INTRODUCTION
The population of middle-aged women in Korea has grown significantly, increasing from 7.53 million in 2010 to approximately 8.23 million as of 2023[1]. This demo-graphic represents a crucial phase of life where individuals typically work toward achieving life goals and pre-paring for old age, accounting for about one-third of the life cycle. In addition to the societal roles they play, mid-dle-aged women often experience various physiological changes, which make them more susceptible to chronic diseases, one of which is menopause.
Menopause is a normative developmental phase that marks a significant shift in a woman's social roles and serves as a preparatory stage for aging [2]. However, this transition is frequently accompanied by complex emotional responses, such as confusion and distress, as women navigate both the physical and psychological changes that occur during this period [3]. One of the most significant issues observed during menopause is depression, which has been shown to contribute considerably to sexual dysfunction in postmenopausal women. Depression, commonly seen during the menopausal transition, can di-minish sexual desire and lead to difficulties with arousal and orgasm [4,5]. These effects are largely driven by the emotional distress and psychological challenges stem-ming from the hormonal fluctuations of menopause [4,5]. Furthermore, depression often exacerbates feelings of sadness and isolation, further distancing individuals from sexual activities and negatively impacting sexual satisfaction [5].
Marital intimacy is another crucial factor influencing sexual function in this population. A lack of emotional closeness and intimacy between partners is frequently associated with reduced sexual satisfaction and performance. Emotional connection is essential for fostering a healthy sexual relationship, and studies indicate that women who report higher levels of marital intimacy tend to experience fewer sexual function issues. Conversely, those with lower levels of intimacy often face more significant challenges in maintaining a fulfilling sexual relationship [5-7]. According to previous research, further exploration of spousal factors-such as age and sexual dysfunction-is recommended, as these variables may also affect middle-aged women's sexual function [6].
The common symptoms of menopause, including sweating, hot flashes, insomnia, fatigue, mood fluctuations, vaginal dryness, urinary symptoms, and decreased sexual desire, frequently contribute to sexual dysfunction in postmenopausal women [8,9]. Sexual function is a multifaceted concept encompassing physiological, psychological, and social aspects, such as sexual desire, arousal, orgasm, and overall satisfaction. These components collectively shape an individual's comprehensive sexual experience and sense of fulfillment [10]. Consequently, menopausal symptoms can exacerbate emotional states such as sadness and depression, contributing to negative image issues in postmenopausal women [3]. Furthermore, it is well-documented that middle-aged women undergoing menopause are at increased risk for chronic diseases [11]. For example, the incidence of hypertension-a chronic con-dition that poses significant health risks for menopausal women-increases with age, affecting 26.7% of women over 50 and 45.5% of women over 60 [12]. Hypertension negatively impacts vascular function and stimulates the re-lease of the stress hormone cortisol, which, in turn, lowers sex hormone levels. Additionally, the psychological stress and anxiety associated with hypertension may further reduce libido and exacerbate sexual response disorders. De-spite these findings, research specifically examining the sexual function of postmenopausal women with hypertension remains limited [13].
Many middle-aged women seek to alleviate menopausal symptoms through hormone therapy. However, due to side effects such as breast pain, irregular bleeding, and weight gain, many are reluctant to continue hormone therapy or discontinue its use due to fears of cancer [14,15]. Studies have shown that sexual dysfunction is more prev-alent among postmenopausal women who do not receive hormone therapy, underscoring the need for targeted as-sessments of their sexual function. International studies on sexual function in middle-aged women have reported varying rates of dysfunction, ranging from 34% to 88%, with sexual problems primarily caused by the rapid de-cline in sex hormones during menopause [4]. Some over-seas studies have shown that 50% to 65.2% of middle-aged women experience sexual dysfunction [16,17]. In a South Korean study, 81.6% of sexually inactive women were found to have sexual dysfunction [5]. Sexual health, which encompasses physical, mental, and social well-being, is an integral aspect of the overall quality of life for women [17]. Thus, a multidimensional approach is required to improve the sexual health of middle-aged women. Menopause marks a significant turning point that can influence sexual behavior in middle-aged women. As blood levels of sex hormones decrease during menopause, the frequency of sexual intercourse typically declines, leading to various forms of sexual dysfunction, including sexual arousal disorders and painful intercourse due to reduced vaginal lubrication [4]. If women are unable to effectively manage and adapt to these physical changes, they may face more serious health challenges as they age [2]. The factors most commonly linked to sexual dysfunction in middle-aged women include menopausal symptoms [18,19], depression [4], and marital intimacy [4,7]. However, previous studies have typically examined these variables in isolation, and few have sought to understand the dynamic, causal relationships among them.
