Sexual distress and quality of life among women with bipolar disorder
Sørensen et al. Int J Bipolar Disord
Sexual distress and quality of life among women with bipolar disorder
Thea Sørensen 0 2
A. Giraldi 1 2
M. Vinberg 0 1
0 Copenhagen Affective Disorder Clinic, Psychiatric Centre Copenhagen, Copenhagen University Hospital, Rigshospitalet , Dep. 6233, Blegdamsvej 9, 2100 Copenhagen , Denmark
1 Department of Clinical Medicine, University of Copenhagen , Copenhagen , Denmark
2 Sexological Clinic, Psychiatric Centre Copenha- gen, Copenhagen University Hospital , Copenhagen , Denmark
Background: Information on the association between bipolar disorder (BD), sexual satisfaction, sexual function, sexual distress and quality of life (QoL) is sparse. This study aims, in women with BD, to (i) investigate sexual dysfunction, sexual distress, general sexual satisfaction and QoL; (ii) explore whether sexual distress was related to affective symptoms and (iii) investigate whether QoL was associated with sexual distress. The study is a questionnaire survey in an outpatient cohort of women with BD using: Changes in Sexual Functioning Questionnaire, Female Sexual Distress Scale, Altman Self-Rating Mania Scale (ASRM), Major Depression Inventory (MDI) and The World Health Organisation Quality of Life-Brief. Results: In total, 61 women (age range 19-63, mean 33.7 years) were recruited. Overall, 54% reported sexual distress (n = 33) and 39% were not satisfied with their sexual life (n = 24). Women with BD were significantly more sexually distressed in comparison with Danish women from the background population but they did not have a higher prevalence of impaired sexual function. Better sexual function was positively associated with ASRM scores while MDI scores were associated with more distress. Finally, the group of non-sexually distressed women with BD reported higher QoL scores compared with the sexually distressed group. Conclusions: Women with BD exhibited a high prevalence of sexual distress and their sexual function seemed associated with their actual mood symptoms and perception of QoL.
Sexual distress; Sexual functioning; Quality of life; Bipolar disorder
Sexual dysfunction is defined as an impaired sexual
function that causes distress. The definition has changed
several times over the course of time but a division into four
categories overall has remained: desire/interest, arousal,
orgasm and pain disorders (Basson et al. 2000, 2004,
2010; McCabe et al. 2016). Sexual dysfunction is caused
by biological, psychological and social interactions and
factors with negative influence on human well-being.
Additionally, the risk of sexual dysfunction is increased
by factors such as socio-economic status (Christensen
et al. 2011a), psychiatric disorders (Brotto et al. 2011),
partner status and the length of relationship (Hayes et al.
2008; Eplov et al. 2007), menopause (Ornat et al. 2013)
and the side effects of psychotropic treatment (Bergh and
Giraldi 2014; Serretti and Chiesa 2011a; Zemishlany and
Weizman 2008). A Danish study (n = 4415) concluded
that mental health problems and poor self-rated health
problems were strongly associated with female sexual
dysfunction (Christensen et al. 2011b).
Information on the association between bipolar
disorder, quality of life, sexual satisfaction, sexual function and
distress is sparse. It is well known that depression and
antidepressants affect sexual function negatively (Clayton
et al. 2014), but only a few studies include women with
BD. Besides, the studies have small study populations
and different questionnaires, none of which include
sexual distress (Dell’Osso et al. 2009; Ghadirian et al. 1992;
Grover et al. 2014). In an Italian study (Dell’Osso et al.
2009) comparing 142 patients (60 with BD and 82 with
unipolar depression) with 101 healthy controls, patients
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with BD reported more sexual dysfunction compared to
healthy control persons. Patients with BD had increased
sexual desire in comparison with patients with unipolar
disorder in the Italian study. Also, the presence of
periods characterised by frequent sexual partners was
significantly associated with the feeling that life is not worth
living and sexual dysfunction was associated with
lifetime suicide attempts. Finally, a Dutch study in the
general population of the Netherlands showed an association
between BD and sexual dissatisfaction (Vanwesenbeeck
et al. 2014).
Episodes of depression or mania can be trigged by
stress. Patients with BD are probably more easily
distressed, and therefore, sexual distress could be a potential
trigger for depression and/or mania. The possible
relationship between sexual distress and affective symptoms
in patients with BD has not been evaluated previously.
