Female Sexual Function and Dysfunction in the Reproductive Years: The Influence of Endogenous and Exogenous Sex Hormones

Prevalence and predictors of sexual dysfunction in females with type 1 diabetes: a systematic review and meta-analysis

BACKGROUND

Several observational studies have explored the prevalence and predictors of female sexual dysfunction (FSD) among females with type 1 diabetes. However, no systematic review and meta-analysis of pooled data provide reliable estimates of FSD prevalence among females with type 1 diabetes.

AIM

To investigate the global prevalence of FSD, analyze the association between FSD risk and type 1 diabetes, and evaluate the predictors of FSD among females with type 1 diabetes.

METHODS

The study search of the present systematic review was conducted through the Wanfang Database, China National Knowledge Infrastructure, PubMed, and Embase from the inception date to February 28, 2023. Heterogeneity among the studies was analyzed with the Q and I2 tests. The sources of heterogeneity were detected through subgroup analyses and meta-regression.

OUTCOMES

Outcomes included the pooled prevalence of FSD among females with type 1 diabetes, the association between FSD risk and type 1 diabetes, and the predictors of FSD among females with type 1 diabetes.

RESULTS

The pooled prevalence of FSD among females with type 1 diabetes was 38.5% (95% CI, 32.1%-45.0%). The risk of FSD was higher in patients with type 1 diabetes than in healthy controls (odds ratio [OR], 3.77; 95% CI, 2.24-6.35). The significant predictors of FSD among females with type 1 diabetes were depression status (OR, 2.77; 95% CI, 1.29-5.93) and longer diabetes duration (OR, 1.19; 95% CI, 1.06-1.34).

CLINICAL IMPLICATIONS

Females with type 1 diabetes had a significantly increased prevalence of FSD, indicating that clinicians should be concerned about FSD among females with type 1 diabetes.

STRENGTHS AND LIMITATIONS

The strength of the present study is that it is the first systematic review and meta-analysis to investigate the global prevalence and predictors of FSD among females with type 1 diabetes. The limitation is that the results revealed significant heterogeneity after pooling the articles.

CONCLUSIONS

The present systematic review and meta-analysis revealed that the overall prevalence of FSD among females with type 1 diabetes was 38.5%, demonstrating a significant association between FSD risk and type 1 diabetes among females. Furthermore, we found that the significant predictors for FSD among females with type 1 diabetes were depression and a longer duration of diabetes.

Prevalence of female sexual dysfunction during pregnancy in Eastern Mediterranean Regional Office Countries (EMRO): a systematic review and meta-analysis

BACKGROUND

Sexual dysfunction is potential abnormality in the ability of a person to sexual respond or enjoy sexual experience. During pregnancy, sexual function is at risk and disorder due to physical, hormonal and psychological changes. The prevalence of female sexual dysfunction is very variable during pregnancy.

OBJECTIVE

The aim of this study was to determine the prevalence of sexual dysfunction in pregnant women in the Eastern Mediterranean Regional Office Countries (EMRO) by meta-analysis and systematic methods.

MATERIALS AND METHODS

This study was reported based on the PRISMA checklist for systematic review and meta-analysis. This study investigated all articles with full English text in the EMRO region, from the international databases from 2000 to January 2019, which examined the prevalence of the sexual dysfunction in pregnant women. Statistical analysis was performed by using STATA12.1software.

RESULTS

The results reveal that the prevalence of the sexual dysfunction in pregnant women is65% (95% CI: 54-75%). The mean of total sexual dysfunction in women was 22.71 (95% CI: 18.52-28.51%) and for the first, second and third trimester of pregnancy were obtained as 23.77 (95% CI: 28.56-28.96%), 23.80 (95% CI: 23.78-23.82%) and 22.60 (95% CI: 22.58-22.62%), respectively.

CONCLUSION

The prevalence rate of sexual dysfunction is high in pregnant women in the EMRO region. The high rate of sexual dysfunction can be due to the difference in sexual performance scoring using the female sexual function questionnaire and on the other hand, pregnant women may be due to incorrect beliefs about sexual activity and cultural, religious and social restrictions and taboos, they have been avoiding to express their sexual function correctly.

Opioid-Induced Sexual Dysfunction in Cancer Patients

Simple Summary

Sexual disorders affect up to 80% of cancer patients, depending on the type of cancer, yet they are commonly overlooked and untreated. Opioid-induced sexual dysfunction (OISD) is reported in half of opioid users. The pathophysiology of OISD—still a subject for research—may include disorders of both the endocrine and nervous systems, expressed in, among other things, erectile dysfunction and declined sexual desire, sexual arousal, orgasm, and general satisfaction with one’s sex life. The etiology of sexual dysfunction in cancer patients is usually multifactorial, so the management should be multifaceted and individualized by targeting pathophysiological factors. The treatment options for OISD are few and include testosterone replacement therapy, bupropion, opioid antagonists, phosphodiesterase type 5 inhibitors, plant-derived substances, and non-pharmacological treatments, although the evidence is insufficient. One of the treatment options may also be a choice of an opioid that is less likely to cause sexual dysfunction, yet further research is necessary.

Abstract

Sexual dysfunction is common in patients with advanced cancer, although it is frequently belittled, and thus consistently underdiagnosed and untreated. Opioid analgesics remain fundamental and are widely used in cancer pain treatment. However, they affect sexual functions primarily due to their action on the hypothalamus–pituitary–gonadal axis. Other mechanisms such as the impact on the central and peripheral nervous systems are also possible. The opioid-induced sexual dysfunction includes erectile dysfunction, lack of desire and arousal, orgasmic disorder, and lowered overall sexual satisfaction. Around half of the individuals taking opioids chronically may be affected by sexual dysfunction. The relative risk of sexual dysfunction in patients on chronic opioid therapy and opioid addicts increased two-fold in a large meta-analysis. Opioids differ in their potential to induce sexual dysfunctions. Partial agonists and short-acting opioids may likely cause sexual dysfunction to a lesser extent. Few pharmaceutical therapies proved effective: testosterone replacement therapy, PDE5 inhibitors, bupropion, trazodone, opioid antagonists, and plant-derived medicines such as Rosa damascena and ginseng. Non-pharmacological options, such as psychosexual or physical therapies, should also be considered. However, the evidence is scarce and projected primarily from non-cancer populations, including opioid addicts. Further research is necessary to explore the problem of sexuality in cancer patients and the role of opioids in inducing sexual dysfunction.

