When birth control has unwanted side effects, what are your options?

For the first time in more than 30 years, a contraceptive pill has been added to the Pharmaceutical Benefits Scheme (PBS).

The PBS is a government program that subsidises medicines, meaning the government partially covers the cost, making treatments more accessible for people with a Medicare card.

The federal government has also pledged to increase subsidies for insertion and removal of hormonal intra-uterine devices (IUDs) and implants, making a wider range of methods more accessible and affordable.

These changes offer an opportunity for women who have struggled with unwanted side effects from birth control to reassess their options.

What's changed?

On March 1, the Yaz and Yasmin contraceptive was added to the PBS.

The inclusion will reduce the cost of these pills from about $380 a year to $126.40, or just $30.80 with a concession card.

According to the Department of Health and Aged Care this will benefit around 50,000 women annually.

Last month, the federal government announced a $573.3 million package for women’s health, which includes adding new medications to the PBS. 

Previously, only pills containing levonorgestrel and norethisterone were listed on the PBS. That includes the brands Levlen ED, Femme-Tab ED and more (for the full list see Table 1 here). 

There are also ongoing efforts to progress the listing of other contraceptive pills.

The federal government has also pledged to increase Medicare rebates for insertion and removal of hormonal IUDs and implants, by up to 150 per cent, potentially saving around 300,000 women up to $400 in out-of-pocket costs each year.

While IUDs (which go by the names Mirena and Kyleena in Australia) and implants have already been listed on the PBS, patients have had to foot the bill for the cost of their insertion and removal.

It is worth noting that at this stage, pain relief during IUD insertion and removal (Penthrox, also known as the 'green whistle') is not subsidised, and patients will need to pay between $40 and $55 out of pocket for this.

When hormonal contraception affects your mood

While these subsidies are welcomed by the  Royal Australian College of General Practitioners (RACGP) and the Australian College of Midwives, some women experience mood changes, such as anxiety, irritability, or depression, while using hormonal contraception.

When Issy started taking the pill, she enjoyed the freedom it provided, but after a few months, she noticed significant changes in her mood.

"I was feeling quite depressed and I was also acting really erratically, I would be crying excessively and when I calmed down, I couldn't even place why I'd been upset about it, I felt like I was kind of disassociating," she explained.

Initially, Issy attributed her mood changes to environmental factors, such as the difficulties of a long-distance relationship and the pandemic. But over time, she began to suspect that the pill might be responsible.

"I knew that I wasn't fine, I knew that every month experiencing extreme anxiety and feeling really depressed wasn't normal and wasn't something that I should accept."

Professor Jayashri Kulkarni, director of Monash University's Health Education Research Centre, confirms that hormonal contraception can impact mood.

Some women, she says, "can experience depression or sadness and tearfulness and rage."

"It can be quite insidious and take a few months to come on, but when it comes on, it can often show itself in being irritable and just not enjoying life as much."

Mood changes may be under-reported and overlooked

Professor Kulkarni explains that Issy's experience is part of a broader, often overlooked issue.

"It is under-reported, and there is sometimes, unfortunately, an invalidation of the woman," Prof Kulkarni noted.

For Issy, the frustration stemmed not just from her symptoms but from the struggle to have them acknowledged by doctors.

According to Professor Kulkarni, the connection between hormones and mental health isn't always recognised by healthcare professionals, despite being well-documented by medical researchers.

"There is a very important connection between reproductive hormones, such as oestrogen and progesterone and testosterone, and the brain, and in particular, the expression of mood and cognition."

She notes that in her clinical experience, some doctors are unaware of this link, which is concerning given that millions of Australian women use synthetic hormones in oral contraceptives.

What options do you have if you've experienced mood changes on the pill?

Some hormonal combinations may be better tolerated than others.

"We particularly like pills that have oestradiol in them, that's a purer form of oestrogen, as well as nomegestrol, which tend to have fewer mood-related side effects," Professor Kulkarni said.

"That's what we usually recommend in our clinic, provided there is no physical health contraindication to taking an oral hormone contraceptive. And of course, there's also barrier contraception, such as condoms."

The brand name for the contraceptive pill that contains oestradiol and nomegestrol is Zoely.

