Background: Women's sexual health and physical desire for sex are most important for their emotional and physical well-being. This study aimed to examine the status of sexual dysfunction among postmenopausal women in Bangladesh and assess the significant risk factors behind this. Methods: A cross-sectional study was conducted among 45–55 years in four public and private hospitals in Bangladesh from April 2021 to June 2021 using a multi-stage sampling technique to enroll the study participants. The female sexual function index (FSFI) scale measured the prevalence of FSD, and the relationship of independent risk factors were assessed using a multivariate logistic regression model. Results: The total score of FSFI among postmenopausal Bangladeshi women was 18.07 ± 8.51. Among 260 participants, the prevalence of FSD was 56.9%. Out of all the significant risk factors, increasing age, urban population group, multiparous, homemakers, duration of menopause, and postmenopausal women with no hormone therapy were significantly associated with FSD. In contrast, those with regular physical activity were protective of FSD. Conclusion: In conclusion, a significant proportion of postmenopausal Bangladeshi women are enduring sexual dysfunction. Proper hormonal therapy and non-hormonal therapies such as physical activity and pelvic floor muscle (Kegel) exercise with adequate counseling are helpful to cope in this distressing situation.
Keywords: Hormone therapy; Physical activity; Postmenopausal women; Female sexual dysfunction
Mohammad Ashraful Amin and Nusrat-E Mozid have contributed equally to this work
Menopause is a transitory biological phenomenon, with significant meaning in women's lives [[
Female sexual dysfunction (FSD) is one of the most common health concerns; any sexual health problem causing distress to a woman is considered sexual dysfunction. It can be evaluated by knowing whether a woman is sexually active or has any problems with arousal, orgasm, and pain with sexual activity [[
The female life expectancy in Bangladesh is growing, reaching 73 years, and the mean menopausal age is 51.14 years [[
This cross-sectional study was conducted from April 2021 to June 2021 among postmenopausal women aged 45–55 years in Bangladesh. We excluded women who were divorced and widowed from this study. A multistage sampling technique was performed for collecting the data (Fig. 1). Dhaka and Chattogram districts were chosen as the study site. Four public and private medical hospitals were selected; two in the capital of Dhaka city (urban and rural area), two in Chattogram district (urban and rural area) by using a simple random sampling technique. The selection criterion was each hospital outpatient department size (n > 50) to ensure that sufficient data could be collected in a single visit, as the target sample size was drawn by systematic random sampling technique. Considering 80% power and 95% CI (0.05 to 1.96), the required sample size was 260.
Graph: Fig. 1 Multistage sampling technique
Data was collected using a structured questionnaire by conducting a face-to-face interview. The questionnaire was first constructed in English, then translated into Bangla, and again back-translated to English by a third person to see the accuracy of the original Bangla translation. After each interview, data were checked for completeness and accuracy by a senior researcher. A team of well-trained physician-researchers with postgraduate education and public health training were involved in data collection. Regarding a sensitive issue amongst the Bangladeshi population, a practical training session was arranged for two days before starting data collection. We provided training about the questionnaire approach, maintaining ethical issues concerning social stigma. A pilot study was conducted among 20 participants from a public medical hospital in Dhaka city in a separate sample. The Cronbach's alpha coefficient was found to be 0.962, which showed excellent internal consistency of the questionnaire. The face validity had also done by consulting with experts in the fields. Participants were assured of keeping their information strictly confidential. Interviewers acquired written informed consent from the participants. For participants without formal education interviewers informed and explained them as per ethical guidelines and then they obtained informed consent signed by the participant's legally authorized representative. Participation in this study was entirely voluntary, no one was forced, and participants were allowed to leave any time if they felt uncomfortable answering any questions.
