Sexuality is a multidimensional and complex concept influenced by many bio-psycho-social factors over the life span of women that should be taken into account during the assessment of the most common concerns reported in daily practice (i.e. decreased libido, poor arousal and lubrication, lack of orgasm and satisfaction, dyspareunia) [Citation1]. Although the impact of obesity on reproductive and general women’s health has been studied extensively and is a matter of constant investigation [Citation2], the role of body weight excess in sexuality during the various female reproductive phases is still poorly addressed despite the fact that obesity is an important public health problem [Citation3]. In both genders, global deaths and disabilities related to obesity, a body mass index (BMI) equal or greater than 30 kg/m2, have doubled from 1990 to 2017, largely because of an obesogenic environment [Citation4].
Shifren et al. [Citation5] have reported that the prevalence of any sexual problem in women 18 and older (n = 31581) was 43.1% and 22.2% for sexually related personal distress. Any distressing sexual problem occurred in 12.0% of respondents and was more common in women aged 45–64 years (14.8%) than in younger (10.8%) or older (8.9%) women. Correlates of distressing sexual problems included poor self-assessed health, low education level, depression, anxiety, thyroid conditions, and urinary incontinence [Citation5]. In relation to weight as a covariate, a recent systematic review and meta-analysis revealed that the prevalence of sexual dysfunction in women with overweight and obesity of different ages is high (26.9% and 49.7%, respectively) and the potential benefits following weight loss are numerous and may include improvement of sexuality [Citation6].
Key hormonal changes displayed during the different female reproductive stages are critical for weight gain and adipose tissue distribution [Citation3], which may significantly affect sexual function from both biomedical and psycho-relational standpoints. A complex vicious relationship among estrogen milieu, progesterone modulation and androgen excess on one hand, and low sex hormone binding globulin, high insulin levels and chronic low-grade inflammation on the other hand, may take place from adolescence to the menopausal transition and after menopause significantly affecting neuroendocrine and neurovascular aspects of sexual response. In addition, several complications associated with obesity ranging from associated menstrual dysfunction, infertility, negative outcomes in pregnancy, oncologic risks, pelvic floor abnormalities, as well as chronic medical conditions and drug use may further modulate one or more sexual domain (i.e. desire, arousal, lubrication, satisfaction, orgasm, and pain) [Citation2,Citation6]. On the other hand, poor body image, low self-esteem, depression and other mood disorders, including abnormal eating behaviors, have an impact on physical, mental and sexual well-being, as well as on social and partner relationships [Citation7].
The relationship between obesity and female sexual function is not consistent across studies [Citation8], and this may be related to how obesity individually impacts each population. That being so, every practitioner has the duty to address potential sexual distress associated with obesity in routine consultations managing discrimination and prejudice in healthcare to provide effective strategies in the life span of women.
In girls with increased BMI (overweight and/or obese), early pubertal signs and menarche are common and these translate into an early sexual debut along with other behavioral disorders and at-risk behaviors, including poor decisions regarding self-protection [Citation9]. Whether the early maturation of the hypothalamic-pituitary-gonadal axis brings about precocious sexual impulses in adolescents with obesity posing them at higher risk of some forms of abuse or, alternatively, the obesity condition profoundly affects individual attitudes toward sexuality in order to obtain peer acceptance and to overcome the stigma are not well established. Even the importance of reward mechanisms should be taken into account when exploring the level of sexual satisfaction; however, literature in this area is scant and more focused on food enjoyment. Women with obesity seem to be at a disadvantage in romantic relationships and this may translate into sexual dissatisfaction, especially if they experience physical impairment. Moreover, women with obesity may have unmet contraceptive care needs, due to contraindications on the use of synthetic estrogens, and be at increased risks of morbidity from unintended pregnancies [Citation7]. On the other hand, the time to conceive is longer because of anovulation and the presence of the polycystic ovarian syndrome (PCOS), which are very common in women with increased BMI (overweight and/or obese) who may display many challenges in achieving reproductive success. Both hyperandrogenic signs (i.e. hirsutism, acne, oily skin, alopecia, large waist) and fears or experiences of infertility may impair sexuality in women with obesity, namely because of the scarce appreciation of their own femininity and the strong psychological stress within the relationship [Citation10]. This weight self-stigma may lead to negative attitudes toward sexuality during pregnancy and postpartum which may be affected even by higher risks of gestational complications and long-term puerperal morbidities, including mood disorders, fostering a negative circle in women with obesity [Citation11].
It is important to underline that sexual health in women of any age significantly correlates to body image perceptions. Indeed, in a registry of women suffering from hypoactive sexual desire disorder, dissatisfaction with physical appearance was a factor both triggering and maintaining female sexual dysfunction (FSD) [Citation12]. At the time of menopause, obesity is a major aspect of women’s health, not only because it affects the presence of metabolic and cardiovascular risk factors amplifying the negative cardio-metabolic impact of the endocrine transition, but also because it challenges the hormonal management of menopausal symptoms [Citation13]. It is unknown how much the presence of obesity in postmenopausal women has a role in the occurrence of dysfunctional sexual symptoms. Indeed, the intersection of biopsychosocial variables is even more important during the aging process and involves both individuals and couples [Citation14]. In any case, when prescribing menopause hormone therapy, safety is a priority, as it occurs for hormonal contraception during the fertile period, and bioequivalent estrogens should be the therapy of choice in association with progestogens more similar to natural progesterone [Citation13].
Overall, there is a need for further research in this area of women’s health in order to identify reliable biopsychosocial indicators of specific symptoms of sexual impairment driven by weight excess. Counseling to uncover the subject is the key for effective management of comorbidities affecting sexual health and behavior in the clinical setting. The promotion of healthy life-styles (i.e. self-care, well-balanced diet, regular exercise), the avoidance of negative habits (i.e. smoking, excessive consumption of alcohol and other risky substances), the good practice of maintaining mental well-being (i.e. sufficient sleep, stress management, meditation) represent the first step to keep weight under control and it may be beneficial to sexual health. Other potential anti-obesity strategies (i.e. drugs, bariatric surgery) can be considered, taking into account the risk-benefit balance in each stage of reproduction. However, both clinicians and patients should be aware that there is not an “easy fix” for FSD and psycho-relational and social aspects are equally important to achieve long-lasting positive effects by means of cognitive-behavioral therapies.
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References
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