Abstract
Objective. In patients with systemic sclerosis (SSc), sexual function is somewhat impaired. Our aim was to evaluate sexual function in women with SSc in comparison to controls, and to investigate the association with sociodemographic and disease characteristics, and physical and psychological variables.
Methods. Forty-six women with SSc and 46 healthy women were assessed for sociodemographic characteristics and gynecological development and administered the Female Sexual Function Index (FSFI), Medical Outcomes Study Short Form-36 (SF-36), Health Assessment Questionnaire (HAQ), Hospital Anxiety and Depression Scale (HADS), Rosenberg Self-Esteem Scale, Coping Orientation to Problems Experienced-New Italian Version, and Functional Assessment of Chronic Illness Therapy-Fatigue Scale. Patients were also assessed for disease duration and subset, Female Sexual Function in SSc, Hand Mobility in Scleroderma test (HAMIS), Cochin Hand Functional Disability Scale, Mouth Handicap in Systemic Sclerosis Scale (MHISS), Disability Sexual and Body Esteem Scale (PDSBE); and fist closure, hand opening, and mouth opening.
Results. In patients with SSc, only FSFI desire subscale score was significantly lower (p = 0.035) versus controls. Total FSFI score, similar to controls, was related with Medical Outcomes Study Short Form-36 mental component, HAQ (p = 0.022), MHISS (p = 0.038), and HAMIS (p = 0.037). In SSc, the main factors independently associated with sexual functioning were vaginal dryness [regression coefficient (B) = −0.72; p < 0.001], PDSBE (B = 0.42; p = 0.001), and HADS depression scale (B = −0.23; p = 0.035). Together, these variables explained 70% of the variance in the FSFI total score.
Conclusion. In SSc, sexual function, although not different from controls, is influenced by specific disease-related and psychological concerns. Thus it should be included in patient evaluations and assessed in daily clinical practice.
- SYSTEMIC SCLEROSIS
- FEMALE SEXUAL FUNCTION INDEX
- SEXUAL ABILITY
- QUALITY OF LIFE
Systemic sclerosis (SSc) is a connective tissue disease characterized by microvascular alterations, perivascular inflammation, and excessive accumulation of collagen, causing fibrosis in skin and internal organs. The organ-based complications reduce both health-related quality of life (HRQOL) and overall survival1.
Chronic rheumatic diseases may affect all aspects of life including normal sexual functioning, consisting of sexual activity with transition through the phases from arousal to relaxation, and with a feeling of pleasure, fulfillment, and satisfaction2,3.
Various SSc-related features, such as mouth shrinking, skin tightening around vaginal introitus and breast, vaginal dryness, joint pain, muscle weakness, Raynaud phenomenon, reflux, vomiting, diarrhea, low self-esteem, as well as some drugs, can reduce desire and satisfaction in women and thereby diminish intercourse frequency4,5,6,7.
Sexual function, although important for individuals with and without chronic disease, remains largely ignored in daily clinical practice and is seldom included in research studies in rheumatology. Research items evaluating sex are included in only 2 questionnaires assessing function (World Health Organization Disability Assessment Schedule II and International Classification of Functioning, Disability and Health core sets for rheumatoid arthritis), and instruments evaluating sexual function are rarely used8,9,10.
Few studies have assessed sexual functioning in women with SSc4,5,6,7,8,11,12, and the studies draw different conclusions. Bhadauria, et al reported a lower number and intensity of orgasms in women with SSc in comparison with women with rheumatoid arthritis (RA) or systemic lupus erythematosus, and decreased desire and sexual satisfaction in all 3 patient groups7. Patients with SSc reported skin tightness, heartburn, and muscle weakness as symptoms affecting their sexual relations7. In contrast, in the study by Schouffoer, et al13, although sexual function was reduced in SSc, desire and satisfaction were not impaired, and no disease-specific variables were associated with sexual functioning. One study reported higher sexual impairment in women with diffuse cutaneous (dcSSc) than in those with limited cutaneous SSc (lcSSc)8, while others found sexual dysfunction unrelated to disease subset13,14. Impens, et al, in multivariate analyses, studied sexual functioning and causes of sexual inactivity but did not include factors associated with sexual impairment14.
