Rev. Bras. Reumatol. vol.55 número2

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w w w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Original

article

Prevalence

of

sexual

dysfunction

among

female

patients

followed

in

a

Brasília

Cohort

of

early

rheumatoid

arthritis

Thaís

Ferreira

Costa

a,∗

,

Carolina

Rocha

Silva

a

,

Luciana

Feitosa

Muniz

a

,

Licia

Maria

Henrique

da

Mota

b

a_Service_of_{Rheumatology,}_Hospital_{Universitário}_de_Brasilia,_Universidade_de_Brasília,_Brasilia,_DF,_Brazil b_Medicine_School,_Universidade_de_Brasília,_Brasilia,_DF,_Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received20February2013

Accepted6October2014

Availableonline7January2015

Keywords:

Sexualdysfunction

Sexuality

Rheumatoidarthritis

Qualityoflife

a

b

s

t

r

a

c

t

Objective:Todeterminetheprevalenceofsexualdysfunctioninwomendiagnosedwithearly

rheumatoidarthritis(RA)(lessthanoneyearofsymptomsatthetimeofdiagnosis),aswell

astoevaluatethepossibleassociationbetweensexualdysfunctionwithARactivityand

functionaldisability.

Methods:Cross-sectionalstudyassessingwomendiagnosedwithearlyRA,accompanied

perprotocolintheBrasiliaCohort,HospitalUniversitáriodeBrasília.Demographics,disease

activityindex(DiseaseActivityScore28–DAS28)andfunctionaldisabilityquestionnaire

(HealthAssessmentQuestionnaire–HAQ),wereobtainedbydirectinterviews.TheFemale

SexualFunctionIndex(FSFI)wasusedquestionnairewhichcontains19itemsthatassess

sixdomains:sexualdesire,sexualarousal,vaginallubrication,orgasm,sexualsatisfaction

andpain.

Results:68 patientsstudied,ofwhom54(79.4%)reportedsexualactivityinthelastfour

weeks.Theparticipantswere49.7±13.7(mean±SD)yearsoldandthemajoritywere

mar-ried(61.4%).ThemeanDAS28was3.6±1.5andthemeanHAQwas0.7.Theprevalenceof

sexualdysfunction(FSFI≤26)was79.6%.Therewasnoassociationofdiseaseactivityor

offunctionaldisabilitywiththeoccurrenceofsexualdysfunctioninthefemalepatients

evaluated.

Conclusion: Theprevalenceofsexualdysfunctionfoundinthisstudywashigherthanthat

reportedintheliteratureinhealthywomen.Aknowledgeoftheextentoftheproblemis

neededtoprovideadequatetherapeuticoptionsforthesepatients.

∗ _{Corresponding}_author_.

E-mail:thaisferreiracosta@yahoo.com.br(T.F.Costa).

http://dx.doi.org/10.1016/j.rbre.2014.10.006

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Prevalência

de

disfunc¸ão

sexual

entre

pacientes

acompanhadas

na

coorte

Brasília

de

artrite

reumatoide

inicial

Palavras-chave:

Disfunc¸ãosexual

Sexualidade

Artritereumatoide

Qualidadedevida

r

e

s

u

m

o

Objetivo: Determinaraprevalênciadedisfunc¸ãosexualemmulherescomdiagnósticode

artritereumatoide(AR)inicial(menosdeumanodesintomasaodiagnóstico),bemcomo

avaliarapossívelassociac¸ãoentredisfunc¸ãosexualcomatividadedaAReincapacidade

funcional.

Métodos: Estudotransversal,queavalioumulherescomdiagnósticodeARinicial,

acom-panhadas deforma protocolarnacoorte Brasília,noHospital UniversitáriodeBrasília.

Dadosdemográficos,índicedeatividadedadoenc¸a(DiseaseActivityScore28–DAS28)

edadosdoquestionáriodeincapacidadefuncional(HealthAssessmentQuestionnaire–

HAQ)foramobtidosporentrevistasdiretas.Usou-seoíndicedefunc¸ãosexualfeminina

(FemaleSexualFunctionIndex–FSFI),questionárioquecontém19itensqueavaliamseis

domínios:desejosexual,excitaçãosexual,lubrificaçãovaginal,orgasmo,satisfaçãosexual

edor.

