Introduction

Family planning is a fundamental element of reproductive health, and counseling on this topic is a responsibility of family doctors in primary health care, who should provide complete, impartial, and scientifically correct information about all contraceptive methods.¹ In Portugal, 94% of sexually active women report using a contraceptive method, the most common being the contraceptive pill (58%-75%),^2,3 and frequently look for counseling regarding reproductive health and contraceptive methods in their family physician.²

According to the United Nations and the World Health Organization, reproductive health is a state of complete physical, mental, and social well-being, in all matters relating to the reproductive system and to its functions and processes.⁴ Thus, reproductive health implies the ability to have a satisfying and safe sexual life.⁴ With this in mind, contraceptive counseling should include the choice of a method to avoid pregnancy, but that also has neutral or even positive effects on the sexual function of women.^5,6

Most current contraceptive methods are hormonal in action. The hormonal components of contraceptives could have various effects on mood and libido, which are not clearly understood.^5,7-13 The majority of women are unaffected, but reports of sexual side effects can go up to one in five oral contraceptive pill users,¹⁰ and for the individual woman who is negatively affected, this can have a substantial impact on quality of life and relationship.¹⁴ In addition, these negative sexual side effects can lead to discontinuation of the contraceptive method and loss of the pregnancy prevention effect.^10,11,15-17

Luckily, nowadays women and their health care providers are attributing greater importance to sexual health, including sexual well-being.¹⁸ As such, it is fundamental for health care providers to be aware that contraceptives can have negative effects on female sexuality so they can counsel their patients appropriately.^16,19-22

This review aims at identifying the existing evidence regarding the role of the different contraceptive methods on female sexual function, thus allowing better counseling on this topic by health practitioners.

Methods

This work consists of a review of the existing evidence regarding the role of the different contraceptive methods on female sexual function. In this work, the definitions of contraception and sexual dysfunction are considered as follows.

Contraception is defined as the intentional prevention of conception through the use of various devices, sexual practices, chemicals, drugs, or surgical procedures.²³ The approved contraceptive devices commercialized in Portugal are summarized in Table 1.

Sexual dysfunction is defined a disturbance in sexual desire or the sexual response cycle that cause marked distress and interpersonal difficulty.^24,25 This includes disorders of desire, sexual arousal, or orgasm, as well as conditions related to pain, such as vaginismus and dyspareunia.^24,25

In august 2022, a systematic research of existing clinical trials, reviews, and meta-analyses, published in Portuguese or in English in the previous ten years, was performed. The research was done using PubMed.gov search engine, with the terms “(Contraceptive Agents) AND ((Libido) OR (Sexual Dysfunction) OR (Sexual Arousal) OR (Orgasm))”. The criteria for inclusion were the mention of any contraceptive method on female sexual function on any domain, including libido, arousal, pain, or others. Articles not meeting these criteria were excluded. In the research, 62 articles were found meeting the defined criteria. A direct manual research provided 63 additional articles meeting the previously defined criteria. After reading the title, abstract, and full text, 80 articles were discarded for various reasons, which included duplication, not being related to the topic of research, or not corresponding to studies in humans, leaving 45 articles that were included in this review. This is summarized in Fig. 1.

Figure 1: Flow chart: total number of identified articles and the literature selection process in this analysis. 

Results

This review included 45 articles on the topic of contraceptive methods and female sexual function, 13 reviews and 32 clinical trials. Of the reviews, three were systematic reviews,^27-29 eight were narrative or non-systematic reviews,^{14,17,19-21,30-32} one was a statement from the European Society of Sexual Medicine,¹⁸ and one was a letter to the editor.³³ The 32 clinical trials focused on different contraceptive methods and different outcomes, such as the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale (FSDS), the McCoy Female Sexuality Questionnaire (MFSQ), and the New Sexual Satisfaction Scale (NSSS). The characteristics of the studies were fairly different, with population sizes ranging from 22⁹ to 2612¹³ women (median 164, IQ 269). The studies were performed in different populations and cultures, the majority (n=10; 31%) in Italy,^5-7,9,34-39 six in the United States of America,^10-12,40-42 three in Iran,^43-45 two in Belgium,^46,47 Sweden,^15,22 and Egypt,^48,49 and one in the Netherlands,⁸ Germany,¹³ Austria,⁵⁰ Lithuania,¹⁶ South Africa,⁵¹ and Thailand.⁵² One study was multicenter, involving patients from Australia, Austria, Belgium, Germany, Italy, Spain, and Thailand.⁵³

