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The evaluation of sexual function in women with stroke
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/neuroindia.NI_1102_15
Background: Although very common, sexual dysfunction is a neglected disorder in women with stroke. Keywords: Depression, sexual function, stroke, women
According to the definition by the World Health Organization (WHO), stroke is a clinical syndrome characterized by sudden onset of neurological signs and symptoms due to vascular causes.[1] Stroke is one of the commonest neurological disorders of adults. Epidemiological data from Western countries demonstrate that the incidence of stroke in adults is almost 0.2%. In almost a third of cases, the patients have long-term sequelae. Stroke is the second leading cause of death across the world, and a leading cause of disability and dependence in the elderly population.[2],[3] In addition, stroke negatively influences quality of life, as well as sexual function.[4],[5] Sexuality is an indispensable and important part of human life. Influenced by social, demographic and psychosocial factors, sexual dysfunction is an important and widespread health challenge, and is seen very often in patients with physical disabilities and chronic diseases such as stroke.[6],[7] It is considered that nearly 40–45% of women and 20–30% of men in the general population experience sexual dysfunction.[8] Although functional, cognitive, behavioral, and emotional problems faced after stroke are usually evaluated, sexual functions of stroke patients is rarely assessed. The present study was designed to determine the effect of stroke on women's sexuality, as well as to compare them with those prevalent in the healthy population.
The study comprised of 112 participants, 51 in the study group and 61 in the control group. Sixty-five sexually active premenopausal women with stroke were followed up in the Neurology Department of Konya Education and Research Hospital and were included in the study, while sexually active and healthy 65 premenopausal women constituted the control group. The strokes were either ischemic or hemorrhagic, and the onset of stroke was at least 3 months prior to the recruitment of patients into the study. Fourteen women from the study group and 4 in the control group refused to respond to the questions because of personal reasons. Hence, 51 women with stroke and 61 healthy controls were enrolled in the study. Stroke was diagnosed according to the WHO criteria, which included sudden onset of neurological deficits because of vascular etiology.[9] In addition, infarcts, hemorrhages and their sequelae were confirmed in all patients via imaging techniques such as magnetic resonance imaging (MRI) and/or computed tomography (CT). An ethical approval was obtained from the institutional ethics committee. Participants who agreed to be included in the study were informed about the study design, and written consent forms were obtained from all the participants. In both of the groups, women who were pregnant, those who were exposed to any surgical procedure such as hysterectomy or vaginal surgery that could affect sexuality, those who were sexually inactive for the last 4 weeks, those with the self-reported history of sexual dysfunction prior to stroke, those using hormonal contraceptives, and those treated with oral or vaginal estrogen drugs were excluded from the study. In addition, women with communication problems; using benzodiazepines, antidepressants, anticonvulsants, and anxiolytic drugs; with the history of major psychiatric disorders, and cognitive and psychiatric problems prior to stroke; with fecal and urinary incontinence; with a history of inflammatory disorder such as ankylosing spondilitis or rheumatoid arthritis, with restriction of the hand, knee, and hip joints; and, those who were chronic alcohol users were excluded from the study. Along with obtaining information from their history, all patients were physically examined for residual symptoms and signs. In all participants, sexual function was assessed with the Female Sexual Function Inventory (FSFI), level of depression with the Beck Depression Inventory (BDI), level of independence with the Modified Rankin Scale (MRS), and severity of stroke and clinical status of patients after stroke with National Institute of Health Stroke Scale (NIHSS). A private chamber in the hospital was allocated for participants to fill in the questionnaire in a comfortable and confidential manner. The FSFI is a form with 19 items, which is self-reported, and has been developed in order to determine the primary aspects of sexual function in women, including desire, arousal, lubrication, orgasm, satisfaction, and pain. Along with the total score, the scores of six subscales evaluating sexual function (sexual desire, arousal, lubrication, orgasm, satisfaction, and pain during intercourse) were also measured. In the scale, the responses of each aspect of sexual function were scored between 0 and 5. A higher score correlated with better sexual functions. A zero score implied that the respondent did not have sexual intercourse within the last month.