SOCIETY STATEMENT Hormonal Contraception and Female Sexuality: Position Statements from the European Society of Sexual Medicine (ESSM) Stephanie Both, MD,1 Michal Lew-Starowicz, MD, PhD,2 Mijal Luria, MD,3 Gideon Sartorius, MD,4,5 Elisa Maseroli, MD,6 Francesca Tripodi, PsyD,7 Lior Lowenstein, MD,8,9 Rossella E. Nappi, MD, PhD,10 Giovanni Corona, MD, PhD,11 Yacov Reisman, MD, PhD,12 and Linda Vignozzi, MD, PhD6 ABSTRACT Introduction: Hormonal contraception is available worldwide in many different forms. Fear of side effects and health concerns are among the main reasons for not using contraceptives or discontinuing their use. Although the safety and efficacy of contraceptives have been extensively examined, little is known about their impact on female sexual function, and the evidence on the topic is controversial. Aim: To review the available evidence about the effects of hormonal contraceptives on female sexuality in order to provide a position statement and clinical practice recommendations on behalf of the European Society of Sexual Medicine. Methods: A comprehensive review of the literature was performed. Main Outcome Measure: Several aspects of female sexuality have been investigated, including desire, orgasmic function, lubrication and vulvovaginal symptoms, pelvic floor and urological symptoms, partner preference, and relationship and sexual satisfaction. For each topic, data were analyzed according to the different types of hormonal contraceptives (combined estrogen-progestin methods, progestin-only methods, and oral or non-oral options). Results: Recommendations according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence criteria and specific statements on this topic, summarizing the European Society of Sexual Medicine position, were developed. Clinical Implications: There is not enough evidence to draw a clear algorithm for the management of hormonal contraception-induced sexual dysfunction, and further studies are warranted before conclusions can be drawn. A careful baseline psychological, sexual, and relational assessment is necessary for the health care provider to evaluate eventual effects of hormonal contraceptives at follow-up. Strengths & Limitations: All studies have been evaluated by a panel of experts who have provided recom- mendations for clinical practice. Conclusion: The effects of hormonal contraceptives on sexual function have not been well studied and remain controversial. Available evidence indicates that a minority of women experience a change in sexual functioning with regard to general sexual response, desire, lubrication, orgasm, and relationship satisfaction. The patho- physiological mechanisms leading to reported sexual difficulties such as reduced desire and vulvovaginal atrophy remain unclear. Insufficient evidence is available on the correlation between hormonal contraceptives and pelvic Received June 10, 2019. Accepted August 2, 2019. 8Department of Obstetrics and Gynecology, Rambam Health Care Campus, 1Outpatient Clinic of Psychosomatic Gynecology and Sexology, Leiden Haifa, Israel; University Medical Centre, Leiden, the Netherlands; 9Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; 2Department of Psychiatry, Centre of Postgraduate Medical Education, 10Research Center for Reproductive Medicine, Gynecological Endocrinology Warsaw, Poland; and Menopause, Obstetrics and Gynecology Unit, IRCCS S. Matteo 3Center for Sexual Health, Department of Obstetrics and Gynecology, Foundation, Department of Clinical, Surgical, Diagnostic and Paediatric Hadassah University Hospital, Jerusalem, Israel; Sciences, University of Pavia, Pavia, Italy; 11 4Department of Obstetrics and Gynecology, University Hospital, Basel, Endocrinology Unit, Medical Department, Azienda Usl di Bologna, Switzerland; Maggiore-Bellaria Hospital, Bologna, Italy; 12 5Fertisuisse, Olten and Basel, Switzerland; Ziekenhuis Amstelland, Department of Urology, Amsterdam, the Netherlands 6Andrology, Women’s Endocrinology and Gender Incongruence Unit, ª Department of Experimental and Clinical Biomedical Sciences “Mario Copyright 2019, International Society for Sexual Medicine. Published by Serio,” University of Florence, Florence, Italy; Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsxm.2019.08.005 7Institute of Clinical Sexology, Rome, Italy; J Sex Med 2019;16:1681e1695 1681 1682 Both et al floor function and urological symptoms. Both S, Lew-Starowicz M, Luria M, et al. Hormonal Contraception and Female Sexuality: Position Statements from the European Society of Sexual Medicine (ESSM). J Sex Med 2019;16:1681e1695. Copyright Ó 2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. Key Words: Hormonal Contraception; Female Sexual Dysfunction; Sexual Desire; Vulvovaginal