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| CONCEPT AND ISSUE |
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| Year : 2021 | Volume
: 22
| Issue : 2 | Page : 109-114 |
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Obesity and sexual dysfunction among women: An overview
Princey Shaji1, Maharaj Singh2, Bharti Sahu3
1 Ph.D.Scholar, Jabalpur Institute of Nursing Science and Research, Jabalpur, Madhya Pradesh, India
2 Professor & Research Head, NIMS Nursing College, NIMS University, Jaipur, Rajasthan, India
3 Associate Professor, Department of Obstetrics & Gynaecology, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
| Date of Submission | 09-Jun-2021 |
| Date of Decision | 14-Sep-2021 |
| Date of Acceptance | 18-Nov-2021 |
| Date of Web Publication | 14-Dec-2021 |
Correspondence Address:
Mrs. Princey Shaji
Jabalpur Institute of Nursing Science and Research, Opposite Victoria Hospital, Jabalpur - 482 001, Madhya Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijcn.ijcn_46_21
For many obese and overweight women, sexual functioning is a critical, but often ignored, aspect of their quality of life. Obesity is becoming a global problem. The aim of this article was to provide an introductory insight into the relationship between obesity and sexual dysfunction in women from the recent literature. The link between obesity and sexual functioning is poorly understood, and therapeutic choices are even less well understood. Weight did, however, affect the some aspects of sexual function in studies of special populations such as women with gestational diabetes, polycystic ovarian syndrome, pelvic organ prolapse or urinary incontinence. Surgical weight loss, but not non-surgical weight loss is linked to the resolution of some aspects of sexual dysfunction in women. When it comes to sexual dysfunction, women's weight plays a pivotal role. Non-weight loss surgery has been linked to improved sexual function in women. To fully understand the link between weight and sexual function, more research is needed.
Keywords: Bariatric surgery, obesity, sexual dysfunction, women
How to cite this article:
Shaji P, Singh M, Sahu B. Obesity and sexual dysfunction among women: An overview. Indian J Cont Nsg Edn 2021;22:109-14 |
| Introduction | |  |
Obesity is one of the world's fastest-growing and most difficult public health issues, affecting 1.9 billion adults.[1] Obesity is linked to an increased risk of early death, morbidity and chronic disorders such as heart disease, hypertension, stroke, Type 2 diabetes and metabolic syndrome, all of which harm mental health and lead to poorer quality of life.[2] Furthermore, overweight people are more likely to progress to obesity and the severity of these conditions is linked to obesity and contributes to poor quality of life.[3],[4] Sexual dysfunction affects 20%–50% of obese women.[5]
Female sexual dysfunction (FSD) is a complex sexual health issue which affects a large number of women worldwide.[6] Since the sexual function is an important aspect of health, one might theorise that there is a connection between sexual function and obesity. Sexual rights safeguard all people's rights to fulfil and share their sexuality, as well as to enjoy sexual well-being while taking into account the rights of others and operating within a system of anti-discrimination safeguards.[1] Sexual functioning is influenced generally by the psychological motivators such as attraction and desire, and also conditions such as depression, anxiety, stress, and low self-esteem and poor body image.[7] The relationship between body weight and sexual function is poorly understood and sexual dysfunction may be linked to obesity.[7],[8] It is unclear whether obesity directly raises the likelihood of sexual issues or whether its effects on sexual function are mediated by health and psychological factors.[9] Gender plays a role in the study of the relation between fat and sexual dysfunction. The relationship between obesity and erectile dysfunction in males has been extensively researched and is substantially supported by cross-sectional and prospective studies.[8],[10] The link between sexual function and overweight/obesity in women, however, is still mainly unknown.[11],[12],[13] Female obesity has been linked to particular sexual dysfunctions such as loss of desire, poor sexual function, lack of interest in a sexual relationship and higher sexual unhappiness.[14],[15],[16],[17]
