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Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
The Effect of Fatigue and Fibromyalgia on Sexual Dysfunction in Women With Chronic Fatigue Syndrome a
a
a
a
Alicia Blazquez , Eva Ruiz , Luisa Aliste , Ana García-Quintana & José Alegre
a
a
Unit of CFS and Fibromyalgia, Vall Hebron Hospital, Internal Medicine, Barcelona, Spain Accepted author version posted online: 25 Nov 2013.Published online: 11 Mar 2014.
Click for updates To cite this article: Alicia Blazquez, Eva Ruiz, Luisa Aliste, Ana García-Quintana & José Alegre (2015) The Effect of Fatigue and Fibromyalgia on Sexual Dysfunction in Women With Chronic Fatigue Syndrome, Journal of Sex & Marital Therapy, 41:1, 1-10, DOI: 10.1080/0092623X.2013.864370 To link to this article: http://dx.doi.org/10.1080/0092623X.2013.864370
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
JOURNAL OF SEX & MARITAL THERAPY, 41(1), 1–10, 2015 C Taylor & Francis Group, LLC Copyright ISSN: 0092-623X print / 1521-0715 online DOI: 10.1080/0092623X.2013.864370
The Effect of Fatigue and Fibromyalgia on Sexual Dysfunction in Women With Chronic Fatigue Syndrome Alicia Blazquez, Eva Ruiz, Luisa Aliste, Ana Garc´ıa-Quintana, and Jos´e Alegre
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
Unit of CFS and Fibromyalgia, Vall Hebron Hospital, Internal Medicine, Barcelona, Spain
Sexual dysfunction in patients with chronic fatigue syndrome is attracting growing interest but, to date, few studies have analyzed it. For this reason, the authors evaluated sexual dysfunction in women with chronic fatigue syndrome (using the Golombok Rust Inventory of Sexual Satisfaction) and explore correlations with fatigue and other symptoms. Sexual dysfunction was greater in patients with chronic fatigue syndrome (n = 615) with a higher number of cognitive, neurological, and neurovegetative symptoms, concomitant fibromyalgia, Sj¨ogren’s syndrome, or myofascial pain syndrome, and more intense fatigue (p < .05).
INTRODUCTION Sexual dysfunction is an important public health problem that affects women more than men (Lauman et al., 2005; Lauman, Paik, & Rosen, 1999; Mercer et al., 2003; Rosen & Laumann, 2003). It is particularly common in women with conditions characterized by chronic fatigue and pain (Basson, 2007) such as chronic fatigue syndrome (CFS; Gilhooly, Ottenweller, Lange, Tiersky, & Natelson, 2001). Furthermore, patients with CFS often have comorbidities such as fibromyalgia, Sj¨ogren’s syndrome, and myofascial pain syndrome—disorders that all have a major effect on women’s sexuality (Aaron, Burke, & Buckwald, 2000; Sirisois & Natelson, 2001). Although CFS appears to have a considerable effect on sexual function, few studies have analyzed this issue (G´omez, God´as, & Fern´andez-Sol`a, 2005). The potential association between CFS and sexual dysfunction was first highlighted in a study of Gulf War veterans by Gilhooly and colleagues (2001), who showed that sexual dysfunction and decreased libido were more common in women with CFS than in healthy controls (60% vs. 10% and 81% vs. 19%, respectively). The study also reported that sexual dysfunction correlated with fatigue but not with psychiatric problems. In contrast with the findings of Gilhooly and colleagues (2001), a Dutch study by Vermeulen and Scholte (2004) did not find a higher prevalence of sexual dysfunction in fatigued women (n = 35) compared with controls (n = 36). However, in 2008, a study of 27 women with CFS and 15 healthy controls published by our group (Blazquez et al., 2008) provided evidence in support of the hypothesis proposed by Gilhooly and colleagues (2001). More studies have focused on sexuality Address correspondence to Alicia Blazquez. E-mail: [email protected]
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
2
BLAZQUEZ ET AL.
