Exploring the association between polycystic ovary syndrome and female sexual dysfunction: a cross-sectional study

Abstract

Background

Data regarding associations between polycystic ovary syndrome (PCOS) and female sexual function are limited.

Objective

To evaluate the association between a self-reported diagnosis of PCOS and female sexual dysfunction (FSD).

Methods

This cross-sectional study was performed in sexually active women, aged ≥ 20 years, who sought care at Mayo Clinic Women’s Health specialty clinics between May 1, 2015, to December 31, 2019. Participants’ sexual function was assessed with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R) questionnaires. Multivariable logistic regression was used to assess the association between a self-reported diagnosis of PCOS and FSD (defined by the combined diagnostic thresholds for the FSFI and FSDS-R), after adjusting for participant demographics and potential mediators known to impact female sexual function including age, BMI, hormone therapy use, anxiety, depression and relationship satisfaction.

Results

Responses from 4,405 sexually active women were analyzed including 1,481 pre/perimenopausal women and 2,924 postmenopausal women. History of PCOS was reported by 6.1% of pre/perimenopausal women and 3.9% of postmenopausal women. FSD was frequently reported in women with and without PCOS (52.7% among pre/perimenopausal; 64.6% among postmenopausal and 50.6% among pre/perimenopausal; 58.5% among postmenopausal, respectively). Independent of the reproductive stage, PCOS was not associated with FSD, but when adjusted for PCOS, FSD was associated with age less than 40 years, anxiety, depression, and relationship dissatisfaction.

Conclusion

In this large cross-sectional study, a self-reported history of PCOS was not independently associated with FSD after adjusting for key psychosocial and health-related factors.

Background

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age, characterized by polycystic ovarian morphology, clinical and/or biochemical hyperandrogenism (e.g., acne, hirsutism), and chronic anovulation leading to menstrual irregularities and subfertility [1–5]. Beyond reproductive symptoms, PCOS is a complex metabolic condition associated with obesity, insulin resistance, and increased cardiometabolic risk [1].

Women with PCOS also face heightened psychological burdens, including anxiety, depression, reduced quality of life, poor body image, and low self-esteem [6]. These factors, along with physical health and relationship satisfaction, are known determinants of female sexual function. It is therefore plausible that women with PCOS may be at elevated risk for sexual dysfunction. However, existing studies examining this relationship are limited in scope and quality. Many rely on small samples, use varied assessment tools, and do not adequately account for confounding factors such as hormonal status, mental health, substance use, body image, and relationship quality [7]. Findings remain inconsistent, with some studies reporting no difference in sexual activity between women with and without PCOS, while others suggest conflicting associations with sexual dysfunction [7–10].

Importantly, prior research has largely focused on reproductive-aged women, with postmenopausal women underrepresented or excluded [7, 8]. Given that the metabolic and psychological changes associated with PCOS may persist or worsen after menopause, women with a history of PCOS could remain at elevated risk for sexual dysfunction later in life [11, 12]. Yet, evidence in postmenopausal populations is lacking.

Evaluating sexual function across reproductive stages, including post menopause, is essential to understanding the long-term implications of PCOS. Differences in hormonal milieu and aging-related factors may influence sexual function differently in pre- vs. postmenopausal women [11–13]. Therefore, separating these groups allows for more precise assessment of the association between PCOS and sexual dysfunction at different reproductive stages.

The objective of this study was to examine the association between self-reported PCOS and sexual dysfunction in a large, community-based sample of women across reproductive stages, including those who are postmenopausal.

