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 Table of Contents  
Year : 2022  |  Volume : 13  |  Issue : 2  |  Page : 139-144

Sexual dysfunction in women with type 2 diabetes mellitus: An observational study

1 Regency Health Care, Centre for Diabetes and Endocrine, Kanpur, Uttar Pradesh, India
2 Department of Diabetes and Endocrine, Regency Health Care, Centre for Diabetes and Endocrine, Kanpur, Uttar Pradesh, India
3 Department of Medicine, GSVM College, Kanpur, Uttar Pradesh, India
4 Royal Glamorgan Hospital, Cardiff & Vale University Health Board, Cardiff, United Kingdom

Date of Submission11-Sep-2021
Date of Acceptance06-Nov-2021
Date of Web Publication21-Jul-2022

Correspondence Address:
Dr. Manisha Gupta
Department of Diabetes and Endocrine, Regency Hospital Private Limited, Kanpur, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jod.jod_108_21

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Introduction: There is a dearth of studies evaluating sexual dysfunction in women with Type 2 Diabetes Mellitus (T2DM), despite anecdotal evidence suggesting an association between glycemic control and female sexual health. Materials and Methods: An observational cross-sectional study was carried out in 100 women with T2DM under follow-up at a regional diabetes center. Validated questionnaires, Female Sexual Function Index (FSFI), and Female Sexual Distress Scale (FSDS) were used to collate the prevalence and severity of female sexual dysfunction (FSD) in the subjects. Anthropometric and metabolic parameters were recorded by clinical examination and blood tests, respectively. Results: FSD was reported in 18% (95% CI: 10.5–25.5%) of the women enrolled in the study. The women with FSD were significantly older (50 ± 9.3 years vs. 43.9 ± 8.2 years, P = 0.006). In addition, the mean body mass index (BMI) (31.96 ± 5.5 Kg/m2 vs. 28.98 ± 4.63Kg/m2, P = 0.02) and waist circumference (38.88 ± 6.6 inches vs. 35.54 ± 5.62 inches, P = 0.03) were higher in the women with FSD compared with those without FSD. However, we observed no statistically significant association between FSD and the duration of diabetes, level of glycemic control, and serum testosterone level. Conclusion: Advanced age, higher BMI, and central adiposity were related with the development of FSD, whereas the duration of diabetes and level of HbA1c did not increase FSD risk.

Keywords: BCA: Body Composition Analysis, BMI: Basal Metabolic Index, FSD: Female Sexual Dysfunction, FSDI: Female Sexual Distress Index, FSFI: Female Sexual Function Index, T2DM: Type 2 Diabetes Mellitus

How to cite this article:
Gupta M, Shukla R, Verma S, Kalhan A. Sexual dysfunction in women with type 2 diabetes mellitus: An observational study. J Diabetol 2022;13:139-44

How to cite this URL:
Gupta M, Shukla R, Verma S, Kalhan A. Sexual dysfunction in women with type 2 diabetes mellitus: An observational study. J Diabetol [serial online] 2022 [cited 2022 Nov 29];13:139-44. Available from: https://www.journalofdiabetology.org/text.asp?2022/13/2/139/351751

  Introduction Top

Type 2 Diabetes Mellitus (T2DM) has routed itself firmly as an endemic metabolic condition in the Indian subcontinent based on the epidemiological data, which suggests a high prevalence in most regions over a consistent period of time.[1] Over the years, the simplistic notion of T2DM, being a state of dysregulated glucose metabolism, has been replaced by its factually correct description as a chronic low-grade inflammatory condition with multifactorial etiopathogenesis. The range of macrovascular and microvascular complications associated with T2DM is broad and well known and it includes cardiovascular disease, nephropathy, neuropathy, and retinopathy. In contrast, although sexual dysfunction remains an established microvascular complication of diabetes mellitus affecting a significant proportion of individuals (35–90% of men with T2DM), it still remains a relatively taboo area of discussion due to sociocultural factors.[2] In a predominantly patriarchal society, the impact of T2DM on sexual function in women remains a far more neglected area of study, resulting in the propagation of myths, somatization syndromes, and preventable morbidity. To obtain further factual information on this hitherto underexplored field, we have carried out a cross-sectional qualitative observational study in women with T2DM, focusing on their sexual health by using a prevalidated questionnaire.

