Sexual dysfunction in the women would occur at any age; however, it is more frequent in the middle age or during menopause (1-3). Nearly 40% of the menopause women suffer from sexual dysfunction (1). Studies have shown that the incidence of sexual dysfunction is 33-88% among the middle-aged women (4-6). The sexual responses of the women are complicated and still some of their characteristics are unknown. However, it has been indicated that the hormone changes that occur during the menopause period affect the women’s sexual response through different mechanisms (4).
Aging and menopause process are two main factors that simultaneously cause sexual dysfunction in the menopause women (3). By aging, the women's sexual problems increase, reaching to its climax within the age of 45-65 years (1), which results in the reduction of sexual function (1, 4). Nappi et al. conducted a study on the menopause women. They demonstrated that 35% of the women reported a decrease in sexual function, and 52% of them believed that menopause was the reason of their sexual dysfunction (5).
In another study, it was shown that 31.5% of the Iranian women within the age of 20-60 years were suffering from sexual dysfunction. Accordingly, the incidence of sexual dysfunction was 39% in the women over the age of 50 years. This indicates that the incidence of female sexual dysfunction increases by growing older (7). Meanwhile, the women experience sexual dysfunction 2.3 times more in the post-menopause period than that in the pre-menopause (8).
Female sexual dysfunction during the menopause negatively affects their quality of life and personal relationships (7). One of the main concerns of the women in the menopause period is the negative impact of sexual dysfunction on marital satisfaction. A qualitative study demon-strated that a number of menopause women believed that the decrease in their sexual activity was responsible for the marital conflicts and dissatisfaction.
These females were worried about the falling apart of their families as a result of their sexual dysfunction. They thought their sexual dysfunction during the menopause period probably would lead to remarriage of their husband (9). In a study conducted on 987 women within the age of 20-65 years, Bancfort et al. found that anxiety about the personal sexuality and sexual relationship was increased by aging (10).
Another study carried out in Bahrain demonstrated that 46.5% of the women believed that a wife would have better relation-nship with her husband in the menopause period. The mentioned study also found that the loss of fertility caused by menopause worried most of the women. They were concerned that their husbands might marry a younger woman to have babies and expand their families (11).
In a study conducted by Nappi, the reduction of sexual activity in the Dutch women did not have any effects on their marital satisfaction. Furthermore, the German menopause women believed that having more sexual intercourses would make their lives more pleasant. Many women reported that they cared about maintaining satisfactory sexual relationships. These females believed that they had to preserve sexual relationships with their husbands if they were supposed to have any relationship with them. However, the middle-aged European women believed that menopause was a process, which could change sexual relationship and damage their personal lives (5).
Nowadays, the females spend more than 30 years of their lifetime (i.e., nearly one third of it) as menopause (1). Therefore, it is necessary to pay special attention to the problems of this stage. With this background in mind, the present study was designed to compare the marital satisfaction in the menopause women with or without sexual dysfunction.
Materials and Methods
This cross-sectional study was conducted on the menopause women with or without sexual dysfunction referring to the medical centers affiliated to the Qom University of Medical Sciences, Qom, Iran, in 2012. The implementation of the present study was approved by the Ethics Committee of the Qom University of Medical Sciences. Informed consent was obtained from all the participants. The sample size was determined to be 80
cases (β=0.2, α=0.05, s1=0.71, s2=0.58 and
d=0.41) using the sample size fromula (12).
The participants were selected through the convenience sampling technique. The inclusion criteria were: 1) Iranian nationality, 2) alive husband, 3) living together at the time of the project, 4) an elapse of at least one year from the onset of menopause, 5) no hysterectomy, oophorectomy, cystocele, rectocele, or mastectomy surgery, 6) lack of any mental diseases in the couple, 7) no addiction, and 8) no recent consumption of antidepressants. On the other hand, the women who refused to answer the sexual questions were excluded from the study.
