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\title{Can a high visceral adiposity index predict female sexual dysfunction in
sexually active women? Results of a cross-sectional study.}



\author[1]{Ramazan  Aşçı}%
\author[2]{Mustafa Bolat}%
\author[3]{Cihad Dündar}%
\author[3]{Ayse Zehra Ozdemir}%
\author[3]{Aysegul Atmaca}%
\affil[1]{Ondokuz Mayis University Faculty of Medicine}%
\affil[2]{Gazi State Hospital}%
\affil[3]{Ondokuz Mayis University}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Aims: To our knowledge, this is the first study investigating the impact
of high visceral adiposity index on female sexual dysfunction (FSD). We
aimed to show the impact of increased levels of visceral adiposity index
(VAI) on FSD compared to body mass index (BMI) and waist circumference
(WC). Methods: We included 158 participants in two groups: Group 1 (n=68
with normal sexual function) and Group 2 (n=90 with sexual dysfunction).
Demographic, clinic data, presence of metabolic syndrome (MeTS) and
comorbidities were recorded. The BMI, WC and the visceral adiposity
index were calculated. Sexual function was assessed using the female
sexual function index (FSFI). Results: The mean age and all the
anthropometric variables were similar between the groups
(p\textgreater{}0.05). Metabolic syndrome was associated with lower
arousal and lubrication scores than those without metabolic syndrome
(p=0.023). The higher VAI was associated with lower desire, lubrication
and orgasm scores (p\textless{}0.05). Each integer increase of the VAI
weakly predicted decrease of desire (p=0.015), arousal (p=0.015),
lubrication (p=0.005) and satisfaction (p=0.046). Conclusion: The VAI
was linked with lower scores in some female sexual function subdomains,
but the correlation coefficient was low, indicating a weak association.
Further studies with a higher number of participants are needed to
conclude that the VAI may increase the risk of FSD, particularly in
patients with metabolic syndrome.%
\end{abstract}%



\sloppy


\textbf{Title: Can a high visceral adiposity index predict female sexual
dysfunction in sexually active women? Results of a cross-sectional
study}

\textbf{Abstract}

\textbf{Aims:} To our knowledge, this is the first study investigating
the impact of high visceral adiposity index on female sexual dysfunction
(FSD). We aimed to show the impact of increased levels of visceral
adiposity index (VAI) on FSD compared to body mass index (BMI) and waist
circumference (WC).

Methods: We included 158 participants in two groups: Group 1 (n=68 with
normal sexual function) and Group 2 (n=90 with sexual dysfunction).
Demographic, clinic data, presence of metabolic syndrome (MeTS) and
comorbidities were recorded. The BMI, WC and the visceral adiposity
index were calculated. Sexual function was assessed using the female
sexual function index (FSFI).

\textbf{Results:} The mean age and all the anthropometric variables were
similar between the groups (p\textgreater{}0.05). Metabolic syndrome was
associated with lower arousal and lubrication scores than those without
metabolic syndrome (p=0.023). The higher VAI was associated with lower
desire, lubrication and orgasm scores (p\textless{}0.05). Each integer
increase of the VAI weakly predicted decrease of desire (p=0.015),
arousal (p=0.015), lubrication (p=0.005) and satisfaction (p=0.046).

\textbf{Conclusion:} The VAI was linked with lower scores in some female
sexual function subdomains, but the correlation coefficient was low,
indicating a weak association. Further studies with a higher number of
participants are needed to conclude that the VAI may increase the risk
of FSD, particularly in patients with metabolic syndrome.

\textbf{Key Words: Body mass index, female, sexual dysfunction, obesity,
visceral adiposity index, waist circumference}

\textbf{What's already known about this topic?}

1. Female sexual dysfunction (FSD) is a considerably underestimated
condition, affects almost half of premenopausal sexually active women.

2. Various mediators, including dopamine, norepinephrine, melanocortin,
oxytocin, testosterone, estradiol, progesterone, vasoactive intestinal
polypeptide, nitric oxide, calcitonin gene-related peptide and
neuropeptide-Y play a role in female sexual function.

3. Many factors may contribute to FSD, including obesity, diabetes
mellitus, smoking, hyperlipidemia, heart diseases, liver failure,
alcoholism, depression, drug abuse or medications.

\textbf{What does this article add?}

This study is the first to evaluate the impact of visceral adiposity
index on different domains of female sexual function compared to body
mass index and waist circumference.

