Abstract
Background
Sexual health is an important part of life; however, it has long been overlooked in patients with immune thrombocytopenia (ITP), primarily due to concerns regarding low platelet counts and bleeding risk.
Objective
This study aimed to assess the prevalence of sexual dysfunction in female patients with ITP and to analyze the factors contributing to this condition.
Methods
This was a single-center longitudinal follow-up study that enrolled female patients aged 18 to 65 years with newly diagnosed ITP between January 2021 and December 2023. Sexual function was assessed using the Female Sexual Function Index (FSFI) at baseline (within 48 h of admission) and at the 6- and 12-month follow-up. Demographic and clinical data of patients were additionally collected, and their fatigue burden, anxiety levels, and quality of life were assessed. Logistic regression analysis was employed to identify risk factors.
Results
A total of 146 patients were enrolled in this study. At baseline, sexual dysfunction was identified in 36.30% of female patients with ITP. At 6-month and 12-month follow-ups, the proportion of patients with sexual dysfunction was 41.84% and 54.07%, respectively. Compared with patients without corticosteroid dependence (49.54%), those on two or fewer medications (44.83%), and those with only isolated cutaneous bleeding (51.90%), the prevalence of sexual dysfunction was significantly higher in patients with corticosteroid dependence (73.08%, P = 0.047), those receiving more than two medications (70.83%, P = 0.004), and those with wet or internal bleeding (70%, P = 0.007). Spearman correlation analysis revealed that as the follow-up duration increased, the correlation between fatigue and the FSFI score weakened, whereas the correlations between anxiety, quality of life, and the FSFI score strengthened. A platelet count of <30 × 109/L (OR = 4.996; P = 0.039), wet or internal bleeding (OR = 3.744; P = 0.016), and the use of more than two medications (OR = 2.861; P = 0.031) were independent risk factors for sexual dysfunction in patients with ITP at the 12-month follow-up.
Conclusions
ITP can adversely affect female patients’ sexual function. Based on the results of logistic regression analysis, rational and individualized intervention plans should be developed to improve sexual function in female patients with ITP.
Keywords: Sexual dysfunction, Immune thrombocytopenia, Female patients
Introduction
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder characterised by isolated peripheral blood thrombocytopenia (a platelet count < 100 × 10⁹/L), which can be caused by multiple factors, such as infection, genetics, immunodeficiency, medications, and rheumatic diseases [1]. In general, the incidence of ITP is slightly higher in adult women than in men [2, 3]. Moreover, epidemiological studies have demonstrated a significantly elevated incidence of ITP in adult women [4]. In recent years, the emergence of novel therapeutic agents, such as eltrombopag and romiplostim, has led to a paradigm shift in the management of ITP. The conventional treatment paradigm, which primarily focused on rapidly elevating platelet counts and reducing bleeding manifestations, has been replaced by a high-quality, individualized treatment strategy. This new approach places greater emphasis on maintaining stable platelet counts and improving patients’ quality of life [5].
Currently, the primary instruments used to assess the quality of life in adult patients with ITP are the ITP Life Quality Index (ILQI) and the ITP Patient Assessment Questionnaire (ITP-PAQ) [6]. Despite the extensive validation of these two scales [7, 8], their assessment of patients’ sexual function remains markedly inadequate. ILQI employs a single question—“How often has your ITP affected your sex life?“—to evaluate the sexual function of ITP patients. In contrast, the ITP-PAQ places greater emphasis on the impact of the disease on the reproductive system. Although ITP patients are advised to avoid sexual activity when their platelet counts are low or when bleeding symptoms are present, this is not a valid reason to disregard their sexual function.
Female sexual function refers to a woman’s overall capacity to engage in sexual activities. It is not merely a simple physiological response, but rather the integrated result of multiple dimensions—including biological, psychological, and social factors [9]. Female sexual dysfunction is defined as the presence of one or more of the following symptoms: the inability to attain or sustain sexual arousal, the absence of sexual desire, the inability to achieve orgasm, or the experience of sexual pain [10]. It has been reported that the prevalence of sexual dysfunction among Chinese women ranges from 21.6% to 45.68% [11, 12]. In comparison, the prevalence is over 30% among women in Europe, the United States, and Africa, and exceeds 50% among women in South Asia and the Middle East [13–17]. In addition to the disease itself, the prevalence of female sexual dysfunction is also influenced by multiple factors, including but not limited to variations in sample size, ethnic differences, and disparities in assessment methods. Unfortunately, the lack of sufficient data hinders the clarification of sexual function status in female patients with ITP. Therefore, it is crucial to adopt appropriate assessment tools to evaluate the sexual function of this patient population. The Female Sexual Function Index (FSFI) is a psychometric scale used to assess female sexual dysfunction. Its validity has been confirmed in the evaluation of various systemic diseases, such as diabetes, hypertension, and rheumatic diseases [18–20].