The questionnaires included participants' characteristics with personal details (age of menstrual cessation, duration of menopause, previous contraception uses for family planning, hormonal replacement therapy (HRT) intake, familiar with pelvic floor muscle exercise, physical activity). Based on the researchers' experience, the respondent's records accumulated seven significant diseases, hypertension, diabetes, chronic kidney disease (CKD), asthma, cancer, polycystic ovary syndrome (PCOS), and hyperprolactinemia. Trained female hospital staff conducted anthropometric measurements for estimating BMI. Women in their postmenopausal years were included wearing light indoor clothes, without shoes, and empty pockets whenever necessary. The individual's height was measured by gazing straight ahead and attaching their heels to a wall-mounted stadiometer precise to the closest 0.1 cm (Leicester Tanita HR 001). Tanita HA 503 weight scale, Tanita Corporation, Tokyo, Japan, was used to calculate the closest 0.1 kg weight. BMI was determined by multiplying weight in kilos divided by height squared in meters. In this formula (BMI = weight/height^2). BMI values were estimated as normal/healthy (between 18.5 and 24.9), overweight (between 25 and 29.9), and obese (30.0 or higher).
Postmenopausal women's last four weeks' sexual history was assessed to see the sexual function. The Female Sexual Function Index (FSFI)-19 item, a multidimensional self-reported questionnaire providing scores on six sexual function domains (desire, arousal, lubrication, orgasm, satisfaction, and pain), was used. Each of the domain's scores ranged from 0 (or 1) to 5. All six domains were multiplied by a homogenization factor and, the total FSFI-19 score was the sum of each domain. Validity test for the mean values of each domain and total FSFI-19 shows excellent internal consistency reliability co-efficient (0.949–0.965), and a high-test correlation was evaluated by applying intraclass correlation coefficient (ICC) to the full scale of FSFI-19 (0.809) (Table 2).
The concept of sexual dysfunction and sexual health-related personal distress is paramount to diagnosing all female sexual dysfunctions (FSD) [[
Graph: Fig. 2 ROC curve; total FSFI scale
Data were analyzed using Statistical Package for the Social Sciences (SPSS) software version 25.0. Descriptive statistics were used to calculate the frequencies, percentages, mean and standard deviation of all independent variables, FSFI domain score, and total score. The outcomes measured were reported as the prevalence of FSD. Additionally, Pearson (r) correlational coefficients were stated as evidence of concurrent validity for each domain and full FSFI scale. A multivariate logistic regression analysis was employed to adjust all significant independent variables as covariates in the fitted model. Hosmer–Lemeshow goodness of fit test showed model fitness. Logistic regression co-efficient from the model were exponentiated and presented as adjusted odds ratios (AOR) with a corresponding 95% confidence interval, with p value < 0.05 statistically significant. We also obtained logistic regression models' tolerance and variance inflation factors (VIF) to evaluate potential multicollinearity.
Three hundred and thirty-six participants expressed an interest in the study, and 269 gave consent to participate. After analyzing and checking for consistency verification and reduction, 260 data were included in the subsequent analysis with a response rate of 77.38%. The mean age of the postmenopausal women was 51.3 years, where 61.5% belong to the age group of 51–55 years. More than half of our participants were from urban areas (59.6%), and 62.7% of women had 2–4 children. 36.2% of women had a graduate degree, and the majority (46.5%) of our participants were homemakers. 47.7% of women were overweight. The mean age of menstrual cessation was 46.3 (in years). Amongst all our study participants, 53.5% were experiencing menopause for 2–5 years. Almost 91.5% of our participants had used contraceptives for family planning purposes. 37.3% of them had started or used HRT, which can be highly beneficial after menopause. We asked our participants whether they were familiar with the term pelvic floor muscle exercise or not, and only 19.2% responded positively. In terms of physical exercise, 44.2% of women had never had any physical activity in their lifetime. We recorded seven significant diseases from the investigation profile; where 20.4% were hypertensive, 29.6% were diabetic, 10.4% with bronchial asthma, 4.2% with chronic kidney disease, 1.5% with cancer, 3.5% with PCOS, and 1.5% with hyperprolactinemia (Table 1).
