Postpartum care: Clinical considerations for improving genital and sexual health.

The postpartum period encompasses the biological and psychoaffective transition to motherhood. However, it remains a most neglected phase in a woman's life. Furthermore, the transition to parenthood is a critical and potentially disrupting factor in a couple's relationship, which can be complicated by undiagnosed biological and psychosexual difficulties. Lack of recognition of the many biological and medical factors that can affect women's health and sexuality in the postpartum period is a common and persistent clinical omission worldwide. Communication difficulties exist between healthcare professionals and women and there are wording biases in describing female genitalia. This can further contribute to the diagnostic lack of attention and timely diagnosis and treatment of even very bothersome symptoms. Early diagnosis and treatment of common postpartum conditions is vital and quality care for new mothers should include psychological and emotional support, lactation assistance, early diagnosis and treatment of genital and sexual pain symptoms, pelvic floor rehabilitation and sexual health guidance. The inclusion of correct genital hygiene practices is a critical element of postpartum gynaecological counselling and can help improve overall genital and sexual health. In this review, we summarise the variability in global professional guidelines for postpartum care, identify common health problems faced by postpartum women and discuss appropriate postpartum care. We pay specific attention to prominent biological or medical factors that can impact the emotional and psychosexual wellbeing of women and couples. The aetiology, diagnosis and treatment of sexual dysfunction, in particular sexual pain disorders, is therefore discussed with a pragmatic approach. Finally, the role of intimate hygiene care is discussed with special attention given to cleanser ingredients with solid scientific evidence to help clinicians adopt a more tailored approach with their clinical recommendations.

Maintaining vulvar, vaginal and perineal health: Clinical considerations.

Knowledge of female genital anatomy and physiology is often inadequate or incorrect among women. Precise patient-physician conversations can be inhibited by a reluctance or inability to speak accurately about the vulva and vagina, with the terms often being used interchangeably. There is a paucity of scientific evidence and clinical guidelines to support women and physicians in ensuring best practices in feminine hygiene. In this review, the unmet needs in the field are highlighted. Evidence is provided for the complex array of physiological and pathological systems, mechanisms and behaviours that either protect or, if inappropriate, predispose the vulva and vagina to infections, irritation or other conditions. The need for attention to perineal health is recommended, given the interdependence of perineal and vulvar microbiota and the risk of colonic pathogens reaching the vulva and the vagina. Differences in feminine hygiene practices can vary widely across the world and among varying age groups, and suboptimal habits (such as vaginal douching or the use of certain cleansers) can be associated with increased risks of vulvar and vaginal conditions. Critical areas for discussion when advising women on their intimate health include: advice surrounding aesthetic vulvar cosmetic trends (such as depilation and genital cosmetic surgery), bowel health and habits, and protection against sexually transmitted infections. Routine, once-daily (maximum twice-daily) washing of the vulva with a pH-balanced, mild cleanser is optimal, ideally soon after bowel voiding, when feasible. Due to the finely balanced ecosystems of the vulva, the vagina and the perineal area, a scientific and clinical perspective is essential when determining the most appropriate vulvar cleansers based on their components. Correct intimate care may contribute to improved genital and sexual health and overall well-being. An increased awareness of correct practices will empower women to be the advocates of their own intimate health.

The impact of combined contraceptive vaginal ring on vaginal environment: an observational, longitudinal study.

PURPOSE: To assess the relationship between combined contraceptive vaginal ring (CVR) and vaginal microbiome using 16S rRNA gene sequencing. MATERIALS AND METHODS: We enrolled 20 women for 8 weeks in an open-label study using CVR (NuvaRing®) that delivered 15 mcg ethinylestradiol and 120 mcg etonogestrel daily. The vaginal microbiome was assessed at baseline and after 2 months by sequencing the 16S rRNA genes amplified from the total genomic DNA isolated from the sample. RESULTS: Bacterial distribution richness and equity did not significantly change after 2 months, and the dominant bacterial strain was Lactobacillus crispatus. Only one woman with a history of vestibulodynia and recurrent vulvovaginitis showed an increase in bacterial biodiversity, with a switch to the relative abundance of anaerobic bacteria. CONCLUSIONS: Our results suggest that CVR does not adversely affect the composition and structure of the vaginal microbiome. However, special care should be taken in patients with a history of vestibulodynia and/or recurrent vulvovaginal infections.

