http://orcid.org/0000-0003-0755-1887
Abstract
Objective: To increase the understanding of women who experience negative effects on sexual function when using hormonal contraception.
Methods: We performed 24 in-depth interviews with women who had previously experienced negative sexual function effects while using hormonal contraceptives. The thematic analysis method was used.
Results: ‘After experience comes insight’, ‘Lubrication and desire go hand in hand’, ‘Mental wellbeing comes before desire’ and ‘The contraceptive counsellor potentially facilitates insight and decision-making’ were the main themes found in the study.
Conclusions: This selected group of women described lubrication difficulties and decreased sexual desire associated with both contraceptive use and the menstrual cycle. Contraceptive use became easier with age and with better understanding. The contraceptive counsellor could facilitate the process. Further choice between hormonal or non-hormonal contraceptive methods depended primarily on experienced adverse effects on mood, and secondarily on sexual function, weighed against the advantages or disadvantages experienced during the person’s own menstrual cycle.
摘要
目的：增加对应用激素避孕对性功能有负面影响的妇女的了解。
方法：我们对曾在使用激素避孕药时经历过性功能负面影响的女性进行了24次深入访谈。使用专题分析方法。
结果：研究中发现的主题是“经验之后的洞察力”, “润滑和欲望是相辅相成的”, “心理健康比欲望更重要”和“避孕咨询师可能有助于洞察力和决策”。
结论：这组被选中的女性描述了与应用避孕药和月经周期有关的润滑困难和性欲下降。随着年龄的增长和对避孕方法的更好理解, 避孕方法的应用变得更加容易。避孕咨询师可以帮助实现这一过程。选择激素类或非激素类的避孕方法主要取决于对情绪的不良影响, 其次是对性功能的不良影响, 并与个人在月经周期中经历的有利或不利因素进行权衡。
Introduction
To control reproduction is central to sexual freedom and allowing women to decide about sexual relations on equal terms to men [Citation1,Citation2]. The effect of hormonal contraceptives on female sexuality has long been a matter of discussion [Citation3]. The existing literature is conflicting and mainly based on observational studies and a few randomised clinical trials focussing on the question of causality, comparisons between different oral contraceptives and reproductive hormone level changes [Citation4–6]. One randomised study found no causality [Citation7], another reported a small but clinically non-significant negative effect of combined oral contraceptives on sexual desire and lubrication [Citation6]. Despite these uncertainties, many women may attribute impaired sexual function to their hormonal contraceptives, leading to difficulties finding a suitable method [Citation8]. Negative experiences regarding mood and sexual function are reported as major causes of discontinuation and/or change of contraceptive method in observational studies [Citation9–12]. The need to understand women’s experiences of mental health side effects is in qualitative research pointed out as important to reduce the barriers of an optimal contraceptive use [Citation13,Citation14]. Qualitative studies with the specific aim to deepen the understanding of women that report sexual function changes that they attribute to their contraceptive method, are lacking.
As the number of contraceptive alternatives increases, the role of the contraceptive counsellor is becoming more important to enhance compliance and high continuation [Citation15,Citation16]. Considering the large number of women using hormonal contraception [Citation17–19], the complaint of adverse sexual function effects is an issue that deserves attention from the researchers even if the prevalence of sexual side effects [Citation4] is presumed to be low. Increased knowledge of women’s experiences, especially those who report adverse sexual function effects which they relate to hormonal contraceptive use, could enhance contraceptive counselling, and in a wider perspective contribute to tailored recommendations for contraceptives, increased compliance and thereby a decreased number of unwanted pregnancies and induced abortions [Citation15,Citation20].
This study aimed to increase the understanding of women who had experienced negative effects on sexual function which they attributed to hormonal contraceptive use. Our main study questions were: What do women really mean when stating they experience impaired sexual function? How do these experiences affect contraceptive method choice? How are these matters discussed with the contraceptive counsellor?
Method
Design
This was a qualitative study based on in-depth interviews. Interpretive thematic analysis was performed with a constructionist stance. Hence, knowledge was assumed to be situated and interpreted in the specific setting and created by the researchers and informants together.
