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doi:10.1111/jog.12313
J. Obstet. Gynaecol. Res. Vol. 40, No. 4: 1023–1029, April 2014
Prevalence of female sexual dysfunction during pregnancy among Egyptian women Magdy R. Ahmed, Elham H. Madny and Waleed A. Sayed Ahmed Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
Abstract Aim: The aim of this study was to assess the prevalence of female sexual dysfunction (FSD) during pregnancy in a sample of women from Egypt. Materials and Methods: This prospective cohort study was conducted among pregnant women who presented to the Obstetrics Outpatient Clinic – Suez Canal University Hospital for routine antenatal care between February 2012 and February 2013. The 451 women who completed the study attended during their first trimester with a singleton pregnancy and were in a stable relationship with their partners for the last 6 months. Sexual function was assessed using the Female Sexual Function Index (FSFI) questionnaire during the 4 weeks preceding pregnancy and then in each trimester during the antenatal visits. Results: Prevalence of FSD during pregnancy was estimated to be 68.8%. According to the FSFI, scores of all domains and total score were significantly reduced during the whole period of pregnancy (average 22.5 ± 3.7) compared to the pre-conception period (30.5 ± 5.6). However, there was significant increase of all domains and total score during the second trimester (26.6 ± 3.9) in comparison to the first and third trimesters (22.4 ± 4.1 and 18.6 ± 3.8, respectively). Total FSFI score was found to be positively correlated to pre-conception total FSFI score. However, age, parity and duration of marriage were negatively correlated. Conclusion: FSD is a prevalent problem during pregnancy among Egyptian women. The magnitude of the problem is highest during the third trimester while the second trimester represents the peak of sexual function during pregnancy. Key words: female sexual dysfunction, Female Sexual Function Index, pregnancy, sexuality.
Introduction Female sexuality depends on the woman’s physical, emotional and psychological states and involves the complex and dynamic interaction between these variables. Female sexual functioning is the ability to achieve sexual domains as arousal, lubrication, orgasm and satisfaction resulting in a better well-being with good quality of life.1 Female sexual dysfunction (FSD) is defined as disorders of libido, arousal and orgasm that can lead to negative impact on women’s quality of life, low self-
esteem and emotional distress.2 Between 30% and 77% of women may experience different degrees of sexual dysfunction during their lives.2–5 However, this incidence varies, probably due to differences in the defining criteria of sexual dysfunction, variable research methodology used in these studies and factors affecting sexual dysfunction, that is, the population involved, culture or lifestyle of studied women, socioeconomic level and traditions from various societies.6–8 Pregnancy is a physiological process that causes various anatomical and physiological changes to the pregnant woman; such changes may play a part in
Received: May 27 2013. Accepted: September 29 2013. Reprint request to: Dr Magdy R. Ahmed, Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Round Road, Ismailia 41111, Egypt. Email: [email protected]
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
1023
M. R. Ahmed et al.
affecting her sexual behavior and activity. Although many previous studies have confirmed that sexual intercourse in normal pregnant women has no significant adverse effects, such as an increased risk of miscarriage, premature rupture of membranes or preterm labor,9–11 many women are still skeptical about that and their concern is considered one of the main causes for FSD during pregnancy.11–14 As sexual dysfunction during the reproductive years is obtaining more and more global interest by public health providers, various diagnostic tools have been used by different researchers. The Female Sexual Function Index (FSFI) is the most widely used and acceptable tool due to its high validity.7,15 Despite the increasing number of epidemiologic studies, there are no sufficient data in the medical literature regarding the prevalence of sexual dysfunction during pregnancy in Egypt. Egypt, as a Muslim conservative community, is lacking adequate studies addressing sexual dysfunction during pregnancy, probably owing to the sensitivity of the topic as well as the lack of a proper instrument to assess the problem. To the best of our knowledge, this is the first study to address FSD during pregnancy in an organized structured manner in the Suez Canal district in Egypt.
