Androgens and Psychosocial Factors Related to Sexual Dysfunctions in Premenopausal Women∗: ∗2016 ISSM Female Sexual Dysfunction Prize

Understanding sexual distress related to sexual function (SDRSF): A preliminary framework based on a qualitative study with clinical sexologists

Introduction

Sexual distress related to sexual function (SDRSF) is pivotal in diagnosing sexual dysfunction. However, there is a lack of theoretical models for its comprehension and of knowledge concerning how to address it in clinical practice.

Aim

To contribute to theory building and clinical practice about SDRSF by collecting clinicians' accounts, aiming to inform a preliminary framework to study and intervene in SDRSF.

Method

Reflexive thematic analysis was used to analyze the data from 16 semi-structured interviews with clinical sexologists. Results: Three main themes were created: (1) Burning from the inside, (2) Wicked games, and (3) Running up that hill. Participants revealed a multidimensional understanding of SDRSF in clinical settings that integrates individual, sociocultural, interpersonal and situational factors. This underscores the interconnected nature of SDRSF, revealing its links to different facets of overall distress in clinical settings. We present a preliminary framework that may be analytically generalized to enhance the comprehension of the specificities of SDRSF.

Conclusion

These insights frame a comprehensive conceptualization of SDRSF in clinical settings that goes beyond sexual activity and implies that interpersonal and societal factors need to be considered in research and intervention in this field.

Correlation of sexual desire with sexual hormone binding globulin and free androgen index in women using combined contraceptives

PURPOSE

To correlate the sexual desire levels with sexual hormone binding globulin and free androgen index in women taking different types of hormonal contraceptives (HCs) containing ethinylestradiol (EE), oestradiol valerate (E2V), 17β-oestradiol (E2), or estetrol (E4), combined or in phasic formulation with different progestogens having antiandrogenic properties.

METHODS

Three hundred and sixty-seven women (age range 18-46) participated in the study. SHBG and total testosterone (TT) were measured, and the Free Androgen Index (FAI) was calculated. The Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) questionnaires were used to assess sexual function and distress, respectively.

RESULTS

The highest SHBG values and the lowest FAIs were obtained of women on HCs containing EE than those of women on HCs containing E2V/17β E2 or E4 (p < 0.001). Desire scores and FSFI total scores were lower in women on HCs with EE than in those using HCs containing E2V, 17β E2, or E4 (p ≤ 0.001). The women who were on HCs containing EE reported FSDS levels higher than those containing all the other types of oestrogen. Finally, sexual desire and FSFI total scores had a negative correlation with the SHBG values and a positive correlation with FAI percentage (p ≤ 0.0001).

CONCLUSIONS

A minority of women using HCs with EE might experience a decreased sexual desire. This was not observed in women on HCs containing E2V, 17 E2, or E4. To avoid HC discontinuation, due to sexual desire reduction, HCs having minor antiandrogenic effects could be taken into consideration.

Longitudinal changes in sexual desire and attraction among women who started using the Natural Cycles app

Many women experience sexual side effects, such as decreased libido, when taking hormonal contraceptives (HCs). However, little is known about the extent to which libido recovers after discontinuing HCs, nor about the timeframe in which recovery is expected to occur. Given that HCs suppress the activities of multiple endogenous hormones that regulate both the ovulatory cycle and women's sexual function, resumption of cycles should predict libido recovery. Here, using a combination of repeated and retrospective measures, we examined changes in sexual desire and partner attraction (among partnered women) across a three-month period in a sample of Natural Cycles users (Survey 1: n = 1596; Survey 2: n = 550) who recently discontinued HCs. We also tested whether changes in these outcomes coincided with resumption of the ovulatory cycle and whether they were associated with additional factors related to HC use (e.g., duration of HC use) or relationship characteristics (e.g., relationship length). Results revealed that both sexual desire and partner attraction, on average, increased across three months after beginning to use Natural Cycles. While the prediction that changes in sexual desire would co-occur with cycle resumption was supported, there was also evidence that libido continued to increase even after cycles resumed. Together, these results offer new insights into relationships between HC discontinuation and women's sexual psychology and lay the groundwork for future research exploring the mechanisms underlying these effects.