Methods and materials

Study design and participants

This was a cross-sectional study performed in women seeking care at Mayo Clinic Women’s Health Clinics in Rochester, Minnesota, Scottsdale, Arizona, and Jacksonville, Florida. As part of their clinical visits, women completed validated questionnaires assessing multiple aspects of their health including menopause symptoms and sexual function. Responses from sexually active women aged 20 and over were included. Data collected from May 1, 2015, to December 31, 2019 were used to assess the association between PCOS and FSD. All women who provided permission for the use of their medical records for research purposes were included in the study. Demographic information (age, relationship status, education, employment, and race/ethnicity), and body mass index (BMI) were obtained from the medical record. History of PCOS, current use of menopausal hormone therapy, and reproductive stage (premenopause- having regular menses; perimenopause- changes in cycles with less than 12 consecutive months of amenorrhea; postmenopause- after menopause) were obtained by self-report at the time of the clinical visit. Women with missing data or unknown reproductive status were excluded. The study was approved by the Mayo Clinic Institutional Review Board.

Measures

Sexual function and distress were measured using the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale- Revised (FSDS-R), respectively. In sexually active women, the FSFI assesses sexual function in the preceding 4 weeks in 6 domains including desire, arousal, lubrication, orgasm, pain, and satisfaction. Scores range from 2 to 36 with a total score ≤ 26.55 indicating poor sexual function [14, 15]. The FSDS-R measures the level of distress related to sexual problems over a 4-week time frame. Scores range from 0 to 52 with scores ≥ 11 indicating clinically significant sexual distress [16]. Women who met diagnostic thresholds defined for both the FSFI and FSDS-R questionnaires (FSFI ≤ 26.55 and FSDS-R ≥ 11) were considered to have FSD for the purposes of the study.

Covariates

Age, BMI, hormone therapy use, anxiety, depression, and relationship satisfaction were also assessed as potential mediators influencing female sexual function. Anxiety was evaluated using the GAD-7 questionnaire. GAD-7 scores range from 0 to 21. The presence of depression was assessed using the PHQ-9 questionnaire with scores ranging from 0 to 27 [17]. For both of these validated measures, scores of 5 or greater indicate anxiety or depression, respectively [17]. The Kansas Marital Satisfaction Scale (KMSS), a 3 item validated questionnaire, was used to assess relationship satisfaction [18]. On a scale of 3–21, a score of ≤ 17 corresponds to relationship dissatisfaction.

Statistical analysis

Data were summarized using mean (standard deviation, SD) or median (interquartile range) for continuous variables, and frequencies and percentages for categorical variables. T-tests or Wilcoxon rank sum tests were used to compare continuous variables between groups, and a chi-square test was used to compare categorical variables. Multivariable logistic regression was used to assess the association between FSD and PCOS after individually adjusting for other patient characteristics in sexually active women. All two-way interactions were assessed, and no significant interactions were found. Covariates were also assessed as potential mediators, and no significant mediation was found. All analyses were conducted using SAS version 9.4 (SAS Institute Inc, Cary, NC), and P values ≤ 0.05 were considered statistically significant.

Results

A total of 4,405 sexually active women were included in the analysis, comprising 1,481 pre/perimenopausal women (mean age 43.0 years) and 2,924 postmenopausal women (mean age 57.3 years). The majority of participants were white, partnered, and had at least some college education (Table 1). A history of PCOS was reported by 6.1% of pre/perimenopausal women and 3.9% of postmenopausal women.

Table 1.

Patient demographics by reproductive and PCOS status

Variable	Pre/Perimenopausal PCOS (n = 91)	Pre/Perimenopausal No PCOS (n = 1390)	p-value	Postmenopausal PCOS (n = 113)	Postmenopausal No PCOS (n = 2811)	p-value
Age (mean, SD)	40.6 (8.4)	43.1 (9.0)	0.002	50.4 (11.1)	57.5 (8.9)	< 0.001
Obesity (%)	42.0%	18.6%	< 0.001	40.7%	20.5%	< 0.001
Anxiety (GAD-7 ≥ 5)	53.6%	35.8%	0.001	43.4%	28.2%	0.001
Depression (PHQ-9 ≥ 5)	55.8%	39.8%	0.003	59.4%	32.1%	< 0.001
Relationship Dissatisfaction (KMSS-M < 17)	32.9%	26.5%	0.19	29.9%	23.8%	0.15
Hormone Therapy Use	7.7%	10.1%	0.46	43.4%	40.2%	0.51
FSD (%)	52.7%	50.6%	0.70	64.6%	58.5%	0.20

