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Porst H, Lewis R, Virag R, Goldstein I. A comprehensive history of injection therapy for erectile dysfunction, 1982-2023. Sex Med Rev 2024:qeae020. [PMID: 38644056 DOI: 10.1093/sxmrev/qeae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/29/2024] [Accepted: 03/18/2024] [Indexed: 04/23/2024]
Abstract
INTRODUCTION Although oral phosphodiesterase 5 inhibitors represent a first choice and long-term option for about half of all patients with erectile dysfunction (ED), self-injection therapy with vasoactive drugs remains a viable alternative for all those who are not reacting or cannot tolerate oral drug therapy. This current injection therapy has an interesting history beginning in 1982. OBJECTIVES To provide a comprehensive history of self-injection therapy from the very beginnings in 1982 by contemporary witnesses and some members of the International Society for Sexual Medicine's History Committee, a complete history of injection therapy is prepared from eyewitness accounts and review of the published literature on the subject, as well as an update of the current status of self-injection therapy. METHODS Published data on injection therapy, as a diagnostic and therapeutic tool for ED, were reviewed thoroughly by PubMed and Medline research from 1982 until June 2023. Early pioneers and witnesses added firsthand details to this historical review. Therapeutic reports of injection therapy were reviewed, and results of side effects and complications were thoroughly reviewed. RESULTS The pioneers of the first hours were Ronal Virag (1982) for papaverine, Giles Brindley (1983) for cavernosal alpha-blockade (phentolamine and phenoxybenzamine), Adrian Zorgniotti (1985) for papaverine/phentolamine, and Ganesan Adaikan and N. Ishii (1986) for prostaglandin E1. Moxisylyte (thymoxamine) was originally marketed but later withdrawn. The most common side effect is priapism, with the greatest risk of this from papaverine, which has modified its use for therapy. Currently, prostaglandin E1 and trimixes continue to be the agents of choice for diagnostic and therapeutic use in ED. A recent agent is a mixture of a vasoactive intestinal polypeptide (aviptadil) and phentolamine. CONCLUSIONS After 40 years, self-injection therapy represents the medication with the highest efficacy and reliability rates and remains a viable option for many couples with ED. The history of this therapy is rich.
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Affiliation(s)
- Hartmut Porst
- European Institute for Sexual Medicine, Hamburg 20095, Germany
| | - Ronald Lewis
- Medical College of Georgia at Augusta University, Marietta, GA 30064, United States
| | - Ronald Virag
- Centre d'explorations et Traitements de l'impuissance, Paris 75008, France
| | - Irwin Goldstein
- San Diego Sexual Medicine, San Diego CA 92120, United States
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Goldstein I, Goldstein SW. Fighting for sexual medicine. Sex Med Rev 2024; 12:114-115. [PMID: 38462738 DOI: 10.1093/sxmrev/qeae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 02/11/2024] [Indexed: 03/12/2024]
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Drian A, Goldstein SW, Kim NN, Goldstein AS, Hartzell-Cushanick R, Yee A, Goldstein I. Immunohistochemical staining with CD117 and PGP9.5 of excised vestibular tissue from patients with neuroproliferative vestibulodynia. J Sex Med 2024:qdae030. [PMID: 38521973 DOI: 10.1093/jsxmed/qdae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/16/2024] [Accepted: 02/14/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Neuroproliferative vestibulodynia (NPV), a provoked genital pain characterized by severe allodynia and hyperalgesia, is confirmed in excised vestibular tissue by immunohistochemical staining (>8 CD117-positive immunostained cells/100× microscopic field) rather than by hematoxylin and eosin staining. AIM In this study we sought to assess immunostaining of tissue samples obtained during vestibulectomy surgery and to correlate results with patient outcomes. METHODS Patients (n = 65) meeting criteria for NPV who underwent vestibulectomy during the period from June 2019 through December 2022 formed the study cohort. We performed assessment of pathology of vestibular tissues by use of immunohistochemical staining, including quantitation of mast cells by CD117 (mast cell marker) and nerve fibers by protein gene product (PGP) 9.5 (neuronal marker). We analyzed 725 photomicrographs of immunostained tissue sections (100× and 200×) by manual counting and computer-assisted histometry and correlated these data to clinical assessments. OUTCOMES Outcomes included density of CD117 and PGP9.5 immunostaining in the 1:00-11:00 o'clock and 12:00 o'clock vestibular regions, and patient-reported outcomes assessing sexual function, pain, distress, and symptom improvement. RESULTS All 65 NPV patients (median age 26 years), 45 with lifelong and 20 with acquired NPV, had severe pain documented by PROs and vulvoscopy and had >8 CD117-immunopositive cells/100× microscopic field. Median cell count values were similar in the 1:00-11:00 o'clock and 12:00 vestibular regions (28.5 and 29.5/100× field, respectively). Likewise, the marker) and nerve fibers by protein gene product (PGP) 9.5 (neuronal marker). We analyzed 725 photomicrographs of immunostained tissue sections (100× and 200×) by manual counting and computer-assisted histometry and correlated these data to clinical assessments. OUTCOMES Outcomes included density of CD117 and PGP9.5 immunostaining in the 1:00-11:00 o'clock and 12:00 o'clock vestibular regions, and patient-reported outcomes assessing sexual function, pain, distress, and symptom improvement. RESULTS All 65 NPV patients (median age 26 years), 45 with lifelong and 20 with acquired NPV, had severe pain documented by PROs and vulvoscopy and had >8 CD117-immunopositive cells/100× microscopic field. Median cell count values were similar in the 1:00-11:00 o'clock and 12:00 vestibular regions (28.5 and 29.5/100× field, respectively). Likewise, the median area of CD117 immunostaining was similar in both regions (0.69% and 0.73%). The median area of PGP9.5 immunostaining was 0.47% and 0.31% in these same regions. Pain scores determined with cotton-tipped swab testing were nominally higher in lifelong vs acquired NPV patients, reaching statistical significance in the 1:00-11:00 o'clock region (P < .001). The median score for the McGill Pain Questionnaire affective subscale dimension was also significantly higher in lifelong vs acquired NPV patients (P = .011). No correlations were observed between hematoxylin and eosin results and density of mast cells or neuronal markers. Of note, 63% of the patient cohort reported having additional conditions associated with aberrant mast cell activity. CLINICAL IMPLICATIONS The pathology of NPV is primarily localized to the vestibular epithelial basement membrane and subepithelial stroma with no visible vulvoscopic findings, making clinical diagnosis challenging. STRENGTHS AND LIMITATIONS Strengths of this study include the large number of tissues examined with what is to our knowledge the first-ever assessment of the 12:00 vestibule. Major limitations are specimens from a single timepoint within the disease state and lack of control tissues. CONCLUSIONS Performing immunohistochemical staining of excised vestibular tissue with CD117 and PGP9.5 led to histometric confirmation of NPV, indications that NPV is a field disease involving all vestibular regions, validation for patients whose pain had been ignored and who had experienced negative psychosocial impact, and appreciation that such staining can advance knowledge.
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Affiliation(s)
- Alexandra Drian
- San Diego Sexual Medicine, San Diego, CA 92120, United States
| | - Sue W Goldstein
- San Diego Sexual Medicine, San Diego, CA 92120, United States
| | - Noel N Kim
- Institute for Sexual Medicine, San Diego, CA 92120, United States
| | - Andrew S Goldstein
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, Los Angeles, CA 90095, United States
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, United States
| | | | - Alyssa Yee
- San Diego Sexual Medicine, San Diego, CA 92120, United States
| | - Irwin Goldstein
- San Diego Sexual Medicine, San Diego, CA 92120, United States
- Sexual Medicine, University of California San Diego East Campus, San Diego, CA 92120, United States
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Kloner RA, Burnett AL, Miner M, Blaha MJ, Ganz P, Goldstein I, Kim NN, Kohler T, Lue T, McVary KT, Mulhall JP, Parish SJ, Sadeghi-Nejad H, Sadovsky R, Sharlip ID, Rosen RC. Princeton IV consensus guidelines: PDE5 inhibitors and cardiac health. J Sex Med 2024; 21:90-116. [PMID: 38148297 DOI: 10.1093/jsxmed/qdad163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND In 1999, 1 year after the approval of the first oral phosphodiesterase type 5 (PDE5) inhibitor for the treatment of erectile dysfunction (ED), the first Princeton Consensus Conference was held to address the clinical management of men with ED who also had cardiovascular disease. These issues were readdressed in the second and third conferences. In the 13 years since the last Princeton Consensus Conference, the experience with PDE5 inhibitors is more robust, and recent new data have emerged regarding not only safety and drug-drug interactions, but also a potential cardioprotective effect of these drugs. AIM In March 2023, an interdisciplinary group of scientists and practitioners met for the fourth Princeton Consensus Guidelines at the Huntington Medical Research Institutes in Pasadena, California, to readdress the cardiovascular workup of men presenting with ED as well as the approach to treatment of ED in men with known cardiovascular disease. METHOD A series of lectures from experts in the field followed by Delphi-type discussions were developed to reach consensus. OUTCOMES Consensus was reached regarding a number of issues related to erectile dysfunction and the interaction with cardiovascular health and phosphodiesterase-5 inhibitors. RESULTS An algorithm based on recent recommendations of the American College of Cardiology and American Heart Association, including the use of computed tomography coronary artery calcium scoring, was integrated into the evaluation of men presenting with ED. Additionally, the issue of nitrate use was further considered in an algorithm regarding the treatment of ED patients with coronary artery disease. Other topics included the psychological effect of ED and the benefits of treating it; the mechanism of action of the PDE5 inhibitors; drug-drug interactions; optimizing use of a PDE5 inhibitors; rare adverse events; potential cardiovascular benefits observed in recent retrospective studies; adulteration of dietary supplements with PDE5 inhibitors; the pros and cons of over-the-counter PDE5 inhibitors; non-PDE5 inhibitor therapy for ED including restorative therapies such as stem cells, platelet-rich plasma, and shock therapy; other non-PDE5 inhibitor therapies, including injection therapy and penile prostheses; the issue of safety and effectiveness of PDE5 inhibitors in women; and recommendations for future studies in the field of sexual dysfunction and PDE5 inhibitor use were discussed. CLINICAL IMPLICATIONS Algorithms and tables were developed to help guide the clinician in dealing with the interaction of ED and cardiovascular risk and disease. STRENGTHS AND LIMITATIONS Strengths include the expertise of the participants and consensus recommendations. Limitations included that participants were from the United States only for this particular meeting. CONCLUSION The issue of the intersection between cardiovascular health and sexual health remains an important topic with new studies suggesting the cardiovascular safety of PDE5 inhibitors.