\textbf{INTRODUCTION}

Female sexual dysfunction (FSD) is a considerably underestimated
condition, affects 41\% of sexually active women aged 45-64 in the
dimensions of sexual desire, arousal, lubrication, orgasm, satisfaction,
and pain.\textsuperscript{1} Prevalence for FSD is reported in up to
50\% of women, at least in one dimension, regardless of
age.\textsuperscript{2} Oksuz et al. stated that FSD prevalence was
48.3\% in Turkish women, and smoking, older age, menopause and marital
status were contributing risk factors.\textsuperscript{3}

Distal vagina, urethra and clitoris create the clitoral complex.
Clitoris receive (a) somatic fibres (a branch of the pudendal nerve)
that supply the skin as the dorsal nerve of the clitoris, and (b)
visceral fibres (cavernous nerves) that supply arteries to the erectile
tissue. Vascular engorgement and clitoral tumescence are controlled by
visceral nerves in the reflex arc and motor fibres that may be augmented
or suppressed voluntarily. Sexual desire and arousal are thought to be
under the control of parasympathetic and sympathetic arousal with the
support of sex hormones and psychological factors. Cortex, limbic
hippocampal structures, midbrain central gray, hypothalamic nuclei (the
medial preoptic area, ventromedial nucleus, paraventricular nucleus, and
anterior hypothalamic region) are the highest centers where the control
of sexual arousal is regulated. Dopamine, norepinephrine, melanocortin,
oxytocin, testosterone, estradiol and progesterone were central sexual
stimulating mediators; serotonin, prolactin and opioids are sexually
inhibiting neuromediators\textsuperscript{4} and serotonergic
stimulation increases blood flow in the clitoris, bulbs, periurethral
erotic tissue and vagina. Testosterone and estradiol also contribute to
vasocongestion.\textsuperscript{5} Serotonin reduces genital sensation;
sympathetic stimulation decreases genital blood flow. While vasoactive
intestinal polypeptide (VIP) and NO are the primary neurotransmitters
that provide tumescence by relaxing the clitoral smooth muscles during
sexual stimulation; VIP, NO, calcitonin gene-related peptide (CGRP),
neuropeptide-Y (NPY) and noradrenaline (NA) are peripheral
neurotransmitters involved in vasomotion that provide vaginal
transudation.\textsuperscript{6} As a consequence, engorgement of the
clitoral complex with sexual stimulus, vulvar swelling occurs, and
secretory response is initiated in the distal vagina and urethra.
Depending on the increase in blood flow with sexual stimulation, a 2-3
fold increase in size occurs in the labia minora. The labial evertion
caused by the increase in size makes vaginal introitus suitable for
penile penetration. Non-erectile vascular tissues in the urethral
orifice and vaginal wall are also sensitive to sexual stimuli.
Sufficient sexual arousal stimulates the Skene (female prostate) and
Bartholin's glands, causing an increase in secretion. Sexual function in
women is achieved not only by psychological but also by the harmonious
interaction of neurochemical and organic
factors.\textsuperscript{7}Somatic diseases such as diabetes mellitus,
spinal cord injury or pelvic surgeries can complicate FSD by causing
damage to the blood vessels and nervous system.\textsuperscript{8}
Chronic ischemia in female genital tissues causes structural and
functional changes leading to decreased arousal and
lubrication.\textsuperscript{9}

According to the Basson's sexual response cycle, enhancing intimacy or
bonding to feel attractive or desired may be motivated to engage in
sexual activity, and a state of ``sexual neutrality'' may result in a
sexual experience.\textsuperscript{10} Disruption of at least one of
these stages can cause a decrease in desire and lubrication. Except for
sexual activity, surfaces of the vagina are covered by a thin film of
fluid, preventing friction. However, the amount of fluid is insufficient
for painless penile penetration. One of the subdomains of FSD is pain
that can be explained by hypersensitivity to pain sensation or a
decreased vestibular nociceptor threshold.\textsuperscript{10}

Many factors may contribute to FSD, including diabetes mellitus,
smoking, hyperlipidemia, heart diseases, liver failure, alcoholism,
depression, drug abuse or medications. Diabetes mellitus may provoke an
atherosclerotic process that could be a reason for decreased vaginal
lubrication.\textsuperscript{8} The FSD associated with obesity is one
of the commonly reported etiological factors.

To date, obesity and its impact on various diseases have been studied in
many studies using the body mass index (BMI) or waist circumference
(WC).\textsuperscript{12} The fact that WC mainly measures subcutaneous
tissue and BMI cannot predict body fat homogeneously has led to an
increase in scientific studies investigating more reliable
markers.\textsuperscript{13} The visceral adiposity index (VAI) measures
visceral adiposity.\textsuperscript{14} The VAI was used in many studies
as a useful tool.\textsuperscript{15}

Conflicting data have been published regarding the impact of metabolic
syndrome or obesity without metabolic syndrome on female sexual
function. Based on this, we aimed whether the VAI was a good predictor
of female sexual dysfunction. To our knowledge, this study is the first
to evaluate the impact of visceral adiposity index on different domains
of female sexual function compared to body mass index and waist
circumference.

