Valentina Santamaria

Hormonal and psycho-relational aspects of sexual function during menopausal transition and at early menopause

OBJECTIVE The aim of the present observational, cross-sectional study was to examine the effects of hormonal and psycho-relational variables on sexual function during menopausal transition and at early postmenopause in women with hot flushes. STUDY DESIGN The sample comprised 138 women referred to a clinic for the treatment of hot flushes. They were categorised according to their stage of menopausal transition using the STRAW criteria: early menopausal transition (EMT) if their menstrual cycle was 7 or more days different from normal; late perimenopause (LMT) if they had experienced 60 days or more of amenorrhoea; and early postmenopause (EPM) if their amenorrhoea had lasted for at least 12 months but less than 4 years. MAIN OUTCOME MEASURES Sexual function was measured by using the Female Sexual Function Index (FSFI), while anxiety (state and trait), depression, eating disorder and marital adjustment were evaluated by validated self-report questionnaires. Levels of free testosterone (FT), dehydroepiandrosterone sulfate (DHEAS) and estradiol (E2) were also measured. RESULTS Overall sexual function varied significantly with stage of menopause, with total FSFI score less in EPM than in EMT (p=.009). A similar pattern was evident on FSFI sub-scales for sexual desire (p=.02), arousal (p=.01) orgasm (p=.01) and also pain (p=.02), but not for lubrication and satisfaction. Ratings for anxiety, depression and eating disorder did not differ across the menopausal sub-groups, and neither did ratings of marital adjustment. Both FT (p=.01) and DHEAS (p=.03) levels were slightly reduced at EPM in comparison with EMT, as were E2 levels (p=.001 EMT versus LMT; p=.0001 LMT versus EPM). In multiple regression analyses, plasma FT level was the only factor to predict FSFI full score (beta=.48; p=0.004) in women at EMT, while in women at LMT the depression score was the only factor to do so (beta=-.62; p=0.0001). The best model predicting FSFI full score at EPM included levels of DHEAS and E2 levels and state anxiety score. CONCLUSIONS Hormonal and some psychological variables are relevant to sexual function in symptomatic women during menopausal transition and at early menopause but their role differs with the specific stage of reproductive ageing.

Effect of a contraceptive pill containing estradiol valerate and dienogest (E2V/DNG) in women with menstrually-related migraine (MRM)

BACKGROUND Combined hormonal contraception might worsen migraine in sensitive women, especially during the free-hormone interval, and raise concerns about the vascular risk. The characteristics of a contraceptive pill containing estradiol valerate/dienogest (E2V/DNG) might be of potential benefit in women with menstrually related migraine (MRM) who choose to use oral contraception for birth control. STUDY DESIGN This was a prospective diary-based pilot study. Thirty-two women (age >35 years) [n=18 who had never used combined oral contraceptives (COCs) and n=14 who had previously used COCs] diagnosed with MRMs according to the International Headache Society criteria were included. During the observational period, women filled in a diary with the clinical characteristics of migraine attacks. After a three-cycle run-in period, each subject received a COC containing E2V/DNG (Qlaira®/Natazia®; Bayer HealthCare, Berlin, Germany) administered using an estrogen step-down and progestogen step-up approach. Follow-up evaluations were scheduled at the last cycle of run-in and at the third and sixth cycles of treatment. RESULTS The number of migraine attacks was significantly reduced at the third (p<.001) and sixth cycles (p<.001) in comparison with the run-in period. A similar result was evident for the duration (p<.001 at the third and p<.001 at the sixth cycle) as well as for the severity of head pain (p<.001 at the third and p<.001 at the sixth month). Indeed, a significantly lower number of analgesics were used at the third cycle (p<.001) in comparison with baseline, and a further decrease was evident at the sixth cycle (p<.001) in comparison with the third cycle of E2V/DNG use. Interestingly, duration and severity of head pain were significantly correlated with the number of days of dysmenorrhea at the third cycle (r=.89, p=.000 and r=.67, p=.02; respectively) and at the sixth cycle (r=.76, p=.000 and r=.62, p=.04; respectively) in women without complete remission of menstrual cramps during the study period. CONCLUSIONS The present diary-based pilot study indicates that the use of a pill containing EV2/DNG for six cycles has a positive effect in women with MRM and suggests an association between dysmenorrhea with COCs use as a potential feature of refractory head pain.