How hormonal contraceptives shape brain and behavior: A review of preclinical studies

Steroid hormones influence different aspects of brain function, including development, neurogenesis, neuronal excitability, and plasticity, thus affecting emotional states, cognition, sociality, and reward. In women, their levels fluctuate across the lifespan and through the reproductive stages but are also altered by exogenous administration of hormonal contraceptives (HC). HC are widely used by women throughout their fertile life both for contraceptive and therapeutic benefits. However, awareness of their effects on brain function and behavior is still poorly appreciated, despite the emerging evidence of their action at the level of the central nervous system. Here, we summarize results obtained in preclinical studies, mostly conducted in intact female rodents, aimed at investigating the neurobiological effects of HC. HC can alter neuroactive hormones, neurotransmitters, neuropeptides, as well as emotional states, cognition, social and sexual behaviors. Animal studies provide insights into the neurobiological effects of HC with the aim to improve women's health and well-being.

High estradiol level is associated with erectile dysfunction: A systematic review and meta-analysis

Numerous studies conducted to study the role of testosterone in erectile dysfunction (ED) extensively, but less is known of the association between estradiol level and ED. To assess the strong association between estradiol and ED by quantitatively synthesizing all studies evaluating the relationship between estradiol and ED. An extensive literature search was conducted by two authors independently in three electronic databases, including PubMed, Web of Science and Cochrane Library, up to January 10, 2021. The Patient Population or Problem, Intervention, Comparison, Outcomes and Setting (PICOS) were used for inclusion criteria to identify studies. The Newcastle-Ottawa Scale was applied to assess the quality of studies. The standardized mean difference (SMD) and their corresponding 95% confidence intervals (95% CIs) were used to compare the estradiol level between ED patients and healthy subjects, and the pooled OR and 95%CI were used to evaluate the strong association between estradiol level and ED. Finally, six studies were included in this meta-analysis, satisfying predefined inclusion criteria. Five studies were considered to be high quality, and only one was judged of moderate quality. The estradiol level of ED patients was statistically higher than that in healthy subjects (SMD 0.45, 95%CI 0.28-0.63, p <0.0001). The pooled OR demonstrated that the estradiol was correlated to the ED significantly (OR 1.08, 95%CI 1.05-1.12, p <0.0001). Subgroup analyses were conducted based on age, diagnosis way, country, sample size, detection method and estradiol level. There was no substantial change in the result of SMD ranging from 0.41 (95% CI 0.31-0.51) to 0.53 (95% CI 0.44-0.62) when performing sensitivity analysis. No publication bias was detected by the Begg test or Egger test. This meta-analysis demonstrated that the estradiol level is correlated to ED significantly.

Minority Stress and Sexual Functioning Among African American Women With At-Risk Partners in South Los Angeles

BACKGROUND

Preliminary evidence indicates that acute and chronic psychological stress affect sexual arousal and satisfaction. African American women, in particular, are vulnerable to the impacts of gender- and race-related stress, given their socially constructed identities as African Americans and as women.

AIM

We examined associations between minority stress and sexual function using data from 248 African American women.

METHODS

Surveys were conducted with 248 African American women in South LA with male partners at risk for acquiring HIV. We analyzed self-reports on (i) stress indicators: chronic burden, perceived racism/sexism, and histories of trauma/sexual abuse; (ii) Female Sexual Function Index domains: desire, arousal, and satisfaction; and (iii) potential moderators: social support and spirituality. We used multiple regression, adjusting for potential confounding factors, to examine the relationships between stress indictors, potential moderators, and sexual function domains.

OUTCOMES

The outcomes were the female sexual function index domains of desire, arousal, and satisfaction.

RESULTS

This largely low-income sample experienced significant chronic and acute stressors, was highly spiritual and reported strong social support. Moderate-high chronic burden and increasing sexism scores were independently associated with decreased arousal (B = -0.38, 95%CI = -0.75, -0.02) and satisfaction (B = -0.03, 95%CI = -0.06, 0.00) scores, respectively.

CLINICAL IMPLICATIONS

Providers may want to explore chronic burden in patients who complain about low sexual arousal. Additionally, to develop effective HIV- and other STI-related interventions that impact behaviors that can confer sexual risk, prevention strategies are needed that either reduce contextual stressors or mitigate their impact.

STRENGTHS

Strengths of this research are that it focuses on sexual function among previously under-studied, low-income African American women and that it takes into account the unique set of stressors faced by these women.

LIMITATIONS

A limitation is that the sample size may have been too small to capture the effects of potential moderators.

CONCLUSIONS

Low-income African American women accumulate life stressors that may harm sexual function. Schrode K, Poareo E, Li M, et al. Minority Stress and Sexual Functioning Among African American Women With At-Risk Partners in South Los Angeles. J Sex Med 2022;19:603-612.

How Does Contraceptive Use Affect Women's Sexuality? A Novel Look at Sexual Acceptability

Among the components of a healthy life, sexuality is essential, contributing to both the psychophysical and social well-being of women and, consequently, to their quality of life. A poorly investigated standpoint is the acceptability of contraceptive methods, both in terms of their tolerability and metabolic neutrality and in terms of their impact on sexual life. In this context, we will provide an overview of the different methods of contraception and their effects on female sexuality, from biological changes to organic, social, and psychological factors, which can all shape sexuality. A MEDLINE/PubMed review of the literature between 2010 and 2021 was conducted using the following key words and phrases: hormonal contraception, contraceptives, female sexual function, libido, sexual arousal and desire, and sexual pain. Recent studies have supported the effects of contraceptives on women's sexuality, describing a variety of positive and negative events in several domains of sexual function (desire, arousal, orgasm, pain, enjoyment). However, satisfaction with sexual activity depends on factors that extend beyond sexual functioning alone. A more holistic approach is needed to better understand the multitude of factors linked to women's sexuality and contraception. Contraceptive counseling must consider these important elements since they are closely related to good compliance and maximize non-contraceptive health benefits.