This study aimed to use the FSFI to assess the prevalence of sexual dysfunction in patients with ITP and to identify the factors influencing its development.
Methods
This was a longitudinal study that enrolled newly diagnosed female patients with ITP who were treated at the Department of Hematology at Rudong People’s Hospital from January 2021 to December 2023. Notably, this study was limited to newly diagnosed patients, and none of the enrolled subjects were in the chronic phase of ITP. The exclusion criteria were as follows: (1) Age < 18 or age > 65; (2) Self-identification as not-female; (3) Diagnosis of a serious disease (e.g., tumour, cardiovascular disease); (4) Impaired consciousness or inability to cooperate with study-related evaluations (such as questionnaire filling or effective communication); (5) Pregnant or within 12 months postpartum. The study was approved by the Ethics Committee of Rudong People’s Hospital (approval number: 2020-57; date of approval: December 30, 2020). Prior to the commencement of the study, all participants were informed of the study details and provided written informed consent. The confidentiality of all patient-related information was maintained throughout the study.
The assessment of sexual function
In this study, all patients underwent three sexual function assessments: one at baseline (within 48 h of admission) and two during follow-up (at 6 and 12 months after baseline). At the initiation of the study, all patients received targeted sexual health education that was formulated by the research team based on the unique pathological features of ITP. The educational content covered the following key dimensions: (1) Sexual activity should be adjusted based on the patient’s platelet count to minimize bleeding risks. When the platelet count is ≤ 30 × 10⁹/L, sexual activity should be avoided as much as possible, particularly vigorous penetrative intercourse; when the platelet count exceeds 30 × 10⁹/L, sexual activity should be moderate to avoid excessive physical exertion, thereby preventing a decrease in platelet count. (2) If any bleeding symptoms occur, patients are advised to avoid sexual activity regardless of their platelet count at that time.
In this study, the Chinese version of the FSFI was used to assess sexual function in female patients with ITP. This version has been validated for sexually active women who have engaged in at least one sexual activity involving subjective sexual stimulation, intentional sexual arousal, or sexual experience within the preceding 4 weeks [21]. The FSFI employs a summative scoring method to generate final results, with total scores calculated by summing individual scores from six distinct domains: sexual desire, sexual arousal, lubrication, orgasm, sexual satisfaction, and sexual pain. A total FSFI score of ≤ 23.45 was defined as indicative of sexual dysfunction [21]. To minimize the potential influence of confounding factors on the study results, all participants were required to complete the questionnaire independently in a quiet environment.
To investigate the risk factors for sexual dysfunction in female ITP patients, the following information was collected: biological factors (age, menopausal status, fertility status, chronic comorbidities, BMI, and unhealthy lifestyle habits); psychological factors (anxiety); social factors (educational level, marital status, and living environment); and ITP-related disease factors (complete blood count, medications, bleeding manifestations, fatigue, and quality of life).
The assessment of quality of life
The ILQI was used to evaluate the direct impact of the disease on patients’ quality of life. The ILQI consists of 10 items. Since patients might decline to answer certain items, the method proposed by Ricardo et al. was adopted, with the ILQI total (alternative) score used as the final outcome [22]. The ILQI total (alternative) score was calculated as follows: ( total score of all answered items ÷ number of answered items) × 10. Impaired quality of life was defined as an ILQI score of ≥ 17.
The assessment of fatigue burden
The Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F) Scale was utilized to evaluate the patients’ fatigue burden. Fatigue levels were categorized into four grades: a FACIT-F score of 40 or higher indicated minimal or no fatigue; a score of 27—39 indicated mild fatigue; a score of 14—26 indicated substantial fatigue; and a score of 13 or lower indicated severe fatigue [23].
The assessment of anxiety
The Hamilton Anxiety Scale (HAMA) was used to assess the patients’ psychological burden. A HAMA score of 7 to 13 indicated mild anxiety; a score of 14 to 20 indicated moderate anxiety; and a HAMA score of ≥ 21 indicated severe anxiety [24].
Statistical analysis
One-way analysis of variance (ANOVA) was used to compare data among three groups with a normal distribution and homogeneous variances. In contrast, the Kruskal-Wallis H test was employed for comparisons of three groups of data that did not follow a normal distribution or had heterogeneous variances. Categorical data were analyzed using the chi-square test, and were presented as percentages. Logistic regression analysis was performed to identify risk factors for sexual dysfunction in female patients with ITP. Variables that showed statistical significance in univariate analysis were further included in multivariate analysis. All data were analyzed using SPSS 26.0 software and P < 0.05 was considered statistically significant.