\textbf{PATIENTS AND METHODS}

Following the local ethics board's approval (B.30.2.ODM.0.20.08/501), of
the 213 heterosexual sexually active women of reproductive age, 158 were
included in the study. Women with the following conditions were excluded
from the study: neurological (n=19), psychiatric (n=9), hormonal (n=17),
gynecological surgery including bilateral oophorectomy (n=9), and
malignant gynecological disease (n=4). Patients were informed about the
study, and informed consent was obtained. Sexual function was evaluated
using the Turkish-version of the Female Sexual Function Index (FSFI),
which consists of 17 questions provided by the Turkish Society of
Andrology. According to the FSFI, higher the FSFI scores indicate better
sexual functioning that includes 19 questions on six topics, including
sexual desire (first two questions), arousal (questions 3 to 6),
lubrication (questions 7 to 10), orgasm (questions 11 to 13),
satisfaction (questions 14 to 16), and pain (questions 17 to 19). The
lowest score is 2, and the highest score is 36. The total FSFI score
under 26.55 was accepted as FSD.\textsuperscript{16} Women with BMI
\textless{}25 kg/m\textsuperscript{2} were considered healthy weight
(BMI-1), those between 25.0-29.9 kg/m\textsuperscript{2} were overweight
(BMI-2) and those with a BMI greater than 30
kg/m\textsuperscript{2}obese (BMI-3). The WC was measured at the level
of the umbilicus in cm. The WC lower than 90 cm was considered healthy
(WC-1), and WC \textgreater{} 90 cm was considered an obesity-related
condition (WC-2). The VAI was calculated using the formula WC / (36.58 +
(1.89 x BMI) x (TG / 0.81) x (1.52 / HDL).\textsuperscript{16} Regarding
the individual domains, a domain score of zero indicates that the
respondent reported having no sexual activity. Different ''factors''
have been created for all domains. The factors for desire, arousal, and
lubrication and orgasm, satisfaction and pain are 0.6, 0.3, and 0.4,
respectively. Individual scores of the domains were multiplied by the
corresponding domain factor. The total FSFI score varies from 2 to 36,
and scores equal to or higher than 26.55 show normal female sexuality,
and when a respondent's total scale score was below 26.55, FSD is
considered. Sixty-eight women with normal sexual function were included
in Group 1 group, and 90 women with sexual dysfunction were assigned to
Group 2. Age, length, body weight, body mass index (BMI), waist
circumference (WC), comorbidities such as hypertension, diabetes and
coronary artery disease, hormonal disease, drug use, smoking in
pack/year, and alcohol consumption were recorded. Serum high-density
lipoprotein (HDL) and triglyceride (TG) levels were recorded. Total FSFI
measured the sexual function, and individual scores of sexual desire,
arousal, lubrication, orgasm, satisfaction and pain subdomains were
calculated.

MeTS criteria are described according to the National Cholesterol
Education Program.\textsuperscript{17}

A waist circumference of greater than 102 cm,

\begin{enumerate}
\tightlist
\item
  Triglyceride level higher than 150 mg/dL, or receiving treatment for
  hypertriglyceridemia,
\item
  HDL cholesterol of less than 40 mg/dL,
\item
  Systolic blood pressure higher than 130 mm Hg, or diastolic blood
  pressure higher than 85 mm Hg, or receiving antihypertensive treatment
\item
  Fasting glucose level greater than 100 mg/dL, or receiving treatment
  for hyperglycemia.
\end{enumerate}

\textbf{Statistical Analysis}

The Statistical package program SPPS v. 15 (2012. IBM SPSS Statistics
for Mac, Version 21.0.0.0, Armonk, NY, USA: IBM Corp.) was performed.
Numerical variables normally distributed were given as mean \selectlanguage{ngerman}± SD and
categorical variables as frequency (\%). The inter\selectlanguage{english}-group differences
were determined using the Mann--Whitney U and Kruskal--Wallis tests for
numerical variables. The relationships between the categorical variables
were analyzed using Pearson's Chi-square and Fisher's exact tests. The
factors including VAI score, BMI and waist circumference affecting the
FSFI score as a dependent variable were determined by multivariate
logistic regression analysis. A p-value lower than 0.05 was accepted as
statistically significant.

\textbf{RESULTS}

Regardless of the grouping, the mean VAI was 4.45. The mean age, WC,
BMI, VAI fasting serum glucose, HDL-cholesterol and TG levels levels
were similar between the groups (p\textgreater{}0.05) (Table 1).
Sensitivity and specificity for the cut-off values of WC 89 cm, BMI
\textless{}25, 25.0-29.9 and \selectlanguage{english}[?]30.0 kg/m2 and VAI 4.45 were 53.3\% and
54.4\%; 18.9\% and 88.2\%; and 52.2\% and 48.5\%, respectively (Fig. 1).
Groups were similar in terms of MeTS, hypertension, diabetes, smoking
and alcohol abuse (p\textgreater{}0.05) (Table 2). The mean total FSFI
score and all the subgroups were significantly higher in Group 1 group
than Group 2 (p\textless{}0.05) (Table 3). Participants with MeTS had
substantially lower total FSFI scores than those without MeTS (p=0.023).
Considering the subdomains, arousal and lubrication scores significantly
lower in patients with MeTS than without MeTS (p\textless{}0.05),
whereas desire, orgasm, satisfaction and pain scores were similar
(p\textgreater{}0.05) (Table 4). For different cut-off levels of WC
(WC-1 and WC-2) and BMI (BMI-1, BMI-2 and BMI-3), all the subdomain
scores were similar (p\textgreater{}0.05). Only desire, lubrication and
orgasm scores were significantly lower in participants with VAI \selectlanguage{english}[?] 4.45
than with VAI\textless{}4.45 (p\textless{}0.05) (Table 5). Logistic
regression analysis showed that each integer increase of VAI weakly
predicted decrease of desire (r=0.193, p=0.015), arousal (r=0.193,
p=0.015), lubrication (r=0.222, p=0.005) and satisfaction (r=0.159,
p=0.046), but did not predicted orgasm (r=0.156, p=0.050) and pain
(r=0.017, p=0.830) (Table 6).