Impaired Sexual Function in Young Women With PCOS: The Detrimental Effect of Anovulation

BACKGROUND

Even though polycystic ovary syndrome (PCOS) is a common reproductive disorder affecting young women, its impact on their sexual health is not well known.

AIM

To examine the different aspects of female sexuality in young women with PCOS and attempt to associate hormonal changes and ovulatory status with their sexual function.

METHODS

Anthropometric characteristics, hormonal levels and sexual function based on the Female Sexual Function Index (FSFI) questionnaire were assessed in 76 young women with PCOS and 133 matched controls.

OUTCOMES

Sexual function is significantly impaired in young women with PCOS.

RESULTS

Women with PCOS demonstrated lower scores than controls in arousal (5.04 ± 1.19 vs 4.48 ± 1.44, P < .001), lubrication (5.29 ± 1.17 vs 4.69 ± 1.54, P < .001), orgasm (4.78 ± 1.40 vs 4.11 ± 1.61, P = .001), satisfaction (5.22 ± 1.10 vs 4.78 ± 1.31, P = .016), and total score of the FSFI (29.51 ± 5.83 vs 26.76 ± 6.81, P < .001), even after correction for BMI. When corrected for total testosterone, the domains of lubrication, satisfaction, and total score of FSFI remained significantly impaired in women with PCOS (P values .037, .024, & .044 respectively). In multivariate logistic regression analysis, after adjusting for the effect of BMI and hormone levels, dysfunction in orgasm, satisfaction and the total FSFI score were still 3-4 times more common in PCOS (adjusted OR [95% CI]: 3.54, P = .020; 2.96, P = .050; 3.87, P = .027). Even though no statistically significant differences were observed between women with ovulatory PCOS and controls, we detected statistically significant differences in all domains of sexual function apart from pain between controls and PCOS women with anovulation (desire P value .04, arousal P value <.001, lubrication P value <.001, orgasm P value .001, satisfaction P value .001 and FSFI total score P value <.001).

CLINICAL IMPLICATIONS

Women with PCOS have compromised sexual function, which is independent of their BMI and highly dependent on their ovulatory status.

STRENGTHS AND LIMITATIONS

This is the first study in women with PCOS that implicates anovulation as a risk factor for sexual impairment in PCOS. Further studies are needed to elucidate the mechanisms implicated and to examine the effect of PCOS therapy on the patients' sexual function.

CONCLUSION

The adverse effect of PCOS status on the female sexual function is independent of BMI and only partially dependent on hormonal changes characterizing the syndrome. Anovulation appears to be the major determinant of sexual impairment among women with PCOS. Mantzou D, Stamou MI, Armeni AK, et al. Impaired Sexual Function in Young Women With PCOS: The Detrimental Effect of Anovulation. J Sex Med 2021;18:1872-1879.

Sexual Function in Women With Polycystic Ovary Syndrome: Design of an Observational Prospective Multicenter Case Control Study

INTRODUCTION

The prevalence of polycystic ovary syndrome (PCOS) is 10-15% in women of reproductive age. Its characteristics are (i) clinical or biochemical hyperandrogenism, (ii) oligomenorrhea or amenorrhea, and (iii) polycystic ovaries on ultrasound. PCOS is associated with lower quality of life, depression, anxiety, diabetes, and cardiovascular disease. Treatment commonly entails oral contraceptive use to lower endogenous androgen levels. Androgen levels and comorbidities may affect sexual function. Previous studies have addressed a limited range of possible contributing factors. We will assess sexual function as well as genital and self-reported sexual arousal in a laboratory setting in women with PCOS compared to an age-matched healthy control group. Modulation by biopsychosocial factors mentioned will be studied.

METHODS

This is a multicenter prospective case control study. The study population includes healthy women with and without PCOS, aged 18-40 years, in a stable heterosexual relationship for at least 6 months. Power is calculated at 67 participants in each group. Anticipating a drop out of 10%, 150 participants will be recruited.

MAIN OUTCOME MEASURES

The main outcomes measured are sexual function using the Female Sexual Function Index, Sexual Desire Inventory, and Female Sexual Distress Scale-Revised; genital sexual arousal measured as vaginal pulse amplitude; and self-reported sexual arousal in response to erotic stimuli in a laboratory setting. The mediators that will be investigated include testosterone, free androgen levels, oral contraceptive use, sensitivity to androgens (using CAG repeat length), body mass index, body image, mental health, and self-esteem.

CONCLUSION

Strengths of this study are the inclusion of a broad range of biopsychosocial outcome measures including DNA analysis, a healthy control group, and standardized assessment of genital and self-reported sexual arousal in a laboratory setting. With the design of this study we aim to provide an insight into which biopsychosocial factors associated with PCOS are related to sexual function, and how sexual function may be affected by treatment. These new insights may help to improve clinical management of PCOS while improving the quality of life. Pastoor H, Both S, Timman R, et al. Sexual Function in Women With Polycystic Ovary Syndrome: Design of an Observational Prospective Multicenter Case Control Study. Sex Med 2020;8:718-729.

Sexual activities of pregnant women attending antenatal clinic of a tertiary hospital in North-West Nigeria

Introduction

myths about sex during pregnancy harming fetus and leading to preterm labor or miscarriage are very strong factors releasing fear and leading to avoidance of sexual contact during gestation. We therefore evaluated the attitude, sexual experiences and changes in sexual function during pregnancy.

Methods

a cross-sectional study was conducted among 170 pregnant women who were selected using systematic sampling. Data were collected using an interviewer-administered questionnaire. Data was analysed using IBM SPSS® version 22.0. Descriptive statistics, Chi-square test and Cochran´s Q-test were estimated.