To the best of our knowledge, only 2 studies had a design including controls11,13. However, none of the studies assessing sexual function in SSc examined hand and mouth disability, coping styles, self-esteem, and their potential association with sexual functioning5,6,7,8,11,12.
Our objective was to evaluate sexual function in women with SSc compared with healthy women, the association of the disease with sociodemographic and disease characteristics, and with physical and psychological variables.
MATERIALS AND METHODS
The study had a cross-sectional design with a control group. Eighty-seven consecutive patients with SSc15 classified as lcSSc or dcSSc16 were enrolled from the outpatient clinic and day hospital of the Division of Rheumatology of Florence University.
A general practitioner (GP) invited 60 consecutive apparently healthy women aged more than 35 years to participate in the study as a control group. This population was composed of women without SSc, other rheumatic diseases, or chronic infections. They frequented the GP’s office either to accompany chronic patients (mainly, their parents) for regular examinations, or because of periodic controls and/or prescription of occasional medications for themselves.
Of the 87 women with SSc who were invited to participate, 46 (53%) returned completed questionnaires. The 41 patients with SSc who did not return the questionnaires had the same clinical and laboratory characteristics as subjects who completed the survey [p = not significant (NS) for all the comparisons; data not shown].
Among controls, the final response rate was 77%: 46 out of 60 women, of whom 32 (69.56%) were caregivers of chronic patients regularly attending a GP clinic, and 14 (30.44%) were visiting a doctor’s office for periodic appointments and/or prescription of occasional medications.
The percentage of responses, although higher in controls than in SSc, was not significantly different between groups (p = NS by chi-square test).
All participants gave their written informed consent to participate and the procedures followed were in accordance with the Helsinki Declaration of 1975/83. The study was approved by the local ethical committee.
Assessment
During a routine visit, all participants were assessed for sociodemographic data (age, marital status, level of education, occupation) and gynecological characteristics (menstrual status, dyspareunia, vaginal dryness). They were also given the Female Sexual Function index (FSFI), Medical Outcomes Study Short Form-36 (SF-36), Health Assessment Questionnaire (HAQ), Hospital Anxiety and Depression Scale (HADS), Rosenberg Self-esteem Scale (RSES), Coping Orientation to Problems Experienced-New Italian Version (COPE-NIV), and the Functional Assessment of Chronic Illness Therapy-Fatigue Scale (FACIT-F).
For the patients with SSc, assessment included the Female Sexual Function in SSc (FSFS) test, the Hand Mobility In Scleroderma Test (HAMIS), the Cochin Hand Functional Disability Scale (CHFDS), the Mouth Handicap in Systemic Sclerosis Scale (MHISS), Disability Sexual and Body Esteem Scale (PDSBE), and tests of fist closure and hand and mouth opening.
Patients and controls were instructed to return the completed questionnaires to the physicians who administered them at the following visit.
Patients with SSc were assessed by a rheumatologist for disease duration (years) and subset (lcSSc, dcSSc)16. Skin involvement was evaluated by the modified Rodnan Skin Thickness Score17; interstitial lung disease was examined by high-resolution computed tomography, respiratory functionality tests, and/or bronchoalveolar lavage; pulmonary arterial hypertension by color Doppler echocardiography and right heart catheterization; heart involvement was defined if pericarditis, arrhythmia, or left ventricular congestive heart failure were present; esophagus involvement was defined by the presence of hypomotility at barium radiography and/or manometry. Also the presence of hand ulcers was recorded. Hand involvement was defined by the finding of arthralgias, arthritis, flexion contractures, or hand ulcers. Positivity to antinuclear antibodies, anti-Scl 70, and anticentromere antibodies (ACA) was recorded.
Sexual function assessment
FSFS, administered only to patients with SSc, measures the effect of SSc on sexual function. Patients are asked if they were sexually active, and if not, for what reason; to list which SSc-related problems affect their sexual functioning; and to specify the 3 most critical ones in order of importance14.
FSFI, administered both to patients with SSc and healthy controls, is a 19-item self-report measure of female sexual function measuring 6 domains (desire, arousal, lubrication, orgasm, satisfaction, pain). Higher FSFI subscale or total scores (range 2–36) indicate a better sexual function18. The cutoff score > 26.55 was used to discriminate between subjects with impaired and unimpaired sexual functioning18.
