SciELO - Scientific Electronic Library Online

 
vol.57 issue3Impact of rheumatoid arthritis in the public health system in Santa Catarina, Brazil: a descriptive and temporal trend analysis from 1996 to 2009Falls and their association with physical tests, functional capacity, clinical and demographic factors in patients with rheumatoid arthritis author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

Share


Revista Brasileira de Reumatologia

Print version ISSN 0482-5004On-line version ISSN 1809-4570

Rev. Bras. Reumatol. vol.57 no.3 São Paulo May/June 2017

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

Original articles

Are the women with Sjögren's Syndrome satisfied with their sexual activity?

Hatice Isika  b  * 

Metin Isikc 

Oner Aynioglua 

Deniz Karcaaltincabad 

Ahmet Sahbaza 

Tugba Beyazciceke 

Mehmet Ibrahim Harmaa 

Nejat Demircane 

aBulent Ecevit University, School of Medicine, Department of Obstetrics and Gynecology, Zonguldak, Turkey

bMevlana University, School of Medicine, Department of Obstetrics and Gynecology, Konya, Turkey

cBulent Ecevit University, School of Medicine, Department of Rheumatology, Zonguldak, Turkey

dGazi University, School of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey

eBulent Ecevit University, School of Medicine, Department of Family Medicine, Zonguldak, Turkey

ABSTRACT

Objective:

Females with Sjögren's Syndrome (SS) often experience vaginal dryness and dyspareunia, along with glandular and extraglandular symptoms. We aimed to evaluate sexual function and life quality in women with SS.

Methods:

Forty-six premenopausal women with SS and 47 age-matched controls were studied. Age, duration of the disease, medications, and comorbid diseases were noted. Participants completed 36-Item Short Form Health Survey (SF-36) and Female Sexual Function Index (FSFI). Patients were asked about vaginal discharge and itching in the last month, and if they informed their rheumatologists about any sexual problems. Gynecologic examinations were performed and vaginal smears were taken on each participant.

Results:

The median total scores of FSFI were significantly lower in the SS group than the controls [17.12 (2.4-27.8) and 27.4 (16.9-36.0), respectively, p < 0.001]. In the SS group, 37 (80.4%) and in the control group 18 (38.3%) of patients were sexually dissatisfied (p < 0.001). Vaginal dryness and lubricant use were significantly increased in patients with SS compared to controls (p < 0.001). Life quality scores were significantly lower in patients with SS than the controls (p < 0.001). Vaginal dryness was negatively correlated with FSFI total (r = −0.312, p = 0.035) and subscores except desire and arousal. Physical functioning, role physical and role emotional scores were positively correlated with total FSFI scores (r = 0.449, p = 0.002, r = 0.371, p = 0.011, r = 0.299, p = 0.043, respectively).

Conclusions:

Women with SS experience less satisfaction with sexual activity, which can be affected by age, vaginal dryness, physical pain, and impaired function due to the disease. Therefore, rheumatologists should pay attention to these symptoms and management.

Keywords: Sjögren's syndrome; Chronic dyspareunia; Sexual dissatisfaction

Introduction

Sjögren's Syndrome (SS) is a common multisystemic autoimmune disease, which mainly affects exocrine glands. The clinical symptoms are dryness of the mouth and eyes (sicca symptoms), due to dysfunction of salivary and lacrimal glands.1,2 Extraglandular symptoms such as disabling fatigue, interstitial lung disease, neurologic involvement, and arthritis are less frequently described.3 In the histopathology of SS, lymphocytic infiltration of the affected organs is seen.3 SS is a systemic disease classified as primary or secondary, each associated with specific symptoms. Rheumatoid arthritis is the main disease related to secondary SS.4

The incidence and prevalence rates of primary Sjögren's Syndrome (pSS) vary in different populations.5,6 In a systemic review and meta-analysis, the overall prevalence of pSS was 60.82 (95% CI 43.69-77.94) cases per 100,000 inhabitants and the overall age of pSS patients was 56.16 years (95% CI 52.54-59.78).7 Females are nine times more at risk for SS than men.8 Women with pSS often experience vaginal dryness and dyspareunia, along with glandular and extraglandular symptoms.8 Chronic dyspareunia may be the first presenting symptom of SSp.9 Vaginal dryness and dyspareunia affect life quality more than other SS symptoms.10