Results

the mean age of respondents was 27.2 ± 6.2 years. Most of the respondents, 107 (62.7%) had formal education. One-fifth of the respondents, 34 (20.2%) have been married for over 10 years. More than half of them were multiparous, 112 (68.3%) and in the third trimester of pregnancy, 99 (59.6%). Majority of the respondents, 153 (87.9%) thought coitus was safe in pregnancy. More than half 89 (58.2%) had coitus at least thrice a week before pregnancy and 98.8% have engaged in sexual activities during pregnancy. Most of the respondents, 105 (61.1%) enjoyed coitus during pregnancy. The desire for coitus significantly reduced in the third trimester, p=0.001.

Conclusion

sexual intercourse during pregnancy was universal and respondents engaged in sexual activities during different stages of pregnancy. Although sexual frequency declined in pregnancy compared to pre-pregnancy period, most of the respondents desired and enjoyed it. We recommend that couples are well educated to understand the normal fluctuations in sexual interest and practices during pregnancy.

The 6-item Female Sexual Function Index (FSFI-6): factor structure, reliability, and demographic correlates among infertile women in Iran

Background

The 6-item Female Sexual Function Index (FSFI) is a short form of the original 19-item FSFI that measures sexual function in women. The aim of this study was to examine the factor structure and reliability of the FSFI-6 and to determine the demographic correlates of sexual dysfunction among infertile women in Iran.

Results

In total, 250 infertile women participated in this study. The mean total FSFI-6 score was 20.71 ± 5.09. Internal consistency of the FSFI-6 was high (Cronbach’s alpha = 0.856). All inter-item correlations and item-total correlations were in acceptable range. The results of confirmatory factor analysis provided support for a unidimensional model of the FSFI-6. Among demographic and infertility variables, higher women’s age, low education, unwanted marriage, short infertility duration, and low frequency of intercourse were associated with sexual dysfunction.

Conclusions

The FSFI-6 demonstrated sound reliability and validity in this study, supporting its continued use for measuring sexual disfunction among infertile women. Its brevity and comprehensiveness allow a quick assessment both in clinical and research settings.

The brain as a target of hormonal contraceptives: Evidence from animal studies

Hormonal contraceptives are frequently prescribed drugs among women, mainly for their reversible contraceptive purposes but also for beneficial effects in some gynecological pathologies. Despite extensive studies aimed at elucidating the physical effects of hormonal contraceptives and ameliorating some unwanted outcomes, little is known yet about the effects of these drugs on brain function and related behavior, which are known to be modulated by endogenous steroid hormones. We describe the current literature on preclinical studies in animals undertaken to investigate effects of hormonal contraceptives on brain function and behavior. These studies suggest that hormonal contraceptives influence neurohormones, neurotransmitters, neuropeptides, and emotional, cognitive, social and sexual behaviors. Animals allow examination of the basic biological mechanisms of these drugs, devoid of the psychological aspect often associated to hormonal contraceptives' use in women. Understanding the neurobiological effects of these drugs may improve women's health and may help women making informed choices on hormonal contraception.

The Relational and Bodily Experiences Theory of Sexual Desire in Women

We review the theory and research on women's sexual desire and present a theory that incorporates internalized representations of relational and bodily experiences into our understanding of the full range of desire in women. To this end, we move away from the current tendency to focus on low sexual desire in women and instead consider desire on a spectrum or continuum from absent or diminished to high desire across multiple sexual orientations, including heterosexual, bisexual, and lesbian. We review definitions of sexual desire, as well as the epidemiology and etiology of hypoactive sexual desire, the most prevalent sexual complaint in women, including the biological, psychological, and relationship correlates of inhibited sexual desire. Subsequently, we examine the research on highly sexual women, who tend to experience high levels of sexual desire, sexual agency, and sexual esteem, and distinguish between high sexual desire and hypersexuality. We introduce two important constructs that are integrated into the Relational and Bodily Experiences Theory (RBET) of sexual desire in women: attachment and sexual body self-representations, suggesting that women's internalized representations of self and other that stem from childhood and their capacity to embody their sexual bodies are integral to our understanding of the phenomenology of sexual desire in women. RBET calls for further research into the links between attachment, sexual body self-representations, and desire, and suggests that clinical interventions for sexual desire difficulties in women should emphasize internalized working models of relationships (i.e., attachment) and integrate bodily based approaches.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction

AIMS

The terminology in current use for sexual function and dysfunction in women with pelvic floor disorders lacks uniformity, which leads to uncertainty, confusion, and unintended ambiguity. The terminology for the sexual health of women with pelvic floor dysfunction needs to be collated in a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Importantly, this report is not meant to replace, but rather complement current terminology used in other fields for female sexual health and to clarify terms specific to women with pelvic floor dysfunction.

RESULTS

A clinically based terminology report for sexual health in women with pelvic floor dysfunction encompassing over 100 separate definitions, has been developed. Key aims have been to make the terminology interpretable by practitioners, trainees, and researchers in female pelvic floor dysfunction. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for female sexual health in women with pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

A Model of Female Sexual Desire: Internalized Working Models of Parent-Child Relationships and Sexual Body Self-Representations

The etiology of low female sexual desire, the most prevalent sexual complaint in women, is multi-determined, implicating biological and psychological factors, including women's early parent-child relationships and bodily self-representations. The current study evaluated a model that hypothesized that sexual body self-representations (sexual subjectivity, self-objectification, genital self-image) explain (i.e., mediate) the relation between internalized working models of parent-child relationships (attachment, separation-individuation, parental identification) and sexual desire in heterosexual women. We recruited 614 young, heterosexual women (M = 25.5 years, SD = 4.63) through social media. The women completed an online survey. Structural equation modeling was used. The hypotheses were supported in that the relation between internalized working models of parent-child relationships (attachment and separation-individuation) and sexual desire was mediated by sexual body self-representations (sexual body esteem, self-objectification, genital self-image). However, parental identification was not related significantly to sexual body self-representations or sexual desire in the model. Current findings demonstrated that understanding female sexual desire necessitates considering women's internalized working models of early parent-child relationships and their experiences of their bodies in a sexual context. Treatment of low or absent desire in women would benefit from modalities that emphasize early parent-child relationships as well as interventions that foster mind-body integration.

