Position statements from the European Society of Sexual Medicine (ESSM)
Outpatient Clinic of Psychosomatic Gynecology and Sexology, Leiden University Medical Centre Leiden, The Netherlands
The Center for Sexual Health, Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel
Andrology, Women’s Endocrinology and Gender
Incongruence Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Italy
Department of Psychiatry, Centre of Postgraduate Medical Education, Warsaw, Poland
Department of Obstetrics and Gynecology, University Hospital, Basel, Switzerland
Institute of Clinical Sexology, Rome, Italy
Andrology, Women’s Endocrinology and Gender Incongruence Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Italy
In the majority of industrialized countries about 60-75% of women of reproductive age married or in a stable relationship use some form of contraception . The most commonly hormonal contraceptives (HCs) in European countries are short-acting reversible contraceptives (SARC), including Combined Oral Contraceptives (COCs), the patch and the vaginal ring, followed by long-acting reversible contraceptives (LARC), i.e. levonorgestrel (LNG) or copper IUD and the etonogestrel implant . Fear of side effects and health concerns are among the main reasons for non-prescription or discontinuation. Although safety and efficacy of HCs have been extensively examined, little is known about their impact of on female sexual function, and the evidence on the topic is controversial.
A position statement and recommendations for clinical practice about the effects of HCs on female sexuality have been recently published on behalf of the European Society of Sexual Medicine (ESSM)  and are briefly summarized in this article.
HCs, sexual desire and the role of (free) androgens deficiency
Hormonal Contraceptives (HCs) can positively affect sexuality by different means, including a) overcoming fear of unwanted pregnancy during sexual activity, b) resolution of painful or troublesome gynecologic disorders such as endometriosis and dysmenorrhea and c) reduction of body image concerns with an increase in self-esteem for women with clinical hyperandrogenism (i.e., acne and or hirsutism) (Level 4; Grade C).
All available combined HCs reduce androgen levels regardless of estrogen dosage and progestin type (Level 2; Grade B).
Both combined oral contraceptives (COCs), transdermal patches and vaginal rings showed a similar effect in increasing Sex Hormone Binding Globulin (SHBG) levels and in reducing androgens levels (Level 2; Grade B).
In the vast majority of the cases the use of COCs resulted in an increase or no change in sexual desire (Level 2; Grade B).
Studies on the effects of non-oral forms of hormonal contraception are scarce precluding definite conclusions.
Testosterone is well known to be a pivotal positive modulator of male sexuality; its facilitating role in female sexuality, albeit less well-defined, has been consistently suggested in women with surgically induced menopause and reduced sex drive, who show an increase in sexual interest and activity after supplementation of transdermal testosterone . Therefore, it has been acknowledged that androgen deficiency might be related to negative mood and sexual side effects of combined HCs. However, whether the reduction in the free testosterone fraction that occurs in women who have an increase in SHBG is clinically important is uncertain, and the sexual clinical implications of suppressed total and/or free androgen levels during COCs use are still a matter of debate .
Very few placebo-controlled randomized trials (RCTs) have been conducted on the topic. In a recent one, 340 women receiving COC [ethinylestradiol (EE)/levonorgestrel)] or placebo for 3 months, significantly lower sexual desire, arousal and pleasure scores in COC users compared to placebo were observed, with a small effect size . COC users showed a significant reduction in total and free testosterone, but no significant correlation with changes in sexual function was found . Only one RCT in patients with COC-associated Female Sexual Dysfunction (FSD) evaluated the effect of switching to a COC containing either anti-androgenic or androgenic progestins; while both groups showed improvement of sexual function, no difference was observed between anti-androgenic or androgenic progestins .
Studies on the effects of non-oral forms of HCs (i.e. vaginal ring, patch, IUD and implant) are very scarce, but do not point to differential effects on desire versus oral contraception.
HCs and orgasm
HCs induce a reduction in orgasm frequency (Level 3; Grade C). The LNG-IUD seems not to have an impact on orgasmic function (Level 2; Grade C).
No large and powered enough RCTs are available on the effect of HC on orgasmic function. A study performed on 1,101 women taking part in an online health and sexuality survey found that women using HC were more likely to report lower sexual pleasure and less frequent orgasms than women using non-hormonal methods . However, other authors observed an increase in sexual enjoyment and orgasm frequency with COCs containing anti-androgenic progestins vs. baseline . A multi-center cross-sectional study enrolling LNG-IUD and copper IUD users reported that the prevalence of problems with orgasm was comparable in both groups (7.1% vs. 10.2%) and to the prevalence reported in the general population .
HCs and lubrication
Good quality data assessing the role of COC on vaginal lubrication and symptoms of vulvo-vaginal atrophy (VVA) are lacking and no conclusion can be drawn.
No difference on lubrication and VVA symptoms are observed when COCs containing an anti-androgenic vs. an androgenic progestin are compared (Level 2; Grade C).
Other types (etonorgestrel implant, the vaginal ring and the LNG-IUD) of HCs do not seem to show any negative effect on vulvo-vaginal morphology and lubrication (Level 3; Grade C).
