BMC Women's Health Volume 21, Article Number: 403 (2021) Cite this article
Postmenopausal physiological changes may change the body image (BI) during the postmenopausal period of life. Dissatisfaction with body image may have a negative impact on women's sexual function. This study aims to evaluate the relationship between postmenopausal body image and sexual function.
This cross-sectional study was conducted on 231 postmenopausal women who had menopause in the last 5 years and were >40 years old and referred to the Tehran-Iran Health Center. Recruit participants using a multi-stage sampling method. Three questionnaires were used to collect data, including sociodemographics, Fisher body image, and Female Sexual Function Index (FSFI). SPSS 24 and multiple regression, Mann-Whitey, Pearson and Spearman correlation tests were used to analyze the data.
231 postmenopausal women aged 52.53 ± 5.32 (mean ± SD) participated in this study. The mean and standard deviation of women's FSFI and BI were 19.59 ± 11.11 (range 1.2-36) and 155.43 ± 37.09 (range 46 to 230), respectively. According to FSFI, 62.8% of female sexual dysfunction (FSD) is reported. There is a significant correlation between the total score of FSFI and the scores of all fields and the total score of BI and the scores of all dimensions. Female education level is positively correlated with family income, and husband’s age and menopause duration are negatively correlated with their sexual function. There is also a significant relationship between women’s and husband’s work and women’s total scores of sexual function. According to the multiple linear regression model, BI is an important predictor of postmenopausal female sexual function.
Body image is effective for the sexual function of postmenopausal women. Therefore, it is necessary to consider body image in future postmenopausal health promotion programs.
Menopause is defined as the permanent cessation of menstruation due to loss of ovarian function, thus representing the end of female reproductive life [1]. With the gradual decrease of estrogen and progesterone, leading to complete ovarian failure and menopause, women will experience physical, psychological or sexual changes [2]. Hormonal fluctuations during perimenopause can cause women to face various physical and mental disorders [3]. By 2030, there will be 1.2 billion menopausal and postmenopausal women in the world [4].
Menopause is one of the factors that affect female sexual function [5]. Most middle-aged women (approximately 40-60 years old) are sexually active, and sex is important to them [6], however, some studies have shown that women have negative changes in sexual function during middle age [7, 8].
Sexual function is the result of the interaction of vascular, neurological and hormonal factors, and is also affected by personal and interpersonal relationship factors, social norms, and cultural and religious values [9]. Sexual dysfunction is defined as a clinically significant disorder of a person's sexual response or ability to experience sexual pleasure [10]. Many women experience sexual dysfunction during menopause. According to reports, the prevalence of female sexual dysfunction (FSD) in postmenopausal women is between 25% and 85.2% [11, 12]. A study showed that the prevalence of FSD among postmenopausal women in Iran was 61% [13].
Sexual dysfunction in postmenopausal women is a complex disease with many reasons [1]. Reasons for these negative changes in sexual function may include biology (for example, reduction in sex hormones), psychology (for example, the development of emotional symptoms), interpersonal relationships (for example, sexual dysfunction of a sexual partner), and sociocultural (for example, negative influences) . Sex discrimination among older women) factors [1, 8, 14].
Menopause is a short-lived biological phenomenon, but it also marks a social stage whose meaning varies in different cultures. It is generally considered to be a negative reinforcement of the aging process and loss of sexual attraction [15]. Therefore, cultural and social background may affect women's perception and experience of sexual function during menopause [16]. A qualitative study conducted in Iran showed that many Iranian women regard menopause as the end of their sexual life [17]. A study also found that most postmenopausal women do not pay much attention to their sexual health, but consider restrictive activities [18]. Another study also showed that there is a relationship between social demographic characteristics such as race and body mass index of middle-aged Iranian women and sexual function [19].
