Safety and Efficacy of Sildenafil Citrate for the Treatment of Female Sexual Arousal Disorder: A Double-Blind, Placebo Controlled Study

Preliminary Efficacy of Topical Sildenafil Cream for the Treatment of Female Sexual Arousal Disorder: A Randomized Controlled Trial

OBJECTIVE

To assess the efficacy of topical sildenafil cream, 3.6% among healthy premenopausal women with female sexual arousal disorder.

METHODS

We conducted a phase 2b, exploratory, randomized, placebo-controlled, double-blind study of sildenafil cream. Coprimary efficacy endpoints were the change from baseline to week 12 in the Arousal Sensation domain of the SFQ28 (Sexual Function Questionnaire) and question 14 of the FSDS-DAO (Female Sexual Distress Scale-Desire, Arousal, Orgasm).

RESULTS

Two hundred women with female sexual arousal disorder were randomized to sildenafil cream (n=101) or placebo cream (n=99). A total of 174 participants completed the study (sildenafil 90, placebo 84). Among the intention-to-treat (ITT) population, which included women with only female sexual arousal disorder and those with female sexual arousal disorder with concomitant sexual dysfunction diagnoses or genital pain, although the sildenafil cream group demonstrated greater improvement in the SFQ28 Arousal Sensation domain scores, there were no statistically significant differences between sildenafil and placebo cream users in the coprimary and secondary efficacy endpoints. An exploratory post hoc subset of the ITT population with an enrollment diagnosis of female sexual arousal disorder with or without concomitant decreased desire randomized to sildenafil cream reported significant increases in their SFQ28 Arousal Sensation domain score (least squares mean 2.03 [SE 0.62]) compared with placebo cream (least squares mean 0.08 [SE 0.71], P =.04). This subset achieved a larger mean improvement in the SFQ28 Desire and Orgasm domain scores. This subset population also had significantly reduced sexual distress and interpersonal difficulties with sildenafil cream use as measured by FSDS-DAO questions 3, 5, and 10 (all P ≤.04).

CONCLUSION

Topical sildenafil cream improved outcomes among women with female sexual arousal disorder, most significantly in those who did not have concomitant orgasmic dysfunction. In particular, in an exploratory analysis of a subset of women with female sexual arousal disorder with or without concomitant decreased desire, topical sildenafil cream increased sexual arousal sensation, desire, and orgasm and reduced sexual distress.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT04948151.

The use of phosphodiesterase inhibitors in the treatment of female sexual dysfunction: scoping review

Objective

The purpose of this study was to analyze the available evidence regarding the efficacy of iPDE5 in the treatment of female sexual dysfunction (FSD).

Methods

A comprehensive literature search was conducted in March 2023 through the main scientific databases.

Results

A total of 53 articles were identified, out of which, 6 met the predefined inclusion criteria. All of these were randomized controlled trials. Among the included studies, 4 demonstrated the effectiveness of sildenafil in improving sexual response and addressing FSD, while 2 studies failed to establish its efficacy in this context.

Conclusion

Overall, the efficacy of sildenafil in the treatment of FSD remains controversial and inconclusive based on the available evidence. Further research is necessary to clarify the therapeutic potential of iPDE5 in addressing FSD and to better understand the factors that influence treatment outcomes.

Non-pharmacological and drug treatment of autonomic dysfunction in multiple system atrophy: current status and future directions

Multiple system atrophy (MSA) is a sporadic, fatal, and rapidly progressive neurodegenerative disease of unknown etiology that is clinically characterized by autonomic failure, parkinsonism, cerebellar ataxia, and pyramidal signs in any combination. Early onset and extensive autonomic dysfunction, including cardiovascular dysfunction characterized by orthostatic hypotension (OH) and supine hypertension, urinary dysfunction characterized by overactive bladder and incomplete bladder emptying, sexual dysfunction characterized by sexual desire deficiency and erectile dysfunction, and gastrointestinal dysfunction characterized by delayed gastric emptying and constipation, are the main features of MSA. Autonomic dysfunction greatly reduces quality of life and increases mortality. Therefore, early diagnosis and intervention are urgently needed to benefit MSA patients. In this review, we aim to discuss the systematic treatment of autonomic dysfunction in MSA, and focus on the current methods, starting from non-pharmacological methods, such as patient education, psychotherapy, diet change, surgery, and neuromodulation, to various drug treatments targeting autonomic nerve and its projection fibers. In addition, we also draw attention to the interactions among various treatments, and introduce novel methods proposed in recent years, such as gene therapy, stem cell therapy, and neural prosthesis implantation. Furthermore, we elaborate on the specific targets and mechanisms of action of various drugs. We would like to call for large-scale research to determine the efficacy of these methods in the future. Finally, we point out that studies on the pathogenesis of MSA and pathophysiological mechanisms of various autonomic dysfunction would also contribute to the development of new promising treatments and concepts.

Comparative Evaluation of Sildenafil Citrate and Estrogen as an Adjuvant Therapy for Treatment of Unexplained Infertility in Women

BACKGROUND

Uterine blood flow determines endometrial thickness. This study examined how vaginal sildenafil citrate and estradiol valerate altered endometrial thickness, blood flow, and fertility in infertile women.

METHODS

This study observed 148 infertile women whose infertility was unexplained. Group 1 comprised 48 patients who received oral estradiol valerate (Cyclo-Progynova 2 mg/12 h white tablets) from day 6 till ovulation was initiated with clomiphene citrate. A number of 50 participants in group 2 received oral sildenafil (Respatio 20 mg/12 h film-coated tablets) for 5 days starting the day after their previous menstrual period and finishing on the day they ovulated with clomiphene citrate. Group 3 was the control group, with 50 patients receiving clomiphene citrate (Technovula 50 mg/12 h tablets) ovulation induction from the 2nd to 7th day of cycle. All patients had transvaginal ultrasounds to determine ovulation, follicle count, and fertility. Miscarriage, ectopic pregnancy, and multiple pregnancies were monitored for three months.