Further, quality of life (QoL), the general well-being and
observed life satisfaction in many aspects—for example,
physical and psychological health, education,
employment, wealth, finance, environment, social relations and
sexual function—are important aspects of QoL. Patients
with affective disorders have a lower score of QoL
compared to the general population (Nørholm 2008; Yatham
et al. 2004; Nørholm and Bech 2001). When measuring
QoL, according to World Health Organisation, sexual
satisfaction is included as part of the total score (WHOQOL
Group 1998). To improve treatment and QoL clinically
in patients with BD, it is thus important to also focus on
and include sexual function. The aim of the present study
was, in a cohort of women with BD, to (i) investigate
sexual function, sexual distress, general sexual satisfaction
and QoL; (ii) explore whether sexual distress was related
to affective symptoms and (iii) investigate whether QoL
was associated to sexual distress.
Women with BD were recruited to the questionnaire
survey from the waiting room at the Copenhagen
Affective Disorder Clinic, Psychiatric Centre Copenhagen.
The included sample was derived from 1 March to 9 May
2015 from patients attending a region-wide secondary
service for patients with primary bipolar disorders. The
patients received written and oral information about the
project before deciding whether to participate. Further, at
the time the questionnaire was answered and diagnosis
confirmed, medication was assessed from the patients’
The self-assessment questionnaire included
parameters, among others, previously shown to affect sexual
function: basic demographic information (age, education,
civil status, sexual orientation, length of relationship,
employment and information about children) and
lifestyle (alcohol, smoking and weight). The other part of the
questionnaire included is described below.
The inclusion criteria were as follows: being women with
a clinical diagnosis of BD, aged 18–70 years, reading and
understanding Danish and willing to participate in the
study. Participants were included in analyses
independent of their answers, sexual preference, civil status, age
and sexual activity. They were excluded from analysis
when not diagnosed with BD according to their
electronic hospital records.
The control group consisted of a group of Danish
women from a previous study conducted by our group
(Giraldi et al. 2015) describing sexual function. In
summary, these data were collected from a cross-sectional
study of a large, broadly sampled, non-clinical population
cohort of Danish women (573 women participated). They
were drawn randomly from the Danish Central National
Register and invited to participate by letter. The Danish
women were included if they were sexually active with a
partner within the 4 weeks prior (n = 429). As the
control group had a significant higher mean age, we
conducted an age-matched analysis between women with
BD and a subsample of age-matched women from the
control group (n = 122).
The Female Sexual Function Index (FSFI) and Female
Sexual Distress Scale (FSDS) were used to describe sexual
function among the Danish women in the background
population. They were categorised as having female
sexual dysfunction (FSD) when FSFI score was ≤26.55
(impaired sexual function) and FSDS score ≥15 (Giraldi
et al. 2015). In the present cohort, female sexual
dysfunction was defined as a CSFQ-14 score ≤41 (impaired
sexual function) and FSDS score ≥15 (distress).
WHOQoL‑BREF, Quality of Life measure
Quality of life was assessed using an abbreviated
version of the World Health Organisation Quality of Life
Assessment brief version, WHOQoL-BREF (WHOQOL
Group 1998), Danish version. The WHOQoL-BREF is a
26-item questionnaire developed from the original
100item questionnaire the WHOQoL-100. The
WHOQoLBREF covers four different subscales (WHOQoL Group
1998): physical health (energy and fatigue, pain and
discomfort, sleep and rest), psychological health
(bodily image and appearance, negative feelings, positive
feelings, self-esteem, thinking, learning, memory and
concentration), social relationships (personal
relationships, social support and sexual activity) and
environment (e.g. financial resources, freedom, physical safety
and security, health and social care). Besides, one global
item scores overall quality of life (overall QoL) and one
global item scores general health. Each individual item
of the WHOQoL-BREF is scored from one to five on a
response scale. The scores are then transformed linearly
to a 0–100 scale except items one and two, overall QoL
and general health which are displayed in raw scores 1–5
(Noerholm et al. 2004). Higher scores indicate better
QoL. The internal consistency of the Danish
WHOQoLBREF was, in a pilot study, found to be psychometrically
valid (Nørholm and Bech 2001). Finally, satisfaction with
sexual life was assessed from item 21 (WHOQoL-BREF,
“How satisfied are you with your sexual life?”) and
categorised as unsatisfied when answered as “very
unsatisfied” or “unsatisfied”.