Menopause and sexual desire: the role of testosterone

The present short review underlines the role of testosterone (T) in the motivational and satisfaction components of womens sexuality and critically discusses the strategies to treat hypoactive sexual desire disorder (HSDD), a condition of low desire associated with personal and/or interpersonal difficulties, which is more common in surgical menopausal women. There are multiple ways androgens target the brain regions (hypothalamic, limbic and cortical) involved in sexual function and behaviour. Even though circulating available androgens have been implicated in several domains of sexual response, they seem to be related weakly to symptoms, such as low sexual desire, poor sexual arousal, orgasm and diminished well-being in postmenopausal women. The possibilities of treating low sexual desire/HSDD are multifaceted and should include the combination of pharmacological treatments able to maximize biological signals driving the sexual response, and individualized psychosocial therapies in order to overcome personal and relational difficulties. Transdermal T has been shown to be effective at a dose of 300 µg/day both in surgically and naturally menopausal women replaced with estrogen or not, without any relevant side-effects. However, the decision to treat postmenopausal women with HSDD with T is mainly based on clinical judgement, after informed consent regarding the unknown long-term risks.

Management of hypoactive sexual desire disorder in women: Current and emerging therapies

Hypoactive sexual desire disorder (HSDD) is a common multifactorial condition which is characterized by a decrease in sexual desire that causes marked personal distress and/or interpersonal difficulty. The general idea that HSDD is a sexual dysfunction difficult to treat is due to the large number of potential causes and contributing factors. Indeed, a balanced approach comprising both biological and psycho-relational factors is mandatory for accurate diagnosis and tailored management in clinical practice. There are currently no approved pharmacological treatments for premenopausal women with HSDD, while transdermal testosterone is approved in Europe for postmenopausal women who experience HSDD as a result of a bilateral oophorectomy. Even though the role of sex hormones in modulating the sexual response during the entire reproductive life span of women is crucial, a better understanding of the neurobiological basis of sexual desire supports the idea that selective psychoactive agents may be proposed as nonhormonal treatments to restore the balance between excitatory and inhibitory stimuli leading to a normal sexual response cycle. We conclude that the ideal clinical approach to HSDD remains to be established in term of efficacy and safety, and further research is needed to develop specific hormonal and nonhormonal pharmacotherapies for individualized care in women.

Mood disorders and sexual functioning in women with functional hypothalamic amenorrhea

OBJECTIVE To investigate the sexual function of women with functional hypothalamic amenorrhea (FHA) and to test the mediating effects of depression and anxiety on the sexual functioning of women with FHA. DESIGN In this cross-sectional study, participants completed questionnaires on sexual function, depression, and anxiety. SETTING Tertiary care university hospital. PATIENT(S) Women with (n=41) and without (n=39) FHA recruited from a gynecologic endocrinology unit. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The McCoy Female Sexuality Questionnaire assessed sexual function, and the Zung Scale measured depression and anxiety. RESULT(S) Women with FHA experienced more sexual function problems and significantly higher depression and anxiety compared to women without menstrual dysfunction. In addition, depression offered a significant explanation for the sexual problems experienced by women with FHA. CONCLUSION(S) The psychologic symptoms that contribute to the onset of FHA partially mediate the relationship between FHA and sexual dysfunction.

Robotic Single-Site Surgery for Female-to-Male Transsexuals: Preliminary Experience

Hysterectomy with bilateral salpingo-oophorectomy is a part of gender reassignment surgery for the treatment of female-to-male transsexualism. Over the last years many efforts were made in order to reduce invasiveness of laparoscopic and robotic surgery such as the introduction of single-site approach. We report our preliminary experience on single-site robotic hysterectomy for cross-sex reassignment surgery. Our data suggest that single-site robotic hysterectomy is feasible and safe in female-to-male transsexualism with some benefits in terms of postoperative pain and aesthetic results.

Hypoactive sexual desire disorder: can we treat it with drugs?

Hypoactive sexual desire disorder (HSDD) is a common multidimensional condition which is characterized by a decrease in sexual desire that causes marked personal distress and/or interpersonal difficulty. There are a number of potential causes and contributing factors to HSDD and a balanced approach comprising both biological and psycho-relational factors is mandatory for accurate diagnosis and tailored management in clinical practice. It is clearly evident that sex hormones play a crucial role in modulating sexual response during the entire reproductive life span of women. On the other hand, a better understanding of the neurobiological basis of sexual desire supports the idea that selective psychoactive agents may be proposed as non-hormonal treatments to restore the balance between excitatory and inhibitory stimuli leading to a normal sexual response cycle. However, there are currently no approved pharmacological treatments for premenopausal women with HSDD, while transdermal testosterone is approved in Europe for post-menopausal women who experience HSDD as a result of a bilateral oophorectomy. That being so, the ideal clinical approach remains to be established in term of efficacy and safety and further research is needed to develop specific pharmacotherapies for individualized care of women with sexual dysfunction of any age.

Effects of combined hormonal contraception on health and wellbeing: Women's knowledge in northern Italy

Abstract Objectives We investigated levels of knowledge of the effects of combined hormonal contraceptives (CHCs) on general/reproductive health and physical/psychosexual wellbeing. Methods A cross-sectional study was conducted in two university hospitals in northern Italy. Healthy current-, past- and never CHC users (n = 545; age 18–44 years) completed a self-administered questionnaire. Results Ninety-three percent of current-, 74% of past-, and 56% of never users believed they were sufficiently informed (χ2: 67.1; p = 0.001) about the benefits and risks of CHCs. Respondents mentioned: (i) a reduced risk of ovarian (67%) and endometrial (53%) cancer; (ii) an increased risk of thrombosis (82%); (iii) an increased risk of breast cancer (45%); (iv) a decreased fertility (19%) and no influence on risk of sexually transmitted infections (48%); (v) a reduced risk of menstrual abnormalities (77%) and acne (79%); (vi) less dysmenorrhoea (83%) and more headache (56%), weight gain (74%), increased appetite (51%), leg cramps (77%), mood swings (45%), vaginal dryness (47%), and low sex drive (48%). Beliefs about diseases/conditions and symptoms were influenced by CHC use. Conclusions CHC use is linked to good knowledge of risks and benefits. Our data suggest HCPs must be proactive in providing relevant information so that women can choose their contraception with a balanced insight of side effects. Chinese Abstract 摘要： 目的我们调查复方激素避孕药（CHCs）对全身/生殖健康以及身体/心理健康影响的知识水平。 方法一项横断面研究在意大利北部的两所大学医院进行。目前使用、过去使用和从没使用CHC的受访者（N =545；年龄18–44岁）完成自填问卷。 结果93%目前使用CHC、74%过去使用CHC和56%从没使用CHC的受访者认为他们被充分告知了CHC的好处和风险（χ2: 67.1；p =0.001）。受访者提到：（i）卵巢癌的风险降低（67%）和子宫内膜癌的风险降低（53%）；（ii）血栓形成的风险增加（82%）；（iii）乳腺癌的风险增加（45%）；（iv）生育率降低（19%），对性传播疾病的风险没有影响（48%）；（v）月经异常的风险降低（77%）、痤疮的风险降低（79%）；（vi）痛经减少（83%）、头痛增加（56%），体重增加（74%），食欲增加（51%），小腿抽筋（77%），情绪波动（45%），阴道干涩（47%），和性欲降低（48%）。使用CHC使其对疾病/健康状况和症状的观念受到了影响。 结论CHC使用与良好的风险和受益的知识相关。我们的数据表明，医疗专业人员必须主动提供相关信息，从而使女性能平衡各种副作用后选择他们的避孕方法。

News on the treatment of women with Hypoactive Sexual Desire Disorder (HSDD)

A significant proportion of women reporting female sexual dysfunction (FSD) suffer from hypoactive sexual desire disorder (HSDD) which is characterized by a loss of sexual desire leading to distress. HSDD is highly prevalent in women of any age, but only in the recent years some research has been conducted to uncover the potential causes and to find therapeutic strategies. A complex interplay of biological, psychological and socio-relational factors is related to womens sexual health during the entire reproductive life span. Menopause is a time of vulnerability to sexual symptoms as a result of sex hormonal changes inducing climacteric syndrome. Vaginal dryness is a common feature significantly affecting genital arousal and, consequently, desire, orgasm and satisfaction. Recently, HSDD has been well described especially in surgical menopause, a clinical condition clearly characterized by the loss of both estrogens and androgens. Therefore, the major focus is on hormonal treatments, in particular the testosterone (T) patch which is able to restore T levels to premenopausal stage with a significant improvement of sexual activity, desire and satisfaction, reducing women’distress both in surgical and natural menopause. However, there is a medical need to develop novel therapies that can be used even in younger women. A great hope comes from drugs acting on central nervous dopaminergic, serotoninergic and noradrenergic pathways involved in mental drive, arousal and satisfaction. In any case, hormonal and non hormonal treatments and/or psychosexual strategies should be individualized and tailored on womens history and current needs to counteract the distress associated with HSDD.