Assessment of the effect of cannabis use before partnered sex on women with and without orgasm difficulty

Background

Up to 41% of women face challenges achieving orgasm, a statistic unchanged for 50 years.

Aim

To evaluate the effect of cannabis use before partnered sex on women with and without difficulty achieving orgasm.

Methods

This observational study evaluated responses from female study participants relating to their demographics, sexual activities, mental well-being, cannabis usage, and orgasm-related questions from the Female Sexual Function Index (FSFI).

Outcomes

Outcomes included orgasm frequency, difficulty, and satisfaction related to cannabis use or lack of use before partnered sex, largely based on the FSFI orgasm subscale.

Results

Of the 1037 survey responses, 410 were valid and complete. Twenty-three surveys (5.6% returned) were excluded due to failure to meet the study's criteria. Of the valid surveys, most women (52%, n = 202) reported difficulty achieving orgasm during sexual activity with a partner. These women were primarily between 25 and 34 years of age (45%, n = 91); 75% identified their race as White (n = 152/202); 52% (n = 105) identified as LGBTQI+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, or other); and 82% (n = 165) were married or in a relationship. Among participants who experienced challenges in achieving orgasm, 72.8% (n = 147, P < .001) reported that cannabis use before partnered sex increased orgasm frequency, 67% stated that it improved orgasm satisfaction (n = 136, P < .001), and 71% indicated that cannabis use made orgasm easier (n = 143, P < .001). The frequency of cannabis use before partnered sex correlated with increased orgasm frequency for women who experienced difficulties achieving orgasm (n = 202, P < .001). The reasons for cannabis use before partnered sex resulted in a more positive orgasm response (n = 202, P = .22).

Clinical Implications

Cannabis may be a treatment for women with difficulty achieving orgasm during partnered sex.

Strengths and Limitations

The researchers examined the challenge of achieving orgasm and considered the covariates reported in the literature, including the FSFI orgasm subscale. The findings may not be generalizable to women who rarely or never use cannabis before sex, women who have never experienced an orgasm, or women who do not have female genitalia. Additionally, the specific type of cannabis used, its chemical composition, the quantity used, and whether or not the partner used cannabis were not assessed in this study.

Conclusion

Cannabis-related treatment appears to provide benefit to women who have female orgasm difficulties or dysfunction.

Sexual dysfunction in women with PCOS: a case control study

STUDY QUESTION

What is the relationship of sex steroid levels with sexual function in women with and without polycystic ovary syndrome (PCOS)?

SUMMARY ANSWER

Women with PCOS reported more sexual dysfunction and more sexual distress compared to those without PCOS, but only few and weak associations between androgen levels and sexual function were observed.

WHAT IS KNOWN ALREADY

The literature shows that women with PCOS report lower levels of sexual function and sexual satisfactionand more sexual distress. Contributing factors seem to be obesity, alopecia, hirsutism, acne, infertility, anxiety, depression, and low self-esteem. In women with PCOS clinical and/or biochemical hyperandrogenism is common; its relationship with sexualfunction is, however, inconclusive.

