Within mere weeks of trying her second contraceptive pill, Dutch Meike (25) noticed that she was becoming a different person. It all started out as a suggestion from her mother: maybe she should make an appointment with her general practitioner to start on birth control. Not only did her mother want to make sure her daughter wasn’t getting pregnant, Meike had also been experiencing severe stomach aches during her period. Hesitation arose with the doctor, however, as their family had a history of Factor V Leiden, a protein mutation that in combination with the pill might raise Meike’s chance to get thrombosis. Her doctor first had her try out a pill with a low risk for thrombosis. Other side effects, however, were never mentioned to the then 16-year-old, nor did she think to ask for them herself: “I actually thought the hormones wouldn’t be influencing me. It never came to my mind that I would be consuming artificial hormones in way larger quantities than I was used to.” Unfortunately she experienced apathy but at the same time she “burst into tears much more often”. “I could throw a temper tantrum about every little thing”. Hence, Meike switched to a new option - which made matters even worse.

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Like a “power struggle between the omniscient doctor and the supplicant”, is how German Linda (23) described the day she went home with a prescription for the birth control pill in her hand. “I basically just came to pick up what works for everyone else and was therefore assumed to work for me.” As for the power gap, the doctor stuck to her monologue. No interaction where risks and benefits were weighed out against each other took place. At some point, Linda gave up and consented to the hormones of the pill that she had tried to bypass by asking for long-acting reversible contraceptives such as the copper IUD. Linda didn’t feel treated individually. Instead, she was sent home with a goodie bag that one would pick up on the way out after listening to a speech along with thousands of others.

 

Anna Mayr (28), a German journalist, never opted for the pill in the first place. Because of her “fear of hormones”, condoms did the trick for her basically all throughout her adolescent years. When she also started writing about personal experiences during her journalistic career, Anna started asking questions about the choices she had made on contraception. “I was incredibly angry because I found out that it’s a huge lie that you have to bleed for a week on the pill when there’s no health concerns associated with skipping menstruation. I turned 20 years old without knowing it."

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Linda first informed herself with the booklets once handed to her during sexual education classes, she had nostalgically kept for five years. After meeting her first boyfriend, their first date, first kiss and one ripped condom later, Linda dug out these printed remainders of her teenage years and made an appointment with a gynaecologist. Her first gynaecologist started the conversation about contraception with asking about pre-existing conditions that might run in the family – a method of figuring out if the patient might run a higher risk of thrombosis. “I had also done my own research previously because I had heard so much from friends and I wanted to be informed about alternatives to the pill,” the 23-year old recalls the booklets. When she asked for these alternatives during her first consultation, her gynaecologist “pushed” her in the direction of the pill. “Apparently it was my only option if I set great store by the contraceptive’s reliability.”

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"I think that if you got a better sex education at school, you could approach doctors in a completely different way,” Anna says. Just like Linda, who lived with the side effects she had never been informed about for a year. After two months, Linda’s goodie bag had started to cause her headaches, then tractions in her breasts whenever her period was approaching and skin issues that she had never experienced before. “On the one hand I felt like everything was muted a little bit, like in a bubble”, Linda recalls. “But I also went from the happiest highs to the deepest lows, just like that.”

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Germany’s system of resident gynaecological practices is quite unique, compared to the rest of the world. When young girls first want to start out on birth control, no matter if it is for contraceptive reasons or because of menstrual symptoms, they see a gynaecologist. In the Netherlands, as with many other countries, it is much more common to visit your general practitioner for the matter of birth control. Although the Dutch and German systems are different, the outcomes are similar: young girls like Linda and Meike who want to start birth control are usually prescribed the pill.

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Roughly 30 percent of women in the Netherlands and Germany who are on birth control are prescribed the contraceptive pill. For young women, these numbers are higher. The Dutch large scale “Sex Under 25” survey shows that 50.4 percent of sexually active girls under 25 are on the pill. In Germany, the youngest age group was surveyed by the Federal Centre for Health Education in 2018 from the age of 18 to 29, with 56 percent of sexually active women on birth control resorting to the pill. However, the youngest age cohort shows the strongest decrease in pill use, compared to the previous survey of 2011. Besides abstinence, with correct usage, it’s the safest option on the market to prevent pregnancy. It can also help with skin and stomach troubles, is very easy to use, cheap, and non-intrusive. As a young woman first getting into the challenge that is reproductive health, it seems a reasonable advice to take from your doctor. However, both mental and physical side effects are lurking. Depression, the feeling of being in some kind of bubble and a lower libido are just a fraction of the secondary effects that can arise from the pill. As Linda and Meike’s stories show, however, doctors aren’t actively considering their patients’ mental health during consultations. Why’s that? Investigations into the Western health care education show that mental health is neither on the curriculum nor seen as something tangible with a potential for treatment.