\textbf{DISCUSSION}

Sexual dysfunction in women has a multifactorial etiology, including
psychosocial factors and the difficulty of marital relationships, but
the relationship between sexual function and obesity remains
unclear.\textsuperscript{18} Female sexual dysfunction is reported in
40\% of women in the United States.\textsuperscript{19} However, the
prevalence of FSD in women of reproductive age may vary due to different
geographical and cultural factors. In Turkey, previous studies reported
the FSD prevalence between 46.9\% and 53.2\%.\textsuperscript{20}

Consistent with these reports, a slightly higher rate of FSD with 56.9\%
was reported in this study. Obesity is generally assessed using
anthropometric measurements such as WC and BMI. Considering the WC, only
several reports investigated the impact of increased WC levels on female
sexual function. We recently showed that WC was not a reliable marker
for erectile dysfunction in sexually active men. In that report, the WC
failed to show the real burden of body fat because it only measures the
subcutaneous adipose tissue.\textsuperscript{21} Unlike many studies in
men, only a few conflicting reports have been reported investigating the
relationship between WC and FSD in women. The present study showed that
the WC was not a good predictor for all the subdomains of FSD in women
with a sensitivity of 53.3\% and specificity of 54.4\%, as shown in Fig.
1 and Table 5 (OR=1.019, p=0.318). Data provided by Paningbatan et al.
similarly showed that greater WC than 35 inches was not associated with
FSD.\textsuperscript{22}

Contrary to these reports, Trompeter et al. stated that women with high
WC were more sexually inactive than those with low
WC.\textsuperscript{23} In another report, the WC was shown to decrease
vaginal orgasm.\textsuperscript{24}

In our opinion, only a few studies with limited data have been conducted
in the literature showing the relationship between WC and FSD.
Therefore, further studies are needed to reach satisfactory results in
this regard.

BMI's sensitivity and specificity are low due to individual differences
such as age, gender, race, muscle mass, and fluid intake
habits.\textsuperscript{25} Our results showed that BMI did not affect
the female sexual function index (OR=0.983, p=0.742). Conflicting data
have been published regarding the BMI and FSD. Some authors reported
significant relationships between the BMI and the
FSD.\textsuperscript{26}

Besides, some authors stated that the BMI affected some of the
subdomains of female sexual function. Rabeipoor et al. stated that BMI
only affected sexual satisfaction but did not impair sexual function in
overweight or obese women.\textsuperscript{27} Another study showed that
the BMI impaired arousal, lubrication, orgasm and satisfaction, whereas
the desire and pain scores remained stable\textsuperscript{28}. However,
some authors reported similar FSFI scores between the obese women and an
age-matched control group.\textsuperscript{29}

When interpreting data on BMI and FSD, one should keep in mind that BMI,
as an anthropometric measure, may cause different results in different
individuals for various reasons.

Recent reports showed a significant correlation between visceral
adiposity index and male sexual function.\textsuperscript{13} Although
many disciplines other than andrology carried out numerous studies on
VAI, as far as we know, the current study is the first in the English
literature investigating the relationship between the FSD and VAI.
Studies previously conducted in our clinic showed that each integer
increase of VAI in men increased the likelihood of erectile dysfunction
by 1.4 times. The VAI, especially in those with metabolic syndrome, was
two-fold higher than those without metabolic
syndrome.\textsuperscript{21}

Considering the VAI level of less than or greater than 4.45; our results
showed that arousal, satisfaction and pain scores remained stable,
whereas desire, lubrication and orgasm scores were lower (Table 5).
Although the VAI scores were similar in both groups, a significant
decrease in the arousal, satisfaction and pain scores did not reach a
statistical significance in the logistic regression analysis in
individuals with higher VAI values \selectlanguage{english}\selectlanguage{english}regardless of the groups. This
study was conducted based on anthropometric (such as WC, BMI, VAI) and
biochemical parameters. Besides the low number of participants, one of
the reasons the logistic regression analysis could not show the VAI as a
risk factor can be attributed to its anthropometric basis. In this
context and the psychogenic situation, the lack of consideration of
various factors such as parity, number of births, birth type, partner
characteristics, comfort during the sexual relationship, and privacy
issues can be perceived as limiting factors. Although it may be
considered a limiting factor, providing the parameters mentioned above
is challenging, especially in populations where sexual privacy is at the
forefront. Multiparity was associated with less orgasmic and pain
problems compared to nulliparity.\textsuperscript{30} With psychological
and biological aspects, childbirth has an essential impact on female
sexual function.\textsuperscript{31}

Female sexual dysfunctions related to MeTS may be a messenger of severe
conditions such as cardiovascular and cerebrovascular
diseases.\textsuperscript{32} The relationship between the MeTS and FSD
has been studied in several studies. Di Francesco et al. showed that
MeTS was associated with a higher prevalence of low sexual desire,
orgasm and satisfaction than those without
MeTS.\textsuperscript{33}Metabolic syndrome has been reported to cause
reduced vaginal engorgement via neuropathy and pelvic vascular
injury.\textsuperscript{34} Excessive adipose tissue accumulation is
strongly associated with MeTS. As a continuous process, adipogenesis
works not only for energy storage but also for immune and endocrine
functions. Therefore increased adipogenesis may result in inflammatory,
immune and cardiovascular disorders secondary to
MeTS.\textsuperscript{33}

Based on this, it is thought that MeTS may affect female sexual function
by disrupting oxygenation by reducing pelvic blood flow through chronic
vascular inflammation, oxidative stress and atherosclerosis that can
explain the higher rate of FSD in postmenopausal and premenopausal
relatively older women.\textsuperscript{35}

In the present study, logistic regression analysis showed that the Odds
ratio between MeTS and FSD was 2.27, which could not reach statistical
significance (p = 0.153). This finding can be explained by the
relatively young patients in this study and the relatively low number of
participants (six were in Group 1 group (8.8\% and 19 were in Group 2
(17.8\%). Unlike other anthropometric variables such as BMI and WC, our
opinion is that the significant decrease in desire, lubrication and
orgasm scores is remarkable considering the VAI\textgreater{} 4.45.
Nevertheless, although the presence of MetS was not reached statistical
significance in this study, it may have a higher impact on FSD compared
to other possible risk factors in a higher cohort of participants.

\textbf{Strength \& limitations}

The present is the first investigating the effect of the VAI on female
sexual dysfunction in the literature compared to the BMI and WC. A
relatively low number of participants, lack of information on parity,
education, employment, partner status, income, presence of mood
disorders are the limiting factors. Excessively high VAI levels in some
participants might affect the results, which may be a limiting factor.
Another factor that limits the study is that the participants'
psychosocial status was not taken into account.

\textbf{CONCLUSION}

The VAI was not related to decreased subdomains of the FSFI, it was
linked with lower scores in some subdomains of the FSFI, but the
correlation coefficient was low, indicating a weak association. Further
studies with a high number of participants are needed to conclude that
the VAI and metabolic syndrome may increase the risk of FSD.

\textbf{Conflict of Interest: The authors report no conflicts of
interest.}

\textbf{Funding: None.}

\textbf{Data available on request due to privacy/ethical restrictions.}

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  Bolat MS, Ozbek ML, \selectlanguage{polish}Ş\selectlanguage{english}ahin B, et al. Impact of high visceral adiposity
  index associated with metabolic syndrome on erectile function in
  sexually active men: Results of a cross-sectional study. J Sex Med.
  2021;e14111.
\item
  Paningbatan J, Aragon J, Landicho-Kanapi MP et al. Prevalence of
  Sexual Dysfunction and its Associated Factors among Women with
  Diabetes Mellitus Type 2 at Makati Medical Center Outpatient
  Department. J ASEAN Fed Endocr Soc.2018;33:165-173.
\item
  Trompeter SE, Bettencourt R, Barrett-Connor E. Metabolic Syndrome and
  Sexual Function in Postmenopausal Women. Am J Med. 2016;129:1270-1277.
\item
  Costa RM, Brody S. Orgasm and women's waist circumference. Eur J
  Obstet Gynecol Reprod Biol. 2014;182:118-22.
\item
  Flegal KM, Graubard BI, Williamson DF, et al. Excess deaths associated
  with underweight, overweight obesity. J Am Med Assoc.
  2005;293:1861-1867.
\item
  Bond DS, Vithiananthan, S, Leahey TM, et al. Prevalence and degree of
  sexual dysfunction in a sample of women seeking bariatric surgery.
  Surg Obes Relat Dis. 2017;5:698-704.
\item
  Rabiepoor S, Khalkhali H, Sadeghi, E. What kind of sexual dysfunction
  is most common among overweight and obese women in reproductive age?
  Int J Impot Res. 2017;29: 61--64.
\item
  Esposito K, Ciotola M, Giugliano F, et al. Association of body weight
  with sexual function in women. Int J Impot Res. 2007;19:353--357.
\item
  Yaylali GF, Tekekoglu S, Akin F. Sexual dysfunction in obese and
  overweight women. Int J Impot Res. 2010;22(4):220-6.
\item
  Witting K, Santtila P, Alanko K, et al. Female sexual function and its
  associations with number of children, pregnancy, and relationship
  satisfaction. J Sex Marital Ther. 2008;34(2):89-106.
\item
  von Sydow K. Sexuality during pregnancy and after childbirth: a
  metacontent analysis of 59 studies. J Psychosom Res. 1999;47(1):27-49.
\item
  McCabe MP, Sharlip ID, Lewis R, et al. Incidence and Prevalence of
  Sexual Dysfunction in Women and Men: A Consensus Statement from the
  Fourth International Consultation on Sexual Medicine 2015. J Sex Med.
  2016;13(2):144-52.
\item
  Di Francesco S, Caruso M, Robuffo I, et al. The Impact of Metabolic
  Syndrome and Its Components on Female Sexual Dysfunction: A Narrative
  Mini-Review. Curr Urol. 2019;12:57-63.
\item
  Gragasin FS, Michelakis ED, Hogan A, et al. The neurovascular
  mechanism of clitoral erection: nitric oxide and cGMP-stimulated
  activation of BKCa channels. FASEB J, 2004;18:1382-91.
\item
  Miner M, Esposito K, Guay A, et al. Cardiometabolic risk and female
  sexual health: the Princeton III summary. J Sex Med. 2012;9:641-51;
  quiz 652.
\end{enumerate}

