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. 2023 Jul 4;23:352. doi: 10.1186/s12905-023-02501-1

Prevalence and risk of developing sexual dysfunction in women with multiple sclerosis (MS): a systematic review and meta-analysis

Amid Yazdani 1, Narges Ebrahimi 2, Omid Mirmosayyeb 2, Mahsa Ghajarzadeh 3,✉
PMCID: PMC10318690  PMID: 37403051

Abstract

Objective

To estimate the pooled prevalence of sexual dysfunction (SD) in women with multiple sclerosis (MS).

Methods

We systematically searched PubMed, Scopus, EMBASE, Web of Science, and google scholar and also gray literature up to October 2021.

The search strategy includes:

(“Multiple Sclerosis” OR “MS” OR “Disseminated Sclerosis” OR (Disseminated AND Sclerosis) OR (Sclerosis AND Multiple)) AND (“Sexual Dysfunction” OR (Sexual AND Dysfunction) OR (Sexual AND Dysfunctions) OR (Sexual AND Disorders) OR (Sexual AND Disorder) OR “Sexual Dysfunctions” OR “Sexual Disorders” OR “Sexual Disorder” OR “Psychosexual Dysfunctions” OR (Dysfunction AND Psychosexual) OR (Dysfunctions AND Psychosexual) OR “Psychosexual Dysfunction” OR “Psychosexual Disorders” OR (Disorder AND Psychosexual) OR (Disorders AND Psychosexual) OR “Psychosexual Disorder” OR “Hypoactive Sexual Desire Disorder” OR “Sexual Aversion Disorder” OR (Aversion Disorders AND Sexual) OR (Disorders AND Sexual Aversion) OR “Sexual Aversion Disorders” OR “Orgasmic Disorder” OR (Disorders AND Orgasmic) OR “Orgasmic Disorders” OR “Sexual Arousal Disorder” OR (Arousal Disorders AND Sexual) OR (Disorders AND Sexual Arousal) OR “Sexual Arousal Disorders” OR “Frigidity”).

Results

We found 2150 articles by literature search, after deleting duplicates 1760 remained. Fifty-six articles remained for meta-analysis. The pooled prevalence of SD in MS patients estimated as 61% (95%CI:56–67%) (I2:95.7%, P < 0.001). The pooled prevalence of Anorgasmia in MS patients estimated as 29% (95%CI:20–39%) (I2:85.3%, P < 0.001). The pooled odds of developing SD in MS women estimated as 3.05(95%CI: 1.74–5.35) (I2:78.3%, P < 0.001). The pooled prevalence of decreased vaginal lubrication in MS patients estimated as 32%(95%CI:27–37%) (I2 = 94.2%, P < 0.001). The pooled prevalence of reduced libido was 48%(95%CI:36–61%) (I2:92.6%, P < 0.001). The pooled prevalence of arousal problems was 40%(95%CI: 26–54%) (I2:97.4%, P < 0.001). The pooled prevalence of intercourse satisfaction was 27% (95%CI: 8–46%) (I2:99%, P < 0.001).

Conclusion

The result of this systematic review and meta-analysis show that the pooled prevalence of SD in women with MS is 61% and the odds of developing SD in comparison with controls is 3.05.

Keywords: Sexual dysfunction, Multiple sclerosis, Prevalence

Introduction

Multiple sclerosis (MS) is a degenerative, neurologic disease of the central nervous system (CNS) affecting women more than men [1]. It usually occurs between 20 and 50 years of age, while MS-related complications include both physical and psychological consequences [2]. One of the most common multi-dimensional complications is sexual dysfunction (SD) involving physiological, psychosocial, and interpersonal factors [3]. It is suggested that women with MS have problems regarding finding a partner, building a relationship, and marital issues [3]. SD has negative impacts on health-related quality of life (HRQoL), especially on youth [4, 5]. It can be found at any stages of the disease, and is present at early stage in some cases [6, 7]. The exact etiology of SD in MS is not clear, but physical disability, psychological difficulties, and also side effects of medications could cause SD [8, 9].