Altman Self‑Rating Mania Scale (ASRM)
Manic symptom scale scores were assessed by a short
5-item questionnaire that covered the symptoms of
positive mood, self-confidence, sleep patterns, speech
patterns/amount and motor activity. Each item is scored
from 0 to 4 and depends on how the participants
described their symptoms over the past week. Scores
above five are indicative of mania or hypomania with the
severity of symptoms increasing with higher scores
(Altman et al. 1997).
Major (ICD‑10) Depression Inventory (MDI)
Depression was measured by a 10-item questionnaire
developed to measure DSM-IV and ICD-10 diagnoses
of moderate to severe depression by self-reported
symptoms during the past 2 weeks. The first three items cover
the core symptoms of depression according to ICD-10
(depressed mood, lack of interest and lack of energy)
while the other items cover the accompanying symptoms
(lack of self-confidence, self-blame or guilt, thoughts of
death or suicide, difficulty thinking and concentrating,
agitation or inhibition, sleep disturbances and
appetite and weight change). Each item has a possible score
between 0 and 5 (0 = at no time, 5 = all the time). Items
8 and 10 were divided into two sub-items and only the
highest scores of these items were included in the
analysis. The theoretical score was 50 with a range from 0 (no
depression) to 50 (major depression) and a higher score
indicating the severity of depression. Cut-off scores ≥26
indicate moderate to severe depression. The internal
and external validity were found to be psychometrically
valid in two Danish studies (Bech et al. 2001; Olsen et al.
Changes in Sexual Functioning Questionnaire‑14 (CSFQ‑14)
Sexual function was assessed by a questionnaire
containing 14 questions with a total cut-off score ≤41
indicating impaired sexual function. Each item is scored in a
5-point scale that refers either to frequency (“never” to
“every day”) or to satisfaction (“none” to “great”). The
first item scores overall pleasure with present sexual life
and the other items cover five subscales (sexual pleasure,
sexual desire/frequencies, sexual desire/interest, arousal/
excitement and orgasm), and two items (10 + 14) about
loss of arousal and painful orgasm (de Boer et al. 2014;
Keller et al. 2006). CSFQ-14 has been validated to assess
sexual dysfunction among patients taking antipsychotics
and also covers all stages of sexual functioning compared
to other questionnaires (de Boer et al. 2014). A score ≤41
is seen as an impaired sexual function and thus indicates
sexual dysfunction (Keller et al. 2006).
Female Sexual Distress Scale (FSDS)
Sexual distress was assessed by a 12-item questionnaire
that covers the intensity and frequency of sexual distress
the past 30 days. Each item scores from 0 to 4 (0 = never
and 4 = always). A cut-off score ≥15 indicates sexual
distress. FSDS has been validated in studies, including a
pilot study with 60 healthy women and 18 women with
different kinds of sexual dysfunction. It was concluded
that the questionnaire is able to distinguish between
those with and without sexual dysfunction and the study
showed moderate positive correlation to general mental
distress, and thus seems to be a good estimate of sexual
distress (Derogatis et al. 2002).
Written informed consent was obtained from all
participants. The study was approved by the Danish Data
Protection Agency, Journal Number: 03568 and ID-Number:
All analyses were conducted using the Statistical
Package for Social Sciences (version 22.0). Spearman’s
correlation coefficients were used to test the associations
between the variables (data measured from an ordinal
scale). Chi square tests were used to compare variables
within two groups and prevalence values between two
groups. The study population (women patients with
BD), Danish women from the background population
as well as the age-matched controls were, separately,
dichotomised into two groups: sexually distressed or
not sexually distressed. An independent t test was
used to compare mean scores and standard deviations.
To investigate whether MDI scores or WHOQoL
subscales were predictive of sexual distress, binary logistic
Table 1 Demographic data and background
characteristics of women with BD, N = 61, standard deviation I
regression analyses including age and depression score
according to MDI and the five WHOQoL subscales
(general health, physical health, psychological health,
social relationships and environment), were conducted,
Finally, we compared information on sexual function
among women with BD with data from women from the
Danish background population and age-matched
controls from this group, respectively.
In total, 85 women were asked to participate; 14 did not
answer the questionnaires (response rate 83.5%), eight
were not diagnosed with BD and a further two did not
fully complete the questionnaires, thus leaving 61
participants (72% included). As seen from Table 1, the
participants were characterised by being young, single without
children, heterosexual, well-educated and unemployed.
