Couplepause: A New Paradigm in Treating Sexual Dysfunction During Menopause and Andropause

Efficacy and safety of PDE5 inhibitors in middle-aged and old patients with and without hypogonadism

PURPOSE

Although several reviews have evaluated the use of PDE5 inhibitors (PDE5i) for treating erectile dysfunction (ED), their specific use in middle-aged and old patients has not been fully evaluated. Given that elderly patients with ED often have a complex combination of systemic and sexual health risk factors, the safety and efficacy of PDE5i in such a context are hereby reviewed.

MATERIALS AND METHODS

A thorough examination of existing literature has been conducted on PubMed.

RESULTS

PDE5i has good safety and efficacy, but the situation is more complex for patients with hypogonadism than those with normal testosterone levels, with reduced responsiveness to PDE5i. In this case, combination therapy with testosterone is recommended, safe and effective.

CONCLUSIONS

Eliminating or reducing reversible risk factors and controlling or slowing the development of irreversible factors is an important foundation for using PDE5i to treat ED in all patients, especially middle-aged and elderly ones.

Female and male factors that impact on frequency of sexual intercourse in aging couples: a cross-sectional study

OBJECTIVES

To assess the prevalence and factors associated with dyspareunia and the lack of sexual intercourse in women between 50 and 70 years cohabiting with their partners.

METHODS

This is a descriptive and exploratory cross-sectional study using the snowball technique with prospective data collection using a structured questionnaire to describe multiple aspects of health and sexuality among 266 cohabiting Brazilian couples aged 50 to 70.

RESULTS

The prevalence of lack of sexual activity was 20%. Factors associated with sexual inactivity were female sexual dysfunction (OR: 9.87, 95% CI: 3.24-30.10, P < 0.001), female dissatisfaction with the partner as a lover (OR: 5.86, 95% CI: 2.03-16.88, P = 0.001), male sexual dysfunction (OR: 4.51, 95% CI: 1.60-12.70, P = 0.004), and poor self-rated male health (OR: 3.66, 95% CI: 1.29-10.40, P = 0.015). The prevalence of dyspareunia was 42.3% in the sample of sexually active women. Factors associated with dyspareunia were female sexual dysfunction (OR: 2.7, 95%, CI: 1.26-5.77, P = 0.010), moderate/severe vaginal dryness (OR: 4.67, 95% CI: 2.21-9.87, P < 0.001), and vaginal discomfort (OR: 4.03, 95% CI: 1.77-9.17, P < 0.001).

CONCLUSIONS

The results showed that male, female, and dyadic factors were associated with a lack of sexual activity. On the other hand, only female factors were associated with dyspareunia among sexually active couples.

Getting old in the desired gender: a systematic review on aging diseases in transgender people

INTRODUCTION

The growing demographic presence of the transgender (TGD) population has sparked an increase in clinical investigations focusing on the impacts of gender-affirming hormone therapy (GAHT) in adults with gender dysphoria. Despite this surge in studies, there remains a significant gap in the literature regarding the health status of older TGD individuals. This review aims to assess prevalent pathological conditions within the TGD population, specifically concentrating on aging-related diseases investigated to date.

METHODS

A systematic search across Embase Ovid, Scopus, PubMed, Cochrane Library, and Web of Science databases was conducted to identify articles reporting on the aging process in TGD individuals. Methodological quality was evaluated using Newcastle-Ottawa Scale (NOS) scores.

RESULTS

Initial database searches yielded 12,688 studies, which were refined to 18 through elimination of duplicates and title/abstract review. Following a comprehensive appraisal, nine studies were included in the systematic review. These articles, published between 2017 and 2023, involved a total of 5403 participants. The evidence indicates a noteworthy percentage of the TGD population being at risk for cardiovascular diseases, experiencing depression or disability, and demonstrating hesitancy toward major recommended screening programs.

CONCLUSIONS

Limited studies on older TGD individuals highlight not only an organic risk of chronic diseases but also a cognitive/psychiatric risk that should not be underestimated. Further research is imperative to deepen our understanding of the pathophysiological mechanisms involved in the health challenges faced by older TGD individuals.

From couplepause to doublepause: the impact of midlife physical, psychological, and social changes on the sexual life of aging couples

INTRODUCTION

Midlife men and women are facing frequent sexual problems that affect not only individuals' sexual health but also the sexual health of aging couples.

OBJECTIVES

To review the main sexual life challenges faced by midlife couples, to present the concepts of couplepause and doublepause as 2 new paradigms to address the sexual health needs of aging couples, and to discuss key aspects in couple-focused care.

METHODS

An online meeting attended by 5 European experts in sexual health was carried out in June 2023 to discuss the topic. The conversation centered on their clinical experience and expert opinion. Additionally, the indexed literature was reviewed to endorse and complement the expert opinions obtained in the aforementioned meeting.

RESULTS

Midlife men and women face physical, psychological, and sociocultural changes that affect their sexual activity. These changes may be experienced differently between genders. Both members of a couple may experience age-related changes concurrently or in an unsynchronized manner affecting their sexual health. Communication, sharing expectations, defining sexual dynamics, and couple goals are determinant for the sexual health of a midlife couple. Couplepause and doublepause are 2 new complementary paradigms that effectively address the sexual health needs of aging couples as a unit, considering physical, psychological, cultural, social, and dyadic-related factors. Couple-centered strategies should promote open communication about couple intimacy issues, understanding the diverse expectations according to gender and orientation, communication styles, and goals. The following are identified as crucial aspects to promote couple-focused care: education and training of health care professionals, the provision of information to aging couples, physician involvement in addressing sexual problems, the need for collaboration across medical specialties, and the development of effective tools and strategies.

CONCLUSIONS

The sexual problems of aging couples should be managed following couple-centered strategies that effectively address their sexual health needs as a couple.

Psychosexological correlates of 372 women with vulvodynia, overactive pelvic floor, postcoital cystitis, and interstitial cystitis

BACKGROUND

Among the plethora of urogynecological conditions possibly affecting women, some of them, less explored, have significant impacts on sexological and psychological health, with a mutual influence.

AIM

The aim of this study was to investigate the sexological and psychological correlates of four urogynecological pathologies in a sample of women of childbearing age: overactive pelvic floor, vulvodynia, postcoital cystitis, and interstitial cystitis. Women cured of these conditions were also included, to assess the same aspects after the remission of physical symptoms.

METHODS

We recruited 372 women with an average age of 33.5 years through an online platform shared by a popular forum for women with urogynecological pathologies between March and May 2021. The participants filled out a socio-anamnestic questionnaire and a set of psychometric tests.

OUTCOMES

Participant data were collected by use of the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Toronto Alexithymia Scale-20, Female Sexual Function Index, and Orgasmometer-F, and the SPSS (Statistical Package for Social Sciences) v.26 was used for data analysis.

RESULTS

Overactive pelvic floor was reported by 66.4% of the women, vulvodynia by 55%, postcoital cystitis by 58.8%, and interstitial cystitis by 8.3%, and these conditions were often comorbid with each other, with 9.4% and 7% of women reporting having suffered psychological and sexual abuse, respectively. The presence of past abuse was correlated with overactive pelvic floor (P < .05), vulvodynia (P < .01), and major depression (P < .01). Significantly more depression occurred in women with vulvodynia than in the other subgroups (P < .05), except for women with only an overactive pelvic floor. There was no difference between the subgroups in the occurrence of alexithymia, sexual function, and orgasm (P < .05). Interestingly, the prevalence of sexual dysfunction increased in cured women.