The informed consent was obtained from all the participants. The data were collected using the demographic form, Female Sexual Function Index (FSFI-19), and ENRICH marital satis-faction questionnaire. The demographic form included such information as woman’s age, husband’s age, age difference of the couple, height, weight, number of children, and the age of menopause. The FSFI-19 is a general standard questionnaire, which was developed by Rosen et al. to measure the sexual function (13).
The validity and reliability of this index were approved by Rosen et al. in 2000 (13). In a study conducted in the Shahed University, Iran, Mohammadi et al. (2004) confirmed its validity and reliability, rendering a Cronbach’s alpha coefficient of 0.70 for the total scale (14). This index contains 19 items in six domains, including sexual desire, sexual arousal, lubrication, orgasm, sexual satisfaction, and pain.
The score of each domain is calculated by summing up the scores of all items in each domain and multiplying them in the factor number (i.e., desire=0.6; lubrication and arousal=0.3; pain, orgasm, and satisfaction=0.4). By summing up the scores of all the six domains, we calculated the total score of scale, ranging within 2-36. In this index, a total score of ≥ 23 indicates no sexual dysfunction. On the other hand, the score of < 65% on each domain signifies the dysfunction in that domain (7).
In the present study, the ENRICH marital satisfaction scale was used for the assessment of the marital satisfaction of the participants. The questionnaire involves some subscales, including personality issues, marital satisfaction, conflict resolution, financial management, leisure activities, sexual relationship, children and parenting, family and friends, and religious orientation. This questionnaire has been employed as a reliable tool in many studies for the assessment of marital satisfaction. Considering the fact that the original questionnaire was long (i.e., 115 items), several shorter versions have been developed.
For the first time in Iran, Soleimanian et al. designed a 47-item form of this questionnaire. They calculated and reported its internal consistency as 0.95 (15). The 47-item form was rated on a 5-Likert point scale (ranging from completely agree=1 to totally disagree=5). Reverse scoring was used for some items. In this questionnaire, a higher total score indicates higher degree of marital satisfaction. The women with scores of < 23 on the FSFI were considered as suffering from sexual dysfunction (n=40).
On the other hand, those with scores of ≥ 23 had no sexual dysfunction (n=40). After the administration of the FSFI, the marital satisfaction levels of the two groups were compared, using the ENRICH questionnaire. The collected data were analyzed by the independent t-test and Mann-Whitney U test through the SPSS version 18. The p-value less than 0.05 was considered statistically significant.
According to the results, the mean ages of the menopausal women were 48.03±5.26 and 47.57±5.08 years in the groups with and without sexual dysfunction, respectively. The results of the independent t-test revealed no significant differences between the two groups in terms of the demographic variables (P>0.05) (Table 1). Based on the t-test, we found no significant difference between the two groups regarding the total score of marital satisfaction (t=-1.19, P=0.526) (Table 2).
Out of the six domains of the ENRICH marital satisfaction questionnaire, the Man-Whitney U test revealed statistically significant differences between the two groups in terms of the personality issues (P<0.001), marital satisfaction (P=0.006), as well as children and marriage
(P=0.035), in a way that the sexual dysfunction group gained a higher score. Furthermore, the scores of leisure activities (P=0.01) and sexual relationship (P<0.001) were significantly higher in the group without sexual dysfunction. There were no significant differences between the two groups regarding the conflict resolution, financial management, religious orientation, and family/relatives (P>0.05).
In addition, the two groups were significantly different regarding all domains of desire, arousal, lubrication, orgasm, satisfaction, and pain (P<0.001). The most common sexual dysfunctions of the menopause women in the sexual dysfunction group were desire (100%, n=40) and arousal (95%, n=38). On the other hand, the least common dysfunction was related to pain (57.6%, n=22). In the group without sexual dysfunction, the most common sexual dysfunctions were desire (63.3%, n=25), and then arousal (26.5%, n=8). The least common dysfunction was related to satisfaction (8.2%, n=3) in this group.
