Profile of Female Sexual Function: a patient-based, international, psychometric instrument for the assessment of hypoactive sexual desire in oophorectomized women

Menstrual cycle-related changes in circulating androgens in healthy women with self-reported normal sexual function

INTRODUCTION

There is currently neither a clinically useful, reliable and inexpensive assay to measure circulating levels of free testosterone (T) in the range observed in women, nor is there agreement on the serum free T threshold defining hypoandrogenism that is associated with female-impaired sexual function.

AIM

Following the Clinical and Laboratory Standards Institute guidelines, we generated clinically applicable ranges for circulating androgens during specific phases of the menstrual cycle in a convenience sample of 120 reproductive-aged, regularly cycling healthy European Caucasian women with self-reported normal sexual function.

METHODS

All participants were asked to complete a semistructured interview and fill out a set of validated questionnaires, including the Female Sexual Function Index, the Female Sexual Distress Scale, and the 21-item Beck's Inventory for Depression. Between 8 am and 10 am, a venous blood sample was drawn from each participant during the midfollicular (day 5 to 8), the ovulatory (day 13 to 15), and the midluteal phase (day 19 to 22) of the same menstrual cycle.

MAIN OUTCOME MEASURES

Serum levels of total and free testosterone, Delta(4)-androstenedione, dehydroepiandrosterone sulphate and sex hormone-binding globulin during the midfollicular, ovulatory and midluteal phase of the same menstrual cycle.

RESULTS

Total and free T levels showed significant fluctuations, peaking during the ovulatory phase. No significant variation during the menstrual cycle were observed for Delta(4)-androstenedione and dehydroepiandrosterone sulphate. Despite the careful selection of participants that yielded an homogeneous group of women without sexual disorders, we observed a wide range of distribution for each of the circulating androgens measured in this study.

CONCLUSIONS

This report provides clinically applicable ranges for androgens throughout the menstrual cycle in reproductive-aged, regularly cycling, young healthy Caucasian European women with self-reported normal sexual function.

Development and validation of a new screening tool for hypoactive sexual desire disorder: The Brief Profile of Female Sexual Function (B-PFSF)

AIM

To develop a screening tool to allow a postmenopausal woman to determine whether to seek evaluation for hypoactive sexual desire disorder (HSDD).

METHODS

The Brief Profile of Female Sexual Function (B-PFSF) was developed using items from the Profile of Female Sexual Function (PFSF) and the Personal Distress Scale (PDS). Logistic regression analysis was used to select items best able to discriminate between women with HSDD (n = 743) and controls (n = 226) and a screening cut-off score was identified. Cross-validation analyses were conducted using PFSF and PDS responses from an independent group of 147 HSDD women and 104 controls. Forty cognitive interviews were additionally conducted to assess validity of the final tool.

RESULTS

A seven-item instrument was found to provide good discrimination between postmenopausal women with HSDD and controls and to be a reliable and valid tool. Ninety-six percent of women with HSDD and 97% of control women in the independent validation were classified correctly using the identified cut-off score. In the cognitive interviews, all women stated that the questionnaire was easy to complete and covered relevant aspects of sexual function.

CONCLUSION

The Brief Profile of Female Sexual Function (B-PFSF) is psychometrically valid and appropriate for use as a self-administered screening tool.

Assessment of sexual function/dysfunction via patient reported outcomes

The recent recognition of the high prevalence of sexual dysfunctions and disorders in our society, along with the substantial investment of the pharmaceutical industry in the field of sexual functioning, has resulted in a significant expansion in the development of valid and reliable measures of sexual function/dysfunction. The instruments tend to be brief self-report inventories, typically requiring 10-20 min of patient time for completion. Most measures were initially developed as screening and outcomes measures for use in clinical drug trials of new treatments for sexual dysfunction, but are beginning to see more widespread use in the clinic. All these instruments must adhere to recently prescribed rigorous guidelines set forth by the Food and Drug Administration, and have been demonstrated to be valid and reliable indicators of the status and quality of sexual functioning in both men and women. The constructs that form the framework of our diagnostic system for sexual dysfunctions are not amenable to direct physical measurement, so that currently they must be assessed via these self-report scales. Although not as precise as physical measures, these inventories do an admirable job of quantifying and registering sexual functioning status in a concise and reliable manner, and have become indispensable tools in our clinical and research programs.