in association with fibromyalgia than with CFS (Shaver, Wilbur, Robinson, Wang, & Buntin, 2006), although some studies have analyzed both conditions (Blazquez, Alegre, & Ruiz, 2009). Fibromyalgia is one of the most common comorbidities in CFS, with a prevalence of between 20% and 70% (Jason, Taylor, & Kennedy, 2000). An article published in 2007 observed associations between vulvodynia and fibromyalgia (and CFS), with 40% of patients reporting effect on sexual experiences (Arnold, Bachmann, Rosen, & Rhoads, 2007). Another study published in the same year described an association between vestibulodynia and fibromyalgia (Johannesson, Nygren, Brodda, & Bohm-Starke, 2007). Vulvar pain in fibromyalgia can considerably affect patients’ sex lives as it can lower self-esteem and cause relationship problems (Bazzichi et al., 2012; Gordon, Panahian-Jand, McComb, Melegari, & Sharp, 2003); symptoms of CFS have been seen to have ¨ u and colleagues (2006), a considerable effect on patients’ sex lives (Blazquez et al., 2011). Unl¨ who also used the Golombok Rust Inventory of Sexual Satisfaction (GRISS), reported a higher prevalence of sexual dysfunction in Turkish patients with fibromyalgia, while Kool, Woertman, Prins, Van Middendorp, and Geenen (2006), in a study performed in The Netherlands in the same year, reported that low relationship satisfaction and active engagement of the spouse may cause more sexual problems. Prins, Van der Meer, and Bleijenberg (2006) reported that the most common disorder in patients with fibromyalgia (and CFS) was hypoactive sexual desire, a finding that is consistent with the observation of decreased libido in women with CFS by Gilhooly and colleagues (2001). A more recent study comparing 31 women with fibromyalgia with 20 healthy controls and 26 women with rheumatoid arthritis reported significantly higher rates of sexual dysfunction in patients with fibromyalgia and rheumatoid arthritis compared with controls (Orellana et al., 2008). Sexual dysfunction was also more common in fibromyalgia (97%) than in rheumatoid arthritis (84%). Aims In view of the paucity of data on sexual dysfunction in CFS, we set out to assess the association between CFS and sexuality in a number of respects. We hypothesized that (a) cognitive, neurological, and neurovegative symptoms would be associated with sexual dysfunction; (b) sexual dysfunction would be more prevalent in patients with concomitant fibromyalgia, Sj¨ogren’s syndrome, or myofascial pain syndrome (three of the most common comorbidities in CFS and known to influence sexual activity); and (c) that sexual dysfunction would be correlated with intensity of fatigue.
METHOD Participants A team of CFS and fibromyalgia specialists recruited 615 women with a diagnosis of CFS according to the definitions established by Holmes and colleagues (1988) and Fukuda and colleagues (1994). Included were women older than 18 years of age who were sexually active, who had had a stable heterosexual partner in the past 2 years, and who provided written consent to participating in the study. Excluded were women who had participated in a clinical trial of any type
THE EFFECT OF FATIGUE AND FIBROMYALGIA
3
in the 30 days before recruitment or who, in the investigators’ opinion, would not be capable of following instructions or completing the evaluation.
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
Procedure The patients were recruited consecutively at the CFS and fibromyalgia unit in the Department of Internal Medicine at University Hospital Vall d’Hebron in Barcelona. The study was led by two clinical investigators between the middle of 2007 and the end of 2010. It was approved by the hospital’s research ethics committee, and informed written consent was obtained from all participants before participation. The presence of fibromyalgia was established according to the criteria of Wolfe and colleagues (1990), while that of Sj¨ogren’s syndrome and myofascial pain syndrome was established according to the criteria of Vitali and colleagues (2002) and Travell and Simon (1991), respectively. Measurement Instruments The following data were collected for each patient: personal details (age); demographic characteristics (marital status, educational level, occupation, and occupational status), and clinical history (family history of immune disorders, trigger, form of onset, course of fatigue, time since onset of CFS, age at appearance of symptoms, presence of cognitive, neurological, and neurovegetative symptoms, and presence of fibromyalgia, Sj¨ogren’s syndrome, or myofascial pain syndrome. The effect of fatigue and sexual dysfunction was also measured. Sexual response was measured using the GRISS (Rust & Golombok, 1986), chosen because it is both simple to use and evaluates the variables of interest in this study. The GRISS is a 28-item questionnaire used to assess the presence and degree of sexual dysfunction in men and women. The female version has seven subscales: frequency (number of times a week on which sexual intercourse takes place); communication (extent to which a couple are able to talk about sexual problems); satisfaction (extent to which a woman is satisfied with her sexual partner); avoidance (extent to which a woman actively avoids having sex); sensuality (extent to which a woman gains pleasure from touching and caressing); vaginismus (extent of any tightness around the vagina that interferes with sex); and anorgasmia (extent to which a woman is able to attain orgasm). Fatigue was evaluated on the FIS-40 scale, which measures an individual’s perception of functional limitations that have caused them fatigue in the past month (Fisk et al., 1994). It measures the intensity of fatigue using 40 items divided into three domains, with scores on a 5-point scale ranging from 0 (no fatigue) to 4 (extreme fatigue). The three domains are physical functioning (motivation, effort, stamina and coordination), cognitive functioning (concentration, memory, thinking, reasoning, and organization of thoughts), and psychosocial functioning (isolation, emotions, workload, and coping). Statistical Analysis Variables were described using absolute and relative measures of central tendency and dispersion. The Pearson correlation was calculated to explore associations between qualitative variables, and
4
BLAZQUEZ ET AL.
