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Danan ER, Sowerby C, Ullman KE, Ensrud K, Forte ML, Zerzan N, Anthony M, Kalinowski C, Abdi HI, Friedman JK, Landsteiner A, Greer N, Nardos R, Fok C, Dahm P, Butler M, Wilt TJ, Diem S. Hormonal Treatments and Vaginal Moisturizers for Genitourinary Syndrome of Menopause : A Systematic Review. Ann Intern Med 2024. [PMID: 39250810 DOI: 10.7326/annals-24-00610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND Postmenopausal women commonly experience vulvovaginal, urinary, and sexual symptoms associated with genitourinary syndrome of menopause (GSM). PURPOSE To evaluate effectiveness and harms of vaginal estrogen, nonestrogen hormone therapies, and vaginal moisturizers for treatment of GSM symptoms. DATA SOURCES Medline, Embase, and CINAHL through 11 December 2023. STUDY SELECTION Randomized controlled trials (RCTs) of at least 8 weeks' duration enrolling postmenopausal women with at least 1 GSM symptom and reporting effectiveness or harms of hormonal interventions or vaginal moisturizers. DATA EXTRACTION Risk of bias and data extraction were performed by one reviewer and verified by a second reviewer. Certainty of evidence (COE) was assessed by one reviewer and verified by consensus. DATA SYNTHESIS From 11 993 citations, 46 RCTs evaluating vaginal estrogen (k = 22), nonestrogen hormones (k = 16), vaginal moisturizers (k = 4), or multiple interventions (k = 4) were identified. Variation in populations, interventions, comparators, and outcomes precluded meta-analysis. Compared with placebo or no treatment, vaginal estrogen may improve vulvovaginal dryness, dyspareunia, most bothersome symptom, and treatment satisfaction. Compared with placebo, vaginal dehydroepiandrosterone (DHEA) may improve dryness, dyspareunia, and distress, bother, or interference from genitourinary symptoms; oral ospemifene may improve dryness, dyspareunia, and treatment satisfaction; and vaginal moisturizers may improve dryness (all low COE). Vaginal testosterone, systemic DHEA, vaginal oxytocin, and oral raloxifene or bazedoxifene may provide no benefit (low COE) or had uncertain effects (very low COE). Although studies did not report frequent serious harms, reporting was limited by short-duration studies that were insufficiently powered to evaluate infrequent serious harms. LIMITATIONS Most studies were 12 weeks or less in duration and used heterogeneous GSM diagnostic criteria and outcome measures. Few studies enrolled women with a history of cancer. CONCLUSION Vaginal estrogen, vaginal DHEA, oral ospemifene, and vaginal moisturizers may improve some GSM symptoms in the short term. Few long-term data exist on efficacy, comparative effectiveness, tolerability, and safety of GSM treatments. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42023400684).
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Affiliation(s)
- Elisheva R Danan
- Center for Care Delivery & Outcomes Research, VA Health Care System, and Department of Medicine, University of Minnesota, Minneapolis, Minnesota (E.R.D., S.D.)
| | - Catherine Sowerby
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Kristen E Ullman
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Kristine Ensrud
- Center for Care Delivery & Outcomes Research, VA Health Care System; Department of Medicine, University of Minnesota; and Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota (K.E.)
| | - Mary L Forte
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota (M.L.F., H.I.A., M.B.)
| | - Nicholas Zerzan
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Maylen Anthony
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Caleb Kalinowski
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Hamdi I Abdi
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota (M.L.F., H.I.A., M.B.)
| | - Jessica K Friedman
- VA Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, California (J.K.F.)
| | - Adrienne Landsteiner
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Nancy Greer
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Rahel Nardos
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, Minnesota (R.N.)
| | - Cynthia Fok
- Department of Urology, University of Minnesota, Minneapolis, Minnesota (C.F.)
| | - Philipp Dahm
- Urology Section, VA Health Care System, and Department of Urology, University of Minnesota, Minneapolis, Minnesota (P.D.)
| | - Mary Butler
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota (M.L.F., H.I.A., M.B.)
| | - Timothy J Wilt
- Center for Care Delivery & Outcomes Research, VA Health Care System; Department of Medicine, University of Minnesota; and Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota (T.J.W.)
| | - Susan Diem
- Center for Care Delivery & Outcomes Research, VA Health Care System, and Department of Medicine, University of Minnesota, Minneapolis, Minnesota (E.R.D., S.D.)
