The impact of frequently encountered cardiovascular risk factors on sexual dysfunction in rheumatic disorders

Authors


Correspondence:

Michael Doumas, Aristotle University, 126, Vas. Olgas street, 54645 Thessaloniki, Greece.

E-mail: michalisdoumas@yahoo.co.uk

Summary

Traditional cardiovascular risk factors have been acknowledged as major contributors to sexual dysfunction in the general population. The purpose of this study was to explore their impact on sexual function in rheumatologic patients. A total of 557 consecutive rheumatologic patients, 449 females and 108 males, had their sexual function evaluated with the Female Sexual Functioning Index (FSFI) and the International Index of Erectile Function (IIEF) questionnaire respectively. Personal data regarding presence of cardiovascular risk factors were collected and analysed in association with the FSFI and IIEF scores. Mean age of the participants was 54.1 ± 14.1 years, mean body mass index was 27.5 ± 5.29 and mean systolic and diastolic blood pressure was 130.5 ± 19.82 and 79.5 ± 10.51 mmHg respectively. Hypertension was present in 39% of the participants, diabetes mellitus in 10.2%, dyslipidaemia in 33.6% and history of cardiovascular events in 8.6%, whereas smoking was recorded by 28.4% and alcohol consumption by 7.4%. Sexual dysfunction affected 68.6% of our study population (73.5% of females and 48.1% of males, p < 0.001). Logistic regression analysis revealed that age was the only factor associated with a significantly higher prevalence of sexual dysfunction (p < 0.001 for both genders, p = 0.013 in males and p < 0.001 in females). Increased age was identified as the only independent predictor of sexual dysfunction in our population. Apart from age, traditional cardiovascular risk factors failed to explain the increased prevalence of sexual dysfunction in these patients. Other contributing factors (physical and/or psychological) might account for the increased occurrence of sexual dysfunction in rheumatic disorders.

Introduction

The already wide spectrum of rheumatic diseases is not only growing but also has an important impact on both individual and public health. Doctor-diagnosed arthritis was reported by 27% of US adults in 2005 (Bolen et al., 2011) and its prevalence increases with age, with more than half of the elderly population suffering from rheumatic disorders (Centers for Disease Control and Prevention (CDC), 2003). Arthritis has been identified as the leading cause of disability in the United States, representing a major burden in terms of health care cost (Verbrugge & Juarez, 2006). Pain is the predominant symptom in most people with rheumatic diseases, and it is closely associated with physical disability (Walker & Littlejohn, 2007). Rheumatic disorders negatively affect quality of life and lead to restrictions in work and daily activities, including a deterioration of sexual function (Manolis & Doumas, 2008; Tristano, 2009).

Sexuality and its expression are not only a physical function but also an integral part of personal health and well-being. Erectile dysfunction (ED) is defined as the persistent inability to attain and/or maintain penile erection sufficient for sexual intercourse (NIH Consensus Development Panel on Impotence, 1993). Female sexual dysfunction is described in a more complex way, as persistent or recurrent decrease in sexual desire or in sexual arousal, or the difficulty or the inability to achieve an orgasm, or the feeling of pain during sexual intercourse (Bachman & Avci, 2004). The prevalence of ED in the general population varies in different reports according to the methodology or the population used, and ranges from 7 to 53%, with 15 to 20% being the most probable estimation (Viigimaa et al., 2011). Data regarding female sexual dysfunction are even scarcer. However, a higher prevalence has been recorded compared with ED (43% vs. 31% in the United States in 1999 (Laumann et al., 1999). Although available epidemiological data provide a rough estimation of sexual dysfunction in the general population, less is known about specific population subgroups. With the only probable exception of cardiovascular disease, where ED has been identified not only as an early clinical manifestation but also as an independent predictor of cardiovascular events (Thompson et al., 2005; Vlachopoulos et al., 2005a,b), sexual dysfunction in patients suffering from other chronic conditions like musculoskeletal diseases remains substantially understudied.