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Affiliation(s)
- Robert A Kloner
- Department of Cardiovascular Research Pasadena, Huntington Medical Research Institutes, CA 91105, United States
- Department of Medicine, Keck School of Medicine at University of Southern California, Los Angeles, CA, United States
| | - Arthur L Burnett
- Department of Urology, Johns Hopkins University, Baltimore, MD, United States
| | - Martin Miner
- Men's Health Center, Miriam Hospital, Providence, RI, United States
| | - Michael J Blaha
- Cardiology and Epidemiology, Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, United States
| | - Peter Ganz
- Department of Medicine (PG); Department of Urology (TL, IDS); Department of Psychiatry and Behavioral Sciences, (RCR), University of California, San Francisco, San Francisco, CA, United States
| | - Irwin Goldstein
- Department of Sexual Medicine, Institute for Sexual Medicine, Alvarado Hospital, San Diego, CA, United States
| | - Noel N Kim
- Department of Sexual Medicine, Institute for Sexual Medicine, Alvarado Hospital, San Diego, CA, United States
| | | | - Tom Lue
- Department of Medicine (PG); Department of Urology (TL, IDS); Department of Psychiatry and Behavioral Sciences, (RCR), University of California, San Francisco, San Francisco, CA, United States
| | - Kevin T McVary
- Center for Male Health, Stritch School of Medicine at Loyola University Medical Center, Maywood, IL, United States
| | - John P Mulhall
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sharon J Parish
- Weill Cornell Medicine, New York, NY, United States
- Department of Medicine and Psychiatry White Plains, Westchester Behavioral Health Center, NewYork-Presbyterian Hospital, NY, United States
| | - Hossein Sadeghi-Nejad
- Department of Urology NY, NYU Langone Grossman School of Medicine, NY, United States
| | - Richard Sadovsky
- Department of Family and Community Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, United States
| | - Ira D Sharlip
- Department of Medicine (PG); Department of Urology (TL, IDS); Department of Psychiatry and Behavioral Sciences, (RCR), University of California, San Francisco, San Francisco, CA, United States
| | - Raymond C Rosen
- Department of Medicine (PG); Department of Urology (TL, IDS); Department of Psychiatry and Behavioral Sciences, (RCR), University of California, San Francisco, San Francisco, CA, United States
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Goldstein I. Making Choices Wisely. Sex Med Rev 2023; 12:1-2. [PMID: 38112595 DOI: 10.1093/sxmrev/qead049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 12/21/2023]
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Komisaruk BR, Del Cerro MCR, Goldstein I. Orgasm utilizes the pain pathway: is orgasm "nonaversive pain"? Sex Med Rev 2023; 11:291-295. [PMID: 37635366 DOI: 10.1093/sxmrev/qead037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/29/2023]
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Goldstein I, Hassan T, Zou K, Divino V, DeKoven M, Imperato J, Anupindi VR, Li J. Health-Care Resource Utilization and Treatment Patterns in Men with Erectile Dysfunction and Benign Prostatic Hyperplasia-Associated Lower Urinary Tract Symptoms in the United States: A Retrospective Database Study. Patient Prefer Adherence 2023; 17:2187-2200. [PMID: 37701428 PMCID: PMC10493135 DOI: 10.2147/ppa.s412969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/04/2023] [Indexed: 09/14/2023] Open
Abstract
Objective To compare health-care resource utilization (HCRU) outcomes in patients with erectile dysfunction (ED) and benign prostatic hyperplasia-associated lower urinary tract symptoms (BPH-LUTS) treated with tadalafil or non-phosphodiesterase-5 inhibitor (PDE5i), adherence to and persistence with tadalafil by dose in the United States (US). Methods This was a noninterventional, real-world evidence study of men (aged ≥45 years) with ED and BPH-LUTS treated with tadalafil or non-PDE5i. The IQVIA US PharMetrics Plus claims database was used. Outcomes included all-cause and disease-specific HCRU over a 12-month follow-up. Persistence with and adherence to tadalafil were evaluated stratified by dose (10 or 20 mg as needed; 2.5 or 5 mg as once daily [OD]). Results The final sample comprised 11,351 tadalafil and 48,722 non-PDE5i patients. For all-cause and disease-specific HCRU, including prescription fills, physician office visits, emergency room visits, laboratory tests, radiology examinations, outpatient surgical services, ancillary services, hospitalizations, mean number of utilizations, and proportions of patients with one or more utilizations, were lower for tadalafil compared with non-PDE5i patients. For all-cause HCRU, proportions of patients with one or more emergency room visits (18.6% vs 21.7%, p<0.0001) and outpatient surgical visits (63.0% vs 68.8%, p<0.0001) were significantly lower for tadalafil compared with non-PDE5i patients. For disease-specific HCRU, the proportion with one or more disease-specific physician office visits (55.1% vs 91.4%), laboratory tests (34.8% vs 58.2%), outpatient surgery (24.3% vs 38.9%), or outpatient ancillary services (18.0% vs 29.8%) were significantly lower for tadalafil compared with non-PDE5i patients (all comparisons, p<0.0001). Mean persistence days (179.8 vs 61.2), proportion persistence (35.8% vs 6.5%), and mean adherence (0.5 vs 0.2) were higher for tadalafil OD doses than as-needed tadalafil doses. Conclusion Patients on tadalafil demonstrated less HCRU and higher persistence and adherence (OD versus as-needed tadalafil) than non-PDE5i patients, which demonstrates its benefit in the management of ED and BPH-LUTS in the US.
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Affiliation(s)
- Irwin Goldstein
- Department of Sexual Medicine, Alvarado Hospital, San Diego, CA, USA
| | - Tarek Hassan
- Department of Urology, Viatris Inc, Canonsburg, PA, USA
| | - Kelly Zou
- Global Medical Analytics and Real World Evidence, Viatris Inc, Canonsburg, PA, USA
| | - Victoria Divino
- Health Economics/Outcomes Research and Real-World Insights, IQVIA, Falls Church, VA, USA
| | - Mitch DeKoven
- Health Economics/Outcomes Research and Real-World Insights, IQVIA, Falls Church, VA, USA
| | - Joseph Imperato
- Global Medical Analytics and Real World Evidence, Viatris Inc, Canonsburg, PA, USA
| | | | - Jim Li
- Global Medical Analytics and Real World Evidence, Viatris Inc, Canonsburg, PA, USA
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Handy AB, McMahon LN, Goldstein I, Meston CM. Reduction in genital sexual arousal varies by type of oral contraceptive pill. J Sex Med 2023; 20:1094-1102. [PMID: 37295939 DOI: 10.1093/jsxmed/qdad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/27/2023] [Accepted: 04/25/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Although oral contraceptive pills (OCPs) have been associated with decrements in self-reported genital arousal and vaginal lubrication, 1,2 little is known about how these outcomes vary across types of OCPs. AIM The present study examined differences in physiological lubrication and vaginal blood flow, as well as rates of self-reported vulvovaginal atrophy and female sexual arousal disorder, among women using OCPs with varying androgenic properties. METHODS Participants in this study were 130 women: 59 naturally cycling control women, 50 women taking androgenic OCPs, and 21 women taking antiandrogenic OCPs. Participants watched sexual films while their sexual arousal responses were measured, completed questionnaires, and participated in a clinical interview. OUTCOMES Vaginal blood flow, vaginal lubrication, self-reported vulvovaginal atrophy, and female sexual arousal disorder were assessed. RESULTS Results indicated deficits in vaginal pulse amplitude and lubrication for women taking either form of OCP, with marked inhibitory effects found in women taking antiandrogenic OCPs. Rates of self-reported vulvovaginal atrophy and female sexual arousal disorder were also significantly greater in the antiandrogenic group compared with the control group. CLINICAL IMPLICATIONS It is recommended that prescribing clinicians consult patients on such physiological effects of OCPs. STRENGTHS AND LIMITATIONS To our knowledge, this was the first study to compare multiple measures of physiological sexual arousal across groups of women taking OCPs with varying hormonal profiles. Because all OCPs included in this study contained low doses of ethinylestradiol, we were able to identify the specific effects of the androgenic properties on women's sexual arousal responses. However, the self-administered lubrication test strip was subject to user error. Additionally, the generalizability of findings is limited by the largely heterosexual and college-aged sample. CONCLUSION Compared with naturally cycling women, women taking OCPs that contain antiandrogenic progestins experienced decreased vaginal blood flow and lubrication as well as higher rates of self-reported vaginal bleeding and female sexual arousal disorder.
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Affiliation(s)
- Ariel B Handy
- Department of Psychology, McLean Hospital, Belmont, MA 02478, United States
| | - Leah N McMahon
- Department of Psychology, University of Texas at Austin, Austin, TX 78712, United States
| | - Irwin Goldstein
- Department of Sexual Medicine, Alvarado Hospital, San Diego, CA 92120, United States
| | - Cindy M Meston
- Department of Psychology, University of Texas at Austin, Austin, TX 78712, United States
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Goldstein SW, Goldstein I, Kim NN. Vestibular tissue changes following administration of intravaginal prasterone: a vulvoscopic open-label pilot study in menopausal women with dyspareunia. Sex Med 2023; 11:qfad028. [PMID: 37351544 PMCID: PMC10281961 DOI: 10.1093/sexmed/qfad028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/07/2023] [Accepted: 05/20/2023] [Indexed: 06/24/2023] Open
Abstract
Background Prasterone, an intravaginal dyspareunia treatment in menopausal women, improves vaginal health through intracellular conversion of dehydroepiandrosterone into androgens and estrogens. Phase 3 trials for prasterone showed significant improvement in vaginal tissue health and reduction of pain. Aim To assess vestibular changes with daily use of intravaginal prasterone in menopausal women with moderate to severe dyspareunia. Methods This open-label prospective pilot study was conducted over 20 weeks. It included 11 menopausal women (median age, 56 years) who were treated daily with intravaginal inserts of 6.5-mg prasterone and assessed monthly. During vulvoscopy, vestibular pain was assessed by cotton-tipped swab testing, and vestibular and vaginal health was independently assessed with the Visual Scale (VS). In addition, vulvoscopic photographs were obtained and assessed via the Vulvoscopic Genital Tissue Appearance (VGTA) scale to evaluate overall genital tissue health. Mean changes from baseline for genital tissue health and pain assessments were analyzed by repeated measures 1-way analysis of variance, followed by a Dunnett post hoc test. Sexual event diaries were completed and adverse events recorded. Outcomes Outcomes included indices of genital tissue health: pain assessment by cotton-tipped swab testing, VS of the vestibule and vagina, VGTA, and sexual event diary. Results Aggregate scores from the cotton-tipped swab test progressively improved, reaching statistical significance at week 16, which was maintained through week 20 (-7.27, P = .019). VS scores significantly improved from baseline by week 4 and were maintained through week 20 for the vestibule (-3.00, P = .004) and vagina (-4.00, P = .002). An overall 1607 vulvoscopic photographs were examined; all showed reduction in vestibular erythema and pallor at the end of the study. The mean change from baseline at week 20 for the VGTA score was -7.9 (P = .0016). Intercourse associated with pain was reduced from 81.3% of initiated events during the first month of the study to 8.3% during the last month. Sexual activities that were discontinued due to discomfort were reduced from 45.8% to 6.3%. No prasterone-related serious adverse events were reported. Clinical Implications Prasterone, a safe and effective intravaginal hormone treatment, significantly improves vestibular health parameters. Strengths and Limitations Strengths are the prospective study design and the use of multiple outcome measures to assess vestibular tissue health and pain associated with sexual activity. Limitations are the small study cohort and use of nonvalidated outcome measures. Conclusion Our findings suggest that intravaginal prasterone exerts biologic activity on the androgenic endodermal vestibule, as the medication passes from vagina to vestibule, resulting in amelioration of pain associated with sexual activity.