Resultados: Foramestudadas68pacientes,dasquais54(79,4%)relataramatividade

sex-ualnasúltimasquatrosemanas.Amédiadeidadefoide49,7±13,7anoseamaioriaera

casada(61,4%).ODAS-28médiofoide3,6±1,5eamédiadoHAQfoide0,7.A

prevalên-ciade disfunc¸ãosexual(FSFI≤26)foi de79,6%. Nãohouveassociac¸ãode atividadede

doenc¸anemdeincapacidadefuncionalcomaocorrênciadedisfunc¸ãosexualnaspacientes

avaliadas.

Conclusão: A prevalência de disfunc¸ão sexual encontrada neste estudo foi superior

à relatado na literatura em mulheres saudáveis. Há necessidade de conhecimento

da extensão do problema para oferecer possibilidades terapêuticas adequadas aos

pacientes.

Introduction

Rheumatoidarthritis(RA)isasystemicchronicand

progres-sivediseasethatpreferentiallyaffectsthesynovialmembrane

ofjointsand canlead toboneand cartilage destruction.1,2

Thediseaseleadstovariousdegreesofdisabilityandhasa

profoundimpactonthesocial,economicandpsychological

aspectsofthepatient’slife.3

Sexualfunction(FS) isamajorcomponent ofquality of

life,withhigheramplitudethansexualintercourseitself.4,5

Sexual expressionis acrucial partof the individual’sown

identity,andthereforeimportantinallstagesofhealthand

disease.6_A_full_sexual_functioning_consists_in_the_transition

betweenphases, from excitement torelaxation,with

plea-sureandsatisfaction.7_Sexual_dysfunction_(SD)_is_defined_as

the inability to participatein the sexual actwith

satisfac-tion,compromisingthedesireand/orarousaland/ororgasm.4

Sexualityinfluencesbehavioranddefinesgenderroles;and

bothinthephysicalandpsychologicalsense,becomespart

of the lifestyle of the individual ofall ages.3 _SD _not _only

compromisessexualsatisfaction,but alsooverall life

satis-faction,determiningalowerqualityoflife,lowself-esteem,

depression,anxietyandprejudiceininterpersonaland

part-nerrelationship.4_The_main_risk_factors_for_SD_have_organic,

psychosocialandsociodemographicorigin,withemphasison

age,familyincomeandeducation.4,8 _Some_authors_suggest

thatfemalesexualdysfunctionsometimesreachesmorethan

40%ofwomen.9

Competence, motivation and sexual expression are

decreasedinpatientswithRA.10_Most_of_the_sexual_problems

experiencedbythesepatientsarerelatedtodiseaseactivity,

pain, lossofjointmotion,functional disability,orfatigue.11

Otherfactorsincludedepression,anxiety,lossofself-esteem

anddifficultyindiscussingthedisease.11_The_percentage_of

patientswitharthritiswhoexperiencesexualproblemsvaries

acrossstudies,from31to76%.4,7,10–12

Thetwo mainfields ofsexual problemsexperiencedby

patientswithRAare:difficultyinperformingthesexualact

(sexualdisability)anddecreasedsexdrive,reflectedbothin

sexualdesireandinadecreasedsexualsatisfaction.Sexual

incapacityismanifestedbyproblemssuchasjointpainand

fatigueduringintercourse,presentedby50–61%ofpatients

withRA. Difficultyinassumingcertainpositionswhen hip

orkneemovementsarelimitedanddyspareuniadueto

vagi-naldrynessinsecondarySjögren’ssyndromeare observed.

Decreasedsexdriveismanifested byadecreaseddesirein

50–60%ofpatientswithRA,andbyalowfrequencyofsexual

intercoursein73%ofpatients.3,7,13

AlthoughSF’scommitmentisamajorproblemforpatients

diagnosedwithRA,adequateinformationonthissubjectare

scarce.3 _Sexuality _is _rarely_addressed _in _{questionnaires}_on

(3)

Itisvery importantthatrheumatologists and other health

professionals acknowledge the impact that RA promotes

insexuality,sincethisknowledgefacilitatesthediscussion

betweendoctorandpatient,whenaddressingtheinfluence

ofthediseaseinseveraldomainsofpatients’qualityoflife.