SS is generally seen in sexually active women, which may have a serious impact on the patient's quality of life; these include emotional, functional, psychological, sexual, and reproductive health matters. Sexual health impacts many aspects of an individual's life, involving sexual activity and satisfaction.11 Sexual dysfunction has been reported in 24-72% of rheumatic disorders.12,13 In these diseases, pain, fatigue, stiffness, functional impairment, depression, treatment side effects, and reduced libido can affect sexual function as well.14 Vaginal dryness and dyspareunia may create sexual dissatisfaction.15

Previous studies have largely focused on vaginal symptoms and dyspareunia, but only a few studies highlighted sexual dysfunction and distress in women with SS.12,13,16,17 In this study we aimed to evaluate life quality and sexual dysfunction in a group of Turkish women with SS. In addition, we aimed to assess whether social, physical and emotional functions undermine sexual function in these women.

Materials and methods

The study was conducted from January 2014 to February 2016 in a hospital at a state university, following approval of the local ethics committee. Patients with SS were between 28 and 48 years of age, and met the American College of Rheumatology (ACR) 2012 classification criteria for SS.17 Postmenopausal women, patients with severe systemic diseases and complications, and patients who were taking medications which may cause a decrease in vaginal lubrication such as antidepressants or diuretics were excluded from the study. Of eighty six women who were diagnosed with SS at rheumatology outpatient clinics, 46 of them who agreed to participate to the study complying our inclusion criteria, included in the study group. Age-matched 47 healthy, non-menopausal women were included as a control group. Written informed consent, compliant with the Helsinki Declaration, was obtained from all participants.

Age, menstrual status, duration of the disease, medications, and comorbid diseases were noted in the medical records. Participants were informed about the scope of the study and asked to complete two questionnaires: 36-Item Short Form Health Survey (SF-36) and Female Sexual Function Index (FSFI). Any unclear questions were explained by the two authors (H.I. and T.B.).

Patient health quality was assessed with the 36-Item Short Form Health Survey (SF-36) questionnaire, which consists of 36 questions and 8 subgroups; it is a frequently-used scale, developed by Ware and Sherbourne in 1992. Koçyigit et al. in 1999 established its validity and reliability for Turkish people. The domains of the SF-36 are physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional and mental health. Subjects answered all 36 questions within the allowed maximum 10-minute time. All domains were scored, and the sum of subscale scores was calculated. The lowest and highest possible scores were assigned as 0 and 100, respectively, with the highest score indicating better life quality.

The 19-item FSFI evaluated the patient's sexual function, as reported by Rosen et al., 18 and validated for Turkish people by Oksuz et al. in 2005.19 Sexual function is measured in 6 subdomains: desire, arousal, orgasm, lubrication, satisfaction, and pain. Each subdomain is calculated, with the sum yielding the total FSFI, ranging from 2 to 36.19 A cut-off score of <26 is seen as sexual dysfunction in the Turkish version,20 with higher scores indicating better sexual function.

Patients were asked about vaginal discharge and itching in the last month, or at examination time, and asked if they had informed their rheumatologists about any sexual problems. Gynecologic examinations were performed on each participant, with vaginal smears taken at the same time. Treatment was given for any infections.

Statistical analysis

Statistical analyses were performed with SPSS 18.0 software (SPSS Inc., Chicago, IL, USA). The distribution of data was determined via the Shapiro-Wilk test. Categorical variables were presented as frequency and percentages and continuous variables were presented as mean followed by standard deviation and median with maximum-minimum. Continuous variables were expressed as mean ± standard deviation, and categorical variables were expressed as frequency and percent. For statistical analysis, independent samples t test and Mann-Whitney U test were used to compare the continuous variables and Pearson Chi-square test was used to compare categorical variables. Spearman's Rho correlation test was used to evaluate the relationship between FSFI score, life quality domains, and vaginal symptoms such as dryness, infection and itching.

