The validity and reliability of the Turkish version of the Postmenopause Sexuality Questionnaire

To translate and to validate the Postmenopause Sexuality Questionnaire (PMSQ) for Turkish women in the climacteric.

the Postmenopause Sexuality Questionnaire (PMSQ) for Turkish women in the climacteric, to evaluate the sexual function multidimensionally, through a reliable, validated and standardized questionnaire according to cultural adaptation.

| MATERIAL S AND ME THODS
This clinical research is a cross-sectional observational study.
We invited 370 menopausal women who presented to Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Pelvic and Women's Health Unit, between 21 October 2020 and 21 October 2021.Evaluations were conducted face to face and online (Google Forms) using questionnaires.All participants were informed about the study protocol based on the Declaration of Helsinki, and a signed informed consent was obtained from all participants.
Women's detailed medical and menstrual histories (chronic diseases, age at menarche, age at menopause) and demographic and physical characteristics (age, weight, height, education level, employment status, marital status) were recorded.The inclusion criteria were experiencing spontaneous menopause, being sexually active, the ability to read and write, and volunteering to participate in the study.Women with a current/past history of cancer, those who had undergone gynecological surgery, and those with pelvic pain were excluded from the study.Based on the baseline eligibility criteria, 356 women were included in the study.The study protocol was approved by the university's ethics committee (ethics no: GO 20/957).
In order to initiate the translation and cultural adaptation process, we obtained permission via e-mail from Maria Jose Ferreira Lima, the developer of the PMSQ.Translation and cultural adaptation processes were carried out in accordance with appropriate guidelines.The Turkish version was piloted in 20 people (approximately 5% of the target audience).In the pilot application, whether the individuals experienced problems in understanding the items and the scoring system was evaluated with an additional question.
The Turkish version of the questionnaire, which was the final version, was obtained according to the feedback of the individuals.
Medical and menstrual histories and demographic and physical characteristics of the participants were recorded.The women (n = 356) completed the PMSQ, as well as the Menopause Specific Quality of Life Questionnaire (MENQOL) and the Sexual Function Index (FSFI), which are considered the gold standard for criterion validity.One week later, 66 of these women (19%) completed the PMSQ again to assess test-retest reliability.

| Postmenopause Sexuality Questionnaire
The PMSQ was developed in 2020 by Lima et al. 18,19 to evaluate sexual function in postmenopausal women.The scale consists of 36 items and nine sub-dimensions in total: self-image (two items), quality of sexual life (three items), sexual intimacy (six items), desire (four items), importance of sexual life (three items), arousal (six items), orgasm (three items), satisfaction (six items), and influence of menopause (three items).Items are answered according to the ordinal Likert scale (0-5).In terms of the frequency of the findings, the items were "none, never, strongly disagree" (0 points); "very rare, disagree, very bad" (1 point); "sometimes, partially disagree, bad" (2 points); "frequently, partially agree, no change" (3 points); "quite often, agree, good" (4 points); and "always, strongly agree, very good" (5 points).In the questionnaire, there are items that are scored in reverse; these are 3, 4, 5, 17, 18, 24, 25, 33, and 35.Although the total score of the scale is shown as 215, the total score is a maximum of 100 due to the reverse-scored items.Zero points indicate the worst sexual function and 100 points indicate the best sexual function (0-100).The original version of the scale consisted of 43 items and the scoring system was made according to this number of items.However, with the revision of the original version, the number of items in the scale became 36 and the scoring system did not change. 18

| Female Sexual Function Index
The FSFI was developed by Rosen et al. 16 in 2000 to evaluate female sexual functions.The Likert-type scale, consisting of 19 items, has six sub-dimensions: desire, arousal, lubrication, orgasm, satisfaction, and pain.The scale reflects the sexual functions of women in the last month by calculating six subgroup scores and the FSFI total score.
In the validity and reliability study of the scale conducted in Turkey in 2005 by Aygin and Eti Aslan, 20 it was found that the internal consistency coefficient was between 0.70 and 0.90, Cronbach's α-value was 0.98, and the test-retest reliability coefficient was 0.75 based on retesting carried out after 1 week.The FSFI is a valid and reliable scale for the evaluation of the sexual function of Turkish women. 20The FSFI and the MENQOL were used as the gold standard for criterion validity.Pearson correlation analysis and correlations between the FSFI and the MENQOL total and sub-dimensions were examined.The ICC and correlation coefficients were categorized as follows: 0.00-0.40,unreliable; 0.40-0.60,less reliable; 0.60-0.80,sufficiently reliable; and 0.80-1.00,quite reliable.The statistical significance level was set as P < 0.05.