[10] Beck Depression Inventory (BDI) is a valid and reliable inventory used to measure the depressive symptoms in an individual, and to investigate quantitatively the intensity of depression experienced during the last week. It is composed of 21 items related to several depressive hallmarks, such as sadness, pessimism, past failure, loss of pleasure, feelings of guilt, fear of being punished, irritability, fatigue, changes in appetite, indecisiveness, loss of interest in sex, changes in sleeping pattern, and social withdrawal. Each item is scored between 0 and 3 with the total score changing between 0 and 63. The Turkish version was developed by Hisli et al. The score of 17 and above is accepted to reflect depression.[11] Consistent with the study by Hisli et al., a BDI score of ≥17 was taken to be indicating the presence of depression. Modified Rankin Score (mRS) was developed to evaluate the functional dependence in patients with stroke and measures the effects of stroke on the patients' daily activities. The stages are defined as follows: 0, no symptoms; 1, no definite disability despite symptoms, able to carry out all usual duties and activities; 2, mild disability, unable to carry out all previous activities, but able to look after own affairs without assistance; 3, moderate disability, the patient requires some help but is able to walk without assistance; 4, moderately severe disability, the patient is unable to walk without assistance and unable to attend to own bodily needs without assistance; and 5, severe disability, patient is bedridden, incontinent and requires constant nursing care and attention.[12] The NIHSS is a clinical scale used for the follow up of stroke patients, which defines the severity of stroke and consists of 11 items, each including three subscales used to measure stroke severity. The highest score possible on the scale is 36. The lesser the NIHSS score, the better is the post-stroke outcome.[13],[14] Statistical analysis For statistical analysis, the Statistical Package for the Social Sciences version 21.0 software (SPSS; IBM, New York, NY) was used. The collected data were summarized as mean ± standard deviation. The consistency of variables to normal distribution rates was detected using the histogram and the Kolmogorov–Smirnov test. Parametric data of patients were analyzed with the student's t- test and non-parametric data with the Chi-square analysis. For abnormally distributed data, the Mann–Whitney U test was used. In the patients' group, the association between the FSFI scores, and the visual analog scale (VAS), BDI, NIHSS, mRS scores, age, body mass index (BMI) and duration of complaints was evaluated via the Spearman's correlation analysis. P values less than 0.05 were considered to be statistically significant. In determining correlation coefficients, those between 0 and 0.25 were accepted as no correlation; between 0.25 and 0.50 as moderate correlation; between 0.50 and 0.75 as strong correlation; and between 0.75 and 1.00 as very strong correlation.
All participants were married. The participants were similar with regard to age, BMI, duration of marriage, number of births, monthly income level, and familial, educational, and professional status (P > 0.05) [Table 1]. The mean duration of the disease in women with stroke was 4.22 ± 4.36 years. The existing co-morbidities in these patients were hypertension (14, 27.5%), diabetes mellitus (2, 3.9%), cardiac pathology (2, 3.9%), and both diabetes and hypertension (4, 7.8%). In stroke patients, a left sided stroke was found in 21 patients (41.2%), while a right sided stroke was seen in 30 patients (58.8%). The total FSFI and FSFI subscale scores were lower in those with stroke than the controls. The BDI scores were higher in women with stroke as compared to the healthy controls (P < 0.001) [Table 2]. We found that depression (BDI score >17) was present in 60.8% of women with stroke (n = 31) and in 9.8% of controls (n = 6) (P < 0.001). The FSFI and FSFI subscale scores of stroke patients with BDI ≥17 were significantly lower than those of stroke patients with BDI <17 (P < 0.001) [Table 3]. The FSFI total scores, and the subscale scores including lubrication, orgasm, satisfaction, and pain scores were found to be significantly lower in stroke patients with BDI <17 as compared to the controls [Table 4].
Temporal lobe involvement was seen in 8 patients with stroke. In terms of the FSFI and FSFI subscale scores, no difference was observed between the patients with temporal lobe involvement (n = 8) and those with extratemporal lobe involvement (n = 43) with regard to desire, arousal, lubrication, orgasm, satisfaction, and pain (total FSFI scores: 13.76 ± 7.56 and 16.44 ± 9.08, respectively; P > 0.05). The FSFI and FSFI subscale scores of women with stroke were similar in patients with right and left lobar involvement (P > 0.05) [Table 5]. In women with stroke, there was a negative correlation between the total FSFI score, and the BDI (r = −0.810), mRS (r = −0.706), NIHSS (r = −0.724), age (r = −0.483), duration of marriage (r = −0.510), and number of births (r = −0.253); while there was a positive correlation between the total FSFI score and educational status (r = 0.357). No correlation was detected between the total FSFI score, duration of illness (r = −0.119), and level of income in women with stroke (r = −0.142).
