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Dyspareunia appears to be a common sexual dysfunction. There is a lack of studies that address female sexual dysfunction (FSD) in Puerto Rico. The present cross- sectional study characterized dyspareunia in a sample of Puerto Rican women aged 40–59 years and evaluated the relationship between reported dyspareunia with demographic, lifestyle and health factors. Nine-hundred and twenty Puerto Rican women participated in health fairs conducted in 22 municipalities between May 2000 and November 2001 where they filled out a questionnaire. Contingency table and chi-squarestatistics were used to evaluate the bivariate associations of dyspareunia with demographic, lifestyle and health factors. Crude and multivariate logistic regression model were used to estimate the magnitude of the association between dyspareunia and demographic, lifestyle and health factors. The overall prevalence of dyspareunia in this population was 18%. Dyspareunia was somewhat lower among women aged 40–49 years (17%) than among those aged 50–59 years(21%), not reaching statistical significance. Dyspareunia was associated to educational attainment, employment status, menopausal status, current hormone therapy use, genitourinary symptoms, and loss of libido (p < 0.05). Current cigarette smoking, body mass index, physical activity, alcohol use, parity, and ever use of oral contraceptives were not associated with dyspareunia in bivariate analysis (p>0.05). In the multivariate analysis, incontinence (POR=1.67, 95% CI=1.02–2.73), vaginal dryness (POR=3.97, 95% CI=2.49–6.31), vaginal itching (POR=2.44, 95% CI=1.55–3.83), loss of libido (POR=3.08, 95% CI=1.92–4.94) and partnership (POR=2.22, 95% CI=1.29–3.82) remained associated with dyspareunia. Our results agree with prior studies. Additional studies of FSD in Puerto Rican women are highly warranted.
Female sexual dysfunction is a multicausal and multidimensional problem that combines sexual, physiological, physical, psychological, and interpersonal determinants, having a major impact on interpersonal relationships and quality of life.1,2 Data from the National Health and Social Life Survey found that sexual dysfunction is highly prevalent in women (43%).2,3,4 Community-based studies indicate a prevalence of sexual dysfunction among all women between 25% and 63%, 2,3,5 while the prevalence of sexual dysfunction in post menopausal women varies from 68% to 87%.3,6 Among the sexual dysfunctions described in females, dyspareunia appears to be common, with a prevalence of 7% in a national probability sample assessing sexual dysfunction in the United States.2 In a more recent meta-analysis of subtypes of chronic pelvic pain sponsored by the World Health Organization (WHO), the prevalence of dyspareunia varied from 1% in Sweden to 45% in the United States, and ranging from 8% to 21%, when high quality studies with representative samples were analyzed.7,8
Dyspareunia is defined by the American College of Obstetricians and Gynecologists (ACOG)9 as genital pain experienced just before, during, or after sexual intercourse. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) describes dyspareunia as recurrent or persistent vaginal pain associated with sexual intercourse in either a male or a female.10 Historically, dyspareunia has been classified as a sexual disorder involving pain.1,10 Other studies classify dyspareunia into a pain syndrome resulting in sexual dysfunction.11–14 Dyspareunia can be subdivided into two groups, superficial/entry/introital dyspareunia and deep dyspareunia, with different etiologies and treatment options.8,11,15 The Report of the International Consensus Development Conference on Female Sexual Dysfunction evaluated and revised existing definitions and classifications of female sexual dysfunction. As part of this revision, a new category of noncoital sexual pain was added that recognizes that sexual activity for women does not necessarily involve penile vaginal intercourse and may apply to non-heterosexual women engaging in alternative sexual behaviors.1 Sexual pain is also characterized by vulvodynia, classified as any type of vulvar pain, and vulvar vestibulitis syndrome (VVS), a subcategory of vulvodynia and a diagnosis of exclusion.15 According to Friedrich, VVS is defined as severe pain with vestibular touch or attempted vaginal entry, tenderness to cotton swab pressure localized to the vulvar vestibule, and physical findings confined to various degrees of vestibular erythema.8 Vaginismus, classified in the DSM-IV as a sexual pain disorder is defined as recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with penis, finger, tampon, or speculum is attempted.10 There is marked overlap in the definitions of dyspareunia, VVS, and vaginismus, making the diagnosis and treatment of these conditions a challenge for clinicians.