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2
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Alarcon-Rodriguez R, Fernández-Sola C, García-Alvarez R, Fadul-Calderón R, Ruiz-Ortiz A, Requena-Mullor M, Garcia-Gonzalez J. Experiences of Dyspareunia in Dominican Women with a History of Sexual Abuse: A Phenomenological Study. J Midwifery Womens Health 2023; 68:637-644. [PMID: 37288822 DOI: 10.1111/jmwh.13520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/29/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Dyspareunia refers to painful sexual intercourse that negatively affects a person's psychological well-being and quality of life and can also have an impact on their partner, family, and social circle. The objective of this study was to understand the experiences of women with dyspareunia and a history of sexual abuse in the Dominican Republic. METHODS This was a qualitative study based on Merleau-Ponty's hermeneutic phenomenology. Fifteen women with a diagnosis of dyspareunia and a history of sexual abuse participated. The study was carried out in Santo Domingo, Dominican Republic. RESULTS In-depth interviews were conducted for data collection. Through inductive analysis using ATLAS.ti, 3 main themes were developed that represent women's experiences of dyspareunia and sexual abuse: (1) a history of sexual abuse as a background to dyspareunia, (2) living in fear in a society that revictimizes the survivor, and (3) the sexual consequences of dyspareunia. DISCUSSION In some Dominican women, dyspareunia stems from their history of sexual abuse, which was unknown to their families and partners. The participants experienced dyspareunia in silence and found it difficult to seek help from health care professionals. In addition, their sexual health was marked by fear and physical pain. There are individual, cultural, and social factors that influence the occurrence of dyspareunia; a better understanding of these factors is vital for planning innovative preventive strategies that reduce the progression of sexual dysfunction and its impact on the quality of life of people with dyspareunia.
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Affiliation(s)
- Raquel Alarcon-Rodriguez
- Department of Nursing, Physiotherapy and Medicine, Faculty of Health Sciences, University of Almería, Almería, Spain
| | - Cayetano Fernández-Sola
- Department of Nursing, Physiotherapy and Medicine, Faculty of Health Sciences, University of Almería, Almería, Spain
| | - Rafael García-Alvarez
- Faculty of Health Sciences, Human Sexuality Institute, Autonomous University of Santo Domingo, Santo Domingo, Dominican Republic
| | - Rosario Fadul-Calderón
- Faculty of Health Sciences, Human Sexuality Institute, Autonomous University of Santo Domingo, Santo Domingo, Dominican Republic
| | - Antonio Ruiz-Ortiz
- Faculty of Health Sciences, Human Sexuality Institute, Autonomous University of Santo Domingo, Santo Domingo, Dominican Republic
| | - Mar Requena-Mullor
- Department of Nursing, Physiotherapy and Medicine, Faculty of Health Sciences, University of Almería, Almería, Spain
| | - Jessica Garcia-Gonzalez
- Department of Nursing, Physiotherapy and Medicine, Faculty of Health Sciences, University of Almería, Almería, Spain
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3
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Abstract
IMPORTANCE AND OBJECTIVES Evaluation and treatment of dyspareunia remains a significant unmet need despite the availability of safe and effective treatments. The objectives of this review are to consider evaluation techniques, the medical causes, and treatment options for dyspareunia in postmenopausal women. METHODS This narrative review used PubMed to search for English-language articles related to postmenopausal dyspareunia. Search terms included, but were not limited to, dyspareunia, genitourinary syndrome of menopause, sexual dysfunction, postmenopausal dyspareunia, posthysterectomy dyspareunia, and postcancer dyspareunia. FINDINGS Many postmenopausal women with dyspareunia do not discuss their symptoms with their physicians. Healthcare clinicians should broach the topic of dyspareunia with their patients using oral or written questionnaires. In addition to a thorough medical history and physical examination, various tools can be used as further assessments, including vaginal pH, vaginal dilators, imaging, vulvar biopsy, vulvoscopy and photography, the cotton swab test, sexually transmitted infection screening, and vaginitis testing. Although dyspareunia in postmenopausal women is often due to the genitourinary syndrome of menopause, other conditions can also cause dyspareunia, including hypertonic pelvic floor, hysterectomy, cancer treatment, lichen conditions, vulvar cancer, vestibulodynia, and pelvic organ prolapse. Some of the treatments discussed include lubricants, moisturizers, vaginal estrogen, ospemifene, dehydroepiandrosterone, local testosterone therapy, cannabidiol, and fractional CO2 laser treatments. In some cases, dyspareunia may need to be specifically addressed by pelvic floor physical or sex therapists. CONCLUSIONS Dyspareunia is a common issue in postmenopausal women, which remains largely untreated. Women with dyspareunia require a thorough history, targeted physical examination, and coordination of multiple disciplines including medical clinicians, pelvic floor physical therapists, and sex therapists.
