Sexual dysfunction in women who received breast cancer treatment: a cross-sectional study

Abstract

Breast cancer has a major impact on global public health. This cross-sectional study aimed to investigate the prevalence and associated factors of sexual dysfunction in women who received breast cancer treatment (BCT). Data were collected from sexually active adult women in Natal, Brazil, who had completed at least one year of BCT. The Female Sexual Function Index (FSFI) was used to assess sexual function in 88 participants. The prevalence of sexual dysfunction was found to be 76.1%, with the most affected domains being sexual desire and vaginal lubrication. Factors associated with sexual dysfunction included difficulty adjusting to post-surgery body changes, pre-existing comorbidities, and the absence of breast reconstruction. These findings highlight the significant impact of BCT on sexual function and underscore the need for targeted prevention and treatment interventions to address the sexual health needs of women undergoing this experience.

Introduction

Considered the most incident type of cancer in women worldwide, breast cancer (BC) has a major impact on global public health¹. In the global scenario, the estimate for the year 2045 indicates an increase of 46.5% in new cases of BC². Therefore, this malignancy has become one of the main causes of mortality in the female population³. In Brazil, the BC incidence rate is 41.89 cases per 100,000 women, with an estimate of 73,610 new cases for each year of the 2023–2025 period⁴. National data also reveal that BC ranks first as a cause of death from cancer in the female population in four Brazilian regions, except for the northern region⁵.

Because of advances in therapeutic intervention methods, the availability and timely access to adequate treatment by the Brazilian Unified Health System (SUS), BC patients may have a longer survival period (> 5 years after diagnosis). Although the increase in the survival rate is relevant, aspects related to sexual life may have a negative impact on health and, consequently, quality of life for these women^6,7. Studies point to a high prevalence (from 30 to 80%) of sexual dysfunction in women who received breast cancer treatment (BCT)^8–11.

It is known that sexual dysfunction itself causes a profound implication on female quality of life, since it is responsible for changes in sexual response, including decreased libido, sexual arousal disorders, decreased lubrication, orgasm disturbances and clinical conditions such as dyspareunia and vaginismus^13,14. When this aspect is brought to BC survivors, in addition to the implications, sexual dysfunction can generate emotional exhaustion, negatively affect self-perception of body image, interfere with the person’s love relationships and be a constant reminder of the disease^14,15. Women exposed to BCT may constitute a high-risk group for developing sexual dysfunction¹⁶. This may be explained by BC-specific treatment experiences such as changes in body image after breast conserving surgery or mastectomy, the physiopsychological effects of chemoradiotherapy and the iatrogenic impact of hormone therapy on sexuality¹⁶.

Given this scenario, there is a need to better understand the magnitude of sexual dysfunction and its associated factors in this group. Understanding the current sexual dysfunction situation is fundamental for the development of intervention strategies, improving the well-being and sexual function (SF) of these women. Furthermore, the majority of studies on factors associated with sexual dysfunction in women who received BCT have been carried out in developed countries^8,9,11,12, with different socioeconomic and health-related characteristics from the Brazilian Northeast. Thus, the aim of this study is to verify sexual dysfunction prevalence and identify its associated factors in women who received BCT.

Methods

This is a cross-sectional study conducted in accordance with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE, 2007)¹⁷. Data were collected from February 2019 to October 2021 at a non-profit care units for patients with breast cancer (Liga Norte Riograndense Against Cancer, Natal, Rio Grande do Norte, Brazil) in the city of Natal, Brazil and via telephone due to the Covid-19 pandemic. The LNRGC is a philanthropic initiative that provides medical assistance, specialized diagnosis and treatment, as well as prevention, follow-up, rehabilitation, and palliative care to patients.

The study was approved by the committee for ethics in research with humans of the Liga Norte Riograndense Against Cancer (no 2.197.925). All participants signed the informed consent form, and for illiterate participants, we obtained informed consent from parents/or legal guardians. This process was carried out as recommended by the CNS Resolution 510/2016, Operational Norm 001/2013, and accordance with the Declaration of Helsinki. Data collection started only after the consent of the participants.

The sample was constituted by women diagnosed with malignant neoplasm of the breast (C50), according to the International Classification of Diseases (ICD-10), who received to one or more oncological treatments (surgery, chemotherapy, radiotherapy, or hormone therapy) between 2013 and 2017 in Natal, Rio Grande do Norte, Brazil.

