Ellids Kristensen

Sexual Dysfunction in Women with Diabetes Mellitus

Diabetes mellitus (DM) is an increasing health concern throughout the world. DM is categorized as either type 1 (DM-1) or type 2 (DM-2), where DM-1 represents a lack of insulin production, and DM-2 is characterized by a relative lack of insulin (i.e., decreased sensitivity to the effect of insulin). DM has long been considered a risk factor for sexual dysfunction in men and women, although the evidence in women is less clear. This review attempts to give an overview of female sexual dysfunction in women with DM. Although women with DM are at higher risk of developing sexual dysfunction than women without DM, there is great variability in results across studies, with the incidence of sexual dysfunction in women with DM generally linked less to organic factors and more to psychological factors, especially coexisting depression. This review hypothesizes several presumed causes for such variation in findings across studies and uses these explanations as the basis for a discussion of differences between mens and womens sexuality.

Botulinum Toxin Type A—A Novel Treatment for Provoked Vestibulodynia? Results from a Randomized, Placebo Controlled, Double Blinded Study

INTRODUCTION Vestibulodynia is an increasingly recognized problem among women and is often difficult to treat. AIM This randomized, double blinded, placebo-controlled study aimed to evaluate the efficacy of Botox in the treatment of vestibulodynia. METHODS Sixty-four women were randomized to receive Botox (N = 32) or saline placebo (N = 32). Botulinum toxin A (20 I.E.) diluted in 0.5 mL saline or 0.5 mL saline was injected in the musculus bulbospongiosus at baseline. MAIN OUTCOME MEASURES Pain was measured monthly on a visual analog scale (VAS) Likert scale. Sexual function was measured using the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale at baseline and at 3 and 6 months follow up. Quality of life was measured using the 36-item short-form (SF-36). RESULTS Sixty women (94%) completed the 6 months follow up. Both Botox and placebo produced significantly pain reduction (P < 0.001). There was no significant difference in the median VAS score between the groups at 6 months follow up (P = 0.984). An improvement on the FSFI full score from baseline until 6 months was not significantly different between the groups (P = 0.635). In the placebo group a statistical significant larger reduction in sexual distress was observed from baseline until 6 months follow up compared to the Botox group (P = 0.044). No statistical significant differences were observed between the B- and P-groups in regard to the SF-36 scores. CONCLUSION Injection of 20 I.E. Botox in the vestibule of women diagnosed with vestibulodynia does not reduce pain, improve sexual functioning, or impact the quality of life compared to placebo and evaluated at 3 and 6 moths follow up. Both the Botox group and the placebo groups experienced a reduction in pain on the VAS Likert scale at 6 months follow up. Women with vestibulodynia have difficulty with sexual function and present with sexual distress, which has to be addressed in conjunction with pain to eliminate the disorder.

RE: Is There a Correlation Between Androgens and Sexual Desire in Women?

