Original research articleA prospective study of the effects of oral contraceptives on sexuality and well-being and their relationship to discontinuation
Introduction
The need for methods of contraception and fertility regulation that are acceptable and widely used remains a world-wide problem of major proportions. The scope for developing new techniques for fertility regulation is considerable, and much research effort is currently being expended on this goal. However, the ultimate value of a method depends on its acceptability and usage. The two new hormonal methods introduced in the early 1990s in the US—hormonal implants and injectables—have had limited impact. In 1995, fewer than 2% of US women were using the implant, and under 3% were using the injectable [1]. Although US trends in contraceptive use suggest that there has been a decline in oral contraceptive (OC) use among certain subgroups of women (e.g. low income women and those under 25 years), the pill remains the most widely used form of reversible contraception, used by 27% of all contraceptive users [2]. However, in spite of the introduction of low-dose OCs with assumed reduction in side effects, a substantial proportion of women who begin taking the pill discontinue the method within the first few months of use. American surveys report annual discontinuation rates of 29% among OC users [3], with a much higher percentage among adolescents [4], [5]. Comparable evidence from developing countries is limited, but suggests consistently higher discontinuation rates for OCs [6], [7].
Although many authors cite the experience of side effects as a major factor involved in early discontinuation of OCs [8], the available data mainly relate to adolescent populations and focus on problems with “cycle control,” with only superficial attention paid to other behavioral side effects, such as changes in mood and sexuality. Few studies have attempted any systematic investigation of the factors related to discontinuation, and most of the past research has relied on retrospective recall for past OC experiences; many studies have, for example, interviewed “past” OC users about their experiences with OCs [9].
In 1987, the Human Reproduction Program (HRP) and Division of Mental Health of the World Health Organization (WHO) commissioned a review of the literature on the effects of OC on the sexuality and well-being of women [10] that demonstrated the paucity of research in this area, particularly with more modern low-dose OCs. Two types of study were proposed to address the problem: (1) assessment of the direct pharmacological or hormonal effect of OCs on well-being and sexuality in women who have been sterilized, so that placebo control is possible and there are no complicating psychological implications of fertility control; and (2) study of women about to start on OCs for contraceptive purposes allowing for assessment of interactions between psychological factors and the direct hormonal effects of the OC.
The only example of the first type of study since that time, a placebo-controlled, double-blind comparison of combined (COC) and progestogen-only (POP) OCs carried out in two contrasting cultures (Scotland and Philippines) and funded by the HRP was reported by Graham et al. [11]. This showed negative effects of the COC on sexual interest in the Scottish women, approximately half of whom reported loss of sexual interest as a side effect. The lack of this effect in the Filipino women was probably caused by the fact that they reported significantly lower sexual interest and generally more negative sexual relationships than the Scottish women before starting on the OC. In both centers, the COC was associated with more negative mood change than the POP, which in general was strikingly free of adverse effects apart from the expected disruption of bleeding patterns.
The study reported in this article is one of the few examples of the second type in which pre-OC-use characteristics and changes from the pre-OC-use baseline were assessed to see if they predict the acceptability and continuation of OC when used specifically for fertility control. Two earlier studies relating pre-OC-use characteristics to patterns of discontinuation focused on expectations of bleeding changes [12] and social/situational factors associated with switching to another method [13]. In contrast, the present study involved a comprehensive assessment of women before starting on OCs, providing a baseline of a woman’s mood and sexuality as well as her attitudes and expectations about the pill, motivation for parenthood, etc. The present small study was intended as a pilot for a larger study that will require external funding. It nevertheless is sufficient to demonstrate the relevance to discontinuation of adverse effects of OCs on mood and sexuality.
Section snippets
Participants
Women attending family planning clinics and a university health center in Indiana who were aged 18 years and older, sexually active, in a committed relationship, and intending to use OCs for fertility control for at least 1 year were invited to participate. Other inclusion criteria included (1) no previous use of OC, Norplant, or Depo-Provera in the preceding year; (2) no contraindications to oral contraceptive use; (3) good physical health; (4) menstrual cycle length of 21 to 35 days; (5) not
Participants
One hundred seven women entered the study; 26 were lost to follow-up1, 2 became pregnant, leaving 79 participants with a known outcome. Of these, 30 (38%) were still on the same OC at the end of 12 months, 37 (47%) had discontinued OCs, and 12 (14%) had switched to another pill. The cumulative numbers of participants who discontinued, switched to
Discussion
The discontinuation rate found in this study falls within the range reported by others using different samples and methodologies [3], [4], [5], [6], [7]. It is difficult to ascertain whether the methodology used in this study might have influenced discontinuation. It is possible that participation in a prospective study with payment for reassessments for as long as OC use continued during the first year may have influenced more women to continue than would have otherwise been the case. On the
Acknowledgements
We thank Stephanie Hinton for assistance with interviewing and data collection; Dr. Judy Klein, Planned Parenthood of Central and Southern Indiana, and the Indiana University Health Center for help with recruitment; and Lori Carnes who worked on data entry and management. The opinions in this article do not necessarily reflect those of Planned Parenthood Federation of America, Inc., or others acknowledged here.
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