Women with a history of PCOS were more likely to have obesity, anxiety, and depression compared to those without PCOS. Among pre/perimenopausal women, obesity was reported in 42.0% of those with PCOS compared to 18.6% without (p < 0.001), anxiety in 53.6% vs. 35.8% (p = 0.001), and depression in 55.8% vs. 39.8% (p = 0.003). Among postmenopausal women, obesity was reported in 40.7% of those with PCOS compared to 20.5% without (p < 0.001); anxiety in 43.4% vs. 28.2% (p = 0.001); and depression in 59.4% vs. 32.1% (p < 0.001).

FSD was frequently reported in both groups, regardless of PCOS status. Among women with PCOS, FSD was reported by 52.7% of pre/perimenopausal and 64.6% of postmenopausal women. Among those without PCOS, FSD was reported by 50.6% of pre/perimenopausal and 58.5% of postmenopausal women. There were no significant differences in sexual function, sexual distress, or relationship satisfaction between women with and without PCOS in either reproductive group.

Multivariable analysis among pre/perimenopausal women showed that after adjusting for PCOS, FSD was significantly associated with younger age (compared to age 40–49: age 20–29, OR 2.67, 95% CI 1.85–3.87, p < 0.001; age 30–39, OR 1.81, 95% CI 1.37–2.38, p < 0.001), anxiety (OR 2.10, 95% CI 1.68–2.64, p < 0.001), depression (OR 2.28, 95% CI 1.83–2.83, p < 0.001), and relationship dissatisfaction (OR 2.13, 95% CI 1.67–2.71, p < 0.001). However, after individually adjusting for each of these variables, PCOS was not significantly associated with FSD (Table 2).

Table 2.

Factors associated with female sexual dysfunction in pre/perimenopausal women: univariate and two- variable models

	Univariate model for FSD		Two-variable models for FSD**
	Odds Ratio (95% CI)	p-value	Variable 1 Odds Ratio (95% CI)	p-value	PCOS Odds Ratio (95% CI)	p-value
History of PCOS (Y vs. N)	1.08 (0.71–1.66)	0.70
Age		< 0.001		< 0.001	0.97 (0.63–1.50)	0.90
20–29	2.68 (1.85–3.87)	< 0.001	2.67 (1.85–3.87)	< 0.001
30–39	1.81 (1.37–2.38)	< 0.001	1.81 (1.37–2.38)	< 0.001
40–49	Reference		Reference
50–59	0.76 (0.59–0.98)	0.037	0.76 (0.59–0.98)	0.037
60–69	0.33 (0.01–36.14)	0.64	0.32 (0.01–36.59)	0.63
BMI		0.72		0.71	1.04 (0.67–1.61)	0.85
Normal	Reference		Reference
Overweight	1.05 (0.83–1.35)	0.67	1.05 (0.83–1.35)	0.68
Obese	0.93 (0.71–1.22)	0.59	0.93 (0.71–1.22)	0.58
Hormone Therapy (Y vs. N)	1.11 (0.79–1.56)	0.55	1.11 (0.79–1.56)	0.55	1.09 (0.71–1.67)	0.69
GAD-7 (≥ 5 vs. < 5)	2.10 (1.67–2.63)	< 0.001	2.10 (1.68–2.64)	< 0.001	0.92 (0.59–1.45)	0.72
PHQ-9 (≥ 5 vs. < 5)	2.28 (1.83–2.83)	< 0.001	2.28 (1.83–2.83)	< 0.001	0.97 (0.62–1.52)	0.90
KMSS (< 17 vs. ≥ 17)	2.13 (1.67–2.71)	< 0.001	2.13 (1.67–2.71)	< 0.001	1.03 (0.66–1.60)	0.92

**Mediation p-values > 0.5, no significant mediators

Among postmenopausal women, use of menopausal hormone therapy was associated with a lower rate of FSD. In this group, adjusted analyses showed significant associations between FSD and anxiety (OR 2.49, 95% CI 2.07–3.00, p < 0.001), depression (OR 2.36, 95% CI 1.99–2.81, p < 0.001), and relationship dissatisfaction (OR 2.32, 95% CI 1.92–2.81, p < 0.001). As in the pre/perimenopausal group, after adjusting individually for these variables, no significant association between PCOS and FSD was identified (Table 3).