Results

Demographic and disease characteristics are shown in Table 1. There was no difference between the mean ages of SS patients and the controls (40.43 ± 5.1 and 39.77 ± 3.2, respectively, p = 0.674). The median disease duration was 5 (3-8) years. Approximately three-fourths of SS patients were free of comorbid disease (71.7%). Rheumatoid arthritis, systemic lupus erythematosus (SLE), and interstitial lung disease (ILD) were coexisting diseases with SS in 13 (27.3%) of the patients.

Table 1 Demographic and disease characteristics of the patients. 

Demographics Patients with SS
(n = 46)
Control
(n = 47)
Age, mean ± SD (years)a 40.43 ± 5.1 39.77 ± 3.2
Disease duration, median (min-max) 5.3 (3-8) -
Comorbid disease, n (%)
Yes 13 (27.3%) -
RA 5 (10.9%) -
SLE 6 (13.0%) -
IL D 2 (4.4%) -
No 33 (71.7%) 47 (100%)
Medical Treatment, 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, rheumatoid arthritis; SLE, systemic lupus erythematosus; ILD, interstitial lung disease; HCQ, hydroxychloroquine; NSAIDs, nonsteroid anti-inflammatory drugs.

ap = 0.674.

Sexual function evaluation

The median total score of FSFI was 17.12 (2.4-27.8) in the SS group and 27.4 (16.9-36.0) in the control group which was significantly lower in the SS group (p < 0.001) (Table 2). In the SS group, 37 (80.4%) of patients were sexually dissatisfied and 9(19.6%) were satisfied and, in the control group 18 (38.3%) of patients were sexually dissatisfied and 29 (61.7%) were satisfied with sexual functions (p < 0.001). Moreover, all FSFI subscores (desire, arousal, orgasm, lubrication satisfaction and pain) in control group were significantly higher than the subscores of patients with SS (p < 0.001). Vaginal itching was present in 14 (35%) patients, and vaginal leucorrhea or infectious complaints were present in 19 (45%) patients in SS patients. There were no statistically significant difference in the frequencies of vaginal leucorrhea or infectious complaints between SS patients and controls (p = 0.613).

Table 2 Sexual function, vaginal complaints and life quality of the patients with Sjögren Syndrome and healthy controls. 

Variables Patients with SS
(n = 46)
Control
(n = 47)
p value
FSFI total score, (range 2-36) median (min-max) 17.12 (2.4-27.8) 27.4 (16.9-36.0)
Sexual dysfunction, n (%) 37 (80.4%) 18 (38.3%) <0.001
Satisfactory sexual function, n (%) 9 (19.6%) 29 (61.7%) <0.001a
FSFI subscale scores
Desire (range 1, 2-6) median (min-max) 2.6 (1.2-4.8) 3.8 (2.4-6.0) <0.001
Arousal (range 0-6) median (min-max) 2.7 (0.0-4.8) 4.4 (2.4-6.0) <0.001
Orgasm (range 0-6) median (min-max) 2.6 (0-5.2) 4.7(2.4-6.0) <0.001
Lubrication (range 0-6) median (min-max) 2.8 (0.0-6.0) 4.8 (2.7-6.0) <0.001
Satisfaction (range 0,8-6) median (min-max) 3.0 (0.0-5.6) 4.9 (3.2-6.0) <0.001
Pain (range 0-6) median (min-max) 3.1 (0.0-6.0) 4.6 (2.4-6.0) <0.001
Vaginal itching complaints, n (%) 14 (30.4%) 8 (17%) 0.130
Vaginal leucorrhea complaints, n (%) 19 (41.3%) 17 (36.2%) 0.613
Vaginal dryness, n (%) 37 (80.4%) 4 (8.5%) <0.001
Lubricant use, n (%) 24 (52.2%) 5 (10.6%) <0.001
SF-36 domains (0-100)
Physical functioning median (min-max) 19.78 (10-30) 26.15 (18-30) <0.001
Role physical median (min-max) 0.85 (0-4) 3.64 (1-5) <0.001
Role emotional median (min-max) 0.80 (0-5) 2.47 (0-3) <0.001
Social functioning median (min-max) 5.67 (2-10) 7.26 (4-10) <0.001
Bodily pain median (min-max) 5.70 (3-11) 8 (5-11) <0.001
Mental health median (min-max) 16.98 (10-26) 20.57 (13-28) <0.001
Vitality median (min-max) 11.93 (6-21) 15.30 (6-22) <0.001
General health, median (min-max) 16.87 (14-22) 18.13 (15-21) <0.001

aChi-square test.