Contraceptive vaginal ring does not adversely affect vaginal microbiome except in the case of recurrent vulvovaginal infections or vestibulodynia.

The love-shaper: role of the foetus in modulating mother-child attachment through stem cell migration to the maternal brain.

BACKGROUND: Foetal PAPCs (pregnancy-associated progenitor cells) begin to cross the placenta in a scheduled manner from early pregnancy and colonise many maternal organs, both in mammals and humans, during each pregnancy. The maternal limbic system appears to be colonised with a 100% frequency when compared with other maternal organs. Once they arrive in the limbic system, foetal PAPCs differentiate into neurons and glial cells, resulting in the formation of new synapses with and among maternal neurons. This process is accompanied by major structural neurobiological alterations orchestrated by hormonal changes characteristic of gestation and involves the limbic system, reward areas, and other closely connected brain structures, i.e., the same areas colonised by foetal PAPCs. OBJECTIVE: To correlate findings regarding microscopic and macroscopic changes induced by foetal stem cell migration into the maternal limbic system and hormonal surges during pregnancy with the biological basis of mother-child attachment dynamics, with a focus on the clinical implications this discovery has for normal, complicated, and assisted pregnancies. EVIDENCE REVIEW: A literature review of evidence regarding the neuroanatomical correlation between the targeted, colonising migration of foetal PAPCs into the maternal brain and the structural neurobiological alterations within the affective areas related to attachment and reward was conducted. RESULTS AND CONCLUSIONS: These findings suggest a synergic effect of cellular and morphological changes, with a common biological aim of conferring an adaptive advantage in motherhood, and with the foetus playing a surprisingly active role in modulating the mother's ability to love and care for it.

Fetal stem cells migration into the maternal brain and the morphological alterations of the latter occurring during pregnancy appear to confer an adaptive advantage in motherhood, with the fetus playing a surprisingly active role in modulating the mother's ability to love and care for it.

Real-World Practices and Attitudes Towards Intimate Self- Care: Results From An International Women's Survey.

OBJECTIVE: Vulvovaginal health is important to women's overall health, fertility, sexuality, self-perception, self-confidence and intimacy. It is important to identify the existing perceptions and levels of knowledge about intimate care practices from women in different countries, and with different cultures, religions, and perspectives to help women overcome barriers to optimal intimate care. METHODS: An anonymous online survey about general and intimate hygiene routines/habits was distributed across 10 countries (England, France, Germany, Italy, Portugal, Russia, China, Philippines, Taiwan, Thailand). The sample consisted of around 10,000 women (aged 18 to 60 years) recruited through an online panel. RESULTS: The survey indicates that for many women, cleaning the intimate area is not just about hygiene, but also about taking care of themselves. Intimate care practices, performed daily, varies widely among the countries (from 38% to 91%). Italy, Philippines Portugal, Russia and Thailand were the countries with higher percentage. Intimate care is mainly associated with hygiene and health benefit, but interestingly women engage in intimate care more often with age. Most women worldwide are comfortable talking about female genitalia but still consider it a taboo topic, particularly among younger generations. Asian countries continue to carry negative connotations. CONCLUSIONS: This survey is the first of its kind for number of women involved in this research and for multi-cultural design. Women perceive that practicing intimate care positively impacts their health and wellbeing. However, intimate care is still not one of the most frequent daily routines for many women.

The Gynogram: A Multicentric Validation of a New Psychometric Tool to Assess Coital Pain Associated With VVA and Its Impact on Sexual Quality of Life in Menopausal Women.

