Sexual Dysfunction in Premenopausal Women With Obstructive Sleep Apnea Zahide Yilmaz1*, Pinar Bekdik Sirinocak1, Bekir Voyvoda2, Levent Ozcan2 Purpose: Sexual functions in the males with obstructive sleep apnea syndrome (OSAS) have been well investi- gated in the literature; however sexual functions in the premenopausal women with OSAS have been studied to a lesser extent. Materials and methods: The study included 22 premenopausal women diagnosed as OSAS by the polysom- nographic (PSG) evaluation. The control group included 13 premenopausal women suspected of sleep-related respiratory disorder, but whose PSG tests were determined to be normal. Both groups were administered Epworth Sleep Scale (ESS), Beck Depression Scale (BDS), and Female Sexual Function Index (FSFI) questionnaire forms. Relations between disease parameters, and the total FSFI score, and scores of the six FSFI parameter were ana- lyzed. Results: The total FSFI score in the cases with OSAS, was determined to be significantly lower than that of the control subjects (P = .031). Scores of the desire, arousal, and orgasm were determined to be significantly lower in the patient group, compared to control group (P = .034; P = .048; P = .039). The total FSFI scores, and scores of the desire, arousal, lubrication, orgasm, satisfaction and pain subscales in the cases did not correlate significantly with the apnea-hypopnea index (AHI), Non-Rapid Eye Movement 1 (NREM1)%, NREM2%, NREM3%, REM%, the time spent with saturation O 2 < 90%, minimum oxygen saturation (%), ESS scores, and BDS scores (all P > .05). Conclusion: Women with OSAS experience sexual dysfunction when compared with normal population. Clinical evaluation has to include also the evaluation of sexual life in women. Key words: obstructive sleep apnea; sexual dysfunction; women. INTRODUCTION Female sexual dysfunction (FSD) is a highly preva-lent and often underestimated problem in the gen- eral community.(1) FSD may occur at any age, and it affects roughly 40% of women at some point in their lifetime, with 12% of women reporting afflictive sexual problems.(2) FSD is a public health problem, but little epidemiological data are available regarding its extent and magnitude of the psychogenic and organic caus- es of decreased sexual desire, arousal, and orgasm, as well as pain, which all cause personal distress. Previ- ous studies discovered that factors, such as age, obesity, menopausal status, educational level, financial income, psychological factors, hormonal dysfunction, par- ticularly thyroid disease, and physical health status of women, could affect women’s chances of having FSD. (3-5) Among the multitude of factors influencing the sex- ual integrity of women, the different aspects of lifestyle are considered to play a significant role in the genesis of FSD.(6,7) However effect of obstructive sleep apnea syn- drome (OSAS) on sexual dysfunction in premenopausal women has not been well defined yet. OSAS is a chronic disease characterized by the repeti- tive episodes of apnea and upper airway collapse dur- ing sleep. OSAS affects the middle-aged men nearly by 4%, and the middle-aged women by 2%.(8) OSAS has been known for more than 30 years. As it is the case in many chronic diseases, sexual functions are affected by sleep apnea both in the males and females. Especially erectile dysfunction has been a frequently reported sex- ual dysfunction in the males with OSAS. These patients have been shown to improve by the continuous positive airway pressure (CPAP) treatment.