Hormone therapy for sexual function in perimenopausal and postmenopausal women.

BACKGROUND: The perimenopausal and postmenopausal periods are associated with many symptoms, including sexual complaints. This review is an update of a review first published in 2013. OBJECTIVES: We aimed to assess the effect of hormone therapy on sexual function in perimenopausal and postmenopausal women. SEARCH METHODS: On 19 December 2022 we searched the Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, ISI Web of Science, two trials registries, and OpenGrey, together with reference checking and contact with experts in the field for any additional studies. SELECTION CRITERIA: We included randomized controlled trials that compared hormone therapy to either placebo or no intervention (control) using any validated assessment tool to evaluate sexual function. We considered hormone therapy: estrogen alone; estrogen in combination with progestogens; synthetic steroids, for example, tibolone; selective estrogen receptor modulators (SERMs), for example, raloxifene, bazedoxifene; and SERMs in combination with estrogen. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures recommended by Cochrane. We analyzed data using mean differences (MDs) and standardized mean differences (SMDs). The primary outcome was the sexual function score. Secondary outcomes were the domains of sexual response: desire; arousal; lubrication; orgasm; satisfaction; and pain. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included 36 studies (23,299 women; 12,225 intervention group; 11,074 control group), of which 35 evaluated postmenopausal women; only one study evaluated perimenopausal women. The 'symptomatic or early postmenopausal women' subgroup included 10 studies, which included women experiencing menopausal symptoms (symptoms such as hot flushes, night sweats, sleep disturbance, vaginal atrophy, and dyspareunia) or early postmenopausal women (within five years after menopause). The 'unselected postmenopausal women' subgroup included 26 studies, which included women regardless of menopausal symptoms and women whose last menstrual period was more than five years earlier. No study included only women with sexual dysfunction and only seven studies evaluated sexual function as a primary outcome. We deemed 20 studies at high risk of bias, two studies at low risk, and the other 14 studies at unclear risk of bias. Nineteen studies received commercial funding. Estrogen alone versus control probably slightly improves the sexual function composite score in symptomatic or early postmenopausal women (SMD 0.50, 95% confidence interval (CI) (0.04 to 0.96; I² = 88%; 3 studies, 699 women; moderate-quality evidence), and probably makes little or no difference to the sexual function composite score in unselected postmenopausal women (SMD 0.64, 95% CI -0.12 to 1.41; I² = 94%; 6 studies, 608 women; moderate-quality evidence). The pooled result suggests that estrogen alone versus placebo or no intervention probably slightly improves sexual function composite score (SMD 0.60, 95% CI 0.16 to 1.04; I² = 92%; 9 studies, 1307 women, moderate-quality evidence). We are uncertain of the effect of estrogen combined with progestogens versus placebo or no intervention on the sexual function composite score in unselected postmenopausal women (MD 0.08 95% CI -1.52 to 1.68; 1 study, 104 women; very low-quality evidence). We are uncertain of the effect of synthetic steroids versus control on the sexual function composite score in symptomatic or early postmenopausal women (SMD 1.32, 95% CI 1.18 to 1.47; 1 study, 883 women; very low-quality evidence) and of their effect in unselected postmenopausal women (SMD 0.46, 95% CI 0.07 to 0.85; 1 study, 105 women; very low-quality evidence). We are uncertain of the effect of SERMs versus control on the sexual function composite score in symptomatic or early postmenopausal women (MD -1.00, 95% CI -2.00 to -0.00; 1 study, 215 women; very low-quality evidence) and of their effect in unselected postmenopausal women (MD 2.24, 95% 1.37 to 3.11 2 studies, 1525 women, I² = 1%, low-quality evidence). We are uncertain of the effect of SERMs combined with estrogen versus control on the sexual function composite score in symptomatic or early postmenopausal women (SMD 0.22, 95% CI 0.00 to 0.43; 1 study, 542 women; very low-quality evidence) and of their effect in unselected postmenopausal women (SMD 2.79, 95% CI 2.41 to 3.18; 1 study, 272 women; very low-quality evidence). The observed heterogeneity in many analyses may be caused by variations in the interventions and doses used, and by different tools used for assessment. AUTHORS' CONCLUSIONS: Hormone therapy treatment with estrogen alone probably slightly improves the sexual function composite score in women with menopausal symptoms or in early postmenopause (within five years of amenorrhoea), and in unselected postmenopausal women, especially in the lubrication, pain, and satisfaction domains. We are uncertain whether estrogen combined with progestogens improves the sexual function composite score in unselected postmenopausal women. Evidence regarding other hormone therapies (synthetic steroids and SERMs) is of very low quality and we are uncertain of their effect on sexual function. The current evidence does not suggest the beneficial effects of synthetic steroids (for example tibolone) or SERMs alone or combined with estrogen on sexual function. More studies that evaluate the effect of estrogen combined with progestogens, synthetic steroids, SERMs, and SERMs combined with estrogen would improve the quality of the evidence for the effect of these treatments on sexual function in perimenopausal and postmenopausal women.