Quality of life and fatigue assessment
The SF-36, assessing HRQOL, consists of 36 items organized into 8 domains measuring 8 health concepts: physical functioning (PF), role limitations due to physical problems (PP), bodily pain (BP), general health perceptions (GH), vitality (V), social functioning (SF), role limitations due to emotional problems (EP), and general mental health (MH), combined into a summary physical index (SPI) and a summary mental index (SMI), with higher scores corresponding to better HRQOL (range 0–100)19.
Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) evaluates consequences of fatigue on daily activities. Total score range is 0–52, with high scores representing less fatigue20.
Psychological and self-esteem assessment
The HADS identifies psychological distress by 2 subscales: HADS-A (anxiety) and HADS-D (depression). Each score ranges from 0 (no depression or anxiety) to 21 (maximal depression or anxiety)21.
The Rosenberg Self-esteem Scale (RSES) is used to assess global self-esteem by 10 questions. In the scale (range 0–30), higher scores indicate higher self-esteem22.
COPE-NIV is a 60-item questionnaire exploring 15 types of coping grouped into 5 dimensions: social support (SS), avoidance strategies (AS), positive attitude (PA), problem solving (PS), and transcendent orientation (TO)23. Higher scores indicate better ability to overcome stress.
Disability assessment in patients with SSc
HAQ24 assesses global disability. It is organized into 20 items and divided into 8 domains of activities of daily living, rated from 0 (no difficulty) to 3 (unable to do).
HAMIS is a performance-based test evaluating hand function in SSc and composed of 9 items related to movements that are part of daily activities, with a total score of 27 for each hand; higher scores indicate greater disability25,26.
CHFDS measures hand ability in performing 18 hand tasks. Total score range is 0–90, with higher scores meaning higher disability27,28.
MHISS assesses handicaps associated with SSc mouth disability. It consists of 12 items (with total score ranging 0–48) divided into 3 subscales: subscale 1 examines handicap related to reduced mouth opening; subscale 2 assesses handicap related to sicca syndrome; subscale 3 examines aesthetic concerns29,30.
The PDSBE Scale is a 10-item questionnaire evaluating respondents’ capacity to feel positive about their sexuality and body while living with a physical impairment. Total score range is 10–50, with higher values reflecting a more positive evaluation of disability and body esteem31.
Range of motion measures in patients with SSc
Fist closure is valued as the distance between the fingertip of the third finger and the thenar eminence when making a fist, and hand opening as the distance between the fingertip of the third finger, when extended, and the table.
Maximal oral aperture is measured as the distance between the lower and upper lip vermilion border while the patient opens the mouth as widely as possible.
All measures were reported in cm and as the mean of 2 consecutive measurements.
Statistics
Continuous and binomial variables are presented as mean ± SD (median, range) and as numbers and percentages, respectively. To compare the clinical characteristics of groups, Fischer’s exact test or the chi-square test were used to test for binomial variables, and the Student t test and Mann-Whitney test for continuous variables (as appropriate).
In patients with SSc and controls, bivariate association between sexual functioning, psychological, physical, and disease-associated variables were assessed by Spearman’s correlation. Variables significantly correlated with sexual functioning were entered in hierarchical multiple regression models in which the FSFI score was the dependent variable.
For all tests, the significance was set at a p value < 0.05. All analyses were performed using SPSS version 20.0 for Windows.
RESULTS
There were no significant differences between patients and controls in age, education level, and marital status.
Compared to controls, fewer women with SSc had a paid profession (p = 0.009) and more of them were pensioners (p = 0.014). The patients with SSc more often reported dyspareunia (p = 0.044) and vaginal dryness (p = 0.044), and more of them were in menopause (p = 0.029; Table 1).
The clinical and laboratory characteristics of patients with SSc are shown in Table 2.
Sexual function assessment
Of the patients with SSc, 13/46 (28%) were no longer sexually active. Reasons for sexual inactivity were lack of a partner (n = 6; 46%), health status of the partner (n = 1; 8%), or personal choice (n = 6; 46%). No patient indicated SSc as the primary reason for sexual inactivity.
When asked about disease-related problems potentially affecting sexual functioning, the symptoms most often mentioned were vaginal dryness (52%), inability to use hands (48%), vaginal pain (45%), finger sores (45%), and hand pain (42%; Table 3).
