To the best of our knowledge, the current study is the first to evaluate both SF and LUTS in Syrian women with PCOS. Our results revealed a high prevalence of SD in PCOS patients, with about 66% of them having a total FSFI score < 26.55. Additionally, Orgasm and satisfaction were significantly affected by PCOS compared to controls in our study. Our findings are supported by Mojahed et al., who found significantly lower scores of total FSFI, lubrication, orgasm, satisfaction, and pain in PCOS patients [17]. Pastoor et al. reported lower FSFI score in PCOS women compared to control in their systematic review and meta-analysis. Furthermore, all FSFI subdomains had lower scores in PCOS patients [7]. Similar results were also reported by Aba et al. [24] and Pastoor et al. [15] who found that women with PCOS exhibited lower FSFI scores in all subdimensions except for satisfaction and pain, respectively. Nonetheless, results by Ercan et al. revealed no significant difference between the PCOS and control groups regarding any subdomain score of FSFI. However, the relatively small sample size of their study (32 women in each group) may affect the reliability of their results [16]. PCOS-related features can adversely affect SF in females. While androgens in physiological levels seem to play a role in SF and reduced androgen levels may impair SF in females, some studies revealed that hyperandrogenism which is usually associated with PCOS contribute to the development of SD [12, 26]. Furthermore, hyperandrogenism may indirectly affect SF as it is closely related to hirsutism, acne, and altered body image, which may negatively affect self-esteem and body image, leading to disrupted SF in PCOS patients [8].
PCOS-related mental health issues such as depression and anxiety have been reported to negatively impact SF in PCOS women [17]. Although we did not evaluate mental well-being in our study, we think that mental health disorders are closely related to the declined FSFI score in our PCOS sample, as Syrians, especially females, have already experienced stressors imposed by the ongoing Syrian crisis, resulting in a high prevalence of mental health conditions [25]. Therefore, PCOS diagnosis in a female belonging to this mentally vulnerable population may exacerbate the preexisting psychological disorders or promoting the onset of new cases, leading to impairment of SF. This may also explain the relatively high prevalence of SD in the control group (about 50%). Infertility is a stressful experience that was reported to contribute to SD etiology [17, 26]. However, our findings did not reveal a relationship between having infertility issues and SD. Our findings align with the results reported by Pastoor et al. in their systematic review and meta-analysis [7]. This may be explained by having children after the management of infertility problems may diminish the effect of previous infertility status on SD in women with PCOS.
Regarding the impact of demographics on SD, an inverse correlation was found between total FSFI score and BMI in the PCOS group but not in the control group. Hence, increased BMI may inderictly disrupt SF in PCOS patient by aggravating othrer PCOS-related symptoms such as low-self steem and reduced body image. Pastoor et al. have not also found a relationship between BMI and FSFI [7]. Arab women are usually hesitant to discuss their sexual problems with healthcare providers due to cultural and religious reasons. Moreover, even healthcare providers do not discuss such issues with their patients. Thus, sexual problems are underestimated in this population [27, 28]. Therefore, as there a relationship between BMI and total FSFI score in PCOS group, we set a BMI cutoff value of 24.16, which may predict the presence of SD in PCOS women with a sensitivity of 62.1% and specificity of 70%. However, this value may only be used to predict the presence of SD in PCOS women who have a BMI ≥ 24.16 and not for the diagnosis of this issue in this group. If the prediction of the presence of SD is made, then more accurate diagnostic tests may be done.
Total BFLUTS score was significantly higher in the PCOS group, indicating a negative impact of PCOS on lower urinary tract which led to LUTS. This result is supported by findings reported by Kölükçü et al., who found higher scores of BFLUTS and all of its subdomains in PCOS women [6]. Although voiding score was significantly higher in the PCOS groups, filing, incontinence, quality of life and sexual life scores did not differ between the two groups. Antônio et al. found that PCOS patients showed an absence of urinary incontinence and control group exihabated higher prevalence of urinary incontinence [18]. Additionally, Montezuma et al. reported that urinary incontenece was more related to obesity not to PCOS in their study [14]. It was hypothesized that hyperandrogenism in PCOS may be protective against urinary incontinence since it may increase muscle mass and thereby pelvic floor muscle strength [14, 18]. However, Antônio et al. reported that pelvic floor muscle strength in their non-obese sample was higher in the PCOS group but without a statistically significan, and higher testosterone levels in PCOS patients may influence urinary incontinence through better support of the pelvic floor structure without being enough to enhance of pelvic floor muscle strength [18]. Another study on female rats showed that testosterone-based treatment enhances stress urinary inconteneace [29]. Nevertheless, Kölükçü et al. reported that increased testosterone levels were associated with elevated frequency of LUTS [6].
Although obesity is related to urinary inconteneace [14], our results showed that BMI did not correlate with the overall BFLUTS score or any of its subdomains, which is contradictory to other studies. [6, 14]. we think that the low percentage of obese participants in our sample negatively affected the accuracy of our results. As testosterone levels have not been measured in the current study, and BMI did not correlate with LUTS, the higher BFLUTS score in our PCOS patients may be explained by having previous mental health issues, especially anxiety, which may be associated with the experience of LUTS in Syrian PCOS patients, as Syrians are vulnerable to these mental health issues [25]. The current study did not reveal a relationship between SD and LUTS in PCOS patients. This can be explained by that PCOS-related features, especially low self-esteem, depression, and anxiety, are more likely to have a higher impact on SD rather than LUTS.
Our findings have significant implications for research and clinical practice. Future research should further investigate the complex relationship between PCOS, SF, and LUTS. The current study has many limitations, including being a single-center study that did not assess hormonal levels such as testosterone. Another limitation is that we did not evaluate mental health issues, such as depression and anxiety, which may also have a significant impact on SF and LUTS in women with PCOS. One reason for this is that the questionnaire used was long (45 questions) and addressed sensitive aspects of women's lives. Therefore, we preferred to keep it as simple as possible to encourage participants to fully complete it.