\textbf{Table 1. Demographic, anthropometric, and clinical variables}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Variable}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group 1 (Patients with non-FSD*)} \textbf{(n=68)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group 2 (patients with FSD)} \textbf{(n=90)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{Age (year) (mean ± SD)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
38.2 \selectlanguage{ngerman}± 6.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
39.6 \selectlanguage{ngerman}± 7.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.397\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{Waist circumference (cm) (mean ± SD**)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
85.8 \selectlanguage{ngerman}± 12.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
88.8 \selectlanguage{ngerman}± 13.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.162\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{Body mass index (kg/m2) (mean ± SD)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
25.2 \selectlanguage{ngerman}± 4.8\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
26.3 \selectlanguage{ngerman}± 5.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.578\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{Visceral adiposity index (mean ± SD)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5.21 \selectlanguage{ngerman}± 3.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5.33 \selectlanguage{ngerman}± 3.3\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.644\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{Female sexual function index (mean ± SD)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
19.1 \selectlanguage{ngerman}± 7.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
30.0 \selectlanguage{ngerman}± 2.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Fasting serum glucose (mg(dL)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
93.6 \selectlanguage{ngerman}± 15.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
99.7 \selectlanguage{ngerman}± 33.9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.154\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{HDL-cholesterol (mg/dL)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
58.5 \selectlanguage{ngerman}± 23.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
56.1 \selectlanguage{ngerman}± 16.8\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.717\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Triglyceride (mg/dL)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
140.5 \selectlanguage{ngerman}± 78.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
141.5 \selectlanguage{ngerman}± 70.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.382\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{*FSD, female sexual dysfunction, **Standard deviation}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{*FSD, female sexual dysfunction, **Standard deviation}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{*FSD, female sexual dysfunction, **Standard deviation}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{*FSD, female sexual dysfunction, **Standard deviation}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2. Relationships between subcategories of the variables}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Variable}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group 1} \textbf{(n=68)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group 2} \textbf{(n=90)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Waist circumference (n, \%)} \textbf{\textless{} 89 cm}
\textbf{[?] 89 cm}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
37 (54.4) 31 (45.6)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
42 (46.7) 48 (55.3)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.422\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Body mass index (kg/m\textsuperscript{2}), (n, \%)}
\textbf{BMI-1 (\textless{}25.0)} \textbf{BMI-2 (25.0-29.9)}
\textbf{BMI-3 ([?] 30.0)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
30 (44.1) 30 (44.1) 8 (11.8)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
45 (50.0) 28 (31.1) 17 (18.9)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.191\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Visceral adiposity index (n, \%)} \textbf{\textless{}4.45}
\textbf{[?]4.45}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
33 (48.5) 35 (51.5)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
43 (47.8) 47 (52.2)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Metabolic Syndrome} \textbf{No} \textbf{Yes}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
62 (91,2) 6 (8.8)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
74 (82.2) 19 (17.8)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.163\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Diabetes Mellitus} \textbf{No} \textbf{Yes}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
67 (98.5) 1 (1.5)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
85 (94.4) 5 (5.6)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.237\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Hypertension} \textbf{No} \textbf{Yes}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
62 (91,2) 6 (8.8)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
83 (92.2) 7 (7.8)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Smoking} \textbf{No} \textbf{Yes}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
44 (64.7) 24 (35.3)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
66 (73.3) 24 (26.7)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.295\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Alcohol abuse (n, \%)} \textbf{No} \textbf{Yes}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
9 (96.7) 2 (3.3)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
92 (94.8) 5 (5.2)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.707\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 3. The mean score of Female Sexual Function Index (FSFI)
