This section discusses the effects of smoking on reproductive health, including the menstrual cycle and menopause, fertility, the treatment of infertility, contraception, and sexual function. For information about smoking and cancers of reproductive organs, see Section 3.5. For a discussion about smoking and infections of the reproductive system, see Section 3.9.
The health of an individual’s reproductive system is influenced by several factors, one of which is smoking. According to the US Surgeon General’s reports, smoking adversely affects the reproductive health of both men and women.1-4
3.6.1 The menstrual cycle and menopause
The menstrual cycle is a cycle of changes in sex hormone levels and in the female reproductive tract. The menstrual cycle begins with menstruation, and is followed by the follicular phase (when oestrogen levels rise and the ovaries prepare eggs to be released), ovulation (when a mature egg (or eggs) are released), and then the luteal phase (when the lining of the uterus thickens in preparation for a possible pregnancy).5
The 2001 US Surgeon General’s report concluded that there is some evidence to suggest that smoking increases the risk of menstrual irregularity, secondary amenorrhea (lack of menstruation among women who have previously menstruated), and dysmenorrhea (painful menstruation). Several studies published after this report have also found that smoking is associated with an increased risk of dysmenorrhoea.6-8 A 2020 meta-analysis found that women who currently smoke have 1.5-fold higher odds of experiencing dysmenorrhoea, compared to women who never smoked.8 An Australian study found that smoking, and early initiation of smoking, are both associated with an increased risk of chronic dysmenorrhoea.9
The hormonal fluctuations that occur during the menstrual cycle may cause premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). There is some evidence to suggest that smoking is associated with an increased risk and severity of PMS and PMDD.10-12 A 2020 meta-analysis found that women who smoke have 1.27-fold increased odds of experiencing PMS, and 3.15-fold increased odds of experiencing PMDD, compared to women who never smoked.12
Menopause refers to the time in a person’s life when menstruation stops and is defined as occurring 12 months after the last menstruation. Menopause may occur naturally, or because of a medical intervention such as a hysterectomy, chemotherapy, or radiation therapy. The typical age at which natural menopause occurs is 51 years.13 There is evidence to suggest that smoking is associated with early natural menopause, with the 2001 US Surgeon General’s Report concluding that women who smoke enter menopause at a younger age compared to women who do not smoke.1 Several studies published since this report have made similar conclusions.14-20 One study that analysed data from the Nurses’ Health Study II, found that women who currently smoke have a 1.9-fold increased risk of entering menopause before the age of 45 years, compared to women who never smoked.17 Moreover, a pooled analysis found that women who currently smoke have about twice the risk of entering menopause before the age of 40, compared to women who never smoked. This analysis also demonstrated that the relationship between smoking and early menopause is likely dose-dependent, with the risk of entering early menopause increasing with the intensity of smoking, duration of smoking, cumulative dose of smoking (i.e. pack years smoked), and an earlier age of smoking initiation.18
There are several potential mechanisms that may explain why smoking is associated with early menopause. It has been suggested that the polycyclic aromatic hydrocarbons (PAHs) found in tobacco smoke can increase the rate of oocyte apoptosis (death of eggs in the ovaries) and damage ovarian follicles (the sacs in the ovaries that contain the eggs), both of which can lead to early menopause.1,21 It has also been hypothesised that the anti-oestrogenic effects of smoking can lead to an earlier menopause.21,22
Menopause is characterised by changes in hormones that can cause hot flushes, sleep disturbances, mood changes, urinary incontinence, vaginal dryness, and sexual dysfunction. There is evidence to suggest that smoking increases the risk of experiencing some of these symptoms.23-26 A 2015 meta-analysis found that women who currently smoke had a 1.97-fold increased odds of experiencing hot flushes, compared to women who had never smoked.24 Similarly, a 2020 pooled analysis found that current smoking was associated with increased frequency and severity of vasomotor menopausal symptoms (i.e. hot flushes and night sweats) compared to never smoking.26
3.6.2 Fertility
Measures of fertility include fecundability (the monthly probability of conception), infertility (defined as lack of conception after one year of unprotected intercourse), and sub-fertility (reduced fertility, measured by time to conception or inability to conceive within six months).