| Sexual Dysfunction | | |
Definitions
Overweight and obesity are described by the WHO[18] as 'abnormal or excessive fat accumulation that poses a health risk.' The distribution of body fat is a key predictor of the associated health risk, as central or abdominal obesity is linked to a higher risk of disease than gynoid fat distribution, which is fat distributed equally across the body. Body mass index (BMI) is a metric that can be used to categorise people's weight status based on their weight and height. It is measured by dividing an individual's weight in kilograms by their squared height in metres (kg/m2). Overweight is defined as having a BMI between 25 and 29.9 and obesity is defined as having a BMI of 30 or more.[18]
Sexual health is defined as 'A state of physical, physiological, mental and social well-being in relation to sexuality' it is not simply the absence of illness, dysfunction, or infirmity and positive and supportive attitude toward sexuality and sexual relationship.[19],[20] Sexual dysfunction is defined as a disruption in sexual function including one or more phases of the sexual response cycle, as well as pain related with sexual activity.[7],[8]
Physiology of sexual function in women
Female sexual function is a complex neurovascular phenomenon that is under the control of psychological, neurovascular and hormonal factors. During sexual arousal, blood flow to the clitoris and the labia minora increases, leading to engorgement of these organs, which in turn results in protrusion of the glans clitoris and eversion and engorgement of the labia minora. This increases in the blood flow to the vagina and uterus leading to increased secretion from the uterus and Bartholin's glands, which lubricates the vagina. Additional lubrication comes from the transudation of plasma from engorged vessels in the vaginal wall.
Estradiol is a female sex hormone that promotes lubrication and helps maintain the integrity of the vaginal mucosal epithelium. Oestrogen regulates sexual function and nitric oxide generation in the vaginal and clitoris regions. It also possesses vaginal vasoprotective and vasodilator properties. Vaginal lubrication, sexual desire, and frequency diminish after menopause, which can lead to vaginismus. Oestrogen replacement therapy has been demonstrated to boost vaginal lubrication and sexual desire in post-menopausal women.[21],[22]
In women, testosterone (T) is the most common androgen and is synthesised mostly in the adrenal glands and ovaries. The ovaries and adrenal glands produce circulating and rostenedione, which is a key source of 'T'. Testosterone levels tend to drop as people get older. When a woman has a bilateral oophorectomy, her 'T' and dehydroepiandrosterones (DHEAS) levels drop dramatically.[23] 'T' deficiency is linked to lower sexual arousal, desire, sexual response, genital sensation and orgasm.[24] Testosterone acts on the central nervous system and affects sexual behavior. 'T' may increase nitric oxide synthase activity, which causes vascular smooth muscle relaxation. Replacement of androgens, on the other hand, is linked to virilisation, acne and hirsutism.[25]
Female sexual dysfunction
A complete understanding of the physiologic and pathologic aspects of FSD is essential to develop any therapeutic strategies. Sexual dysfunction in women can be caused by persistent medical conditions. Women with atherosclerosis of the pelvic vasculature are more likely to develop vasculogenic impotence. Clitoral vascular insufficiency syndrome occurs when atherosclerosis affects the hypogastric/pudendal arterial bed in women, reducing blood supply to the clitoris and vagina.[26] Reduced blood flow in the vagina and clitoris can lead to the loss of corporal smooth muscle, which can lead to fibrosis.[27] Furthermore, physical trauma, radiation and pelvic fractures can all reduce vaginal and clitoral blood flow, leading to sexual dysfunction. Sexual dysfunction after pelvic surgeries may be due to the interruption of the vascular supply and neurologic innervation. Contraction of the pelvic floor muscles (the pelvic diaphragm in particular) intensifies the orgasm. However, a non-voluntary contraction commonly leads to vaginismus.