Additionally, it allows anoptimization ofthe treatment of

RA,hereencompassingtheattentiontothepatient’ssexual

difficulties.11

NoBraziliandataexiston theprevalenceofsexual

dys-functioninwomenwithearlyRA.Thisstudyaimstodescribe

theprevalenceofsexualdysfunctioninfemalepatientswith

earlyrheumatoidarthritisfollowedintheoutpatientclinicof

RAandtoevaluatethepossibleassociationbetweensexual

dysfunctionwithdiseaseactivityandfunctionaldisability.

Patients

and

methods

RApatientspertainingtotheBrasíliaCohortwereevaluated.

BrasiliaCohort14–17_is_an_incident_cohort_of_patients_with_early

RA,accompaniedattheoutpatientclinicofRheumatology,

HospitalUniversitário de Brasília, Universidade de Brasília.

Forinclusioninthiscohort,earlyRAisdefinedasthe

occur-renceofcompatiblejointsymptoms(jointpainandswelling

withaninflammatorypattern,withorwithoutmorning

stiff-nessorothermanifestationssuggestiveofinflammatoryjoint

disease,assessedbyasingleobserver)lastingmorethan 6

weeksandlessthan12months,regardlessofthefulfillment

ofthe American College of Rheumatology (ACR) criteria.18

AllpatientsselectedfulfilledretrospectivelyEULAR/ACR2010

criteria.19

From the time of diagnosis, the patients are followed

prospectively,receivingthestandardtreatmentregimenused

in the Service, including the traditional disease-modifying

antirheumaticdrugs(DMARDs)orbiologicalresponse

mod-ifiers (biological therapy), according to the patient’s need.

Currently,patientsfollowedperprotocolforupto10yearsafter

theinitialdiagnosisparticipateinthiscohort.

ThestudywasconductedfromJanuarytoMay2012,with

directinterviewsandclinicalrecordreviews.Informationon

age, durationofdisease,yearsofeducation,maritalstatus,

DiseaseActivityScore28(DAS-28)20_and_functional_disability

questionnaire(HealthAssessmentQuestionnaire–HAQ)were

obtained.21

Thepresenceofsexualdysfunctionwasassessedthrough

completion of the Female Sexual Function Index (FSFI), a

questionnaireproposedbyRosenetal.in200022,23_and

vali-datedforthePortugueseidiombyPacagnellaetal.in20099

FSFIisaself-administeredquestionnairethataimstoassess

femalesexualresponseintosixdomains:sexualdesire,sexual

arousal,vaginallubrication,orgasm,sexualsatisfactionand

pain. FSFIpresents 19questions thatevaluatesexual

func-tion inthe last four weeks.Eachquestion receives ascore

rangingfrom0to5points,andtheendresultisthesumof

the scoresforeachdomain,multipliedbyacorrection

fac-torthathomogenizestheinfluenceofeachdomain.Atotal

score≤26indicatessexualdysfunction.9,22,23_Given_that_the

instrumentusedinthisstudytoassesssexualfunction

con-templatedonlyfemalepatients,malepatientswereexcluded

fromtheanalysis.

FemalepatientsselectedconsecutivelyintoBrasiliaCohort

participated as volunteers in the study, after clarification

on its content and after signing the Free and Informed

ConsentForm.ThestudywasapprovedbytheEthics

Com-mittee, Medicine School, Universidade de Brasília (CEP-FM

030/2010).

Statisticalanalysis

Adescriptiveanalysiswasusedtodescribethegeneral

char-acteristics ofthe population. Student’st or Mann–Whitney

Table1–ComparisonsbetweenpatientswithearlyRAdividedintogroupswithandwithoutsexualdysfunction.

Characteristics ♀Withsexualdysfunction(n=43) ♀Withoutsexualdysfunction(n=11) P

Ageinyears,mean(±SD) 48.51(±12.59) 42.09(±12.64) 0.208a

Diseaseduration(±SD) 6.05(±2.19) 5.0(±2.28) 0.13a

DAS-28(±SD) 3.84(±1.53) 3.32(±1.29) 0.29a

HAQ 0.80 0.39 0.09a

Education

Illiterate(n%) 2(4.65%) 1(9.09%) 0.502b

<7yearsofeducation(n%) 13(30.23%) 2(18.18%) 0.253b

>7yearsofeducation(n%) 28(65.11%) 9(81.81%) 0.470b

Maritalstatus

Married(n%) 24(55.81%) 8(72.72%) 0.493b

Stableunion(n%) 8(18.60%) 0 0.184b

Single(n%) 3(6.97%) 2(18.18%) 0.266b

Separate(n%) 6(13.95%) 1(9.09%) 1.0b

Widower(n%) 2(4.65%) 0 1.0b

Weight

Normalweight(n%) 17(40.47%) 4(44.44%) 1.000b

Overweight(n%) 17(40.47%) 4(44.44%) 1.000b

Obesity(n%) 8(19.04%) 1(11.11%) 0.667b

a _Student’s_t_-test.