Cervicovaginal smear examination revealed vaginal atrophy in 3 (6.5%) of patients, inflammatory changes in 23 (50%) and normal in 20 (43.5%) of patients in SS group. The cervicovaginal smears of 17 (36.2%) patients in the control group were inflammatory and of 30 (63.8%) were normal. More than half of the patients (n = 24, 52.2%) in SS reported use of lubricants due to vaginal dryness before sexual intercourse in the detailed questioning on medications. Vaginal dryness and lubricant use were significantly increased in patients with SS compared to controls (p < 0.001). Patients who used lubricants experienced that sexual satisfaction was improved with lubricant use, but the rest of them were unaware of the lubricants. Of the patients who used lubricants, 9 (37.5%) had satisfactory sexual scores, however none of the women who did not use the lubricants had satisfactory FSFI scores.

Quality of life assessment

All life quality scores - physical, emotional and social functions, bodily pain, general health, vitality, mental aspect and functional capacity - were significantly lower in patients with SS than the life scores of the control patients (Table 2).

Parameters related to sexual dysfunction

Age was negatively correlated with total FSFI score (r = −0.545, p < 0.001) and subscores in patients with SS. Vaginal itching and infectious symptoms were unrelated to total FSFI score and subscores. Vaginal dryness was negatively correlated with total FSFI (r = −0.312, p = 0.035) and subscores except desire and arousal (Table 3). Lubrication use was positively correlated with total FSFI scores (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 pain scores (r = 0.672, p < 0.001). Physical functioning, role physical and role emotional scores were positively correlated with total FSFI scores (r = 0.449, p = 0.002; r = 0.371, p = 0.011; r = 0.299, p = 0.043) (Table 3).

Table 3 Relationship between sexual dysfunction, patient characteristics and patients’ clinical properties in study group (patients with Sjögren's Syndrome). 

Variable Desire Arousal Lubrication Orgasm Satisfaction Pain FSFI total score
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
Disease Duration 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
Comorbid disease 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
Vaginal itching 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
Vaginal infection 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
Vaginal dryness 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
Lubrication use 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-36 physical 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-36 role physical 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-36 role emotional 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-36 social 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-36 bodily pain 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-36 mental health 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-36 vitality 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-36 general health 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-36 mental health summary measure 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: Female Sexual Function Index; NS, non-significant; r: correlation coefficient.

When patients were asked about whether or not they discussed their vaginal symptoms or sexual dysfunction with their rheumatologists, 26 (56.5%) women told that they did not talk about sexual dysfunction with their rheumatologists because they did not think sexual dysfunction was being assessed. Only 8 (17.3%) mentioned about their vaginal symptoms to their physicians. The rest 12 (26.2%) tried to talk about their vaginal dryness but they were ashamed to talk.

Discussion

Women with SS often experience vaginal dryness and dyspareunia which can lead to sexual dysfunction.8 We found that patients with SS had lower sexual function scores compared to age- matched controls and 80.4% of them were sexually dissatisfied according to previously determined cut-off values (FSFI score of <26).19,20 All domains of sexual function, including desire, arousal, orgasm, lubrication, pain, and satisfaction were affected in these women. Life quality subscores including role social, physical functioning, role emotional and general health scores were all significantly lower in SS patients than the controls. Since vaginal dryness was significantly increased in SS patients, the incidence of lubricant use is much higher in these patients when compared to controls. Vaginal dryness, lubricant use, physical functioning score, role physical score and role emotional score were correlated with sexual dysfunction. Vaginal dryness was the important symptom which had significant correlation with sexual dysfunction in women with SS.