Atrophy; Oral Contraceptives; Intrauterine Device INTRODUCTION in order to provide a position statement and recommendations The development of modern forms of contraception had a for clinical practice on behalf of the European Society of Sexual major social, economic, and political impact by empowering Medicine. women to take greater control over family planning. In partic- ular, development of the contraceptive pill and the “sexual rev- METHODS olution” that followed broadened the availability of A comprehensive search conducted on the main medical contraception in industrialized countries and led to the separa- database included studies up to July 30, 2018. The statements tion of sexuality from procreation. This development changed were internally discussed, and levels of evidence were provided our perspectives on sex and the values linked to sexuality beyond according to the Oxford 2011 Levels of Evidence criteria reproduction, such as emotional and physical pleasure, intimacy, (https://www.cebm.net/2009/06/oxford-centre-evidence-based- and bonding. Within the last decades, an increasing variety of medicine-levels-evidence-march-2009); moreover, the quality of contraceptive options have been developed, and women can now evidence was graded applying the Oxford Centre for Evidence- select the most appropriate method for their individual situa- Based Medicine recommendations. tions, as needs and preferences change from woman to woman across the reproductive life span. A skilled approach that includes shared decision making in the selection of optimal contraceptive RESULTS methods not only improves patient satisfaction but also might Hormonal Contraceptives and Sexual Function: fi optimize contraceptive ef cacy by fostering correct use of a Potential Mechanisms of Action 1 contraceptive agent. Statement #1. Hormonal contraceptives can positively affect There is a huge discrepancy among countries in the use of sexuality by different means, including (i) overcoming fear of modern methods of contraception, including barrier methods, unwanted pregnancy during sexual activity, (ii) resolution of sterilization, injections, implants, intrauterine devices (IUDs), painful or troublesome gynecologic disorders such as endome- and oral contraceptives. Rates vary from 1.7% in South Sudan to triosis and dysmenorrhea, and (iii) reduction of body image 81.6% in Finland, with the majority of industrialized countries concerns with an increase in self-esteem for women with clinical having rates of use of about 60e75% in women of reproductive hyperandrogenism (eg, acne, hirsutism) (Level 4; Grade C). e 2 age (15 49 years) who are married or in a stable relationship. Statement #2. All available combined HCs reduce androgen Among hormonal contraceptives (HCs), the most commonly levels regardless of estrogen dosage and progestin type (Level 2; used in European countries are short-acting reversible contra- Grade B). ceptives, including combined oral contraceptives (COCs), the Statement #3. Combined oral contraceptives, transdermal patch, and the vaginal ring, followed by long-acting reversible patches, and vaginal rings showed a similar effect in increasing contraceptives, such as levonorgestrel (LNG) or copper IUDs sex hormone binding globulin (SHBG) levels and in reducing and etonogestrel implants.2 androgens levels (Level 2; Grade B). Despite good health education and the availability of contra- ceptives, it is estimated that around 34% and 54% of pregnan- Evidence cies in Western and Eastern Europe, respectively, are currently 3 HCs can positively affect sexuality by different means, unintended. Women who neither desire pregnancy nor use including (i) overcoming fear of unwanted pregnancy during contraception report that a fear of side effects and health con- sexual activity; (ii) resolution of painful or troublesome gyne- cerns are among the main reasons for not using them or dis- 4 cologic disorders, such as endometriosis, dysmenorrhea, menor- continuing their use. In the last decades, extensive literature has rhagia, and menometrorrhagia; and (iii) reduction of body image fi examined the safety and ef cacy of contraceptives, but surpris- concerns with an increase in self-esteem for women with clinical ingly little is known about the impact of HCs on female sexual hyperandrogenism (eg, acne, hirsutism).5 On the other hand, function, and available evidence on the topic is controversial. concerns about the negative sexual impact of HCs have been The aim of the present study is to review the available evidence expressed ever since they have become commercially available, about the effects of hormonal contraceptives on female sexuality with reports of detrimental effects on desire, arousal, lubrication,