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
TABLE 1 Participants’ Scores on the Golombok Rust Inventory of Sexual Satisfaction (N = 615) GRISS subscales
Score
M
SD
Median
Range
Frequency Communication Satisfaction Avoidance Sensuality Vaginismus Anorgasmia
0–8 0–8 0–20 0–16 0–24 0–20 0–16
1.9 4.0 12.0 7.6 13.0 9.4 7.8
2.0 2.4 5.5 4.2 5.0 4.9 4.4
1.0 4.0 13.0 8.0 13.0 9.0 8.0
0–8 0–8 0–20 0–16 0–24 0–20 0–16
the Mann-Whitney U test was used to compare means. Type 1 (α) error was set at 5% (95% confidence intervals). Statistical analyses were performed using the R statistical software. RESULTS The mean age of patients was 47.4 years (SD = 8.6 years). Most of the patients were married (82.6%, n = 508). The majority of the patients had at least a primary educational level and were skilled workers. Table 1 shows the scores obtained on the GRISS. Of note in the patients’ clinical history was that 34.1% (n = 210) had a family history of CFS and that a stressful life event was the apparent trigger of the disease in 20.3% (n = 125). The Effect of Symptoms on Sexual Dysfunction The frequency of cognitive, neurological, and neurovegetative symptoms and their correlations with sexual dysfunction are shown in Tables 2 and 3, respectively. Cognitive symptoms correlated with sexual dysfunction on all the GRISS subscales except communication and satisfaction. Patients with a higher number of cognitive symptoms reported less frequency (r = −0.087, p = .03) and sensuality (r = −0.083, p = .039) in their sexual relations, and more avoidance (r = 0.113, p = .005), vaginismus (r = 0.128, p = .001) and anorgasmia (r = 0.082, p = .043). Patients with a higher number of neurosensorial symptoms reported less frequency (r = −0.100, p = .013), satisfaction (r = −0.109, p = .007), and sensuality (r = −0.137, p = .001), and more avoidance (r = 0.164, p < .001), vaginismus (r = 0.171, p < .001), and anorgasmia (r = 0.146, p < .001). Patients with a higher number of neurovegetative symptoms reported less frequency (r = −0.150, p < .001), satisfaction (r = −0.165, p < .001), and sensuality (r = −0.209, p < .001) in their sexual relations, and more avoidance (r = 0.269, p < .001), vaginismus (r = 0.238, p < .001), and anorgasmia (r = 0.174, p < .001). Influence of Fibromyalgia, Sjogren’s Syndrome, and Myofascial Pain Syndrome ¨ With respect to the prevalence of comorbidities, 58.7% of the patients (n = 361) had fibromyalgia, 82.9% (n = 510) had Sj¨ogren’s syndrome, and 65.5% (n = 403) had myofascial pain syndrome.