Compared to controls, patients with SSc had a lower FSFI desire subscale score (p = 0.035). There were no significant differences in FSFI total score and all the other subscale scores (including arousal, lubrication, orgasm, satisfaction, and pain) between women with SSc and controls (Table 4).
With the application of the FSFI cutoff score of > 26.5517, 31/46 (67%) of patients with SSc and 25/46 (54%) of controls (p = NS) may be considered to have an impaired sexual function.
FSFI scores according to sexual activity
When assessed for sexual activity, 5/46 (11%) of controls were not sexually active (p = NS vs patients with SSc), because of personal choice (n = 3; 60%) and lack of a partner (n = 2; 40%).
In patients with SSc and in healthy controls, sexually active women presented a higher FSFI total score than inactive subjects (24.24 ± 8.54 vs 2.00 ± 0.00; p < 0.001 and 23.46 ± 9.81 vs 2.00 ± 0.00; p < 0.001, respectively).
No significant difference was found in FSFI total score between sexually active patients with SSc and active healthy women (24.24 ± 8.54 vs 23.46 ± 9.81; p = NS) and between sexually inactive patients with SSc and inactive healthy women (2.00 ± 0.00 vs 2.00 ± 0.00; p = NS).
Thirty-eight out of 46 patients with SSc (83%) and 37/46 (80%) of healthy women have a partner (p = NS). Among subjects without a partner, a higher number of controls (8/10; 80%) than patients with SSc (1/8; 13%) reported to be sexually active (p = 0.015).
Patients with SSc who had a partner had higher FSFI total score than patients without a partner (21.37 ± 10.92 vs 2.13 ± 0.35; p < 0.001). Healthy women living with a partner presented higher FSFI total scores than those without a partner (23.89 ± 9.82 vs 11.20 ± 11.88; p = 0.001).
FSFI total score was not different between patients with SSc and controls with a partner (21.37 ± 10.92 vs 23.89 ± 9.82, p = NS), while controls without a partner had a significantly higher FSFI total score than patients with SSc who did not have a partner (11.20 ± 11.88 vs 2.13 ± 0.35; p = 0.039).
Quality of life and fatigue assessment (Table 4)
SF-36 scores of SPI, PF, PP, BP, GH were lower in patients with SSc than in controls (p < 0.05 for all comparisons). No other differences were found in the other SF-36 domains and in SMI according to groups.
No difference in FACIT-F between patients with SSc and controls was shown (p = NS for all comparisons).
Psychological and self-esteem assessment (Table 4)
Patients with SSc reported higher levels of self-esteem than controls on the RSES (p < 0.001).
No difference was shown in HADS-D and HADS-A between patients with SSc and controls (p = NS for all comparisons).
Compared to controls, patients with SSc presented lower values in COPE-NIV total score (p < 0.001), AS (p < 0.001), and PS subscale scores (p < 0.001).
Comparison between lcSSc and SSc
Patients with dcSSc (age and disease duration: 55.00 ± 12.60 and 10.71 ± 6.86 yrs, respectively) compared to patients with lcSSc (age and disease duration: 57.10 ± 12.61 and 9.30 ± 5.30 yrs, respectively) presented higher skin scores (p < 0.0001), higher positivity for Scl70 (p = 0.02), and lower positivity for ACA (p = 0.02; Table 2).
No significant differences according to subset were found in FSFI score and subscores or in HRQOL, fatigue, psychological and self-esteem variables, or scales and anthropometric measures assessing disability (p = NS for all comparisons; Table 5).
Correlations
In the women with SSc, total FSFI score was negatively correlated with age (p = 0.014), HADS-D (p < 0.001), total HADS (p = 0.002), FACIT-F (p = 0.044), and COPE-NIV AS subscale (p = 0.012).
Patients with SSc showed positive correlations of FSFI total score with PDSBE (p < 0.001) and these SF-36 domains: SMI (p = 0.006), GH (p = 0.029), EP (p = 0.011), and MH (p = 0.034).
Among disease-associated variables, patients with SSc showed negative correlations of FSFI total score with HAQ (p = 0.022), total MHISS (p = 0.038), and mean HAMIS (p = 0.037) scores (Table 6).