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Affiliation(s)
- Sue W Goldstein
- Corresponding author: San Diego Sexual Medicine, 5555 Reservoir Dr, Suite 300, San Diego, CA 92120, United States.
| | - Irwin Goldstein
- San Diego Sexual Medicine, San Diego, CA 92120, United States
- Sexual Medicine, Alvarado Hospital, San Diego, CA 92120, United States
| | - Noel N Kim
- Institute for Sexual Medicine, San Diego, CA 92121, United States
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Tomalty D, Giovannetti O, Magliocchetti S, Williams A, Hannan J, Komisaruk B, Goldstein S, Goldstein I, Adams MA. Characterizing the innervation of the vulvar vestibule and the immunohistochemical features of neuroproliferative vestibulodynia. J Sex Med 2023; 20:716-731. [PMID: 37132034 DOI: 10.1093/jsxmed/qdad040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/03/2023] [Accepted: 03/01/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Provoked vestibulodynia (PVD) is a chronic pain condition characterized by allodynia localized to the vulvar vestibule. The finding of increased densities of nerve fibers in the vestibular mucosa of patients with PVD has led to the identification of a neuroproliferative subtype. The etiology of PVD, including neuroproliferative vestibulodynia (NPV), is not fully understood. The gross and microscopic innervation of the vulvar vestibule remains incompletely described, despite the preliminary data supporting the role of peripheral innervation in PVD. AIM To characterize the gross anatomic and microscopic innervation of the vulvar vestibule through cadaveric dissection and immunohistochemistry. METHODS The pudendal nerve and inferior hypogastric plexus (IHP) were dissected using 6 cadaveric donors. Histology and immunohistochemistry were used to confirm patterns of innervation identified gross anatomically. Immunohistochemistry was performed on vestibulectomy specimens obtained from 6 patients diagnosed with NPV and compared with cadaveric vestibular tissues. OUTCOMES Outcomes included (1) dissection of pelvic innervation and (2) immunohistochemical localization of markers for the following: general innervation protein gene product 9.5 (PGP9.5), sensory innervation (calcitonin gene-related peptide), autonomic innervation (vasoactive intestinal polypeptide, tyrosine hydroxylase), neuroproliferation (nerve growth factor [NGF]), and immune activation (C-kit). RESULTS Perineal (pudendal) nerve branches were traced to the external wall of the vulvar vestibule. Some anatomic heterogeneity was observed in perineal nerve-branching patterns. Fibers from the IHP were identified in close proximity to the vulvar vestibule. Autonomic and sensory nerve fibers were identified in both patient and cadaveric vulvar vestibule samples. Patient samples were characterized by the proliferation of PGP9.5-positive nerve fibers and C-kit-positive mast cells, which were in proximity to neve bundles and showed coexpression with putative NGF-positive cells. NGF expression was localized to a subset of nerves, including those that demonstrated co-expression of sensory and autonomic nerve markers. Increased densities of autonomic fibers positive for vasoactive intestinal polypeptide and tyrosine hydroxylase were observed in 1 patient sample. CLINICAL TRANSLATION Heterogeneity in gross and microscopic patterns of innervation could explain variability in clinical response to treatment and should be used to inform future therapeutic interventions. STRENGTHS AND LIMITATIONS This study used a combination of approaches to elucidate the innervation of the vulvar vestibule, including in NPV. The small sample size is a limitation. CONCLUSION The vulvar vestibule contains both sensory and autonomic innervation, which may originate from the pudendal nerve and IHP. Our results support the existence of a neuroproliferative subtype that is characterized by the proliferation of sensory and autonomic nerve fibers and neuroimmune interactions.
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Affiliation(s)
- Diane Tomalty
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Olivia Giovannetti
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Stephen Magliocchetti
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Andre Williams
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Johanna Hannan
- Department of Physiology, East Carolina University, Greenville, NC, 27834, United States
| | - Barry Komisaruk
- Department of Psychology, Rutgers University, Newark, NJ, 07102, United States
| | - Sue Goldstein
- San Diego Sexual Medicine, San Diego, CA, 92120, United States
| | - Irwin Goldstein
- San Diego Sexual Medicine, San Diego, CA, 92120, United States
| | - Michael A Adams
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
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Giovannetti O, Tomalty D, Greco S, Kment B, Komisaruk B, Hannan J, Goldstein S, Goldstein I, Adams MA. Patient and provider perspectives on LEEP/LLETZ treatment and outcomes: an interview study. J Sex Med 2023:7077154. [PMID: 36918387 DOI: 10.1093/jsxmed/qdad026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/20/2023] [Accepted: 01/27/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND The loop electrosurgical excision procedure (LEEP) and large loop excision of the transformation zone (LLETZ) effectively treat cervical dysplasia, though some women have reported negative outcomes postoperatively (e.g., sexual dysfunction, psychosexual sequalae). There is insufficient understanding of patient experiences with these symptoms and perspectives from the providers who perform LEEP/LLETZ. AIM To characterize the perceptions and experiences of LEEP/LLETZ treatment from providers and patients, including whether there is a characteristic symptom profile of women who report negative outcomes. METHODS Patients who had LEEP/LLETZ treatment and reported negative outcomes and providers who perform LEEP/LLETZ completed semistructured interviews about their perceptions and experiences, which were coded through thematic analysis (NVivo 12; QSR International). Patients also completed an online survey assessing demographics, medical history, and sexual function. OUTCOMES Outcomes included perspectives generated from patient and provider interviews regarding LEEP/LLETZ procedural outcomes, including symptoms and experiences related to sexual functioning. RESULTS Perspectives and experiences gathered from patient and provider interviews revealed misaligned narratives surrounding LEEP/LLETZ outcomes and treatment. We identified 4 overarching themes encapsulating provider and patient responses: Expectations for Preoperative Consultation; Procedure Experiences; Attitudes; and Resources. Patients reported a unique symptom profile and negative outcome experiences, namely surrounding domains of sexual functioning: decreased physical sensations, orgasm response, and vaginal discharge, as well as loss of arousal, interest, and desire. Patients described changes to overall quality of life, with impacts to interpersonal relationships. Patients discussed preferring open-ended and directed questions to comprehensively elucidate negative outcomes. Provider narratives outlined the current process of care, emphasizing limited experiences with adverse outcomes (e.g., sexual issues) and the use of open-ended questions during counseling. Providers described an evolving intention to create comfortable clinical spaces. Regarding pre- and postoperative resources, patients described seeking support from online patient groups, and providers disclosed limitations to providing resources. CLINICAL IMPLICATIONS Evidence of discordance between patient and provider perspectives of LEEP/LLETZ reveals a need to reassess clinical practices surrounding this procedure at the level of discussions regarding informed consent, sexual function, and available resources. STRENGTHS AND LIMITATIONS This study is the first to examine patient and provider perspectives on LEEP/LLETZ treatment. Only patients who self-report negative outcomes were recruited, to elicit narratives from this specific subpopulation. CONCLUSION Results indicate a characteristic symptom profile of women who undergo LEEP/LLETZ and report negative outcomes and that the perceptions of patients and providers differ regarding several aspects of the treatment experience, supporting the need for directed open conversation and comprehensive pre- and postoperative sexual counseling.
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Affiliation(s)
- Olivia Giovannetti
- Department of Biomedical and Molecular Science, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Diane Tomalty
- Department of Biomedical and Molecular Science, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Sabrina Greco
- Department of Biomedical and Molecular Science, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Brian Kment
- Department of Biomedical and Molecular Science, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Barry Komisaruk
- Department of Psychology, Rutgers University, Newark, NJ 07102, United States
| | - Johanna Hannan
- Department of Physiology, Brody School of Medicine at East Carolina University, Greenville, NC 27834, United States
| | - Sue Goldstein
- San Diego Sexual Medicine, San Diego, CA 92120, United States.,Department of Sexual Medicine, Alvarado Hospital, San Diego, CA 92120, United States
| | - Irwin Goldstein
- Department of Sexual Medicine, Alvarado Hospital, San Diego, CA 92120, United States
| | - Michael A Adams
- Department of Biomedical and Molecular Science, Queen's University, Kingston, ON K7L 3N6, Canada
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12
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Kim CW, Goldstein I, Komisaruk BR, Goldstein SW, Kim NN, Hartzell-Cushanick R, Uloko M, Yee A. Lumbar endoscopic spine surgery for persistent genital arousal disorder/genitopelvic dysesthesia resulting from lumbosacral annular tear-induced sacral radiculopathy. J Sex Med 2023; 20:210-223. [PMID: 36763933 DOI: 10.1093/jsxmed/qdac017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Persistent genital arousal disorder/genitopelvic dysesthesia (PGAD/GPD) is characterized by distressing, abnormal genitopelvic sensations, especially unwanted arousal. In a subgroup of patients with PGAD/GPD, cauda equina Tarlov cyst-induced sacral radiculopathy has been reported to trigger the disorder. In our evaluation of lumbosacral magnetic resonance images in patients with PGAD/GPD and suspected sacral radiculopathy, some had no Tarlov cysts but showed lumbosacral disc annular tear pathology. AIM The aims were 2-fold: (1) to utilize a novel multidisciplinary step-care management algorithm designed to identify a subgroup of patients with PGAD/GPD and lumbosacral annular tear-induced sacral radiculopathy who could benefit from lumbar endoscopic spine surgery (LESS) and (2) to evaluate long-term safety and efficacy of LESS. METHODS Clinical data were collected on patients with PGAD/GPD who underwent LESS between 2016 and 2020 with at least 1-year follow-up. LESS was indicated because all had lumbosacral annular tear-induced sacral radiculopathy confirmed by our multidisciplinary management algorithm that included the following: step A, a detailed psychosocial and medical history; step B, noninvasive assessments for sacral radiculopathy; step C, targeted diagnostic transforaminal epidural spinal injections resulting in a temporary, clinically significant reduction of PGAD/GPD symptoms; and step D, surgical intervention with LESS and postoperative follow-up. OUTCOMES Treatment outcome was based on the validated Patient Global Impression of Improvement, measured at postoperative intervals. RESULTS Our cohort included 15 cisgendered women and 5 cisgendered men (mean ± SD age, 40.3 ± 16.8 years) with PGAD/GPD who fulfilled the criteria of lumbosacral annular tear-induced sacral radiculopathy based on our multidisciplinary management algorithm. Patients were followed for an average of 20 months (range, 12-37) post-LESS. Lumbosacral annular tear pathology was identified at multiple levels, the most common being L4-L5 and L5-S1. Twenty-two LESS procedures were performed in 20 patients. Overall, 80% (16/20) reported improvement on the Patient Global Impression of Improvement; 65% (13/20) reported improvement as much better or very much better. All patients were discharged the same day. There were no surgical complications. CLINICAL IMPLICATIONS Among the many recognized triggers for PGAD/GPD, this subgroup exhibited lumbosacral annular tear-induced sacral radiculopathy and experienced long-term alleviation of symptoms by LESS. STRENGTHS AND LIMITATIONS Strengths include long-term post-surgical follow-up and demonstration that LESS effectively treats patients with PGAD/GPD who have lumbosacral annular tear-induced sacral radiculopathy, as established by a multidisciplinary step-care management algorithm. Limitations include the small study cohort and the unavailability of a clinical measure specific for PGAD/GPD. CONCLUSION LESS is safe and effective in treating patients with PGAD/GPD who are diagnosed with lumbosacral annular tear-induced sacral radiculopathy.