Table 1 Participant characteristics (n = 260)
Characteristics Frequency (n) Percentage (%) 45–50 100 38.5 51–55 160 61.5 Mean (SD) 51.3 (2.8) Rural 105 40.4 Urban 155 59.6 One 63 24.2 Two–Four 163 62.7 > Four 26 10.0 None 8 3.1 No formal education 27 10.4 Up to class 8 29 11.2 Class 9–12 53 20.4 Graduation 94 36.2 Postgraduation 57 21.9 Homemakers 121 46.5 Govt. Employee 62 23.8 Private Service 66 25.4 Business 11 4.2 Normal 119 45.8 Overweight 124 47.7 Obese 17 6.5 ≤ 45 88 33.8 46–50 165 63.5 51+ 7 2.7 Mean (SD) 46.3 (2.7) 1 year 26 10.0 2–5 years 139 53.5 6+ years 95 36.5 No 22 8.5 Yes 238 91.5 No 163 62.7 Yes 97 37.3 No 210 80.8 Yes 50 19.2 Daily 34 13.1 2–3 times per week 75 28.8 Once a week 36 13.8 Rarely/never 115 44.2 HTN (+) 53 20.4 Diabetes (+) 77 29.6 Cancer (+) 4 1.5 Asthma (+) 27 10.4 CKD (+) 11 4.2 PCOS (+) 9 3.5 Hyperprolactinemia (+) 4 1.5
SD = standard deviation; HTN = hypertension; CKD = chronic kidney disease; PCOS = polycystic ovarian syndrome
The mean and standard deviation of all six domains (Desire, Arousal, Lubrication, Orgasm, Satisfaction, Pain) and the total score of the FSFI had presented in (Table 2). The mean score of FSFI was 18.07 ± 8.51 (mean ± SD). Among six domains, the lowest score was arousal (2.65 ± 1.46), and the highest score was satisfaction (3.42 ± 1.52). The prevalence of FSD was 56.9%. This high prevalence implies the deplorable status of postmenopausal women in Bangladesh.
Table 2 The mean, SD and reliability of the FSFI domains and total Scores
FSFI domains Mean ± SD Score range α ICC Desire 3.17 ± 1.32 1.2–6.0 0.965 Arousal 2.65 ± 1.46 0.0–6.0 0.949 Lubrication 2.96 ± 1.63 0.0–6.0 0.950 Orgasm 2.79 ± 1.59 0.0–6.0 0.948 0.809 Satisfaction 3.42 ± 1.52 0.8–6.0 0.958 Pain 3.10 ± 1.74 0.0–6.0 0.959 FSFI total score 18.07 ± 8.51 2.0–36.0 0.962
Cronbach's α coefficients showed excellent internal consistency reliability of the total and domain scores of the FSFI. ICC showed good reliability for the individual domains as well as to the full scale of the FSFI SD: standard-deviation; α: Cronbach's alpha; ICC: intra-class correlations coefficient
In Table 3, the concurrent validity for all the domains and full FSFI-19 inter-correlations had shown significant correlation ranged from r = 0.628 to r = 0.921 (p value < 0.001).
Table 3 Domain inter-correlations of the FSFI questionnaire
Desire Arousal Lubrication Orgasm Satisfaction Pain Desire – Arousal 0.845** – Lubrication 0.773** 0.921** – Orgasm 0.768** 0.913** 0.900** – Satisfaction 0.674** 0.795** 0.794** 0.865** – Pain 0.628** 0.822** 0.845** 0.843** 0.800** –
**Correlation is significant at the 0.01 level (2-tailed)
The relationship between independent risk factors for FSD among postmenopausal women was performed by multivariable logistic regression analysis as presented in Table 4. Among all the factors, the age group 45–50 years were 32% less likely towards FSD than the 51–55 years (OR = 0.68, CI 0.41–1.12). The rural population group was 85% less likely towards FSD than the urban population group (OR = 0.15, CI 0.08–0.27). Women with more than four children showed 1.83 times higher risk towards FSD comparing others (OR = 1.83, CI 0.27–12.54). Homemakers were 4.61 times higher odds towards FSD (OR = 4.61, CI 1.30–16.34). Women with a duration of menopause of one year were 73% less likely towards FSD than those with two-five years and above (OR = 0.27, CI 0.11–0.67). Hormonal replacement therapy (HRT) also showed a significant association with female sexual function. Postmenopausal women with no HRT use were 5.42 times more likely to have FSD (OR = 5.42, CI 3.14–9.35). Low physical activity is related to female sexual dysfunction. In our study, women who were physically active daily in their life showed 89% less likely risk towards FSD in comparison to others (OR = 0.11, CI 0.05–0.25).
