Sexual Dysfunction in Women who are Human Papillomavirus Positive

Female Sexual Dysfunction (FSD) is a prevalent disorder among women that has negative impacts on life quality. Human Papillomavirus (HPV) infection is the most common sexually-transmitted disease and has a negative emotional effect on women because of causing cervical cancer. This study aimed to investigate whether there is any effect of HPV infection on FSD. Women aged between 20-50 years with positive HPV results who were consulted to our hospital’s gynecologic oncology department were included in this study. The Female Sexual Function Index (FSFI) was used to evaluate FSD and scores below 26 were considered FSD. HPV negative women who were matched for age, parity, BMI, socio-cultural and educational levels were taken as a control group. A total of 108 women were included in this study. 56 of them are HPV positive, 52 women are HPV negative. The mean score of the HPV positive group is 21.4 ± 1.4 and HPV negative group is 23.3 ± 0.9. Although there was a minimal lower mean score in HPV positive group, however, this difference was not statistically significant. FSD is prevalent among women independent of HPV status. Routine checking should be applied for FSD whether HPV positive or not.

often with vulva, vagina, anus, rectum, oropharynx and penis cancer [2,3]. The screening test for HPV is Papanicolau (PAP) smear test or HPV test or both. More than 30 HPV types were detected specifically for the genital tract. Most oncogenic types are 16 and 18 among them. Abnormal PAP results and positive HPV tests can be stressful and cause anxiety and fear of cancer [4]. In a study that included more than 400 women, HPV positive test results broke down the women's sexual relationship with their partners [5]. In addition, precancerous genital lesions, especially on the vulva, are likely to result in apprehensions about sexual health according to the study of Naegele et al., More information and time should be given to these patients to reduce the anxiety and improve the adverse sexual outcomes [6]. Several studies were conducted about the socio-demographic features and sexual behavior of the HPV positive women, however, fewer studies were conducted to investigate the sexual disfunction of these women [7,8].
Female Sexual Dysfunction (FSD) is seen by approximately 40% of women of all ages. It harms the quality of life [9]. Although it is a common problem, patients cannot tell their doctors about this. The main reason is the shame about talking about this issue because of cultural infrastructure, especially in countries like us. FSD has several subtypes like reduced desire, impaired arousal, lack of lubrication, failed to achieve orgasm, reduced satisfaction and pain [10]. Low desire is the most detected subtype among them and approximately 39% of the women suffer from it [9]. Therefore, this study aims to determine the effect of HPV on sexual relations in women.

Study design
This study is a cross-sectional and based on a questionnaire comparing women with and without HPV positivity. The study was performed between January 2020 and April 2020 at the Department of Obstetrics and Gynecology, Dokuz Eylul University Hospital, Izmır, Turkey. The study was approved by the local ethics committee. Written informed consent was obtained from all patients.
Family health centers have screened women age between 30 and 65 with HPV-DNA tests to detect HPV status to prevent them from cervical cancer. Also any woman who wants to learn HPV status has access to go to special health centers to take the test. Women who visited the gynecologic oncology clinic with the positive HPV results were asked to complete questionnaire form. The patient's and partner's age, BMI, educational level, parity, and obstetric history were also recorded. In addition, the HPV type and duration of follow-up were recorded. HPV negative group was identified as a control group. The groups were matched for BMI, educational level, age, sociodemographic level and parity.

Patient selection
Sexually active women aged between 20 and 50 years with HPV positive test results were included in the study. Exclusion criteria were as following; women with the systemic-chronic disease, Sexual Dysfunction in Women who are Human Papillomavirus Positive Abstract Female Sexual Dysfunction (FSD) is a prevalent disorder among women that has negative impacts on life quality. Human Papillomavirus (HPV) infection is the most common sexually-transmitted disease and has a negative emotional effect on women because of causing cervical cancer. This study aimed to investigate whether there is any effect of HPV infection on FSD. Women aged between 20-50 years with positive HPV results who were consulted to our hospital's gynecologic oncology department were included in this study. The Female Sexual Function Index (FSFI) was used to evaluate FSD and scores below 26 were considered FSD. HPV negative women who were matched for age, parity, BMI, socio-cultural and educational levels were taken as a control group. A total of 108 women were included in this study. 56 of them are HPV positive, 52 women are HPV negative. The mean score of the HPV positive group is 21.4 ± 1.4 and HPV negative group is 23.3 ± 0.9. Although there was a minimal lower mean score in HPV positive group, however, this difference was not statistically significant. FSD is prevalent among women independent of HPV status. Routine checking should be applied for FSD whether HPV positive or not. psychiatric disorder or taking psychiatric medication, pregnancy, obesity (BMI>30), premature menopause, pelvic surgery that causes FSD, pelvic organ prolapse, a medication that effect sexual-function such as anti-arrhythmic, anti-hypertensive, sedative drugs, etc., dermatologic disorders that affect the genital area.

Questionnaire form
Female Sexual Function Index (FSFI) forms were used as a questionnaire. This self-report questionnaire was developed by Rosen et al., to evaluate the sexual function of women to detect FSD. There are 19 questions and 6 domains that evaluate desire, arousal, lubrication, orgasm, satisfaction and pain during the last four weeks [11]. Each domain has a score range between 0 to 5 and a higher score means better sexual function. Two of the questions are about sexual desire, followed four questions are to detect arousal, four questions for lubrication, three questions for orgasm, three questions for satisfaction, and the last three questions for evaluating the pain. The total score ranges between a minimum of 1.2 to a maximum of 36 points. Lower scores indicate the impaired sexual function that implies FSD. Turkish reliability and validity for this test were performed and the Cronbach alfa coefficient was determined 0.98 in the reliability study. That means FSFI is a reliable and valid measure of sexual function for Turkish women. A total score of less than 26 was considered as FSD.

Statistical analysis
All analyses were performed by using IBM SPSS Statistics Version 25. The normality test was performed by the Kolmogorov-Smirnov test. Data were presented as means ± SD for continuous variables. The Independent t-test was used to determine the differences between variables. Mann-Whitney U and Kruskal-Wallis tests were used for variables without normal distribution p<0.05 was considered statistically significant.

Results
A total of 108 women were included in this study. 56 of them were HPV positive, 52 women are HPV negative. The descriptive characteristics of the patients were shown in table 1. No significant difference was determined between the age, partner's age, BMI and parity. There was also no significant difference between the educational level and obstetric history according to HPV status.
According to total FSFI scores, the mean score of the HPV positive group is 21.4 ± 1.4 and HPV negative group is 23.3 ± 0.9. The FSFI scores between groups were shown in table 2. Although there was a minimal lower mean score in HPV positive group, however, this difference was not statistically significant. All of the domain scores that include desire, arousal, lubrication, orgasm, satisfaction, pain were lower in HPV positive group in comparison to HPV negative group, however, no significant difference between was determined between them.

Discussion
This study was designed to determine whether there is any difference according to FSD between the HPV positive and negative women. FSD is a very common disorder in women especially with HPV positive. However, there was no significant detected difference between groups in this conducted study. By contrast to our study, Uysal et al., found that FSFI scores were lower in HPV positive patients [12]. Cervical cancer caused by HPV is common cancer among females [3]. Although with the HPV test screening, preinvasive lesions are diagnosed earlier and give us a chance to take cautions before developed cancer, these diagnoses constitute anxiety in women with HPV. FSD is a little known area in the field of medicine, there were lots of women suffering from it worldwide [9,10].
FSD is not a rare disorder in Turkey. FSD prevalence was detected by 25% by Cayan et al., Another study was determined the FSD prevalence of 41% in women with the age range between 18 to 30 [13,14]. This difference comes from socio-cultural and educational level differences. Low desire, the most common sexual dysfunction, was determined by 39% of women and found an association with distress [9]. HPV positive results result in worries about the hygiene of the sexual partner [5]. In addition, colposcopic evaluation is another additive distress factor [15]. FSFI domains with lower scores were considered as a result of anxiety in HPV positive women. Lower scores were also obtained from HPV positive group in the present study. The reasons that cause FSD are multifactorial. Although the history of pelvic surgery was excluded, fatigue and reliance on relationships are also the strong factors that affect FSFI scores independent of HPV status.
Genital warts among men were found associated with sexual dysfunction in a study that was conducted by Kucukunal et al., [15]. However, in this study women with genital warts excluded because sexual dysfunction in people with genital warts not only comes from anxiety but also from physical effects that make intercourse  uncomfortable. By contrast to genital warts, less is known about the deteriorative effect of HPV on the cervix that has a possible negative effect on the FSFI domains such as orgasm, satisfaction, lubrication, and arousal. In a study that had a purpose to determine the differences in sexual activity between the women who had cesarean section and vaginal delivery, however, there was no detected significant difference in FSFI scores between groups [16]. In our study, the total FSFI score was found lower in the vaginal birth group in comparison to the caesarian section group. However, this result was not statistically significant.
Limitations of this study are that; firstly we did not evaluate the sexual function of the male partner and did not ask the participants to fill Beck or Stress questionaries to assess anxiety status. However, patients who were asked whether they have any psychological disorders were excluded from this study. Also, we did not follow the patients for a long time, therefore, this study did not include the long-term effects of HPV infection on FSD. The strength of this study is coming from the use of standard, reliable, and proved questionnaires to determine FSD. In conclusion, the results of this study showed that, FSD is a prevalent disorder among women whether HPV positive or not. FSFI scores can be lower in HPV positive women, however, this cannot be meaningful.

Conclusion
Therefore, checking for sexual dysfunction should be in our routine in the field of gynecology and comprehensive care should be given to the women who are suffering from FSD by a multi-disciplinary team.

Disclosure Statement
The authors declare that they have no conflicts of interest.

Statement of Ethics
The study was approved by the local ethics committee of Dokuz Eylul University, Izmir, Turkey. Written informed consent was obtained from all patients.