A number of factors have been consistently described in the literature to be associated with dyspareunia, including lower educational attainment, interpersonal relationships, depressive symptoms, menopause, low sexual desire, and pelvic floor disorders.2,8,11,13, 15–24 In addition, differences in ethnicity and cultural beliefs have been shown to influence the occurrence and reporting of sexual dysfunction.2,25 Laumann et al. reported lower rates of sexual problems in Hispanic women in the US than in whites and blacks.2 Nonetheless, recent studies conducted in Hispanic populations in their native countries have reported high rates of female sexual dysfunction.25,26 There is a lack of studies that address female sexual dysfunction in Puerto Rican women living in Puerto Rico. To our knowledge, this is the first study conducted in this population that intends to describe health and life-style factors associated with dyspareunia. The present cross-sectional study characterized dyspareunia, defined as pain or discomfort when having sexual relationships, in a sample of middle-aged (40–59 years) Puerto Rican women; and evaluated the relationship between reported dyspareunia and demographic, lifestyle and health factors.
Between May 2000 and November 2001, the Centro Mujer y Salud of the School of Medicine of the University of Puerto Rico hosted 73 health fairs in 22 municipalities across Puerto Rico. The data collection instrument, a self-administered history questionnaire, obtained information on demographic characteristics, lifestyle practices, obstetric and gynecologic history, including menstrual status, the use of oral contraceptives, hormonal therapy (HT) use and symptom experience, and sexual problems. Additional details about the study design and data collection have been previously described elsewhere.27, 28 A total of 3,258 women attended these fairs, although 777 did not fill out the questionnaire. Seventy women did not sign the informed consent, 711 women were outside the eligible age group of 40–59 years, and 39 were not from a Puerto Rican ethnic background. Among the 1,661 eligible women, 350 did not provide responses to demographic and reproductive sections of the questionnaire, 39 did not identify cessation of menses or provide sufficient information to determine current status of HT use and 352 women did not provide information about symptom experience, including dyspareunia. Thus, among age eligible study participants, 920 (55%) women were eligible for this analysis. This study was approved by the Institutional Review Board (IRB) from the University of Puerto Rico, Medical Sciences Campus.
Dyspareunia was defined as pain or discomfort when having sexual relationships experienced during the two months previous to answering the questionnaire. Demographic variables included: age, defined as a categorical variable (40–49 and 50–59 years); educational level attained, categorized into two levels (≤ High-school/Technical course and ≥ Associate Degree); current employment status (employed/unemployed); and relationship status [partner (married/living together) or no partner (single, widowed, divorced, separated)]. Lifestyle characteristics considered included: current cigarette smoking (yes/no), physical activity defined as exercising at least twice a week (yes/no), and any alcohol consumption (yes/no). The health factors considered were: body mass index (BMI), obstetric and gynecologic history, and genitourinary and sexual symptoms. BMI was determined using self reported height and weight and classified into three categories [<25 kg/m2 (underweight/normal), 25–29.9 kg/m2 (overweight), and ≥30 kg/m2 (obese)]. Obstetric history included parity measured as number of live births and categorized as: 0, 1–2, and ≥3 children. Gynecologic history included menopausal status and use of HT, and was defined as follows: pre-menopausal, post-menopausal without current use of HT, and post-menopausal with current use of HT. Women were defined to be premenopausal if their menses had occurred within the last 12 months previous to the interview. Post-menopause was defined as natural menopause, menses stopping for at least 12 months without surgery, pregnancy, or other obvious cause, and surgical menopause, menses stopping as a result of hysterectomy and/or bilateral oophorectomy. Lifetime use of oral contraception (OC) was also gathered (never/ever). Genitourinary and sexual symptoms were described by: vaginal itching (yes/no), vaginal dryness (yes/no), incontinence (yes/no), and loss of libido (yes/no).
Bivariate analyses were performed using contingency tables in order to assess the relationship between dyspareunia and the following variables: demographic, lifestyle, and health factors. Chi-square tests were used in each contingency table to explore how individual factors affected dyspareunia.29
To determine the magnitude of the association between dyspareunia and demographic, life-style and health factors, the prevalence odds ratio (crude and adjusted) were estimated with 95% confidence intervals using logistic regression models.30 Those variables associated (p<0.05) in bivariate analysis to dyspareunia where included in the multivariate regression model; in addition, we adjusted for the potential confounding effects of age. Interaction terms in the multivariate logistic regression model were analyzed using the Likelihood Ratio Test (LRT) 30 No interaction was found (X2 = 29.13, p = 0.61). Data were analyzed using SAS version 8 (SAS Institute Inc., Cay, NC).