Primary SD is the consequence of neurological changes in the body, while secondary SD is due to MS-related complications such as fatigue, pain, spasticity, bladder, and bowel dysfunction [10]. Tertiary SD is related to psychological consequences of MS such as depression, anxiety, and cognitive impairment / and cultural issues regarding sexual consultant in different nations [10].

Loss of orgasm, libido, lubrication, and increased spasticity are common during sexual activity in women with MS  [11, 12].

Different factors such as age, disease duration, disability level, bladder dysfunction, cognitive impairment, and disease course influence SD in MS women [13–15].

Up to now, different original studies have been conducted and three previous systematic reviews and meta-analyses estimated the pooled prevalence of SD in women with MS [16–18]. The aim of this system and meta-analysis is to update the prevalence of SD in MS women.

Methods

Eligibility criteria

Inclusion criteria were

Cross-sectional studies, Articles that had been published in the English language.

Exclusion criteria

Case-report, RCT studies.

We followed The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 for reporting this systematic review [19].

Information sources

Two independent researchers systematically searched PubMed, Scopus, EMBASE, Web of Science, and google scholar and also gray literature up to October 2021.

The search strategy includes

(“Multiple Sclerosis” OR “MS” OR “Disseminated Sclerosis” OR (Disseminated AND Sclerosis) OR (Sclerosis AND Multiple)) AND (“Sexual Dysfunction” OR (Sexual AND Dysfunction) OR (Sexual AND Dysfunctions) OR (Sexual AND Disorders) OR (Sexual AND Disorder) OR “Sexual Dysfunctions” OR “Sexual Disorders” OR “Sexual Disorder” OR “Psychosexual Dysfunctions” OR (Dysfunction AND Psychosexual) OR (Dysfunctions AND Psychosexual) OR “Psychosexual Dysfunction” OR “Psychosexual Disorders” OR (Disorder AND Psychosexual) OR (Disorders AND Psychosexual) OR “Psychosexual Disorder” OR “Hypoactive Sexual Desire Disorder” OR “Sexual Aversion Disorder” OR (Aversion Disorders AND Sexual) OR (Disorders AND Sexual Aversion) OR “Sexual Aversion Disorders” OR “Orgasmic Disorder” OR (Disorders AND Orgasmic) OR “Orgasmic Disorders” OR “Sexual Arousal Disorder” OR (Arousal Disorders AND Sexual) OR (Disorders AND Sexual Arousal) OR “Sexual Arousal Disorders” OR “Frigidity”).

Selection process

After obtaining the results, and importing them to Endnote, they omitted duplicates. Then titles, and abstracts were screening, and potential full texts were obtained. The researchers extracted data from each study, entered in Excel, and in the case of discrepancies, the third researcher solved the problem.

Data items

Data regarding first author, country of origin, number of enrolled patients, number of cases with SD, mean age, mean EDSS, mean duration of the disease, were collected.

Statistical analysis

All statistical analyses were performed using STATA (Version 14.0; Stata Corp LP, College Station, TX, USA). To determine heterogeneity, Inconsistency (I2) was calculated.

We used random effects model.

Effect measures

The pooled prevalence of domains of sexual function were estimated. The pooled odds ratio(OR) of developing sexual dysfunction in women with MS comparing to healthy controls were calculated.

Results

We found 2150 articles by literature search, after deleting duplicates 1760 remained. Fifty-six articles remained for meta-analysis (Fig. 1).

Fig. 1.

Fig. 1

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Flow diagram summarizing the selection of eligible studies

Included studies were published between 1996, and 2021.Most included studies were from Iran, followed by Italy, and Turkey. The mean age of participants ranged between 24.7, and 50.7 years, and EDSS ranged between 1.7 and 5. The most frequent applied questionnaire was FSFI (Table 1).

Table 1.