Age was negatively correlated with sexual function in SS group, which was similar with the previous studies.13,21 Anyfanti et al. evaluated 557 patients with rheumatologic disease and found that older age was the only predictive factor for sexual dysfunction.21 They reported that age could also affect physical and psychological attitudes, in turn causing sexual dysfunction.21 Even if the age affects negatively on sexual functions in our study, SS patients had lower FSFI scores and more sexual dysfunction comparing healthy age-matched controls which shows SS has prominent negative impact on sexual functions after adjusting age.

Infectious vaginal complaints, leucorrhea and itching were not correlated with sexual function in our study, in agreement with van Nimwegen et al.13 There were no difference between leucorrhea and itching symptoms between study and control group. Even if rates of inflammatory changes and atrophy in vaginal smears were higher in SS patients, they were not statistically significant.

Vaginal dryness was present almost ten times more in SS patients than the controls. Likewise, lubricant use in SS patients was 5 times more. Lubricants are recommended by the International Menopause Society and the North American Menopause Society in the postmenopausal period.22,23 In this study we showed that SS women may need lubricants also in the perimenopausal period due to vaginal dryness. Patients who used lubricants experienced that sexual satisfaction was improved with lubricant use, so it can be advised to SS patients by their physician even if they are premenopausal. Moreover in our study women who reported more vaginal moisture than other participants had less sexual pain and better sexual pain scores (r = −0.341, p = 0.020, Table 3). Jozkowski et al. assessed women's’ perceptions about lubricants and why they were more inclined to use them. Their findings showed that female preferred lubricants to feel more wet during intercourse. They concluded that lubricant use recommendations from health professionals and sex educators could be helpful.24

Comorbid rheumatologic disease was found in 27.3% of our study group. However, the presence of RA or SLE with SS was not correlated with sexual dysfunction in our study. Anyfanti et al. evaluated cardiovascular risk factors as creating sexual dysfunction in patients with rheumatologic disease; they reported that traditional cardiovascular risk factors failed to explain the increased prevalence of sexual dysfunction.21 Our sample size is relatively small but we included comparatively young, premenopausal women in our study. We excluded women with severe systemic diseases and complications, and patients who were using antidepressants or diuretics to eliminate the unfavorable effect of them on the sexual function.

We sought to evaluate the differences between sexual function scores of Turkish women and those from other countries. Our FSFI scores both in SS patients [17.12 (2.4-27.89)] and control group [27.4 (16.9-36.0)] were lower than previous studies,9,12,16 which may be explained by cultural differences. Van Nimwegen et al. reported median FSFI score of 20.6 in the SS patients and 30.3 in the controls.13 Priori et al. reported a mean FSFI score of 19.1 ± 7.33 in the SS patients. Priori et al, also suggested that both premenopausal and postmenopausal women with SS have worse sexual quality of life which is similar to finding of our study.16 Ferreira et al. reported the prevalence of sexual dysfunction as 18.4% in rheumatologic patients with the mean age of 40.4 years. Patients with fibromyalgia and SS had the highest sexual dysfunction (33%) which was lower than our finding of sexual dysfunction rate of 80.4% in SS patients in the similar age group.12 Sexual attitudes can vary among cultures for social and psychosocial issues, so function scores vary accordingly.9,15,16 This is the first study performed in Turkey on sexual function of SS patients. Sexual dysfunction incidence of healthy women was found as 28.6-48.3% in studies performed in different cities of Turkey.25,26 In our study sexual dysfunction rate was 38.3% in the control group which was compatible with the previous reports.