STUDY DESIGN, SIZE, DURATION

This observational prospective case control study with 135 women (68 PCOS, 67 control) was conductedfrom March 2017 until March 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Heterosexual women with and without PCOS, aged 18-40 years, in a steady relationshipand without any comorbidities, underwent an extensive medical and endocrine screening using liquid chromatography-tandem mass spectrometry and validated sexual function questionnaires.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with PCOS reported significantly lower sexual function (Female Sexual Function Index (FSFI) P < 0.001, partial η2 = 0.104), higher levels of sexual distress (Female Sexual Distress Scale-Revised P < 0.001, partial η2 = 0.090), and they more often complied with the definition of sexual dysfunction (41.2% vs 11.9%, P < 0.001, Phi V = 0.331) and clinical sexual distress (51.5% vs 19.4%, P < 0.001, Phi V = 0.335). Regression analysis adjusted for confounders showed only few and weak associations between androgen levels and sexual function, with each model explaining a maximum of 15% sexual function. Following significant Group × Hormone interactions, analyses for both groups separately showed no significant associations in the PCOS group. The control group showed only weak negative associations between testosterone and FSFI pain (β = -6.022, P = 0.044, Adj R2 = 0.050), between FAI and FSFI orgasm (β = -3.360, P = 0.023, Adj R2 = 0.049) and between androstenedione and clinical sexual distress (β = -7.293, P = 0.036, exp(β) = 0.001).

LIMITATIONS, REASONS FOR CAUTION

The focus of the study on sexual functioning potentially creates selection bias. Possibly women with more severe sexual disturbances did or did not choose to participate. Differences between women with PCOS and controls in relationship duration and hormonal contraceptive use might have skewed the sexual function outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

Sexual function is impaired in women with PCOS. However, endocrine perturbations seem to have minimal direct impact on sexual function. Addressing sexuality and offering psychosexual counseling is important in the clinical care for women with PCOS.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the departments of the participating centers: Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Psychosomatic OBGYN and Sexology, Leiden University Medical Center, Leiden, the Netherlands; and Department of Sexology and Psychosomatic OBGYN, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands. J.S.E.L. received unrestricted research grants from the following companies (in alphabetical order): Ansh Labs, Ferring, Merck Serono and Roche Diagnostics. He also received consultancy fees from Ansh Labs, Ferring, Titus Healthcare and Roche Diagnostics. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

CCMO register, registration number: NL55484.078.16, 10 March 2016. https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm.

The Sexual Incentive Motivation Model and Its Clinical Applications

Sexual motivation (desire) requires the simultaneous presence of an active central motive state and a stimulus with sexual significance. Once activated, sexual motivation leads to visceral responses and approach behaviors directed toward the emitter of the sexual stimulus. In humans, such behaviors follow cognitive evaluation of the context, including predictions of the approached individual's response. After successful approach and establishment of physical contact, manifest sexual activities may be initiated. Sexual interaction is associated with and followed by a state of positive affect in most animals, whereas aversive consequences may be experienced by humans. The affective reactions may become associated with stimuli present during sexual interaction, and these stimuli may thereby alter their incentive properties. Here we show how the incentive motivation model can be used to explain the origins and possible treatments of sexual dysfunctions, notably disorders of desire. We propose that associations formed between negative outcomes of sexual interaction and the salient stimuli, for example, the partner, underlies hypoactive desire disorder. Highly positive outcomes of sexual interaction enhance the incentive value of the stimuli present, and eventually lead to hyperactive sexual desire. Treatments aim to alter the impact of sexual incentives, mainly by modifying cognitive processes.

Incidence and Predictors of Low Sexual Desire and Hypoactive Sexual Desire Disorder in Women: A Systematic Review and Meta-Analysis

Determining the true incidence and identifying the risk factors of low sexual desire (LSD) and hypoactive sexual desire disorder (HSDD) are essential to prevent sexual dysfunctions and provide adequate treatment resources. This systematic review and meta-analysis were performed on research articles reporting women with LSD and HSDD in PsycArticles, Scopus, MEDLINE, Web of Science databases, and reference lists till October 2021. All cross-sectional studies published in English that assessed both sexual desire and sexual distress were included. Of 891 full-text articles identified, 24 were eligible, all of which had a low risk of overall bias. We did separate random-effects meta-analyses for LSD and HSDD outcomes. The incidence of LSD and HSDD were 29% and 12%, respectively. Studies that used the convenience sampling method reported a higher incidence of HSDD than studies that used the probability sampling method. No differences were found between the assessment method and across cultures in LSD and HSDD. A majority of studies reviewed addressed demographic (e.g. age, education), physiological (e. g. menopausal status, body mass index), psychological (e.g. depression, daily internal stress), relational (e.g. relationship length, relationship satisfaction), and sexual predictors (e.g. sexual activity, sexual pleasure) between LSD and HSDD. This systematic review may inform researchers, guideline developers, and policy-makers about LSD associated with distress and help health professionals to identify women most at risk.

