While generally well-tolerated among women, reports of decreased sex drive after going on a combined oral contraceptive pill - which contains the hormones oestrogen and progestogen to suppress ovulation - are not unheard of.
After having two children, Mr and Mrs Gerald Lim (not their real names) had looked forward to worry-free sex when they started contraception.
But what was supposed to rev up their sex life had the opposite effect.
Weeks after being on the combined oral contraceptive pill, which contains the hormones oestrogen and progestogen to suppress ovulation, Mrs Lim’s libido nosedived and she occasionally experienced discomfort during intercourse. The symptoms put a damper on the bedroom activities of the couple, who are in their 30s.
According to doctors, the combined oral contraceptive pill is one of the most popular forms of contraception used in Singapore.
"Doctors should consider the side effects of female sexual dysfunction when prescribing combined oral contraceptives, say KKH experts"
At least half of urogynaecologist Christopher Chong’s patients who are on birth control are on the combined pill. The majority of them are under the age of 40, and a substantial proportion is unmarried.
While generally well-tolerated among women, reports of decreased sex drive after going on the combined pill are not unheard of. Every year, the Family Medicine Service at KK Women’s and Children’s Hospital (KKH) sees about five to six cases similar to the Lims’. But the figure is likely the tip of the iceberg.
“Due to poor awareness (that the combined oral contraceptive may cause female sexual dysfunction), it is very likely there are many undiagnosed cases,” said Dr Ang Seng Bin, head and consultant family physician at KKH’s Menopause Unit and Family Medicine Service.
Other side effects include headaches, particularly in women above the age of 35, and breast tenderness.
NEW RECOMMENDATIONS FOR DOCTORS PRESCRIBING THE PILL
These circumstances prompted KKH experts to propose a set of recommendations for doctors to consider sexuality-related effects of the combined pill when prescribing it to women of reproductive age.
In a paper published in June in the Singapore Medical Journal, the team recommended physicians screen patients for any existing female sexual dysfunction, and inform them of the possible sexual side effects of combined oral contraceptives before prescribing them.
Women should also undergo regular follow-ups with their doctors after starting combined oral contraceptives.
This would allow those who experience female sexual dysfunction to be managed early, such as by switching to newer-generation combined oral contraceptives or other forms of contraceptives, the authors wrote.
“The reason for taking combined oral contraceptive pills is to avoid unwanted pregnancy while still maintaining a sexually-active life and quality relationship. If the couple’s sexuality is affected, it can have an adverse effect on their relationship,” said Dr Ang, senior author of the paper.
Presently, neither the World Health Organisation nor the United States’ Centres for Disease Control and Prevention mentions the possible effects the combined pill may have on sexuality in existing guidelines, although some studies suggest a link, particularly for women on older-generation oral contraceptives.
The side effect could be due to the pill’s impact on testosterone, a male hormone that is also present in women and which drives libido or sexual desire.
It is postulated that the pill lowers this male hormone, hence decreasing drive, said Dr Chong, director of Chris Chong Women and Urogynae Centre at Gleneagles Hospital. The other hypothesisis that it may thin the vulva (outer part of female genitals), causing abrasions and discomfort during sexual intercourse, he said.
Women concerned about a libido slump should not ditch this birth control option just yet. Dr Ang said the majority of women do not experience side effects and, if they do, most resolve after three months. If symptoms persist, they should consult their doctors.
Dr Chong estimated less than 5 per cent of his patients who are on the pill experience sexual dysfunction symptoms, which are usually linked to the older-generation oral contraceptives that contain high doses of synthetic hormones. The newer options contain “very low doses” of hormones so such a side effect is not common.
“A very small proportion of women may complain of vaginal dryness, perhaps a slight decrease in sex drive and arousal. Usually, these symptoms are not significant. For side effects to occur, one needs to take the pill for many years but many of my patients are not on it for long-term,” said Dr Chong. Newer-generation combined oral contraceptives are also known to reduce cancer of the womb and ovaries by up to 50 per cent, he said. Some brands have the added benefits of treating facial skin issues like acne, regulating menstrual cycle, as well as reducing menstrual pain and symptoms of premenstrual syndrome.
The pill may indirectly increase sexual function in couples, he added.“It takes away the fear of pregnancy, and the couple can throw caution to the wind while having sex.”.
The combined pill is not suitable for women who are forgetful (missing doses makes it less effective), have deep-vein thrombosis, a history of migraines, or unexplained abnormal vaginal bleeding, said Dr Chong.
Women who are already on the combined pill should avoid smoking as it increases the risk of deep vein thrombosis or blood clots in the legs, advised Dr Ang. They should also maintain a healthy lifestyle and diet. If they develop persistent headaches or other symptoms, they should seek their doctor’s advice early. Dr Ang also recommended that women undergo regular follow-ups with their doctors one, three and six months after starting the contraceptive, and at yearly intervals subsequently.
