The researcher protected the rights of the samples of this study from the beginning of data collection. Before collecting data, the researcher sent all documents and asked for permission to study from the Human Research Ethics Committee of the Faculty of Medicine from the university hospital before conducting research. The research was approved by the committee with document number 2021/492, 16 June 2021.

After cleaning the data, the researcher analyzed it using the SPSS/PC (Statistical Package for the Social Science Personal Computer IBM SPSS Statistics Version 21, IBM Corp., Armonk, NY, USA) program using a significance level of 0.05. The details were as follows:

1. Personal information and health status were analyzed by descriptive statistics: frequency distribution, percentage, mean, and standard deviation.

2. Information about the sexual health of women with gynecological problems—data were analyzed by using descriptive statistics such as frequency distribution, percentage, mean, and standard deviation.

3. A comparison of the differences in mean scores on sexual health problems found in two independent sample groups. These two groups were women with gynecological problems who had pain and abnormal bleeding symptoms using the t-test for independent samples (unpaired t-test) with preliminary testing of agreement between the statistics. In the matter of the normal distribution of sexual health in women with gynecological problems (normality), the standard value (Z-score) was first calculated from the value of skewness (Skewness) by Z-score Skewness/SE_skewness, where the Z-value Scores with values between –1.96 and +1.96 were considered to have a normal curve distribution. In addition, the equality of variances between the two groups of data was tested using the F-test or Levene’s test first to choose the t-test with pooled variance (in the case of equal variance) or by using t-test statistics with separated variance (in the case of unequal variance). However, if the data were not normally distributed, differences between the two groups were tested using the Man and Whitney test (Mann-Whitney U test), which was utilized when data do not meet the assumptions.

Table 2 summarizes the personal data of the 140 participants. It shows an age range of 21 to 54 years, with a mean age of 36.9 years (standard deviation (SD) = 8.1), with 38.6% of participants over the age of 40. The vast majority of participants (93.6%) were Buddhist. Most graduated with a bachelor’s degree or higher (63.6%). The average duration of marriage was 9.1 years (SD = 7.0), and half of them had no children.

Table 3 summarizes the health status information. It was found that 50 participants had normal menstruation, including 3 who were in their menopausal period. A further 4 participants were amenorrhoeic due to having received hormone treatment. Abnormal menstruation was reported by 64.3% of participants. The mean score of pain associated with dysmenorrhea was 5.8 (SD = 2.4); chronic pelvic pain (5.4, SD = 1.9); dyspareunia (4.6, SD = 1.5). A total of 35.7% of participants had paleness/fatigue, and nearly a half of them were diagnosed with endometriosis.

The study indicated that the participants had an average overall sexual health score of 37.3 (SD = 12.1), with a possible range of 0–114. Just over half (54.3%) had mild sexual problems, and 45.7% had moderate sexual problems.

When considering sexual health problems in the physical aspects, it was found that most respondents (77.2%; mean = 13.3, SD = 3.5) had moderate problems with sexual desire. With respect to sexual arousal, 49.3% (mean = 6.2, SD = 2.8) reported moderate sexual problems. Just over half (50.7%; mean = 5.8, SD = 2.8) reported mild problems achieving sexual orgasm, and 58.6% (mean = 2.2, SD = 1.8) reported mild problems with pain during sexual intercourse.

The other two aspects are the psychological and social aspects. Most women with gynecological problems had mild problems with these psychological and social aspects (73.6%; mean = 7.3, SD = 3.8). Mild problems were also reported with respect to the relationship and love aspect (47.1%; mean = 2.5, SD = 2.9), as shown in Table 4.

The study found that women with abnormal uterine bleeding had a mean score for overall sexual health problems of 38.1 (SD = 11.9), which was not different from the asymptomatic group (mean = 35.8, SD = 12.4) at p = 0.290. It was also found that there was no significant difference for physical, psychological and social, and relationship and love aspects, at the 0.05 level, as shown in Table 5.

For those suffering from dysmenorrhea, 3 participants were in menopause, and 4 participants were amenorrhoeic following receipt of hormones. The study found that women with moderate to severe dysmenorrhea had a mean score of overall sexual health problems of 37.9 (SD = 11.9), which was not different from those reporting none to mild dysmenorrhea (mean = 36.1, SD = 12.6) with p = 0.393. Further, no significant differences were found between women with no to mild dysmenorrhea and those with moderate to severe dysmenorrhea with respect to physical, psychological and social, and relationship and love aspects, as shown in Table 6.

The study found that women with chronic pelvic pain had an overall sexual health mean score of 39.3 (SD = 12.3). Meanwhile, the mean overall score of sexual health for women without symptom was 36.1 (SD = 11.9). There was not a significant difference between the 2 groups at p = 0.128. By aspect, it was found that physical, psychological and social, and relationships and love aspects had no significant difference, as shown in Table 7.