Postmenopausal sexual function and steroid hormone levels: a hospital-based cross-sectional study

OBJECTIVE

Steroid hormone levels, particularly androgens, play an important role in sexual function in premenopausal women, but this relationship is not so well determined after menopause. This study aimed to assess the association between steroid hormone levels and sexual function in postmenopausal women.

METHODS

A total of 84 postmenopausal women with intact ovaries, who had never used systemic hormone therapy, were enrolled in a cross-sectional study. Sexual function was assessed using the Female Sexual Function Index (FSFI) questionnaire and serum levels of steroid hormones were quantified by gas chromatography and tandem mass spectrometry. Associations between estradiol, testosterone, dehydroepiandrosterone, androstenedione and FSFI domain scores were evaluated.

RESULTS

After adjustment for confounding variables, the analysis revealed a statistically significant association between androstenedione and overall sexual function (β = 1.23, 95% confidence interval [CI] [0.37; 1.98], p = 0.010), arousal (β = 0.19, 95% CI [0.02; 0.37], p = 0.034), orgasm (β = 0.33, 95% CI [0.15; 0.45], p = 0.001) and satisfaction (β = 0.25, 95% CI [0.11; 0.36], p = 0.001). No associations were found between the other hormones and FSFI domains.

CONCLUSION

The main finding of this study is the association of androstenedione with sexual function in postmenopausal women, not verified for other steroid hormones. Further studies are necessary to determine the importance of androstenedione for postmenopausal sexual function.

Association between testosterone levels and mood disorders: A minireview

BACKGROUND

Although many studies reported the neuropsychiatric involvement of testosterone (T) levels in the development of mood disorders, its role in this disabling disorder is still not well understood. Therefore, in this review, we aim to summarize the current literature exploring serum testosterone levels in both major depressive disorder (MDD) and bipolar disorder (BD), with particular attention given to the possible causal relationship between pathological mood alterations and T levels.

METHODS

We selected 9 original studies from a bibliographic search on PubMed, excluding studies on hormonal therapy and other psychiatric disorders other than mood disorders.

RESULTS

The results reported by the reviewed studies were conflicting especially with regards to the presence of dysfunctional levels of T in patients with BD. Specifically, while MDD was found to be associated with low levels of T compared to healthy controls (HC), in BD the results were highly heterogeneous, with a mixed picture of reduced, increased or no difference in T levels in BD patients compared to HC.

LIMITATIONS

Studies were highly heterogeneous in terms of samples employed, psychometric scales used for assessing depressive symptoms, T assay methods and therapeutic regimens.

CONCLUSIONS

Overall, T levels were shown to be reduced in both MDD and BD patients, ultimately suggesting that T could be useful as a biomarker in mood disorders and provide guidance for future research.

Sexual Health and Women Living With Spinal Cord Injury: The Unheard Voice

Women's sexual health within the context of sexual function and psychosocial dimensions while living with a spinal cord injury (SCI) has rarely been discussed separately from men living with a SCI or from a collective with other chronic conditions. To date, over 64,000 women in the U.S. are currently living with SCI, with total numbers increasing each year, as well as the demographics shifting to include more diversity in race and incidences occurring later in life. On average, SCI tends to be acquired during the childbearing years (~30–50 years old), as well as when women experience other health concerns associated with aging, including perimenopause and menopause. Additionally, women's sexual health is often conceptualized from the position of the absence of disease and dysfunction. However, consistent with definitions furthered by the World Health Organization (WHO) and World Association of Sexual Health (WAS), we believe women's sexual health is multifaceted, moving beyond a focus on reproduction to also encompass sexual function and the psychosocial dimensions of sexual health both living with and without disabling conditions and diseases. Within this lens, we present prior research that has been conducted, conclusions from these studies, implications for practice, and recommendations for future research. Thus, the paper will expand the understanding of both sexual function and psychosocial dimensions for women living with SCI.

Are Endogenous Androgens Linked to Female Sexual Function? A Systemic Review and Meta-Analysis

BACKGROUND

The benefits of treatment with testosterone (T) in women with loss of desire suggest that low androgens may distinguish women with sexual dysfunction (SD) from others; however, evidence on this point is lacking.

AIM

To answer the question: is there an association between endogenous levels of androgens and sexual function in women?

METHODS

An extensive search was performed in MEDLINE, Embase and PsycInfo. Four separate meta-analyses were conducted for total T, free T, Free Androgen Index (FAI), and Dehydroepiandrosterone sulphate (DHEAS). Cohort, cross-sectional, and prospective studies were included.

OUTCOMES

The main outcome was the association between endogenous androgens and sexual desire. Global sexual function was considered as a secondary outcome. The effect measure was expressed as standardized mean difference (SMD).

RESULTS

The meta-analysis on total T included 34 studies involving 3,268 women, mean age 36.5 years. In 11 studies, a significant association was found between sexual desire, measured by validated psychometric instruments, and total T (SMD = 0.59 [0.29;0.88], P < 0.0001), with a moderate effect. The association with global sexual function (n = 12 studies) was also significant (SMD = 0.44 [0.21;0.67], P <0.0001). Overall, total T was associated with a better sexual function (SMD = 0.55 [0.28;0.82)], P < 0.0001), with similar results obtained when poor quality studies were removed. Age showed a negative relationship with the overall outcome. No differences were found when stratifying the studies according to menopausal status, type of menopause, age at menopause, use of hormonal replacement therapy, relationship status, method for T measurement, phase of the menstrual cycle or use of hormonal contraception. The meta-analysis of T derivatives (free T and FAI) also showed a significant, moderate association with sexual desire. In contrast, DHEAS seems not to exert any significant influence on desire, whilst showing a positive association with global sexual function.

CLINICAL IMPLICATIONS

Endogenous androgens show a moderate association with a better sexual function in women; however, the role of psychological, relational and other hormonal factors should not be overlooked.

STRENGTHS & LIMITATIONS

This represents the first attempt at meta-analyzing data available on the topic. A significant publication bias was found for total T.

CONCLUSION

There appears to be a moderate association between total T and sexual desire/global sexual function, which is confirmed, although weak, in studies employing liquid chromatography-mass spectrometry (LC-MS). Similar results on desire were obtained for free T and FAI. DHEAS only showed a positive association with global sexual function. More research is needed. Maseroli E and Vignozzi L. Are Endogenous Androgens Linked to Female Sexual Function? A Systemic Review and Meta-Analysis. J Sex Med 2022;19:553-568.

Bremelanotide for Treatment of Female Hypoactive Sexual Desire

Hypoactive sexual desire disorder (HSDD) is a persistent deficiency or absence of sexual fantasies and desire resulting in significant distress or interpersonal difficulty. Women with this disorder may display a lack of motivation for sexual activity, reduced responsiveness to erotic cues, a loss of interest during sexual activity, and avoidance of situations that could lead to sexual activity. The pathophysiology of HSDD is thought to be centered around inhibitory and excitatory hormones, neurotransmitters, and specific brain anatomy. Due to the multifactorial nature of HSDD, treatment can be complex and must attempt to target the biological and psychosocial aspects of the disorder. Bremelanotide is a melanocortin receptor agonist and has been recently approved by the FDA to treat HSDD. Bremelanotide is administered intranasally or as a subcutaneous injection. The recommended dosage of bremelanotide is 1.75 mg injected subcutaneously in the abdomen or thigh at least 45 min before sexual activity. Studies showed improvements in desire, arousal, and orgasm scores when 1.75 mg of bremelanotide was administered before sexual activity compared to a placebo. Bremelanotide is a promising way to treat HSDD.

What is the "weight" of body mass index on sexual functioning in women? A mediation model

PURPOSE

It is well known that body mass index (BMI) affects how individuals perceive their well-being and that obese individuals tend to report poorer levels of subjective health status. The aim of this study was to compare subjects with and without FSD and to examine the direct and indirect impact of BMI on female sexual dysfunction (FSD) in overweight/obese and normal-weight women.

METHODS

A cross-sectional study was conducted on 186 overweight/obese and 233 normal-weight women. FSD assessed with the Female Sexual Function Index (FSFI) was investigated in relation to body satisfaction assessed with the Body Uneasiness Test (BUT-A) and self-esteem assessed with the Rosenberg Self-Esteem scale (RSE).

RESULTS

No difference in the prevalence of FSD was found between overweight/obese (44.4%) and normal-weight women (55.6%), even though significant between-group differences in body image were found. Structural Equation Modelling (SEM) showed that BMI contribute to FSD only through the mediating role of body dissatisfaction and self-esteem.

CONCLUSIONS

The present results support the notion that sexual functioning is not related directly to BMI in women but to a more complex interactions of body weight, satisfaction with one's own body image, and levels of self-esteem. Clinicians should take into account that for women having a good sexual life seems not related to body weight but to the way their body weight is perceived within the context of self-image.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women

AIM

To provide a clinical practice guideline for the use of testosterone including identification of patients, laboratory testing, dosing, post-treatment monitoring, and follow-up care in women with hypoactive sexual desire disorder (HSDD).

METHODS

The International Society for the Study of Women's Sexual Health appointed a multidisciplinary panel of experts who performed a literature review of original research, meta-analyses, review papers, and consensus guidelines regarding testosterone use in women. Consensus was reached using a modified Delphi method.

OUTCOMES

A clinically useful guideline following a biopsychosocial assessment and treatment approach for the safe and efficacious use of testosterone in women with HSDD was developed including measurement, indications, formulations, prescribing, dosing, monitoring, and follow-up.

RESULTS

Although the Global Position Statement endorses testosterone therapy for only postmenopausal women, limited data also support the use in late reproductive age premenopausal women, consistent with the International Society for the Study of Women's Sexual Health Process of Care for the Management of HSDD. Systemic transdermal testosterone is recommended for women with HSDD not primarily related to modifiable factors or comorbidities such as relationship or mental health problems. Current available research supports a moderate therapeutic benefit. Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established. Before initiation of therapy, clinicians should provide an informed consent. Shared decision-making involves a comprehensive discussion of off-label use, as well as benefits and risks. A total testosterone level should not be used to diagnose HSDD, but as a baseline for monitoring. Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women. Patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range. Compounded products cannot be recommended because of the lack of efficacy and safety data.

CLINICAL IMPLICATIONS

This clinical practice guideline provides standards for safely prescribing testosterone to women with HSDD, including identification of appropriate patients, dosing, and monitoring.

STRENGTHS AND LIMITATIONS

This evidence-based guideline builds on a recently published comprehensive meta-analysis and the Global Position Statement endorsed by numerous societies. The limitation is that testosterone therapy is not approved for women by most regulatory agencies, thereby making prescribing and proper dosing challenging.

CONCLUSION

Despite substantial evidence regarding safety, efficacy, and clinical use, access to testosterone therapy for the treatment of HSDD in women remains a significant unmet need.

