INTRODUCTION

Sexuality, according to the World Health Organization (WHO), can influence a woman’s quality of life by having effects on her emotional, physical, and psychological well-being, one of its fundamental components¹. There is a widespread and mistaken belief that as people age, they lose both interest in and ability to have sexual relations². However, many women continue to maintain sexual interest; in fact, 76% of women aged 42–52 years consider sex to be important to them³. Thus, approximately 67% of American women aged 65–74 years express the importance they give to sex⁴. At the same time, it is widely recognized that sexual activity declines during the transition to menopause and beyond^4-7. Despite the importance of sexual function in women at this stage of life, sexual dysfunction also tends to increase with age⁸. Sexual dysfunction in women is usually associated with the menopausal transition and menopause since they are times characterized by hormonal, physiological, and social changes⁸. Up to 85% of women experience symptoms linked to this transition that vary in intensity and can affect their quality of life⁹. From a physiological point of view, the variation in hormonal levels negatively affects the elasticity of the vaginal mucosa and vaginal lubrication, which leads to vaginal atrophy. Additionally, as we age, the likelihood of weakening of the pelvic floor increases, leading to conditions such as dyspareunia, chronic pelvic pain, and pelvic organ prolapse⁸.

Pelvic floor problems encompass various problems that can affect this muscular structure. These disorders include situations such as urinary incontinence, pelvic organ prolapse in women, fecal incontinence, and pelvic-perineal regional pain syndrome, among others¹⁰. It is a public health problem with a high prevalence and can affect a quarter of adult women¹¹ negatively, influencing the sexual function of women with these symptoms^8,12,13.

Women with pelvic floor dysfunction may experience a decrease in their quality of life and compromised sexual function due to factors such as a negative perception of their body image, anxiety related to incontinence during sexual activity, feelings of shame, dyspareunia, and difficulties in achieving a satisfying orgasm^14-16.

Since the relationship between pelvic floor disorders and sexual function in women during menopause has been investigated to a limited extent^12,13, and considering that there are contradictory findings, and further research on the topic is recommended^17,18. The aim of the present study was to investigate the association between pelvic floor disorders and sexual dysfunction in women during menopause.

METHODS

RESULTS

A total of 197 women participated. The mean age was 57.7 years (SD=8.4), with a mean BMI of 26.6 (SD=4.3); 86.3% (170) of the participants were non-smokers and 53.8% (106) drank alcohol occasionally, 50.3% (99) of the women had University level in terms of education level.

Regarding personal history, 13.6% (7) of the women had a history of gynecological disease, and 4.6% (9) had gastrointestinal disease. Regarding obstetric history, 85.8% (169) of the women had been pregnant on more than one occasion and 33.5% (66) of the women had experienced a miscarriage. Regarding the type of delivery, 78.7% (155) of the women did not undergo a caesarean section, 71.6% (141) had an episiotomy, and 37.1% (73) who suffered an episiotomy had a tear at the same time (Table 1).

Table 2 shows the distribution of the different domains that evaluate women’s sexual function (hypoactive sexual desire dysfunction, female sexual arousal dysfunction, female orgasmic dysfunction, female genital-pelvic pain dysfunction, persistent genital arousal disorder, postcoital syndrome, hypohedonic orgasm, and painful orgasm). It stands out that 51.3% (101) of the women reported having sexual dysfunction. In general terms, 79.5% (155) expressed satisfaction with their sexual health and 75.5% (148) indicated having communication with their partners in intimate relationships. However, 25.5% (50) experienced problems when initiating sexual interaction.

Regarding symptoms, 22.9% (45) stated that they had a severe or moderate problem reaching orgasm, and 29% (57) of women stated that they had never or occasionally felt excitement in the last month. Finally, of the 16 women who had difficulties with vaginal penetration, 43.8% (7) of the women indicated that it was because they felt pain, and 31.3% (5) attributed it to a lack of interest.

