Rev. Bras. Reumatol. vol.57 número3

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

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Original

article

Are

the

women

with

Sjögren’s

Syndrome

satisfied

with

their

sexual

activity?

Hatice

Isik

,

Metin

Isik

,

Oner

Aynioglu

,

Deniz

Karcaaltincaba

,

Ahmet

Sahbaz

,

Tugba

Beyazcicek

_,

_Mehmet

_Ibrahim

_Harma

_,

_Nejat

_Demircan

a_{BulentEcevitUniversity,SchoolofMedicine,DepartmentofObstetricsandGynecology,Zonguldak,Turkey} b_{MevlanaUniversity,SchoolofMedicine,DepartmentofObstetricsandGynecology,Konya,Turkey}

c_{BulentEcevitUniversity,SchoolofMedicine,DepartmentofRheumatology,Zonguldak,Turkey} d_{GaziUniversity,SchoolofMedicine,DepartmentofObstetricsandGynecology,Ankara,Turkey} e_{BulentEcevitUniversity,SchoolofMedicine,DepartmentofFamilyMedicine,Zonguldak,Turkey}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received25August2015 Accepted18May2016

Availableonline8February2017

Keywords:

Sjögren’ssyndrome Chronicdyspareunia Sexualdissatisfaction

a

b

s

t

r

a

c

t

Objective:FemaleswithSjögren’sSyndrome(SS)oftenexperiencevaginaldrynessand dys-pareunia,alongwithglandularandextraglandularsymptoms.Weaimedtoevaluatesexual functionandlifequalityinwomenwithSS.

Methods:Forty-six premenopausal women with SS and 47 age-matched controls were studied.Age,durationofthedisease,medications,andcomorbiddiseaseswerenoted. Par-ticipantscompleted36-ItemShortFormHealthSurvey(SF-36)andFemaleSexualFunction Index(FSFI).Patientswereaskedaboutvaginaldischargeanditchinginthelastmonth,andif theyinformedtheirrheumatologistsaboutanysexualproblems.Gynecologicexaminations wereperformedandvaginalsmearsweretakenoneachparticipant.

Results:ThemediantotalscoresofFSFIweresignificantlylowerintheSSgroupthanthe con-trols[17.12(2.4–27.8)and27.4(16.9–36.0),respectively,p<0.001].IntheSSgroup,37(80.4%) andinthecontrolgroup18(38.3%)ofpatientsweresexuallydissatisfied(p<0.001). Vagi-naldrynessandlubricantuseweresignificantlyincreasedinpatientswithSScompared tocontrols(p<0.001).LifequalityscoresweresignificantlylowerinpatientswithSSthan thecontrols(p<0.001).VaginaldrynesswasnegativelycorrelatedwithFSFItotal(r=−0.312,

p=0.035)andsubscoresexceptdesireandarousal.Physicalfunctioning,rolephysicaland roleemotionalscoreswerepositivelycorrelatedwithtotalFSFIscores(r=0.449,p=0.002,

r=0.371,p=0.011,r=0.299,p=0.043,respectively).

Conclusions:WomenwithSSexperiencelesssatisfactionwithsexualactivity,whichcanbe affectedbyage,vaginaldryness,physicalpain,andimpairedfunctionduetothedisease. Therefore,rheumatologistsshouldpayattentiontothesesymptomsandmanagement.

©2017ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗ _{Correspondingauthor.}

E-mails:k.hgonbe@gmail.com,hgonbe2000@yahoo.com(H.Isik).

http://dx.doi.org/10.1016/j.rbre.2017.01.002

2255-5021/©2017ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

As

mulheres

com

síndrome

de

Sjögren

estão

satisfeitas

com

sua

atividade

sexual?

Palavras-chave:

SíndromedeSjögren Dispareuniacrônica Insatisfac¸ãosexual

r

e

s

u

m

o

Objetivo: AsmulherescomsíndromedeSjögren(SS)muitasvezesexperimentamsecura vaginal e dispareunia, juntamentecom sintomas glandulares e extraglandulares.Este estudoobjetivouavaliarafunc¸ãosexualeaqualidadedevidademulherescomSS.

