The intimate link: a systematic review of highly effective reversible contraception and women's sexual experience

Do oral combined contraceptive pills modify body image and sexual function?

BACKGROUND

The effect of hormonal contraceptives on sexual function and body image is still controversial. Existing studies have not come to definite conclusions on the association between hormonal contraceptive use and sexual function/presence of sexual dysfunction or changes in body image perception. Thus, this study aimed to evaluate the prevalence of sexual problems/dysfunction in Polish women of reproductive age (18-45 years) and to assess to what extent oral combined contraceptive pills (OCCP) impact body image, sexual function and the prevalence of female sexual dysfunction (FSD).

METHODS

A total of 495 women were included in this cross-sectional questionnaire-based study. Sexual function was assessed by the Changes in Sexual Function Questionnaire (CSFQ), the prevalence of FSD was assessed by DSM-5 criteria, and body image was assessed by the Body Exposure during Sexual Activity Questionnaire (BESAQ). A total of 237 women using OCCP were the study group (HC), and the rest were controls (CG). A regression model was used to evaluate the influence of the selected variables on sexual function and the presence of FSD.

RESULTS

The prevalence of FSD was 7.5% in HC and 2.6% in CG, and 22% compared to 14% of women in HC and CG, respectively, reported sexual problems (CSFQ). The demographic characteristics of those using other contraception methods or not using any contraception (control group) were similar. The contraceptive group was characterized by significantly higher importance of sex (4.03 vs. 3.79), worse partner's attitude toward sex (4.35 vs. 4.47), worse self-attitude toward sex (4.35 vs. 4.47), and worse body image (BESAQ) compared to controls. Among all of the variables, a lower level of anxiety (t = -1.99), positive attitudes toward sex (t = 2.05), watching erotic videos (t = 5.58) and a higher importance of sex (t = 5.66) were predictive of better sexual function (R2-0.38, F = 28.9, p = 0.0001).

CONCLUSION

Sexual behaviors and function are different in those using OCCP compared to nonusers. The prevalence of sexual problems and dysfunction was higher in those using this hormonal method of contraception; however, using OCCP was not a risk factor for either worse sexual function or sexual dysfunction. Partners' attitudes toward sex and general anxiety level were factors contributing to sexual function and the risk of sexual dysfunction in the population of women of reproductive age and should be routinely evaluated in clinical practice, especially before prescribing hormonal contraceptives.

Female sexual function in women using LARC methods

OBJECTIVE

This study aims to assess sexual function (SF) and quality of life (QoL) among women using copper intrauterine devices (Cu-IUD), levonorgestrel-releasing intrauterine system (LNG-IUS) or etonogestrel(ENG)-releasing subdermal implant.

METHODS

This is a cross-sectional study involving 213 women who are sexually active, using Cu-IUD, LNG-IUS or ENG implant for at least one year. SF assessment was carried out through the Female Sexual Function Index (FSFI) and QoL was made through The Short Form Health Research.

RESULTS

Frequency of sexual dysfunction score in Cu-IUD users was 33.8%; 47.2% in LNG-IUS users and 47.8% in ENG-implant users, without difference between groups. Desire domain had higher score in Cu-IUD users (Cu-IUD:4.20 ± 1.15 × LNG-IUS:3.76 ± 1.17 × ENG-implant:3.63 ± 1.15; p = .009). Between Cu-IUD and LNG-IUS users there was no difference in FSFI score. Total FSFI score was higher in Cu-IUD group when compared only to ENG-implant (Cu-IUD:27.48 ± 6.14 × Implant:25.07 ± 6.89; p = .029). Regarding the QoL score, difference was found only in general health domain (Cu-IUD:65.22 ± 14.91 × LNG-IUS:62.61 ± 19.04 × Implant:58.33 ± 16.46; p = .034), with lower score for implant group.

CONCLUSION

There was no difference in the SF total score between the users of Cu-IUD, LNG-IUS and ENG implant. However, the score of the FSFI desire domain and general health status were higher among users of the Cu-IUD.

Is There an Association Between Contraception and Sexual Dysfunction in Women? A Systematic Review and Meta-analysis Based on Female Sexual Function Index

BACKGROUND

A growing body of research investigates the sexual functioning status in women with contraceptives use; however, the evidence is still inconclusive.

AIM

To examine whether contraceptives use is associated with a higher risk of female sexual dysfunction (FSD).

METHODS

The electronic databases MEDLINE, Embase, Cochrane Library databases, and PsychINFO were systematically screened for eligible studies before December 2019. We only included those studies assessing women's sexual functioning by the Female Sexual Function Index (FSFI). This study was registered on the PROSPERO (ID: CRD42020167723, http://www.crd.york.ac.uk/PROSPERO).

OUTCOMES

The strength of the association between contraceptives use and risk of FSD was presented by calculating the standard mean dierences (SMDs) and the relative risk (RR) with a 95% confidence interval (CI). The pooled results were calculated using a random-effects model.

