3.6.1 Menstrual function, menarche and menopause
The US Surgeon General’s reports have examined the impact of smoking on menstrual cycles and reproductive lifespan: the period from the commencement of menstruation (menarche) to its cessation (menopause).1, 2
Women who smoke are, generally, at higher risk of dysmenorrhoea (painful menstruation) and a range of other symptoms such as premenstrual tension and heavy periods.2-4 In the US Nurses’ Health Study, for example, smokers were twice as likely as non-smokers to develop premenstrual syndrome over a two- to four-year period.5 Women who smoke are also more likely to develop its most severe form, Premenstrual Dysphoric Disorder.6 Smokers also tend to have a shorter and more variable menstrual cycle. The former has been attributed to a shortening of the follicular phase. A non-statistically significant higher risk of anovulation in smokers has been found in some studies. These effects are consistent with an increased risk of infertility (see Section 3.6.2) as the timing of ovulation is less predictable in women with variable cycle length and a shortened follicular phase may indicate abnormal formation of follicles and maturation of ova.2
Smoking may also result in an earlier menopause. A meta-analysis found that smokers were between 0.8 to 1.7 years younger than non-smokers at menopause,2 and several major population-based studies have similarly found that smokers reach menopause significantly earlier than never smokers.7-10 The relationship appears to be dose-response in nature, such that the highest risk of early natural menopause is observed among current heavy smokers.11 More menopausal symptoms have also been reported among women who smoke, such as night sweats and hot flushes.2, 12-15 It has been suggested that shorter cycles may deplete oocytes earlier leading to an earlier menopause and thus a shorter reproductive life span. An earlier age at menarche has been reported for the daughters of women who smoked heavily during pregnancy.2
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 reduces fertility in women. Studies have found reduced pregnancy rates, longer time to pregnancy and decreased fecundability in women who smoke.2, 7, 16-18 A recent review concluded that smoking compromises nearly every system involved in the reproductive process.19 A trend of decreased fertility with increasing number of cigarettes smoked has been reported.20 The American Society for Reproductive Medicine estimated that 13% of infertility may be attributable to smoking. Impaired fertility has been attributed to the polycyclic aromatic hydrocarbons in cigarette smoke and diminished oviductal functioning.2
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 number, and increase the number of abnormal forms present, it was insufficient to establish causality.21 The 2010 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.2 A large number of more recent studies and reviews have similarly found associations between smoking and decreased sperm quality and sperm DNA damage.22-42
3.6.3 Treatment of infertility including assisted reproduction
As detailed in Section 3.6.2, women who smoke have reduced fertility, as smoking has been found to affect ovarian function and reserve,43 and there is emerging evidence that fertility may also be reduced in male smokers.2
Smoking also has a negative impact on the outcomes of infertility treatment.44 In women participating in assisted reproduction programmes, smoking is associated with lower pregnancy rates, higher chances of miscarriage, and a lower probability of a live birth.44, 45 A meta-analysis found that smokers had a lower number of oocytes retrieved compared to non-smokers, and a reduced rate of fertilisation.45
There is also evidence that smokers undergoing assisted reproduction also have an increased risk of ectopic pregnancy.46
One study found that for couples undergoing in vitro fertilization (IVF) who smoked (either female, male or both), the risk of not achieving a pregnancy was about twice as high as for non-smokers.47 Researchers have estimated that women who smoke need up to twice the number IVF cycles to conceive and suggest there is a correlation between the number of smoking years and the risk of not conceiving through IVF.48 Smoking cessation for both women and men is recommended for couples aiming to become pregnant49, 50 and it has been suggested that access to fertility treatment should be conditional on quitting smoking.48
Interestingly, there is some evidence that paternal smoking can increase the rate of pregnancy loss after IVF, likely as a result of damage to spermatozoa.51
Of note, smoking appears to affect infant outcomes in assisted reproduction pregnancies in the same way as unassisted pregnancies52 (see Section 3.8).
3.6.4 Contraception
As detailed in Section 3.2, smoking causes coronary heart disease, increasing the risk two- to four-fold.21 The ‘combined’ oral contraceptive pill (which contains the hormone oestrogen) also increases the risk of myocardial infarction two-fold.53 Women who take the oral contraceptive pill and smoke have a 20-fold increase in the risk of coronary heart disease, compared with non-smokers who are not taking the contraceptive pill.54 The impact of smoking and the contraceptive pill is therefore ‘synergistic’, meaning that the risk of disease is multiplicative rather than additive. Heavier smokers have an even higher risk of coronary heart disease.55
Although the newer ‘lower dose’ versions of the contraceptive pill may be associated with a lesser risk of developing coronary heart disease, risk is still elevated in smokers. There is insufficient evidence to evaluate the risk profile of the ‘third-generation’ pills (containing 30 μg or less of ethynyl estradiol and either gestodene or desogestrel) combined with smoking, but clinicians are advised to be wary when prescribing oral contraceptives to smokers aged in their mid-30s and to exercise extreme caution or avoid using them altogether in smokers aged over 40 years.55
In past decades the risk of stroke, particularly subarachnoid haemorrhage, has been significantly higher among smokers using the contraceptive pill. However research published since the 1990s following up women using lower dose pills is conflicting; some studies show increased risk, other studies have shown no significant effect.55
There is some evidence to suggest that the combined contraceptive pill has a higher failure rate in smokers than in non-smokers.54
3.6.5 Sexual function
The link between smoking and erectile dysfunction (ED; defined as the persistent inability to attain and maintain penile erection adequate for satisfactory sexual performance) has been studied extensively.56 The 2014 US Surgeon General’s report concluded that smoking causes ED,57 and several more recent reviews further support this conclusion.58, 59 Vasospasm induced by the nicotine in cigarette smoke has been suggested as a mechanism for the acute deleterious effects of smoking on erectile function, while the chronic effects are caused by impaired vascular physiology of the erectile tissue. The Surgeon General has recommended promoting non-smoking to prevent ED, and cessation to limit the risk of ED.57
A study of about 130 Italian women found that smokers have decreased blood flow to genital blood vessels, which may impair sexual function.60 While some studies have found no relationship between smoking and sexual function among women,61 others have found smoking to be an independent risk factor for female sexual dysfunction (recurrent or persistent deficiency in sexual desire and arousal, difficulty or absence of reaching orgasm, and genital pain) in a dose-response manner (i.e., the higher the pack-years, the greater the dysfunction).62 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.63
Relevant news and research
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References
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