Alessandra Graziottin

Libido: the biologic scenario

Libido is a comprehensive and yet elusive word that indicates basic human mental states--and their biological counterparts--involved in the beginning of sexual behavior. It has three main roots: biological, motivational-affective and cognitive. All these dimensions may be variably affected in the post menopause, contributing to a progressive decrease of sexual drive that parallels the process of aging. Loss of estrogens and, specifically, of androgens deprives female libido of major biological fuel. The effect of this loss is pervading, affecting the central nervous system, the sensory organs that are the major windows to environmental sexual stimuli and the quality of sexual response, central, peripheral non-genital and genital. Prolactin increase may further inhibit libido. Arousal disorders, dyspareunia, orgasmic difficulties, dissatisfaction, both physical and emotional, may contribute to a secondary loss of libido. Depression, anxiety and chronic stress, may interfere with central and peripheral pathways of the sexual response, reducing the quality of sexual function mostly in its motivational root. Relational conflicts and/or marital delusions and partner-specific problems, erectile deficit first, may contribute to the fading of sexual drive in the post-menopausal years. Well tailored HRT, including androgens in selected cases, may reduce the biological causes of loss of libido. A comprehensive treatment requires a balanced evaluation between biological and psychodynamic factors.

Depression and the menopause: why antidepressants are not enough?

Background Gender differences, related to varying sexual hormone levels and hormone secretion patterns across the lifespan, contribute to womens vulnerability to mood disorders and major depression. Women are more prone than men to depression, from puberty onwards, with a specific exposure across the menopausal transition. However, controversy still exists in considering fluctuation/loss of estrogen as a specific aetiologic factor contributing to depression in perimenopause and beyond. Aims To briefly review the interaction between changes in menopausal hormone levels, mood disorders, associated neuropsychological co-morbidities and ageing, and to evaluate the currently available therapeutic options for perimenopausal mood disorders: (a) treatment of light to moderate mood disorders with hormonal therapy (HT); (b) treatment of major depression with antidepressants; (c) the synergistic effect between HT and antidepressants in treating menopausal depression. Results Depression across the menopause has a multifactorial aetiology. Predictive factors include: previous depressive episodes such as premenstrual syndrome and/or postpartum depression; co-morbidity with major menopausal symptoms, especially hot flashes, nocturnal sweating, insomnia; menopause not treated with HT; major existential stress; elevated body mass index; low socioeconomic level and ethnicity. Postmenopausal depression is more severe, has a more insidious course, is more resistant to conventional antidepressants in comparison with premenopausal women and has better outcomes when antidepressants are combined with HT. Conclusion The current evidence contributes to a re-reading of the relationship between menopause and depression. The combination of the antidepressant with HT seems to offer the best therapeutic potential in terms of efficacy, rapidity of improvement and consistency of remission in the follow-up.

Aetiology, diagnostic algorithms and prognosis of female sexual dysfunction.

OBJECTIVEnThe aim of this paper is to describe the aetiology, diagnosis and prognosis of female sexual dysfunction (FSD), so as to increase the physicians competence in the management of women with these problems.nnnMETHODnA literature review of the most relevant publications was undertaken evaluating each sexual dysfunction.nnnRESULTSnThe aetiology of FSD is multifactorial. The most important causes include biological, psychosexual and contextual factors. When assessing FSD, the clinical history should assess if: (a) the disorder is generalized or situational; (b) the disorder is lifelong or acquired after months or years of satisfying sexual intercourse; (c) the level of distress is mild, moderate, or severe in terms of the impact of FSD on personal life; and (d) the leading aetiologies. To diagnose a sexual dysfunction, it is crucial to ask specifically about sexual function and avoid a collusion of silence that is all too common. A structured clinical history, selected investigations and physical examination are fundamental to diagnosis.nnnCONCLUSIONSnA structured multidisciplinary, integrative approach is fundamental to the evaluation and management of FSD.

Cardioprotective effects of ovarian hormones and the HERS in perspective

The increased population of women in menopause living in the industrialized countries is associated with an increase of diseases which are dependent or facilitated by a state of estrogen deficiency such as cardiovascular and cerebrovascular diseases. Several studies have shown that estrogen replacement therapy reduces the occurrence of coronary and may be of cerebrovascular disease by nearly 50% in treated women compared to non-users. These findings are supported by the evidence that estrogens have a beneficial effect on cholesterol metabolism and deposition, contributing to the inhibition of atherosclerotic plaque formation in arterial walls as well as a direct effect on the vessel wall. Progestins may, in some cases, counteract the beneficial effect of estrogens upon cardiovascular functions. More androgenic progestins may have a detrimental effect upon vascular reactivity while less androgenic progestins seem not to reduce the beneficial effect of estrogens. Of interest, continuous combined administration of hormone replacement therapy seem to be preferable for women with coronary artery disease or for those with increased cardiovascular risk. Case-control and cohort studies have shown that estrogen progestin therapy is associated with a significant reduction of cardiovascular mortality and morbidity. The HERS study has added critical data regarding the cardioprotective effect of hormone replacement therapy in elderly women with proven coronary artery disease. Because of the several methodological and statistical flaws of the HERS study, further studies are warranted to evaluate the effect of hormone replacement therapy on cardiovascular prognosis. Large scale randomized studies will evaluate the effect of estrogen and estrogen-progestin replacement therapy upon cardiovascular events in menopausal women. Until completion of these studies hormone replacement therapy in women with increased cardiovascular risk should be seen with no enthusiasm but also with no fear.

Sexual Rehabilitation After Gynaecological Cancers

Women’s quality of sexual life is an urgent issue in gynecological oncology. The multifactorial etiology of gynecological cancers (GC) and the increasing prevalence of such cancers at younger ages require a comprehensive medical and psychosexual perspective, even more so when sexual rehabilitation is the ultimate goal. The high rate of long-term survival makes GC more of a chronic than a fatal disease. Premature iatrogenic menopause is an important factor to be considered.

Patient scenario: a 53-year-old woman with hypoactive sexual desire disorder.

OBJECTIVEnTo provide an expert review of the clinical management of hypoactive sexual desire disorder.nnnMETHODnThe importance of diagnosing and providing therapeutic management for hypoactive sexual desire disorder will be explained with a case scenario which is resolved by drawing on original trial publications and meta-analyses published in English.nnnRESULTSnHypoactive sexual desire disorder (HSDD) is highly prevalent (9-16%) and has a strong impact on the quality of life of both women and their partners. Medical and sexual history, physical and laboratory examinations as well as validated questionnaires will help us make an accurate diagnosis. Treatment should begin by focusing on lifestyle and psychosexual therapy. Women randomized to oestrogen-testosterone transdermal patch combination or testosterone transdermal patch alone reported significantly increased frequency of satisfying sexual activity (p<0.05). Hormonal treatment with oestrogen and testosterone or with testosterone alone should be personalized, as should follow-up.nnnCONCLUSIONSnGuidelines for the medical management of hypoactive sexual desire disorder are now available and this starts by understanding the importance of this disorder and knowing that accurate diagnosis and treatment options exist.

Medical Treatments for Sexual Problems in Women

Cancer today is more of a chronic than a fatal disease: the improving survival rates increase the likelihood of long survival after the diagnosis. Unfortunately, cancer treatment is the most frequent cause of premature iatrogenic menopause and psychosexual dysfunction. Therefore, an increasing number of cancer survivors have to cope with both the consequences of cancer treatment per se, the complex physical and psychological changes secondary to a premature iatrogenic menopause, and the burden of sexual dysfunctions, more difficult to accept in the youngest patients. Female sexual identity may be variably affected by a cancer diagnosis and treatment depending on the age at diagnosis (and the age at the time of any recurrences). Age is the first biological factor that may modify the outcome of cancer diagnosis and treatment, when sexuality is considered as an independent variable in the quality of life (QOL) evaluation. The impact of cancer is increasingly worse in younger patients, especially if radical surgery, adjuvant systemic chemotherapy, and/or local radiotherapy further reduce the biological chances of a fulfilling sexual and procreative life.