Informant/participant selection
The selection of the informants was done in two steps. A few years ago, our research group designed and published a descriptive study of contraceptive use among Swedish women [Citation12]. After the participants in that study had completed a questionnaire, we asked if any of the women were interested in being a part of the current study involving in-depth interviews. Women who expressed interest, understood Swedish and had also reported adverse sexual function which they attributed to a hormonal contraceptive method, were regarded as eligible (). Since as many as 156 women were eligible a second selection was needed. The eligible women were listed and grouped into the three age groups found in the questionnaire. An estimation of the sample size was done prior to the second selection to ensure that the final number of participants would be large enough to yield a rich data set. Twenty-one interviews would be needed according to Fugard’s sample size calculation method for 80% power [Citation20]. This calculation assumed: a lowest prevalence of 60% of a theme worth discovering, 90% of the informants having something to say about the theme, and that the theme should be recognised at least ten times in the data. We expected a substantial loss of potential informants from the first selection until the second contact for interviewing. Therefore, 100 (31, 35 and 34 women, respectively, from each age group) of the initially eligible participants were arbitrarily selected and contacted by email. We explained why they had been contacted, and included study information. The selection of the informants is described in . In total, 24 women aged 27, 30 or 33 years were interviewed.
Figure 1. Selection process of informants. ‘a’ The arbitrary selection was performed manually, and to yield three similar sized age-groups.
The research team
All team members had previous knowledge about either contraceptive counselling or qualitative methodology or both. None of the researchers had any personal or professional relation to the informants. AM and LB were involved in all steps of data collection and analysis. The initial coding was triangulated by GF who was also involved in all steps of the analysis. The themes were discussed and input in finalisation of the themes was made by MH and JB. The analysis was supervised and guided in all steps by CB.
Data collection
Interviews followed an interview guide () with two main topics the interviewers strived to cover. The researchers were allowed to iteratively add, remove, change and reorder the interview questions. Each interview was conducted by either AM or LB. In 11 interviews out of 24, the other researcher was present making notes and adding further clarifying questions. When just one interviewer was present the field notes were written directly after the interview. All informants were informed about and accepted the second researcher’s presence prior to the interview.
Table 1. Interview guide (translated into English) – the order of questions and wording is flexible.
The duration of the interviews was 32–102 min (median 60 min) and they were audio-recorded with a high-quality electronic sound recorder with accompanying computer software. The interviews were transcribed verbatim systematically by AM and LB and a secretary. All the interviews were conducted during September and October 2018.
Data analysis
Thematic analysis [Citation21] was used, focussing on latent themes. The whole data set was analysed. Although we focussed on the content that answered our areas of interest, we kept an open mind and included non-expected aspects for further analysis [Citation22]. The analysis followed six steps: (1) The text from each interview was read and re-read several times to gain data familiarity. (2) An initial coding was performed. (3) The codes were re-read, and preliminary themes were generated (4). The themes were checked with the coded extracts and data and used to generate a thematic map. (5) Thereafter, all themes were merged into a comprehensive map representing all interviews. The themes were again processed, redefined and clarified to obtain a few distinct themes. Only frequently occurring themes were formed to become the main themes. (6) The themes were presented as a coherent pattern and were strengthened with quotes.
The NVivo 12 Pro software programme was used for allocation of the text for initial coding and for keeping track of the citations used. Manual analysis was performed.
Ethics
The study was approved by the Regional Ethics Committee, Linköping, Sweden (No. 2013/257-3). All women gave informed consent prior to the interview. Confidentiality was assured. The interviews took place wherever the participant herself wished and where it could be held without disturbance. Both interviewers had previous qualifications related to counselling women with sexual health concerns, which enhanced their empathic stance.
In two of the cases the interview revealed health or psychological problems, for which professional help was offered at the clinic. No financial or other compensation was given.
Results
General information about the informants is shown in the Supplemental Table. All the informants had previous experiences of at least one hormonal contraceptive method. All the women had also at some point used condoms as the sole method of contraception or as a complement to other methods.
The analysis of the interviews resulted in the four main themes presented further in the next sections.