Types of sexual dysfunction in women
The Second International Consensus on Sexual Medicine classification described sexual dysfunction as the following sexual difficulties encountered by women.[8],[28]
- Sexual desire disorder: Lack of sexual attraction or desire
- Persistent sexual arousal dysfunction: Presence of genital arousal that is involuntary, disruptive and unwelcome in the absence of sexual desire
- Orgasmic dysfunction: Absence, delay or decreased intensity of orgasmic sensation
- Sexual arousal disorder: Existence of genital sexual arousal dysfunction, subjective sexual arousal dysfunction, or both
- Dyspareunia: Pain that lasts or returns after vaginal penetration is attempted or completed
- Vaginismus: Painful spasmodic vaginal contractions during intercourse.
Prevalence of sexual dysfunction
FSD is generally under addressed. Approximately 40%–45% of women have at least one sexual dysfunction.[8],[29] Low sexual desire was found in 17%–55% of people, with the percentage rising with age. Orgasmic dysfunction was found to be more common in western cultures, with a prevalence rate of 25% among women aged 18–74, compared to an 80% prevalence rate in Nordic countries.[29]
Indian women rarely express sexual function-related issues. The issues are either unrealised as present or ignored if reported. Studies from India have shown that a similar prevalence patterns of sexual disorders in women. About 44.54% women in the rural area reported more than one sexual disorder.[30] Another study from Ahmedabad reported that 55.5% had some kind of sexual dysfunction.[31] In another study from New Delhi, sexual desire dysfunction, arousal disorder and lubrication dysfunction were found among 63%, 77% and 51% women, respectively.[32] FSD was registered by 41% of women.[33]
Assessing sexual dysfunction
Various rating systems have been developed over the years to measure the various elements of sexual dysfunction and other sexual disorder. Some of these scales are more specific, assessing various domains of sexual functioning, sexual dysfunction or other aspects of sexual disorders, whilst others are more general, assessing multiple aspects of sexual functioning, sexual dysfunction or other aspects of sexual disorders. This article elaborates on these tools that are used in assessing the sexual dysfunction among women and men.
Arizona sexual experience scale
This is a 5-item rating scale that assesses sexual drive, arousal with sexual stimuli, vaginal lubrication/penile erection, ability to reach orgasm and satisfaction with orgasm (i.e., sexual drive, arousal with sexual stimuli, vaginal lubrication/penile erection, ability to reach orgasm and satisfaction with orgasm). A total score of 5–30 indicates sexual dysfunction, with a score of 19 or above indicating sexual dysfunction. Scores of 4 or 5 in particular domains are regarded indicative of sexual dysfunction in that domain. It is accessible in both clinician and self-rated scales and can be used by both men and women. It has strong internal consistency and test-retest reliability, as well as convergent and discriminant validity. It has been translated in many different languages including Hindi.[34]
Sexual functioning questionnaire
This is a 38-item clinician-rated measure for evaluating sexual dysfunction in the last month. It was created primarily to assess sexual functionality in people with serious mental disorders. It measures desire, sexual arousal (male erection and female vaginal lubrication), masturbation, orgasm and ejaculation. The scale has high reliability and internal consistency (Cronbach's α 0.852) and has been validated in India too.[35]
Female sexual function index (FSFI)
This is a 19-item self-report questionnaire for assessing female sexual function. Desire (2 items), arousal (4 items), lubrication (4 items), orgasm (3 items), pleasure (3 items) and pain (3 items) are the six domains of sexual functioning assessed (3 items). It has good construct validity, high test-retest reliability (r = 0.79–0.86), and high internal consistency (Cronbach's values of 0.82 and higher).[34]
| Obesity and Sexual Dysfunction in Women | | |