We were very interested to read the results of the study by WåhlinJacobsen et al. [1] titled “Is there a correlation between androgens and sexual desire in women?” The researchers used mass spectrometry methods to investigate age-adjusted serum levels of dehydroepiandrosterone sulfate (DHEA-S), androstenedione, and testosterone, as well as androsterone glucuronide (ADT-G)—a measure of total androgen activity. The results were consistent with our published study of 121 women with and 124 women without a diagnosis of Hypoactive Sexual Desire Disorder (using the definition of the Diagnostic and Statistical Manual, 4th edition, text-revised), where no group differences in androgen metabolites were found [2]. We were somewhat perplexed by the apparent change in Wåhlin-Jacobsen et al.’s [1] objective in their paper from investigating a possible correlation between serum levels of testosterone and/or androgen metabolites and sexual desire, to finding a measure that does indeed correlate with desire and to apparently suggest its use hereon. The conclusion in the abstract that ADT-G did not correlate more strongly than circulating androgens with sexual desire and therefore is not superior to measuring circulating androgens with mass spectrometry presupposes an established correlation between androgens and sexual desire. The authors note that “measuring the degradation product of the intracellular testosterone turnover should therefore yield a better estimate of both the intracellular turnover and the total activity of androgens. In contrast to what we expected, however, no statistically significant correlations were established between ADT-G and sexual desire. Therefore, based on these current and previous results, we cannot conclude that ADT-G is a better biomarker of the link between androgens and women’s sexual desire than measuring the amount of circulating androgens.” (p. 12). An explanation for these findings can, however, be based upon the understanding that the metabolite of androgens chosen as a parameter of total androgenic activity, namely ADT-G, although a logical suggestion, could have to take into account a more complex pattern than originally believed [3]. As mentioned by the authors, it could well be that ADT-G represents only a fraction of all androgen metabolites. In fact, it could be that ADT-sulfate and epi-ADT-G (and likely others) could represent a much larger proportion of androgen metabolites than ADT-G alone. However, since the very low serum levels of testosterone observed in women during their whole life essentially result from some leakage of the intracellular testosterone synthesized locally from DHEA [4], it might be reasonable, at the present time, to measure the precursors of intracellular testosterone, namely serum DHEA, DHEA-S, androstene-3β,17β-diol, and androstenedione. In fact, low serum levels of all these four androgen precursors have been correlated with sexual dysfunction [1,2,5]. The authors did find a correlation between total testosterone, free testosterone, androstenedione, and DHEA-S in the subgroup of women aged 25–44 who were not using any hormonal contraception (n = 168). In our study, 246 women were more stringently recruited to exclude confounds such as any medication potentially altering sexual response and desire, scoring in the clinically significant depressed range on a validated measure of depression, significant relationship conflict, and sexual pain, and this study failed to show a correlation between mass spectrometry-measured serum testosterone and desire but showed a correlation with low serum DHEA-S [2]. We maintain our conclusion [2] that in large samples of women, there is not yet conclusive evidence of a significant correlation between accurately measured total testosterone activity and sexual desire. This is not to say androgen activity may not be important, but at this point, such evidence of a correlation has not been empirically supported. As indicated above, it could well be that serum testosterone is not a reliable marker since it represents only leakage of intracellular testosterone made by the intracellular mechanisms of intracrinology [4]. The conclusion of Wåhlin-Jacobsen et al. [1] that as measurement of ADT-G showed no significant correlation with women’s sexual desire, such measurement “did not seem to be an improvement over measuring circulating androgens with MS” (p. 14) suggests that there was a very different a priori objective to the study than what was published. A recent editorial reminds us of the significant dangers inherent to modification of a priori hypotheses and the threat to statistical analyses as well as interpretation of the findings [6]. That the identification/measurement of the most appropriate metabolites of androgens has not yet been determined in no way negates the importance of intracellular testosterone production. We offer this analogy: the hypothetical investigation of a correlation between intake of vitamin C supplements and susceptibility to influenza. Imagine researchers counting vitamin C supplements taken by patients and finding the numbers to correlate negatively with number of influenza infections. However, when measuring their serum vitamin C levels, no correlation is found between vitamin C levels and cases of influenza. If the researchers then said “from here-on just count vitamin C supplements as this correlates better with influenza susceptibility,” perhaps the lack of a scientific demonstration would be more obvious. In summary, with the strong caveat of relatively lax exclusion criteria, the findings by Wåhlin-Jacobsen et al. have added to the literature on women’s sexual desire and androgens, which are based on the currently available most optimal assays for serum androgens and precursor hormones (liquid chromatography-mass spectrometry), and for total (intracellular plus serum) androgens (ADT-G). As in our study [2], precursors of intracellular testosterone correlated with sexual desire in women aged 25–65 years, none of whom were taking systemic sex hormones. In contrast to our study, in the subgroup of 168 women aged 25–45 years, desire also correlated with measures of serum testosterone. It will be important to repeat these measures on this targeted subgroup, but with stricter exclusion criteria as well as the entry criterion of a diagnosis of sexual interest/arousal disorder assessed by detailed interview as currently available questionnaires do not reflect current conceptualization of women’s sexual response or current 1

Endorsement of Models Describing Sexual Response of Men and Women with a Sexual Partner: An Online Survey in a Population Sample of Danish Adults Ages 20–65 Years

