Original Article

Comparison of Sexual Dysfunction in Women Using Depo-Medroxyprogesterone

Acetate (DMPA) and Cyclofem
Giti Ozgoli 1, Zohre Sheikhan 1*, Mahrokh Dolatian 1, Masoumeh Simbar 1, Maryam Bakhtyari 2, Malihe Nasiri 3

1- The Research Centre for Safe Motherhood, Department of Midwifery and Reproductive Health, Faculty of Nursing and
Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2- Department of Clinical Psychology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3- Department of Biostatics, Faculty of Paramedic, Shahid Beheshti University, Tehran, Iran

Abstract
Background: Sexual affairs are one of the physiological needs affecting human
health. Sexual functioning disorders can reduce individual’s capabilities and creativi-
ties. Sexual relations are in the center of women’s quality of life. The most important
family planning is to prevent unintended pregnancies. Injectable contraceptives pro-
tect women exposed to many complications and mortality due to unintended preg-
nancies, with tolerable effects on other aspects of women’s life. An important aspect
of women’s life is sexual health. This study aimed to compare sexual function of
women using DMPA with women using Cyclofem presented to health centers affili-
ated to Shahid Beheshti University of Medical Sciences in Tehran, Iran in 2013.
Methods: This descriptive-comparative study was conducted on 240 women in health
* Corresponding Author: centers in Tehran, Iran. They were selected by multistage sampling. The data was
Zohre Sheikhan, The collected using a questionnaire completed by interviewing. The questionnaire had 2
Research Centre for Safe
parts, demographic characteristic section and Female Sexual Function Index (FSFI).
Motherhood, Department
of Midwifery and Data was analyzed by descriptive statistics, independent T-test, U-test, Chi-square,
Reproductive Health, Fisher exact test. The p-value less than 0.05 were applied for all statistical tests as
Faculty of Nursing and significance level.
Midwifery, Shahid Results: The difference in sexual function between Cyclofem and DMPA groups
Beheshti University of
Medical Sciences, Niayesh
was insignificant, but in terms of sexual desire in DMPA users better than and sexu-
Highway, Vali-asr Street, al pain them less than in Cyclofem users, the difference between the groups was sig-
Tehran, Iran nificant (p<0.05).
E-mail: Conclusion: In introducing hormonal contraceptive methods, health workers should
zsheikhan@Gmail.com
emphasize their adverse effects on sexual function. Women who use Cyclofem and
Received: Jun. 20, 2014 DMPA should be aware that they may experience some changes in libido and sexual
Accepted: Nov. 18, 2014 pain.

Keywords: Cyclofem, DMPA, Sexual dysfunction.

To cite this article: Ozgoli G, Sheikhan Z, Dolatian M, Simbar M, Bakhtyari M, Nasiri M.
Comparison of Sexual Dysfunction in Women Using Depo-Medroxyprogesterone Acetate
(DMPA) and Cyclofem. J Reprod Infertil. 2015;16(2):102-108.

Introduction
ex is an important aspect of quality of life ish women 48.3% (3). In Austria, 9.1% of women
that affects both physical and psychological had sexual desire disorders, 20% had sexual arousal
aspects. According to a report by American disorder, 20% had orgasm disorder, and 12.8%
Center for Health, 43% of women had unfavora- had pain (4). In another study, a third of women
ble sexual function, and 2% were unable to expe- had no sexual desires, and a fourth had not experi-
rience orgasm (1). Sexual dysfunction in German enced orgasm (5). In Iran, sexual dysfunctions are
women was reported to be 38% (2), and in Turk- wide ranging, from 17.8% to 74.6% (6-8). This is