(8,9) Female sexual dysfunction is vastly under-recognized but has been previously described in chronic disease states. Sexual dysfunction in male patients with OSAS is well described, but not in females. In light of these informations we aimed in this study to evaluate sexu- al dysfunction by the use of Female Sexual Function Index (FSFI), in the premenopausal women diagnosed with sleep apnea. MATERIALS AND METHODS Study design Patients who were newly diagnosed with OSAS at the Sleep and Sleep Disorders Laboratory of the Neurolo- gy Clinic of Kocaeli Derince Education and Research Hospital, Turkey between 2015 and 2016 were included 1Derince Training and Research Hospital, Department of Neurology, Kocaeli, Turkey. 2 Derince Training and Research Hospital, Department of Urology, Kocaeli, Turkey. *Correspondence: Derince Training and Research Hospital, Department of Neurology, 41900 Derince, Kocaeli, Turkey. Tel: (+90) -262-317 8000. Fax: (+90)- 262- 233 4641. E-mail: yilmazzahide@hotmail.com. Received February 2017 & Accepted June 2017 Urological Oncology 5051 SEXUAL DYSFUNCTION AND ANDROLOGY in the study. Ethical approval An informed consent was obtained from each partici- pant.The study protocol was approved by the local Eth- ics Committeeof KocaeliUniversty Non-Intervational Clinical Researches Ethics Board with the permission number and date of KU GOKAEK-2017/11. The study was conducted in accordance with the principles of the Declaration of Helsinki. Study population Participants who had no sexual activity within the past month were not included in the study. Participants with sexual problems, including decreased libido, a history of sexual abuse; organic, and/or psychiatric disorders were excluded from the study. Peri- and postmenopau- sal women, psychoactive medication users, and patients with depression, diabetes and cancer were also exclud- ed. Sample size The study included a total of 22 premenopausal women diagnosed with OSAS by the PSG results. The control group included 13 premenopausal women suspected of sleep-related respiratory disorder, but whose PSG re- sults were found to be normal. Measurements Patients were questioned for the following variables : Sexual Dysfunction and Sleep Apnea-Yilmaz et al. Table 1.Evaluation of descriptive characteristics of the groups. Total (n=35) Patient (n=22) Control (n=13) p Age (year) Min-Max (Median) 35-54(42) 35-51 (44) 35-54 (40) a0,100 Meant ± SD 42.06 ± 5.60 43,59 ± 4,82 40.54 ± 5.70 BMI (Kg/m2) Min-Max (Median) 21,5-46,9 (32,5) 21,9-46,9 (33,9) 21,5-43,3 (31,3) a0,116 Meant ± SD 32,91 ± 6,88 34,24 ± 6,65 30,65 ± 6,92 Education (year) Elementary 26 (74,3) 16 (72,7) 10 (76,9) b0,698 Secondary 7 (20,0) 4 (18,2) 3 (23,1) High school 2 (5,7) 2 (9,1) 0 (0) Operations None 16 (45,7) 11 (50,0) 5 (38,5) b0,904 Once 11 (31,4) 7 (31,8) 4 (30,8) Twice 6 (17,1) 3 (13,6) 3 (23,1) 3 times 2 (5,7) 1 (4,5) 1 (7,7) Parity None 2 (5,7) 0 (0) 2 (15,4) b0,022* Once 4 (11,4) 1 (4,5) 3 (23,1) Twice 11 (31,4) 10 (45,5) 1 (7,7) 3 times 13 (37,1) 7 (31,8) 6 (46,2) ≥ 4 times 5 (14,3) 4 (18,2) 1 (7,7) Hypertension 6 (17,1) 2 (9,1) 4 (30,8) c0,106 Diabetes 10 (28,6) 7 (31,8) 3 (23,1) c0,576 COPD 2 (5,7) 1 (4,5) 1 (7,7) c1,000 Cardiac disease 1 (2,9) 0 (0) 1 (7,7) - Smoking habit 18 (51,4) 13 (59,1) 5 (38,5) c0,305 Abbreviations: BMI, Body Mass Index; DM, Diabetes Mellitus; COPD, Chronic Obstructive Pulmonary Disease. aMann Whitney U Test; bFisher-Freeman-Halton Test; cFisher’s Exact Test; *p < 0,05. Total (n=35) Patient (n=22) Control (n=13) ap NREM1 % Min-Max (Median) 1,5-34,3 (7,5) 1,5-34,3 (7,3) 1,8-32,8 (7,7) 0,322 Mean ± SD 9,68 ± 8,44 8,56 ± 7,73 11,56 ± 9,55 NREM2 % Min-Max (Median) 2,9-49,1 (20,4) 2,9-47,2 (20,6) 3,1-49,1 (16,4) 0,733 Mean ± SD 21,39 ± 14,27 20,12 ± 12,21 23,55 ± 17,54 NREM3 % Min-Max (Median) 12,1-77,3 (48) 14,5-77,3(53,3) 12,1-75,7(35,6) 0,306 Mean ± SD 47,24 ± 19,66 50,05 ± 18,63 42,48 ± 21,17 REM % Min-Max (Median) 0-22,8 (11,9) 4,2-22,8 (13,9) 0-18,8 (10,9) 0,068 Meant ± SD 11,35 ± 5,10 12,47 ± 4,77 9,46 ± 5,27 TIME SO 2 < %90 % Min-Max (Median) 0-22,5 (0) 0-22,5 (0) 0-0 (0) 0,009** Mean ± SD 1,94 ± 5,95 3,09 ± 7,32 0,00 ± 0,00 Min SO2 % Min-Max (Median) 67,8-95 (90) 67,8-93 (88,5) 91-95 (93) 0,001** Mean ± SD 89,05 ± 5,59 86,81 ± 5,97 92,85 ± 1,14 ESS Min-Max (Median) 0-17 (7) 0-17 (6) 0-17 (11) 0,266 Mean ± SD 7,69 ± 5,06 6,91 ± 4,77 9,00 ± 5,45 BECK Min-Max (Median) 0-38 (19) 0-38 (21) 2-27 (17) 0,047* Mean ± SD 18,66 ± 7,99 20,50 ± 8,17 15,54 ± 6,89 Disease duration(year) Min-Max (Median) 0,33-20 (4) 1-20 (5) 0,33-10 (3) 0,346 Mean ± SD 5,58 ± 5,20 6,45 ± 5,84 4,10 ± 3,66 AHI Min-Max (Median) 0,7-102,7 (7,4) 5,2-102,7(12,1) 0,7-4,4 (1,9) Mean ± SD 14,29 ± 20,27 21,44 ± 22,96 2,18 ± 1,11 Disease severity; n (%) Normal 13 (37,1) 0 (0) 13 (100) Mild 13 (37,1) 13 (59,1) 0 (0) Moderate 4 (11,4) 4 (18,2) 0 (0) Severe 5 (14,3) 5 (22,7) 0 (0) Abbreviations: NREM, Non-Rapid Eye Movement; REM, Rapid Eye Movement; TIME SO 2 < %90, Time Saturation Oxygen <%90;Min SO 2 , Minimum Saturatin Oxygen; ESS, Epworth Sleep Scale; BDS, Beck Depression Scale; AHI,Apnea-Hypopnea Index aMann Whitney U Test; bYates Continuity Correction Test; cFisher’s Exact Test; *p < 0,05; **p < 0,01 Table 2. Evaluation of disease variables in the groups. Vol 14 No 06 November-December 2017 5052 age, body mass index (BMI), number of obstetric-gyne- cologic operations, parity, hypertension (HT), diabetes mellitus (DM), cardiac disease, chronic obstructive pul- monary disease (COPD), disease duration, and smok- ing habit. In addition, PSG parameters were recorded. Both groups were administered the Epworth Sleep Scale (ESS), Beck Depression Scale (BDS), and FSFI questionnaire forms. All patients were grouped as mild, moderate, and severe OSAS based on the Apnea-Hy- popnea Index (AHI). Mild, moderate, and severe sleep apneas were defined as (AHI) 5-15/hour, 15-30/hour, and 30 and over/hour, respectively. The FSFI questionnaire was previously validated in the native language of the participants(10) and partner ver- sion of the premature ejaculation profile scale (PEP) for the assessment of sexual function. The women filled the PEP form (in Turkish) themselves. The FSFI includes a total of 19 questions in six categories: desire, arousal, lubrication, orgasm, satisfaction, and pain. Scores range from 2 to 36, and lower scores indicate more severe fe- male sexual dysfunction.(11) Patients were also administered BDS. This scale in- cludes 21 questions. Higher scores indicate higher lev- els of clinical signs related with depression.(12) The patients and control subjects underwent PSG anal- ysis all night long (Embla N 7000). The PSG evalua- tion included electroencephalogram, electrooculogram, chin, and tibial electromyogram, electrocardiogram, snoring, oro-nasal thermistor, nasal pressure transduc- er, finger pulse oximeter, thoracic and abdominal res- piratory movements, and body position. Scoring was performed according to the criteria of the American Academy of Sleep Medicine (AASM), 2007. Apnea was defined as a reduction in the amplitude of oro-nasal thermistor signal by ≥ 90% for at least 10 sec, compared to the baseline. Hypopnea was defined as a reduction in the amplitude of nasal cannula signal by ≥50 % for at least 10 sec, compared to the baseline, a decline in oxygen saturation by ≥ 3 %, or it was considered to be related with arousal. Statistical Analysis Statistical analyses were performed using the Number Cruncher Statistical System(NCSS, 2007) (Kaysville, Utah, USA) software. Descriptive data were expressed in mean, standard deviation (SD), median, frequency, percentage, and minimum and maximum values. The Mann-Whitney U test was used to compare abnormal- ly distributed quantitative variables between the two groups. Qualitative data were compared using the Fish- er-Freeman-Halton test, Fisher’s Exact test, and Yates’ Continuity Correction test (Yates corrected chi-square). Relations between the variables were evaluated using the Spearman’s correlation analysis. P values of < 0.01 or < 0.05 were considered