Results
Demographic information of the patient
A total of 159 patients were enrolled in this study. Thirteen patients were excluded due to sexual inactivity, rendering them ineligible for FSFI assessment. Ultimately, 146 patients were included in the final cohort. A total of 142 patients completed the questionnaire at the 6-month follow-up after baseline (3 were lost to follow-up and 1 died). At the 12-month follow-up after baseline, 135 patients completed the questionnaire (5 withdrew and 2 died). Table 1 shows the demographic characteristics of all patients at the time of study enrollment. Among the 21 patients with chronic diseases, 13 had hypertension, 6 had diabetes, and 2 had both hypertension and diabetes.
Table 1.
Demographic information of the patient
| Variable | N = 146 |
|---|---|
| Age(year) | |
| M (range) | 51 (23–65) |
| 23 ≤ Age <40 | 44 (30.14%) |
| 40 ≤ Age ≤ 65 | 102 (69.86%) |
| Menopause | |
| Yes | 58 (39.73%) |
| No | 88 (60.27%) |
| Education level [n (%)] | |
| High school and above | 56(38.37%) |
| Junior high school and below | 90(61.64%) |
| Marital status [n (%)] | |
| Married | 121 (82.88%) |
| Unmarried and divorced | 25 (17.12%) |
| Fertility Status [n (%)] | |
| <2 children | 112 (76.71%) |
| ≥ 2 children | 34 (23.29%) |
| Living environment [n (%)] | |
| Urban | 83 (56.85%) |
| Rural | 63 (43.15%) |
| Chronic disease [n (%)] | |
| Yes | 21 (36.99%) |
| No | 125 (63.01%) |
| BMI [n (%)] | |
| BMI ≤ 24 kg/m2 | 91(62.33%) |
| BMI>24 kg/m2 | 55(37.67%) |
| Smoking [n (%)] | |
| Yes | 23 (15.75%) |
| No | 123 (84.25%) |
| Drinking [n (%)] | |
| Yes | 32 (21.92%) |
| No | 114 (78.08%) |
BMI Body mass index
Table 2 presents the clinical data and treatment regimens for all patients. After a 12-month follow-up, a total of 87 (64.44%) patients experienced disease recurrence (defined as a platelet count falling below 30 × 109/L after effective treatment, falling to less than twice the baseline platelet count, or the emergence of bleeding symptoms) [25], and 71 (52.59%) patients had received one or more second-line regimens. Thrombopoietic agents were the most frequently used second-line treatment regimens. At the 6-month follow-up, one patient was treated with rituximab and another with cyclosporine. At the 12-month follow-up, a total of three patients had received rituximab. No patients underwent splenectomy during the study.
Table 2.
Characteristics of the study population
| Initial | 6-months FU |
12-Months FU |
|
|---|---|---|---|
| Patients at FU | 146 | 141 | 135 |
| Platelet count (n, %) | |||
| <20*109/L | 78 (53.42%) | 19 (13.48%) | 14 (10.37%) |
| 20–49*109/L | 52 (35.62%) | 25 (17.73%) | 18 (13.33%) |
| 50–99*109/L | 16 (10.96%) | 49 (34.75%) | 46 (34.07%) |
| > 100*109/L | - | 48 (34.04%) | 57 (42.42%) |
| Bleeding in the last FU period (n, %) | |||
| Yes | 113 (77.40%) | 33 (23.40%) | 21 (15.56%) |
| No | 33 (22.60%) | 67 (76.60%) | 114 (84.44%) |
| Bleeding location (n, % of bleeding patients) | |||
| Skin | 75 (66.37%) | 21 (63.64%) | 11 (52.38%) |
| Oral | 19 (16.81%) | 9 (27.27%) | 2 (9.52%) |
| Epistaxis | 17 (15.04%) | 2 (6.06%) | 4 (19.05%) |
| Gastrointestinal and/or hematuria | 5 (4.42%) | 5 (15.15%) | 3 (14.29%) |
| Intracranial hemorrhage | 1(0.88%) | 0 | 2 (9.52%) |