BACKGROUND: Vulvo-Vaginal Atrophy (VVA) affects about fifty percent of postmenopausal women, contributing more vulnerable sexual and psycho-relational equilibrium. To date, no psychometric instruments have been designed to assess the impact of coital pain associated with VVA on sexual quality of life. AIM: To validate a new psychometric tool, the Gynogram, able to investigate coital pain and to quantify its impact on sexual well-being in menopause. METHODS: 214 sexually active postmenopausal women were enrolled in the study during clinical consultations in gynecological outpatient clinics in Italy. After gynecological examination and evaluation of the presence of VVA, the study sample was divided in a clinical group (103 women with certified diagnosis of VVA) and in a control group (111 women without certified diagnosis of VVA) according to the Vaginal Health Index (VHI) cut-off. Factor, Reliability and Receiving Operating Characteristics (ROC) analysis were performed in order to validate our newly created Gynogram. OUTCOMES: A structured questionnaire, named Gynogram, to assess coital pain and its impact, and the Female Sexual Function Index (FSFI). RESULTS: The factor analysis performed on the original form (80 items) reduced the Gynogram to 24 items. Reliability analysis conducted with Cronbach's Alpha coefficients showed high values in all the components (ranging from .813 to .972), both in the long and in the short form. The sensitivity analysis demonstrated that the Gynogram, with a cut-off ≤93, is able to recognize a clinically significant coital pain. With respect to the FSFI, statistically significant differences were found for all the domains. In addition, statistically significant differences were found for all the twelve factors of the Gynogram, showing that VVA profoundly affects the sexual quality of life of women in post-menopause. CLINICAL TRANSLATION: The utility of this tool consists in the possibility to improve prognosis, compliance/adherence and treatment outcomes. STRENGTHS AND LIMITATIONS: The Gynogram is able to evaluate and to quantify the impact of coital pain associated with VVA. Moreover, it can also recognize the areas of biopsychosocial functioning being more affected by this clinical condition. The main limit of the study is the impossibility to evaluate both mental health and partner's general and sexual health. CONCLUSIONS: The Gynogram is a new and validated psychometric tool able to detect the impact of symptomatic VVA on sexual quality of life among post-menopausal women, with a specific focus on the different areas of sexual functioning. Nappi RE, Graziottin A, Mollaioli A, et al. The Gynogram: A Multicentric Validation of a New Psychometric Tool to Assess Coital Pain Associated With VVA and Its Impact on Sexual Quality of Life in Menopausal Women. J Sex Med 2021;18:955-965.

Laser-Evoked Potentials to Pudendal Stimulation in Healthy Subjects: A Pilot Study.

PURPOSE: Laser-evoked potentials (LEPs) are useful neurophysiological tools for investigating the A-delta sensory peripheral fibers and the central nociceptive pathway. The current investigation aims to obtain normative values of LEPs via pudendal nerve stimulation in healthy adult volunteers. METHODS: Laser-evoked potentials were recorded in 16 men and 22 women, 22 to 75 years of age, using neodymium and yttrium and aluminum and perovskite laser bilateral stimulation to the pudendal nerve-supplied skin and the dorsal surface of the hands and feet. We assessed the perceptive threshold, latency, and amplitude of the N1 component and main vertex N2-P2 complex. The relationship between gender, age, height, and site of stimulation was statistically analyzed. RESULTS: Both in men and in women, laser perceptive threshold increased from genitalia to foot and from hand to foot (P ≤ 0.001). N1 and N2-P2 latencies progressively increased from pudendal area to hand to foot (P ≤ 0.008). N1 and N2-P2 complex LEP amplitudes progressively decreased from hand to genitalia to foot (P ≤ 0.04). The latencies of N1 component and N2-P2 complex of LEPs correlated with body height, whereas the amplitude of the N2-P2 complex correlated negatively with age; no correlations were observed between the latencies and amplitudes with gender. CONCLUSIONS: This study provides normative data on pudendal LEPs versus hand and foot LEPs. Incorporation of pudendal LEPs into clinical practice could provide a valuable neurophysiological tool for the study of pelvic pain syndromes.

Vulvar pain: The revealing scenario of leading comorbidities in 1183 cases.

