Management of perimenopausal and menopausal symptoms.

Most women worldwide experience menopausal symptoms during the menopause transition or postmenopause. Vasomotor symptoms are most pronounced during the first four to seven years but can persist for more than a decade, and genitourinary symptoms tend to be progressive. Although the hallmark symptoms are hot flashes, night sweats, disrupted sleep, and genitourinary discomfort, other common symptoms and conditions are mood fluctuations, cognitive changes, low sexual desire, bone loss, increase in abdominal fat, and adverse changes in metabolic health. These symptoms and signs can occur in any combination or sequence, and the link to menopause may even be elusive. Estrogen based hormonal therapies are the most effective treatments for many of the symptoms and, in the absence of contraindications to treatment, have a generally favorable benefit:risk ratio for women below age 60 and within 10 years of the onset of menopause. Non-hormonal treatment options are also available. Although a symptom driven treatment approach with individualized decision making can improve health and quality of life for midlife women, menopausal symptoms remain substantially undertreated by healthcare providers.

Urinary Incontinence and Associated Female Sexual Dysfunction.

INTRODUCTION: Urinary incontinence (UI) and sexual dysfunction are common conditions often undiagnosed and untreated in women and are associated with decreased quality of life. AIM: To evaluate the relation between UI and female sexual dysfunction (FSD), considering incontinence type and the psychosocial and physiologic aspects of sexual function. METHODS: PubMed search of terms related to UI and FSD from 1979 to 2016 generated 603 published references, of which 26 were included. Nine additional studies came from bibliographic review. MAIN OUTCOME MEASURE: Rates and types of sexual dysfunction. RESULTS: In cross-sectional and case-control studies, UI was associated with increased rates and severity of FSD. Coital UI occurred in 24% to 66% of women with UI. Impaired body image, fear of coital UI, avoidance of sex, and complete abstinence were more common in women with UI. Deficits in desire, lubrication, satisfaction, and increased pain were found across numerous studies. Mixed UI was associated with more FSD than urgency UI and stress UI. Multiple studies suggest urgent UI is more bothersome than stress UI. Coital UI was associated with a urodynamic diagnosis other than genuine stress incontinence in 25% to 50%. Leakage at penetration was associated with stress UI; leakage at orgasm was associated more often with detrusor overactivity. CONCLUSION: Women's UI is associated with increased rates of sexual dysfunction, suggesting concurrent screening is warranted. Clarifying timing of coital leakage would facilitate targeted treatment. Standardization of FSD measurements could better elucidate the relation between UI and FSD. Duralde ER, Rowen TS. Urinary Incontinence and Associated Female Sexual Dysfunction. Sex Med Rev 2017;5:470-485.

Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women.

BACKGROUND: More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated. OBJECTIVE: We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women. STUDY DESIGN: We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment. RESULTS: Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ≥ $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ≥ $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician. CONCLUSION: Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.