J Reprod Infertil. 2015;16(2):102-108

 Ozgoli G, et al. JRI
such an important problem that accounts for 88% sistent pattern for sexual effects of hormonal con-
of divorces (6). Women suffer from sexual dys- traceptive methods (23). Women using hormonal
function more than men. In fact, sexual relation- contraceptive methods have experienced positive,
ship is central to quality of women’s life, and it negative or no effects on their libido (21). In a
reflects the psychosocial and life aspects (9). Dif- study, 87% of women had to discontinue hormo-
ferent factors such as health, emotional problems, nal contraceptive methods because of emotional
stress, and hormones affect sexual function (10). complications, exacerbated premenstrual syn-
Furthermore, unintended pregnancies can be a drome (PMS), and decreased libido and sexual
serious threat to mother’s and child’s health, since excitement (24). In another study, sexual inter-
a large number of them are terminated using dan- course disorders were the reason for discontinua-
gerous methods that result in mother’s death or tion of hormonal contraceptive methods (25). Cur-
disability (11). Nearly 80 million out of 210 preg- rently, there are effective methods for regulating
nancies worldwide are unintended. According to fertility, but none is definitely without complica-
studies in Iran, a third of pregnancies are unin- tions (26). In choosing contraceptive methods,
tended (12). Injectable contraceptives are safe and women are faced with many challenges, including
effective options to prevent unintended pregnan- benefits and side-effects (27). Although, in Iran,
cy. Currently, there are two types of contraceptiv- Cyclofem has been available for a short time, con-
es available, monthly progestin only and com- flicting results have been observed in relation to
bined contraceptive injections. Progestin com- its side-effects. This study aimed to compare sex-
pounds are extraordinarily efficient, but have sig- ual function of women using DMPA with women
nificant side-effects. This is just as effective as using Cyclofem presented to health centers affil-
sterilization, and more effective than oral and bar- iated to Shahid Beheshti University of Medical
rier contraceptive methods (13). Since menstrual Sciences in Tehran, Iran in 2013.
irregularities in users of this method are attributed
to estrogen deficiency, addition of an estrogen Methods
part to injectable products is said to regulate men- This descriptive-comparative study was conduct-
struation (14) and reduce side-effects (15). With a ed in health centers affiliated to Shahid Beheshti
growing usage (16), Cyclofem is another type of University of Medical Sciences in Tehran, Iran,
combined injectable hormonal contraceptive. Cy- between May and November 2013. Participants
clofem combination formula is hormonal and it is were selected by multistage sampling. The area of
injected monthly. In the United States, this drug is health care centers related to Shahid Beheshti
known with its brand name Lunelle (17). The effi- University of Medical Sciences in Tehran was di-
cacy of this method is 99.8% in the first year (18). vided into four zones, namely North, South, West
This rate of efficacy is similar to that of steriliza- and East, and then two centers were selected from
tion in women (19). The use of hormonal injecta- each zone randomly. Eligible women presented to
ble contraceptives is a highly effective method, the above health centers were selected for partici-
and it is favored because of its simplicity and non- pation in study, so 240 subjects were divided into
interference with sexual intercourse. Sex hor- two equal groups of 120 each (Figure 1).
mones such as estrogen and progesterone can im- DMPA ampoule (Caspian Tamin pharmaceutical
pose different effects on women’s sexual behav- Co., Iran) containing 150 mg of medroxyproges-
iors and functions through vaginal tissue and the trone acetate, and Cyclofem ampoule (Iran Hor-
central nervous system (20). Studies indicate that mone, Iran) containing 25 mg of medroxyproges-
hormones used in contraceptive methods have trone acetate and 5 mg of estradiol cypionate, in-
contradictory effects on sexual function (17). jected in monthly intervals, was administered in
Some reports reveal the effect of hormones, and health centers.
conversely, some report lack of the effect (21-22). Data collection tool was a questionnaire, com-
The emergence of sexual disorders is one of the pleted by the researchers through interviews. Be-
most important adverse effects that may occur cause of the impact of depression and anxiety on
during the use of hormonal methods of contracep- sexual function, the 28-item General Health Ques-
tion. In some cases, disorders will even lead to the tionnaire (GHQ-28) was first completed and was
discontinuation of the method. Although sexual scored in Likert scale. Subjects scoring 22 marks
adverse effects that lead to discontinuation are or more were excluded (N=21). The question-
controversial, studies show that there is no con- naire, Female Sexual Function Index (FSFI), is

