Fibromyalgia is a chronic pain disorder characterized by widespread musculoskeletal pain, fatigue, and cognitive disturbances. Beyond its physical symptoms, fibromyalgia significantly impacts patients’ quality of life, including sexual health—a subject often overlooked in clinical practice. Many patients experience reduced libido, sexual dysfunction, and relationship strain, which can be attributed to both physiological and psychological factors. This paper explores the causes, diagnostic challenges, and treatment options for sexual problems in individuals with fibromyalgia, emphasizing the need for a holistic and empathetic approach in patient care.

What is fibromyalgia?

Fibromyalgia is a long-term (chronic) disorder that causes widespread pain throughout the body, along with other symptoms such as:

• Muscle and joint stiffness
• Fatigue, even after rest or sleep
• Sleep disturbances
• Cognitive issues (“fibro fog”) such as memory problems and difficulty concentrating
• Sensitivity to pain, touch, light, sound, or temperature
• Mood disorders, including anxiety and depression

• Cause: The exact cause of fibromyalgia is unknown, but it’s believed to involve abnormal processing of pain signals in the brain and nervous system. It may be triggered or worsened by stress, infections, or physical trauma.
• Diagnosis: There is no specific test for fibromyalgia. Diagnosis is usually made based on symptoms and by ruling out other conditions.
• Treatment: While there is no cure, symptoms can be managed through a combination of medication, exercise, stress management, therapy, and lifestyle changes.

Fibromyalgia is more common in women and often starts in middle adulthood, though it can affect people of all ages.

Common sexual problems in patients with fibromyalgia

Patients with fibromyalgia often experience a range of sexual problems, which can affect both physical and emotional aspects of intimacy. These issues are common and multifactorial, involving pain, fatigue, mood disturbances, and self-image concerns.

Common Sexual Problems in Fibromyalgia Patients:

1. Decreased Libido (Low Sexual Desire): One of the most frequently reported issues. Chronic pain, fatigue, and depression can reduce interest in sexual activity.
   1. Dyspareunia (Pain During Intercourse): Muscle tenderness, joint stiffness, and hypersensitivity can make physical intimacy painful, especially for women.
   1. Difficulty Reaching Orgasm: Neurological changes and medication side effects may interfere with arousal and orgasmic response.
   1. Fatigue and Lack of Energy. Persistent exhaustion makes it physically and emotionally challenging to engage in or enjoy sexual activity.
   1. Vaginal Dryness (in women): Often linked to hormonal changes, medication use (e.g., antidepressants), or anxiety, leading to discomfort during intercourse.
   1. Erectile Dysfunction (in men): Though less studied in men with fibromyalgia, chronic pain, depression, and medications can contribute to ED.
   1. Negative Body Image and Low Self-Esteem: Physical limitations and emotional distress may lead to reduced confidence and avoidance of intimacy.
   1. Anxiety and Depression: These are common in fibromyalgia and can significantly impair sexual function and satisfaction.
   1. Relationship Strain: Sexual difficulties can lead to frustration, communication problems, and emotional distance between partners.

Sexual dysfunction in fibromyalgia is not only a result of physical pain but also deeply tied to emotional well-being, hormonal balance, and interpersonal dynamics. Addressing these problems requires a holistic, multidisciplinary approach, including medical, psychological, and sometimes couples therapy support.

Causes of sexual problems in patients with fibromyalgia

The causes of sexual problems in patients with fibromyalgia are complex and often involve a combination of biological, psychological, and social factors. Understanding these causes can help guide effective diagnosis and treatment.

1. Chronic Pain and Muscle Tenderness

• Persistent widespread pain, especially in areas involved in sexual activity (e.g., pelvic region, back, thighs), can make physical intimacy uncomfortable or painful.
• Pain during movement or touch can cause patients to avoid or fear sexual contact (dyspareunia is common in women).

2. Fatigue and Sleep Disturbances

• Severe fatigue is a hallmark of fibromyalgia and can result in low energy and lack of motivation for sexual activity.
• Poor sleep quality exacerbates exhaustion and decreases libido.

3. Hormonal and Neurochemical Imbalances

• Fibromyalgia may involve dysregulation of neurotransmitters like serotonin, dopamine, and norepinephrine, which are important for both pain perception and sexual desire.
• Altered hormone levels, including reduced estrogen or testosterone, can also impact sexual function.

4. Psychological Factors

• Depression and anxiety are common in fibromyalgia and strongly affect sexual interest and satisfaction.
• Body image issues, due to chronic illness or weight changes, can reduce confidence and sexual self-esteem.
• Emotional distress may also interfere with arousal or orgasm.

5. Medication Side Effects

• Medications used to treat fibromyalgia symptoms—such as antidepressants (SSRIs, SNRIs), muscle relaxants, and painkillers—can cause side effects like: Reduced libido, vaginal dryness or erectile dysfunction and difficulty achieving orgasm.

6. Relationship and Social Issues

• Chronic illness can strain relationships, leading to reduced intimacy, poor communication, and emotional distance.
• Partners may not fully understand the patient’s physical limitations, contributing to stress or guilt around sex.

7. Autonomic Nervous System Dysfunction

• Fibromyalgia is associated with autonomic dysregulation, which may impact blood flow, lubrication, and genital sensitivity—all essential for normal sexual function.

Sexual dysfunction in fibromyalgia arises from the interaction of physical pain, emotional distress, hormonal imbalances, side effects of treatment, and relationship dynamics. A thorough assessment must consider all these dimensions for effective management.

