Discussion:
While there are many studies in the literature showing the positive effects of smoking cessation on ED in men,10 there are very few studies showing the relationship between FSD and smoking,11 and moreover, there are no studies investigating the effect of smoking cessation on FSD.
Sexual activity is process including desire, desire, arousal, lubrication, orgasm and satisfaction follows each other in women. Many psycho-physiological mechanisms such as hormonal, vascular and neural play a role in this process.14 Risk factors that lead to decreased blood flow of female external genital organs cause impairment in the arousal and lubrication phases. Disruption in these stages can cause dyspareunia, preventing sexual intercourse from reaching orgasm and satisfaction, and may lead to FSD. There are studies in the literature showing that clitoral vascularization and clitoral tissue perfusion are associated with FSD in healthy women.15,16 It has been revealed that smoking, which is one of the main risk factors of cardiovascular and cerebrovascular diseases, decreases genital vascularization.15-17Also, the anti-estrogenic effect of smoking causes a decrease in estrogen levels, which leads to a decrease in blood flow of the genital organs.15-17 The reduction in genital vascularization (especially the impairment of the clitoral tissue perfusion), negatively affects the arousal and lubrication phases, which are very important for orgasm and satisfaction.18 Coppalo et al. demonstrated that clitoral tissue perfusion was worse in women with FSD according to FSFI total scores.16 However, no difference was found between the groups in terms of smoking.16 Choi et al. showed that women who had a smoking history, had lower FSFI total score and sub-domain scores than women who did not smoke.11Similarly, in our study, we demonstrated that there was a significant decrease in the total scores of the FSFI questionnaire and especially in the arousal and lubrication domain scores in smoking patients.
In this study, it was shown that there is an inverse relationship between smoking duration and total FSF scores and sub domain scores. Choi et al. demonstrated that there was a dose-response relationship between smoking and FSD.11 They found that higher cumulative smoking (package years) was related to lower total FSFI score.11 The findings of this study and our study may be important in terms of showing that the effects of smoking on female sexual functions are time and dose dependent.
There are studies in the literature that show that the deterioration in women’s sexual health for various reasons, affects the QOL of women. It has been demonstrated in studies conducted in women with depression, menopause, and salpingo-oophorectomy to reduce the risk of breast cancer that FSD has a negative impact on QOL.19-21 Goldenberg et al showed that there was a negative relationship between smoking and QOL and that this relationship was directly proportional to the number of cigarettes smoked.22 In this study, we demonstrated that smoking causes FSD and negatively affects the QOL in all sub-domains. We also showed that there was a relationship between severity of FSD and QOL sub-domain scores. It can be deduced from the findings of our study that, smoking both negatively affects the QOL by causing FSD and that smoking has a direct negative effect on QOL. In addition, it can be deduced that smoking cessation may lead to improvement in FSD, thus both the improvement in FSD and the elimination of the negative effect caused by smoking can increase the QOL.
Although there are studies evaluating the effect of smoking cessation on QOL in the literature, there are no studies investigating the effect of smoking cessation on FSD.23,24 In this study, unlike the literature, changes in FSD and QOL in female smoking patients after smoking cessation were evaluated together. Our results showed that smoking cessation significantly improved both FSFI total and sub-domain scores and SF-36 sub-domain scores especially physical and emotional role subdomain scores. The reasons for the improvement in FSD after smoking cessation may be the increase in blood flow in the genital area, especially in the vagina and clitoral tissue; the decrease in oxidative stress, and the disappearance of the anti-estrogenic effects of smoking. As a result of these pathophysiological improvements, the increase in blood supply in the vagina and clitoral tissue can lead to an improvement in arousal and lubrication and resulting ease of reaching orgasm and satisfaction. Also, improvement in lubrication may prevent pain during sexual intercourse. These improvements mentioned above may also explain the improvement in FSD and thus the improvement in QOL, as shown in the results of our study.
In this study, the positive effects of smoking cessation were mostly observed in the arousal, lubrication and orgasm sub-domains of the FSFI questionnaire and in the sub domains of the SF-36 questionnaire where the physical and emotional role problems were evaluated. According to these results, it can be concluded that FSD, which is in the arousal, lubrication and orgasm stages, causes physical and emotional problems in women and impairs the QOL.