For sample calculation, a prevalence of 75% of sexual dysfunction was considered in women who received to neoadjuvant and/or adjuvant BCT, according to a study by Bartula & Sherman¹⁵. An Error Factor (EF) of 10% was considered, requiring the inclusion of 72 participants in the composition of the study sample. The systematic sampling technique was used to select the participants with cancer through medical records, in which a fixed interval of cases was calculated, using the sampling constant (k) (number of cases in the population (N)/sample size).

The study included sexually active women living in Rio Grande do Norte state (considering different cities and areas), aged 18 and over, who underwent oncological treatment for at least one year and are still undergoing clinical follow-up at the specialized care unit, CECAN, from the LNRGC. Being sexually active is a precondition for the application of the FSFI questionnaire that assessed the presence or absence of sexual dysfunction¹⁸. Exclusion criteria were women who presented a cognitive deficit that could impair the understanding of the questionnaires during the interviews; women who have debilitating/disabling morbidities not associated with BC and its treatment; patients with metastases, in critical oncological status under palliative care and cancer recurrence.

The Female Sexual Function Index (FSFI), translated and validated into Portuguese by Thiel et al.¹⁸, was used to measure SF. It consists of a brief questionnaire, with 19 questions, based on the self-report of women during the last four weeks, and evaluates female sexual response in the domains: sexual desire, arousal, vaginal lubrication, orgasm, sexual satisfaction and pain. The questions have a response pattern, in which they are scored individually by a Likert scale (0 to 5). The total score is obtained by adding the scores for each domain multiplied by a correction value. Based on the 26-point cutoff point proposed by Wiegel et al. (2005)¹⁹, it became possible to discriminate between women with higher and lower risk of having). A score equal to or less than 26 points is indicative of sexual dysfunction. The FSFI has high levels of test-retest reliability and internal consistency²⁰.

The theoretical model was hypothesized based on a systematic review of the literature of observational studies¹². The variables most frequently found in the studies and that could help answer our research question were included and are present in the semi-structured questionnaire.

Data collection consisted of two main phases: initially, it was performed through access to the archived medical records of patients who were previously selected in the cancer support group system. Data were collected from the medical records, such as clinical history (chosen therapy; types of treatment; surgical and breast reconstruction techniques; axillary approach) as well as the presence of patient follow-up by a multidisciplinary team.

Data of the patients selected to participate in the study underwent individual interviews in person or via telephone, were collected using medical records and transferred to a digital form including sociodemographic information (name, age, body mass index, race, marital status, educational level, income according to Brazilian minimum wage in 2017, and access to health services); life habits (tobacco and alcohol consumption and physical activity frequency); gynecological and obstetric history (pregnancies, deliveries, abortions, breastfeeding, nulliparity, gynecological appointments and pap smear exam frequency, menopausal status, hormonal replacement, mammography, breast self-examination, and family and personal history of cancer); sexual activity (investigated with the questions “are you sexually active?” and “did you have sexual activity before treatment for breast cancer?”); comorbidities (hypertension, diabetes, arthritis, arthrosis, dyslipidemia); depression (investigated with the question “have you received a diagnosis of depression from a medical professional?“); use of medications; body image (investigated with the questions “do you have difficulty dealing with your body after surgery? and “what is your degree of satisfaction with your body image?”) and clinical variables (chosen therapy; types of treatment; surgical and breast reconstruction techniques; axillary approach) as well as the presence of patient follow-up by a multidisciplinary team (diagnosis, staging, type and duration of treatment, and postoperative complications). Women were classified according to the presence or absence of sexual dysfunction based on the Female Sexual Function Index (FSFI) questionnaire.

For data analysis, the SF-dependent variable was dichotomized into sexual dysfunction and no sexual dysfunction. Initially, the results were presented using descriptive statistics. Then, the bivariate analysis was performed using Pearson’s Chi-square and Fisher’s Exact tests, and the magnitude of the association was verified by the prevalence ratio (PR) for each of the nominal categorical independent variables related to the dependent variable. To identify factors associated with SF, multivariate analysis was performed using Poisson regression with robust variance for a 95% confidence level. The variables with statistical significance, according to the Wald Test (α = 0.05), and those with theoretical plausibility were kept in the model.

Quantitative variables were categorized into tertiles or as dichotomous variables (categorization through the median), when necessary for the bivariate analysis. All analysis was performed using Stata 15.13 software.

