Female genital lichen sclerosus is connected with a higher depression rate, decreased sexual quality of life and diminished work productivity

Lichen sclerosus (LS) is a chronic, distressing skin condition characterised by relapses and remissions. The pathogenesis of LS is still not clear. The symptoms of the disease include itching, burning, sexual dysfunctions, pain during voiding or defecation and may lead to decreased quality of life. The disease is diagnosed in men and women of all ages, with the highest prevalence in postmenopausal women, reaching up to 3% of this population [ 1 ]. However, recent studies suggest that the true incidence of LS in younger women is underestimated [ 2 , 3 ]. The disease usually affects anogenital region, in 15–20% of cases extragenital area is involved [ 4 , 5 ]. About 6% of patients present only with extragenital lesions [ 6 ]. Due to the frequent involvement of genital organs there are some reports about impaired quality of sexual life in LS patients [ 7 – 11 ]. Additionally, skin diseases were associated with increased self-disgust, which to a greater extent was experienced by females [ 12 ]. Furthermore, the sexual needs of women and professional career aspects are often neglected. Therefore the aim of this retrospective case-control study was to assess the influence of female genital LS on sexual satisfaction, screen for depressive disorder and determine whether LS is connected with diminished productivity in the workplace.

Fifty-one women filled out the WPAI:GH questionnaire. Seven of the participants were not professionally active. There were 3 pensioners, 2 students and 2 women who did not work due to unknown reasons. The influence of lichen sclerosus on work activity was further analysed in the remaining 44 employed women. During the last 7 days the disease caused excused absence from work in 7 people (16%). One person did not work due to depression and was qualified for rehabilitation allowance. Other 6 women (15%) were on sick leave which lasted from 1 to 24 hours during the last 7 days, with the median duration of 10.5 hours. Moreover 20 women (45%) during past week took the vacation leave which lasted for 2–56 hours, reaching 18.8 hours on average. The working time during past week ranged from 0 to 55 hours, approximately 25.5 h. Twenty eight women (64%) claimed that health problems impaired theirs work (≥2 points). The influence of the disease on work activity was assessed as moderate (5-7/10 points) in 10 individuals (23%) and significant (8-10/10 points) in 4 women (9%). Fig 2 Regarding the impact of the disease on daily activities 11 women (25%) determined it as moderate (5-7/10 points) and 7 (16%) as significant (8-10/10 points). Mean percentages for absenteeism and presenteeism were 5.32% and 31.35%, respectively. The total work productivity loss was established as 36.67%. The influence of the disease on work productivity of 44 professionally active females with genital LS based on question No. 5 from WPAI:GH questionnaire. The median PHQ-9 score was 10 (IQR = 10) points in the study group and 6 (IQR = 5) points in the control group (p = 0.0006). Twenty seven women from the study group (53%) and 7 (16%) from the control group had a score ≥10 points (p = 0.0001). Using the alternative ‘diagnostic algorithm’ the results indicated that 15/51 (29%) women with LS and 2/45 (4%) controls could suffer from major depressive syndrome (MDS) (p = 0.0034). Moreover 9/51 (18%) females from the study group and 4/45 (9%) controls fulfilled the criteria of other depressive syndrome (ODS) (p = 0.3408) [ 14 , 19 ]. The prevalence rate of depressive disorder based on PHQ-9 was altogether 47% in the study group and 13% in the control group (p = 0.0004) Table 1 . Comparison of the median value of the Patient Health Questionnaire-9 (p = 0.0006), frequency of major depressive syndrome (p = 0.0034), other depressive syndrome (p = 0.3408) and depressive disorder based on Patient Health Questionnaire-9 in the study and control group. In our study 51 female patients with LS and 45 healthy women filled out the online SQoL-F questionnaire. The median of the total score was 47 (IQR = 13) points in the study and 79 (IQR = 13) points in the control group (p = <0.0001). The median score obtained in each of four factors ‘psychosexual feelings’, ‘sexual and relationship satisfaction’, ‘self-worthlessness’, ‘sexual repression’ was 13, 19, 7, 6 points in women with genital LS and 36, 11, 16, 16 points in controls, respectively (p<0.0001 for all four factors) Fig 3 . Comparison of the median value of the Sexual Quality of Life-Female Questionnaire results in the study and control group (p<0.0001).

The results of our study showed that not only the sexual quality of life is diminished in women with genital LS, but also the disease may be connected with a higher rate of depression and a negative influence on work. Thus, it is our role as medical practitioners to offer multidisciplinary care to every woman with genital LS because its physical and psychological aspects are strongly related. Work productivity may improve with the better control of the disease and a higher self-esteem.

Between January and December 2021 an online survey including: Work Productivity and Activity Impairment: General Health (WPAI:GH), Patient Health Questionnaire-9 (PHQ-9), The Sexual Quality of Life-Female (SQOL-F) questionnaires was conducted [ 13 – 15 ]. Fifty-one adult female patients with genital LS, filled out an online questionnaire and were enrolled in the study group. Also demographic and clinical data: age, place of residence, professional activity, previous and current treatment, was collected. The diagnosis of LS was set clinically by the doctor, based on characteristic features of skin lesions and concomitant symptoms. In a few cases it was additionally confirmed by a skin biopsy. Thirty women declared to be using topical corticosteroids, 4 of whom only milder potency ones, 6 applied calcineurin inhibitors, 16 mentioned using other treatment options (e.g. photodynamic therapy, laser, platelet rich plasma), 3 did not use any form of treatment. The corresponding control group consisted of 45 healthy women with a similar demographic status (p>0.05). Fig 1 The study was exempt from research ethics review by the formal opinion of the Bioethics Committee of the Medical University of Lodz (No. RNN/282/22/KE). Written informed consent was obtained from all participants of the study. Characteristics of the study and control group (p>0.05). Patient Health Questionnaire-9 (PHQ-9)–a validated screening tool for diagnosing and measuring the severity of depression—was performed in the study and control groups [ 14 ]. As a screening method for major depression the cut-off score was established at 10 points [ 16 – 18 ]. Using an alternative ‘diagnostic algorithm’ major depressive syndrome (MDS) and other depressive syndrome (ODS) can be detected. In MDS five items, whereas in ODS two, three or four items from PHQ-9, have to be scored for 2 points or more. Additionally, to fulfil the alternative criteria of MDS and ODS one of these items should concern depressed mood or anhedonia [ 14 ]. Sexual Quality of Life Questionnaire-Female is a psychomteric instrument developed by Symonds et al. which aims to measure the influence of sexual dysfunctions on the quality of women’s sexual life [ 15 ]. It is composed of 18 questions with a 6-point rating scale each. The total score ranges between 18–108 points. The cut-off indicating adequate sexual quality of life is not determined. The higher the score, the better the quality of sexual life. Four factors concerning four different aspects of sexual life can be distinguished: psychosexual feelings (seven items), sexual and relationship satisfaction (five items), self-worthlessness (three items), sexual repression (three items). Statistical analysis using the Mann Whitney U test and Chi-squared test was performed. A p-value ≤ 0.05 was considered statistically significant.