Clin Rheumatol (2012) 31:601–606 DOI 10.1007/s10067-011-1891-2

ORIGINAL ARTICLE

Sexual dysfunction in rheumatoid arthritis patients: arthritis and beyond Y. El Miedany & M. El Gaafary & N. El Aroussy & S. Youssef & I. Ahmed

Received: 16 March 2011 / Revised: 30 October 2011 / Accepted: 1 November 2011 / Published online: 24 November 2011 # Clinical Rheumatology 2011

Abstract Rheumatoid arthritis treatment has been shown to improve quality of life. There is little data regarding the impact of the disease and treatments on sexual function. The aim of this study was to describe the results of an assessment of sexual activity/sexual satisfaction of rheumatoid arthritis patients, identify the sexual dysfunction features, and assess their association with disease activity/ disease activity parameters and other systemic risk factors/ comorbidities. Consecutive rheumatoid arthritis patients attending the outpatient rheumatology clinic completed the multidimensional patient-reported outcome measures questionnaire. There are three questions screening for sexual dysfunction: patients who ticked any of the boxes were further assessed. Men completed the Sexual Health Inventory for Men; whereas women completed the Female Sexual Function Index. All patients underwent clinical Y. El Miedany (*) : N. El Aroussy : S. Youssef Department of Rheumatology and Rehabilitation, Ain Shams University, 2Italian Hospital st. Abbassia, Cairo, Egypt e-mail: [email protected]

assessment of disease activity parameters and cardiovascular risk. Among 231 rheumatoid arthritis patients included in this study, 49/91 (53.8%) men and 64/140 (45.7%) women reported sexual dysfunction. Among men, erectile dysfunction significantly correlated (p<0.01) with pain score, cardiovascular disease, age, disease activity, fatigue score, intramuscular steroid injection, and tender joint count. Among women, sexual dysfunction was significantly correlated (p<0.01) with occurrence of secondary Sjogren's syndrome, pain score, cardiovascular disease, hip joint involvement, disease activity, and tender joint count. Sexual dysfunction is common among rheumatoid arthritis patients. Erectile dysfunction in men, and problems with orgasm, arousal, and satisfaction in women, were the most prevalent manifestations. The significant correlation of sexual dysfunction with CVD may help to identify patients at high risk of cardiovascular disorders. Keywords PROMs . Rheumatoid arthritis . Sexual dysfunction

Introduction Y. Miedany e-mail: [email protected] Y. El Miedany Darent Valley Hospital, Kent, UK M. El Gaafary Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt I. Ahmed Department of Internal Medicine, Cairo University, Cairo, Egypt

Recently, biologic therapy has been shown to improve rheumatoid arthritis (RA) patients' functional ability and quality of life, as well as clinical inflammation and radiologic disease progression. Thus, physician caring for RA patient have accordingly directed focus to objectively assess their patients' well-being [1]. Sexuality influences behavior, defines gender and roles, and shapes lifestyle in all ages [2]. Sexual motivation, competence, and expression are all diminished in RA patients [3–5], leading to marital unhappiness [6] or, sometimes, ending marriage and family life when sexual function becomes difficult or impossible [3].

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RA can influence sexual function due to several reasons. People with RA suffer from pain, restricted joint movements, and fatigue, and they can have problems with selfesteem and body image. It is also possible that medication causes sexual problems. Research on the subject is limited and shows a divergent picture [7]. The percentage of arthritic patients who experience sexual problems ranged in these studies from 31% to 76% [8]. Sexual problems, however, were defined in different ways: from not specified “sexual difficulties” [9] to specific forms of sexual dysfunction. Previous research has established that different disorders may be influenced differently by RA disease parameters. For example, sexual desire and satisfaction are influenced more by pain and depression, while sexual disability is influenced more by physical disability [10]. Similarly, for men, disease aspects that have an impact on libido may be different from those affecting erectile function or ejaculation [6]. Sexuality is rarely addressed in quality of life questionnaires or during physician–patient interviews [11, 12]. It has been suggested that questions about sexuality asked via a self questionnaire or during a face-to-face interview may deserve to be among the domains used to monitor the course of the disease, as well as functional capabilities, quality of life, and fatigue. The objectives of this study were: (1) to describe an assessment of sexual activity/sexual satisfaction problems among men and women suffering from rheumatoid arthritis as part of the patient-reported outcome measures assessment; (2) to identify the underlying problems in sexual contact with the partner among RA patients; (3) to assess the correlation of the disease activity/disease activity parameters with sexual functioning; and (4) to investigate whether other systemic risk factors/comorbidities which correlate with the patients' sexual dysfunction.