The Sexual Acceptability of Contraception: Reviewing the Literature and Building a New Concept

How contraceptives affect women's sexual well-being is critically understudied. Fortunately, a growing literature focuses on sexual aspects of contraception, especially hormonal contraception's associations with libido. However, a more holistic approach to contraceptive sexual acceptability is needed to capture the full range of women's sexual experiences. We conducted a narrative literature review of this topic, working with an original sample of 3,001 citations published from 2005 to 2015. In Part 1, we draw from a subset of this literature (264 citations) to build a new conceptual model of sexual acceptability. Aspects include macro factors (gender, social inequality, culture, and structure), relationship factors (dyadic influences and partner preferences), and individual factors (sexual functioning, sexual preferences, such as dis/inhibition, spontaneity, pleasure, the sexual aspects of side effects, such as bleeding, mood changes, sexual identity and sexual minority status, and pregnancy intentions). In Part 2, we review the empirical literature on the sexual acceptability of individual methods (103 citations), applying the model as much as possible. Results suggest contraceptives can affect women's sexuality in a wide variety of positive and negative ways that extend beyond sexual functioning alone. More attention to sexual acceptability could promote both women's sexual well-being and more widespread, user-friendly contraceptive practices.

The intimate link: a systematic review of highly effective reversible contraception and women's sexual experience

Contraception is expressly designed for nonprocreative sexual activity, but we know little about how methods shape women's sexual experience. To systematically review the literature on highly effective reversible contraception (HERC) and sexual experiences. MEDLINE, SCOPUS, and Google Scholar were searched for relevant literature. Eleven studies met the inclusion criteria; all were conducted outside of the United States. All studies reviewed found either improvements or no change in sexual experience and function outcomes with HERC use. A need exists for more prospective studies with a wider range of measures to assess HERC methods' impact on women's sexual experiences.

Sexual Activity during Pregnancy in Taiwan: A Qualitative Study

Background

Pregnancy is a special period in a woman's life that involves physical and mental changes. These changes are influenced by cultural, social, religious, and emotional factors among others.

Aim

The aims of this article were to gather information, to describe the changes and behavior of sexual experiences in pregnancy, and to identify the reasons why pregnant women from central Taiwan decrease coital frequency during pregnancy.

Methods

This phenomenological qualitative research was intended to respond to open-ended questions that allowed the respondents to elaborate on the individuals' experiences. We collected data from in-depth, tape-recorded, and semi-structured interviews conducted in a cross-sectional study of 62 healthy pregnant women. The investigation ended when three consecutive interviewed subjects could not offer any new activities, which indicated that the study had reached its saturation point.

Main Outcome Measures

We performed data collection and content analysis to ensure standards of rigor and reliability. Credibility was enhanced by prolonged engagement, triangulation, referential adequacy, member checking, and expert review; we categorized meaningful unit-codes in a mutually exclusive and exhaustive manner into perceptions, experiences, and practices such that common themes were grouped into categories.

Results

Three themes emerged: negative aspects of sexual experiences; stress and emotional responses; and changes in sexual practices. The majority of the women stopped engaging in coital activities during pregnancy. We determined that in most cases, the 62 participants obtained information regarding sexual activity during pregnancy from postpartum women and the Internet.

Conclusions

The current evidence-based findings encourage the provision of sexuality education to newlyweds and the discussion of sex-related issues during pregnancy. We propose developing strategies for increasing sexual knowledge and focusing on emotional support to decrease pregnant women's anxiety regarding sexuality in Taiwan. Liu HL, Hsu P, and Chen KH. Sexual activity during pregnancy in Taiwan: A qualitative study. Sex Med 2013;1:54–61.

Decreased allopregnanolone induced by hormonal contraceptives is associated with a reduction in social behavior and sexual motivation in female rats

RATIONALE

Allopregnanolone is a neurosteroid involved in depression, memory, social, and sexual behavior. We have previously demonstrated that treatment with a combination of ethinylestradiol (EE) and levonorgestrel (LNG), two compounds frequently used in hormonal contraception, decreased brain allopregnanolone concentrations. These changes may contribute to some of the emotional and sexual disorders observed in hormonal contraceptive users.

OBJECTIVES

We thus examined whether the reduction in allopregnanolone concentrations induced by long-term EE/LNG administration was associated with altered emotional, learning, social, and sexual behaviors.

METHODS

Rats were orally treated with a combination of EE (0.030 mg) and LNG (0.125 mg) once a day for 4 weeks and were subjected to behavioral tests 24 h after the last administration.

RESULTS

EE/LNG treatment reduced immobility behavior in the forced swim test, without affecting sucrose preference and spatial learning and memory. In the resident-intruder test, EE/LNG-treated rats displayed a decrease in dominant behaviors associated with a reduction in social investigation. In the paced mating test, EE/LNG treated rats showed a reduction in proceptive behaviors, while the lordosis quotient was not affected. Progesterone, but not estradiol, administration to EE/LNG-treated rats increased sexual activity and cerebrocortical allopregnanolone concentrations. Prior administration of finasteride decreased allopregnanolone concentrations and abolished the increase in proceptivity induced by progesterone administration.

CONCLUSIONS

The decrease in brain allopregnanolone concentrations induced by EE/LNG treatment is associated with a reduction in social behavior and sexual motivation in female rats. These results might be relevant to the side effects sometimes exhibited by women taking hormonal contraceptives.

Factors associated with sexual function in Iranian women with type 2 diabetes mellitus: partner relationship as the most important predictor

Background:

No comprehensive study has been conducted on risk factors of sexual dysfunction in women with diabetes mellitus.

Objectives:

The aim of this study was to consider all possible influencing variables including hormonal, physical and, psychological status, socioeconomic status, and dietary intake to get more accurate and reliable results.

Patients and Methods:

Sexual function was assessed by Iranian validated female sexual function index (FSFI).The variables of the study were demographic and diabetes-related factors, stress-depression, physical activity, blood pressure, anthropometric measurements, lipid profile, cortisol, sex and thyroid hormones, 25-hydroxy vitamin D, and dietary intake.

Results:

Among all investigated variables, partner relationship showed a strong positive association with FSFI (β = 1.93 ± 0.41, P < 0.0001). In addition, not considering partner relationship, FSFI showed a significant negative association with age (β = -0.19 ± 0.20, P = 0.04), stress-depression score (β = -0.08 ± 0.04, P = 0.04), DD (β = -0.03 ± 0.01, P = 0.04), and systolic blood pressure (β = -0.14 ± 0.06, P = 0.03). Significant associations between FSFI and serum sex hormones and other biochemical were found in neither postmenopausal nor non-menopausal women. The means of SFSI in postmenopausal women were greater than non-menopausal (P = 0.02).

Conclusions:

It seems that in our population, female sexual function was much more than just a hormonal or physical problem and psychological factors, especially partner relationship and stress-depression, are the most determinants. In addition, age, duration of challenging with disease, and the lack of controlling systolic blood pressure were common factors that decreased sexual function.

Current Hormonal Contraceptive Use Predicts Female Extra-Pair and Dyadic Sexual Behavior: Evidence Based on Czech National Survey Data

Data from 1155 Czech women (493 using oral contraception, 662 non-users), obtained from the Czech National Survey of Sexual Behavior, were used to investigate evolutionary-based hypotheses concerning the predictive value of current oral contraceptive (OC) use on extra-pair and dyadic (in-pair) sexual behavior of coupled women. Specifically, the aim was to determine whether current OC use was associated with lower extra-pair and higher in-pair sexual interest and behavior, because OC use suppresses cyclical shifts in mating psychology that occur in normally cycling women. Zero-inflated Poisson (ZIP) regression and negative binomial models were used to test associations between OC use and these sexual measures, controlling for other relevant predictors (e.g., age, parity, in-pair sexual satisfaction, relationship length). The overall incidence of having had an extra-pair partner or one-night stand in the previous year was not related to current OC use (the majority of the sample had not). However, among the women who had engaged in extra-pair sexual behavior, OC users had fewer one-night stands than non-users, and tended to have fewer partners, than non-users. OC users also had more frequent dyadic intercourse than non-users, potentially indicating higher commitment to their current relationship. These results suggest that suppression of fertility through OC use may alter important aspects of female sexual behavior, with potential implications for relationship functioning and stability.

The influence of combined oral contraceptives on female sexual desire: a systematic review

OBJECTIVES

To determine the relationship between the use of combined oral contraceptives (COCs) and sexual desire based on a systematic review of the literature.

METHODS

MEDLINE Complete, Google Scholar and the Cochrane Library were searched for articles published between 1975 and 2011, reporting the effects of oral contraceptives on sexual desire. Reports fully meeting all the predefined criteria were analysed and included in a final reference list. In addition, a review of the reference list of selected articles was carried out.

RESULTS

We evaluated 36 studies (1978-2011; 13,673 women). Of the COC users (n = 8,422), 85% reported an increase (n = 1,826) or no change (n = 5,358) in libido and 15% reported a decrease (n = 1,238). We found no significant difference in sexual desire in the case of COCs with 20-35 μg ethinylestradiol; libido decreased only with pills containing 15 μg ethinylestradiol.

CONCLUSIONS

The majority of COC users report no significant change in libido although in most studies a decline in plasma levels of free testosterone and an increase in those of sex hormone binding globulin were observed.

Effects of long-term high dose testosterone administration on vaginal epithelium structure and estrogen receptor-α and -β expression of young women

To date, the effects of long-term testosterone (T) administration on the human vagina are not completely understood. Thus, the aim of this study was to investigate the effects of long-term T treatment on vaginal tissue histology, estrogen receptor alpha (ERα) and beta (ERβ) expression and proliferation in female to male transsexual subjects (FtM). We compared vaginal samples from FtM subjects with those of premenopausal women (PrM) and postmenopausal women (M) not receiving any hormonal treatment for at least 2 years. Vaginal tissue samples from 16 FtM subjects treated with T (intramuscular injections of 100 mg Testoviron Depot/7-10 days for at least 1 year), undergoing sex reassignment surgery, and 16 PrM and 16 M subjects undergoing a vaginal hysterectomy for prolapse, were collected. For each sample, morphology, glycogen content, proliferation (ki-67), ERα and ERβ expression were evaluated. Vaginal samples from FtM showed a loss of normal architecture of the epithelium, intermediate and superficial layers were completely lost, and glycogen content was depleted. T administration resulted in a strong proliferation reduction when compared with both M and PrM subjects. Stromal and epithelial ERα as well as ERβ were significantly decreased in FtM when compared with PrM subjects. In conclusion, our data suggests that systemic T administration at supraphysiological dosage, determines profound changes in histomorphology and reduces ERs expression and proliferation of vaginal epithelium.

Hormonal predictors of sexual motivation in natural menstrual cycles

Little is known regarding which hormonal signals may best predict within- and between-women variance in sexual motivation among naturally cycling women. To address this, we collected daily saliva samples across 1-2 menstrual cycles from a sample of young women; assayed samples for estradiol, progesterone, and testosterone; and also collected daily diary reports of women's sexual behavior and subjective sexual desire. With respect to within-cycle, day-to-day fluctuations in subjective desire, we found evidence for positive effects of estradiol and negative effects of progesterone. Desire exhibited a mid-cycle peak, similar to previous findings; measured progesterone concentrations statistically mediated the fall in desire from mid-cycle to the luteal phase, but no combination of hormone measures substantially mediated the follicular phase rise in desire, which suggests that other signals may be implicated in this effect. Hormonal predictors of within-cycle fluctuations in sexual behavior generally reached only trend levels of statistical significance, though the patterns again suggested positive effects of estradiol and negative effects of progesterone. Between-women and within-women, between-cycle effects of hormone concentrations were generally absent, although statistical power was more limited at these higher levels of analysis. There were no significant effects of testosterone concentrations when controlling for the effects of estradiol and progesterone, which raises questions regarding the importance of this hormone for the regulation of sexual motivation in natural cycles. Our study is among the first to identify hormonal predictors of within-cycle fluctuations in sexual motivation, and thus adds novel evidence regarding the endocrine correlates of human sexuality.

