What most affects contraceptive continuation?

Research indicates that sexual acceptability influences contraceptive use over time—perhaps more so than all other factors, according to Jennifer Higgins, PhD, MPH, Patty Cason, MS, FNP-PC, and Jessica Sanders, PhD, MSPH, writing in the new 22nd edition of Contraceptive Technology. (1) A prospective study in the United States followed 100 new combined oral contraceptive users for 1 year. Among the 47% of patients who stopped using their pills over the course of the study, decreased sexual thoughts and decreased psychosexual arousal were the strongest predictors of discontinuation. In a study of over 2,000 new-start contraceptive users, sexual acceptability had the largest measured effect on continuation over time. (2) Contraceptive users’ perceptions that their new method negatively affected their sex lives were strongly associated with discontinuation by 6 months.

Researchers and providers often focus on contraceptive continuation or “adherence,” but “satisfaction” is a more person-centered outcome that better captures users’ actual experiences of their contraceptive method. (3) Many people report contraceptive nonuse or inconsistent use because of method dissatisfaction. While relatively little research examines the method characteristics and other factors most strongly associated with satisfaction, preliminary research suggests that sexual acceptability can play a key role. 

In a study of over 1,800 new-start contraceptive clients, researchers found that users’ perceived impact of their method on their sex life in the first month strongly predicted satisfaction at 3 months. (4)(5) Compared with patients in this study who said their contraceptive method made their sex life “a lot” worse in the first month of use, patients whose method improved their sex life “a lot” had a 7.7 times increased odds of greater satisfaction at 3 months. 

A 2020 meta-analysis of contraception and sexual dysfunction observed no significant associations between contraceptive use and sexual arousal, lubrication, orgasm, satisfaction, or pain. (6) The researchers did find significant associations between contraceptive use and desire. 

Notably, investigators in the studies above found that patients’ perceptions of their method’s sexual impact were strikingly similar across methods. This similarity suggests two things. First, on average, no particular methods appear significantly more likely than others to improve, or detract from, users’ sexual experiences. Thus, providers should not recommend one method as more sexually acceptable than another, and they should recognize that patients as a group can have significantly different sexual experiences with a given method. Second, we cannot predict which users will experience which sexual effects with which methods. The key is to impart to patients the importance of their sexual experiences with their methods, encouraging and supporting method change when their method makes their sex life worse. 

In a recent longitudinal study (2) of over 2,000 new-start contraceptive users, participants in the study reported no significant changes in sexual functioning or sexual satisfaction scores. (7) However, at 1 month, over half (53%) of participants said their new method improved their sex life (26% “improved a lot”; 27% “improved a little”); 17% said it made their sex life worse (14% “a little worse”; 3% “a lot worse”); and 30% reported no sexual effect. In other words, even when their sexual functioning and satisfaction measures remain stable, a significant proportion of contraceptive users perceive sexual effects—mostly positive sexual effects—of their methods. These findings were similar in a study of 159 new-start IUD and implant users. (8)

In one US study of 382 participants, the most frequently desired contraceptive feature was “does not interfere with the pleasure of sex,”. (9) In another study of family planning and abortion clinic patients, 68% of 1,783 participants said it was “extremely important” that a “method doesn’t detract from my sexual enjoyment.” (10)

We wish to underscore the strong similarity across methods in terms of users’ sexual experiences. For example, levonorgestrel IUD users appear no more likely than users of combined oral contraceptives or injectables to report that their method has improved or detracted from their sex life.7 Patients should be supported in finding methods that are most acceptable to them at various points in their lives,(9),(11),(12) sexually and otherwise. People differ in what they desire in a contraceptive method and what helps them feel sexually well. Providers and researchers alike should prioritize support both for people’s contraceptive satisfaction and for their sexual well-being.

1. Higgins JA, Cason P, Sanders JN. Sexuality and contraception. In: Cason P, Cwiak C, Edelman A, et al. (eds). Contraceptive technology. 22nd edition. Burlington, MA: Jones-Bartlett Learning, 2023.
2.  Higgins JA, Kramer RD, Everett B, et al. Association between patients’ perceptions of the sexual acceptability of contraceptive methods and continued use over time. JAMA Intern Med. 2021;181-(6): 874-6. 
3.  Dehlendorf C, Reed R, Fox E, et al Ensuring our research reflects our values: The role of family planning research in advancing reproductive autonomy. Contraception. 2018;98(1):4-7.
4. Moreau C, Cleland K, Trussell J. Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception. 2007;76(4):267-72.
5. Kramer RD, Higgins JA, Everett B, et al. A prospective analysis of the relationship between sexual acceptability and contraceptive satisfaction over time. Am J Obstet Gynecol. [Internet] 2021 [cited 2022 Jan 31]. Available from https://www.sciencedirect.com/science/article/pii/5002937821011091]
6. Huang M, Li G, Liu J, et al. Is there an association between contraception and sexual dysfunction in women? A systematic review and meta-analysis based on Female Sexual Function Index. J Sex Med. 2020;17(10):1942-55.
7.  Higgins JA, Kramer RD, Wright KQ, et al. Sexual functioning, satisfaction, and well-being among contraceptive users: A three-month assessment from the HER Salt Lake Contraceptive Initiative. J Sex Res. 2021;59(4):435-44.
8. Higgins JA, Sanders JN, Palta M, Turok DK. Women’s sexual function, satisfaction, and perceptions after starting long-acting reversible contraceptives. Obstet Gynecol. 2016;128(5):1143-51.
9. Gomez AM, Clark JB. The relationship between contraceptive features preferred by young women and interest in IUDs: An exploratory analysis. Perspect Sex Reprod Health. 2014;46(3);157-63.
10. Jackson AV, Karasek D, Dehlendorf C, et al. Racial and ethnic differences in women’s preferences for features of contraceptive methods. Contraception. 2016;93950:406-11.
11. Dehlendorf C, Levy K, Kelley A, et al. Women’s preferences for contraceptive counseling and decision making. Contraception. 2013;88(2):250-6.
12.  Lessaard LN, Karasek D, Ma S, ert al. Contraceptive features preferred by women at high risk of unintended pregnancy. Perspect Sex Repreod Health. 2012;44(3);194-200.