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The terms transgender and gender diverse (TGD) describe persons whose gender is different from the sex assigned to them at birth. While TGD persons have experienced a rise in cultural and social visibility in recent decades, they continue to experience significant health inequities, including adverse health outcomes and multiple barriers to accessing medical care. Transgender and gender-diverse persons are at a higher risk for pain conditions than their cisgender counterparts, but research on chronic pain management for TGD persons is lacking. Clinicians from all disciplines must be informed of best practices for managing chronic pain in the TGD population. This includes all aspects of care including history, physical examination, diagnosis, treatment, and perioperative management. Many TGD persons report delaying or avoiding care because of negative interactions with medical practitioners who do not have sufficient training in navigating the specific health care needs of TGD patients. Furthermore, TGD persons who do seek care are often forced to educate their practitioners on their specific health care needs. This paper provides an overview of existing knowledge and recommendations for physicians to provide culturally and medically appropriate care for TGD persons.
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Pessoas Transgênero , Humanos , Masculino , Feminino , Dor Crônica/terapia , Manejo da Dor/métodos , Acessibilidade aos Serviços de Saúde , Relações Médico-PacienteRESUMO
The number of midlife women transitioning into menopause is substantial, with more than 1 million women in the United States entering menopause each year. Vasomotor symptoms (VMS), mood and sleep disturbances, and sexual problems are common during the menopause transition yet often go untreated. Menopausal hormone therapy is the most effective treatment of VMS, and the benefits typically outweigh the risks for women without contraindications who are younger than 60 years or within 10 years from menopause onset. For women who cannot or choose not to use hormone therapy, nonhormone prescription options exist to treat VMS. Many of these therapies have secondary benefits beyond VMS relief. For example, whereas paroxetine is Food and Drug Administration approved to treat VMS, it can also help with depressive and anxiety symptoms. The aim of this paper is to summarize prescription treatments of VMS and their secondary benefits for other common symptoms experienced by midlife women. The tools presented will help clinicians caring for midlife women provide individualized, comprehensive care with the goal of improving their quality of life during the menopause transition and beyond.
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Fogachos , Menopausa , Humanos , Feminino , Menopausa/fisiologia , Fogachos/terapia , Fogachos/tratamento farmacológico , Pessoa de Meia-Idade , Terapia de Reposição de Estrogênios/métodos , Sistema Vasomotor/fisiopatologia , Sistema Vasomotor/efeitos dos fármacos , Qualidade de VidaRESUMO
BACKGROUND: Breast imaging clinics in the United States (U.S.) are increasingly implementing breast cancer risk assessment (BCRA) to align with evolving guideline recommendations but with limited uptake of risk-reduction care. Effectively communicating risk information to women is central to implementation efforts, but remains understudied in the U.S. This study aims to characterize, and identify factors associated with women's interest in and preferences for breast cancer risk communication. METHODS: This is a cross-sectional survey study of U.S. women presenting for a mammogram between January and March of 2021 at a large, tertiary breast imaging clinic. Survey items assessed women's interest in knowing their risk and preferences for risk communication if considered to be at high risk in hypothetical situations. Multivariable logistic regression modeling assessed factors associated with women's interest in knowing their personal risk and preferences for details around exact risk estimates. RESULTS: Among 1119 women, 72.7% were interested in knowing their breast cancer risk. If at high risk, 77% preferred to receive their exact risk estimate and preferred verbal (52.9% phone/47% in-person) vs. written (26.5% online/19.5% letter) communications. Adjusted regression analyses found that those with a primary family history of breast cancer were significantly more interested in knowing their risk (OR 1.5, 95% CI 1.0, 2.1, p = 0.04), while those categorized as "more than one race or other" were significantly less interested in knowing their risk (OR 0.4, 95% CI 0.2, 0.9, p = 0.02). Women 60 + years of age were significantly less likely to prefer exact estimates of their risk (OR 0.6, 95% CI 0.5, 0.98, p < 0.01), while women with greater than a high school education were significantly more likely to prefer exact risk estimates (OR 2.5, 95% CI 1.5, 4.2, p < 0.001). CONCLUSION: U.S. women in this study expressed strong interest in knowing their risk and preferred to receive exact risk estimates verbally if found to be at high risk. Sociodemographic and family history influenced women's interest and preferences for risk communication. Breast imaging centers implementing risk assessment should consider strategies tailored to women's preferences to increase interest in risk estimates and improve risk communication.