CLINICAL IMPLICATIONS

The lack of significant differences, except for depression, between the pathological subgroups suggests a similar clinical and psychological relevance of the four pathologies studied. The persistence of sexual dysfunctions in cured women may be related to a residual dysfunctional relational modality with the partner.

STRENGTHS AND LIMITATIONS

The evaluation of both psychological and sexological variables in a group of less-explored urogynecological conditions represents a strength of this study, while a lack of a face-to-face assessment could represent a limitation.

CONCLUSION

The results of the present study should promote psychosexological interventions in women with these diseases, both during the pathological state and after remission.

Determinants of Sexual Health Status of Menopausal Women in Osun State, Nigeria

OBJECTIVES

This study aimed to assess sexual health status and associated factors in menopausal women.

METHODS

The study employed a descriptive, cross-sectional design. It included 420 menopausal women aged 40-65 years from Ilesa West Local Government Area of Osun State. A structured questionnaire was used, and the data were analyzed using descriptive and inferential statistics.

RESULTS

The mean age of the study respondents was 54.74 ± 5.49 years. A little over half (52.4%) of the respondents exhibited good sexual health status, whereas 47.6% had poor sexual health status. Logistic regression analysis revealed that lack of financial resources (P = 0.01; odds ratio [OR], 4.00; 95% confidence interval [95% CI], 1.45-11.02), loss of partner (P = 0.01; OR, 9.18; 95% CI, 2.89-29.09), and limited communication with partner (P = 0.01; OR, 3.12; 95% CI, 1.51-6.46) were predictors of poor sexual health status.

CONCLUSIONS

This study provides insight into the determinants of the sexual health status of menopausal women, which may help health care providers and policymakers develop effective strategies to improve the sexual health of menopausal women.

Obesity and sexual health: focus on postmenopausal women

Menopause is a cardiometabolic transition with many women experiencing weight gain and redistribution of body fat. Hormonal changes may affect also several dimensions of well-being, including sexual function, with a high rate of female sexual dysfunction (FSD), which displays a multifactorial etiology. The most important biological factors range from chronic low-grade inflammation, associated with hypertrophic adipocytes that may translate into endothelial dysfunction and compromised blood flow through the genitourinary system, to insulin resistance and other neuroendocrine mechanisms targeting the sexual response. Psychosocial factors include poor body image, mood disorders, low self-esteem and life satisfaction, as well as partner's health and quality of relationship, and social stigma. Even unhealthy lifestyle, chronic conditions and putative weight-promoting medications may play a role. The aim of the present narrative review is to update and summarize the state of the art on the link between obesity and FSD in postmenopausal women, pointing to the paucity of high-quality studies and the need for further research with validated end points to assess both biomarkers of obesity and FSD. In addition, we provide general information on the diagnosis and treatment of FSD at menopause with a focus on dietary interventions, physical activity, anti-obesity drugs and bariatric surgery.

The severity of andropause symptoms and its relationship with social well-being among retired male nurses: a preliminary cross-sectional study

BACKGROUND

Andropause is a syndrome that occurs due to decreased androgen levels in men. Various aspects of health, such as social well-being, can affect andropause status during men's retirement. This study aimed to determine the severity of andropause symptoms and its relationship with social well-being among retired male nurses.

METHODS

This preliminary cross-sectional study was conducted on 284 retired male nurses in Ardabil (northwest of Iran). The participants were selected through the census sampling method. Data were collected using a demographic information form, the Male Andropause Symptoms Self-Assessment Questionnaire (MASSQ), and the Social Well-Being Scale (SWBS). Data were analyzed using SPSS software (version 22.0).

RESULTS

The study found that the overall mean scores of the severity of andropause symptoms and social well-being among retired male nurses were 57.24 ± 12.62 (range = 35-91) and 94.54 ± 12.77 (range = 75-123), respectively. The highest and lowest mean scores between dimensions of social well-being were related to social contribution (20.26 ± 2.47) and social acceptance (15.26 ± 2.77), respectively. Multiple linear regression analysis revealed that subscales of social well-being, age, marital status, and spouse's menopause were predictors of the severity of andropause symptoms among retired male nurses. The selected predictors accounted for 53.1% of the total variance in severity of andropause symptoms (F = 36.613, p < 0.001).

CONCLUSION

The results showed a moderate to severe prevalence of andropause among retired male nurses and a significant association between andropause and social well-being. The study suggests further research to examine sexual orientation and other factors that may affect andropause in retired male nurses.

Female sexual dysfunction in an outpatient andrology clinic-A therapeutic opportunity?

INTRODUCTION

The sexual life of a couple is a dynamic entity, in which the two influence each other mutually, thus the existence of female sexual dysfunction (FSD) can influence the treatment of the man who seeks clinical help. Identify sexual dysfunction in female partners of patients attending an andrology clinic may provide a therapeutic opportunity. The authors aim to assess proportion of FSD in this population by comparison with a control group.

MATERIAL AND METHODS

A longitudinal study over 12 months timespan. The female partners of patients attending the andrology clinic participating in the study (study group - SG) completed the Female Sexual Function Index (FSFI), as did the women serving as controls (control group - CG). Further data such as age, duration and quality of the relationship and previous relationships was also collected.

RESULTS

Of the 30 women included in the SG, 14 (46.6%) considered that their current sex life was worse than in previous relationships. Of the 20 women in the CG, 60% considered that their current sex life was better. In the SG, 22 (73.3%) had FSD, with a mean score in the FSFI of 20.5, whereas only 3 women in the CG (15%) had FSD, with a mean score of 30.7 (p<0.01).

CONCLUSIONS

Our study demonstrated that the proportion of FSD in female partners of patients attending an andrology clinic is significantly higher than control group. FSD treatment should be considered as a therapeutic opportunity for the couple in this setting.

The Italian Society of Andrology and Sexual Medicine (SIAMS), along with ten other Italian Scientific Societies, guidelines on the diagnosis and management of erectile dysfunction

PURPOSE

Erectile dysfunction (ED) is one of the most prevalent male sexual dysfunctions. ED has been in the past mistakenly considered a purely psycho-sexological symptom by patients and doctors. However, an ever-growing body of evidence supporting the role of several organic factors in the pathophysiological mechanisms underlying ED has been recognized.

METHODS

The Italian Society of Andrology and Sexual Medicine (SIAMS) commissioned an expert task force involving several other National Societies to provide an updated guideline on the diagnosis and management of ED. Derived recommendations were based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Several evidence-based statements were released providing the necessary up-to-date guidance in the context of ED with organic and psychosexual comorbidities. Many of them were related to incorrect lifestyle habits suggesting how to associate pharmacotherapies and counseling, in a couple-centered approach. Having the oral therapy with phosphodiesterase type 5 inhibitors as the gold standard along with several other medical and surgical therapies, new therapeutic or controversial options were also discussed.

CONCLUSIONS

These are the first guidelines based on a multidisciplinary approach that involves the most important Societies related to the field of sexual medicine. This fruitful discussion allowed for a general agreement on several recommendations and suggestions to be reached, which can support all stakeholders in improving couple sexual satisfaction and overall general health.

Unconsummated marriage among Chinese couples: a retrospective study

Background

Unconsummated marriage (UCM) is a significant problem among couples who are unable to achieve successful sexual intercourse and penovaginal penetration, and the etiology and clinical characteristics of UCM in Chinese couples remain unknown.

Aim

In a retrospective analysis of patients with UCM, we investigated clinical characteristics and treatment outcomes among Chinese couples with UCM.

Methods

During the period from January 2019 to May 2021, we examined 127 consecutive couples with unconsummated marriage. The couples were evaluated separately by andrologists and gynecologists, and combined treatments were conducted by therapists.

