Sexual dysfunction in women with PCOS: a case control study

STUDY QUESTION

What is the relationship of sex steroid levels with sexual function in women with and without polycystic ovary syndrome (PCOS)?

SUMMARY ANSWER

Women with PCOS reported more sexual dysfunction and more sexual distress compared to those without PCOS, but only few and weak associations between androgen levels and sexual function were observed.

WHAT IS KNOWN ALREADY

The literature shows that women with PCOS report lower levels of sexual function and sexual satisfactionand more sexual distress. Contributing factors seem to be obesity, alopecia, hirsutism, acne, infertility, anxiety, depression, and low self-esteem. In women with PCOS clinical and/or biochemical hyperandrogenism is common; its relationship with sexualfunction is, however, inconclusive.

STUDY DESIGN, SIZE, DURATION

This observational prospective case control study with 135 women (68 PCOS, 67 control) was conductedfrom March 2017 until March 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Heterosexual women with and without PCOS, aged 18-40 years, in a steady relationshipand without any comorbidities, underwent an extensive medical and endocrine screening using liquid chromatography-tandem mass spectrometry and validated sexual function questionnaires.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with PCOS reported significantly lower sexual function (Female Sexual Function Index (FSFI) P < 0.001, partial η2 = 0.104), higher levels of sexual distress (Female Sexual Distress Scale-Revised P < 0.001, partial η2 = 0.090), and they more often complied with the definition of sexual dysfunction (41.2% vs 11.9%, P < 0.001, Phi V = 0.331) and clinical sexual distress (51.5% vs 19.4%, P < 0.001, Phi V = 0.335). Regression analysis adjusted for confounders showed only few and weak associations between androgen levels and sexual function, with each model explaining a maximum of 15% sexual function. Following significant Group × Hormone interactions, analyses for both groups separately showed no significant associations in the PCOS group. The control group showed only weak negative associations between testosterone and FSFI pain (β = -6.022, P = 0.044, Adj R2 = 0.050), between FAI and FSFI orgasm (β = -3.360, P = 0.023, Adj R2 = 0.049) and between androstenedione and clinical sexual distress (β = -7.293, P = 0.036, exp(β) = 0.001).

LIMITATIONS, REASONS FOR CAUTION

The focus of the study on sexual functioning potentially creates selection bias. Possibly women with more severe sexual disturbances did or did not choose to participate. Differences between women with PCOS and controls in relationship duration and hormonal contraceptive use might have skewed the sexual function outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

Sexual function is impaired in women with PCOS. However, endocrine perturbations seem to have minimal direct impact on sexual function. Addressing sexuality and offering psychosexual counseling is important in the clinical care for women with PCOS.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the departments of the participating centers: Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Psychosomatic OBGYN and Sexology, Leiden University Medical Center, Leiden, the Netherlands; and Department of Sexology and Psychosomatic OBGYN, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands. J.S.E.L. received unrestricted research grants from the following companies (in alphabetical order): Ansh Labs, Ferring, Merck Serono and Roche Diagnostics. He also received consultancy fees from Ansh Labs, Ferring, Titus Healthcare and Roche Diagnostics. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

CCMO register, registration number: NL55484.078.16, 10 March 2016. https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm.

Prioritizing Toxicities in Automated Outcome-Directed Treatment Plan Optimization

PURPOSE/OBJECTIVE(S)

We recently reported on quality of life (QOL)-guided radiotherapy including NTCP-based treatment plan optimization. This method employs NTCP objective functions, prioritized based on their impact on QOL, instead of conventional dose-based objective functions for individual organs at risk (OAR). We recently expanded this method to include simple models for tumor control probability (TCP) and general plan quality (e.g., hotspot reduction, target dose homogeneity), allowing for fully automated planning. The aim of this study was to test the feasibility of this method and to study predicted toxicity profiles of various plans by prioritizing toxicities differently during treatment plan optimization.

MATERIALS/METHODS

Thirty patients, representative of our population receiving definitive (chemo)radiotherapy for head and neck cancer, were selected for this study. Fully automated VMAT treatment plans were created using a mix of NTCP and TCP objective functions. TCP objective functions were based on a PTV D98 ≥ 95% of the prescribed dose. Automated plans were created for each patient using different priorities for 20 toxicities including salivary, swallowing and speech problems, pain and general symptoms. Toxicities were prioritized in different ways: 1) minimizing the impact on QOL; 2) minimizing salivary toxicity; 3) minimizing swallowing related toxicity; 4) equal weights for each toxicity. Manually created clinical VMAT plans were used as reference.

RESULTS

Toxicity priorities were easily selected prior to optimization and resulting plans did not need any manual post-processing. Fully automated NTCP-TCP-based optimization consistently resulted in superior plans when compared to the clinical reference plans and always in lower NTCPs for swallowing, speech, pain and general toxicities. Dose reductions in OARs depended on which toxicities were prioritized during plan optimization, e.g., the mean dose in the parotid glands was on average 13 Gy lower in salivary sparing plans compared with plans focused on swallowing sparing, and the average NTCP of salivary toxicities in those plans was 7% lower. However, these reductions were at the cost of higher NTCPs for dysphagia and moderate-to-severe general symptoms such as fatigue. Plans optimized based on the QOL model had the highest QOL scores.