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Affiliation(s)
- Lauren F Streicher
- From the Northwestern Medicine Center for Sexual Medicine and Menopause, Northwestern Medicine, Chicago, IL
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Salvatore S, Benini V, Ruffolo AF, Degliuomini RS, Redaelli A, Casiraghi A, Candiani M. Current challenges in the pharmacological management of genitourinary syndrome of menopause. Expert Opin Pharmacother 2023; 24:23-28. [PMID: 36444726 DOI: 10.1080/14656566.2022.2152326] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Genitourinary syndrome of menopause is caused by climacteric estrogens drop and leads to bothersome and progressive genital and urinary symptoms. Considering the high frequency in the population and the impact on quality of life, it is crucial to find a safe and effective treatment. Pharmacological therapies aim to modulate the hormonal system and reverse tissue changes due to hypoestrogenism and consequently the symptoms. AREAS COVERED We analyzed the scientific evidence concerning the main pharmacological treatments, which include systemic and topical estrogens, prasterone and ospemifene. This literature review focused on recent safety and efficacy findings in an attempt to identify the best treatment choice for each individual patient. EXPERT OPINION There are encouraging data regarding the efficacy of all currently available pharmacological options and concerning their short and long-term safety. There are still doubts regarding best treatment choice for oncological high-risk population, in particular for breast cancer survivors, and some issues relative to patients' poor compliance and treatment adherence. For these reasons further studies need to be conducted with a patient-tailored focus.
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Affiliation(s)
- Stefano Salvatore
- Department of Urogynecology, Gynecology and Obstetrics Unit, San Raffaele Hospital, Milan, Italy
| | - Vittoria Benini
- Department of Urogynecology, Gynecology and Obstetrics Unit, San Raffaele Hospital, Milan, Italy
| | | | - Rebecca S Degliuomini
- Department of Urogynecology, Gynecology and Obstetrics Unit, San Raffaele Hospital, Milan, Italy
| | - Anna Redaelli
- Department of Urogynecology, Gynecology and Obstetrics Unit, San Raffaele Hospital, Milan, Italy
| | - Arianna Casiraghi
- Department of Urogynecology, Gynecology and Obstetrics Unit, San Raffaele Hospital, Milan, Italy
| | - Massimo Candiani
- Department of Urogynecology, Gynecology and Obstetrics Unit, San Raffaele Hospital, Milan, Italy
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5
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Mension E, Alonso I, Cebrecos I, Castrejon N, Tortajada M, Matas I, Gómez S, Ribera L, Anglès-Acedo S, Castelo-Branco C. Safety of prasterone in breast cancer survivors treated with aromatase inhibitors: the VIBRA pilot study. Climacteric 2022; 25:476-482. [PMID: 35343852 DOI: 10.1080/13697137.2022.2050208] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Due to safety concerns on estrogen-based treatments for genitourinary syndrome of menopause (GSM) in breast cancer survivors (BCS), new options are appearing, such as androgen-based treatments, which according to proprieties would not be transformed systemically to estrogens in patients receiving aromatase inhibitors (AIs). OBJECTIVE The aim of this pilot study is to assess the security and efficacy of vaginal prasterone (dehydroepiandrostenedione [DHEA]) in BCS treated with AIs. METHODS This open, prospective, pilot study included 10 BCS treated with AIs. All participants complained of severe GSM. DHEA was administrated as a vaginal ovule. Participants were instructed to use one ovule every night during the first month, and one ovule every two nights for the entire five remaining months. The patients were requested to attend seriated visits after the beginning of the prasterone treatment to evaluate symptoms, physical improvement and serum estradiol. RESULTS Mean serum estradiol remained low from 3.4 pg/ml to 4.3 pg/ml (p = 0.9136) after 6 months of follow-up. The visual analog scale of dyspareunia improved from 8.5 to mean values after treatment of 0.4 (p = 0.0178). The Vaginal Health Index (VHI) scale and Female Sexual Function Index improved from 9.75 to 15.8 (p = 0.0277) and from an initial score of 11.2 to 20.6 (p = 0.0277), respectively. Vaginal pH changed from basal 8.1 to final 6.5 (p = 0.0330). CONCLUSION Symptoms and physical examination regarding sexuality and vaginal health improved significantly, while serum estradiol remained at low levels. Prasterone seems a safe and effective option to treat GSM in BCS receiving AIs.
