Introduction.Sexual dysfunction is found to be highly prevalent in western and Indian literature. Limited studies are available on drug naive depression in western literature and in Indian population. Depression is known to have negative effects on reproduction, but little is known about role of serum cortisol in sexual function. The present study examined the prevalence of sexual dysfunction and relationship of serum cortisol level with sexual dysfunction in MDD subjects.
Aim.This study aimed to assess the prevalence and symptom profile of Sexual dysfunction in drug naïve MDD subjects and to ascertain the relationship ofcortisol with sexual dysfunction.
Methods.A cross sectional study was designed. The subjects were assessed using DSM-5 to confirm the diagnosis of MDD .80 subjects who fulfilled the selection criteria were recruited. Blood samples were collected of all subjects to measure serum cortisol level. All subjects were rated on ASEX–F scale (Arizona sexual experience scale) for their sexual experiences and were divided into two groups on the basis of ASEX score, one with sexual dysfunction (group A) and other without sexual dysfunction (group B).
Results.The study showed that sexual dysfunction was reported in 72.5% of the MDD subjects. Low drive (39.66%) was most frequently reported SD. Higher non-significant mean cortisol score was observed in patients with sexual dysfunction while in female subjects with sexual dysfunction this difference was insignificant.
Conclusions. Sexual dysfunction are common in patients with major depressive disorder. Increased mean cortisol level was observed in both male and females. In females this correlation was strong .So identi?cation of sexual dysfunction in MDD patients and evaluation of cortisol level in this population should be encouraged for better management.
Key Words: major depressive disorder; Serum cortisol; sexual dysfunction;
Depression is one of the common diseases that is serious and disabling. Depression is characterized by low mood, decreased energy level, loss of interest, poor self-esteem and unable to feel pleasure, which may hamper intimate relationships (1). It is obvious that depression have a negative impact on sexual functioning. Prevalence of Sexual dysfunction (SD) in major depressive disorder (MDD), ranges from 30-70% (1). It is equally possible that sexual dysfunction may adversely affect depression. Common aetiology between depression and sexual dysfunction has been suggested (5) .The causal relationship is far from clear and the precise effects of depression on sexuality are variable.Various studies suggest that relationship between sexual dysfunction and MDD may also be associated with hormonal dysregulation(4)(5)(6)(7)(8)(9). Historical evidences are available that recognize role of depression and stress in sexual dysfunction (10) (11) .
The connection between stress and sexual function have probably role of both psychological (distraction) and physiological (hormonal effects and sympathetic nervous system SNS activity) components. Chronic stressors, whether they are daily stressors or major life events, increase an individual’s allostatic load (i.e., the body’s response to the accumulation Of Chronic or recurring stressors). Human body defiance the stress by modifying the physiological system to keep allostasis which de?ned as maintaining stability under changing demands (4). Increased chronic stress leads to higher levels of cortisol (10) , which can cause harmful effects when elevated over extended periods of time (12).Cortisol release from the adrenal cortex is a key component of the stress response. Although there are a series of autonomic and endocrine responses that occur when an organism is faced with a stressor, cortisol has become commonly known as “the stress hormone.” the information processing model of sexual response suggests that while the genital sexual response relies on the automatic processing of sexual stimuli, subjective sexual response relies on controlled processes that are affected by central pathway function (13) (14).cortisolhyperactivity lead to lowered desire and subjective sexual arousal by increased attention towards negative stimuli while potentiallyhaving little impact on physiological (genital) sexual response (11).
AIM AND OBJECTIVES
This study aimed to assess the prevalence of Sexual dysfunction in MDD subjects and to ascertain the relationship of cortisol with sexual dysfunction.
Materials and methods-
This was a cross sectional study conducted at the outpatient services of SMS Medical College and hospital Jaipur. The study was approved by the Ethics Review Committee of the Institute. The subjects were assessed using DSM-5 to confirm the diagnosis of MDD and to rule out the presence of other psychiatric disorders. A detailed history and complete physical examination along with related investigations were performed to rule out any medical comorbidity. 80 subjects who fulfilled the selection criteria were recruited. The purpose of the study was explained and those who provided written informed consent were evaluated further. Blood samples were collected from left cubital vein of all subjects to measure serum cortisol level.Samples were drawn when cortisol were at their peak (i.e. in the morning hours between 09.00AM and 11.00AM hours) (16) (17) and in women during the middle third of the menstrual cycle (between days 8 and 15) (18) (19).All subjects were rated on ASEX -F (16) scale(Arizona sexual experience scale) for their sexual experiences and were divided into two groups on the basis of ASEX score, one with sexual dysfunction(group A) and other without sexual dysfunction(group B).ASEX is a 5 item scale with 5 domains – sexdrive, arousal, lubrication, orgasm and satisfaction following orgasm. Scale evaluates sexual functioning in the past week including the day of interview. A total ASEX score of ?19, any one item with a score of ?5, or any three items with a score of ?4 would have sexual dysfunction.
Age 18–45 years, either sex.
Meeting the (DSM-5)(16) criteria for MDD.
patients with untreated depression
Literate enough to understand the text.
A severe disorder either in terms of behaviour, communication or language that will make the interview almost impossible.
History of significant substance abuse, in last 3 months, except nicotine (ICD-10)(17).
History of electroconvulsive therapy in the previous six months.
History of past psychiatric illness/ neurological disorder/ significant head injury.
History of any chronic medical (including thyroid, diabetics and gonadal disorders) /surgical illness.
Data Analysis-The data was pooled and statistical analysis was done using SPSS version 20(SPSS Inc., Chicago, ILL). Chi square tests, two sample t tests and correlationanalysis using Pearson’s correlation was performed where necessary.