In the attempt to sufficiently address the causal pathways, pathophysiological links and clinical implications of sexual dysfunction, scientific research has gradually focused on the vascular origin of sexual dysfunction (Manolis & Doumas, 2008). Endothelial dysfunction plays a key role in the pathogenesis of vasculogenic ED (Billups et al., 2005) and is promoted by low-grade chronic inflammation. Inflammatory stimuli are also responsible for structural changes in the vessel wall and the development of atherosclerosis, which is the major contributor in the occlusion of the carvernosal arteries (Vlachopoulos et al., 2005a,b; Doumas & Douma, 2006). Longitudinal population-based studies have shown that cardiovascular risk factors sharing a mutual inflammatory background (hypertension, dyslipidaemia, obesity, smoking and diabetes mellitus) serve as risk factors for vasculogenic ED (Grover et al., 2006). Many of these proinflammatory and cardiovascular disease–promoting conditions are present in a variety of rheumatic conditions and could therefore potentially interfere with the development of sexual dysfunction (Turesson & Matteson, 2007). Indeed, inflammatory arthropathies have been associated with both a higher occurrence of cardiovascular risk factors and cardiovascular events (Fischer et al., 2004; Boyer et al., 2011), and an increased prevalence of sexual dysfunction (Manolis & Doumas, 2008). However, the absence of available studies examining the effect of cardiovascular risk factors on sexual dysfunction in rheumatologic disorders is remarkable. We therefore hypothesized that traditional cardiovascular risk factors mediate the occurrence of sexual dysfunction in patients with rheumatic disorders.

Materials and methods

Our study population consisted of consecutive patients who attended the hospital outpatient rheumatology clinic during a 6-month period. This cross-sectional study was conducted in accordance with the Helsinki declaration and was approved by the Hospital Ethics Committee. All patients who were included agreed to participate in the study and gave their written informed consent. Patients were asked to participate provided they fulfilled the following criteria: age 18 years and above, an established diagnosis of a rheumatologic disease and sufficient knowledge of the Greek language to complete a self-reported questionnaire. Individuals with confounders for sexual dysfunction (endocrine or urologic disease, genital tract abnormalities including previous hysterectomy or vaginal surgery) verified by history, laboratory and clinical examination were not included in the study. Patient demographic data, medication use, current cigarette consumption and alcohol intake were recorded. A thorough medical history was taken, including assessment of diabetes mellitus, dyslipidaemia, hypertension and previous cardiovascular events (stroke, angina, myocardial infarction). In female patients, medical files were reviewed to determine their menopausal status. Dyslipidaemia was defined according to Adult Treatment Panel III guidelines. Essential hypertension was defined as blood pressure higher than 140/90 mmHg according to the recently published guidelines [Seventh Report of the Joint National Committee (Chobanian et al., 2003) and European society of Hypertension–European Society of Cardiology (Mancia et al., 2007)] or current use of antihypertensive drugs. Blood pressure was measured with a mercury sphygmomanometer according to the guidelines (Chobanian et al., 2003; Mancia et al., 2007) and was determined as the mean of the second and third value of three consecutive blood pressure recordings.

Patients were asked to fill an anonymous questionnaire regarding sexual function to restrict potential bias. Assessment of male sexual function was based on the International Index of Erectile Function (IIEF) (Rosen et al., 1997), whereas female sexual dysfunction was measured with the Female Sexual Functioning Index (FSFI) (Rosen et al., 2000). Both are short, multidimensional, self-administered and validated questionnaires, which are widely applied in daily practice and in clinical trials studying sexual function. In particular, IIEF consists of 15 items addressing 5 subscales of male sexual function: erectile function (6 questions), orgasmic function (2 questions), sexual drive (2 questions), intercourse satisfaction (3 questions) and overall satisfaction (2 questions). Patients were asked to respond to each question on a 5-point scale. Total score ranged from 0 to 30, with a cut-off score ≤25 considered as indicative of ED. According to this scoring, ED was further classified as mild (17–25), moderate (11–16) or severe (0–10) (Rosen et al., 1997). Regarding FSFI, 19 items comprise the questionnaire and six subscales are used to address female sexual function, including: desire (2 questions), arousal (4 questions), lubrication (4 questions), orgasm (3 questions), satisfaction (3 questions) and pain (3 questions). Responses for each item are rated from 1 to 5. With a total score ranging from 2 to 36, a cut-off score ≤26.55 was representative of female sexual dysfunction (Wiegel et al., 2005).