THE EFFECT OF FATIGUE AND FIBROMYALGIA
5
TABLE 2 Symptoms in Patients With Chronic Fatigue Syndrome (N = 615)
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
Variable Cognitive symptoms Concentration problems Short-term memory problems Task planning problems Calculation problems Reading difficulties Confusion and frequent oversights Disorientation in time and space Nominal aphasia Visual and auditory agnosia Neurological symptoms Ataxia and/or dysmetria Sensory hypersensitivity Light Noise Smells Visual disorders Blurred vision Seeing spots Amaurosis Motor discoordination with or without falls Neurovegetative symptoms Lightheadedness Vertigo Orthostatic hypotension Fainting without loss of consciousness Syncope Frequent palpitations Trembling Excessive sweating Intestinal disturbances Miction disorders Decreased libido/anorgasmia/impotence Visual accommodation problems
n
%
591 575 532 548 562 554 442 528 241
96.1 93.5 86.5 89.1 91.4 90.1 71.9 85.9 39.2
456 574 463 507 391 463 419 265 98 436
74.1 93.3 80.7 88.3 68.1 75.3 90.5 57.2 21.2 70.9
510 431 472 180 102 469 220 440 466 371 539 463
82.9 70.1 76.7 29.3 16.6 76.3 35.8 71.5 75.8 60.3 87.6 75.3
Comparing the mean scores obtained on the GRISS according to the presence or absence of fibromyalgia, Sj¨ogren’s syndrome, and myofascial pain syndrome, we obtained the following results: Patients with fibromyalgia reported less frequency (p = .003), satisfaction (p = .005), and sensuality (p < .001) in their sexual relations, and more avoidance (p = .037), vaginismus (p < .001), and anorgasmia (p = .035). Those with myofascial pain syndrome reported less satisfaction (p = .005) and sensuality (p = .001), and more avoidance (p < .001) and vaginismus (p = .001), while those with Sj¨ogren’s syndrome reported less communication (p = .036), satisfaction (p < .001), and sensuality (p < .001), and more avoidance (p < .001), vaginismus (p < .001), and anorgasmia (p = .001).
6
BLAZQUEZ ET AL.
TABLE 3 Association Between Symptoms and Sexual Dysfunction Measured Using the Golombok Rust Inventory of Sexual Satisfaction (N = 615) Symptoms
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
Subscale Frequency Pearson ρ p Communication Pearson ρ p Satisfaction Pearson ρ p Avoidance Pearson ρ p Sensuality Pearson ρ p Vaginismus Pearson ρ p Anorgasmia Pearson ρ p
Cognitive
Neurological
Neurovegetative
−.087 .030
−.100 .013
−.150
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
The Effect of Fatigue and Fibromyalgia on Sexual Dysfunction in Women With Chronic Fatigue Syndrome a
a
a
a
Alicia Blazquez , Eva Ruiz , Luisa Aliste , Ana García-Quintana & José Alegre
a
a
Unit of CFS and Fibromyalgia, Vall Hebron Hospital, Internal Medicine, Barcelona, Spain Accepted author version posted online: 25 Nov 2013.Published online: 11 Mar 2014.
Click for updates To cite this article: Alicia Blazquez, Eva Ruiz, Luisa Aliste, Ana García-Quintana & José Alegre (2015) The Effect of Fatigue and Fibromyalgia on Sexual Dysfunction in Women With Chronic Fatigue Syndrome, Journal of Sex & Marital Therapy, 41:1, 1-10, DOI: 10.1080/0092623X.2013.864370 To link to this article: http://dx.doi.org/10.1080/0092623X.2013.864370
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
JOURNAL OF SEX & MARITAL THERAPY, 41(1), 1–10, 2015 C Taylor & Francis Group, LLC Copyright ISSN: 0092-623X print / 1521-0715 online DOI: 10.1080/0092623X.2013.864370
The Effect of Fatigue and Fibromyalgia on Sexual Dysfunction in Women With Chronic Fatigue Syndrome Alicia Blazquez, Eva Ruiz, Luisa Aliste, Ana Garc´ıa-Quintana, and Jos´e Alegre
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
Unit of CFS and Fibromyalgia, Vall Hebron Hospital, Internal Medicine, Barcelona, Spain
Sexual dysfunction in patients with chronic fatigue syndrome is attracting growing interest but, to date, few studies have analyzed it. For this reason, the authors evaluated sexual dysfunction in women with chronic fatigue syndrome (using the Golombok Rust Inventory of Sexual Satisfaction) and explore correlations with fatigue and other symptoms. Sexual dysfunction was greater in patients with chronic fatigue syndrome (n = 615) with a higher number of cognitive, neurological, and neurovegetative symptoms, concomitant fibromyalgia, Sj¨ogren’s syndrome, or myofascial pain syndrome, and more intense fatigue (p < .05).
