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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 3  |  Page : 902-908

Influence of various methods of contraception on female sexual functions


1 Department of Dermatology and Andrology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Dermatology, Al Shohadaa Hospital, Al Shohadaa City, Menoufia, Egypt

Date of Submission21-Feb-2020
Date of Decision05-Apr-2020
Date of Acceptance12-Apr-2020
Date of Web Publication18-Oct-2021

Correspondence Address:
Amany A Salama
Al Shohadaa, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_47_20

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  Abstract 


Objective
The aim was to evaluate female sexual functions in women using different methods of contraception.
Background
Contraception is a common practice among women during their childbearing periods. Contraception may affect female sexual function both positively and negatively.
Patients and methods
A cross-sectional study was done on 200 married women in the childbearing period, who were recruited from different health care centers at Menoufia Governorate, Egypt, between October 2019 and January 2020.
Results
In the present study, 56.5% (more than half) of the participating women who used contraception were at high risk for sexual dysfunction. Women using nonhormonal contraceptives reported the highest mean scores (26.99 ± 4.13), with statistically significant difference between them and those using combined hormonal contraceptives and progesterone-only hormonal contraceptives, who reported lower mean scores (24.34 ± 4.94 and 24.13 ± 4.27, respectively). Nonhormonal contraceptive users reported the highest scores of female sexual function index regarding total, desire, arousal, lubrication, orgasm, satisfaction, and pain scores.
Conclusion
Female sexual dysfunction is commonly seen in women using contraception and the nonhormonal methods have the least effect on female sexual function.

Keywords: contraception, desire, female sexual function, lubrication, satisfaction


How to cite this article:
Gaber MA, Salama AA. Influence of various methods of contraception on female sexual functions. Menoufia Med J 2021;34:902-8

How to cite this URL:
Gaber MA, Salama AA. Influence of various methods of contraception on female sexual functions. Menoufia Med J [serial online] 2021 [cited 2024 Mar 28];34:902-8. Available from: http://www.mmj.eg.net/text.asp?2021/34/3/902/328338




  Introduction Top


Contraception is a common practice among women during their childbearing periods [1]. It was reported that contraceptive use was ∼60% in Egypt during the period from 2003 to 2014. The commonly used methods were the mechanical method [Copper-T intrauterine device (IUD)], the pills, and the injectable, which represented 30, 16, and 9%, respectively [2].

Contraceptives can bother women through physical, psychological, and/or sexual adverse effects. It was found that Copper-T IUDs can cause excessive vaginal bleeding in some women, and women placed on hormonal contraception had significantly higher rates of depression, anxiety, fatigue, neurotic symptoms, and interest in short-term sexual relationships [3].

Contraception may affect female sexual function both positively and negatively [4]. Female sexual dysfunction (FSD) encompasses a heterogeneous group of disorders typically characterized by a clinically significant disturbance in a woman's ability to respond sexually or experience sexual pleasure. Several sexual dysfunctions may be present at the same time, and they should all be diagnosed [5].

The potential for negative influences from female contraceptive methods on female sexuality is still a matter of debate, especially for the hormonal methods. Previous studies, performed on women placed on hormonal contraception, have yielded conflicting results, whereas some studies reported impairment of sexual function in contrast to other studies that reported unaffected or improved sexual experiences [4],[6],[7].

The aim of this study was to evaluate female sexual functions in women using different methods of contraception.


  Patients and methods Top


A cross-sectional study was done between October 2019 and January 2020 on 200 married women in the childbearing period, who were recruited from different health care centers in Menoufia Governorate, Egypt. We used the female sexual function index (FSFI) questionnaire to assess different aspects of sexual activity and FSD during the period of contraceptive use.

Regarding the study sample, random sampling was used to choose women using contraceptive methods from those attending different health care centers in Menoufia Governorate, Egypt. A total of 200 women using different methods of contraception participated in this study. We divided the participating women into three main groups regarding the type of contraceptive method: group I (GI) included 60 women using hormonal contraceptives containing both estrogen and progesterone (pills and injections), group II (GII) included 60 women using hormonal contraceptives containing progesterone only (pills and injections), and group III (GIII) included 80 women using nonhormonal contraception: IUD (nonhormonally medicated), male condoms, spermicidal gel, and suppositories.