Hormones and sexual dysfunction
Hormones have direct and indirect effects on BMI and sexual function. Recent studies have shown that the relationship between oestrogen and female sexual functioning is not as clear[36] as it for testosterone in men.[7] The connection between sex hormones, weight, and sexual function has been investigated in some studies. Using free testosterone, total testosterone, estradiol, sex hormone-binding globulin, Follicle stimulating hormone (FSH), Lutenizing hormone (LH), prolactin, and DHEA-S levels, Yaylali et al.[37] compared obese women to controls in terms of sexual function and sex hormone levels. The satisfaction domain of the FSFI was negatively associated with total testosterone levels (r = 0.385). However, no other associations between the hormones studied and the total FSFI were discovered. When Kadioglu et al., compared obese women to safety controls, they found that there were substantial differences in free testosterone levels (P = 0.02). However, there were no major differences between the two classes for LH (P = 0.21), FSH (P = 0.06), estradiol (P = 0.90), and DHEA (P = 0.16). Total FSFI (r = 0.329, P = 0.02), lubrication (r = 0.329, P = 0.002), orgasm (r = 0.345, P = 0.001), pleasure (r = 0.272, P = 0.01), and pain (r = 0.364, P = 0.001) were all negatively associated with free testosterone. It was not, however, linked to an attraction (P = 0.64) or arousal (P = 0.06). Orgasm was negatively associated with total testosterone (r = 0.251, P = 0.02).[38]
A correlation between psychosocial factors and sexual dysfunction has been discovered in several other studies involving women. In 229 women who lost weight through intensive lifestyle changes, Wing et al.[39] discovered that a reduction in depression as calculated by the BDI was associated with an increase in sexual function (odds ratio [OR] = 1.54, P = 0.005). In a cross-sectional sample of 193 women, Erbil[40] used the body image score to assess body image. BIS and BMI were found to have a negative correlation (r = 0.157, P = 0.029). There was also a significant (P < 0.001) association between BIS and FSFI total (r = 0.343), desire (r = 0.351), arousal (r = 0.335), lubrication (r = 0.242), orgasm (r = 0.335), and pleasure (r = 0.339). BIS and pain, on the other hand, had no meaningful relationship (r = 0.044, P > 0.05). Body image and depression, as well as sex hormones, have been shown to play a role in mediated weight-related sexual dysfunction in women.
Weight and sexual dysfunction
Obesity tends to harm sexual performance.[41],[42] Obesity and sexual dysfunction tend to be linked in particular for those with more adiposity. For example, Bond et al., discovered that approximately 60% of women seeking bariatric surgery had sexual dysfunction.[43]
There are currently few findings on the relationship between body weight and sexual function. Yaylali et al.[37] researched to determine the connection between FSD and being overweight or obese. A total of 45 obese and overweight patients and 30 healthy controls were studied, and it was found that 86% of obese patients and 83% of healthy controls had sexual dysfunction. A review of the evidence on the connection between sexual dysfunction and obesity found no evidence that sexual dysfunction induced obesity; although there was clear evidence that obesity caused sexual dysfunction. Erbil[40] employed the FSFI and the body image scale (BIS) in a 2013 cross-sectional study of 193 women and found that being overweight or obese did not effect on the total FSD Index (FSFI) score (P = 0.395) or any individual domain scores. Using the FSFI, Javadnoori et al.[44] studied 330 fertile women in Iran. There was no difference in mean FSFI scores between patients with a normal BMI and those who were overweight (P = 0.756), according to the authors. Furthermore, no significant differences in any domain scores were seen between the two groups. As a result, the authors concluded that while BMI does not alter sexual function in and of itself, a high BMI can lead to a poor body image, which can have a major impact on sexual functioning.