Statistical analysis

Data analysis was performed using spss (Statistical Package for Social Sciences) software, version 16 (SPSS, Chicago, IL, USA). Results are expressed as mean ± standard deviation (m ± SD) for continuous variables, and as frequencies for qualitative variables. Student's t-test or Mann–Whitney U-test was used to estimate differences between mean values. Comparison of frequencies was performed by Pearson's chi-squared test with the Yates' correction when appropriate (continuity correction was used to improve the fit to the exact probability) and Kendall's tau b-test, or phi and Cramer's V-test for ordinal and nominal variables with more than two groups. Multivariate logistic regression was used to assess independence of association between sexual dysfunction and cardiovascular risk factors. A probability value of p < 0.05 was considered statistically significant. In addition, 95% confidence intervals (95% CI) are provided when relevant.

Results

Overall, 557 rheumatologic patients, 449 females and 108 males, were studied. Five patients denied completing the questionnaires and participating in the study for personal reasons. A description of the baseline characteristics of the study population can be found in Table 1. Sexual dysfunction of any degree was found in 68.6% of the patients. Female sexual dysfunction was more common than ED, 73.5% vs. 48.1%, respectively, p < 0.001. Severe ED was found in 15 (13.9%), moderate ED in 9 (8.3%) and mild ED in 28 (25.9%) of 108 male rheumatologic patients.

Table 1. Baseline characteristics of the study population
 Overall (n = 557)Women (n = 449)Men (n = 108)p valueb
  1. RA: Rheumatoid arthritis; SLE: Systemic lupus erythematosus; PSA: Psoriatic arthritis; OA: Osteoarthritis; SS: Seronegative spondyloarthropathies; Other: Scleroderma, Sjogren's syndrome, polymyalgia rheumatica, mixed connective tissue disease, antiphospholipid syndrome and vasculitis; BMI: Body mass index; ofSBP: office systolic blood pressure; ofDBP: office diastolic blood pressure; DM: Diabetes mellitus; CV: Cardiovascular; bpm: Beats per minute; NA: Not applicable.

  2. a

    Data are expressed as mean ± SD (standard deviation).

  3. b

    p values are estimated from the comparison of cardiovascular risk factors between males and females.

Agea (years)54.1 ± 14.154.7 ± 14.251.4 ± 13.70.015
Disease (%)
RA31.8 (177)33(148)26.9 (29) 
SLE8.4 (47)10.2 (46)0.9 (1) 
PSA9.2 (51)5.6 (25)24.1 (26) 
OA16.3 (91)19.1 (86)4.6 (5) 
SS11.5 (64)6.2 (28)33.3 (36) 
Osteoporosis5.4 (30)6.7 (30)0 (0) 
Other17.4 (97)19.2 (86)10.2 (11) 
Post- menopausal statusNA72.4 (325)NANA
BMIa (kg/m2)27.5 ± 5.2927.6 ± 5.627.2 ± 3.90.935
ofSBPa (mmHg)130.5 ± 19.82130.4 ± 20.4129.8 ± 17.60.991
ofDBPa (mmHg)79.5 ± 10.5179.2 ± 10.681.2 ± 10.10.171
Heart ratea (bpm)76.9 ± 12.377.3 ± 12.475.8 ± 11.90.268
Smoking (%)28.4 (158)22.9 (103)50.9 (55)<0.001
Alcohol (%)7.4 (41)2.9 (13)25.9 (28)<0.001
Hypertension (%)39.0 (217)41.2 (185)29.6 (32)0.043
DM (%)10.2 (57)10.5 (47)9.3 (10)0.917
CV events (%)8.6 (48)7.8 (35)12 (13)0.282
Dyslipidaemia (%)33.6 (187)35.4 (159)25.9 (28)0.072

Prevalence of ED gradually increased in older compared with younger male participants (18–45 years, 30.3%; 45–64 years, 48.1%; ≥65 years, 80%), with a statistically significant difference between these age groups (p < 0.001). The same pattern regarding sexual dysfunction and age was observed in female patients (18–45 years, 47.1%; 45–64 years, 75.5%; ≥65 years, 93%), and the between-group difference was also statistically significant (p < 0.001). The same pattern was confirmed when both age and IIEF and FSFI score were studied as continuous variables. A strong and negative correlation was found between increasing age and both the IIEF score (r = −0.413, p < 0.001) and the FSFI score (r = −0.536, p < 0.001).

