Andrew T. Goldstein

The Effects of Hormonal Contraceptives on Female Sexuality: A Review

INTRODUCTION Hormonal contraceptives can influence female sexual function. AIM The goal of this article was to provide a comprehensive review of the effects that various hormonal contraceptives may have on female sexual function. METHODS A Medline search was conducted using several terms related to and including the terms contraception, oral contraceptive, female sexual function, dyspareunia, libido, and sexual desire. RESULTS A thorough review of the effects of hormonal contraceptives on female sexual function. CONCLUSIONS The sexual side effects of hormonal contraceptives are not well studied, particularly with regard to impact on libido. There appears to be mixed effects on libido, with a small percentage of women experiencing an increase or a decrease, and the majority being unaffected. Healthcare providers must be aware that hormonal contraceptive can have negative effects on female sexuality so they can counsel and care for their patients appropriately.

A double-blind, randomized controlled trial of clobetasol versus pimecrolimus in patients with vulvar lichen sclerosus

BACKGROUND Lichen sclerosus (LS) is a lymphocyte-mediated chronic cutaneous disorder with a predilection for the vulva. The current gold standard treatment is topical ultrapotent corticosteroids such as clobetasol. OBJECTIVE We sought to compare the safety and efficacy of clobetasol and pimecrolimus in the treatment of vulvar LS. METHODS This double-blind, randomized trial enrolled 38 women with biopsy-proven vulvar LS. This study consisted of a 2-week screening period and a 12-week treatment period. The primary efficacy variable was the change in inflammation, as determined by a dermatopathologist, on the biopsy specimens obtained at screening and at the week 12 visit. Secondary efficacy variables included the change from baseline in pruritus and burning/pain as assessed by patients using a visual analog scale and a clinical evaluation by the investigator. RESULTS Clobetasol was found to be superior in improving inflammation when compared with pimecrolimus (P = .015). Both groups showed improvement in pruritus and burning/pain but this difference was not statistically significant (P = .32 and .93, respectively). Both clobetasol and pimecrolimus were found to be effective in decreasing both the total score on the Investigator Global Assessment (P = .001) and all 3 subscales. Serum levels of pimecrolimus and clobetasol did not approach levels of concern during the study period. No adverse events were reported. LIMITATIONS This study was limited by the relatively short study duration. CONCLUSION Both clobetasol and pimecrolimus appear efficacious and well tolerated for the treatment of vulvar LS; however, clobetasol is more effective than pimecrolimus and should remain first-line therapy for LS.

Vulvodynia: Definition, Prevalence, Impact, and Pathophysiological Factors

INTRODUCTION Vulvodynia constitutes a highly prevalent form of chronic genital pain in women, and current information regarding its definition, prevalence, impact, and pathophysiologic factors involved is needed. AIM To update the scientific evidence published in 2010 from the Third International Consultation of Sexual Medicine pertaining to the definition, prevalence, impact, and pathophysiologic factors of womens sexual pain. METHODS An expert committee, as part of the Fourth International Consultation of Sexual Medicine, comprised of researchers and clinicians from biological and social science disciplines, reviewed the scientific evidence on the definition, prevalence, impact, and pathophysiologic factors related to chronic genital pain. MAIN OUTCOME MEASURES A review of the definition, prevalence, impact, and pathophysiological factors involved in vulvodynia. RESULTS Vulvodynia is a prevalent and highly impactful genital pain condition. Numerous factors have been implicated in its development and maintenance. CONCLUSION What is becoming increasingly apparent is that it likely represents the end point of different factors that can differ from patient to patient. Longitudinal research is needed to shed light on risk factors involved in the expression of vulvodynia, as well as in potential subgroups of affected patients, in order to develop an empirically supported treatment algorithm.

Vulvodynia: Assessment and Treatment.

INTRODUCTION Vulvodynia constitutes a highly prevalent form of sexual pain in women, and current information regarding its assessment and treatment is needed. AIM To update the scientific evidence published in 2010, from the Third International Consultation on Sexual Medicine, pertaining to the assessment and treatment of womens sexual pain. METHODS An expert committee, as part of the Fourth International Consultation on Sexual Medicine, was comprised of researchers and clinicians from biological and social science disciplines for the review of the scientific evidence on the assessment and treatment of womens genital pain. MAIN OUTCOME MEASURES A review of assessment and treatment strategies involved in vulvodynia. RESULTS We recommend the following treatments for the management of vulvodynia: psychological interventions, pelvic floor physical therapy, and vestibulectomy (for provoked vestibulodynia). We also support the use of multidisciplinary treatment approaches for the management of vulvodynia; however, more studies are needed to determine which components are most important. We recommend waiting for more empirical evidence before recommending alternative treatment options, anti-inflammatory agents, hormonal agents, and anticonvulsant medications. Although we do not recommend lidocaine, topical corticosteroids, or antidepressant medication for the management of vulvodynia, we suggest that capsaicin, botulinum toxin, and interferon be considered second-line avenues and that their recommendation be revisited once further research is conducted. CONCLUSION A comprehensive assessment is needed to understand the pain experience of women presenting with vulvodynia. In addition, treatment typically progresses from less invasive to more invasive, and several treatment options are worth pursuing.

Management of female sexual problems: perceived barriers, practice patterns, and confidence among primary care physicians and gynecologists.

INTRODUCTION Although approximately 40% of women report female sexual problems--and particularly sexual desire disorders, there are numerous practical, professional, and personal barriers to their diagnosis and management by treating clinicians. AIM To identify practice patterns, perceptions, and barriers to the diagnosis and management of female sexual problems among U.S. practicing primary care physicians (PCPs) and obstetrician/gynecologists (OB/GYNs). METHODS A random sample of practicing U.S. PCPs and OB/GYNs were sent a case-vignette survey by e-mail and fax. Response to the survey was considered consent. A regression model was analyzed to assess predictors of confidence. MAIN OUTCOME MEASURE Frequency and variability in diagnostic tests ordered and treatment recommendations provided for a patient with diminished sexual desire. Percent of physicians who reported they were confident in treating hypoactive sexual desire disorder (HSDD) and percent who reported significant barriers to initiating a dialogue about sexual health with female patients. RESULTS A total of 505 responses were analyzed (8.8% response rate). Of respondents, 21% of OB/GYNs and 38% of PCPs stated they were not at all confident in treating HSDD. The majority of physicians would order a thyroid panel (PCP = 63%, OB/GYN = 53%) to assess a patients diminished desire and recommended counseling and stress management to treat a patient with sexual complaints (PCP = 48%, OB/GYN = 54%). Regression results identified time constraints, the perceived lack of effective therapies, perceptions regarding patient-physician gender discordance, years in practice, number of patients seen per week, and perceptions regarding continuing medical education and practice experience as significant and independent predictors of confidence in treating HSDD patients.

Polymorphisms of the Androgen Receptor Gene and Hormonal Contraceptive Induced Provoked Vestibulodynia

AIM Women who developed vestibulodynia (vulvar vestibulitis) while taking combined hormonal contraceptives (CHCs) and a control group of women were tested for polymorphisms of the gene coding for the androgen receptor (AR) that is located on the X chromosome. STUDY DESIGN DNA from 30 women who developed vestibulodynia while taking CHCs and 17 control women were tested for the number of cytosine-adenine-guanine (CAG) trinucleotide repeats in the AR. In addition, serum-free testosterone was tested in both groups. RESULTS The mean number of CAG repeats in the study group was significantly greater than the control group (22.05 ± 2.98 vs. 20.61 ± 2.19, respectively; P = 0.025). This significant difference persisted when analyzing the CAG repeats from the longer allele from each subject. Among those who were taking drospirenone-containing CHCs, the mean calculated free testosterone was 0.189 ± 0.115 ng/dL in the study group and 0.127 ± 0.054 ng/dL in the control group, all of whom were taking drospirenone-containing CHCs (P = 0.042). CONCLUSION In the study cohort, women who developed vestibulodynia while taking CHCs are more likely to have longer CAG repeats in the AR than women who took the same type of CHC but did not develop vestibulodynia. We speculate that the risk of developing CHC-induced vestibulodynia may be due to lowered free testosterone combined with an inefficient AR that predisposes women to vestibular pain.

