Can Oral Contraceptive Pills (OCPs) cause low libido?

Can Oral Contraceptive Pills Cause Low Libido?

Yes, oral contraceptive pills can cause decreased libido in approximately 15% of users, though the majority of women (85%) report either no change or an increase in sexual desire. 1

Mechanism of Libido Changes

The hormonal components of OCPs affect sexual desire through several pathways:

• Estrogen increases sex hormone-binding globulin (SHBG), which binds free testosterone and reduces bioavailable androgens that are important for libido 1
• Synthetic progestins have varying effects on androgen receptors through off-target effects that can enhance the libido-reducing effects of estrogen 2
• First-generation progestins (like norethindrone) had potent androgenic effects that could impact sexual function 3

Evidence on Libido Effects

The data shows mixed but predominantly neutral-to-positive effects:

• In systematic review of 8,422 COC users: 22% reported increased libido, 63% reported no change, and 15% reported decreased libido 1
• Prospective controlled studies show both increases and decreases compared to non-users, with the most recent well-conducted randomized trial demonstrating decreased libido in OC users versus placebo 4
• One specific study of drospirenone/ethinylestradiol showed significant decreases in sexual desire scores, reduced intercourse frequency, and increased pain during intercourse 5

Formulation-Specific Considerations

Estrogen dose matters:

• Pills containing 20-35 μg ethinylestradiol show no significant difference in sexual desire 1
• Pills with only 15 μg ethinylestradiol are associated with decreased libido 1

Progestin-only pills (POPs) may be preferable for women experiencing libido issues:

• POPs do not cause the same degree of SHBG elevation as combined OCPs 2
• Women with decreased libido on combined OCPs may benefit from switching to progestin-only methods 2

Clinical Management Algorithm

For women reporting decreased libido on OCPs:

1. First-line approach: Switch to a different combined OCP formulation with a different estrogen/progestin balance 2

2. Second-line approach: Consider switching to progestin-only contraceptives, which have less impact on SHBG and free testosterone 2

3. Avoid ultra-low dose estrogen: Do not use formulations containing only 15 μg ethinylestradiol if libido is a concern 1

Important Caveats

• Psychological factors play a significant role: One older study suggested that prompt restoration of libido with various interventions (including just changing pill brands) indicates an important psychological component 6
• Individual variation is substantial: While biochemical changes (decreased free testosterone, increased SHBG) occur in most users, these do not consistently correlate with subjective libido changes 1, 7
• The majority of women are unaffected: Most studies show that 63-85% of women report no change in sexual desire with OCP use 4, 1