During the postmenopausal period, many women experience physical changes, including increased body mass index, changes in sexual organs (such as sagging breasts, vaginal dryness and atrophy), and the appearance of facial wrinkles or excessive hair [8, 20], which may cause Dissatisfaction with body image and psychological problems [21]. Body image is a multidimensional, subjective and dynamic concept that contains a person's perception, thoughts, and feelings about one's own body. It is one of the main elements of personal personality [22]. These physiological changes related to aging make the female body far away from the beautiful social norms of thin and young ideals. In addition, aging will change the life focus and psychological state of postmenopausal women, which may affect their life-long body image [23]. These factors that have a potential impact on women's body image will in turn affect their sexual satisfaction and sexual function [8]. There are some studies on the body image of middle-aged women. It seems that making a positive body image can improve the sexual satisfaction and self-confidence of middle-aged women [8, 24].
In Iran, there are more than 8.5 million middle-aged women (40-65 years old), and women over 40 years old account for more than 14.5% of the total population [25]. It is estimated that by 2022, about 5 million women in Iran will be in menopause [26]. Considering the developing population of menopausal women and the importance of planning menopausal health programs and the high incidence of sexual dysfunction, as well as the limited research on the possible association between body image and sexual function of postmenopausal women, this study aims to determine the correlation between body image And the sexual function of postmenopausal women.
This study is a descriptive cross-sectional study involving 231 eligible postmenopausal women who were recruited from the participants to the health center affiliated to Shahid Beheshti Medical University in Tehran, Iran.
The inclusion criteria are: natural menopause in the past 5 years, age> 40 years old, married, and sexually active. Exclusion criteria are: history of physical and mental illness, severe stress such as accidents or loss of family members in the last 3 months, taking drugs containing phytoestrogens or estrogen and progesterone, impotence husbands.
The minimum sample size is calculated as 194, and the correlation study is calculated using the following formula as follows:
α = Zα = 1.96 standard normal deviation
β = Zβ = 0.84 standard normal deviation
Total sample size = N = [(Zα + Zβ)/C]2 + 3 = 194
Considering the 20% probability of loss, 231 samples were recruited.
A multi-stage sampling method was adopted for the recruitment of research subjects. In the first stage, eight health centers were randomly selected from four geographic regions in Tehran through the random option of Excel. Then, quota sampling was performed to recruit menopausal women who met the inclusion criteria in selected centers (28 samples from 6 centers each selected in the North, East, and West; 63 samples from two centers in the South). Eligible participants complete written consent, and then fill out the questionnaire through interviews.
Three questionnaires are used for data collection, including the socio-demographic questionnaire prepared by the researchers, the Fisher body image questionnaire [27] and Rosen et al. Female Sexual Function Index (FSFI) questionnaire [28].
Socio-Demographic Questionnaire This questionnaire contains 22 questions, including demographic, socio-economic and birth history questions.
Female Sexual Function Index (FSFI) This questionnaire consists of 19 questions, measuring women's sexual function from six aspects, including (desire, arousal, lubrication, orgasm, satisfaction and pain). The minimum and maximum values of all domains except desire are zero to 6.0, and desire is 1.2-6.0. The total score of the scale is obtained by adding the scores of the six fields. The total score of FSFI is between 1.2 and 36. The higher the score, the better the function. FSFI assesses women's sexual function in the past 4 weeks. A total score equal to or less than 26.55 is considered FSD [28, 29]. Mohammadi et al. confirmed the reliability and validity of the Persian version of the FSFI questionnaire. [29] and Fakhri et al. [30]. Nazarpour and colleagues also showed that Cronbach's alpha is 0.938, and the intra-class correlation coefficient is 0.997 [31].
Fisher's body image questionnaire was developed in 1970 by Fisher, with 46 items in total. Items from 1 to 5 are very dissatisfied, dissatisfied, fair, satisfied and very satisfied. The total score ranges from 46 to 230, with a high score indicating a positive body image. Dimensions include: head and face (12 items), upper limbs (10 items), lower limbs (6 items) and other 18 items to measure the subject's attitude towards general physical characteristics [32]. The effectiveness of this test was evaluated in Iran [32, 33]. In a study by Nazarpour and Khazai [34], the reliability of the Fisher body Image questionnaire was shown by α-Cronbach, Spearman, and Guttman Split-half coefficients of 0.918, 0.861, and 0.861, respectively. In previous studies, the retest Pearson correlation coefficient was calculated to be 0.84 [32, 33].