Gender commonalities and differences in the neural processing of visual sexual stimuli

INTRODUCTION

Few studies so far have directly compared the neural processing of visual sexual stimuli in men and women. Also, most of these studies only compared sexual with neutral stimuli, making it difficult to disentangle sexual stimulus processing from general emotional processing.

AIM

The current study aimed to explore gender commonalities and differences in neural activity associated with the processing of visual sexual stimuli in a large sample of 50 men and 50 women. In order to disentangle effects of sexual processing from those of general emotional processing, we employed sexual, neutral, positive, and negative emotional pictures.

METHODS

Subjects passively viewed sexual, neutral, positive, and negative emotional pictures during a functional magnetic resonance imaging (fMRI) session. Pictures were presented in 24 blocks of five pictures each. Every block was rated immediately after its presentation with respect to valence, arousal, and sexual arousal.

MAIN OUTCOME MEASURES

Blood oxygen level dependent responses measured by fMRI and subjective ratings.

RESULTS

fMRI analysis revealed a distributed network for the neural processing of sexual stimuli comprising the hypothalamus, the nucleus accumbens, as well as orbitofrontal, occipital, and parietal areas. This network could be identified (i) for both men and women, with men showing overall stronger activations than women and (ii) independent of general emotional arousal or valence effects.

CONCLUSION

Our data speak in favor of a common neural network associated with the processing of visual sexual stimuli in men and women. Apart from the observed gender commonalities, overall stronger responses in men were observed that might indicate stronger sexual responsivity in men.

Neural correlates of erotic stimulation under different levels of female sexual hormones

Previous studies have demonstrated variable influences of sexual hormonal states on female brain activation and the necessity to control for these in neuroimaging studies. However, systematic investigations of these influences, particularly those of hormonal contraceptives as compared to the physiological menstrual cycle are scarce. In the present study, we investigated the hormonal modulation of neural correlates of erotic processing in a group of females under hormonal contraceptives (C group; N = 12), and a different group of females (nC group; N = 12) not taking contraceptives during their mid-follicular and mid-luteal phases of the cycle. We used functional magnetic resonance imaging to measure hemodynamic responses as an estimate of brain activation during three different experimental conditions of visual erotic stimulation: dynamic videos, static erotic pictures, and expectation of erotic pictures. Plasma estrogen and progesterone levels were assessed in all subjects. No strong hormonally modulating effect was detected upon more direct and explicit stimulation (viewing of videos or pictures) with significant activations in cortical and subcortical brain regions previously linked to erotic stimulation consistent across hormonal levels and stimulation type. Upon less direct and less explicit stimulation (expectation), activation patterns varied between the different hormonal conditions with various, predominantly frontal brain regions showing significant within- or between-group differences. Activation in the precentral gyrus during the follicular phase in the nC group was found elevated compared to the C group and positively correlated with estrogen levels. From the results we conclude that effects of hormonal influences on brain activation during erotic stimulation are weak if stimulation is direct and explicit but that female sexual hormones may modulate more subtle aspects of sexual arousal and behaviour as involved in sexual expectation. Results may provide a basis for future imaging studies on sexual processing in females, especially in the context of less explicit erotic stimulation.

Depressive symptoms as a predictor of sexual function during pregnancy

INTRODUCTION

Biopsychological and sociocultural factors have been reported to be associated with sexual function in pregnancy. To date, very few studies have focused on the relationship between sexual function and depression during pregnancy.

AIM

To determine whether depressive symptoms predict overall sexual function, desire, arousal, lubrication, orgasm, satisfaction, and pain during pregnancy by using the Female Sexual Function Index (FSFI).

METHODS

Pregnant women undergoing prenatal examinations were randomly selected for this cross-sectional investigation. The study included 555 pregnant women who completed the Taiwanese versions of the Center for Epidemiologic Studies Depression Scale (CES-D), FSFI, and a demographic questionnaire during pregnancy.

MAIN OUTCOME MEASURES

CES-D scores for depressive symptoms, scores for overall sexual function on the FSFI, and the FSFI domains: desire, arousal, lubrication, orgasm, satisfaction, and pain.

RESULTS

After adjusting for demographic factors, CES-D scores during the first trimester negatively predicted overall sexual function (P=0.0004), arousal (P=0.0104), lubrication (P=0.0016), orgasm (P=0.0022), and pain (P<0.0001). Moreover, CES-D scores during the third trimester negatively predicted sexual desire (P=0.0005) and satisfaction (P<0.0001). Furthermore, gestational age negatively predicted overall sexual function, arousal, lubrication, orgasm, and pain (all P<0.0001). Parity was a positive predictor of overall sexual function, arousal, lubrication, and orgasm (all P<0.0005). Medical conditions were positive predictors of sexual desire (P=0.0023).

CONCLUSIONS

The present study revealed that depressive symptom scores during early and late pregnancy were significant negative predictors of sexual function during pregnancy.

Mediators of sexual functions in women with diabetes

INTRODUCTION

Sexual disorders in women with diabetes mellitus (DM) may not necessarily have only the biological etiology.

AIMS

To establish the mediators of sexual functions in the population of women with DM.

METHODS

Five hundred seventeen females, aged 18-55 years old, were included in a questionnaire-based, cross-sectional study. This is the second part of the study on sexual functions in females with DM where only females with DM (n=242) were analyzed. Sexual functions were compared between women with type 1 (n=109) and type 2 DM (N=133).