  Background Top

Previous epidemiological studies including those by Pontiroli et al[3] and Mazzilli[4]et al. have reported the prevalence of female sexual dysfunction (FSD) in women with T2DM to be between 25–71% and 53.6%, respectively. Broadly speaking, FSD has multiple etiologies related to desire, arousal, lubrication, orgasm, satisfaction, and pain during sexual intercourse. T2DM in women is commonly associated with increased prevalence of sexual dysfunction. The etiologies contributing to FSD in such women are multifactorial and include an increased risk of recurrent genitourinary infections, especially in the background of suboptimal glycemic control.[5] Autonomic neuropathy and endothelial dysfunction contribute toward a loss of genital sexual sensitivity. Diabetes is associated with poor engorgement of the vascular sinusoidal tissue of the clitoris and thus the massaging of these structures during sexual stimulation fails to elicit appropriate sexual sensations, thus compromising arousal and failing to achieve orgasm.[6] Vulvovaginal atrophy comprises vaginal dryness, itching, irritation, pain on urination, and pain and bleeding on intercourse. In a particular study, the prevalence of vulvovaginal atrophy (57%) and FSD (55%) was high and women with FSD were 3.84 times more likely to have vulvovaginal atrophy than women without FSD (95% CI: 2.99–4.94).[7]

FSD may vary across region, ethnicity, study inclusion and exclusion criteria, menstruation history, age, and duration of diabetes, possibly with body mass index (BMI), endocrine disorders including hypothyroidism,[8] hyperthyroidism,[9] hyper-prolactinemia,[10] congenital adrenal hyperplasia,[11] and adrenal insufficiency.[12] The etiology of FSD includes vasculogenic, neurogenic, hormonal/endocrine, musculogenic, and psychogenic factors.[13] T2DM can affect all these domains, for example, uncontrolled hyperglycemia causes dryness in the genital region and concomitant urinary tract infection may result in decreased desire and lubrication, which leads to pain while having intimate relations. Vaginismus and dyspareunia are associated with fear of penetration, although more commonly the pain domain is causally related with perfectionism, fear of negative evaluation, hypervigilance for pain, shyness, vaginal candidiasis, anxiety, and urinary tract infection. T2DM also affects desire and arousal domains as well and other risk factors are depression (past/current), negative feeling for one’s partner, and low self-esteem, which are quite common in longstanding T2DM. Psychological stress also contributes to FSD.[14]

  Aim and Objectives Top


  1. To calculate Female Sexual Function Index (FSFI) by using a validated questionnaire

  2. To calculate Female Sexual Distress Index (FSDI) by using a validated questionnaire

  3. To calculate the prevalence of FSD based on a well-defined level of FSFI

  4. To explore a possible association and correlation between various metabolic parameters and FSFI

  Materials and Methods Top

Sample size

This observational cross-sectional study was conducted at Regency Hospital Ltd, Kanpur, India. We assessed the prevalence of sexual dysfunction in women with T2DM representing the predominantly suburban population under follow-up at our hospital. The sample size was calculated from the study by Rossella Mazzilli,[4] which was used as a benchmark. The patients were selected based on the predefined inclusion–exclusion criteria [see [Table 1] and [Table 2]].
Table 1: Inclusion criteria

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Table 2: Exclusion criteria

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The sample size was calculated by using the following formula:

n = Desired Sample Size

p = prevalence female sexual dysfunction. We have used the results of Jamshid Vafaeimanesh et al[15] (53.6%),

d = Allowable error 20% of p,

Z = Value of standard Normal Variable, for 95% confidence Z = 1.96.

The sample size turned to be 84. We recruited 100 subjects for the study.


Sexual dysfunction in women with diabetes were assessed by FSFI; the distress levels were assessed by FSD, a revised scale developed by Rosen et al[17] and Derogatis L et al,[18] respectively. Both the questionnaires were first translated into the local vernacular language, internally validated, and linguistically adapted. We had validated this questionnaire on the first 20 healthy women.

