Robin J. Bell

ORIGINAL RESEARCH—PSYCHOLOGY: The Relationship between Self-Reported Sexual Satisfaction and General Well-Being in Women

INTRODUCTION The extent to which low sexual function or sexual dissatisfaction in women impacts on well-being remains uncertain, yet this is a critical issue in the controversy as to the benefits of pharmacotherapy for women seeking treatment for female sexual dysfunction. Aim. To explore the relationship between well-being and self-perceived satisfaction with sexual function in women and to determine if there is an independent effect of menopausal status or age. DESIGN A community-based cross-sectional study. PATIENTS A total of 421 women, aged 18 to 65 years were recruited from the community. Women were required to self-identify at study outset as being either satisfied or dissatisfied with their sexual life and be premenopausal or postmenopausal. MAIN OUTCOME MEASURES Scores from the Psychological General Well-Being Index (PGWB), the Beck Depression Index (BDI) and a daily diary of sexual function. RESULTS A group of 349 women were included in the analysis. Total PGWB and domain scores of positive well-being and vitality were lower in dissatisfied women compared to satisfied women. PGWB total and domain scores of depressed mood, positive well-being and vitality were higher in older women. Menopause did not have an independent effect on well-being. CONCLUSIONS Women who self-identify as having sexual dissatisfaction have lower psychological general well-being. These findings reinforce the importance of addressing sexual health and well-being in women as an essential component of their health care.

Sexual Function after Breast Cancer

INTRODUCTION Breast cancer (BC) remains the most common non-skin cancer in women and an increasing number are living as BC survivors. AIM The aim of this article is to evaluate the impact of the first diagnosis of invasive BC and its treatment, menopausal symptoms, and body image on sexual function. METHODS The BUPA Foundation Health and Wellbeing after Breast Cancer Study is a prospective cohort study of 1,684 women recruited within 12 months of their first diagnosis with invasive BC. Each participant completed an enrollment questionnaire (EQ) and first follow-up questionnaire (FQ1) 12 months post-EQ. MAIN OUTCOME MEASURE Sexual function was evaluated by the Menopause-Specific Quality of Life Questionnaire embedded within the FQ1. RESULTS Of the 1,011 women in the analyses, 70% experienced sexual function problems and 77% reported vasomotor symptoms. Women experiencing sexual function problems were postmenopausal (P = 0.02), experienced vasomotor symptoms (P < 0.01), and used aromatase inhibitors (P = 0.03). Women with vasomotor symptoms were twice as likely to experience sexual function problems (odds ratio [OR] 1.93, 95% confidence interval [CI] 141, 2.63; P < 0.001). This association was more extreme for women on aromatase inhibitors (OR 3.49, 95% CI 1.72, 7.09; P = 0.001) but did not persist in women not using endocrine therapies (OR 1.41, 95% CI 0.84, 2.36; P = 0.19). Women on aromatase inhibitors were more likely to report sexual function problems (OR 1.50, 95% CI 1.0, 2.2, P = 0.04) and women with body image issues were 2.5 times more likely to report sexual function problems (OR 2.5 95% CI 1.6, 3.7, P < 0.001). Women using tamoxifen were not more likely to experience sexual function problems (OR 1.1, 95% CI 0.8, 1.5, P = 0.6); however, women with body image issues were twice as likely to experience sexual function problems (OR 2.1, 95% CI 1.5, 3.0, P < 0.001). CONCLUSION Seventy percent of partnered BC survivors less than 70 experienced sexual function problems. Sexual problems are related to the use of aromatase inhibitors which can exacerbate menopausal symptoms.

Prevalence and incidence of urinary incontinence in women: Review of the literature and investigation of methodological issues

Objectives:  Urinary incontinence in women is common and has a significant impact on the physical, psychological and socio‐economic aspects of life. The aims of this study were to review the published reports on the prevalence and incidence of urinary incontinence in Australian women and to examine the methodological issues associated with these studies.

THE EFFECT OF VIGOROUS EXERCISE DURING PREGNANCY ON BIRTH-WEIGHT

EDITORIAL COMMENT: When this paper was reviewed the question was raised that the period of gestation is an obvious factor which can determine birth‐weight and the authors were asked how this may have affected their results The authors response was as follows:

Effects of aromatase inhibition on sexual function and well-being in postmenopausal women treated with testosterone: a randomized, placebo-controlled trial.

Objective:The extent to which aromatization of testosterone (T) to estradiol is required for the observed effects of testosterone therapy on sexual function and well-being are not known. Therefore, the authors investigated the effects of aromatase enzyme inhibition on sexual function, well-being, and mood in estrogen- and T-replete postmenopausal women in a double-blind, randomized, placebo-controlled study. Design:Postmenopausal women using transdermal estrogen therapy for at least 8 weeks and reporting low sexual satisfaction (score <42 for the Sabbatsberg Sexual Self-rating Scale [SSS]) with a total T value of less than 1.2 nmol/L were treated with 400 μL of a 0.5% T gel (total dose 2 mg) and were randomly assigned to receive treatment with either 2.5 mg/day of letrozole or an identical placebo tablet. Women were assessed at baseline (week −2) and at 0, 4, 8, and 16 weeks. Sexual function was assessed with the SSS, well-being was assessed with the Psychological General Well-being Index, and mood was assessed with the Beck Depression Inventory at 0 and 16 weeks. Eighty-one women were screened, 76 were randomly assigned to a treatment group, and 30 in each group completed the study. Because this was a mechanistic study, only the 60 women who completed the study per protocol were included in the final analysis. Results:Total T and calculated free T increased from baseline in both groups, with no difference between groups. At 16 weeks, estradiol, sex hormone-binding globulin, fasting lipids, lipoprotein(a), and C-reactive protein did not differ from baseline or between groups. Significant increases in total Sabbatsberg Sexual Self-rating Scale scores, total Psychological General Well-being Index scores, and a reduction in Beck Depression Inventory scores from baseline to 16 weeks was seen for both treatment groups, with no effect of treatment allocation. No adverse treatment effects were reported. Conclusions:Increases in total and free T in the physiologic range in postmenopausal women were associated with improved sexual satisfaction, well-being, and mood. In this study, aromatase inhibition did not influence any of these outcomes. Short-term transdermal T therapy did not modify fasting lipids, lipoprotein(a), or C-reactive protein.

Well‐being, health‐related quality of life and cardiovascular disease risk profile in women with subclinical thyroid disease – a community‐based study

Objectives  The aim of this study was to evaluate whether subclinical thyroid disease is associated with impaired health‐related quality of life and a more adverse cardiovascular disease risk profile.

Sexual Function in Well Women: Stratification by Sexual Satisfaction, Hormone Use, and Menopause Status

INTRODUCTION Satisfaction with sexual function in community-based women has not been well-described, and little is known of differences in sexual function between pre-(PreM) and postmenopausal (PM) women. AIM The aim of this article was to describe sexual function in PreM and PM women who self-identify as being satisfied or dissatisfied with their sexual life. METHODS A cross-sectional questionnaire study was conducted among 349 sexually active community-based women, aged 20-65 years, who self-identified as being either satisfied or dissatisfied with their sexual life. MAIN OUTCOME MEASURES Scores from a daily diary of sexual function for 4 weeks, examining the frequency of sexual thoughts, interest, and activity. RESULTS One hundred and eighty-four women (53%) were PreM, and 165 (47%) were dissatisfied with their sexual life. The median number of days with sexual activity or events per month for all women was 8 (ranges 2-28 days; 2-57 events). Ninety-two percent of reported events involved a partner, 86% involved intercourse, and in 40% the woman initiated the activity. Women satisfied with their sexual life had higher frequencies of sexual thoughts, interest, events, and initiation of activity than dissatisfied women (P < 0.0001). PreM satisfied women had higher frequencies of sexual thoughts, numbers of days with sexual activity, and events per month than PM satisfied women (P < 0.05). PreM oral contraceptive pill (OCP) users had significantly lower average frequencies of sexual thoughts, interest, and days of sexual activity per month (P < 0.05), whereas PM women hormone therapy (HT) users had higher frequencies of sexual thoughts and sexual interest (P = 0.04 and P = 0.05, respectively) compared to nonusers. There were no differences in sexual function between PreM and PM women who were sexually dissatisfied. CONCLUSIONS Sexual activity mostly involved a partner, partner initiation, and intercourse. Sexually satisfied women reported more sexual thoughts, interest, events, and initiation of sexual activity than dissatisfied women. PreM sexually satisfied women reported more sexual thoughts, days with sexual activity, and sexual events per month compared to PM satisfied women. OCP and HT use appeared to have contrasting effects on sexual function.