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“If I were interested in mental health, I would’ve studied something else,” says a medical student at Leiden University, who wishes to remain anonymous. “That’s obviously put very bluntly, but I would say the majority of my peers are more interested in the physical than the mental.” Although an interest might never be developed when nobody sparks it during interesting lectures or even a mandatory assignment, where interest can be a motivational factor.

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Only 2 out of 30 mandatory courses at Leiden University, one of the top universities for studying medicine in the Netherlands, have a specific focus on mental health and psychiatry within their medical curriculum, roughly 7 percent. Looking at the medical curricula for two of the top rated universities for medicine in Germany - Ruprecht-Karls University clinic Heidelberg and the RWTH Aachen respectively - our analysis shows that only 5 percent of course content is allocated to psychiatry on average, displaying a low engagement with mental health topics. In another top rated Dutch university for medicine - the University of Maastricht - the investigation showed a slightly higher engagement with psychiatric content as up to 7 percent of teaching was allocated to it.

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Additionally, a study by Choudry and Farooq, that investigated the recruitment crisis within the UK field of psychiatry, found that interest might also develop through professional interaction with the field. After all, that’s why many people opt for precarious internship placements during the early years of their careers - it’s always an experience. However, development opportunities of German and Dutch medical students during their practical year are very few. Only 4 out of 29 hospitals in the Heidelberg study region offer psychiatric training. The study argues that especially these few existing professional interactions with the field would lead to students’ higher interest in psychiatry and accordingly patients’ mental health.

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Inherently interlinked with the curriculum is the stigma surrounding mental health and psychiatry among medical students and professionals. The study by Choudry and Farooq argues that this might be enforced by the focus among medical scholars on the profession’s low success rates. There’s a common belief, that little evidence exists concerning psychiatric practices and their benefit for patients’ mental health. The matter is no different in the Netherlands, the anonymous Leiden University student claims. “The brain is intangible. Although some information can be traced through scans, when push comes to shove we really do not know why some people have mental issues and others don’t.” She goes on to remark that this “doesn’t mean that I would never take mental issues into consideration”. “Patients can experience all kinds of physical side effects from mental issues - stress, for instance, can cause you extreme stomach aches. It’s all interconnected.” All in all, however, she thinks that “psychiatry is just very different from other medical fields”, because of its difficulty in providing material evidence.

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The lack of funding from the German and Dutch governments in the field of mental health doesn’t improve the situation, either. German doctors and psychotherapists hoping to treat patients ambulatory need what is called a “free doctor’s chair”, which entails permission from the government to open a praxis within this field. The National Association of Statutory Health Insurance Physicians, part of the German Ministry of Health, regulates the amount of chairs available in each region. However, research at the University of Göttingen shows that this planning, for now, doesn’t succeed in eliminating the shortage in physicians. In the Netherlands, long queues at the Dutch Association of Mental Health and Addiction Care unveil underlying issues within the system of government funding towards mental health care. The waiting time has become so long that recently one patient initiated a protest, after having been waiting for help for 800 days. Charlotte Bouwman, who has been suicidal for eight years, bivouacked in the entrance hall of the Dutch Ministry of Health for weeks - stating that she wouldn’t leave until she was offered help. The activism sparked a nation-wide discussion and a promise from State Secretary of Health, Paul Blokhuis, to take concrete action.

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Another gap already exists at university level, where the health industry plays an important part in funding research. This funding is not replaced by tax money from the government once the industry pulls away its financing from projects. Susanna Kramarz, press officer of the German Professional Association of Gynecologists, ties mental medication concerns in the field of reproductive health to the topic of hormonal disorders. “The problem is that everything that revolves around hormones is taking up less and less space in university research. This is mainly due to the fact that the industry, which co-finances the universities, is no longer funding research here.” Consequently, many universities are closing their hormone research departments, which means that everything to do with hormonal diseases is being neglected. “The pill is really only a very small part of this concerning development,” Kramarz adds.