Table 3.

Factors associated with female sexual dysfunction in postmenopausal women: univariate and two- variable models

	Univariate model for FSD		Two-variable models for FSD**
	Odds Ratio (95% CI)	p-value	Variable 1 Odds Ratio (95% CI)	p-value	PCOS Odds Ratio (95% CI)	p-value
History of PCOS (Y vs. N)	1.30 (0.88–1.92)	0.20
Age		0.11		0.14	1.23 (0.83–1.84)	0.30
20–29	0.68 (0.26–1.80)	0.44	0.67 (0.25–1.79)	0.43
30–39	1.00 (0.66–1.52)	0.99	0.98 (0.65–1.49)	0.93
40–49	Reference		Reference
50–59	0.90 (0.70–1.15)	0.38	0.91 (0.71–1.16)	0.43
60–69	0.81 (0.63–1.05)	0.12	0.82 (0.63–1.07)	0.14
70+	0.63 (0.44–0.90)	0.010	0.64 (0.45–0.91)	0.012
BMI		0.67		0.60	1.27 (0.85–1.88)	0.24
Normal	Reference		Reference
Overweight	1.01 (0.85–1.20)	0.94	1.00 (0.84–1.19)	0.98
Obese	1.11 (0.92–1.35)	0.28	1.10 (0.91–1.34)	0.34
Hormone Therapy (Y vs. N)	0.60 (0.52–0.70)	< 0.001	0.60 (0.52–0.70)	< 0.001	1.32 (0.89–1.97)	0.17
GAD-7 (≥ 5 vs. < 5)	2.50 (2.08–3.00.08.00)	< 0.001	2.49 (2.07–3.00.07.00)	< 0.001	1.08 (0.70–1.65)	0.74
PHQ-9 (≥ 5 vs. < 5)	2.36 (1.99–2.80)	< 0.001	2.36 (1.99–2.81)	< 0.001	0.97 (0.64–1.47)	0.89
KMSS (< 17 vs. ≥ 17)	2.33 (1.92–2.81)	< 0.001	2.32 (1.92–2.81)	< 0.001	1.29 (0.85–1.94)	0.23

**Mediation p-values > 0.3, no significant mediators

Discussion

In this large, cross-sectional study of women seen for women’s health specialty care, sexual dysfunction was prevalent across all groups, with no significant differences based on PCOS history or reproductive stage. Although women with PCOS were more likely to report obesity, anxiety, and depression, these factors did not contribute to a higher risk of FSD when compared to women without PCOS. FSDS-R responses indicated that women with PCOS experienced greater feelings of embarrassment, guilt, inferiority, and stress related to sexual difficulties. No significant differences were observed between the PCOS versus non-PCOS groups in arousal, desire, lubrication, or orgasm. However, women with PCOS were more likely to report lower sexual satisfaction and increased pain or discomfort during vaginal penetration on the FSFI. Despite these differences, the overall rate of FSD did not differ significantly between groups. This finding aligns with several previous studies reporting no statistically significant differences in overall sexual function between women with and without PCOS, despite observed differences in specific domains such as arousal, satisfaction, or lubrication [8–10, 19]. For example, a meta-analysis of 10 studies found lower sexual satisfaction among women with PCOS but no increased risk of FSD overall [10]. Similarly, Mansson et al. reported that while women with PCOS experienced more difficulty with vaginal lubrication and reported greater partner dissatisfaction, their total sexual health scores were not significantly different from controls. [19] Sexual function in women with PCOS may be influenced less by PCOS-specific physiological factors (e.g., hyperandrogenism, anovulation) and more by broader psychosocial contributors, such as relationship satisfaction, body image, and mental health, factors that can affect all women, regardless of PCOS status.