OBJECTIVES: This study set out to investigate the epidemiological characteristics and comorbidities of chronic vulvar pain. Secondary goals were to identify the preferred approaches for managing vulvodynia in Italy. STUDY DESIGN: A cross-sectional study (the VuNet -Vulvodynia Network project) was performed in consecutive female patients with chronic vulvar pain attending 21 Italian medical centers (public hospitals, university clinics and private outpatient services) in the period December 2016 to November 2018. Study data were entered by healthcare professionals in a special web-based medical record system (PRIDE- Progetto Rete Italiana Dolore vulvarE). These data covered epidemiological aspects, demographic characteristics, obstetric and gynecological history, presence and duration of current and/or past symptoms, associated disorders, details of physical examination and treatment approaches. RESULTS: A total of 1183 subjects with a diagnosis of chronic vulvar pain were included in the study. The main reason for consultation was superficial dyspareunia, present in 64.2 % of the women. 43.4 % of the sample reported comorbid sexual disorders (of desire in 22.1 % and arousal in 21.3 %). 48.3 % of the patients reported prolonged pain lasting between one and five years. Factors associated with vulvar pain included a relatively high family history of diabetes mellitus (father = 8.6 %; mother = 8.4 %), recurrent vulvovaginal candidiasis (32 %), and urinary tract infections (37.4 %: recurrent cystitis in 19.5 % and post-coital cystitis in 17.9 %). Irritable bowel syndrome (28 %), constipation (23.5 %), headache (25.7 %: migraine in 18.0 % and menstrual headache in 7.7 %), allergies (17.5 %: food allergies in 10.1 %, respiratory allergies in 7.4 %), anxiety (15.0 %), dyschezia (11.7 %), invalidating dysmenorrhea/endometriosis (11.1 %), and major depression (7.6 %) were also reported. Vestibulodynia was diagnosed in 837 of the 1183 patients (70.8 %) and generalized vulvodynia in 323 (27.3 %). Notably, 69.1 % of the patients stated that previous therapies had not changed their pain. CONCLUSIONS: The diagnoses of vestibulodynia and vulvodynia must be considered in patients with chronic vulvar pain. The VuNet study contributes to a more comprehensive reading of the predisposing, precipitating and maintaining factors that contribute to vulvar pain, and of the key comorbidities.

Hormone therapy for first-line management of menopausal symptoms: Practical recommendations.

Hormone therapy use has undergone dramatic changes over the past 20 years. Widespread use of hormone therapy in the 1980s and 1990s came to an abrupt halt in the early 2000s after initial findings of the Women's Health Initiative trial were published and the study was terminated. Since then, much has been learned about the characteristics of women most likely to benefit from hormone therapy. There is general agreement that women younger than 60 years or who initiate hormone therapy within 10 years of menopause onset gain short-term benefit in terms of symptomatic relief and long-term benefit in terms of protection from chronic diseases that affect postmenopausal women. Despite accumulating evidence in support of hormone therapy for symptomatic menopausal women, the slow response by the medical community has led to a 'large and unnecessary burden of suffering' by women worldwide. Greater efforts are clearly needed to educate physicians and medical students about the pathophysiology of menopause and the role of hormone therapy in supporting women through the transition. This article provides a brief historical perspective of events that led to the backlash against hormone therapy, explores the current position of guideline groups, and provides practical recommendations to guide first-line management of symptomatic menopausal women.

Vasomotor symptoms and neurovegetative comorbidities on the menopause: insights from an Italian quantitative research.

Vasomotor symptoms (VMSs) are the most common symptoms affecting women during the menopause. Besides, affective symptoms may share with VMS a common biological pathophysiology. The current multicenter quantitative research was based on an online survey aimed to evaluate the impact of VMS in peri- and post-menopausal Italian women and to identify the main barriers to seeking help. The most frequent bothersome VMSs were hot flashes (41%), night sweats (31%), and over-heating (31%). Almost 87% of women experienced three or more simultaneous symptoms. Emotions verbalized by women indicate how intensely hot flushes and neuro-vegetative symptoms impact life: embarrassment, confusion, depression, impact on social/personal relationships, and guiltiness. Up to 43% of all women suffering from VMS were not treating the symptoms. Although 92% of women reported prior knowledge of the VMS condition, only 12% do something about it straight away after the appearance of VMS. This survey provided real-life observational data from a large population of peri-menopausal women and highlighted the important impact of VMS, its neurovegetative comorbidities and its significant burden effect on social life. Physicians must be more adaptive and inquisitive to evaluate and detect incipient VMS, as this will indicate the vulnerability to severe symptomatology and pathological brain aging.

