Future Targets for Female Sexual Dysfunction

Is marijuana a foe of male sexuality? Data from a large cohort of men with sexual dysfunction

BACKGROUND

Although it has been assumed that chronic cannabis use may have an unfavorable impact on male sexual function and its metabolic correlates, evidence from clinical studies remains inconclusive.

OBJECTIVE

To investigate the relationship between cannabis use and sexual behavior, anthropometrics and metabolic/vascular profiles in a large series of men evaluated for sexual dysfunction.

METHODS

A total of 4800 men (mean age 50.8 years) attending an andrology outpatient clinic for sexual dysfunction were studied. Sexual symptoms, hormonal, metabolic, and instrumental (penile color Doppler ultrasound, PCDU) parameters were evaluated according to the reported habitual use of recreational substances (no use, 1-2 joints/week, >2 joints/week, and use of illicit drugs other than cannabis).

RESULTS

When compared with non-users, cannabis users were younger and exhibited a lower prevalence of comorbidities as well as better PCDU parameters, despite reporting higher alcohol and tobacco consumption. After adjustment for confounders, cannabis use was associated with a greater instability in the couple's relationship and a higher frequency of masturbation. In addition, the group smoking >2 joints/week showed a significantly lower body mass index than both controls and users of substances other than cannabis. Men who reported using recreational drugs (either cannabis or other) exhibited significantly lower levels of both total and low-density lipoprotein cholesterol than non-users. At the PCDU, smoking 1-2 joints/week was associated with significantly higher dynamic peak systolic velocity than both non-drug use and use of >2 joints/week. Prolactin levels were significantly higher in individuals smoking 1-2 joints/week and in those who used substances other than cannabis when compared with controls, whereas no difference in total testosterone levels was observed.

DISCUSSION

In men with sexual dysfunction, mild cannabis consumption may be associated with a more favorable anthropometric and lipid profile and with a better penile arterial vascular response to intracavernous prostaglandin injection.

The impact of cell-based therapy on female sexual dysfunction: a systematic review and meta-analysis

INTRODUCTION

Female sexual dysfunction (FSD) is a complex issue affecting women of all ages; it involves several overlapping body systems and profoundly affects quality of life. The use of cell-based therapy, such as mesenchymal stem cells, has recently been investigated as a potential treatment for FSD.

OBJECTIVES

This systematic review and meta-analysis aim to assess FSD outcomes following cell-based therapy.

METHODS

We evaluated peer-reviewed articles from multiple online databases through November 2022 to identify studies that used cell-based therapy and reported sexual function outcomes in women. We performed a meta-analysis using data pooled from 3 clinical trials at our institution: CRATUS (NCT02065245), ACESO (NCT02886884), and CERES (NCT03059355). All 3 trials collected data from the Sexual Quality of Life-Female (SQOL-F) questionnaire as an exploratory outcome.

RESULTS

Existing literature on this topic is scarce. Five clinical studies and 1 animal study were included in the systematic review, and only 2 clinical studies were considered good quality: 1 reported significant SQOL-F improvement in women 6 months after cell therapy, and 1 reported posttherapy sexual satisfaction in all women. When individual patient data were pooled in a meta-analysis from 29 women across 3 trials at our institution, the SQOL-F was not significantly improved.

CONCLUSION

Despite growing interest in cell-based therapy for women's sexual health, this important issue is understudied in the literature. The optimal route, source, and dose of cell therapy to produce clinically meaningful change have yet to be determined, and further research is needed in larger randomized placebo-controlled clinical trials.

Pharmacotherapy for female sexual dysfunctions (FSDs): what is on the market and where is this field heading?

INTRODUCTION

Female sexual dysfunctions (FSDs) are common in women of any age and have a huge impact on quality of life and relationships. They have a multifaceted etiology limiting the development of pharmacotherapies with a high rate of effectiveness. Safety issues are also a concern.