However, our results differ from those of other studies, including larger meta-analyses, which have reported significant associations between PCOS and FSD [7, 8, 20, 21]. For instance, a meta-analysis of 21 observational studies found that women under 30 years of age with PCOS were 40% more likely to experience FSD compared to similar aged women without PCOS, with about one-third meeting diagnostic criteria for FSD [9]. Other small studies have identified impaired sexual function, higher sexual insecurity, and lower FSFI scores among women with PCOS compared to controls [21]. A prospective case control study by Pastoor et al. confirmed significantly lower sexual function and higher sexual distress, thus meeting the criteria for FSD, in women with PCOS. [22] These discrepancies may be explained by methodological differences across studies, such as smaller sample sizes, narrower age ranges, or inconsistent definitions and assessments of sexual function. Importantly, many previous studies did not evaluate sexual distress, a critical criterion for the diagnosis of FSD, or failed to adjust for key confounders like mood and relationship satisfaction.

Our study adjusted for multiple psychosocial and behavioral factors known to influence sexual function, including depression, anxiety, and relationship quality. After these adjustments, the association between PCOS and FSD was no longer significant, highlighting the potential role of non-PCOS-specific factors in determining sexual health outcomes. Furthermore, cultural or demographic factors may have contributed to divergent findings across studies. For example, Hashemi et al. reported a high prevalence of FSD (63.5%) among Iranian women with PCOS, but acknowledged that cultural norms and marital status likely influenced these results. [23]

Body image is a well-established and complex factor affecting sexual function and satisfaction [24–28]. Several studies, including work by Benetti-Pinto et al., have documented a negative association between BMI and sexual satisfaction in women with PCOS, with lower scores in domains such as arousal, lubrication, satisfaction, and pain, as well as overall FSFI scores. [19, 29] One unexpected finding in our study was that women with obesity, including those with PCOS, were less likely to report FSD than women of normal BMI. This contrasts with much of the literature suggesting a negative association between obesity and sexual function [30–33]. However, the relationship between BMI and sexual function is complex and may be mediated by factors such as body image, rather than the physiological impact of obesity alone [34]. Pastoor et al. found greater impairment in lean women with PCOS than in overweight counterparts, suggesting that body image may play a larger role in sexual functioning than weight and/or obesity. [35] Other studies have shown that women with PCOS often report body dissatisfaction related to physical manifestations like hirsutism and acne, which may negatively affect sexual confidence and function, regardless of weight [19, 31, 36, 37].

Although obesity is commonly linked with reduced sexual satisfaction, some research, including that by De Frène et al., has suggested that body image, not weight per se, is more predictive of sexual and relational satisfaction. [30] The psychosocial burden of PCOS, including perceived loss of femininity, subfertility, and altered body image, can influence sexual well-being [31, 38–41]. For example, Elsenbruch et al. found that facial hair, rather than BMI, was a primary concern affecting sexual confidence. [31] In our study, although women with PCOS reported more pain with vaginal penetration and feelings of guilt or embarrassment about sexual difficulties, these did not translate into higher rates of FSD when distress and relationship factors were accounted for in the analysis.

Hormonal mechanisms, particularly androgen levels, have also been investigated as potential contributors to sexual dysfunction in PCOS, with conflicting evidence [38, 42]. Ercan et al. hypothesized that either the clinical manifestations of PCOS would negatively impact sexuality or that high androgen levels would enhance sexual function, but neither hypothesis was validated. [43] Some studies report a negative correlation between androgens and sexual function, noting lower FSFI scores in women with higher testosterone levels [43, 44]. Caruso et al. demonstrated improved sexual satisfaction and orgasm after lowering androgen levels with oral contraceptives. [45] Androgen excess has also been linked to altered microRNA profiles that may affect hormonal pathways relevant to sexual function [46]. Conversely, other studies suggest that elevated testosterone may enhance libido and satisfaction [19, 32]. The inconsistent findings likely reflect the multifactorial nature of female sexual function, with androgens playing a limited or context-dependent role [22].