| Muscle and/or joint | 0 | 1 (3.03%) | 2 (9.52%) |
| Platelet count (median)*109/L at FU | |||
| Only cutaneous bleeding | 16 (6;25) | 28 (16;60) | 47 (19;74) |
| Wet or internal bleeding | 8 (2;18) | 19 (9;52) | 33 (18;67) |
| No bleeding | 37 (17;69) | 74 (42;163) | 102 (71;202) |
| Drug treatment in the last FU period (n, %) | |||
| Yes | 117 (80.13%) | 84(59.57%) | 45 (33.33%) |
| No (watch and wait) | 29 (19.86%) | 57 (40.43%) | 90 (66.67%) |
| Drug used (n, % of treated patients) | |||
| Corticosteroid | 113 (96.58%) | 62 (73.81%) | 22 (48.89%) |
| IVIG and/or anti-D | 7 (5.98%) | 4 (4.76%) | 4 (8.89%) |
| TCM | 5 (4.27%) | 11 (13.10%) | 9 (20%) |
| Second-line and/or third line | 18 (15.92%) | 45 (53.57%) | 38 (84.44%) |
| Type of second / third-line drugs | |||
| rhTPO | 13 | 34 | 19 |
| TPO-RA | 5 | 17 | 29 |
| Anti-CD20 (rituximab) | - | 1 | 3 |
| Other | - | 1 | 0 |
| New Splenectomy at each FU (not cumulative) | - | - | - |
| Platelet transfusion(not cumulative) | 16 (10.96%) | 11 (7.80%) | 14 (10.37%) |
IVIG Intravenous immunoglobulin, TCM Traditional Chinese Medicine, rhTPO Recombinant human thrombopoietin, TPO-RA Thrombopoietin receptor agonists
Prevalence of sexual dysfunction
As shown in Table 3, the prevalence of sexual dysfunction among female ITP patients was 36.30% at baseline, 41.84% at the 6-month follow-up, and 54.07% at the 12-month follow-up. Notably, a significant increase in the prevalence of sexual dysfunction among female ITP patients was observed between the two follow-up assessments (P = 0.009). In the individual domain analysis, scores for desire (P<0.001), arousal (P<0.001), and satisfaction (P = 0.043) were found to progressively decrease with longer follow-up duration. When comparing the two follow-up time points, the total FSFI score (P = 0.004), along with the individual scores for desire (P = 0.006), arousal (P<0.001), and orgasm (P<0.001) were lower at the 12-month follow-up than at the 6-month follow-up. Table 4 shows the prevalence of sexual dysfunction stratified by platelet count, revealing that lower platelet counts were associated with a higher prevalence of sexual dysfunction.
Table 3.
Prevalence of sexual dysfunction among ITP patients and fundings of the FSFI assessment
| Initial (n = 146) |
6- months FU (n = 141) |
12- months FU (n = 135) |
χ2/F | P | |
|---|---|---|---|---|---|
| Sexual dysfunction [n (%)] | 9.341 | 0.009 | |||
| Yes | 53 (36.30%) | 59 (41.84%) | 73 (54.07%) | ||
| No | 93 (63.70%) | 82 (58.16%) | 62 (45.93%) | ||
| FISI (score) | |||||
| Desire | 2.45 ± 0.64a | 2.24 ± 0.63b | 2.01 ± 0.55c | 18.901 | < 0.001 |
| Arousal | 4.17 ± 1.72a | 3.54 ± 1.96b | 3.15 ± 2.03c | 29.064 | < 0.001 |
| Lubrication | 4.75 ± 1.84a | 4.49 ± 2.11b | 4.45 ± 2.43b | 1.710 | 0.692 |
| Orgasm | 3.94 ± 1.84a | 3.81 ± 2.04a | 3.59 ± 2.34b | 5.445 | 0.315 |
| Satisfaction | 3.57 ± 1.52a | 3.35 ± 1.60b | 3.24 ± 1.46c | 3.172 | 0.043 |
| Pain | 4.69 ± 1.35a | 4.51 ± 1.86b | 4.53 ± 2.01b | 2.106 | 0.734 |
| Total | 23.51 ± 8.16a | 22.08 ± 9.54b | 20.27 ± 10.34c | 7.309 | 0.006 |
FISI Female Sexual Function Index
a, b, cWhen comparing among groups, data labeled with the same letter indicate that there is no statistical significance, while data labeled with different letters imply statistical significance
Table 4.
Results of FSFI assessment stratified by platelet count (12-months FU)
| PLT ≤ 30 (n = 19) |
30< PLT ≤ 50 (n = 13) |
PLT>50 (n = 103) |
χ2/F | P | |
|---|---|---|---|---|---|
| Sexual dysfunction[n (%)] | 32.486 | < 0.001 | |||
| Yes | 16 (84.21%) | 9 (69.23%) | 24(23.30%) | ||
| No | 3 (15.79%) | 4 (30.77%) | 79(76.70%) | ||
| FISI (score) | |||||
| Desire | 1.94 ± 0.36a | 2.28 ± 0.77b | 2.51 ± 0.64c | 24.108 | < 0.001 |
| Arousal | 2.27 ± 0.95a | 3.54 ± 1.46b | 4.42 ± 1.93c | 19.331 | < 0.001 |
| Lubrication | 4.84 ± 2.90a | 4.76 ± 1.94a | 4.88 ± 2.02a | 0.965 | 0.814 |
| Orgasm | 1.93 ± 0.74a | 3.71 ± 1.39b | 4.13 ± 1.84b | 3.049 | 0.011 |
| Satisfaction | 2.30 ± 0.73a | 3.42 ± 1.17b | 3.59 ± 1.89b | 3.191 | 0.008 |
| Pain | 2.51 ± 0.36a | 4.70 ± 1.98b | 4.79 ± 2.32b | 6.816 | < 0.001 |
| Total | 15.73 ± 6.48a | 22.56 ± 9.19b | 24.13 ± 10.05c | 11.177 | < 0.001 |
FISI Female Sexual Function Index
a, b, cWhen comparing among groups, data labeled with the same letter indicate that there is no statistical significance, while data labeled with different letters imply statistical significance
Table 5 depicts the prevalence of sexual dysfunction stratified by disease states and treatment regimens after two follow-up assessments. Sexual dysfunction was significantly more prevalent in patients with a history of corticosteroid dependence (defined as the need for continuous corticosteroid use for at least 2 months to maintain a platelet count ≥ 30 × 109/L and/or to avoid bleeding [26]), and in those receiving more than two medications, compared to patients without corticosteroid dependence (P = 0.047), and those taking two or fewer medications (P = 0.004). No statistically significant differences in the prevalence of sexual dysfunction were observed between patients with disease recurrence and those without disease recurrence (P = 0.296), nor between patients who had received second-line treatment and those who had not (P = 0.059). The prevalence of sexual dysfunction in patients with wet or internal bleeding (70%) was significantly higher than that in patients with isolated cutaneous bleeding (51.90%) (P = 0.007).
Table 5.
The prevalence of sexual dysfunction stratified by disease state and treatment modalities (n = 135 )
| Stratification factor | Group (n, %) | Sexual dysfunction [n (%)] | χ2 | P |
|---|---|---|---|---|
| Corticosteroid dependent | Yes (n = 26, 19.26%) | 19 (73.08%) | 4.682 | 0.047 |
| No (n = 109, 80.74% ) | 54 (49.54%) | |||
| Second-line treatment | Yes (n = 71, 52.59%) | 44 (61.97%) | 3.762 | 0.059 |
| No (n = 64, 47.41%) | 29 (45.31%) | |||
| Number of drugs > 2 | Yes (n = 48, 35.56%) | 34 (70.83%) | 8.424 | 0.004 |
| No (n = 87, 64.44%) | 39 (44.83%) | |||
| Recurrence | Yes (n = 87, 64.44%) | 51 (58.62%) | 2.037 | 0.206 |
| No (n = 48, 35.56%) | 22 (45.83%) | |||
| Bleeding | Only cutaneous bleeding (n = 79, 58.52%) | 41 (51.90%) | 9.682 | 0.007 |
| Wet or internal bleeding (n = 40, 29.63%) | 28 (70%) | |||
| No bleeding (n = 16, 11.85%) | 4 (25%) |
The relationship between sexual function and disease burden
Table 6 shows the correlations among fatigue, quality of life, anxiety, and sexual dysfunction. Spearman correlation analysis revealed that FACIT-F scores, ILQI scores, and HAMA scores were positively correlated with the total FSFI scores. Notably, the correlation between the FACIT-F scores and the total FSFI scores weakened over time. Initially, the correlations between ILQI scores and HAMA scores and the total FSFI scores were weak. However, these correlations became stronger as follow-up progressed.
Table 6.