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Neoplasias da Mama , Mamografia , Preferência do Paciente , Humanos , Feminino , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/psicologia , Neoplasias da Mama/diagnóstico por imagem , Estudos Transversais , Pessoa de Meia-Idade , Preferência do Paciente/estatística & dados numéricos , Preferência do Paciente/psicologia , Estados Unidos , Adulto , Mamografia/estatística & dados numéricos , Mamografia/psicologia , Medição de Risco/métodos , Idoso , Comunicação , Inquéritos e Questionários , Centros de Atenção Terciária , Conhecimentos, Atitudes e Prática em SaúdeRESUMO
INTRODUCTION: Menopause is a natural part of a woman's life that coincides with a time when many women play significant roles in the workforce. Menopause symptoms, such as hot flashes, fatigue, and difficulty with concentration and memory, can have a negative effect on work productivity and efficiency. OBJECTIVES: This paper summarizes the impact of menopause in the workplace, with an emphasis on the impact of symptoms on employed women and how the workplace influences their experiences. It highlights economic implications, promotes awareness, and suggests potential next steps. METHODS: A search for papers was conducted between August and November 2023 in the PubMed and Medline databases. Papers were selected based on personal experience and interpretation of the findings. Recommendations for managing menopause symptoms in the workplace and guidance on an optimal workplace intervention strategy were provided. RESULTS: Women experiencing severe menopause symptoms are more likely to report adverse work outcomes, including absenteeism and job-related decisions such as quitting, retiring early, or declining promotions than women experiencing few symptoms. Factors such as a lack of awareness about menopause, inflexible work conditions, and high-stress jobs can exacerbate the severity of these symptoms. Additionally, unaddressed menopause symptoms contribute to both direct and indirect economic costs, including medical resource utilization and lost work productivity, resulting in a substantial economic burden. CONCLUSION: Menopause symptoms impair women's work experiences and productivity. In addition to dismantling the stigma associated with menopause, it is critical to create and implement menopause workplace policies and interventions aimed at supporting women in this universal life stage.
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Menopausa , Local de Trabalho , Humanos , Feminino , Fogachos , Absenteísmo , Eficiência , Fadiga , EmpregoRESUMO
BACKGROUND: Breast cancer screening trends of transgender and gender diverse (TGD) people remain largely unknown. This is concerning, as data are necessary to inform recommendations made by clinicians to their patients and by national guidelines to clinicians. The aim of this review is to explore the state of existing research literature and provide a summary report of current breast cancer screening rates in TGD adults. METHODS: All articles were identified using Medical Subject Headings terms. Inclusion criteria were all the following: (1) documents inclusion of at least one participant who identifies as a TGD person; (2) at least one TGD participant with top surgery or currently receiving estrogen-based gender-affirming hormone therapy; (3) results that report rates of breast cancer screening or mammogram referral. RESULTS: Twelve articles met inclusion criteria, six cross-sectional studies and six retrospective chart reviews. Three studies conducted secondary analysis of the Behavioral Risk Factor Surveillance System national dataset, and nine articles recruited their own sample with number of TGD participants ranging from 30 to 1,822 and number of cisgender women ranging from 242 to 18,275. Three studies found lower rates of screening in transfeminine persons receiving gender-affirming care compared with cisgender women; two studies found lower rates among TGD people compared with cisgender women; and three studies found no differences between the breast cancer screening rates of TGD and cisgender participants. CONCLUSION: Limited studies recruit and report trends in breast cancer screening of TGD people. Those that do include TGD participants have mixed results, but overall TGD people had lower rates of breast cancer screening. More research is needed regarding breast cancer screening of TGD people to inform the development of protocols that ensure equitable access to preventative care.