RESULTS

The three groups' mean ETs differed statistically at p = 0.0004. A statistically significant difference was found between the three groups in terms of the number of follicles, with 69% of patients in group 1 having one and 31% having two or more, 76% of patients in group 2 having one and 24% having two or more, and 90% of patients in the control group having one and 10% having two or more (p = 0.038). The clinical pregnancy rates of the three groups were 58%, 46%, and 27%, respectively (p = 0.005). The distribution of all side effects was not statistically different between the three groups.

CONCLUSION

It is possible to claim that adding oral estrogen to clomiphene citrate therapy as an adjuvant therapy can improve endometrial thickness and, as a result, increase the pregnancy rates in unexplained infertility compared to sildenafil, especially in cases where the infertility has lasted less than two years. Most people who take sildenafil end up with a mild headache.

Pharmacologic therapeutic options for sexual dysfunction

PURPOSE OF REVIEW

Sexual problems are reported by up to 45% of individuals assigned female at birth. Although sexual function is a complex biopsychosocial construct, there are a number of pharmacologic treatment options aimed at addressing the changing vaginal hormonal milieu in postmenopausal individuals and moderating the excitatory and inhibitory aspects of the central nervous system in those with hypoactive sexual desire disorder.

RECENT FINDINGS

The last decade has seen an increase in the number and type of pharmacologic treatment options for dysfunction primarily associated with menopause and hypoactive sexual desire disorder. Recent publications and systematic reviews have strengthened the safety data of existing FDA-approved medications as well as off-label therapies.

SUMMARY

Pharmacologic treatment with local estrogen and testosterone replacement in postmenopausal individuals and with centrally-acting therapies such as flibanserin, bremelanotide, and testosterone in premenopausal individuals assigned female at birth are safe and can be used to improve sexual desire and sexual satisfaction.

Sexual Health in the Elderly Population

PURPOSE OF REVIEW

Among the growing elderly population, sexual health remains an important concern for individuals and couples. An understanding of the expected changes with aging and taking care of aging men and women is important for treating sexual dysfunction. Sexual health issues related to aging can be both linked between men and women and independent. The aim of this study is to determine the most important considerations that contribute to sexual satisfaction in men and women in this population.

RECENT FINDINGS

Many factors contribute to the overall sexual health of men and women. Hypogonadism and erectile dysfunction both warrant thorough evaluation and consideration of treatment to improve sexual satisfaction. Underlying cardiovascular issues may be present in men presenting with these concerns. In addition to hormone replacement and traditional therapy for erectile dysfunction, therapeutic stem cell injection has shown some promise. Menopause, vaginal dryness, and dyspareunia play important roles in sexual satisfaction in women. Vaginal moisturizers, topical estrogen, and MonaLisa Touch laser therapy all may aid in improving these symptoms and ultimately sex lives. Studies have also demonstrated some benefit in populations with arousal disorders, which can be present in the elderly.

SUMMARY

Male patients often describe issues related to erectile dysfunction and hypogonadism, and issues with sexual drive. The pathophysiology is linked between these conditions and treatment of one component can provide symptom relief on a larger scale. A combination of testosterone therapy, lifestyle modifications, and therapy for erectile dysfunction relates to sexual satisfaction in men. In women, an understanding of the physiological process of menopause and offering therapy when indicated can improve the quality of sexual health and provide satisfaction to both patient and partner. While aging can diminish drive and desire, proper counseling and treatment may significantly benefit some patients. A multimodal approach involving the physician, patient, and partner will optimize care and may improve the quality of life in the elderly. This review outlines some normal changes due to aging and identifies some current treatment options for a population in which sexual health can be often ignored or dismissed. By understanding the available tools, a more comprehensive approach can be taken to achieve satisfaction in couples and individuals alike.

Female Sexual Dysfunction: Pharmacologic and Therapeutic Interventions

Female sexual dysfunction is associated with personal distress and includes female sexual interest and arousal disorder (including former hypoactive sexual desire disorder), female orgasmic disorder, genitopelvic pain and penetration disorder, and substance- or medication-induced sexual dysfunction. These disorders are remarkably common among women, with an estimated prevalence of 20-40%. It is our responsibility as obstetrician-gynecologists to identify risk factors and screen for female sexual dysfunction. Appropriate screening allows for further exploration into sexual function and dysfunction and, ultimately, determination of associated distress. Treatment often involves addressing the underlying issue through therapy or medical management. For female sexual interest and arousal disorder, treatment generally includes cognitive behavioral therapy, often with a mindfulness focus, and consideration of pharmaceutical management. Female orgasmic disorder is treated with education and awareness, as well as therapy. Evaluation for underlying etiology is particularly critical for genitopelvic pain and penetration disorder to allow treatment of an underlying condition. Finally, substance- or medication-induced sexual dysfunction is best managed by cessation of the implicated substance and consideration of adjunctive therapy if dysfunction is related to antidepressants. Female sexual dysfunction is often overlooked in clinical practice; however, there are effective medical and psychological options for management.

A randomized clinical trial of sildenafil plus clomiphene citrate to improve the success rate of ovulation induction in patients with unexplained infertility

OBJECTIVES

To investigate the role of sildenafil citrate in improving ovulation induction success rate in women with unexplained infertility.

METHODS

A randomized clinical trial from January to December 2018 of 80 women with unexplained infertility randomized into two groups. Both groups received 100 mg clomiphene citrate once daily from days 3-7 of the menstrual cycle. The study group also received 25 mg oral sildenafil citrate twice daily from days 8-12 of the same cycle. Transvaginal ultrasound assessed ovulation, endometrial thickness, and number of follicles. Pregnancy was assessed 2 weeks after ovulation. Primary outcome measures were endometrial thickness, number of mature follicles, and pregnancy rates.

RESULTS

Pregnancy rates (26 (65%) and 16 (40%), P=0.043) and endometrial thickness (10.4 ± 1.4 and 9.2 ± 1.9, P=0.007) were significantly higher in the study group. More women in the study group reported adverse effects compared with the control group (17 [42.5%] vs 9 [22.5%]; P=0.034), with headache the most common adverse effect in the study group, reported by 8 (20.0%) patients.

CONCLUSION

Adding sildenafil citrate improved ovulation success rate and increased pregnancy rate.

PAN AFRICAN CLINICAL TRIAL REGISTRY

PACTR201907658492123.

Testosterone therapy and other treatment modalities for female sexual dysfunction

PURPOSE OF REVIEW

Recently in October 2019 a Global Consensus Position on the use of Testosterone Therapy for Women was published. The use of testosterone and other agents for female sexual dysfunction (FSD) is an important topic for the urologist focusing on sexual health. This review describes the known causes for FSD, and discusses the role of androgens in this disorder, the evidence for using testosterone treatment, and other current and emerging therapies.

RECENT FINDINGS

A recent meta-analysis, published in The Lancet Diabetes & Endocrinology evaluated a total of 36 randomized control trials spanning 1990-2018 and includes a total of 8480 patients. The primary findings were that testosterone therapy (TTh) increased sexual function including satisfactory sexual event frequency, sexual desire, pleasure, arousal, orgasm, responsiveness, and self-image when compared with either a placebo or drug-control (e.g., estrogen ± progestogen). In addition, TTh reduced sexual concerns and distress in postmenopausal women. Side effects included an increase in weight, acne, and hair growth, but there was no increase in serious adverse events. Importantly, TTh duration was greater than 12 weeks in all randomized control trials included in this meta-analysis.

SUMMARY

TTh is effective to treat FSD in postmenopausal women. More data is required to evaluate the long-term safety data on the effects of TTh on cardiovascular health, breast health, cognitive function, and the musculoskeletal system in women.

The rodent vaginal microbiome across the estrous cycle and the effect of genital nerve electrical stimulation

Treatment options are limited for the approximately 40% of postmenopausal women worldwide who suffer from female sexual dysfunction (FSD). Neural stimulation has shown potential as a treatment for genital arousal FSD, however the mechanisms for its improvement are unknown. One potential cause of some cases of genital arousal FSD are changes to the composition of the vaginal microbiota, which is associated with vulvovaginal atrophy. The primary hypothesis of this study was that neural stimulation may induce healthy changes in the vaginal microbiome, thereby improving genital arousal FSD symptoms. In this study we used healthy rats, which are a common animal model for sexual function, however the rat vaginal microbiome is understudied. Thus this study also sought to examine the composition of the rat vaginal microbiota. Treatment rats (n = 5) received 30 minutes of cutaneous electrical stimulation targeting the genital branch of the pudendal nerve, and Control animals (n = 4) had 30-minute sessions without stimulation. Vaginal lavage samples were taken during a 14-day baseline period including multiple estrous periods and after twice-weekly 30-minute sessions across a six-week trial period. Analysis of 16S rRNA gene sequences was used to characterize the rat vaginal microbiota in baseline samples and determine the effect of stimulation. We found that the rat vaginal microbiota is dominated by Proteobacteria, Firmicutes, and Actinobacteria, which changed in relative abundance during the estrous cycle and in relationship to each other. While the overall stimulation effects were unclear in these healthy rats, some Treatment animals had less alteration in microbiota composition between sequential samples than Control animals, suggesting that stimulation may help stabilize the vaginal microbiome. Future studies may consider additional physiological parameters, in addition to the microbiome composition, to further examine vaginal health and the effects of stimulation.

Female Sexual Dysfunction: ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician-Gynecologists, Number 213

Female sexual dysfunction encompasses various conditions that are characterized by reported personal distress in one or more of the following areas: desire, arousal, orgasm, or pain (). Although female sexual dysfunction is relatively prevalent, women are unlikely to discuss it with their health care providers unless asked (), and many health care providers are uncomfortable asking for a variety of reasons, including a lack of adequate knowledge and training in diagnosis and management, inadequate clinical time to address the issue, and an underestimation of the prevalence (). The purpose of this document is to provide an overview of female sexual dysfunction, to outline updated criteria for diagnosis, and to discuss currently recommended management strategies based on the best available evidence.

Comparison of the effect of Elaeagnus angustifolia flower capsule and sildenafil citrate tablet female sexual interest/arousal disorder in clinical trial study

Background and Aims:

Sexual desire is one of the main issues affecting people's individual and social life. The present study aimed to compare the effects of Elaeagnus angustifolia extract and sildenafil citrate tablet on female sexual interest/arousal disorder (FSIAD) among the women referring to health centers in 2013.

Methods:

In this randomized clinical trial, 125 women between 18 and 40 years old who suffered from FSIAD were divided into Elaeagnus angustifolia, sildenafil citrate, and control groups. The study data were gathered using Female Sexual Function Index (FSFI) and through measurement of TSH and prolactin. The first intervention group had to consume 4.5 g Elaeagnus angustifolia in two divided doses for 35 days and the second one had to use 50 mg sildenafil citrate tablets for 4 weeks one hour before their sexual relationships. On the other hand, the control group was required to consume the placebo. The data were analyzed using the SPSS statistical software (v. 18) and P < 0.05 was considered as statistically significant.

Results:

The frequency of sexual interest/arousal before the intervention was 53.7%, 50. %, and 66.7% in the Elaeagnus angustifolia, sildenafil citrate, and control groups, respectively (P = 0.269). However, these measures were respectively obtained as 19.5%, 33.3%, and 52.4% after the intervention (P = 0.007).

Conclusion:

Both interventions were effective in improvement of sexual interest/arousal. Yet, further studies are required to be conducted on the issue. Therefore, direct examination of health care providers, identifying and diagnosing sexual problems are the most important primary care.

Influences the process of couples’ sexual problems.

Female Sexual Dysfunction and the Placebo Effect: A Meta-analysis

OBJECTIVE

To quantify the placebo effect of various pharmacologic modalities including neuromodulators, hormonal agents, and onabotulinum toxin A for female sexual dysfunction.

DATA SOURCES

Using Meta-analyses Of Observational Studies in Epidemiology guidelines, we conducted a systematic review of PubMed, EMBASE, ClinicalTrials.gov, and the Cochrane Review databases.

METHODS OF STUDY SELECTION

Eleven search terms, "female sexual dysfunction" "treatment" in combination with "hypoactive sexual desire," "arousal disorder," "sexual pain disorder," "genitourinary syndrome of menopause," "orgasmic disorder," "vulvovaginal atrophy," "vaginismus," "vaginal atrophy," "vulvodynia," and "vestibulitis," were used. Studies were included if their design was randomized, included a placebo arm, and used the Female Sexual Function Index as an outcome measure.