Basic characteristics of included studies

Author Year Country Design T. MS
All female		 MS type
RRMS
SPMS
PPMS
CIS		 Age EDSS Disease duration Measurements Total sexual dysfunction in PwMS Anorgasmia
M Zorzon [12] 1999 Italy Case control 70

RR 50

PP 16

SP 4

 40.2(10.9) 2.6(1.7) 10.7(8.5) Szasz Sexual Functioning Scale 44 21
M. Zorzon [20] 2001 Italy Cohort 64 NR NR NR NR Szasz Sexual Functioning Scale 24 24
Kisic-Tepavcevic Darija [21] 2015 Serbia cohort 66 NR NR NR NR Szasz sexual functioning scale 45 8
DK Tepavcevic [5] 2008 Serbia cross-sectional 78

RR 54

SP 22

PP 2

 41.7(9.3) 4.6(1.6) 9.1(6.7) Szasz sexual functioning scale 66 12
Marita P. McCabe [22] 1996 Australia Cross-sectional 74 NR NR NR NR

Szasz

At least one problem

 59 17
Iris Zavoreo [23] 2016 Croatia Cross sectional 56 NR NR NR NR SSS NR NR
Aleksandra Kołtuniuk [24] 2020 Poland Cross-sectional 101

RR 82

SP 14

PP 5

 36.7(9.56) NR 75.1(50.2) months SSQ 55 NR
M. Lew-Starowicz [25] 2013 Poland Cross-sectional 137 NR 50.7(7) NR 16.4(8.6) SFQ28 113 NR
MW Nortvedt [26] 2001 Norway Cross-sectional 118 NR NR NR NR SF-36 67 NR
Sacco E [27] 2011 Italy Cross-sectional 65 NR NR NR NR PISQ-12 22 24
R Vazirinejad [28] 2008 Iran Cross-sectional 126 NR NR NR NR MSQOL-54 115 NR
Jing Wu [29] 2020 Australia Cross-sectional 1591 NR NR NR NR MSQOL-54 NR NR
Z. Tulek [30] 2011 Turkey cross-sectional 70 NR NR NR NR MSQOL-54 NR NR
MW Nortvedt [31] 2007 Norway Cross-sectional 40 NR NR NR NR MSQoL-54 NR NR
Claudia H. Marck [32] 2016 Australia Cross-sectional 1663 NR NR NR NR MSQOL-54 925 NR
Effat Merghati-Khoei [33] 2013 Iran Cross-sectional 132 NR 36.9(8.3) NR 6.8(5.3) MSISQ-19 115 NR
Vida Ghasemi [34] 2020 Iran Cross-sectional 260

RR 212

SP 36

PP 12

 37.83(7.34) 2.02 (1.52) 6.96(5.06)

MSISQ-19

44.19(16)

198

Primary SD 176

Secondary SD 158

Tertiary SD 126

 NR
Dilaram Billur Çelik [13] 2013 Turkey Cross-sectional 44 NR NR NR NR MSISQ-19

32

Primary SD 19

Seconder SD 25

Tertiary SD 13

 NR
M. Demirkiran [35] 2006 Turkey Cross-sectional 33 NR NR NR NR MSISQ-19 27 NR
Sarah Abdo [36] 2020 Egypt

Cross-sectional

ABS

 43 NR 24.71(3.55) NR NR MSISQ-19

24

Primary SD 43

secondary SD 7

Tertiary SD 43

 NR
Edgar Carnero Contentti [37] 2019 Argentina Cross-sectional 137

RR 112

PP 9

SP 18

 49.1(10.2) NR 7.5(0.5) MSISQ-19

119

Primary SD 99

Secondary SD 103

Tertiary SD 88

 NR
Patrick Altmann [38] 2021 Italy cross-sectional 53 NR NR NR NR MSISQ-19 25 NA
Fereshteh Ashtari [39] 2014 Iran cross-sectional 271 NR

36.1(8) n = 173

33.6(7.9) n = 98

 NR

78.4(53.5) n = 173

60.4(36.8) n = 98

 MSISQ-19

173

Primary SD 142

secondary SD 102

tertiary SD 120

 NA
Kowsar Qaderi [40] 2014 Iran Cross-sectional 132 NR 36.9(8.3) NR NR MSISQ-19 110 NR
Sabine Salhofer-Polanyi [41] 2016 Austria Cross-sectional 42 NR 34(7) Median 1.75 NR MSISQ-19