The Treatment of Vestibulodynia with Topical Estradiol and Testosterone

Introduction Combined hormonal contraceptives (CHCs) use is becoming an increasingly recognized causes of vestibulodynia. Aim This study aims to describe pre- and posttreatment vestibular pain, sex hormone binding globulin (SHBG), and calculated free testosterone levels in women undergoing treatment for vestibulodynia. Methods This was a chart review of 50 premenopausal women who presented with vestibular pain while currently using CHCs. Pre- and posttreatment vestibular pain, SHBG, and calculated free testosterone levels were assessed. Results There was a statistically significant improvement in posttreatment vestibular pain scores (P = 0.001), SHBG (P = 0.001), and calculated free testosterone (P = 0.001) levels from baseline. Conclusion Women with vestibulodynia that began while on CHC may effectively be treated by discontinuing the CHC combined with the application topical hormone therapy. Symptomatic improvement is accompanied by normalization of calculated free testosterone and SHBG values. Burrows LJ and Goldstein AT. The treatment of vestibulodynia with topical estradiol and testosterone. Sex Med 2013;1:30–33.

Can oral contraceptives cause vestibulodynia

AIM To describe the clinical course of a young woman who developed vestibulodynia with introital dyspareunia while on oral contraceptive (OCs) and to provide a possible explanation for the etiology of her symptoms as well as her recovery after treatment. METHODS A single case is presented including subjective reporting, laboratory evaluation, and quantitative sensory testing. RESULTS After topical hormonal therapy, the patient reported resolution of her dyspareunia and and her laboratory values normalized.

The Treatment of Vulvar Lichen Sclerosus and Female Sexual Dysfunction

INTRODUCTION Women with lichen sclerosus (LS) are more likely to have dyspareunia, decreased orgasm, and decreased coital frequency as compared to unaffected women. It is unknown whether standard medical therapy to treat LS results in improved sexual functioning. AIMS To describe sexual function in women with LS and to assess if LS-associated sexual dysfunction decreases after appropriate medical therapy. METHODS Women enrolled in a double-blind trial 12-week trial comparing clobetasol vs. pimecrolimus for the treatment of LS were administered the Female Sexual Distress Scale (FSDS) upon enrollment and at the end of the trial. The difference in the total score on the FSDS between the two groups before and after treatment was assessed with a paired t-test. MAIN OUTCOME MEASURES The change in mean FSDS score from baseline to 12 weeks. RESULTS A total of 31 out of 36 enrolled women had adequate treatment of LS as determined by a dermatopathologists evaluation of pre and post-treatment biopsy specimens. The mean baseline FSDS score for the clobetasol group was 29 and, post-treatment, it was 15 (P=0.001). In the pimecrolimus group, the mean baseline FSDS score was 27 and, post-treatment, it was 21 (P=0.001). CONCLUSIONS Despite adequate treatment, women with LS continue to have significant sexual dysfunction as assessed by the FSDS.

2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia.

IntroductionIn 2014, the executive council of the International Society for the Study of Vulvovaginal Disease, the boards of directors of the International Society for the Study of Womens Sexual Health, and the International Pelvic Pain Society acknowledged the need to revise the current terminology of vulvar pain, on the basis of the significant increase in high-quality etiologic studies published in the last decade. Materials and MethodsThe new terminology was achieved in the following 4 steps. The first involved a terminology consensus conference with representatives of the 3 societies, held in April 2015. Then, an analysis of the relevant published studies was used to establish a level of evidence for each factor associated with vulvodynia. The terminology was amended on the basis of feedback from members of the societies. Finally, each societys board accepted the new terminology. Results and ConclusionsIn 2015, the International Society for the Study of Vulvovaginal Disease, International Society for the Study of Womens Sexual Health, and International Pelvic Pain Society adopted a new vulvar pain and vulvodynia terminology that acknowledges the complexity of the clinical presentation and pathophysiology involved in vulvar pain and vulvodynia, and incorporates new information derived from evidence-based studies conducted since the last terminology published in 2003.