Outcomes

We calculated the distribution of etiologies of UCM in Chinese couples.

Results

Among the couples whose data were evaluated, 93 couples visited the andrologist first and 34 couples visited the gynecologist first. The most common complaints associated with sexual dysfunction were erectile dysfunction (ED) in male patients and vaginismus and dyspareunia in female patients. Unconsummated marriage among Chinese couples was caused primarily by female factors (55.8%). With couple-oriented treatment conducted by sexual therapists, the success rate was 67.7%.

Clinical Translation

If a couple is diagnosed with UCM, both the husband and wife should be treated individually receive guidance from a sex therapist toward successful sexual intercourse.

Strengths and Limitations

This is to our knowledge the first report regarding the etiology of UCM in Chinese couples. Here we report our routine diagnostic and therapeutic workups. However, we were not able to perform hormonal and imaging studies of the female partners. Moreover, patients presenting with UCM who visited our department without a partner were not included in the statistics.

Conclusions

Unconsummated marriage among Chinese couples may be caused byfactors affecting both the husband and wife or the husband and wife individually; however, factors affecting women are the predominant causes of UCM. Lack of knowledge about sex-related issues, as well as cultural beliefs, play an important role. A preliminary evaluation by an andrologist and a gynecologist, followed by couple treatment conducted by the sex therapist, is highly `recommended to treat UCM effectively.

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.

Male Sexual Dysfunction

Male sexual dysfunction is a series of conditions, most notably including erectile dysfunction (ED), Peyronie's disease (PD), and premature ejaculation (PE), defined by impaired sexual functioning. The prevalence of male sexual dysfunction increases with age and is relatively high with greater than 50% of men aged 40 to 70 describing some degree of erectile dysfunction. Risk factors for male sexual dysfunction include age, diabetes mellitus (DM), cancer, stroke, hypertension, penile trauma, depression, anxiety, and disturbance in central serotonin neurotransmission and 5-HT postsynaptic receptor functioning. Sexual questionnaires including the International Index of Erectile Dysfunction, Sexual Health Inventory for Men, and the Premature Ejaculation Diagnostic Tool are useful in screening for these disorders. Focused history and physical can establish diagnoses. For a condition to be diagnosed as male sexual dysfunction, the patient or their partner must view their sexual functioning as impaired. Treatment of male sexual dysfunction is etiology dependent. For ED, first-line therapy is a phosphodiesterase-5 inhibitor or mental health care for psychogenic ED. More complicated cases may be treated with injections, surgery, or shockwave therapy. PD is either treated with medications for pain management, collagenase clostridium histolyticum injection, corpoplasty, plication, or shockwave therapy. PE may be treated behaviorally or with SSRIs as first line medication.

Managing vulvar and vestibular pain in postmenopausal women: recommendations from the Spanish Menopause Society, Sociedad Española de Ginecología y Obstetricia, Sociedad Española de Medicos de Atención Primaria y Federación Española de Sociedades de Sexología

Background: Relieving vulvar pain caused by atrophy in postmenopausal women is a challenge in our clinical practice. We know more and more about the vulva, its anatomy and physiology and we are realizing that it is different from the vagina. The importance of the vulvar approach in the management of vulvar or vestibular pain (VP) due to atrophy in postmenopausal women is becoming increasingly important. A panel of experts from several Spanish scientific societies (Spanish Menopause Society, AEEM; Spanish Federation of Sexology Societies, FESS; Spanish Society of Primary Care Physicians, SEMERGEN; and the Spanish Society of Gynecology and Obstetrics) held a meeting to discuss treatment recommendations for women with vulvar and VP based on the best available evidence, creating a report to describe grades of recommendations.

Menopause and female sexual dysfunctions (FSDs)

Biological and psycho-relational factors contribute equally to the development of sexual symptoms and associated distress, a key element to diagnose female sexual dysfunctions (FSDs) in menopausal women. Consultation at midlife represents an optimal time to discuss sexual life, and healthcare providers (HCPs) have to be proactive in rising the conversation, as patients may not report their sexual concerns spontaneously. An accurate sexual history is essential to characterize the primary symptom, determine the impact on patient's quality of life and identify risk and precipitating factors. Among FSDs, hypoactive sexual desire disorder (HSDD) is very frequent at midlife together with genitourinary syndrome of menopause (GSM), a chronic condition negatively affecting the full sexual response. A multidimensional approach targeted to the patient's characteristics, goals and expectations is mandatory and should start from educative counselling and correction of modifiable risk factors. When specific treatments are required, they should include non-pharmacological and pharmacological options, often prescribed in combination to address concomitantly the biological and psychosocial components of FSDs.

Dyadic Satisfaction and Shared Affectivity Are Associated with Psycho-Sexual Functioning in Elderly Men and Women

Objectives The quality of sexual life of elderly people represents an understudied topic of sexual medicine and of psycho-sexology. Hence, we aimed to evaluate the association of specific psycho-relational variables, such as intimacy, increased affective gestures towards a partner (AGtP), daily shared activities, and dyadic satisfaction, with the psychosexual wellbeing of elderly people, expressed in terms of sexual satisfaction. Methods: A cohort of elderly people was selected from a sample of a broader study evaluating the role of sexual activity in protecting the emotional wellbeing of a population subjected to quarantine due to the COVID-19 pandemic. Specifically, the presence of sexual dysfunctions, the emotional wellbeing (i.e., absence of anxiety and/or depression), and the quality of the partners’ relationships were studied. For the study’s purpose, the Sexual Health Inventory for Males (SHIM), the Female Sexual Function Index (FSFI), the Orgasmometer and the Orgasmometer-F, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire (PHQ-9), and the Dyadic Adjustment Scale were adopted. Results: A group of 124 elderly subjects (≥60) was selected for the study’s purposes. Among these, 84% were males (120/124), and 16% were females (20/124). All the subjects declared to be in a stable relationship and to be sexually active during the first lockdown period. Gender differences were found for the Dyadic Satisfaction subscale (males: 37.04 ± 6.57; females: 32.85 ± 10.04; p < 0.05) and the Orgasmometer (males: 7.64 ± 1.30; females: 6.60 ± 2.46; p < 0.01). Linear regression analysis showed the association between higher Orgasmometer scores and: (i) the absence of sexual dysfunctions (β = −1.213; SE = 0.271; p < 0.0001), (ii) higher dyadic satisfaction (β = 0.042; SE = 0.019; p < 0.05), and (iii) reduced shared activities with partner (β = −0.463; SE = 0.143; p < 0.01) and increased affective gestures towards partner (DAS measured AGtP) (β = 0.595; SE = 0.065; p < 0.0001). Post hoc analysis of ANCOVA with the Bonferroni correction method showed a significant difference in the Orgasmometer scores between subjects with and without sexual dysfunction (mean difference: 2.102; SE = 0.340; pBonf < 0.001), with healthy subjects reporting higher scores compared to dysfunctional ones. Conclusions: It is reasonable to suppose that, beyond the presence of sexual dysfunctions, the sexual health of elderly people may benefit from the quality of the relationship, and, specifically, from the presence of affective gestures towards the partner and the dyadic satisfaction. To the contrary, the quantity of time spent together, sharing specific activities, may be considered a factor worsening relational and sexual health. These data should be considered during the evaluation of sexual health among elderly people.

Educational Programs and Sexual Counselling for Postmenopausal Sexual Dysfunction: A Systematic Review and Meta-Analysis

BACKGROUND

Female sexual dysfunction has a high prevalence in women in the postmenopausal period. Not only factors like comorbidities and chronic illnesses are responsible for this high prevalence, but also psychological and interpersonal factors play a significant role. Sexual counselling educational programs have shown positive sexual behavioral changes and they should be considered the first line approach to female sexual dysfunction in this group of women.