International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women

Background: The Global Consensus Position Statement on the Use of Testosterone Therapy for Women (Global Position Statement) recommended testosterone therapy for postmenopausal women with hypoactive sexual desire disorder (HSDD).

Aim: To provide a clinical practice guideline for the use of testosterone including identification of patients, laboratory testing, dosing, post-treatment monitoring, and follow-up care in women with HSDD.

Methods: The International Society for the Study of Women's Sexual Health appointed a multidisciplinary panel of experts who performed a literature review of original research, meta-analyses, review papers, and consensus guidelines regarding testosterone use in women. Consensus was reached using a modified Delphi method.

Outcomes: A clinically useful guideline following a biopsychosocial assessment and treatment approach for the safe and efficacious use of testosterone in women with HSDD was developed including measurement, indications, formulations, prescribing, dosing, monitoring, and follow-up.

Results: Although the Global Position Statement endorses testosterone therapy for only postmenopausal women, limited data also support the use in late reproductive age premenopausal women, consistent with the International Society for the Study of Women's Sexual Health Process of Care for the Management of HSDD. Systemic transdermal testosterone is recommended for women with HSDD not primarily related to modifiable factors or comorbidities such as relationship or mental health problems. Current available research supports a moderate therapeutic benefit. Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established. Before initiation of therapy, clinicians should provide an informed consent. Shared decision-making involves a comprehensive discussion of off-label use, as well as benefits and risks. A total testosterone level should not be used to diagnose HSDD, but as a baseline for monitoring. Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women. Patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range. Compounded products cannot be recommended because of the lack of efficacy and safety data.

Clinical Implications: This clinical practice guideline provides standards for safely prescribing testosterone to women with HSDD, including identification of appropriate patients, dosing, and monitoring.

Strengths & Limitations: This evidence-based guideline builds on a recently published comprehensive meta-analysis and the Global Position Statement endorsed by numerous societies. The limitation is that testosterone therapy is not approved for women by most regulatory agencies, thereby making prescribing and proper dosing challenging.

Conclusion: Despite substantial evidence regarding safety, efficacy, and clinical use, access to testosterone therapy for the treatment of HSDD in women remains a significant unmet need.

Dehydroepiandrosterone and cortisol as markers of HPA axis dysregulation in women with low sexual desire

Previous research has found lower serum levels of dehydroepiandrosterone (DHEA) or its sulfated form, DHEA-S, in women diagnosed with Hypoactive Sexual Desire Disorder (HSDD). Given that DHEA and DHEA-S have multiple direct actions on the brain as well as anti-glucocorticoid properties, it is possible that lower levels of DHEA directly impact women's sexual functioning. To date, the significance of the lower DHEA levels remains unclear. To our knowledge, there has been no empirical study of stress hormones as markers of HPA dysregulation in women with HSDD. To attend to this gap, the present study utilized several measures of HPA axis function - morning and evening cortisol and DHEA, the cortisol awakening response (CAR), diurnal cortisol slope, and cortisol:DHEA ratio - and examined their relationship with sexual functioning in N = 275 women with (n = 137) and without (n = 138) HSDD. Results demonstrated multiple hormonal markers of HPA dysregulation in women diagnosed with HSDD compared to control participants, specifically, lower AM cortisol and AM DHEA levels, a flatter diurnal cortisol slope, and a lower CAR. Overall, results of the present study indicate that persistently low sexual desire in women is associated with HPA axis dysregulation, with both cortisol and DHEA alterations potentially detrimental to sexual desire.

What are the prevalence and factors associated with sexual dysfunction in breastfeeding women? A Brazilian cross-sectional analytical study

OBJECTIVE

This study determined the prevalence and factors associated with sexual dysfunction in breastfeeding women.

DESIGN

Cross-sectional analytical study.

SETTING

Population-based study of individuals living in the northeast region of São Paulo state, Brazil.