Métodos: Estudaram-se46mulherespré-menopáusicascomSSe47controlespareadospor idade.Avaliou-seaidade,adurac¸ãodadoenc¸a,osmedicamentosutilizadoseas comor-bidades.Asparticipantespreencheramoquestionáriodequalidadedevida36-ItemShort FormHealthSurvey(SF-36)eoFemaleSexualFunctionIndex(FSFI).Aspacientesforam questionadasquantoàpresenc¸adecorrimentoepruridovaginalnoúltimomês,esehaviam informadoseusreumatologistassobrequaisquerproblemassexuais.Realizaram-seexames ginecológicoseesfregac¸osvaginaisdetodasasparticipantes.

Resultados: AmedianadoescoretotaldoFSFIfoisignificativamentemenornogrupoSSdo quenogrupocontrole[17,12(2,4a27,8)e27,4(16,9a36,0),respectivamente,p<0,001].Nos gruposSSecontrole,37(80,4%)e18(38,3%)daspacientesestavamsexualmenteinsatisfeitas, respectivamente(p<0,001).Apresenc¸adesecuravaginaleousodelubrificantesforam sig-nificativamentemaisfrequentesempacientescomSSemrelac¸ãoaoscontroles(p<0,001). OsíndicesdequalidadedevidaforamsignificativamentemenoresnaspacientescomSS doquenoscontroles(p<0,001).Asecuravaginalestevenegativamentecorrelacionadocom oFSFItotal(r=-0,312p=0,035)ecomtodososseussubescores,excetodesejoeexcitac¸ão. Osescoresdecapacidadefuncional,aspectofísicoeaspectoemocionalsecorrelacionaram positivamentecomapontuac¸ãototaldoFSFI(r=0,449,p=0,002;r=0,371,p=0,011;r=0,299, p=0,043,respectivamente).

Conclusões: AsmulherescomSStêmmenorsatisfac¸ãocomaatividadesexual,oquepode serafetadopelaidade,securavaginal,dorfísicaefunc¸ãoprejudicadaemrazãodadoenc¸a. Portanto,osreumatologistadevemprestaratenc¸ãoaestessintomaseseutratamento.

©2017ElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCC BY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Sjögren’sSyndrome(SS)isacommonmultisystemic autoim-mune disease, which mainly affects exocrine glands. The clinicalsymptomsaredrynessofthemouthandeyes(sicca symptoms), due to dysfunction of salivary and lacrimal glands.1,2_{Extraglandularsymptomssuchasdisablingfatigue,}

interstitiallungdisease,neurologicinvolvement,and arthri-tisarelessfrequentlydescribed.3_{InthehistopathologyofSS,}

lymphocyticinfiltrationoftheaffectedorgansisseen.3_SSis

asystemicdiseaseclassifiedasprimaryor secondary,each associatedwithspecificsymptoms.Rheumatoid arthritisis themaindiseaserelatedtosecondarySS.4

TheincidenceandprevalenceratesofprimarySjögren’s Syndrome (pSS) vary in different populations.5,6 _{In a}

sys-temic review and meta-analysis, the overall prevalence of pSSwas60.82(95%CI43.69–77.94)casesper100,000 inhabi-tantsandtheoverallageofpSSpatientswas56.16years(95% CI52.54–59.78).7 _{FemalesareninetimesmoreatriskforSS}

thanmen.8_{WomenwithpSSoftenexperiencevaginaldryness}

and dyspareunia, along withglandular and extraglandular symptoms.8_{Chronicdyspareuniamaybethefirstpresenting}

symptomofSSp.9_{Vaginaldrynessanddyspareuniaaffectlife}

qualitymorethanotherSSsymptoms.10

SS is generally seen in sexually active women, which may havea seriousimpact on the patient’s qualityoflife;

these include emotional, functional, psychological, sexual, and reproductive health matters. Sexual health impacts many aspectsofanindividual’slife,involvingsexual activ-ityandsatisfaction.11_{Sexualdysfunctionhasbeenreported}