AIM

To review the evidence of the efficacy of sexual counselling educational programs for sexual dysfunction in postmenopausal women.

METHODS

A systematic search was performed in February 2021 from electronic databases (MEDLINE, CENTRAL, and Scopus), unpublished studies, ongoing clinical trials, conference abstracts and journal archives, dissertations and theses, gray literature and free search on the Google Scholar search engine. Studies that evaluate the effectiveness of sexual educational programs in postmenopausal women were selected. Study selection and data extraction were performed by 2 independent researchers. Extracted data included author identification, publication date, geographic location, study population and sample size, type of intervention, sexual function evaluation tool and outcome. Studies that evaluate sexual function by using the Female Sexual Function Index (FSFI) were included in the meta-analysis, calculating the mean difference.

OUTCOMES

Improvement of sexual function in postmenopausal women.

RESULTS

We included 8 studies in the systematic review, 6 randomized and 2 nonrandomized controlled trials, with a total sample size of 619 women, aged between 39 and 75 years old, all in menopause for less than 5 years. The studies described sexual education programs, with 4-10 sessions, 45-60 minutes each, including themes like sexual anatomy, physiological sexual response, menopause, methods of stimulation, and common sexual myths. Five studies also included cognitive-behavior therapy and 3 studies assessed mindfulness techniques. Six studies evaluated the effectiveness of sexual educational programs using FSFI. The results showed that sexual counselling educational programs had statistically significant effects on enhancing the total FSFI score (mean difference = +7.14, 95% confidence interval = 3.70-10.6, P < .0001) in comparison to routine care. Results were also significant in all evaluated sex domains: pain, arousal, lubrication, desire, orgasm and satisfaction (P < .05).

CONCLUSION

Our meta-analysis shows that sexual counselling educational programs are effective in improving sexual dysfunction in postmenopausal women when compared to routine care. These are simple approaches, easily administered with minimal resources that help prevent the psychological and social consequences of sexual dysfunction at this age.

Sexuality, pelvic floor/vaginal health and contraception at menopause

A multitude of biopsychosocial factors influences sexual health at midlife, a common concern in daily practice along with vaginal and pelvic health. Health-care providers (HCPs) need to be proactive in dealing with possible symptoms because in most cases early management prevents distress and improves quality of life. Female sexual dysfunctions (FSDs) may have a complex etiology but sexual history is not difficult implementing basic knowledge of risk factors and some skills helping women to cope with hormonal and age-related changes. This work summarizes key points to approach sexual symptoms in midlife women, providing principles to diagnose and manage hypoactive sexual desire disorder (HSDD) and genitourinary syndrome of menopause (GSM)/vulvovaginal atrophy (VVA), as well as manage contraceptive needs.

Genitourinary Syndrome of Menopause: Epidemiology, Physiopathology, Clinical Manifestation and Diagnostic

Genitourinary syndrome of menopause (GSM) is a term used to define a compilation of signs and symptoms arising from decreased estrogenic stimulation of the vulvovaginal and lower urinary tract. Among 27–84% of women in postmenopausal are affected for symptoms of GSM, and these can unquestionably impair health, sexual function, consequently the quality of life of these women. The main signs and symptoms of GSM include, among others, burning, irritation, vulvovaginal dryness, dyspareunia, urinary symptoms of urgency, dysuria, or recurrent urinary tract infection. The diagnosis can be made through anamnesis, questionnaires, physical exams, and, sometimes, complementary exams. Objective vaginal assessment is essential and can be complemented by using the Vaginal Health Index (VHI), Vaginal Maturation Index (VMI), or vaginal pH measurement. The acknowledgment of this condition by health professionals is crucial for its identification and proper management and exclusion of other conditions that make a differential diagnosis with it.

Serum concentrations of dihydrotestosterone are associated with symptoms of hypogonadism in biochemically eugonadal men

PURPOSE

Symptoms of hypogonadism are often reported by subjects with normal serum testosterone (T) levels. We aimed to assess the association between clinical symptoms in andrological outpatients and sex steroids levels.

METHODS

This is a retrospective cross-sectional cohort study in an Academic clinic and research unit. International Index of Erectile Function (IIEF, EF domain) and Aging Males Symptoms scale (AMS) questionnaires were completed by 635 and 574 men, respectively (mean age: 47.3 ± 13.9 and 47.4 ± 13.8 years, p = 0.829), free of interfering medications with complaints possibly related to hypogonadism.

RESULTS

Serum total/free T as well as dihydro-T (DHT) was associated with IIEF-EF and AMS scores in the overall population using univariate analyses. Multivariate approaches revealed DHT concentrations in subjects with normal T levels (n = 416, Total T > 12 nmol/L) to be significant predictors of AMS scores. A 0.1 nmol/l serum DHT increase within the eugonadal range was associated with a 4.67% decrease in odds of having worse symptoms (p = 0.011). In men with biochemical hypogonadism (Total T < 12 nmol/L), total and free T rather than DHT were associated with AMS results. This association was not found for IIEF-EF scores. Indirect effects of age and BMI were seen for relations with hormone concentrations but not questionnaire scores.

CONCLUSION

DHT can be associated with symptoms of hypogonadism in biochemically eugonadal men. Serum DHT measurement might be helpful once the diagnosis of hypogonadism has been ruled out but should not be routinely included in the primary diagnostic process.

The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine

INTRODUCTION

The "lost penis syndrome" (LPS) is a term often used in non-clinical settings to describe the subjective perception of the loss of cutaneous and proprioceptive feelings of the male organ during vaginal penetration. Although deserving clinical attention, this syndrome did not receive any consideration in the medical literature. Notwithstanding, it represents a relatively unexceptional condition among patients in sexual medicine clinics, and it is often reported together with other sexual dysfunctions, especially delayed ejaculation, anejaculation, male anorgasmia and inability to maintain a full erection.

OBJECTIVES

To draft a new conceptual characterization of the LPS, defined as a lack of penile somesthetic sensations during sexual penetration due to various causes and leading to several sexual consequences in both partners.

METHODS

Based on an extensive literature review and physiological assumptions, the mechanisms contributing to friction during penovaginal intercourse, and their correlation to LPS, have been explored, as well as other nonanatomical factors possibly contributing to the loss of penile sensations.

RESULTS

Efficient penile erection and sensitivity, optimal vaginal lubrication and trophism contribute to penovaginal friction. Whenever one of these processes does not occur, loss of penile sensation defined as LPS can occur. Sociocultural, psychopathological and age-related (ie, couplepause) factors are also implicated in the etiology. Four types of LPS emerged from the literature review: anatomical and/or functional, behavioral, psychopathological and iatrogenic. According to the subtype, a wide variety of treatments can be employed, including PDE5i, testosterone replacement therapy and vaginal cosmetic surgery, as well as targeted therapy for concomitant sexual comorbidity.

CONCLUSION

We held up the mirror on LPS as a clinically existing multifactorial entity and provided medical features and hypotheses contributing to or causing the occurrence of LPS. In the light of a sociocultural and scientific perspective, we proposed a description and categorization of this syndrome hypothesizing its usefulness in daily clinical practice. Colonnello E, Limoncin E, Ciocca G, et al. The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine. Sex Med Rev 2021;XX:XXX-XXX.

Sexual Health

Women's sexual health is a frequently ignored area of geriatric medicine. There are clearly defined criteria for sexual dysfunction that are organized by phase of sexual function, including desire, arousal, orgasm, and pain. The menopause transition and comorbid medical conditions (as well as their treatments) can contribute to alterations in sexual function. The partner must be included and involved in the evaluation and management to achieve a better intimate relationship in an established couple. A variety of effective and evidence-based treatments are available to women for sexual concerns in the geriatric population.