After evaluating the inclusion criteria of women, a written consent was obtained, and then interviewers trained by researchers and eligible participants conducted face-to-face interviews to complete the questionnaire. Face-to-face interviews are used to improve the accuracy of answering questions because researchers predict that some interviewees will be illiterate.
Use SPSS version-24 statistical software to analyze the data. The calculation method of the correlation coefficient is to use the Pearson correlation test for the quantitative variables of the normal distribution, and the Spearman correlation test for the ranking and non-normal variables. The Mann-Whitey test is also used to compare groups. Multiple linear regression is used to predict factors of deterministic function.
Our assumption for the multiple linear regression model is that sexual function (FSFI) is related to body image. In multiple linear regression, the total FSFI score is used as the dependent variable, and the total body image score is used as the main independent variable. Age, husband’s age, duration of menopause, women and their spouses’ jobs, women’s and their spouses’ education levels, and monthly income are considered as potential confounding variables and are therefore included in the regression model. These variables have been shown to be related to sexual function [12].
The significance level is set to P less than 0.05.
231 postmenopausal women with a mean age of 52.53 ± 5.23 (Mean ± SD) years participated in the study. The age of menopause and the duration of menopause were 50.28 ± 4.83 and 2.22 ± 1.49 years, respectively. The sociodemographic and obstetric characteristics of women are shown in Table 1.
The average score of FSFI is 19.59 ± 11 (range 1.2-36). FSD is observed in 62.8% of postmenopausal women. The average scores of FSFI and its fields are shown in Table 2.
The average score for body image was 155.43 ± 37.09 (range from 46 to 230). The average scores of body image and its fields are shown in Table 2.
The results of the study showed that the total score was significantly positively correlated with the scores of various areas of sexual function, and the total score was significantly positively correlated with the scores of various dimensions of body image (P <0.001) (Table 3).
The results showed that the total score of FSFI was significantly positively correlated with the subjects’ education level (P<0.001, r=0.267) and whether the family's monthly income was sufficient (P=0.021, r=0.154). In addition, a significant negative correlation was observed between the total FSFI score and the age of the spouse (P = 0.032, r =-0.144) and the duration of menopause (P = 0.001, r =-0.214) (Table 4).
The total FSFI score of employed persons was significantly higher than that of non-employed persons (housewives and retirees) (P=0.001). In addition, compared with women whose husbands were retired or unemployed, women whose husbands had a job had significantly higher FSFI scores (P <0.001) (Table 4).
The multiple linear regression model predicted 25% of the total score of postmenopausal women's sexual function. Linear multiple regression results show that body image is a potential predictor of sexual function; thus, for every unit increase in the total body image score, the total score of sexual function increases by 0.09 units (P <0.001). According to this model, female education (P = 0.002) and husband’s work (P <0.001) are also potential predictors of postmenopausal female sexual function (Table 5).
This study aims to evaluate the relationship between body image and sexual function in postmenopausal women. The study shows that there is a significant positive correlation between postmenopausal women's body image and sexual function. It also shows that there is a significant positive correlation between all areas of sexual function (desire, arousal, lubrication, orgasm, satisfaction, and pain) and all dimensions of body image. The multiple linear regression model also showed that for every unit increase in the total body image score, the total score for sexual function would increase by 0.09 units. Consistent with these results, various studies have emphasized the role of body image in all aspects of sexual activity and sexual function in postmenopausal women [8, 35, 36]. In a similar cross-sectional study of middle-aged women by Afshari et al. In Iran, there is a significant correlation between body image and female sexual function (FSFI) and all areas. They proved that compared with women with negative body image, women with positive body image scored higher in sexual function. In their analysis, women’s satisfaction with body shape is a predictor of sexual function [35]. However, they use the Body Type Questionnaire (BSQ) for body image measurement. In a qualitative study by Thomas and colleagues in Pennsylvania and middle-aged women aged 45-60, they found that women's body image is an important factor affecting their sexual satisfaction and attractiveness [8]. Although the research of Thomas et al. It was not performed for middle-aged women, nor was it specifically for postmenopausal women, and the participants were within the menopausal age range. Pujols and colleagues also proved that there is a positive correlation between body image, sexual function, and sexual satisfaction. Studies have found that several aspects of body image, including weight problems, physical conditions, sexual attractiveness, and psychological attention to appearance during sexual activity, can predict women’s sexual satisfaction [37]. In addition, it is also recommended to focus on reducing the physical complications, negative attitudes and feelings, worries and psychological complications related to menopause to improve the sexual function of postmenopausal women [38].