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In addition to the stigma surrounding the success of mental health treatment, institutional structures and the lack of funding from both the industry as well as the government, legal requirements also play a role in doctor’s obligation to inform about side effects. Why don’t doctors just mention potential changes in pill users’ mental state during consultations when diving into the pool of side effects anyway? Risk assessment rules instruct doctors what to disregard in the first place. In the case of Germany, the Federal Institute for Risk Assessment as well as the Institute for Drugs and Medical Devices direct doctors to provide information on adverse drug reactions with a probability of 10 percent. This risk assessment doesn’t include thrombosis either, a rather common side effect to the pill when the patient’s medical history has laid the path. “Nevertheless, the information is provided because thrombosis is a dangerous side effect. Headaches are explained because they occur more often. But the changes in the psyche - these depressive changes - are an alteration that gynaecologists, from their day-to-day practice, do not experience as such a common side effect with their patients. Therefore, they’re not encouraged to inform. There are no regulations,” Kramarz explains. All the side effects that are reported at a lower rate than 10 percent of patients suffering them, are tied together under the doctor’s advice “Get back to us, if you’re not feeling well on the medication,” she clarifies. And as for the Netherlands, no rules for informing patients on side effects are known to the authors of this article, although doctors are encouraged to inform about side effects that often occur as well as rarer occurring severe side effects. It’s thus up to the doctor to decide as to what the patient should know about.

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So what is important to consider from a doctor’s point of view? “The reliability of not getting pregnant and the avoidance of very dangerous side effects," Kramarz says. But as with most contraceptive methods, they are only reliable if the patient follows through with them with a certain discipline. The pill is only reliable if it’s an everyday routine. According to these standards, it is rather left to doctors’ own interpretation of reliability how to inform.

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Sense, a Dutch health website targeted at 12-25 year-olds, confirms the importance of not getting pregnant for both patients and doctors. The website informing youngsters is created by four major players within the field of reproductive health in the Netherlands - Rutgers Institute for Sexual Health, SOA Aids Netherlands, the Municipal Health Services and the National Institute for Public Health and the Environment. Although some physical side effects of the pill like headaches are mentioned, the information on Sense’s website puts its focus on preventing pregnancy. Yuri Ohlrichs, sexologist of the Dutch Scientific Association for Sexology and Sense, remarks that the contents of the site are based on a nationwide research project “Sex Under 25” conducted every five years among 20,500 young Dutch. “If, for example, it appears that the number of negative experiences with sexting is increasing in our target group, we will add tips to keep sexting fun and safe.” So does not mentioning mental health concerns on their website mean that research hasn’t found mental side effects of importance to young women? The most recent version of “Sex Under 25” from 2017 does neither ask participants about their experience of side effects nor their motivations to take the pill. It is therefore quite unclear whether mental health reactions to the pill are of concern to young people in the Netherlands.

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However, clear numbers for how the birth control pill correlates with an increased vulnerability to depression can be derived from numerous studies as for example from Hannaford (2010) and the most recent one from Anderl (2020). These estimate those affected by depressive episodes at around two percent. However, studies haven’t researched the so-called bubble that many women mention when describing their mental state during pill use. "The pill can change your mood - this is a ‘can’ and not widely prevalent. Certain types of the pill can intensify a depressive mood if a basic tension is already present,” Kramarz explains. But how are doctor’s made aware of what the young women in front of them might be suffering underneath the surface? Kramarz mentions the dilemmas of the alleged “Nocebo effect” here, a reaction which causes the symptoms the doctor informs the patient about - just because they’ve heard that it is a possible side effect.

 

The German Gynecologist Association explains: “Suppose you’re prescribed an antibiotic by your doctor and your doctor tells you that 80 percent of patients get headaches from this. You’ll probably go out the door and have your migraine attack right in front of their office. Doctors must be very careful here and learn not to cause these unconscious reactions, but to leave it open in conversation.” Patients might experience the “profound sadness” the pill can cause, after the doctor has elaborated on these symptoms of depression, Kramarz clarifies. The “you can return the goodie bag when it doesn’t suit your needs”-motto on the other hand, does not name these specific symptoms - a very easy way out of the obligation to inform.

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A study by Wells and Kaptchuk discusses a “golden rule” doctors could be following in order to avoid nocebo effects. This moral rule implies that doctors inform patients in the same manner as they would wish to be informed themselves if they were on the other side of the table. Following this golden rule would mean medical professionals transmit their expectations directly by expressing their views of a medication to a patient. The low interest in mental health that is inherently connected to the stigma surrounding it and a low interaction with mental health themes during education, might leave doctors unlikely to consider psychical reactions to the pill. The lack of interest and knowledge results in a biased implementation of the golden rule: practitioners only inform patients about the implications of contraceptives which they care about themselves. Doctors don’t give sufficient advice on mental health side effects of the contraceptive pill, because they do not see these side effects as important. In Meike’s opinion, however, doctors really should put more attention into the potential side effects: “It even seems as if they just don’t know enough about the topic to sufficiently assess these kinds of situations.”