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Affiliation(s)
- Choll W Kim
- Excel Spine Center, San Diego, CA 92120, United States.,Alvarado Hospital, San Diego, CA 92120, United States
| | - Irwin Goldstein
- Alvarado Hospital, San Diego, CA 92120, United States.,San Diego Sexual Medicine, San Diego, CA 92120, United States
| | | | - Sue W Goldstein
- San Diego Sexual Medicine, San Diego, CA 92120, United States
| | - Noel N Kim
- Institute for Sexual Medicine, San Diego, CA 92121, United States
| | | | - Maria Uloko
- Alvarado Hospital, San Diego, CA 92120, United States.,San Diego Sexual Medicine, San Diego, CA 92120, United States.,University of California San Diego, San Diego, CA 92093, United States
| | - Alyssa Yee
- Alvarado Hospital, San Diego, CA 92120, United States.,San Diego Sexual Medicine, San Diego, CA 92120, United States
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13
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Goldstein SW, Goldstein I, Kim NN, Kellogg-Spadt S, Murina F. Safety and efficacy of fractional CO2 laser treatment to the vestibule: a randomized, double-blind, sham-controlled, prospective 3-site clinical study in women with vestibular pain. J Sex Med 2023; 20:800-812. [PMID: 36779572 DOI: 10.1093/jsxmed/qdac053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/26/2022] [Accepted: 12/28/2022] [Indexed: 02/14/2023]
Abstract
BACKGROUND Data are limited regarding fractional CO2 laser as a nonhormonal treatment for vestibular pain. AIM We sought to perform what is, to our knowledge, the first multisite prospective randomized, double-blind, sham-controlled clinical trial to assess the safety and efficacy of fractional CO2 laser treatment to the vestibule in women with vestibular pain. METHODS Subjects (n = 70) meeting inclusion/exclusion criteria at each of 3 sites were randomized 2:1 to active or sham (zero energy) fractional CO2 laser treatment using the vestibular probe (SmartXide2 V2LR - MonaLisa Touch, DEKA, Florence, Italy). Subjects in each treatment arm received 3 treatments 4 weeks apart. At the initial follow-up (week 12), subjects were unblinded and those initially assigned to sham started active treatment. OUTCOMES Outcome measures included changes from baseline in sexual activity diaries and scores for the Vulvoscopic Genital Tissue Appearance Scale (VGTA), vestibular cotton-tipped swab testing, McGill Pain Questionnaire, Female Sexual Function Index (FSFI), Female Sexual Distress Scale-Revised (FSDS-R), and the O'Leary-Sant voiding and pain indices, the Interstitial Cystitis Symptom Index (ICSI) and Interstitial Cystitis Problem Index (ICPI). RESULTS After active treatment, VGTA scores significantly improved in 5 parameters. Pain associated with cotton-tipped swab testing was significantly reduced at weeks 4 through 16 (mean change from baseline -0.64 [95% CI, -0.79 to -0.50] and -1.31 [95% CI, -1.46 to -1.16], respectively). FSFI pain domain scores improved significantly at weeks 12 and 16 (mean change from baseline 0.925 [95% CI, 0.10-1.75] and 1.22 [95% CI, 0.40-2.05], respectively). FSFI total scores increased significantly at weeks 12 and 16 (mean change from baseline 6.24 [95% CI, 2.64-9.85] and 4.96 [95% CI, 1.36-8.57], respectively). FSDS-R scores decreased significantly at weeks 12 and 16 (mean change from baseline -5.84 [95% CI, -8.80 to -2.87] and -9.15 [95% CI, -12.11 to -6.18], respectively). ICSI scores decreased significantly at weeks 12 and 16 (mean change from baseline -0.91 [95% CI, -1.65 to -0.18] and -0.754 [95% CI, -1.49 to -0.02], respectively). ICPI scores decreased significantly at week 16 (mean change from baseline -0.99 [95% CI, -1.63 to -0.34]). In contrast, there were no significant changes in outcomes in the sham arm. No serious adverse events occurred. CLINICAL IMPLICATIONS Fractional CO2 laser treatment in women with vestibular pain resulted in improvement from baseline in multiple key outcome measures of vestibular health. STRENGTHS AND LIMITATIONS Strengths of the study were that it was a multisite prospective randomized double-blind, sham-controlled clinical trial that included multiple measures related to vestibular pain and sexual function. Limitations were the nonvalidated primary outcome measure and limited study cohort. CONCLUSION Fractional CO2 laser therapy is a safe and effective nonhormonal treatment for vestibular pain.
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Affiliation(s)
| | - Irwin Goldstein
- San Diego Sexual Medicine, San Diego, CA United States.,Sexual Medicine, Alvarado Hospital, San Diego, CA United States
| | - Noel N Kim
- Institute for Sexual Medicine, San Diego, CA United States
| | | | - Filippo Murina
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milan, Italy.,Università degli Studi, Milan, Italy
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Tomalty D, Giovannetti O, Gaudet D, Clohosey D, Harvey MA, Johnston S, Komisaruk B, Hannan J, Goldstein S, Goldstein I, Adams MA. The prostate in women: an updated histological and immunohistochemical profile of the female periurethral glands and their relationship to an implanted midurethral sling. J Sex Med 2023; 20:612-625. [PMID: 36763941 DOI: 10.1093/jsxmed/qdac046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/11/2022] [Accepted: 12/09/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND There is evidence of glandular tissue in the region of the anterior vaginal wall-female periurethral tissue (AVW-FPT) that has similar morphology and immunohistochemistry to the prostate in men. Surgical injury to this tissue has been suggested as a potential cause of sexual dysfunction following midurethral sling (MUS) procedures. However, the anatomy and embryology of these glands have not been fully resolved. This has led to difficulties in classifying this tissue as a prostate and defining its clinical significance related to MUS procedures. AIM To describe the histological and immunohistochemical characteristics of the female periurethral glands using markers of prostate tissue and innervation and to examine their anatomical relationships to an implanted MUS. METHODS Using gross and fine dissection, the AVW-FPT was dissected from 9 cadavers. Prior to dissection, 2 cadavers underwent simulation of the MUS procedure by a urogynecologist. Samples were paraffin embedded and serially sectioned. Immunohistochemistry was performed using markers of prostate tissue and innervation. OUTCOMES Redundant immunohistochemical localization of markers for prostatic tissue and innervation of the glandular tissue of the AVW-FPT, including the region of MUS implantation. RESULTS Female periurethral glands were immunoreactive for markers of male prostatic tissue, including prostate-specific antigen, androgen receptor, HOXB13, and NKX3.1. Markers of innervation (protein gene product 9.5, choline acetyl transferase, and vasoactive intestinal polypeptide) also localized to certain regions of the glandular tissue and associated blood supply. Surgical simulation of the MUS procedure demonstrated that some periurethral glands are located in close proximity to an implanted sling. CLINICAL TRANSLATION The AVW-FPT contains glandular tissue in the surgical field of MUS implantation. Iatrogenic damage to the female periurethral glands and the associated innervation during surgery could explain the negative impacts on sexual dysfunction reported following MUS procedures. STRENGTHS AND LIMITATIONS This is the first study to characterize the female periurethral glands using markers of prostatic tissue in concert with markers of general and autonomic innervation and characterize their anatomical relationships within the surgical field of MUS implantation. The small sample size is a limitation of this study. CONCLUSION We provide further evidence that the AVW-FPT contains innervated glands that are phenotypically similar to the male prostate and may share a common embryonic origin. The microscopic and immunohistochemical features of the periurethral glands may be indicative of their functional capacity in sexual responses. The location of these glands in the surgical field of MUS procedures underscores the clinical significance of this tissue.
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Affiliation(s)
- Diane Tomalty
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Olivia Giovannetti
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Dionne Gaudet
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Diandra Clohosey
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Marie-Andrée Harvey
- Obstetrics and Gynaecology, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
| | - Shawna Johnston
- Obstetrics and Gynaecology, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
| | - Barry Komisaruk
- Department of Psychology, Rutgers University, Newark, NJ 07102, United States
| | - Johanna Hannan
- Department of Physiology, East Carolina University, Greenville, NC 27834, United States
| | - Sue Goldstein
- San Diego Sexual Medicine, San Diego, CA 92120, United States
| | - Irwin Goldstein
- San Diego Sexual Medicine, San Diego, CA 92120, United States
| | - Michael A Adams
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
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15
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Giovannetti O, Tomalty D, Gilmore S, Pattison A, Komisaruk B, Goldstein S, Hannan J, Goldstein I, Pukall C, Adams MA. The contribution of the cervix to sexual response: an online survey study. J Sex Med 2023; 20:49-56. [PMID: 36897237 DOI: 10.1093/jsxmed/qdac010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/12/2022] [Accepted: 10/07/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND The role of the cervix in sexual response has been poorly studied, despite previous research indicating that some women experience pleasurable sexual sensations from cervical stimulation; given previous reports of sexual issues after cervix electrocautery, it is possible that cervical injury may compromise the role of the cervix in sexual functioning. AIM The aims of this study were to examine locations of pleasurable sexual sensations, to identify sexual communication barriers, and to investigate if cervical procedures are associated with negative impacts on sexual function. METHODS Women with (n = 72) and without (n = 235) a history of a gynecological procedure completed an online survey assessing demographics, medical history, sexual function (including locations of sexual pleasure and pain on diagrams), and barriers. The procedure group was divided into subgroups of those who had experienced a cervical (n = 47) or noncervical (n = 25) procedure. Chi-square analyses and t tests were conducted. OUTCOMES Outcomes included locations and ratings of pleasurable and painful sexual stimulation, as well as sexual function. RESULTS Over 16% of participants reported experiencing some pleasurable sexual sensations from the cervix. The gynecological procedure group (n = 72) reported significantly higher pain in the vagina and lower rates of pleasure in their external genitals, vagina, deep vagina, anterior and posterior vaginal walls, and clitoris vs the non-gynecological procedure (n = 235) group. The gynecological procedure group and the cervical procedure subgroup (n = 47) reported significant decreases in desire, arousal, and lubrication and increased avoidance of sexual activity due to vaginal dryness. The gynecological procedure group reported significant pain with vaginal stimulation, whereas the cervical subgroup identified significant pain with cervical and clitoral stimulation. CLINICAL IMPLICATIONS Cervical stimulation elicits some pleasurable sexual sensations for many women, and gynecological procedures that affect the cervix are associated with pain and sexual issues; thus, health care providers should counsel patients about the possibility of related sexual concerns. STRENGTHS AND LIMITATIONS This study is the first to examine locations of pleasure and pain and experiences of sexual pleasure and function in participants who underwent a gynecological procedure. A hybrid measure was used to assess sexual issues, including symptoms of dysfunction. CONCLUSION Results indicate an association between cervical procedures and sexual issues, supporting the need to inform patients of this possibility following cervical procedures.
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Affiliation(s)
- Olivia Giovannetti
- Department of Biomedical and Molecular Science, Queen's University, Kingston K7L 2V5, Canada
| | - Diane Tomalty
- Department of Biomedical and Molecular Science, Queen's University, Kingston K7L 2V5, Canada
| | - Shelby Gilmore
- Department of Biomedical and Molecular Science, Queen's University, Kingston K7L 2V5, Canada
| | - Anne Pattison
- Department of Psychology, Queen's University, Kingston K7L 3L3, Canada
| | - Barry Komisaruk
- Department of Psychology, Rutgers University, Newark, NJ 08854, United States
| | - Sue Goldstein
- San Diego Sexual Medicine, San Diego, CA 92120, United States
| | - Johanna Hannan
- Department of Physiology, Brody School of Medicine at East Carolina University, Greenville, NC 27834, United States
| | - Irwin Goldstein
- Alvarado Hospital, Department of Sexual Medicine, San Diego, CA 92120, United States
| | - Caroline Pukall
- Department of Psychology, Queen's University, Kingston K7L 3L3, Canada
| | - Michael A Adams
- Department of Biomedical and Molecular Science, Queen's University, Kingston K7L 2V5, Canada
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Komisaruk B, del Cerro MCR, Goldstein I. A neurologic excitation/inhibition “faucet model” for orgasm and pain. Sex Med Rev 2023. [DOI: 10.1093/sxmrev/qeac009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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17
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Simon JA, Clayton AH, Goldstein I, Kingsberg SA, Shapiro M, Patel S, Kim NN. Response to Commentary by Spielmans. Sex Med 2022; 10:100585. [PMID: 36529480 PMCID: PMC9780765 DOI: 10.1016/j.esxm.2022.100585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- James A Simon
- IntimMedicine Specialists and George Washington University School of Medicine, Washington, DC, USA
| | - Anita H Clayton
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Irwin Goldstein
- San Diego Sexual Medicine and Alvarado Hospital, San Diego, CA, USA
| | - Sheryl A Kingsberg
- University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | | | - Sejal Patel
- Sprout Pharmaceuticals, Inc., Raleigh, NC, USA
| | - Noel N Kim
- Institute for Sexual Medicine, San Diego, CA, USA.