The GENDER ATTENTION Observational Study: Gender and Hormonal Status Differences in the Incidence of Adverse Events During Cyclosporine Treatment in Psoriatic Patients.

INTRODUCTION: Female sex has been shown to be a risk factor for the development of adverse drug reactions; however, this has not been studied for cyclosporine (CsA). The aim of this study was to investigate, in Italian dermatological practice, the influence of gender and menopause and related hormones on the incidence of adverse events (AEs) during CsA treatment in psoriatic patients. METHODS: Multicenter, prospective, observational study conducted from May 2011 to June 2013. Patients with plaque psoriasis, undergoing a new CsA administration course, or about to start it, were enrolled in the outpatient clinics of Italian dermatological centers. During the 2-6 months of study duration, patients had to note all AEs that occurred in a diary that was reviewed by the investigators at the follow-up visit. Sex hormone levels were measured within 7 days from the start date of a menstrual cycle. RESULTS: A total of 969 adult psoriatic patients were enrolled in the study, divided into four cohorts: fertile women and corresponding age-matched men; postmenopausal women and corresponding age-matched men. A significant difference in the percentage of patients with AEs was observed between fertile and postmenopausal women, but not between women and age-matched men. AE incidence rate was about 37% higher in fertile women than in age-matched men and about 18% higher in postmenopausal women than in age-matched men, but differences were not statistically significant. Incidence rate ratio of fertile vs. postmenopausal women was 0.67, reaching statistical significance. AEs were mild or moderate in severity in the great majority of patients of all cohorts and postmenopausal women had significantly less grade 1-2 AEs compared to fertile women, but more grade 3-4 AEs. FSH levels were significantly higher in postmenopausal women reporting no AEs, and DHEA sulfate levels were about 10% higher in men with no AEs, compared to those reporting at least one AE. Cortisol levels were slightly though significantly higher in postmenopausal women with no AE. CONCLUSIONS: A better understanding of sex- and hormone-related influences on drug responses may help to improve drug safety and efficacy, by permitting one to tailor pharmacological treatments to individual subjects or defined patient cohorts. FUNDING: Novartis Farma S.p.A., Italy.

Alpha Lipoic Acid Plus Omega-3 Fatty Acids for Vestibulodynia Associated With Painful Bladder Syndrome.

OBJECTIVE: This study assessed the effectiveness of alpha lipoic acid (ALA) plus omega-3 polyunsaturated fatty acids (n-3 PUFAs) in combination with amitriptyline therapy in patients with vestibulodynia/painful bladder syndrome (VBD/PBS). METHODS: Women with VBD/PBS were randomly assigned to receive amitriptyline or amitriptyline plus a commercially available preparation (ALAnerv Age; Alfa Wassermann, Bologna, Italy) containing, in 2 capsules, ALA 600 mg plus docosahexaenoic acid 250 mg and eicosapentaenoic acid 16.67 mg. Symptoms of burning and pain were assessed using a 10-cm visual analog scale and the short form of the McGill-Melzack Pain Questionnaire. RESULTS: Among 84 women who were randomized, the mean ± standard deviation dose of amitriptyline was 21.7 ± 6.6 mg/day, without statistical difference between the two groups. Pain, as assessed using both the pain rating index of the visual analog scale and the short-form McGill Pain Questionnaire, decreased significantly in both trial groups, with a greater effect seen with the addition of ALA and n-3 PUFAs. The addition of ALA/n-3 PUFAs to amitriptyline treatment was also associated with improvements in dyspareunia and pelvic floor muscle tone. The overall incidence of adverse events was low, and none led to treatment discontinuation. CONCLUSIONS: The addition of ALA/n-3 PUFAs to amitriptyline treatment in patients with VBD/PBS appears to improve outcomes and may allow for a lower dosage of amitriptyline, which may lead to fewer adverse effects.