Reduced levels of estrogens commonly determine VVA, leading to sensitivity to touch, burning, itching and dryness during sexual activity, as observed in menopause (also called genito-urinary syndrome of menopause, GSM) and – to a lesser extent – in HCs users . Also hypoandrogenism is considered a pathogenic factor inducing or worsening VVA . In this context some authors have suggested that COCs, in particular those containing low-dose (20 mcg or less) EE, were associated with morphological alterations of the vulvar vestibular mucosa, leading to atrophy, secondary vulvar vestibulitis, and dyspareunia .
In a prospective study on women randomized to two different COCs (low and very-low EE dose) or to the vaginal ring, COC use was associated with a significantly higher prevalence of vaginal dryness than the vaginal ring (up to approximately 30% and 2% of women, respectively); however, the prevalence significantly decreased by cycle 12 . Consistently, color Doppler ultrasonography performed in 22 healthy women in baseline conditions and after a 3-month treatment with a COC (30 mcg EE + 3 mg drospirenone), was able to highlight that labia minora thickness and vaginal introitus area were decreased, while vascular resistance indexes of clitoral and labial arteries increased . In the same study, COC use exacerbated dyspareunia and worsened spontaneous arousability .
HCs and pelvic floor and urological symptoms
Prior or current use of COCs has been associated with an increased risk of painful bladder syndrome (Level 3; Grade C).
No sufficient evidence is available on the correlation between HCs and incontinence. pelvic floor function and urinary tract infection (UTIs (Level 4; Grade D).
A meta-analysis of two trials showed a statistically significant association between painful bladder syndrome and the prior or current use of COCs (OR 2.31) .
In a large mail survey on more than 21,000 premenopausal women, the investigators highlighted a statistically significant 27% increased odds of developing urinary incontinence for prior or current users of COCs compared with never users; COCs use was specifically associated with urge – and not stress – urinary incontinence . In contrast, a Swedish cohort study of 10,791 women observed that COCs was significantly related to a reduced risk for symptoms of stress (OR 0.57), mixed (OR 0.52) and urge urinary incontinence (OR 0.36), independent of age, body mass index and pregnancy history . In an internet survey conducted on a university population, low dose (<20 mcg EE) COCs appeared to increase the incidence of chronic pelvic pain symptoms and pain during sexual climax, while >20 mcg EE COCs users had similar incidence of pelvic pain to non-users; in fact, normal dose COCs showed a protective effect in individual pelvic pain symptoms .
Hormonal contraception and partner preference, relationship and sexual satisfaction
HCs may be associated with changes in female perception of male attractiveness with a generally weaker overall preference for cues of genetic fitness (Level 3; Grade C).
HCs discontinuation can induce women’s sexual dissatisfaction due to less positive perception of partner’s attractiveness(Level 3; Grade D).
HCs use non-congruency between the initial phase (mate choice) and long-term relationship may have implications for relationship satisfaction related to the female preferences for partner genetic fitness (Level 4; Grade D).
Women using HCs and their male partners manifest more frequent mate retention behaviors as compared to HCs non-users and their male partners (Level 3; Grade C).
In a few controlled, non-randomized studies it was shown that women using HCs demonstrate weaker overall preferences for cues of genetic fitness (choosing less masculine faces) than do non-users [18, 19]. In a double-blind RCT using fMRI (functional Magnetic Resonance Imaging) it was found that the mechanism of oxytocin-related reinforcement of partner value representations via the brain reward system may be disturbed in women using HCs .
It has been suggested that congruency in current and previous HCs use (when the relationship formed), and not current use alone, predicted women’s sexual (but not nonsexual) satisfaction with their partners (“congruency hypothesis”) . Finally, women using HCs and their male partners reported more frequent mate retention behaviors as compared to HCs non-users and their male partners in a cross-sectional study . This is all in line with the preference of less-masculine but more reliable and responsible partners (“non-genetic” benefits), more intense affective responses to partner infidelity and greater overall sexual jealousy in HCs users .
Available evidence indicates that a minority of women experience a change in sexual functioning regards to general sexual response, desire, lubrication, orgasm and relationship satisfaction. However, the effects of HCs on sexual function have been understudied and remain to date controversial. The pathophysiological mechanisms leading to reported sexual difficulties such as reduced desire and VVA remain unclear. No sufficient evidence is available on the correlation between HCs and pelvic floor function and urological symptoms.
For these reasons, it is not possible to draw a clear algorithm for the management of HC-induced FSD. It has to be stressed that a careful psycho-sexual-relational assessment is necessary for the health care provider to evaluate eventual sexual effects of HCs, both at baseline and at follow-up. Potential sexual (and non-sexual) side effects for each method should be carefully explained and a patient-centered decision should always be supported.
In clinical practice, it is suggested to deal with HC-related distressing low desire by switching from hormonal to non-hormonal, from oral to non-oral (such as LNG-IUD, the vaginal ring or implants) or from estrogen-containing to no-estrogen containing forms of contraception (Level of Evidence 3). Similarly, in case of contraception-related reduced lubrication or VVA, it is suggested to switch from hormonal to non-hormonal or from oral to non-oral forms of contraception; in addition, a switch to COCs with higher EE doses may be advisable in these cases (Level of Evidence 3).