PARTICIPANTS

From May to August 2017, 372 women aged ≥18 years were selected who gave exclusive, predominant or complementary breast feeding up to 23 months postpartum, and who did not have contraindications for the resumption of intercourse. Pregnant women, those diagnosed with mental health problems, users of medications that affect sexual function (antihypertensives, antidepressants or antipsychotics) and women unable to read or understand the instructions for the study were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The breastfeeding women completed the Female Sexual Function Index, the EUROHIS-QOL 8-item index and a questionnaire to collect participants' sociodemographic, clinical and interpersonal data. A bivariate analysis was performed, and variables with p values<0.20 were analysed by multivariate logistic regression.

RESULTS

Sexual dysfunction was present in 58.3% of the study population. Factors significantly associated with female sexual dysfunction (FSD) included placing a low importance on sexual intercourse (adjusted OR [AOR]=2.49, 95% CI=1.22 to 5.09), limited communication with the partner (AOR=2.64, 95% CI=1.43 to 4.86), decreased frequency of sexual intercourse (AOR=2.17, 95% CI=1.30 to 3.61) and low quality of life (AOR=2.23, 95% CI=1.33 to 3.74).

CONCLUSIONS

The prevalence of FSD appears with a great magnitude in breastfeeding women. The risk factors for sexual dysfunction are biopsychosocial and these findings may lead to improved counselling for prenatal and postnatal care.

The Potential of Hormonal Contraception to Influence Female Sexuality

The association between female sexual function and hormonal contraception is controversial. Recognition and management of sexual side effects in women using hormonal contraceptives are challenging. An unsatisfactory number of studies report the influence of the available contraceptives on female sexuality. This article provides an updated narrative review regarding the effect and the magnitude of the impact that hormonal contraceptives play in female sexual function.

Evaluation of the association between sexual dysfunction and demyelinating plaque location and number in female multiple sclerosis patients

Purpose To investigate the frequency of sexual dysfunction (SD) in female multiple sclerosis (MS) patients and to explore its association with the location and number of demyelinating lesions. Material and Methods We evaluated 42 female patients and 41 healthy subjects. All patients underwent neurological examination and 1.5 T brain and full spinal MRI. All subjects completed the female sexual function index (FSFI), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Short-Form 36 Quality of Life Scale (SF-36). All participants were also evaluated for serum thyroid stimulating hormone (TSH), T4, estradiol, and total testosterone. Results No statistically significant differences between the MS and control groups were found for age, body mass index (BMI), serum TSH, T4, E2, and total testosterone level. MS patients had a statistically significantly lower FSFI and SF-36 scores and higher BDI and BAI scores compared with healthy subjects. The location and number of demyelinating lesions were not associated with SD. Conclusion In our cohort, this difference in SD appears unrelated to the location and number of demyelinating lesions. These findings highlight the importance of the assessment and treatment of psychiatric comorbidities, such as depression and anxiety, in MS patients reporting SD.

Women's sexual dysfunction associated with psychiatric disorders and their treatment

Impairment of mental health is the most important risk factor for female sexual dysfunction. Women living with psychiatric illness, despite their frequent sexual difficulties, consider sexuality to be an important aspect of their quality of life. Antidepressant and antipsychotic medication, the neurobiology and symptoms of the illness, past trauma, difficulties in establishing relationships and stigmatization can all contribute to sexual dysfunction. Low sexual desire is strongly linked to depression. Lack of subjective arousal and pleasure are linked to trait anxiety: the sensations of physical sexual arousal may lead to fear rather than to pleasure. The most common type of sexual pain is 10 times more common in women with previous diagnoses of anxiety disorder. Clinicians often do not routinely inquire about their patients' sexual concerns, particularly in the context of psychotic illness but careful assessment, diagnosis and explanation of their situation is necessary and in keeping with patients' wishes. Evidence-based pharmacological and non-pharmacological interventions are available but poorly researched in the context of psychotic illness.