Although sexual function weakens after the onset of menopause and aging (6), the findings of our study indicated no significant differences between the two groups with and without sexual dysfunction in marital satisfaction. Different studies showed that the marital satisfaction was higher in the women at two stages of life, namely the early years of marriage and long-term marriage. When a couple lives together for a long time, the aging and common experience help increase the marital satisfaction. Laninghan found that the marital happiness had a U-shaped form; in other words, the happiness increased in the early and late married life (16).
Abbasi conducted a study to assess the changes in the marital satisfaction and its aspects in the living cycle of family in 2010. She found that the marital satisfaction was at its peak in the early years of marriage and also in the menopause period (17). In line with this study, Lodge found that marital sex was a cause of conflicts for the couples who were in their midlife because they did not have compatible experiences. Nevertheless, in the later years of marriage, the couples were willing to be more compatible and adjusted in their sexual and marital relationships (18). This could be due to the enhancement of age and gaining the same experiences by the couples.
The other reasons are the cultural and religious values that affect the people's attitude toward the family in all societies (5, 6). In Iran, the cultural and religious beliefs emphasize that the women should satisfy their husbands and establish good relationships within the family. Probably, this is why sexual dysfunction has no effect on the marital satisfaction of the menopause women in Iran.
Studies demonstrated that marital satis-faction in the women is influenced by sexual function. Khazaee et al. conducted a study on the married students. They found that sexual dysfunction significantly decreased the marital satisfaction in the young women (19). The difference between the aforementioned study and our research may be due to the differences in the age of the participants.
Another study carried out by Shah Siah assessed the role of sexual instruction in enhancing the marital satisfaction of the couples in the city of Isfahan, Iran. The mentioned study found that the women's marital satisfaction increased after attending a training course on sexual issues (20). Rahmani et al. also conducted a study on sexual satisfaction and marital happiness of the women within the age of 19-58 years. They found that the marital happiness was significantly associated with sexual satisfaction (21).
Unlike our study, these studies have been conducted on the women with various ages. Litzinger conducted a study on the married women within the fertility age to assess the association between sexual and marital satisfaction. The results revealed that the sexual satisfaction was not a predictor of marital satisfaction (22). Through the passage of time, the sexual satisfaction decreases (21), whereas the marital satisfaction increases (23).
The present study also indicated no significant difference between the two groups regarding some domains of marital satisfaction, including religious orientation and also family and friends. In this regard, in another study conducted by Abbasi et al. (17), some domains of marital satisfaction (e.g., leisure time, relationships, resolutions of conflicts, personal issues, and parenting) remained the same over time and showed no considerable fluctuations through married life.
In our study, the most common sexual dysfunction in both groups with (100%) and without (63.3%) sexual dysfunction was desire. The prevalence of desire dysfunction in a study conducted by Lindau and Hayes was reported to be nearly 43-53% (23, 24) in the old women. This value was reported to be 48% among the menopause women in another study conducted by Graziottin (3). Moreover, in a study carried out in Malaysia, the sexual desire decreased in two-thirds of the menopause women (23). In addition, the mean ages of the menopause women in our study were the same as the menopause ages reported in Nigeria (47±4.2 years) (26) and Bahrain (48.67±2.92 years) (11).
As the findings of the present study indicated, the marital satisfaction of the menopause women was not probably influenced by sexual dysfunction. Accordingly, it is unreasonable for the menopause women to worry about the marital conflicts and disruption of marital relationship due to sexual dysfunction. Fur-thermore, the factors responsible for the marital conflicts in the older women are probably different from those in the younger ones.
On the other hand, some factors have different impacts on marital conflicts in various stages of married life. Consequently, it is necessary to separately recognize and prioritize some factors affecting marital satisfaction in the different stages of life in order to improve the effectiveness of marital and sexual consultations.
The limitations of this study were related to the women's willingness to answer sexual questions. Some of them did not have a good feeling about responding to such questions and refused to participate in the study. Accordingly, some of the participants declining to answer most of the sexual questions were excluded from the study.
Hereby, we express our gratitude to the participants and midwifery students for their contributions.
Conflicts of Interest
The authors declare no conflicts of interest.