Published: May 13, 2013

Action Points

• This study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
• Note that this cross-sectional survey revealed an association between low-dose oral contraceptives and pelvic pain.
• Be aware that, barring longitudinal data, it remains unclear whether changing oral contraceptive dose or usage will ameliorate these symptoms.

SAN DIEGO — Women taking low-dose oral contraceptives were twice as likely to report pain during or after sexual climax than women not using oral birth control, results of a large survey showed.

A fourth of low-dose oral contraceptive (≤20 mcg ethinyl estradiol), users reported pain in association with orgasm compared with 12% of women who did not use oral contraceptives, reported Margarita Aponte, MD, of New York University in New York City, and colleagues.

However, users of standard-dose oral contraceptives (>20 mcg ethinyl estradiol) had a 13% prevalence of pain during sexual climax, similar to that of nonusers, they reported here at the American Urological Association meeting.

“Contraception has many benefits, but this side effect is not something that is discussed with the provider,” Aponte said during an AUA press briefing. “It’s really not out in the community. It’s not in the package insert. For providers and patients, I think it is good to get some information out there, so that more people know that this is a side effect that can occur and that it can be recognized and treated.”

Aponte said the pain often resolves upon discontinuation of oral contraceptive use. Switching to a standard-dose oral contraceptive also would be a reasonable option for women who have pelvic pain while taking low-dose oral contraceptives.

Low-dose oral contraceptives evolved in response to concern about the cardiovascular risks associated with first-generation agents, particularly venous thromboembolism and myocardial infarction. Newer oral contraceptives with low concentrations of ethinyl estradiol can induce hypoestrogenic effects in vaginal tissue. The relationship between low-dose oral contraceptives and pelvic pain had not been carefully examined, providing a rationale for a survey of reproductive-age women.

Conducted via the Internet, the survey elicited information from women ages 18 to 39. Survey items included questions about contraceptive use. Investigators excluded women who were pregnant or who had a history of endometriosis or pelvic pain. The primary objective of the study was to assess the relationship between pelvic pain symptoms and use of oral contraceptives.

Of 957 women with complete survey data, 612 did not use oral contraceptives, 169 reported use of low-dose oral contraceptives, and 176 reported using standard-dose oral contraceptives.

The results showed a self-reported prevalence of pain in association with sexual climax of 25.2% among users of low-dose oral contraceptives versus 12.3% among women who reported no use of oral contraceptives (P=0.045). Women who used standard-dose oral contraceptives had a prevalence of 15.8%, which did not differ from the nonuser group.

Asked about pain below the waist, pubic area, bladder, or urethral area, 15% of women using standard-dose oral contraceptives gave positive responses compared with 27.5% of nonusers (P=0.012) and 24.3% of low-dose oral contraceptive users.

There was a trend toward reports of perineal pain in the low-dose oral contraceptive group compared with nonusers (15% versus 8.9%, P=0.054), whereas the standard-dose oral contraceptive users had a rate similar to that of nonusers (6%). The low-dose oral contraceptive group demonstrated a trend toward an increased prevalence of pain or burning during urination versus nonusers (14.3% versus 9%, P=0.094).

Significantly more nonusers reported rectal pain compared with the high-dose oral contraceptive group (8% versus 2.9%, P=0.023) but not compared with the low-dose oral contraceptive group (5%).

A similar proportion of women in each group reported labial pain and clitoral pain.

Overall, 19.5% of the women met criteria for chronic pelvic pain syndrome (CPPS). Users of low-dose oral contraceptives had a significantly higher prevalence compared with nonusers (27.1% versus 17.5%, P=0.045), whereas users of standard-dose oral contraceptives had a rate similar to that of nonusers (19.7%).

The latter finding led the authors to state that standard-dose oral contraceptives “appear to be protective in individual pelvic pain symptoms.”

A comparison of oral contraceptive use with onset of pelvic pain symptoms showed that the pain preceded the start of oral contraceptive use in 55.6% of patients and during oral contraceptive use in the minority of patients. Among 89 oral contraceptive users with pelvic pain but not CPPS, the pain began before they started using oral contraceptives. In contrast, pain onset was after the start of oral contraceptive use in 61.9% of CPPS-positive oral contraceptive users with pelvic pain symptoms.

Aponte acknowledged several limitations of the study, including lack of laboratory and physician-reported information and potential imprecision in the classification of oral contraceptives (low or standard dose).

“I think the gynecology community is not aware of this complication of oral contraceptive use, especially low-dose oral contraceptives, unless you’re in a very specific field where you see this frequently,” said AUA press briefing moderator Kristene Whitmore, MD, who has dual appointments in urology and ob/gyn at Drexel University in Philadelphia. “If you’re a general gynecologist, I don’t think this is the first thing you’re going to think about.”

“As we get more referrals of young women with these symptoms who have been to see multiple gynecologists, urologists, and primary care providers, this is something we can address,” she added. “We can take them off the oral contraceptives and their symptoms improve significantly.”