RESULTS

A total of 12 studies (7 cross-sectional studies, 3 cohorts, and 1 case-control study) involving 9,427 participants were included. The mean age in the contraceptive users ranged from 22.5 ± 2.4 years to 38.2 ± 4.6 years, while the mean age in the nonusers was 22.5 ± 2.4 years to 36.0 ± 1.0 years. Pooled results showed that no significant difference in the total FSFI scores was observed between contraceptives use and noncontraception (SMD = -1.03, 95% CI: -2.08 to 0.01, P = .053; heterogeneity: I² = 98.2%, P < .001). In line with this finding, the pooled RR also yielded no association between contraception use and the risk of FSD (RR = 1.29, 95% CI: 0.72-2.28, P = .392; heterogeneity: I² = 76.0%, P = .0015). However, the subscale sexual desire showed a significant reduction in women who received contraceptives than those did not use contraception (SMD = -1.17, 95% CI: -2.09 to -0.24, P = .014; heterogeneity: I² = 97.7%, P < .001), while no significant differences were found in sexual arousal, lubrication, orgasm, satisfaction, and pain domain.

CLINICAL IMPLICATIONS

Though evidence from this meta-analysis did not support an association between contraceptives use and the risk of FSD, the sexual desire could be significantly impaired by contraceptives use.

STRENGTHS & LIMITATIONS

This is the first meta-analysis quantifying the relationship between contraceptives use and the risks of FSD. However, substantial heterogeneities were presented across the included studies.

CONCLUSION

No direct association between contraceptives use and the risk of FSD was found. Nevertheless, declining sexual desire was significantly associated with contraceptives use. Additional double-blind, randomized, placebo-controlled trials are still warranted. Huang M, Li G, Liu J, et al. Is There an Association Between Contraception and Sexual Dysfunction in Women? A Systematic Review and Meta-analysis Based on Female Sexual Function Index. J Sex Med 2020;17:1942-1955.

The Impact of Sexual Satisfaction, Functioning, and Perceived Contraceptive Effects on Sex Life on IUD and Implant Continuation at 1 Year

INTRODUCTION

Contraceptives improve women's lives and public health, but many women discontinue their contraceptive method owing to dissatisfaction. An underexamined aspect of contraceptive discontinuation is sexual acceptability, or how contraception affects sexual experiences. Investigators' aims were two-fold: 1) to document changes in multiple domains of women's sexual experiences with their intrauterine device (IUD) or contraceptive implant over time and 2) to examine whether these sexuality factors were associated with method continuation at 12 months.

METHODS

We enrolled 200 eligible family planning clients and collected data at baseline and at 1, 3, 6, and 12 months. Sexual acceptability measures included the Female Sexual Function Index-6, the New Sexual Satisfaction Scale, and participants' perceptions of whether their contraceptive method had had a neutral, positive, or negative effect on their sex life. Survival analysis and Cox regression with time-varying covariates related sexuality measures to method continuation over time while controlling for other relevant factors.

RESULTS

Among 193 women who received an IUD or implant, 20% selected the copper IUD, 46% the levonorgestrel IUD, and 34% the etonogestrel implant. Ten percent discontinued their method during the year. Although changes in Female Sexual Function Index-6 and New Sexual Satisfaction Scale scores were not associated with discontinuation, individuals who perceived that their method detracted from their sexual experience had significantly higher removal rates than those who reported no sexual changes or positive sexual changes (adjusted hazard ratio, 8.04; 95% CI, 1.53-42.24), even when controlling for method type, bleeding changes, and a variety of covariates and controls.

CONCLUSIONS

Although limited by the small sample of discontinuers, we found that women's perceptions of how their method affects their sex life were associated with contraceptive continuation over time. Sexual acceptability should receive more attention in both contraceptive research and counseling.

Articulações entre contracepção, sexualidade e relações de gênero

Resumo O artigo propõe uma abordagem socioantropológica para discutir questões ainda candentes em torno da contracepção, sobretudo no contexto brasileiro. A prática contraceptiva compreende uma série de decisões e lógicas complexas entranhadas em múltiplos domínios da vida, requerendo análises acerca de práticas e representações sobre contracepção, maternidade, conjugalidade, família, prazer e sexualidade, sem que se deixe de considerar aspectos materiais cruciais como a oferta contraceptiva (disponibilidade de serviços e métodos). São revisitadas algumas contribuições sociológicas e antropológicas que oferecem chaves de interpretação para o entendimento dos percursos contraceptivos femininos e permitem a discussão acerca dos processos decisórios relativos à contracepção. O artigo problematiza a equação simplista entre gestações imprevistas e falta de informação e/ou acesso adequado aos métodos contraceptivos, ou ainda, como reflexo de uma suposta restrita racionalidade e/ou responsabilidade dos sujeitos em relação à vida contraceptiva - tendências ainda hegemônicas em campos disciplinares como a saúde pública e a demografia. As reflexões propostas ressaltam a necessidade de ponderar as assimetrias de gênero e as mediações biográficas, contextuais e culturais subjacentes nos processos que engendram um evento reprodutivo. Este tipo de análise abre espaço para introdução de discussões sobre sexualidade e sua conexão com as formas como as pessoas lidam com a contracepção e a reprodução. Trata-se de um artigo teórico que procura contribuir para o debate sobre a cultura contraceptiva no Brasil.

