Keywords
menopause - sexuality - physiological sexual dysfunction - psychometric - sensitivity
- specificity
Palavras-chave
menopausa - sexualidade - disfunção sexual fisiológica - psicometria - sensibilidade
- especificidade
Introduction
The climacteric period is a biological phase of life and not a pathological process.[1] Menopause is defined as the last menstrual period, recognized 12 months after its
occurrence.[2] The mean age of menopause ranges from 48 to 52 years globally.[3] In this period, hormonal variations and progressive estrogen deficiency may sometimes
result in debilitating short, medium and long term conditions.[4] Decreased pelvic support, genital atrophy, and decreased lubrication may result
in dyspareunia and finally in sexual dysfunction.[5] Female sexual desire is not spontaneous and the sexual response includes intimacy
and emotional satisfaction as goals.[6] Any disruptions in the response cycle, such as dyspareunia or difficulties with
arousal, reduce motivation and the search for intimacy with the partner. Sexual dysfunction
can affect women of various ages, colors, social status and ethnicities. It is characterized
by psychophysiological changes in the sexual response, including sexual desire, arousal,
orgasm, and even pain.[7] Hormonal changes in the menopause, particularly hypoestrogenism and decreased testosterone
levels, associated with biological, cultural and social processes may have a direct
impact on sexuality, well-being, and quality of life.[8]
[9]
[10]
The prevalence of sexual dysfunction after menopause has shown to increase from 12.1%
to 48.0%.[11] Worldwide, the prevalence of sexual dysfunction in postmenopausal women using questionnaires
that do not include a specific menopause domain has been reported to vary between
61% and 86%.[12]
[13] In sexually active postmenopausal Brazilian women, it seems that 70% suffer from
sexual dysfunction, especially those > 50 years old.[14]
[15] Among the studies on sexual dysfunction in older women, the most commonly used instrument
is the FSFI and its short form FSFI–6, but other instruments have also been used.[16]
[17]
[18]
[19] Even though these instruments measure sexual dysfunction in menopausal, perimenopausal
and postmenopausal women, they do not have a menopause specific domain, and they are
not quite suitable for measuring sexual dysfunction in postmenopausal women. They
do not have questions linking sexual dysfunction to the menopause condition.
The PMSQ tested in the current study was previously and partially validated in Portuguese
to measure the different domains of sexual function in Brazilian postmenopausal women.[20] Therefore, the primary objective of the present study was to assess the construct
and criterion validities of this questionnaire and to determine its cutoff level to
identify postmenopausal women with or without sexual dysfunction.
Methods
This methodological study enrolled postmenopausal women who were selected using accessibility
sampling at the General Gynecology and Climacteric Outpatient Clinics of a teaching
and research hospital, between November 2017 and June 2018. According to the current
recommendations, the sample size criterion for factor analysis was 5 subjects per
item.[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28] A total of 181 postmenopausal women with stable and regular sexual activity, regardless
of marital status or sexual orientation, were examined. Natural menopause was defined
as 12 consecutive months of absence of menstruation. Women with hysterectomy before
menopause were included if age ≥ 48 years old and follicle stimulating hormone (FSH) ≥ 25
mIU/mL.[3] Other hormones such as estradiol, total testosterone, free thyroxin, and thyroid
stimulating hormone were also measured. Women with an earlier diagnose of menopause,
already using estrogen-progestin hormone therapy, were also included. Women with severe
hypertension, decompensated diabetes, severe heart disease, musculoskeletal diseases
with movement disabilities, current or past cancer diagnosis, bilateral oophorectomy,
vulvodynia or using medications that could interfere with the libido were excluded.
Data were collected during a single interview, after signing the free and informed
consent form. Sociodemographic characteristics, body weight, and height were obtained
with the woman standing barefoot. The body mass index (BMI) (weight / height2) was calculated following the Brazilian guidelines.[22]
[23] The waist circumference was verified using an inelastic tape, positioned at the
smallest circumference between the final costal arch and the iliac crest. The PMSQ
and the FSFI questionnaires were both applied in this sequence and face to face. Despite
the referred formal educational level, most of the patients had very little schooling
and little ability to read and answer the questionnaires without help. So, a single
researcher, the main author, carefully read the questions and the participant pointed
out the item that corresponded to the answer she had chosen. Approval of the project
was obtained from the local Ethics and Research Committee.
The PMSQ initially contained 43 items distributed into nine domains, namely: self-image
(5), sexual quality of life (6), sexual intimacy (6), desire (7), arousal (5), orgasm
(4), dyspareunia/vaginism (2), satisfaction (5) and influence of menopause (3). The
questions were answered on an ordinal Likert scale (0–5). The scores (0–100) were
standardized by the formula (X / 215) × 100, where: X is the answer for each item
and 215 is the maximum possible gross score (5 × 43 = 215); 0 indicates the worst
sexual function and 100 indicates the best sexual function. The items were designed
based on sexual domains validated in other questionnaires, and all of them were evaluated
by specialists in sexology and submitted to the test-retest method.[20] For the publication in English, the PMSQ instrument was translated from Portuguese
into English as follows: a native English speaker and a native Brazilian Portuguese
speaker translated the questionnaire independently. Finally, a bilingual author confronted
the two versions, keeping the most appropriate terms. As the instrument was applied
to women of native Portuguese language, the English version of the instrument was
not yet validated in any English speaking population.
The FSFI, a gold standard questionnaire designed to evaluate female sexual function,
was previously validated in Brazilian Portuguese.[24] This instrument contains 19 items in six domains: sexual desire (2), sexual arousal
(4), vaginal lubrication (4), orgasm (3), sexual satisfaction (3) and pain (3). The
items are answered on an ordinal Likert scale (0–5), with increasing scores according
to the presence of the function questioned, with total scores varying from 2 to 36.
Based on validation studies, a cutoff point of 26.5 was proposed.[25] However, its cutoff point to discriminate menopause women with or without sexual
dysfunction was established as 23.[26] Because the FSFI has been used in populations of all ages, including menopausal
women, and already presented a cutoff considering the age, it was chosen for validating
the PMSQ questionnaire.
Descriptive analyses of data included the variable ages, family income in minimum
wages, education, self-declared color, occupation, number of previous pregnancies,
menarche age, sexarche age, menopause age, BMI, waist-hip ratio, clinical comorbidities
and use of menopause hormone therapy. The data distribution was verified using the
Shapiro-Wilk test. The Cronbach α was used to verify the internal consistency of both
PMSQ and FSFI questionnaires. The Pearson coefficient correlation was used to verify
the possible correlation between PMSQ and FSFI questionnaires. Exploratory Factor
Analyses were used to examine the construct validity of the PMSQ. The Kaiser-Mayer-Olkin
test measured the fitness of the sample and the Bartlett sphericity test verified
whether the data were adequate for the analysis; Varimax orthogonal rotation principal
component analysis was used, and any factor loading > 0.40 was retained for interpretation
of the instrument structure.[27]
[28]
The criterion validity was performed using the Pearson correlation coefficient (r),
between the PMSQ and FSFI as gold standard.[29] The cutoff point of the PMSQ questionnaire was established using the ROC curve with
a 95% confidence interval (CI). The scores ≤ 23, suitable for women > 50 years old,
were used as cutoff points of the FSFI.[26]
[30] Proportions between two variables estimated by the FSFI and PMSQ were compared using
the chi-squared test (χ2). The data and this exploratory factorial analysis were performed using the SPSS
Statistics for Windows, version 17 (IBM Corp., Armonk, NY, USA). The ROC curve was
calculated using the Medcalc Statistical Software version 18.9.1 (MedCalc Software,
Ostend, Belgium). Any p-value < 0.05 was considered statistically significant in a
two-tailed test.
Results
Most participants were married (85.1%) and more than half (60.8%) self-declared as
catholic. As for self-declared color, 58.0% (105) were mixed, 28.2% (51) white, and
13.8% (25) black. More than half (53.0%) had a maximum of 8 years of schooling. Almost
two-thirds of them (61.3%) gained a family income of 2 minimum wages, that is, about
£400 per month. The BMI was 29.1 ± 5.0 kg/m2. A total of 96 (53.0%) subjects reported regular physical activity, with a mean of
3.3 ± 1.2 times a week. Smoking was reported by 8.8% (16/181) and 21.0% (38/181) reported
drinking socially; ∼ 1 beer (500ml) per week. The mean ages of menarche and sexarche
were 13.3 ± 1.7 years old and 19.3 ± 3.9 years old, respectively. Women with previous
hysterectomy (27.1%) reported surgery at 41.8 ± 7.0 years old. The age of natural
menopause in 132 participants (72.9%) was 48.4 ± 5.2 years.
The descriptive analysis of the PMSQ questionnaire with 43 items yielded a mean score
of 54.9 ± 15.1 and total α coefficient of 0.93; in the domains self-image and dyspareunia,
the α coefficients were 0.44 and 0.33, respectively. The correlation matrix of the
PMSQ with 43 items showed significant correlations between all items, but the item
34 (I can put my finger in my vagina without feeling pain) presented poor, but still
significant correlations (r < 0.30), and a sampling adequacy measure of 0.42 in the
anti-image matrix; therefore, this item was removed from the exploratory factor analyses.
The remaining 42 items presented Kaiser's test = 0.88, χ2 = 4006, p < 0.001, indicating that the sample and the correlation matrix were adequate to carry
out the exploratory analyses. Almost all items presented commonalities ≥ 0.5 and 10
factors were extracted with an eigenvalue ≥ 1, explaining 66.06% of the total variance.
Afterwards, rotated analyses of the matrix enabled the exclusion of 6 items: item
29 (it is very difficult for me to get aroused, loadings ≤ 0.4); item 22 [(I get aroused
just by thinking about having sex) loading in the same factor as item 25 (I get excited
just thinking about sex)]; item 3 (I am sexually desirable), item 8 (my partner's
sexual performance satisfies me), item 11 (I feel frustrated about my sexual life)
and item 17 (I like my partner to caress my genitals [vagina, clitoris]) because they
loaded in more than one factor. The item 19 (I like to have sex/make love), despite
presenting cross loadings in three factors, was maintained because it is clinically
important to assess the postmenopausal sexuality.
After deleting the previously mentioned items, a new exploratory analysis of the PMSQ
with 36 items was performed. The analysis of this 36-item version showed Kaiser test = 0.88
and χ2 = 3293 (p < 0.001) and commonalities ≥0.5 ([Table 1]). Nine factors were extracted with eigenvalue ≥ 1, explaining 66.3% of the total
variance. After the rotation, item 23 (I feel pleasure during sexual intercourse)
and 32 (I get easily aroused when I am touched), despite having crossed loads, they
were maintained because they are clinically important in evaluating postmenopausal
sexuality.
Table 1
Values of factor load and commonalities of the 36-item PMSQ[a]
|
Items
|
Factors
|
|
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
9
|
h2
|
|
Orgasm
|
I only get an orgasm with great effort
|
0.84
|
0.11
|
0.12
|
0.10
|
0.04
|
0.25
|
0.09
|
0.12
|
0.02
|
0.82
|
|
It is difficult for me to get an orgasm
|
0.78
|
0.20
|
0.20
|
0.14
|
0.11
|
0.23
|
0.14
|
0.12
|
−0.01
|
0.80
|
|
I get an orgasm easily
|
0.74
|
−0.03
|
0.30
|
0.15
|
−0.05
|
0.04
|
0.23
|
0.16
|
0.09
|
0.73
|
|
It is impossible for me to have an orgasm
|
0.65
|
0.13
|
0.14
|
0.27
|
0.13
|
0.21
|
0.07
|
0.08
|
0.12
|
0.62
|
|
Sexual intimacy
|
I hug and caress my partner's body during the intercourse
|
0.25
|
0.72
|
0.14
|
0.21
|
−0.02
|
−0.06
|
0.11
|
0.02
|
0.09
|
0.67
|
|
I like to caress the penis of my partner
|
0.09
|
0.72
|
−0.13
|
0.31
|
0.22
|
0.09
|
0.02
|
0.00
|
−0.03
|
0.69
|
|
I get emotionally involved with my partner during the sexual intercourse
|
0.15
|
0.69
|
0.21
|
0.14
|
0.19
|
0.09
|
0.03
|
0.17
|
0.06
|
0.64
|
|
I like to be caressed by my partner
|
−0.01
|
0.69
|
0.26
|
−0.01
|
0.05
|
−0.02
|
0.19
|
−0.06
|
0.07
|
0.59
|
|
I am concerned with my sexual life
|
−0.14
|
0.48
|
−0.12
|
−0.15
|
0.35
|
0.06
|
0.03
|
−0.35
|
0.06
|
0.54
|
|
I am satisfied with my sentimental life
|
0.07
|
0.42
|
0.25
|
−0.10
|
0.03
|
0.05
|
−0.04
|
0.26
|
0.40
|
0.48
|
|
Satisfaction
|
The feeling of sex is good
|
0.16
|
0.12
|
0.72
|
0.25
|
0.22
|
0.11
|
0.19
|
0.04
|
0.06
|
0.72
|
|
Sex makes me feel accomplished
|
0.32
|
0.21
|
0.67
|
0.26
|
0.07
|
0.13
|
0.02
|
0.12
|
0.13
|
0.71
|
|
I feel satisfied with sex
|
0.24
|
0.20
|
0.63
|
0.32
|
0.18
|
0.19
|
0.17
|
0.09
|
0.10
|
0.71
|
|
Considering the frequency of the relations with my current partner, I am
|
0.23
|
0.38
|
0.53
|
−0.13
|
0.03
|
0.16
|
−0.03
|
0.28
|
0.13
|
0.61
|
|
I get easily aroused when I'm touched
|
0.17
|
0.10
|
0.46
|
0.43
|
0.19
|
0.22
|
0.17
|
−0.08
|
0.21
|
0.59
|
|
I feel uncomfortable during the sexual intercourse
|
0.25
|
−0.07
|
0.44
|
0.08
|
−0.21
|
0.08
|
0.31
|
0.10
|
−0.23
|
0.48
|
|
Arousal
|
I get wet during the intercourse
|
0.25
|
0.01
|
0.14
|
0.69
|
0.01
|
0.07
|
0.01
|
0.06
|
−0.06
|
0.57
|
|
I want to have sex
|
0.29
|
0.14
|
0.14
|
0.64
|
0.20
|
0.05
|
0.24
|
0.22
|
0.09
|
0.69
|
|
I like to have sex/make love
|
0.14
|
0.39
|
0.18
|
0.61
|
0.22
|
0.13
|
0.30
|
0.05
|
0.04
|
0.74
|
|
I feel like having sex when I am caressed
|
−0.07
|
0.24
|
0.33
|
0.51
|
0.17
|
0.16
|
0.39
|
−0.01
|
0.08
|
0.63
|
|
I feel pleasure during sexual intercourse
|
0.43
|
0.18
|
0.34
|
0.47
|
−0.03
|
0.26
|
0.21
|
0.08
|
0.07
|
0.67
|
|
Desire
|
I get excited just by thinking about sex
|
0.08
|
0.03
|
0.10
|
0.27
|
0.77
|
0.19
|
−0.03
|
0.09
|
0.11
|
0.74
|
|
I think, fantasize, dream of having sex/making love
|
−0.01
|
0.26
|
0.10
|
0.25
|
0.74
|
0.07
|
−0.05
|
0.04
|
0.10
|
0.70
|
|
I really want to get sexually excited
|
0.11
|
0.15
|
0.21
|
0.01
|
0.66
|
−0.10
|
0.18
|
−0.10
|
−0.01
|
0.57
|
|
I have less sexual intercourse than I would like to
|
0.01
|
0.01
|
−0.16
|
−0.23
|
0.51
|
−0.09
|
0.31
|
−0.27
|
−0.03
|
0.52
|
|
Menopause
|
The fact that I no longer menstruate increased the frequency of my sexual intercourse
|
0.18
|
−0.06
|
0.13
|
0.06
|
0.04
|
0.80
|
0.05
|
0.09
|
−0.08
|
0.71
|
|
As a result of the menopause I feel less willing to have sex
|
0.24
|
0.16
|
0.09
|
0.08
|
0.03
|
0.77
|
0.18
|
0.08
|
−0.09
|
0.74
|
|
How has your desire to have sex after menopause
|
0.23
|
0.02
|
0.24
|
0.22
|
0.02
|
0.65
|
0.23
|
0.20
|
0.01
|
0.68
|
|
Importance of sexual life
|
I want to have sex
|
0.12
|
0.12
|
0.09
|
0.27
|
0.24
|
0.21
|
0.65
|
0.03
|
0.13
|
0.65
|
|
I am not interested in sex
|
0.30
|
0.16
|
0.25
|
0.21
|
0.14
|
0.15
|
0.63
|
0.15
|
0.05
|
0.68
|
|
I feel sexually cold
|
0.37
|
0.12
|
0.18
|
0.11
|
−0.08
|
0.29
|
0.59
|
0.26
|
0.01
|
0.69
|
|
Quality of sexual life
|
I am unhappy with my sexual activity
|
0.11
|
0.11
|
0.17
|
0.04
|
0.04
|
0.03
|
0.27
|
0.77
|
−0.02
|
0.71
|
|
I want to improve my sensuality
|
0.10
|
−0.15
|
−0.16
|
0.06
|
−0.14
|
0.21
|
−0.09
|
0.66
|
0.09
|
0.57
|
|
I feel dissatisfied with my sexual activity
|
0.24
|
0.19
|
0.35
|
0.13
|
0.02
|
0.13
|
0.12
|
0.63
|
0.00
|
0.65
|
|
Self-image
|
I am still a sensual, charming woman
|
−0.01
|
0.15
|
0.08
|
−0.11
|
0.04
|
−0.04
|
0.23
|
−0.08
|
0.83
|
0.80
|
|
I feel well with my body image
|
0.15
|
0.00
|
0.05
|
0.24
|
0.11
|
−0.12
|
−0.09
|
0.11
|
0.77
|
0.72
|
a Extraction method: principal component analysis; Rotation method: Varimax with Kaiser
normalization.
h2 communality.
The items had factor loadings between 0.4 and 0.8, and total α of 0.92; among the
domains, the α coefficients ranged between 0.63 and 0.87 ([Table 2]).
Table 2
Alpha coefficients of the total instrument and its specific domains (PMSQ)
|
Domain
|
Number of questions
|
Questions
|
Score
|
Cronbach α[**]
|
|
Self-image
|
2
|
1–2
|
0–5
|
0.63
|
|
Quality of sexual life
|
3
|
3–5
|
0–5
|
0.65
|
|
Sexual intimacy
|
6
|
6–11
|
0–5
|
0.75
|
|
Desire
|
4
|
12–15
|
0–5
|
0.68
|
|
Importance of sexual life
|
3
|
16–18
|
0–5
|
0.77
|
|
Arousal
|
5
|
19–23
|
0–5
|
0.82
|
|
Orgasm
|
4
|
24–27
|
0–5
|
0.87
|
|
Satisfaction
|
6
|
28–33
|
0–5
|
0.80
|
|
Influence of menopause
|
3
|
34–36
|
0–5
|
0.79
|
|
Total
|
36
|
–
|
–
|
0.92
|
** Cronbach α, measure of the internal consistency for each domain and the total questionnaire.
The PMSQ, with 36 items, yielded a total mean score of 54.5 ± 15.4, whereas the specific
menopause influence domain showed the lower mean (37 ± 24.5). The self-image domain
presented the highest mean (65.9 ± 24.6). The average score obtained with the FSFI
was 22.6 ± 6.5. The lowest mean was found in the desire domain (3.1 ± 1.2), and the
highest one was found in the pain domain (4.2 ± 1.7). The FSFI presented a total α
coefficient of 0.93 and, among the domains, the Cronbach α varied between 0.76 and
0.94. As shown in [Fig. 1], the Pearson coefficient correlation between the two questionnaires was r = 0.788
(p < 0.001).
Fig. 1 Correlation between FSFI and PMSQ scores.
The association between the PMSQ and FSFI scores in the orgasm domain was strong (r = 0.70;
p < 0.001). The influence of menopause showed moderate (r = 0.40–0.59; p < 0.001) correlations with all FSFI domains, except with the pain domain. The self-image
domain, which was not evaluated in the FSFI, presented weak (r = 0.15–0.19) but significant
correlations with all other domains of this questionnaire (p < 0.05 for all comparisons).
The total score of ≤ 23 obtained in the FSFI was used as the classification variable.
In the ROC curve analysis, an area under the curve of 0.90 (95% CI: 0.85–0.94) and
cutoff point of ≤ 55.6 was observed in the PMSQ, and sensitivity of 87.9% and specificity
of 78.9% (p < 0.001) was detected using this instrument ([Fig. 2], panel A). Using the cutoff point of ≤ 23, the FSFI identified 91/181 (50.3%) women
with sexual dysfunction. When the PMSQ questionnaire was used, 99/181 (54.7%) women
reported sexual dysfunction. Therefore, regarding the ability to identify sexual dysfunction,
no difference was found between the two questionnaires (4.42%; 95% CI: 5.82–14.53;
χ2 = 0.71; p = 0.400). The areas of the ROC curves of the FSFI and PMSQ questionnaires were similar
(difference of 4%; 95% CI: - 0.003–0.08; p = 0.07) ([Fig. 2], panel B).
Fig. 2 Panel A - ROC curve with cutoff point of PMSQ questionnaire. Panel B - Comparison
between total areas of FSFI and PMSQ questionnaire.
The comparison between proportions of menopausal women with sexual dysfunction and
menopausal women without sexual dysfunction, either in the total or in a particular
domain score in the PMSQ is shown in [Table 3]. It is worth noticing that because the primary objective was to validate this questionnaire,
the analysis was not stratified by any patient characteristic.
Table 3
Comparison of the scores total and by domain of the PMSQ between women with and without
sexual dysfunction
|
Domains
|
Without SD (82)
|
With SD (99)
|
T[***]
|
|
|
 (sd)
|
(sd)
|
p-value
|
|
Orgasm
|
69.21 (20.99)
|
30.15 (18.74)
|
13.08
|
0.000
|
|
Menopause
|
51.63 (23.02)
|
24.85 (18.29)
|
8.54
|
0.000
|
|
Sexual intimacy
|
73.58 (15.63)
|
51.38 (18.93)
|
8.64
|
0.000
|
|
Quality sexual life
|
53.01 (20,84)
|
34.41 (19.28)
|
6.18
|
0.000
|
|
Self-image
|
72.68 (22.72)
|
60.20 (24.83)
|
3.53
|
0.001
|
|
Desire
|
53.66 (21.84)
|
38.99 (17.50)
|
4.91
|
0.000
|
|
Satisfaction
|
79.96 (8.60)
|
53.23 (17.86)
|
13.16
|
0.000
|
|
Arousal
|
71.95 (16.64)
|
40.69 (17.77)
|
12.20
|
0.000
|
|
Importance sexual life
|
77.97 (17.43)
|
45.86 (22.03)
|
10.94
|
0.000
|
|
Total
|
68.49 (7.45)
|
42.87 (9.36)
|
20.50
|
0.000
|
Abbreviations: SD, sexual dysfunction; sd, standard deviation.
*** Student's t-test.
Discussion
The demographic profile of the study participants is similar to the profile already
performed in other studies in Brazil and other countries.[12]
[31]
[32] More than half (62.4%) of the participants were overweight or obese. About half
of them exercised regularly and had concluded their fourth grade education, and more
than half (61.3%) had a monthly family income of £400. The vast majority (85.0%) were
married. Natural menopause occurred in 72.9% of the women and the mean age of the
menopause was 48.4 ± 5.2 years. The PMSQ with 36 items demonstrated that this questionnaire
is an adequate instrument to evaluate sexual dysfunction in menopausal women. The
correlation between the FSFI, used as a gold standard, and the PMSQ was high (r = 0.79;
p < 0.001). The PMSQ cutoff point was established as ≤ 55.6, assuming a sensitivity
of 87.9% and specificity of 78.9% (p < 0.001). The PMSQ identified 54.7% of the women with sexual dysfunction and, when
the FSFI was used, that proportion was 50.3%.
The current study has several strengths. Factor analysis assured that the PMSQ fit
the theoretical concepts of Basson female sexual response cycle.[28]
[33]
[34] In addition, the factor loading of the individual items met the expected standard,
supporting the factorial validity of this instrument. The results met the statistical
requirements of the factorial structure and the internal consistency of the total
instrument and its domains were high. Another aspect to be considered is that the
criterion validity was verified using the gold standard FSFI questionnaire.[35] The PMSQ also has the ability of measuring both peripheral (lubricating) and central
sexual response (arousal, desire), important domains for assessing sexual response,
such as sexual intimacy and self-image.
Among the potential limitations of the present study, the number of participants of
five per item was close to the average that is recommended.[28] Another drawback was the low socioeconomic level of the population included in the
study, and the low level of education. In addition, the researcher needed to conduct
the interviews face to face. Therefore, for external validation, the authors are aware
of the need to examine the applicability of the instrument to other populations with
different socioeconomic levels and different levels of education.
Moderate correlation was found between the domain influence of menopause in the PMSQ
and all FSFI domains, except for the pain domain, which showed weak correlations with
almost all other domains. The low correlation between the FSFI pain domain and the
other PMSQ domains suggests that pain during sex may be only slightly related to the
sexual response components. These results are in accordance with the theoretical framework
adopted for the construct, in which the sexual response involves a coordinated sequence
of several phases, including desire, arousal, orgasm, and sexual intimacy.[6]
A study conducted in Brazil with 540 women, at the ages between 45 and 60 years old
with sexual dysfunction has shown association between lubrication condition and sexual
dysfunction, but those who presented satisfaction in the relationship to their partners
had lower sexual complaints.[36] Sexual intimacy domain in the questionnaire assesses intimacy with the partner during
sexual intercourse and many older women maintain sexual satisfaction because of the
protective role of the psychosocial factors clearly associated with a happy relationship.
In a postal survey conducted in Australia, the relationship factors had a more negative
impact on desire than the age or menopause condition. This same study showed that
physiological and psychological factors may be more significant for low genital arousal
and low orgastic function.[37] The moderate but significant correlations between sexual intimacy (r = 0.40) with
desire, satisfaction, arousal and a weak correlation with menopause (r = 0.20), orgasm
(r = 0.30) and self-image (r = 0.30) in the current study support the knowledge that
sexual intimacy is an important factor and should weigh among the domains of any instrument
designed to evaluate the female sexual function.
A general decline in postmenopausal self-esteem and well-being may also contribute
to the loss of sexual intimacy with the partner.[38] The physical and psychological symptoms of menopause and the simultaneous decline
in sexual function may result in an inferiority sensation and negative body image
in postmenopausal women, thus reducing their quality of life.[39] The self-image domain, being directly related to self-esteem, showed a better correlation
with sexual intimacy in the present study, but no significant correlation with sexual
quality of life and menopause domains. In the group of women classified with sexual
dysfunction, the PMSQ showed the lowest mean score in the menopause domain, indicating
that the menopause condition itself has a negative impact on the sexual response cycle,
sexual quality of life, arousal and desire. In the analysis of the FSFI scores, except
for the menopause domain, the domains that obtained low scores the most in this population
were the desire and arousal domains.[12]
Conclusion
The psychometric validity of the PMSQ, including construct and criterion validity,
responded satisfactorily to the tests performed. The current instrument showed adequate
factor loadings, good internal consistency, and high coefficient correlation with
the gold standard instrument. Therefore, the evaluation of sexual dysfunctions during
menopause has a valid and reliable instrument that includes specific domain. The PMSQ
can be used to examine sexual function in postmenopausal women, but further studies
in other populations with different social levels and lifestyles are needed.