Table No 1
Socio-demographic profile MDD subjects
Age (Mean ±SD)
Table 1 shows that 48.75% of total subjects were males and 51.25% were females. Most of the subjects were educated up to graduate/post graduate (47.5%)level, followed by subjects who were educated up to middle(30%). Among the total subjects 73.75% belonged to middle socioeconomic status. Majority of the subjects were Hindus by religionandof 2nd birthorder (28.75%).Nuclear extended was the most common (61.25%) family type followed by nuclear family type(21.25%). subjects equally represent both rural and urban communities (48.75% each) and remaining (2.5%) belong to suburban community. family history of psychiatric illness was reported in 33.75% subjects.
Table 2: Distribution of the cases according to Sexual Dysfunction
Table 2 depicts Sexual dysfunction being reported in 72.5% of the subjects. Low drive (39.66%) was most frequently reported SD followed by difficulty in arousal (17.24%). Erection (15.52%) and orgasm (15.52%) problems were equally reported. Poor satisfaction (12.07%) & lubrication (10.34%) were least common.
Table3: Correlation of the severity of sexual dysfunction with serum Cortisol level.
Table – 4: Distribution of cases according to SerumCortisol level
Cortisol (4.3-22.4 microgram/dl)
t = -2.072 with 39 degrees of freedom; P = 0.045
t = – 1.36 with 37 degrees of freedom; P = 0.196
t = -1.829 with 78 degrees of freedom; P = 0.071
Comparisons of serum Cortisol level between Group A and Group B revealed that serum levels of Cortisol was non significantly higher in subjects with sexual dysfunction. In male subjects no significant difference in cortisol level was observed between the groups. While we observed significantly higher level of cortisol in females having sexual dysfunction.
A high prevalence of sexual dysfunction (72.5%) in MDD patients was reported on the basis of ASEX-F scores . The results were comparable to that of Casper et al. (24) who reported 72% prevalence of SD in persons with Depression. A study done by Kendurkar and Kaur (25) in India also reported 76% SD in 50 drug naïve depressed subjects. On evaluating the ASEX-F score significant dysfunction was found in domain of Low drive (39.66%) followed by arousal(17.24%). Assessment of serum cortisol didn’t show any significant difference between the groups. Further stratification and evaluation gender wise revealed that male subjects with sexual dysfunction had higher mean score of cortisol though insignificant, while female subjects with sexual dysfunction had significantly higher mean score of cortisol.Pearson’s correlation conducted to test relationship of ASEX score severity with mean serum cortisol level and poor, nonsignificant association observed. To
In line with our results for females a recent study demonstrated a varied pattern of cortisol responses during sexual arousal in women with and without a history of sexual abuse in childhood(32).Although most of the of women in both the groups responded with decreased cortisol when exposed to an erotic ?lm, a substantially greater percentage of women with a history of childhood sexual abuse vs. non-abused women showed an increase in cortisol in-response to an erotic ?lm. Lisa Dawn Hamilton et al 130 noted a lower genital arousal and higher level of Cortisol levels in the women of high stress group. In her another study 131 she demonstrated that women having history of sexual abuse showed a rise in cortisol level with sexual stimulation. Increased cortisol in turn suppress the release of hypothalamic gonadotropin-releasing hormone, and pituitary LH and FSH (33)(34) . Lowered concentrations of HPG axis hormones leads to decrease synthesis of sex steroids in the ovaries, that may have a negative effect on peripheral sexual function (35). Moreover, since the central neurosteroid production is regulated by HPG axis through a feedback loop, it is possible that disruption of HPG axis may result in adverse effects on sexual function and mood at the central level (33)(34)(36).Opposite to results of our study three studies found inactive cortisol response during during orgasm and sexual arousal (29)(30)(31). these studies suggest cortisol either does not change or decreases in response to sexual arousal or orgasm.
In male subjects the relationship between cortisol and sexual stimuli is not so evident 65,195,196. Contrarily Kobori et al demonstrated a negative correlation of International Index of Erectile Function (IIEF) score with bioavailable cortisol and salivary cortisol67. Sympathetic activity increases with stress relative to parasympathetic activity, as a result of which the penis gets contracted. Blood cortisol level tends to increase in the HPA axis at the same time, with norepinephrine level in sympathetic nervous–adrenal medullary system .Thus, ED may occur in presence of high cortisol level. Another study documented a 69% decrease of libido in men that have excess level of serum cortisol197. Higher levels of cortisol may suppress production of gonadotropins and Testosterone. This suggests An inhibitory action of cortisol in the mechanisms of male sexual behaviour and response 65.
This study was done on 80 subjects to find the prevalence and symptom profile pertaining to sexual dysfunction and their relation with cortisol level in drug naive depression. A high prevalence (72.5%) of sexual dysfunction in MDD subjects was seen with a strong role of cortisol in female sexual response and behaviour. Sexual functioning in the areas of drive, arousal, lubrication, orgasm, and satisfaction was impaired in female subjects. Hence, every doctor should dutifully and empathetically assess the female sexual needs and functions using rating scales which can aid in treatment and drug selection .Our study also revealed a high mean cortisol score in male patients with sexual dysfunction. All these findings suggest an important role of cortisol in depression and sexual dysfunction.so cortisol may thus become a useful index for the evaluation of sexual function.
Future studies should include healthy persons. This may reveal whether or not there are differences in the cortisol serum profiles of healthy persons and patients. If such differences exist it will be of significance in the pathophysiology of sexual dysfunction.More research is needed into the pathophysiology of sexual dysfunction in depression. This will help improve our understanding of depression, sexual function and dysfunction and sexual side effects of medications and improve quality of life inpatients.