TABULATION, INTEGRATION, AND RESULTS

The placebo effect on the Female Sexual Function Index was compared with each respective study's treatment effect using inverse-variance weighting in a random-effects analysis model. Six hundred five relevant articles were retrieved. Twenty-four randomized controlled trials included a placebo arm. Of these, eight studies used the Female Sexual Function Index. Across these studies, 1,723 women with clinical pretreatment female sexual dysfunction received placebo. Two thousand two hundred thirty-six women were in the treatment arm of the respective studies and received various pharmacologic interventions including flibanserin, bupropion, onabotulinum toxin A, intravaginal prasterone, intranasal oxytocin, ospemifene, and bremelanotide. Women receiving placebo improved 3.62 (95% CI 3.29-3.94) on the Female Sexual Function Index. The treatment arm had a corresponding increase of 5.35 (95% CI 4.13-6.57).

CONCLUSION

This meta-analysis of Level I evidence demonstrates that 67.7% of the treatment effect for female sexual dysfunction is accounted for by placebo. Our findings suggest that the current treatments for female sexual dysfunction are, overall, minimally superior to placebo, which emphasizes the ongoing need for more efficacious treatment for female sexual dysfunction.

The characteristics of hypoactive sexual desire disorder in Korean women who visited a community-based gynaecology hospital for sexual dysfunction

This cross-sectional study analysed the characteristics of HSDD (hypoactive sexual desire disorder) in Korean women. Two hundred and seventeen women seen for sexual dysfunction were assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised (DMS IV-TR) and the Female Sexual Function Index (FSFI). A diagnosis of HSDD was more common in women in their 40 s (56%), who had previously undergone surgery for a feeling of 'wide vagina'. Both too much or too little sexual activity caused HSDD. Longer physical contact and sexual foreplay duration lessened the prevalence of HSDD. We concluded that special attention should be paid to women in their 40 s, particularly those with a history of vaginal surgery as they are at risk of HSDD. Potential treatment options should include couple counselling about the optimal frequency and duration of sexual activity, as well as treatment specific to the disorders identified by the FSFI. Impact statement What is already known on this subject: Many socio-medical factors affect the prevalence of HSDD (Hypoactive sexual desire disorder). Age, cultural factors, relationship status, education, religion, employment, mental distress, depression, medications, menopausal status, multiple psychiatric disorders and a variety of medical conditions impact on sexual function. What do the results of this study add: A history of wide vaginal surgery (perineoplasty, vaginal rogation rejuvenation, or anterior vaginal introitoplasty) affects the incidence of HSDD (and have not been evaluated before). Both too much or too little sexual activity were found to have caused HSDD. A longer physical contact and duration of sexual foreplay lessened the prevalence of HSDD. What are the implications of these findings for clinical practice and/or further research: We concluded that special attention should be paid to women in their 40 s; particularly those with a history of wide vaginal surgery, as they are at risk of HSDD. Potential treatment options should include couple counselling about the optimal frequency and duration of sexual activity, as well as treatment specific to the disorders identified by the FSFI.

Female sexual dysfunction: a focus on flibanserin

Flibanserin is the first US Food and Drug Administration (FDA)-approved option for sexual dysfunction, specifically low sexual desire. Until recently, there were no FDA-approved medication options to assist the ~40% of women affected by female sexual dysfunction (FSD). Often, patients report feeling uncomfortable discussing sexual health, identifying a strong need for health care professionals (HCPs) to proactively reach out to patients to identify concerns and initiate a discussion about sexual health and the available treatment options. Within the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DMS-5), the criteria of female sexual interest/arousal disorder (FSIAD) are outlined, encompassing one of the most common sexual concerns, formerly in its own category defined as hypoactive sexual desire disorder (HSDD) or low sexual desire. HSDD is the absence or deficiency of sexual interest and/or desire leading to significant distress and interpersonal difficulties. HCPs offer an important service in assessing their patients and providing information about treatment considerations while ensuring patient comfort with this topic. This article provides an overview of the types and potential causes associated with FSD and the role of flibanserin in practice as a treatment option. Despite a need for additional study in diverse populations, flibanserin has demonstrated efficacy with increased female sexual function index (FSFI) total and desire domain scores in clinical studies indicating benefit in sexual desire. Common patient or provider-administered assessment tools to assist in identifying affected patients and patient counseling strategies are reviewed.

Survivorship, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology

Many cancer survivors experience menopausal symptoms, including female survivors taking aromatase inhibitors or with a history of oophorectomy or chemotherapy, and male survivors who received or are receiving androgen-ablative therapies. Sexual dysfunction is also common in cancer survivors. Sexual dysfunction and menopause-related symptoms can increase distress and have a significant negative impact on quality of life. This portion of the NCCN Guidelines for Survivorship provide recommendations for screening, evaluation, and treatment of sexual dysfunction and menopausal symptoms to help healthcare professionals who work with survivors of adult-onset cancer in the posttreatment period.

Sexual Dysfunction and Intimacy for Ostomates

Sex and intimacy presents special challenges for the ostomate. Since some colorectal surgery patients will require either temporary or permanent stomas, intimacy and sexuality is a common issue for ostomates. In addition to the stoma, nerve damage, radiotherapy, and chemotherapy are often used in conjunction with stoma creation for cancer patients, thereby adding physiological dysfunction to the personal psychological impact of the stoma, leading to sexual dysfunction. The purpose of this paper is to describe the prevalence, etiology, and the most common types of sexual dysfunction in men and women after colorectal surgery and particularly those patients with stomas. In addition, treatment strategies for sexual dysfunction will also be described.