Smoking adversely impacts the fertility of women, with the 2004 US Surgeon General’s report concluding that the evidence is sufficient to infer a causal relationship between smoking and reduced fertility.2 Multiple studies have found that smoking increases the risk of delayed conception, decreased fecundability, and infertility.14,27-29 The relationship between smoking and impaired fertility among women appears to be dose-dependent.3,30 It has been suggested that the PAHs in cigarette smoke diminish the functioning of the ovaries and the fallopian tubes (the tissue connecting the ovaries to the uterus), thereby impairing fertilisation and fertility.3
In relation to the impact of male smoking on sperm quality and fertility, the 2004 US Surgeon General’s report concluded that although the evidence suggests that smoking may decrease semen volume and sperm count, and increase the number of abnormal forms present, it was insufficient to establish causality.2 The 2010 US Surgeon General’s report found strengthened evidence for decreased semen quality and fertility associated with exposure to tobacco smoke either in utero or in adulthood. The report found consistent evidence linking smoking to chromosome changes or DNA damage in sperm, adversely affecting male fertility and pregnancy viability as well as anomalies in offspring.3 Meta-analyses published since this report have found similar associations between smoking and decreased sperm quality and count, and sperm DNA damage.31,32
3.6.3 Treatment of infertility
Assisted reproductive technology is used to address infertility and help people conceive, and includes treatments such as in vitro fertilisation (IVF). Smoking can have a negative effect on the outcomes of such treatments.33 Some studies have found that among women accessing assisted reproductive technology, smoking is associated with lower pregnancy rates, higher chances of miscarriage, and a lower probability of a live birth.33,34 A 2018 meta-analysis found that women accessing reproductive technology who smoke have a lower number of eggs retrieved and a reduced rate of fertilisation, compared to women who do not smoke.34 There is also some evidence to suggest that women undergoing assisted reproduction who smoke also have an increased risk of ectopic pregnancy.35
One study found that for couples undergoing IVF who smoke (either female, male or both), the risk of not achieving a pregnancy was about twice as high compared to couples that did not smoke.36 It has been estimated that women who smoke need up to twice the number IVF cycles to conceive, and suggested that there is a correlation between the number of smoking years and the risk of not conceiving through IVF.37 Smoking cessation for both women and men is recommended for couples trying to conceive,38,39 and it has been suggested that access to fertility treatment should be conditional on quitting smoking.37
Interestingly, there is some evidence that paternal smoking can increase the rate of pregnancy loss after IVF, likely because of damage to sperm.40
Of note, smoking appears to affect infant outcomes in assisted reproduction pregnancies in the same way as unassisted pregnancies.41 See Section 3.8 for further information about smoking and child health outcomes.
3.6.4 Contraception
The oral contraceptive pill is a commonly used method of contraception. It contains oestrogen and progesterone (or progesterone alone), and is taken to reduce the chances of pregnancy. The oral contraceptive pill has been found to increase the risk of myocardial infarction by about two-fold.42 As detailed in Section 3.1, smoking also increases the risk coronary heart disease and myocardial infarction by about two- to four-fold.2 Women who take the oral contraceptive pill and smoke have a 20-fold increase in the risk of coronary heart disease, compared with women who do not smoke and are not taking the oral contraceptive pill.43 The impact of smoking and the oral contraceptive pill appears to be synergistic, meaning that the risk of disease is multiplicative rather than additive. Women who smoke heavily and are taking the oral contraceptive pill have an even higher risk of coronary heart disease.1
Although the newer ‘lower oestrogen’ versions of the oral contraceptive pill may be associated with a lesser risk of developing coronary heart disease, the risk is still elevated among women who smoke. There is insufficient evidence to evaluate the risk profile of the newer oral contraceptive pills (containing 30 μg or less of ethynyl oestradiol and either gestodene or desogestrel) combined with smoking, but clinicians are advised to be wary when prescribing oral contraceptive pills to women in their mid-30s who smoke, and to exercise extreme caution or avoid prescribing them altogether to women over 40 years of age who smoke.1
In past decades, the risk of stroke, particularly subarachnoid haemorrhage, has been significantly higher among women who take the oral contraceptive pill and smoke. However, research published since the 1990s following-up women taking the ‘lower oestrogen’ versions is conflicting; some studies show increased risk, other studies have shown no significant effect.1
There is some evidence to suggest that the oral contraceptive pill has a higher failure rate in women who smoke compared to women who do not smoke.43
3.6.5 Sexual function
Erectile dysfunction, also known as impotence, refers to the inability to obtain or maintain an erection that is sufficient for sex.44 The 2014 US Surgeon General’s report concluded that smoking is a cause of erectile dysfunction,4 with subsequent research supporting this conclusion.45-47 It has been suggested that the nicotine in cigarette smoke can induce vasospasm of penile arteries, which reduces the blood flow required for an erection. Long-term smoking can impair the vascular physiology of erectile tissue, thereby causing erectile dysfunction.4 To reduce the risk of erectile function, the US Surgeon General recommended that smoking cessation and avoidance of smoking be promoted in clinical settings.4
There is some evidence to suggest that smoking is associated with other forms of sexual dysfunction, including decreased libido and arousal, and difficulty of reaching orgasm. A 2022 study found that the prevalence of low libido was greater among men who currently smoke compared to men who had never smoked.47 A meta-analysis found that women who smoke were 48% more susceptible to sexual dysfunction compared to women who did not smoke.48 One of the studies included in this meta-analysis demonstrated that smoking is an independent risk factor for female sexual dysfunction, and that the association is likely dose-dependent.49 An Australian study found that smoking was associated with sexual difficulties in both men and women. For women, even light smoking was associated with not finding sex pleasurable and being unable to orgasm.50
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References
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