Summary
Sexual dysfunction is a common problem around the menopause and postmenopause which is multifactorial. In this retrospective cross-sectional study from Brazil the authors looked at female sexual function (as measured by the Female Sexual Function Index: FSFI) in relation to pelvic floor muscle strength, as well as age and other demographic data [1]. The sample of almost 1,000 women were volunteers selected from previous studies on the databases from laboratories. All had given their prior consent and only those with a complete data set were included in the final analysis. Women with neurological, collagen or muscle related diseases were excluded as were those with prolapse (> grade 3), those with apical prolapse and those with previous pelvic floor muscle training (PFMT) by a health professional. Pelvic floor muscle strength (PFMS) was tested by vaginal examination using the modified oxford scale (MOS) which is a recognized scale that runs from 0-5: 0 = no contraction; 1 = minor muscle ‘flicker’; 2 = weak muscle contraction; 3 = moderate muscle contraction; 4 = good muscle contraction and 5 = strong muscle contraction. Sexual function was assessed using the FSFI with scores that range from 2-36. The higher the score the better the sexual function. A total score of 26.55 was taken as a cut off value so any woman with a score <26.55 was considered to have sexual dysfunction. Finally, 982 women were included in the study with an average age of 45.76 (range: 30.51 -61.01). 69% had a total FSFI score < 26.55 i.e. sexual dysfunction, 31% had FSFI > 26.55 i.e. normal sexual function. Characteristics of those with highest scores when compared with the lower scores: had age < 45, were white, single, had higher education, higher income, a body mass index ( BMI) < 25, lower parity, undertook regular physical activity and had a higher PFMS (MOS 4-5). Women with MOS 4-5 had higher desire, arousal, lubrication and orgasm and those with MOS 3-5 had higher satisfaction and less pain. The authors conclude that women good PFMS had less complaints about sexual dysfunction.
Commentary
Pelvic floor muscle anatomy and contractility are important for pelvic floor and sexual function. The prevalence of sexual dysfunction in postmenopausal women is high thus theoretically PFMS could be an important factor related to sexual dysfunction. To date there has been limited evidence on the topic in relation to menopausal women. This latest paper [1] highlights the importance of good PFMS in sexual function and looking at sexual function and dysfunction in its entirety. Whilst this paper did not look specifically at menopausal status, based on the age range of the participants (30.51 -61.01, mean 45.76), many women would be peri- or early postmenopausal. The findings of this study concur with some of the existing literature on this subject. Kanter et al. [2] reported that a strong pelvic floor is associated with higher rates of sexual activity as well as higher sexual function scores on both the PISQ-IR and the orgasm domain of the FSFI. Although this study also didn’t look specifically at menopausal status, the mean age was 54.9 so the majority would have been menopausal or postmenopausal. Zhuo et al. [3] found that perimenopausal women with pelvic floor dysfunction had worse sexual function than women with functional PFM, especially in obese women, those with central adiposity, and those not using hormone replacement therapy. PFMS was weakly positively correlated with sexual arousal, orgasm, sexual satisfaction, and FSFI scores. In an analytical cross-sectional study of 226 sexually active postmenopausal women aged 45−65 years without pelvic floor disorders Omodei et al. [4] found that postmenopausal women with PFM dysfunction had poorer sexual function than women with functional PFM. The authors concluded that the maintenance of PFMS during the climacteric period is an important factor in postmenopausal women’s sexual function. De Menezes Franco et al. [5] conducted a cross-sectional study of 113 postmenopausal women with a median age of 53 years to evaluate the relationship between PFMS and sexual function in postmenopausal women. They found that women with sexual dysfunction showed significantly lower PFMS than women without sexual dysfunction (p = 0.02).
The literature seems to tell us that postmenopausal women with good PFMS have less sexual dysfunction. The next question is ¿can women with poor sexual function improve their sexual function with PFM training? In a randomized controlled trial, Franco et al. [6] assessed the effect of a PFM training protocol on sexual function in 77 postmenopausal women with and without sexual dysfunction. They observed that after 12 weeks a higher percentage of women without sexual dysfunction was found in the intervention group when compared to the control group and concluded that PFM training in postmenopausal women can improve sexual function. In another randomized trial of 99 postmenopausal women some of whom were on menopausal hormone therapy (MHT), Ignácio Antônio et al. [7] found that PFM training increased PFMS more in women who were not using MHT as compared to those using it.
Sexual dysfunction is a common problem around the menopause and our focus tends to be on psychosocial issues, sexual counselling, and ensuring adequate estrogenisation of the vaginal tissues and the potential addition of testosterone [8]. The present commented paper [1] reminds us of the importance of good PFMS in sexual function. Women should be encouraged to maintain good PFMS throughout their life and particularly around the perimenopause to reduce the possibility of sexual dysfunction. In addition, PFM training should be considered a potential intervention for postmenopausal women with sexual dysfunction.
Tim Hillard
Department of Gynaecology, University Hospitals Dorset, Poole, UK
References
- Pasqualotto L, Riccetto C, Biella AF, et al. Impact of pelvic floor muscle strength on female sexual function: retrospective multicentric cross-sectional study. Int Urogynecol J. 2022;33(6):1591-1599. 1
https://pubmed.ncbi.nlm.nih.gov/35066656/ - Kanter G, Rogers RG, Pauls RN, Kammerer-Doak D, Thakar R. A strong pelvic floor is associated with higher rates of sexual activity in women with pelvic floor disorders. Int Urogynecol J. 2015;26(7):991-6.
https://pubmed.ncbi.nlm.nih.gov/25994625/ - Zhuo Z, Wang C, Yu H, Li J. The Relationship Between Pelvic Floor Function and Sexual Function in Perimenopausal Women. Sex Med. 2021;9(6):100441.
https://pubmed.ncbi.nlm.nih.gov/34628115/ - Omodei MS, Marques Gomes Delmanto LR, Carvalho-Pessoa E, Schmitt EB, Nahas GP, Petri Nahas EA. Association Between Pelvic Floor Muscle Strength and Sexual Function in Postmenopausal Women. J Sex Med. 2019;16(12):1938-1946.
https://pubmed.ncbi.nlm.nih.gov/31680007/ - de Menezes Franco M, Driusso P, Bø K, et al. Relationship between pelvic floor muscle strength and sexual dysfunction in postmenopausal women: a cross-sectional study. Int Urogynecol J. 2017;28(6):931-936.
https://pubmed.ncbi.nlm.nih.gov/27924379/ - Franco MM, Pena CC, de Freitas LM, Antônio FI, Lara LAS, Ferreira CHJ. Pelvic Floor Muscle Training Effect in Sexual Function in Postmenopausal Women: A Randomized Controlled Trial. J Sex Med. 2021;18(7):1236-1244.
https://pubmed.ncbi.nlm.nih.gov/34187758/ - Ignácio Antônio F, Herbert RD, Bø K, Rosa-E-Silva ACJS, Lara LAS, Franco MM, Ferreira CHJ. Pelvic floor muscle training increases pelvic floor muscle strength more in post-menopausal women who are not using hormone therapy than in women who are using hormone therapy: a randomised trial. J Physiother. 2018;64(3):166-171.
https://pubmed.ncbi.nlm.nih.gov/29914808/ - Simon JA, Davis SR, Althof SE, et al. Sexual well-being after menopause: An International Menopause Society White Paper. 2018;21(5):415-427.
https://pubmed.ncbi.nlm.nih.gov/29987939/
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