Table 4 Relationship of independent risk factors for FSD using multivariate logistic regression
Risk factors Adjusted OR 95% CI 45–50 0.68 0.41–1.12** 51–55 Reference Rural 0.15 0.08–0.27** Urban Reference One 0.23 0.04–1.25 Two-Four 0.45 0.09–2.32 > Four 1.83 0.27–12.54** None Reference No formal education 5.32 5.35–16.84 Up to class 8 7.00 5.79–25.73 Class 9–12 4.24 1.91–9.40 Graduation 1.55 0.78–3.07 Postgraduation Reference Homemakers 4.61 1.30–16.34** Govt. Employee 0.87 0.24–3.15 Private Service 0.56 0.15–2.04 Business Reference Normal 1.51 0.50–4.57 Overweight 2.32 0.77–6.98 Obese Reference 1 year 0.27 0.11–0.67** 2–5 years 0.61 0.36–1.05 6 + years Reference No 8.59 1.97–37.59 Yes Reference No 5.42 3.14–9.35** Yes Reference Daily 0.11 0.05–0.25** 2–3 times per week 0.12 0.06–0.23** Once a week 0.20 0.09–0.45** Rarely/never Reference HTN No 0.68 0.32–1.44 Yes Reference Diabetes No 0.28 0.15–0.55 Yes Reference Cancer No - - Yes Asthma No 1.87 0.74–4.71 Yes Reference CKD No - - Yes PCOS No 3.13 0.52–11.45 Yes Reference Hyperprolactinemia No 3.54 0.27–31.65 Yes Reference
AOR = adjusted odds ratio; CI = confidence interval; HTN = hypertension; CKD = chronic kidney disease; PCOS = polycystic ovarian syndrome **p < 0.01
Sexual dysfunction is a prevalent problem with the sexual response cycle that interferes with regular, satisfying sexual activity. There is a dearth of literature querying FSD in low- and middle-income countries. Considering the taboo and sensitive cultural issues of FSD, our study from Bangladesh could be an essential contribution to the field. Our study has some noteworthy findings from Bangladesh context. Several risk factors were strongly associated with sexual dysfunction of the postmenopausal women in Bangladesh: advancing age (51–55 vs 45–50), urban vs rural, more than 4 children, homemaker vs employed; longer duration since menopause (2–5 years vs 1 year), no hormonal replacement therapy vs hormonal replacement therapy, and low physical activity.