Diagnosis of sexual problems in patients with fibromyalgia

Diagnosing sexual dysfunction in patients with fibromyalgia involves a comprehensive, multidisciplinary approach that takes into account physical, psychological, and social factors. Since sexual problems are often underreported due to embarrassment or lack of awareness, healthcare providers must proactively screen for these issues during routine care.

1. Patient History and Symptom Assessment

• Detailed sexual history: Ask about changes in libido, arousal, orgasm, and any pain or discomfort during sexual activity.
• Fibromyalgia symptom review: Assess fatigue, pain severity, sleep disturbances, and medication use.
• Duration and impact: Evaluate how long the sexual issues have been present and their effect on the patient’s quality of life and relationships.

2. Use of Standardized Questionnaires

Validated tools can help identify and quantify sexual dysfunction:

• For Women: Female Sexual Function Index (FSFI) – assesses desire, arousal, lubrication, orgasm, satisfaction, and pain.
  • For Men: International Index of Erectile Function (IIEF) – evaluates erectile function, orgasmic function, sexual desire, and satisfaction.

Other tools:

• Beck Depression Inventory (BDI) or Patient Health Questionnaire (PHQ-9) – to screen for depression.
• Generalized Anxiety Disorder 7-item scale (GAD-7) – to assess anxiety levels.

3. Physical Examination

• Assess for pelvic pain, tenderness, or musculoskeletal limitations that might affect sexual activity.
• In women, a gynecological exam may be needed to identify vulvodynia, vaginal atrophy, or other conditions.
• In men, urological evaluation may be required for erectile or ejaculatory issues.

4. Laboratory Testing

To rule out or identify contributing factors:

• Hormone levels: Estrogen, testosterone, thyroid hormones, prolactin
• Blood tests: To check for anemia, vitamin deficiencies, or other systemic conditions
• Medication review: Identify drugs that may affect sexual function (e.g., SSRIs, opioids)

5. Psychological and Relationship Assessment

• Evaluate mental health status, particularly for anxiety, depression, trauma history, or body image issues.
• Discuss relationship dynamics, communication with the partner, and emotional intimacy.

6. Referral to Specialists (If Needed)

• Rheumatologist: For fibromyalgia management
• Sex therapist or psychologist: For emotional and relational aspects
• Gynecologist or urologist: For detailed sexual health evaluation
• Physical therapist: For pelvic floor issues or musculoskeletal pain affecting sex

Treatment of sexual problems in patients with fibromyalgia

Treating sexual dysfunction in fibromyalgia patients requires a holistic, multidisciplinary approach that addresses the underlying causes—including chronic pain, fatigue, mood disorders, medication side effects, and relationship issues. Treatment should be individualized and focus on both physical and psychological well-being.

1. Pain and Fibromyalgia Symptom Management

Managing fibromyalgia symptoms is foundational for improving sexual function.

• Medications:
  • Pregabalin, duloxetine, milnacipran: Can reduce pain and improve mood.
  • Low-dose tricyclic antidepressants (e.g., amitriptyline): May help with pain and sleep.
  • Avoid or monitor SSRIs and opioids that can worsen sexual function.
• Non-pharmacologic strategies:
  • Aerobic and strength exercises: Improve energy, mood, and reduce pain.
  • Sleep hygiene: Better sleep improves fatigue and sexual interest.
  • Cognitive Behavioral Therapy (CBT): Helps patients manage pain and stress, improving overall quality of life.

2. Specific Treatments for Sexual Dysfunction

For Women:

• Vaginal moisturizers and lubricants: For vaginal dryness or pain during intercourse.
• Local estrogen therapy (if appropriate): For postmenopausal women with vaginal atrophy.
• Pelvic floor physical therapy: For muscle tension or pain that interferes with sex.

For Men:

• Phosphodiesterase-5 inhibitors (e.g., sildenafil): For erectile dysfunction.
• Address contributing factors such as cardiovascular health, testosterone levels, or medication side effects.

3. Psychological and Emotional Support

• Sex therapy or couples counseling:
  • Helps patients and partners improve communication and intimacy.
  • Teaches techniques to reduce anxiety related to sex and build emotional closeness.
• Mental health treatment:
  • Antidepressants or psychotherapy to manage depression and anxiety.
  • Body image counseling: To boost self-esteem and confidence.

4. Relationship and Communication Enhancement

• Encourage open dialogue between partners about needs, limitations, and expectations.
• Suggest scheduling sexual activity during times of lower pain and fatigue, or adapting positions to minimize discomfort.

5. Lifestyle and Supportive Therapies

• Yoga, meditation, or mindfulness: Reduce stress and improve body awareness and relaxation.
• Patient education: Teaching about the link between fibromyalgia and sexual health helps reduce guilt and encourages active problem-solving.
• Support groups: Provide emotional support and practical advice from others with similar experiences.

Summary

Sexual problems are common but often overlooked in patients with fibromyalgia. These issues include reduced libido, pain during intercourse, fatigue, and emotional distress, stemming from chronic pain, hormonal imbalances, psychological factors, and medication side effects. Diagnosis involves a comprehensive approach, including clinical interviews, physical exams, and standardized questionnaires to assess sexual function and related symptoms. Treatment focuses on managing fibromyalgia symptoms, addressing psychological well-being, improving relationship dynamics, and using targeted therapies such as pelvic floor therapy, sexual counseling, or medication adjustments. A multidisciplinary and empathetic approach is essential to improving sexual health and overall quality of life in these patients.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE