Title: Fatigue Have Impact on the Sexual Problems in Chinese Females with Systemic Lupus
Erythematosus
Version: 1 Date: 13 May 2022
Reviewer's report:
The Ms entitled "Fatigue Have Impact on the Sexual Dysfunction in Chinese Females with
Systemic Lupus Erythematosus" is aimed at investigating the effects of Systemic Lupus
Erythematosus (SLE) on female patients’ sexual function compared with healthy subjects and
to investigate the relationship among fatigue, disease parameters, depression, quality of life and
sexual function in  female patients with SLE.  The MS deals with a very interesting topic, but
several issues need to be raised and solved before publication. My main points are as follows:
-The authors intended to show that the prevalence of female sexual dysfunction (FSD) was
higher in SLE (rougly 70%) patients than the controls (56.7%) . However the authors designed
a study aimed at assessing sexual dysfunction without considering the sexual distress. The only
use of FSFI  questionnaire is not sufficient for investigating and making a diagnosis of sexual
dysfunction. If Sexual Distress questionnaire score is not available they should revise the entire
MS by removing the words "sexual dysfunction" and using "FSFI score"
- Another major concern is related to the fact that control are not age-matched (the authors stated
that "A total of 121 convenience sample of women employees aged 18 years were recruited
in 2020–2021". The mean age of SLE patients was roughly 43 years. However, in the results
section and table 1 they reported that age was not different abetween the two groups.
- Another concern is related to Figure 1 , which was without any statistical data . Apparently and
looking at the SD or SEM (no reference in the figure legend) it seems that the two subscale are not
so different among the two groups. Most probably the authors should use an appropriate Y-axis
range to appreciate differences and add statistical significance in the figure when appropriate.
- Fatigue (one of the main  outcome of the study) was not significantly associated to FSFI score.
The authors should clearly state whether they investigate this association and was not significant.
If so they should discuss on this negative finding.
-Another important issue is related to the lack of blood androgens assessment. Indeed previous
study clearly showed that serum levels of testosterone and DHEA-S were significantly lower in
SLE patients than control (Front Immunol
. 2020 Jun 23;11:1271. doi: 10.3389/fimmu.2020.01271. eCollection 2020). The authors should
recognize this important limitation.
- In the same line the authors should spend a part of the discussion in emphasizing
the role of sex steroid in modulating anti-inflammatory response not only in male (J
Endocrinol. 2012 Jan;212(1):71-84. doi: 10.1530/JOE-11-0289. Epub 2011 Oct 18; Prostate.
2013 Jun;73(8):789-800. doi: 10.1002/pros.22623. Epub 2012 Nov 28; J Endocrinol. 2012
Jul;214(1):31-43. doi: 10.1530/JOE-12-0142. Epub 2012 May 4) but also  in the female
counterpart (J Mol Endocrinol. 2020 Oct;65(3):109-124. doi: 10.1530/JME-20-0147).
-The authors should emphasize also a potential role of low androgen in fatigue (Cancer. 2021
May 1;127(9):1371-1373. doi: 10.1002/cncr.33398. Epub 2020 Dec 30; Front Cell Dev Biol.
2021 May 17;9:642307. doi: 10.3389/fcell.2021.642307. eCollection 2021).
- The authors should refer also to Important evidence on the role of low androgen in female
sexual dysfunction (J Sex Med. 2022 Apr;19(4):553-568. doi: 10.1016/j.jsxm.2022.01.515.
Epub 2022 Feb 25)
- Also referring to potential testosterone treatment for this kind of patients ( J Sex Med.
2021 May;18(5):849-867. doi: 10.1016/j.jsxm.2020.10.009. Epub 2021 Apr 1; Climacteric.
2021 Dec;24(6):533-550. doi: 10.1080/13697137.2021.1891773. Epub 2021 Apr 1; Menopause,
2018, 25(7), pp. 837–847), also reporting that a GLOBAL CONSENSUS STATEMENT has
recommended the treatment with testosterone in patients with sexula concerns (Journal of
Clinical Endocrinology and Metabolism, 2019, 104(10), pp. 4660–4666)
-Therefore low androgen level could be the underinvestigated link between sexual function
impairment /fatigue and SLE. and Testosterone treatment could be a therapeutic option. These
missed mechanisms and concepts  should be discussed.