Table 3 indicates the bivariate analysis between the different pelvic floor disorders and their association with sexual dysfunctions. It was observed that women who experienced urinary incontinence [49 (42.6%) vs 66 (57.4%), p=0.043] and pelvic pain [12 (25.0) vs 36 (75.0), p<0.001] were more likely to report sexual dysfunction.

The impact of pelvic floor problems was evaluated using the PFDI-20 questionnaire and its association with sexual dysfunctions. Women with sexual dysfunctions were found to have significantly higher mean scores on the POPDI-6 [9.99 (11.82) vs 22.23 (23.31), p<0.001], CRADI-8 [14.84 (15.76) vs 22.43 (20.21), p=0.002], and UDI-6 [18.71 (SD=19.29) vs 32.38 (30.46), p<0.001] subscales compared to those women without sexual dysfunction.

Table 4 below shows the results of the analysis of variance (ANOVA) and Kruskall-Wallis tests, which indicate that the mean scores on the impact of prolapse, colorectal-anal, and urinary symptoms showed statistically significant associations in most of the studied domains of sexual function. However, none of the subscales showed a statistical association with problems related to vaginal penetration. Furthermore, no statistical significance was observed between general sexual satisfaction and colorectal-anal symptoms. In addition, the mean scores, standard deviations, and different p values in the ANOVA and Kruskall-Wallis are shown, as well as the post hoc contrasts with the Dunnett C test.

Finally, a multivariate analysis (Table 5) was carried out to control for confounding and determine which factors were associated with sexual dysfunction. Specifically, pelvic floor dysfunction evaluated through the PFDI-20 scale was identified as the main risk factor, observing that women who had a higher score on this scale were more likely to present sexual dysfunction (AOR=1.01; 95% CI: 1.01–1.02).

DISCUSSION

The women who experienced urinary incontinence and pelvic pain, had a higher frequency of sexual dysfunction. Specifically, pelvic floor dysfunction evaluated through the PFDI-20 scale was identified as the main risk factor, observing that menopausal women who had a higher score on this scale were more likely to present sexual dysfunction.

Sexual health in women is affected during menopause, and there are studies that, among other factors, relate it to the presence of pelvic floor dysfunctions^14,21. Incidence reported by Verbeek and Hayward¹⁶ on sexual dysfunction in women with pelvic floor disorders amounts to 50–83%, with our prevalence being 51.3% of women who suffered from sexual dysfunction.

In relation to sexual function, in a study in which 93 women with urinary incontinence participated, altered items of disorders in sexual desire, orgasmic dysfunction, and sexual satisfaction were observed²². It is important to note that, in our results, no statistically significant alterations were observed with vaginal penetration.

Regarding fecal incontinence, Pauls et al.²³, in a study carried out with women with this dysfunction, identified that women presented a decrease in sexual desire, sexual satisfaction, arousal, lubrication, and orgasmic capacity, but was only significant in the desired domain, whereas Visscher et al.²⁴ observed statistical significance in all domains. In the case of pelvic pain, a study with 200 women, of which 100 had this dysfunction, and in line with our results, showed that the dimensions affected were the domains of sexual desire, arousal, lubrication, orgasm, and pain²⁵. Furthermore, in the study by Verit and Verit with 200 women, including 100 with pelvic pain, it was observed that women who suffered from it reported worse sexual function with respect to desire, arousal, lubrication, orgasm, satisfaction, and greater frequency and severity of pain on vaginal penetration²⁶.

Pelvic pain has been described as an important risk factor in sexual dysfunction, which, combined with other symptoms, can be responsible for up to 50% of sexual dysfunctions²⁷. Faubion et al.²⁸ determined that the impact of these symptoms on women’s sexuality can be very important. Finally, in our study, we identified that pelvic organ prolapse affects all sexual dimensions except penetration; in contrast, Tola et al.²⁹ did not find that prolapse, or any other pelvic floor dysfunction, affects female sexual function.

CONCLUSIONS

Pelvic floor dysfunctions in menopausal women are associated with their sexual health. Pelvic floor dysfunctions symptoms that influence sexual function are colo-rectal, urinary and prolapse. Pelvic floor disorders such as urinary incontinence and pelvic pain are those that most influence sexual function.