Of 920 women in the study sample, 169 (18%) reported dyspareunia. Dyspareunia was somewhat lower among women aged 40–49 years (17%) than among those aged 50–59 years (21%), but it did not reach statistical significance. Dyspareunia was associated to educational attainment and working status; being less reported among women with higher educational attainment (22% vs. 14%) and less reported among those currently working (15% vs. 22%). Meanwhile, dyspareunia was higher among women with a partner (24%) than among those without a partner (8%) (Table 1). Among those categorized as having no partner, the specific prevalence of dyspareunia in each subgroup was 8% for single women, 5% among widowed women and 9% among those separated/divorced (data not shown
Among gynecologic characteristics, menopausal/HT status was associated with dyspareunia (premenopause: 14%, postmenopause using HT: 25%, postmenopause not using HT: 19%; p=0.0037). In addition, dyspareunia was more common in women with urinary incontinence (29%), vaginal dryness (37%), and those with vaginal itching (34%) than in women not reporting these symptoms (16%, 8% and 14%, respectively) (p<0.0001). No association of parity and OC use with dyspareunia was observed (p > 0.05). In addition, none of the lifestyle characteristics studied (current cigarette smoking, BMI, physical activity, and alcohol use) were associated with dyspareunia in bivariate analysis (p > 0.05) (Table 1).
In the multivariate analysis, incontinence (POR=1.67, 95% CI=1.02–2.73), vaginal dryness (POR=3.97, 95% CI=2.49–6.31), vaginal itching (POR=2.44, 95% CI=1.55–3.83) and loss of libido (POR=3.08, 95% CI=1.92–4.94) were associated to dyspareunia. In addition, women who reported having a partner were 2.22 times as likely as those without a partner to report dyspareunia (POR=2.22, 95% CI=1.29–3.82). Menopausal status/current HT use, educational attainment, and employment status were no longer associated to dyspareunia in the multivariate analysis (Table 2).
This cross-sectional study characterized the relationship of dyspareunia with lifestyle and health characteristics in a sample of middle-aged Puerto Rican women aged 40–59 years living in Puerto Rico. Overall, 18% of the study sample reported having experienced dyspareunia during the two months previous to the interview. Although we do not expect this result to be representative of the prevalence of dyspareunia in Puerto Rican women, the frequency of dyspareunia observed in our study sample falls within the range (8%–21%) recently reported by the World Health Organization (WHO) in a meta-analysis of subtypes of chronic pelvic pain.7,8 However, the proportion of women with dyspareunia in our study sample (18%) is higher than the one reported in a national probability sample assessing sexual dysfunction (7%) in the United States.2 Differences in age groups included for analysis, other population characteristics, the time frame used to define prevalence, the method of data-collection used (self-administered questionnaires or interviews), and the differences in definitions of dyspareunia and pelvic pain, may account for some of these differences.
Consistent with previous studied31,32, we found no association between age and dyspareunia. Nonetheless, the association between age and dyspareunia has not always been consistent. Age has also been found to be a protective factor against dyspareunia, with the prevalence of dyspareunia decreasing with increasing age.2, 23, 24 Laumann et al. (1998) found that young women are more likely to be single, with a higher turnover of partners leading to instability and inexperience, thus generating stressful sexual encounters and consequently suffering from sexual pain.2 On the contrary, a study by Nappi et al. (2002) did find an association with dyspareunia and increasing age.18
Meanwhile, relationship status was found to have a significant association with dyspareunia in multivariate analysis, with women with a partner having 2.3 times the possibility of having dyspareunia than those without a partner, a result not consistent with previous studies.2, 33 This variation may be due to differences in how relationship status is defined. In our population, only those women married or living in a consensual relationship were considered as having a partner, while single, divorced, widowed, and women separated from their husbands were considered as not having a partner. Thus, it may be possible that some of the women categorized as without a partner may indeed have a stable relationship with a partner. Also, the amount of current and lifetime sexual partners might influence a woman’s sexual intimacy with a partner. Thus, these and other factors affecting a couple’s relationship such as, the quality of the interpersonal relationship and adjustment with the partner, the partner’s psychological and physical state, the couple’s sexual habits and the frequency of intercourse, should be evaluated in order to establish if the marital relationship of Puerto Rican women is being affected by the dysfunction or the dysfunction appeared as a consequence of the relationship.