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18
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Simon JA, Clayton AH, Goldstein I, Kingsberg SA, Shapiro M, Patel S, Kim NN. Effects of Flibanserin on Subdomain Scores of the Female Sexual Function Index in Women With Hypoactive Sexual Desire Disorder. Sex Med 2022; 10:100570. [PMID: 36400683 PMCID: PMC9780775 DOI: 10.1016/j.esxm.2022.100570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 07/26/2022] [Accepted: 07/30/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Flibanserin treatment increases sexual desire and satisfying sexual events while decreasing distress in certain women diagnosed with acquired, generalized hypoactive sexual desire disorder (HSDD). Additional aspects of sexual function and the time course of response have not been fully characterized. AIM To evaluate changes in sexual function assessed by the subdomains of the Female Sexual Function Index (FSFI) in women with HSDD treated with flibanserin. METHODS FSFI data pooled from 3 pivotal flibanserin trials in premenopausal women (flibanserin = 1,165; placebo = 1,203) and FSFI data from one complete flibanserin trial in postmenopausal women (flibanserin = 432; placebo = 463) were subjected to post-hoc analyses. For each FSFI subdomain, least squares mean change from baseline was calculated at each assessment visit (treatment weeks 4, 8, 16, 24) and treatment groups were compared using analysis of covariance. Standardized effect size (Cohen's d) was also determined for each FSFI subdomain. MAIN OUTCOME MEASURE Changes from baseline in FSFI subdomains. RESULTS Compared to placebo, both premenopausal (P < .02) and postmenopausal (P < .045) patients in the flibanserin group reported significantly greater increases over baseline in the FSFI subdomain scores of desire, arousal, lubrication, orgasm, and satisfaction. In premenopausal patients, significant improvements were observed at the first assessment of response (week 4) and were maintained through week 24. In postmenopausal patients, significant improvements were observed at week 4 for desire and arousal, while significant improvements in lubrication, orgasm, and satisfaction were observed at week 8. At week 24, excluding the pain subdomain, standardized effect sizes ranged from 0.18 to 0.28 in the premenopausal cohort and 0.12 to 0.29 in the postmenopausal cohort. In both pre- and postmenopausal patients, improvements in pain were smaller and largely undifferentiated between treatment groups. CLINICAL IMPLICATIONS While variations in time to response should be taken into consideration, on average, the beneficial impact of flibanserin on overall sexual function occurs within the first month of treatment. The data also suggest that the response to flibanserin is sustained for the duration of treatment. STRENGTHS AND LIMITATIONS Sexual function assessments were performed in a large cohort of 2,368 premenopausal women and 895 postmenopausal women. However, the FSFI assesses changes over a 1-month period and time points earlier than 4 weeks could not be assessed. CONCLUSION These analyses suggest that assessment of benefit of flibanserin in HSDD should include improvements across all domains of sexual function, not only desire. Simon JA, Clayton AH, Goldstein I, et al. Effects of Flibanserin on Subdomain Scores of the Female Sexual Function Index in Women With Hypoactive Sexual Desire Disorder. Sex Med 2022;10:100570.
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Affiliation(s)
- James A. Simon
- IntimMedicine Specialists and George Washington University School of Medicine, Washington, DC, USA
| | - Anita H. Clayton
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Irwin Goldstein
- San Diego Sexual Medicine and Alvarado Hospital, San Diego, CA, USA
| | - Sheryl A. Kingsberg
- University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | | | - Sejal Patel
- Sprout Pharmaceuticals, Inc., Raleigh, NC, USA
| | - Noel N. Kim
- Institute for Sexual Medicine, San Diego, CA, USA,Corresponding Author: Noel N. Kim, PhD, Institute for Sexual Medicine, 6330 Nancy Ridge Drive, Suite 105, San Diego, CA 92121, USA.
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Goldstein SW, Goldstein I. Options in Today's World. Sex Med Rev 2022; 10:479-480. [PMID: 37051955 DOI: 10.1016/j.sxmr.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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20
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Goldstein I. Legends in Urology v29I05. Can J Urol 2022; 29:11272-11274. [PMID: 36245195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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21
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Goldstein S, Yee A, Goldstein I. Severe Allergic, Inflammatory and Traumatic Reactions of the Vestibule Associated with Acquired Neuroproliferative Vestibulodynia. J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Yee A, Uloko M, Mueller J, Goldstein I. Perineural 5% Dextrose Injection Treatment and Central Core Excision of the 12:00 Vestibule as Adjunctive Therapies to Complete Vestibulectomy in Select Patients with Neuroproliferative Vestibulodynia. J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.05.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Yee A, Goldstein S, Goldstein I. Complete Vestibulectomy in Women with Persistent Entrance Dyspareunia Following Partial Posterior Vestibulectomy. J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Kim C, Komisaruk B, Kim N, Goldstein S, Yee A, Goldstein I. Surgical Outcomes of PGAD/GPD Patients with Sacral Radiculopathy Associated with Tarlov Cyst. J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Goldstein I, Gelbard MK, Lipshultz LI. Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease. Sex Med Rev 2022; 10:409-420. [PMID: 35772849 DOI: 10.1016/j.sxmr.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Across many cultures, penis size has been associated with virility, and concerns about penile length are commonplace. Peyronie's disease (PD) is a known acquired cause of penile shortening. OBJECTIVES This paper describes the psychosocial impacts of penile length on men and their partners, both generally and in men with PD, and evaluates the effect of PD treatments (eg, collagenase clostridium histolyticum , surgery, mechanical therapy) on this outcome measure. METHODS A PubMed database search was performed for English language articles through July 2021. Main outcome measures were association of penile length with emotional well-being, selfesteem, and relationship satisfaction in men with PD, and change from baseline penile length after treatment. RESULTS Shortened penile length caused by PD can negatively impact patient and partner quality of life, including effects on body image, emotional well-being, sexual function, and interpersonal relationships. In men with PD, studies have demonstrated an association between loss of penile length and emotional problems, reduced satisfaction with sexual performance, poor self-esteem, depression, and relationship difficulties. Loss of penile length can frequently occur after surgery for PD (including plication, plaque incision/excision with grafting, and penile implant). Advanced surgical techniques may preserve/increase penile length, but the increased risks associated with these complex procedures must be carefully considered. Treatment with collagenase clostridium histolyticum does not appear to negatively impact penile length, and 5-year follow-up data suggest potential longterm posttreatment improvements in this outcome measure. Penile traction therapy, either alone or as adjunctive therapy, may increase penile length in men with PD, but nonadherence may limit improvement. CONCLUSION Changes in penile length are important to many men, particularly those with PD, and should be considered during PD treatment selection. Penile length should be measured objectively before and after treatment for PD and should be included as an outcome measure in future studies on treatment effectiveness. Goldstein I, Gelbard MK, Lipshultz LI. Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease. Sex Med Rev 2022;10:409-420.
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Goldstein I, Yee A, Uloko M, Goldstein A. Extent of surgical excision of the vestibule based on positive CD117 and PGP9.5 staining of mast cells in women with neuroproliferative vestibulodynia. J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.03.394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Goldstein I, Hassan T, Li J, Riad M, Vignesh S, Zou K. Treatment and comorbidities of patients with erectile dysfunction before and during COVID-19 in the United States: A real-world data analysis. J Sex Med 2022. [PMCID: PMC9080966 DOI: 10.1016/j.jsxm.2022.03.428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Introduction Objectives Methods Results Conclusions Disclosure
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Yee A, Uloko M, Goldstein I. Clinical experience with testosterone undecanoate capsules (Jatenzo): The first 50 patients. J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.03.547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Yee A, Uloko M, Goldstein I. A vestibular examination must include the 12:00 region. J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.03.392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Goldstein I, Uloko M, Butera M, Cook M. Inflatable penile prosthesis infection successfully managed by non-operative novel treatment strategies: A case report. J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.03.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Goldstein S, Yee A, Goldstein I. Systemic Estradiol Menopause Management: Return to the Old-Fashioned Way. J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.01.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Goldstein I, Patel S, Donatucci S, Faragasso A, Tojino S. Unexpected Therapeutic Responses in Sexual Function in Women Prescribed Flibanserin for Hypoactive Sexual Desire Disorder. J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.01.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Uloko M, Yee A, Goldstein S, Goldstein I. Vascular and Erectile Tissue Health Changes Pre- and Post- Low Intensity Shockwave Treatment of the Erect Penis. J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.01.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Yee A, Uloko M, Goldstein I. Clinical Experience of our First 50 Patients with Testosterone Undecanoate Capsules (Jatenzo). J Sex Med 2022. [DOI: 10.1016/j.jsxm.2022.01.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Goldstein I, Goldstein SW, Komisaruk BR. Should We Call it (G-Spot) a G-Zone? Sex Med Rev 2022; 10:181-182. [DOI: 10.1016/j.sxmr.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Tomalty D, Giovannetti O, Hannan J, Komisaruk B, Goldstein S, Goldstein I, Adams M. Should We Call It a Prostate? A Review of the Female Periurethral Glandular Tissue Morphology, Histochemistry, Nomenclature, and Role in Iatrogenic Sexual Dysfunction. Sex Med Rev 2022; 10:183-194. [PMID: 35074318 DOI: 10.1016/j.sxmr.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/13/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION There is evidence of glandular tissue within the region of the anterior vaginal wall-female periurethral tissue (AVW-FPT) having similar morphology and immunohistochemistry to the prostate in men and having physiological roles in the female sexual response (FSR). Whether this tissue should be called a prostate in women has been debated. Iatrogenic injury to structures of the AVW-FPT, including these glands and the associated neurovasculature, could be a cause of female sexual dysfunction (FSD). OBJECTIVES To consolidate the current knowledge concerning the glandular tissue surrounding the urethra in women, evidence was reviewed to address whether: (i) these glands comprise the prostate in women, (ii) they have specific functions in the FSR, and (iii) injury to the AVW-FPT and prostate has sexual dysfunction as a likely outcome. METHODS A literature review was conducted using keywords including female prostate, Skene's/paraurethral glands, periurethral tissue, Gräfenberg (G)-spot, female ejaculation, mid-urethral sling (MUS), and sexual dysfunction. RESULTS Histological and immunohistochemical studies of the glandular tissue surrounding the urethra support the existence of prostate in women. Evidence suggests this tissue may have physiologically and clinically relevant autonomic and sensory innervation, and during sexual arousal may contribute to secretions involved in ejaculation and orgasm. Gaps in knowledge relating to the functional anatomy, physiological roles, and embryological origins of this tissue have impeded the acceptance of a prostate in women. Injury to the innervation, vasculature, and/or glandular tissue within the surgical field of MUS implantation suggests iatrogenic sexual dysfunction is plausible. CONCLUSIONS Continuing to advance our understanding of the morphology, histochemistry, and physiologic capacity of this glandular tissue will clarify the characterization of this tissue as the "prostate" involved in the FSR, and its role in FSD following surgical injury. Tomalty D, Giovannetti O, Hannan J, et al. Should We Call It a Prostate? A Review of the Female Periurethral Glandular Tissue Morphology, Histochemistry, Nomenclature, and Role in Iatrogenic Sexual Dysfunction. Sex Med Rev 2021;XX:XXX-XXX.