Therefore, this study aims to investigate the causal relationships between menopausal symptoms, depression, and marital intimacy as factors influencing sexual function in postmenopausal women. This research will provide a foundation for the development of sexual counseling and intervention programs aimed at improving sexual function. Specifically, the objectives of this study are to 1) assess the levels of menopausal symptoms, depression, marital intimacy, and sexual function, 2) examine the relationships among these variables, and 3) identify the mediating effects of depression and marital intimacy on the relationship between menopausal symptoms and sexual function in postmenopausal women with hypertension not receiving hormone replacement therapy.
METHODS
1. Study Design
This is a study on the path analysis to construct a theoretical model based on existing literature and subsequent-ly assesses the model's fit and hypotheses to investigate the causal relationships among various factors influencing the sexual function of postmenopausal women with hypertension who are not receiving hormone replacement therapy.
2. Study Participants
The study involved postmenopausal women aged 45 to 60 with hypertension. Participants were selected from a pool of healthy individuals who had been naturally menopausal for a minimum of one year and were in a commit-ted sexual relationship. Both clinically diagnosed and self-diagnosed menopausal women were included in the study, while individuals receiving hormone replacement therapy were excluded from participation, an early menopause woman before the age of 42, taking antidepressants, any medication excluded hypertensive drug suspected of affecting their sexual performance or had done so in the past three months, had pelvic malignancies, had repro-ductive surgery, and those who were unwilling to participate in the present study.
According to recommendations for path analysis, an appropriate sample size should range between 100 and 400 participants when fewer than 12 variables are being observed [20]. Additionally, in bootstrap analysis, a suffi-cient sample size is required to ensure high reliability, with a sample size of over 300 generally considered adequate [21]. Considering the commonly accepted 10% dropout rate for offline surveys [22], the target sample size was set at 330 participants to account for potential attrition. Ultimately, 308 complete responses were analyzed after excluding 22 incomplete or insufficiently answered questionnaires. Therefore, the final sample size of 308 was deemed adequate for this study.
3. Measurements
The questionnaire for data collection in this study consists of general characteristics, menopausal symptoms, depression, marital intimacy, and sexuality questions, and each measurement tool received permission to use the tool by e-mail to the original developer.
1) General characteristics
The sociodemographic characteristics assessed in the study included age, duration of marriage, occupation, ed-ucation level, religion, and monthly household income. Gynecological characteristics included age at the onset of menopause, frequency of pregnancies and deliveries, and Body Mass Index (BMI). Partner-related characteristics considered in the study involved the partner's age and the presence of erectile dysfunction.
2) Menopause symptoms
Menopausal symptoms were assessed using the Korean version of the Menopause Rating Scale (MRS) developed by Heinemann et al. [23]. The MRS is a widely recognized instrument for evaluating menopausal symptoms in women during the climacteric phase and is available in nine different language versions, including Korean [24]. The scale consists of 11 items, each rated on a scale from 0 to 4 points. It is divided into three subdomains: somato-vege-tative, urogenital, and psychological.
The total score ranges from 0 to 44, reflecting the severity of menopausal symptoms. Higher scores indicate greater symptom severity. A score between 0 and 4 reflects minimal menopausal symptoms, 5 to 7 is mild, 8 to 15 is moderate, and scores above 16 are severe. Heinemann et al. [23] conducted a reliability and validity analysis of the MRS across nine countries on four continents between 2001 and 2002. The Cronbach's ⍺ coefficient for the tool during its development phase was reported as .86 [23], with country-specific values ranging from .65 to .87. In the present study, Cronbach's ⍺ was measured at .87.