CONCLUSION

Automated outcome-directed treatment plan optimization is feasible and consistently outperforms manually generated VMAT plans in terms of NTCP and QOL scores. Predicted toxicity profiles depend on toxicity priority settings prior to planning. The highest QOL score was obtained when toxicities were prioritized according to relative impact on QOL.

Excitation Transfer Between Sexual Arousal and Other Emotions in a Community Sample

Excitation transfer, the transfer of arousal from one emotion to another, might be a mechanism in the development of unusual sexual interests. In this pilot study, we investigated whether we could induce excitation transfer between various emotions and sexual arousal in a laboratory setting with 30 male volunteers. We induced low-level sexual arousal in four different emotional states (aggression/dominance, endearment, fear, disgust) and a neutral state. Sexual arousal was measured using penile plethysmography and self-report. Although there was no mean group effect, possibly due to large interindividual variations, 60% of the subjects showed more sexual arousal in response to sexual stimulation in at least one of the emotional states than in the neutral state. Excitation transfer was most prominent with aggression/dominance and least prominent with disgust. Genital excitation transfer was strongly related to lower penile reactivity and to higher self-reported erotophilia. This pilot study paves the way for further research into excitation transfer as a mechanism to increase the salience of stimuli that otherwise would not have been sexual in nature.

Preoperative pain measurements in correlation to deep endometriosis classification with Enzian. Deep endometriosis classification in relation to pain

Background: Deep Endometriosis (DE) classification studies with Enzian never compared solitary (A, B, C, F), and combinations of anatomical locations (A&B, A&C, B&C, A&B&C), in correlation to pain. Therefore, the results of these studies are challenging to translate to the clinical situation. Objectives: We studied pain symptoms and their correlation with the solitary and combinations of anatomical locations of deep endometriosis lesion(s) classified by the Enzian score. Materials and Methods: A prospective multi-centre study was conducted with data from university and non-university hospitals. A total of 419 surgical DE cases were collected with the web-based application called EQUSUM (www.equsum.org). Main outcome measures: Preoperative reported numeric rating scale (NRS) were collected along with the Enzian classification. Baseline characteristics, pain scores, surgical procedure and extent of the disease were also collected. Results: In general, more extensive involvement of DE does not lead to an increase in the numerical rating scale for pain measures. However, dysuria and bladder involvement do show a clear correlation AUC 0.62 (SE 0.04, CI 0.54-0.71, p< 0.01). Regarding the predictive value of dyschezia, we found a weak, but significant correlation with ureteric involvement; AUC 0.60 (SE 0.04, CI 0.53-0.67, p< 0.01). Conclusions:TPain symptoms poorly correlate with anatomical locations of deep endometriosis in almost all pain scores, with the exception of bladder involvement and dysuria which did show a correlation. Also, dyschezia seems to have predictive value for DE ureteric involvement and therefore MRI or ultrasound imaging (ureter and kidney) could be recommended in the preoperative workup of these patients. What’s new? Dyschezia might have a predictive value in detecting ureteric involvement.

Crossroad decisions in deep endometriosis treatment options: a qualitative study among patients

OBJECTIVE

To study the experiences, considerations, and motivations of patients with endometriosis in the decision-making process for deep endometriosis (DE) treatment options.

DESIGN

Qualitative study using semi-structured in-depth focus group methodology.

SETTING

University medical center.

PATIENT(S)

A total of 19 Dutch women diagnosed with DE between 27 and 47 years of age.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Focus group topics were disease impact and motives for treatment, expectations of the treatment process, and important factors in the decision process.

RESULT(S)

Women reported that pain, fertility, and strong fear of complications are important decisive factors in the treatment process. The goal of conceiving a child is considered important, however, sometimes doctors emphasize this topic too much. It emerged that complication counseling is frequently about surgical complications, whereas side effects of hormonal treatments are neglected. Shared decision making and information about treatment options, complications, and side effects are not always optimal, making it difficult to make a well-considered choice. Despite negative experiences encountered after surgery, the positive effect of surgery ensures that most women do not regret their choice.

CONCLUSION(S)

In the treatment decision process for patients with DE, pain is almost always the most important decisive factor. The wish to conceive and strong fear of complications can change this choice. Doctors should understand the importance of fertility for the majority of women, but, also, if this is not considered paramount, respect that view. To improve shared decision making, exploration of treatment goals, training of healthcare providers, and better patient information provision are desirable.