The Inferto-Sex Syndrome (ISS): sexual dysfunction in fertility care setting and assisted reproduction

PURPOSE

Infertility represents a peculiar social burden affecting more than 15% of couples, provoking it a real threat to the general quality of life and to the sexual health. The medicalization (diagnosis, therapy and follow up) of the lack of fertility is frequently a challenge in term of personal and couple's involvement. In particular, while the Assisted Reproductive Technology (ART) has allowed many infertile couples to achieve pregnancy, the therapeutic process faced by the couple bears a strong psychological stress that can affect the couple's quality of life, relationship and sexuality. Despite infertility affects both female and male sexual health, only recently the interest in the effects of ART on the couple's sexuality has grown, especially for women.

METHODS

A literature research on the sexual dysfunction in fertility care and particularly in ART setting was performed.

RESULTS

Literature largely found that intimacy and sexuality appear specifically impaired by intrusiveness of treatments and medical prescriptions. Moreover, there is a close relationship between emotional, psychological and sexual aspects, which can be integrated in the new concept of Inferto-Sex Syndrome (ISS) that can impair the ART treatment outcomes. Evidence demonstrates that the assessment of sexual function is necessary in couples undergoing diagnosis of infertility and ART.

CONCLUSION

A close relationship between infertility and sexuality, both in the female and male partners, was detected. ART treatments may heavily impact on the couple's psychosexual health. A couple-centred program for the integrated management of psychological and sexual dysfunction should be considered in the context of ART programs.

Effects of Menopause on Sexual Function in Indian Women: A McCoy's Questionnaire-Based Assessment

Background:

Menopause is associated with physical, physiological, psychological changes and may lead to sexual dysfunction (SD) effecting woman's health and well-being. Scientific research in the area of female sexuality in India is scant. Therefore, this study aimed to investigate female sexual function at perimenopause and menopause and determine the association between sociodemographic and physiological factors with sexual function.

Materials and Methods:

This was a cross-sectional hospital-based study carried out in perimenopausal and menopausal women. Study participant's details were collected by gynecologists and clinical research professionals following the participant's informed consent. The case report and McCoy female sexuality questionnaire were used. The association between sociodemographic status and sexual function was determined. Data were summarized using descriptive statistics for portraying profile of the participants and t-test for comparison.

Results:

A total of 129 women in the menopausal (SD − 3.26) and 112 in the premenopausal group (SD − 6.01) were enrolled. The sociodemographic parameters did not significantly affect the sexual function scores in both groups. In terms of vaginal atrophy, a significant increase in urgency was noted in the postmenopause group. The general domain of sexual function was significantly lower in menopausal than and perimenopausal with a P < 0.001. Looking at individual domains of sexual function, for sexual interest, satisfaction, vaginal lubrication, and orgasm, the mean value of perimenopausal participants was significantly higher when compared to menopausal women; for a primary partner domain, no significant differences between the two groups were noted.

Conclusion:

Overall, the sociodemographic profile did not impact sexual function in this study. Compared with menopausal women, perimenopausal women showed better, more complete sexual function based on McCoy's score except partner-related domain that is constant from perimenopause to menopause in a monogamous relationship.

Carbon Dioxide Laser Vulvovaginal Rejuvenation: A Systematic Review

Genitourinary syndrome of menopause (GSM) causes significant symptomatic aggravation that affects the quality of life (QoL). Vulvovaginal atrophy (VVA), the hallmark of GSM, is managed with topical non-hormonal therapy, including moisturizers and lubricants, and topical estrogen application. Patients not responding/being unsatisfied with previous local estrogen therapies are candidates for a noninvasive modality. Carbon dioxide (CO2) laser therapy, especially the fractionated type (FrCO2), has drawn considerable attention over the past two decades as a non-invasive treatment for GSM. This systematic review describes the accumulated evidence from 40 FrCO2 laser studies (3466 participants) in GSM/VVA. MEDLINE, Scopus and Cochrane databases were searched through April 2021. We analyze the effects of FrCO2 laser therapy on symptoms, sexual function, and QoL of patients with GSM/VVA. As shown in this review, FrCO2 laser therapy for GSM shows good efficacy and safety. This modality has the potential to advance female sexual wellness. Patient satisfaction was high in the studies included in this systematic review. However, there is a lack of level I evidence, and more randomized sham-controlled trials are required. Furthermore, several clinical questions, such as the number of sessions required that determine cost-effectiveness, should be addressed. Also, whether FrCO2 laser therapy may exert a synergistic effect with systemic and/or local hormonal/non-hormonal treatments, energy-based devices, and other modalities to treat GMS requires further investigation. Lastly, studies are required to compare FrCO2 laser therapy with other energy-based devices such as erbium:YAG laser and radiofrequency.

Impact of postmenopausal vaginal discomfort on sex and relationships in Brazil: the CLOSER survey

OBJECTIVE

The CLOSER (CLarifying Vaginal Atrophy's Impact On SEx and Relationships) survey investigated how postmenopausal vaginal atrophy (VA) affects relationships between Brazilian women and male partners.

METHODS

Postmenopausal women (age 55-65 years) with VA, and male partners of women with the condition, completed an online survey on the impact of VA and local estrogen treatment on intimacy and relationships.

RESULTS

A total of 360 women and 352 men from Brazil were included. Women (83%) and men (91%) reported that they were comfortable discussing VA with their partners. Women's key source of information on VA was health-care providers (HCPs), but 44% felt that not enough information is available. VA caused 70% of women to avoid sexual intimacy and resulted in less satisfying sex. VA had a negative impact on women's feelings and self-esteem. Women (76%) and men (70%) both reported that treatment with vaginal estrogen improved their sexual relationship, primarily by alleviating women's pain during sex. Women (56%) and men (59%) felt closer to each other after treatment.

CONCLUSIONS

VA had a negative impact on sexual relationships for both women and men in Brazil, and reduced women's self-confidence. Vaginal hormone therapy improved couples' sexual relationships. A proactive attitude of HCPs is essential to educate women on VA and the potential benefits of treatment.

The Gynogram: A Multicentric Validation of a New Psychometric Tool to Assess Coital Pain Associated With VVA and Its Impact on Sexual Quality of Life in Menopausal Women

BACKGROUND

Vulvo-Vaginal Atrophy (VVA) affects about fifty percent of postmenopausal women, contributing more vulnerable sexual and psycho-relational equilibrium. To date, no psychometric instruments have been designed to assess the impact of coital pain associated with VVA on sexual quality of life.

AIM

To validate a new psychometric tool, the Gynogram, able to investigate coital pain and to quantify its impact on sexual well-being in menopause.

METHODS

214 sexually active postmenopausal women were enrolled in the study during clinical consultations in gynecological outpatient clinics in Italy. After gynecological examination and evaluation of the presence of VVA, the study sample was divided in a clinical group (103 women with certified diagnosis of VVA) and in a control group (111 women without certified diagnosis of VVA) according to the Vaginal Health Index (VHI) cut-off. Factor, Reliability and Receiving Operating Characteristics (ROC) analysis were performed in order to validate our newly created Gynogram.

OUTCOMES

A structured questionnaire, named Gynogram, to assess coital pain and its impact, and the Female Sexual Function Index (FSFI).