and its subdomains by the groups.}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Subdomain}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Group 1} \textbf{(n=68)}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Group 1} \textbf{(n=90)}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Desire}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.95\selectlanguage{ngerman}±0.9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2.83\selectlanguage{ngerman}±1.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Arousal}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.64\selectlanguage{ngerman}±0.9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2.82\selectlanguage{ngerman}±1.3\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Lubrication}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5.16\selectlanguage{ngerman}±0.8\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.02\selectlanguage{ngerman}±1.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Orgasm}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5.17\selectlanguage{ngerman}±0.8\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2.98\selectlanguage{ngerman}±1.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Satisfaction}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5.32\selectlanguage{ngerman}±0.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.36\selectlanguage{ngerman}±1.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0,001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pain}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5.41\selectlanguage{ngerman}±0.9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.33\selectlanguage{ngerman}±1.9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Total FSFI}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
29.7\selectlanguage{ngerman}±2.8\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
18.3\selectlanguage{ngerman}±7.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0,001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 4. Female Sexual Function Index (FSFI) and its subdomains
according to having or not MetS.}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Subdomain}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{No MeTS} \textbf{(n=136)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{MetS} \textbf{(n=22)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Desire}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.39\selectlanguage{ngerman}±1.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2.82\selectlanguage{ngerman}±1.2\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.062\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Arousal}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.72\selectlanguage{ngerman}±1.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2.89\selectlanguage{ngerman}±1.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.020\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Lubrication}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.05\selectlanguage{ngerman}±1.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.22\selectlanguage{ngerman}±1.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.023\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Orgasm}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.01\selectlanguage{ngerman}±1.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.42\selectlanguage{ngerman}±1.8\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.110\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Satisfaction}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.25\selectlanguage{ngerman}±1.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.91\selectlanguage{ngerman}±1.8\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.439\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pain}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.31\selectlanguage{ngerman}±1.9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.7\selectlanguage{ngerman}±1.9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.155\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Total FSFI}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
23.8\selectlanguage{ngerman}±7.8\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
19.9\selectlanguage{ngerman}±8.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.023\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllllllllll@{}}
\toprule
\textbf{Table 5. Relationships of female sexual function scores with
different cut-off values of waist circumference, body mass index and
visceral adiposity index.} & \textbf{Table 5. Relationships of female
sexual function scores with different cut-off values of waist
circumference, body mass index and visceral adiposity index.} &
\textbf{Table 5. Relationships of female sexual function scores with
different cut-off values of waist circumference, body mass index and
visceral adiposity index.} & \textbf{Table 5. Relationships of female
sexual function scores with different cut-off values of waist
circumference, body mass index and visceral adiposity index.} &
\textbf{Table 5. Relationships of female sexual function scores with
different cut-off values of waist circumference, body mass index and
visceral adiposity index.} & \textbf{Table 5. Relationships of female
sexual function scores with different cut-off values of waist
circumference, body mass index and visceral adiposity index.} &
\textbf{Table 5. Relationships of female sexual function scores with
different cut-off values of waist circumference, body mass index and
visceral adiposity index.} & \textbf{Table 5. Relationships of female
sexual function scores with different cut-off values of waist
circumference, body mass index and visceral adiposity index.} &
\textbf{Table 5. Relationships of female sexual function scores with
different cut-off values of waist circumference, body mass index and
visceral adiposity index.} & \textbf{Table 5. Relationships of female