Female sexual dysfunctions: an overview on the available therapeutic interventions.

INTRODUCTION: There are different types of female sexual dysfunctions (FSDs), and FSD in general has a high prevalence worldwide. Studies of FSD should consider it as a multifactorial disorder that has biological, psychological, environmental, and relational aspects. In this review we discuss the available therapeutic interventions for FSD. EVIDENCE ACQUISITION: For the current narrative review the PubMed database was searched to identify all publications up to 30 March 2021 that were systematic reviews and meta-analyses which examined therapeutic interventions for FSDs based on the diagnostic classifications of ICD-10 and ICD-11. EVIDENCE SYNTHESIS: Thirty systematic reviews and meta-analyses were included in this review. Hormone therapy (HT) and testosterone are effective to improve sexual desire in menopausal women. In these women HT and ospemiphene may improve pain during intercourse. Flibanserin may improve sexual desire and may reduce desire-related distress in premenopausal women. Bremelanotide is effective to improve desire, arousal, and orgasm scores. Evidence are still limited on the efficacy of psychoactive drugs, phosphodiesterase type 5 (PDE5), oxytocin, herbal drugs, and tibolone to treat FSDs. Psychological interventions such as cognitive-behavior therapy, mindfulness training, sensate focus, bibliotherapy are effective for the management of several different FSDs. CONCLUSIONS: The management of FSDs may require multidisciplinary and interdisciplinary approaches. Pharmacological and nonpharmacological interventions appears to have potential as a treatment for FSDs, but there are currently no gold standards regarding recommended treatment modalities, and the duration, frequency, and intensity of therapy sessions.

Pelvic Floor Muscle Training Effect in Sexual Function in Postmenopausal Women: A Randomized Controlled Trial.

BACKGROUND: The prevalence of sexual dysfunction is high in postmenopausal women and pelvic floor muscle training (PFMT) could improve sexual function during this period. AIM: To assess the effect of a PFMT protocol on sexual function in postmenopausal women and to investigate the effect of this protocol on pelvic floor muscle function. METHODS: This is an assessor blinded randomized controlled trial including 77 postmenopausal women. The study was registered in ReBEC Trial: RBR-3s3ff7. The intervention group (n = 40) received an intensive supervised PFMT protocol during 12 weeks and the control group (n = 37) received no intervention. OUTCOMES: The primary outcome of the study was assessed by the Female Sexual Function Index (FSFI) questionnaire and the secondary outcome was the evaluation of pelvic floor muscle function performed by digital palpation using the modified Oxford scale at baseline and after 12 weeks. RESULTS: No difference between groups was found in the FSFI domains and total score at baseline and in the second evaluation after 12 weeks. However, after 12 weeks, a higher percentage of women without sexual dysfunction was found in the intervention group (95% CI = 27.97-72.03) when compared to the control group (95% CI = 7.13-92.87). No difference was found between groups in relation to the pelvic floor muscle function at the baseline (P = .2) and after 12 weeks (P = .06). CLINICAL IMPLICATIONS: PFMT is a conservative intervention that can lead women to have less sexual dysfunction. STRENGTHS & LIMITATIONS: The protocol provided a reduced number of women with sexual dysfunction, the strength of this research is the study design and the limitation is to have used only one tool to assess sexual function although it is a validated questionnaire. CONCLUSION: PFMT decreases sexual dysfunction in postmenopausal women. MM Franco, CC Pena, LM de Freitas, et al. Pelvic Floor Muscle Training Effect in Sexual Function in Postmenopausal Women: A Randomized Controlled Trial. J Sex Med 2021;18:1236-1244.

Comparison of Sexual Dysfunction in Women Who Were or Were Not Victims of Sexual Violence.

The victims of sexual violence may develop FSD. This retrospective study examined the characteristics of women victims of sexual abuse who had FSD who attended a tertiary hospital from 2004 to 2017. Patients were divided in two groups: women who were victims of sexual violence and women who were not victims (controls). One thousand and ten women (60.4%) presented with FSD and 610 of them were eligible for inclusion, 134 (21.97%) reported they were victims of sexual violence, and the abuser was mostly someone close to the victim (92.31%). Depression was more prevalent in the women who were victims (32.1% vs. 18.3%; p<0.05), 74.0% vs. 59.8% had hypoactive sexual desire disorder (HSDD) (p<0.05), 20.3% of victims vs. 7.19% of controls (p<0.05) had primary anorgasmia, and 51.15% of the victims and 39.61% of controls reported anorgasmia. The victims reported a lower sex drive (39.6% vs. 52.3%), and reduced arousal (48.8% vs. 61.3%; all p<0.05). More of the victims than controls reported that their partners had engaged in an extramarital relationship (19.0% vs. 9.25%, p<0.05).

Determinants of Female Sexual Function in Breastfeeding Women.

Knowledge about the determinants of female sexual function in breastfeeding women is limited. A total of 355 breastfeeding women completed the Female Sexual Function Index (FSFI) and the Qol-8 quality of life questionnaire. FSFI scores decreased in the first six months of breast feeding. There was a positive relationship between FSFI scores and the importance of sex, level of communication, income, quality of life, and receiving brief sexual counseling.

