To our knowledge this is one of the first papers that used strict DSM-5 criteria to assess the prevalence of sexual dysfunction in the Polish population of women in the reproductive age especially those using OCCP’s. Additionally, partner-related factors, sexual self-schemas and body avoidance were also evaluated picturing multidimensional dependencies in regulation of sexual function in that group of women. The results might serve as a background for discission on implementing of anxiety, body image and attitudes toward sex evaluation when consulting women before starting hormonal contraceptives.
Based on the study result the prevalence of FSD in general population was 5.1% and in those using OCCP’s – 7.5%. That prevalence was much lower compared to our previous studies in general population – 14.7% (22); however, women in the present report were younger (mean age 29 vs 39, respectively), what might influence the results. Similar proportion of FSD but based of Female Sexual Function Index (FSFI) was presented in Finish report (21). No previous studies have evaluated FSD based on DSM-5 criteria.
The recent metanalysis of studies on hormonal contraceptives and sexual dysfunction reported that based on FSFI scores up to 36.7% of hormonal contraceptive users reported some sexual problems (17, 26). That is in line with our results showing that 22% of users reported sexual problems. When analysis the prevalence of disturbances in particular domain, the numbers were much higher; however, that has to be interpreted with caution, as the scale might not be suitable for assessing the sexual problems and FSFI might be better screening tool (20).
Some differences were also noted between users and non-users in sexual behaviors – those in HC group were more frequently sexually active, had more vaginal sex a month but had lower frequency of orgasm. That is in line with other studies showing fewer orgasm (t = −2.39, P < 0.05), but higher rate of lubrication problems (t = 2.00, P < 0.05), and lower frequency of pleasure (−1.95, P < 0.05), with no differences in pain (in contrast to our study results) (19). Despite aforementioned differences in users and non-users regression model showed no influence of hormonal contraceptives on neither sexual function nor prevalence of dysfunction. That is similar to recently published summary of conducted studies reporting increase or no change in desire, decrease orgasm frequency (except Mirena users), or no impact on vulvovaginal symptoms or lubrication (1, 20, 21). No effect on estrogens dose or regimen, similar to our study, was also noted in other papiers (27). In contrast, some papers showed increase likelihood of worsening sexual desire (OR=2.47), arousal (OR=2.85) and sexual function in general (OR=2.01) assessed by FSFI after 3 months of using Drospirenon containing oral contraceptives (20, 28). However, the population induced in the study was small to draw the definite conclusion. Some differences might be also due to cultural script and ethnicity – women from Europe seems to have higher prevalence of pain during intercourse when using hormonal contraceptives compared to other continents (20)
When asked about subjective opinion on the influence of hormonal contraceptives women declared no effect or slightly decrease in sexual response, what is in line with some previous observation – no effect in 55% of users (29).
Finally, some other factors were important in predicting sexual function and the risk of dysfunction, namely anxiety level, watching erotic videos, importance of sex, and partners attitude toward sex. It seems, like presented in Rausch and Rettenberger recent paper, that partner-related factors might play a major role (30). Similarly, erotic material(30), importance of sexual acts (31) in a positive way and anxiety in negative (32) were also reported to be predictive by other authors.
It has to be underlined that, undoubtedly, hormonal contraceptives might influence some aspect of sexuality like might change the perception of partners attractiveness thus modifies the sexual receptivity or change the concentration of oxytocin during sexual cycle (1, 33). However, the extent to what sexuality might be modified seems to be more complexed and depend on genetic and partner-related factors (having a partner, attitude toward sex) factors (31, 34). In that light an afford has to be made in consulting women before introducing contraceptive or when sexual dysfunction emerges during hormonal conceptive uses. Changing the contraceptive preparation (13) or, if indicated, adding androgens (35) might be an option. However, education intervention and anxiety reduction may be better alternative.
The paper has also some limitation. Firstly, sexual satisfaction and relationship quality were assessed by one single question. However, similar methodology was used in other studies and is generally accepted (36). Secondly, propensity for inhibition/excitation could also be evaluated, what is currently being pain more and more attention (22). Thirdly, we have not evaluated the effect of progestin-only pills (POP), hormonal IUD, patches, ringd and injections, like in Hassanin et al study where 95% and 84% of injectable contraceptive and POP users reported decline in sexual function (29). Finally, a prospective character of the study with sexual function evaluation before introducing the hormonal contraceptive would be more reliable in showing the association. Although all that limitation, a large nr of participant and validated instruments used in the study makes it a valuable contribution to current knowledge of hormonal contraceptives’ effect on sexuality.