in 24–72% of rheumatic disorders.12,13 _{In these diseases,}

pain, fatigue, stiffness, functional impairment, depression, treatmentsideeffects,andreducedlibidocanaffectsexual functionaswell.14_{Vaginaldrynessanddyspareuniamay}

cre-atesexualdissatisfaction.15

Previousstudieshavelargelyfocusedonvaginalsymptoms and dyspareunia,but onlyafewstudies highlightedsexual dysfunctionanddistress inwomenwithSS.12,13,16,17 _Inthis

studyweaimedtoevaluatelifequalityandsexualdysfunction inagroupofTurkishwomenwithSS.Inaddition,weaimed toassess whether social,physicalandemotionalfunctions underminesexualfunctioninthesewomen.

Materials

and

methods

ThestudywasconductedfromJanuary2014toFebruary2016 inahospitalatastateuniversity,followingapprovalofthe localethicscommittee.PatientswithSSwerebetween28and 48yearsofage,andmettheAmericanCollegeof Rheumatol-ogy(ACR)2012classificationcriteriaforSS.17_{Postmenopausal}

causeadecrease invaginallubricationsuchas antidepres-santsordiureticswereexcludedfromthestudy.Ofeightysix womenwho werediagnosedwithSS atrheumatology out-patientclinics,46ofthemwho agreedtoparticipatetothe studycomplyingourinclusioncriteria,includedinthestudy group. Age-matched 47 healthy, non-menopausal women wereincludedasacontrolgroup.Writteninformedconsent, compliantwiththeHelsinkiDeclaration,wasobtainedfrom allparticipants.

Age, menstrualstatus, duration ofthe disease, medica-tions, and comorbid diseases were noted in the medical records.Participantswere informedabout the scopeofthe study and asked to complete two questionnaires: 36-Item ShortFormHealthSurvey(SF-36)andFemaleSexualFunction Index(FSFI).Anyunclearquestionswereexplainedbythetwo authors(H.I.andT.B.).

Patienthealthqualitywasassessedwiththe36-ItemShort FormHealthSurvey(SF-36)questionnaire,whichconsistsof 36questionsand8subgroups;itisafrequently-usedscale, developedbyWareandSherbournein1992.Koc¸yigitetal.in 1999establisheditsvalidityandreliabilityforTurkishpeople. ThedomainsoftheSF-36arephysicalfunctioning,role phys-ical,bodilypain, generalhealth, vitality,socialfunctioning, roleemotionaland mentalhealth.Subjectsansweredall36 questionswithintheallowedmaximum10-minutetime.All domainswerescored,andthesumofsubscalescoreswas cal-culated.Thelowestandhighestpossiblescoreswereassigned as0and100,respectively,withthehighestscoreindicating betterlifequality.

The19-itemFSFIevaluatedthepatient’ssexualfunction, asreportedbyRosenetal.,18_{andvalidatedforTurkishpeople}

byOksuz etal.in2005.19 _{Sexualfunctionismeasuredin6}

subdomains:desire,arousal,orgasm,lubrication,satisfaction, andpain.Eachsubdomainiscalculated,withthesumyielding thetotalFSFI,rangingfrom2to36.19_{Acut-offscoreof<26}

isseenassexualdysfunctionintheTurkishversion,20 _with

higherscoresindicatingbettersexualfunction.

Patientswereaskedaboutvaginaldischargeanditchingin thelastmonth,oratexaminationtime,andaskediftheyhad informedtheirrheumatologistsaboutanysexualproblems. Gynecologicexaminationswereperformed oneach partici-pant,withvaginalsmearstakenatthesametime.Treatment wasgivenforanyinfections.

