Document Type : Original Article
1 Hormozgan Fertility and Infertility Research Center, Hormozgan University of Medical Sciences, Bandarabbas, Iran
2 Faculty of Medical Science, Tarbiat Modares University, Tehran, Iran
3 Mental Health Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran
4 4Gametogenesis Research Center, Kashan University of Medical Sciences, Kashan, Iran
5 5Department of Biostatistics, Tarbiat Modares University, Tehran, Iran
6 6Faculty of Medical Sciences, Zanjan University of Medical Sciences, Zanjan, Iran
Polycystic ovary syndrome (PCOS) is the most
common endocrine disorder in women of reproductive
age. It is estimated that 5 to 10% of women
suffer from the disease (
Sexuality is an important and complex domain
in QOL studies. Prevalence of female sexual dysfunction
(FSD) may vary according to cultural,
racial and health status. Impaired sexual functioning
in women with PCOS has been often neglected or studied incidentally. Characteristics associated
with PCOS may adversely affect sexual health.
Women struggling with PCO, have reported feeling
less attractive and having lower sexual satisfaction
when compared to women without PCOS
Studies examining the sexuality of patients with
PCOS focused on the psychosexuality or subject’s
sexual orientation (
This was a cross-sectional study of women
with PCOS who attended two private gynecology
clinics in Kashan, Isfahan Province,
Iran, from May to October 2012. The Ethics
Committee of the Tarbiat Modares University
approved the study. Patients with confirmed
diagnosis of PCOS were invited to participate
in the study. After explaining the study objectives,
a written informed consent was obtained
from all participants and they were then requested
to complete the study questionnaires.
Inclusion criteria were as follows: 15-40 years
of age, married, Iranian, as well as having two
of the following Rotterdam diagnostic criteria:
i. polycystic ovaries being detected by ultrasound
scan (presence of 12 follicles or more in
one or both ovaries and/or increased ovarian
volume >10 ml), ii. clinical signs of hyperandrogenism
(hirsutism score based on hirsutism
score greater than 7 or obvious acne) and/or an
elevated plasma testosterone (testosterone >2.
0 nmol/l) (
Female sexual function was evaluated using a
detailed 19-item questionnaire [the Female Sexual
Function Index (FSFI)] described by Rosen et
Menstrual history: patients were asked to choose the best option indicating their menstruation interval during the preceding 12 months of the following category: <21 days, 21-34 days, 35-60 days, >199 days, and being variable.
Reproductive history: women were asked to categorize their reproductive history based on the following criteria: i. having been pregnant: all births, no losses; ii. having been pregnant: some births, some losses; iii. having been pregnant: no births, all losses; and iv. never being pregnant.
BMI: weight and height were calculated by the following formula for all participants, weight/ height squared (kg/m2).
Body hair: clinical assessment of hirsutism was determined using the Ferriman-Gallwey scoring system (F-G score). Nine body sites (the upper lip, chin, chest, upper back, lower back, upper abdomen, lower abdomen, arm, and thigh) were graded from 0 (no terminal hair) to 4 (severe hirsutism). Scores can range from 0 to 36. A score of 7 or above was considered positive for hirsutism (
Acne: acne was determined using the Global Acne Grading System (GAGS). The GAGS considers six locations on the face and chest/upper back. The borders on the face are defined by the hairline, jawline, and ears. The score of each location is a factor presenting affected surface area as well as distribution and density of pilosebaceous units. The chest and upper back are also included because their involvement is critical in order to assess the severity of acne and to decide on treatment option. The score of each location is separately determined in a 0-4 point scale that means the sum of scores belonging to a location (
The study used years of formal education as a measure of socioeconomic status that was categorized into five levels: no education, first level (1 to 5 years), second level (6-9 years), third level (10-12 years) and fourth level (more than 12 years). Different studies from Iran showed that education could be a good proxy measure for socioeconomic status of Iranians (
An overnight 8-hour fasting venous blood sample was obtained from each subject on the second or third day of their spontaneous or progesterone-induced menstrual cycles. Serum total testosterone (TT), sex hormone-binding globulin (SHBG), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) were concomitantly assessed in all participants by ELISA (DRG Instruments GmbH, Marburg, Germany). TT and SHBG were used to calculate the free androgen index (FAI) as TT (nmol/l)/ SHBG (nmol/l) ×100, suggesting to be a useful indicator of abnormal androgen status (
Data are presented as number (%), unless otherwise indicated. To explore the association between the socio-demographic and PCOS characteristics with sexual function (
Demographic and (bio) clinical characteristics of PCOS patients
|26.56 ± 4.44|
|The first level||32(10.7)|
|The second level||50(16.7)|
|The third level||126 (42)|
|The fourth level||92(30.7)|
|10.02 ± 4.20|
|0.51 ± 0.77|
|6.7 ± 5.73|
|10.54 ± 7.26|
|Never being pregnant||193 (64.3)|
|Having been pregnant: all births, no losses||32(10.7)|
|Having been pregnant: some births, some losses||17(5.7)|
|Having been pregnant: no births, all losses||58(19.3)|
|8.28 ± 6.16|
|6.09 ± 4.42|
|1.24 ± 0.23|
|55.57 ± 43.87|
|10.21 ± 34.45|
PCOS; Polycystic ovary syndrome, BMI; Body mass index, LH; Luteinizing hormone, FSH; Follicle-stimulating hormone, SHBG; Sex hormone-binding globulin, FAI; Free androgen index, *; Mean ± SD and **; N (%).