statistically significant. RESULTS The study included a total of 35 participants (22 pa- tients and 13 controls) with a mean age of 42.06 ± 5.60 (range: 32 to 54) years. The mean age and BMI did not differ significantly between the groups (p > 0.05). Only the rate of two-childbearing (higher parity) was higher in the patient group (P = .022). Education status, num- ber of obstetric-gynecologic operations, and comorbid- ities such as HT, DM, and COPD, and smoking habit also did not show significant differences between the groups (P > .05). Demographic data of the OSAS and control groups are presented in Table 1. The BDS scores were statistically significantly higher in the patient group, compared to the control group (P Sexual Dysfunction and Sleep Apnea-Yilmaz et al. Urological Oncology 5053 Table 3. Evaluation of groups with regard to the FSFI scale. Total (n=35) Patient (n=22) Control (n=13) ap DESIRE Min-Max (Median) 2-10 (5) 2-7 (5) 2-10 (6) 0,034* Meant ± SD 4,94 ± 1,98 4,36 ± 1,59 5,92 ± 2,25 AROUSAL Min-Max (Median) 0-19 (11) 0-16 (9,5) 6-19 (11) 0,048* Meant ± SD 10,31 ± 4,32 9,14 ± 4,26 12,31 ± 3,77 LUBRICATION Min-Max (Median) 0-20 (13) 0-20 (12) 8-20 (14) 0,100 Mean ± SD 12,54 ± 5,65 11,27 ± 6,28 14,69 ± 3,66 ORGASM Min-Max (Median) 0-14 (10) 0-13 (9) 4-14 (11) 0,039* Mean ± SD 8,86 ± 3,99 7,82 ± 4,28 10,62 ± 2,75 SATISFACTION Min-Max (Median) 2-15 (10) 2-15 (9,5) 3-15 (10) 0,547 Mean ± SD 9,37 ± 3,72 8,95 ± 4,02 10,08 ± 3,17 PAIN Min-Max (Median) 0-15 (11) 0-15 (10,5) 3-15 (11) 0,201 Mean ± SD 9,46 ± 4,64 8,59 ± 5,10 10,92 ± 3,45 Total FSFI Score Min-Max (Median) 5-85 (56) 5-77 (54) 35-85 (63) 0,031* Mean ± SD 54,74 ± 20,53 48,95 ± 21,64 64,54 ± 14,45 Abbreviations: FSFI, Female Sexual Function Index aMann Whitney U Test; *p < 0,05 Mild (n=13) Moderate+severe (n=9) ap n=22 Mean ± SD (Median) Mean ± SD (Median) DESIRE 4,23 ± 1,48 (4) 4,56 ± 1,81 (5) 0,539 AROUSAL 9,77 ± 3,79 (10) 8,22 ± 4,94 (9) 0,421 LUBRICATION 11,23 ± 4,55 (11) 11,33 ± 8,51 (15) 0,402 ORGASM 8,08 ± 3,40 (9) 7,44 ± 5,53 (10) 0,638 SATISFACTION 9,92 ± 2,75 (10) 7,56 ± 5,22 (9) 0,439 PAIN 9,46 ± 3,71 (10) 7,33 ± 6,67 (11) 0,813 Total FSFI Score 51,69 ± 15,97 (54) 45,00 ± 28,58 (56) 0,894 Abbreviations: FSFI, Female Sexual Function Index aMann Whitney U Test Table 4. Evaluation of FSFI scale scores with regard to disease severity. = .047). Disease variables of both groups are shown in Table 2. The mean scores of desire, arousal, and orgasm were found to be significantly lower in the patient group, compared to the control group (P = .034; P = .048; P = .039). The mean scores of lubrication, satisfaction, and pain did not differ significantly between the groups (P > .05). The mean value of total FSFI score in the patient group was significantly lower, compared to the control group (P = .031). Evaluation of the patient and control groups with regard to the FSFI subscales is shown in Table 3. The mean scores of the desire, arousal, lubrication, or- gasm, satisfaction, and pain, which are the FSFI sub- scales, did not show statistically significant differences among the patients, depending on the disease severity (P > .05). The mean value of total FSFI score also did not differ significantly between patients, depending on disease severity (P > .05). Evaluation of FSFI scale with regard to disease severity is presented in Table 4. No statistically significant correlations between the val- ues of total FSFI scores of the patients, and the AHI, Non-Rapid Eye Movement 1 (NREM1) %, NREM2 %, NREM3 %, Rapid Eye Movement(REM) %, time spent with saturation oxygen (O 2 ) < 90%, minimum satura- tion oxygen(min sO 2 ) %, ESS scores, BDS scores, and BMI were seen (p > 0.05). Scores of FSFI subscales, which are the sexual desire, sexual arousal, lubrication, orgasm, satisfaction and pain, did not correlate signifi- cantly with the AHI, NREM1 %, NREM2 %, NREM3 %, REM %, time spent with sO 2 < 90%, min sO 2 %, ESS scores, BDS, disease duration, age, and BMI in the pa- tient group (P > .05). In addition, we found no significant correlations be- tween the values of total FSFI scores of the cases and the disease duration (P > .05). Evaluation of correlations between the FSFI subscale scores and total scores, and the other variables in the patient group, are shown in Table 5. DISCUSSION In this study, by excluding postmenopausal or perimen- opausal women, we excluded the potential effects of menopause or estrogen deficiency itself as well as that of aging, both of which are independent factors of FSD. Our results shows a high prevalance of sexual dysfunc- tion in pre-menopausal women with OSAS compared to healthy controls. Sexual function in females is related with complex neurophysiological and psychological processes. The pathophysiology of sexual dysfunction in females with OSAS is multifactorial. Endothelial dysfunction has been demonstrated to play a critical role.(13-15) The genital tract is primarily innervated by the puden- dal nerve. The integrity of the pudendal nerve is im- portant for the normal female sexual function. It has been reported that peripheral neuropathy may develop in OSAS, which is related with severity of the chron- ic intermittent nocturnal hypoxia.(16) In addition, CPAP treatment has been shown to improve neural functions in males.(17) Levels of testosterone have been shown to be lower in the women with OSAS, which was found to be related with the severity of disease.(18) The quality of life, and the mood may also contribute to sexual dys- function in women.(8) Sexual dysfunction has been well defined in the males with OSAS. The rate of sexual dysfunction has been reported to be 30 to 50 % in the men with OSAS.(19,20) There is a considerably limited number of studies re- lated to sexual dysfunction in the females with OSAS. In a prospective study on pre-menopausal women with OSAS in Turkey, Koseoglu et al.(21) found a high prev- alence of impaired sexual function.They also found that all scores in sexual function domains except enjoyment and pain decreased significantly with increasing sever- ity of OSAS. In our study, the total FSFI score in the patient group was significantly lower than that of the control group. The patient group had significantly low- er scores of sexual desire, sexual arousal, and orgasm, compared to the controls. In our study, the total FSFI scores, and the scores of desire, arousal, lubrication, orgasm, satisfaction, and pain subscales were not found to be significantly corre- lated with the AHI, NREM1 %, NREM2%, NREM3 %, Sexual Dysfunction and Sleep Apnea-Yilmaz et al. DESIRE AROUSAL LUBRICATION ORGASM SATISFACTION PAIN Total n=22 r P r p R p r p R p r p r p AHI 0,046 0,840 -0,208 0,354 0,120 0,596 0,030 0,894 -0,186 0,408 -0,064 0,777 0,007 0,974 NREM1 0,033 0,885 -0,091 0,688 -0,161 0,475 -0,071 0,752 -0,051 0,821 0,011 0,961 -0,131 0,561 % NREM2 0,035 0,876 0,092 0,684 -0,176 0,433 0,112 0,619 -0,073 0,747 0,034 0,880 0,084 0,709 % NREM3 -0,196 0,382 -0,057 0,802 -0,044 0,847 -0,237 0,288 -0,014 0,952 -0,007 0,974 -0,094 0,676 % REM % -0,201 0,370 0,219 0,327 0,110 0,627 0,060 0,790 0,246 0,269 0,195 0,384 0,197 0,380 sO 2 <90 0,051 0,821 -0,164 0,467 0,096 0,671 0,054 0,813 -0,190 0,396 0,083 0,715 0,076 0,736 % Min sO 2 -0,059 0,796 0,041 0,858 -0,137 0,542 -0,047 0,835 0,183 0,414 -0,262 0,239 -0,166 0,461 % ESS -0,153 0,496 0,127 0,573 0,051 0,820 -0,002 0,992 -0,076 0,738 0,403 0,063 0,169 0,453 Disease duration -0,112 0,619 -0,100 0,657 0,120 0,595 0,117 0,603 -0,250 0,261 0,131 0,560 0,039 0,864 (year) Age -0,033 0,883 -0,093 0,679 -0,136 0,546 -0,073 0,745 -0,210 0,347 -0,051 0,820 -0,076 0,735 BMI 0,052 0,819 -0,027 0,904 0,019 0,933 0,083 0,713 -0,044 0,845 0,024 0,917 0,071 0,753 (kg/m2) Table 5.Evaluation of relations between the FSFI subscale scores and total scores, and the other variables in the patient group. Abbreviations: r, Spearman’s coefficient of correlation; AHI,Apnea-Hypopnea Index; NREM, Non-Rapid Eye Movement; REM, Rapid Eye Movement; TIME SO 2 < %90, Time Saturation Oxygen<%90; Min SO 2 , Minimum Saturatin Oxygen; BMI, Body Mass Index Vol 14 No 06 November-December 2017 5054 REM %, time spent with sO 2 < 90 %, min sO 2 , and ESS scores. In the study of Stavaras et al.