One of the aims of our study was to assess life quality and its effects on sexual function in patients with SS. We found that physical function scores in life quality tests positively correlated with sexual function scores. If a patient has a better physical function and less physical restriction, she tends to have more satisfaction. Social functioning was not linked to sexual function. Mental domain scores, when the mental health score and emotional score were summed, were not correlated with FSFI scores (Table 3). Psychological aspects of sexual function were evaluated in previous studies. Anyfanti et al. stated that in rheumatologic patients, mental distress and sexual dysfunction are extremely common.20 Researchers concluded that depression and anxiety were related to sexual dysfunction in rheumatologic disease, as well as in patients with SS13,27; van Nimwegen et al. reported depression as being the most important predictor of sexual dysfunction in patients with SS.13 We found decreased role emotional and mental health scores in SS patients when compared to controls similar to other studies in the SS population.13,20 In this study we only evaluated psychological characteristics with only the subscales of the SF-36 questionnaire (role emotional and mental health) which could not be sufficient for detailed evaluation. We did not evaluated depression or anxiety with more specific questionnaires, which may be the limitation of our study. Even if emotional dysfunction were linked to sexual dysfunction in our study, we could not find correlation between mental health scores and FSFI scores.

In addition, we asked women if they had discussed sexual 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 with their physicians, as the medical field tends to neglect sexual dysfunction in rheumatologic disease. Many Turkish women are also hesitant to discuss sexual problems. We talked with patients in person. We felt sometimes that they might be embarrassed to answer questions about sexuality due to social pressure. Vaginal dryness is one of the symptoms of SS, so rheumatologists should bring up any issues regarding their patients’ intimate relationships. Women could then be referred to gynecologists or sexologists. Psychosocial support may be given to women and their partners to improve their relationship, as disabilities in communication and interrelation may increase sexual dysfunction and physical complaints. On the other hand, for women who have decreased performance in sexuality due to vaginal dryness or other vaginal symptoms, lubricants or estrogens can be recommended.

In conclusion, women with SS experienced low satisfaction with sexual activity, which could be affected by age, increased vaginal dryness and impaired physical and emotional function due to the disease. Lubricant use was associated with better sexual satisfaction and increase in FSFI total and subscores. Therefore, lubricants should be considered as a symptomatic treatment in SS. This study emphasizes common SS symptoms, which have typically been underestimated by rheumatologists. Further trials with larger study groups are necessary for the support of our results.

Acknowledgements

We all thank to participants who agreed to complete the questionnaires. No foundation was taken from any company.

References

1 Kassan SS, Moutsopoulos HM. Clinical manifestations and early diagnosis of Sjögren syndrome. Arch Intern Med. 2004;164:1275-84. [ Links ]

2 Ramos-Casals M, Tzioufas AG, Font J. Primary Sjögren's syndrome: new clinical and therapeutic concepts. Ann Rheum Dis. 2005;64:347-54. [ Links ]

3 Kabasakal Y, Kitapcioglu G, Turk T, Oder G, Durusoy R, Mete N, et al. The prevalance of Sjögren's syndrome in adult women. Scand J Rheumatol. 2006;35:379-83. [ Links ]

4 Seror R, Theander E, Bootsma H, Bowman SJ, Tzioufas A, Gottenberg JE, et al. Outcome measures for primary Sjögren's syndrome: a comprehensive review. J Autoimmun. 2014;51:51-6. [ Links ]

5 Valim V, Zandonade E, Pereira AM, de Brito Filho OH, Serrano EV, Musso C, et al. Primary Sjögren's syndrome prevalence in a major metropolitan area in Brazil. Rev Bras Reumatol. 2013;53:24-34. [ Links ]

6 Gøransson LG, Haldorsen K, Brun JG, Harboe E, Jonsson MV, Skarstein K, et al. The point prevalence of clinically relevant primary Sjögren's syndrome in two Norwegian counties. Scand J Rheumatol. 2011;40:221-4. [ Links ]

7 Qin B, Wang J, Yang Z, Yang M, Ma N, Huang F, et al. Epidemiology of primary Sjögren's syndrome: a systematic review and meta-analysis. Ann Rheum Dis. 2015;74:1983-9. [ Links ]

8 Fox RI. Sjögren's syndrome. Lancet. 2005;366:321-31. [ Links ]

9 Mulherin DM, Sheeran TP, Kumararatne DS, Speculand B, Luesley D, Situnayake RD. Sjögren's syndrome in women presenting with chronic dyspareunia. Br J Obstet Gynaecol. 1997;104:101923. [ Links ]