Methods Subjects This was a multicenter study, involving consecutive Egyptian RA patients attending the rheumatology outpatient clinic over 6 months in 2009/2010. All the patients met the American College of Rheumatology diagnostic criteria for rheumatoid arthritis [13]. All patients included in this work had a partner of the opposite sex. Patient-reported outcome measures assessment Every patient was asked to complete a copy of the multidimensional patient-reported outcome measures (PROMs) questionnaire for inflammatory arthritis [14] while sitting in the

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waiting area prior to their visit to the clinic. A trained health care staff nurse was available for assistance. The questionnaire involves 11 domains assessing functional disability, quality of life, visual analogue scale (VAS) for joint pain, global status, fatigue, duration of morning stiffness, review of the systems, falls and cardiovascular risks, the modified rheumatology attitudes index, and self-reported joint pain. One of the quality of life scale questions was asking the patient to rate his ability to continue his/her relationship with his/her partner (husband/wife). The patient should respond using one of the four standard response options: 0=without any difficulty, 1=with some difficulty, 2=with much difficulty, and 3=unable to do. In addition to assessing the systemic impact of the disease, there are three questions screening for the possibility of sexual dysfunction: (1) “Do you have sexual relationship problems with your partner?” (2) “Do you have any gynecological problems (for women)?,” and (3) “Do you have problems with erection (for men)?” Participating patients were informed about the study and further assessment. Men with possible erectile dysfunction (ED) or relationship problems were asked to complete the Sexual Health Inventory for Men (SHIM) [15]; whereas women who reported sexual relationship problems were asked to complete the Female Sexual Function Index (FSFI) [16]. For men with suspected ED, an initial evaluation included a clear assessment of the nature of the sexual problem, so that ED can be differentiated from premature ejaculation, lack of libido, relationship problems, or other problems that may require specialist referral. Sociodemographics Data were recorded for each patient regarding his/her sociodemographics figures e.g., age, marital status, length of relationship, educational level, and current work status. History of smoking, alcohol intake, diet, diabetes mellitus, hypertension, IHD, hyperlipidemia, physical activity, as well as history of psychological stress were also recorded. Assessment of cardiovascular risk was carried out using Systematic Coronary Risk Evaluation Risk Chart [17, 18], Disease activity All patients were subjected to clinical assessment for parameters of disease activity, as well as cardiovascular risk. Disease Activity Score was calculated for every patient as a measure of disease activity. It includes (1) a joint index of 28 joints evaluated for tenderness and swelling, (2) erythrocyte sedimentation rate (ESR), and (3) general health assessment scored on a VAS [19]; the higher the score, the more active the disease.

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Use of medication Details of current and past medications and hormonal therapy were checked. Current list of the patient's medication were recorded. Medications were classified into (1) drugs specifically prescribed for RA (e.g., disease-modifying antirheumatic drugs (DMARDs) or biologic therapy) or often taken together with RA medication including antiinflammatory or analgesic therapy, proton pump inhibitors, antihypertensive as well as medications for hypercholesterolemia and (2) drugs for other indications. The effect of these medications on sexual functioning—as far as known from literature—were scored, i.e., the effect on libido, erection, and orgasm/ejaculation as regard to men and on libido, lubrication, and orgasm as regard to women [20]. Laboratory assessment In addition to the basic rheumatology laboratory tests (full blood count, liver and kidney functions, ESR, and CRP), patients were tested for lipid profile, glucose, and hormonal profile (testosterone, LH, FSH, prolactin, and thyroid). In men, LH was measured if serum testosterone level is low. Local ethical and methodological protocols for approval of the study were followed. All patients who shared in the study signed an informed consent according to the Declaration of Helsinki. Statistical analysis Data analysis was performed using SPSS-PC software (version 11.0). Descriptive statistics are presented in the form of number and percentage for categorical data and mean ±standard deviation for continuous variables. Inferential statistics employed the Chi-square test for categorical variable association assessment and the Student t test for two group comparisons. For skewed data Mann–Whitney U test was performed. Spearman correlation was used for testing scores correlation. p value <0.05 was considered significant.