INTRODUCTION Several models have been used to describe mens and womens sexual responses. These models have been conceptualized as linear or circular models. The circular models were proposed to describe womens sexual function best. AIM This study aims to determine whether men and women thought that current theoretical models of sexual responses accurately reflected their own sexual experience and to what extent this was influenced by sexual dysfunction. METHODS A cross-sectional study of a large, broadly sampled, nonclinical population, cohort of Danish men and women. The Female Sexual Function Index, Female Sexual Distress Scale, and the International Index of Erectile Function were used to describe sexual function. Also, participants completed questionnaires with written descriptions of different sexual responses to describe their most experienced sexual response. MAIN OUTCOME MEASURE For women, we measured desire, arousal, lubrication, orgasm, sexual satisfaction, pain during sexual activity, sexual distress, and satisfaction with sexual life. For men, we measured erectile function, orgasm, desire, intercourse satisfaction, overall satisfaction, and satisfaction with sexual life. RESULTS A total of 499 men and 573 women participated. We only analyzed responses from sexually active participants with a partner (401 men and 429 women). The majority of men endorsed the Masters & Johnson model (48.5%) or the Kaplan model (38.3%); only 5.4% endorsed the Basson model, and 7.3% endorsed none of the models. Among women, 34% endorsed the Kaplan model, 28% the Masters & Johnson model, 25.6% the Basson model, and 12.5% none of the models. Among women, sexual dysfunction and distress were significantly (P = 0.01) related to endorsement of the Basson model or none of the models. Among men, erectile dysfunction and dissatisfaction with sexual life were significantly related to endorsement of the Basson model or none of the models (P = 0.01). CONCLUSIONS No single model of sexual response could describe mens and womens sexual responses. The majority of men and women with no sexual dysfunction that were satisfied with their sexual life endorsed the linear models.

Sexual revictimization in a clinical sample of women reporting childhood sexual abuse

Background: Child and adolescent sexual abuse (CSA) increases the risk for adult sexual assault (ASA), and psychological vulnerability as well as aspects of CSA and upbringing might influence the risk. Aims: The aims of this study were to investigate whether women who reported both CSA and ASA: 1) have been exposed to more severe CSA and 2) have greater psychological distress and vulnerability than women who were not revictimized. Methods: The study was a cross-sectional study of 161 adult women with a reported history of intrafamilial CSA. Thirty-six per cent of the women stated they had been exposed to ASA. The severity of CSA, psychological distress (Symptoms Checklist-90-R) and Cognitive Distortion were assessed. Five factors of Cognitive Distortion (fearful, scared, shy, mistrust and vulnerable) were identified by factor analysis of Symptoms Checklist-90-R sub-scale. Results: The CSA was significantly more severe (penetration: 77%/60%; multiple offenders: 67%/25%) in women exposed to ASA compared with their counterparts, as was the rate of suicide attempts (47%/30%). Also, the psychological distress and the factors: fearful, scared, shy and mistrust were significant higher. Conclusion: The results showed an increased psychological vulnerability among women with ASA, but whether the results are cause or effect of sexual revictimization or can be generalized to other clinical samples are not clear. Interventions targeting the increased risk of ASA should be developed, implemented and tested in prevention as well treatment programmes.

Vulvodynia. Definition, diagnosis and treatment

Vulvodynia is a chronic painful disorder with an estimated prevalence of 9–12%. A rising incidence of the condition constitutes a growing problem. This has lead to an increased focus on etiology and treatment, while the definition also requires attention. Previous assumptions stating that the problem is solely a psychological disorder have been abandoned, because inflammatory mechanisms and genetic factors have been found to be involved in the pathogenesis as well as psychosexual contributors.

Sexual Function in Female Patients with Obstructive Sleep Apnea.