Methods With approval from the ethics committee of the Faculty of Medicine, Suez Canal University, this prospective cohort study was conducted among pregnant women who presented to the outpatient clinic of the Obstetrics Department, Suez Canal University Hospital for routine antenatal care from the start of February 2012 till the end of February 2013. Women included in the study presented during their first trimester with a singleton pregnancy and had a stable relationship with their partners for the preceding 6 months. A total of 451 pregnant women completed the study. Gestational age was determined by the date of the last menstrual cycle and confirmed by ultrasound scan. Women were followed up throughout the whole period of pregnancy and were excluded from the study if any maternal or fetal complications – that could restrain sexual activity – were diagnosed during any period of pregnancy (e.g. threatened miscarriage, antepartum hemorrhage, and premature rupture of membranes). The required sample size was calculated based on power of the study of 80% and α-error of 0.05.16 A flow chart of studied patients is presented in Figure 1. Sexual dysfunction was assessed using the FSFI.15 The FSFI is a validated 19-item, self-administered,
Pregnant women who presented for antenatal care during the period of study (n = 1097)
Women who presented during first trimester (Recruited women) (n = 748)
• Excluded due to maternal or fetal complicaƟons (n = 114) • Lost during follow-up period (n = 79) • Excluded due to FSD before pregnancy (n = 104)
1024
Completed the study (n = 451) Figure 1 Flow chart of the studied population. FSD, female sexual dysfunction.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Female sexual dysfunction in pregnancy
screening questionnaire that measures the aspects of sexual function in women (desire, arousal, lubrication, orgasm, satisfaction, and pain). For this study, the Arabic translation was used. The translation was based on the original FSFI questionnaire and was validated before the study population was included. Validation was tested to confirm that the questions were consistently delivered to women and that they carry the intended meaning they were designed for. Responses to each question related to the previous month were reported and scored either from 0 (no sexual activity) or 1 (suggestive of dysfunction) to 5 (suggestive of normal sexual activity). Individual domain scores are obtained by adding the scores of the individual questions that comprise the domain and multiplying the sum by the domain factor provided in the FSFI for each domain. The full scale score is obtained by adding the six domain scores (minimum score possible is 2 and the maximum is 36). Regarding the cut-off level, a total FSFI score of less than 26.5 was considered as sexual dysfunction.17 Women included in the study were seen at 4–8 weeks of gestation and were asked to complete the FSFI to assess the preconception sexual function that would serve as baseline data for further comparison as pregnancy went on. Women who were found to have FSD before pregnancy were excluded from the study. Subsequently, the included women were asked to repeat the questionnaire again roughly at the end of each trimester during antenatal visits to assess the sexual function during these periods. The data obtained for all patients were kept in their records and then extracted at the end of pregnancy for analysis. As a significant proportion of women in our community are illiterate, one of the authors was always available to help with filling out the questionnaire. Due to the sensitivity of the subject, women were assured about the confidentiality of the data obtained and were encouraged to provide data as clearly and as accurately as possible.
Statistical analysis Microsoft Excel 2003 and spss version 15 for Windows were used to analyze data. Data were statistically described in terms of mean, standard deviation, frequencies (number of cases) and percentages. For quantitative variables, the Student’s t-test and anova were used to test significance of difference; and for categorical data, the χ2-test was performed. Multiple logistic regression was used to evaluate risk factors for FSD during pregnancy among the studied participants.
Results Out of the 748 pregnant women recruited, a total of 451 completed the study. The 297 dropouts were due to several factors, including women lost to follow-up (n = 79) and maternal or fetal complications (including miscarriage) (n = 114) in addition to those excluded as a result of existing FSD prior to the start of the study (Fig. 1). Data analysis included only the 451 women who completed the study throughout pregnancy. Table 1 presents the sociodemographic characteristics of studied women. The mean age was 26.5 ± 4.9 years. About half of the studied women (48.3%) were of low parity (P 1–2), followed by primigravidae (30.2%). More than half of the studied women (53.9%) had been married for ≤ 5 years while 13.5% had been married for more than 10 years. Regarding the educational level, 46.7% of women had high educational level while 10.2% were illiterate. According to the FSFI, we found that scores of all domains in addition to the total score were significantly reduced during the whole period of pregnancy compared to the pre-conception period. However, there was significant increase of all domains and total score during the second trimester in comparison to the first and third trimesters. Lowest scores were reported during the third trimester (Table 2). According to the FSFI total score, studied women were classified into two groups: women with FSD who had FSFI total score < 26.5 and women without FSD who had FSFI total score ≥ 26.5. During the first trimester, 56.1% of women had FSD. This percentage decreased to 40.4% during the second trimester and then surged again during the third trimester to be 63.4%. The prevalence of FSD during any period of