Flibanserin for hypoactive sexual desire disorder: place in therapy

The pathophysiology, diagnosis and treatment of female sexual interest in pre- and post-menopausal women present a complex arena for patients and physicians to navigate. Flibanserin was the first pharmacologic treatment, approved by the United States Food and Drug Administration in August 2015, for hypoactive sexual desire disorder (HSDD) in premenopausal women. Side effects, contraindications and lack of approval in postmenopausal women are all limitations, as are issues surrounding patient and physician knowledge and access. Testosterone, buspirone, sildenafil, bupropion, bremelanotide, as well as herbal medications (Herbal vX or Tribulus terrestris) have demonstrated some clinical benefit in women with sexual dysfunction disorders however, trials have significant design, dosing or generalizability limitations. Nonpharmaceutical cognitive behavioral therapy, mindfulness meditation, pelvic floor therapy, and clitoral stimulators are also interventions women may pursue. This manuscript will explore the clinical data regarding these therapeutic modalities so as to bring attention to this issue of female HSDD, to offer an overview of current research, and to incite providers to initiate discussion among themselves and their patients.

Controversies of Women’s Sexual Arousal and Desire

Abstract. The past three decades have seen an unprecedented increase in empirical research on women’s sexual response. In this review, we critically examine current controversies and assumptions associated with the nature of women’s sexual arousal and desire. We focus specifically on four assumptions: (1) the assumption that women should be aroused by stimuli that align with their stated preferences, (2) the assumption that women’s physiological and self-reported arousal should perfectly align, (3) the assumption that sexual desire precedes sexual arousal, and (4) the assumption that a single pharmaceutical compound will adequately restore women’s sexual response to her level of satisfaction. Engaging a gendered psychological framework for conceptualizing women’s sexuality, we emphasize the need for models of women’s sexual response to be sensitive to the sexed biological processes and gendered psychosocial factors that contribute to a woman’s unique sexual experience.

Women's Sexual Health and Reproductive Function After SCI

Sexual function and to a lesser extent reproduction are often disrupted in women with spinal cord injuries (SCI), who must be educated to better understand their sexual and reproductive health. Women with SCI are sexually active; they can use psychogenic or reflexogenic stimulation to obtain sexual pleasure and orgasm. Treatment should consider a holistic approach using autonomic standards to describe remaining sexual function and to assess both genital function and psychosocial factors. Assessment of genital function should include thoracolumbar dermatomes, vulvar sensitivity (touch, pressure, vibration), and sacral reflexes. Self-exploration should include not only clitoral stimulation, but also stimulation of the vagina (G spot), cervix, and nipples conveyed by different innervation sources. Treatments may consider PDE5 inhibitors and flibanserin on an individual basis, and secondary consequences of SCI should address concerns with spasticity, pain, incontinence, and side effects of medications. Psychosocial issues must be addressed as possible contributors to sexual dysfunctions (eg, lower self-esteem, past sexual history, depression, dating habits). Pregnancy is possible for women with SCI; younger age at the time of injury and at the time of pregnancy being significant predictors of successful pregnancy, along with marital status, motor score, mobility, and occupational scores. Pregnancy may decrease the level of functioning (eg, self-care, ambulation, upper-extremity tasks), may involve complications (eg, decubitus ulcers, weight gain, urological complications), and must be monitored for postural hypotension and autonomic dysreflexia. Taking into consideration the physical and psychosocial determinants of sexuality and childbearing allows women with SCI to achieve positive sexual and reproductive health.

Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations

In the World Health Organization's forthcoming eleventh revision of the International Classification of Diseases and Related Health Problems (ICD-11), substantial changes have been proposed to the ICD-10 classification of mental and behavioural disorders related to sexuality and gender identity. These concern the following ICD-10 disorder groupings: F52 Sexual dysfunctions, not caused by organic disorder or disease; F64 Gender identity disorders; F65 Disorders of sexual preference; and F66 Psychological and behavioural disorders associated with sexual development and orientation. Changes have been proposed based on advances in research and clinical practice, and major shifts in social attitudes and in relevant policies, laws, and human rights standards. This paper describes the main recommended changes, the rationale and evidence considered, and important differences from the DSM-5. An integrated classification of sexual dysfunctions has been proposed for a new chapter on Conditions Related to Sexual Health, overcoming the mind/body separation that is inherent in ICD-10. Gender identity disorders in ICD-10 have been reconceptualized as Gender incongruence, and also proposed to be moved to the new chapter on sexual health. The proposed classification of Paraphilic disorders distinguishes between conditions that are relevant to public health and clinical psychopathology and those that merely reflect private behaviour. ICD-10 categories related to sexual orientation have been recommended for deletion from the ICD-11.

Pharmacologic Treatment Options for Hypoactive Sexual Desire Disorder

Hypoactive sexual desire disorder is the most common cause of sexual dysfunction in women. According to a national survey, approximately a third of all women experience low sexual desire. The etiology of the disorder is often multifactorial. Research in treatment options for hypoactive sexual desire disorder is limited. In this article, treatment options including sex therapy, hormone therapy (estrogen, testosterone, dehydroepiandrosterone, tibolone), non-hormonal medical therapies (buproprion, buspirone, phosphodiesterase-5 inhibitors, amantadine and apomorphine) and herbal therapies (Avlimil®, Arginmax®, Zestra®, yohimbine and Ginkgo biloba) are reviewed.

Comparing the effects of treatment with sildenafil and cognitive-behavioral therapy on treatment of sexual dysfunction in women: a randomized controlled clinical trial

Background

Sexual dysfunction in women is prevalent and common in women after menopause. Many attempts to treat patients with sexual dysfunction by cognitive-behavioral therapy (CBT) methods. But to the best of our knowledge, there has been no study that compared these two methods.

Objective

The aim of this study was to assess and compare the effects of sildenafil and cognitive-behavioral therapy on treatment of sexual dysfunction in women.

Methods

In this randomized, controlled, clinical trial, 86 women with arousal and orgasm dysfunction were surveyed. The patients were divided into two groups, i.e., sildenafil and CBT groups. The patients in the sildenafil group were treated by 50 mg of oral sildenafil one hour before intercourse, and the other group had weekly sessions of CBT for eight weeks. Sexual dysfunctions were evaluated by the Female Sexual Function Index (FSFI), a sexual satisfaction questionnaire, and the Enrich marital satisfaction scale.