AREAS COVERED

The authors report the most recent advances in pharmacotherapy for premenopausal and postmenopausal women with a main focus on hypoactive sexual desire disorders (HSDD) and associated sexual symptoms. Good levels of evidence have emerged for psychoactive agents, such as flibanserin and bremelanotide, as well as hormonal compounds (transdermal testosterone). The authors also report briefly on intravaginal DHEA (prasterone), local estrogen therapy (LET), and ospemifene to manage effectively vulvovaginal atrophy/genitourinary syndrome of menopause (VVA/GSM). In addition, they discuss promising therapeutic options highlighting the main reasons that hamper the availability of new labeled products. Finally, they include the importance of the multimodal approach to address FSDs.

EXPERT OPINION

Approved pharmacotherapies for FSD are limited. Validated multidimensional instruments and adequate objective measures of physical and mental responses to sexual external and internal incentives are mandatory to identify women suitable to chronic or on-demand treatments and to assess their pattern of response in research and practice.

Paced Mating Behaviour Is Influenced by Duration of Female Post-Ejaculatory Interval

BACKGROUND

Laboratory paradigms that enable the female rat to control the frequency and temporal distribution of sexual stimulation are well-suited to gaining knowledge about female sexual function; however, the variety of procedures used influence the specific behaviors exhibited by female rats and bring uncertainty into the conclusions that can be drawn.

AIM

In this study, we evaluated the effects of test parameters on the display of paced mating behavior in female rats to develop better preclinical models for exploring female sexual health.

METHODS

Sexually experienced, estradiol- and progesterone-primed female rats were tested under paced mating conditions to determine whether sexual behavior differed as a function of number of male partners (1 or 3; Experiment 1), the time span between receipt of an ejaculation and the next intromission (ie, the post-ejaculatory interval or PEI; Experiment 2), or the duration of ejaculations (Experiment 3).

OUTCOMES

Contact-return latency, exit latency, and withdrawal duration after mounts, intromissions, and ejaculations.

RESULTS

The shorter withdrawal latency after intromission and longer return latency after ejaculation observed in 30-minute paced mating tests is best attributed to the female's PEI. The duration of the PEI is a specific factor that affects the display of paced mating behavior.

CLINICAL TRANSLATION

Understanding of neurobiological mechanisms and sensory factors influencing sexual behavior learned from these models can be applied to studies of human female sexual health.

STRENGTHS & LIMITATIONS

Sexual motivation is indicated by analogous behaviors and supported by evolutionarily conserved systems in women and rats, meaning that animal models can be used to identify neurobiological mechanisms subserving these behaviors. Nonetheless, data related specifically to physiological effects of different mating paradigms are needed in future research.

CONCLUSION

Procedures that mimic naturalistic settings, and thus enable female sexual motivation to drive behavior, are apt for studies aimed at understanding mechanisms supporting female sexual function whereas artificially lengthening the interval between an ejaculation and subsequent intromission may provide a model to study female sexual dysfunction.

Characteristics of Female Sexual Health Programs and Providers in the United States

Background

Female sexual dysfunction is a prevalent condition affecting 12% of women, yet few academic centers in the US have female sexual medicine programs.

Aim

To characterize female sexual health programs in the United States, services offered, and training of female sexual health providers.

Methods

We performed an internet search to identify female sexual health programs and clinics in the US. From each programs’ website we abstracted the location, clinic setting (academic vs private), training of providers, and whether the clinic provided investigational services (ie, PRP injections, laser/radiofrequency therapy). We categorized clinics as specialized in sexual medicine, specialized with a focus on cancer patients, general, aesthetics-focused, general & aesthetic, or specialized & aesthetic. We used Chi-square and Fisher's exact test to evaluate association between practice setting and provision of investigational therapies with a Bonferroni-adjusted critical P-value of 0.017.

Outcomes

Our outcomes were the number of clinics in each setting, in each category, and each state, as well as the number of providers by training type.

Results

We identified 235 female sexual medicine programs in the United States. Seventeen percent were in the academic setting. Clinics in the non-academic setting were significantly (α = 0.017) more likely to offer PRP injections (0% vs 47%, P < .001), laser/radiofrequency therapy (14% vs 56%, P < .0001), and shockwave therapy (0% vs 14%, P = .011). Among all clinics, 22% provided specialized care, 2% provided care for cancer patients, 29% were more general clinics that advertised female sexual healthcare, 23% were aesthetics-focused, 22% were general practices that provided aesthetics services, and 2% were specialized clinics that offered aesthetics services. 81% of aesthetics-focused clinics advertised PRP injections. Seven states had no clinics and 26 states lacked a clinic specializing in female sexual health. The most frequent providers were OB/Gyns (40%), nurse practitioners (22%), urologists (13%), and physicians assistants (10%).

Clinical Implications

The geographic distribution of clinics and pervasiveness of clinics offering investigational services for female sexual dysfunction may be a barrier for patients seeking care.

Limitations

As a result of our internet search methodology, we likely did not capture all clinics providing female sexual health services. Further, the accuracy of our data depends on the level of detail provided on each clinics’ website.

Conclusion

Online search identified few clinics providing female sexual healthcare in academic medicine: development of such clinics could benefit patients by improving access to evidence-based care and promoting training of future providers.

Elizabeth E. Stanley and Rachel J. Pope, Characteristics of Female Sexual Health Programs and Providers in the United States. Sex Med 2022;10:100524.

Preparation and In Vitro and In Vivo Evaluation of a Testosterone Film Forming Gel for the Treatment of Hypoactive Sexual Desire Disorder in Women

Hypoactive sexual desire disorder (HSDD) is one of the most common sexual complaints in women. Currently, there is an unmet need for a drug treatment for this disorder. The purpose of this study was to develop a testosterone (TS) film forming gel used for women to treat HSDD by measuring the tackiness, peel adhesion force, tensile strength, and elasticity of the formulation. Diethylene glycol monoethyl ether (Transcutol P), an efficient penetration enhancer, was added to the optimized formulation and the transdermal permeation characteristics in vitro were studied using Franz-diffusion cells. The quantitative determination of TS was performed by high-performance liquid chromatography (HPLC). After 24 h, Transcutol P at 3% had the largest cumulative amount of drug and enhancement ratio of TS of 75.14 μg/cm² and 2.82, respectively. After the screening of film forming polymers and penetration enhancers, the optimal formulation was as follows: glycerol (1%, w/w); 12.5% sodium carboxymethylcellulose (CMC-Na) aqueous solution (0.5%, w/w); 2.5% Carbomer ethanol solution (0.5%, w/w); Transcutol P ethanol solution (3%, w/w) containing 0.5% TS; and 8% Poly vinyl alcohol (PVA) aqueous solution (30%, w/w). The optimized film forming gel had good uniformity and the release of TS in vitro was close to 100% within 24 h. In vivo studies showed the formulations had optimal area under blood drug concentration curve values in the order of 3% Transcutol P > 1% Transcutol P > 5% Transcutol P > control preparation. The formulation with 3% Transcutol P provided the highest permeation effect both in vitro and in vivo. The safety of this formulation was further evaluated with a skin irritation test. It could effectively improve the rabbit skin irritation observed with a marketed transdermal patch Androderm®. The present study provides a promising approach for the development of a novel TS film forming gel for the treatment of HSDD in women.

Erectile Function and Sexual Behavior: A Review of the Role of Nitric Oxide in the Central Nervous System

Nitric oxide (NO), the neuromodulator/neurotransmitter formed from l-arginine by neuronal, endothelial and inducible NO synthases, is involved in numerous functions across the body, from the control of arterial blood pressure to penile erection, and at central level from energy homeostasis regulation to memory, learning and sexual behavior. The aim of this work is to review earlier studies showing that NO plays a role in erectile function and sexual behavior in the hypothalamus and its paraventricular nucleus and the medial preoptic area, and integrate these findings with those of recent studies on this matter. This revisitation shows that NO influences erectile function and sexual behavior in males and females by acting not only in the paraventricular nucleus and medial preoptic area but also in extrahypothalamic brain areas, often with different mechanisms. Most importantly, since these areas are strictly interconnected with the paraventricular nucleus and medial preoptic area, send to and receive neural projections from the spinal cord, in which sexual communication between brain and genital apparatus takes place, this review reveals that central NO participates in concert with neurotransmitters/neuropeptides to a neural circuit controlling both the consummatory (penile erection, copulation, lordosis) and appetitive components (sexual motivation, arousal, reward) of sexual behavior.

Evaluation of temporal changes in the sexual function among Japanese women using the female sexual function index: An Internet survey

Objectives:

Female sexual dysfunction is an underestimated problem that negatively affects women’s quality of life. Although the overall prevalence of sexual dysfunction in women is high, only a few studies have focused on this problem. In Japan, an index of female sexual function has not been clearly defined. Hence, this study aimed to investigate the sexual function of normal Japanese women and the temporal changes they experienced using the Female Sexual Function Index administered online in 2012 and 2019.

Methods:

The subjects were Japanese women aged 20–79 years registered in an Internet research company. We collected data of 1034 and 2031 women in 2012 and 2019, respectively, based on Japan’s population distribution according to age. Subsequently, we analyzed the collected data using a Japanese version of the Female Sexual Function Index. We investigated the temporal changes in the Female Sexual Function Index total score, the ratio of women who did not engage in sexual activities and women having “no sexual activity” with their partners, and the total Female Sexual Function Index scores according to age.

Results:

The average Female Sexual Function Index total score decreased from 14.6 in 2012 to 12.5 in 2019 (p < 0.001). No significant difference was observed in the average Female Sexual Function Index score of the group with sexual activity between 2012 (22.2) and 2019 (22.4). The ratio of women not engaging in sexual activities increased from 42.2% in 2012 to 54.0% in 2019. The ratio of women having “no sexual activity” with their partners increased by 10%.

Conclusion:

Comparison of data between 2012 and 2019 indicated that Japanese women have become less sexually active. The average Female Sexual Function Index total score of 22 may be useful as a reference value for diagnosing female sexual dysfunction in Japan.

[Interest of transcranial stimulation in pelvic and perineal disorders]

OBJECTIVE

The aim of this article was to describe the diagnostic and therapeutic value of transcranial stimulation in pelvic and perineal disorders.

METHODS

A literature review (Medline database and Google scholar) with no time limit was performed using keywords: "transcranial direct stimulation", "transcranial magnetic stimulation", "neurogenic bladder", "urinary incontinence", "Parkinson disease", "multiple sclerosis", "stroke", "muscle spasticity", "pelvic pain", "visceral pain".

RESULTS

Twelve articles have been selected. Transcranial magnetic or electrical stimulation is a noninvasive neuromodulation technique widely used to establish brain maps to highlight causal relationships between brain and function. Regarding pelvic-perineal disorders, repeated transcranial stimulation has shown significant effects for the treatment of overactive bladder in Parkinson's disease (P<0.05) and multiple sclerosis, but also for the treatment of refractory chronic pelvic pain (P=0.026). Finally, therapeutic effects have also been demonstrated in irritable bowel syndrome. No evidence of efficacy was found on genito-sexual disorders.

CONCLUSION

Data from the literature suggest that transcranial stimulation is a noninvasive treatment that may have a role in the management of pelvic and perineal disorders. Its promising field of action would require prospective and randomized studies on a larger scale.

Autologous Platelet-Released Growth Factor and Sexual Dysfunction Amendment: A Pilot Clinical Trial of Successful Improvement Sexual Dysfunction after Pelvic Irradiation

Sexual dysfunction (SDF) is a common sequel to cancer treatment which affects the quality of life in women treated with pelvic radiotherapy. The aim of this study was to evaluate the safety, symptom resolution and objective improvement the injection of autologous platelet released growth factor (APRGF) for treatment of SDF in cited patients. This prospective pilot study enrolled 10 cancer-free patients with SDF who underwent pelvic radiotherapy at least 5 years ago, randomly. Each patient was received 1-2 cc APRGF within four weeks and all patients were re-evaluated at eight weeks and six months. CD34 immuno histochemistry and Masson’s trichrome staining were performed on vaginal biopsy section for angiogenesis and fibrosis assay respectively. Sexual satisfaction after the injection of APRFG was clinically difference and the entire patient had sexual satisfaction. In the patient’s follow-up, none of them needs to repeat the treatment. Our results declared that APRGF injection was effective and symptoms were disappeared in the entire patients. Significant objective improvements in vaginal diameter (mean before injection, 6.5 cm vs 7.1 cm after injection) (p-value = 0.001) and vaginal flexibility (mean before treatment, 0.72 cm vs 1.85 cm after injection) (P-value = 0.026) were observed. Characteristics of discharge before the injection in 60% of patients were included dry vagina and 40% had mild discharge but after injection 40% of patients had moderate and also 60% had mild and sufficient discharge (P-value= 0.190). Overally, our patients reported better sexual function and showed better vaginal function indexes, after APRFG injection.

Efficacy and tolerability of a spray formulation containing Visnadine in women self-reporting sexual symptoms: a randomized double-blind placebo-controlled pilot study

PURPOSE

The aim of this pilot, double-blind, randomized, placebo-controlled study, was to evaluate both the efficacy and the tolerability of a formulation for vulvar application containing Visnadine, a natural extractive substance with vasoactive properties, (ReFeel^® spray, IDI Integratori Dietetici Italiani S.r.l., Italy) in women self-reporting sexual symptoms.

METHODS

Sixty women (age range 18-60 years) volunteered to test the product against placebo (PL): Two puffs in the vulvar area, 10 min before sexual stimulation, for 30 days and for a minimum of six times. The main outcome measure was the improvement of the Female Sexual Function Index (FSFI) score (cut-off ≤ 26.55 for female sexual dysfunction [FSD]). Secondary outcomes were sexual satisfaction and tolerability with the product.

RESULTS

PL group (n = 28) and Visnadine group (n = 30) were comparable for age, sexual function and rate of FSD at baseline (T0). After 1 month (T1), women in Visnadine group scored from 25.0 ± 3.8 to 27.9 ± 2.4 (p < 0.001), whereas no changes were evident in PL group (from 25.4 ± 5.0 to 25.6 ± 4.7). Statistically significant differences at T1 were reported in women with a positive (p < 0.001) or a negative FSD diagnosis (p < 0.01) using active treatment. Women with FSD reported significantly more improvement in satisfaction with their sexual function when treated with Visnadine spray compared to PL (p < 0.001), as well as more excitation (p < 0.001), pleasure (p < 0.001) and less time to reach orgasm (p < 0.003). No significant side effects were evident in both groups.

CONCLUSIONS

On demand, 1-month use of Visnadine spray displayed positive effects on sexual function in women with and without FSD and it was well tolerated. Topical Visnadine may not only be part of multimodal strategies to manage clinically relevant sexual symptoms but also simply to help women to enhance their subjective impaired perception of sexual response.

A Pilot Study of a Topical Intervention for Treatment of Female Sexual Dysfunction

PURPOSE/BACKGROUND

Many investigators reported that pharmacological treatment of female sexual dysfunction (FSD) has been a promising field yet to be explored. The purpose of this pilot study was to investigate the efficacy and safety of a topical cream containing small concentrations of three vasodilators with different mechanisms of action in treating FSD.

METHODS

In this randomized, controlled pilot trial, premenopausal (n = 30) and postmenopausal (n = 30) cases of 21- to 62-year age range with FSD were allocated randomly into 15 given placebo or 15 given active cream in each group. The women included had FSD for more than a 6-month duration and a total score of Female Sexual Distress Scale-Revised of at least 15. Assessing sexual function by measuring female sexual function index (FSFI) during five clinic visits, one at the end of baseline week and at the end of each week of the 4-week treatment period. The primary end point was changed from baseline FSFI total scores to week 4 treatment. Secondary end point included the changes from baseline arousal, desire, orgasm, and satisfaction scores to week 4 treatment.

FINDINGS/RESULTS

The sexual problem reported by patients was orgasmic or/and arousal disorders. In premenopausal cases, active cream led to a high significant increase in mean change FSFI total score from the baseline to week 4 compared with placebo (1.7 ± 1.886 vs 13.35 ± 4.646, respectively; P < 0.0001). Greater improvement of mean change of orgasm and arousal domain score was also observed (0.3 ± 0.45 and 0.35 ± 0.39 vs. 2.66 ± 0.63 and 1.87 ± 0.168, respectively; P < 0.0001). In postmenopausal cases, there were significantly greater improvements with active cream in all sexual functions compared with placebo cream (P < 0.0001). In triple cream, mean change of FSFI total score, orgasm domain score, and arousal score domain were 14.85 ± 6.33, 1.87 ± 0.168 and 2.66 ± 1.182, whereas in the placebo cream, they were 1.54 ± 2.1,0.7 ± 0.76 and 0.22 ± 0.44, respectively. Meanwhile, orgasm scores increased significantly after the use of placebo cream. No serious adverse effects were reported during treatment.

IMPLICATIONS/CONCLUSIONS

The results of the pilot trial suggest that topical cream containing small concentrations of three vasodilators may act synergistically, and was effective in improving arousal, orgasmic, and satisfaction disorder with a safer profile for premenopausal and postmenopausal women with FSD. Further studies are recommended to be conducted using a large number of nondepressive and depressive patients.

Randomized crossover study investigating daily versus on-demand vulvar Visnadine spray in women affected by female sexual arousal disorder

The aim of the study was to verify the efficacy of vulvar Visnadine spray in premenopausal women affected by female sexual arousal disorder (FSAD). Thirty-eight women aged 25-40 years affected by FSAD were enrolled in the randomized crossover study, by two possible sequences: on-demand, washout, daily (A sequence); and daily, washout, on-demand (B sequence). The Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) were used to assess sexual function and sexual distress, respectively. Color Doppler ultrasonography was used to measure clitoral blood flow. The study had two follow-ups at 30 (T1) and 60 days (T2). Thirty-one women completed the study. Mean (SD) sexual activity and vulvar Visnadine spray usage was 1 ± 0.9 weekly during on-demand administration for both the sequences (Vs T0, p = NS). The mean sexual activity during daily usage was 2 ± 0.9 (Vs T0, p < .004) and 2 ± 0.8 (Vs T0, p < .001) for A and B sequences, respectively. FSFI total score, particularly genital arousal, improved more during the daily than during on-demand phases of both sequences (p < .001). Finally, clitoral blood flow improved significantly during daily usage of both the sequences (p < .001). Our study suggests that vulvar Visnadine spray could improve sexual performance of women affected by FSAD, producing changes in subjective and objective sexual aspects.

Evidence-based treatments for low sexual desire in women

Low sexual desire is the most common sexual complaint in women, with multinational studies finding that at least a third of women experience low sexual desire. No single etiology for the development of Female Sexual Interest/Arousal Disorder, the diagnosis laid out by the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, has been established. There has been considerable interest in pharmacological approaches to improving low desire, and agents targeting a range of neurotransmitters have been examined. To date, only flibanserin, a centrally acting medication targeting the serotonin, dopamine, and norepinephrine systems, has been approved by the Food and Drug Administration (FDA). Despite statistically significant effects on sexual desire, sexual distress, and sexually satisfying events, side-effects are significant, and flibanserin is completely contraindicated with alcohol. As such, there has been renewed interest in advancing the science of psychological approaches to low desire, including cognitive behavioral and mindfulness therapies.

Women’s Sexual Desire

Abstract. Recent changes in the classification of female sexual dysfunction in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the US Food and Drug Administration’s (FDA) approval of the first drug to treat low sexual desire in women (flibanserin) have highlighted the intense focus on sexual desire problems in women. We first discuss the rationale for the DSM changes and outline the DSM-5 criteria for Female Sexual Interest/Arousal Disorder. We provide an overview of some of the key events leading up to the approval of flibanserin for the treatment of hypoactive sexual desire disorder in women, including the role of the “Even the Score” advocacy campaign, that accused the FDA of gender bias in not giving women with sexual desire problems access to treatment options. Incorporating narratives from testimonials of female patients attending the 2014 FDA Patient-Focused Drug Development Public Meeting, we examine some of the prevalent beliefs around sexual “normalcy” and the immutability of sexual desire. We critique how the media and pharmaceutical companies depict sexual norms and female sexual desire and how pharmaceutical trials often narrowly define and assess sexual desire and “sex.” We end with some recommendations for how researchers, clinicians, and journalists can better acknowledge that sex and desire have multiple meanings and interpretations with a view to women being offered a truly informed choice when seeking help for sexual problems.