10 Belenguer R, Ramos-Casals M, Brito-Zerón P, del Pino J, Sentís J, Aguiló S, et al. Influence of clinical and immunological parameters on the health-related quality of life of patients with primary Sjögren's syndrome. Clin Exp Rheumatol. 2005;23:3516. [ Links ]

11 Stephenson KR, Meston CM. The conditional importance of sex: exploring the association between sexual wellbeing and life satisfaction. J Sex Marital Ther. 2015;41:2538. [ Links ]

12 Ferreira Cde C, da Mota LM, Oliveira AC, de Carvalho JF, Lima RA, Simaan CK, et al. Frequency of sexual dysfunction in women with rheumatic diseases. Rev Bras Reumatol. 2013;53:3546. [ Links ]

13 van Nimwegen JF, Arends S, van Zuiden GS, Vissink A, Kroese FG, Bootsma H. The impact of primary Sjögren's syndrome on female sexual function. Rheumatology (Oxford). 2015;54:1286-93. [ Links ]

14 Østensen M. New insights into sexual functioning and fertility in rheumatic diseases. Best Pract Res Clin Rheumatol. 2004;18:219-32. [ Links ]

15 Tristano AG. The impact of rheumatic diseases on sexual function. Rheumatol Int. 2009;29:853-60. [ Links ]

16 Priori R, Minniti A, Derme M, Antonazzo B, Brancatisano F, Ghirini S, et al. Quality of sexual life in women with primary Sjögren Syndrome. J Rheumatol. 2015;42:1427-31. [ Links ]

17 Shiboski SC, Shiboski CH, Criswell L, Baer A, Challacombe S, Lanfranchi H, et al. American College of Rheumatology classification criteria for Sjögren's syndrome: a data-driven, expert consensus approach in the Sjögren's International Collaborative Clinical Alliance cohort. Arthritis Care Res (Hoboken). 2012;64:475-87. [ Links ]

18 Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26:191-208. [ Links ]

19 Oksuz E, Malhan S. Kadin cinsel fonksiyon indeksi: Türkçe uyarlamasinin geçerlilik ve güvenilirlik analizi. Sendrom. 2005;17:54-60. [ Links ]

20 Anyfanti P, Pyrpasopoulou A, Triantafyllou A, Triantafyllou G, Gavriilaki E, Chatzimichailidou S, et al. Association between mental health disorders and sexual dysfunction in patients suffering from rheumatic diseases. J Sex Med. 2014;11:2653-60. [ Links ]

21 Anyfanti P, Pyrpasopoulou A, Triantafyllou A, Doumas M, Gavriilaki E, Triantafyllou G, et al. The impact of frequently encountered cardiovascular risk factors on sexual dysfunction in rheumatic disorders. Andrology. 2013;1:556-62. [ Links ]

22 2013 position statement of The North American Menopause Society Management of symptomatic vulvovaginal atrophy. Menopause. 2013;20:888-902. [ Links ]

23 Sturdee DW, Panay N. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22. [ Links ]

24 Jozkowski KN, Herbenick D, Schick V, Reece M, Sanders SA, Fortenberry JD. Women's perceptions about lubricant use and vaginal wetness during sexual activities. J Sex Med. 2013;10:484-92. [ Links ]

25 Öksüz E, Malhan S. Prevalence and risk factors for female sexual dysfunction in Turkish women. J Urol. 2006;175:654-8. [ Links ]

26 Demir Ö, Parlakay N, Gök G, Esen AA. Sexual dysfunction in a female hospital staff. Andrology. 2007;33:156-60. [ Links ]

27 Maddali Bongi S, Del Rosso A, Orlandi M, Matucci-Cerinic M. Gynaecological symptoms and sexual disability in women with primary Sjögren's Syndrome and sicca syndrome. Clin Exp Rheumatol. 2013;31:683-90. [ Links ]

Received: August 25, 2015; Accepted: May 18, 2016

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

Conflicts of interest

The authors declare no conflicts of interest.

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivative License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the original work is properly cited and the work is not changed in any way.