The majority were non-smokers and overweight to obese
(BMI > 25).
Almost all were prescribed medication, especially
mood stabilisers (mean number of medication: 2.2), and
half were in remission. Women with BD and BMI > 25
were not prescribed more types of medication (mean 2.1)
than those with BMI < 25 (mean 2.3). Four women (6.6%)
did take lithium in combination with benzodiazepines
and three of them reported sexual dysfunction.
Most women were sexually active (87%). All the
sexually inactive (n = 8) women reported impaired sexual
function but three of them did not report sexual distress.
Half of the sexually inactive women with BD were older
than 50 years, single or in a relationship for many years
(25 or 31 years). Four women with BD were older than
50 years old and they all reported impaired sexual
function but we did not find a correlation between a lower
CSFQ-14 score and higher age (r = −0.17, P = 0.20).
Impaired sexual function, sexual distress and general
sexual satisfaction—prevalence, mean scores
and correlation to affective symptoms
As seen from Table 2, 21 (34.4%) women with BD
reported impaired sexual function (CSFQ-14 score ≤41).
However, six patients were not distressed by this
resulting in 15 (24.6%) out of 21 patients having a sexual
dysfunction (impaired sexual function combined with sexual
distress). Thirty-three (54.1%) women with BD had sexual
distress. More than one-third was unsatisfied (answering
“very unsatisfied” or “unsatisfied” to the question “How
satisfied are you with your sexual life?”) with their
sexual life. The study population had a mean score ± SD of
Altman Self-Rating Mania Scale (ASRM) number of patients with current
hypomania/manias defined as a score >5. Major Depression Inventory (MDI)
number of patients with current depression defined as a score ≥26 (moderate/
severe). Remission defined as ASRM scores <5 and MDI score <26
WHOQoL-BREF World Health Organisation Quality of Life-BREF
a Five patients were prescribed selective serotonin reuptake inhibitors (SSRI)
and serotonin and noradrenaline reuptake inhibitors (SNRI), one patient a
combination of SNRI and Agomelatin and two patients Agomelatin
b Five patients with depression also reported ASRM scores with a mean score
ASRM = 10
Table 2 Sexual dysfunction and sexual distress
Prevalence and comparison between women with bipolar disorder and women from the Danish background population including age-matched control persons
Data are prevalence (%). Data from the background population is from a Danish study (Giraldi et al. 2015). FSFI = Female Sexual Function Index (background
population, impaired sexual function cut-off ≤26.55). CSFQ-14 = Changes of Sexual Functioning Questionnaire (study population, impaired sexual function cut-off
score ≤41). FSDS = Female Sexual Distress Scale (score ≥15 = sexual distress). Sexual dysfunction (FSFI cut-off ≤26.55 or CSFQ cut-off score ≤41 combined with FSDS
a Answering “very unsatisfied” or “unsatisfied” to “How satisfied are you with your sexual life?” In background population: “bad” or “very bad” to “How do you appraise
your sexual life?”
CSFQ-14 score of 45.2 ± 10.4; FSDS score 15.9 ± 11.3;
ASRM scores 3.7 ± 3.8 and MDI score 19.7 ± 12.1.
Using Spearman’s correlation, sexual function
(CSFQ14 score) was positively correlated with ASRM scores
(r = 0.26, P = 0.04) but not with MDI scores (r = −0.02,
P = 0.88). However, sexual distress was positively
correlated with MDI scores (r = 0.33, P = 0.01) but not with
ASRM scores (r = 0.11, P = 0.42). Thus overall, general
sexual satisfaction did not correlate with affective
symptom scale scores (ASRM scores r = 0.13, P = 0.32; MDI
scores r = −0.21, P = 0.10).
Comparison with the background population
As seen from Table 2, women with BD did not have a
significantly higher prevalence of impaired sexual function
or sexual dysfunction compared to Danish women from
the background population but they were significantly
more often sexually distressed (P = 0.001, n = 429), also
when using an age-matched subsample from the
background population (P = 0.04, n = 122). Age-matched
controls (n = 122) also had a lower BMI than the study
population but almost equal percentage of women in
menopause (8% vs. 7%).
Quality of life
Sexual function was positively associated with QoL and
social relationships. Better sexual function and less
sexual distress was associated with a higher degree of
satisfaction with sexual life (r = 0.51, P = 0.00, r = −0.32,
P = 0.01) and higher QoL score (Table 3), respectively.