We included in our study married women who were 15–49 years of age, had stable marital state in the last 6 months, had active sexual life defined as sexual activity with penetration within the previous 4 weeks, and had regular administration of a contraceptive method during the last 6 months.

We excluded those with presence of medical conditions such as heart disease, hypertension, diabetes, or other serious diseases which restrict sexual activity or with a psychiatric condition that makes completion of the questionnaire impossible. Moreover, we excluded pregnant women, women in menopause stage, women taking psychiatric drugs, or women who had any sexual problem with the male partner, such as erectile dysfunction or premature ejaculation.

Data collection tool used was the FSFI, which is a 19-item questionnaire originally developed by Rosen et al. [8]. It was developed as a brief, multidimensional self-report instrument for assessing the key dimensions of sexual function in women. It is a well-accepted instrument for assessing sexual function in women throughout the world. The FSFI consisted of six domains. Four domains are related to the four major categories of sexual function: desire, arousal, orgasm, and sexual pain disorder. The fifth domain assesses the quality of vaginal lubrication, and the sixth domain is related to global sexual and relationship satisfaction. The Arabic version of FSFI questionnaire (Ar-FSFI) was used in this study [9],[10]. The questionnaire used also contained questions concerning demographic data, such as maternal age, educational level, job, residence, number of children, and circumcision.

Procedures

After informed consent was obtained from the women who were willing to participate in the study, the FSFI was used by the researcher using face-to face interview technique in a private room with guaranteed confidentiality. The questionnaire was completed by the participants, and in subjects who had low literacy or illiterate, it was conducted by trained interviewers in health care centers. The data collection tools were completed in ∼20–30 min. Permission to carry out the study was obtained from the Ethical Committee at the Department of Dermatology, Andrology, and Sexually Transmitted Diseases at the Faculty of Medicine Menoufia University.

Calculation of FSFI score was done as follows: the answers for each question in FSFI had values that generate a score for each domain. The score is the sum of the responses to each question of certain domain multiplied by a factor that potentates the effect of the domain on the total score. The final result ranges from 2 to 36) points; it represents the sum of all domains, and the higher the score, the better the sexual function of the participant. Total scores of 26.5 or less denote that there is FSD. In addition, each domain was assessed separately to interpret the data [8].

Statistical analysis

The clinical data were recorded on a report form. These data were tabulated and analyzed by DELL computer using Statistical Package for the Social Sciences, Version 22 (SPSS Inc., Chicago, Illinois, USA). Descriptive data were in the form of mean and SD for quantitative data and frequency and distribution for qualitative data.

Regarding analytical statistics, in the statistical comparison between the different groups, the significance of difference was tested using Student t-test, which was used to compare mean of two groups of quantitative data. Z test was used to compare proportion between two groups of qualitative data. P value less than 0.05 was considered statistically significant (S), whereas greater than 0.05 was considered statistically insignificant in all analyses.


  Results Top


A total of 200 women using different contraceptive methods [60 (30%) women used combined hormonal methods, 60 (30%) used progesterone-only method, and 80 (40%) using nonhormonal methods] participated in this study.