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Table2–FSFIdomainsdiscriminated.

FSFIdomains Possibleanswers

Domain:sexualdesire

Question#1–Inthelastfourweeks,howoftendid youfeeldesireorsexualinterest?

1.Almostalwaysoralways

2.Mostofthetime(morethanhalfofthetime) 3.Sometimes(abouthalfofthetime)

4.Afewtimes(lessthanhalfthetime) 5.Almostnever,ornever

Question#2–Inthelastfourweeks,howdoyou rateyourlevelofdesireorsexualinterest?

1Veryhigh 2.High 3Moderate 4Low

5Veryloworabsolutelyabsent Domain:sexualarousal

Question#3–Inthelastfourweeks,howoftenyou feltsexuallyarousedduringsexualactivityor intercourse?

1.Nosexualactivity 2.Almostalways,oralways

Question#4–Inthepast4weeks,howwouldyou rateyourlevelofsexualarousalduringsexual activityorintercourse?

1.Nosexualactivity 2.Veryhigh 3.High 4.Moderate 5.Low

6.Verylow,orabsolutelyabsent Question#5–Inthelastfourweeks,howdoyou

rateyourlevelofassurancetobecomesexually arousedduringsexualactivityorintercourse?

1.Nosexualactivity 2.Veryhighassurance 3.Highassurance 4.Moderateassurance 5.Lowassurance

6.Verylowornoassurance Question#6–Inthepast4weeks,howoftenyou

weresatisfiedwithyoursexualarousalduring sexualactivityorintercourse?

Domain:vaginallubrication

Question#7–Inthelastfourweeks,howoftenyou hadvaginallubrication(gota“wet”vagina)during sexualactivityorintercourse?

Question#8–Inthelastfourweeks,howdoyou rateyourdifficultyinhavingvaginallubrication(got a“wet”vagina)duringintercourseorsexual activities?

1.Nosexualactivity

2.Extremelydifficult,orimpossible 3.Verydifficult

4.Difficult 5.Slightlydifficult 6.Notatalldifficult Question#8–Inthelastfourweeks,howdoyou

rateyourdifficultyinhavingvaginallubrication(got a“wet”vagina)duringintercourseorsexual activities?

1.Nosexualactivity

4.Difficult 5.Slightlydifficult 6.Notatalldifficult Question#9–Inthelastfourweeks,howoftenyou

keptvaginallubrication(gota“wet”vagina)until theendofsexualactivityorintercourse?

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Table2–(Continued₎

FSFIdomains Possibleanswers

6.Almostnever,ornever Question#10–Inthelastfourweeks,whichwas

yourdifficultyinmaintainingvaginallubrication (staywitha“wet”vagina)untiltheendofthesexual activityorintercourse?

1.Nosexualactivity

4.Difficult 5.Slightlydifficult 6.Notatalldifficult Domain:orgasm

Question#11–Inthelastfourweeks,whenyouhad sexualstimulationorpracticedintercourse,how oftenyoureachedorgasm(“sexualclimax”)?

Question#12–Inthelastfourweeks,whenyouhad sexualstimulationorpracticedintercourse,which wasyourdifficultyinreachingorgasm(sexual climax)?

1.Nosexualactivity

4.Difficult 5.Slightlydifficult 6.Notatalldifficult Question#13–Inthepast4weeks,howsatisfied

wereyouwithyourabilitytoreachorgasm(sexual climax)duringsexualactivityorintercourse?

1.Nosexualactivity 2.Verysatisfied 3.Moderatelysatisfied

4.Almostequallysatisfiedanddissatisfied 5.Moderatelydissatisfied

6.Verydissatisfied Domain:sexualsatisfaction

Question#14–Inthepast4weeks,howsatisfied haveyoubeenwiththeemotionalcloseness betweenyouandyourpartnerduringsexual activity?