Statisticalanalysis

StatisticalanalyseswereperformedwithSPSS18.0software (SPSS Inc., Chicago,IL, USA). The distribution ofdata was determined viathe Shapiro–Wilk test.Categoricalvariables werepresentedasfrequencyandpercentagesand continu-ousvariableswerepresentedasmeanfollowedbystandard deviationandmedianwithmaximum–minimum.Continuous variableswereexpressedasmean±standarddeviation,and categoricalvariables were expressedasfrequencyand per-cent.Forstatisticalanalysis,independentsamplesttestand Mann–WhitneyUtestwereusedtocomparethecontinuous variablesandPearsonChi-squaretestwasusedtocompare categorical variables. Spearman’s Rho correlation test was used to evaluate the relationship between FSFI score, life

Table1–Demographicanddiseasecharacteristicsofthe patients.

Demographics PatientswithSS (n=46)

Control (n=47)

Age,mean±SD(years)a _{40.43±5.1 39.77±3.2} Diseaseduration,median

(min–max)

5.3(3–8) –

Comorbiddisease,n(%)

Yes 13(27.3%) –

RA 5(10.9%) –

SLE 6(13.0%) –

ILD 2(4.4%) –

No 33(71.7%) 47(100%)

MedicalTreatment,n(%) –

HCQ 5(10.9%)

Corticosteroids 8(17.4%)

NSAIDs 11(23.9%)

HCQ+corticosteroid 15(32.6%)

HCQ+corticosteroid+NSAIDs

7(15.2%)

RA,rheumatoidarthritis;SLE,systemiclupuserythematosus;ILD, interstitiallungdisease;HCQ,hydroxychloroquine;NSAIDs, nons-teroidanti-inflammatorydrugs.

a _p=0.674.

quality domains, and vaginal symptoms such as dryness, infectionanditching.

Results

DemographicanddiseasecharacteristicsareshowninTable1. There was no difference between the mean ages of SS patientsandthecontrols(40.43±5.1and39.77±3.2, respec-tively, p=0.674). The median disease duration was 5 (3–8) years.Approximatelythree-fourthsofSSpatientswerefree ofcomorbiddisease(71.7%).Rheumatoidarthritis,systemic lupuserythematosus(SLE),andinterstitiallungdisease(ILD) werecoexistingdiseaseswithSSin13(27.3%)ofthepatients.

Sexualfunctionevaluation

ThemediantotalscoreofFSFIwas17.12(2.4–27.8)intheSS group and 27.4 (16.9–36.0) inthe control group which was significantly lower in the SS group (p<0.001) (Table 2). In the SS group,37 (80.4%)ofpatientswere sexually dissatis-fiedand9(19.6%)weresatisfiedand,inthecontrolgroup18 (38.3%)ofpatientswere sexuallydissatisfiedand29(61.7%) weresatisfiedwithsexualfunctions(p<0.001).Moreover,all FSFIsubscores(desire,arousal,orgasm,lubrication satisfac-tionandpain)incontrolgroupweresignificantlyhigherthan thesubscoresofpatientswithSS(p<0.001).Vaginalitching waspresent in14(35%)patients,andvaginalleucorrheaor infectiouscomplaintswerepresentin19(45%)patientsinSS patients.Therewerenostatisticallysignificantdifferencein thefrequenciesofvaginalleucorrheaorinfectiouscomplaints betweenSSpatientsandcontrols(p=0.613).

Table2–Sexualfunction,vaginalcomplaintsandlifequalityofthepatientswithSjögrenSyndromeandhealthycontrols.

Variables PatientswithSS

(n=46)

Control (n=47)

pvalue

FSFItotalscore,(range2–36)median(min–max) 17.12(2.4–27.8) 27.4(16.9–36.0)

Sexualdysfunction,n(%) 37(80.4%) 18(38.3%) <0.001 Satisfactorysexualfunction,n(%) 9(19.6%) 29(61.7%) <0.001a FSFIsubscalescores