Results

The mean age of the participants was 33.14 ± 7.34 years. The mean scores for female sexual function index, sexual satisfaction, and the Enrich marital satisfaction scale were increased in both groups during treatment (p < 0.001). It was found that cognitive-behavioral therapy compared to treatment with sildenafil increased all subscales, except arousal, orgasm, and lubrication.

Conclusion

Cognitive-behavioral therapy is more effective than treatment with sildenafil for improving female sexual function.

Clinical trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the IRCT ID: IRCT2014070318338N1.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Peripheral Female Genital Arousal as Assessed by Thermography Following Topical Genital Application of Alprostadil vs Placebo Arousal Gel: A Proof-of-Principle Study Without Visual Sexual Stimulation

Introduction

Female sexual arousal disorder is a pathophysiologic state characterized clinically by persistent or recurrent inability to attain or maintain an adequate lubrication-swelling response of sexual excitement until completion of sexual activity. Prior clinical experience with alprostadil products for men with erectile dysfunction supports its use in women with female sexual arousal disorder.

Aim

To compare the effect of topical alprostadil with over-the-counter (OTC) lubricant on female genital arousal in the absence of visual sexual stimuli.

Methods

Healthy premenopausal women without sexual dysfunction were recruited from the community to participate in the study. Of 17 women who consented, 10 were enrolled and completed the trial. The mean age of subjects was 32 years (range = 27–43). Study drug or placebo was applied topically to the genitals. Continuous temperature monitoring was performed. Participants completed questionnaires assessing genital sensation, effect, intensity, and duration.

Main Outcome Measures

Change in temperature from baseline in vestibule, clitoris and vulva.

Results

In all 10 subjects, topical alprostadil induced a statistically significant increase in temperature of the vestibule, clitoris, and vulva compared with the OTC lubricant. The most rapid difference in genital temperature between placebo and alprostadil was seen on the vulva, which demonstrated a significant difference at approximately 9 minutes. There was a significant difference in temperature seen for the vestibule and clitoris at 11 and 19 minutes, respectively. Sixty percent of women reported being aware or conscious of genital sensations with topical alprostadil, but not with OTC lubricant. Discordance was noted in 30% of subjects who reported being aware or conscious of genital sensations with the two treatments and 10% who reported not being aware or conscious of genital sensations with either treatment.

Conclusion

Topical alprostadil administered to healthy premenopausal women induced statistically significant, sustained increases in genital temperatures of the vestibule, clitoris, and vulva within 20 minutes compared with OTC lubricant.

Impact of libido at 2 weeks after stroke on risk of stroke recurrence at 1-year in a chinese stroke cohort study

Background:

There were few studies on the relation between changes in libido and incidence of stroke recurrence. The aim of this study was to investigate the relationship between libido decrease at 2 weeks after stroke and recurrent stroke at 1-year.

Methods:

It is a multi-centered, prospective cohort study. The 14^th item of the Hamilton Depression Rating Scale-17 was used to evaluate changes of libido in poststroke patients at 2 weeks. Stroke recurrence was defined as an aggravation of former neurological functional deficit, new local or overall symptoms, or stroke diagnosed at re-admission.

Results:

Among 2341 enrolled patients, 1757 patients had completed follow-up data, 533 (30.34%) patients had decreased libido at 2 weeks, and 166 (9.45%) patients had recurrent stroke at 1-year. Multivariate logistic regression analysis showed that, compared with patients with normal libido, the odds ratio (OR) of recurrent stroke in patients with decreased libido was reduced by 41% (OR = 0.59, 95% confidence interval [CI]: 0.40–0.87). The correlation was more prominent among male patients (OR = 0.52, 95% CI: 0.31–0.85) and patients of ≥60 years of age (OR = 0.57, 95% CI: 0.35–0.93).

Conclusions:

One out of three stroke patients in mainland China has decreased libido at 2 weeks after stroke. Decreased libido is a protective factor for stroke recurrence at 1-year, which is more prominent among older male patients.

Interventions for sexual dysfunction following treatments for cancer in women

BACKGROUND

The proportion of people living with and surviving cancer is growing. This has led to increased awareness of the importance of quality of life, including sexual function, in those affected by cancer. Sexual dysfunction is a potential long-term complication of many cancer treatments. This includes treatments that have a direct impact on the pelvic area and genitals, and also treatments that have a more generalised (systemic) impact on sexual function.This is an update of the original Cochrane review published in Issue 4, 2007, on interventions for treating sexual dysfunction following treatments for cancer for men and women. Since publication in 2007, there has been an increase in the number of trials for both men and women and this current review critiques only those for women. A review in press will present those for men.

OBJECTIVES

To evaluate the effectiveness of interventions for treating sexual dysfunction in women following treatments for cancer. To assess adverse events associated with interventions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 9), MEDLINE, EMBASE, PsycINFO, AMED, CINAHL, Dissertation Abstracts and the NHS Research Register. The searches were originally run in January 2007 and we updated these to September 2015.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed the effectiveness of a treatment for sexual dysfunction. The trial participants were women who had developed sexual dysfunction as a consequence of a cancer treatment. We sought evaluations of interventions that were pharmaceutical, mechanical, psychotherapeutic, complementary or that involved physical exercise.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed trial quality. We considered meta-analysis for trials with comparable key characteristics.

MAIN RESULTS

Since the original version of this review we have identified 11 new studies in women. The one study identified in the earlier version of this review was excluded in this update as it did not meet our narrower inclusion criteria to include only interventions for the treatment, not prevention, of sexual dysfunction.In total 1509 female participants were randomised across 11 trials. All trials explored interventions following treatment either for gynaecological or breast cancer. Eight trials evaluated a psychotherapeutic or psycho-educational intervention. Two trials evaluated a pharmaceutical intervention and one pelvic floor exercises. All involved heterosexual women. Eight studies were at a high risk of bias as they involved a sample of fewer than 50 participants per trial arm. The trials varied not only in intervention content but in outcome measurements, thereby restricting combined analysis. In the trials evaluating a psychotherapeutic intervention the effect on sexual dysfunction was mixed; in three trials benefit was found for some measures of sexual function and in five trials no benefit was found. Evidence from the other three trials, two on different pharmaceutical applications and one on exercise, differed and was limited by small sample sizes. Only the trial of a pH-balanced vaginal gel found significant improvements in sexual function. The trials of pharmaceutical interventions measured harm: neither reported any. Only one psychological intervention trial reported that no harm occurred because of the intervention; the other trials of psychological support did not measure harm.