Prevalence of sexual dysfunction in the study participants with respect to the most predominant diseases is depicted in Table 2. Male patients suffering from rheumatoid arthritis exhibited the greatest prevalence of ED (62.1%). Sexual dysfunction was most frequent in female patients with osteoarthritis (81.4%), followed by those with rheumatoid arthritis (77.7%).

Table 2. Prevalence of sexual dysfunction by gender, age and rheumatologic disease
Sexual dysfunctionTotal (n = 557)p valueMale (n = 108)p valueFemale (n = 449)p value
  1. RA: Rheumatoid arthritis; SLE: Systemic lupus erythematosus; PSA: Psoriatic arthritis; OA: Osteoarthritis; SS: Seronegative spondyloarthropathies; Other: Scleroderma, Sjogren's syndrome, polymyalgia rheumatica, mixed connective tissue disease, antiphospholipid syndrome and vasculitis.

  2. a

    p values are estimated from the comparison of the percentages of sexual dysfunction between males and females.

  3. b

    p values are estimated (with kendall's tau b-test) from the comparison of the percentages of sexual dysfunction between the different age groups.

  4. c

    p values are estimated (with phi and cramer's test) from the comparison of the percentages of sexual dysfunction between the different disease categories.

Entire cohort68.6 (382) 48.1 (52) 73.5 (330)<0.001a
Age, % (n)
18–44 (n = 136)42.6 (58)<0.001b30.3 (10)<0.001b47.1 (48)<0.001b
45–64 (n = 285)70.2 (200) 48.1 (26) 75.5 (174) 
≥65 (n = 136)91.2 (124) 80.0 (16) 93.0 (108) 
Disease, % (n)
RA75.1 (133)<0.001c62.1 (18)0.389c77.7 (115)0.027c
SLE66.0 (31) 0 (0) 67.4 (31) 
PSA49.0 (25) 38.5 (10) 60.0 (15) 
OA80.2 (73) 60.0 (3) 81.4 (70) 
SS46.9 (30) 41.7 (15) 53.6 (15) 
Osteoporosis80 (24) 0 (0) 80 (24) 
Other68 (66) 54.5 (6) 67.8 (60) 

Prevalence of factors known to impair sexual function (hypertension, diabetes mellitus, dyslipidaemia, obesity, history of cardiovascular events, smoking, alcohol consumption, menopausal status, treatment with b-blockers, anxiolytics, antidepressants or glucocorticoids), as well as mean age, office systolic and diastolic blood pressure and heart rate, in male and female patients according to their sexual function, is depicted in Table 3. Among these predictors, age was the only factor with a statistically significant difference between males with and without ED (p = 0.001). In females, age (p < 0.001), menopausal status (<0.001), body mass index (BMI, p < 0.001), office systolic blood pressure (p < 0.001), smoking (p = 0.004), hypertension (p < 0.001), diabetes mellitus (p = 0.006) and dyslipidaemia (p = 0.017) differed significantly between the groups of impaired and normal sexual function. BMI was strongly and negatively correlated with FSFI score (r = −0.226, p < 0.001), but correlation with IIEF score was not statistically significant (r = 0.081, p = 0.408). However, logistic multiple regression analysis of these same variables in our sample revealed that only age (p < 0.001) and gender (p = 0.001) were significant factors affecting sexual dysfunction (Table 4). Similarly, in multiple regression models that separately included male and female patients, only age was significantly associated with lower IIEF total score (p = 0.013) and lower FSFI score (p < 0.001) respectively (Table 4). It should be noted that menopausal status was not included in the multiple regression model for female patients, owing to its strong correlation with age (p < 0.001).