Six Out of Ten Women with Recurrent Urinary Tract Infections Complain of Distressful Sexual Dysfunction - A Case-Control Study.

Uncomplicated recurrent urinary tract infections (rUTIs) are common among reproductive-aged women. We aimed to assess the prevalence and predictors of sexual dysfunction (FSD) in a cohort of women with rUTIs and compare their psychometric scores to those of matched controls. Data from 147 rUTIs women and 150 healthy controls were analysed. Participants completed the International Prostatic Symptoms Score (IPSS), the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (SDS). Descriptive statistics and logistic regression models tested prevalence and predictors of distressful FSD. Women with rUTIs had lower FSFI scores (p < 0.001) and a greater proportion of pathological FSFI (78.9% vs. 21.4%; p < 0.001) and SDS scores (77.8% vs. 21.4%; p < 0.001) than controls. Of rUTIs patients, 88 (60%), 77 (52.2%), and 75 (51.1%) reported pathological scores for FSFI-pain, lubrication and arousal, respectively; moreover, 64% had concomitant pathological FSFI and SDS scores. Age, IPSS severity, rUTIs, a history of ≥6 UTIs/year and a history of constipation were independent predictors of pathologic FSFI and SDS (all p ≤ 0.05). In conclusion, up to 80% of women with rUTIs showed pathologic FSFI and SDS scores, with 60% reporting scores suggestive of distressful FSD. Having ≥6 UTIs/year and a history of constipation independently predicted distressful FSD.

Coital pain in the elderly: could a low dose estriol gel thrill the vulvar vestibule?

OBJECTIVE: The aim of this study was to evaluate the effectiveness of the application of 0.005% estriol gel to the vulvar vestibule in the management of postmenopausal dyspareunia. STUDY DESIGN: Postmenopausal women with dyspareunia were enrolled in this study. Patients were instructed to use a fingertip to apply 0.25g of vaginal gel containing 25µg of estriol to the vulvar vestibule daily for three weeks and then twice weekly for up to 12 weeks. RESULTS: Assessment of symptoms (dyspareunia and cotton swab test) and signs of vestibular atrophy were performed, and changes between baseline and weeks 3 and 12 were assessed. Adverse events were recorded. A total of 63 women were included. Of the 63, 59 (93.6%) completed the 12-week treatment period, and four dropped out for vestibular burning. Dyspareunia improved or was cured (score ≤1) by week 12 in 81.4% of patients. The patients also showed a statistically significant reduction in vestibular atrophy and cotton swab test at the end of treatment. CONCLUSIONS: Application of 0.005% estriol gel to the vulvar vestibule is effective in correcting menopausal coital pain. This suggests that reduction in sensory vestibular innervation sensitivity is likely to play a pivotal role in the relief of dyspareunia. One limitation of this study is the limited follow-up, but the therapy may be continued for as long as the patients are distressed by their symptoms without estrogen intervention.

Perimenstrual asthma: from pathophysiology to treatment strategies.

The prevalence of asthma is about 9,7 % in women and 5,5 % in men. Asthma can deteriorate during the perimenstrual period, a phenomenon known as perimenstrual asthma (PMA), which represents a unique, highly symptomatic asthma phenotype. It is distinguished from traditional allergic asthma by aspirin sensitivity, less atopy, and lower lung capacity. PMA incidence is reported to vary between 19 and 40 % of asthmatic women. The presence of PMA has been related to increases in asthma-related emergency department visits, hospitalizations and emergency treatment including intubations. It is hypothesized that hormonal status may influence asthma in women, focusing on the role of sex hormones, and specifically on the impact of estrogens' fluctuations at ovulation and before periods. This paper will focus on the pathophysiology of hormone triggered cycle related inflammatory/allergic events and their relation with asthma. We reviewed the scientific literature on Pubmed database for studies on PMA. Key word were PMA, mastcells, estrogens, inflammation, oral contraception, hormonal replacement therapy (HRT), and hormone free interval (HFI). Special attention will be devoted to the possibility of reducing the perimenstrual worsening of asthma and associated symptoms by reducing estrogens fluctuations, with appropriate hormonal contraception and reduced HFI. This novel therapeutical approach will be finally discussed.