sexual function scores with different cut-off values of waist
circumference, body mass index and visceral adiposity index.} &
\textbf{Table 5. Relationships of female sexual function scores with
different cut-off values of waist circumference, body mass index and
visceral adiposity index.} & \textbf{Table 5. Relationships of female
sexual function scores with different cut-off values of waist
circumference, body mass index and visceral adiposity index.} &
\textbf{Table 5. Relationships of female sexual function scores with
different cut-off values of waist circumference, body mass index and
visceral adiposity index.} & \textbf{Table 5. Relationships of female
sexual function scores with different cut-off values of waist
circumference, body mass index and visceral adiposity index.} &
\textbf{Table 5. Relationships of female sexual function scores with
different cut-off values of waist circumference, body mass index and
visceral adiposity index.} & \textbf{Table 5. Relationships of female
sexual function scores with different cut-off values of waist
circumference, body mass index and visceral adiposity index.} &
\textbf{Table 5. Relationships of female sexual function scores with
different cut-off values of waist circumference, body mass index and
visceral adiposity index.} & \textbf{Table 5. Relationships of female
sexual function scores with different cut-off values of waist
circumference, body mass index and visceral adiposity
index.}\tabularnewline
& \textbf{Waist Circumference} & \textbf{Waist Circumference} &
\textbf{Waist Circumference} & \textbf{Waist Circumference} &
\textbf{Body Mass Index} & \textbf{Body Mass Index} & \textbf{Body Mass
Index} & \textbf{Body Mass Index} & \textbf{Body Mass Index} &
\textbf{Body Mass Index} & \textbf{Body Mass Index} & \textbf{Visceral
adiposity Index} & \textbf{Visceral adiposity Index} & \textbf{Visceral
adiposity Index} & \textbf{Visceral adiposity Index} & \textbf{Visceral
adiposity Index} & \textbf{Visceral adiposity Index}\tabularnewline
& \textbf{\textless{}89} & \textbf{[?]89} & \textbf{[?]89} & \textbf{p} &
\textbf{\textless{}25} & \textbf{25.0-29.9} & \textbf{25.0-29.9} &
\textbf{[?]30.0} & \textbf{[?]30.0} & \textbf{p} & \textbf{p} &
\textbf{\textless{}4.45} & \textbf{\textless{}4.45} &
\textbf{\textless{}4.45} & \textbf{[?]4.45} & \textbf{[?]4.45} &
\textbf{p}\tabularnewline
\textbf{Desire} & 3.3\selectlanguage{ngerman}±1.2 & 3.3\selectlanguage{ngerman}±1.2 & 3.3\selectlanguage{ngerman}±1.2 & 0.999 & 3.3\selectlanguage{ngerman}±1.2 &
3.3\selectlanguage{ngerman}±1.2 & 3.3\selectlanguage{ngerman}±1.2 & 3.3\selectlanguage{ngerman}±1.0 & 3.3\selectlanguage{ngerman}±1.0 & 0896 & 0896 & 3.5\selectlanguage{ngerman}±1.1 & 3.5\selectlanguage{ngerman}±1.1
& 3.5\selectlanguage{ngerman}±1.1 & 3.0\selectlanguage{ngerman}±1.2 & 3.0\selectlanguage{ngerman}±1.2 & \textbf{0.030}\tabularnewline
\textbf{Arousal} & 3.8\selectlanguage{ngerman}±1.4 & 3.4\selectlanguage{ngerman}±1.5 & 3.4\selectlanguage{ngerman}±1.5 & 0.124 & 3.6\selectlanguage{ngerman}±1.6 &
3.7\selectlanguage{ngerman}±1.5 & 3.7\selectlanguage{ngerman}±1.5 & 3.4\selectlanguage{ngerman}±1.1 & 3.4\selectlanguage{ngerman}±1.1 & 0.517 & 0.517 & 3.9\selectlanguage{ngerman}±1.2 &
3.9\selectlanguage{ngerman}±1.2 & 3.9\selectlanguage{ngerman}±1.2 & 3.2\selectlanguage{ngerman}±1.7 & 3.2\selectlanguage{ngerman}±1.7 & 0.084\tabularnewline
\textbf{Lubrication} & 4.1\selectlanguage{ngerman}±1.7 & 3.8\selectlanguage{ngerman}±1.5 & 3.8\selectlanguage{ngerman}±1.5 & 0.173 & 3.7\selectlanguage{ngerman}±1.8 &
4.2\selectlanguage{ngerman}±1.7 & 4.2\selectlanguage{ngerman}±1.7 & 3.9\selectlanguage{ngerman}±0.9 & 3.9\selectlanguage{ngerman}±0.9 & 0.176 & 0.176 & 4.3\selectlanguage{ngerman}±1.5 &
4.3\selectlanguage{ngerman}±1.5 & 4.3\selectlanguage{ngerman}±1.5 & 3.4\selectlanguage{ngerman}±1.8 & 3.4\selectlanguage{ngerman}±1.8 & \textbf{0.020}\tabularnewline
\textbf{Orgasm} & 3.9\selectlanguage{ngerman}±1.8 & 4.0\selectlanguage{ngerman}±1.6 & 4.0\selectlanguage{ngerman}±1.6 & 0.946 & 3.7\selectlanguage{ngerman}±1.9 &
4.2\selectlanguage{ngerman}±1.5 & 4.2\selectlanguage{ngerman}±1.5 & 3.7\selectlanguage{ngerman}±1.3 & 3.7\selectlanguage{ngerman}±1.3 & 0.193 & 0.193 & 4.2\selectlanguage{ngerman}±1.6 &
4.2\selectlanguage{ngerman}±1.6 & 4.2\selectlanguage{ngerman}±1.6 & 3.5\selectlanguage{ngerman}±1.9 & 3.5\selectlanguage{ngerman}±1.9 & \textbf{0.040}\tabularnewline
\textbf{Satisfaction} & 4.3\selectlanguage{ngerman}±1.8 & 4.1\selectlanguage{ngerman}±1.6 & 4.1\selectlanguage{ngerman}±1.6 & 0.273 & 4.1\selectlanguage{ngerman}±1.9 &
4.4\selectlanguage{ngerman}±1.5 & 4.4\selectlanguage{ngerman}±1.5 & 4.1\selectlanguage{ngerman}±1.2 & 4.1\selectlanguage{ngerman}±1.2 & 0.359 & 0.359 & 4.4\selectlanguage{ngerman}±1.5 &
4.4\selectlanguage{ngerman}±1.5 & 4.4\selectlanguage{ngerman}±1.5 & 3.9\selectlanguage{ngerman}±1.9 & 3.9\selectlanguage{ngerman}±1.9 & 0.244\tabularnewline
\textbf{Pain} & 4.0\selectlanguage{ngerman}±2.0 & 4.5\selectlanguage{ngerman}±1.7 & 4.5\selectlanguage{ngerman}±1.7 & 0.166 & 3.9\selectlanguage{ngerman}±2.1 & 4.6\selectlanguage{ngerman}±1.7
& 4.6\selectlanguage{ngerman}±1.7 & 4.4\selectlanguage{ngerman}±1.5 & 4.4\selectlanguage{ngerman}±1.5 & 0.129 & 0.129 & 4.4\selectlanguage{ngerman}±1.7 & 4.4\selectlanguage{ngerman}±1.7 &
4.4\selectlanguage{ngerman}±1.7 & 4.0\selectlanguage{ngerman}±2.1 & 4.0\selectlanguage{ngerman}±2.1 & 0.888\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 6. Impact of variables on female sexual dysfunction
according to the logistic regression analysis.}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
& B & S.E. & Wald & df & Significance & Exp (B)\tabularnewline
\textbf{Constant} \textbf{WC} \textbf{BMI} \textbf{VAI}
\textbf{MeTS\textsuperscript{\&}} & 0.786 .019 -.017 -.040 .821 & 1.161
0.019 -.017 -.040 0.574 & .459 .995 .109 .552 2.045 & 1 1 1 1 1 & .498
.318 .742 .457 .153 & .455 1.019 .983 .961 2.272\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/12/12}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