15

Primary SD 28

Secondary SD 17

Tertiary SD 14

 NR
Hanna Pašiü [42] 2019 Croatia Cross-sectional 75 NR NR NR NR MSISQ-15 NR NR
Stenager E [43] 1996 Denmark cohort 27 NR NR NR NR MRD 16 NR
Marita P. McCabe [44] 2002 Australia Case–control 237 NR 44.45 NR NR ISS 194 NR
Marita P. Mccabe [45] 2003 Australia Cohort 321 NR NR NR NR ISS 278 NR
Cira Fraser [14] 2008 USA cross-sectional 219 NR 45.4(9.3) NR NR Guy’s Neurological Disability Scale 106 NR
Simon Dupont [46] 1996 UK Cross-sectional 65 NR NR NR NR GRISS 11 18
Vassilios Tzortzis [7] 2008 Greece Cross-sectional 63

RR 58

PP 5

 33(6.4)

mean

2.5, range 0–3.5

Mean 2.7

Range 19–51

 FSFI 22 NR
Aleksandra Kołtuniuk [24] 2020 Poland Cross-sectional 101

RR 82

SP 14

PP 5

 36.7(9.56) NR 75.1(50.2) months FSFI 45 NR
Katharina M. Hösl [47] 2018 USA Cross-sectional 83

RR 76

SP 6

PP 1

 Median 36.2 NR NR FSFI 37 NR
Fatemeh Nazari [48] 2020 Iran Cross-sectional 300

RR 243

PMS 39

CIS 18

 36.35(7.33) 2.06(1.85) 7.37(5.40) FSFI 209 NR
Pawel Bartnik [49] 2017 Poland Cross-sectional 86 RR 86 32.03(7.22) 2.03(1.44) 7.87(5.38) FSFI 21 NR
Marcin Popek [50] 2018 Poland case–control 55 NR NR NR NR

FSFI

26.24(7.22)

 22 NR
Fatih Firdolas [51] 2012 Turkey Cross sectional 23

RR 17

SP 6

 NR

2(0.22) N = 17

5.91(0.53) N = 6

 NR FSFI 12 NR
Giulia Gava [52] 2019 Italy Case–control 153 NR 47.3(10.5) 3.1(2.2) 13.5(8.7)

FSFI

17.9(12.7)

 64 NR
Ilan Gruenwald [53] 2007 Israel cross-sectional 41

RR 38

SP 3

 Median 2.5 Median 10 FSFI 25 NR
Charalampos Konstantinidis [54] 2018 Greece cross-sectional 248 NR 45.84(8.448) NR 12.78(2.18) FSFI 160 NR
Giuseppe Lombardi [55] 2011 Italy Cross-sectional 54 NR

Mean:34.7

(26–44)

Mean:2.9

(1.5–6)

Mean 8.6

(2–18)

 FSFI 31 NR
Fariba Askari [2] 2016 Iran Cross-sectional 86

RR 81

SP 5

 33.4(6.5) NR NR FSFI 58 NR
Khadijeh Mohammadi [56] 2013 Iran cross-sectional 226

RR 169

PP 4

SP 53

 35.7(8.07) NR 1.8(0.79) FSFI 125 NR
Alireza Alehashemi [57] 2019 Iran case–control 64

RR 60

SP 4

 35.25(8.07)

Mean 2

Range 0–6

 Mean 52.5 months (ranging from 6 to 84.5)

FSFI

22.86 (5.36)

 53 NR
Ramezani, M.A [58] 2018 Iran Cross-sectional 70 NR NR NR NR FSFI 44 NR
Jeroen R. Scheepe [59] 2015 Netherlands Cross-sectional 50 NR NR NR NR FSFI 16 NR
Tzitzika, M [54] 2018 Greece

Cross-sectional

ABS

 267 NR NR NR NR FSFI 172 NR
Julia Koehn [60] 2014 Germany Cross-sectional 82 NR 36.7(9.5) NR 69(75.1) Months

FSFI

3.31(1.2)

 37 NR
Mahsa Ghajarzadeh [11] 2013 Iran Case–control 100

RR 95

SP 5

 32.8(7.6) 5(4.8) 13(3.1)

FSFI

23.2(7.1)