Results

Sample

A total of 3,645 new cases of breast cancer were registered from 2013 to 2017 (869 in 2013, 857 in 2014, 624 in 2015, 678 in 2016, and 617 in 2017). The first phase of this study encompassed collecting data from medical records of women under clinical follow-up to recruit for inclusion after systematic sampling was performed. Women were contacted by telephone and invited to participate in the study. Of 525 women, 386 were not included in the study. The remaining 139 women were interviewed, and 88 were included. Reasons for not participating in the study are shown in Fig. 1.

Fig. 1.

Flowchart of sample.

A total of 88 women who received BCT were included in this study. Participants were predominantly white (53.41%), with an average age of 53.7 years (± 11.2), married (78.41%), in the menopause at the time of the interview (78.41%) with higher education (43.18%), Catholic (72.73%), with family income between 2 and 4 minimum wages (38.64%). Sociodemographic characteristics and clinical conditions are described in Table 1.

Table 1.

Sociodemographic characteristics and clinical conditions of the sample (n = 88).

	N (88)	%
Religion
Catholic	64	72.7
Protestant	16	18.2
Spiritist	1	1.1
Others	7	7.9
Education
Illiterate	1	1.1
Incomplete elementary school	18	20.4
Complete elementary school	6	6.8
Incomplete high school	4	4.5
Complete high school	21	23.8
Higher education	38	43.2
Occupation before treatment
Yes	72	81.8
No	16	18.2
Occupation after treatment
Yes	41	46.6
No	47	53.4
Income
N/A	33	37.5
2 to 4 minimum wages	34	38.6
5 to 10 minimum wages	18	20.4
10 to 20 minimum wages	3	3.4
Healthcare service access
N/A	1	1.1
Public	46	52.3
Private	6	6.8
Health insurance	23	26.1
Public and private	7	7.9
Public and health insurance	5	5.7
Smoking
Yes	3	3.4
No	66	75.0
Quit smoking	19	21.6
Drinking
Yes	17	19.3
No	61	69.3
Quit drinking	10	11.4
Chronic disease
Yes	46	52.3
No	42	47.7
BMI
Normal	25	28.4
Overweight	35	39.8
Obesity	26	29.5
N/A	2	2.3
Physical activity
No	3	3.4
2 times/week	4	4.6
3 times/week	18	20.4
≥ 4 times/week	34	38.6
N/A	29	32.9
Menopause
Yes	69	78.4
No	19	21.6
Hormone replacement therapy
Yes	13	14.8
No	69	78.4
N/A	6	6.8
Type of treatment
Radiotherapy	77	87.5
Chemotherapy	66	75.0
Surgery	79	89.8
Hormonotherapy	28	31.8
Breast reconstruction
No	57	64.8
Yes	31	35.2
Cancer familial history
Yes	61	69.3
No	27	30.7
Use of medication
No	10	11.4
Yes	71	80.7
N/A	7	8.0
Sexual dysfunction
Yes	67	76.1
No	21	23.9

N/A: Not assessed.

Sexual dysfunction prevalence rate recorded in this study was 76.1%. FSFI results showed an average score of 22.84. Domains with the worst scores were sexual desire and vaginal lubrication. The overall average score and the score for each domain are shown in Table 2.

Table 2.

FSFI scores in women who received breast cancer treatment (n = 88).

FSFI domains	Mean (SD)	Sexual dysfunction	CI (95%)
Sexual desire	3.13 (1.17)	Yes	2.85 (2.60–3.11)
		No	4.0 (3.47–4.2)
Arousal	3.68 (1.34)	Yes	3.30 (3.01–3.58)
		No	4.90 (4.41–5.38)
Lubrication	3.21 (0.79)	Yes	3.14 (2.93–3.36)
		No	3.44 (3.25–3.57)
Orgasm	3.55 (0.83)	Yes	3.37 (3.17–3.58)
		No	4.11 (3.91–4.31)
Satisfaction	4.63 (1.41)	Yes	4.37 (4.02–4.71)
		No	5.48 (5.0–5.97)
Pain	4.62 (1.56)	Yes	4.34 (3.94–4.74)
		No	5.52 (5.15–5.89)
Total FSFI Score	22.84 (5.12)	Yes	21.40 (20.23–22.56)
		No	27.43 (25.98–28.89)

FSFI: Female Sexual Function Index. SD: standard deviation. CI: confidence interval.

Table 3 summarizes a bivariate and multivariate analysis of the variables related to sexual dysfunction. Based on these analyses, sexual dysfunction was associated with difficulty in dealing with the body after surgery, non-reconstruction of the breast and previous comorbidities.