MAIN OUTCOME MEASURES

To assess reported female sexual functions by using the Female Sexual Function Index (FSFI) in women with type 1 and type 2 DM. To establish the risk factors of female sexual dysfunction (FSD) in women with DM by using multivariate logistic regression model.

RESULTS

Sexual dysfunction was diagnosed in 32.65% (n=64) of women with DM. Women with type 2 DM had a significantly lower number of points scored in all FSFI domains except pain compared to type 1 respondents. The only variables associated with DM significantly influencing sexual functioning were: type 2 diabetes in desire, arousal, as well as in global FSD (odds ratio [OR]=1.40; 2.70 and 3.31, respectively), the presence of retinopathy in lubrication (OR=7.8), and treatment with insulin in satisfaction domain (OR=0.29). Neither the presence of comorbidities, the duration of diabetes, the presence of diabetes complications nor the glycemic control was a moderator of FSD. The strongest significant predictors of FSD were: the presence of depressive symptoms, the importance of sex to the respondent, and satisfaction with the partner as a lover.

CONCLUSIONS

Women with DM, especially type 2, are at risk of sexual dysfunctions. Diabetes-related factors have little impact on sexual functions in women with DM. Depressive symptoms, partner-related factors, and individual perception of sexuality should be evaluated when counseling females with DM.

Female extrapair mating behavior can evolve via indirect selection on males

In many species that form socially monogamous pair bonds, a considerable proportion of the offspring is sired by extrapair males. This observation has remained a puzzle for evolutionary biologists: although mating outside the pair bond can obviously increase the offspring production of males, the benefits of such behavior to females are less clear, yet females are known to actively solicit extrapair copulations. For more than two decades adaptionist explanations have dominated the discussions, yet remain controversial, and genetic constraint arguments have been dismissed without much consideration. An intriguing but still untested hypothesis states that extrapair mating behavior by females may be affected by the same genetic variants (alleles) as extrapair mating behavior by males, such that the female behavior could evolve through indirect selection on the male behavior. Here we show that in the socially monogamous zebra finch, individual differences in extrapair mating behavior have a hereditary component. Intriguingly, this genetic basis is shared between the sexes, as shown by a strong genetic correlation between male and female measurements of extrapair mating behavior. Hence, positive selection on males to sire extrapair young will lead to increased extrapair mating by females as a correlated evolutionary response. This behavior leads to a fundamentally different view of female extrapair mating: it may exist even if females obtain no net benefit from it, simply because the corresponding alleles were positively selected in the male ancestors.

Future sexual medicine physiological treatment targets

INTRODUCTION

Sexual function in men and women incorporates physiologic processes and regulation of the central and peripheral nervous systems, the vascular system, and the endocrine system. There is need for state-of-the-art information as there is an evolving research understanding of the underlying molecular biological factors and mechanisms governing sexual physiologic functions.

AIM

To develop an evidence-based, state-of-the-art consensus report on the current knowledge of the major cellular and molecular targets of biologic systems responsible for sexual physiologic function.

METHODS

State-of-the-art knowledge representing the opinions of seven experts from four countries was developed in a consensus process over a 2-year period.

MAIN OUTCOME MEASURES

Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

RESULTS

Scientific investigation in this field is needed to increase knowledge and foster development of the future line of treatments for all forms of biological-based sexual dysfunction. This article addresses the current knowledge of the major cellular and molecular targets of biological systems responsible for sexual physiologic function. Future treatment targets include growth factor therapy, gene therapy, stem and cell-based therapies, and regenerative medicine.

CONCLUSIONS

Scientific discovery is critically important for developing new and increasingly effective treatments in sexual medicine. Broad physiologic directions should be vigorously explored and considered for future management of sexual disorders.

Voice Pitch Influences Perceptions of Sexual Infidelity

Sexual infidelity can be costly to members of both the extra-pair and the paired couple. Thus, detecting infidelity risk is potentially adaptive if it aids in avoiding cuckoldry or loss of parental and relationship investment. Among men, testosterone is inversely related to voice pitch, relationship and offspring investment, and is positively related to the pursuit of short-term relationships, including extra-pair sex. Among women, estrogen is positively related to voice pitch, attractiveness, and the likelihood of extra-pair involvement. Although prior work has demonstrated a positive relationship between men's testosterone levels and infidelity, this study is the first to investigate attributions of infidelity as a function of sexual dimorphism in male and female voices. We found that men attributed high infidelity risk to feminized women's voices, but not significantly more often than did women. Women attributed high infidelity risk to masculinized men's voices at significantly higher rates than did men. These data suggest that voice pitch is used as an indicator of sexual strategy in addition to underlying mate value. The aforementioned attributions may be adaptive if they prevent cuckoldry and/or loss of parental and relationship investment via avoidance of partners who may be more likely to be unfaithful.

Sexual problems in 18-67-year-old Norwegians

AIM

The aim of this study was to describe and analyse the prevalence of sexual problems in Norway.

METHODS

The results are based on two samples from 2008, one of which was taken from 1671 web interviews in December among persons ranging from 18-67 years of age, and the other being a survey on sexual behaviour among a random sample of 12,000 Norwegians between the ages of 18 and 59, taken in April.

MAIN OUTCOME MEASURES

The prevalence of sexual problems during the past 12 months.

RESULTS

Generalised linear model analyses showed that the highest expected prevalence of manifest problems was found in the following groups: reduced sexual desire problems in 60-67-year-old women with university education (52%); orgasm problems in 18-29-year-old women with less than university education (32%); genital pain in 18-29-year-old women with less than university education (19%); premature ejaculation problems in 18-29-year-old men with less than university education (27%); delayed ejaculation problems in men with less than university education (12%); erectile dysfunction in 60-67-year-old men (34%); and lubrication problems in 60-67-year-old women living in southeast Norway (29%). Sexual problems correlated negatively with sexual wellbeing.

CONCLUSIONS

This research indicates that sexual problems represent a public health problem.