Qlaira is another pill that contains oestradiol and also presents with fewer mood-related side effects but according to Professor Kulkarni, it is not as effective as Zoely.

Currently, Zoely and Qlaira are not listed on the PBS.

Dr Phoebe Holdenson Kimura, a lecturer in the General Practice Clinical School at the University of Sydney, has welcomed more contraceptive options on the PBS, emphasising that access to a range of options is crucial for women experiencing side effects.

"The side effect profile can vary between the different types of pills for each individual woman, so it is important in clinical practice to have a range of combined oral contraceptive pill options to support women’s choice," she said.

Issy eventually switched to a copper IUD, which is the only non-hormonal, long-acting contraceptive available in Australia.

"I decided to get a copper IUD because I was so exhausted by all the hormonal changes I'd noticed while being on the pill," she said.

Though it comes with its own set of challenges, such as heavier periods and period pain, she found it worth it.

Unfortunately, copper IUDs are not subsidised under PBS, costing roughly $100, and there were supply shortages reported last year.

A rare case of blood clots on Yasmin

Sammy's decision to reassess her contraception came after a serious health scare.

She had been using Yasmin for over six years when she began to experience unexplained exhaustion, muscle soreness, and shortness of breath.

As someone who led a very active lifestyle, having completed multiple marathons, her lack of energy was unusual.

At first, she dismissed her symptoms, rationalising that it was likely the stress of starting a new job.

But when seemingly minor activities, like carrying her small dog at a weekend event, left her with intense muscle soreness in her chest and back, she started to suspect something more serious.

"I felt like I had just done the biggest HIIT work-out of my life but I hadn't done anything," Sammy said.

Still, Sammy pushed through the workday before deciding to go to the emergency room where she found out she had blood clots in her lungs.

Yaz and Yasmin contain the progestogen component drospirenone which has a slightly higher risk of developing blood clots than other contraceptive pills. 

According to the TGA, approximately 9 to 12 per 10,000 women (0.09 to 0.12 per cent risk) taking a contraceptive pill containing drospirenone may develop blood clots annually. 

While blood clots are an exceptionally rare side effect of oral contraceptives, cases like Sammy’s underscore the importance of ongoing review and awareness of potential side effects.

Contraception is not a 'set and forget' decision

Sammy’s experience highlights how easily the use of contraception can go unchecked over time.

"I would just go into any doctor I could get into because by the time you realise your script is running out, you're like, I'll just get into whoever will see me," Sammy said, explaining that she visited five to six different doctors each year.

Yet, not one doctor in those six years suggested reviewing her prescription or checking her blood pressure.

International guidelines specify that a blood pressure check is required prior to a prescription of the combined oral contraceptive.

"I would say 'I want the pill, this one', and off you go, and you'd be out within five minutes," Sammy said.

Dr Holdenson Kimura, emphasises the importance of ongoing review and being proactive.

"GPs need to be proactive … you should be taking blood pressure, talking about those risk factors exploring why that woman is on that particular pill and then also talking about the other options," she said. 

This is particularly concerning, given women who use the pill in NSW can get a 12-month refill from a pharmacist without a new script.

The RACGP argued at the time that a patient's suitability for certain contraceptive pills could change over time, and that regular GP visits were necessary.

Birth control beyond the pill

While the pill remains the most commonly prescribed form of contraception in Australia, there are other more effective options, such as long-acting reversible contraceptives (LARCs), including the Mirena and Kyleena IUD and the contraceptive implant.

Despite their effectiveness, the uptake of LARCs remains low in Australia compared to other developed countries.

"Uptake is very low in Australia… I think part of it is that a lot of Australian women, culturally, are comfortable with the combined pill," Dr Holdenson Kimura said.

"They are started on it as teenagers or young women and stay on it, maybe it's also about that whole lack of review process, not being aware that LARCs are available."

The RACGP said it welcomed the Medicare rebates for IUDs and implants and is hopeful the uptake of LARCs will increase.

"We’ve seen in other countries that if you remove barriers, you’ve got an increased uptake," chair of RACGP Specific Interests Sexual Health Medicine Dr Sara Whitburn said.