INTRODUCTION Sexual dysfunction is an important public health problem that affects women more than men (Lauman et al., 2005; Lauman, Paik, & Rosen, 1999; Mercer et al., 2003; Rosen & Laumann, 2003). It is particularly common in women with conditions characterized by chronic fatigue and pain (Basson, 2007) such as chronic fatigue syndrome (CFS; Gilhooly, Ottenweller, Lange, Tiersky, & Natelson, 2001). Furthermore, patients with CFS often have comorbidities such as fibromyalgia, Sj¨ogren’s syndrome, and myofascial pain syndrome—disorders that all have a major effect on women’s sexuality (Aaron, Burke, & Buckwald, 2000; Sirisois & Natelson, 2001). Although CFS appears to have a considerable effect on sexual function, few studies have analyzed this issue (G´omez, God´as, & Fern´andez-Sol`a, 2005). The potential association between CFS and sexual dysfunction was first highlighted in a study of Gulf War veterans by Gilhooly and colleagues (2001), who showed that sexual dysfunction and decreased libido were more common in women with CFS than in healthy controls (60% vs. 10% and 81% vs. 19%, respectively). The study also reported that sexual dysfunction correlated with fatigue but not with psychiatric problems. In contrast with the findings of Gilhooly and colleagues (2001), a Dutch study by Vermeulen and Scholte (2004) did not find a higher prevalence of sexual dysfunction in fatigued women (n = 35) compared with controls (n = 36). However, in 2008, a study of 27 women with CFS and 15 healthy controls published by our group (Blazquez et al., 2008) provided evidence in support of the hypothesis proposed by Gilhooly and colleagues (2001). More studies have focused on sexuality Address correspondence to Alicia Blazquez. E-mail: [email protected]
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
2
BLAZQUEZ ET AL.
in association with fibromyalgia than with CFS (Shaver, Wilbur, Robinson, Wang, & Buntin, 2006), although some studies have analyzed both conditions (Blazquez, Alegre, & Ruiz, 2009). Fibromyalgia is one of the most common comorbidities in CFS, with a prevalence of between 20% and 70% (Jason, Taylor, & Kennedy, 2000). An article published in 2007 observed associations between vulvodynia and fibromyalgia (and CFS), with 40% of patients reporting effect on sexual experiences (Arnold, Bachmann, Rosen, & Rhoads, 2007). Another study published in the same year described an association between vestibulodynia and fibromyalgia (Johannesson, Nygren, Brodda, & Bohm-Starke, 2007). Vulvar pain in fibromyalgia can considerably affect patients’ sex lives as it can lower self-esteem and cause relationship problems (Bazzichi et al., 2012; Gordon, Panahian-Jand, McComb, Melegari, & Sharp, 2003); symptoms of CFS have been seen to have ¨ u and colleagues (2006), a considerable effect on patients’ sex lives (Blazquez et al., 2011). Unl¨ who also used the Golombok Rust Inventory of Sexual Satisfaction (GRISS), reported a higher prevalence of sexual dysfunction in Turkish patients with fibromyalgia, while Kool, Woertman, Prins, Van Middendorp, and Geenen (2006), in a study performed in The Netherlands in the same year, reported that low relationship satisfaction and active engagement of the spouse may cause more sexual problems. Prins, Van der Meer, and Bleijenberg (2006) reported that the most common disorder in patients with fibromyalgia (and CFS) was hypoactive sexual desire, a finding that is consistent with the observation of decreased libido in women with CFS by Gilhooly and colleagues (2001). A more recent study comparing 31 women with fibromyalgia with 20 healthy controls and 26 women with rheumatoid arthritis reported significantly higher rates of sexual dysfunction in patients with fibromyalgia and rheumatoid arthritis compared with controls (Orellana et al., 2008). Sexual dysfunction was also more common in fibromyalgia (97%) than in rheumatoid arthritis (84%). Aims In view of the paucity of data on sexual dysfunction in CFS, we set out to assess the association between CFS and sexuality in a number of respects. We hypothesized that (a) cognitive, neurological, and neurovegative symptoms would be associated with sexual dysfunction; (b) sexual dysfunction would be more prevalent in patients with concomitant fibromyalgia, Sj¨ogren’s syndrome, or myofascial pain syndrome (three of the most common comorbidities in CFS and known to influence sexual activity); and (c) that sexual dysfunction would be correlated with intensity of fatigue.