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Affiliation(s)
- E Mension
- Faculty of Medicine - University of Barcelona, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - I Alonso
- Faculty of Medicine - University of Barcelona, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - I Cebrecos
- Faculty of Medicine - University of Barcelona, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - N Castrejon
- Department of Pathology, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - M Tortajada
- Faculty of Medicine - University of Barcelona, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - I Matas
- Faculty of Medicine - University of Barcelona, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - S Gómez
- Faculty of Medicine - University of Barcelona, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - L Ribera
- Faculty of Medicine - University of Barcelona, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - S Anglès-Acedo
- Faculty of Medicine - University of Barcelona, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - C Castelo-Branco
- Faculty of Medicine - University of Barcelona, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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6
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Marko KI, Simon JA. Androgen therapy for women after menopause. Best Pract Res Clin Endocrinol Metab 2021; 35:101592. [PMID: 34674962 DOI: 10.1016/j.beem.2021.101592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Androgens are essential hormones in women. Yet, androgen therapy is understudied and underutilized despite showing improvement in postmenopausal hypoactive sexual desire disorder (HSDD) and the genitourinary syndrome of menopause (GSM). Additionally, regulatory concerns have left a significant gap in commercially available testosterone preparations, formulated specifically for women, in most countries. This has led to off-label use of male formulations and compounded therapies which are under-regulated. Beyond HSDD and GSM, testosterone likely influences the brain, breast, cardiovascular and musculoskeletal systems. These effects are not well studied, and therefore it is difficult to counsel patients on testosterone therapy when used for these endpoints. Ultimately, further study is needed to elucidate these effects, create a fuller picture of the risks and benefits, and encourage product development specifically designed for women.
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Affiliation(s)
- Kathryn I Marko
- The George Washington University School of Medicine and Health Sciences, USA.
| | - James A Simon
- The George Washington University School of Medicine and Health Sciences, USA.
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7
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Managing Female Sexual Pain. Urol Clin North Am 2021; 48:487-497. [PMID: 34602170 DOI: 10.1016/j.ucl.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Female sexual pain disorder or genito-pelvic pain/penetration disorder (GPPPD), previously known as dyspareunia, is defined as persistent or recurrent symptoms with one or more of the following for at least 6 months: marked vulvovaginal or pelvic pain during penetrative intercourse or penetration attempts, marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of penetration, and marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration. In this review, we discuss etiology, diagnosis, and treatment for common disorders that cause GPPD.