The FSFI encompasses 19 items, which include an assessment of sexual function in the past four weeks under the heading of six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. Derogatis L et al[18] utilized the FSD (revised version). It is a 13-item questionnaire score: minimum 0 (never) to maximum 4 (always). Items were summed to create a total score ranging from 0 to 52, with higher scores indicating more sexually related distress (Janet S Carpenter et al).[19] Appropriate lab investigations were conducted. Written informed consent was obtained from each participant in the local vernacular language.

Statistical analysis

The data were analyzed by using SPSS software (version 21). The quantitative data were analyzed by using descriptive statistical tools that included mean and standard deviation. The Chi-Square test was used, and logistic regression analysis was performed for finding the risk factors in case of qualitative variables. Wherever necessary, we converted quantitative to qualitative variables and coded them by using “0” for normal and “1” for disease state in case of binary response.

Test of hypothesis (t-test) and 95% confidence interval have been calculated for inferential statistics. Wherever we encountered more than two options in the domain, we performed multinomial logistic regression analysis.

If the coefficient of the intercept was not statistically significant, then Logistic Regression Analysis (LRA) was redone after neglecting the intercept.

  Results Top

The prevalence of FSD in women with T2DM was 18% (95% CI 10.5% to 25.5%). The age range, duration of T2DM, Hba1c, duration of marriage, and BMI were quite variable with wide ranges [Table 3].
Table 3: Demographic details

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On comparing the two groups with and without FSD, we found a significant difference in age, BMI, and waist circumference; the former had a worse clinical profile though there was an overlap in these parameters. Women with FSD also had a longer duration of marriage compared with women without FSD. The other clinical and biochemical parameters were not significant [Table 4] and [Table 5].
Table 4: Differences between normal and FSD group

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Table 5: Differences between normal and FSD group in laboratory parameters

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We also looked at the other social and physical parameters between the two groups, and none had been found to be statistically significant [Table 6].
Table 6: Physical and social parameters between two groups

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In addition, we performed multinomial logistic regression analysis for different degrees of diabetes control and serum testosterone with FSFI domains. Only in the pain domain, the regression coefficient for moderate control, odds ratio was 1.49 (95% CI 1.11- 2.01) whereas no association was established with testosterone and other FSFI domains.

On correlating FSFI and FSDS, our results showed a poor correlation (Pearson’s correlation coefficient, ‘r’ = 0.18, P = 0.074). Thus, based on our data, distress score and sexual satisfaction are not correlated [Figure 1].
Figure 1: Correlation of Female Sexual Function Index (FSFI) and Female Sexual Distress Scale (FSDS). Scatter plot representation of the correlation between FSFI and FSDS

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  Discussion Top

To the best of our knowledge, this is the first study from India that has comprehensively evaluated the clinical, biochemical, and psychosocial parameters in T2DM women that are associated with FSD. The prevalence of FSD in our study group was 18% (CI: 10.5%–25.5%). This is surprising and far lower than the prevalence of FSD reported in previous studies. Jamshid Vafaeimanesh et al[15] reported a prevalence of FSD in 53.6% of women whereas McCool et al[20] estimated the global FSD prevalence among premenopausal women to be 40.9%. The lower reported FSD prevalence in our study could be due to sociocultural barriers that are challenging to address, especially in cross-sectional surveys. We observed a significant relationship between age and FSD (P = 0.006). A gradual age-related decline in estrogen levels leading to vaginal dryness, dyspareunia, and low desire for sexual intimacy low libido remain plausible explanations for this association.[21] In a previous survey, more than a third of the 833 peri-menopausal women reported concerns about their sexual function to their physicians.[22] This nullifies the previous assumption about low libido: A statistically significant difference was/is observed between the mean BMI and FSD (P = 0.019); the results are consistent with the findings of Antonio E. Pontiroli et al,[3] who had reported the frequency of FSD being higher in “any diabetes” (type 1 and 2) as compared with the controls independent of the duration of diabetes (2.02 [1.49, 2.72]). In addition, a higher BMI was significantly associated with effect size (P = 0.005) in meta-regression only. It was interesting to note that the duration of T2DM was unrelated to the development of FSD, which is contrary to our initial hypothesis (P = 0.703), and our study was supported by work published by Enzlin P et al.[23]