After experience comes insight
Most of the interviewed women expressed an experience and timeline-related insight into how they perceived their bodies/minds were affected by hormones. The experiences of hormone related variations were made throughout the menstrual cycle as well as when hormonal contraceptives were used. The history of contraceptive use was often described in terms of a journey from adolescence to adulthood, from chaos of feelings and reactions to understandable associations and interpretive existence.
Many women started to use hormonal contraceptives in adolescence, a turbulent time of life. Feelings, reactions and the ability to note sexual function changes were difficult due to immaturity and yet unclear reference of the own sexual function. Only after cessation of a treatment or after experiencing variations during the own menstrual cycle, did the women perceive some sexual function changes as hormone-related.
Yes, well, during the teenage period (.) it was difficult to get a grip of it you know. But I was feeling down and my sexual desire came and went in periods. But when I got older (.) then in the stable relationship I had for the time being, I really noticed when I started to take them [refers to the pill] It just disappeared,(.) my desire (.), you know completely disappeared…’ (W12)
For some women this self-awareness was dramatic, an epiphany with long-lasting consequences for further contraceptive choices. Others perceived just a minor change of sexual desire which they felt was easy to accept and live with.
Overall, pregnancy, childbirth and breastfeeding were common ways to achieve self-awareness which afterwards could lead to the wish for no further use of hormonal methods. Insights were sometimes referred to been acquired by coincidence, like after forgetting to renew a prescription or in connection to planned pregnancies.
‘And then it just occurred to me that I would like to try to be without (.)[refers to the pill] and it was then that I noticed a great difference on my desire. It wasn’t like I had noticed that it was suppressed before, but afterwards (.) I just, you know, ‘wow, okay, okay (giggling) is it how it is?’ So, well, since then I haven’t used any hormones again, I just use other methods instead.’ (W4)
Some women continued to search for a more suitable hormonal method, experimenting with different types of formula and substances as a result of insights into associations they felt between sexual function and menstrual cycle variations or hormone use. Others changed to non-hormonal methods instead. A few of the informants expressed no clear thoughts about hormones and their own sexual function but instead a desire not to use any hormones. Others described experiences of both negative and positive effects of hormone use, and were after hand questioning their own conclusions, realising that both sexual function and mental wellbeing are multifactorial. These women were generally more tolerant of the possible negative effects on sexual desire, and in some cases accepted the compromise of high efficacy at the expense of a slightly lower sexual desire.
In general, overall sexual function seemed to improve with experience and time, unless the woman did not have a disease such as depression, endometriosis or, as in one case, multiple sclerosis. As the understanding of a perceived relation between hormones and wellbeing became clearer with time, the satisfaction with the current contraceptive choice also increased. In many cases, method choice was described as becoming easier with age, experiences and increased self-confidence.
‘Especially now, as a grown up when having things sorted out a little. I have you know… I know that my body has a certain rhythm and I know how it works. And I think…you know, it was that above all, that was the positive part by stopping the pill, that I started to get to know my body and how it works…’(W2)
Lubrication and desire go hand in hand
In depth questions about sexual function revealed that most women found associations between hormonal changes and the ability to achieve sexual arousal. Most of the women found that an increased physical readiness, sometimes as the primary cause of increased sexual drive, was noticed around the time for expected ovulation. A favourable genital environment, well lubricated and easily responding to stimuli, was described by many of the women experiencing and preferring their own menstrual cycle variations. Physical stimuli such as touching or caresses and sexual thoughts or willingness to engage in sexual activity were described as stimuli leading to a more rapid and intense sexual arousal around mid-cycle. The sole sensation of spontaneously more swollen and lubricated genitals, associated with the period of expected ovulation and sometimes menstruation, was also described as awakening an urge for sex.
‘But the most important I was thinking of, was the difference I actually noticed physically when I stopped using it [refers to hormones]. Cause it was so remarkable. […] measurable in a very obvious way. Getting wet and actually feeling desire, to take initiatives and even if I didn’t have a partner I could satisfy myself much, much more often […]it was somehow measurable […] and it was awesome to see…’ (W24)
‘…I have such a lot of fertile secretion too, it’s so smooth and slippery […]You get more horny, cause it’s just there from the start, so to say…’ (W21)
In relation to this, hormonal contraceptives were described as preventing the advantages of the own cycle. These women perceived themselves as being secluded, dull, and non-responsive when using hormonal contraceptives.