The effect of differential disgust conditioning and subsequent extinction versus counterconditioning procedures on women's sexual responses to erotic stimuli

Recent theoretical accounts point to disgust as an important factor in the development and persistence of sexual dysfunctions. This study tested if (i) contingent disgust experiences can render initially sexually arousing stimuli disgusting, and (ii) such acquired disgust responses could be best neutralized via a CS-only extinction or a counterconditioning procedure. Participants (N = 74) were exposed to a differential conditioning procedure that was followed by either a CS-only extinction or a counterconditioning procedure. Erotic films served as the CS+/CS-. A disgusting film served as the US. During the extinction procedure, the CS+ was no longer followed by the disgusting US. During counterconditioning the CS+ was paired with positive stimuli. After conditioning, the CS + elicited lower genital arousal and was rated as significantly more disgusting, less pleasant, and less sexually arousing than the CS-. These diminished genital and subjective sexual arousal responses to the CS+ were successfully restored after both the extinction and the counterconditioning procedure, whereas conditioned feelings of disgust and behavioral avoidance persisted. There was no evidence for differential effectiveness of either procedure. Thus, sexual responses can be attenuated by learned sex-disgust associations and restored by extinction and counterconditioning procedures, but conditioned feelings of disgust seem more resistant.

Sexual functioning, sexual esteem, genital self-image and psychological and relational functioning in women with Mayer-Rokitansky-Küster-Hauser syndrome: a case-control study

STUDY QUESTION

Do sexual functioning, sexual esteem, genital self-image and psychological and relational functioning in women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome differ from a comparison group of women without the condition?

SUMMARY ANSWER

In comparison to controls, women with MRKH with a non-surgically or surgically created neovagina did not differ in psychological and relational functioning but reported lower sexual esteem and more negative genital self-image, intercourse-related pain, clinically relevant sexual distress and sexual dysfunction, with sexual esteem levels strongly associated with sexual distress and sexual dysfunction.

WHAT IS KNOWN ALREADY

Studies on sexual functioning measured with standardized questionnaires in women with MRKH syndrome compared with women without the condition have yielded contradictory results. Factors associated with sexual functioning in this patient population have rarely been investigated.

STUDY DESIGN, SIZE, DURATION

Between November 2015 and May 2017, 54 women with MRKH syndrome with a neovagina and 79 age-matched healthy women without the condition were enrolled in this case-control study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All participants had to be at least 18-years old and had to live in a steady heterosexual relationship. Women with MRKH syndrome were asked to participate by their (former) gynecologists at three university hospitals and by MRKH peer support group. Controls were recruited via advertisement in local newspapers and social media. Standardized questionnaires were administered to assess sexual functioning, sexual esteem, genital self-image and psychological and relational functioning.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with MRKH syndrome with a surgically or non-surgically created neovagina reported significantly more pain during intercourse (P < 0.05, d = 0.5), but did not differ in overall sexual functioning from control women. More women with MRKH syndrome reported clinically relevant sexuality-related distress (P < 0.05, odds ratio (OR): 2.756, 95% CI 1.219-6.232) and suffered a sexual dysfunction (P < 0.05, OR: 2.654, 95% CI: 1.088-6.471) in comparison with controls. MRKH women scored significantly lower on the sexual esteem scale (SES) (P < 0.01, d = 0.5) and the female genital self-image scale (FGSIS) (P < 0.01, d = 0.6) than controls. No significant differences were found between the two groups regarding psychological distress, anxiety and depression, global self-esteem and relational dissatisfaction. Sexual esteem was significantly associated with the presence of clinically relevant sexual distress (ß = 0.455, P = 0.001) and suffering a sexual dysfunction (ß = 0.554, P = 0.001) and explained, respectively, 40% and 28% of the variance.

LIMITATIONS, REASONS FOR CAUTION

Given the nature of the study focusing on sexual functioning, a potential selection bias cannot be excluded. It is possible that those women with the most severe sexual and/or psychological disturbances did or did not choose to participate in our study.

WIDER IMPLICATIONS OF THE FINDINGS

The study results add new data to the very limited knowledge about psychosexual functioning of women with MRKH syndrome and are of importance for more adequate counseling and treatment of these women.

STUDY FUNDING/COMPETING INTEREST(S)

The research was financially supported by the Dutch Scientific Society of Sexology (Nederlandse wetenschappelijke Vereniging Voor Seksuologie). The funding was unrestricted, and there was no involvement in the conduct of the research. There are no conflicts of interest to declare.

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

Introduction

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

Methods

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

Main outcome measures

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

Conclusion

Strengths of this study are the inclusion of a broad range of biopsychosocial outcome measures including DNA analysis, a healthy control group, and standardized assessment of genital and self-reported sexual arousal in a laboratory setting. With the design of this study we aim to provide an insight into which biopsychosocial factors associated with PCOS are related to sexual function, and how sexual function may be affected by treatment. These new insights may help to improve clinical management of PCOS while improving the quality of life.

Pastoor H, Both S, Timman R, et al. Sexual Function in Women With Polycystic Ovary Syndrome: Design of an Observational Prospective Multicenter Case Control Study. Sex Med 2020;8:718–729.