J Reprod Infertil, Vol 16, No 2, Apr-Jun 2015 103

 JRI Sexual Dysfunction in Women Using DMPA or Cyclofem

double publication and/or submission, redundan-

Assessed for eligibility
(n=272) cy, etc.-have been considered carefully by the au-
n=253 thors. The respondents were anonymous and par-
ticipated willingly and voluntarily in this study.
Study inclusion criteria were Iranian nationality,
Enrollment minimum 3 month use of contraceptive methods,
(n=268) no lactating, no addiction of women or their
spouses, no known psychological disorders in
women or their spouses, no use of antidepressants
GHQ Excluded by women or their spouses, the normal life of
(n=21) women over the 6 months prior to study, no par-
ticular adverse life events such as death of a dear
one, incurable diseases in family members, changes
of residence, retirement of spouse, or loss of job
Cyclofem (n=123) DMPA (n=124) by women or their spouse. To analyze data, descrip-
Excluded (n=3) Not meeting=1 Excluded (n=4) Not meeting=1 tive statistics, T-test, U-test, Chi-square, Fisher
Lactation= 2 have psychological disorders=3
exact test and SPSS 16 software were used. The
significance level of p-value less than 0.05 was
applied for all the statistical tests.
Cyclofem DMPA
n=120 n=120
Results
This study was conducted on 240 women, and
Figure 1. Flow diagram showing numbers of women in each
their demographic details are presented in table 1.
group
Mean age of participants was 28.26±5.08 years in
Cyclofem group and 28.63±7.16 in DMPA group.
used in various studies (28-29). In this study, it The mean age of marriage in participants was
contained 19 questions with 5 options (0-5), with 18.55±3.62 years in Cyclofem group and 19.58±
2 questions on sexual desire, 4 on arousal, 4 on 3.66 years in DMPA group. In Cyclofem group,
vaginal lubrication, 3 on orgasm, 3 on pain, and 3 the length of marriage was 8.70±4.89 years and
on sexual satisfaction, designed in Likert scale, 10.37±6.15 in DMPA group with a statistically
and evaluated sexual function over the past 4 significant difference between the two groups.
weeks. Maximum score was 36, and scores less Mean age of first conception was 21.12±4.84 years
than 28 indicated unfavorable sexual functions. In in Cyclofem group and 19.76±4.88 in DMPA
each area, the highest score was 6. Internal con- group. Mean of gravidity was 2.15±1.22 in Cyclo-
sistency was ensured using Cronbach’s alpha co- fem group and 1.83±0.96 in DMPA group. Mean
efficient (α=0.81). For reliability, test-retest meth- of duration of using contraception was 50.32±7.83
od was used with a 10-day interval (r=0.83). An- months in Cyclofem group and 47.65±6.98 months
other questionnaire contained 33 questions on in DMPA group. Menstruation status in Cyclofem
demographic details. group was regular (85%) but in DMPA group was
Only eligible women presented to health centers irregular (46.7%). In Cyclofem group, there were
affiliated to Shahid Beheshti University of Medi- no adverse effects in 84.2% of women, but in
cal Sciences in Tehran were selected. After ex- DMPA group there were no adverse effects in
plaining objectives of the study, the first condition 60% of women. In Cyclofem group, the level of
for participation in study was obtaining consents education was high school diploma in 60% of
of women and their spouses, and subjects were women, while the level of education was high
included in the study if they were so inclined. The school diploma in 46.6% of women in DMPA
participants were assured that all their information group. In Cyclofem group, 100% of women were
was confidential, and that they did not need to Muslim while in DMPA group 97.7% of women
mention their names on the questionnaires. This were Muslim.
study was approved by Ethics Committee (No: Sexual function in women using DMPA was fa-
312/770, Dated 2012/12/7). All ethical issues- vorite (60.8%) and 65.8% in women using Cyclo-
informed consent, conflict of interest, plagiarism, fem. The difference in sexual function between
misconduct, data fabrication and/or falsification, Cyclofem and DMPA groups was not significant,

