Hormonal Contraception and Painful Sex

Hormonal contraceptives (HCs) are endocrine disrupting chemicals that interfere with your hormone balance and make you temporarily “infertile” in order to prevent unwanted pregnancy. They do this through several different effects on the body which may include preventing ovulation, irritating the uterus, or decreasing fertile cervical mucus.

Each hormonal contraception will contain a differing composition of synthetic oestrogen and progesterone and this will determine the mechanism by which they work. The synthetic chemicals in hormonal contraceptives are not the same as the oestrogen and progesterone your body makes and therefore they do not act the same but rather they create changes that are similar in some way and different in others, to their natural counterparts. This can result in a range of unwanted side effects which can include vaginal dryness, low libido, and painful intercourse.

 

How do hormonal contraceptives work?

The way hormonal contraceptives work is by releasing a combination of synthetic oestrogen and progestins, or just progestins, into the bloodstream. This acts similarly to the natural form of oestrogen and progesterone that we naturally produce at different doses on a cyclic basis during our normal menstrual cycle. These hormones, depending on which contraceptive you choose to take, will affect your ability to be fertile in a few different ways.

Preventing ovulation: Preventing your ovaries from releasing endocrine hormones such as oestrogen and progesterone will interfere with the communication between your ovaries and your pituitary gland by decreasing the production of follicle stimulating hormone (FSH) and luteinising hormone (LH). This will prevent your ability to ovulate and without ovulation you cannot get pregnant. 

* Note: This is why you cannot have a menstrual bleed or “period” while on hormonal birth control as you are not cycling. 

Changing your cervical mucus: Your cervical mucus can either foster or prevent sperm from surviving. Normally you only have “fertile mucus” on a few days per month and this is considered your fertile window and on the other days, your cervical mucus is too acidic for sperm to survive and it will die on contact. Hormonal contraceptives alter your mucus viscosity and literally creates a roadblock for the sperm to enter your cervix as well as creating a hostile environment that will eventually kill the sperm. 

Changing the uterus lining: Some contraceptives work by decreasing the thickness and ability of your uterus to hold and nurture an egg and therefore preventing the egg from ever implanting and being viable.

 

What are the differences between hormonal contraceptives?

There are many different types of hormonal contraceptives such as “the pill”, the Implanon, three-monthly injections, and the IUD, just to name a few. 

The pill is the most commonly used contraceptive method and approximately 50–80% of Australian women use it at some stage during their reproductive lives. It releases both progesterone and oestrogen like hormones into the bloodstream that prevent unwanted pregnancy in several different ways. There are also progestogen only hormonal birth control options such as the Implanon and Mirena. There is also the non-hormonal copper IUD, which whilst it doesn’t release hormones from within the device itself, it still interferes with your natural interplay. There are of course other options, such as a three-monthly hormonal injection (the shot), and “the patch”, but they all work in a similar way and all come with their own pros and cons.

All hormonal contraceptives alter your hormones and many will release their own synthetic forms of the body’s natural hormones. This is different to non-hormonal forms of contraception such as the copper IUD, withdrawal, female or male condoms or the fertility awareness method. 

 

Side effects of hormonal contraceptives. 

As the pill is the most commonly prescribed form of birth control, we will focus on that, however there is cross over to other forms of contraception also. 

The pill is a fantastic invention that has prevented many unwanted pregnancies since its beginnings. However, as it is by nature interfering with our natural hormones it is not without side effects. Below is a list of some common side effects of major pill brands such as Yaz and Implanon:

• Nausea

• Headache, including migraines

• Mood changes, including depression

• Unscheduled vaginal bleeding

• Abnormal periods

• Irregular bleeding between periods

• Breast tenderness or pain

• Blood clots/thrombosis

• Decreased bone density 

• Shrinkage of vulva tissue and decrease of clitoral size

• Irritability

• Cervical dysplasia

• Vulvodynia (panful sex)

• Increased risk of cervical cancer

• Increased risk of breast cancer

• Vaginal dryness

• Decreased libido/sex drive

• Nausea and vomiting

• Dizziness

• Breast tenderness

• Increased risk of vaginal infections, and urinary tract infections and candida overgrowth

• Changes to the gut microbiome and increased rates of IBS

• Nutrient deficiencies - specifically vitamin B2, vitamin B6, vitamin B12, Folate, vitamin C, magnesium and zinc

On this list of above side effects, there are few that will directly have an impact on your pain during sex: 

• Vaginal dryness

• Decreased libido/sex drive

• Vulvodynia (pain at the vulva)

• Shrinkage of vulva tissue and decrease of clitoral size

 

These are the known side effects. Clitoral shrinkage! Can you believe it?! As we discussed above, the way hormonal contraceptives work is literally by suppressing your natural hormones and either preventing ovulation or changing your cervical mucus. Both of those things contribute to enjoyment of sex, libido, arousal, and natural lubrication. Not only that but if your clitoris has decreased in size you may find that reaching orgasm is more difficult or that the intensity of your orgasms is less. If you have been on the pill for a long time or since your first sexual experience, you may not know any different. Often I hear that when individuals come off the pill, only retrospectively do they realise how many side effects they were having as they had nothing else to compare it to. 

 

So, what can you do?

If you are experiencing painful sex or any unwanted side effects of birth control, you have a few options:

Change your birth control: you could use non hormonal types of birth control like the copper IUD, condoms, fertility awareness method or diaphragms

See a Pelvic Floor Physiotherapist: before you place all the blame on your contraceptive choice, seeing a pelvic floor physio may be helpful to see if pelvic floor relaxation strategies, neural stretches or dilator therapy may be able to assist with your symptoms prior to changing your hormonal contraceptives.
 

Using lube: if there is a lack of natural lubrication then there is more likely to be friction involved with penetration, which can make sex painful. Using water-based gel or lubricant can be a great option to try to decrease friction and therefore pain. You can read about other reasons for lack of lubrication here. 

Dilator therapy: if you have recently come off the pill and you still have pain with intercourse, or if you are still on it but want to treat painful sex, then going through a program of dilator therapy may assist in reducing pelvic floor tightness and neural sensitivity. Use our dilator guide to get started. You can purchase our dilators here. 

NOTE: This is general advice only and should not replace medical advice. If you have any concerns or are unsure if you have any contraindications to perineal massage, please speak to your health care provider.