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Everything changed for Linda, however, when she started drawing her own connections. Without consulting her gynaecologist, Linda dropped her use of the pill and cracked the bubble that she felt she was in. Still very much in love with her boyfriend, they chose to prevent with the method furthest away from the pill: natural family planning. With her calendar, she calculates her fertile days and on those, the couple sticks to condoms. Despite having changed her gynaecologist twice since then, Linda, who now studies social work in German Wiesbaden, still only uses her calendar to prevent an unwanted pregnancy. She tried the copper ball, but her body didn’t take it well, flushing it out with extensive bleeding. Would she ever go back to one of the approximately 100 birth control pills that are prescribed in Germany? “If the industry made progress concerning the side effects – maybe.

 

But is that even possible?” The aspiring social worker aims to stay informed; it is rather crucial to her. “I want to work in Mother and Child facilities and I believe it will be a relevant topic for me professionally.” In the end, Linda knows the feeling of finding out herself, after her gynaecologist sat in front of her and could’ve just told her at the time she asked for it. Yet, what must be done so that women feel sufficiently informed about alternatives?

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Unfortunately, there is no universe of alternative contraceptives that doctors can choose from when informing patients, although there are numerous variants of different pills a different hormonal contraceptive. “There would have to be non-hormonal methods that are just as reliable as the pill, then no gynaecologist would have a problem prescribing them too,” Kramarz concludes on the view of the professional association. Bayer, one of the largest pharmaceutical companies in the world, recently bought a license for what “could be the first very reliable, non-hormonal contraceptive which, unlike the copper IUD, does not interfere with the body,” she says.

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To get off the hormones, Meike decided to switch to condoms full time for a while. “After literally four days, I felt so much better. Those horrible feelings were fading away quickly, until they were completely gone!” After she had been in a stable relationship for quite some time, she decided she would try another form of contraception again. “Condoms were becoming quite a hassle, really, so I did some research and chose to get a hormonal IUD implanted. I also took the copper version into consideration, but due to my history of stomach aches I thought this might be a bad idea.” She hoped for her doctor to be understanding, but it turned out to be quite the contrary: “Although she did agree to implant the IUD, she also seemed to think that my previous mental issues had just been because of me being an erratic teenager. She put all the focus on my risk of getting thrombosis.” It turned out that the hormonal IUD worked much better for Meike, as its side effects were hardly noticeable. This month, she has had the implant for five years - the deadline which is commonly cited as the time to replace it. “Because it has been a while, I have decided to get it removed instead of replaced, to see if I might feel different - better - again. I might have started to see the way I’m feeling now as a standard, even though it might not be the case.” The appointment has already been made. One thing is clear for Meike: “I will never use the contraceptive pill ever again.”

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Anna Mayr says the lack of information coming from doctors is especially problematic for a whole generation of young girls, that her, Linda and Meike were once part of. "I am interested in challenging the idea of telling young girls 'Here is your nature, live with it!’ I just believe that you don't have to live with it,” she says. “here we are back to the idea, that young girls have to live with everything that comes with their period. If young girls weren’t told that, then maybe something better than the pill would have been developed by now." This refers to the need that women should be sufficiently informed about mental side effects of hormonal contraception, but it also sheds a light on structural problems in doctors’ education. In the end doctors, themselves are not sufficiently informed about mental side effects of medication throughout their education.

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Conducting this investigative piece, several important organisations in the field, like the The Dutch College of General Practitioners (NHG), Leiden University and the University of Maastricht were approached but either denied an interview or resorted to radio silence. Note that these contacts are all Dutch, while the German institutions concerned with reproductive health and professional associations of gynaecologists were more willing to address the topic of mental health related to the pill. However, it becomes clear that we still have much to inform about. Change might be in the future. Although NHG did not get in touch with us, their website does make clear that they are renewing their Standard for Contraceptives from 2011(!), a guideline used by all Dutch doctors, to include more about mental health. The German Association of Gynecologist also clarifies: “Leading gynaecologists are saying they're going to pay more attention to whether young girls are suicidal or at risk, and then the pill won't be recommended." Nevertheless, Kramarz also says: “But how can a young woman keep track of her own contraception other than with the pill?” The glass ceiling of contraception persists.