The mean of the total FSFI score in GI, GII, and GIII was 24.34 ± 4.94, 24.13 ± 4.27, and 26.99 ± 4.13, respectively, and in comparing between them, there was no statistically significant difference between GI and GII (P = 801), whereas there was a statistically significant difference between GI and GIII and between GII and GIII (P = 0.001 and <0.001, respectively). Regarding the desire domain, the mean score in GI, GII, and GIII was 3.60 ± 1.27, 3.40 ± 0.87, and 4.09 ± 0.95, respectively, and in comparing between them, there was no statistically significant difference between GI and GII (P = 0.316), whereas there was a statistically significant difference between GI and GIII and between GII and GIII (P = 0.014 and <0.001, respectively). Regarding the arousal domain, the mean score in GI, GII, and GIII was 4.05 ± 1.08, 4.11 ± 0.93, and 4.41 ± 0.85, respectively, and in comparing between them, there was no statistically significant difference between GI and GII (P = 0.765), whereas there was a statistically significant difference between GI and GIII and between GII and GIII (P = 0.035 and 0.048, respectively). Regarding the lubrication domain, the mean score in GI, GII, and GIII was 4.36 ± 0.86, 4.42 ± 0.90, and 4.70 ± 1.01, respectively, and in comparing between them, there was no statistically significant difference between GI and GII and between GII and GIII (P = 0.687 and 0.088, respectively), whereas there was a statistically significant difference between GI and GIII (P = 0.031). Regarding the orgasm domain, the mean score in GI, GII, and GIII was 4.12 ± 1.29, 4.11 ± 0.93, and 4.52 ± 1.07 respectively, and in comparing between them, there was no statistically significant difference between GI and GII and between GI and GIII (P = 0.948 and 0.057, respectively), whereas there was a statistically significant difference between GII and GIII (P = 0.018). Regarding the satisfaction domain, the mean score in GI, GII, and GIII was 4.52 ± 1.18, 4.32 ± 1.14, and 4.88 ± 1.10, respectively, and in comparing between them, there was no statistically significant difference between GI and GII and GI and GIII (P = 0.347 and 0.072, respectively), whereas there was a statistically significant difference between GII and GIII (P = 0.004). Regarding the pain domain, the mean score in GI, GII, and GIII was 3.69 ± 1.17, 3.77 ± 0.77, and 4.40 ± 0.92, respectively, and in comparing between them, there was no statistically significant difference between GI and GII (P = 0.658), whereas there was a statistically significant difference between GI and GIII and between GII and GIII (P < 0.001) [Table 1].
Table 1: Comparison between the female sexual function index scores among the three studied groups

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FSD significantly increased in those using the hormonal methods, as the percentage of females having sexual dysfunction was 60 and 68.33% in those using the combined and progesterone only, respectively. In comparing the women having sexual dysfunction (FSFI score ≤26.5), there was no statistically significant difference between GI and GII (P = 0.305), whereas there was a statistically significant difference between GI and GIII and between GII and GIII (P = 0.002 and 0.021, respectively) [Table 2].
Table 2: Comparing the female sexual function index score according to cutoff point (26.5) between the studied groups

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In comparing the women having sexual dysfunction (FSFI score ≤26.5) and those not having according to women age distribution in GI, GII, and GIII, there was no statistically significant difference. Moreover, there was no statistically significant difference in women having sexual dysfunction (FSFI ≤26.5) between young group (≤30 years old) and older (>30) in each studied group [Table 3].
Table 3: Relation between the female having sexual dysfunction (female sexual function index score ≤26.5) and women age in each studied group

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  Discussion Top


The desire of women in the reproductive age in many societies to control their fertility is reflected in the range of contraceptive methods available and the large proportion of women who use contraception [11]. A woman's sexual response may influence the particular choice and acceptance of a contraceptive. A method that is not psychologically acceptable is likely to result in discontinuation. This could perhaps be attributed to preparations containing progestational compounds. However, the effects of contraceptive steroids on sexual desire and motivation are a question still under debate [12].

The objective of the present study was to evaluate and compare possible relations between the effects of different, commonly used contraceptive methods on female sexual functions. The study was conducted on 200 healthy, sexually active women in a stable marital relationship using the most common contraceptive methods, including hormonal contraceptives containing both estrogen and progesterone (pills and injections), which were used by 30% of the participating women; hormonal contraceptives containing progesterone only (pills and injections), which were used by 30% of women; and the nonhormonal contraception methods, such as IUD (nonhormonally medicated), male condoms, spermicidal gel, and suppositories, used by 40% of the participants.

According to the interpretation proposed by Wiegel et al. [13], women with total FSFI scores less than or equal to 26.5 are classified as 'at high risk' for sexual dysfunction. In the present study, 56.5% of the participating women who used contraception were at high risk for sexual dysfunction. These results are slightly lower than the 63% found by Shindel et al. [14] in their sample of 78 female US medical students, but was higher than the 43% determined by the National Health and Social Life Survey [15], in the USA, in women aged 18–29 years, and much higher than the 32% detected by Wallwiener et al. [5]. This difference may be explained by different sample sizes, populations, age ranges, and instruments [16], and also because of different cutoff levels for the same instrument. Moreover, sexual problems tend to be higher in clinical samples and women seeking medical attention than in community samples.