Desire(range1,2–6)median(min–max) 2.6(1.2–4.8) 3.8(2.4–6.0) <0.001

Arousal(range0–6)median(min–max) 2.7(0.0–4.8) 4.4(2.4–6.0) <0.001

Orgasm(range0–6)median(min–max) 2.6(0–5.2) 4.7(2.4–6.0) <0.001

Lubrication(range0–6)median(min–max) 2.8(0.0–6.0) 4.8(2.7–6.0) <0.001

Satisfaction(range0,8–6)median(min–max) 3.0(0.0–5.6) 4.9(3.2–6.0) <0.001

Pain(range0–6)median(min–max) 3.1(0.0–6.0) 4.6(2.4–6.0) <0.001

Vaginalitchingcomplaints,n(%) 14(30.4%) 8(17%) 0.130

Vaginalleucorrheacomplaints,n(%) 19(41.3%) 17(36.2%) 0.613

Vaginaldryness,n(%) 37(80.4%) 4(8.5%) <0.001

Lubricantuse,n(%) 24(52.2%) 5(10.6%) <0.001

SF-36domains(0–100)

Physicalfunctioningmedian(min–max) 19.78(10–30) 26.15(18–30) <0.001

Rolephysicalmedian(min–max) 0.85(0–4) 3.64(1–5) <0.001

Roleemotionalmedian(min–max) 0.80(0–5) 2.47(0–3) <0.001

Socialfunctioningmedian(min–max) 5.67(2–10) 7.26(4–10) <0.001

Bodilypainmedian(min–max) 5.70(3–11) 8(5–11) <0.001

Mentalhealthmedian(min–max) 16.98(10–26) 20.57(13–28) <0.001

Vitalitymedian(min–max) 11.93(6–21) 15.30(6–22) <0.001

Generalhealth,median(min–max) 16.87(14–22) 18.13(15–21) <0.001

a _{Chi-squaretest.}

inflammatoryandof30(63.8%)werenormal.Morethanhalfof thepatients(n=24,52.2%)inSSreporteduseoflubricantsdue tovaginaldrynessbeforesexualintercourseinthedetailed questioningon medications.Vaginal drynessand lubricant useweresignificantlyincreasedinpatientswithSScompared tocontrols(p<0.001). Patientswho usedlubricants experi-encedthatsexualsatisfactionwasimprovedwithlubricant use,buttherestofthemwereunawareofthelubricants.Of thepatientswho usedlubricants,9(37.5%)hadsatisfactory sexualscores,howevernoneofthewomenwhodidnotuse thelubricantshadsatisfactoryFSFIscores.

Qualityoflifeassessment

Alllifequalityscores–physical,emotionalandsocial func-tions,bodilypain,generalhealth,vitality,mentalaspectand functionalcapacity–weresignificantlylowerinpatientswith SSthanthelifescoresofthecontrolpatients(Table2).

Parametersrelatedtosexualdysfunction

AgewasnegativelycorrelatedwithtotalFSFIscore(r=−0.545,

p<0.001)andsubscoresinpatientswithSS.Vaginal itching andinfectioussymptomswereunrelatedtototalFSFIscore andsubscores.Vaginaldrynesswasnegativelycorrelatedwith totalFSFI (r=−0.312, p=0.035)and subscores exceptdesire andarousal (Table3).Lubricationuse was positively corre-latedwithtotalFSFIscores(r=0.695,p<0.001),desire(r=0.645,

p<0.001), arousal (r=0.738, p<0.001), lubrication (r=0.667,

p<0.001), orgasm (r=0.675, p<0.001), satisfaction (r=0.586,

p<0.001)and painscores(r=0.672,p<0.001).Physical func-tioning,rolephysicalandroleemotionalscoreswerepositively

correlatedwithtotalFSFIscores(r=0.449,p=0.002;r=0.371,

p=0.011;r=0.299,p=0.043)(Table3).

Whenpatientswereaskedaboutwhetherornotthey dis-cussed their vaginalsymptomsor sexual dysfunctionwith their rheumatologists,26 (56.5%)womentoldthattheydid nottalkaboutsexualdysfunctionwiththeirrheumatologists because they did not think sexual dysfunction was being assessed.Only8(17.3%)mentionedabouttheirvaginal symp-tomstotheirphysicians.Therest12(26.2%)triedtotalkabout theirvaginaldrynessbuttheywereashamedtotalk.