3) Depression
Depression was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) developed by Radloff [25]. The reliability and validity of the Korean version of the CES-D have been well-established in the literature [26]. The scale consists of 20 items, each scored on a range from 0 to 3, with total scores ranging from 0 to 60. Higher scores indicate higher levels of perceived depression. A total score of 16 or above suggests probable depression, while scores of 25 or above indicate definitive depression [25]. The original CES-D demonstrated a Cronbach's ⍺ ranging from .85 to .90 [25], while the Korean version of the scale exhibited a reliability coefficient of .91[26]. In the present study, Cronbach's ⍺ was measured at .90.
4) Marital intimacy
Marital intimacy was evaluated using the Marital Intimacy Questionnaire (MIQ) developed by Waring and Reddon [27] and translated into Korean by Kim [28]. The reliability and validity of the Korean adaptation of the MIQ have been extensively documented [28]. The assessment tool consisted of 8 items, each scored on a scale of 1 to 4 points. Scores ranged from 8 to 32, with higher scores indicating greater levels of marital intimacy. During the development phase of the tool, the reliability coefficients were observed to range between .62 and .86 [27]. The Cronbach's ⍺ for the Korean version of the questionnaire was .92 [28] and .97 in this study.
5) Sexual function
The evaluation of sexual function was carried out using the Female Sexual Functioning Index (FSFI) developed by Rosen et al. [10] and translated into Korean by Kim et al. [29]. The FSFI consists of 19 items distributed across six domains: two on sexual desire, four on sexual arousal, four on vaginal lubrication, three on orgasm, three on satisfaction, and three on pain during intercourse. The initial two items on sexual desire are assessed on a 5-point scale ranging from ‘ nearly or very low’ to ‘ always or very high,’ while the remaining 17 items are rated on a 6-point scale from ‘ no sexual activity’ to ‘ always.’ Each domain-specific score is multiplied by a weighted factor, and the cumu-lative scores from all six domains yield the total sexual function score. Scores vary from 2 to 36, with higher scores indicating better perceived sexual function. The identification of sexual dysfunction in individuals is determined by a cut-off score of 14.1, specifically derived for postmenopausal women not receiving hormone replacement therapy [30]. Therefore, a score of 14.1 points or below on the FSFI suggests the presence of female sexual dysfunction (FSD) [30]. The Cronbach's ⍺ for the scale was 0.97 upon its development [10]. In the study by Kim et al. [29], Cronbach's ⍺ was .99, and in this study, it ranged from .93 to .98.
4. Data Collection
Participants were recruited from three provinces in Korea: Jeollanam-do, Jeollabuk-do, and Chungcheongnam-do. From September to November 2017, four trained assistant researchers conducted surveys with postmenopausal women who agreed to participate in the study after being in-formed about its purpose and objectives during visits to 4 civil service offices and 4 health offices. The researcher personally visited the institutions, explained the study to the heads of the organizations, and obtained permission to conduct data collection.
Data collection commenced after obtaining written in-formed consent from participants who voluntarily agreed to participate and met the selection criteria. The female participants completed self-administered questionnaires in a private and quiet setting. Once completed, the surveys were placed in sealed envelopes and collected by the research assistants. Each questionnaire took approximately 20 minutes to complete. As a token of appreciation, participants received a small gift following the completion of the survey.
5. Data Analysis
The statistical software packages SPSS/WIN 27.0 and AMOS 23.0 were used for data analysis (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corporation). In this investigation, the normality assessment of individual variables was validated through skewness and kurtosis, all of which exhibited a normal distribution. The statistical sig-nificance threshold was established p<.05. Data presen-tation included numerical values (percentages), means with standard deviations (SD), or medians with ranges. A path analysis was conducted to examine the proposed path model, utilizing AMOS software with maximum likelihood estimation and a bootstrap method employing 2,000 samples. The standard estimates for direct, indirect, and total effects of the research variables on sexual function were computed based on the hypothetical path model. The validity and adequacy of the model were subsequent-ly assessed using absolute fit indices, including the standard x2 test, root mean square residual (RMSR), goodness of fit index (GFI), and adjusted goodness of fit index (AGFI), as well as incremental fit indices such as the normed fit index (NFI), comparative fit index (CFI), and root mean square error of approximation (RMSEA). The model is considered to fit the data well if the p-value for the x2 test is greater than .05. Both GFI and AGFI values of .90 or higher indicate that the model adequately explains the data. An RMSR value of .08 or less suggests a good model fit, and NFI and CFI values of .90 or higher are also considered indicative of a suitable model. Finally, RMSEA reflects how well the model approximates the ideal fit, with values of .06 or lower indicating a good fit and values up to .08 being acceptable. Additionally, to enhance the generalizability of the derived path model, cross-vali-dation was conducted using multi-group analysis. Finally, squared multiple correlations (SMC) were calculated for the research variables in relation to sexual function within the path model.