When considering the effects of dyspareunia, with respect to overall sexual health problems (p 0.000), sexual desire (p = 0.005), achieving sexual orgasm (p = 0.011), pain during sexual intercourse (p 0.000), and the psychological and social aspects (p = 0.011), there were significant differences between women who had dyspareunia and those who did not. However, the mean scores of the sexual arousal part and the relationship and love aspects did not exhibit significant differences between the two groups, as shown in Table 8.

The findings of the study make it clear that there were significant differences in the sexual health problems between women with paleness/fatigue and those without symptoms, specifically in the aspects of overall sexual health problems (p = 0.004), sexual desire (p = 0.016), sexual arousal (p = 0.027), and achieving sexual orgasm (p = 0.043). However, when considering pain during sexual intercourse, as well as psychological and social aspects, and in terms of the relationship and love aspect, no significant difference was found in relation to sexual health problems between women with paleness/fatigue and those without symptoms. Details are displayed in Table 9.

Women with gynecological problems who suffered from dyspareunia had a different mean score on sexual health regarding sexual desire (mean = 14.7, SD = 3.6) than women who did not (mean = 12.8, SD = 3.3) (p = 0.005). This is due to the fact that dyspareunia cannot cause sexual emotion until reaching climax during sexual intercourse. This finding is consistent with the study of Norinho et al. (2020) [9], in which it was found that 17.9 percent reported moderate to severe pain, and reported fear, anxiety, and avoidance of sexual intercourse. It was also mentioned that dyspareunia leads to sexual problems such as decreased sexual desire or no sexual desire. Dyspareunia has a significant impact on physical and mental well-being. It can lead to depression, anxiety, and being overly wary of pain. Bad experiences create painful memories of sex, resulting in decreased sexual desire or failure or inability to reach sexual climax. It is also consistent with the study of Taburee et al. [10] and the study of Ampaijit [11], each of which studied the quality of life in women after uterine and ovarian surgery combined with radiotherapy, and in women with cervical cancer. These women experienced side effects from various treatments, such as a narrowing of the vagina and pain, sexual problems, and decreased sexual desire. However, in this current study, we focused on women who have benign gynecological problems unrelated to surgery.

Women with gynecological problems experience dyspareunia. The mean sexual health score in terms of sexual arousal (mean = 6.9, SD = 3.4) was not different from the group without symptoms (mean = 6.0, SD = 2.5) (p = 0.136). This is because sexual arousal is a response that begins to occur when stimulated by touching parts of the body that are emotionally stimulating points; the activities that include this kind of touching include hugging, kissing, caressing, or touching the chest, neck, thighs, genitals, etc. It is also possible to be ‘caressed’ by an idea, or by hearing a sex partner speaking with sweet or loving words. All of these things cause sexual arousal [12, 13, 14].

For women with gynecological problems who experience dyspareunia, the mean sexual health score in terms of achieving sexual orgasm (mean = 6.8, SD = 2.7) was different from the group without symptoms (mean = 5.4, SD = 2.8) (p = 0.011). This can be explained in the same way as sexual desire. Dyspareunia mutes the desire to have sex and heightens feelings of anxiety throughout sexual intercourse up until climax is achieved. This finding is consistent with the studies of Thamwirach et al. [15] and Auejittaweechai [13], in which it was found that women who had dyspareunia did not achieve sexual orgasm due to adhesion resulting from conditions such as endometriosis; the discomfort leads to a decrease in sexual stimulation and, frequently, failure to reach sexual climax. Moreover, women who had symptoms may feel stressed and unable to relax while having sex, making it impossible to reach sexual climax [16, 17].

In addition, women with gynecological problems experiencing symptoms of paleness/fatigue had a different mean score regarding sexual desire (p = 0.016), sexual arousal (p = 0.027), and achieving sexual orgasm (p = 0.043) than women without paleness/fatigue. This is because their energy is affected and, as a result, they have low sexual desire, sexual arousal, and ability to achieve sexual orgasm. These women may need treatment and support from health care providers. However, it was surprising that there was no significant difference found between women who had chronic pelvic pain and who did not. The results were incongruent with other studies. This may be because more than half of the participants (87 participants, 62.1%) did not experience chronic pelvic pain, while only 53 participants (37.9%) did. Of these, 38 reported mild (9 participants) to moderate (29 participants) pain. There were only 15 participants who reported severe pain. This relatively small sample size might explain the lack of significant difference between groups. In addition, some of these participants were receiving some treatment and medication to relieve pain, which may have further minimized the differences between the groups [8].