| RE SULTS
A total of 370 postmenopausal women were invited to the study.1.
The internal consistency of the nine sub-dimensions of the Turkish PMSQ were "sufficiently reliable" and "highly reliable" (Cronbach's α, 0.75-0.96)and the Turkish PMSQ total score was 72.27 ± 19.42 at baseline and 75.89 ± 20.49 at retest.The test-retest reliability for each sub-dimension and total score of the PMSQ ranged from "sufficiently reliable" to "highly reliable" (ICC, 0.77-0.98,P < 0.001) as shown in Table 2.
The PMSQ was examined by three experts in the field and it was stated that there were no problems that should be removed from/ added to the scale.During the adaptation phase of the translations, it was reported that the translation of one item, "I want to be more lustful", was changed to "I want to be more sensual", taking into account cultural differences.It was stated that the other items and answers that made up the questionnaire were simple and understandable.In addition, the PMSQ was applied in a pilot group, and whether the women had difficulties in understanding the questions was evaluated with an additional question.In the light of these results, it was decided that the PMSQ had content validity.
The correlation coefficients of the total and sub-dimension scores of the PMSQ, the FSFI, and the MENQOL are presented in Table 3.A moderate correlation was found between FSFI and PMSQ total scores (r = 0.76), and a moderate negative correlation was found between MENQOL and PMSQ total scores (r = −0.47).
The results of this study showed that the Turkish PMSQ is a reliable and valid measurement tool for assessing sexual function in postmenopausal women.Considering the results, the scale can easily be used in clinical studies planned to evaluate sexual functions of Turkish women in the postmenopausal period.However, there is a need for further research investigating the sensitivity of the Turkish PMSQ to diagnose sexual dysfunction.

| DISCUSS ION
The results of this study showed that the Turkish version of the PMSQ is a reliable and valid scale for assessing postmenopausal sexual function in a sample of 356 postmenopausal women.In addition, it is a scale that can be used not only to evaluate sexual function but also to help diagnose the presence of sexual dysfunction, if any.This is the first study to evaluate the validity of the Turkish PMSQ using menopause-specific questionnaires.The menopausal transition, which is a period characterized by hormonal, physiological, and social changes, is generally associated with sexual dysfunction. 2Sexual dysfunction in the postmenopausal period is associated with vulvovaginal atrophy (VVA) and hormonal changes.
VVA is characterized by atrophy of estrogen-sensitive structures in the vulva and vagina and decreased mucus secretion.Studies have shown that postmenopausal women with VVA have a higher risk of sexual dysfunction due to vaginal dryness and dyspareunia. 21,22Hormonal changes are the decrease and fluctuation of gonadal steroid hormone levels.This hormonal change negatively affects the elasticity of the vaginal mucosa and mucus secretion.
As a result, vaginal atrophy and dyspareunia cause sexual dysfunction. 23Various treatment methods are available to manage hormonal changes.One of the most commonly used methods is hormone replacement therapy (HRT). 23In recent studies, various treatment methods such as cell-based HRT (cHRT) and stem cell (SC) transplantation have been developed to facilitate folliculogenesis. 24,25en we look at the studies in the literature, it can be seen that a small number of women report their sexual function problems to health professionals and seek solutions. 26,27Therefore, healthcare professionals should routinely question perimenopausal, menopausal, and postmenopausal women about their satisfaction with their sexual function.
There are a limited number of menopausal-specific measurement tools to evaluate sexual function in postmenopausal women. 28,29There is no valid and reliable measurement tool that evaluates sexual function in postmenopausal Turkish women.
Among the related studies, the most widely used questionnaire in postmenopausal women in Turkey is the FSFI. 20Although this scale assesses sexual function in menopausal, perimenopausal, and postmenopausal women, it is not menopause-specific and was not created to assess sexual function in postmenopausal women.
It does not contain menopause-specific questions assessing sexual dysfunction.
Within the scope of content validity, following the completion of the translation process, the items of the PMSQ were examined by expert health professionals.The fact that only one statement needed a terminological revision indicates that the content validity of the scale is good.
In the present study, the reliability of the scale was evaluated by test-retest and internal consistency methods.the test-retest reliability of the Turkish PMSQ sub-dimensions was moderate to very strong (ICC was 0.94 for the total score and 0.77-0.98 for the sub-dimensions).Considering these results, it was noted that similar answers were obtained by applying the scale to the same population in different time periods, an outcome that revealed its invariance with respect to time.Test-retest was performed in the original version of the scale, but ICC values were not calculated. 18,19e internal consistency of the scale was evaluated using Cronbach's α coefficient: the Turkish PMSQ total score Cronbach's α coefficient was 0.97, while the Cronbach's α coefficients of the Turkish PMSQ sub-dimensions varied between 0.21 and 0.96.These results show that the internal consistency of the scale and its subdimensions is at an acceptable level.When the α coefficients of the Turkish PMSQ and the original version were compared, the Turkish values were higher in all but one sub-dimension (the quality of sexual life) and for the total score. 18,19iterion validity was tested with the FSFI, which is the most commonly used measurement tool to evaluate sexual function, and the MENQOL, which evaluates the menopause-specific quality of life and also has a sexuality sub-dimension.A positive, moderate correlation was found between PMSQ and FSFI total scores (r = 0.76).
Moderate correlations were found between the PMSQ and FSFI sub-dimension scores (r = −0.47-0.81).While there was a negative, moderate (r = 0.47) correlation between PMSQ and MENQOL total scores, a moderate (r = −0.64)correlation was found between PMSQ and MENQOL sexual sub-dimension scores.These results show that the scale is compatible within itself and that sufficient criterion validity is provided.In the original version study, the valid and reliable Portuguese version of the FSFI was used for criterion validity. 18,19e of the strengths of our study is that the scale included menopause-specific questions about women's sexual functioning.
Even if the scales used in the literature evaluate the sexual functions of women, the lack of questions about menopause is a subject cited in the literature.This is the first reliability and validity study of a scale evaluating postmenopausal sexuality in Turkey.In addition, we believe that the women who participated in the study online did not hesitate to share their sexual functions.In addition, the COVID-19 pandemic caused a decrease in human relations due to social isolation and quarantine requirements.We believe that the online surveys throughout this period both mitigated the feeling of social isolation and positively supported it.