In our analysis, FSD was primarily associated with mood or anxiety symptoms and relationship dissatisfaction, rather than PCOS-specific factors. This aligns with large-scale population data, such as the PRESIDE study, which found that approximately 40% of women with sexual concerns also had depressive symptoms [47]. Similarly, Shifren et al. reported that women with depressive symptoms were twice as likely to have distressing sexual problems. [48] These associations appear to be consistent across populations, with or without PCOS [21, 49–51].

Relationship quality also emerged as a key determinant of sexual function in our study. Poor partner satisfaction was associated with higher rates of FSD in both PCOS and non-PCOS groups. Prior research supports this finding, demonstrating that sexual satisfaction is closely tied to emotional and relational dynamics [51–55]. For example, Oberg et al. found that partner dissatisfaction and male sexual dysfunction were significant contributors to female sexual concerns. [56] Notably, our study is among the few to adjust for relationship satisfaction, which may explain why FSD was not directly linked to PCOS after adjustment [57].

Reproductive stage also influenced sexual function independent of PCOS diagnosis. As expected, postmenopausal women had higher rates of FSD, consistent with previous studies reporting declines in sexual function due to reduced estrogen, comorbidities, and aging-related changes [48, 58–61]. Our findings support existing literature showing that sexual concerns affect up to 86% of postmenopausal women, with risk increasing with time since menopause [58]. Despite these changes, we observed no significant differences in FSD between postmenopausal women with and without a history of PCOS, suggesting that menopausal changes may overshadow any residual PCOS-related effects on sexual function.

Strengths and limitations

This study’s strengths include its large, diverse sample drawn from multiple U.S. regions and the inclusion of women across reproductive stages, including post menopause, a group often excluded from prior PCOS research. The use of validated instruments to assess sexual function, including sexually-related distress, mood, anxiety, and relationship satisfaction adds further rigor.

However, several limitations should be considered. The sample lacked racial, ethnic, and socioeconomic diversity, limiting generalizability. Cultural factors may influence both the experience and reporting of sexual dysfunction, and our findings may not apply to more diverse populations [62–64]. Sexual function was not assessed in women who were not recently sexually active, even though sexual inactivity may reflect underlying dysfunction. Moreover, infertility, an important factor linked to sexual distress in reproductive-aged women, was not measured, potentially introducing residual confounding [65, 66]. While infertility appears to have less impact on sexual function in midlife, its absence still limits interpretation [67]. The cross-sectional design precludes causal inference. Finally, PCOS status was self-reported and not confirmed by clinical or biochemical criteria. The agreement between self-reported PCOS and a documented diagnosis by a health care practitioner has not been reported in the literature.

Conclusion

In this large cross-sectional study, a self-reported history of PCOS was not independently associated with FSD after adjusting for key psychosocial and health-related factors. Instead, FSD appeared to be more strongly influenced by biopsychosocial factors, including mood and anxiety symptoms, relationship dissatisfaction, and postmenopausal status, regardless of PCOS diagnosis. These findings underscore the complex, multifactorial nature of female sexual dysfunction and support the importance of a holistic, individualized approach to assessment and management of sexual concerns in all women.

Authors’ contributions

Taryn Smith, MD : Conceptualization, Methodology, Writing – original draft, Writing – review & editing, Visualization. Stephanie S. Faubion, MD, MBA : Conceptualization, Supervision, Writing – review & editing. Jana Karam, MD : Writing – original draft, Writing – review & editing. Juliana M. Kling, MD, MPH : Writing – review & editing. Kristin Cole, MS : Data curation, Formal analysis, Methodology, Writing – review & editing. Felicity Enders PhD : Data curation, Writing – review & editing. Ekta Kapoor, MBBS : Conceptualization, Methodology, Supervision, Writing – review & editing.

Funding

None.

Data availability

The data set used and/or analyze during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Mayo Clinic Institutional Review Board. Collected data was historical information thus, participants were not required to give consent specific to this study. Participants granted general authorization for the use of their medical records in research, in accordance with Minnesota state law.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.