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OBJECTIVES: Female sexual dysfunction (FSD), a common concern affecting women of all ages, is often mediated by important psychological factors. Resilience has been shown to correlate with psychological well-being across different groups of people. The aim of this study was to assess if there is an association between resilience and FSD. STUDY DESIGN: This cross-sectional study included 4,366 women (mean [SD] age, 51.7 [11]) seen in women's health clinics at 1 of 3 geographic Mayo Clinic locations. Participants completed the Brief Resilience Scale, the Female Sexual Function Index (FSFI), and the Female Sexual Distress Scale-Revised (FSDS-R). MAIN OUTCOME MEASURES: We used univariate and multivariable logistic regression analyses to assess associations between resilience, sexual function, and sexual distress, adjusting for potential confounding variables. RESULTS: FSD criteria (FSFI ≤26.55 and FSDS-R ≥ 11) were met by 55.8 % of women. Low, normal, and high levels of resilience were reported by 17.3 %, 57.1 %, and 25.6 % of participants, respectively. The univariate analysis showed that higher resilience was associated with lower sexual distress, lower odds of FSD, and better sexual function. Multivariable analysis adjusted for potential confounders showed that the association persisted and that higher resilience correlated with better sexual function and lower odds of FSD. CONCLUSIONS: In this large cross-sectional study, women with higher resilience scores had better sexual function and lower odds of FSD. Additional studies with diverse women are needed to confirm this association and to determine whether women with FSD could benefit from enhancing resilience as a therapeutic strategy.
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Testes Psicológicos , Resiliência Psicológica , Disfunções Sexuais Psicogênicas , Feminino , Humanos , Disfunções Sexuais Psicogênicas/etiologia , Disfunções Sexuais Psicogênicas/psicologia , Estudos Transversais , Inquéritos e Questionários , Comportamento Sexual/psicologiaRESUMO
ABSTRACT: Sex and gender influence every aspect of human health; thus, sex- and gender-related topics should be incorporated in all aspects of health education curricula. Sex and gender health education (SGHE) is the rigorous, intersectional, data-driven integration of sex and gender into all elements of health education. A multisectoral group of thought leaders has collaborated to advance SGHE since 2012. This cross-sector collaboration to advance SGHE has been successful on several fronts, primarily developing robust interprofessional SGHE programs, hosting a series of international SGHE summits, developing sex- and gender-specific resources, and broadening the collaboration beyond medical education. However, other deeply entrenched challenges have proven more difficult to address, including accurate and consistent sex and gender reporting in research publications, broadening institutional support for SGHE, and the development and implementation of evaluation plans for assessing learner outcomes and the downstream effects of SGHE on patient care. This commentary reflects on progress made in SGHE over the first decade of the current collaboration (2012-2022), articulates a vision for next steps to advance SGHE, and proposes 4 benchmarks to guide the next decade of SGHE: (1) integrate sex, gender, and intersectionality across health curricula; (2) develop sex- and gender-specific resources for health professionals; (3) improve sex and gender reporting in research publications; and (4) develop evaluation plans to assess learner and patient outcomes.
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Benchmarking , Educação Médica , Masculino , Feminino , Humanos , Currículo , Educação em Saúde , Pessoal de Saúde/educaçãoRESUMO
OBJECTIVE: The severity of menopause-related symptoms varies considerably among women. The determinants of this variation are incompletely understood. The aim of this study was to assess the association between genetic variation in estrogen metabolism and transport pathways and the severity of menopause symptoms. METHODS: This was a cross-sectional study of 60 peri- and postmenopausal women in the Mayo Clinic RIGHT study (which involved sequencing of genes involved in drug metabolism and transport), who had also been evaluated in the Women's Health Clinic at Mayo Clinic in Rochester, MN. All participants completed the Menopause Rating Scale (MRS) for assessment of menopause symptoms, including hot flashes. The association between severity of menopause symptoms and the variation in genes encoding 8 enzymes and transporters involved in estrogen metabolism was evaluated. RESULTS: Lower CYP3A4 activity and higher COMT activity were associated with lower severity of somatic menopause symptoms (p = 0.04 and 0.06, respectively). These associations did not persist after adjustment for hormone therapy use. No differences in MRS scores or hot flash severity were noted among other genetic variant groups. Age at natural menopause was not affected by variations in the genes studied. CONCLUSION: The current study did not show an association between genetic variation in estrogen metabolism and transport pathways and the severity of menopause symptoms. Further studies with larger sample sizes may be required to understand this potentially complex association.