The correlations between sexual function and disease burden (Spearman’s correlation analysis)
| Disease burden | Total FISI score | ||
|---|---|---|---|
| Baseline (n = 146) | 6-month FU (n = 141) | 12-month FU (n = 135) | |
| r (P) | r (P) | r (P) | |
| FACIT-F score | 0.458 (<0.001) | 0.327 (<0.001) | 0.213 (0.013) |
| ILQI score | 0.224 (0.031) | 0.357 (0.002) | 0.407 (<0.001) |
| HAMA score | 0.291 (0.006) | 0.421 (<0.001) | 0.427 (<0.001) |
FISI Female Sexual Function Index, FACIT-F Functional Assessment of Chronic Illness Therapy- Fatigue, ILQI Immune Thrombocytopenia Life Quality Index, HAMA Hamilton Anxiety Scale
Risk factors for sexual dysfunction
We performed multivariate logistic regression analysis to identify factors influencing sexual dysfunction in female patients with ITP. At baseline, incorporated variables included demographic characteristics, fatigue, quality of life, and anxiety, among others. Univariate analysis revealed that having two or more children (OR = 0.513; P = 0.041), overweight or obesity (OR = 1.513; P = 0.024), fatigue (OR = 1.917; P < 0.001), impaired quality of life (OR = 1.128; P = 0.037), anxiety (OR = 1.104; P = 0.016), and a platelet count of <30 × 109/L (OR = 1.417; P = 0.029) were associated with sexual dysfunction in female patients with ITP. The results of the final multivariate analysis (Table 7) indicated that overweight or obesity (OR = 2.557; P = 0.021), fatigue (OR = 1.532; P < 0.001), and a platelet count of <30 × 109/L (OR = 2.363; P = 0.045) were independent risk factors for sexual dysfunction in female patients with ITP.
Table 7.
Results of multivariate logistic regression analysis of sexual dysfunction in ITP patients at the initial stage
| B | Walds | P | OR | 95%CI | ||
|---|---|---|---|---|---|---|
| Upper bound | Lower bound | |||||
| Fertility Status (≥ 2 children) | 0.142 | 0.474 | 0.765 | 1.152 | 0.455 | 2.921 |
| BMI>24 kg/m2 (Yes) | 0.939 | 0.406 | 0.021 | 2.557 | 1.154 | 5.664 |
| FACIT-F ≤ 40 score (Yes) | 1.532 | 0.401 | <0.001 | 4.628 | 2.110 | 10.151 |
| ILQI ≥ 17 score (Yes) | -0.440 | 0.412 | 0.286 | 0.644 | 0.287 | 1.146 |
| HAMA ≥ 14 score (Yes) | 0.457 | 0.400 | 0.253 | 1.580 | 0.721 | 3.460 |
| Platelet count (<30 × 109/L) | 0.860 | 0.429 | 0.045 | 2.363 | 1.019 | 5.478 |
BMI Body mass index, FISI Female Sexual Function Index, FACIT-F Functional Assessment of Chronic Illness Therapy-Fatigue, ILQI Immune Thrombocytopenia Life Quality Index, HAMA Hamilton Anxiety Scale
After two follow-up assessments, we incorporated demographic characteristics, fatigue, quality of life, anxiety, disease status, and treatment details into the analysis. Univariate analysis results indicated that factors such as overweight or obesity (OR = 0.374; P = 0.039), fatigue (OR = 1.226; P = 0.033), anxiety (OR = 1.759; P < 0.001), platelet count <30 × 109/L (OR = 2.724; P = 0.027), wet or internal bleeding (OR = 3.881; P = 0.002), a history of corticosteroid dependence (OR = 1.191; P = 0.045), receipt of second-line treatment (OR = 1.184; P = 0.044), use of more than two medications (OR = 1.403; P = 0.017), platelet transfusion within the preceding 3 months (OR = 1.336; P = 0.028), and hospitalization within the preceding 3 months (OR = 1.571; P = 0.008) were associated with sexual dysfunction in female patients with ITP. The final multivariate analysis (Table 8) indicated that impaired quality of life (OR = 3.813; P = 0.004), anxiety (OR = 4.095; P = 0.003), a platelet count of <30 × 109/L (OR = 4.996; P = 0.039), wet or internal bleeding (OR = 3.744; P = 0.016), and use of more than two medications (OR = 2.861; P = 0.031) were independent risk factors for sexual dysfunction in female patients with ITP.
Table 8.