Regarding education, our results show no association between educational attainment and dyspareunia in multivariate analysis. This is consistent with a study conducted by Jamieson et al. However, other studies support the association that having a greater educational attainment reduces the likelihood of dyspareunia. 20, 23, 24, 32.
Parity and OC pills were not found to be associated with dyspareunia in our population. Jamieson et al. 31 reported no significant association between dyspareunia and parity while Sobhgol et al. 32 did find a significant relation, owing it mostly to the impairment of pelvic floor functioning during pregnancy and delivery. The mode of delivery and its complications and the use of OC pills, which has been implicated in adverse sexual response, 39 should be further evaluated in this population, as these two factors could influence the prevalence of dyspareunia.
There is conflicting data as to whether the menopausal transition increases the risk of dyspareunia. In our study, menopausal status/current HT use was associated to dyspareunia in the bivariate analysis, with post-menopausal women using HT (25%) reporting more dyspareunia than post-menopausal women not using HT (19%) and than premenopausal women (14%). However, in multiple regression analysis, the association was no longer present. Some studies show that dyspareunia increases throughout the menopausal transition,16,18,22,24,33,34 while others show no association.23,35,36 Estradiol levels are negatively associated with dyspareunia;35,36 while estrogen therapy has been found to reduce dyspareunia.22,24 In the US, the percentage of postmenopausal women using HT is approximately 38%, higher than that of our study population, which was 24%. In our study, we could not show that dyspareunia increases with post-menopausal status or that HT improves dyspareunia. This could be due to the small number of postmenopausal women currently using HT, the type, dose, and route of HT used, and the compliance with treatment.
Vaginal dryness and vaginal itching, common symptoms of vaginal atrophy, can also cause pain with sexual activity.16,35,37 Vaginal atrophy is a consequence of urogenital aging and affects 50% of menopausal women.38 It occurs as a result of a decrease in estrogen levels and its prevalence markedly increases from early to late perimenopause and then to postmenopause.16,34 In our study, women with vaginal itching and women with vaginal dryness were 2 to 4 times (respectively) as likely than those without these symptoms to have dyspareunia, supporting the relationship between vaginal atrophy and dyspareunia. Sexual pharmacology is the mainstay of treatment for many sexual female complaints as is the use of topical estrogen and nonmedicated, nonhormonal vaginal moisturizers and lubricants.15, 37–39 These treatment modalities have been used to relieve symptoms of vaginal atrophy successfully, showing improvement or prevention of dyspareunia, with the possibility of establishing a causal relationship between vaginal atrophy and dyspareunia.
Loss of libido as a result of dyspareunia has been documented 37 and dyspareunia has been associated with more sexual function impairment.13,15 In this study, women with loss of libido had higher possibility of having dyspareunia than women without desire problems. Women with dyspareunia have been found to have lower levels of desire and arousal and less orgasmic response with oral stimulation and intercourse2, 15 Vaginal atrophy causing dyspareunia can lead to loss of interest in sex.37 However, some studies have proposed that dyspareunia might reflect a sexual arousal problem, masked by the symptoms of vaginal atrophy, rather than a direct consequence of the symptoms.18,37 Further research is needed to address this issue.
Urinary tract symptoms, including urinary incontinence have also been associated with dyspareunia in previous studies. 2,16,19,20 Consistent with these studies, women in our study with incontinence were 70% more likely to have dyspareunia than those without incontinence. Thus, the severity and type of incontinence should be evaluated in this population, as this could influence the prevalence of dyspareunia in our population.
