Female sexual dysfunction is a common problem, affecting 20–50% of women. Problems with sexual function have also been reported to occur commonly in pregnant women. A combination of biological and psychological risk factors has been suggested in the etiology of sexual dysfunction 1.
The Female Sexual Function Index (FSFI) is a questionnaire that has been developed as a brief, multidimensional self-report instrument for the assessment of the key dimensions of sexual function in women. It is psychometrically sound, easy to administer, and has shown ability to differentiate between clinical and nonclinical populations. The questionnaire described was designed and validated for the assessment of female sexual function and quality of life in clinical trials or epidemiological studies 2.
FSFI is a validated and reliable measure for assessment of female sexual function. It includes 19 questions, which assess the six domains of sexual function including desire, arousal, lubrication, orgasm, satisfaction, and pain. The full scale score range is from 2 to 36, with higher scores associated with a lower degree of sexual dysfunction. The aim of this study is to assess changes in sexual behavior during pregnancy using the FSFI.
Participants and methods
The present study included 500 pregnant women attending the outpatient clinic of Obstetrics and Gynecology in Mataria Teaching Hospital for routine antenatal care during the period from April 2009 to October 2009. The study was approved by the ethical committee and consent was obtained from all the participants.
Women were divided into three groups: group I included patients in the first trimester (134 patients), group II included patients in the second trimester (106 patients), and group III included patients in the third trimester (260 patients). Full history was taken, with special focus on the age, number of gravidity, origin, level of education, and any indications that may prevent sexual intercourse during pregnancy or if the pregnant woman has any systemic diseases. A careful gynecological examination was performed to determine whether a patient was circumcised.
All pregnant women were interviewed according to the adapted Arabic translation of FSFI, which included 19 questions translated by us, and were scored for domains of desire, arousal, lubrication, orgasm, satisfaction, and pain 2. We explained the questions of the questionnaire and the answer options, which were scored (higher scores reflect better sexual function). Each question was asked twice: one during her pregnancy and the same question for the period before pregnancy.
We excluded women with systemic diseases such as diabetes mellitus, hypertension, and cardiovascular diseases, those with conditions requiring abstinence from sexual intercourse such as unexplained vaginal bleeding, discharge, cramping, or rupture of membranes, and women who have special situations leading to separation from their husbands such as divorce, death or the husband working away for a long period, which resulted in the absence of regular sexual relations.
Female Sexual Function Index
Each FSFI domain score was calculated and the mean scores in each domain were compared according to the trimesters of pregnancy. Domains included desire (frequency and level), lubrication (frequency, difficulty, frequency of maintaining lubrication, difficulty in maintaining lubrication), arousal (frequency, level, confidence, satisfaction), orgasm (frequency, difficulty, satisfaction), satisfaction (with amount of closeness with partner, with a sexual relationship, with overall sexual life), and pain (frequency during vaginal penetration, frequency following vaginal penetration, level during or following vaginal penetration).
Subgroup analysis was performed according to the age; the patients were divided into three groups: the first group included patients younger than 20 years of age (45 women), the second group included patients ranging in age between 20 and 30 years (407 women), and the third group included patients older than 30 years of age (48 women). According to the level of education, they were classified as illiterate, primary, secondary, technical and higher education. In terms of place of residence, they were either urban (133 women) or rural (367 women). In terms of gravidity, they were divided into few (number of gravidity one or two), moderate (number of gravidity three or four), and many (number of gravidity five or more). Data were analyzed using one-way analysis of variance. Multiple comparisons were performed using the Bonferroni test 3.
The demographic data of our participants are presented in Table 1. Our FSFI scores worsened with pregnancy as the mean was 26.78±3.08 before pregnancy and 22.45±4.47 after pregnancy (Table 2). However, interestingly, the mean scores of the first trimester (21.56) increased in the second trimester (24.75) and then decreased in the third trimester to (22.17). There was a significant decrease in most of the domains investigated in the first trimester as shown in Table 3. The most prevalent sexual dysfunction in the pregnancy was the pain (1.66±0.75), followed by a decrease in sexual desire (3.30±0.96). The most prevalent sexual problems during pregnancy were pain, followed by desire disorders.
Pain or vaginal discomfort may be attributed to vaginal physiology, which is significantly influenced by the endocrine environment necessary for adaption to the pregnancy and delivery. Generally, the connective tissue of the vagina decreases and the muscle fibers of the vaginal wall increase in size in preparation for delivery under the influence of hormones 4. This interpretation is supported in our study as the mean score of the pain decreases as pregnancy advances.