Results of multivariate logistic regression analysis of sexual dysfunction in ITP patients after 12- months follow-up
| B | Walds | P | OR | 95%CI | ||
|---|---|---|---|---|---|---|
| Upper bound | Lower bound | |||||
| BMI>24 kg/m2 (Yes) | 0.293 | 0.403 | 0.525 | 1.341 | 0.542 | 3.315 |
| FACIT-F ≤ 40 score (Yes) | -0.722 | 2.467 | 0.116 | 0.486 | 1.197 | 1.196 |
| ILQI ≥ 17 score (Yes) | 1.338 | 8.347 | 0.004 | 3.813 | 1.538 | 9.445 |
| HAMA ≥ 14 score (Yes) | 1.410 | 9.002 | 0.003 | 4.095 | 1.630 | 10.286 |
| Platelet count (<30 × 109/L) | 1.609 | 4.260 | 0.039 | 4.996 | 1.084 | 23.017 |
| Wet or internal bleeding (Yes) | 1.320 | 5.851 | 0.016 | 3.744 | 1.285 | 10.911 |
| Corticosteroid-dependent (Yes) | 0.540 | 0.651 | 0.420 | 1.731 | 0.456 | 6.565 |
| Second-line treatment (Yes) | -0.216 | 0.229 | 0.633 | 0.806 | 0.333 | 1.952 |
| Number of drugs > 2 (Yes) | 1.051 | 4.653 | 0.031 | 2.861 | 1.101 | 7.434 |
| Platelet infusion within 3 months (Yes) | 0.830 | 1.388 | 0.239 | 2.292 | 0.577 | 9.111 |
| Hospitalization within 3 months (Yes) | 00.449 | 0.278 | 0.598 | 1.566 | 0.295 | 8.313 |
BMI Body mass index, FISI Female Sexual Function Index, FACIT-F Functional Assessment of Chronic Illness Therapy-Fatigue, ILQI Immune Thrombocytopenia Life Quality Index, HAMA Hamilton Anxiety Scale
Discussion
In recent years, the quality of life among patients with ITP has attracted substantial research attention; however, investigations specifically addressing sexual health in this population remain notably limited. The I-WISH study investigated the impact of ITP on sexual function using the question: “How often does your ITP impact your sex life?” Among the respondents, 14% answered “more than half the time” and 10% answered “all the time” [27], while in the analysis of the Chinese subgroup, these proportions were 16.1% and 13.1%, respectively [28]. However, the I-WISH study was limited in depth and did not quantify the prevalence of sexual dysfunction among patients with ITP. Our findings revealed that 36.30% of female patients with ITP had sexual dysfunction at baseline, and the prevalence increased to 54.07% at the 12-month follow-up. The sexual health of ITP patients urgently requires clinicians’ attention and professional guidance.
At baseline, 96.58% of patients requiring treatment received glucocorticoid therapy, whereas only 5.98% received intravenous immunoglobulin (IVIG) therapy—a proportion that was markedly lower than that reported in data from Adam et al. [29]. The primary reason for this discrepancy was a prolonged shortage of IVIG supply at our medical center for the majority of the study period. Additionally, 52.59% of patients in this study were treated with at least one second-line agent, a proportion that was consistent with the follow-up data reported by Adam et al. [29]. This study confirmed that a platelet count of < 30 × 10⁹/L (OR = 4.996; P = 0.039), a history of wet or internal bleeding (OR = 3.744; P = 0.016), and the use of more than two medications (OR = 2.861; P = 0.031) were independent risk factors for sexual dysfunction in female patients with ITP. On the one hand, patients who received more than two medications may experience more significant fluctuations in their platelet counts and face greater difficulties in elevating their platelet counts. A lower platelet count indicates a higher risk of bleeding, and patients with a prior history of wet or internal bleeding may have concerns about vaginal or genital bleeding during sexual activity; such fear can lead to subjective avoidance of sexual behavior, thereby causing suppressed libido. Similar findings have been confirmed in patients with hemophilia, in whom psychological problems induced by the risk of bleeding significantly impair sexual experience [30]. On the other hand, ITP is accompanied by systemic immune dysregulation and inflammatory responses throughout the disease course [31]. Inflammatory cytokines (e.g., TNF-α) can induce vascular remodeling of the genitalia, decrease vaginal lubrication, and impair the physiological basis of sexual function [32]. In addition, glucocorticoids, the first-line therapeutic agents for ITP, can inhibit gonadal function, leading to a decrease in estrogen levels, a reduction in vaginal lubrication, and impaired libido [33].