Sexuality is a fundamental part of human life and sexual dysfunction has a negative impact on both quality of life and emotional well-being.^16,20,32 Female sexual dysfunction is a very common disorder, with an estimated prevalence of 22%-43% of women worldwide, with low desire being the most common.^16,19,20,42 Female sexual function is believed to be multifactorial, involving biologic, physiologic, anatomic, medical, affective, interpersonal, psychological, and context-related factors.^{14,15,20,31,32}

Contraceptive methods may be hormonal or non-hormonal, depending on their mechanism of action. Mode of usage, efficacy, and side-effects vary accordingly.²⁶ As was previously thought, most studies report a negative impact of contraception on sexual function, specially of hormonal contraceptives.^12,22,44

The impact of hormonal contraception extends in many domains of sexual function, including arousal, lubrication, pain, orgasm, pleasure, and frequency of sexual activity.^12,22,41 Contraceptives may affect women’s sexuality in both positive (relief of gynecologic pain,^14,18 elimination of the fear of pregnancy,^7,14,18,38 increase of self-esteem in cases of acne or hirsutism,^14,18 increase of intrapartner satisfaction,³⁰ and increase in number of sexual intercourses³⁰) and negative ways (hormonal deregulation,¹⁸ decrease of sexual desire,³⁰ decrease of lubrication,^14,30 decrease of orgasm,³⁰ and increase of pain¹⁴). However, when controlled for other factors, such as relationship length, the impact tends to be lower or even disappear, thus meaning that contextual factors may be stronger predictors of sexual desire than contraception type.⁴¹

Up to 27% of women report a decrease in sexual drive attributed to hormonal contraceptive use.³⁰ In a study in German female medical students, contraceptive use was shown to increase FSFI total score compared to non-users, with FSFI scores higher in non-hormonal contraceptives, followed by non-oral hormonal contraceptives and, lastly, by oral hormonal contraceptives.¹³ In an analysis of all contraceptive methods, the least sexual dysfunction was detected with condom use.⁴⁴

Discussion

Contraception is widely used for birth control and is also used for the treatment of different gynecological disorders.⁷ Many studies evaluating the impact of contraceptive methods on female sexual function have been published throughout the times, but no clear conclusions have been found so far. The existing studies differ widely regarding population size and characteristics, the contraceptive method evaluated, and the parameters used for sexual function, which means that, when individual results are analyzed to draw specific conclusions, there is not enough quality data. As such, more quality and large-scale studies are needed, including all existing contraceptive methods, to allow for specific recommendations regarding this subject.

Considering the evaluated data, one can infer that contraceptive methods have an impact on female sexual function and that, depending on the contraceptive method and maybe even on the population, the effect may be positive, neutral, or negative. As previously mentioned, the estimated prevalence of contraceptive-induced female sexual dysfunction ranges from 5% to 20% worldwide,³² which means most women using contraceptive methods do not experience sexual dysfunction,¹⁰ but for the individual woman who is negatively affected, this can have a substantial impact on her quality of life and relationship.¹⁴

Regarding hormonal contraceptives, the analyzed studies report mainly positive or neutral effects on female sexual function regarding the levonorgestrel intrauterine system, the vaginal ring, and the transdermal patch. The subcutaneous implant and combined oral contraceptives led to mixed results, which studies reporting a good, neutral, or negative effect on female sexual function, and no specific associations were identified. The progestogen-only oral contraceptive and the DMPA intramuscular injections were associated mainly with negative sexual effects on women, even though not many studies were performed.

The impact of hormonal contraceptives on sexual function appears to depend on the quality and quantity of estrogen and progestogen, and on their regimen.³⁶ The three groups of sex steroid hormones (estrogens, progestins, and androgens), are known to influence female sexual function via different effects on the vaginal tissue and the central nervous system.¹³ Ever since the introduction of hormonal contraceptive methods, the components have been modified to diminish the adverse metabolic effects on lipid and carbohydrate metabolism and hemostasis, and to reduce spotting and other menstrual disorders, but effects on sexual function have been different.⁹