Women's Sexual Function, Satisfaction, and Perceptions After Starting Long-Acting Reversible Contraceptives

OBJECTIVE

To document how long-acting reversible contraception (LARC) affects women's sexual outcomes.

METHODS

In this prospective, observational cohort study, we enrolled new-start intrauterine device and contraceptive implant users attending four family planning clinics. Data collection occurred at baseline, 1 month, and 3 months. Primary outcomes were the Female Sexual Function Index, New Sexual Satisfaction Scale, and perceived sexual effects of method (positive, negative, or none). Secondary outcomes included other factors associated with LARC's sexual acceptability, including the ability to "let go" in sex, sense of control over pregnancy, and bleeding changes. Chi square and F-tests assessed differences between method groups at baseline. Mixed-effects models, robust Wald χ tests, and conditional logistic regression documented differences from baseline and trends over time.

RESULTS

In December 2014 to April 2015, 200 patients consented and enrolled in the study. Among 159 women who completed three survey rounds, 20% selected copper intrauterine devices, 46% levonorgestrel intrauterine devices, and 34% implants. Sexual functioning and satisfaction scores did not change over time. However, across methods, participants were more likely to report improvements to their sexual lives compared with baseline (χ P<.001). By 3 months, 40% (n=64) reported positive changes and 17% (n=27) negative changes. Positive sexual changes were associated with one's sense of control over pregnancy and one's ability to "let go" in sex. Negative sexual changes were largely attributable to increased vaginal bleeding.

CONCLUSION

Although new LARC users reported no measurable objective change in sexual function or satisfaction, a sizable minority reported perceived positive, method-related sexual changes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT02734199.

The Sexual Acceptability of Contraception: Reviewing the Literature and Building a New Concept

How contraceptives affect women's sexual well-being is critically understudied. Fortunately, a growing literature focuses on sexual aspects of contraception, especially hormonal contraception's associations with libido. However, a more holistic approach to contraceptive sexual acceptability is needed to capture the full range of women's sexual experiences. We conducted a narrative literature review of this topic, working with an original sample of 3,001 citations published from 2005 to 2015. In Part 1, we draw from a subset of this literature (264 citations) to build a new conceptual model of sexual acceptability. Aspects include macro factors (gender, social inequality, culture, and structure), relationship factors (dyadic influences and partner preferences), and individual factors (sexual functioning, sexual preferences, such as dis/inhibition, spontaneity, pleasure, the sexual aspects of side effects, such as bleeding, mood changes, sexual identity and sexual minority status, and pregnancy intentions). In Part 2, we review the empirical literature on the sexual acceptability of individual methods (103 citations), applying the model as much as possible. Results suggest contraceptives can affect women's sexuality in a wide variety of positive and negative ways that extend beyond sexual functioning alone. More attention to sexual acceptability could promote both women's sexual well-being and more widespread, user-friendly contraceptive practices.

The Sexual Acceptability of Intrauterine Contraception: A Qualitative Study of Young Adult Women

CONTEXT

The IUD is extremely effective but infrequently used by young adult women, who disproportionately experience unintended pregnancies. Research has not examined how IUD use may affect sexuality, which could in turn affect method acceptability, continuation and marketing efforts.

METHODS

Focus group discussions and interviews were conducted in 2014 with 50 women between the ages of 18 and 29-either University of Wisconsin students or women from the surrounding community who received public assistance-to explore their thoughts about whether and how IUD use can affect sexual experiences. A modified grounded theory approach was used to identify common themes in terms of both experienced and anticipated sexual acceptability of the IUD.

RESULTS

Six themes emerged: security (IUD's efficacy can reduce sexual inhibition), spontaneity (IUD can allow for free-flowing sex), sexual aspects of bleeding and cramping (IUD's side effects can affect sex), scarcity of hormones (IUD has a low level of or no hormones, and reduces libido less than hormonal methods, such as the pill), string (IUD's string can detract from a partner's sexual experience) and stasis (IUD use can have no impact on sex). Some reported sexual aspects of IUD use were negative, but most were positive and described ever-users' method satisfaction and never-users' openness to use the method.

DISCUSSION

Future research and interventions should attend to issues of sexual acceptability: Positive sexual aspects of the IUD could be used promotionally, and counseling about sexual concerns could increase women's willingness to try the method.

Intrauterine devices and other forms of contraception: thinking outside the pack

A variety of contraception options are available in addition to traditional combined oral contraceptive pills. Newer long-acting reversible contraceptive (LARC) methods such as intrauterine devices and subcutaneous implants are preferred because they do not depend on patient compliance. They are highly effective and appropriate for most women. Female and male sterilization are other effective but they are irreversible and require counseling to minimize regret. The contraceptive injection, patch, and ring do not require daily administration, but their typical efficacy rates are lower than LARC methods and similar to those for combined oral contraceptive pills.