6.Verydissatisfied Question#15–Inthepast4weeks,howsatisfied

haveyoubeenwithsexualrelationshipbetweenyou andyourpartner?

6.Verydissatisfied Question#16–Inthepast4weeks,howsatisfied

haveyoubeenwithyoursexuallifeingeneral?

6.Verydissatisfied Domain:pain

Question#17–Inthelastfourweeks,howoftenyou feltdiscomfortorpainduringvaginalpenetration?

Question#18–Inthelastfourweeks,howoftenyou feeldiscomfortorpainfollowingvaginal

penetration?

Question19–Inthepast4weeks,howwouldyou rateyourlevelofdiscomfortorpainduringor followingvaginalpenetration?

1.Nosexualactivity 2.Veryhigh 3.High 4.Moderate 5.Low

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test was usedto analyze continuous variables. Categorical

variableswereanalyzedbyChi-squaredorFisher’sexacttest,

whereappropriate.WeconsideredP<0.05asstatistically

sig-nificant.

Results

Ofthe78patientswithearlyRAevaluatedintheperiod,68

femalepatients(87.1%ofthesample)wereselected;10male

patients(12.8%ofthesample)wereexcluded.Themeanage

ofthestudypopulationwas49.7±13.7years(mean±SD).

Regardingmaritalstatus,61.4%(35patients)reportedbeing

married,11.7%(8patients)reportedmaintainingastable

rela-tionship with a partner, 13.2% (9 patients) reported being

single,8patients(11.7%)declaredthemselvesseparateand8

patients(11.7%)reportedbeingwidowed.Withregardto

edu-cation,4.4%ofpatientswereilliterate,32.3%hadbetween1

and7yearsofformaleducationand63.2%reportedmorethan

7yearsofschooling.

Fifty-fourwomen(79.4%)reportedsexualactivityinthelast

fourweeksand14(20.5%)declaredthemselveswithnosexual

activityinthemonthprecedingthequestionnaire.The

preva-lenceofsexualdysfunction(FSFI≤26)amongthe54patients

withsexualactivitywas79.6%(43patients).

The general characteristics of patient groups with and

withoutsexualdysfunctionareshowninTable1.Inthesexual

dysfunctiongroup(43patients),97.67%wereusingsynthetic

DMARDsand 13.95%were usingbiologicalDMARDs

(inflix-imab,2;adalimumab,1;abatacept,2;andrituximab,1patient).

In the group without sexual dysfunction (11 patients),

90.90%wereusingsyntheticDMARDsand18.18%wereusing

biological DMARDs (infliximab,1 patient; and rituximab, 1

patient).

Tables2and3show,respectively,thedomainsofFSFIand

thepossibleoutcomes,separatelyforeachoneof

question-naire’squestions.

Intheevaluationofdifferentagegroups,weobserved

dif-ferencesinaffecteddomainsinFSFIinthegroupswithand

withoutsexualdysfunction(Table4).Inthegroupaged51–60

yearsandinthatgroup≥61years,onlyonepatientineach

groupshowednosexualdysfunction.Regardingthestatusof

“nosexualactivity”inthelastfourweeks,weobservedthe

followingdistribution according toage groups: ≤ 30 years,

20%(n=1)ofpatientshadnosexualactivity;31–40years,all

patientshadanactivesexuallife;41–50,6.7%hadnosexual

activity;51–60,24%(n=4)hadnosexualintercourse;≥61years,

47%(n=8)hadnosexualactivity.

Therewasnostatisticaldifferencebetweengroups(with

andwithoutsexualdysfunction)withrespecttomarital

sta-tus, length of formal education, body mass index (BMI),

disease activity(DAS-28), functional disability(HAQ) oruse

medications(syntheticDMARDsandbiologicals).

Discussion

RAcaninfluencesexualfunctioninseveralaspects.10_The

rea-sonsfordisturbanceinsexualfunctioningaremultifactorial

andincludeaspectsrelatedtothedisease itself,aswell as

Table3–Resultsdetailedforeachofthesixdomainsof FSFI.