Coronary Heart Disease, Diabetes, and Sexuality in Men.

Erectile dysfunction (ED) has been well recognized as a marker of increased cardiovascular risk for more than 15 years, especially in younger men. Early detection of ED represents an opportunity to intervene to decrease the risk of future cardiovascular events and limit the progression of ED severity. Evidence suggests there is a window of opportunity of 3 to 5 years from the onset of ED to subsequent cardiovascular events. This opportunity is usually missed if the onus is placed on the patient to seek care for his sexual problems. Unfortunately, these clear messages have not been incorporated into routine cardiovascular care. The reasons for these disparities within specialties are discussed in this article, in addition to management algorithms. Lifestyle modification is usually recommended as the first-line treatment to correct ED and lessen cardiovascular risk, but evidence suggests that this might be effective only in men without established cardiovascular comorbidities. In men with type 2 diabetes mellitus and established cardiovascular disease, lifestyle modification alone is unlikely to be effective. Cardiovascular medications are often associated with sexual dysfunction but changes in medication are more likely to be beneficial in men with milder recent-onset ED. A balanced view must be taken related to medication adverse events, taking into account optimal management of established cardiovascular disease. Testosterone deficiency has been associated with different metabolic disorders, especially metabolic syndrome and type 2 diabetes mellitus. Testosterone deficiency syndrome has been associated with an independent burden on sexual function globally and increased cardiovascular and all-cause mortality. Testosterone replacement therapy has been shown to improve multiple aspects of sexual function and, in some studies, has been associated with a decrease in mortality, especially in men with type 2 diabetes mellitus. Recent studies have suggested that phosphodiesterase type 5 inhibitors, the first-line medications to treat ED, could decrease cardiovascular and all-cause mortality, through multiple mechanisms, predominantly related to improved endothelial function.

Cancer, Benign Gynecology, and Sexual Function--Issues and Answers.

INTRODUCTION: The diagnosis, treatment, and survivorship of cancer have a profound effect on the quality of life and psychological well-being of men and women. Indeed, the perturbation of sexual function because of neoplasm has far-reaching implications. AIMS: To explore the prevalence, pathophysiology, and treatment of sexual issues in persons with cancer and offer evidence-based recommendations regarding optimal prevention and treatment strategies. METHODS: A committee of multidisciplinary specialists was formed as part of the larger International Sexual Medicine Consultation working with urologic and sexual medicine societies over a 1-year period to review the result of chronic-illness management on sexual function and satisfaction. The aims, goals, data collection techniques, and report format were defined by a central committee. MAIN OUTCOMES MEASURES: Expert consensus was based on evidence-based medical and psychosocial literature review, extensive group discussion, and an open presentation with a substantial discussion period. RESULTS: This summary evaluates contemporary literature concerning the prevalence, pathophysiology, and psychological impact of cancer diagnosis and treatment on sexual dysfunction. Evidence-based recommendations and guidelines for evaluation and management are presented. CONCLUSION: The diagnosis and treatment of cancer have a significant negative impact on sexual function and satisfaction. Comprehension of baseline sexual function, role of psychological supports, and available treatment options could attenuate the heavy burden of decreased sexual function.

The shorter, the better: A review of the evidence for a shorter contraceptive hormone-free interval.