In the present study, when comparing the means of total FSFI scores among the three main groups, women using nonhormonal contraceptives reported the highest mean scores (26.99 ± 4.13), with statistically significant difference between them and those using combined hormonal contraceptives and progesterone-only hormonal contraceptives, who reported lower mean scores (24.34 ± 4.94 and 24.13 ± 4.27, respectively). These results are in agreement with those found by Wallwiener et al. [5], who stated that women using nonhormonal contraception had higher total, desire, and arousal scores than women using oral contraceptives, that is, hormonal methods. Our data show that hormonal methods are associated with lower desire scores (mean 3.60 ± 1.27 for combined methods and 3.40 ± 0.87 for methods containing progesterone only) when compared with nonhormonal methods (mean 4.09 ± 0.95). Literature studies in other countries are in agreement with our results, as they also found a decrease in sexual desire upon hormonal contraceptive use in general. They calculated the decrease in sexual desire to be up to 31% in studies by Gomez [17]. One explanation for a possible effect of oral contraception (OC), that is, hormonal methods, on sexual function may be that they have been found to decrease the circulating levels of androgens by direct inhibition of androgen production in the ovaries and by a marked increase in the hepatic synthesis of sex hormone-binding globulin, the major binding protein for gonadal steroids in the circulation [18]. The combination of these two mechanisms may lead to low circulating levels of free and bioavailable testosterone, which is needed to stimulate sexual desire and regulate genital blood flow and the structural and functional integrity of the genitals [19],[20].

The group of women using nonhormonal contraceptives in the current study reported the highest scores for both arousal and lubrication (mean = 4.41 ± 0.85 and 4.70 ± 1.01 respectively), whereas those using combined hormonal contraceptives reported the lowest scores (mean = 4.05 ± 1.08 for arousal and 4.36 ± 0.86 for lubrication). These results are in agreement with the results obtained by Sabatini and Cagiano [21], who concluded that combined hormonal contraception (COC) users initially reported vaginal dryness, although this effect decreased by cycle 12. This can be owing to decreased androgens with hormonal methods that are required for the synthesis of the glycol-proteins needed for mucous formation with subsequent decreased lubrication. Furthermore, vaginal dryness could be owing to the low estrogenic dosage, with consequent arousal or enjoyment disorder. For this reason, it is possible that COC use may cause or predispose to atrophic vulvo-vaginitis [22]. However, Hatcher [23] found that combined oral contraceptives may increase natural vaginal lubrication. Another study on pills containing 30 mg ethinyl estradiol and 3 mg drospirenone found an improvement in sexual arousal [24]. This contrast can be explained that fears about unwanted pregnancy had a very negative effect on sexual arousal, and hence COC is a reliable form of contraception, so pregnancy is not predicted and the sexual arousal is enhanced [25].

Regarding the orgasm domain of FSFI, those using nonhormonal contraceptives reported the highest scores (mean = 4.52 ± 1.07), whereas those using hormonal methods containing progesterone only reported the lowest score (mean = 4.11 ± 0.93). Moreover, hormonal methods containing both estrogen and progesterone reported lower scores (mean = 4.12 ± 1.29) than nonhormonal methods, although this difference was statistically nonsignificant. Some studies are in agreement with our study, as they showed that women using a hormonal contraceptive method experienced less frequent sexual activity, pleasure, and orgasm even when controlling for sociodemographic variables [26]. This finding was not in harmony with another study which assessed the sexual effect of combined OC, where a significant improvement in sexual enjoyment and orgasm frequency from the third month onward was found [27]. One reason for these differences may be cultural differences in the perception of sexual dysfunction. Moreover, the difference in the applied instruments may contribute to this disparity [14].

In the present study, the nonhormonal contraceptive users reported the highest satisfaction scores (mean = 4.88 ± 1.10), whereas those using progesterone-only contraceptives (mean = 4.32 ± 1.14) reported the lowest scores, and those using combined hormonal methods reported intermediate scores (mean = 4.52 ± 1.18). Klusmann [28] concluded that an increase in ability to achieve orgasm was associated with higher satisfaction scores. This is constant with our results, as the nonhormonal contraceptive users reported the highest scores for both orgasm and satisfaction.

