Young Feminists: The Irony of Oral Contraceptives

By Natieka Samuels

What if you saw an ad for a winter coat that kept you indoors? How about a life jacket that made you afraid of the water? You probably wouldn’t buy these products because they prevent you from enjoying the very activities that are made possible or safer through their use. How about this: what if your doctor prescribed a pill that prevented you from getting pregnant, but left you totally uninterested in having sex? For many women taking oral contraceptive pills (OCs) or using other forms of hormonal birth control, this example hits close to home.

Of course, not every woman on hormonal birth control experiences reduced libido: some experience no change, and some women report an increase. But, in women’s on-line communities, complaints about the negative side effects of OCs (and other hormonal methods like the Nuvaring ring, implants, patches, and the Mirena IUD) are ubiquitous. Hormonal birth control users complain of reduced vaginal lubrication, lack of interest in sex, and increased emotional instability. Sometimes the problems are due to incompatibility: once a woman identifies a brand that works for her, the adverse effects subside and all is well. For others, however, it seems that no amount of trial-and-error identifies a method without uncomfortable side effects. The Kinsey Institute estimates that approximately one in four women using OCs experiences negative sexual side effects, but only about one in one hundred discontinues use. Because the latter includes women who discontinue the Pill for any reason (including wanting to get pregnant or switching methods), it’s unclear how many discontinue OCs specifically due to decreased libido. A bigger mystery is why doctors, researchers, and (most of all) women find these side effects acceptable.

A few theories exist purporting to explain why synthetic hormones like those in OCs may decrease female sexual desire and arousal. A woman who isn’t taking hormonal contraception experiences many physical, emotional, and sexual changes during her cycle that include continual hormonal fluctuations. Many experience an increased libido around ovulation (a little reminder that it’s prime time to procreate!), before, or during menses. Women taking OCs don’t have this experience because the Pill works by controlling hormone levels and “tricking” the body into thinking it’s already pregnant; there’s no hormonal ebb and flow. This is particularly true of monophasic OCs, which deliver a constant dose of synthetic hormones (vs. triphasic OCs, which vary hormone levels and are thought to better mimic a woman’s natural hormonal changes and result in fewer reports of decreased libido).¹  Synthetic hormones can also inhibit the ovaries’ androgen production. Testosterone, the most prominent androgen, plays a significant part in the chemistry of sexual desire and enjoyment in both sexes, so lower testosterone levels may be associated with less sexual desire and arousal. Finally, OCs have been found to increase the level of sex-hormone binding globulin (SHBG) in the body, and high SHBG levels have been linked to decreased sexual desire and libido. (It’s not known if this protein is really central to female sexuality, however.) The scientific community seems to be starting to take OCs’ sexual side effects seriously; Bayer is currently recruiting participants for a study on the side effects of its popular OC, Yaz, on general health and sexual well-being.

Perhaps scientists are baffled by female sexuality because they try to model it on male sexuality, and become frustrated. For example, sending more blood to the genitals gives men erections and supposedly increases libido but, for women, increased blood flow alone is not enough. This explains why Viagra, which works by increasing blood flow, has not been a successful stimulant for women. The view that female sexual function is “complicated” because it differs from male sexuality and no single hormone, chemical, or action controls it is reflected in research surrounding female sexuality. Confusion surrounding female arousal may also stem from the fact that scientists have no standard way to measure female sexuality. Although devices like the vaginal photoplethysmograph (a tampon-like device to measure vaginal arousal) have been around since the late 1970s, the lack of established guidelines for their use has led to methodological variability across studies, difficulties making cross-study comparisons, and gaps in knowledge.² 

When researchers tested Viagra’s effectiveness in men with erectile dysfunction, the criteria for measuring its success or failure was fairly simple: could an erection be achieved and sustained? The clinical trial captured self-reports of sexual arousal using the International Index of Erectile Function Questionnaire (IIEF), a 15-item questionnaire developed expressly for the Viagra trials. The IIEF asks about how much men desire sex and their ability to maintain erection, enjoy intercourse, and have an orgasm. After Viagra proved effective for men, researchers explored how it affected women using, among other tools, the Female Sexual Function Index (FSFI), which reflects perceived complexities of female sexuality. The FSFI parallels the IIEF, and most questions can be translated from the male to female survey by replacing the word “erection” with “sexual desire” or “ejaculation” with “lubrication”.  Both the FSFI and IIEF contain questions about levels of sexual desire, ability to orgasm, and general arousal. Unlike the IIEF, the FSFI asks women about the amount of “emotional closeness” perceived during sexual activity. The IIEF’s lack of questions about men’s emotional connectedness highlights different assumptions about men and women’s sexual response. And, unlike the male Viagra trials, self-reports were not adequate in female trials; instead, women’s brains and pelvises were scanned and vaginal lubrication and swelling measured to evaluate female subjects’ response to Viagra.  Given that studies have shown that there can be discrepancies between clinically measured indicators of genital arousal and subjective acknowledgement of arousal, I feel that women couldn’t be trusted to understand and describe their own experiences.

There is light at the end of the tunnel. Female sexual desire and satisfaction are becoming more of a priority for researchers. And, new research methods are helping to diagnose problems with, and find commonalities between, male and female sexual response. The question remains: how do we acknowledge the differences and similarities between male and female sexual response without oversimplifying one or overcomplicating the other? While more work is needed to determine why some women experience lowered libido while using OCs and other hormonal contraceptives (and how to create products without this side effect) the field of male contraceptives also needs to be taken more seriously. There is currently one form of male-controlled contraception: the condom. The burden of contraception is disproportionately placed on females and hormonal methods are currently the most effective options. The only long-term, reversible, non-hormonal method that currently exists is the Paragard IUD, which is not an ideal method for women who are allergic or sensitive to copper, and tends to produce more painful, heavier menstrual periods. U.S. doctors are hesitant to give childless women any IUD, because these women experience more complications than those who have given birth. Women’s health advocates need to urge the development of more effective contraceptive options for the millions who need and want them. Better products and more options in the contraceptive field could not only make for great public health outcomes, but also, on an individual level, create happier and healthier consumers.
 

References

1. McCoy NL and JR Matyas, Oral contraceptives and sexuality in university women. Archives of Sexual Behavior 1996; 25:73-91.
2. Seal BN, Brotto LA, and BB Gorzalka, Oral contraceptive use and female genital arousal: Methodological considerations. Journal of Sex Research 2005; 42(3):249-258.