Women with gynecological problems in the group who had dyspareunia had a different mean score on the psychological and social aspect (mean = 8.7, SD = 3.9) than those without symptoms (mean = 6.8, SD = 3.6), with statistical significance at the 0.05 level. This may be because women who experience pain each time they have sex experience feelings of stress, anxiety, and fear, especially if they are aware of their perceived role as a wife and worry their husbands becoming unfaithful. In some cases, they may continue to have sex in accordance with their husbands’ wishes even though they are reluctant because of the pain, which causes discomfort and confusion. This is consistent with the study of Seehusen et al. (2014) [18], in which it was found that dyspareunia in women is a condition that reoccurs or may occur every time they have sex. This can result in stress or conflict in relationships for these women, an outcome which was found in 10–20% of American women studied. This is an important problem that affects mental health, physical health, image, and relationship between spouses. Dyspareunia in women is a symptom that may occur each time or inconsistently. It can occur during or after penetrative sex, thereby causing fear or anxiety when anticipating deep penetration intercourse [19]. However, from the results indicate that there were no significant differences between women who had abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, or paleness/fatigue and those in the group without symptoms. This might be because the women have sufficient social support from their partners, especially in light of the long average duration of marriage (mean = 9.1 years, SD = 7.0). This may create a sense of understanding and support from their spouses.

Women with gynecological problems in the group who had experienced abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, dyspareunia, or paleness/fatigue had a mean score for sexual health problems that was not different from those in the group without symptoms, with a statistical significance at the 0.05 level (p $>$ 0.05). This may be due to the basis of married life even whether the woman has gynecological symptoms or not, the couple starts with love, which is usually expressed through concern, sympathy, and mutual care. This finding is consistent with the study of Tasripoo [20], which considered couples’ expressions of love. These expressions can make women feel closer to their husbands, and this may lead to greater sexual satisfaction in which the women’s sexual happiness can occur through intercourse. The finding is also consistent with the study of Poonyathalang [21], which found that women’s sexual happiness does not only come from having sex, but it also includes other forms of expression, such as expressions of emotion from embracing or kissing, showing love and concern, or talking about sex and sexual behavior. This is supported by the study by Prakobkit et al. [22], which found that women with cervical cancer, after treatment, experienced feelings of fear and pain when having sex for the first time after treatment ended. Yet, with the husband’s love and understanding, the fear and pain could be reduced when having sex. Women who are in good marital relationships and who receive support from their spouses are able to reduce the occurrence of sexual problems, and this can lead to sexual satisfaction [22, 23, 24, 25]. Therefore, there is no impact on sexual health, relationships and love, which is consistent with the study of Prakobkit et al. [22] and Wattanapansak et al. [25]. It was found that the results of breast cancer treatment and prostate cancer can cause sexual health problems, such as decreased libido or pain during intercourse. However, if a good relationship existed between the spouses before the treatment, they sympathized with each other and loved and understood each other. Expressing love in other ways, such as hugging, kissing on the cheek, and talking to encourage each other, etc., results in low levels of sexual health problems; consequently, no sexual health problems occur.

The results of the study show that women with gynecological problems had sexual health problems. Sexual health problems should be assessed in planning nursing care for women with gynecological problems. This assessment should cover all dimensions of sexual health, including reducing other abnormalities and various pains and promoting sexual health in women with gynecological problems. There should be health education about “knowledge of the disease and how to manage abnormal symptoms” in clinics. These activities would provide health care providers the requisite knowledge and ability to promote and support the prevention of sexual health problems both in women with gynecological problems and their spouses. Service points or counseling clinics should be opened for women and couples with sexual health problems. These clinics should be staffed by gynecological experts in sexual health.

There should be further research into factors related to sexual health in women with gynecological problems, such as frequency of sexual intercourse, relationship between spouses and the sexual health of married couples in women with gynecological problems, etc., to be used to develop guidelines for problem management. Different methods used for pain management should be studied, including the effects that occur when pain is managed, in order to provide guidelines for appropriate pain management in this group of patients. This area of research may be extended to include development of interventions to care for groups of patients with sexual health problems that match the relevant diseases and symptoms. There should be a study of sexual health in other problematic disease groups, including spouses of women with other diseases. In addition, there should be studies in the field of relationships, sexual intercourse, work, economy, and spouses of women with gynecological problems so that nursing care can cover all dimensions of sexual health.

This research utilized a descriptive and comparative study design which was conducted in one university hospital to study the sexual health of women with gynecological problems. Data was collected using a self-reporting questionnaire that was completed only by women who were sexually active with their partners. The results cannot be generalized to encompass the sexual health of all women with gynecological problems or other health problems. However, data used to analyze in this study had no missing. This is the strength of this study.