Several study limitations need to be considered when interpreting our results. Our results may be affected by selection bias, as only women who attended the health fairs were recruited into the study. Since one of the main focuses of the health fairs was to provide information on menopause and HT, women recruited into the study might have been those most affected by symptoms, thus selection bias might account for the high prevalence of symptoms observed among our study sample. To assess the potential of this selection bias, previous comparisons of our study sample with data from the Puerto Rico Public Use Microdata Sample (5%) from the Census 2000 and the 2000 Behavioral Risk Factor Surveillance Survey for women aged 40–59 have been made.27 Overall, our study sample was similar to the Census 2000 in the distribution of marital status, although a larger proportion of women aged 45–49 (30%) and a smaller proportion of women aged 55–59 (17%) were included in the study as compared with the census (26% and 21%, respectively). Study participants were also more likely to be employed (56%) than in the census (41%) and had higher educational attainment. Another source of selection bias could be the fact that 21% of eligible women (n=352) did not answer the section of symptoms of the questionnaire. As a result, women with symptoms could have been less likely to answer this section of the survey, potentially underestimating the prevalence of dyspareunia in the study population. Nonetheless, information on dyspareunia was collected as part of a section that assessed information on 22 symptoms related to women’s health. Thus, the missing information was not selective to dyspareunia, as women who did not provide information on this condition did so because they left the complete symptoms section blank, not providing information on any of the symptoms. To assess the potential for this selection bias, we compared the demographic characteristics of the study population (n=920) with that of those eligible women excluded from the analysis because they did not provide information on dyspareunia (n=352). Results showed that these groups did not differed in educational attainment, relationship or working status (p > 0.05); although a higher proportion of women aged 40–49 years did not answer the symptoms section of the survey (36.2%) as compared to those aged 50–59 (18.6%) p < 0.0001).
Our results may also be affected by information bias, as the definition of dyspareunia and other characteristics studied were based on self-reports, and not based on official diagnostic definitions. According to the DSM-4, dyspareunia is defined as recurrent or persistent genital pain associated with sexual intercourse in either a male or a female. Although the symptoms of sexual pain reported by the women in this study are mostly included in the definition of dyspareunia, the onset of symptoms, the length of time of symptom duration since its onset, the frequency of symptoms, the previous sexual functioning of study participants, and the impact of the sexual complaint on quality-of-life was not assessed in the questionnaire. In addition, the type of dyspareunia, superficial/entry/introital or deep, was not described. A medical evaluation was also not performed in which to exclude other forms of sexual pain such as vaginismus and vulvodynia.
This study constitutes the first attempt to characterize health and life-style factors associated with dyspareunia in a middle-aged sample of Puerto Rican women living in Puerto Rico. Female sexual dysfunction is a complex disorder including sexual well-being, physiological, and psychosocial factors poorly studied in our population. Nonetheless, our results agreed with prior studies regarding the potential association between health and life-style factors and dyspareunia. Given the high complexity and the recent biopsychosocial approach given to the study of female sexual dysfunction, along with the high prevalence of self-reported dyspareunia observed in our study population, additional studies of female sexual dysfunction and its association with biopsychosocial factors are highly warranted, as well as studies focused on determining additional independent factors associated with other sexual symptoms and dysfunctions in Puerto Rico. The studies should recruit population-based samples of Puerto Rican women; in order to provide unbiased estimates of the prevalence of dyspareunia and its risk factors in our population; and should employ appropriate diagnostic tools, in order to correctly measure dyspareunia and reduce the potential for misclassification bias. In addition, future research should include a thorough personal history on socio-demographic matters, a past psychosexual history, including history on traumatic sexual acts during childhood or adolescence, along with a complete obstetric and gynecologic history detailing reproductive matters such as mode of delivery and its complications and breastfeeding practices, surgical history, surgical sterilization and hysterectomy, and pelvic floor disorders. All of these factors were not analyzed in our study, and could also be associated with sexual symptoms and dysfunctions in Puerto Rican women.
Sexual dysfunction and its implications in the quality of life of women are relevant areas of women’s health, still not openly discussed in women in general,40 that require further attention within our health care setting. Clinicians must consider the need to inquire and orient patients about the presence of sexual matters when at clinics in order to increase the patients’ awareness of sexual health problems and to assess the effect of these problems on their quality of life. This will be essential for developing appropriate intervention strategies, including a broad-spectrum diagnosis and treatment approach that promotes and maintains the sexual health of female populations.
Health fairs were partially sponsored by an unrestricted grant of Wyeth-Ayerst Pharmaceutical, Puerto Rico. Data analysis was supported by NIH NCRR RCMI Grant G12RR03051. Scientific editing was possible by Grant Number 5P20RR011126 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH.
Disclosure of funding: Data analysis was funded by NIH NCRR RCMI Grant G12RR03051. Scientific editing was possible by Grant Number 5P20RR011126 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH).