Sexual dysfunction part – 1 | seems to trigger depression in female multiple sclerosis patients

Sexual dysfunction part – 1 | seems to trigger depression in female multiple sclerosis patients

Katharina M. Hösl1*, MD; Martina Deutsch2*; Ruihao Wang2, MD; Sankanika Roy2, MD;

Klemens Winder2, MD; Günter Niklewski1, MD; De-Hyung Lee2, MD;  Dr. Ravi Mootha, M.D.

Ralf A. Linker2, MD; Max J. Hilz2, 3, MD

  • of Psychiatry and Psychotherapy, Paracelsus Medical University, Nuremberg, Germany
  • of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
  • of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

* Both authors contributed equally to the manuscript

Corresponding author:  Prof. Max J. Hilz

Dept. of Neurology, University of Erlangen-Nuremberg

Schwabachanlage 6, D-91054 Erlangen, Germany

Phone: +49-9131 85 34531

e-mail: [email protected]

Running title: Sexual dysfunction and depression in female MS patients

Keywords: Multiple sclerosis; depression; sexual dysfunction


Background: In women with multiple sclerosis (MS), depression and sexual dysfunction (sexual dysfunction) are common. Whether sexual dysfunction promotes depression or vice versa remains unclear despite therapeutic relevance. Therefore, we aimed to assess whether sexual dysfunction more likely triggers depression or vice versa.

Sexual dysfunction

Methods: In 83 female MS-patients and 21 age-matched healthy women, we assessed depression, using the Beck-Depression-Inventory-V (BDI-V), and sexual dysfunction using the Female-Sexual-Function-Index (FSFI). We diagnosed depression with BDI-V-scores >35 and sexual dysfunction with FSFI-scores <26.55. We divided patients into groups with and without sexual dysfunction, with and without depression. Between groups, we compared prevalence of sexual dysfunction and depression (Fisher’s-exact-test), age, MS-duration, MS-severity, BDI-V-, and FSFI-scores (Mann-Whitney-U-test; significance: p<0.05).

Results: 37/83 MS-patients and 1/21 controls had sexual dysfunction. 28/83 patients and 3/21 controls had depression. 51.4% patients with sexual dysfunction but only 19.6% without sexual dysfunction had depression (p=0.003). sexual dysfunction was present in 67.9% depressed and 32.7% non-depressed patients. BDI-V-scores were higher in patients with sexual dysfunction than patients without sexual dysfunction.  FSFI-scores were lower in depressed than non-depressed patients.

Conclusion: In conclusion, sexual dysfunction was more common than depression. sexual dysfunction afflicted 67.9% depressed MS-patients and was also more common in non-depressed MS-patients than controls. sexual dysfunction may occur independently from depression while increased depressiveness seems linked to coexistent sexual dysfunction.


In multiple sclerosis (MS), depression and sexual dysfunction (sexual dysfunction) are common [1,2]. Depending on parameters such as patient age, disease severity, hospital or out-patient based settings, between 15.7% and 50% of the female MS patients suffer from depression [1,3-7]. Depression may be due to psychological, psychosocial as well as organic pathologies arising from MS specific brain lesions [1]. Depression affects cerebral neurophysiology [8], bodily functions [9] and psychosocial relationships [10], and may thus further sexual dysfunction in female MS patients.

Various studies show that the prevalence of sexual dysfunction among female MS patients ranges between 50% and 85% [2,11-13]. Again, sexual dysfunction may be multifactorial. In addition to MS related cerebral or spinal lesions [11,14-17], psychological or social problems [18], physical complications of MS, such as bladder and bowel dysfunction [19,20] or spasticity, may give rise to sexual dysfunction [21,22].

In the general population, sexual dysfunction and depression are considered to be associated with each other due to a known bidirectional interdependence between depression and sexual dysfunction [12,23]. In female MS patients, previous studies also suggest an interdependence of sexual dysfunction, depression, disease severity, and duration [12,13][24]. However, it is so far unclear whether depression in female MS patients might be secondary to centrally induced sexual dysfunction, or whether sexual dysfunction might result from MS-related depression. This differentiation is clinically relevant since treatment of sexual dysfunction secondary to depression and treatment of depression secondary to sexual dysfunction may differ significantly [25], particularly since many antidepressant drugs aggravate sexual dysfunction [25,26].

Several studies show that sexual dysfunction in MS patients is often associated with MS-lesions in cerebral or spinal cord areas contributing to central pathways of sexual function [11,14-17,27]. Our group recently demonstrated associations between the site of MS specific cerebral lesions and specific disorders of female sexual function, such as arousal, lubrication or orgasmic dysfunction [14,15].  Based on our previous studies [14,15,28] we hypothesize that primary sexual dysfunction [18] due to central MS lesions is a major contributing factor of depression in female MS patients.