In addition to the disease- and treatment-related factors, the impact of patients’ physical and mental status on sexual function cannot be overlooked. Our findings indicated that fatigue is a significant factor contributing to sexual dysfunction in female patients with ITP at baseline. After a 12-month follow-up, impaired quality of life and anxiety emerged as crucial factors responsible for sexual dysfunction in female patients with ITP. Fatigue, which is caused by a variety of diseases—including chronic obstructive pulmonary disease, multiple sclerosis, and systemic lupus erythematosus—has adverse effects on patients’ sexual function [34–36], and ITP is no exception. Over 60% of Chinese patients with ITP experience severe fatigue [28]. Mechanistically, fatigue in patients with ITP may be associated with cytokine imbalance, which involves the upregulation of proinflammatory cytokines. Studies have shown that fatigue substantially reduces sexual activity, and impairs sexual function [37]. Anxiety and depression are common mental health issues among patients with ITP, stemming from concerns about platelet count fluctuations and fear of bleeding. Studies have indicated that fatigue, anxiety, and depression lead to decreased testosterone secretion, which negatively impacts sexual behavior [38]. As a sex hormone, testosterone plays a direct and pivotal role in promoting female sexual function, as it can augment sexual interest and intensify responsiveness to sexual stimuli [39]. Spearman correlation analysis indicated that the impact of fatigue on sexual function might gradually diminish as ITP patients’ symptoms are alleviated following treatment or as they adapt to chronic fatigue. This finding provides a plausible explanation for why fatigue is no longer a significant factor for sexual dysfunction at the 12-month follow-up. In contrast, at baseline, the degree of impairment to patients’ quality of life was relatively mild, and patients had only a superficial understanding of their condition, which led to relatively low psychological stress. However, recurrent disease exacerbations and concomitant platelet count fluctuations further worsen patients’ quality of life; consequently, those issues impose a substantially greater psychological burden on them. Impaired quality of life caused by chronic diseases can indirectly compromise sexual function through adverse changes in interpersonal relationships and self-image [40].
Furthermore, our findings indicate that overweight or obesity is one of the contributing factors to sexual dysfunction in female patients with ITP at baseline. The impact of overweight or obesity on sexual function is manifested in the following aspects [41]: (1) Psychological distress stemming from body image concerns, combined with the physical limitations caused by overweight or obesity, can reduce satisfaction with sexual activity; (2) Overweight or obesity adversely affects various hormones (e.g., free steroids) that are essential for sexual behavior and reproductive capacity; (3) Overweight or obesity is often associated with a decline in the quality of life. In addition, overweight or obesity is likely to increase the incidence of various complications, which may in turn indirectly contribute to the development of sexual dysfunction. Notably, obese patients with ITP generally have a poorer prognosis. Multiple studies have confirmed that obese patients receiving hormonal therapy experience shorter remission periods and have a higher risk of steroid dependence compared to non-obese patients undergoing the same treatment [42, 43].
In the field of ITP, rapidly increasing platelet counts, minimizing disease recurrence, and improving patients’ quality of life have long been crucial issues that attract scholarly attention. However, due to low platelet counts or bleeding symptoms, clinicians often overlook ITP patients’ core medical needs related to sexual health. Given the inherent characteristics of ITP, providing sex education to patients is of great significance. Our study is the first to reveal the prevalence of sexual dysfunction in female patients with ITP at baseline and during follow-up, and to conduct an in-depth analysis of its contributing factors in this population. This study has the following limitations: (1) Despite extensive follow-up efforts, the sample size remains relatively small; therefore, the findings need to be validated by large-scale cohort studies. (2) Although China is a multiethnic country, all participants in this study were Han Chinese—the largest and dominant ethnic group in China—due to the geographical location of the research center, where the population of ethnic minorities is extremely small. Therefore, the findings and conclusions of this study cannot be generalized to other ethnic groups. (3) Sexual dysfunction was defined using a single scale in this study, and there was a lack of more objective laboratory data. (4) This study did not incorporate appearance-related psychological factors (e.g., the impact of cutaneous ecchymoses on patients’ physical appearance and self-esteem), and therefore it cannot comprehensively evaluate the potential role of such psychological factors in sexual function of patients with ITP.
Conclusions
ITP can adversely affect female patients’ sexual function. It is imperative to formulate more rational and personalized treatment regimens that can achieve more effective elevation of platelets, alleviate anxiety, improve patients’ quality of life, and thereby protect the sexual health of female patients with ITP.
Acknowledgements
We sincerely appreciate the active cooperation of all patients, as well as the entire staff involved in the patient management of this study.
Informed Consent
Due to the sensitive nature of the topic of this study, its purpose was clearly explained to all participants, who signed informed consent forms authorizing the use of their medical data for this study.
Authors’ contributions
Xing Tan and Tingting Zhu designed this study. Tongtong Zhang, Wei Wang, and Wang Quanjie evaluated fatigue, anxiety, quality of life, and sexual function. Tongtong Zhang, Tingting Zhu and Wei Wang collected clinical data from patients. Xing Tan and Yu Tian analyzed all the data and wrote this paper. All the authors participated in .
Funding
This research has not been supported by any funding sources.
Data availability
The data presented in this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
The study was approved by the Ethics Committee of Rudong People,s Hospital (approval number: 2020-57; date of approval: December 30, 2020). All methods were carried out in accordance with relevant guidelines and regulations.
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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Associated Data
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Data Availability Statement
The data presented in this study are available from the corresponding author upon reasonable request.