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8
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Parish SJ, Simon JA, Davis SR, Giraldi A, Goldstein I, Goldstein SW, Kim NN, Kingsberg SA, Morgentaler A, Nappi RE, Park K, Stuenkel CA, Traish AM, Vignozzi L. 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. Climacteric 2021; 24:533-550. [PMID: 33792440 DOI: 10.1080/13697137.2021.1891773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Sharon J Parish
- Department of Psychiatry & Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - James A Simon
- IntimMedicine Specialists, George Washington University School of Medicine, Washington, DC, USA
| | - Susan R Davis
- Women's Health Research Program, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Annamaria Giraldi
- Sexological Clinic, Psychiatric Center, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Irwin Goldstein
- Sexual Medicine, Alvarado Hospital, San Diego, CA, USA.,San Diego Sexual Medicine, San Diego, CA, USA
| | | | - Noel N Kim
- Institute for Sexual Medicine, San Diego, CA, USA
| | - Sheryl A Kingsberg
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Abraham Morgentaler
- Men's Health Boston, Beth Israel Deaconess Medical Center, Harvard Medical School, Chestnut Hill, MA, USA
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, Obstetrics and Gynecology Unit, IRCCS S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Kwangsung Park
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Cynthia A Stuenkel
- Department of Medicine, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Abdulmaged M Traish
- Departments of Biochemistry and Urology, Boston University School of Medicine, Boston, MA, USA
| | - Linda Vignozzi
- Andrology, Women's Endocrinology & Gender Incongruence Unit, Department of "Excellence" Experimental and Clinical Biomedical Sciences "Mario Serio", Careggi Hospital-University of Florence, Florence, Italy.,Consorzio Interuniversitario I.N.B.B., Rome, Italy
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9
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Parish SJ, Simon JA, Davis SR, Giraldi A, Goldstein I, Goldstein SW, Kim NN, Kingsberg SA, Morgentaler A, Nappi RE, Park K, Stuenkel CA, Traish AM, Vignozzi L. 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. J Sex Med 2021; 18:849-867. [PMID: 33814355 DOI: 10.1016/j.jsxm.2020.10.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/12/2020] [Accepted: 10/19/2020] [Indexed: 02/06/2023]
Abstract
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. Parish SJ, Simon JA, Davis SR, et al. 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. J Sex Med 2021;18:849-867.
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Affiliation(s)
- Sharon J Parish
- Department of Psychiatry & Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
| | - James A Simon
- IntimMedicine Specialists, George Washington University School of Medicine, Washington, DC, USA
| | - Susan R Davis
- Women's Health Research Program, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Annamaria Giraldi
- Sexological Clinic, Psychiatric Center, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Irwin Goldstein
- Sexual Medicine, Alvarado Hospital, San Diego, CA, USA; San Diego Sexual Medicine, San Diego, CA, USA
| | | | - Noel N Kim
- Institute for Sexual Medicine, San Diego, CA, USA
| | - Sheryl A Kingsberg
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Abraham Morgentaler
- Men's Health Boston, Beth Israel Deaconess Medical Center, Harvard Medical School, Chestnut Hill, MA, USA
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, Obstetrics and Gynecology Unit, IRCCS S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Kwangsung Park
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Cynthia A Stuenkel
- Department of Medicine, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Abdulmaged M Traish
- Departments of Biochemistry and Urology, Boston University School of Medicine, Boston, MA, USA
| | - Linda Vignozzi
- Andrology, Women's Endocrinology & Gender Incongruence Unit, Department of "Excellence" Experimental and Clinical Biomedical Sciences "Mario Serio"-Careggi Hospital-University of Florence, Florence, Italy; Consorzio Interuniversitario I.N.B.B., Rome, Italy
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10
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Parish SJ, Simon JA, Davis SR, Giraldi A, Goldstein I, Goldstein SW, Kim NN, Kingsberg SA, Morgentaler A, Nappi RE, Park K, Stuenkel CA, Traish AM, Vignozzi L. 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. J Womens Health (Larchmt) 2021; 30:474-491. [PMID: 33797277 PMCID: PMC8064950 DOI: 10.1089/jwh.2021.29037] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
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.