| CON CLUS IONS
In conclusion, the results of the present study have determined that the Turkish version of the PMSQ can be a valid and reliable scale to evaluate sexual activity in Turkish menopausal women.
The MENQOL was developed by Hilditch et al. in 1996.The scale consists of four sub-dimensions: vasomotor, psychosocial, physical, and sexual.It contains 29 Likert-type items.As the score obtained from the scale increases, the severity of the complaint increases, that is, the quality of life decreases.The lowest score that can be obtained from the scale is 0, and the highest score is 6 because the average score is used in calculating the total of the scale.In the MENQOL, the score is ranked from 0 to 6 in each sub-domain.A score of 0 indicates that there was no problem with the individual.A score of 1 indicates that the problem exists, but it is not disturbing at all, while scores of 2-6 indicate the severity and increasing degrees of the existing problem.In the validity and reliability study of the scale in Turkey by Kharbouch and Şahin in 2005, Cronbach's α-value of the internal consistency coefficient was 0.90; it is a valid and reliable tool in Turkish women.17 Data analyses were performed using IBM SPSS software, version 25 (IBM Corporation, Armonk, NY, USA).The normal distribution was determined by analytical methods (Kolmogorov-Smirnov test).Descriptive statistics are presented as mean ± standard deviation (SD) values for normally distributed quantitative variables.Non-normally distributed continuous variables are presented as median (25%-75% percentile) values and categorical variables are presented as numbers (n) and frequency (%).The reliability of the PMSQ was examined with internal consistency and test-retest reliability.The internal consistency of the PMSQ was determined by Cronbach's α coefficient.A value of Cronbach's α of 0.80 and above was considered quite reliable.In addition, testretest reliability was evaluated using the intraclass correlation coefficient (ICC).

Fourteen
of the women (past cancer history [n = 8] and reluctance to participate in the study [n = 6]) did not meet the inclusion criteria.The remaining 356 postmenopausal women complied with the protocols and completed the study.Demographic and physical characteristics and menstrual and medical histories of the participants in the study are shown in Table Demographic and physical characteristics and menstrual and medical histories (n = 356).
TA B L E 1Note: Data are mean ± SD or n (%).Abbreviation: BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters).
While the testretest reliability of the Turkish PMSQ total score was very strong, TA B L E 2 The Postmenopause Sexuality Questionnaire (PMSQ)'s internal consistency and test-retest reliability and descriptive statistics.PMSQ total a Spearman correlation test.