Parts I, II, III, IV and V.
This is part IV of V of my series on hormonal contraception.
Behavior and cognition
In western culture, media, commercials, and magazines, the menstrual cycle is almost universally considered to be negative. Pharmaceutical companies advertise pills to improve mood, from SaraFem (this was another name for Prozac, targeted just to women), to Midol, to the new hormonal contraceptive Yaz (which has recently gotten in trouble for the way they promoted their mood improvement, if you look at their new ads). Different tampons and pads are advertised to reduce discomfort, improve sleep, reduce smell or the possibility of being ‘discovered.’
That’s not to say there aren’t some at least moderately positive portrayals of menses: the coming-of-age feeling that comes with the first period, the relief that comes from getting a late period after a pregnancy scare. And if you can think of other positive portrayals, please do share them in the comments. That said, it’s no surprise that most people who study periods study it from a negative perspective. They tend to look for negative mood disturbances, for incidences of PMS, for variations in PMS or PMDD symptomology. Most of the studies I’ve read over the years have negative mood or stress questionnaires (like the Moos Menstrual Distress Questionnaire); they often preempt women to confirm symptoms by providing them with a list. Very few of them attempt to discover variation in positive emotions through the menstrual cycle.
Notable examples to this are Emily Martin’s book The Woman in the Body (1980) and a smattering of articles. In 1994, Walker was interested in dispelling the notion that women’s experiences of their menstrual cycle had little cycle-to-cycle variation, and that these experiences were negative. What she found was that most women experience significant cycle-to-cycle variation, which she says means that hormones explain only a small amount of the variation in mood (Walker 1994). Walker also found more positive mood at midcycle and more negative mood premenstrually and menstrually. Brown et al (2008) also found increased positive well-being at midcycle. There is other evidence that menstrual cycle phase does not strongly predict mood: Mansfield et al (1989) found that women’s negative mood and arousal were more strongly predicted by the day of the week than menstrual cycle phase – negative mood and arousal decreased on weekends. I don’t know that I have enough information to agree or disagree with Walker’s conclusion that hormones explain a very small portion of mood, but I do think that hormones are important, and cultural conditioning is important. Which one is more important may not be as relevant to this discussion as just noticing that we need to pay attention to both.
How do reproductive hormones impact behavior and cognition, if they do at all? Unfortunately, there just isn’t enough evidence for me to be comfortable with sharing much of an answer. There are potential mechanisms aplenty, particularly regarding estrogens. Shively and Bethea (2004) review monkey literature and, while they find consistent results regarding estrogen-cognition-mood relationships, they temper this finding because the sample sizes of most of the studies reviewed were quite small. Further, most of the studies involve inducing menopause, which means they are comparing monkeys essentially with and without estrogen, rather than measuring cognitive differences in monkeys with naturally occurring variation; this would be far more useful if we are at all interested in premenopausal women.
The next question to ask is, what do we know of any impacts oral contraceptives may have on behavior or cognition? And again, the answer isn’t too satisfying. Brown et al (2008) found women on hormonal contraception reported more negative well-being than non-contracepting women. Walker (1994) found that the cycle-to-cycle variability she found in non-contracepting women was significantly reduced in contracepting women. Bancroft and Sartorius (1990) found significant variation in improvement or deterioration of libido on oral contraceptives: libido seemed to depend on which type of hormonal contraception, but results were also complicated by the fact that they found women who had negative experiences of hormonal contraception tended to stop using them, creating a data set that appeared more satisfied with their prescriptions than perhaps was the case. Joffe et al (2003) found that women with a history of depression were more likely to experience complications with contraceptives, and those with the potential to get early-onset premenstrual mood disturbance or dysmenorrhea saw an improvement. Finally, women who use both a barrier method and hormonal contraception report much higher sexual satisfaction than condom-only or hormone-only users (and in fact, hormone-only users had the lowest satisfaction) (Higgins et al. 2008).
Where does this put us? Well, the relationships between hormones and mood and cognition are very complicated, and hormones only constitute part of the process. Culture, personality, heck, even day of the week is important. That said, the few results we have on oral contraceptives do seem to indicate that they have an impact on mood – some of this may be physiological, but some, such as the improvement in sexual satisfaction by dual users in the Higgins et al (2008), are more likely related to the calm afforded by feeling doubly protected from pregnancy rather than an effect of the estrogens or progestins. I would like to see further study on natural cycles and contracepting cycles on all sorts of behavioral and cognitive factors, and should oral contraceptives prove to negatively impact any of them, this should be a labeled side effect.
My final part of the series will briefly discuss my own opinion on hormonal contraceptives, as well as information on other contraception options available.
Bancroft J, & Sartorius N (1990). The effects of oral contraceptives on well-being and sexuality Oxford Reviews of Reproductive Biology, 12, 57-92 DOI: 2075004
Brown, S., Morrison, L., Larkspur, L., Marsh, A., & Nicolaisen, N. (2008). Well-Being, Sleep, Exercise Patterns, and the Menstrual Cycle: A Comparison of Natural Hormones, Oral Contraceptives and Depo-Provera Women & Health, 47 (1), 105-121 DOI: 10.1300/J013v47n01_06
Higgins, J., Hoffman, S., Graham, C., & Sanders, S. (2008). Relationships between condoms, hormonal methods, and sexual pleasure and satisfaction: an exploratory analysis from the Women's Well-Being and Sexuality Study Sexual Health, 5 (4) DOI: 10.1071/SH08021
Joffe, H., Cohen, L., & Harlow, B. (2003). Impact of oral contraceptive pill use on premenstrual mood: Predictors of improvement and deterioration American Journal of Obstetrics and Gynecology, 189 (6), 1523-1530 DOI: 10.1016/S0002-9378(03)00927-X
Mansfield PK, Hood KE, & Henderson J (1989). Women and their husbands: mood and arousal fluctuations across the menstrual cycle and days of the week Psychosomatic Medicine, 51 (1), 66-80 DOI: 2928462
Martin E. 1980. The woman in the body: A cultural analysis of reproduction. Beacon Press Books: Boston.
Shively, C, & Bethea C (2004). Cognition, mood disorders, and sex hormones ILAR J, 45 (2), 189-199 DOI: 15111738
Walker, A (1994). Mood and well-being in consecutive menstrual cycles Psychology of Women Quarterly, 18 (2), 271-290