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Affiliation(s)
- Diane Tomalty
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada.
| | - Olivia Giovannetti
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Johanna Hannan
- Department of Physiology, East Carolina University, Greenville, NC, USA
| | - Barry Komisaruk
- Department of Psychology, Rutgers University, Newark, NJ, USA
| | | | - Irwin Goldstein
- San Diego Sexual Medicine, San Diego, CA, USA; Alvarado Hospital, San Diego, CA, USA
| | - Michael Adams
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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DelConte A, Papangkorn K, Kim K, Bruno BJ, Chidambaram N, Khera M, Goldstein I, Kohler TS, Miner M, Dobs AS, Patel MV. A new oral testosterone (TLANDO
®
) treatment regimen without dose titration requirement for male hypogonadism. Andrology 2022; 10:669-676. [PMID: 34994093 PMCID: PMC9304136 DOI: 10.1111/andr.13153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/09/2021] [Accepted: 12/17/2021] [Indexed: 11/28/2022]
Abstract
Background Male hypogonadism (testosterone level < 300 ng/dl) is a clinical syndrome that results from failure of the testis to produce physiological levels of testosterone. Most marketed testosterone replacement therapy products often require multiple dose adjustment clinic visits to achieve the desired, eugonadal testosterone levels. Objective To evaluate the efficacy and safety of a novel oral testosterone undecanoate therapy for the treatment of hypogonadism. Material and methods Ninety‐five (N = 95) hypogonadal men were enrolled in this open‐label, single‐arm, multicenter study in the United States (NCT03242590). Subjects received 225 mg of oral testosterone undecanoate (TLANDO) twice a day for 24 days without dose adjustment. Primary efficacy was percentages of subjects who achieved mean 24‐h testosterone levels within the eugonadal range and secondary efficacies were evaluated based on the upper limit of lab normal range of testosterone concentration. Results Subjects enrolled were on average age of 56 years, with about 17% of subjects older than 65 years. The mean body mass index was 32.8 kg/m2. The baseline mean total testosterone values were below the normal range (202 ± 74 ng/dl). Post‐treatment with 450 mg testosterone undecanoate daily dose without dose adjustment, 80% of subjects (95% confidence interval of 72%–88%) achieved a testosterone Cavg in the normal range and restored testosterone levels to mean testosterone Cavg of 476 ± 184 ng/dl at steady state. Testosterone restoration was comparable to other approved testosterone replacement therapy products. TLANDO was well tolerated with no deaths, no drug‐related serious adverse events, and no hepatic adverse events. Discussion and conclusions TLANDO restored testosterone levels to the normal range in the majority of hypogonadal males. This new oral testosterone replacement therapy can provide an option for no‐titration oral testosterone replacement therapy. This therapy has the potential to improve patient compliance in testosterone replacement therapy.
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Affiliation(s)
- Anthony DelConte
- Lipocine Inc. Salt Lake City UT 84108 USA
- Pharmaceutical and Healthcare Marketing Saint Joseph's University Philadelphia PA 19131 USA
| | | | | | | | | | - Mohit Khera
- Urology Baylor College of Medicine Houston TX 77030 USA
| | - Irwin Goldstein
- San Diego Sexual Medicine Alvarado Hospital Medical Center San Diego CA 92120 USA
| | | | - Martin Miner
- Family Medicine and Urology Warran Alpert Medical School Brown University Providence RI 02903 USA
| | - Adrian S. Dobs
- Division of Endocrinology Johns Hopkins University Baltimore MD 21287 USA
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38
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Goldstein I. Planting Seeds: The First Decade of Sexual Medicine Reviews. Sex Med Rev 2021; 10:1-2. [PMID: 34896062 DOI: 10.1016/j.sxmr.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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39
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Machtinger R, Fallach N, Goldstein I, Chodick G, Schiff E, Orvieto R, Mashiach R. Ovarian stimulation for fertility treatments and risk of breast cancer: a matched cohort study. Hum Reprod 2021; 37:577-585. [PMID: 34871410 DOI: 10.1093/humrep/deab270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 10/17/2021] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Is there a difference in the breast cancer risk among women who underwent ART treatments compared to those who underwent medically assisted reproduction (MAR) infertility treatments or women of reproductive age in the general population? SUMMARY ANSWER The risk of breast cancer among women treated by ART was similar to the risk among women treated by MAR and women who did not undergo fertility treatments. WHAT IS KNOWN ALREADY Studies investigating breast cancer risk in women who have undergone fertility treatments have provided conflicting results. STUDY DESIGN, SIZE, DURATION A retrospective, population-based cohort study included women who underwent ART or MAR treatments and women who did not undergo fertility treatments from 1994 to 2019. PARTICIPANTS/MATERIALS, SETTING, METHODS Women who underwent ART were matched one to one with women who underwent MAR treatments and one to one with woman from the general population of reproductive age, by year of birth and year of first delivery or nulliparity status. MAR women were also matched to ART women by treatment initiation calendar year. All included women were members of Maccabi Healthcare Services. Data regarding demographics, fertility treatments, BRCA mutation and possible confounders were obtained from the computerized database of electronic health records. The incidence of breast cancer after fertility treatments was compared to the matched controls. MAIN RESULTS AND THE ROLE OF CHANCE Of 8 25 721 women of reproductive age, 32 366 women who underwent ART were matched with patients treated by MAR (n = 32 366) and 32 366 women of reproductive age. A total of 984 women (1.0%) were diagnosed with breast cancer (mean follow-up period, 9.1 ± 6.3 years; interquartile range [IQR], 3.8-13.7 years). The incidence rates of breast cancer per 10 000 person-years were 11.9 (95% CI, 10.7-13.3), 10.7 (95% CI, 9.6-11.9) and 10.7 (95% CI, 9.6-12.0) in the ART group, MAR group and general population, respectively. The crude risk for breast cancer was similar in the ART group compared with the general population (hazard ratio (HR) = 1.10, 95% CI, 0.94-1.28) and in the ART group compared with the MAR group (HR = 1.00, 95% CI, 0.86-1.16). Further adjustment for age, BMI, smoking, socioeconomic status and parity did not substantially impact the hazard rates for breast cancer (ART vs general population: HR = 1.10, 95% CI, 0.94-1.28; ART vs MAR: HR = 0.99, 95% CI, 0.85-1.16). Among women diagnosed with breast cancer, the prevalence of BRCA1/2 mutations and tumour staging did not differ between the ART, MAR and general population groups. Among women who underwent ART, no correlation was found between breast cancer and the number of ART cycles or the use of recombinant medications or urine-derived medications. LIMITATIONS, REASONS FOR CAUTION The mean age of women at the end of follow-up was only 42 years thus the study was not powered to detect potential differences in the risk of postmenopausal breast cancer. In addition, we did not sub-classify the exposed patients by the reason for infertility. WIDER IMPLICATIONS OF THE FINDINGS Breast cancer incidence following ART was comparable to that in the general population or following MAR. Women undergoing fertility treatments and their clinicians may be reassured about the safety of assisted reproduction technologies in terms of premenopausal breast cancer risk. STUDY FUNDING/COMPETING INTEREST(S) No specific funding was used and there are no competing interests. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- R Machtinger
- Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - N Fallach
- Kahn-Sagol-Maccabi Research and Innovation Institute, Maccabi Healthcare Services, Tel Aviv, Israel
| | - I Goldstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Kahn-Sagol-Maccabi Research and Innovation Institute, Maccabi Healthcare Services, Tel Aviv, Israel
| | - G Chodick
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Kahn-Sagol-Maccabi Research and Innovation Institute, Maccabi Healthcare Services, Tel Aviv, Israel
| | - E Schiff
- Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Orvieto
- Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Mashiach
- Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Healy D, Bahrick A, Bak M, Barbato A, Calabrò RS, Chubak BM, Cosci F, Csoka AB, D'Avanzo B, Diviccaro S, Giatti S, Goldstein I, Graf H, Hellstrom WJG, Irwig MS, Jannini EA, Janssen PKC, Khera M, Kumar MT, Le Noury J, Lew-Starowicz M, Linden DEJ, Lüning C, Mangin D, Melcangi RC, Rodríguez OWMAAS, Panicker JN, Patacchini A, Pearlman AM, Pukall CF, Raj S, Reisman Y, Rubin RS, Schreiber R, Shipko S, Vašečková B, Waraich A. Diagnostic criteria for enduring sexual dysfunction after treatment with antidepressants, finasteride and isotretinoin. Int J Risk Saf Med 2021; 33:65-76. [PMID: 34719438 PMCID: PMC8925105 DOI: 10.3233/jrs-210023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND: A set of enduring conditions have been reported in the literature involving persistent sexual dysfunction after discontinuation of serotonin reuptake inhibiting antidepressants, 5 alpha-reductase inhibitors and isotretinoin. OBJECTIVE: To develop diagnostic criteria for post-SSRI sexual dysfunction (PSSD), persistent genital arousal disorder (PGAD) following serotonin reuptake inhibitors, post-finasteride syndrome (PFS) and post-retinoid sexual dysfunction (PRSD). METHODS: The original draft was designed using data from two published case series (Hogan et al., 2014 and Healy et al., 2018), which represent the largest public collections of data on these enduring conditions. It was further developed with the involvement of a multidisciplinary panel of experts. RESULTS: A set of criteria were agreed upon for each of the above conditions. Features of PSSD, PFS and PRSD commonly include decreased genital and orgasmic sensation, decreased sexual desire and erectile dysfunction. Ancillary non-sexual symptoms vary depending on the specific condition but can include emotional blunting and cognitive impairment. PGAD presents with an almost mirror image of unwanted sensations of genital arousal or irritability in the absence of sexual desire. A new term, post-SSRI asexuality, is introduced to describe a dampening of sexual interest and pleasure resulting from a pre-natal or pre-teen exposure to a serotonin reuptake inhibitor. CONCLUSIONS: These criteria will help in both clinical and research settings. As with all criteria, they will likely need modification in the light of developments.
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Affiliation(s)
- David Healy
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Audrey Bahrick
- University Counseling Service, University of Iowa, Iowa City, IA, USA
| | - Maarten Bak
- Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands.,FACT, Mondriaan Mental Health, Maastricht/Heerlen, The Netherlands
| | - Angelo Barbato
- Unit for Quality of Care and Rights Promotion in Mental Health, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | | | - Barbara M Chubak
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Fiammetta Cosci
- Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands.,Department of Health Sciences, University of Florence, Florence, Italy.,Clinical Pharmacopsychology Laboratory, University of Florence, Florence, Italy
| | - Antonei B Csoka
- Department of Anatomy, Howard University College of Medicine, Washington, DC, USA
| | - Barbara D'Avanzo
- Unit for Quality of Care and Rights Promotion in Mental Health, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Silvia Diviccaro
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Silvia Giatti
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Irwin Goldstein
- Alvarado Hospital, San Diego, CA, USA.,San Diego Sexual Medicine, San Diego, CA, USA
| | - Heiko Graf
- Department of Psychiatry and Psychotherapy, Ulm University, Ulm, Germany
| | - Wayne J G Hellstrom
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Michael S Irwig
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Paddy K C Janssen
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Hospital Pharmacy, VieCuri Medical Center, Venlo, The Netherlands
| | - Mohit Khera
- Department of Urology, Baylor School of Medicine, Houston, TX, USA
| | | | - Joanna Le Noury
- North Wales Department of Psychological Medicine, Bangor, Wales, UK
| | - Michał Lew-Starowicz
- Department of Psychiatry, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - David E J Linden
- School for Mental Health and Neuroscience, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Celine Lüning
- Department of Psychology and Psychotherapy, Witten/Herdecke University, Germany
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Jalesh N Panicker
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.,Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | | | - Amy M Pearlman
- Carver College of Medicine, University of Iowa Health Care, Iowa City, IA, USA
| | | | - Sanjana Raj
- Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands
| | | | - Rachel S Rubin
- Department of Urology, Georgetown University School of Medicine, Washington, DC, USA
| | - Rudy Schreiber
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | | | - Barbora Vašečková
- Psychiatric Clinic, Slovak Medical University and University Hospital, Bratislava, Slovakia
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Lynn BK, Grabenhorst C, Komisaruk BR, Goldstein I, Pfaus J. The Use of Pramipexole to Treat Persistent Genital Arousal Disorder: A Case Report. Sex Med 2021; 9:100372. [PMID: 34126431 PMCID: PMC8360918 DOI: 10.1016/j.esxm.2021.100372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Persistent Genital Arousal Disorder (PGAD) is defined as "spontaneous, intrusive, and unwanted genital arousal (tingling, throbbing, pulsating) in the absence of sexual interest and desire" and traditionally causes marked distress, embarrassment and shame. PGAD may be caused by starting, discontinuing, or making adjustments in certain antidepressants or other medications. AIM To report the case of a 36- year- old woman with PGAD, likely due to changes in her psychiatric medications, who was treated with pramipexole and experienced improvement in her PGAD symptoms. METHODS Patient self-report and literature review. Written informed consent was obtained from the patient. MAIN OUTCOME MEASURE Improvement in PGAD symptoms. RESULTS Patient reported improvement in her symptoms by "90%" on a low dose of pramipexole, although higher doses exacerbated her symptoms. CONCLUSIONS It is likely that an effective treatment window exists for the treatment of PGAD with drugs that possess the ability to exert their control of dopaminergic transmission. This includes direct acting receptor agonists like pramipexole, which produce feedback inhibition. Limitations to their efficacy then involve co-treatments that counteract their ability to exert a dampening effect on hyperstimulated dopamine transmission. It is recommended that clinicians be aware of drugs taken by patients to treat psychiatric disorders that could induce PGAD symptoms, drugs recently discontinued where a rebound effect could lead to PGAD symptoms, and drug mechanisms that could counteract the effect of treatments for PGAD. Lynn BK, Grabenhorst C, Komisaruk BR, et al. The Use of Pramipexole to Treat Persistent Genital Arousal Disorder: A Case Report. Sex Med 2021;9:100372.
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Affiliation(s)
- Becky Kaufman Lynn
- Saint Louis University School of Medicine, OBGYN, Saint Louis, MO, USA; Evora Women's Health, Chesterfield, MO, USA.
| | | | | | - Irwin Goldstein
- Sexual Medicine. Alvarado Hospital, Alvarado Hospital, Sexual Medicine, San Diego, CA, USA
| | - Jim Pfaus
- Universidad Veracruzana, Centro de Investidaciones Cerebrales, Veracruz, MX
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Giovannetti O, Tomalty D, Gaudet D, Clohosey D, Forster A, Monaghan M, Harvey MA, Johnston S, Komisaruk B, Goldstein S, Hannan J, Goldstein I, Adams MA. Immunohistochemical Investigation of Autonomic and Sensory Innervation of Anterior Vaginal Wall Female Periurethral Tissue: A Study of the Surgical Field of Mid-Urethral Sling Surgery Using Cadaveric Simulation. J Sex Med 2021; 18:1167-1180. [PMID: 37057425 DOI: 10.1016/j.jsxm.2021.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/26/2021] [Accepted: 05/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Female sexual dysfunction, including female orgasm disorder, has been reported following mid-urethral sling (MUS) surgery to treat bothersome stress urinary incontinence. Anterior vaginal wall-female periurethral tissue (AVW-FPT) likely contains autonomic and sensory innervation involved in the female sexual response, and injury to these nerves may result from MUS implantation. AIM To characterize, using fresh cadaveric tissue, autonomic and sensory nerves in AVW- FPT using immunohistochemistry (IHC), and to assess their proximity to an implanted MUS. METHODS AVW-FPT was excised following careful dissection from four fresh cadavers. Prior to dissection, one cadaver underwent simulation of the MUS procedure by a urogynegologist, using a fascial sling. All samples were paraffin embedded, sectioned, and stained with hematoxylin. Serial sectioning and IHC were performed to identify nerves. IHC markers were used to characterize the sensory and autonomic innervation. OUTCOMES IHC localization of autonomic and sensory nerve markers consistent with neural tissue within the region of MUS implantation. RESULTS IHC of AVW-FPT using protein gene product 9.5 (PGP9.5), a general nerve stain, revealed innervation throughout the region targeted by the MUS implantation. More specifically, immunoreactivity for both autonomic (tyrosine hydroxylase, TH) and sensory (Nav1.8 and S100ß) nerves were found in close proximity (<1 mm) to the implanted MUS. In addition, a subset of S100ß positive nerves also showed immunoreactivity for calcitonin gene-related peptide (CGRP). Combining the IHC findings with the surgical simulation of the MUS implantation revealed the potential for damage to both autonomic and sensory nerves as a direct result of the MUS procedure. CLINICAL TRANSLATION The identified autonomic and sensory nerves of the AVW-FPT may contribute to the female sexual response, and yet are potentially negatively impacted by MUS procedures. Given that surgeries performed on male genital tissue, including the prostate, may cause sexual dysfunction secondary to nerve damage, and that urologists routinely provide informed consent regarding this possibility, urogynaecologists are encouraged to obtain appropriate informed consent from prospective patients undergoing the MUS procedure. STRENGTHS & LIMITATIONS This is the first study to characterize the sensory and autonomic innervation within the surgical field of MUS implantation and demonstrate its relationship to an implanted MUS. The small sample size is a limitation of this study. CONCLUSION The present study provides evidence of potential injury to autonomic and sensory innervation of AVW-FPT as a consequence of MUS implantation, which may help explain the underlying mechanisms involved in the reported post-operative female sexual dysfunction in some women. Giovannetti O, Tomalty D, Gaudet D, et al. Immunohistochemical Investigation of Autonomic and Sensory Innervation of Anterior Vaginal Wall Female Periurethral Tissue: A Study of the Surgical Field of Mid-Urethral Sling Surgery Using Cadaveric Simulation. J Sex Med 2021;18:1168-1180.
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Bruno BJ, Vangara K, Kim K, Papangkorn K, Chidambaram N, Patel MV, DelConte A, Carson III CC, Goldstein I, Kaminetsky J, Miner M, Khera M. TLANDO, a Novel Oral TRT, Improves Sexual and Mental Domain Outcomes in Hypogonadal Men. J Endocr Soc 2021. [PMCID: PMC8090604 DOI: 10.1210/jendso/bvab048.1012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Male hypogonadism is characterized by symptoms and deficiency (<300 ng/dL) in levels of in total testosterone (TT), a critical hormone for sexual, cognitive, and body function and development. TLANDO, a testosterone undecanoate (TU) comprising lymphatically delivered oral testosterone replacement therapy (TRT) option not requiring dose titration, treatment has demonstrated effective restoration in hypogonadal men of TT levels to the eugonadal range in multiple clinical studies. TLANDO therapy resulted in decreased sex hormone binding globulin with increased free testosterone (FT). TLANDO’s unique delivery system enables consistent restoration of TT regardless of meal fat content. Moreover, TLANDO has shown potential to improve liver health through resolution of fatty liver disease in hypogonadal men and is not known to have any adverse liver effects. However, it is unclear if fixed dose TLANDO therapy without dose adjustment improves symptoms of psychosexual functions. The objective is to assess key sexual and mental domain Patient Reported Outcomes (PRO) post 52 weeks of treatment using TLANDO on the to-be-marketed dosing regimen in comparison with a widely used topical TRT, Androgel 1.62%. Data analysis was performed in in hypogonadal males post TLANDO treatment without dose adjustment, and in patients on the active control from a randomized, multi-center, open label, active controlled 52-week trial (SOAR, NCT02081300). Sexual and mental domain function PROs were measured at baseline (BL) and end of study (EOS) using Psychosexual Daily Questionnaire (PDQ) and Short Form (SF)-36 surveys and compared between TLANDO and active control. Post treatment with TLANDO dosing regimen not requiring dose titration, key sexual domain function PROs at week 52 were significantly (p<0.05) improved from BL: positive mood (BL:4.5 vs EOS:5.1, p<0.001), negative mood (1.8 vs 1.4, p<0.01), overall sexual desire (2.5 vs 3.7, p<0.001), sexual activity (2.5 vs 4.0, p<0.001), highest pleasure with partner (2.0 vs 2.8, p=0.06), highest pleasure without partner (1.8 vs 2.4, p<0.05), weekly maintained erection (3.3 vs 4.5, p<0.001), and weekly full erection % (50.5% vs 68.9%, p<0.001). Most sexual and mental function PROs were comparable to Androgel 1.62. TLANDO therapy was well tolerated through 52 weeks of treatment exposure. In conclusion, TLANDO, a novel easy to use and prescribe TRT not requiring dose titration, demonstrated improvement in sexual and mental PROs, a significant unmet need in hypogonadal males. Further placebo-controlled studies are warranted to better elucidate these improvements.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Martin Miner
- Men’s Health Center The Miriam Hotel, Providence, RI, USA
| | - Mohit Khera
- Baylor College of Medicine, Houston, TX, USA
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Papangkorn K, Vangara K, Bruno BJ, Kim K, Chidambaram N, DelConte A, Patel M, Carson III CC, Goldstein I, Kaminetsky J, Miner M, Khera M, Dobs AS. Efficacy and Safety of TLANDO, A Novel Oral Easy to Prescribe and Use TRT Option. J Endocr Soc 2021. [PMCID: PMC8090132 DOI: 10.1210/jendso/bvab048.994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Most widely used testosterone replacement therapy (TRT) products can be inconvenient and cumbersome topical and invasive injectable requiring dose adjustments to attain efficacy. In a pivotal study, a recently approved oral TRT only 26% of patients did not require any dose adjustment. Typically, patients start on a sub-therapeutic dose with gradual dose increases to attain efficacy resulting in additional visit(s) to clinic and pharmacy. Physician research data (N=402) suggested it typically takes 3-6 months of titrations to reach an efficacious dose for majority of patients, a significant barrier in effecting a switch without a period of “efficacy gap”. The requirement of additional visit(s) presents significant challenges for new and current patients desiring to start and to switch to a convenient TRT option, especially in the current COVID-19 pandemic. Recent reports suggest increase of disease severity/mortality in men with low testosterone is possibly due to underlying co-morbidities commonly associated with male hypogonadism. There remains a need for an effective, safe, and easy to use and prescribe product that does not require dose titration. TLANDO is a “triglyceride-free” oral single strength TRT with single dose designed to lymphatically deliver effective and safe levels of testosterone regardless of meal fat content. Moreover, dose titration is prone to some inherent titration decision errors and requires understanding of often complex titration rules. The objective is to assess whether TLANDO, an oral TRT without requiring dose titration, safely restores effective testosterone (T) levels in hypogonadal men. An open-label, single-arm, multicenter study (NCT03242590) was performed with TLANDO in hypogonadal males (N=95). Subjects received orally 225 mg twice a day testosterone undecanoate (TU) for 24 days without dose adjustment. Efficacy was evaluated by % of subjects who achieved daily T Cavg within the eugonadal range. Using 450mg daily dose without dose adjustment, 80% of subjects (95% CI of 72% to 88%) achieved a T Cavg in the normal range and safely restored with mean T Cavg of 476±184 ng/dL post steady state. T restoration was comparable to other non-oral TRT products. TLANDO was well tolerated with no deaths, no drug-related severe AEs, and no hepatic AEs. In conclusion, effective T restoration using TLANDO, an easy to use and prescribe oral TRT option, was confirmed. Minimal AEs were reported with no hepatic AEs. Upon approval, TLANDO will be the first convenient TRT option without requiring dose adjustments; therefore, enabling selection of an efficacious dose from the start of therapy. TLANDO is well suited for new or existing TRT patients desiring a convenient oral option.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Martin Miner
- Men’s Health Center The Miriam Hotel, Providence, RI, USA
| | - Mohit Khera
- Baylor College of Medicine, Houston, TX, USA
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Parish SJ, Simon JA, Davis SR, Giraldi A, Goldstein I, Goldstein SW, Kim NN, Kingsberg SA, Morgentaler A, Nappi RE, Park K, Stuenkel CA, Traish AM, Vignozzi L. International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. Climacteric 2021; 24:533-550. [PMID: 33792440 DOI: 10.1080/13697137.2021.1891773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM To provide a clinical practice guideline for the use of testosterone including identification of patients, laboratory testing, dosing, post-treatment monitoring, and follow-up care in women with hypoactive sexual desire disorder (HSDD). METHODS The International Society for the Study of Women's Sexual Health appointed a multidisciplinary panel of experts who performed a literature review of original research, meta-analyses, review papers, and consensus guidelines regarding testosterone use in women. Consensus was reached using a modified Delphi method. OUTCOMES A clinically useful guideline following a biopsychosocial assessment and treatment approach for the safe and efficacious use of testosterone in women with HSDD was developed including measurement, indications, formulations, prescribing, dosing, monitoring, and follow-up. RESULTS Although the Global Position Statement endorses testosterone therapy for only postmenopausal women, limited data also support the use in late reproductive age premenopausal women, consistent with the International Society for the Study of Women's Sexual Health Process of Care for the Management of HSDD. Systemic transdermal testosterone is recommended for women with HSDD not primarily related to modifiable factors or comorbidities such as relationship or mental health problems. Current available research supports a moderate therapeutic benefit. Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established. Before initiation of therapy, clinicians should provide an informed consent. Shared decision-making involves a comprehensive discussion of off-label use, as well as benefits and risks. A total testosterone level should not be used to diagnose HSDD, but as a baseline for monitoring. Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women. Patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range. Compounded products cannot be recommended because of the lack of efficacy and safety data. CLINICAL IMPLICATIONS This clinical practice guideline provides standards for safely prescribing testosterone to women with HSDD, including identification of appropriate patients, dosing, and monitoring. STRENGTHS AND LIMITATIONS This evidence-based guideline builds on a recently published comprehensive meta-analysis and the Global Position Statement endorsed by numerous societies. The limitation is that testosterone therapy is not approved for women by most regulatory agencies, thereby making prescribing and proper dosing challenging. CONCLUSION Despite substantial evidence regarding safety, efficacy, and clinical use, access to testosterone therapy for the treatment of HSDD in women remains a significant unmet need.
