better for mood changes.”
- Make sure she knows when/how to follow up: “It can sometimes take a month or two to get a good sense of whether this new pill is helping with the mood changes you’ve noticed. If after that, you’re not noticing much of a difference, or if at any point you want to talk about other options, please come in and see me. We can also schedule a follow up visit before you leave today so you know you have that appointment if you need it.”
Key Points
- Mood changes are a common reason for discontinuing COCs. While research on mood impacts mostly shows minimal impact, patient experiences should be taken seriously and validated.
- Progestin is the most likely hormone to impact mood in combined pills. Switching to a different progestin family—such as from levonorgestrel to drospirenone—may reduce mood-related side effects.
- Support patient-centered care with clear counseling and follow-up plans. Normalize that it can take time to find the right birth control fit. Explain the rationale for switching pills and offer reassurance with a concrete follow-up plan.