FSFIdomains ♀Withsexual dysfunction(n=43)

♀Withoutsexual dysfunction(n=11)

Domain:sexualdesire

Question#1(n%) 1(2.32%) 3(27.27%) 1(2.32%) 3(27.27%) 5(11.62%) 3(27.27%) 21(48.83%) 2(18.18%) 15(34.88%) 0 Question#2(n%) 0 0

0 2(18.18%) 12(27.90%) 8(72.72%) 19(44.18%) 1(9.09%) 12(27.90%) 0 Domain:sexualarousal

Question#3(n%) 2(4.65%) 0 2(4.65%) 5(45.45%) 2(4.65%) 1(9.09%) 6(13.95%) 5(45.45%) 16(37.20%) 0 15(34.88%) 0 Question#4(n%) 1(2.32%) 0

0 1(9.09%) 0 5(45.45%) 12(27.90%) 5(45.45%) 15(34.88%) 0 15(34.88%) 0 Question#5(n%) 10(23.25%) 0

1(2.32%) 2(18.18%) 0 4(36.36%) 15(34.88%) 5(45.45%)

7(16.27%) 0 10(23.25%) 0 Question#6(n%) 10(23.25%) 0

2(4.65%) 8(72.72%) 4(9.30%) 2(18.18%) 8(18.60%) 1(9.09%) 11(25.58%) 0

8(18.60%) 0 Domain:vaginallubrication 8(18.60%) 0

Question#7(n%) 4(9.30%) 6(54.54%) 4(9.30%) 1(9.09%) 5(11.62%) 4(36.36%) 14(32.55%) 0

8(18.60%) 0 Question#8(n%) 10(23.25%) 0 1(2.32%) 0 6(13.95%) 1(9.09%) 10(23.25%) 1(9.09%) 8(18.60%) 2(18.18%) 8(18.60%) 7(63.63%) Question#9(n%) 9(20.93%) 0

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Table3–(Continued₎

FSFIdomains ♀Withsexual dysfunction(n=43)

Domain:orgasm

Question#11(n%) 11(25.58%) 0 0 5(45.45%) 2(4.65%) 4(36.36%) 5(11.62%) 1(9.09%) 16(37.20%) 1(9.09%)

9(20.93%) 0 Question#12(n%) 11(25.58%) 0 1(2.32%) 0 7(16.27%) 0 10(23.25%) 0

9(20.93%) 3(27.27%) 5(11.62%) 8(72.72%) Question#13(n%) 14(32.55%) 0

2(4.65%) 7(63.63%) 10(23.25%) 4(36.36%)

5(11.62%) 0 6(13.95%) 0 6(13.95%) 0 Domain:sexualsatisfaction

Question#14(n%) 14(32.55%) 0 5(11.62%) 9(81.81%) 9(20.93%) 1(9.09%) 6(13.95%) 0 5(11.62%) 1(9.09%) 4(9.30%) 0 Question#15(n%) 15(34.88%) 0

5(11.62%) 10(90.90%) 9(20.93%) 1(9.09%) 8(18.60%) 0 5(11.62%) 0 1(2.32%) 0 Question#16(n%) 13(30.23%) 0

1(2.32%) 8(72.72%) 11(25.58%) 3(27.27%)

5(11.62%) 0 6(13.95%) 0 7(16.27%) 0

Domain:pain

Question#17(n%) 11(25.58%) 0 6(13.95%) 0 2(4.65%) 1(9.09%) 7(16.27%) 0 8(18.60%) 0 9(20.93%) 10(90.90%) Question#18(n%) 11(25.58%) 0

4(9.30%) 0 3(6.97%) 0 3(6.97%) 1(9.09%) 10(23.25%) 1(9.09%) 12(27.90%) 9(81.81%) Question#19(n%) 12(27.90%) 0

3(6.97%) 0 1(2.32%) 0 11(25.58%) 1(9.09%)