Results Two hundred and thirty-one RA patients were included in this study: 91 men, mean age 51.4+9.4 years; 140 females, mean age 50.1+11.6 years. The total number of the nonresponders was 62 of whom 24/62 nonresponders were men whereas 38/ 62 were women. Among 31/62 patients who declined to take part in the study as their partners had been working away from home therefore they felt their input would not be a true representation of their sexual activity. Another 31 patients did complete the questionnaire and had sexual problems but did not like to share in the study. The patients felt their problem

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was too personal and they felt uncomfortable taking part in this study. These patients who did complete the questionnaire and had sexual problems were managed following this study protocol; however, their data were not included. There were 113 RA patients, 49 men and 64 women with sexual dysfunction included in this work answered “Yes” to the question about “having difficulties to continue marital relationship with their partners (husband/wife).” Among men 23/49 (46.9%) highlighted some difficulty, whereas 24/49 (48.9%) reported much difficulty whereas 2/49 (4%) were unable to have a regular marital relationship due to erectile problems. In the female group, 26/64 (41%) had some difficulty, 31/64 (48.4%) had much difficulty, whereas 7/64 (11%) were unable to continue regular marital relationship due to sexual difficulties. Table 1 shows the sociodemographic and clinical characteristics of the patients included in this work. Systemic affection analysis for comorbidities revealed 20% had hypertension (66/231), 15% hyperlipidemia (34/231), 10% heart problems (23/231), 4% diabetes (9/231), 4% cancer (9/231), 8% lung disease (18/231), 2% kidney disease (4/231), 1% liver disease (2/231), 9% stomach problems (20/231), 1% blood disease, and 17% had other health problems (39/231). Of the male group 60.5% (59/91) and 61.4% of the female group (86/140) were on DMARDs therapy. One male and two females were taking analgesics and complementary therapy only. The rest of the patients (31/91 males and 52/140 females) were on anti-TNF biologic therapy. Table 2 shows the patterns of sexual dysfunction among RA men and women suffering from sexual dysfunction assessed in this study. Table 3 shows a comparison of the FSFI domains among RA women reporting sexual dysfunction versus RA women who did not report the problem. Pain domain, although affecting 73% of women with sexual dysfunction, was the least contributing domain in sexual dysfunction. Arousal and satisfaction were impaired in 7% of women showing no sexual dysfunction in their total score. There was significant correlation (p<0.001) between patient-reported sexual dysfunction in both RA men and women and their SHIM and FSFI scores, respectively. Studying the correlation of SHIM score in men as well as FSFI score in women suffering from RA with disease activity parameters (Table 4) revealed high Spearman coefficient values among both RA men and women suffering from sexual dysfunction. The disease was moderately active in both patients groups. Cardiovascular score was significantly correlated with erectile dysfunction and to less extent with FSFI score. Sexual dysfunction, among men, correlated significantly (p<0.01) with pain score (ρ=−0.564), cardiovascular disease (ρ=−0.593), age (ρ=0.471), disease activity (ρ=−0.587), psychological status (ρ=−0.525), fatigue score (ρ=−0.522), number of intramuscular steroid injection (ρ=0.431), and tender joint count (ρ=−0.495). On the other hand, among women, sexual dysfunction was significantly

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Table 1 Sociodemographic of the RA patients with and without sexual dysfunction

Sexual dysfunction

Age (years); mean (SD) Sex: N (%) Men

p value

Present

Absent

47.9 (10.4)

47.3 (9.7)

0.599 0.199

49 (53.3)

42 (46.7)