104 J Reprod Infertil, Vol 16, No 2, Apr-Jun 2015

 Ozgoli G, et al. JRI
Table 1. Distribution of women who used Cyclofem and DMPA by their characteristics
Cyclofem DMPA
Variable p-value
n=120 n=120
Mean age (year) ∗
28.26±5.08 28.63±7.16 NS a
Mean age of marriage (year) ∗ 18.55±3.62 19.58±3.66 NS a
Mean duration of marriage (year) ∗ 8.70±4.89 10.37±6.15 p<0.05 a
Mean age of first conception (year) ∗ 21.12±4.84 19.76±4.88 NS a
Mean of gravidity ∗ 2.15±1.22 1.83±0.96 NS a
Mean duration of use of contraception (months) ∗ 50.32±7.83 47.56±6.98 NS a
Menstruation status ∗∗
Regular 102 (85) 26 (21.6)
Irregular 17 (14.2) 56 (46.7) NS b
Amenorrhea 1 (0.8) 38 (31.7)
Adverse effects of contraception ∗∗
No 101 (84.2) 72 (60)
NS b
Yes 19 (15.8) 48 (40)
Education ∗∗
Illiterate 2 (1.7) 12 (10)
Primary school 12 (10) 14 (11.7)
Secondary school 28 (23.3) 26 (21.7) NS b
High school 72 (60) 56 (46.6)
Above 6 (5) 12 (10)
Religion ∗∗
Muslim 120 (100) 117 (97.5)
NS b
Other 0 (0) 3 (2.5)
a: Independent t-test; b: Chi square test
∗ M±SD, ∗∗ n (%)

Table 2. Comparison of sexual function in two groups (120 suppress or prevent the release of LH and FSH
women in each group) from the pituitary gland, resulting in increased
Cyclofem DMPA levels of SHBG. In decreased libido, the testos-
Domain p-value
n=120 n=120 terone level is bound to SHBG and free testos-
Desire ∗
3.60 (3.0-4.8) 3.60 (2.4-5.4) 0.018 a terone declines. This trend is intensified by an
Arousal ∗ 4.20 (3.6-4.8) 4.20 (3.6-4.5) 0.837 a
increase in estrogen (30). The first stage in sexual
Lubrication ∗ 5.25 (4.5-6.0) 5.10 (3.9-6.0) 0.273 a response cycle may be the desire stage. Women
Orgasm ∗ 4.80 (4.0-6.0) 5.20 (3.6-6.0) 0.816 a begin or consent to a sexual relationship for many
Pain ∗
6.00 (5.2-6.0) 5.20 (4.0-6.0) 0.002 a different reasons that include desire to increase
Satisfaction ∗ 4.80 (3.6-6.0) 5.20 (4.8-6.0) 0.267 a
emotional intimacy with sexual partnership. Sexu-
Total ∗∗ 29.53 (4.23) 29.78 (5.48) 0.239 b al desire leads to arousal to have sexual relation-
a: Mann-whitney test; b: Independent t-test ship. Sexual feelings may start through internal
∗ Median (IQR), ∗∗ M±SD
and external sexual innuendos, and depend on
neuroendocrine function. Neurotransmitters, pep-
but in terms of sexual desire and sexual pain, the tides, and many hormones moderate desire and
difference between the groups was significant (p< motivation. Sexual response is hastened by nore-
0.05) (Table 2). pinephrine, dopamine, oxytocin, serotonin, and is
inhibited by prolactin and GABA. Yet, it has been
Discussion found that biological factors do not function inde-
In this study, there was a significant difference in pendently of environmental factors. Dopamine and
sexual desire between DMPA and Cyclofem groups, progesterone that act upon receptors in hypothal-
and mean sexual desire score in women using DMPA amus increase sexual behaviors (17). Clayton
was higher than Cyclofem. One of the mecha- (2003) argues that perhaps sexual hormones such
nisms of hormonal contraceptive methods is to as dopamine and serotonin in contraceptives affect

J Reprod Infertil, Vol 16, No 2, Apr-Jun 2015 105

JRI Sexual Dysfunction in Women Using DMPA or Cyclofem

neurotransmitters and cause a change in sexual tigated. With aging of spouse, erectile and ejacu-
desire, with an unknown mechanism (31). Berek latory dysfunction increases, and daily fatigue,
(2011) believes women’s sexual desire is affected work and stress can affect sexual function of men.
by their psychological status, beliefs and values, Study results showed satisfactory level of sexual
expectations, sexual preference, priorities and en- function in women using DMPA and Cyclofem,
vironmental conditions. Sexual desire is at its with insignificant difference between them. Our
peak between 20 and 40 years of age, and declines study was in agreement with previous studies (3,
beyond that (17). Another finding in this study 20, 28, 36-37). Sexual function is very complicat-
was the significant relationship between the two ed and is affected by many factors, including the
contraceptive methods in the pain area. Mean person’s lifestyle, interpersonal relationships and
score of pain in women using Cyclofem was high- cultural conditions. Berek (2011) argues that sex-
er than in women using DMPA. Nijland et al. ual response occurs through complex mediating
(2008) admits reduced estrogen level, causing psychological, social, environmental, and biologi-
reduced blood supply to vagina, affects lubrica- cal factors (hormonal, vascular, muscular, and
tion and results in a painful intercourse (32). Van nervous) (17). Despite numerous studies, mecha-
lunsen and Laan (2004) believes that hormonal nisms of sexual disorders in hormonal contracep-
balance is necessary for initiating and continuing tive methods are still unknown and they cannot be
sexual function. Estradiol, nitric oxide, and poly- predicted for all women (38). Basson (2006) be-
peptides have an important effect on vaginal epi- lieves that despite sexual disorder symptoms,
thelium and lubrication, and estrogen has a major women can enjoy pleasant sexual relations by in-
role in effectiveness of these factors (33). Suffi- creasing their knowledge in this regard (39). It is
cient levels of estradiol are necessary for main- worth noting that women that are not afraid of
taining vaginal lubrication and preventing dyspa- unintended pregnancies may enjoy sexual rela-
reunia. In the present study, estradiol level in tionships more and score higher in sexual func-
women using Cyclofem was not measured. How- tion.
ever, in a study by Modelska et al. (2004), the im- In Iran, as one of the traditional and religious
provement in sexual function due to the effect of communities, sexual affairs are ambiguous. Lack
estradiol level was demonstrated (34). Schaffir et of training and providing information on sexual
al. (2010) argues that estradiol level had no effect affairs are the main concerns in Iranian women.
on dyspareunia and lubrication score in women Cyclofem and DMPA may be used as highly ef-
studied, and believed that, because of effects of fective, safe and convenient methods for long
progesterone on vaginal epithelium in women us- term reversible contraception. Satisfaction from a
ing DMPA, estradiol level was tangibly low, and method is often influenced by frequency of side
may even cause suppression of estrogen. On the effects and the outcomes on individuals’ health
other hand, many women using DMPA, had amen- (40).
orrhea, which may have affected their sexual de- Clearly, according to reproductive rights, women
sire or sexual enjoyment, through unexpected have the rights to experience a safe and enjoyable
bleeding (28). In family planning counseling, the sexual relationship.
effects of hormonal methods on women’s sexual
function and menstrual patterns and their adjust- Conclusion
ment with the methods should be considered. In In introducing hormonal contraceptive methods,
both groups, there was a statistically significant health workers should emphasize their adverse ef-
difference between the duration of marriage in fects on sexual function so that in addition to pre-
women which is consistent with studies of Bar- venting negative outcomes such as unintended
rientos and Dario (2006) (35). Berek (2011) ar- pregnancy, they can improve the quality of sexual
gues that sexual desire, interest, and arousal are relations and sexual satisfaction with increasing
immensely influenced by mental health and feel- people’s awareness. Women who use Cyclofem
ings of sexual partner on the occasion of relation- and DMPA should be aware that they may experi-
ship. Other factors affecting sexual response in- ence some changes in dimensions of libido and
clude duration and quality of sexual relationship sexual pain. Discontinuation of hormonal contra-
and personal-psychological factors (17). In this ceptive methods because of this reason depends
study, spouses’ sexual dysfunction was not inves- on the severity of complications.

106 J Reprod Infertil, Vol 16, No 2, Apr-Jun 2015

 Ozgoli G, et al. JRI
Acknowledgement among South African women. Contraception.
Authors thank Shahid Beheshti University of 2006;73(6):598-601.
Medical Sciences, Tehran, Iran and all the women 13. Canto de Cetina TE, Luna MO, Cetina Canto JA,
who took part in this research. Bassol S. Menstrual pattern and lipid profiles dur-
ing use of medroxyprogesterone acetate and estra-
Conflict of Interest diol cypionate and NET-EN (200 mg) as contra-
The authors declare no conflict of interest. ceptive injections. Contraception. 2004;69(2):115-
9.
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