Sexual dysfunction is common in infertile couples, which is likely to be a "side effect" of frustration with their inability to have a child [15]. In our study, the mean score of total FSFI in the endometriosis group was lower than in other groups. This decrease was mainly attributed to the decrease in subscale scores of orgasm, pain, and satisfaction. The rate of sexual dysfunction in the endometriosis group reported 97.1% that can be attributed to the high percentage of women with stages 3 (36.2%) and 4 (54.8%) of endometriosis. The study of Donato et al [8] showed that each domain of the SF (satisfaction, desire, orgasm, and pelvic problem interference) had significantly affected endometriosis patients compared with healthy women. In our study, it was observed that in higher stages of endometriosis, the total FSFI score was lower. It was shown in a study that women with deep infiltrating endometriosis have a SF impairment [16].
Various studies have provided that endometriosis has a negative effect on the different dimensions of SF [17–19]. In our study, the mean pain score in the endometriosis group was lower than the control group and the PCOS group. The cause of sexual dysfunction in endometriosis patients can be attributed to the association between deep endometriosis infiltration and dyspareunia which reduces sexual intercourses and causes a lower SF [20]. It seems that experiencing this annoying situation, women with endometriosis develop negative expectations of their sexual life which leads to threatening their sexuality [21].
PCOS is characterized by a range of hormonal and body changes including obesity, acne, hirsutism, hyperinsulinemia, hyperprolactinemia, insufficient gonadotropin secretion, and hyperandrogenism. These changes can affect the sexuality of women with PCOS [22]. Menstrual irregularity and infertility caused by PCOS can damage SF [23]. Women with PCOS are also at risk of depression and anxiety that can negatively affect their SF [24]. In our study, the total score of FSFI and its subscales were lower in the PCOS group than in the control group and the rate of sexual dysfunction in the PCOS group reported as 70.5%. In contrast, Shafti and his colleagues [7] concluded that there was no significant difference in SF of women with PCOS with the control group in their study. In the present study, scores of desire, arousal, and lubrication subscales in the PCOS group were lower than the endometriosis and control group. In a study, a desire was the most impaired domain of SF in PCOS patients which was highly correlated with hirsutism which had the most impact on patients’ body image [25]. PCOS is an endocrine disorder. Receptors for hormones (androgens, estrogens, and progesterone) are found in the brain and also in genital tissues, suggesting that they are important both in central (desire, arousal) and peripheral SF [26].
In our study, the mean BMI was higher in the PCOS group. In a review study by Murgel et al [27], it was concluded that BMI and infertility affect sexuality in women with PCOS. In the study of Dashti et al [28], BMI level higher than normal was associated with decreased desire and satisfaction and education was one of the factors affecting SF in women with PCOS. The result of the meta-analysis of Pastoor et al [29] was in line with our study conclusion. In this meta-analysis, in women with PCOS, SF and sexual attractiveness were damaged. The findings of our study are similar to the research findings of Hashemi et al [30]. In this study, stimulation and wetting disorders were the most sexual dysfunction in infertile women with PCOS, and SF in women with PCOS was mostly affected by infertility. In women with PCOS, the factors affecting sexual functioning include disarranged hormone levels especially androgens, infertility, obesity, and associated problems like metabolic syndrome, body image issues, and low self-esteem. High testosterone levels directly have an effect on sexual motivation and desire. Obesity leads to sexual inhibition, decreased sexual desire, and poor body image, and low self- esteem which in turn have an effect on sexual functioning [31]. In our study, the mean score of the orgasm subscale in the PCOS group was not significantly different with the control group.
In examining the relationship between various socio-demographic sexual dysfunction and variables between groups, just the level of education was significantly correlated with sexual dysfunction (Tables 2 and 3). Compared to women who do not have a university education, women with a university education are less likely to have sexual dysfunction. Our research samples were only women of reproductive age and had higher education (65% had college-level education). On the other hand, some studies have shown that higher education can be a protection against sexual dysfunction [22–25]. This is probably due to the search for better health behaviors associated with higher education [26].