‘No, it simply didn’t get wet. I didn’t get aroused. […] It just didn’t happen anything. In such way’. (W7)
‘…and this thing that even if I felt desire (.) my body didn’t react. I was (.) I had a yearning, but I didn’t get horny, I mean the tingling wasn’t there, even though I felt, oh God, I would like to have sex (.) my body didn’t react. And the problem disappeared when I removed the implant’. (W19)
Women with cycle-related problems such as irregular or heavy bleeding, pain or disturbing premenstrual symptoms could also describe ovulation-related increased sexual desire, but felt that the drawbacks of their own cycle were simply not worth it. These women preferred hormonal contraceptives, and in some cases they were even a necessity for better sexual, and overall, wellbeing.
‘…If I recall when I used the pill everything was more even, I mean, sexual desire, irritation, and all that abdominal pain and tiredness, but (.) however (.) times without the pill there were more ups and downs. All that was good got even better and all that was bad got even worse. So, (.) I will for now continue with this new pill even at a cost…’ (W22)
‘…with the Copper IUD I was bleeding all the time […] since then I’m using the Depo Injection. And it’s great! I’ve learned that I have to take it every ten weeks to get rid of bleedings. And above all I have a stable and normal state of mind…’ (W16)
Mental wellbeing comes before desire
Several of the women interviewed made associations of mental wellbeing with contraceptive use which emerged as one of the main themes. Without exception, all informants who had experienced poor mental health of some reason valued their mental wellbeing higher than a well-functioning sex life. The ones experiencing negative effects on mental wellbeing which they attributed to contraceptive use, described it as a crucial experience which overshadowed any experiences of impaired sexual function.
Mood symptoms such as feeling low, being out of initiatives, increased anxiety and irritation or anger, were by some women attributed to hormonal contraceptive use, and reported to diminish sexual desire. None of the interviewed women described though that what they perceived as a hormonal contraceptive associated sexual function impairment, would considerably affect their mental wellbeing.
One of the women reported a death wish and another suicidal ideation which ceased when they stopped using a contraceptive agent. Consequently, decision-making on contraceptive choice varied according to the severity of symptoms but generally the experience of mood symptoms was more decisive than adverse sexual function effects when it came to future contraceptive choice. Having the experience of mood symptoms attributed to contraceptive use, the woman was reluctant or even frightened to try another type of hormonal contraceptive.
‘But you get such information… you should stand it for half a year with the adverse effects, it will subside. And I felt that…suicidal thoughts…for half a year it’s not reasonable just to be able to have sex without a condom…’ (W23)
Also, for women with more severe premenstrual symptoms, sexual desire was of secondary importance when it came to the choice of contraceptive method. Even if sexual desire and lubrication could be hampered, a stable mental status was preferred if it could be achieved with hormonal treatment.
…but my fear, it’s still my fear I will feel that bad again, it weighs more than sex life… (W5)
The contraceptive counsellor potentially facilitates insight and decision-making
All the interviewed women had heterogeneous experiences of both contraceptive use and different counselling situations. Common to all informants was that they preferred individually designed counselling.
Some women were satisfied with the counselling and found that the midwife or the gynaecologist was open to, and listened to, their personal history and showed interest in previous experiences and current side effects. Most of the women expressed disappointment with caregivers who were not affirmative, like the ones who made the women feel they were being called into question when it came to sexual function and mental side effects. The interviewed women made the reflection that the counsellor either alleviated or delayed the insights and thereby also anticipated or delayed the discovery of the most suitable contraceptive method.
The women reflected that as teenagers they would have needed upfront questions about feelings, sexual function and mental health, posed by the counsellor. They also expressed a need for clear information on all available contraceptive alternatives with potential positive and negative side effects, including mood and sexual function changes. The counsellor role was wished to be quite directive. With increasing age and experiences of own sexuality, previously used contraceptives and own menstrual cycle function, the role of the ideal adviser shifted towards supporting rather than directing. This approach helped the women to synthesise earlier experiences with current demands.