6. Ethical Considerations
This study was approved by the Institutional Review Board (IRB) of Sunchon National University (IRB No. 1040173-201708-HR-019-01). Before participation, individuals were required to provide written consent following a comprehensive explanation of the study's objectives, methodology, voluntary nature, assurance of anonymity, and the option to withdraw from the study at any point. The research adhered to the principles outlined in the De-claration of Helsinki.
RESULTS
1. General Characteristics of Participants
The general characteristics of the participants are outlined in Table 1. The mean age and duration of marriage of the participants was 53.21±4.86 years (range: 45∼60 years). The range of marriage duration was 25∼30 years for 45.5% (n=140). Regarding gynecological characteristics, the mean age of menopause onset was 50.70±3.18 years (range: 46∼ 56 years). Approximately 64.3%(n=198) had been preg-nant four or five times, and 70.1%(n=216) had been deliv-ered two or three times. The mean age of participants’ partners was 55.21±6.56 years (range: 42∼72 years). Regarding the continuity of the partner's erection, approximately 79.3%(n=244) were normal.
Table 1.
General Characteristics of Participants (N=308)
2. Menopause Symptoms, Depression, Marital Intimacy, and Sexual Function of Participants
The mean score of menopause symptoms, depression, marital intimacy, and sexual function were 12.94±7.05, 16.08±6.00, 22.18±8.46 and 17.31±8.12, respectively. The subscale scores for sexual desire, arousal, lubrication, orgasm, satisfaction, and pain were 2.47±1.01, 2.23±1.23, 2.71±1.32, 2.33±1.29, 2.38±1.28, and 3.95±2.03, respectively (Table 2).
Table 2.
Degree of Menopause Symptoms, Depression, Marital Intimacy and Sexual Function (N=308)
Of the participants, seventeen point four %(n=54) were classified as not having menopause symptoms (cut-off score ≥5). Fifty-two point six %(n=162) was classified as having probable depression (cut-off score range: 16∼24), and eleven point four %(n=35) was classified as having definite depression (cut-off score ≥25). Finally, sixty-five point three % (n=201) were classified as having female sexual dysfunction (cut-off score <14.1).
3. Correlations among the Research Variables
Menopause symptoms had a positive correlation with depression (r=.51, p<.001) and negative correlations with marital intimacy and sexual function (r=-.30, p<.001; r= -.60, p<.001), respectively. And depression had negative correlations with marital intimacy and sexual function (r=-.53, p <.001; r=-.65, p <.001), respectively. Finally, marital intimacy had positive correlations with sexual function (r=.65, p<.001). These results are summarized in Table 3.
4. Evaluation of the Path Model
Our hypothetical path model was constructed based on a conceptual link among menopause symptoms, depression, marital intimacy, and sexual function (Figure 1). The theoretical path model suggested in this study exhibited a strong alignment with the data obtained. The x2 was not significant (x2/df=0.35, p=.557), which indicated that the model did not differ significantly from the data and a fit of model was supported. The goodness-of-fit test results showed GFI, AGFI, SRMR, NFI, CFI, and RMSEA values of .99, .99, .01, .99, 1.00, and .00, respectively. The SRMR and RMSEA should be less than .05, and the GFI, AGFI, NFI, and CFI should be at least .90. Although these fit indices indicate that the model fits well with the sample data, the excessively high values suggest the possibility of overfitting to the sample. Therefore, to improve the generalizability of the results, the researchers conducted a cross-validation analysis to further validate the model's fit. First, the collected sample (n=308) was randomly divided into an estimation sample and a validation sample, and cross-validation was performed using a multi-group analysis method to assess cross-validation. In the uncon-strained model, the x2 value was 0.69 with 2 df and the p-value was .709. Additionally, in the structural weights, structural covariances, and structural residuals models, all p-values were greater than .05, indicating that the model remained well-suited to both groups even with added constraints. Furthermore, all fit indices supported the model's goodness of fit (GFI, AGFI, SRMR, NFI, CFI, and RMSEA values of .99, .99, .01, .99, 1.00, and .00, respectively). It can be concluded that cross-validation was achieved.