Table 3. Prevalence of cardiovascular risk factors of male and female patients according to their sexual function
 MaleFemale
Cardiovascular risk factorsSD (n = 52)Normal (n = 56) p SD (n = 330)Normal (n = 119) p
  1. SD: Sexual dysfunction; BMI: Body mass index; ofSBP: office systolic blood pressure; ofDBP: office diastolic blood pressure; DM: Diabetes mellitus; CV: Cardiovascular; NA: Not applicable.

Age (mean ± SD)55.9 ± 13.947.4 ± 12.30.00157.8 ± 13.446.1 ± 12.7<0.001
BMI (mean ± SD)26.9 ± 3.827.5 ± 4.00.43028.0 ± 5.125.9 ± 5.2<0.001
ofSBP (mean ± SD)132.4 ± 18.8127.6 ± 16.40.194132.4 ± 19.6124.7 ± 21.6<0.001
ofDBP (mean ± SD)82.5 ± 11.380.1 ± 9.00.35279.6 ± 10.678.2 ± 10.60.163
Heart rate (mean ± SD)77.1 ± 12.676.7 ± 11.40.45876.7 ± 11.978.9 ± 13.40.218
Smoking (%)48.1 (25)53.6 (30)0.44319.4 (64)32.8 (39)0.004
Alcohol consumption (%)30.7 (16)21.4 (12)0.4632.7 (9)3.4 (4)0.982
Hypertension (%)35.3 (18)25 (14)0.34246.7 (154)26.1 (31)<0.001
DM (%)9.6 (5)8.9 (5)1.00013.0 (43)3.4 (4)0.006
CV events (%)17.9 (10)5.4 (3)0.0629.1 (30)4.2 (5)0.156
Dyslipidaemia (%)26.9 (14)25(14)0.82038.9 (128)26.1 (31)0.017
Post-menopausal status (%)NANANA81.8 (270)46.2 (55)<0.001
Glucocorticoids (%)23.0 (12)7.1 (4)0.05524.8 (82)21.0 (25)0.391
Anxiolytics (%)3.8 (2)8.9 (5)0.2566.9 (23)10.9 (13)0.221
Antidepressants (%)3.8 (2)8.9 (5)0.2566.7 (22)6.7 (8)0.995
B-blockers (%)7.6 (4)3.6 (4)0.47012.2 (40)18.5 (22)0.130
Table 4. Multiple regression analysis of cardiovascular risk factors for both sexes and each sex separately
 Total populationFemalesMales
Predictor for sexual dysfunctionBetaOdds ratiopBetaOdds ratiopBetaOdds ratiop
  1. BMI: Body mass index; ofSBP: office systolic blood pressure; ofDBP: office diastolic blood pressure; CV: Cardiovascular event; DM: Diabetes mellitus.

Sex−1.3100.2700.001
Age−0.0690.934<0.001−0.0630.939<0.001−0.0880.9160.013
BMI−0.0240.9760.442−0.0470.9540.1790.1211.1280.266
ofSBP−0.080.9920.471−0.0030.9970.828−0.320.9680.264
ofDBP0.0161.0160.3690.0221.0220.285−0.0170.9830.750
Heart rate−0.070.9930.593−0.0030.9970.848−0.0120.9380.738
Smoking−0.0080.9920.9810.1541.1660.685−1.2320.2920.176
Alcohol−0.3420.7110.576−0.5970.5500.606−0.5870.5560.531
Hyperlipidemia0.1831.2010.5691.2960.9090.736−0.5830.6990.701
CV event0.1531.1650.7870.5691.7670.404−0.3760.6860.753
DM−0.1330.8250.825−0.5070.6030.470−0.2280.7960.778