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Estrogênios , Metabolismo dos Lipídeos , Feminino , Humanos , Estudos Transversais , Fogachos/genética , Variação GenéticaRESUMO
BACKGROUND: Infertility has been linked with an increased risk of sexual dysfunction in reproductive-aged women, with longer periods of infertility associated with a greater risk. AIM: The study's aim was to examine whether a history of infertility treatment in women is linked to sexual dysfunction during midlife. METHODS: The cross-sectional study was conducted among sexually active women, between the ages of 45 and 65 years, who sought consultation at the women's health clinics at a US tertiary care center. History of infertility treatment was assessed with a single question that asked participants if they were treated for infertility in the past. The association between a history of infertility treatment and sexual dysfunction-which was diagnosed by a combination of Female Sexual Function Index score ≤26.55 and Female Sexual Distress Scale-Revised score ≥11-was assessed in a multivariable logistic regression model that adjusted for multiple confounders. OUTCOMES: The primary outcome was sexual dysfunction in midlife women. RESULTS: The analysis included 5912 women, with a mean age of 54.1 years. Nearly 16% of women reported receiving treatment for infertility. More than half the women (55%) had sexual dysfunction: 56.3% of those with previous fertility treatments and 54.4% of those without any fertility treatment (P = .3). Receiving treatment for infertility in the younger years did not significantly increase the odds of sexual dysfunction in midlife in univariate (odds ratio, 1.08; 95% CI, 0.94-1.24; P = .3) and multivariable analyses (odds ratio, 1.11; 95% CI, 0.96-1.29; P = .17). CLINICAL IMPLICATIONS: While infertility is known to be predictive of sexual dysfunction in women during their reproductive years, there was no association between a history of infertility treatment and sexual dysfunction in midlife women in the current study. STRENGTHS AND LIMITATIONS: The study used validated questionnaires accounting for sexual complaints and distress and adjusted for multiple confounding factors. Limitations include the selection bias introduced by the study of women presenting for evaluation of sexual dysfunction, which may have been a result of factors stronger than the influence of infertility. Other limitations include the study's cross-sectional nature with suboptimal racial and ethnic representation. CONCLUSION: Although infertility is commonly associated with female sexual dysfunction in women of reproductive age, the association was not present in midlife women in the current study.
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Infertilidade , Disfunções Sexuais Fisiológicas , Feminino , Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Estudos Transversais , Comportamento Sexual , Disfunções Sexuais Fisiológicas/epidemiologia , Disfunções Sexuais Fisiológicas/etiologia , Saúde da MulherRESUMO
OBJECTIVE: Adverse childhood experiences (ACEs) are reported in more than half of the women in the United States and have been shown to negatively impact the menopause experience. The objective of this study was to evaluate the association between ACEs and age at natural menopause. METHODS: This is a cross-sectional study conducted among participants of the Data Registry on the Experiences of Aging, Menopause, and Sexuality (DREAMS). The registry included women who were seen for consultations in the women's health clinic at Mayo Clinic, Rochester, between May 2015 and December 2016. Only postmenopausal women were included in this analysis. Childhood adversity was assessed with the validated ACE questionnaire. Age at natural menopause was self-reported. The association between ACEs and age at menopause was evaluated using a multivariable linear regression model adjusting for multiple confounders. RESULTS: A total of 350 women were evaluated. The mean age was 59.2 years, and a majority were White (92.9%), married/partnered (82%), and educated (91.2% with at least some college education). Women with a history of at least four ACEs were estimated to reach natural menopause 1.3 years sooner than women with no ACE in multivariable analysis, but the results were not statistically significant (95% confidence interval, -3.2 to 0.6; P = 0.18). CONCLUSIONS: Although stressful life experiences such as ACEs may negatively influence health for midlife women, this study did not find an association with the age at natural menopause.