Sexuality is an indispensable and significant part of life, and is a complex phenomenon which includes physical, psychological, biological, behavioral, and interpersonal dimensions of quality of life.[8] Sexual dysfunction is an important and widespread health challenge, and is influenced by medical and psychosocial conditions, such as disease and disabilities.[5],[15] Sexual dysfunction is encountered in approximately 40–45% of women and 20–30% of men in the general population, and affects the women's general health status by decreasing the quality of life, leading to stress.[8] Stroke is one of the leading causes of death and disability across the world.[16] Neurological deficits arising from stroke lead to significant functional restrictions in patients. In a study by Patel et al., the restriction of physical abilities is seen in 26.1% patients, and the rate of disability is as high as 55%.[17] As a chronic disease, stroke also leads to sexual dysfunction, in addition to other serious disabilities.[13],[18],[19],[20] In various studies, it has been reported that the rates of sexual dysfunction ranged between 57 and 75% after stroke.[21],[22],[23] Although numerous studies have investigated the physical problems in patients after stroke, studies investigating the crucial aspects of quality of life such as sexual function and satisfaction in stroke patients are limited in number.[24] It is reported that sexual lives of women are affected negatively after stroke, and such women are unable to share their sexual challenges with healthcare providers because of their shyness and privacy, and are not supported in terms of their sexual problems by the providers. Further, some studies assert that sexual dysfunctions in stroke patients are generally neglected by healthcare providers and are not questioned satisfactorily. [5],[13],[23],[24],[25],[26] Sexual dysfunctions experienced by stroke patients are a complex group of disorders and that have a multifactorial etiology that also includes psychosocial factors and organ-related deficiencies. Sexual function after stroke is negatively affected by medical conditions such as diabetes mellitus, hypertension, cardiac failure, previous illnessess, use of medication, as well as psychological factors such as fear of re-experiencing stroke, depression, anxiety, decrease in self-esteem, changing roles, rejection by a partner or spouse, communication problems due to aphasia or unwillingness to communicate, and changes seen in relationships between spouses.[5],[8],[18],[20],[23],[27],[28] It was also reported that problems such as muscle weakness, fatigue, and spasticity occur following stroke.[5],[8] In several studies, sexual intercourse was found to be negatively affected after stroke in women. While the frequency of intercourse, desire, vaginal lubrication, satisfaction, arousal and orgasm decreases in women after stroke, sexual pain is reported to increase, and is the most common symptom influencing sexual dysfunction.[5],[13],[19],[20],[21],[22],[26],[27],[28],[29],[30] In our study, sexual function scores determined via the FSFI were significantly lower in women with stroke (16.02 ± 8.85), compared to controls (27.55 ± 5.11; P< 0.001). In another study performed on 1009 Turkish women, the mean FSFI score was 24.3 ± 9.5.[31] Another study reported the FSFI cutoff score as being 26.55.[32] The mean FSFI score in our control group was higher than that of the aforementioned two studies. We considered that our controls had no sexual dysfunction while they were compared with stroke patients. We found that the mean total FSFI and FSFI subscale scores of women with stroke were lower than those found in our control group. Sexual satisfaction is a significant hallmark of total satisfaction obtained from all aspects of life. A low score on the sexual well-being scale reflects in a decreased sense of happiness in life as a whole.[33] Hence, in order to increase the quality of life in women who have suffered stroke, the factors that are known to lead to sexual dysfunction should be rectified. In our study, the FSFI score was observed to reduce with a higher dependence level of the patients as determined by the mRS (r = −706), as well as an increasing severity of stroke as determined by the NIHSS (r = −0.724). This finding shows that the dependence level of patients for activities of daily living and the severity of stroke are the two most important determinants of sexual dysfunction experienced by women with stroke. Likewise, in previous studies, mobility-restricting and physical problems caused by stroke were reported to affect sexual intercourse and sexual function negatively.[5],[8],[19],[23],[34],[35],[36] Problems such as muscle weakness, pain, and flexor spasms were reported to lead to difficulties in sexual positioning during intercourse.[8],[23],[34] In the study by Sjögren and Fugl-Meyer, it was reported that coital frequency after stroke becomes rapidly and permenantly decreased, and the decrease in coital frequency is seen more in hemiplegics than in hemiparetics.[37] Stroke reduces various aspects of a patient's quality of life, while increasing the physical, psychological, biological, and social challenges. It also leads to serious emotional stresses on both the patients themselves and their families.[38],[39] In a meta-analysis, depression was reported to be very frequent in stroke patients.