The standardized estimates for the direct, indirect, and total impacts of exogenous factors on endogenous factors, as well as the squared multiple correlation (SMC) values for the path model, are presented in Table 4. Menopause symptoms (β=-.36, p=.001), depression (β=-.25, p=.001), and marital intimacy (β=.41, p =.001) had a significant direct effect on sexual function. In addition, Menopause symptoms were found to have a direct effect on depression (β=.51, p=.001), and depression was found to have a direct effect on marital intimacy (β=-.53, p=.001). Menopause symptoms had both indirect and total effects on marital intimacy (β=-.27, p<.001; β=-.27, p<.001). Moreover, menopause symptoms (β=-.24, p=.001; β=-.60, p=.001) and depression (β=-.22, p=.001; β=-.47, p=.001) each demonstrated indirect and total effects on sexual function. These findings suggest that depression and marital intimacy mediate the relationship between menopause symptoms and sexual function. The total variance in sexual function, as indicated by the SMC, was explained by menopausal symptoms, depression, and marital intimacy, accounting for approximately 64%
Table 4.
Standard Direct, Indirect and Total Effect and Squared Multiple Correlation of Variables on Sexual Function (N=308)
DISCUSSION
Sexual dysfunction has emerged as a significant issue affecting the quality of life, mental health, and interpersonal relationships of women, particularly during menopause [31]. This study aimed to establish a foundation for developing nursing interventions to reduce sexual dysfunction in middle-aged women with hypertension ex-periencing menopause. By examining both direct and indirect relationships among factors such as menopausal symptoms, depression, and marital intimacy, this study confirmed that menopausal symptoms directly impact sexual function and explain 64% of the variation in sexual function outcomes mediated by depression and marital intimacy.
The FSFI (Female Sexual Function Index), used to assess sexual function in this study, proved to be a suitable tool for evaluating postmenopausal women [10]. Women who had not undergone hormone replacement therapy were classified as having Female Sexual Dysfunction (FSD) if their FSFI score was 14.1 or lower, with 65.3% of the sub-jects meeting this criterion [30]. These findings are consistent with international studies, where 69.73% of women not using hormone replacement therapy reported sexual dysfunction [9]. Additionally, other studies have demonstrated an increased prevalence of sexual dysfunction among menopausal women not receiving hormone replacement therapy, with rates ranging from 55% in women aged 40 to 45 to 82.8% in those aged 52 to 55[32]. Based on the lower reference score observed in this study, future research should focus on the subgroup of postmenopausal women not undergoing hormone therapy to better understand their unique challenges. In this study, the average sexual function score was 17.31, which aligns with scores from late-menopausal married women [18] but is lower than the 19.49 reported in studies of women in the menopausal transition [33]. This emphasizes the need to examine changes in sexual function from the premenopausal to postmenopausal stages. Moreover, in this study, sexual function scores were lowest in the arousal subdomain, while pain scored the highest. These findings are consistent with previous studies using the same measurement tools [16]. Cardiovascular issues, particularly hypertension, were associated with increased sexual dysfunction in terms of lubrication, orgasm, sexual satisfaction, and pain [4]. Women with hypertension were 2.7 times more likely to experience sexual dysfunction than their non-hyper-tensive counterparts [13], highlighting the need for future research on sexual dysfunction in relation to chronic diseases in middle-aged women. This study also revealed significant direct, indirect, and total effects of menopausal symptoms on sexual function, consistent with previous research [7,31].