Physical changes, especially weight gain, are common in middle age [8]. In addition, the occurrence of menopause and physical and psychological changes may lead to negative feelings about attractiveness and body image. Therefore, as an aspect of sexual function, menopause seems to impair sexual satisfaction. A South Korean study of middle-aged perimenopausal women also showed that menopausal symptoms are significantly related to sexual functions that may be mediated through their body image, depression, and intercourse [36]. Although this study was conducted on perimenopausal women, the results are consistent with our results because we considered the participants in the first 5 years after menopause.
Studies have also shown that low body image is associated with high levels of orgasm disorder [39], while positive body image and a high degree of self-acceptance of one's appearance are related to proper orgasm and sexual function [40]. This relationship between sexual function and body image may be due to the fact that women's attention to their own body may distract them from positive sexual feelings and the sexual signs of their partners, which in turn may lead to self-efficacy and sexual pleasure The reduction. Therefore, a negative body image may reduce sexual desire, intimacy with a partner, and sexual response [39].
The findings of this study also indicate that there is a significant positive correlation between FSFI and female education. Multiple linear regression analysis also showed that education is a predictor of FSFI. This result is consistent with similar studies [19, 41,42,43,44], indicating that education is a predictor of psychological complications and negative emotions during menopause, and has a potential negative impact on the sexual function of menopausal women. The high level of awareness gained through higher education can improve women's attitudes and ideas about gender, reduce anxiety, and help women cope with menopausal changes [45].
The results of this study show that the age of spouse is significantly negatively correlated with the sexual function of postmenopausal women. This result is consistent with other studies [12, 41, 43, 46]. This association may be due to the hormonal changes caused by aging and its influence on the sexual function of sexual partners [12], which may affect the sexual function of women. Contrary to previous studies [12, 45], since we recruited menopausal women in the past 5 years, there was no significant correlation between the female menopausal age and sexual function. Therefore, the average age of the participants was 52.5 years, and this The scope of the postmenopausal age variable is limited, because we only want to limit it to postmenopause.
The sexual function of postmenopausal women is significantly negatively correlated with the duration of menopause. A few studies have not confirmed this result [47, 48]. However, one study shows that female sexual dysfunction in the first year after menopause is more than that in the second to fifth years, but after 5 years of menopause, it is more severe. Many sexual dysfunctions are reported with age. This result may be due to menopausal symptoms caused by the sudden stop of hormones in the first year of menopause. Menopausal women may gradually adapt to the changes and enjoy sex after about a year [49]. This controversy is due to the menopause duration of 0 to 5 years considered in our study, so it is necessary to further study the impact of menopause duration on female sexual function.
The results of the study show that women’s sexual function is significantly positively correlated with their monthly family income. This result is consistent with the results of other studies [12, 42, 45, 50, 51]. It seems that high income is related to high quality of life and less anxiety and depression, which leads to sexual satisfaction [31, 45, 52].
According to the results of this study, the employment of menopausal women and their husbands is related to the improvement of sexual function. Multiple linear regression analysis also showed that their husband’s work is a potential predictor of sexual function. Although some other studies have confirmed that female employment is associated with better sexual function [42, 44], one study has not confirmed this [53]. There is no research on the relationship between the husband’s employment of postmenopausal women and their sexual function, but in the study of Jafarzadeh-Esfahai and colleagues, this relationship is not significant among women of different ages [54].
Therefore, it can be assumed that socioeconomic factors such as education, employment, and family income are related to higher quality of life, body image, and sexual function. These factors are also effective for individuals and society’s perceptions of gender and sexual behavior [45]. Accordingly, consideration should be given to promoting the social demographic, socio-demographic and cultural background of the sexual health of postmenopausal women.
This study was conducted on women in the first 5 years of menopause, because we aimed to assess the relationship between menopausal changes and sexual function, not the effect of aging on sexual function. In addition, the study was conducted on a group of postmenopausal women with a normal distribution, which reduces participation bias.