Sexual dysfunction and weight in special population
Several studies have done to find the effect of weight on specific populations. Ribeiro et al.[45] conducted a cross-sectional study on 143 women with gestational diabetes in the third trimester of pregnancy. Sixty-seven of them were of average pre-pregnancy weight, while 76 were overweight or obese before becoming pregnant. The authors discovered that people who were overweight prior to pregnancy were more likely to experience sexual dysfunction symptoms. Benetti-Pinto et al.[46] looked at the connection between weight and sexual function in women with polycystic ovarian syndrome (PCOS), contrasting 56 PCOS women to 102 healthy women. The BMI of the two groups was substantially different (31.9 8.5 vs. 28.5 5.4 kg/m2, P < 0.02) Arousal (P = 0.03), lubrication (P = 0.04), satisfaction (P = 0.001), discomfort (P = 0.01) and total FSFI score (P = 0.005) were all significantly lower in the PCOS community. Only satisfaction (P = 0.002) and total FSFI score (P = 0.02) remained important after adjusting for age differences between the two classes. When age was taken into account, orgasm was found to be negatively associated with BMI. Weight remains a factor in deciding sexual functioning in women, even with additional co-morbidities or medical conditions, according to studies.
Sexual dysfunction and weight loss
Given the existence of a connection between obesity and sexual dysfunction, the next step will be to see whether reducing body weight improves sexual functioning in obese people. A number of studies have documented changes in sexual functioning and quality of life in persons who have lost significant amounts of weight after bariatric surgery.[47] As part of the Look AHEAD research, Wing et al.[39] conducted a multicentre randomised control trial of women with type 2 diabetes. In the sexual function ancillary sub-study, 375 women were divided into two groups: one received intensive lifestyle intervention, while the other received only diabetes support and education. The FSFI questionnaire was given at the start of the study and again after a year. When compared to a group of healthy women of a similar age, women in both groups had significantly lower total FSFI and all domain scores at baseline (P < 0.001 for both). BMI, on the other hand, was not significantly correlated with FSD at the start (P > 0.05). The intervention group lost substantially more weight than the control group after 1 year (P < 0.0001). The only variable correlated with an increased probability of women with FSD being sexually active at 1 year (OR 1.149; 95% confidence interval [CI], 1.018–1.297, P = 0.025) after adjusting for race and depression was the amount of weight loss (OR 1.149; 95% CI, 1.018–1.297, P = 0.025).
These findings support other research on the effects of weight loss on the sexual functioning of women who are overweight or obese Kolotkin et al.[47] A 2-year study of 187 gastric bypass patients who had daily meetings with a dietitian, customised diets, an exercise regimen and medication BMI decreases were significantly correlated with changes in sexual quality of life (P = 0.0001), according to the data collected every 3 months on sexual quality of life and BMI. This research demonstrates the beneficial effects of weight loss (achieved by multiple intervention methods) on women's sexual functioning. More research is required to establish the connection between sexual functioning and the psychological and metabolic conditions associated with obesity, as well as to look into the effects of weight loss on these variables.
| Effects of Bariatric Surgery Weight Loss on Sexual functioning in Women | | |
Studies on the impact of bariatric surgery on female sexual function shows weight reduction improves sexual functioning in women. Efthymiou et al.[48] analysed 50 obese women who had Roux-en-Y surgery, biliary pancreatic diversion with Roux-en-Y reconstruction or sleeve gastrectomy. At 1 year, participants lost substantial weight (P = 0.0005), and all FSFI domains (desire P = 0.001, arousal P = 0.001, lubrication P = 0.005, orgasm P = 0.005 and pain P = 0.021) and overall FSFI score (P = 0.001) increased. Sarwer and Steffen[42] used data from the Longitudinal Assessment of Bariatric Surgery consortium to conduct a prospective cohort study involving 106 women who had Roux-en-Y or adjustable gastric banding bariatric surgery. One hundred and six women who had Roux-en-Y or flexible gastric banding surgery were included in the study. Participants' overall FSFI (P = 0.04), desire (p0.001) and satisfaction (P = 0.001) domain scores all increased significantly 1 year after surgery. As compared to baseline, total FSFI, happiness and desire (P = 0.002, P = 0.002, and P = 0.001, respectively) domain scores continued to rise, with arousal (P = 0.01) and lubrication (P = 0.045) domain scores also growing. Other FSFI domain scores did not show any major changes.