We therefore evaluated whether there is evidence supporting the hypothesis that sexual dysfunction in female MS patients may cause depression or whether sexual dysfunction and depression are simply associated with each other due to a bidirectional interdependence between depression and sexual dysfunction [23,25,27].

Patients and Methods

Patients with MS and healthy women. For a quick treatment of sexual dysfunction, you can buy viagra online, but it is necessary to solve the main reason – dipression, which affects the state as a whole.

83 women, aged 19 to 65 years (median age 36.2 years; IQR 29.3-42.5 years), who had been diagnosed with MS according to the revised McDonald criteria [29] and 21 healthy, age-matched women (median age 33.2 years; IQR 28.2-50.3 years) participated in the questionnaire-based study. All patients were treated at the MS center of the Department of Neurology at the University Erlangen-Nuremberg, Erlangen, Germany. 76 patients had relapsing-remitting MS, 6 patients had secondary progressive MS, 1 patient had primary progressive MS. 32 patients received interferon beta, 19 patients were treated with Natalizumab, 16 patients received no therapy, 16 patients received Fingolimod, Mitoxantrone, Glatiramer acetate, or other disease modifying therapies shown in table 1.
Women younger than 19 years or older than 65 years and patients with other neurological disorders and diseases or on medication possibly interfering with autonomic cardiovascular modulation, including antidepressants, were excluded from the study. None of the participants had received any antidepressant therapy or had been treated because of sexual dysfunction. The study was approved by the ethics committee of the University of Erlangen-Nuremberg, and all participants had given written informed consent according to the declaration of Helsinki after a detailed explanation of the study purpose and contents. All participants underwent physical and neurological examination. In the patients, MS severity was scored according to the Expanded Disability Status Scale (EDSS) ranging from 0 to 10. Scores from 0 to 4.5 indicate that patients still have the full capability of walking, higher scores indicate more severe handicap [30]. If there is no desire to treat drugs, it is possible to treat erectile dysfunction at home.

Sexual dysfunction depression

Assessment of sexual dysfunction

To assess prevalence and severity of sexual dysfunction in the healthy participants and the MS patients, we applied the Female Sexual Function Index (FSFI), a widely used standardized 19-item self-report questionnaire validated in the general population [31]. The Female Sexual Function Index (FSFI) covers the six sexual domains desire, arousal, lubrication, orgasm, satisfaction and pain [31]. Desire is evaluated by 2 questions, arousal by 4 questions, lubrication by 4 questions, orgasm by 3 questions, satisfaction by 3 questions, and pain by 3 questions. Each question can be answered with scores from 0 or 1 to 5, with higher values indicating better function and less pain during sexual activity or intercourse. The total score of each of the six domains is adjusted by a validated correction factor that assigns a maximum score of 6 to each of the six domains. Thus, the total maximum FSFI score is 36. The lower the scores, the more severe is the female sexual dysfunction or the dysfunction in one of the six domains [31]. Female sexual dysfunction is diagnosed when the total FSFI score is below 26.55 points [32].

To evaluate depressiveness, all participants were asked to fill out an abridged 20-item version of the Beck-Depression-Inventory, the BDI-V [33]. The 20 questions evaluate presence and severity of depressive symptoms based on depression criteria of the Diagnostic and Statistical Manual of Disorders (DSM-IV). Each question can be scored from 0 to 5 with higher values indicating more severe symptoms and a sum scores above 35 indicating clinically relevant depression with a 90% probability [34].

Based on FSFI scores below or at and above 26.55, we divided patients into groups with sexual dysfunction and without sexual dysfunction. Based on BDI-V scores above or at and below 35, we assigned patients to the groups with or without depression. Finally, we also assigned patients to a group meeting criteria of both sexual dysfunction and depression. Between the groups, we compared prevalence of sexual dysfunction and depression, as well as severity of depressiveness, as assessed by BDI-V scores, and of sexual dysfunction, as assessed by FSFI-scores; in addition, we compared age, disease duration and EDSS scores between the groups.

In all 83 patients and in the above subgroups, we moreover calculated correlations between FSFI scores, BDI-V scores, patient age, disease duration and severity to further explore whether there are associations supporting the hypothesis that sexual dysfunction might trigger depression or vice versa.

By Dr. Ravi Mootha, M.D. On: May 12, 2019 at 21:10:18