There is ample evidence that sexual difficulties can accompany chronic disease.1–4 The association between sexual activity and asthma was observed some time ago, but little quantitative information is available. The notion that sex can trigger an asthma exacerbation is not implausible, and some cases have been documented. In a letter to The Lancet in 1976, the investigators Symington and Kerr found that sexual activity could induce both asthma and rhinitis.5–8 It has been reported that sexual intercourse can trigger severe asthma exacerbations requiring emergency care, hospitalization or even assisted ventilation.9,10

The physical requirements of sexual activity may cause an exacerbation of asthma, although some authors believe that emotional arousal alone is sufficient to cause or aggravate the condition. Sexercise-induced asthma,5–8 as it has been called, is for some no more than a variant of exercise-induced asthma.

However, very few studies have evaluated the sexual quality of life of patients with asthma, and the design and methodology of those that do are questionable. In a study carried out in the emergency department of the Harlem Hospital Center, New York,11 researchers asked 356 patients to assess the degree to which their asthma had adversely affected how they performed specific activities. Of these, sexual limitation was the third most frequently mentioned. Recently, Basar et al.12 found sexual dysfunction in 18 female asthma patients (47.4%) compared to four women in the control group (20%). Finally, some singular cases of erectile dysfunction (ED) in asthmatic men and the resulting impact on their sexual relations have been reported.13,14

Given these shortcomings, our objective in this study was twofold. Our first aim was to assess the potential impact of asthma on the sexual function of male and female asthma patients, and our second aim was to determine the possible factors associated with dysfunction, such as disease severity, level of control and comorbidities.

This was an observational, cross-sectional, multicenter study conducted in a group of asthma patients of both sexes, 18 years of age and older, selected consecutively in the outpatient clinics of seven Spanish tertiary hospitals. The study was performed after approval was obtained from the respective local ethics committees. All patients were asked for written consent before participation.

Asthma was diagnosed according to GEMA criteria,15 on the basis of corresponding clinical criteria and reversible airflow obstruction documented in at least one previous lung function study. Disease severity and degree of control were also evaluated according to GEMA criteria.15 Data were collected on smoking, time since onset of asthma, possible exercise-induced asthma, pre-existing morbidity (exacerbations and hospitalizations in the year prior to inclusion), spirometry, comorbidities (allergic rhinitis, nasal polyposis, reflux, fibromyalgia, anxiety, depression, high blood pressure, diabetes), and maintenance therapy. Rhinitis was classified by severity according to the ARIA guidelines.16 All patients had stable asthma at the time of inclusion, defined as no exacerbations in the four weeks prior to inclusion.

A control group of healthy volunteers was selected from among the visitors or companions of the patients in the same outpatient clinics at the participating centers. The group selected was of a similar age to the asthma group and had no chronic respiratory diseases nor significant comorbidities.

Both groups were asked if they were concerned about their sex life, and if so, for what reasons.

In total, 276 cases were included, of which 172 were asthma patients (109 men and 63 women). The demographic characteristics of the study population and the clinical characteristics of asthma are reflected in Tables 1 and 2. It is interesting to note that the group of asthma patients had a significantly higher body mass index (BMI) than the control group, the percentage of smokers was similar, and asthma patients’ GADS scores were higher, both overall and in the anxiety domain. A higher proportion of men presented controlled asthma compared to women. The most common treatment for asthma was the combination of inhaled corticosteroids and long-acting beta-2 adrenoceptor agonists (LABA) (78.6%). The most significant comorbidities among the asthma group were rhinitis (80.8%), gastroesophageal reflux (20.3%), anxiety (16.8%), nasal polyposis (14.6%), depression (11.1%), arterial hypertension (11%), diabetes (4.7%), and fibromyalgia (2.9%). Concern about sexual function was expressed by 47.2% of the healthy volunteers and by 39.9% of the asthma group. Reasons for concern are listed in Fig. 1. Almost a quarter of the asthma patients associated their sexual problems with the fact of having asthma.

Fig. 1.

Concern about sexual functioning and reasons given by asthma patients and the control group.

(0.22MB).

Differences in sexual function observed between asthma patients and controls are shown in Tables 3 and 4. Among women with asthma, overall dysfunction was significant, both in the total score and in the different dimensions of the FSFI. A significantly worse overall score was also observed in the IIEF questionnaire in men, the most affected dimensions being desire and overall satisfaction. Although there were no significant differences in the score for erectile difficulties between the group of asthma patients and the control group, according to the erectile function score only 56% of asthmatic patients reported no impotence problems compared to 74.3% in the control group. In total, 36% of asthma patients had mild ED, 4% moderate ED, and 4% severe ED.

Among women with asthma, significant correlations were observed between the overall FSFI score and the following variables: age (−0.37; P<.001), BMI (−0.23; P=.03), time since onset of the disease (−0.36; P<.001), FEV1% (0.23; P=.02), severity and control of asthma (−0.21 and −0.27; P<.05), and emotional aspects, such as the prior existence of depression or anxiety (−0.32 and 0.26; P<.01), GADS questionnaire score (−0.32; P=.001), and previous arterial hypertension or diabetes (−0.33 and −0.32; P=.001). In men, significant correlations were found between the IIEF score and the following variables: age (−0.53; P<.0001), asthma severity (−0.41; P=.001), impaired lung function (0.39; P=.005), smoking (−0.38; P=.003), upper airway involvement (perennial rhinitis; −0.28; P=.04). In neither group, men nor women, did a previous diagnosis of exercise-induced asthma appear to be associated with sexual dysfunction.