 66 NR
Volkan Solmaz, [61] 2018 Turkey Case–control 42

RR 34

SP 7

PP 1

 41.9(8.06)

Median

2.2(0–7)

 Mean range: 8.9(25–1)

FSFI

15.84(6.33)

 40 NR
E. Fragala [62] 2015 Italy Cross-sectional 75 NR NR NR NR

FSFI

median (IQR) 16.0 (2.0–25.5)

 51 NR
Marian Petersen [63] 2020 Denmark Cross-sectional 180 NR NR NR NR CSFQ 116 NR
Dilaram Billur Çelik [13] 2013 Turkey Cross-sectional 44 NR NR NR NR ASEX NR NA
Betu¨l Kılıc [64] 2012 Turkey cross-sectional 23 NR Mean 39.83 (8.88) NR 8.09(7.29)

Arizona Sexual Experiences Scale

17.91(5.75)

 14 NR
Rocco Salvatore CalabrJ [65] 2018 Italy Cross-sectional 54 NR NR NR NR 40-item ad hoc questionnaire NR 31
Author Hyporgasmia Decrease vaginal lubrication Change in vaginal sensation Reduce libido Painful intercourse Lack of sexual desire Partner satisfaction problems satisfaction Arousal Problems T
control		 Total sexual dysfunction in control
M Zorzon [12] 17 25 19 22 NR NR NR NR NR 71 8
M. Zorzon [20] 25 25 28 NR NR NR NR NR NA NA
Kisic-Tepavcevic Darija [21] 27 27 18 47 NR NR NR NR NR NA NA
DK Tepavcevic [5] 35 30 21 58 NR NR NR NR NR NA NA
Marita P. McCabe [22] NR 14 NR NR 1 21 NR NR NR NA NA
Iris Zavoreo [23] 12 11 NR NR NR 14 NR NR NR NA NA
Aleksandra Kołtuniuk [24] NR NR NR NR NR NR NR NR NR
M. Lew-Starowicz [25] 54 66 65 NR NR 79 NR NR 62 NA NA
MW Nortvedt [26] NR NR NR NR NR NR NR NR NR NA NA
Sacco E [27] NR NR NR NR 20 21 NR 29 NR NA NA
R Vazirinejad [28] NR NR NR NR NR NR NR NR NR NA NA
Jing Wu [29] 929 808 NR NR NR 1017 549 NR NR NA NA
Z. Tulek [30] 35 28 NR NR NR 37 23 NR NR NA NA
MW Nortvedt [31] 28 20 NR NR NR 25 18 NR NR NA NA
Claudia H. Marck [32] 599 514 NR NR NR 695 238 NR NR NA NA
Effat Merghati-Khoei [33] 100 80 46 77 NR NR NR NR NR NA NA
Vida Ghasemi [34] 156 82 31 NA NR 966 NR NR NR NA NA
Dilaram Billur Çelik [13] 10 10 NR NR NR 9 NR NR NR NA NA
M. Demirkiran [35] 22 17 19 21 NR NR NR NR 20 NA NA
Sarah Abdo [36] NR 3 NA 11 NR NR NR NR NR NA NA
Edgar Carnero Contentti [37] 55 44 27 NR NR 53 NR NA NA NA NA
Patrick Altmann [38] NA NA NA NA NA NA NA NA NA NA NA
Fereshteh Ashtari [39] 112 70 48 NR NR 92 NR NR NR NA NA
Kowsar Qaderi [40] 83 67 38 64 NR NR NR NR NR NA NA
Sabine Salhofer-Polanyi [41] 17 12 6 20 NR NR NR NR 11 NA NA
Hanna Pašiü [42] 19 16 13 NR NR 19 11 NR NR NA NA
Stenager E [43] 3 4 6 15 NR NR NR NR NR NA NA
Marita P. McCabe [44] 101 78 81 NR 40 96 NR NR 73 190 mean age = 44.35 years 146
Marita P. Mccabe [45] 101 78 81 NR 40 96 NR NR 73 239 191
Cira Fraser [14] NR NR 5 NR NR 15 2 NA NA
Simon Dupont [46] NR NR NR NR 26 NR NR 7 NR NA NA
Vassilios Tzortzis [7] NR NR NR NR NR NR NR NR NR 61 13
Aleksandra Kołtuniuk [24] NR NR NR NR NR NR NR NR NR NA NA
Katharina M. Hösl [47] NR NR NR NR NR NR NR NR NR 21 1
Fatemeh Nazari [48] 111 71 NR NR 51 116 NR 70 116 NA NA
Pawel Bartnik [49] NR NR NR NR NR NR NR NR NR NA NA
Marcin Popek [50] NR NR NR NR NR NR NR NR NR