Evaluation of the Clinical Relevance of Benefits Associated with Transdermal Testosterone Treatment in Postmenopausal Women with Hypoactive Sexual Desire Disorder

INTRODUCTION

Postmenopausal women with hypoactive sexual desire disorder (HSDD) experienced statistically significant improvements in the frequency of satisfying sexual activity, sexual desire, and distress with testosterone treatment in phase III trials, but it was not known whether the magnitude of these effects was clinically meaningful. The clinical relevance study was designed to answer this question.

AIM

To evaluate the clinical relevance of the treatment benefits.

METHODS

This study involved a representative sample of 132 surgically postmenopausal women with HSDD who were enrolled in two randomized, placebo-controlled trials (N = 1094) assessing the efficacy and safety of transdermal testosterone treatment (300 mcg/day) for 6 months. At the end of the studies, prior to unblinding, a sample of women (12%) was interviewed concerning their experiences with the treatment.

MAIN OUTCOME MEASURES

Women were asked "Overall, would you say that you experienced a meaningful benefit from the study patches?" Changes in the efficacy end points in the double-blind studies were compared for the women who did and did not experience an overall meaningful benefit.

RESULTS

Overall, 33 of 64 women (52%) who received testosterone reported experiencing a meaningful treatment benefit, compared with 21 of 68 women (31%) who received placebo (P = 0.025). Among the women who identified themselves as experiencing a meaningful benefit, the mean (SE) change from baseline in 4-week frequency of satisfying sexual activity was 4.4 (0.76), in desire score was 21.0 (2.78), moving from "seldom" to "sometimes" feeling sexual desire, and in distress score was -36.5 (3.96), moving from "often" to "seldom" being distressed. Among the women who identified themselves as not experiencing a meaningful benefit, the mean (SE) change from baseline in 4-week frequency of satisfying sexual activity was 0.5 (0.31), in desire score was 2.9 (1.42), and in distress score was -8.8 (2.23).

CONCLUSIONS

Surgically menopausal women with HSDD in these studies received clinically meaningful benefits, including improvements in satisfying sexual activity, sexual desire, and personal distress.

Testosterone Treatment for Hypoactive Sexual Desire Disorder in Postmenopausal Women

INTRODUCTION

The reduced levels of testosterone in postmenopausal women are associated with loss of libido, decreased sexual activity, diminished feelings of physical well-being, and fatigue. A bilateral oophorectomy can lead to decreases in sexual desire in 50% of cases by removing ovarian contribution to the circulating levels of testosterone. Testosterone therapy is an option for the restoration of sexual drive.

AIM

Transdermal testosterone administration may bypass the effects of first pass hepatic metabolism. To this end a series of studies have been carried out using a novel transdermal testosterone system. A review of the results from these studies are presented here.

MAIN OUTCOME MEASURES

A key feature of these studies was the use of validated study instruments to measure sexual function: Sexual Activity Log (SAL), Profile of Female Sexual Function (PFSF) and Personal Distress Scale.

METHODS

The data from the Phase III studies, known as the Investigation of Natural Testosterone in Menopausal women Also Taking Estrogen in Surgically Menopausal women (INTIMATE SM) 1 and 2 were reviewed and the salient information is presented here.

RESULTS

Both INTIMATE 1 and 2 showed a significant increase in total satisfying sexual activity, via the SAL in those women receiving testosterone, compared with those women in the placebo group. Total satisfying sexual activity increased by 74% and 51% for INTIMATE 1 and 2, respectively. The PFSF instrument demonstrated significant improvements in INTIMATE 1 and 2 in all domains of sexual function in testosterone-treated women compared with the placebo patients. In both studies, personal distress decreased in those patients receiving testosterone, compared with the placebo group. The most commonly reported adverse events were application site reactions. Eight-five percent of patients said they would probably or definitely continue treatment. Conclusions. The transdermal testosterone patch is an effective treatment for hypoactive sexual desire disorder in surgically postmenopausal women receiving concomitant estrogen therapy. The treatment has a favorable safety profile.