Finally, QoL scores, including the four subscales of
WHOQoL, were negatively correlated with MDI scores.
In post hoc analyses dividing the women with BD
into two groups—not sexually distressed and sexually
distressed—the sexually distressed group had
significantly lower scores for psychological health and a trend
towards higher depression score according to MDI
(P = 0.07) (Table 4). In further analyses exploring the
influence of MDI scores on the level of reported sexual
distress, a multiple linear regression analysis adjusted
for age and self-reported depressive symptoms
according to MDI was conducted and showed that the MDI
Table 3 Spearman’s correlations between WHOQoL-BREF scores, affective symptoms and sexual function and distress
in a cohort of women with bipolar disorder
R and P values (in brackets)
WHOQoL-BREF World Health Organisation Quality of Life-BREF, ASRM Altman Self-Rating Mania Scale, MDI Major Depression Inventory, FSDS Female Sexual Distress
Scale, CSFQ-14 Changes of Sexual Functioning Questionnaire
Table 4 Comparison of mood symptoms and quality of life
dividing the dividing the cohort of women with bipolar
disorder according to the Female Sexual Distress Scale
(score <15 = not sexually distressed
and score ≥15 = sexual distressed)
distressed (n = 28)
ASRM scores defined as Altman Self-Rating Mania Scale (ASRM) score >5.
Depression defined as Major Depression Inventory (MDI) score ≥26
SD standard deviation, BMI body mass index, WHOQoL-BREF World Health
Organisation Quality of Life-BREF, CSFQ-14 Changes of Sexual Functioning
Questionnaire score ≤41)
a Married, cohabiting with a partner or in a relationship but living apart
score was borderline associated with being sexually
distressed [P = 0.06, Wald = 3.6, exp(B) = −0.04 (CI
0.92–1.00)]. In further regression analyses, the
WHOQoL subscales were added and none of these were
associated with a significant higher level of sexual distress:
general health: P = 0.70, Wald = 0.15, exp(B) = 0.99 (CI
0.95–1.03); psychological health: P = 0.33, Wald = 0.97,
exp(B) = 1.02 (CI 0.98–1.07); social relationships:
P = 0.95, Wald = 0.003, exp(B) = 1.01 (CI 0.98–1.03);
environment: P = 0.71, Wald = 0.14, exp(B) = 0.97 (CI
The present study investigated sexual dysfunction,
sexual distress, general sexual satisfaction and QoL in a
cohort of women with BD and whether sexual distress
was related to affective symptoms and QoL. Overall, 61
women with BD were included; one-fourth had a sexual
dysfunction (an impaired sexual function combined with
sexual distress), more than half of the study population
was sexually distressed and one-third was unsatisfied
with their sexual life. Better sexual function was related
to higher ASRM scores while sexual distress and lower
OoL score were associated to higher MDI scores.
In comparison, an Italian study (142 patients, 60 with
BD and 82 with unipolar depression) found a higher
prevalence of sexual dysfunction among men and women
with BD compared to patients with unipolar
depression and healthy control persons (n = 101) (Dell’Osso
et al. 2009). Another population-based Danish study
(n = 4415, 2295 women) found that 11% of Danish
women had at least one sexually related problem
(lubrication, anorgasmia, dyspareunia and/or vaginismus)
considered as a problem (Christensen et al. 2011a). The
latter study did not include problems with sexual desire
which might have underestimated the prevalence of
sexual dysfunction since it is the most common sexually
related problem (Hayes et al. 2006). In comparison with
the Danish background population included as
comparison group in the present study, the women with BD did
not have a significantly higher prevalence of sexual
dysfunction but they reported sexual distress more often.
Anyhow, it can be difficult to compare the prevalence of
sexual dysfunction across studies due to different
definitions of sexual dysfunction and varying time frames in
questionnaires (Hayes et al. 2006; Giraldi et al. 2011).
One might have expected a higher prevalence of
sexual dysfunction among women with BD; however, some
of the women in the background population might have
been diagnosed with BD as well. We did include age
as a potential confounder in the regression analyses.
When compared with the entire group of women in the
Danish background population (20–65 years) (Giraldi
et al. 2015), the present study cohort (19–63 years) was
younger and the prevalence of sexual dysfunction was
more equal among age-matched control persons and
women with BD than compared to all women in the
Danish background population. It seemed that higher age did
not predict sexual dysfunction in the background
population even though the risk of developing sexual
dysfunction is higher below 30 years or above 50 years of age
(Christensen et al. 2011a) and additionally, lower sexual
desire is also associated with increasing age (Eplov et al.