AUTHORS' CONCLUSIONS

Since the last version of this review, the new studies do not provide clear information on the impact of interventions for sexual dysfunction following treatments for cancer in women. The sexual dysfunction interventions in this review are not representative of the range that is available for women, or of the wider range of cancers in which treatments are known to increase the risk of sexual problems. Further evaluations are needed.

Effect of sexual diary keeping and self-evaluation on female sexual function and depression: A pilot study

OBJECTIVES

The aim of the trial was to assess the effect of self-evaluation and sexual diary keeping on female sexual function and depressive symptoms in women diagnosed with sexual dysfunction.

METHODS

A single-arm non-randomised trial included 30 women (53 ± 7 years of age) with female sexual dysfunction (Female Sexual Function Index [FSFI] < 27) and a stable partnership duration of 5-40 years. Female sexual function was assessed by sexual, psychological and gynaecological history taking and validated questionnaires including the FSFI, Female Sexual Distress Scale (FSDS) and Hamilton Depression Scale (HDS), before and after 4 weeks of sexual diary keeping.

RESULTS

A subjective improvement in communication of sexual problems was reported by 60% of participants; no participants reported any worsening of communication. FSFI and FSDS scores were, respectively, 18.0 ± 7.7 and 22.0 ± 10.0 at baseline and 20.2 ± 7.2 and 20.6 ± 11.5 after 4 weeks. HDS score decreased from 6.0 ± 4.0 at baseline to 4.4 ± 2.7 after 4 weeks (p = 0.042).

CONCLUSIONS

Self-evaluation and sexual diary keeping may improve aspects of sexual life, such as couple communication, without a direct effect on variables measured with validated questionnaires on different domains of sexual function.

Sexual dysfunction in patients with spinal cord lesions

Many aspects of sexuality can be disrupted following a spinal cord lesion (SCL). It can alter an individual's self-esteem and body image, interfere with positioning and mobility, introduce unexpected problems with incontinence and spasticity, decrease pleasure, and delay orgasm. Sexual concerns in men can involve erectile function, essential for intercourse, ejaculation function, necessary for fertility, and the ability to reach orgasm. In women they can involve concerns with vaginal lubrication, genital congestion, and vaginal infections, which can all go unnoticed, and orgasm, which may be lost. All of these concerns must be addressed during rehabilitation as individuals with SCL continue to live an active sexual life, and consider sexuality among their top priority for quality of life. This chapter describes the impact of SCL on various phases of men's and women's sexual responses and on various aspects of sexuality. Treatments are described in terms of what is currently available and what is specific to the SCL population. New approaches in particular for women are described, along with tips from sexual counseling which consider an overall approach, taking into account the primary, secondary, and tertiary consequences of the SCL on the individual's sexuality. Throughout the chapter, attempts are made to integrate neurophysiologic knowledge, findings from the literature on SCL, and clinical experience in sexual rehabilitation.

Women taking the "blue pill" (sildenafil citrate): such a big deal?

For years, phosphodiesterase type 5 inhibitors have been used for the treatment of erectile dysfunctions. Due to the similarities between male and female sexual response, several studies have assessed the effects of sildenafil citrate (Viagra^®) in women affected by female sexual arousal disorder. The results are still conflicting and the drug is not devoid of adverse effects. Furthermore, female sexual arousal disorder is a heterogeneous condition whose underlying causes are difficult to diagnose and appropriate treatment requires a thorough sexual, psychological, and medical history along with specialist consultations. The clinician should pursue a global approach to the patient with sexual difficulties, while non-hormonal treatment such as phosphodiesterase type 5 inhibitors (ie, sildenafil citrate) should be kept as the last option.

Survivorship: sexual dysfunction (female), version 1.2013

Cancer treatment, especially hormonal therapy and therapy directed toward the pelvis, can contribute to sexual problems, as can depression and anxiety, which are common in cancer survivors. Thus, sexual dysfunction is common in survivors and can cause increased distress and have a significant negative impact on quality of life. This section of the NCCN Guidelines for Survivorship provides screening, evaluation, and treatment recommendations for female sexual problems, including those related to sexual desire, arousal, orgasm, and pain.

Hypoactive sexual desire disorder in women: treatment options beyond testosterone and approaches to communicating with patients on sexual health

Hypoactive sexual desire disorder (HSDD) affects nearly 1 in 10 women. Thus, it is essential for pharmacists and other health care providers to be comfortable when discussing a patient's sexual health to ensure appropriate triage so that the specific causes of HSDD can be identified and potential recommendations provided. HSDD is defined as the absence or deficiency of sexual interest and/or desire, leading to significant distress and interpersonal difficulties. As health care providers, pharmacists have a critical role in assessing the presence of HSDD and providing education on available treatment options. This article will review the potential causes of HSDD and low sexual desire, the screening tools available, and the significant role of health care professionals in communicating with patients about their sexual health. An overview of the importance of behavioral modifications, the current pharmacologic options being investigated, and the use of complementary and alternative therapies will also be explored. Currently, buproprion is the primary pharmacologic agent that has shown positive results in treating patients with HSDD. The use of testosterone therapy will not be addressed in this article, as this therapy is described in greater detail elsewhere.

Diabetes and sexual dysfunction: current perspectives

Diabetes mellitus is one of the most common chronic diseases in nearly all countries. It has been associated with sexual dysfunction, both in males and in females. Diabetes is an established risk factor for sexual dysfunction in men, as a threefold increased risk of erectile dysfunction was documented in diabetic men, as compared with nondiabetic men. Among women, evidence regarding the association between diabetes and sexual dysfunction are less conclusive, although most studies have reported a higher prevalence of female sexual dysfunction in diabetic women as compared with nondiabetic women. Female sexual function appears to be more related to social and psychological components than to the physiological consequence of diabetes. Hyperglycemia, which is a main determinant of vascular and microvascular diabetic complications, may participate in the pathogenetic mechanisms of sexual dysfunction in diabetes. Moreover, diabetic people may present several clinical conditions, including hypertension, overweight and obesity, metabolic syndrome, cigarette smoking, and atherogenic dyslipidemia, which are themselves risk factors for sexual dysfunction, both in men and in women. The adoption of healthy lifestyles may reduce insulin resistance, endothelial dysfunction, and oxidative stress - all of which are desirable achievements in diabetic patients. Improved well-being may further contribute to reduce and prevent sexual dysfunction in both sexes.