RESULTS

The factor analysis performed on the original form (80 items) reduced the Gynogram to 24 items. Reliability analysis conducted with Cronbach's Alpha coefficients showed high values in all the components (ranging from .813 to .972), both in the long and in the short form. The sensitivity analysis demonstrated that the Gynogram, with a cut-off ≤93, is able to recognize a clinically significant coital pain. With respect to the FSFI, statistically significant differences were found for all the domains. In addition, statistically significant differences were found for all the twelve factors of the Gynogram, showing that VVA profoundly affects the sexual quality of life of women in post-menopause.

CLINICAL TRANSLATION

The utility of this tool consists in the possibility to improve prognosis, compliance/adherence and treatment outcomes.

STRENGTHS AND LIMITATIONS

The Gynogram is able to evaluate and to quantify the impact of coital pain associated with VVA. Moreover, it can also recognize the areas of biopsychosocial functioning being more affected by this clinical condition. The main limit of the study is the impossibility to evaluate both mental health and partner's general and sexual health.

CONCLUSIONS

The Gynogram is a new and validated psychometric tool able to detect the impact of symptomatic VVA on sexual quality of life among post-menopausal women, with a specific focus on the different areas of sexual functioning. Nappi RE, Graziottin A, Mollaioli A, et al. The Gynogram: A Multicentric Validation of a New Psychometric Tool to Assess Coital Pain Associated With VVA and Its Impact on Sexual Quality of Life in Menopausal Women. J Sex Med 2021;18:955-965.

Sexual function in men undergoing androgen deprivation therapy

Androgen deprivation therapy (ADT) has a deleterious effect on sexual functions and general well-being in men. Despite this evidence, however, patient and couple knowledge about ADT side effects as well as their management is poor. Similar considerations can be made for physician endorsement of management strategies. In this paper, we summarize and critically discuss available evidence regarding the possible associations between ADT and sexual dysfunction as well as the best therapeutical options. Preclinical data show that ADT is associated with penile contractility impairment as well as lower response to phosphodiesterase type 5 inhibitors (PDE5i). Available data indicate that ADT resulted in a five to sixfold increased risk of reduced libido and in a threefold increased risk of ED confirming the main role of testosterone in regulating sexual desire. Despite this evidence, sexuality remains an important aspect of health and well-being for men and their partner. The best therapeutical options depend on patient and couple desires and needs. When nonpenetrative erections are still possible, nonpenetrative activities should be encouraged to maintain sexual intimacy. A combined and personal educational program including the collaboration of different professional figures (including general physicians, oncologists, andrologists, sexologists, and psychologists) trained in sexual medicine is advisable in order to provide the best support to subjects undergoing ADT.

Redefining a sexual medicine paradigm: subclinical premature ejaculation as a new taxonomic entity

Premature ejaculation (PE) and poor ejaculatory control are multidimensional sexual symptoms estimated to affect almost one-third of men, severely impairing the overall quality of life of patients and their partners. However, patients who do not completely fulfil the definition criteria for PE rarely receive a diagnosis or adequate treatment, with the risk of subsequent progression from initial, subclinical symptoms to clinically overt PE, frequently with other sexual comorbidities. Thus, the current definitions of PE warrant review, in order to consider and propose a new taxonomy encompassing other unaddressed, crucial clinical aspects of PE. These newly proposed criteria include the recommendation for a primary screening for erectile dysfunction (ED), as PE and ED can be comorbid in up to 50% of patients but have never before been considered as a unified clinical entity. In order to facilitate clinical practice and improve clinical management of men with PE and comorbid conditions, we propose and define the new taxonomic clinical entities of subclinical PE (SPE) and loss of control of erection and ejaculation (LCEE). Application of these diagnoses to men who meet the criteria for SPE and/or LCEE, but not the overt conditions, could improve access to treatment for these patients and reduce progression to the more serious clinical disorder.

Introducing sexual dysfunction in mental care

Introduction: People with any psychiatric disorder tend to have difficulties in responding sexually. However,sexual dysfunction (SD) is usually under-recognized, even the tightly hormonal and neuronal common connexions through the brain-sex axis. Multiple sources of resistance to SD assessment and intervention persist. Areas covered: The present review aims to underline the feasibility to introduce SD evaluation in patients with any psychiatric disorders, evaluating the potential mutual benefits of their management. Expert opinion: Women and men living with mental disorders frequently display sexual difficulties; however, some of them consider sexuality as a relevant parameter of their quality of life. In fact, SD as a side effect is a frequent reason for stopping the intake of medication. What is more, a holistic approach integrating sexual function could foster a better understanding of mental pathologies due to a common origin of pathogenesis. This could improve care quality, in keeping with the global tendency toward the development of personalized medicine. Consistently, the integration of SD assessment is highly recommended in mental health, all the more so when a psychotropic drug is prescribed. An expected consequence would be a reconstruction of the healthcare professional's consideration for the sexuality of people experiencing mental disorders.

The impact of menopause on sexual function in women and their spouses

Background

The purpose of this study is to evaluate the impact of menopause on sexual function in women and their spouses.

Methods

This is a cross-sectional study that was conducted from January 2018 to May 2019 in Rasht (North of Iran). The participants included 215 menopausal women and their spouses. Data were collected using the demographic questionnaire, the Female Sexual Function Index (FSFI) questionnaire, and the International Index of Erectile Function (IIEF) questionnaire.

Results

On the basis of the FSFI and IIEF scores, 36.28% (78/215) women reported female sexual dysfunction (FSD) and 17.2% (37/215) men reported erectile dysfunction (ED) with 8.37% (N = 18) being mild, 5.58% (N = 12) mild to moderate, and 3.25% (N = 7) moderate ED. After adjusting differences in the female age distribution, the total score and scores of the IIEF subscales were also not significantly lower in the spouses of women with FSD than women without FSD.

Conclusion

Although, significant correlations between male erectile function and menopausal female sexual function have not identified; but, low scores of the subscales of FSFI in female participants mostly impaired sexual satisfaction and overall satisfaction in their spouses.

Prevalence of andropause among Iranian men and its relationship with quality of life

INTRODUCTION

Andropause is a complicated process in men's life which can negatively affect their quality of life in both physical and psychological dimensions.

OBJECTIVES

The aim of this study was to determine the prevalence of andropause among Iranian men age 40-85 years and its relationship with quality of life.

MATERIALS AND METHODS

This was a cross-sectional study among 393 men attending ten urban healthcare centers in Ilam province in southwestern Iran. Study participants were recruited using proportional random sampling. The Male andropause symptoms self-assessment questionnaire (MASSQ) and SF-12 were used for data collection. Data were analyzed using SPSS version 22 (Chicago, IL).

RESULTS

The mean (SD) of participants scores in MASSQ was 57.46 (17.56). Only 61 (15.5%) men were classified at "don't need testosterone" category based on MASSQ. There were significant associations between the eight aspects of HRQoL and the andropause severity (p < .001). Older age, lower education, having depression, coronary heart disease, and incontinence were associated with increased odds of andropause (p < .05).

CONCLUSION

This study confirmed findings of previous studies regarding andropause and its relationship with men's quality of life. Future studies in this topic are needed to discover all the factors that may influence men andropause.