METHOD Participants A team of CFS and fibromyalgia specialists recruited 615 women with a diagnosis of CFS according to the definitions established by Holmes and colleagues (1988) and Fukuda and colleagues (1994). Included were women older than 18 years of age who were sexually active, who had had a stable heterosexual partner in the past 2 years, and who provided written consent to participating in the study. Excluded were women who had participated in a clinical trial of any type
THE EFFECT OF FATIGUE AND FIBROMYALGIA
3
in the 30 days before recruitment or who, in the investigators’ opinion, would not be capable of following instructions or completing the evaluation.
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
Procedure The patients were recruited consecutively at the CFS and fibromyalgia unit in the Department of Internal Medicine at University Hospital Vall d’Hebron in Barcelona. The study was led by two clinical investigators between the middle of 2007 and the end of 2010. It was approved by the hospital’s research ethics committee, and informed written consent was obtained from all participants before participation. The presence of fibromyalgia was established according to the criteria of Wolfe and colleagues (1990), while that of Sj¨ogren’s syndrome and myofascial pain syndrome was established according to the criteria of Vitali and colleagues (2002) and Travell and Simon (1991), respectively. Measurement Instruments The following data were collected for each patient: personal details (age); demographic characteristics (marital status, educational level, occupation, and occupational status), and clinical history (family history of immune disorders, trigger, form of onset, course of fatigue, time since onset of CFS, age at appearance of symptoms, presence of cognitive, neurological, and neurovegetative symptoms, and presence of fibromyalgia, Sj¨ogren’s syndrome, or myofascial pain syndrome. The effect of fatigue and sexual dysfunction was also measured. Sexual response was measured using the GRISS (Rust & Golombok, 1986), chosen because it is both simple to use and evaluates the variables of interest in this study. The GRISS is a 28-item questionnaire used to assess the presence and degree of sexual dysfunction in men and women. The female version has seven subscales: frequency (number of times a week on which sexual intercourse takes place); communication (extent to which a couple are able to talk about sexual problems); satisfaction (extent to which a woman is satisfied with her sexual partner); avoidance (extent to which a woman actively avoids having sex); sensuality (extent to which a woman gains pleasure from touching and caressing); vaginismus (extent of any tightness around the vagina that interferes with sex); and anorgasmia (extent to which a woman is able to attain orgasm). Fatigue was evaluated on the FIS-40 scale, which measures an individual’s perception of functional limitations that have caused them fatigue in the past month (Fisk et al., 1994). It measures the intensity of fatigue using 40 items divided into three domains, with scores on a 5-point scale ranging from 0 (no fatigue) to 4 (extreme fatigue). The three domains are physical functioning (motivation, effort, stamina and coordination), cognitive functioning (concentration, memory, thinking, reasoning, and organization of thoughts), and psychosocial functioning (isolation, emotions, workload, and coping). Statistical Analysis Variables were described using absolute and relative measures of central tendency and dispersion. The Pearson correlation was calculated to explore associations between qualitative variables, and
4
BLAZQUEZ ET AL.