Sexual distress was negatively associated with sexual
satisfaction and distress was associated with depressive
symptom scale scores in line with other studies (Hayes
et al. 2008). More than half of the present study
population was unsatisfied with their sexual life and it was not
related to MDI or ASRM scores. Sanders et al. (2011)
found that worries about sexual life increased the risk of
developing an impaired sexual function. This is in line
with a study reporting that less distress was reported
among those who were better at communicating their
sexual needs (Hayes 2008).
Quality of life (overall, general health and the four
subscales) was associated with higher MDI scores.
Better sexual function was associated with higher scores for
QoL overall, and for social relationships, including item
21 also (“How satisfied are you with your sexual life?”),
separately. Not surprisingly, those with better sexual
function also seemed more satisfied with their sexual
life. In comparison with the Danish background
population (a study including 568 women), the present cohort
had lower scores on the four WHOQoL subscales
(physical health: 75 ± 19 vs. 62.7 ± 17.5, psychological health:
67 ± 17 vs. 46.9 ± 19.8, social relationships: 70 ± 18 vs.
58.7 ± 22.4 and environment: 74 ± 16 vs. 62.6 ± 14.6)
(Noerholm et al. 2004). This is in line with other
studies where patients with affective disorders were found to
have lower quality of life scores (Nørholm 2008; Yatham
et al. 2004). Sexual distress was related to a lower overall
QoL score and for psychological health. Dichotomising
the study population into sexually distressed and not
sexually distressed groups, no difference was found between
their scores for social relationships but psychological
health differed. This may be explained by the influence
of psychopathology related to BD rather than social
relationships that may have had influence on QoL in a
negative way. The two groups did not differ according to
age, BMI and MDI scores (although MDI scores showed
a trend, Table 4). Those who were sexually distressed
reported higher MDI scores which included negative
thoughts about oneself, reduced self-esteem, problems
with memory and concentration. It may partly contribute
to the lower score on psychological health reported by
the sexually distressed women with BD.
The study population had a higher BMI compared to
the age-matched controls. The majority of women with
BD were prescribed antipsychotics and/or mood
stabilisers, frequently quetiapine, lamotrigine and/or lithium
(Table 1). Weight gain is a well-known side effect of
antipsychotics and lithium which might have
contributed to more than half of the study population being
overweight or obese (BMI > 25, Table 1). High BMI is
associated with impaired sexual function and sexual
inactivity (Christensen et al. 2011c). It is difficult to
distinguish whether women who are obese (BMI ≥ 30) and
diagnosed with BD had sexual dysfunction due to their
psychiatric diagnosis, side effects of medication and/or
because of their obesity or other factors. However, the
obese participants were not prescribed more medicine
than the rest of the cohort.
Quetiapine seems to be associated with less
sexually related side effects than other antipsychotics and
lamotrigine seems not to be related to sexual
dysfunction (Serretti and Chiesa 2011a, b). In a study with only
15 women with BD, it was estimated that around 50%
who started treatment with lithium developed a sexual
dysfunction (Grover et al. 2014), while another study
(including n = 105, 59 women with BD) concluded that
lithium monotherapy did not present a risk factor for
sexual dysfunction only when combined with
benzodiazepines (Ghadirian et al. 1992). In the present study,
four women did take lithium in combination with
benzodiazepines and three of them had sexual dysfunction.
Since they were taking more types of medication it may
be assumed that these patients were difficult to treat and
thereby also more clinically unstable with an impact on
sexual function. Finally, it is well known that selective
serotonin reuptake inhibitors (SSRI) and serotonin and
noradrenaline reuptake inhibitors (SNRI) often have side
effects, especially anorgasmia (Bergh and Giraldi 2014).
However, only one of the sexually inactive women
having problems with orgasm in the present study was
prescribed an SSRI or SNRI but the remaining five patients
(sexually active) taking SSRI and/or SNRI medication
also reported problems with orgasm.
Menopause may be a risk factor for sexual
dysfunction. All the post-menopausal women with BD reported
impaired sexual function. In line with that, a Spanish
study (n = 260) found that menopause was associated
with a lower score for CSFQ-14 (worse sexual function)
(Ornat et al. 2013) but in this study no association was
found between a lower score of CSFQ-14 and higher age.