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Affiliation(s)
- Sharon J Parish
- Department of Psychiatry & Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - James A Simon
- IntimMedicine Specialists, George Washington University School of Medicine, Washington, DC, USA
| | - Susan R Davis
- Women's Health Research Program, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Annamaria Giraldi
- Sexological Clinic, Psychiatric Center, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Irwin Goldstein
- Sexual Medicine, Alvarado Hospital, San Diego, CA, USA.,San Diego Sexual Medicine, San Diego, CA, USA
| | | | - Noel N Kim
- Institute for Sexual Medicine, San Diego, CA, USA
| | - Sheryl A Kingsberg
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Abraham Morgentaler
- Men's Health Boston, Beth Israel Deaconess Medical Center, Harvard Medical School, Chestnut Hill, MA, USA
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, Obstetrics and Gynecology Unit, IRCCS S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Kwangsung Park
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Cynthia A Stuenkel
- Department of Medicine, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Abdulmaged M Traish
- Departments of Biochemistry and Urology, Boston University School of Medicine, Boston, MA, USA
| | - Linda Vignozzi
- Andrology, Women's Endocrinology & Gender Incongruence Unit, Department of "Excellence" Experimental and Clinical Biomedical Sciences "Mario Serio", Careggi Hospital-University of Florence, Florence, Italy.,Consorzio Interuniversitario I.N.B.B., Rome, Italy
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Parish SJ, Simon JA, Davis SR, Giraldi A, Goldstein I, Goldstein SW, Kim NN, Kingsberg SA, Morgentaler A, Nappi RE, Park K, Stuenkel CA, Traish AM, Vignozzi L. International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. J Sex Med 2021; 18:849-867. [PMID: 33814355 DOI: 10.1016/j.jsxm.2020.10.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/12/2020] [Accepted: 10/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Global Consensus Position Statement on the Use of Testosterone Therapy for Women (Global Position Statement) recommended testosterone therapy for postmenopausal women with hypoactive sexual desire disorder (HSDD). AIM To provide a clinical practice guideline for the use of testosterone including identification of patients, laboratory testing, dosing, post-treatment monitoring, and follow-up care in women with HSDD. METHODS The International Society for the Study of Women's Sexual Health appointed a multidisciplinary panel of experts who performed a literature review of original research, meta-analyses, review papers, and consensus guidelines regarding testosterone use in women. Consensus was reached using a modified Delphi method. OUTCOMES A clinically useful guideline following a biopsychosocial assessment and treatment approach for the safe and efficacious use of testosterone in women with HSDD was developed including measurement, indications, formulations, prescribing, dosing, monitoring, and follow-up. RESULTS Although the Global Position Statement endorses testosterone therapy for only postmenopausal women, limited data also support the use in late reproductive age premenopausal women, consistent with the International Society for the Study of Women's Sexual Health Process of Care for the Management of HSDD. Systemic transdermal testosterone is recommended for women with HSDD not primarily related to modifiable factors or comorbidities such as relationship or mental health problems. Current available research supports a moderate therapeutic benefit. Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established. Before initiation of therapy, clinicians should provide an informed consent. Shared decision-making involves a comprehensive discussion of off-label use, as well as benefits and risks. A total testosterone level should not be used to diagnose HSDD, but as a baseline for monitoring. Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women. Patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range. Compounded products cannot be recommended because of the lack of efficacy and safety data. CLINICAL IMPLICATIONS This clinical practice guideline provides standards for safely prescribing testosterone to women with HSDD, including identification of appropriate patients, dosing, and monitoring. STRENGTHS & LIMITATIONS This evidence-based guideline builds on a recently published comprehensive meta-analysis and the Global Position Statement endorsed by numerous societies. The limitation is that testosterone therapy is not approved for women by most regulatory agencies, thereby making prescribing and proper dosing challenging. CONCLUSION Despite substantial evidence regarding safety, efficacy, and clinical use, access to testosterone therapy for the treatment of HSDD in women remains a significant unmet need. Parish SJ, Simon JA, Davis SR, et al. International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. J Sex Med 2021;18:849-867.
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Affiliation(s)
- Sharon J Parish
- Department of Psychiatry & Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
| | - James A Simon
- IntimMedicine Specialists, George Washington University School of Medicine, Washington, DC, USA
| | - Susan R Davis
- Women's Health Research Program, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Annamaria Giraldi
- Sexological Clinic, Psychiatric Center, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Irwin Goldstein
- Sexual Medicine, Alvarado Hospital, San Diego, CA, USA; San Diego Sexual Medicine, San Diego, CA, USA
| | | | - Noel N Kim
- Institute for Sexual Medicine, San Diego, CA, USA
| | - Sheryl A Kingsberg
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Abraham Morgentaler
- Men's Health Boston, Beth Israel Deaconess Medical Center, Harvard Medical School, Chestnut Hill, MA, USA
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, Obstetrics and Gynecology Unit, IRCCS S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Kwangsung Park
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Cynthia A Stuenkel
- Department of Medicine, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Abdulmaged M Traish
- Departments of Biochemistry and Urology, Boston University School of Medicine, Boston, MA, USA
| | - Linda Vignozzi
- Andrology, Women's Endocrinology & Gender Incongruence Unit, Department of "Excellence" Experimental and Clinical Biomedical Sciences "Mario Serio"-Careggi Hospital-University of Florence, Florence, Italy; Consorzio Interuniversitario I.N.B.B., Rome, Italy
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Parish SJ, Simon JA, Davis SR, Giraldi A, Goldstein I, Goldstein SW, Kim NN, Kingsberg SA, Morgentaler A, Nappi RE, Park K, Stuenkel CA, Traish AM, Vignozzi L. International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. J Womens Health (Larchmt) 2021; 30:474-491. [PMID: 33797277 PMCID: PMC8064950 DOI: 10.1089/jwh.2021.29037] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: The Global Consensus Position Statement on the Use of Testosterone Therapy for Women (Global Position Statement) recommended testosterone therapy for postmenopausal women with hypoactive sexual desire disorder (HSDD). Aim: To provide a clinical practice guideline for the use of testosterone including identification of patients, laboratory testing, dosing, post-treatment monitoring, and follow-up care in women with HSDD. Methods: The International Society for the Study of Women's Sexual Health appointed a multidisciplinary panel of experts who performed a literature review of original research, meta-analyses, review papers, and consensus guidelines regarding testosterone use in women. Consensus was reached using a modified Delphi method. Outcomes: A clinically useful guideline following a biopsychosocial assessment and treatment approach for the safe and efficacious use of testosterone in women with HSDD was developed including measurement, indications, formulations, prescribing, dosing, monitoring, and follow-up. Results: Although the Global Position Statement endorses testosterone therapy for only postmenopausal women, limited data also support the use in late reproductive age premenopausal women, consistent with the International Society for the Study of Women's Sexual Health Process of Care for the Management of HSDD. Systemic transdermal testosterone is recommended for women with HSDD not primarily related to modifiable factors or comorbidities such as relationship or mental health problems. Current available research supports a moderate therapeutic benefit. Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established. Before initiation of therapy, clinicians should provide an informed consent. Shared decision-making involves a comprehensive discussion of off-label use, as well as benefits and risks. A total testosterone level should not be used to diagnose HSDD, but as a baseline for monitoring. Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women. Patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range. Compounded products cannot be recommended because of the lack of efficacy and safety data. Clinical Implications: This clinical practice guideline provides standards for safely prescribing testosterone to women with HSDD, including identification of appropriate patients, dosing, and monitoring. Strengths & Limitations: This evidence-based guideline builds on a recently published comprehensive meta-analysis and the Global Position Statement endorsed by numerous societies. The limitation is that testosterone therapy is not approved for women by most regulatory agencies, thereby making prescribing and proper dosing challenging. Conclusion: Despite substantial evidence regarding safety, efficacy, and clinical use, access to testosterone therapy for the treatment of HSDD in women remains a significant unmet need.
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Affiliation(s)
- Sharon J Parish
- Department of Psychiatry, New York Presbyterian Hospital/Westchester Behavioral Health Center, White Plains, New York, USA.,Department of Medicine, New York Presbyterian Hospital/Westchester Behavioral Health Center, White Plains, New York, USA
| | - James A Simon
- IntimMedicine Specialists, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Susan R Davis
- Women's Health Research Program, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Annamaria Giraldi
- Sexological Clinic, Psychiatric Center, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Irwin Goldstein
- Sexual Medicine, Alvarado Hospital, San Diego, California, USA.,San Diego Sexual Medicine, San Diego, California, USA
| | | | - Noel N Kim
- Institute for Sexual Medicine, San Diego, California, USA
| | - Sheryl A Kingsberg
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Abraham Morgentaler
- Men's Health Boston, Beth Israel Deaconess Medical Center, Harvard Medical School, Chestnut Hill, Massachusetts, USA
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, Obstetrics and Gynecology Unit, IRCCS S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Kwangsung Park
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Cynthia A Stuenkel
- Department of Medicine, UC San Diego School of Medicine, La Jolla, California, USA
| | - Abdulmaged M Traish
- Departments of Biochemistry and Urology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Linda Vignozzi
- Andrology, Women's Endocrinology & Gender Incongruence Unit, Department of "Excellence" Experimental and Clinical Biomedical Sciences "Mario Serio"-Careggi Hospital-University of Florence, Florence, Italy.,Consorzio Interuniversitario I.N.B.B., Rome, Italy
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Goldstein I, Goldstein SW. Making a Difference: Persistent Genital Arousal Disorder. Sex Med Rev 2021; 9:183-185. [PMID: 33853726 DOI: 10.1016/j.sxmr.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Yih J, Minton J, Gagnon C, Goldstein S, Goldstein I. 092 Proposed Mechanisms of Erectile Function Improvement with Low Intensity Shockwave Therapy: Vascular and Erectile Tissue Health Changes Pre- and Post-Treatment. J Sex Med 2021. [DOI: 10.1016/j.jsxm.2021.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kim C, Blevins J, Komisaruk B, Uloko M, Goldstein S, Goldstein I. 126 A Novel Collaborative Protocol for Successful Management of Genito-Pelvic Dysesthesia Mediated by Radiculopathy of Sacral Spinal Nerve Roots Within the Cauda Equina: Four Year Experience. J Sex Med 2021. [DOI: 10.1016/j.jsxm.2021.01.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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