In one another study, Hernández et al.[49] discovered that total FSFI increased substantially at 6 and 12 months after surgery (P = 0.001 for both) in another prospective study of morbidly obese women with FSD. In addition, ratings for all FSFI domains increased significantly (P = 0.001). At the 12-month mark, both participants' FSD had been resolved. Sarwer and Steffen[42] tracked the same patients for 4 years after surgery in a subsequent report. Total FSFI, arousal, desire and happiness (P = 0.01, 0.02, 0.01 and 0.001, respectively) were all significantly higher than baseline at year 3. Lubrication, orgasm and pain (P = 0.14, 0.06 and 0.17, respectively) were not substantially different from baseline. At the end of the 4th year, sexual function had diminished. No domains changed substantially from baseline (P > 0.05 for all). At last, the reviews can be summarised by post-operatively, both studies observed improvements in total FSFI, arousal, desire and satisfaction domain ratings. However, research on the impact of bariatric weight loss surgery on pain and orgasm is inconsistent.
| Summary | | |
FSD is under addressed. The majority of recent studies have found a link between weight and sexual function in women, although numerous nuances of the association remain unknown. Several studies have discovered that bariatric surgery reduces FSD in women. Non-surgical weight loss studies and research comparing obese/overweight women to control populations, on the other hand, have not found a reduction in FSD despite weight loss. Weight-related sexual dysfunction in women is influenced by psychosocial factors such as depressive symptoms and body image. Testosterone levels have also been linked to sexual function in women. More research is needed to identify if bariatric surgery or the weight loss that results from bariatric surgery is the driving force behind these patients' improved sexual function. Studies comparing weight-loss bariatric surgery patients to those who do not lose weight could provide vital insight into the relationship between weight loss, bariatric surgery and sexual function. Furthermore, while physical activity has been shown to promote mental health, it is unknown whether increasing physical activity and hence mental health may enhance sexual functioning in overweight and obese people with sexual dysfunction.
While it is well documented that obesity has a deleterious impact on sexual function, the complicated interrelationships between excessive body weight and sexual function remain unknown. Many of the studies cited in this review were unable to prove causation or reveal probable pathways linking obesity and sexual functioning. New recommendation for clinical practice in obese and overweight women who suffering from sexual problem. Future research could, for example, concentrate on lifestyle changes that can help women who are overweight or obese enhance their sexual functioning. Another potential target for research and treatment is increasing physical exercise, such as walking, as an alternative treatment for improving sexual functioning in women. Dietary plans for weight loss, as an alternative to bariatric surgery, may need to be looked to help and treat people who are overweight or obese enhance their sexual function.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | |
| 2. | Law DC, Maclehose RF, Longnecker MP. Obesity and time to pregnancy. Hum Reprod 2007;22:414-20.  |
| 3. | Kranjac AW, Wagmiller RL. Decomposing trends in adult body mass index, obesity, and morbid obesity, 1971-2012. Soc Sci Med 2016;167:37-44. |