A relationship between sexual dysfunction and urogenital symptoms has been well documented [31]. Given that the participants in this study were menopausal women with hypertension who were not receiving hormone replacement therapy, future studies should compare sexual function in women with and without hormone replacement therapy. Depression was also found to have significant direct and indirect effects on sexual function, with findings supported by Heidari's systematic review [4], which indicated that mental and emotional depression significantly affects sexual dysfunction. Pérez-Herrezuelo's study [31] similarly demonstrated that more severe depression correlates with worse sexual function. Marital intimacy was also found to have a significant direct and total effect on sexual function, reinforcing the findings of other studies showing the importance of marital intimacy in maintaining sexual health [7]. This research suggests that improving couple dynamics is crucial for enhancing sexual function [4]. Therefore, any program designed to improve sexual function in middle-aged women should include components that address marital intimacy. Menopausal symptoms that are associated with depression have a substantial impact on sexual function, both directly and indirectly, by reducing marital intimacy. This aligns with previous research [4,5], which has shown that depression can impair both emotional and physical intimacy between partners, leading to increased sexual dysfunction. Higher levels of marital intimacy, on the other hand, have been shown to mitigate the negative effects of depression on sexual function [5,7]. Therefore, addressing both depression and marital intimacy is crucial for improving sexual health in postmenopausal women.
In this study, menopausal symptoms had the strongest total effect on sexual function, both directly and indirectly, through their impact on depression and marital intimacy. These findings are consistent with Hong's study [34], which showed that menopausal symptoms indirectly af-fected sexual function by mediating psychosocial variables like depression. Previous studies have also demonstrated that the severity of menopausal symptoms in mid-dle-aged women is positively correlated with higher levels of depression [15]. Furthermore, research [5] has shown that as depression worsens, marital intimacy decreases, leading to increased sexual dysfunction, particularly in married women in late menopause, regardless of sexual activity [5].
This study provides essential data for developing sex-related counseling and nursing interventions by identifying the causal relationships between menopausal symptoms, depression, marital intimacy, and sexual function. Severe menopausal symptoms relate to depression, which negatively impacts sexual function. Moreover, depression relates to decreased marital intimacy, further affecting negatively sexual function. The use of a path diagram in this study allowed for a precise visualization of the relationships between variables, enabling an in-depth analy-sis of the causal mechanisms. Based on these findings, new interventions focused on individual and marital-cen-tered approaches should be developed to enhance sexual function, alleviate menopausal symptoms, and improve both depression and marital intimacy, ultimately improving the quality of life for middle-aged women with hypertension in menopause. Future research should apply the biopsychosocial model to gain a more nuanced understanding of the complex dynamics influencing sexual function in postmenopausal women with hypertension not receiving hormone replacement therapy. According to the systematic review by Carcelén-Fraile et al. [35], various exercise programs significantly improve the cardiovascular autonomic system in postmenopausal women. The study highlights that exercise alone has a positive impact on the effects of menopausal symptoms on quality of life, as well as on psychological health and depression. Based on these findings, there is a need to develop integrated programs that incorporate both physical and mental health. Furthermore, future research should adopt a comprehensive approach using the biopsychosocial model, addressing the physical, psychological, and relational aspects of sexual function improvement in postmenopausal women with hypertension.
CONCLUSION
This study contributes to the understanding of sexual function in middle-aged menopausal women, particularly in the context of Korean culture, where discussing sexual dysfunction remains somewhat taboo. This study has sev-eral limitations. First, the sample was restricted to women who were not undergoing hormone therapy and had hypertension, which should be considered when interpreting the findings. Future studies could broaden the sample to enhance generalizability. Second, the sample size of 308 generally meets the criterion for bootstrapping; however, this may result in wider confidence intervals, potentially limiting interpretation and generalizability. Thus, results should be interpreted with these sample size characteristics in mind. Additional samples or alternative analytical methods in future research could improve reliability and generalizability. Third, model fit indices such as RMSEA, CFI, NFI, and GFI were very high, indicating a strong fit but also suggesting potential overfitting to this specific sample. Overfitting can limit the model's applicability to new data, implying that these findings may not extend to other populations. Future research should consider cross-validation or an independent validation sample to improve the generalizability of the model's fit in other contexts.
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