In the present study, more women with BD identified
themselves as homo- or bisexual (18%, Table 1) in
comparison with the Danish background population (1.6%)
(Graugaard et al. 2015). According to the latter study,
non-heterosexual Danes reported more often that their
sexual needs were not met, which might contribute to
sexual distress. It is of interest that more women with
BD identify themselves as non-heterosexual in
comparison to the general population and that they have sexual
distress to a higher extent. However, these questions are
beyond the limits of the present study and need larger
study samples to answer them.
Strengths and limitations
This study was limited by the cross-sectional design
and a questionnaire survey does not fully explain the
causations of sexual function, affective symptoms and
quality of life. The study included women only and it
is therefore recommended in future studies to include
both sexes. However, it is the first study including
sexual distress in a definition of sexual dysfunction among
women with BD. There was a high response rate (84.7%)
which might have minimised the risk of selection bias
towards women with BD without manic or
depressive symptoms—they might be more likely to answer
the questionnaire. The study included clinical data and
the questionnaires were validated in order to estimate
sexual function, sexual distress, affective symptoms
and quality of life. Unfortunately, time frames varied
between the questionnaires, and as it was not possible
to change this in the present validated form, it
represents a limitation.
It was a strength that age was included as a
potential confounder due to the data being age- matched
when comparing the prevalence of sexual
dysfunction and distress among women with BD and Danish
women from the background population. The present
study was limited by not being matched according to
sexual activity and civil status as women with BD were
not excluded if sexually inactive (13%) or not in a
current relationship (46%). If we had excluded the
sexually inactive women, the prevalence of impaired sexual
function would have been lower. It is further a
limitation that the cross-sectional design of the present study
did not allow us to explore whether they were inactive
because of a present sexual dysfunction or whether
they had a sexual dysfunction due to sexual inactivity
at the time of answering the questionnaire—they might
not have had problems with orgasm, desire or
lubrication. Finally, as described, the psychopharmacological
treatment can induce sexual dysfunction and only 7%
of the included women were without any medication.
Due to the low number of participants it was not
possible to correlate sexual function and the different kinds
Women with BD reported a high prevalence of sexual
distress (more than 50%) and significantly higher than
age-matched Danish women; more than one-third were
unsatisfied with their sexual lives. Further, sexual
function seemed related to higher manic scores (positive
correlation) while sexual distress was negatively correlated
with higher depressive scores. QoL scores were
negatively correlated with depression scores. Further, women
reporting sexual distress had lower scores on the QoL
subscale for psychological health, thus suggesting that
the impact of BD influences overall QoL. Finally, the
present findings point to the fact that sexual distress can be
an expression of depression.
However, in line with a recent review (Kopeykina et al.
2016), although patients with BD experience
diseasespecific impaired sexual functions, the existing literature
on patients with BD sexual behaviour is mostly outdated.
Novel research is thus needed to address sexual
symptomatology in BD and longitudinal studies are important
to disentangle the causal relationship between sexual
distress, affective symptoms and QoL.
ASRM: Altman Self-Rating Mania Scale; BD: bipolar disorder; BMI: body mass
index; DSM-V: Diagnostic and Statistical Manual of Mental Disorders, fifth
version; CSFQ-14: Changes in Sexual Functioning Questionnaire; FSDS: Female
Sexual Distress Scale; MDI: Major (ICD-10) Depression Inventory; QoL: quality
of life; WHOQoL-BREF: World Health Organisation Quality of Life Assessment,
TS, AG and MV wrote the protocol. TS and MV did all the patient recruitment.
TS, AG and MV performed the primary statistical analysis and drafted the first
version of the manuscript. TS and MV drafted subsequent versions of the
manuscript. All authors read and approved the final manuscript.
All authors have (1) made substantial contributions to conception and design,
(2) been involved in revising the manuscript, (3) given final approval of the
version to be published and (4) agreed to be accountable for all aspects of the
TS declare that they have no competing interests. AG has within the last three
years been a consultant/or speaker for Eli Lilly and Pfizer. MV has within the
last three years been a consultant for AstraZeneca and Lundbeck.
Availability of data and materials
Assess to data and material can be received by contacting the authors.
Consent for publication
The present submission is approved by all authors.
Ethics approval and consent to participate
Written informed consent was obtained from all participants and the study
was approved by the Danish Data Protection Agency, Journal Number: 03568
and ID-Number: RHP-2015-004.
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