The Sexual Side Effects of Hormones and Other Drugs

This transcript has been edited for clarity. 
Rachel S. Rubin, MD: I brought Dr Ashley Winter, a board-certified urologist who is trained in sexual medicine, with me today to talk about the fact that hormones have consequences. They are sometimes good and sometimes bad, but they always have consequences. And when you play with hormones, you’re going to see those consequences. 
So, Dr Winter, what does this mean to you, the idea that hormones are neither good nor bad, right nor wrong, but that they can have consequences?
Ashley Winter, MD: When we think about topics that are applicable across medicine, the first thing that comes to my mind is combined oral contraceptives. They are amazing medications. They have revolutionized the place of women in society. They are probably the most common medicines prescribed to young women.
Oral contraceptives reduce testosterone in 100% of the women who take them. Testosterone is a very active sex steroid in young women. If I could turn back the clock to medical school, when we had our lecture about contraception, this fact would have been presented in big font on the first page. Instead, it wasn’t there. 
Rubin: Combined oral contraceptives turn the ovaries off and add back synthetic estrogen and progestogen. They don’t do anything directly to testosterone, but they increase a protein called sex hormone binding globulin (SHBG), which, like Pac-Man, eats any free testosterone.
This happens in everyone who takes birth control pills. There’s an elevation in SHBG and a lower free testosterone level. So, the question is whether everybody is symptomatic from this, and that’s where the data get a little bit murky. What kind of sexual or nonsexual side effects might they experience?
Winter: They can experience low libido, pain with sex, or vaginal dryness. There have even been studies showing that you can have recurrent UTIs in your early 20s because you’re on an ultra–low-dose oral contraceptive pill. 
Rubin: What’s the physiology there? 
Winter: There is a belief that when you take a combined oral contraceptive, you’re adding on a layer of hormone, but you actually have less — you can be in a state of hormone deficiency. People think, I’m adding a hormone, but instead they are halting production of a hormone because they are stopping ovulation and reducing natural estrogen production, while giving a small amount back.
But women can become symptomatic in ways that are similar to and mimic early menopause or normal menopause. This is what we mean when we say that when you play with hormones, there are consequences. Not everyone is symptomatic; there is a balance and an effect.
So, we have this great benefit of reproductive freedom, but we potentially have the downside of adversely affecting quality of life. When we talk about this, it’s not to demonize this category of very important medications, but rather to inform providers about sexual health and how that relates to contraception, and be able to manage side effects or give people options.
Rubin: All medications that we prescribe have side effects. Not a single medication on Earth is without a side effect. But when you’re giving someone a birth control pill, we talk about the risk for blood clots. Rarely do sexual side effects come up in conversation, but our patients are asking about them.
We just published a paper on Reddit threads being full of patients saying that their birth control has lowered their libido or caused pain with sex. But patients are often being dismissed by their clinicians, but not because they are cruel. Clinicians are not taught about the sexual side effects of birth control, but the physiology kind of makes sense there.
The idea that all hormones are the same is just not true. How do you counsel patients about the different forms of birth control? 
Winter: An IUD has fewer effects. The copper IUD has no effects because it has no hormones in it. A progestin-based IUD will have fewer effects on a woman’s hormones than a combined oral contraceptive pill. You can have a reduction in ovulation from a progestin-based IUD — there actually is some reduction in estrogen levels with that type — but not as much as you would have with a combined oral contraceptive.
I also love this conversation as a starting point to ask, “If you are done with childbearing, does your significant other want a vasectomy?” Many people are starting on birth control pills again after they’re done having kids, but they might have tons of libido and great sex if they stop the birth control pills.
Rubin: I couldn’t agree more. Not having hormones in menopause can lead to fractures, osteoporosis, hot flashes, and night sweats. Testosterone is very important for libido. Sexual health is biology and physiology and understanding the role that hormones play in arousal, orgasm, and genitourinary health.
We see this not only with birth control pills, but also with other drugs that lower testosterone, such as spironolactone. During lactation and breastfeeding, women can experience the genitourinary syndrome of lactation. 
We have to understand the hormone status of our patients, and not only the women. We both see a population of men who are deeply affected by the sexual side effects of hormones. 
Winter: This includes patients who are taking 5-alpha reductase inhibitors, such as finasteride and dutasteride, to shrink the prostate or treat male pattern baldness. And it can happen at all ages; men are coming in at much younger ages as they try to prevent baldness.
These medications work by preventing testosterone from being converted into dihydrotestosterone (DHT). DHT (which contributes to prostate growth and male pattern baldness) is a biologically active hormone throughout our bodies, even in places like the brain. The exact mechanism of action is not known, but a condition called post-finasteride syndrome can have truly devastating consequences.
Rubin: We see not only erection issues, but also orgasm and libido issues. We even see depression, anxiety, and cognitive issues because when you block 5-alpha reductase, it can affect some neurosteroids as well. Not every patient will have these side effects, but there is a significant similarity between the sexual side effects of birth control pills and those of finasteride, and we minimize both of them. Unfortunately, they can be devastating. We’ve seen many suicides in the community because of these types of medications. Their genitals aren’t working. They may go to a urologist, who may not be confident addressing these issues or even picking up on them. The dermatologists men visit for treatment of baldness don’t know how to fix genitals. There’s a lot of siloing. Men are told that this is body dysmorphia, that it’s psychosocial.
But nothing is worse than telling a patient with a biological problem, “It’s all in your head.” Sure, it affects neurosteroids, so it is in your head a little bit, but chemically and biologically, and when you’re 25 years old and your genitals don’t work, that will mess with your brain significantly.
We see consequences of altering hormones, and sometimes they’re really good. Taking birth control pills and not having a baby when you don’t want a baby is a wonderful consequence. With perimenopausal hormone therapy, you can get a woman sleeping and eliminate hot flashes. The return of libido can be a wonderful consequence of testosterone therapy, but we really need to understand how our medications affect sexual health.
Winter: If a patient reports side effects from birth control or finasteride, the most important thing you can do is validate and acknowledge them. Even if you do not have expertise in this and you cannot fix their problem, just say, “I believe you.”
There is therapeutic value in that.