Tables 5 and 6 show the results of the bivariate and multivariate analyses for the dysfunction/no dysfunction variable, according to the factors that might affect patients with asthma, in men and women separately. Table 5b shows the results obtained in the multivariate analysis in men which revealed an association between dysfunction and age. No associations were found for the remaining variables, although the data approached significance for degree of asthma control (P=.006). In women (Table 6b), variables that were significant in the bivariate model and age were included in the multivariate model, but no association was demonstrated, although data for degree of asthma control approached significance.

The main finding of this study is that sexual dysfunction may be more common in both male and female patients with asthma than in the healthy population. Uncontrolled disease is probably among the factors that contribute most to this dysfunction.

Some earlier publications have reported singular cases of asthma associated with ED in men,13,14 with the consequent impact on sexual relations. ED can be defined as the persistent inability to achieve and maintain an adequate erection to allow satisfactory sexual activity. It was reported recently that asthma may be an independent risk factor for developing ED, and the more severe the bronchial disease, the closer the association.24 In our study, no significant differences were observed in the erectile function domain between asthma patients and healthy volunteers, although there was a decrease in other aspects such as sexual desire and overall satisfaction with intercourse in the group with respiratory disease. However, we found that 44% of asthma patients experienced ED, compared to only 25.7% of the control group, and that ED was more intense in the patient group. Age and uncontrolled asthma were also associated with a lower score on male sexual function scales in the multivariate analysis. Our male patients presented a better level of asthma control, and this may have led to some extent to the lack of significant impact observed in some areas of the sexual function questionnaire.

Our study corroborates the findings of recent articles that emphasize the importance of asthma in patients’ sex lives, particularly among women. Meyer et al.11 performed a study in the emergency department of a hospital in New York in which researchers asked patients attending the emergency room to assess the degree to which their asthma had adversely affected how they performed specific activities. Of these, sexual limitations were the third most frequently mentioned by the patients after climbing stairs or performing habitual household chores. Two-thirds of the patients interviewed reported sexual limitations that they associated with their asthma. These were more prevalent in patients with moderate or severe asthma compared to those with mild asthma, and in individuals over 40 years of age compared to those under the age of 40. Women with asthma who attended the emergency room reported greater sexual dysfunction than men.

In a recent study12 carried out in 38 premenopausal married women with asthma compared with 20 healthy women, FSFI was used to identify differences between these groups in terms of possible sexual dysfunction. Sexual dysfunction was observed in 18 of the asthma patients (47.4%), but in only four individuals in the control group (20%). The most severe problem in asthma patients was arousal, reported as reduced by 30 patients (78.9%), followed by decreased desire (44.7%), pain during sexual intercourse (34.2%), and difficulty reaching orgasm (31.6%). However, satisfaction scores were the least affected, and were below normal in only five individuals (13.2%). A strong correlation was also noted between the FSFI score and the scales used to evaluate the psychological status of patients, suggesting that decreased arousal and libido are related to emotional and psychological factors. These results are consistent with our findings. In our larger series, we found differences in all FSFI items, including arousal, lubrication, orgasm, desire and satisfaction, and an initial association with emotional factors, for both previously diagnosed depression or anxiety and the score attained in the psychological questionnaires. However, the multivariate analysis could not subsequently establish an explanatory model of dysfunction in asthma patients.

It should be noted that a third of our patients attributed their sexual problems to their asthma, and there is a relationship between the time since asthma onset and severity, control, and deterioration of lung function. In our series, we found that the control group was more concerned about their sexuality than the asthma group. This may be because we compared a population of patients who are probably more concerned with their many uncontrolled respiratory symptoms than their sexual function, against a healthy population with no concomitant diseases to draw their attention away from possible sexual dysfunction. In our study, it should be noted, we did not take into account the socioeconomic and/or cultural level of the study population. These factors could have an influence on our patients’ sex lives and may need to be taken into consideration in future research examining this topic.

The impact of upper airway involvement on sexual function observed in our study, particularly in men (rhinitis severity), has also been documented by other authors.25,26 Smoking is another concomitant factor to be considered in men, and may be a limiting factor in our study due to the higher consumption of tobacco among our asthma patients; however, smoking was not included the multivariate analysis as a predictor for possible dysfunction in our series. In women, the existence of comorbidities such as arterial hypertension or diabetes produced a lower score in the FSFI questionnaire. The hypothesis of so-called sexercise-induced asthma was not proved in our series, as no relationship was established between the sexual function of our patients and a previous diagnosis of exercise-induced asthma. Finally, the multivariate logistic regression seems to indicate that uncontrolled disease could be a determining factor in sexual dysfunction.

In short, sexuality is a central aspect of the quality of life of men and women and is a reflection of their level of physical, psychological and social well-being, but this issue is very often ignored in routine clinical practice. Our study found that both women and men with asthma have significant sexual dysfunction. The cause of this dysfunction is multifactorial, and several parameters appear to be involved, including the severity of symptoms and the existence of comorbidities typical of asthma, such as rhinitis and psychological dysfunction. Improving asthma control should improve not only sexual function but also other aspects of the patient's life. There is a need, however, for new studies to confirm this conclusion, and specific recommendations should be developed for patients with asthma that include aspects related to sexuality.

The project was funded by a non-restrictive grant from Novartis Farmacéutica, S.A., Spain.

J. Gregorio Soto Campos has received fees in the past two years for speaking engagements in congresses and financial support for attending scientific events from Boehringer, Novartis, Chiesi, Astra, and GSK; Vicente Plaza has received fees in the past three years for participating as a speaker in meetings sponsored by Chiesi, Esteve, GSK, Novartis, Orion and Pfizer and as a consultant for ALK, MundiPharma, Orion and Teva. He has received financial support for attending congresses from AZ, Chiesi and Novartis and research grants from AZ, Chiesi and Menarini.