Women Partner's age (years); mean (SD)

64 (44.7) 48.7 (10.9)

78 (55.3) 49.8 (10.8)

0.426

Relationship duration (years); mean (SD)

19.0 (8.7)

18.7 (7.9)

0.758

Current smoking: N (%) Smoker

0.176 18 (39.1)

28 (60.9)

93 (50.3)

92 (49.7)

Up to secondary

55 (45.5)

66 (54.5)

University

56 (50.9)

54 (49.1)

50 (49.5)

51 (50.5)

61 (46.9)

69 (53.1)

Non Smoker Education level: N (%)

0.407

Currently working: N (%) Working

0.697

Not working

correlated (p<0.01) with occurrence of secondary Sjogren's syndrome (ρ=−0.726), pain score (ρ=−0.342), psychological status (ρ = −0.195), hip joint involvement/replacement (ρ=−0.187), disease activity (ρ=−0.241), cardiovascular disease (ρ=−0.264), and tender joint count (ρ=0.431). There was no significant correlation between sexual dysfunction and neither DMARDs therapy nor oral steroid therapy. Men who received steroid intramuscular injection manifested a higher rate of ED (71.4%) compared with those who did not receive (37.5%) and the association was statistically significant (p<0.001). For women, steroid injection did not affect sexual dysfunction.

Discussion In this report, the prevalence of sexual dysfunction among RA patients with partners is presented and correlated with various markers of disease activity and associated clinical

features. This topic has been largely neglected, so far, in the care of RA patients. Rheumatologists explain the apparent lack of interest in the assessment of sexual dysfunction among RA patients, by time constraints, unease when discussing sexuality and uncertainties about their role and competence regarding their patients' sexuality issues [6]. Another obstacle to open discussion about sexuality is the common feeling of guilt and isolation experienced by the patients, who feel they are somehow different from the norm [21]. Results of this study revealed that the multidimensional PROMs questionnaire was of help to bridge this gap and help the patient as well as the treating rheumatologist identify this problem. The prevalence of sexual dysfunction identified in the RA patients included in this study and identified using the PROMs questionnaire (53.8% in men and 45.7% in women) is comparable to the results of the other most recent studies. In France, two large surveys have been conducted by patient organizations. In 2007, the Association francaise des polyarthritiques mailed

Table 2 Patterns of sexual dysfunction among RA men and women suffering from sexual dysfunction assessed in this study Parameter (men group)

Estimate

Parameter (women group)

Estimate

Sexual dysfunction Mean erectile dysfunction score Mild erectile dysfunction (mean SHIM score=19.4±1.4)

49/91 (53.8%). 15.4±5.1 18/49 (36.7%)

Mild to moderate dysfunction (mean SHIM score 14.2±1.4)

16/49 (32.7)

Moderate ED (mean SHIM 9.3±1.5) Severe ED (mean SHIM 6.1±0.5)

13/49 (26.5%) 2/49 (4.1%)

Sexual dysfunction Mean FSFI score Pain lubrication problems Reduced sexual desire Reduced sexual arousal Reduced experience of orgasm Decreased satisfaction

64/140 (45.7%) 23.2±6.41 46/64 (73%) 58/64 (92.1%) 57/64 (90.5%) 59/64 (93.7%) 61/64 (96.8%) 59/64 (93.7%)

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Table 3 The prevalence of the individual FSFI domains among RA women reporting sexual dysfunction versus RA women who did not report the problem Affected domains

Sexual dysfunction Present (%)

Absent (%)

Desire

57 (90.5)*

5 (6.4)

Arousal Lubrication

59 (93.7)* 58 (92.1)*

6 (7.7) 3 (3.8)

Orgasm

61 (96.8)*

3 (3.8)

Satisfaction

59 (93.7)*

5 (6.4)

Pain

46 (73.0)*

2 (2.6)