Table 3.

Prevalence and prevalence ratios adjusted and unadjusted for the presence of sexual dysfunction in women who received breast cancer treatment in the Rio Grande do Norte state, Brazil (n = 88).

	Sexual dysfunction
	N (67)	%	Unadjusted			Adjusted
			PR	CI (95%)	p*	PR	CI (95%)	p*
Socioeconomic variables
Age group
22–49 years	21	70.0	0.95	0.69–1.32	0.277a
50–59 years	22	73.3	1.00
60–77 years	24	85.7	1.17	0.90–1.52
Race/color
Non-white	28	68.3	0.82	0.64–1.05	0.122a
White	39	83.0	1.00
Education
None/elementary school	22	88.0	1.29	0.99–1.67	0.147b	1.11	0.87–1.43	0.961
High school	19	76.0	1.11	0.81–1.51		1.06	0.79–1.42
Higher education	26	68.4	1.00			1.00
Marital status
Married	55	79.7	1.26	0.88–1.82	0.212a
Not married	12	63.2	1.00
Religion
Non-Catholic	14	82.4	1.10	0.84–1.43	0.486a
Catholic	48	75.0	1.00
Healthcare access
Public (SUS)	35	76.1	1.10	0.82–1.48	0.124b
Private/Insurance	20	69.0	1.00
Mixed	11	91.7	1.33	0.99–1.79
Lifestyle habits variables
Physical exercise
No	24	75.0	0.98	0.76–1.25	0.852a
Yes	43	76.8	1.00
Depression diagnostic
Yes	14	87.5	1.88	0.61–5.76	0.137b
No	49	73.1	1.00
Difficulty dealing with the body
Yes	27	93.1	1.38	1.13–1.70	0.002 a,*	1.39	1.13–1.70	0.002*
No	39	67.2	1.00			1.00
Body image
None/a little satisfied	12	92.3	1.26	0.99–1.58	0.098b
Moderately satisfied	19	73.1	0.99	0.74–1.33
Satisfied/very satisfied	36	73.5	1.00
Clinical variables
BMI
Overweight/obesity	47	71.2	1.06	0.35–3.16	0.561 b
Normal	19	28.8	1.00
Previous comorbidities
Yes	39	84.8	1.28	1.12–1.63	0.047 a,*	1.26	1.11–1.58	0.051*
No	28	66.7	1.00			1.00
Use of medication
Yes	55	88.7	1.47	0.34–6.36	0.430 b
No	7	11.3	1.00
Surgical approach
Radical	38	76.0	0.99	0.78–1.27	0.972a
Conservative	28	75.7	1.00
Breast reconstruction
No	47	82.5	1.28	1.15–1.71	0.046a,*	1.27	1.15–1.64	0.037*
Yes	20	64.5	1.00			1.00
Axillary Approach
Yes	41	80.4	1.06	0.82–1.37	0.672a
No	19	76.0	1.00
PO complications
Yes	21	77.8	1.03	0.80–1.32	0.808a
No	46	75.4	1.00
Menopause
No	12	17.9	0.55	0.26–1.16	0.143 a
Yes	55	82.1	1.00
Hormone replacement therapy
Yes	11	17.7	0.87	0.66–1.14	0.505 a
No	51	82.3	1.00
Radiotherapy
Yes	59	88.1	1.05	0.71–1.54	0.719 a
No	8	11.9	1.00
Hormonotherapy
Yes	22	34.9	1.05	0.82–1.35	0.453 b
No	41	65.1	1.00
Chemotherapy
Yes	50	74.6	0.98	0.75–1.27	0.567 b
No	17	25.4	1.00

PR: Unadjusted and adjusted Prevalence Ratio estimated by Chi-Square test, Fisher’s exact test and Multilevel Poisson model; CI: Confidence Interval, SUS: Brazilian Unified Health System, PO: post-operation.

p*: Wald test.

*Statistically significant.

^aChi-Square Test.

^bFisher’s exact.

Discussion

This study investigated sexual dysfunction in women diagnosed and treated for breast cancer. The high prevalence rate found in our results highlights a significant problem that affects women’s quality of life after BCT. The sample is based on demographic characteristics from the northeastern region of Brazil, yet our findings are supported by other Brazilian surveys from different regions, which show a high sexual dysfunction prevalence in women who received BCT^13,21.