(22), MinSat was found to be correlated with all FSFI subscales, except the sexual desire. Koseoğlu et al.(21) found that MinSat was determined to be significantly correlated with only orgasm. However, we were unable to find such a cor- relation, possibly due to the small sample size in our study. In our study, the total FSFI scores in the patient group did not show statistically significant correlation with the time spent with sO 2 < 90%. Fanfulla et al.(23) reported in 2013, OSAS group existing with sexual dysfunction had a longer time spent with sO 2 < 90 %, than the pa- tients with OSAS who did not have sexual dysfunction. Our patient group included 22 cases; of these, 13 pa- tients had mild, and nine patients had moderate-to-se- vere OSAS. This may be the reason for low values of time spent with sO 2 < 90% in our study. We believe that, with a larger number of patients with severe OSAS, such a correlation can be demonstrated. In the present study, scores of desire, arousal, lubrica- tion, orgasm, satisfaction, and pain subscales of FSFI in the cases, did not differ significantly depending on dis- ease severity. The degree of disease also did not signif- icantly affect the total FSFI score in the patient group. In accordance with our results, Onem et al.(14) found that OSAS presented with sexual dysfunction in women, al- though the degree of sexual dysfunction was not related with OSAS severity. The authors concluded that this might be due to the relations of sexual dysfunction in women with OSAS, with both organic and psychogenic problems. On the contrary, Stavaras et al.(22) found an association between the severity OSAS and sexual dys- function in women. Additional factors including depression are also known to affect sexual dysfunction.(24,25) In several studies, the prevalence of depression has been found to be high- er in patients with OSAS.(26) In our study, we found a statistically significant relationshipbetween the BDS scores and OSAS in the patient group; however total FSFI scores did not correlate with the scores of BDS. In addition, in our study, the total FSFI scores in the pa- tient group did not correlate with BMI, consistent with previous study findings.(8,23) Nonetheless, the limited number of cases in both groups is the main limitation to our study. The reason of this issue is the lesser frequency of OSAS in premenopausal women. CONCLUSIONS In conclusion, there is a relationship between OSAS and sexual dysfunction in women. We, therefore, rec- ommend sexual life evaluation during clinical examina- tion in patients with OSAS. CONFLICT OF INTEREST None declared. ACKNOWLEDGEMENTS We acknowledge that all authors have made substan- tial contribution to the work, and all have read and ap- proved the final manuscript. REFERENCES 1. Raina R, Pahlajani G, Khan S, Gupta S, Agarwal A, Zippe CD. Female sexual dysfunction: classification, pathophysiology, and management. FertilSteril. 2007; 88, 1273– 84. 2. Kammerer-Doak D, Rogers RG. Female sexual function and dysfunction. ObstetGynecolClin North Am. 2008; 35:169–83. 3. Addis IB, Van Den Eeden SK, Wassel-Fyr CL, Vittinghoff E, Brown JS, Thom DH. Sexual activity and function in middle aged and older women. Obstet Gynecol. 2006; 107:755–64. 4. Chedraui P, Perez-Lopez FR, San Miguel G, Avila C. 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