The present study showed that the highest scores for pain domain of FSFI were also reported by women using nonhormonal contraceptives (mean = 4.40 ± 0.92), whereas women using combined hormonal ones reported the lowest scores (mean = 3.69 ± 1.13). This was in agreement with Greenstein et al. [29], who found that COCs increase the relative risk of developing pain in the vulvar vestibule (provoked vestibulodynia) by four to nine fold. Alternatively, others have not found an association between COC use and vestibular pain. Lee et al. [30] assessed genital sensation in low-dose (20 μg ethinyl estradiol) COC users and COC nonusers. They found no difference in vestibular pain threshold among the COC users vs the nonusers.

There were some limitations in this study. We only assessed sexual activities among women who participated voluntarily in the study and many women refused to enroll. This may be because in Arab countries, people are not used to talk about their sexual lives, many taboos persist in our population, and also it is prohibited in Islam to tell the bedroom secrets. Moreover, the data were self-reported, and we did not confirm the information with partners. In addition, the survey was done using a paper-based method, which is more effort and time consuming than the online surveys. We also had no control group, and we are only able to control our findings to prior studies. The relatively wide difference in demographic data among the participating women, absence of baseline data about the original sexual state before contraceptive use, and finally, the relatively small sample size were additional limitations.


  Conclusion Top


Our data suggested that the female sexual function is greatly affected by contraceptive use, as 56.5% (more than half) of the participating females who used contraception were at high risk for sexual dysfunction.

Nonhormonal contraceptive users reported the highest scores of FSFI regarding total, desire, arousal, lubrication, orgasm, satisfaction, and pain scores.

Contraception is a must, and clinicians may be able to predict, and potentially prevent, the discontinuation of effective contraception by carefully assessing and addressing the positive and negative effects of contraception on mood and sexual interest. Our research concluded that nonhormonal contraceptives are the safest methods regarding the general health and also the sexual effects, but the development of new COCs has been directed toward regimens containing the lowest suitable dose of estrogen and using more selective progestogens to minimize steroid-associated unfavorable effects. However, further investigations are required to clarify these results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chola L, McGee S, Tugendhaft A, Buchmann E, Hofman K. Scaling up family planning to reduce maternal and child mortality: the potential costs and benefits of modern contraceptive use in South Africa. PLoS One 2015; 10:e0130077.  Back to cited text no. 1
    
2.
Ministry of Health and Population [Egypt], El-Zanaty and Associates [Egypt], and ICF International. 2015. Egypt Demographic and Health Survey 2014. Cairo, Egypt and Rockville, Maryland, USA: Ministry of Health and Population and ICF International.  Back to cited text no. 2
    
3.
Welling LL. Psychobehavioral effects of hormonal contraceptive use. Evol Psychol 2013; 11:718–742.  Back to cited text no. 3
    
4.
Casey PM, MacLaughlin KL, Faubion SS. Impact of contraception on female sexual function. J Womens Health 2017; 26:207–213.  Back to cited text no. 4
    
5.
Wallwiener CW, Wallwiener LM, Seeger H. Prevalence of sexual dysfunction and impact of contraception in female German medical students. J Sex Med 2010; 7:2139–48.  Back to cited text no. 5
    
6.
Caruso S, Cianci S, Malandrino C, Cicero C, Lo Presti L, Cianci A. Quality of sexual life of women using the contraceptive vaginal ring in extended cycles: preliminary report. Eur J Contracept Reprod Health Care 2014; 19:307–314.  Back to cited text no. 6
    
7.
Gałązka I, Drosdzol-Cop A, Naworska B, Czajkowska M, SkrzypulecPlinta V. Changes in the sexual function during pregnancy. J Sex Med 2015; 12:445–454.  Back to cited text no. 7
    
8.
Rosen C, Brown J, Heiman S, Leiblum C, Meston R, Shabsigh D, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26:191–208.  Back to cited text no. 8
    
9.
Abu Ali RM, Al Hajeri RM, Khader YS, Shegem NS, Adlouni KM. Sexual dysfunction in Jordanion diabetic women. Diabetes Care 2008; 31:1580–1581.  Back to cited text no. 9
    
10.
Anis TH, Samah AG, Hanan SS, Samar A. Arabic translation of female sexual function index and validation in an Egyptian population. J Sex Med 2011; 8:3370–3378.  Back to cited text no. 10
    
11.
Oddens BJ. Women's satisfaction with birth control: a population survey of physical and psychological effects of oral contraceptives, intrauterine devices, condoms, natural family planning, and sterilization among 1466 women. Contraception 2000; 59:277–286.  Back to cited text no. 11
    