In the controls, FSFI total score was negatively correlated with age (p < 0.001), HADS-D, total HADS (p = 0.002 and p = 0.01), FACIT-F (p = 0.026), and COPE-NIV TO subscale (p = 0.034).
Controls showed positive correlation of total FSFI with SF-36 domains PF (p < 0.001), PP (p = 0.005), GH (p = 0.041), and V (p = 0.038).
Total FSFI was positively correlated with COPE-NIV PA (p = 0.007) and PS (p = 0.008; Table 6).
Independent predictors of sexual functioning
In the hierarchical multiple linear regression models, FSFI total score of patients with SSc was significantly associated with vaginal dryness (B = −0.72; t = −5.56; p < 0.001), PDSBE (B = 0.42; t = 3.67; p = 0.001), and HADS-D (B = −0.23; t = −2.22; p = 0.035), which together accounted for 70% of the variance in the FSFI total score.
Healthy participants showed association of FSFI total score with age (B = −0.47; t = −3.52; p = 0.001), FACIT-F (B = −0.36; t = −2.91; p = 0.006), PP of SF-36 (B = 0.29; t = 2.42; p = 0.02), and COPE-NIV TO (B = −0.24; t = −2.15; p = 0.037), which together explained 44% of the variance in total FSFI.
DISCUSSION
In our study, only FSFI desire subscale score was significantly lower in patients with SSc in comparison with healthy controls. Similarly, Bhadauria, et al7 reported a decrease of desire in 57% of women with SSc.
Other studies found impairment in arousal, lubrication, and frequency and intensity of orgasm as measured by FSFI7,13 while, according to our data, scores in those domains were not significantly different in patients with SSc and controls.
The mean FSFI total scores that we found both in SSc patients (18.02) and controls (21.20) were lower than those reported in other studies14,32. However, in agreement with a previous study that used an FSFI cutoff score > 26.5513, the prevalence of sexual dysfunction in our patients with SSc was 67%, a result not significantly different from the controls (54%). Previous studies reported sexual dysfunction in healthy women as ranging from 5% to 63%, varying widely according to countries and age groups33,34,35. Thus, locally validated and age-adapted FSFI cutoff scores should be useful to better understand FSFI results.
The lack of difference in sexual function according to disease subsets (lcSSc and dcSSc) confirmed previous data7,32. Differently from sexual functioning, HRQOL related to physical problems was lower in patients with SSc than in controls. SF-36 SPI, PF, PP, BP, and GH scores were significantly lower in patients with SSc than in controls.
Patients with SSc declaring sexual activity and having a partner had higher FSFI scores than those sexually inactive and without a partner. However, women with SSc who did not have a partner had lower FSFI scores than controls without a partner, and among the patients, subjects declaring sexual activity were fewer than among the controls. Thus, although no patient indicated SSc as the primary reason for sexual inactivity, it is evident that concerns related to the disease affect normal sexual functioning, defined as all the phases of sexual activity, not only as intercourse2,3.
Among disease-specific problems potentially affecting HRQOL36 and sexual functioning, our patients with SSc most often reported vaginal dryness, inability to use hands, vaginal pain, finger sores, and hand pain. The high prevalence of symptoms referring to hands may be related to the selection of patients, mostly enrolled from our day hospital, which is devoted to care for digital ulcers. These results are different from the data of Impens, et al, who found fatigue the most-reported concern affecting sexual activity in patients with SSc14. Further, in contrast with other studies37,38,39,40, our patients with SSc did not present higher levels of fatigue compared to controls.
In the SSc group, menopausal age was lower than in age-matched controls. The number of participants in a menopausal state, as well as those reporting dyspareunia, was significantly higher in patients with SSc, as reported elsewhere7,41,42.
Further, our study showed vaginal dryness as the main factor independently associated with sexual functioning in SSc. Vaginal dryness, chronic inflammation in the vaginal wall, chronic cervicitis, fibrosis, and vaginal ulcerations were already reported as the most important causes of dyspareunia in women with systemic autoimmune disease, especially at postmenopausal age7,12,43.