The limitation of this study is that it is a descriptive study, so the results can only show the correlation of variables, not causality. Therefore, it is necessary to prove the causal influence of body image on the sexual function of postmenopausal women through analysis and research.
The second limitation is the collection of self-reported data on body image and sexual function, as well as the demographic characteristics that may lead to self-reporting bias, which means a deviation between the self-report and the true value of the same measurement.
In addition, sexual function is a personal matter of life, and FSFI is best done by itself. However, it was done through interviews by trained interviewers, because a group of participants were illiterate or illiterate (40.7% had a diploma). In addition, we had to ensure that the conditions for filling in the questionnaire were consistent for all subjects, and also Make sure that no response is lost. It should be noted that all participants have been explained the purpose of the research and agreed with us to ask questions. In addition, FSFI is a self-report of sexual function, which can be done through interviews.
In addition, a cause of sexual dysfunction in postmenopausal women is atrophic vaginitis. However, the purpose of this study is to evaluate the possible correlation between sexual function and body image. As mentioned earlier, vaginal atrophy is a common postmenopausal complication caused by estrogen deficiency and is considered to be one of several possible causes of sexual dysfunction in postmenopausal women. However, it is not necessary to evaluate the cause of each of the two variables (sexual function and body image). In this study, the conditions for participation were the duration of their menopause (up to the first 5 years) and no hormone therapy to recruit samples with similar conditions of atrophic vaginitis. In any case, atrophic vaginitis may be the main cause of sexual dysfunction in postmenopausal women. It is recommended to solve this problem through systemic or local hormones or lubricants [55] to improve the body image such as sexual dysfunction.
Current research shows that the body image of postmenopausal women is related to their sexual function. Since sexual dysfunction is very common among postmenopausal women, healthcare providers should be aware of the relationship between dissatisfaction with body image and sexual dysfunction. The treatment of sexual dysfunction should include obtaining information about women’s attitudes towards their body image. information. It seems that the improvement of postmenopausal women's body image promotes their sexual function, which in turn increases sexual satisfaction. In view of the significant correlation between postmenopausal women’s body image and sexual function, health policies and programs should be formulated in accordance with the mainstream social culture to help postmenopausal women accept and adapt to the physical and psychological changes brought about by menopause, so as not to harm their body image . It should also be emphasized that improving socio-economic factors, such as women’s education, employment and income, are also related to the promotion of female sexual function, which should be considered by the country’s main health policymakers.
The data set used and/or analyzed in the current research can be obtained from the corresponding author upon reasonable request.
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Department of Midwifery, Chalou Islamic Azad University, Chalou, Iran
Midwifery and Reproductive Health Research Center, Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti Medical University, Vali-Asr Avenue, Vali-Asr and H highway intersection, opposite Rajaee Cardiology Hospital, 1996835119, Tehran , Iran
Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti, Tehran, Iran
Masoumeh Simbar, Mobina Khorrami, Zahra Jafari Torkamani and Reyhaneh Saghafi
Department of Biostatistics, School of Complementary Medicine, Shahid Beheshti, Tehran, Iran
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SN develops projects, designs concepts and research, manages data, conducts data analysis, prepares first and revised manuscripts, and critically edits manuscripts. MS developed the project, designed the concept and research, managed the data, prepared the first and revised manuscripts, and edited the manuscript critically. MK, ZJT and RS conducted data collection. HAM contributed to research design and management data analysis. All authors have read and approved the final manuscript.
The study was approved by the Ethics Committee of Shahid Beheshti Medical University, and the code is "IR.SBMU.PHARMACY.REC.1399.160". Written informed consent was also obtained from each participant. All research procedures are carried out in accordance with the principles in the 1964 Helsinki Declaration and subsequent amendments.
This article does not disclose any personally identifiable data in any form, and respects the privacy of participants. Therefore, agreeing to be published here does not apply.
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Nazarpour, S., Simbar, M., Khorrami, M. etc. The relationship between postmenopausal female sexual function and body image: a cross-sectional study. BMC Women's Health 21, 403 (2021). https://doi.org/10.1186/s12905-021-01549-1
DOI: https://doi.org/10.1186/s12905-021-01549-1
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