55

29.91

(3.79)

 12
Fatih Firdolas [51] NR NR NR NR NR NR NR NR NR NA NA
Giulia Gava [52] NR NR NR NR NR NR NR NR NR

153

Age:48.5(9.6)

FSFI:21.1(11.2)

 24
Ilan Gruenwald [53] 22 NR NR NR 3 25 NR NR 13 NA NA
Charalampos Konstantinidis [54] NR NR NR NR NR NR NR NR NR NA NA
Giuseppe Lombardi [55] NR NR NR NR NR 12 NR NR NR NA NA
Fariba Askari [2] NR NR NR NR NR NR NR NR NR NA NA
Khadijeh Mohammadi [56] 81 41 29 77 54 100 NA NA
Alireza Alehashemi [57] NR NR NR NR NR NR NR NR NR

64

24.39 (4.75)

 NR
Ramezani, M.A [58] NR NR NR NR 36 21 NR NR NR NA NA
Jeroen R. Scheepe [59] NR NR NR NR NR NR NR NR NR NA NA
Tzitzika, M [54] NR NR NR NR NR NR NR NR NR NA NA
Julia Koehn [60] NR NR NR NR NR NR NR NR NR

21

Age

36.5(11.8)

FSFI: 4.5(0.7)

 1
Mahsa Ghajarzadeh [11] NR NR NR NR NR NR NR NR NR

50

Age 31.8(8.4)

FSFI:

26.8(5.2)

 NR
Volkan Solmaz, [61] NR NR NR NR NR NR NR NR NR

41

Age:39.7(7.3)

FSFI:31.01(3.53)

 NR
E. Fragala [62] NR NR NR NR NR NR NR NR NR NA NA
Marian Petersen [63] 118 NR NR NR NR 131 NR 131 151 NA NA
Dilaram Billur Çelik [13] 4 5 NA 5 NR NR NR 6 7 NA NA
Betu¨l Kılıc [64] NR NR NR NR NR NR NR NR NR NA NA
Rocco Salvatore CalabrJ [65] NR NR NR NR NR NR NR NR NR NA NA
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Totally 8980 patients were evaluated and the total number of patients with SD was 4245.

The pooled prevalence of SD in MS patients estimated as 61% (95%CI:56–67%) (I2:95.7%, P < 0.001) (Fig. 2).

Fig. 2.

Fig. 2

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The pooled prevalence of SD in MS patients

The pooled prevalence of Anorgasmia in MS patients estimated as 29% (95%CI:20–39%) (I2:85.3%, P < 0.001) (Fig. 3).

Fig. 3.

Fig. 3

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The pooled prevalence of anorgasmia in MS patients

The pooled prevalence of decreased vaginal lubrication in MS patients estimated as 32%(95%CI:27–37%) (I2 = 94.2%, P < 0.001) (Fig. 4).

Fig. 4.

Fig. 4

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The pooled prevalence of decreased vaginal lubrication in MS patients

The pooled prevalence of reduced libido was 48%(95%CI:36–61%) (I2:92.6%, P < 0.001) (Fig. 5).

Fig. 5.

Fig. 5

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The pooled prevalence of reduced libido in MS patients

The pooled prevalence of intercourse satisfaction was 27% (95%CI: 8–46%) (I2:99%, P < 0.001) (Fig. 6).

Fig. 6.

Fig. 6

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The pooled prevalence of reduced libido in MS patients

The pooled prevalence of arousal problems was 40%(95%CI: 26–54%) (I2:97.4%, P < 0.001) (Fig. 7).

Fig. 7.