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Experiências Adversas da Infância , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Transversais , Menopausa , Envelhecimento , Saúde da MulherRESUMO
OBJECTIVES: Few medical schools incorporate formal education on human trafficking (HT) and sex trafficking (ST) into their curriculum. Our objective was to develop, implement, and evaluate education on HT and ST in the first-year medical student curriculum. METHODS: The curriculum included a standardized patient (SP) experience and lecture. As part of their mandatory sexual health course, students interviewed an SP who presented with red flags for ST and then participated in a discussion led by a physician-facilitator in an observed small group setting. A multiple-choice survey to assess knowledge about HT and ST was developed and administered to students before and after the SP interview. RESULTS: Of the 50 first-year medical students, 29 (58%) participated in the survey. Compared with the students' baseline scores (according to the percentage of correct responses), scores after the educational intervention showed a significant increase in percentage correct on questions related to trafficking definition and scope (elder care, P = .01; landscaping, P = .03); victim identification (P < .001); referral to services (P < .001); legal issues (P = .01); and security (P < .001). On the basis of the feedback, a 2-hour lecture, which was adapted from the American Medical Women's Association-Physicians Against the Trafficking of Humans "Learn to Identify and Fight Trafficking" training, was presented the next year to all first-year medical students as part of their longitudinal clinical skills course and before the SP case. Curriculum objectives included learning trafficking definitions, victim/survivor identification, intersections with health care, the local impact of HT, and available resources. CONCLUSION: This curriculum fulfills course objectives and could be replicated at other institutions. Further evaluation of this pilot curriculum is necessary to evaluate its effectiveness.
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Menopause occurs in all women. During the menopause transition, 80% of women experience vasomotor symptoms that can last an average of 7-10 years or longer, sometimes into the seventh and eighth decades of life. Understanding how to manage vasomotor symptoms (VMS) in older menopausal women is important since these symptoms can negatively impact quality of life. This review provides a practical guide on how to approach VMS treatment either with menopausal hormone therapy or non-hormone options. When initiating, as well as continuing hormone therapy, the factors clinicians should consider as they weigh risks and benefits include assessing a woman's risks related to cardiovascular disease, breast cancer, and osteoporosis. Utilizing a shared decision-making approach in regard to menopausal symptom management should aim to support women and help them maintain health and quality of life.
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Terapia de Reposição de Estrogênios , Osteoporose , Feminino , Humanos , Idoso , Terapia de Reposição de Estrogênios/efeitos adversos , Qualidade de Vida , Menopausa , Terapia de Reposição HormonalRESUMO
Testosterone is an important evidence-based therapy for hypoactive sexual desire disorder (HSDD) in postmenopausal women. Clinical practice guidelines based on the most comprehensive meta-analysis of benefits and risks of testosterone therapy to date state that the sole evidence-based indication for testosterone therapy is HSDD in postmenopausal women. The guidelines also provide recommendations regarding identification of patients, dosing, monitoring, and follow-up. This Practice Pearl will discuss evidence-based testosterone therapy for management of HSDD in postmenopausal women.
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Disfunções Sexuais Psicogênicas , Testosterona , Feminino , Humanos , Testosterona/uso terapêutico , Pós-Menopausa , Disfunções Sexuais Psicogênicas/tratamento farmacológico , Administração Cutânea , LibidoRESUMO
OBJECTIVE: To further examine a potential link between migraine and vasomotor symptoms as well as hypertension as a cardiovascular disease risk factor, potentially explaining the association in midlife women. PATIENTS AND METHODS: We conducted a cross-sectional analysis from the Data Registry on Experiences of Aging, Menopause, and Sexuality using questionnaire data from women aged 45 to 60 years seen in women's clinics at a tertiary care center from May 15, 2015, through January 31, 2022. A history of migraine was self-reported; menopause symptoms were assessed with the Menopause Rating Scale. Associations between migraine and vasomotor symptoms were evaluated utilizing multivariable logistic regression models adjusting for multiple factors. RESULTS: Of 5708 women included in the analysis, 1354 (23.7%) reported a migraine history. The total cohort had a mean age of 52.8 years, most (5184 [90.8%]) were White, and 3348 (58.7%) were postmenopausal. In adjusted analysis, women with migraine were significantly more likely to have severe/very severe hot flashes vs no hot flashes compared with women without migraine (odds ratio, 1.34; 95% CI, 1.08 to 1.66; P=.007). Migraine was associated with a diagnosis of hypertension in adjusted analysis (odds ratio, 1.31; 95% CI, 1.11 to 1.55; P=.002). CONCLUSION: This large cross-sectional study confirms an association between migraine and vasomotor symptoms. Migraine also was associated with hypertension, potentially providing a link with cardiovascular disease risk. Given the high prevalence of migraine in women, this association may help identify those at risk for more severe menopause symptoms.