Discussion

Our cross-sectional study demonstrated that sexual function is significantly impaired in the vast majority of patients (68.6%) suffering from rheumatic diseases. We also noticed a remarkable difference in the prevalence of sexual dysfunction between men and women (48.1% vs. 73.5%, respectively). Almost half of male patients (46.2%) with sexual dysfunction experience ED of moderate and severe degree. These findings reveal the extent of the disorder in this population, especially compared with the prevalence of sexual dysfunction in the general population. The prevalence of sexual dysfunction in our study much exceeds the estimated prevalence (15–20%) in the general population, but it follows the same pattern of increased prevalence among women (Viigimaa et al., 2011). Sexual dysfunction in this particular group of patients was comparable or even greater compared with patients suffering from other chronic diseases, like essential hypertension [men: 35.2% (Doumas et al., 2006a,b), women: 42.1% (Doumas et al., 2006a,b)] and diabetes mellitus [men: 60% (Giugliano et al., 2010), women: 53.4% (Esposito et al., 2010)]. Sexual dysfunction has been acknowledged as a multifactorial condition, but whether the increased prevalence of sexual dysfunction in rheumatologic patients is a result of the disease itself, the psychological burden it presumes or the existing comorbidities, and to what extent each of these factors contributes, remains unclarified.

In our attempt to sufficiently study sexual dysfunction in rheumatologic patients, we focused on the physiological factors that are well-known to exert negative impact on sexual function: increased age and BMI, smoking, excessive alcohol consumption, and history of hypertension, diabetes mellitus, cardiovascular events and dyslipidaemia. Of all these factors, only age was significantly increased in male patients suffering from ED. When we isolated the female population and studied the same risk factors, it was found that increased age, BMI, smoking, hypertension, diabetes mellitus and dyslipidaemia were significantly more common in female patients with sexual dysfunction, but the multiple regression model revealed that the only factor significantly affecting female sexual dysfunction was age. When a multiple regression model for the same risk factors was applied to both sexes, it was shown that the only factors independently affecting sexual function were age and gender. In other words, increased age and female gender were identified as the only predictors of sexual dysfunction in our study population.

Hence, it appears that these well-established determinants of sexual dysfunction do not affect its prevalence similarly in healthy individuals and other groups of patients. To the best of our knowledge, this is the first study in the literature to investigate the association between cardiovascular risk factors and sexual dysfunction among patients with rheumatic disorders. Previous reports dealing with sexual dysfunction in rheumatic diseases either excluded patients who were considered at higher risk for developing sexual dysfunction as those with evident cardiovascular risk factors (Ozgül et al., 2006; Cakar et al., 2007; Dincer et al., 2007; Bal et al., 2011), or neglected to perform an appropriate subanalysis of these risk factors in their study population (van Berlo et al., 2007; Schouffoer et al., 2009). Most often, emphasis was placed on the characteristics of each rheumatic disease, and the coexistence of cardiovascular risk factors was not even recorded (Bhadauria et al., 1995; Hill et al., 2003; Abdel-Nasser & Ali, 2006).

Our study clearly demonstrates that the increased prevalence of sexual dysfunction in rheumatic diseases cannot be explained, not even partially, by traditional cardiovascular risk factors. Furthermore, it suggests that in these patients, other predictors of sexual dysfunction should be sought and identified instead; these could be related to physical (duration and/or relapse of the disease, severity of symptoms) and psychological (mood disorders, anxiety, depression) conditions. Another explanation could be that in rheumatic conditions, subclinical atherosclerosis associated with chronic inflammation propels sexual dysfunction independently of traditional cardiovascular risk factors, as it leads to increased cardiovascular mortality and morbidity even in the absence of these factors (Salmon & Roman, 2008). Whether systemic inflammation alone confers an additional risk for sexual dysfunction in the rheumatic patient remains yet to be proven. Available data associate physical disability with impaired sexual function (Clayton & Ramamurthy, 2008), and common disease-related factors associated with sexual dysfunction include pain, joint stiffness, fatigue and functional disorders of the genitourinary system (Østensen, 2004). Such acute or chronic complaints and disabilities may limit sexual desire and activity, but further research is required to reveal the exact spectrum of disease-related factors exerting a negative impact on sexual function in rheumatologic patients. In addition, a complex psychological background may lie behind sexual dysfunction in rheumatologic disease as well. It has been shown that these patients experience a great level of anxiety, depression (Patten et al., 2006; Shih et al., 2006; Hiz et al., 2011) and emotional problems such as low self-esteem and a negative body image (Østensen, 2004; Manolis & Doumas, 2008). Future studies should focus on the association of psychological factors with sexual dysfunction, but whether the emotional burden of the disease causes sexual dysfunction or rather partnership difficulties lead to anxiety and depression is difficult to prove.