12.
Caruso S, Agnello C, Intelisano G. Sexual behavior of women taking low-dose oral contraceptive containing 15μg ethinyl estradiol/60μg gestodene. Contraception 2004; 69:237–245.  Back to cited text no. 12
    
13.
Wiegel M, Meston C, Rosen R. The female sexual function index (FSFI): cross validation and development of clinical cutoff scores. J Sex Marital Ther 2005; 31:1–20.  Back to cited text no. 13
    
14.
Shindel AW, Ferguson GG, Nelson CJ, Brandes SB. The sexual lives of medical students: a single institution survey. J Sex Med 2008; 5:796–803.  Back to cited text no. 14
    
15.
Fugl-Meyer K. Sexual disabilities are not singularities. Int J Impot Res 2002; 14:487–493.  Back to cited text no. 15
    
16.
Basson R, Berman J, Burnett A, Derogatis L, Ferguson D. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol 2000; 163:888–893.  Back to cited text no. 16
    
17.
Gomez MA. Satisfaction of females by hormonal contraceptives. Clin Inves Gin Obst 1997; 24:144–150.  Back to cited text no. 17
    
18.
Wiegratz I, Kutschera E, Lee JH, Winkler UH, Kuhl H. Effect of four different oral contraceptives on various sex hormones and serum-binding globulins. Contraception 2003; 67:25–32.  Back to cited text no. 18
    
19.
Panzer C, Wise S, Fantini G, Guay A, Goldstein I. Impact of oral contraceptives on sex hormone binding globulin and androgen levels: a retrospective study in women with sexual dysfunction. J Sex Med 2006; 3:104–113.  Back to cited text no. 19
    
20.
Warnock JK, Clayton A, Croft H. Comparison of androgens in women with hypoactive sexual desire disorder: those on combined oral contraceptives (COCs) vs those not on COCs. J Sex Med 2006; 3:878–82.  Back to cited text no. 20
    
21.
Sabatini R, Cagiano R. Comparison profiles of cycle control, side effects and sexual satisfaction of three hormonal contraceptives. Contraception 2006; 74:220–223.  Back to cited text no. 21
    
22.
Edgardh K, Abdelnoor M. Vulvar vestibulitis and risk factors: a population- based case control study in Oslo. Acta Derm Venereol 2007; 87:350–354.  Back to cited text no. 22
    
23.
Hatcher N. Combined hormonal contraceptive methods. Contracept Technol 2004; 18:403–434.  Back to cited text no. 23
    
24.
Skrzypulec V, Drosdzol A. Evaluation of the quality of life and sexual functioning of women using a 30 microg ethinyl estradiol and 3 mg drospirenone combined oral contraceptive. Eur J Contracept Reprod Health Care 2008; 13:49–57.  Back to cited text no. 24
    
25.
Graham CA, Sanders SA, Milhausen RR, McBride KR. Turning on and turning off: a focus group study of the factors that affect women's sexual arousal. Arch Sex Behav 2004; 33:527–538.  Back to cited text no. 25
    
26.
Smith NK, Jozkowski KN, Sanders SA. Hormonal contraception and female pain, orgasm and sexual pleasure. J Sex Med 2014; 11:462–470.  Back to cited text no. 26
    
27.
Caruso S, Agnello C, Intelisano G. A prospective study on sexual behavior of women using 30μg ethinyl estradiol and 3 mg drospirenone oral contraceptive. Contraception 2005; 72:19–23.  Back to cited text no. 27
    
28.
Klusmann D. Sexual motivation and the duration of partnership. Arch Sex Behav 2002; 31:275–287.  Back to cited text no. 28
    
29.
Greenstein A, Ben-Aroya Z, Chen J, Abramov L. Vulvar vestibulitis syndrome and estrogen dose of oral contraceptive pills. J Sex Med 2007; 4:1679–1683.  Back to cited text no. 29
    
30.
Lee M, Morgan M, Rapkin A. Clitoral and vulvar vestibular sensation in women taking 20 mcg ethinyl estradiol combined oral contraceptives: a preliminary study. J Sex Med 2011; 8:213–218.  Back to cited text no. 30
    



 
 
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