Research results in other countries corroborate our findings of increased sexual dysfunction prevalence in women who have undergone BCT. Cobo-Cuenca et al.¹¹ conducted a cross-sectional study in Spain, with 514 women who had BC, where 91% showed some type of sexual dysfunction. This higher rate can be explained by sociodemographic and cultural differences between study samples. The study also showed that before treatment, most of the sample did not report sexual dysfunction, indicating significant differences in female SF before and after BC¹¹. In the United States, Raggio et al.²² cross-sectionally evaluated 83 women who survived BC. Volunteers underwent different treatment approaches (radiotherapy, hormone therapy and chemotherapy) of which 77% of all participants and 60% of those who were sexually active qualified as having sexual dysfunction based on the FSFI. Furthermore, cross-sectional studies conducted with healthy women indicate a 25% to 50% prevalence of sexual dysfunction^23–27, which shows us that sexual dysfunction is common among women. However, in the sample of women with breast cancer studied, this frequency was found to be higher.

Regarding sexual function and its domains assessed by FSFI, the lowest mean scores were sexual desire and lubrication. Studies indicate that the reduction of sexual desire and low vaginal lubrication may be due to physiological changes caused by systemic treatment^28,29. In addition, studies indicate that these factors can directly interfere with the quality of sexual activity.

In our study, sexual dysfunction was directly associated with difficulty in dealing with the body. This relationship is complex and multifactorial, and can be influenced by physical, emotional and social factors³⁰. Breasts are important for female beauty and sexuality, constituting the female body image, which includes individual self-perception and observation of the reaction of others^30,31. In breast cancer patients, body image may suffer changes related to the presence of the tumor, such as alterations in the skin (texture and sensitivity), changes in weight, and breast asymmetry and size as well as changes related to the oncologic treatment³¹. Thus, it is possible that the negative perception of body image is associated with higher sexual dysfunction incidence, as already suggested by other authors³².

In a systematic review of longitudinal studies¹² it was observed that women with BC are more susceptible to problems with body image compared to women without BC. Ljungman³³ also reported that a negative perception of body image can be an important predictor for low sexual satisfaction and concludes that this aspect has extreme magnitude in female SF. However, other authors found no association between body image and sexual dysfunction^10,34,35.

The divergence of the findings regarding sexual dysfunction and body image may be related to the heterogeneity in the characteristics of the samples, concerning sociocultural aspects, access to health services and products and other social determinants. Furthermore, the different methods used to assess body image perception and sexual dysfunction in the studies may explain the differences in these results. These conflicting results highlight the importance of investigating the different factors that influence body image perception and SF in women who survived BC in each region, since they will guide effective strategies to improve the quality of life of these women after BCT. For example, programs with multidisciplinary actions involving medical professionals, physiotherapists, psychologists, nurses, physical educators and nutritionists.

Sexual dysfunction was also associated with the absence of breast reconstruction. Breast reconstruction may have a positive impact on the well-being and quality of life of women who have survived BC. This is because the procedure can help improve physical appearance and self-image, which reduces the likelihood of sexual dysfunction in women undergoing breast reconstruction^36,37. A systematic review with meta-analysis points out that, in addition to the improvement in SF, quality of life and body image, women submitted to breast reconstruction report fewer depressive symptoms than those who only underwent isolated mastectomy^37,38.

The presence of previous comorbidities was associated with sexual dysfunction. Bronner³⁹ reveals some effects of chronic diseases that may contribute to sexual dysfunction and a less active sex life, such as physical problems, emotional problems and difficulties in relationships resulting from stress related to the disease, such as chronic pain, fatigue, low self-esteem and medication use. These factors could have an impact on the association of comorbidities and sexual dysfunction. However, they were not evaluated in our study.

The chosen therapy showed no association with sexual dysfunction. Some studies found an association with chemotherapy, hormonotherapy and the presence of sexual dysfunction; when comparing women who underwent chemotherapy and hormonotherapy with women who did not receive this treatment, these authors observed a poorer SF in the group that received chemotherapy^11,40,41. However, our results converge with previous findings from other studies^9,10.

Regarding marital status, the present study did not find an association with sexual dysfunction. Other studies point to an association between these variables^10–12. A likely justification for such divergence is the possibility of selection bias: different studies may have recruited participants in different ways, which may influence sample representativeness and generalizability of results. In addition to the sum of different sociodemographic, cultural and clinical characteristics of the sample. Even so, it is important to consider that an insufficient SF can be influenced by several other factors (age, time since diagnosis and the presence of physical and psychological symptoms), which might lead to confusion during the data analysis process^42,43.