Discussion

WomenwithSSoftenexperience vaginaldrynessand dys-pareuniawhichcanleadtosexualdysfunction.8_Wefoundthat

patientswithSShadlowersexualfunctionscorescompared toage- matchedcontrolsand 80.4%ofthem weresexually dissatisfiedaccordingtopreviouslydeterminedcut-offvalues (FSFIscoreof<26).19,20_{Alldomainsofsexualfunction,}

Table3–Relationshipbetweensexualdysfunction,patientcharacteristicsandpatients’clinicalpropertiesinstudygroup (patientswithSjögren’sSyndrome).

Variable Desire Arousal Lubrication Orgasm Satisfaction Pain FSFItotalscore

Age r=−0.441

p=0.002

r=−0.508 p<0.001

r=−0.521 p<0.001

r=−0.525 p<0.001

r=−0.508 p<0.001

r=−0.451 p=0.002

r=−0.545 p<0.001 DiseaseDuration r=−0.080

p=NS

r=−0.168 p=NS

r=−0.005 p=NS

r=−0.108 p=NS

r=−0.057 p=NS

r=−0.091 p=NS

r=−0.059 p=NS Comorbiddisease r=0.174

p=NS

r=0.158 p=NS

r=0.227 p=NS

r=0.256 p=NS

r=0.194 p=NS

r=0.210 p=NS

r=0.183 p=NS Vaginalitching r=−0.266

p=NS

r=−0.140 p=NS

r=−0.132 p=NS

r=−0.156 p=NS

r=−0.167 p=NS

r=−0.075 p=NS

r=−0.114 p=NS Vaginalinfection

symptoms

r=0.047 p=NS

r=0.064 p=NS

r=0.074 p=NS

r=0.052 p=NS

r=0.069 p=NS

r=0.034 p=NS

r=0.062 p=NS Vaginaldryness r=−0.238

p=NS

r=−0.194 p=NS

r=−0.371 p=0.011

r=−0.380 p=0.009

r=−0.427 p=0.003

r=−0.341 p=0.020

r=−0.312 p=0.035 Lubricationuse r=0.645

p<0.001

r=0.738 p<0.001

r=0.667 p<0.001

r=0.675 p<0.001

r=0.586 p<0.001

r=0.672 p<0.001

r=0.695 p<0.001 SF-36physical

functioning

r=0.434 p=0.003

r=0.401 p=0.006

r=0.486 p=0.001

r=0.400 p=0.006

r=0.394 p=0.007

r=0.448 p=0.002

r=0.449 p=0.002 SF-36rolephysical r=0.250

p=0.094

r=0.370 p=0.011

r=0.431 p=0.003

r=0.286 p=0.054

r=0.388 p=0.008

r=0.370 p=0.011

r=0.371 p=0.011 SF-36roleemotional r=0.180

p=0.232

r=0.220 p=0.142

r=0.310 p=0.036

r=0.280 p=0.060

r=0.312 p=0.035

r=0.297 p=0.045

r=0.299 p=0.043 SF-36social

functioning

r=0.271 p=NS

r=0.162 p=NS

r=0.198 p=NS

r=0.097 p=NS

r=0.110 p=NS

r=0.229 p=NS

r=0.175 p=NS SF-36bodilypain r=0.292

p=0.049

r=0.279 p=NS

r=0.344 p=0.019

r=0.198 p=NS

r=0.218 p=NS

r=0.334 p=0.023

r=0.270 p=NS SF-36mentalhealth

score

r=0.161 p=NS

r=0.058 p=NS

r=0.166 p=NS

r=0.013 p=NS

r=0.073 p=NS

r=0.168 p=NS

r=0.077 p=NS SF-36vitality r=0.292

p=0.049

r=0.215 p=NS

r=0.232 p=NS

r=0.154 p=NS

r=0.213 p=NS

r=0.241 p=NS

r=0.219 p=NS SF-36generalhealth r=0.118

p=NS

r=−0.021 p=NS

r=0.207 p=NS

r=0.150 p=NS

r=0.112 p=NS

r=0.239 p=NS

r=0.132 p=NS SF-36mentalhealth

summarymeasure

r=0.216 p=NS

r=0.127 p=NS

r=0.251 p=NS

r=0.108 p=NS

r=0.174 p=NS

r=0.238 p=NS

r=0.172 p=NS

FSFI:FemaleSexualFunctionIndex;NS,non-significant;r:correlationcoefficient.