[40],[41] The etiology of depression after stroke is multifactorial. Among these risk factors, the feeling of insufficiency and inadequacy is the most important effect. When left untreated, depression leads to decreased success in achieving rehabilitation in stroke patients.[38] Depression leads to significant sexual problems such as decrease in libido and desire, difficulty in sexual arousal, and difficulty in attaining orgasms.[42] In the studies performed in stroke patients, it was reported that women experience intense depressive symptoms such as fatigue, social isolation, fear, anxiety, intolerance with other individuals and nervousness after stroke, and these psychological factors also affect sexual life in a negative manner.[5],[19] In our study, 60.8% of the stroke patients were depressed. The levels of sexual dysfunction in stroke patients who had depression were higher. There was an association between the depression scores and the sexual dysfunction scores. Our results indicate that depression is very common in women with stroke, and has a negative effect on sexual function. Hence, patients with stroke should be carefully followed up for depression, and both patients and their family members should be supported psychosocially when depression is diagnosed. Another important problem observed after stroke is fatigue. While it may be a result of stroke, fatigue may also be a sequele of depression following stroke.[26],[43] In addition, accompanying cardiovascular and endocrinal disorders could be contributory factors leading to fatigue.[8] In a study performed in 51 hemiplegic or hemiparetic patients, Sjogren et al., reported that fatigue is the primary cause of the decreasing sexual satisfaction in female patients.[26] In another study, Thompson emphasized that fatigue is an important factor leading to avoidance of sexual intercourse, and that fatigue or tiredness could diminish the patients'autonomy, causing them to feel guilty and anxious about their physical appearance (in particular, the presence of facial asymmetry and drooling of saliva from angle of mouth). This may give rise to a reluctance of the patients to seek physical contact with their spouse.[23] There are multifactorial reasons responsible for fatigue in stroke patients; there is also difficulty in defining the level of fatigue; hence, the association between the level of fatigue and sexual dysfunction was not investigated in our study. This is one of the limitations of our study. The association between the cerebral hemispheres involved by stroke and the development of sexual dysfunction has been emphasized in various studies. In the studies investigating the correlation between the hemisphere involved and sexual dysfunction in women who have had a stroke, different findings have been reported. One of the studies reported that sexual dysfunction is higher in women with a left hemispheric involvement.[22] However, other studies have not found any correlation between the hemisphere involved and the level of sexual dysfunction.[13],[30] In our study, the total FSFI and FSFI subscale scores of women who suffered from stroke were similar in women with either the right or left lobar involvement. Although there are studies suggesting that temporal lobe lesions may be associated with hypersexuality, such an association still remains controversial.[22],[28] In our study, we detected no difference between the total FSFI scores of patients with and without temporal lobe involvement. However, only 8 patients had temporal lobe involvement in our study. We think that comprehensive studies with larger samples are needed in order to determine whether hypersexuality is present in patients with temporal lobe involvement. Our study has some limitations. Our study findings may not be be generalized to the whole population in Turkey, because it was a single center study within a defined group. Genital sympathetic skin responses were not investigated in our participants. In literature, it has been reported that previous medical co-morbidities, such as diabetes mellitus and hypertension, and the use of medications such as antidepressants, anticonvulsants, and antihypertensives may lead to sexual dysfunction after stroke.[8],[13],[21],[24],[26] This may have led to the confounding of results obtained in the present study. Finally, the fact that we excluded individuals who had already been using antidepressants and anticonvulsants from the study (although we did include patients who were using antihypertensive drugs and those with disorders such as diabetes mellitus and hypertension) may have led to the underreporting of the prevalence of depression. This also forms one of the limitations of our study.
Our study findings show that sexual dysfunction is common in women with stroke, and sexual dysfunction is associated with increased disease severity, dependence levels, and associated depression. Therefore, women with stroke should also be evaluated for sexual dysfunction, along with physical functions during follow-up. We advocate that women diagnosed with sexual dysfunction should be properly counseled and directed to appropriate health centers after determining their psychosocial needs. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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