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The Boys. Swamp Thing. Both overweight and obesity have been identified as risk factors for sexual dysfunction in men, 9 but the relationship between sexual function and amount of body fat in females is still obscure.

Borges et al. The discrepancy among the few reports may mainly be attributed to the different instruments used to assess sexual function in women.

The female sexual function index FSFI is a brief, validated, item self-report instrument used in the assessment of specific sexual dysfunction symptoms.

The relationship between obesity and FSD has been investigated rarely, and no prospective studies have been reported on this topic.

There is clearly a need for more studies with prospective data, on the development of FSD both before and after the menopause. However, until such studies are performed, the association between obesity and development of FSD will remain elusive.

The aim of this study, therefore, was to identify the frequency of FSD among obese and overweight women. Women seeking weight loss at the Endocrinology and Metabolism outpatient clinic of Pamukkale University were screened during a 6-month period.

The study was conducted on 45 otherwise-healthy obese and overweight women. As personal sexual habits were questioned, married women were included in the study, by the assumption that they could talk more comfortably on these subjects.

All subjects met the requirement of having sexual intercourse at least once a month. Control subjects were age- and menopausal status-matched 30 women with a normal BMI from the same population.

The study was approved by the institutional committee of ethical practice of our institution, and all women gave informed written consent.

FSFI, which is a validated, item self-report instrument, was used for assessing key dimensions of female sexual function, as previously described by Rosen et al.

Specific domains analyzed in the FSFI included sexual desire, arousal, lubrication, orgasm, satisfaction and pain during sexual intercourse.

Sexual desire was assessed as frequency and level of sexual desire with two questions. Arousal was assessed as frequency, and level, confidence and satisfaction with four questions.

Lubrication was assessed as frequency, difficulty, frequency of maintaining and difficulty in maintaining with four questions.

Orgasm was assessed as frequency, difficulty and satisfaction with three questions. Satisfaction was assessed as the amount of closeness with partner, sexual relationship and overall sex life with three questions.

Pain was assessed as pain frequency during vaginal penetration and pain frequency after vaginal penetration with three questions.

Each domain was scored on a scale of 0 or 1—6, with a higher score indicating better function. A score was calculated for each of the six domains, and the total score was obtained by adding the scores of the six domains.

The tool was administered during the early follicular days 2—5 phase of the menstrual cycle. Height and weight were recorded with participants wearing lightweight clothing and no shoes using a Seca scale Seca, Hamburg, Germany with an attached stadiometer.

The waist-to-hip ratio WHR was calculated as the waist circumference in cm divided by the hip circumference in cm. Body fat distribution fat percent was assessed by multiple frequency bioelectric impedance measurement using a portable impedance analyzer Tanita, Tokyo, Japan.

Assays for glucose were performed in the biochemistry laboratory of the hospital. The free testosterone levels were calculated according to the Vermeulen formula.

Insulin resistance was evaluated according to the Lebovitz classification using a 2. A two-tailed, unpaired Student's t -test was used for comparison of means between women with or without FSD.

The Mann—Whitney test was used for non-normally distributed parameters. The clinical and metabolic characteristics of women participating in the study are shown in Table 1.

Table 2 lists the scores of FSFI domains for obese and overweight patients. The mean total FSFI score for obese patients was It is unclear whether obese women have sexual dysfunctions more often than non-obese women.

Clinical trial data suggest an ambiguous association between obesity and sexual satisfaction in young women.

In addition, the FSFI global score was negatively correlated with the known risk factors for cardiovascular disease, such as blood pressure, HbA1c, low-density lipoprotein cholesterol and TSH, whereas it was positively correlated with high-density lipoprotein cholesterol.

The prevalence of FSD in different populations is variable. In a national probability sample of women between the ages of 18 and 59 years, Lauman et al.

Lewis et al. Hayes et al. Data on arousal and orgasmic disorders were similar, showing the potential for considerable intercultural variation.

Graziottin 26 subsequently went on to review the implications of these data for clinical assessment, and explored etiologic differentiation and prognostic implications.

According to the FSFI score, The prevalence of FSD was The average FSFI total score was This might be because of the cultural and traditional differences in different parts of the country.

Personal distress levels about sexual behavior may be difficult to estimate. To overcome this drawback and estimate the prevalence of FSD in the general population, studies in different regions with larger populations need to be carried out.

Esposito et al. On the other hand, desire and pain were not affected by obesity. Central fat distribution, as evaluated by the WHR, showed no correlation with the FSFI score, nor with any individual sexual domains, suggesting that the amount of fat is more important than its distribution.

It was speculated that the increasing number of circulating factors produced by the fat cell may have a role, 33 although specifically focused studied are needed.

Women with severe obesity, particularly those seeking bariatric surgery, are at considerable risk of having problems with sexual function. However, when we evaluated the individual sexual domains, we found that BMI effects orgasm in a negative manner.

Compared with the control group, the women who had metabolic syndrome had overall lower FSFI scores Kaneshiro et al. Shah 38 reviewed that one may theorize that there is an increased prevalence of FSD in obese patients, but confirmation with further studies is needed.

Adolfsson et al. There was no difference in terms of sexual life satisfaction between the obese and normal-weight women in both age groups.

However, in the younger age group there was a tendency toward lower sexual satisfaction and sexual desire associated with higher weights.

Kolotkin et al. Among women, there was no association between weight changes and changes in sexual life. The studies generally find that surgery jejunoileal bypass for obesity may affect sexual relationships in a positive manner, but the degree of the effect is not clear.

The most important factors that may contribute to an overall change in sexual function after weight reduction in obese young women are alteration of the sex hormones, estrogen and androgen, and improvement in body image.

Estrogen is produced from cholesterol in the ovaries or by aromatization of steroids in the adipose tissue. A reduction in fatty tissue can therefore result in decreased levels of blood cholesterol, aromatization and estrogen.

We also found a correlation between estrogen and body weight, but no correlation was observed with any of the FSFI domains.

The changes in androgen levels after weight reduction in regularly menstruating obese women reported in several studies indicate that SHBG consistently increases after weight loss, and in turn, free testosterone decreases.

In other words, as people get more obese, they tend to have better satisfaction in sexual life. Several limitations of the study should be mentioned, including the small sample size, and recruitment of patients from a university outpatient clinic and from a small region.

Thus, the findings of this study need to be confirmed in a larger patient population. Because of the limited sample size, our data cannot be of epidemiologic relevance and need to be confirmed in studies of larger size.

On the other hand, our study population consisted of women who applied to the university hospital. This may not represent the sexual behavior of the entire population.

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