Sexual dysfunction in women with diabetic kidney

Few studies address alteration of sexual function in women with diabetes and chronic kidney disease (CKD). Quality of life surveys suggest that discussion of sexual function and other reproductive issues are of psychosocial assessment and that education on sexual function in the setting of chronic diseases such as diabetes and CKD is widely needed. Pharmacologic therapy with estrogen/progesterone and androgens along with glycemic control, correction of anemia, ensuring adequate dialysis delivery, and treatment of underlying depression are important. Changes in lifestyle such as smoking cessation, strength training, and aerobic exercises may decrease depression, enhance body image, and have positive impacts on sexuality. Many hormonal abnormalities which occur in women with diabetes and CKD who suffer from chronic anovulation and lack of progesterone secretion may be treated with oral progesterone at the end of each menstrual cycle to restore menstrual cycles. Hypoactive sexual desire disorder (HSDD) is the most common sexual problem reported by women with diabetes and CKD. Sexual function can be assessed in women, using the 9-item Female Sexual Function Index, questionnaire, or 19 items. It is important for nephrologists and physicians to incorporate assessment of sexual function into the routine evaluation protocols.

Disentangling desire and arousal: a classificatory conundrum

A controversial proposal to collapse sexual disorders of desire and arousal is forthcoming in the diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Yet, no study has attempted to empirically distinguish these disorders by using explicit criteria to recruit and compare distinct groups of low desire and arousal sufferers. The goal of the current study was to test the feasibility of finding medically healthy men and women meeting clearly operationalized DSM-IV-TR criteria for disorders of desire and/or arousal and compare them to matched controls. To assess operational criteria, participants completed a comprehensive telephone screening interview assessing DSM-IV-TR and DSM-5 criteria, as well as standardized self-report measures of sexual functioning. The use of operationalized DSM-IV-TR criteria to recruit participants led to the exclusion of over 75% of those reporting sexual difficulties, with the primary reason for exclusion being failure to meet at least one central diagnostic criterion. The application of the DSM-5 criteria was even more restrictive and led to the exclusion of all but four men and one woman using the original four-symptom criteria, and four men and five women using the revised three-symptom criteria. Cluster analyses supported the distinction between desire and genital arousal difficulties, and suggest that different groups with distinct clusters of symptoms may exist, two of which are consistent with the DSM-5 criteria. Overall, results highlight the need for revisions to the diagnostic criteria, which, as they stand, do not capture the full range of many people's sexual difficulties.

An update on the pharmacological management of female sexual dysfunction

INTRODUCTION

Female sexual dysfunction (FSD) is a global health issue, with as many as 12% of women over 18 years old reporting sexual difficulties associated with distress. It is a multifaceted problem with psychological and biological causes. Affected women tend to have an impaired quality of life, a decreased level of well-being and relationship issues. Hence there is a need for management options for affected women.

AREAS COVERED

This paper focuses on current pharmacological options for the treatment of FSD, particularly estrogens and androgens, which have been extensively studied. Some investigational drugs are also described, including the centrally acting agents such as flibanserin and bupropion, and intravaginal DHEA and testosterone, which may be useful as an alternative for women with specific conditions, such as breast cancer survivors.

EXPERT OPINION

Although approval for the use of testosterone for treatment of FSD is limited to some European countries and restricted to surgically menopausal women, there is extensive off-label use for this purpose. No other product has yet achieved regulatory approval for treatment of FSD. Completion of studies of nonhormonal FSD therapies and safety studies of testosterone may result in regulatory approval of such products for the treatment of FSD in the near future.

Efficacy of psychosocial interventions in men and women with sexual dysfunctions--a systematic review of controlled clinical trials: part 2--the efficacy of psychosocial interventions for female sexual dysfunction

INTRODUCTION

As yet, a summary of the research evidence concerning the efficacy of psychological treatment in female sexual dysfunction is lacking. Previous reviews were often nonsystematic or explored one specific sexual dysfunction.

AIM

Our systematic review provides an overview of the efficacy of psychosocial interventions in all female sexual dysfunction.

MAIN OUTCOME MEASURES

Main outcome measures included for example psychometrically validated scales, diary notes, interviews, and vulvar algesiometer. The efficacy of psychosocial interventions was measured for example by the frequency of and satisfaction with sexual activity and sexual functioning. Safety and acceptance were evaluated on the basis of adverse events and dropout rates.

METHODS

The systematic literature search included electronic database search, handsearch, contact with experts, and an ancestry approach. Studies were included if the woman was given a formal diagnosis of a sexual dysfunction (International Statistical Classification of Diseases and Related Health Problems-ICD10/-9; Diagnostic and Statistical Manual of Mental Disorders-IV/-III-R) and when the intervention was psychosocial or psychotherapeutic. The control group included either another treatment or a waiting-list control group. The report of relevant outcomes was necessary for inclusion as well as the design of the study (randomized, controlled trials [RCTs] and controlled clinical trials). The assessment of methodological quality comprised aspects of randomization, blinding, incomplete outcome data, selective reporting, and allegiance.

RESULTS

We identified 15 RCTs that investigated efficacy in female sexual dysfunction and two further studies that examined male and female sexual dysfunction together. Most trials explored sexual pain disorders. About half of all studies in women used either a concept derived from Masters and Johnson or a cognitive-behavioral treatment program. Both approaches showed significant improvements compared with a control group. Benefit was not always maintained over the (variable) follow-up period.

CONCLUSIONS

Traditional sexual therapeutic concepts proved to be efficacious in the treatment of female sexual dysfunction. A shortcoming was the rather low methodological quality of included studies.