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Affiliation(s)
- Sharon J Parish
- Department of Psychiatry, New York Presbyterian Hospital/Westchester Behavioral Health Center, White Plains, New York, USA.,Department of Medicine, New York Presbyterian Hospital/Westchester Behavioral Health Center, White Plains, New York, USA
| | - James A Simon
- IntimMedicine Specialists, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Susan R Davis
- Women's Health Research Program, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Annamaria Giraldi
- Sexological Clinic, Psychiatric Center, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Irwin Goldstein
- Sexual Medicine, Alvarado Hospital, San Diego, California, USA.,San Diego Sexual Medicine, San Diego, California, USA
| | | | - Noel N Kim
- Institute for Sexual Medicine, San Diego, California, USA
| | - Sheryl A Kingsberg
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Abraham Morgentaler
- Men's Health Boston, Beth Israel Deaconess Medical Center, Harvard Medical School, Chestnut Hill, Massachusetts, USA
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, Obstetrics and Gynecology Unit, IRCCS S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Kwangsung Park
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Cynthia A Stuenkel
- Department of Medicine, UC San Diego School of Medicine, La Jolla, California, USA
| | - Abdulmaged M Traish
- Departments of Biochemistry and Urology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Linda Vignozzi
- Andrology, Women's Endocrinology & Gender Incongruence Unit, Department of "Excellence" Experimental and Clinical Biomedical Sciences "Mario Serio"-Careggi Hospital-University of Florence, Florence, Italy.,Consorzio Interuniversitario I.N.B.B., Rome, Italy
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11
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Li R, Chapman BP, Smith SM. Blood Dehydroepiandrosterone and Dehydroepiandrosterone Sulfate as Pathophysiological Correlates of Chronic Pain: Analyses Using a National Sample of Midlife Adults in the United States. PAIN MEDICINE 2021; 22:243-254. [PMID: 33249441 DOI: 10.1093/pm/pnaa345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Identifying biomarkers is a priority in translational chronic pain research. Dehydroepiandrosterone (DHEA) and its sulfated form, DHEA-S, are adrenocortical steroids in the blood with neuroprotective properties that also produce sex hormones. They may capture key sex-specific neuroendocrine mechanisms of chronic pain. DESIGN Cross-sectional study. METHODS Using data from 1,216 community-dwelling adults aged 34-84 from the Midlife in the United States (MIDUS) cohort, we examined blood DHEA and DHEA-S levels in association with chronic pain in men and women, adjusting for demographics, chronic diseases, medications including opioids, and psychosocial factors. If an association was found, we further explored dose-response relationships by the number of pain locations and the degree of pain interference. RESULTS In women, chronic pain was associated with 0.072 lower (95% confidence interval [CI], -0.127 to -0.017) log10 DHEA-S µg/dL, with pain in one to two locations associated with 0.068 lower (95% CI, -0.131 to -0.006) and in three or more locations 0.071 lower (95% CI, -0.148 to 0.007) log10 DHEA-S (P for trend = 0.074). Furthermore for women, low-interference pain was associated with 0.062 lower (95% CI, -0.125 to -0.000), whereas high-interference pain was associated with 0.138 lower (95% CI, -0.233 to -0.043) log10 DHEA-S (P for trend = 0.004). Chronic pain was not associated with DHEA or DHEA-S levels in men or DHEA levels in women. CONCLUSIONS Chronic pain and its functional interference correspond to lower blood DHEA-S levels in women.
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Affiliation(s)
- Rui Li
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Benjamin P Chapman
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Shannon M Smith
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
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12
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Abstract
ABSTRACT Genitourinary syndrome of menopause (GSM) refers to a collection of symptoms resulting from diminished hormonal, primarily estrogenic stimulation to the vulvovaginal or lower urinary tract and may affect up to 50% of postmenopausal women. Symptoms, which are typically progressive and unlikely to resolve spontaneously, may include, but are not limited to, vulvovaginal dryness, burning or irritation, dyspareunia, or urinary symptoms of urgency, dysuria or recurrent urinary tract infection. These symptoms are typically progressive and unlikely to resolve spontaneously. Diagnosis is clinical. Telemedicine may play a role in diagnosis, initiation of treatment, and follow-up of women with GSM. Effective treatments include moisturizers and lubricants, local hormonal therapy with estrogen or dehydroepiandrosterone, and oral selective estrogen receptor agonists. Laser or radiofrequency procedures, although currently utilized, are being studied to comprehensively understand their overall effectiveness and safety. Additionally, the influence and effect of the vaginal microbiome, as well as potential of treatment via its manipulation, is being studied. We performed a literature search of PubMed, Google Scholar, and Ovid with search terms of vulvovaginal atrophy and GSM and reviewed major US Society Guidelines to create this narrative review of this topic. The literature suggests that healthcare providers can make a significant impact of the health and quality of life of women by being proactive about discussing and providing interventions for GSM. A systematic approach with consideration of current guidelines and attention to developing protocols for interventions should be employed.