In our quantitative cross-sectional study, we found that obesity is statistically significantly corelated with FSD. Visceral adiposity is an important factor for insulin resistance, which ultimately leads to the diagnosis of overt diabetes. In South east Asia, obesity is increasingly being observed in relatively lower socioeconomic groups and rural populations, rather than being confined to the urban and affluent sections of the society.[24] Our results show a statistically significant correlation of FSD and waist circumference (P = 0.029). These results are in keeping with a study done by Jamshid Vafaeimanesh et al[5] and Enzlin P et al,[25] who had observed that more women with diabetes than control subjects reported sexual dysfunction (27 vs. 15%; P = 0.04), but a significant difference was found only for the decreased lubrication domain of FSFI. Our study could not establish an association between sexual dysfunction and age, BMI, the duration of diabetes, HbA1c, use of medication, menopausal status, or complications.

In our study, we could not establish any statistically significant association between FSD and other variables such as physical activity, fertility, education, socioeconomic status, family type, occupation, surgical history, associated comorbidities, and contraception [Table 6]; whereas Zhang C et al[25] had found higher educational attainment and urban residency to be associated with a decreased risk of sexual dysfunction (Odds Ratio = 0.67, 99% CI = 0.47–0.97). The duration of marriage and sexual dysfunction is a common association, as proved in our study (P = 0.005). This relationship was supported by a study conducted by Lauren P. Wallner,[26] in which women with type 1 diabetes mellitus (T1DM) (n = 26) were similar to women without diabetes except for higher depression scores and lower levels of activity.

In our study, no statistically significant association was observed between serum testosterone and sexual dysfunction, which is in contrast to the data published by Sarah Wåhlin‐Jacobsen et al,[27] who had reported a statistically significant relationship between total testosterone, free testosterone, and rostenedione and sexual desire in FSD. Zhang C et al[25] had observed the prevalence rate of domain-wise FSFI to be 21.6% (99% CI = 20.9–22.2) in all domains of FSFI; however, we could only establish the relationship between the pain domain and HbA1c. According to our study, the chances of experiencing pain are at least 1.11 times more in case of moderate glycemic control (HbA1C ≥7.5–9.0%), as compared with what is generally deemed as good glycemic control (HbA1C ≤7.5%). The same difference in case of sub-optimal control (HbA1C >9%) was statistically not significant; the probable reason of this discrepancy could be that patients with poor glycemic control also suffer from autonomic neuropathy involving multiple organs.

We found a strong relationship between age, BMI, waist circumference, and the duration of marriage. As age increases, the duration of marriage also increases; the desire for sexual intimacy tends to decline with age and this is often replaced by tender care, caressing, and affection. The intimacy between couples subsides with the advancement of age.

Overcrowded clinics offering a lack of privacy, social stigma associated with sexuality in women, and lack of self-confidence in the women to express their own selves due to sociocultural conditioning might be a few significant contributing factors for the underreporting of sexual dysfunction noticed in our study as compared with previously published epidemiological data.[28] Health-care professionals who are aware and trained to explore this sensitive topic can potentially mitigate areas of concern and significantly improve the quality of life in women with FSD. The BMI and waist circumference are two interrelated entities and these are strongly associated with FSD. Woman should be motivated for patient-centric weight loss programs to ensure an overall good control of diabetes and quality of life. Vulvovaginal atrophy and its associated symptoms should be treated with judicious intervention with hormone replacement therapy and other recommended therapeutic interventions.[29] Oral, transdermal, or vaginal estrogen preparations are the most effective treatment options for vulvovaginal atrophy-related sexual dysfunction. Vaginal dehydroepiandrostenedione, vaginal testosterone, and tissue selective estrogen complexes are also emerging as promising new therapies.[30]

  Limitation Top

Our study had a cross-sectional design and a relatively small sample size (drawn from suburban middle-aged women) that cannot be deemed representative of the heterogeneous Indian population. In addition, age and confounding factor-matched women without T2DM would have provided useful comparative data; however, since it is a qualitative rather than a quantitative study, this remains an acceptable limitation. The sexual partner questionnaire [31] was not filled due to nonavailability, and, thus, we could not explore the full spectrum of FSD. The FSFI questionnaire could only shed light on the sexual activity of the past four weeks, and this again limits the generalization of results.

