The Pill, Testosterone, and Vulvovaginal Pain: What the Research Suggests

Many women are told the oral contraceptive pill is simple, safe and well tolerated. For many, it might be. But for some women, particularly those experiencing painful sex, vulvar burning, dryness, reduced lubrication or recurrent tearing, it is worth exploring whether the pill may be a contributing factor.

Hormonal Changes: Testosterone and SHBG

Combined oral contraceptives (COCs) work by suppressing ovulation and altering hormone levels i.e., it turns off our own production of oestrogen, progesterone & also impacts on testosterone. The replacements are not the same and do not act the same way in the body. In fact they are are completely different molecular structure. One of the most consistent findings in the literature is their impact on androgens.

A systematic review and meta-analysis found that COCs significantly decrease total testosterone and free testosterone while increasing sex hormone-binding globulin (SHBG) (Zimmerman et al., 2014). Because SHBG binds testosterone, this increase further reduces the amount of bioavailable (free) testosterone (T) in the body.

“Combined oral contraceptives decrease circulating levels of total T and free T and increase SHBG concentrations” (Zimmerman et al., 2014).

This reduction is clinically relevant because testosterone plays a role in sexual desire, arousal, genital blood flow and tissue health.

Impact on Vaginal and Vulvar Tissue

Vulvovaginal tissues are hormonally sensitive. Oestrogen and androgens both contribute to:

• Tissue thickness and elasticity

• Blood flow

• Lubrication

• Nerve sensitivity

  
  

Research suggests that reduced androgen availability may negatively affect these tissues. Handy et al. (2023) found that women taking oral contraceptives—particularly those containing anti-androgenic progestins, demonstrated reduced vaginal blood flow and lubrication compared with naturally cycling women.

“Compared with naturally cycling women, women taking OCPs had lower physiological arousal responses” (Handy et al., 2023).

Notably, decreased lubrication was reported by 61.9% of women using anti-androgenic pills compared with 8.47% of controls (Handy et al., 2023).

The authors also proposed that lower androgen levels may impact epithelial integrity:

“Reductions in androgen levels… may negatively impact the vaginal epithelium” (Handy et al., 2023).

This may contribute to symptoms such as dryness, irritation, and increased susceptibility to microtears.

Vulvovaginal Pain and Dyspareunia

The relationship between oral contraceptive use and vulvovaginal pain conditions (such as vulvodynia) is complex and not fully consistent across studies.

Some research suggests a possible association. For example, Bouchard et al. (2002) found that oral contraceptive use was associated with an increased risk of vulvodynia, particularly when use began at a younger age.

A more integrative review suggests a potential pathway: hormonal contraception may contribute to vulvovaginal atrophy, reduced elasticity and hypolubrication, which in turn may increase the likelihood of pain during intercourse (Aerts et al., 2021).

All of this is obviously very uncomfortable for women and can have a significant psychological impact in addition to the physical effects/injury.

A Biopsychosocial Lens

Pain is rarely caused by a single factor. Even if hormonal changes contribute to tissue sensitivity or dryness, this may interact with:

• Pelvic floor muscle tension

• Fear-avoidance cycles

• Relationship dynamics

• Stress and nervous system activation

  
  

Reduced lubrication alone can initiate a cycle of discomfort → guarding → increased pain sensitivity. There is always more to explore with each individual woman in regards to the underlying factors that may be contributing to her 'guarding' and 'protection'.

Clinical Takeaway

This does not mean the pill causes vulvovaginal pain in all women. However, it is a relevant clinical consideration, particularly when:

• Symptoms began after starting the pill

• A low-dose or anti-androgenic pill is being used

• There is persistent dryness, burning, or pain at the vaginal opening

• There is reduced arousal or lubrication

  
  

In these cases, a collaborative review with a GP, gynaecologist or pelvic health specialist may be helpful. This may include reviewing contraceptive options, assessing hormone patterns, and integrating pelvic floor or psychosexual support where appropriate.

The vulvovaginal area of the body is extremely delicate and very sensitive. Women deserve to explore all options including medical, physical and psychological, so they can embrace their relationship with this area of their body in a positive, healthy and deeply honouring way.

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References

Aerts, L., Pluchino, N., & Wenger, J. M. (2021). Hormonal contraception and vulvodynia: An update. Gynecological and Reproductive Endocrinology & Metabolism, 3(1), 1–5.

Bouchard, C., Brisson, J., Fortier, M., Morin, C., Blanchette, C., & Maunsell, E. (2002). Use of oral contraceptive pills and vulvar vestibulitis: A case-control study. American Journal of Epidemiology, 156(3), 254–261. https://doi.org/10.1093/aje/kwf039

Handy, A. B., Meston, C. M., & Stephenson, K. R. (2023). The effects of hormonal contraceptives on female sexual psychophysiology: A systematic review and meta-analysis. The Journal of Sexual Medicine, 20(6), 873–885.

Reed, B. D., Harlow, S. D., Sen, A., Legocki, L. J., Edwards, R. M., Arato, N., & Haefner, H. K. (2013). Oral contraceptive use and risk of vulvodynia: A population-based longitudinal study. BJOG: An International Journal of Obstetrics & Gynaecology, 120(13), 1678–1684. https://doi.org/10.1111/1471-0528.12368

Zimmerman, Y., Eijkemans, M. J. C., Coelingh Bennink, H. J. T., Blankenstein, M. A., & Fauser, B. C. J. M. (2014). The effect of combined oral contraception on testosterone levels in healthy women: A systematic review and meta-analysis. Human Reproduction Update, 20(1), 76–105. https://doi.org/10.1093/humupd/dmt038