‘…yeah, I mean, you should have more like a dialogue, I mean over time, that you get some follow up after…, not just prescription renewal all the time but some kind of follow up […] some more dialogue with the midwife…’ (W20)
In most interviews the responsibility for controlling reproduction was seen and accepted as an issue for women, even if sometimes it was somewhat frustrating. Most women discussed with their partners whether or not to use contraceptives but more seldom which method to use. A few women considered the responsibility to be equal and some argued using only condoms as a solution. They expressed a strong feministic point of view overall and felt that the counsellor did not have the same starting point.
More than half of the interviewed women had previously used hormonal contraceptive methods but were using a hormone-free alternative at the time of the interview. Some experienced these alternatives as second best choices. Even though several drawbacks with all the methods were mentioned such as heavy bleeding with the Cu-IUD, loss of spontaneity and mechanical problems with the condom, and uncertainty about the natural methods, these women were generally happy with hormone-free alternatives. They preferred the drawbacks instead of what they perceived as hormonal related problems with sexual function or even a feared risk of adverse effects with the hormonal methods, and expected the counsellor to consider this.
Those informants who had one or several diseases, such as depression, endometriosis, dyspareunia or severe premenstrual symptoms, were more often discontent with the contraceptive counselling than the healthy women. They requested a more holistic approach and lacked a counsellor with sufficient medical competence.
‘And then she started to ask about our relationship and stuff. And I think it’s good overall, but I felt she didn’t really… believe in me. That I really wanted to be with him. So…I didn’t get any help. […] And it became more like a challenge. Like, if it’s really that bad why don’t you just quit. And I got mad and I did! And it turned out well…’ (W12)
Overall, searching for the right method, and the courage to continue searching for it seemed to be facilitated by a good counsellor–patient relationship, with counselling adapted to the woman’s age, medical health as well as sexual experience and previous use of contraception.
Discussion
Findings and interpretation
We found two main reported influences on sexual function. First, a decrease of willingness to engage in sexual activity due to few or a complete lack of sexual thoughts or sexual interest, often associated with mood symptoms such as feeling low and initiative-less. Second, a decreased ability to achieve genital arousal, and non-responsiveness to physical or mental sexual stimulation. The decreased arousal was often described with similar wordings of insufficient lubrication or dryness, and sensations from the vulva without pleasure, or a feeling of numbness. The two systems seemed to interact, and one could awake the other, but interestingly many women experienced lacking a genital arousal response despite sexual desire and yearning. This seems to be related to perceived extrinsic and intrinsic hormone changes such as contraceptive use or variations over the natural menstrual cycle. An explanation could be that variations of endogenous as well as exogenous oestrogens and progestogens affect the susceptible woman’s ability to achieve arousal in sexual situations [Citation23–26]. Increased sexual desire related to ovulation has been hypothesised by others [Citation27–31] and was described by the informants of this study. Another explanation could be that the decrease of oestrogens, or increased progestogens might cause a dryer genital environment and less lubrication [Citation32–34].
Insights into the interplay between endogenous and exogenous hormones and sexual desire and lubrication were gained with time and experience, thus they varied between individuals. Often cessation of hormonal contraception use revealed a difference to wellbeing during the spontaneous menstrual cycle. Women’s personal insights affected subsequent contraceptive choice, depending to some extent on the magnitude of the perceived impact on sexual function, but mostly on the impact on mental wellbeing, which overshadowed adverse sexual effects. Similar results of mental impact are shown in other studies [Citation35–37].
The recent large quantitative study TANCO [Citation15] found that 60% of the women wanted more information about contraceptives than they had received. It also showed that 7% of the women used a natural method and that these women were the least satisfied with their method. This might suggest that many women have difficulty finding a suitable hormonal method and choose a less efficient and time-consuming natural method instead. Our study reflects the dilemma of the duality of the sexual self and the reproductive self, which continually affects the decision-making process when choosing a contraceptive method. ‘The best contraceptive is one that fulfils women’s needs with acceptable side effects and at an affordable price in different settings’ [Citation38]. This is a simple conclusion but hard to realise in the often time-restricted consulting situation. According to our findings the ideal counsellor understands the different aspects pointed out above and ensures that there is time for individually designed counselling. This approach could facilitate the women’s insight process as well ensure they make a satisfactory and durable contraceptive choice [Citation39–41].