| 4. | Bhardwaj S, Misra A, Misra R, Goel K, Bhatt SP, Rastogi K, et al. High prevalence of abdominal, intra-abdominal and subcutaneous adiposity and clustering of risk factors among Urban Asian Indians in North India. PLoS One 2011;6:e24362. |
| 5. | Asma FS, Isha C, Kirti G, Rakesh G, Randhir S. Impact of obesity on female sexual dysfunction: A remiss. Curr Womens Health Rev 2021;17:21-8. |
| 6. | Ponholzer A, Roehlich M, Racz U, Temml C, Madersbacher S. Female sexual dysfunction in a healthy austrian cohort: Prevalence and risk factors. Eur Urol 2005;47:366-75. |
| 7. | DeLamater J, Karraker A. Sexual functioning in older adults. Curr Psychiatry Rep 2009;11:6-11. |
| 8. | Esfahani SB, Pal S. Obesity, mental health, and sexual dysfunction: A critical review. Health Psychol Open 2018;5:2055102918786867. |
| 9. | Rowland DL, McNabney SM, Mann AR. Sexual function, obesity, and weight loss in men and women. Sex Med Rev 2017;5:323-38. |
| 10. | Akdemir AO, Karabakan M, Aktas BK, Bozkurt A, Ozgur EG, Akdogan N, et al. Visceral adiposity index is useful for evaluating obesity effect on erectile dysfunction. Andrologia 2019;51:e13282. |
| 11. | Di Nardo M, Conti C, Di Francesco G, Nicolardi G, Guagnano MT, Porcelli P. What is the “weight” of body mass index on sexual functioning in women? A mediation model. Eat Weight Disord 2021;26:1801-11. |
| 12. | Costa RM, Brody S. Obesity, overweight, female sexual function, and penile-vaginal intercourse frequency. J Sex Marital Ther 2016;42:293-6. |
| 13. | Janik MR, Bielecka I, Paśnik K, Kwiatkowski A, Podgórska L. Female sexual function before and after bariatric surgery: A cross-sectional study and review of literature. Obes Surg 2015;25:1511-7. |
| 14. | Mozafari M, Khajavikhan J, Jaafarpour M, Khani A, Direkvand-Moghadam A, Najafi F. Association of body weight and female sexual dysfunction: A case control study. Iran Red Crescent Med J 2015;17:e24685. |
| 15. | Rabiepoor S, Khalkhali HR, Sadeghi E. What kind of sexual dysfunction is most common among overweight and obese women in reproductive age? Int J Impot Res 2017;29:61-4. |
| 16. | Bates JN, Pastuszak AW, Khera M. Effect of body weight on sexual function in men and women. Curr Sex Health Rep 2019;11:52-9. |
| 17. | |
| 18. | |
| 19. | |
| 20. | Rosen, C. Brown, J. Heiman, S. Leib R. The female sexual function index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26:191-208. |
| 21. | Raina R, Pahlajani G, Khan S, Gupta S, Agarwal A, Zippe CD. Female sexual dysfunction: Classification, pathophysiology, and management. Fertil Steril 2007;88:1273-84. |
| 22. | Berman JR, Goldstein I. Female sexual dysfunction. Urol Clin North Am 2001;28:405-16. |
| 23. | Davison SL, Davis SR. Androgens in women. J Steroid Biochem Mol Biol 2003;85:363-6. |
| 24. | Sherwin BB, Gelfand MM. Differential symptom response to parenteral estrogen and/or androgen administration in the surgical menopause. Am J Obstet Gynecol 1985;151:153-60. |
| 25. | Rako S. Testosterone supplemental therapy after hysterectomy with or without concomitant oophorectomy: Estrogen alone is not enough. J Womens Health Gend Based Med 2000;9:917-23. |
| 26. | Goldstein I, Berman JR. Vasculogenic female sexual dysfunction: Vaginal engorgement and clitoral erectile insufficiency syndromes. Int J Impot Res 1998;10 Suppl 2:S84-90; discussion S98-101. |
| 27. | Park K, Goldstein I, Andry C, Siroky MB, Krane RJ, Azadzoi KM. Vasculogenic female sexual dysfunction: the hemodynamic basis for vaginal engorgement insufficiency and clitoral erectile insufficiency. Int J Impot Res 1997;9:27-37. |
| 28. | Grover S, Shouan A. Assessment scales for sexual disorders a review. J Psychosexual Health 2020;2:121-38. |