Socio-demographic characteristics, cultural beliefs, happy marriages, or relationships can alter the prevalence rate of FSD. Epidemiologic research in FSD, particularly in clinical populations, found that the estimated prevalence rate was 43% in a US population aged 18–59 [[
Increasing age had been a concern among Turkish women where 46–55 years age group presented the highest prevalence rate of FSD, 67.9% [[
How long menopausal symptoms last is individual to each woman, but research has shown that menopausal symptoms last an average of 4.5 years following a woman's last period. Healthcare professionals advise people to expect a 7-year duration for their symptoms [[
Physical activity was a protective risk factor in our study. Similarly, in Iran and Brazil, sedentary women had a greater frequency of FSD compared to active and moderately active women [[
The selection criteria of our participants within a hospital setting were random; therefore, it does not show any selection bias. Another strength was using the FSFI-19 specific items and validated scales of each domain to assess the prevalence. However, a larger sample size covering every district could reflect the study result. Some potential confounders were not addressed in our studies, such as stability of the relationship, happy marriage or relationships, smoking and alcohol consumption history, sexually Transmitted Diseases, and psychiatric illness. We tried to cover several significant non-communicable diseases, including common reproductive health concerns for women, for example, PCOS and endocrine disorder hyperprolactinemia. Although we did not find any relationship with FSD, we recommend other studies to cover some clinical health issues such as prior pelvic surgery, endometriosis, uterine fibroids, and the information on whether the presence of erectile dysfunction in a male partner could be a vital factor for female sexual dysfunction. We have considered only seven diseases in the risk factor. However, in a larger study we recommend to including more communicable and non-communicable diseases including family violence and injuries.
Compared with many other Asian countries, we found that the rate of FSD among postmenopausal Bangladeshi women was substantially higher. It offers a broad picture and serves the evidence of the sexual health needs in Bangladesh. Among several potential risk factors increasing age, the number of children, profession, and duration of menopause was significant. On the contrary, hormone replacement therapy, physical exercise, and pelvic floor muscle exercise were found to have a protective effect on FSD. Satisfying sex life is vital to a woman's wellbeing at every age. FSD is treatable; identifying the underlying condition, lifestyle changes, hormone therapy, being physically active has profound benefits. It is crucial to consult physicians and health care providers on this occasion without shame, guilt, or fear. Rather than considering sexual issues taboo, it needs to be openly discussed and portrayed on television, magazines, and the internet to grow awareness and understanding of sexual health problems. The outlook for sexual problems can improve with counseling, education, and communication.
We would like to convey our heartfelt appreciation for the participants' assistance.
MDHH had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. MDHH conceived the study. MDHH, MAA and NEM designed the study in discussion with KD. MDHH oversaw its implementation, and analysis. NEM, SBA, SS, SSJ performed the experiments. MAA, IHM outlined the data collection procedure. IHM, SSJ led the study and field implementation; NEM, SSJ, IHM, SBA, SS, and WS were responsible for data entry. NEM and MDHH verified the underlying data. NEM did the statistical analysis. MDHH, MAA, NEM, SBA, SS, SSJ, IHM, WS and KD wrote the manuscript. KD critically reviewed the manuscript. The manuscript was reviewed and accepted by all contributors. All authors read and approved the final manuscript.
Open access funding provided by Mid Sweden University. This study did not receive any funds from the public or any donor agency.
The data underlying the results presented in this study will be provided on reasonable request to Dr. Mohammad Delwer Hossain Hawlader. Email: mohammad.hawlader@northsouth.edu.
Ethical approval of this study was obtained from the Institutional Review Board (IRB)/Ethical Review Committee (ERC) of North South University (2021/OR-NSU/IRB/0402). Approval to conduct the study was obtained from the Heads of Department of each hospital. All methods were performed in accordance with the relevant guidelines and regulations. Written informed consent was obtained from each respondent. For participants without formal education interviewers informed and explained them as per ethical guidelines and then they obtained informed consent signed by the participant's legally authorized representative.
Not applicable.
The authors declare that they have no competing interests.
• CKD
- Chronic kidney disease
• FSD
- Female sexual dysfunction
• FSFI
- Female sexual function index
• HRT
- Hormonal replacement therapy
• HTN
- Hypertension
• ICC
- Intraclass correlation coefficient
• MHT
- Menopausal hormone therapy
• PCOS
- Polycystic ovarian syndrome
• ROC
- Receiver operating characteristics
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By Mohammad Ashraful Amin; Nusrat-E Mozid; Sanjana Binte Ahmed; Shakila Sharmin; Imran Hossain Monju; Shirin Shahadat Jhumur; Wharesha Sarker; Koustuv Dalal and Mohammad Delwer Hossain Hawlader
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