Table 1 Sociodemographic characteristics of the studied women n Age (years) Parity Duration of marriage Educational level
Mean ± SD Range Nullipara Para 1–2 ≥Para 3 ≤5 years 6–10 years >10 years Illiterate
doi:10.1111/jog.12313
J. Obstet. Gynaecol. Res. Vol. 40, No. 4: 1023–1029, April 2014
Prevalence of female sexual dysfunction during pregnancy among Egyptian women Magdy R. Ahmed, Elham H. Madny and Waleed A. Sayed Ahmed Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
Abstract Aim: The aim of this study was to assess the prevalence of female sexual dysfunction (FSD) during pregnancy in a sample of women from Egypt. Materials and Methods: This prospective cohort study was conducted among pregnant women who presented to the Obstetrics Outpatient Clinic – Suez Canal University Hospital for routine antenatal care between February 2012 and February 2013. The 451 women who completed the study attended during their first trimester with a singleton pregnancy and were in a stable relationship with their partners for the last 6 months. Sexual function was assessed using the Female Sexual Function Index (FSFI) questionnaire during the 4 weeks preceding pregnancy and then in each trimester during the antenatal visits. Results: Prevalence of FSD during pregnancy was estimated to be 68.8%. According to the FSFI, scores of all domains and total score were significantly reduced during the whole period of pregnancy (average 22.5 ± 3.7) compared to the pre-conception period (30.5 ± 5.6). However, there was significant increase of all domains and total score during the second trimester (26.6 ± 3.9) in comparison to the first and third trimesters (22.4 ± 4.1 and 18.6 ± 3.8, respectively). Total FSFI score was found to be positively correlated to pre-conception total FSFI score. However, age, parity and duration of marriage were negatively correlated. Conclusion: FSD is a prevalent problem during pregnancy among Egyptian women. The magnitude of the problem is highest during the third trimester while the second trimester represents the peak of sexual function during pregnancy. Key words: female sexual dysfunction, Female Sexual Function Index, pregnancy, sexuality.
Introduction Female sexuality depends on the woman’s physical, emotional and psychological states and involves the complex and dynamic interaction between these variables. Female sexual functioning is the ability to achieve sexual domains as arousal, lubrication, orgasm and satisfaction resulting in a better well-being with good quality of life.1 Female sexual dysfunction (FSD) is defined as disorders of libido, arousal and orgasm that can lead to negative impact on women’s quality of life, low self-
esteem and emotional distress.2 Between 30% and 77% of women may experience different degrees of sexual dysfunction during their lives.2–5 However, this incidence varies, probably due to differences in the defining criteria of sexual dysfunction, variable research methodology used in these studies and factors affecting sexual dysfunction, that is, the population involved, culture or lifestyle of studied women, socioeconomic level and traditions from various societies.6–8 Pregnancy is a physiological process that causes various anatomical and physiological changes to the pregnant woman; such changes may play a part in
Received: May 27 2013. Accepted: September 29 2013. Reprint request to: Dr Magdy R. Ahmed, Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Round Road, Ismailia 41111, Egypt. Email: [email protected]
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
1023
M. R. Ahmed et al.
affecting her sexual behavior and activity. Although many previous studies have confirmed that sexual intercourse in normal pregnant women has no significant adverse effects, such as an increased risk of miscarriage, premature rupture of membranes or preterm labor,9–11 many women are still skeptical about that and their concern is considered one of the main causes for FSD during pregnancy.11–14 As sexual dysfunction during the reproductive years is obtaining more and more global interest by public health providers, various diagnostic tools have been used by different researchers. The Female Sexual Function Index (FSFI) is the most widely used and acceptable tool due to its high validity.7,15 Despite the increasing number of epidemiologic studies, there are no sufficient data in the medical literature regarding the prevalence of sexual dysfunction during pregnancy in Egypt. Egypt, as a Muslim conservative community, is lacking adequate studies addressing sexual dysfunction during pregnancy, probably owing to the sensitivity of the topic as well as the lack of a proper instrument to assess the problem. To the best of our knowledge, this is the first study to address FSD during pregnancy in an organized structured manner in the Suez Canal district in Egypt.
Methods With approval from the ethics committee of the Faculty of Medicine, Suez Canal University, this prospective cohort study was conducted among pregnant women who presented to the outpatient clinic of the Obstetrics Department, Suez Canal University Hospital for routine antenatal care from the start of February 2012 till the end of February 2013. Women included in the study presented during their first trimester with a singleton pregnancy and had a stable relationship with their partners for the preceding 6 months. A total of 451 pregnant women completed the study. Gestational age was determined by the date of the last menstrual cycle and confirmed by ultrasound scan. Women were followed up throughout the whole period of pregnancy and were excluded from the study if any maternal or fetal complications – that could restrain sexual activity – were diagnosed during any period of pregnancy (e.g. threatened miscarriage, antepartum hemorrhage, and premature rupture of membranes). The required sample size was calculated based on power of the study of 80% and α-error of 0.05.16 A flow chart of studied patients is presented in Figure 1. Sexual dysfunction was assessed using the FSFI.15 The FSFI is a validated 19-item, self-administered,
Pregnant women who presented for antenatal care during the period of study (n = 1097)
Women who presented during first trimester (Recruited women) (n = 748)
• Excluded due to maternal or fetal complicaƟons (n = 114) • Lost during follow-up period (n = 79) • Excluded due to FSD before pregnancy (n = 104)
1024
Completed the study (n = 451) Figure 1 Flow chart of the studied population. FSD, female sexual dysfunction.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Female sexual dysfunction in pregnancy
screening questionnaire that measures the aspects of sexual function in women (desire, arousal, lubrication, orgasm, satisfaction, and pain). For this study, the Arabic translation was used. The translation was based on the original FSFI questionnaire and was validated before the study population was included. Validation was tested to confirm that the questions were consistently delivered to women and that they carry the intended meaning they were designed for. Responses to each question related to the previous month were reported and scored either from 0 (no sexual activity) or 1 (suggestive of dysfunction) to 5 (suggestive of normal sexual activity). Individual domain scores are obtained by adding the scores of the individual questions that comprise the domain and multiplying the sum by the domain factor provided in the FSFI for each domain. The full scale score is obtained by adding the six domain scores (minimum score possible is 2 and the maximum is 36). Regarding the cut-off level, a total FSFI score of less than 26.5 was considered as sexual dysfunction.17 Women included in the study were seen at 4–8 weeks of gestation and were asked to complete the FSFI to assess the preconception sexual function that would serve as baseline data for further comparison as pregnancy went on. Women who were found to have FSD before pregnancy were excluded from the study. Subsequently, the included women were asked to repeat the questionnaire again roughly at the end of each trimester during antenatal visits to assess the sexual function during these periods. The data obtained for all patients were kept in their records and then extracted at the end of pregnancy for analysis. As a significant proportion of women in our community are illiterate, one of the authors was always available to help with filling out the questionnaire. Due to the sensitivity of the subject, women were assured about the confidentiality of the data obtained and were encouraged to provide data as clearly and as accurately as possible.
Statistical analysis Microsoft Excel 2003 and spss version 15 for Windows were used to analyze data. Data were statistically described in terms of mean, standard deviation, frequencies (number of cases) and percentages. For quantitative variables, the Student’s t-test and anova were used to test significance of difference; and for categorical data, the χ2-test was performed. Multiple logistic regression was used to evaluate risk factors for FSD during pregnancy among the studied participants.
Results Out of the 748 pregnant women recruited, a total of 451 completed the study. The 297 dropouts were due to several factors, including women lost to follow-up (n = 79) and maternal or fetal complications (including miscarriage) (n = 114) in addition to those excluded as a result of existing FSD prior to the start of the study (Fig. 1). Data analysis included only the 451 women who completed the study throughout pregnancy. Table 1 presents the sociodemographic characteristics of studied women. The mean age was 26.5 ± 4.9 years. About half of the studied women (48.3%) were of low parity (P 1–2), followed by primigravidae (30.2%). More than half of the studied women (53.9%) had been married for ≤ 5 years while 13.5% had been married for more than 10 years. Regarding the educational level, 46.7% of women had high educational level while 10.2% were illiterate. According to the FSFI, we found that scores of all domains in addition to the total score were significantly reduced during the whole period of pregnancy compared to the pre-conception period. However, there was significant increase of all domains and total score during the second trimester in comparison to the first and third trimesters. Lowest scores were reported during the third trimester (Table 2). According to the FSFI total score, studied women were classified into two groups: women with FSD who had FSFI total score < 26.5 and women without FSD who had FSFI total score ≥ 26.5. During the first trimester, 56.1% of women had FSD. This percentage decreased to 40.4% during the second trimester and then surged again during the third trimester to be 63.4%. The prevalence of FSD during any period of
Table 1 Sociodemographic characteristics of the studied women n Age (years) Parity Duration of marriage Educational level
Mean ± SD Range Nullipara Para 1–2 ≥Para 3 ≤5 years 6–10 years >10 years Illiterate