Differences and similarities in relation to other studies
Several other studies present findings strengthening the potentially negative sexual side effects experienced by some women using hormonal contraception [Citation11,Citation25,Citation33,Citation42,Citation43] as well as the fact that these kinds of adverse effects highly influence contraceptive choice [Citation9,Citation11,Citation38,Citation40,Citation44–46]. Nevertheless, no analysis has, to our knowledge, until now been performed using a qualitative method, focussing on revealing the experiences of this specific subgroup of women, which is why our results add valuable knowledge to the literature.
Strengths and limitations
This study presents consistent results based on in-depth interviews providing a rich variety of experiences. The design and analysis of the study follows the criteria for reporting qualitative research (COREQ) [Citation47]. Interpretive studies can always be questioned, but more than one researcher was involved in the analysis throughout the process, that is, we used researcher triangulation.
Five years had passed since the selection of eligible participants based on a questionnaire study until the current interview study was performed. This could be seen as a method limitation. However, the questionnaire was only used to select the group of women of interest. Since the number of eligible women were as many as 156, the large loss of informants still interested in participation five years later, did not restrict us from including enough participants. On the contrary, the years that passed allowed more experiences to be revealed in the interviews.
Sample size determination a priori is overall questioned and problematic in qualitative research but is commonly used and is often necessary due to the practicalities of managing time and resources. In contrast to the vague description of sample size determination often seen in qualitative studies, we applied the newly introduced empirical model of Fugard and Potts [Citation20]. Using the model increases the transparency of our study and we consider it as a strength. Shortly, the calculation depends on the expected population theme prevalence of the least prevalent theme, the number of desired instances of the theme, and the power of the study. The idea is to adequately power the study and thereby increase the likelihood of finding sufficient themes. Fugards model might be claimed to apply realist assumptions which collides with the epistemological stance of the inductive and interpretive approach used in this study [Citation48]. We believe though that epistemological grounds in our study were preserved by focussing on high quality data collection and analysis and considering sample size decision more pragmatic by anticipating a provisional number of planned interviews. As the calculation can be used alongside other considerations, once the study was under way, we reflected upon theme saturation which also eventually confirmed that the number of participants was enough.
The participants had in general a high level of educational attainment (shown in the Supplemental Material) which restricts transferability of our results.
Implications for clinicians and policymakers
Our study suggests that women reporting sexual function or mood changes while using hormonal contraceptives require a thorough history-taking. This should include previous experiences and knowledge of both hormonal and hormone-free contraceptives, a sexual function assessment, experiences of the menstrual cycle, the actual need for contraception and contraception efficacy needs. We suggest that a discussion about mental wellbeing and sexual function, including sexual desire and lubrication, should be routine in contraceptive counselling. Offering follow-up, especially to teenagers, could potentially prevent years of distress and precipitate the process of acquiring self-knowledge. Hormone-free contraceptive alternatives could be presented as an option together with clarifying information about real-world effectiveness of each method.
Unanswered questions and future research
Our study does not claim to have found any answers concerning causality or the magnitude of the problems regarding sexual function deteriorations while using a certain hormonal contraceptive. Nevertheless, by presenting our results we hope to affirm these women’s difficulties. Further investigations that can strengthen individualised contraceptive counselling are needed. Studies about basic molecular and clinical research on the bio-phsyco-endocrine connections are also needed. Moreover, further studies of the determinants of the susceptibility to experience adverse effects on mood and sexuality from hormonal contraceptive use would be of benefit in the contraceptive counselling situation.
Conclusions
Women with earlier experiences of impaired sexual function while using hormonal contraceptives describe lubrication difficulties as well as decreased sexual desire attributed to not only contraceptive use but also the menstrual cycle. Insight comes with time and it is experience that helps these women to discover and to understand the nature of their hormone-associated sexual function. The process of understanding can be facilitated by the contraceptive counsellor, and with better knowledge and understanding the contraceptive choice becomes easier.
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