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Affiliation(s)
- Nancy A Phillips
- Department Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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13
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Kagan R, Kellogg-Spadt S, Parish SJ. Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause. Drugs Aging 2020; 36:897-908. [PMID: 31452067 PMCID: PMC6764929 DOI: 10.1007/s40266-019-00700-w] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Genitourinary syndrome of menopause is a condition comprising the atrophic symptoms and signs women may experience in the vulvovaginal and bladder-urethral areas as a result of the loss of sex steroids that occurs with menopause. It is a progressive condition that does not resolve without treatment and can adversely affect a woman’s quality of life. For a variety of reasons, many symptomatic women do not seek treatment and, of those who do, many are unhappy with their options. Additionally, many healthcare providers do not actively screen their menopausal patients for the symptoms of genitourinary syndrome of menopause. In this review, we discuss the clinical presentation of genitourinary syndrome of menopause as well as the treatment guidelines recommended by the major societies engaged in women’s health. This is followed by a review of available treatment options that includes both hormonal and non-hormonal therapies. We discuss both the systemic and vaginal estrogen products that have been available for decades and remain important treatment options for patients; however, a major intent of the review is to provide information on the newer, non-estrogen pharmacologic treatment options, in particular oral ospemifene and vaginal prasterone. A discussion of adjunctive therapies such as moisturizers, lubricants, physical therapy/dilators, hyaluronic acid, and laser therapy is included. We also address some of the available data on both the patient and healthcare providers perspectives on treatment, including cost, and touch briefly on the topic of treating women with a history of, or at high risk for, breast cancer.
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Affiliation(s)
- Risa Kagan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Affiliated with Sutter East Bay Medical Foundation, Sutter East Bay Medical Group, 2500 Milvia Street, Berkeley, CA, 94704, USA.
| | - Susan Kellogg-Spadt
- Drexel University College of Medicine, Philadelphia, PA, USA.,Center for Pelvic Medicine, Bryn Mawr, PA, USA
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14
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Holton M, Thorne C, Goldstein AT. An overview of dehydroepiandrosterone (EM-760) as a treatment option for genitourinary syndrome of menopause. Expert Opin Pharmacother 2020; 21:409-415. [PMID: 31928093 DOI: 10.1080/14656566.2019.1703951] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Introduction: Dyspareunia caused by vulvovaginal atrophy is a primary symptom of genitourinary syndrome of menopause (GSM), a chronic, progressive medical condition that results from estrogen and androgen deficiency at menopause. Dehydroepiandrosterone (DHEA, prasterone) is an endogenous precursor steroid hormone that is metabolized into both androgens and estrogens that has been recently been approved by the FDA for the treatment of moderate to severe dyspareunia caused by vulvovaginal atrophy secondary to menopause.Areas covered: This is a comprehensive drug evaluation describing the chemical composition, pharmacokinetics, metabolism, clinical efficacy and safety of dehydroepiandrosterone (prasterone) in the treatment of dyspareunia and VVA secondary to menopause. Preclinical and clinical data suggesting further potential uses, benefits, and contraindications in the genitourinary health of postmenopausal women are also considered.Expert opinion: Intravaginal dehydroepiandrosterone (prasterone) is effective for the management of dyspareunia secondary to menopause and may be effective in the treatment of other types of sexual dysfunction that are secondary to menopause. Further studies should explore additional dosing regimens and different indications.
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Affiliation(s)
- Michelle Holton
- Emergency Department, Baystate Medical Center, Springfield, MA, United States
| | - Chelsea Thorne
- Physiology Department, Georgetown University, Washington, United States
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