  Conclusion Top

The FSD remains an underreported complication of T2DM in view of sociocultural barriers. The FSD has far-reaching implications on the physical and psychological health of women and it shows an inverse correlation with age as well as waist circumference. Interventions such as weight loss, use of estrogen lubricants, and improvement in glycemic control are helpful in the alleviation of distressing symptoms in a significant proportion of women.


I would like to express my sincere gratitude to Dr. Ajay Bhagoliwal for his kind support and guidance in the completion of this study; setting aside time from his busy schedule is key to this study. Without his motivation, patience, and help, this study would not have been possible.

Financial support and sponsorship

The study was not funded by any funding agency, except the institutional resources.

Conflicts of interest

None of the authors had any conflict of interest.

  References Top

Kalra S, Aamir AH, Raza N, Das AK, Azad Khan AK, Shrestha D, et al. Place of sulfonylureas in the management of type 2 diabetes mellitus in South Asia: A consensus statement. J Endocrinol Metab2015;9:577-96.  Back to cited text no. 1
Jumani DK, Patil O Erectile dysfunction in diabetes mellitus: A review. J Diabetol 2020;11:1-7.  Back to cited text no. 2
Pontiroli AE, Cortelazzi D, Morabito A Female sexual dysfunction and diabetes: A systematic review and meta-analysis. J Sex Med 2013;10:1044-51.  Back to cited text no. 3
Mazzilli R, Imbrogno N, Elia J, Delfino M, Bitterman O, et al. Sexual dysfunction in diabetic women: Prevalence and differences in type 1 and type 2 diabetes mellitus. Diabetes Metab Syndr Obes 2015;8:97-101.  Back to cited text no. 4
Basson RJ, Rucker BM, Laird PG, Conry R. Sexuality of women with diabetes. Sex Reprod Med 2001;1:11-20.  Back to cited text no. 5
Doruk H, Akbay E, Çayan S, Akbay E, Bozlu M, Acar D. Effect of diabetes mellitus on female sexual function and risk factors. Arch Androl 2005;51:1-6.  Back to cited text no. 6
Levine KB, Williams RE, Hartmann KE. Vulvovaginal atrophy is strongly associated with female sexual dysfunction among sexually active postmenopausal women. Menopause 2008;15(4 Pt 1):661-6.  Back to cited text no. 7
Pasquali D, Maiorino MI, Renzullo A, Bellastella G, Accardo G, Esposito D, et al. Female sexual dysfunction in women with thyroid disorders. J Endocrinol Investig 2013;36:729-733.  Back to cited text no. 8
Atis G, Dalkilinc A, Altuntas Y, Atis A, Gurbuz C, Ofluoglu Y, et al. Hyperthyroidism: A risk factor for female sexual dysfunction. J Sex Med 2011;8:2327-33.  Back to cited text no. 9
Wierman ME, Nappi RE, Avis N, Davis SR, Labrie F, Rosner W, et al. Endocrine aspects of women’s sexual function. J Sex Med 2010;7:561-85.  Back to cited text no. 10
Frisén L, Nordenström A, Falhammar H, Filipsson H, Holmdahl G, Janson PO, et al. Gender role behavior, sexuality, and psychosocial adaptation in women with congenital adrenal hyperplasia due to Cyp21a2 deficiency. J Clin Endocrinol Metab 2009;94:3432-9.  Back to cited text no. 11
Alkatib AA, Cosma M, Elamin MB, Erickson D, Swiglo BA, Erwin PJ, et al. A systematic review and meta-analysis of randomized placebo-controlled trials of Dhea treatment effects on quality of life in women with adrenal insufficiency. J Clin Endocrinol Metab 2009;94:3676-81.  Back to cited text no. 12
Leedom L, Feldman M, Procci W, Zeidler A Symptoms of sexual dysfunction and depression in diabetic women. J Diabet Complications 1991;5:38-41.  Back to cited text no. 13