INTRODUCTION Obstructive sleep apnea is defined as repetitive (≥5/hour) partial or complete cessation of breathing during sleep. Whereas obstructive sleep apnea is often considered to be associated with sexual problems in men, studies concerning effects of obstructive sleep apnea on female sexual function and distress are sparse. AIM To investigate sexual dysfunction and sexual distress in female patients with obstructive sleep apnea and to determine which factors are of importance for their sexual function. METHODS We investigated 80 female patients (ages 28-64) admitted to a sleep laboratory and who after investigation received a diagnosis of obstructive sleep apnea. All subjects answered questions drawn from three self-administered questionnaires on sexuality. The results were compared with a population sample (N=240). MAIN OUTCOME MEASURE   Data from nocturnal respiratory recordings. Female Sexual Function Index, Female Sexual Distress Scale and four questions from Life Satisfaction-11 (Lisat-11). RESULTS   Female Sexual Function Index indicated that obstructive sleep apnea patients were at a higher risk for having sexual difficulties. Female Sexual Distress Scale showed significantly more sexual distress in the obstructive sleep apnea group. Manifest Female Sexual Dysfunction (combined data from Female Sexual Function Index and Female Sexual Distress Scale) showed that female patients with obstructive sleep apnea also had more sexual dysfunction. Severity of sleep apnea was, however, not related to any of these indices but consumption of psychopharmaca was. In Lisat-11, we found that obstructive sleep apnea females scored lower than women in the population sample regarding life as a whole but not regarding domains of closeness. CONCLUSIONS   This study indicates that sexuality of women with untreated obstructive sleep apnea is negatively affected compared with a female population sample. This was not related to severity of obstructive sleep apnea, whereas psychopharmaca may act as an important confounder.

Sexual function in male patients with obstructive sleep apnoea

Objective:  Our objective was to investigate general and functional aspects of sexuality in male patients with a confirmed diagnosis of obstructive sleep apnoea (OSA) and compare the results with normative data.

Women with a history of childhood sexual abuse. Long-term social and psychiatric aspects

The socio-demographics and psychiatric diagnoses in a clinical sample of women with a history of mainly intrafamilial childhood sexual abuse (CSA) are described. The women were referred to five psychiatric centres for incest group psychotherapy. Data were gathered using interviews and self-administered questionnaires. Over a period of 2.5 years, 385 women with mean age of 33 years were referred with a history of CSA. Three hundred and forty of those had experienced intrafamilial CSA. The average age at first abuse was 6.8 years, and it lasted for a mean of 6 years. The women had been abused by a mean of 1.5 perpetrators. A quarter of the women had been subjected to violence in connection with the sexual abuse. The likelihood of violence having occurred rose significantly if there was more than one perpetrator and/or if penetration had been part of the sexual abuse. Violence was less common if the perpetrator was a brother. The women suffered from a broad spectrum of psychiatric symptoms and illnesses. More than half of the women had previously received psychiatric treatment. Compared to a random sample of the general female population, these women were less advantaged with regards to education, financial circumstances and cohabitation. The results emphasize the importance of offering comprehensive social and psychiatric intervention to help reducing the problems following CSA in women.

Sexual function in women with a history of intrafamilial childhood sexual abuse

This study investigated sexual function in women with a history of severe intrafamilial childhood sexual abuse (CSA) and the correlation between sexual problems and the severity of CSA, adult support during childhood and current psychiatric symptoms. The sample consisted of 158 women who subsequently began specialized group psychotherapy for CSA sequellae. Clinical interview and questionnaires (Present Sexual Function, Sexual and Body Satisfaction, Symptom Check List 90-R) were used for data collection in a cross sectional study design. Non-parametric analysis, linear and logistic regression analysis were applied. Of the women, 63% were unsatisfied with their current sexual life, 39% felt uncomfortable with physical endearments and 71% were unsatisfied with their body. Only 82% had an active sexual life and, of these, 73% reported at least one sexual problem, 48% orgasmic problems and 45% dyspareunia. The occurrence of sexual problems was significantly correlated to childhood physical violence, current psychological distress, flashbacks in sexual situations and discomfort with physical endearment. The prevalence of sexual pain disorders were also positively correlated to “no adult support” in childhood. The present study finds that psychiatric patients in terms of women with a history of intrafamilial CSA have wide-ranging sexual problems. It is crucial to screen for sexual problems and address them during treatment.