Estrogen levels may have a direct or indirect impact on female sexual function. Labia minora, vaginal introitus, and clitoris are sensitive to estrogen modifications,⁹ as reduced estradiol levels in oral contraceptive users have been correlated with a decrease in clitoral volume and an increase in the dorsal clitoral artery pulsatility index, thus inferring a negative impact on sexual function.⁷ The estradiol plasma levels are not significantly decreased in non-oral hormonal formulations, such as the vaginal ring.⁷ This may in part justify the fact that the progressive ethinylestradiol reduction in the most recent formulations may have potential deleterious effects on female sexuality.^7,9 Estrogens may also have an indirect impact through the increase of sex hormone binding globulin (SHBG) plasma levels and reduction of free androgen levels, producing hypoandrogenism.⁵ The reduction of circulating androgen levels is also caused by a direct reduction of androgen production from the ovary due to the action of systemic progestin.^10,19,38 Androgens enhance sexual desire and response, but their impact depends on individual sensitivity,²⁹ and the effect of their reduction, even though it is thought to be of decreased desire and arousability, is not as clear.^{7,8,14,16,29,46} A relative androgen deficiency can contribute to vulvar and vaginal dryness, decreased arousal, sexual pleasure, orgasm frequency, and increased sexual pain.³¹ However, in women with reduced levels of free testosterone, 20% showed a decrease in sexual desire and 80% had unchanged or increased sexual desire,¹⁸ which could mean that some women may be more sensitive to androgen level alterations than others.^18,19 Hormonal contraceptives may also inhibit pituitary production and secretion of FSH and LH, reducing ovarian estradiol secretion and an absence of progesterone production,¹⁴ but this has not correlated with a change in sexual function.¹⁵ As such, the overall impact of an hormonal contraceptive on sexual function may reflect the balance between residual androgenicity of the progestin component and the magnitude of impact of the COC on SHBG, and, hence, free testosterone.⁵³

Hormonal contraception can increase the risk of dyspareunia.²⁷ Reduced concentrations of estrogens and androgens can lead to reduced activation of sex steroid receptors in peripheral tissues and vulvovaginal atrophy, leading to sensitivity to touch, burning, itching, and dryness during sexual activity,¹⁸ and an increased risk of vulvar vestibulitis, especially in those women with longer use, first use before 16 years of age, and when the pill used was of high progestogen, high androgen, and low estrogen content,²⁷ as well as predispose to reduced vaginal lubrication.³⁵ As an opposite, vaginal rings can lead to improved lubrication, which may be due to local activity of estrogens before entering the systemic blood flow and being metabolized.³⁴ Contrary to this, there has also been a study showing a protective role of oral contraceptives regarding vulvodynia.⁴²

Other ways that contraceptive methods may induce negative sexual changes may be related to the experience of increased vaginal bleeding.⁴⁰ Also, some studies have been showing that women using hormonal contraceptives may differ in their mate preferences, reporting higher commitment to their current relationship, faithfulness or loyalty, and frequency of intercourse.³⁰

The reported effects of non-hormonal contraceptives and even of vasectomy on female sexual function may suggest that other factors besides hormonal changes may be involved, including all domains of the biopsychosocial model mentioned above, as well as a possible regret that pregnancy is no longer possible when a definitive method is chosen.¹⁹

All these perspectives try to understand scientifically how contraceptives impact female sexual function, but so far, neither the effects nor the mechanisms behind them are completely understood. This review is in accordance with previously written reviews, which means that the additional evidence produced in more recent years is slowly giving support to previously made assumptions. Although, the need for more quality large-scale clinical trials remains, and hopefully in the future a new literature review performed will be able to create more definite conclusions, and clinical recommendations may be created regarding the role of each contraceptive method on female sexual function. Hopefully in the near future, more contraceptive methods will be developed, with even fewer negative side effects, allowing for the best physical, mental, and sexual well-being possible.

Conclusion

Even though the effects of the different contraceptive methods on female sexual function are not clearly established, it is safe to assume that, for some women, they may have a negative impact on their individual sexual function. A risk-benefit analysis of alternative contraceptive methods is important in those cases, and the identification of a contraceptive without adverse effects on sexual function should be preferred as first choice of treatment.¹⁵ Increased attention to sexual acceptability in contraceptive research could inform more personalized approaches to education, counseling, and decision support tools in the future.¹¹

This review contributes to the increase of knowledge on this subject, mainly within family physicians, which will be more prepared to counsel their female patients with sexual concerns regarding contraceptive methods. First, professionals will be aware of the possibility of these negative effects on female sexuality. Second, knowing that this is a possibility, physicians will be mindful to openly ask patients about sexual concerns and sexual function, including pain, lubrication, or alterations in desire, following a biopsychosocial model of the possible factors predisposing to the symptoms. Regarding those patients who have not yet started a contraceptive method or will be undergoing a change of method, doctors will be alert that a baseline sexual history should be attained, to allow for posterior evaluation of possible side effects.