ORIGINAL RESEARCH—EPIDEMIOLOGY: The Prevalence of Sexual Dysfunction and Potential Risk Factors That May Impair Sexual Function in Malaysian Women

INTRODUCTION

Female sexual dysfunction (FSD) is a prevalent sexual health problem that does not spare the women in Malaysia, a nation with a conservative multiethnic society.

AIM

To investigate the prevalence of FSD and the potential risk factors that may impair sexual function among women at a primary care setting in Malaysia.

MAIN OUTCOME MEASURE

The prevalence, the risk factors, and the main predictors for FSD were measured among these women.

METHODS

A validated Malay version of the Female Sexual Function Index was used to assess FSD. A total of 230 married women aged 18-70 years participated in this study. The sociodemographic and marital profiles of women who had FSD and those who did not were compared; the risk factors for FSD were determined.

RESULTS

The majority of the respondents were younger than 50 years old, predominantly Malays, and had a higher academic achievement. The prevalence of FSD in the primary care population was 29.6%. The prevalence of women with lack of orgasms, low sexual arousal, lack of lubrication, sexual dissatisfaction, and sexual pain were 59.1%, 60.9%, 50.4%, 52.2%, and 67.8%, respectively.

CONCLUSION

The risk factors for FSD are older age, Malays, married longer (more than 14 years), having less sexual intercourse (less than 1-2 times a week), having more children, married to an older husband (aged >42 years), and having a higher academic status. Lack of lubrication is found to be the main predictor for FSD in this study. Is lack of lubrication a cause or a complication of FSD? Prospective research is needed in the near future.

The Sexual Activity Questionnaire: Pychometric Properties And Normative Data in A Norwegian Population Sample

BACKGROUND

The Sexual Activity Questionnaire (SAQ) has been used in several trials of gynecological diseases and breast cancer, but normative data are lacking. The SAQ is the first patient self-administered questionnaire used to assess female sexuality in Norway, and we wanted to examine the psychometrics of the SAQ, reasons for sexual inactivity, and scorings on the SAQ function scale (SAQ-F).

METHODS

From public official address lists 2800 women aged 20-69 years were invited to take part in an anonymous questionnaire study, including the SAQ. Altogether 1165 women (42%) responded, and the response rates varied with age. Descriptive statistics and principal component analysis (PCA) of the SAQ were performed.

RESULTS

PCA confirmed a three-factor structure of the SAQ-F: habit, pleasure, and discomfort from sexual intercourse. The internal consistency of the SAQ-F showed a Cronbach's coefficient alpha of 0.86. "No current partner" was the main reason for sexual inactivity in all age groups. Tiredness as a reason for nonactivity was a significantly more cited cause among women in the age group 35-55 years compared with the younger and older groups. The prevalence of pleasure from sexual intercourse dropped significantly with increasing age. Normative findings on the SAQ-F are presented as percentiles in relation to age groups.

CONCLUSIONS

The SAQ is a short and discrete screening tool for sexual function, with good psychometric properties. Changes with age as to pleasure, habit, and discomfort confirmed construct validity of the SAQ-F, and the findings were used to produce age-related percentile scores of the SAQ-F considered helpful for clinical practice.

REVIEW: Female Sexual Satisfaction and Pharmaceutical Intervention: A Critical Review of the Drug Intervention Studies in Female Sexual Dysfunction

INTRODUCTION

A considerable number of double-blind randomized controlled studies investigating the effects of pharmaceutical intervention on female sexual functioning have been published in recent years. However, a comparison between outcomes of various studies is difficult as no generally accepted/correct approach to research has been established yet. To be able to translate trial results to daily clinical practice, current limitations and issues in drug intervention studies in female sexual dysfunction (FSD) need to be clarified.

AIM

To evaluate the needs in research into intervention in FSD by reviewing published studies.

METHODS

A systematic review of double-blind randomized controlled intervention trials on FSD.

MAIN OUTCOME MEASURES

Definitions of study populations, inclusion and exclusion criteria, use of power calculations, outcome measures and treatment duration.

RESULTS

A total of 25 double-blind randomized controlled trials investigating the effects of pharmaceutical intervention on female sexual functioning have been published. Of these, 11 studies required the diagnosis of FSD as an inclusion criterion. A standard methodology for research in this field is lacking. Significant differences in population inclusion requirements and tools for the measurement of change in sexual functioning were identified as major limiting factors.