The decrease in sexual desire could be attributed to nausea in the first trimester, and a large abdomen and worries that sexual intercourse might harm the baby in the last trimester as some women believed that having sex may cause preterm labor and rupture of the membrane; unattractiveness of the body, insomnia, and not being in the mood because of the anxiety of delivery and motherhood responsibilities were the reasons for low sexual desire. From the physiological point of view, the decrease in free testosterone during pregnancy, which influences sexual desire in women, could be the reason for decreased desire in pregnant women.
In the present study, it was found that women younger than 20 years of age had less sexual dysfunction than the other age groups. According to the level of education, group I (illiterate) had a significantly higher score than group II (moderate education: primary, secondary, and technical) (P<0.0001), with no difference between group I and group III (highly educated) (P=0.11), and between group II and group III (P=0.06).
In terms of the place of residence (urban and rural), there was no statistical significant difference between the two groups (urban and rural) in the scores of desire, arousal, lubrication, orgasm, satisfaction, pain, and the full scale score (P>0.05). In addition, the full scale score was significantly higher in group I (circumcised women) than group II (noncircumcised women) (P<0.0001).
According to the number of gravidity, the highest full scale score was found among cases with a low number of gravidity (one and two), followed by moderate (three and four) and high (five or more), with a significant difference between the three groups (P<0.0001).
The score was higher in the illiterate women than the moderately educated women, which could be because of the fact that illiterate women may not be aware of their sexual function and the stages of normal and satisfying female response and therefore they may not be able to express or detect accurately the point of dysfunction.
It was also found that among the noncircumcised pregnant women, the mean full score was 21.30±3.57, which is lower in comparison with the circumcised women (22.67±4.59); this unexpected result can be attributed to the low number of noncircumcised women in our study (79 women), representing only 15.8% of the total number of women in the study, and this may have affected the statistical results. It may also be attributed to the level of education of noncircumcised women, which was either moderate or high – the percentage of illiterate women was 0% – and the female sexual dysfunction scores were lower in women with a moderate or a high level of education as reported previously.
In terms of the number of gravidity, in our study, the dysfunction increased with the number of gravidity and decreased as the number of gravidity decreased, with a significant difference between them. This can be explained by the fact that women get more physiologically and psychologically exhausted with more and more pregnancies; she may be more exhausted physiologically and psychologically and therefore, may lose sexual desire. In addition, as the lacerations and scars of repeated vaginal deliveries increase, impaired lubrication, sensation, vaginal discomfort, and atrophy also increase.
Other investigators have reported that 76–79% of women had enjoyed intercourse before pregnancy (7–21% not at all); however, this rate decreased to 59% in the first, 75–84% in the second, and 40–41% in the last trimester 1. However, all studies such as that by Jessup 5 and Lamont 6 evaluated in this detailed review were carried out before the development of objective measures of the FSFI.
With the use of FSFI, all the studies reported results in agreement with ours in terms of the decrease in sexual scores after pregnancy as reported by other investigators 7–10, but they reported a significant decrease in sexual dysfunction scores in the third trimester more than the first and second trimesters; most of the results were in agreement with ours in that pain and desire disorders are the most prevalent sexual dysfunction, considering that the pain scores were lower than desire scores.
It was found that the pregnant women in our study were receiving counseling or obtaining information not from a doctor mainly because of hesitation in talking about sex. It was found that sharing problems with a friend was easier, and most of their friends advised them to stop sexual relations, especially in the first trimester. In their opinion, ‘this may lead to abortion as the pregnancy still not fixed’, and this may explain the lower scores in the first trimester in addition to the third trimester, which is not in agreement with the previous studies.
No studies were identified during our search that correlated education and place of residence to sexual dysfunction as in our study. Only one study focused on the number of gravidity and its relation to the sexual dysfunction, and it showed that there was an increase in the frequency of intercourse in primiparous than in multiparous women 11.
There are some limitations to this type of study. Although all the pregnant women enrolled agreed to share, there was difficulty in explaining some questions in detail or in completing the questionnaire, and these incomplete questionnaires were discarded. In addition, our validated index is designed to measure sexual function in the past 4 weeks; we did not collect accurate data from the prepregnancy period, and we were also aware that any prepregnancy data would be subject to recall bias. This limitation has also been reported in the study of Pauls et al. 10. Our patients’ demographics, although possibly representative of an inner-city population, were different from the national average in terms of education, number of gravidity, age, and cultural level, which affect sexuality, a fact that affects the generalizability of these data.
Our results showed that sexual function decreased significantly during pregnancy. Sexual problems during pregnancy were pain, followed by desire disorders. Pregnancy may have a negative effect on marital relationships, and this may be an obstacle for the adaptation of women to this transient phase. Physicians who provide healthcare for childbearing couples should provide information about sexual problems and fluctuations in the patterns of sexuality during pregnancy to reduce the anxiety and the negative feedback not only on the mother but on the couple.
Conflicts of interest
There are no conflicts of interest.
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