Fig. 7

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The pooled prevalence of arousal problems in MS patients

The pooled odds of developing SD in MS women estimated as 3.05(95%CI: 1.74–5.35) (I2:78.3%, P < 0.001) (Fig. 8).

Fig. 8.

Fig. 8

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The pooled odds of developing SD in women with compared to healthy controls

Discussion

MS is a neurological disease characterized by a wide range of physical, and psychological complications. The prevalence of SD in MS is near five times higher than general population [12, 66], although it is considered poorly in this population.

To our knowledge, this is the first comprehensive systematic review and meta-analysis including all related studies evaluating SD in women with MS. We included all studies which used different questionnaires. The pooled prevalence of SD was estimated as 61%, and the most common SD complaint was reduced libido (the pooled prevalence was estimated as 48%), we also found that the pooled prevalence of intercourse satisfaction was 27%.

We included all studies which applied different diagnostic tools, so out estimate would be higher than previous ones.

In a previous systematic review and meta-analysis which was conducted by Zhao et al., the relative risk (RR) of developing SD in MS women was 1.87 which shows that women with MS have 87% increased risk of developing SD [16]. They also reported lower pooled scores of desires, arousal, orgasm, satisfaction, pain, and lubrication in MS group.

In our previous systematic review, which we included only studies that applied FSFI questionnaire for evaluating SD in MS, the pooled prevalence of SD estimated as 55% [18].

In 2008, Tzorts et al. evaluated 63 women with MS using FSFI questionnaire, and reported SD in22 and reported no depression in affected cases [7].

Zorzon et al. used Szasz Sexual Functioning Scale for SD assessment and reported SD in 44 out of 70 cases. Anorgasmia or hyporgasmia followed by decreased vaginal lubrication were the most affected subscales [12].

The variation about the prevalence of SD in included studies is due to unclear definition of SD, diverse inclusion, and exclusion criteria, various diagnostic methods, no standardized tools, and cultural issues.

SD is an important issue in marital life which is ignored by most physicians and patients. It is a multi-dimensional issue which affects quality of life as well as psychological well-being. Different factors such as disease duration, disability level, psychological disorders such as depression, anxiety, and stress are considered to play role in SD development in MS while there is controversies between studies [11].

Most physicians do not pay attention to this part of their patient’s lives, and patients hesitate to talk about intimate issues.

Depression is negatively correlated with FSFI score and its subscales in a previous original study [11]. On the other hand, it is shown that depression is related with both libido reduction and arousal problems [67, 68].

In another study, higher age was associated with increased SD prevalence in MS [69] while Çelik et al. reported that SD should be evaluated in MS women at earlier stages and disease duration or disability level are not prognostic factors for developing SD [13]. Zhao et al. in their meta-analysis showed that disease duration longer than ten years, increases the risk of SD 2.5fold in MS cases [16].

Another influencing factor is bladder dysfunction in MS cases which negatively affects their sexual activity [70]. Fragala et al. investigated SD in 91% of MS women with detrusor over-activity and 66% without detrusor over-activity [62].

The association refers to S2, S3 and S4 innervation of bladder, which control sexual response [10]. On the other hand, detrusor dysfunction as a MS-related complication may reflect severe neurological disability and SD [71].

Zivadinov et al. investigated that physical disorders, depression, age at MS onset, and also neurological impairment while they reported no correlation between SD and duration of the disease [15].

Higher disability level, depression and anxiety were related with SD presence in Demirkian et al. study [72].

This systematic review has some strength. First, we included all studies which evaluated SD. Second, the number of included studies is high. Third, we analyzed all subscales of SD.

We also had some limitations. First, all included studies used various diagnostic tools. Second, there was no clear definition of SD. Third, inclusion criteria of participants differed between studies.

Conclusion

The result of this systematic review and meta-analysis show that the pooled prevalence of SD in women with MS is 61% and the odds of developing SD in comparison with controls is 3.05.

Acknowledgements

None.

Authors’ contributions

A.Y: Study design and data analysis. N.E: Data gathering and article writing. O.M: Data analysis and article writing. M.G: Methodology and article writing. All authors reviewed the manuscript.

Funding

None.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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