AgewasnegativelycorrelatedwithsexualfunctioninSS group,whichwassimilarwiththepreviousstudies.13,21

Any-fantietal.evaluated557patientswithrheumatologicdisease andfoundthatolderagewasthe onlypredictive factorfor sexualdysfunction.21_{Theyreportedthatagecouldalsoaffect}

physicalandpsychologicalattitudes,inturncausingsexual dysfunction.21 _{Even if the age affects negatively onsexual}

functions in our study, SS patients had lower FSFI scores andmoresexualdysfunctioncomparinghealthyage-matched controlswhichshowsSShasprominentnegativeimpacton sexualfunctionsafteradjustingage.

Infectiousvaginalcomplaints,leucorrheaanditchingwere notcorrelatedwithsexualfunctioninourstudy,inagreement withvanNimwegenetal.13_{Therewerenodifferencebetween}

leucorrheaanditchingsymptomsbetweenstudyandcontrol group.Evenifratesofinflammatorychangesandatrophyin vaginalsmearswerehigherinSSpatients,theywerenot sta-tisticallysignificant.

Vaginal dryness was present almost ten times more in SSpatientsthan thecontrols.Likewise,lubricantuseinSS patientswas5timesmore.Lubricantsarerecommendedby theInternationalMenopauseSocietyandtheNorthAmerican MenopauseSocietyinthepostmenopausalperiod.22,23_Inthis

studyweshowedthatSSwomenmayneedlubricantsalsoin theperimenopausalperiodduetovaginaldryness.Patients

whousedlubricantsexperiencedthatsexualsatisfactionwas improvedwithlubricantuse,soitcanbeadvisedtoSSpatients bytheirphysicianeveniftheyarepremenopausal.Moreover inourstudywomenwhoreportedmorevaginalmoisturethan otherparticipantshadlesssexualpainandbettersexualpain scores(r=−0.341,p=0.020,Table3).Jozkowskietal.assessed women’s’ perceptionsabout lubricants and why they were moreinclinedtousethem.Theirfindingsshowedthatfemale preferredlubricantstofeelmorewetduringintercourse.They concludedthatlubricantuserecommendationsfromhealth professionalsandsexeducatorscouldbehelpful.24

Comorbidrheumatologicdiseasewasfoundin27.3%ofour studygroup.However,thepresenceofRAorSLEwithSSwas notcorrelatedwithsexualdysfunctioninourstudy.Anyfanti et al. evaluatedcardiovascular riskfactors ascreating sex-ualdysfunctioninpatientswithrheumatologicdisease;they reportedthattraditionalcardiovascularriskfactorsfailedto explaintheincreasedprevalenceofsexualdysfunction.21_Our

samplesizeisrelativelysmallbutweincludedcomparatively young, premenopausal women in our study. We excluded womenwithseveresystemicdiseasesandcomplications,and patientswhowereusingantidepressantsordiureticsto elim-inatetheunfavorableeffectofthemonthesexualfunction.

countries.OurFSFIscoresbothinSSpatients[17.12(2.4–27.89)] andcontrolgroup[27.4(16.9–36.0)]werelowerthanprevious studies,9,12,16_{whichmaybeexplainedbyculturaldifferences.}

VanNimwegenetal.reportedmedianFSFIscoreof20.6inthe SSpatientsand30.3inthecontrols.13_{Priorietal.reporteda}

meanFSFIscoreof19.1±7.33intheSSpatients.Priorietal, alsosuggestedthatbothpremenopausalandpostmenopausal women with SS have worse sexual quality of life which issimilar to finding ofour study.16 _{Ferreira et al.reported}

theprevalenceofsexualdysfunctionas18.4%in rheumato-logicpatientswiththemeanageof40.4years.Patientswith fibromyalgiaandSShadthehighestsexualdysfunction(33%) whichwaslowerthanourfindingofsexualdysfunctionrate of80.4% inSS patients in the similar age group.12 _Sexual

attitudescanvaryamongculturesforsocialand psychoso-cialissues,sofunctionscoresvaryaccordingly.9,15,16_Thisis

thefirststudyperformedinTurkeyonsexualfunctionofSS patients.Sexualdysfunctionincidenceofhealthywomenwas foundas28.6–48.3%instudiesperformedindifferentcities ofTurkey.25,26_{Inourstudysexualdysfunctionratewas38.3%}

inthecontrolgroupwhichwascompatiblewiththeprevious reports.