CONCLUSIONS

The investigation of FSD is an evolving area in that new definitions and a new model for female sexual functioning have been recently proposed. There is a need for experts in the field and regulating authorities to reach a consensus regarding appropriate inclusion and exclusion criteria for FSD trials and main outcome measures appropriate for the evaluation of drug interventions. This consensus should also determine which treatment effect is considered to be clinically relevant. Treatment efficacy and clinical relevance should be related to outcomes which are meaningful for affected women.

Testosterone patch for the treatment of hypoactive sexual desire disorder in naturally menopausal women

OBJECTIVE

To evaluate the efficacy and safety of a testosterone patch for the treatment of women with hypoactive sexual desire disorder after natural menopause.

DESIGN

A multicenter, randomized, double-blind, placebo-controlled, parallel-group trial was conducted in naturally menopausal women with hypoactive sexual desire disorder receiving a stable dose of oral estrogen with or without progestin (N = 549). Women were randomized to receive testosterone 300 microg/day or placebo patches twice weekly for 24 weeks. The primary efficacy measure was change from baseline in frequency of total satisfying sexual activity over a 4-week period (weeks 21-24).

RESULTS

A total of 483 women (88%) were included in the primary analysis population (those with baseline sex hormone binding globulin levels < or = 160 nmol/L). The change from baseline in number of total satisfying sexual episodes was significantly greater for testosterone compared with placebo (participants with baseline sex hormone binding globulin levels < or = 160 nmol/L, mean change of 2.1 +/- 0.28 versus 0.5 +/- 0.23 episodes/4 weeks; P < 0.0001; intent-to-treat population, mean change from baseline of 1.9 +/- 0.26 versus 0.5 +/- 0.21 episodes/4 weeks, P < 0.0001). Testosterone also produced statistically significant improvements compared with placebo in all secondary efficacy measures, including sexual desire and personal distress. The testosterone patch was well tolerated.

CONCLUSIONS

Testosterone patch treatment increased the frequency of satisfying sexual activity and sexual desire, decreased personal distress, and was well tolerated in naturally menopausal women with hypoactive sexual desire disorder.

Hypoactive sexual desire disorder in postmenopausal women

Decreases in sex hormone levels with menopause may bring about a number of consequences in women's general health and sexual well-being, especially when levels decline suddenly and prematurely, as in surgical menopause. In addition to the well-established role of estrogens in preserving the biological basis of sexual response, there is emerging evidence that androgens are significant independent determinants affecting sexual desire, activity and satisfaction, as well as mood, energy and other components of women's health. Hypoactive sexual desire disorder (HSDD), a persistent absence of sexual fantasies or thoughts and/or desire for and receptivity to sexual activity that causes personal distress, is experienced by some postmenopausal women. Even though conventional hormone therapy with estrogens or estrogens and progestogens may be effective for vaginal atrophy, increasing vaginal lubrication and reducing dyspareunia, it has not been shown to consistently increase sexual desire or activity and many women with sexual dysfunction remain unresponsive. Several recent, large, phase III studies have shown that the addition of transdermal testosterone to conventional hormone therapy can be helpful in surgically menopausal women presenting with HSDD. After 24 weeks of treatment in these studies, testosterone-treated women experienced significantly greater increases in satisfying sexual activity and sexual desire, and greater decreases in distress, than placebo-treated women. Accurate clinical assessment and individualized management of sexual symptoms are fundamentally important for all menopausal women with HSDD or other sexual problems.

Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women

OBJECTIVE

Evaluation of the use of testosterone therapy for hypoactive sexual desire disorder (HSDD) after oophorectomy has mostly involved women treated with oral estrogen preparations. We investigated the efficacy and safety of a testosterone patch in surgically menopausal women receiving concurrent transdermal estrogen.

DESIGN

Women with HSDD after oophorectomy, for whom this was a concern, who were using transdermal estrogen, were recruited to a 24-week, randomized, double-blind, placebo-controlled trial in Europe and Australia. Patients were randomly allocated to placebo (n = 40) or testosterone 300 microg/day (n = 37) treatment. Primary endpoints were changes in sexual desire measured by the sexual desire domain of the Profile of Female Sexual Function and the frequency of satisfying sexual activity at 24 weeks.

RESULTS

Sixty-one women (79%) completed the trial. All subjects who received at least one application of study medication were included in analysis. The testosterone-treated group experienced a significantly greater change from baseline in the domain sexual desire score compared with placebo (change from baseline, 16.43 versus 5.98; P = 0.02). The domain scores for arousal, orgasm, decreased sexual concerns, responsiveness, and self-image as well as decreased distress were also significantly greater with testosterone therapy than placebo. The frequency of satisfactory sexual events increased but was not statistically different between treatment groups (P = 0.06) Adverse events occurred with similar frequency in both groups, and no serious risks of therapy were observed

CONCLUSIONS

In this study, transdermal testosterone therapy via a skin patch improved sexual desire and other sexual function domains. It was well tolerated in these oophorectomized women with HSDD receiving concomitant transdermal estrogen.

Hypoactive Sexual Desire Disorder in Menopausal Women: A Survey of Western European Women

INTRODUCTION

The prevalence of hypoactive sexual desire disorder (HSDD) in menopausal women and the frequency of sexual activity, sexual behavior, and relationship or sexual satisfaction associated with HSDD have not been studied using validated instruments to identify women with HSDD.

AIMS

To determine: (i) the prevalence of HSDD among women who have undergone hysterectomy and bilateral oophorectomy (surgical menopause) with that of premenopausal or naturally menopausal women; (ii) the relationship between low sexual desire and sexual activity and behavior; and (iii) the relationship between low sexual desire and sexual or partner relationship satisfaction.

METHODS

Cross-sectional survey of 2,467 European women aged 20-70 years, resident in France, Germany, Italy, and the United Kingdom. Measures were the Profile of Female Sexual Function (PFSF), Personal Distress Scale (PDS), and a sexual activities measure.

OUTCOME MEASURES

Clinically derived cutoff scores for the desire domain of the PFSF and the PDS were used, sequentially, to classify women as having low sexual desire and to further classify these women with low desire as distressed or nondistressed. Thus, women with HSDD had low sexual desire and were distressed by their low desire. The analysis population included 1,356 women who had current sexual partners and were surgically menopausal, regularly menstruating, or naturally postmenopausal.

RESULTS

A greater proportion of surgically menopausal women had low sexual desire compared with premenopausal or naturally menopausal women (odds ratio [OR] = 1.4; confidence interval [CI] = 1.1, 1.9; P = 0.02). Surgically menopausal women were more likely to have HSDD than premenopausal or naturally menopausal women (OR = 2.1; CI = 1.4, 3.4; P = 0.001). Sexual desire scores and sexual arousal, orgasm, and sexual pleasure were highly correlated (P < 0.001), demonstrating that low sexual desire is frequently associated with decreased functioning in other aspects of sexual response. Women with low sexual desire were less likely to engage in sexual activity and more likely to be dissatisfied with their sex life and partner relationship than women with normal desire (P < 0.001).

CONCLUSIONS

Surgically menopausal women are at increased risk for HSDD. HSDD is associated with diminished sexual and partner relationship satisfaction and negative emotional states.

Hypoactive sexual desire disorder in postmenopausal women: US results from the Women's International Study of Health and Sexuality (WISHeS)

OBJECTIVE

To determine the prevalence of hypoactive sexual desire disorder (HSDD) among US women by reproductive status and age and to explore the correlates of sexually related distress.

DESIGN

The Women's International Study on Health and Sexuality questionnaire was mailed to a national sample of US women in 2000. The survey included validated questionnaires: the Short Form-36, which measures overall health status; the Profile of Female Sexual Function, which assesses sexual desire; and the Personal Distress Scale, which measures distress caused by low desire. Four groups of women were studied: surgically postmenopausal, aged 20 to 49 years and 50 to 70 years; premenopausal, aged 20 to 49 years; and naturally postmenopausal, aged 50 to 70 years. Clinically derived cutoff Profile of Female Sexual Function and Personal Distress Scale scores were used to classify women with HSDD and determine its prevalence. The relations between sexual desire and frequency of sexual activity or relationship satisfaction were assessed. Overall health status of HSDD women and women with normal desire were compared.