4(9.30%) 1(9.09%) 12(27.90%) 9(81.81%)

to treatment.7,24 _Physical_and _emotional_problems_and

dif-ficultiesinfindingpartnershipasaresultofdisease-related

stresscontributetoalessactiveandoftenlesspleasant

sex-ual life.7,24 _Chronic _pain, _fatigue _and _low _self-esteem _can

diminishthesexualinterest,thusreducingthefrequencyof

intercourse.7,24

In ourstudy, wefounda high frequencyofsexual

dys-function(79.6%)ofpatientswithactivesexuallife,ahigher

figurethaninmostpreviousstudiesinpatientswith

estab-lishedRA.4,7,10–12 _Abdel-Nasser_et_al.3_showed_in_their_study

thatover60%offemalepatientswithRAhaddifficultyin

sex-ualperformance(sexualdisability)andasignificantdecrease

insexdrive.3

Inapreviousstudyconductedbyourgroup25_that_evaluated

163 patientswithdiagnoses ofvarious rheumaticdiseases,

including 24 patients with established RA, we found

sex-ual dysfunctionin18.4% ofevaluatedpatients,and 8.3%of

patientswithRAhadaFSFIscore<26.Itisimportantto

men-tion that in this previous study, 24.2% of all patients and

17% ofRApatientshadnosexualactivityduringthestudy

period.However,wewouldexpectalowerfrequencyof

sex-ualdysfunctioninpatientswithearlyRAthaninthosewith

establishedRA,inviewofanearliertreatment,andpossibly

thepresenceoflessdeformityinpatientswithearlydisease.

Thisdifferenceinprevalencemaybeexplainedbyother

fac-torsthatinfluencesexualfunction,suchasemotionalissues

andcomorbidities,suchasdepression,whichwerenot

eval-uatedinourstudy.Insupportofthis explanation,Karlsson

et al.26 _found_that _patients_with_early _RA_are _less _satisfied

withtheirlifeasawhole,comparedwithareferencegroup

ofpatientswithlong-termillness.

Patients withearly RAalsoreported lowlevels of

satis-faction withself-care,work and sexuallifeactivities.7,26 _In

ourstudy,wedidnotevaluatelaborandself-careability

vari-ables.

Hill et al. evaluated the effect of RA on the

rela-tionship between partners and demonstrated that 35% of

patients believed thatthe disease interfered withthe

rela-tionshipwiththepartner,duetoproblemssuchasdecrease

in daily and social activities and emotional and financial

changes.4,6

In the present study,we found no association between

the occurrence of sexual dysfunction and disease activity.

Also,nosignificantassociationbetweenfunctionaldisability

andsexualdysfunctionwasobserved.However,inthestudy

ofAbdel-Nasseretal.,3_sexual_disability_was_related,_among

otherfactors,todiseaseactivity,painanddisabilitymeasured

byHAQ.Inanotherstudy,ElMiedanyetal.10_showed_a

preva-lenceof45.7%ofSDinfemalepatientsdiagnosedwithRA,

showing correlationof SDwith several markersof disease

activity.

We observed the influence ofage in relation to sexual

dysfunction,asexpected.Withincreasingage,moreofFSFI

domainswereaffected,withanincreaseofthepercentageof

patientswithoutsexualactivity.

In 2007, a French study from the Association Franc¸aise

des Polyarthritiquesevaluated theimpact ofRAon patients’

sexuality bysendingquestionnairestoabout7700patients.

(8)

Table4–FSFIdomainsaccordingtoagegroups.

AgegroupsandFSFIdomains ♀Withsexualdysfunction (n=43)

P

≤30years

n 2 2 –

Sexualdesire 2.7±0.42 3.9±0.42 0.10

Sexualarousal 2.7±0.42 5.5±0.21 0.013

Vaginallubrication 3.45±0.21 4.95±1.48 0.29

Orgasm 3.2±0.56 6±0 0.019

Sexualsatisfaction 2.6±0.84 5.8±0.28 0.003

Pain 3.8±0.84 4.6±1.9 0.65

31–40years

n 11 3 –

Sexualdesire 2.56±0.54 4.4±0.91 0.0006

Sexualarousal 2.80±0.98 4.9±0.62 0.005

Orgasm 3.09±1.37 5.3±0.61 0.019

Sexualsatisfaction 3.63±1.5 5.6±0.69 0.05

Pain 4.1±1.66 6±0 0.85

41–50years

n 10 4 –

Sexualdesire 2.34±1.07 4.05±0.9 0.01

Sexualarousal 2.22±1.29 4.57±0.99 0.007

Orgasm 2.76±1.8 5.3±0.94 0.02

Sexualsatisfaction 3±1.84 6±0 0.008

Pain 3.08±2.22 5.9±0.2 0.02

Student’st-testusedinalltheseanalyzes.