Patients with SSc reported significantly higher levels of self-esteem than controls. In assessing global self-esteem, various dimensions (such as interpersonal relationships, ability to control the environment, emotional reactions, professional success, family life, and health) should be considered44. It has been demonstrated that self-esteem development across adult life increases during young and middle adulthood, reaching a peak at about 60 years (near to the mean age of our patients) and then declining in old age45. Thus, the unexpectedly higher level of self-esteem reported in our study by patients with SSc is in agreement with the results of Sandqvist, et al, showing how patients with SSc were able to reach a balance of activities in daily life by prioritizing meaningful activities such as work and private life, and adapting to their own resources and limitations46. Our data, showing that patients with SSc do not have an impaired sexual function compared to controls despite disease-related limitations, and the higher number of subjects in menopausal state, may lead to the hypothesis that such meaningful activities could also include sexual activities.
In the bivariate analyses, sexual functioning of patients and healthy participants was significantly correlated with age, depression, and level of fatigue, in accordance with previous studies13,14,32.
Moreover, sexual functioning in our patients with SSc was associated with mouth and hand disability, as assessed by MHISS and HAMIS, and physical disability and sexual and body esteem, as evaluated by PDSBE.
Studies have reported that hand and mouth involvement can affect the sexuality of patients with SSc. Tightening of face skin and sclerosis and ulcers of the fingers can lead to difficulty in using hands and lips4,7,47. For these reasons, women may feel unattractive and avoid sexual contacts47. However, to date no studies have investigated whether mouth and hand disability and sexual and body esteem could be independently associated with sexual function in SSc.
In our study, body esteem, assessed by PDSBE, was independently associated with decreased sexual function of patients with SSc, confirming that physical changes affect body image and sexuality in our female patients. Schoffeour, et al13 found no correlation of FSFI with global disability, in contrast with our study. These results may be due to a longer disease duration (mean 9.9 vs 6.5 years) and to a different selection of our patients, who were derived both from an outpatient clinic and from a day hospital that treated subjects with more severe forms of disease.
We found that sexual functioning was correlated with SF-36 mental subscales in patients with SSc and with physical subscales in controls. This finding is similar to recent surveys, reporting in women with SSc a stronger association of sexual function with psychological than with physical features13,14.
Patients using avoidance coping strategy, according to our data, were more likely to have an impaired sexual functioning. In patients with chronic pain, one of the most frequently used concepts of adaptation strategies differentiates active and passive coping, such as avoidance48. The use of passive coping in patients with RA and chronic pain was associated with higher levels of pain, depression, and functional disability49,50, found to significantly affect sexual functioning13,32,51.
Age, fatigue, physical role limitation of SF-36, and less active transcendent orientation coping were independently associated with decreased sexual activity in healthy participants. As demonstrated in other studies, age-related physical and psychological changes are included among the causes of female sexual dysfunction in the general population. Hormonal changes in menopause, thinning of the vaginal mucosa and reduced lubrication, cardiovascular disease, fatigue, and partner sexuality may affect sexual functioning52,53.
As underlined by previous studies, sexual function surveys are rarely included in the assessment of patients with rheumatic diseases8,38. However, sexuality is influenced by specific disease-related concerns, as confirmed by our data, thus rheumatologists and GP should discuss sexual health with patients with SSc, paying attention to both psychological and physical problems and helping them to find strategies to adapt to a chronic disease, and referring them to specialists when appropriate.
The relatively low percentage of patients responding to our study (53%) is close to that (54%) obtained by Schouffoer, et al13 who were the first to administer the FSFI to patients with SSc. This response rate underlines how the completion of a complex set of questionnaires including FSFI may be regarded as too demanding by patients who are not used to discussing sexuality with doctors; patients may find it difficult to comply because of the intimate contents of the FSFI itself.
A limitation of our study was the relatively small sample size of patients and controls, making it impossible to compare sexual functioning between sexually active and inactive participants. That comparison is needed, and research to confirm the relationship of psychological, physical, and disease-associated problems with sexual function impairment.
In SSc, sexual function, although not different from controls, is influenced by specific disease-related and psychological concerns, with vaginal dryness, physical disability, sexual and body esteem, and depression as independent predictors of sexual impairment. Also, mouth and hand disabilities, typical of the disease, are related to sexual impairment. Thus, evaluation of sexual function should be included in clinical assessment of patients with SSc, ultimately to help them to improve their HRQOL.
- Accepted for publication July 10, 2013.
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