Oneoftheaimsofourstudywastoassesslifequalityand itseffectsonsexualfunctioninpatientswithSS.Wefound thatphysicalfunction scoresinlifequality testspositively correlatedwithsexualfunctionscores.Ifapatienthasa bet-terphysicalfunctionandlessphysicalrestriction,shetends tohavemoresatisfaction.Socialfunctioningwasnotlinked tosexualfunction.Mentaldomainscores,whenthemental healthscore and emotionalscore were summed, were not correlatedwithFSFIscores(Table3).Psychologicalaspectsof sexualfunctionwereevaluatedinpreviousstudies.Anyfanti etal.statedthatinrheumatologicpatients,mentaldistress andsexualdysfunctionareextremelycommon.20_Researchers

concludedthatdepressionandanxietywererelatedtosexual dysfunctioninrheumatologicdisease,aswellasinpatients with SS13,27_{; van Nimwegen et al. reported depression as}

beingthemostimportantpredictorofsexualdysfunctionin patientswithSS.13 _{Wefounddecreasedroleemotionaland}

mentalhealthscoresinSSpatientswhencomparedto con-trolssimilartootherstudiesintheSSpopulation.13,20_Inthis

study we onlyevaluated psychologicalcharacteristics with onlythesubscalesoftheSF-36questionnaire(roleemotional andmentalhealth)whichcouldnotbesufficientfordetailed evaluation.Wedidnotevaluateddepressionoranxietywith morespecificquestionnaires,whichmaybethelimitationof ourstudy.Evenifemotionaldysfunctionwerelinkedto sex-ualdysfunction inourstudy,wecould notfindcorrelation betweenmentalhealthscoresandFSFIscores.

Inaddition, weaskedwomeniftheyhaddiscussed sex-ual activities or problems with their rheumatologists. We found out that only eight (17.3%) of them talked about vaginal complaints. Women rarely talk about these topics withtheirphysicians,asthe medicalfield tendstoneglect sexualdysfunctioninrheumatologicdisease.ManyTurkish women are also hesitant to discuss sexual problems. We talkedwithpatientsinperson.Wefeltsometimesthatthey mightbeembarrassedtoanswer questions aboutsexuality duetosocialpressure.Vaginaldrynessisoneofthe symp-tomsofSS,so rheumatologistsshouldbringup anyissues

regardingtheirpatients’intimaterelationships.Womencould then be referred togynecologists or sexologists. Psychoso-cialsupportmay begiventowomen andtheir partnersto improvetheirrelationship,asdisabilitiesincommunication andinterrelationmayincreasesexualdysfunctionand phys-ical complaints. On the other hand,for women who have decreased performanceinsexuality duetovaginaldryness or other vaginalsymptoms, lubricants orestrogens canbe recommended.

Inconclusion,womenwithSSexperiencedlowsatisfaction withsexualactivity,whichcouldbeaffectedbyage,increased vaginaldrynessandimpairedphysicalandemotional func-tion duetothe disease.Lubricantuse wasassociatedwith better sexual satisfaction and increase in FSFI total and subscores. Therefore, lubricants should beconsidered as a symptomatictreatmentinSS.Thisstudyemphasizes com-monSSsymptoms,whichhavetypicallybeenunderestimated byrheumatologists.Furthertrialswithlargerstudygroupsare necessaryforthesupportofourresults.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

Weallthanktoparticipantswhoagreedtocompletethe ques-tionnaires.Nofoundationwastakenfromanycompany.

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