Age-specific prevalence of, and factors associated with, different types of urinary incontinence in community-dwelling Australian women assessed with a validated questionnaire

OBJECTIVE The aim of this study was to document the age-specific prevalence of different types of urinary incontinence (UI) in women and to identify the risk factors associated with each type of UI. DESIGN A detailed self-administered questionnaire was mailed to 542 community-dwelling women, aged 24-80 years. The questionnaire included a validated instrument, the Questionnaire for Urinary Incontinence Diagnosis (QUID), for the assessment of stress, urge and mixed UI. RESULTS Five hundred and six of the 542 women provided data (93.4%). The overall prevalence of any UI was 41.7% [95% confidence interval (CI): 37.2-45.8%]. Of the 210 women reporting UI, 16% [95% CI: 12.9-19.3%] reported stress only; 7.5% [95% CI: 5.2-9.8%] reported urge only and 18% [95% CI: 14.7-21.5%] reported a mixed pattern. Stress incontinence was most common amongst middle-aged women (25.3% of women aged 35-44 years), while urge incontinence was most common in women over the age of 75 years (24.2%). In logistic regression analyses, obesity (p<0.001) and being parous (p=0.019) were found to be significantly associated with stress incontinence, increasing age (p=0.002) with urge incontinence, and being overweight (p=0.035) or obese (p<0.001) and having had a hysterectomy (p=0.021) with mixed incontinence. CONCLUSIONS UI is a highly prevalent condition in women living in the community. Stress, urge and mixed incontinence have different age distributions and risk factors. These data are important in understanding the etiology, management and possible prevention of these conditions.

Bone marrow lesions predict increase in knee cartilage defects and loss of cartilage volume in middle-aged women without knee pain over 2 years

Objective: Bone marrow lesions (BML) are important in established knee osteoarthritis, predicting pain and progression of disease. Whether BML are also associated with longitudinal changes in knee structure in an asymptomatic population is unknown. Methods: 148 healthy pain-free women in middle age with no history of knee injury or clinical knee osteoarthritis who had a magnetic resonance imaging (MRI) scan performed on their dominant knee at baseline, had another MRI 2 years later to assess whether having a BML present at baseline affected change in tibiofemoral cartilage defects and tibial cartilage volume. Results: BML were present in 14.9% of women at baseline. The risk of progression of total tibiofemoral cartilage defects was significantly higher when a very large BML was present (odds ratio 5.55, 95% CI 1.04 to 29.6) compared with when no BML was present, after adjusting for potential confounders. In the lateral compartment, the rate of cartilage volume loss was significantly greater when a BML was present after adjusting for confounders (regression coefficient 39.2 mm3, 95% CI 11.1 to 67.2, p = 0.007). Conclusions: In healthy women without pain at baseline, large BML were associated with both progression of cartilage defects in the whole tibiofemoral joint and more rapid lateral tibial cartilage loss. These data suggest that the relationship between BML and knee cartilage in healthy women is similar to that described in established osteoarthritis. It is possible that BML may predict an increased risk of knee osteoarthritis and facilitate the identification of novel interventions to prevent disease.

Adipose aromatase gene expression is greater in older women and is unaffected by postmenopausal estrogen therapy

Objective: Although natural menopause is associated with loss of ovarian estrogen production, this life phase is followed by a significant increase in estrogen-related cancers, namely breast and endometrial cancer. These tissues, as well as adipose, skeletal, and vascular tissues and the brain are important sites of postmenopausal estrogen production. Circulating C19 steroid precursors are essential substrates for extragonadal estrogen synthesis; however, the levels of these androgenic precursors decline markedly with advancing age. This implies an increase in capacity for extragonadal tissues to produce estrogen with age. Design: To explore this, and the effects of the menopause transition and postmenopausal estrogen therapy on extragonadal estrogen biosynthesis, we have compared the expression of the aromatase gene and estrogen (ER) and androgen receptors (AR) in subcutaneous abdominal and gluteal fat taken from premenopausal (group 1: n = 11), postmenopausal (group 2: n = 10), and postmenopausal women taking estrogen therapy (group 3: n = 10). All subjects were of normal body mass index, euglycemic, and normolipemic. Results: The postmenopausal women were older (group 1, 43.1 ± 5.0 vs groups 2 and 3, 57.9 ± 7.4 years, P < 0.001 and 56.1 ± 4.5 years, P < 0.001, respectively) and had lower serum estradiol levels (group 2, 22.2 ± 3.2 vs group 1, 442.5 ± 248.2 pmol/L, P < 0.05), which were restored to premenopausal levels with estrogen therapy. Expression analysis revealed that levels of transcripts encoding aromatase were greater in gluteal than abdominal depots in each group in postmenopausal versus premenopausal women (P < 0.05). Use of hormone therapy did not influence aromatase gene expression in either depot. No differences were detected in the expression of ER or AR between groups of between tissue depots. Conclusion: Thus, the capacity of adipose tissue to produce estrogen seems to increase significantly with age at the time of menopause and to be unaltered by exogenous estrogen therapy. This difference in extragonadal estrogen production with age may play a pivotal role in the increase in estrogen-dependent malignancies in the postmenopausal years.