| 29. | Lewis RW, Fugl-Meyer KS, Bosch R, Fugl-Meyer AR, Laumann EO, Lizza E, et al. Epidemiology/risk factors of sexual dysfunction. J Sex Med 2004;1:35-9. |
| 30. | Sathyanarayana Rao T, Tandon A, Darshan M. An epidemiological study of sexual disorders in south Indian rural population. Indian J Psychiatry 2015;57:150-7. |
| 31. | Singh N, Sharma P, Mishra N. Female sexual dysfunction: Indian perspective and role of Indian gynecologists. Indian J Community Med 2020;45:333-7. [Full text] |
| 32. | Milaneschi Y, Simmons WK, van Rossum EFC, Penninx BW. Depression and obesity: Evidence of shared biological mechanisms. Mol Psychiatry 2019;24:18-33. |
| 33. | Dunn KM, Croft PR, Hackett GI. Satisfaction in the sex life of a general population sample. J Sex Marital Ther 2000;26:141-51. |
| 34. | Krishna, K, Avasthi, A, Grover, S. Validation of sexual functioning questionnaire in Indian patients. Indian J Psychol Med 2014;36:404-7. |
| 35. | Rosen R, Heiman C, Leiblum S, Meston C, Shabsigh R, Ferguson D, D'Agostino R Jr. The female sexual function index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26:191-208. |
| 36. | Diaz-Arjonilla M, Schwarcz M, Swerdloff RS, Wang C. Obesity, low testosterone levels and erectile dysfunction. Int J Impot Res 2009;21:89-98. |
| 37. | Yaylali GF, Tekekoglu S, Akin F. Sexual dysfunction in obese and overweight women. Int J Impot Res 2010;22:220-6. |
| 38. | Kadioglu P, Yetkin DO, Sanli O, Yalin AS, Onem K, Kadioglu A. Obesity might not be a risk factor for female sexual dysfunction. BJU Int 2010;106:1357-61. |
| 39. | Wing RR, Bond DS, Gendrano IN, Wadden T, Bahnson J, Lewis CE, et al. Effect of intensive lifestyle intervention on sexual dysfunction in women with Type 2 diabetes: Results from an ancillary look AHEAD study. Diabetes Care 2013;36:2937-44. |
| 40. | Erbil N. The relationships between sexual function, body image, and body mass index among women. Sex Disabil 2013;31:63-70. |
| 41. | Sarwer DB, Lavery M, Spitzer JC. A review of the relationships between extreme obesity, quality of life, and sexual function. Obes Surg 2012;22:668-76. |
| 42. | Sarwer DB, Steffen KJ. Quality of life, body image and sexual functioning in bariatric surgery patients. Eur Eat Disorders Rev 2015;23:504-8. |
| 43. | Bond DS, Vithiananthan S, Leahey TM, Thomas JG, Sax HC, Pohl D, et al. Prevalence and degree of sexual dysfunction in a sample of women seeking bariatric surgery. Surg Obes Relat Dis 2009;5:698-704. |
| 44. | Javadnoori M, Faridi H, Najar S. The relationship between obesity/overweight and female sexual function. Maturitas 2015;81:202. |
| 45. | Ribeiro MC, Nakamura MU, Torloni MR, de Scanavino MT, Scomparini FB, Mattar R. Female sexual function of overweight women with gestational diabetes mellitus a cross-sectional study. PLoS One 2014;9:e95094. |
| 46. | Benetti-Pinto CL, Ferreira SR, Antunes A, Yela DA. The influence of body weight on sexual function and quality of life in women with polycystic ovary syndrome. Arch Gynecol Obstet 2015;291:451-5. |
| 47. | Kolotkin RL, Crosby RD, Wang Z. Health-related quality of life in randomized controlled trials of lorcaserin for obesity management: What mediates improvement? Clin Obes 2017;7:347-53. |
| 48. | Efthymiou V, Hyphantis T, Karaivazoglou K, Gourzis P, Alexandrides TK, Kalfarentzos F, et al. The effect of bariatric surgery on patient HRQOL and sexual health during a 1-year postoperative period. Obes Surg 2015;25:310-8. |
| 49. | Hernández JR, Fernández EL, Díaz YC, Cabrillana JM, García DM, Jorge VN. Remission of female sexual dysfunction in morbidly obese female patients with the Scopinaro procedure. Surg Obes Relat Dis 2013;9:987-90. |
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