Mishra VV, Nanda S, Vyas B, Aggarwal R, Choudhary S, Saini SR. Prevalence of female sexual dysfunction among Indian fertile females. J Midlife Health 2016;7:154-8.  Back to cited text no. 14
Vafaeimanesh J, Raei M, Hosseinzadeh F, Parham M Evaluation of sexual dysfunction in women with type 2 diabetes. Indian J Endocrinol Metab 2014;18:175-9.  Back to cited text no. 15
Oppo A, Franceschi E, Atzeni F, Taberlet A, Mariotti S. Effects of hyperthyroidism, hypothyroidism, and thyroid autoimmunity on female sexual function. J Endocrinol Investig 2011;34:449-53.  Back to cited text no. 16
Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The female sexual function index (Fsfi): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26:191-208.  Back to cited text no. 17
Derogatis L, Clayton A, Lewis-D’Agostino D, Wunderlich G, Fu Y Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder. J Sex Med 2008;5:357-64.  Back to cited text no. 18
Carpenter JS, Reed SD, Guthrie KA, Larson JC, M Newton K, Lau RJ, et al. Using an FSDS-R item to screen for sexually related distress: A MsFLASH analysis. Sex Med 2015;3:7-13.  Back to cited text no. 19
McCool ME, Zuelke A, Theurich MA, Knuettel H, Ricci C, Apfelbacher C Prevalence of female sexual dysfunction among premenopausal women: A systematic review and meta-analysis of observational studies. Sex Med Rev 2016;4:197-212.  Back to cited text no. 20
Ambler DR, Bieber EJ, Diamond MP. Sexual function in elderly women: A review of current literature. Rev Obstet Gynecol 2012;5:16-27.  Back to cited text no. 21
Hofland SL, Powers J Sexual dysfunction in the menopausal woman: Hormonal causes and management issues. Geriatr Nurs 1996;17:161-5.  Back to cited text no. 22
Enzlin P, Mathieu C, Van den Bruel A, Bosteels J, Vanderschueren D, Demyttenaere K Sexual dysfunction in women with type 1 diabetes: A controlled study. Diabetes Care 2002;25:672-7.  Back to cited text no. 23
Misra A, Khurana L Obesity and the metabolic syndrome in developing countries. J Clin Endocrinol Metab 2008;93:S9-30.  Back to cited text no. 24
Chunni Z, Jiali T, Lan Z, et al. A population-based epidemiologic study of female sexual dysfunction risk in mainland China: Prevalence and predictors. J Sex Med 2017;14:1348-56.  Back to cited text no. 25
Wallner LP, Sarma AV, Kim C. Sexual functioning among women with and without diabetes in the Boston area community health study. J Sex Med 2010;7(2 Pt 2):881-7.  Back to cited text no. 26
Wåhlin-Jacobsen S, Pedersen AT, Kristensen E, Laessøe NC, Lundqvist M, Cohen AS, et al. Is there a correlation between androgens and sexual desire in women? J Sex Med 2015;12:358-73.  Back to cited text no. 27
Bajaj S, Jawad F, Islam N, Mahtab H, Bhattarai J, Shrestha D, et al. South Asian women with diabetes: Psychosocial challenges and management: Consensus statement- Indian J Endocrinol Metab 2013;17:548-62.   Back to cited text no. 28
Levine KB, Williams RE, Hartmann KE Vulvovaginal atrophy is strongly associated with female sexual dysfunction among sexually active postmenopausal women. Menopause 2008;15:661-6.  Back to cited text no. 29
Tan O, Bradshaw K, Carr BR Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review. Menopause 2012 Jan;19(1):109-17. doi: 10.1097/gme.0b013e31821f92df. PMID: 22011753.  Back to cited text no. 30
Rosen RC, Cappelleri JC, Gendrano N 3rd The International Index of Erectile Function (IIEF): A state-of-the-science review. Int J Impot Res 2002;14:226-44.  Back to cited text no. 31


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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