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
TABLE 1 Participants’ Scores on the Golombok Rust Inventory of Sexual Satisfaction (N = 615) GRISS subscales
Score
M
SD
Median
Range
Frequency Communication Satisfaction Avoidance Sensuality Vaginismus Anorgasmia
0–8 0–8 0–20 0–16 0–24 0–20 0–16
1.9 4.0 12.0 7.6 13.0 9.4 7.8
2.0 2.4 5.5 4.2 5.0 4.9 4.4
1.0 4.0 13.0 8.0 13.0 9.0 8.0
0–8 0–8 0–20 0–16 0–24 0–20 0–16
the Mann-Whitney U test was used to compare means. Type 1 (α) error was set at 5% (95% confidence intervals). Statistical analyses were performed using the R statistical software. RESULTS The mean age of patients was 47.4 years (SD = 8.6 years). Most of the patients were married (82.6%, n = 508). The majority of the patients had at least a primary educational level and were skilled workers. Table 1 shows the scores obtained on the GRISS. Of note in the patients’ clinical history was that 34.1% (n = 210) had a family history of CFS and that a stressful life event was the apparent trigger of the disease in 20.3% (n = 125). The Effect of Symptoms on Sexual Dysfunction The frequency of cognitive, neurological, and neurovegetative symptoms and their correlations with sexual dysfunction are shown in Tables 2 and 3, respectively. Cognitive symptoms correlated with sexual dysfunction on all the GRISS subscales except communication and satisfaction. Patients with a higher number of cognitive symptoms reported less frequency (r = −0.087, p = .03) and sensuality (r = −0.083, p = .039) in their sexual relations, and more avoidance (r = 0.113, p = .005), vaginismus (r = 0.128, p = .001) and anorgasmia (r = 0.082, p = .043). Patients with a higher number of neurosensorial symptoms reported less frequency (r = −0.100, p = .013), satisfaction (r = −0.109, p = .007), and sensuality (r = −0.137, p = .001), and more avoidance (r = 0.164, p < .001), vaginismus (r = 0.171, p < .001), and anorgasmia (r = 0.146, p < .001). Patients with a higher number of neurovegetative symptoms reported less frequency (r = −0.150, p < .001), satisfaction (r = −0.165, p < .001), and sensuality (r = −0.209, p < .001) in their sexual relations, and more avoidance (r = 0.269, p < .001), vaginismus (r = 0.238, p < .001), and anorgasmia (r = 0.174, p < .001). Influence of Fibromyalgia, Sjogren’s Syndrome, and Myofascial Pain Syndrome ¨ With respect to the prevalence of comorbidities, 58.7% of the patients (n = 361) had fibromyalgia, 82.9% (n = 510) had Sj¨ogren’s syndrome, and 65.5% (n = 403) had myofascial pain syndrome.
THE EFFECT OF FATIGUE AND FIBROMYALGIA
5
TABLE 2 Symptoms in Patients With Chronic Fatigue Syndrome (N = 615)
Downloaded by [Selcuk Universitesi] at 23:12 11 February 2015
Variable Cognitive symptoms Concentration problems Short-term memory problems Task planning problems Calculation problems Reading difficulties Confusion and frequent oversights Disorientation in time and space Nominal aphasia Visual and auditory agnosia Neurological symptoms Ataxia and/or dysmetria Sensory hypersensitivity Light Noise Smells Visual disorders Blurred vision Seeing spots Amaurosis Motor discoordination with or without falls Neurovegetative symptoms Lightheadedness Vertigo Orthostatic hypotension Fainting without loss of consciousness Syncope Frequent palpitations Trembling Excessive sweating Intestinal disturbances Miction disorders Decreased libido/anorgasmia/impotence Visual accommodation problems
n
%
591 575 532 548 562 554 442 528 241
96.1 93.5 86.5 89.1 91.4 90.1 71.9 85.9 39.2
456 574 463 507 391 463 419 265 98 436
74.1 93.3 80.7 88.3 68.1 75.3 90.5 57.2 21.2 70.9
510 431 472 180 102 469 220 440 466 371 539 463
82.9 70.1 76.7 29.3 16.6 76.3 35.8 71.5 75.8 60.3 87.6 75.3
Comparing the mean scores obtained on the GRISS according to the presence or absence of fibromyalgia, Sj¨ogren’s syndrome, and myofascial pain syndrome, we obtained the following results: Patients with fibromyalgia reported less frequency (p = .003), satisfaction (p = .005), and sensuality (p < .001) in their sexual relations, and more avoidance (p = .037), vaginismus (p < .001), and anorgasmia (p = .035). Those with myofascial pain syndrome reported less satisfaction (p = .005) and sensuality (p = .001), and more avoidance (p < .001) and vaginismus (p = .001), while those with Sj¨ogren’s syndrome reported less communication (p = .036), satisfaction (p < .001), and sensuality (p < .001), and more avoidance (p < .001), vaginismus (p < .001), and anorgasmia (p = .001).
6
BLAZQUEZ ET AL.
TABLE 3 Association Between Symptoms and Sexual Dysfunction Measured Using the Golombok Rust Inventory of Sexual Satisfaction (N = 615) Symptoms
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Subscale Frequency Pearson ρ p Communication Pearson ρ p Satisfaction Pearson ρ p Avoidance Pearson ρ p Sensuality Pearson ρ p Vaginismus Pearson ρ p Anorgasmia Pearson ρ p
Cognitive
Neurological
Neurovegetative
−.087 .030
−.100 .013
−.150