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Doenças Cardiovasculares , Hipertensão , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Transversais , Menopausa , Fogachos/epidemiologia , Fogachos/etiologia , Hipertensão/complicações , Sistema VasomotorRESUMO
Introduction: Female sexual dysfunction (FSD) is common and associated with decreased quality of life, relationship satisfaction, and overall well-being. However, primary care practitioners report discomfort discussing, diagnosing, and treating FSD. Methods: We delivered two sessions on the approach to evaluation and treatment of FSD: a 60-minute didactic session and a 90-minute workshop. The intended audience was primary health care professionals who care for women. The workshop utilized interactive teaching methods including a large-group discussion, case-based discussions, debrief of an observed patient-physician discussion, and language drills to develop participants' knowledge and skills. Participants were surveyed about their practice patterns and attitudes toward FSD following the sessions on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Results: We collected 131 evaluations from a national Veterans Health Administration 60-minute didactic and four evaluations from the Society of General Internal Medicine Annual Meeting 90-minute workshop (response rates were 60% and 15%, respectively). One hundred thirty-five interdisciplinary trainees and practitioners from both audiences highly rated the workshop content (M = 4.1) and the overall session (M = 4.3). Didactic participants (n = 131) also reported high satisfaction (M = 4.5), increased knowledge and skills (M = 4.4), and improved interprofessional collaborative practice (M = 4.4) as a result of the training. Discussion: Our evaluation shows high satisfaction following interactive multimodal sessions on FSD. These adaptable resources can be used in multiple educational settings (didactic and workshop) and for multiple time frames to teach about FSD.
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Pessoal de Saúde , Qualidade de Vida , Humanos , Feminino , Inquéritos e Questionários , Relações Médico-Paciente , Atenção Primária à SaúdeRESUMO
BACKGROUND: One in 3 children has had at least 1 adverse childhood experience (ACE), and ACEs have been associated with multiple medical and psychiatric morbidities in women later in life, including greater menopause symptom burden. AIM: To evaluate the association between ACEs and female sexual dysfunction (FSD) in midlife women. METHODS: A cross-sectional analysis from DREAMS-the Data Registry on Experiences of Aging, Menopause, and Sexuality-was conducted with questionnaires completed by women aged 40 to 65 years who presented to a women's health clinic at Mayo Clinic in Rochester, Minnesota, from May 2015 to December 2016. History of ACEs was obtained with the validated ACE questionnaire. FSD was assessed by the Female Sexual Function Index and the Female Sexual Distress Scale-Revised. OUTCOMES: The association between ACEs and FSD (defined as Female Sexual Function Index score ≤26.55 and Female Sexual Distress Scale-Revised score ≥11) was evaluated via a multivariable logistic regression model, adjusting for age, menopause status, hormone therapy use, anxiety, depression, relationship satisfaction, hot flash severity, and history of abuse in the past year. RESULTS: Women (N = 1572) had a mean age of 53.2 years. Overall 59% reported having at least 1 ACE. When compared with no ACEs, a history of ≥4 ACEs significantly increased the odds of not being sexually active (odds ratio, 1.83; 95% CI, 1.30-2.57; P < .001). Among sexually active women, the proportion of women with FSD increased sequentially as the number of ACEs increased. In the univariate analysis, a history of ≥4 ACEs significantly increased the odds of FSD as compared with no ACEs (odds ratio, 2.12; 95% CI, 1.50-2.99; P < .001). The association remained statistically significant in the multivariable analysis after adjusting for confounders (odds ratio, 1.75; 95% CI, 1.15-2.68; P = .009). CLINICAL IMPLICATIONS: The findings highlight an opportunity for clinicians to screen for ACEs in women with sexual dysfunction and offer appropriate treatment and counseling as indicated. STRENGTHS AND LIMITATIONS: Strengths of the study include the large cohort, the use of validated tools for assessment of ACEs and FSD, and the adjustment for multiple potential confounding factors. Limitations include the cross-sectional study design, recall bias in reporting ACEs and recent abuse, and the low representation of racially and ethnically diverse women in the cohort. CONCLUSION: The study demonstrates an increased risk of sexual inactivity and sexual dysfunction in midlife women who experienced childhood adversity. The sexual dysfunction in women with ACEs seems to be independent of other factors that potentially affect female sexual function in midlife.