Effect of education about andropause health on level of the knowledge and attitude of men referring to the education and training retirement center of Shiraz

Introduction and objective: With the world's older population continuing to grow, andropause (male menopause or late-onset hypogonadism) is considered as one of the most important issues of this era. In this study, we aimed to assess the effect of andropause health education on the level of knowledge and attitude of retired men.Methods: This controlled trial was conducted on 80 retired men (40 in intervention group, 40 in control group), who had been employed by the Department of Education, Shiraz, Iran. Data collection tool was a 38-item questionnaire, designed by the researcher, on participants' knowledge and attitude about andropause. Data were analyzed using SPSS software, version 22 and statistical tests such as independent and paired t tests were used.Findings: There was no significant difference between the intervention and control groups before the intervention. There was a significant difference in knowledge and attitude scores in each group immediately and 1 month after the intervention. The mean score of knowledge in the intervention group increased from 2.92 ± 1.68 before to 16.22 ± 1.34 after the intervention, and the attitude score increased from 14.9 ± 1.08 to 28.52 ± 1.44. Comparison of the two groups and repeated score analysis showed that there was a significant difference between the two groups over the time (p < .001).Conclusion: Educational intervention improved the knowledge and attitude of retired men toward andropause, which can have a positive impact on the timely recognition and proper treatment of the complications of andropause.

Haptic and Somesthetic Communication in Sexual Medicine

INTRODUCTION

The word "haptics" refers to sensory inputs arising from receptors in the skin and in the musculoskeletal system, particularly crucial in sexual economy. Haptic stimuli provide information about mechanical properties of touched objects and about the position and motion of the body. An important area in this field is the development of robotic interfaces for communication through the "haptic channel," which typically requires a collaboration between engineers, neuroscientists, and psychologists. Many aspects of human sexuality, such as arousal and intercourse, can be considered from a haptic perspective.

OBJECTIVES

To review the current literature on haptics and somatosensation, and discuss potential applications of haptic interfaces in sexual medicine.

METHODS

Articles for this review were collected based on the results of a bibliographic search of relevant papers in Cochrane Library, Google Scholar, Web of Science, Scopus, and EBSCO. The search terms used, including asterisks, were "haptic∗," "somatosensor∗," "sexual∗," and related terms describing the role of touch, technology, and sexuality. Additional terms included "interface∗," "touch," and "sex∗."

RESULTS

We have provided a functional and anatomical description of the somatosensory system in humans, with special focus on neural structures involved in affective and erotic touch. One interesting topic is the development of haptic interfaces, which are specialized robots generating mechanical signals that stimulate our somatosensory system. We provided an overview on haptic interfaces and evaluated the role of haptics in sexual medicine.

CONCLUSION

Haptics and studies on the neuroscience of the somatosensory system are expected to provide useful insights for sexual medicine and novel tools for sexual dysfunction. In the future, crosstalk between sexology and haptics may produce a novel generation of user-friendly haptic devices generating a higher level of realism and presence in providing stimuli. Moscatelli A, Nimbi FM, Ciotti S, et al. Haptic and Somesthetic Communication in Sexual Medicine. J Sex Med 2021;9:267-279.

An individualized approach to the management of vaginal atrophy in Latin America

OBJECTIVE

In the absence of guidelines specific for Latin America, a region where the impact of menopause is becoming increasingly important, an evidence-based specialist opinion on management of vaginal atrophy will help improve outcomes.

METHODS

An advisory board meeting was convened in São Paulo, Brazil, to discuss practical recommendations for managing vaginal atrophy in women in Latin America. Before the meeting, physicians considered various aspects of the condition, summarizing information accordingly. This information was discussed during the meeting. The expert consensus is now summarized.

RESULTS

In Latin America, given the relatively early age of menopause, it will be beneficial to raise awareness of vaginal atrophy among women before they enter menopause, considering cultural attitudes and involving partners as appropriate. Women should be advised about lifestyle modifications, including attention to genital hygiene, clothing, and sexual activity, and encouraged to seek help as soon as they experience vaginal discomfort. Although treatment can be started at any time, prompt treatment is preferable. A range of treatments is available. By addressing the underlying pathology, local estrogen therapy can provide effective symptom relief, with choice of preparation guided by patient preference. An individualized treatment approach should be considered, giving attention to patients' specific situations.

CONCLUSIONS

It is critical that women are empowered to understand vaginal atrophy. Educating women and healthcare providers to engage in open dialogue will facilitate appreciation of the benefits and means of maintaining urogenital health, helping to improve outcomes in middle age and beyond. Women should receive this education before menopause.

Effects of Pornography Use and Demographic Parameters on Sexual Response during Masturbation and Partnered Sex in Women

The effect of pornography on sexual response is understudied, particularly among women. A multinational, community-based sample of 2433 women at least 18 years of age completed a 42-item, opt-in questionnaire collecting information on demographic and sexual history characteristics, use of pornography during masturbation, frequency of pornography use, and sexual response parameters. Pornography use and average frequency were compared across demographic variables. We also examined how pornography frequency predicted differences in self-reported arousal difficulty; orgasmic difficulty, latency, and pleasure; and the percent of sexual activities ending in orgasm during both masturbation and partnered sex. On average, women using pornography were younger, and reported more interest in sex. Pornography frequency differed significantly by menopausal status, sexual orientation, anxiety/depression status, number of sexual partners, and origin of data collection. During masturbation, more frequent pornography use predicted lower arousal difficulty and orgasmic difficulty, greater pleasure, and a higher percentage of masturbatory events leading to orgasm. Frequency of pornography use predicted only lower arousal difficulty and longer orgasmic latencies during partnered sex, having no effect on the other outcome variables. Pornography use frequency did not predict overall relationship satisfaction or sexual relationship satisfaction. Overall, more frequent pornography use was generally associated with more favorable sexual response outcomes during masturbation, while not affecting most partnered sex parameters. Several demographic and relationship covariates appear to more consistently and strongly predict orgasmic problems during partnered sexual activity than pornography use.

Sexual Desire Discrepancy: A Position Statement of the European Society for Sexual Medicine

Introduction

There is a lack of theoretical and empirical knowledge on how sexual desire functions and interacts in a relationship.

Aim

To present an overview of the current conceptualization and operationalization of sexual desire discrepancy (SDD), providing clinical recommendations on behalf of the European Society of Sexual Medicine.

Methods

A comprehensive Pubmed, Web of Science, Medline, and Cochrane search was performed. Consensus was guided by a critical reflection on selected literature on SDD and by interactive discussions between expert psychologists, both clinicians and researchers.

Main Outcome Measure

Several aspects have been investigated including the definition and operationalization of SDD and the conditions under which treatment is required.

Results

Because the literature on SDD is scarce and complicated, it is precocious to make solid statements on SDD. Hence, no recommendations as per the Oxford 2011 Levels of Evidence criteria were possible. However, specific statements on this topic, summarizing the ESSM position, were provided. This resulted in an opnion-based rather than evidence-based position statement. Following suggestions were made on how to treat couples who are distressed by SDD: (i) normalize and depathologize variation in sexual desire; (ii) educate about the natural course of sexual desire; (iii) emphasize the dyadic, age-related, and relative nature of SDD; (iv) challenge the myth of spontaneous sexual desire; (v) promote open sexual communication; (vi) assist in developing joint sexual scripts that are mutually satisfying in addition to search for personal sexual needs; (vii) deal with relationship issues and unmet relationship needs; and (viii) stimulate self-differentiation.

Conclusion

More research is needed on the conceptualization and underlying mechanisms of SDD to develop clinical guidelines to treat couples with SDD.

Marieke D, Joana G, Giovanni C, et al. Sexual Desire Discrepancy: A Position Statement of the European Society for Sexual Medicine. J Sex Med 2020;8:121–131.

The association of erectile dysfunction with productivity and absenteeism in eight countries globally

AIM

To evaluate the association of erectile dysfunction (ED) with work productivity loss, activity impairment and health-related quality of life (HRQoL) across Brazil, China, France, Germany, Italy, Spain, the UK and the US.

METHODS

This cross-sectional observational study used data from adult men (40-70 years old; N = 52 697) from the 2015 and 2016 National Health and Wellness Surveys. ED assessment was based on self-reported difficulty in achieving or maintaining an erection in the past 6 months. Impairment to work and non-work activities and HRQoL were assessed for each country and compared against the US. Multivariable models tested interactions between ED status and country for each outcome.