In all, 300 women with PCOS were included in the study during the six-month enrollment. The mean (SD) age of patients was 26.5 (4.44) years. The majority of women had education beyond high school (72.7%, n=218). More than two-thirds of patients had never been pregnant and had not successfully carried a pregnancy to term (n=251), of whom most reported having abnormal menstruation (n=191). Our inclusion criteria were FG score more than >7 and testosterone level >2. However, our findings showed that the mean values of FG score and testosterone were 6.7 and 1.24, respectively. According to Rotterdam criteria, having two of the diagnostic criteria is enough. In other word, if a patient complains of irregular menstrual cycles and her sonography results also indicates polycystic ovary, it is considered as a common case of PCOS. For this reason, the mean scores of hyperandrogenism are lower than inclusion criteria. Socio-economic and clinical characteristic of the patients are presented in table 1.
Fig 1 presents a summary of the mean scores of the six subscales, indicating FSFI, while the overall prevalence of FSD is 16.66% (n=50/300). The items are arranged from highest to lowest scores as follows: i. desire (48.3%, n=145/300), ii. arousal (44.7%, n=134/300), iii. pain (39%, n=183/300), iv. lubrication (21.3%, n=64/300), v. orgasm (15%, n=45/300), and finally vi. satisfaction (13%, n=39/300).
Multiple logistic regression analysis suggested a positive association between FSD and menstrual disturbance (OR: 4.61; 95% CI: 1.93-11). In other word, women with menstrual irregularities reported higher levels of sexual dysfunction when compared to PCOS women with regular menstruation cycles. Moreover, FSD was significantly higher in the presence of low level of education (OR: 2.94; 95% CI: 1.46-5.92,
Mean FSFI scores of subscales in PCOS patients.
Logistic regression analysis including socio-demographic and clinical symptoms predicting FSFI score among PCOS patients
|Independent variables†||OR (95% CI)||SE||P value|
†; Age, F/G and acne scores, duration of marriage, parity, endocrine profile and BMI were included in the regression analysis as continuous variables and other variables were used as dummy variables. Only significant results are presented. FSFI; Fe-male sexual function index, PCOS; Polycystic ovary syndrome, CI; Confidence interval and OR; Odds ratio.
Since PCOS often manifests itself through marriage and having sexual activity, its psychosexual implications are found to cause profound emotional distress in affected women (
Given the effect of PCOS on women’s physical health and emotional well-being, it is undoubted that a substantial proportion of patients reported sexual impairment and problems. In our study, the overall prevalence of FSD was 16.66%. The most significantly influenced domains in these participants were in line with the results of Aslan et al. (
In this study, 15% of the studied sample reported orgasm disorder. Depression, poor body image and low self-esteem were frequently seen in PCOS patients (
In the present study, we further determined factors that may influence sexual function in PCOS women. Of the socio-demographic data analyzed, education level showed strong correlation with the likelihood of FSD. Lower educational levels are positively associated with the presence of sexual dysfunctions, as also shown by similar findings of studies conducted in Turkish, Africa, and USA (
In the current study, women with menstrual irregularities reported higher levels of sexual dysfunction when compared to PCOS women with regular menstruation cycles. A negative effect of menstrual problems on the quality of life of patients has been previously discussed by other authors as well (
Surprisingly, we did not find any association between FAI levels and FSFI domain scores. Our results are consistent with the findings by Davis et al. (
As FSD is known as a common health problem in PCOS women, some controversy exists concerning the prevalence of FSD, while unique national, religious and cultural variations may contribute to risk factors of FSD. However, a thorough evaluation between different studies is affected by the lack of a uniform validated FSD questionnaire, setting, definition of FSD characteristics of the study population and the method of evaluation. A main methodological problem is use of the internationally accepted FSD questionnaires. At present, the FSFI is the most commonly used FSD questionnaire that has acceptable reliability and validity (
The current results, therefore, are applicable to identify the differences within the PCOS population. Secondly, the data were collected from a married Iranian patient sample; therefore, the findings should not be extrapolated to the general population and need to be studied in larger sample size. Thirdly, we were not able to determine the direction of causality between our variables. Moreover, all included patients in this study were married for cultural reasons (sex and infertility) in Iran. Additional prospective researches are needed to investigate the link between infertility and FSD and to determine the relationship between other known risk factors and sexual function.
This is a pioneer study in Iran investigating sexual problems in women with PCOS reporting sexual dysfunction, accounted as one-fifth of total participants. Desire and arousal disorders were the most common sexual dysfunction reported by Iranian women with PCOS. Our finding revealed that subjects with limited or no formal education and a history of menstrual irregularities reported greater sexual dysfunction using the FSD scale. In order to determine the causes of FSD, the topic needs further exploration involving intervention at regular health care visits. Clinician should consider religious and cultural background of their patients, especially in view of the factors influencing FSD.