RESULTS

The prevalence of HSDD ranged from 9% in naturally postmenopausal women to 26% in younger surgically postmenopausal women. The prevalence of HSDD was significantly greater among surgically postmenopausal women, aged 20 to 49 years, than premenopausal women of similar age, whereas there were no significant differences in the prevalence between surgically postmenopausal women, aged 50 to 70 years, and naturally postmenopausal women. For many women, HSDD was associated with emotional and psychological distress as well as significantly lower sexual and partner satisfaction. HSDD was also associated with significant decrements in general health status, including aspects of mental and physical health.

CONCLUSIONS

HSDD is prevalent among women at all reproductive stages, with younger surgically postmenopausal women at greater risk, and is associated with a less active sex life and decreased sexual and relationship satisfaction.

Testosterone patch increases sexual activity and desire in surgically menopausal women with hypoactive sexual desire disorder

CONTEXT

Hypoactive sexual desire disorder (HSDD) is one of the most common sexual problems reported by women, but few studies have been conducted to evaluate treatments for this condition.

OBJECTIVE

The objective of this study was to evaluate the efficacy and safety of a testosterone patch in surgically menopausal women with HSDD.

DESIGN

The design was a randomized, double-blind, parallel-group, placebo-controlled, 24-wk study (the Intimate SM 1 study).

SETTING

The study was performed at private or institutional practices.

PATIENTS

The subjects studied were women, aged 26-70 yr, with HSDD after bilateral salpingo-oophorectomy who were receiving concomitant estrogen therapy. Placebo (n = 279) or testosterone 300 microg/d (n = 283) was administered. There were 19 patients who withdrew due to adverse events in the placebo group and 24 in the 300 mug/d testosterone group.

INTERVENTION

Testosterone (300 microg/d) or placebo patches were applied twice weekly.

MAIN OUTCOME MEASURE(S)

The primary end point was the change in the frequency of total satisfying sexual activity at 24 wk. Secondary end points included other sexual functioning end points and safety assessments.

RESULTS

At 24 wk, there was an increase from baseline in the frequency of total satisfying sexual activity of 2.10 episodes/4 wk in the testosterone group, which was significantly greater than the change of 0.98 episodes/4 wk in the placebo group (P = 0.0003). The testosterone group also experienced statistically significant improvements in sexual desire and a decrease in distress. The overall safety profile was similar in both treatment groups.

CONCLUSION

In the Intimate SM 1 study, the testosterone patch improved sexual function and decreased distress in surgically menopausal women with HSDD and was well tolerated in this trial.

Testosterone Patch for Low Sexual Desire in Surgically Menopausal Women: A Randomized Trial

OBJECTIVE

To assess the efficacy and safety of a 300 mug/d testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women on concomitant estrogen therapy.

METHODS

Five hundred thirty-three women with hypoactive sexual desire disorder who had undergone previous hysterectomy and bilateral oophorectomy were enrolled in a 24-week, multicenter, double-blind, placebo-controlled trial. Patients were randomly assigned to receive placebo or the testosterone patch twice weekly. The primary efficacy endpoint was change from baseline at week 24 in the frequency of total satisfying sexual activity, measured by the Sexual Activity Log. Secondary measures included sexual desire using the Profile of Female Sexual Function and personal distress as measured by the Personal Distress Scale. Hormone levels, adverse events, and clinical laboratory measures were reviewed.

RESULTS

Total satisfying sexual activity significantly improved in the testosterone patch group compared with placebo after 24 weeks (mean change from baseline, 1.56 compared with 0.73 episodes per 4 weeks, P = .001). Treatment with the testosterone patch also significantly improved sexual desire (mean change, 10.57 compared with 4.29, P < .001) and decreased personal distress (P = .009). Serum free, total, and bioavailable testosterone concentrations increased from baseline. Overall, adverse events were similar in both groups (P > .05). The incidence of androgenic adverse events was higher in the testosterone group; most androgenic adverse events were mild.

CONCLUSION

In surgically menopausal women with hypoactive sexual desire disorder, a 300 mug/d testosterone patch significantly increased satisfying sexual activity and sexual desire, while decreasing personal distress, and was well tolerated through up to 24 weeks of use.