The reported high prevalence of sexual dysfunction in rheumatologic patients in our study is impressive, but should not be surprising. This aspect of patients' life is usually neglected both in clinical practice and in research. A number of reasons have been identified, including lack of time in routine visits, insufficient knowledge about diagnosis and treatment of sexual dysfunction, reluctance and discomfort to address this sensitive issue, and doubt whether sexual function should be evaluated among other rheumatologic symptoms (Britto et al., 2000; Ryan & Wylie, 2005; Clayton & Ramamurthy, 2008). Of note, in a previously published survey of ten rheumatologists, screening for sexual activity was performed in only 12% of their patients (Britto et al., 2000). However, as we have shown, problems with sexual functioning are disproportionally present in the vast majority of such patients.

The insufficient approach of sexual dysfunction in rheumatic diseases by health care providers reflects the absence of a systemic approach provided by studies. Considering the significance of sexual functioning for patients and their sexual partners, and the large prevalence of rheumatic diseases in the general population, the lack of available studies sufficiently addressing this issue is remarkable. Some studies used non-validated questionnaires to detect sexual dysfunction, or simply sexual problems or difficulties (Curry et al., 1994; Bhadauria et al., 1995; Ozgül et al., 2006; Rkain et al., 2006; Ryan et al., 2008; Healey et al., 2009); others included an inadequate number of patients (Bhadauria et al., 1995; Pirildar et al., 2004; Ryan et al., 2008; Schouffoer et al., 2009), or studied only male or female patients (Curry et al., 1994; Bhadauria et al., 1995; Pirildar et al., 2004; Ozgül et al., 2006; Dincer et al., 2007; Orellana et al., 2008; Schouffoer et al., 2009; Bal et al., 2011; Hiz et al., 2011), whereas the majority of previous reports confined to specific rheumatologic diseases, especially rheumatoid arthritis (Areskoug-Josefsson & Oberg, 2009). Therefore, it is not surprising that the prevalence of sexual dysfunction in rheumatologic patients ranges in different reports according to gender and rheumatic disease from 12% in male patients with ankylosing spondylitis (Pirildar et al., 2004) to 97% in female patients with fibromyalgia (Orellana et al., 2008), but also varies significantly even in the same disease group, from 36% (Areskoug-Josefsson & Oberg, 2009) to 84% in female patients with rheumatoid arthritis (Orellana et al., 2008). In our study, sexual dysfunction did not differ significantly according to disease classification, indicating that it represents a common problem for rheumatologic patients. Our findings unveil the magnitude of the problem by providing an estimation of the exact prevalence of sexual dysfunction in rheumatic diseases. They also highlight the need for health professionals dealing with rheumatologic patients to incorporate this issue in their clinical routine examination, to provide adequate counselling and intervention in this large group of patients. The absence of a control group as well as of an evaluation of other potential physical or psychological confounders limit the interpretation of our study findings and need to be addressed in future studies. Although the impact of age has been taken into account, inclusion of women in menopause, which might exert a negative effect on sexual function, could be considered as another limitation of the study. Inclusion of rheumatic patients with hip, knee or hand involvement might be considered as another limitation. However, the aforementioned limitations were beyond the scope of our study, which clearly aimed to assess the impact of cardiovascular risk factors on sexual dysfunction among patients with rheumatic disorders.

In conclusion, sexual function in rheumatic disease is severely impaired, with women paying a heavier toll compared with men. As sexual dysfunction in our population was not associated with any of the traditional cardiovascular risk factors affecting sexual function apart from age, further studies are needed to identify predictors of sexual dysfunction in this particular group of patients, either disease related or psychological. Our study raises awareness of the magnitude of the problem and underlines the importance for physicians to routinely address this issue in an open discussion, to improve health-related quality of life in people with musculoskeletal conditions.

Acknowledgement

The authors acknowledge Dr Eirini Christaki for her contribution in the revision of the text.

Disclosure

The authors declare no conflicts of interest.

Funding

None.

Authors' contribution

All authors have substantially contributed to research design, or the acquisition, analysis or interpretation of data; to drafting the study or revising it critically, as well as to approval of the submitted and final versions.

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