51% reported an adverse impact of the disease on their sexuality.10,11,27

StudiesinRApatientsunselectedfordiseaseduration

sug-gestthat obesityisassociatedindependently withaworse

quality oflife.28 _Obesity _is _associated_with _higher

concen-trationsofinflammationmarkerssuchasC-reactiveprotein

(CRP), interleukin 6(IL-6) and tumornecrosis factor alpha

(TNF-␣)andthereforeobeseRApatientsmaypresentwitha

moresevereandactivedisease.28,29

García-Pomaetal.29_reported_that,_in_patients_with_RA,_the

health-relatedqualityoflifeisimpairedduetoseveralfactors.

Intheirstudy,theseauthors suggestthat patientswithRA

whoare obesearemorelikelytopresentareducedquality

oflifecomparedwithnormal-weightpatients, regardlessof

othercharacteristicssuchasgender,age,activityofdisease,

extra-articulardisease,presenceofrheumatoidfactor,levelof

depression,socioeconomicstatus,ordiseaseduration.Inthis

study,wefoundnodirectrelationshipbetweentheprevalence

ofsexualdysfunctionandtheoccurrenceofobesityamong

patientswithearlyRA.

Sexual functioning isa neglected area of quality oflife

inpatients with rheumatic diseases.7 _{Rheumatologists} _are

increasingly willing to discuss areas that are not directly

relatedto thepharmacological treatmentofjoint diseases,

suchasquality oflife,fatigueandpatienteducation.

How-ever,sexualityisrarelyaddressedinrelationtothequalityof

life.11,30

Inarecentsurveywithtenrheumatologists,only12%of

patientsseenintheirclinicalpracticehavebeenevaluatedfor

sexualactivity.31_This_apparent_lack_of_interest,_by_the

physi-cian,withrespectofthesexualfunctionoftheirpatientscould

be explained,according torespondents, byfactors suchas

limitedconsultationtime,discomfortwhendiscussing

sexu-ality(bothbyphysicianandpatient),anduncertaintiesabout

the role ofthe doctorsand theircompetence on issuesof

patients’sexuality.3,7,11,31_This_demonstrates_the_importance

offurtherstudiesthatevaluatesexualfunctioninrheumatic

diseasesandtheirdisclosureamongexperts,aimingatamore

comprehensivetreatmentofpatients.

Ourstudyhassomelimitations.Thisisacross-sectional

study, which, thus,does not allowthe establishment ofa

cause-effect relationship. The number of female patients

evaluated inthis study was relatively small,especially the

number ofpatients withearly RAwithout sexual

dysfunc-tion, which constituted a minority ofthe total number of

assessedwomen. Anotherlimiting factorwas thefact that

the patients were evaluated in a cohort study in a

ter-tiary hospital, aregionalreference inRheumatology. Thus,

probablyourevaluatedfemalepatientshadmoresevere

con-ditions thanpatients followed upina primaryhealthcare

service. Furthermore,wedidnotevaluateother

comorbidi-tiesthatmayinfluencesexualfunction,suchasdepression

andSjögren’ssyndrome.Thesefactorsshouldbetakeninto

consideration, so that the results observed should not be

extrapolated for all female patients diagnosed with early

RA.

However,thisisthefirststudy whichweare awarethat

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RA,withaconcomitantevaluationoffunctionaldisabilityand

diseaseactivity.

Conclusion

Theprevalenceofsexualdysfunctionfoundinthisstudywas

highercomparedbothwiththefigurespublishedinthe

lit-erature in healthy women (up to 40%), as those found in

patientswithrheumatoidarthritis(31–76%),including

previ-ouscasesofestablishedRAinourService.Giventhatsexuality

isregardedasoneofthemajordeterminantsofreduced

qual-ity oflife, questions that address these aspects should be

amongtheparametersthat evaluatethecourseofdisease.

Studiesassessingtheextentofsexualdysfunctioninaspecific

mannerwithrespecttopatientswithearlyRAarenecessary,

sothattherapeuticalternativesaimingtoimprovenotonly

thephysicalhealth,butalsothequalityoflifeofthepatient,

beoffered.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgments

TheauthorswishtothankTatianeVazTeixeiradeOliveira,

MelianeTeixeiraCardosoandGabrielaPorfírioJardimSantos

fortheirassistanceindatacollectionforthepresentstudy.

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