The present study tested whether PCOS could moderate the association between diminished sexual function and increased sexual distress in women with infertility. The results suggested that women with PCOS may have greater sexual distress when their sexual functioning is impaired. Specifically, where PCOS exists, there is greater sexual distress due to sexual pain and, to some extent, arousal and desire dysfunction. Importantly, controlling for depression and anxiety symptoms, the current study highlights the role of PCOS in women with infertility in which sexual pain is linked to elevated sexual distress.
A recent meta-analysis suggested that PCOS does not directly increase the risk of FSD (21). Likewise, our results indicate that although the rate of diminished sexual function in infertile patients with PCOS is similar to that in infertile patients without PCOS, infertile patients with PCOS experience relatively greater sexual distress due to impaired sexual desire, arousal, and pain. Specifically, the effect of depression and anxiety symptoms on sexual function accounted for (37, 38), sexual pain that outstands with respect to elevated sexual distress in PCOS patients. In other words, depression and anxiety symptoms may contribute to elevated sexual distress due to impaired sexual desire and arousal in infertile patients regardless of their PCOS status. However, PCOS, not depression or anxiety, makes infertile patients prone to elevated sexual distress due to increased sexual pain.
Despite the biological, context dependent, and psychosexual etiology of pain in heterosexual penile-vaginal intercourse, PCOS patients experience subjective concern about having genito-pelvic pain/penetration disorder (39). Sexual pain is the most impaired sexual function in Iranian women with infertility (7), while in the population with PCOS, the literature reports discrepant findings from significantly lower (40) to intact values (41). Considering that PCOS is comorbid with infertility, the current study suggested that increased sexual pain is linked to elevated sexual distress, which requires further investigation. Notably, sexual pain is deemed to be a multidimensional phenomenon with both psychosocial and biological roots (42). Thus, one may suggest that PCOS may contribute to a set of intervening physical and psychological factors that underlie the link between sexual pain and sexual distress (43). Further research may elucidate the biopsychosocial factors involved in this phenomenon.
Supported by religious views, childbearing is highly honored, and Muslims believe that “heaven lies at the feet of mothers” (44). Consequently, infertility imposes great pressure on couples and increases their susceptibility to psychological distress (45). A qualitative study in Iran demonstrated that women with infertility experience social pressure, directed chiefly by close relatives and in-laws, for their infertility (46). The current study indicated that sexual distress is associated with diminished sexual function in Iranian women with infertility, and sexual distress is notably elevated in those with comorbid PCOS. Therefore, we call for special attention to address these patients’ needs, notably the experience of sexual dysfunction and its associated distress. The therapeutic team, including nurses, psychotherapists, gynecologists, and sex therapists addressing sexual dysfunction, especially sexual pain, may need to pay special attention to sexual distress as a psychological consequence of PCOS. It is recommended that future studies address the underlying trajectories of pain in women with infertility and PCOS comorbidity, in which they may consider the effect of psychological factors (for instance, an individual’s response to anticipation of pain during sex) as well as physical determinants (43).
The empirical results reported herein should be considered in light of several limitations. A general limitation is that due to the cross-sectional nature of the study, caution should be taken before generalization and causal implications can be achieved. Further prospective research is needed to examine the link between FSD and sexual distress in terms of PCOS. Our study findings might also be affected by the sample size, which lowered the study power. Thus, the findings should be interpreted with caution. In addition, the current findings might be biased by positive sexual attitudes and sexual experience, which have been shown to be predictive factors for willingness to volunteer in sexual studies (47). This study lacked a control group of women without infertility, so it failed to examine any possible differences from the general population. Lacking the patients’ hormonal profile, likewise, we could not account for the effect of hormone levels on sexual dysfunction in patients with PCOS. Hyperandrogenaemia may have a negative effect on sexual function (48). Conversely, however, some studies have indicated that hyperandrogenism could act as a protective agent for sexual functioning by enhancing sexual desire and the frequency of satisfying sexual activity (49, 50). Generally, this hypothesis is worthy of further research because the effect of hormonal imbalance on sexual distress occurs through alopecia, hirsutism and subsequent poor body image because of high testosterone levels in PCOS patients (51). Furthermore, considering that the current PCOS sample was slightly younger than their non-PCOS counterparts, some studies have shown the mitigating effect of older age on the association between sexual dysfunction and sexual distress in the general population (52). Due to the multicausal nature of sexual dysfunction and sexual distress, a more coordinated assessment of psychosocial, hormonal and biological aspects is necessary. Finally, the relationship between sexual dysfunction and sexual distress may be reciprocal because not only can sexual dysfunction lead to sexual distress, but sexual distress might also incite sexual dysfunction (15). The current study could not address this suggestion.