RESULTS

Overall ED prevalence was reported as 49.7%, with Italy reporting the highest rate (54.7%). Men with ED reported significantly higher absenteeism (7.1% vs 3.2%), presenteeism (22.5% vs 10.1%), overall work productivity impairment (24.8% vs 11.2%), activity impairment (28.6% vs 14.5%) and significantly lower Mental Component Summary scores (MCS; 46.7 vs 51.2), Physical Component Summary scores (PCS; 48.3 vs 53.0), and health state utilities (SF-6D: 0.693 vs 0.778; all, P < 0.001) than men with no ED. After adjusting for covariates, compared with the US, the association of ED status with overall work productivity impairment was greatest in the UK (26% higher; P < 0.05), and with MCS, PCS and SF-6D scores was greatest in China (-2.67, -1.58, and -0.043 points, respectively; all, P < 0.001). Greater ED severity was significantly associated with higher impairment to work and non-work activities and lower HRQoL, with China reporting the highest burden, compared with the US (most P < 0.05).

CONCLUSION

ED poses a significant burden with respect to work productivity and HRQoL, with greater severity associated with worse outcomes. Better management and earlier detection may help reduce this burden, especially in countries reporting a strong association between ED and poor economic and health outcomes.

Vaginal Health in Menopausal Women

The aim of this review is to provide an overview of genitourinary health in peri- and postmenopause, particularly of vulvovaginal atrophy (VVA), which is part of genitourinary syndrome (GSM). This condition has a high prevalence among post-menopausal women and negatively affects a woman's quality of life. Epidemiology, signs, symptoms, diagnostic criteria of VVA and target treatments for restoring vaginal health are discussed in light of the most recent literature. Issues related to this condition in menopausal women are under-diagnosed, lack objective diagnostic criteria, and consequently under-treated. Over the years, many treatments have been developed but their long-term effectiveness and safety have yet to be clearly defined. Patients are often dissatisfied and stop treatment, suggesting the need for a more personalized and tailored approach to achieve better compliance and thereby effectiveness. The aim of this paper is to provide an overview of the most recent literature on VVA in order to help the gynecologist in the management of this condition.

Sexual Health in Menopause

Sexual function worsens with advancing menopause status. The most frequently reported symptoms include low sexual desire (40-55%), poor lubrication (25-30%) and dyspareunia (12-45%), one of the complications of genitourinary syndrome of menopause (GSM). Declining levels of sex steroids (estrogens and androgens) play a major role in the impairment of sexual response; however, psychological and relational changes related with aging and an increase in metabolic and cardiovascular comorbidities should also be taken into account. Although first-line therapeutic strategies for menopause-related sexual dysfunction aim at addressing modifiable factors, many hormonal and non-hormonal, local and systemic treatment options are currently available. Treatment should be individualized, taking into account the severity of symptoms, potential adverse effects and personal preferences.

Sleep, Sleep Disorders, and Sexual Dysfunction

Good sleep is necessary for good health. Sleep health is increasingly recognized as important for physical and mental health by both the medical profession and the general public, and there is great interest in how to avoid and treat sleep disorders and problems. Recent research indicates that insufficient sleep, disrupted sleep, and sleep disorders affect many aspects of human health including sexual function. In fact, patients with urological disorders or erectile dysfunction (ED) may have a sleep disorder that contributes to their urological or sexual dysfunction. Obstructive sleep apnea, insomnia, shift work disorder, and restless legs syndrome are all common sleep disorders and are associated with ED and/or other urological disorders. Therefore, careful attention should be paid to the diagnosis and treatment of concomitant sleep disorders in patients with sexual dysfunction. In this review, we provide an overview of what sleep is and how it is assessed in the clinic or laboratory; our current understanding of the functions of sleep and sleep health; a description of common sleep disorders, as well as how they are diagnosed and treated; and how sleep and its disorders are associated with male sexual dysfunction. Sleep is considered to be a 'third pillar of health', along with diet and exercise. With an understanding of common sleep disorders and how they can impact male sexual function, the urologist can ensure that sleep disorders are considered as a contributor to sexual dysfunction in their patients in order to provide them with the optimal treatment for overall health.

Effects of ospemifene on genitourinary health assessed by prospective vulvar-vestibular photography and vaginal/vulvar health indices

OBJECTIVE

To prospectively evaluate the effects of ospemifene on the vulva and vagina in postmenopausal women using vulvar-vestibular photography and direct visual assessments.

METHODS

Postmenopausal women (aged 40-80 years) with moderate to severe vaginal dryness as their most bothersome symptom (MBS) were randomized to daily ospemifene 60 mg or placebo in this 12-week, multicenter, double-blind, phase 3 study. Vulvar-vestibular photographic images were captured at baseline and week 12 and were independently assessed with the Vulvar Imaging Assessment Scale (VIAS). Changes from baseline in Vaginal and Vulvar Health Indices (VHI and VuHI) with ospemifene versus placebo were analyzed at weeks 4, 8, and 12. Correlations between VIAS, VHI, and VuHI, with vaginal dryness severity and the Female Sexual Function Index (FSFI) scores were also assessed.

RESULTS

In all, 631 eligible participants were randomized (ospemifene 316, placebo 315) and included in the intention-to-treat population. Compared with placebo, ospemifene significantly improved total scores for VIAS (P = 0.0154), VHI (P < 0.0001), and VuHI (P < 0.0001) from baseline to week 12; significant VHI (P < 0.0001) and VuHI (P = 0.002) improvements were observed at week 4. Most VHI and VuHI individual items were significantly better with ospemifene versus placebo at week 12 (P < 0.05). Most correlations between the vulvovaginal assessment total scores versus vaginal dryness severity and FSFI scores were significant (P < 0.05).

CONCLUSION

Improvements observed in vulvovaginal health with ospemifene assessed by prospective vulvar-vestibular photography and other direct visual assessments support its efficacy in addition to the treatment of moderate to severe vaginal dryness due to menopause and the use of photographic and direct visual evaluations in future clinical trials.

VIDEO SUMMARY

Supplemental Digital Content 1, http://links.lww.com/MENO/A415.

Ospemifene for the treatment of menopausal vaginal dryness, a symptom of the genitourinary syndrome of menopause

Introduction: Vulvovaginal atrophy (VVA), a component of the genitourinary syndrome of menopause, is a progressive condition due to decline in estrogen leading to vaginal and vulvar epithelial changes. Accompanying symptoms of dryness, irritation, burning, dysuria, and/or dyspareunia have a negative impact on quality of life. Ospemifene is a selective estrogen receptor modulator (SERM) approved by the FDA for moderate to severe dyspareunia and vaginal dryness due to postmenopausal VVA. Areas covered: PubMed was searched from inception to March 2019 with keywords ospemifene and vulvar vaginal atrophy to review preclinical and clinical data describing the safety and efficacy of ospemifene for vaginal dryness and dyspareunia due to VVA. Covered topics include efficacy of ospemifene on vaginal cell populations, vaginal pH, and most bothersome VVA symptoms; imaging studies of vulvar and vaginal tissues; effects on sexual function; and safety of ospemifene on endometrium, cardiovascular system, and breast. Expert opinion: Ospemifene is significantly more effective than placebo in all efficacy analyses studied, working through estrogen receptors and possibly androgen receptors. Safety as assessed by adverse events was generally comparable to that with placebo and to other SERMs, and/or adverse events were not clinically meaningful. No cases of endometrial or breast cancer were reported.