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Sexual Health & Intimacy

Uterine Fibroids and Sexual Dysfunction: True, True, and Related?

Elizabeth Kagan Arleo, MD; Robin M. Masheb, PhD; Michael G. Tal, MD

The impact of chronic medical conditions on sexual function has been well documented,¹ and uterine fibroids—the most common solid pelvic tumors in women—are typically a long-term gynecologic condition in reproductive-aged women until menopause.² However, little information is known regarding the overlap of fibroids and sexual dysfunction. The high prevalence of these two conditions suggests that most physicians providing primary health care to adult women see many patients with either condition, or both. This article reviews the literature on fibroids and sexual dysfunction, examines the potential biologic and psychological influences that fibroids may have on sexual function, and proposes practical management recommendations for physicians caring for women with fibroids and sexual dysfunction.


FIBROIDS

Fibroids (leiomyomata)³ are benign tumors arising from the smooth muscle of the uterus, and are the single most common indication for hysterectomy. The condition occurs in 30% to 40% of women of reproductive age in the United States.⁴ Approximately 35% to 50% of women with fibroids are symptomatic, experiencing menorrhagia, pressure-related symptoms (ie, bloating, urinary frequency, urinary retention, constipation), pain (ie, dysmenorrhea, dyspareunia), and reproductive difficulties (ie, miscarriage, infertility).⁵ The diagnosis of fibroids is made by history, pelvic and abdominal examination, pelvic ultrasonography, and magnetic resonance imaging (MRI).


SEXUAL DYSFUNCTION

Masters and Johnson were the first to study and report on both healthy sexual function and sexual dysfunction. In 1966, in the seminal Human Sexual Response,⁶ they described the four phases of the human sexual response cycle: excitement, plateau, orgasm, and resolution (Figure 1). In 2001, Basson⁷ posited a more contemporary, intimacy-based, female-specific model of sexual response (Figure 2). This includes other aspects such as sexual desire, emotional intimacy, and emotional and physical satisfaction that are known to be necessary for overall sexual satisfaction. The prevalence of sexual dysfunction in women is 43%.⁸ The most recently updated classification system of female sexual dysfunction is from the 1999 International Consensus Development Conference on Female Sexual Dysfunction⁹ (Table 1), which reflects both the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders from 1994 and 10th revision of the World Health Organization's International Classification of Diseases from 1992.

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Figure 1. Masters and Johnson’s human sexual response cycle6

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Figure 2. Basson's female sexual response cycle7

View this table

Table 1. International Consensus Development Conference Classification of Female Sexual Dysfunction9

REVIEW OF THE LITERATURE

As of the writing of this article, only two studies have specifically investigated the sexual function of women with fibroids. Spies et al¹⁰ developed The Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire. This included two questions regarding sexual function, one about how often uterine fibroids reduce sexual desire and one about whether these symptoms led to avoidance of sexual relations. It was found that the 110 subjects with fibroids had worse sexual function overall than the 29 healthy controls.

The authors' own research utilized the Female Sexual Function Index (FSFI), an empirically validated, 19-item, multidimensional, self-report instrument designed for use in clinical trials. This study documented that in all seven sexual function scales of the FSFI—including subscales measuring desire, arousal, lubrication, orgasm, satisfaction, pain, plus the full scale—the mean scores of the 46 subjects with symptomatic fibroids were significantly lower than the mean scores of the 131 healthy controls.¹¹

Other research has investigated sexual function posthysterectomy, but these studies examined women undergoing hysterectomy for a wide range of benign gynecologic conditions and not specifically for fibroids. Such reports are contradictory.^12,13 Dennerstein et al¹² reported that 37% of posthysterectomy patients complained of deterioration in their sexual relationships that they attributed to the surgery. Weber et al¹⁴ reported no change in sexual function after abdominal hysterectomy. Rhodes et al¹⁵ reported that sexual functioning improved overall after hysterectomy, with the frequency of sexual activity increasing and problems with dyspareunia, inorgasmia, and low libido decreasing. More recently, Thakar et al¹⁶ reported that measures of the frequency of intercourse and orgasm and the rating of the sexual relationship with a partner did not change significantly in women undergoing total and subtotal hysterectomies for benign disease. In short, the jury is still out regarding whether hysterectomy affects sexual function in women with symptomatic fibroids.


BIOLOGIC AND PSYCHOLOGICAL INFLUENCES ON SEXUAL FUNCTION

Direct Effects

Mass Effect Theory.—Uterine fibroids can have a direct biologic influence on women's sexual function as a result of mass effect and location (particularly if there is an intramural component). This can make it difficult for the uterus to elevate and enlarge during arousal and contract during orgasm, and interfere overall just because of their general bulk.¹⁷

Vascular Ischemia Theory.—Uterine fibroids can have a direct biologic effect on women's sexual function via vascular changes as well. Goldstein et al,¹⁸ in one of only two papers directly investigating vasculogenic female sexual dysfunction, state that vaginal engorgement and clitoral erectile insufficiency syndromes are present during sexual stimulation when abnormal arterial circulation into the vagina or clitoris interferes with normal vascular physiologic processes, usually due to atherosclerotic vascular disease. Clinical symptoms may include delayed vaginal engorgement, diminished vaginal lubrication, pain or discomfort with intercourse, reduced vaginal sensation, diminished vaginal orgasm, and decreased clitoral sensation and/or clitoral orgasm.