OBJECTIVES: The menstrual cycle is characterised by cyclical fluctuations in oestrogens, progesterone and androgens. Changes in hormone levels in the premenstrual phase with the decline in progesterone trigger a physiological reaction which culminates in menstruation. This process is accompanied in many women by various symptoms such as pelvic pain, headache, mood disorders and gastrointestinal discomfort. The aim of this article was to summarise the latest findings on the physiology and pathophysiology of menstruation and review the impact of shortening the hormone-free interval (HFI) on the health and wellbeing of women. RESULTS: Menstruation can be viewed as an inflammatory event in which local and systemic effects produce symptoms in genital and extragenital regions of the body. The mast cells are the main mediator of this reaction. In women using hormonal contraceptives, menstrual bleeding is not biologically necessary and it may be advantageous to maintain more stable levels of oestrogens, progesterone and androgens throughout the cycle. New combined oral contraceptives (COCs) have been formulated with a progressively shorter HFI (24/4 and 26/2) than traditional 21/7 pills, with the rationale of reducing hormone withdrawal- associated symptoms. Several studies have shown the beneficial effects of these regimens, which reduce the inflammatory exposure of the female organism and thus have the capacity to increase the quality of life of women. A combination of estradiol valerate (E2V) and dienogest (DNG) is administered on the shortest 26/2 regimen. This regimen has a broad evidence base from randomised controlled trials that have examined the impact of E2V/DNG on symptoms and quality of life. CONCLUSIONS: Shortening the HFI reduces the occurrence of bleeding-related inflammatory processes and subsequent physical and mental symptoms. The shortest interval with evidence of reproductive and sexual health benefits is provided by a 26/2 regimen.

Anatomy and physiology of genital organs - women.

"Anatomy is destiny": Sigmund Freud viewed human anatomy as a necessary, although not a sufficient, condition for understanding the complexity of human sexual function with a solid biologic basis. The aim of the chapter is to describe women's genital anatomy and physiology, focusing on women's sexual function with a clinically oriented vision. Key points include: embryology, stressing that the "female" is the anatomic "default" program, differentiated into "male" only in the presence of androgens at physiologic levels for the gestational age; sex determination and sex differentiation, describing the interplay between anatomic and endocrine factors; the "clitoral-urethral-vaginal" complex, the most recent anatomy reading of the corpora cavernosa pattern in women; the controversial G spot; the role of the pelvic floor muscles in modulating vaginal receptivity and intercourse feelings, with hyperactivity leading to introital dyspareunia and contributing to provoked vestibulodynia and recurrent postcoital cystitis, whilst lesions during delivery reduce vaginal sensations, genital arousability, and orgasm; innervation, vessels, bones, ligaments; and the physiology of women's sexual response. Attention to physiologic aging focuses on "low-grade inflammation," genital and systemic, with its impact on women sexual function, especially after the menopause, if the woman does not or cannot use hormone replacement therapy.

Genital and sexual pain in women.

This chapter discusses the all too common problem of sex-related pain in women. Pain is a complex perceptive experience, involving biologic as well as psychologic and relational meanings. They become increasingly important with the chronicity of pain. Neurologists are quite aware of the painful aspect of many neurologic disorders, but lifelong and acquired genital and sexual pain is still neglected in a consistent percentage of women. One reason is the view - still held by many - that psychologic factors play the most important role in sex-related pain complaints. The consequences of diagnostic delay can be dramatic. Persisting tissue inflammation induces pain to change from acute and "nociceptive," which indicates a "friendly signal," alerting one to ongoing tissue damage, to chronic and "neuropathic," a disease per se. Whilst the primary disease is progressing and neuroinflammation becomes a prominent feature, affected women have to bear years of pain and distress, huge quantifiable and non-quantifiable costs, and a progressive deterioration of personal and relational health and happiness. The scenario is even more dramatic when pain complicates an already disabling disease. The main aspects considered in this chapter include neuroinflammation as a key feature of pain; genital and sexual pain as part of neurologic diseases; and genital and sexual pain syndrome (dyspareunia and vaginismus) as primary problems, and their pelvic comorbidities (bladder pain syndrome, endometriosis, irritable bowel syndrome, provoked vestibulodynia/vulvodynia). Finally, we discuss iatrogenic pain, i.e., genital and sexual pain caused by ill-conceived medical, surgical, pharmacologic or radiologic therapeutic interventions.