*p<0.001

questionnaires to its members to collect data on their perception of their disease. Among the 7,700 patients with RA who mailed back the completed questionnaires, about 51% reported an adverse impact of the disease on their sexuality [21]. More recently, the Association nationale de defense contrel’arthriterhumatoide sent a questionnaire on fatigue and sexuality to its members. The response rate was 38% with more than 1,200 respondents. Among the respondents, 70% reported a negative impact of RA on their sexuality and 72% reported never having discussed their sexuality issues with a health care professional [22]. There is very little evidence that the rheumatoid process itself may influence the ability to have sexual intercourse. The identification of factors involved in the sexual problems of RA patients is challenging, given the large number of factors involved and possible need for interpretation [23]. Studies of factors that influence sexuality in patients with chronic diseases have distinguished primary effects, that is, sexual difficulties related directly to the disease process itself; secondary effects in which the disease symptoms cause sexual difficulties; and tertiary effects, related to Table 4 Correlation of SHIM score in men as well as FSFI score in women, suffering from rheumatoid arthritis, included in this study with disease activity parameters

CVS disease cardiovascular disease score, DAS 28 disease activity score 28, TJC tender joint count, SHIM sexual health inventory for men, FSFI female sexual function index

psychological and social impact of the disease [24, 25]. This agrees with the results of this study which revealed most of the sexual problems experienced by RA patients can be stratified under these three main items. In a study of 52 Egyptian women that focused on both disease activity and sexuality, factors significantly associated with sexual difficulties included tender joint count (r=0.56), pain (r=0.45), and functional disability (r=0.75). In addition, hip joint involvement was significantly associated with sexual problems [6]. The significant correlation with the cardiovascular risk among RA patients (both men and women) revealed in this study agree with the available data showing the close link between erectile dysfunction in men and cardiovascular disease. The relation between erectile dysfunction and cardiovascular disease is relevant and important to all fields of medicine. Erectile dysfunction is often not considered in the same context as traditional cardiovascular conditions, such as hypertension, dyslipidemia, ischemic heart disease, diabetes mellitus, or the insulin resistance/metabolic syndrome complex. Specific guidelines for treating men with ED and known CVD have been established and recently updated [26]. The results of this study showed that both men and women suffering from RA and sexual dysfunction, though more significant among men, are at high risk of cardiovascular disease. The increased cardiovascular risk noted among women in this study is multifactorial including the disease activity, the postmenopausal status, and other comorbidities the patients were suffering from. Impotence induced in males by methotrexate therapy is exceedingly rare, and though cyclophosphamide may induce hypogonadism, it is rarely used by RA patients [20]. Results of this study showed that intramuscular injections of methylprednisolone were significantly correlated with erectile dysfunction among men. This was not noted with oral steroids. Reviewing the literature did not reveal reported cases of similar problem.

Men

Women

Spearman (ρ)

p value

Spearman (ρ)

p value

TJC (physician) TJC (patient)

−0.495 −0.513

<0.001* <0.001*

−0.172 −0.164

0.041* 0.552*

SJC PGA

−0.525 −0.587

<0.001* <0.001*

−0.212 −0.208

0.012* 0.013*

Pain score Hip joint pain score DAS 28 Psychological status score Fatigue score CVS score

−0.564 −0.253 −0.587 −0.525 −0.522 −0.593

<0.001* 0.016* <0.001* <0.001* <0.001* 0.001*

−0.342 −0.187 −0.241 −0.195 −0.193 −0.264

<0.001* 0.027* 0.004* 0.020* 0.022* 0.026*

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In conclusion, sexual dysfunction is a common problem in RA patients. Erectile dysfunction in men, as well as problems with orgasm, lubrication, and sexual satisfaction in women were the most prevalent manifestations. Multidimensional PROMs questionnaire helped to incorporate sexual dysfunction screen in the standard practice and helped to identify those patients suffering from sexual disorders. The significant correlation of sexual dysfunction in both men and women with cardiovascular disease may help to identify a subgroup of RA patients at high risk of cardiovascular disorders. Recognition by the rheumatologist and other health care professionals that RA-related factors might have an impact on sexuality open the floor of discussing the patient's experience and the optimal therapy as well as identify patients who might be at high risk of other comorbidities and in particular cardiovascular disease.

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10.

11.

12.

13.

14.

15.

16. Disclosures None. 17.

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