The authors' own research used a computer model that enabled calculation of preembolization and postembolization blood flow to pelvic organs during uterine fibroid embolization (UFE). When blood flow to the uterus is blocked by embolization, there is a substantial increase in cystic and pudendal blood flow that correlates significantly with the improvement in symptoms following UFE.¹⁹ Thus, fibroids may promote relative chronic ischemia of the pelvic organs, potentially impairing circulation and engorgement of the vagina and/or clitoris, and contributing to arousal, orgasmic, and pain disorders.

Indirect Effects

Uterine fibroids can also have an indirect biologic influence on sexual function. Menorrhagia from fibroids can lead to iron-deficiency anemia and fatigue—a common disincentive to sexual desire and activity. In addition, the side effects of medical therapies for fibroids, such as gonadotropin-releasing hormone analogs, may alter serum estrogen levels, which can cause vaginal epithelial atrophy, decreased lubrication, and sexual pain.

Uterine fibroids can also have an indirect psychological influence on sexual function. Abdominal enlargement secondary to fibroids may cause patients to experience negative changes in body- and self-image and to feel unattractive and depressed. These women may fear being rejected sexually. Conversely, worries about bulk, bladder and bowel dysfunction, or vaginal bleeding during intercourse may cause patients with fibroids to reject sexual activity themselves. Reports from focus groups by Spies et al¹⁰ corroborate both of these possibilities. Dyspareunia may also lead to avoidance of intercourse, or cause a woman with fibroids to believe that she must endure pain to satisfy her partner. Furthermore, failure to express these concerns to a partner may then cause difficulties in interpersonal relationships. Thus, fibroids can have profound direct and indirect biologic and psychological influences on sexual function.


MANAGEMENT RECOMMENDATIONS

In another arm of the authors' own research, women were asked why they were seeking interventional treatment for symptomatic fibroids. Only 5% of subjects spontaneously self-reported pain with sexual activity as the reason. However, when given a questionnaire about sexual function, women with fibroids were found to have significantly more dyspareunia than healthy women.¹¹ A number of possibilities may explain this discrepancy. Women may not perceive sexual dysfunction as a reason for seeking treatment for fibroids, or may not associate fibroids with their sexual dysfunction. It is also possible that they are not troubled by their sexual dysfunction, or that they are troubled by it but are not discussing the issue with their physicians.

What can be learned from each possibility? First, patients may not cite sexual dysfunction as a reason for seeking treatment for uterine fibroids. However, if a woman is reluctant to pursue treatment for fibroids for physician-given reasons (eg, anemia), she might be more inclined to pursue treatment if she perceives that an issue more tangible to her (ie, sexual function) would be addressed. Second, patients (and physicians) may not associate fibroids with sexual dysfunction. However, fibroids can represent an opportunity to educate patients not only about leiomyomata and how they can affect sexual response, but also about normal sexual function.

Finally, while it is possible that some women with fibroids experience sexual dysfunction but are not bothered by it, it is more likely that they are troubled by it but are not discussing the issue with their physicians. Given the findings of the 1999 National Health and Social Life Survey that only 10% to 20% of people with sexual dysfunction sought help,¹² and that 75% of all women express fear about raising the issue of sex with their physicians,¹³ this scenario is highly likely.

Procedures to debulk fibroids and/or improve pelvic blood flow can address fibroid-related vascular and mass-effect changes, while fatigue from iron-deficiency anemia can be improved with iron supplementation. Bladder and bowel difficulties during intercourse may be ameliorated by urination and/or defecation before sexual activity. Diminished lubrication can be supplemented with over-the-counter, water-based lubricants. Exploring the patient's concerns about body image and encouraging similar discussion between the patient and her sexual partner may be helpful as well. In addition, psychological assessment of anxiety or depression may be necessary. However, none of these options can be offered if the physician is unaware that the patient with fibroids is experiencing sexual dysfunction.

The solution? The physician must provide a nonjudgmental environment and adequate time for questions to encourage patients to broach the topic themselves. Finally, if the patient does not broach the topic herself, physicians should remember that uterine fibroids and sexual dysfunction may be “true, true, and related,” and raise the issue themselves.


CONCLUSION

Sexual dysfunction should be incorporated into the assessment of the patient with uterine fibroids. It is a basic consideration for female patients, and raising the issue can help to overcome patient reluctance, educate patients about the association between the two conditions, and give the patient a powerful incentive to both seek and comply with fibroid therapy.

Elizabeth Kagan Arleo received her MD degree from the Yale University School of Medicine, New Haven, Conn in May 2004; and will be a resident, Department of Radiology, Cornell New York Presbyterian Hospital. Robin M. Masheb, PhD, is assistant professor, Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. Michael G. Tal, MD, is assistant professor, Department of Vascular and Interventional Radiology, Yale University School of Medicine, New Haven, Conn.

References

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