In our study, we did not observe a relationship between sexual dysfunction and the level of education of women. Although some evidence suggests that women with higher education have a higher sexual frequency, our results did not find this association^10,44. A possible explanation for this lack of association may be the lack of consideration of other factors such as relationship quality, sexual satisfaction and psychological factors that can affect sexuality regardless of educational level.

Furthermore, although we did not specifically assess the sociodemographic determinants of the sample in this study, the general characteristics of social determinants (education, income, age and social class of the population, among others) in the northeast region are different from other regions of Brazil (such as the south and southeast of the country). This region is characterized by a condition of greater social vulnerability. Thus, the study findings can serve as a basis for comparison with less developed countries. This explanation is based on analyses of complex theoretical models that consider living conditions as determinants of health conditions and not only the clinical aspects of the health-disease process⁴⁵.

Menopause was not a significant variable in this study, but the literature cites it as a relevant factor. Chemotherapy and hormone therapy, especially when administered in the pre-and perimenopause, contribute to hormonal changes that may trigger dryness and early vaginal atrophy and induce a sudden onset of menopause^46,47. More than half of the participants reported being in menopause. This might explain the lack of significance of menopause in the final model.

Although the age range of our sample was broad, no interaction was observed between age and sexual dysfunction, which might be explained by the sample size. Among the general population, sexual dysfunction increases with age and is predominant in the reproductive phase. Compared to healthy women, those exposed to cancer had lower sexual activity with increased age, suggesting a physiological effect of ageing^47,48.

Among the limitations of this study, it can be mentioned that the cross-sectional design used does not allow the establishment of a cause-and-effect relationship. In addition, memory bias can be considered an inherent problem in the data collection process through interviews, as, for example, in the case of incompatible responses by volunteers. However, the previous training of the interviewers served to minimize these limitations. Furthermore, patients were evaluated in different survival phases, both in the short survival phase (closer to the end of the oncological treatment) and in the long survival phase (5 years after diagnosis), which could modify the way the individual perceives the symptoms assessed. Therefore, these results should be interpreted with caution. The sample was collected from a specific state of Northeast of Brazil, potentially limiting the generalizability of findings to a broader population. Faced with an expanded concept of health, several aspects must be considered to assess SF, analyzing all of them is a great challenge for science, and new research that addresses this theme is necessary.

These findings are relevant not only for precise clinical decision-making by health professionals, but also for a special look at the prevention of the factors associated with sexual dysfunction found here. This study has practical implications and highlights the importance of a multidisciplinary follow-up of women with sexual dysfunction, such as referral to sex therapy, physical therapy for pelvic floor or psychological counseling.

The elaboration of public health policies in countries with sociocultural and economic conditions like those experienced in Brazil can be supported by our results. It is recommended that new studies with other methodological designs assess the different aspects of female SF in patients with BC so our results can be compared, and other psychosocial and biological determinants of this association can be evaluated.

Conclusions

It was possible to verify a high sexual dysfunction, prevalence among women who received BCT. The most affected domains of SF were sexual desire and vaginal lubrication. Three factors were associated with sexual dysfunction: difficulty dealing with the body after surgery, previous chronic conditions, and failure to perform breast reconstruction.

The results found in this study show it is imperative that SF of women who survive BC should be considered in assessments and interventions aimed at improving their health. The presence of professionals specialized in the follow-up care after the initial therapeutic approach, focusing on aspects that directly influence sexual dysfunction, could minimize the frequent repercussions during this period in order to improve self-esteem, and quality of life of these women.

Author contributions

Conceptualization, T.S.R.G., M.B.O.G.G., J.J.-R., and D.L.B.d.S; methodology, T.S.R.G., M.B.O.G.G., J.J.-R., and D.L.B.d.S.; data curation, T.S.R.G., R.C.S; statistical analysis; N. P. D. O; S. J. C. A.; J. M. L.; writing—original draft preparation, T.S.R.G., R. L. C., R. C.S., M.B.O.G.G., writing—review and editing, T.S.R.G., R. L .C., M.B.O.G.G., J.J. R., and D.L.B.d.S.; supervision, J.J.-R. and D.L.B.d.S. All authors have read and agreed to the published version of the manuscript.

Funding

This study was financed in part by the Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior—Brasil (CAPES)—Finance Code 001. Dyego Leandro Bezerra de Souza thank CNPq (Brazilian National Council for Scientific and Technological Development) productivity grants 315962/2023-2.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to preserve individuals’ privacy, but are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.