Age at Time of Initial Sexual Intercourse and Health of Adolescent Girls.

Adolescence is characterized by marked changes in the body, psychology, and sexual behavior due to increasing production of hormones. In this review we aimed to assess the effect of age at the time of first sexual intercourse (sexarche) on the health of adolescent girls, and identify factors that might protect against early initiation of sexual relations in girls. The PubMed, Lilacs, and Google Scholar databases were searched for clinical trials, comparative studies, case-control studies, cross-sectional studies, cohort studies, multicenter studies, observational studies, meta-analyses, and systematic reviews published up to December 2014 on this theme. The search terms were: "sexual debut," "coitarche," "sexarche," and "young people," "adolescent," "unplanned pregnancy," "adolescent contraception," and "STDs." Data were extracted from 28 studies and 41 references were used to introduce the theme and to support the discussion. Sexarche has been occurring in increasingly younger girls. A young age at sexarche can lead to subsequent risky sexual behavior. Girls who have sexarche when they are 14 years old or younger are less likely to use contraception on this occasion, take more time before they start using contraception in subsequent sexual relations, are more likely to have several sex partners, have a higher risk for depression, have lower self-esteem and more episodes of repentance, and have a higher risk for a sexually transmitted disease and cervical cancer. Girls with low educational, socioeconomic, and cultural status, little parental monitoring, parental separation, and absence of religiosity tend to experience sexarche at a younger age. Adolescent girls who postpone sexarche until they are 16 years old are physically and psychologically healthier than those who have sexarche at a younger age. This suggests that providing adolescent girls with appropriate education about sexual relations might reduce the negative effect of sexual relations at a young age.

Gonadotropin and Estradiol Levels after Leuprolide Stimulation Tests in Brazilian Girls with Precocious Puberty.

STUDY OBJECTIVE: To determine the best cutoff value on the leuprolide stimulation test for the diagnosis of central precocious puberty (CPP) in a Brazilian population. DESIGN, SETTING, AND PARTICIPANTS: This observational study included 60 girls with CPP, as shown on the basis of serum concentrations of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) before and 3 hours after subcutaneous administration of 500 µg leuprolide acetate and by measuring serum estradiol concentrations 24 hours later. Six months later, each subject was clinically evaluated to determine whether she had experienced progressive or nonprogressive puberty. MAIN OUTCOME MEASURES: Analyzing the best cutoff for LH after subcutaneous administration of 500 µg leuprolide acetate. RESULTS: The best cutoff was a 3-hour LH level of greater than 4.0 mIU/mL, providing the highest sensitivity (73%) and specificity (83.1%), whereas a 3-hour LH level greater than 8.4 mIU/mL had a specificity of 100%. A 24-hour E2 concentration greater than 52.9 pg/mL had a sensitivity of 68% and a specificity of 74%. There was no association between pubertal development and disease progression. Signs such as thelarche and pubarche did not determine the evolution of the disease (P = .17). Clinical condition was associated with bone age/chronological age (P = .01), basal LH (P < .01), 3-hour LH (P = .02), baseline LH/FSH indices (P < .01) and after 3 hours (P < .01), and E2 at 24 hours (P = .02). CONCLUSION: The optimal parameter indicating hypothalamic-pituitary-gonadal axis activation in our sample was a 3-hour LH level greater than 4.0 mIU/mL. A diagnosis of CPP, however, should be based on a set of criteria and not on an isolated measurement, because typical laboratory findings associated with CPP may not be present in all patients.

Effect of infertility on the sexual function of couples: state of the art.

OBJECTIVE: Assess the state of the art on the relationship between infertility and the sexual function of couples. DATA SOURCES: The PubMed, Lilacs, and Google Scholar databases were searched for articles that assessed the sexual function of infertile couples (IC). Recent patents on this subject were assessed. STUDY SELECTION: Quantitative studies published in the English language (case-control, cross-sectional, cohort, multicenter, observational studies, randomized controlled trials, meta-analyses, systematic reviews) that used structured and semi-structured questionnaires for quantitative assessment of the sexual function of infertile couples were identified using the search terms: "infertile couple" and "sexuality", "sexual dysfunction", "sexual function", "sexual disorder", "hypoactive sexual desire". DATA EXTRACTION: One researcher identified 12 studies, and extracted data on 1871 IC. Five studies used different instruments to assess different aspects of sexual function and 7 studies assessed sexual function based on sub-domains of instruments used to evaluate marital relationships. DATA SYNTHESIS: Incongruent results due to different objectives and methodologies, the lack of specific questionnaires to assess sexual function, and uncontrolled social and relationship variables that could have interfered with sexual function were evident in most studies. CONCLUSION: The lack of standardized methodology or validated tools in most studies prevents to establish the impact of infertility on the sexual function of IC.

Cytology for the detection of early recurrence of gynecologic cancer in the vaginal vault.

OBJECTIVE: The real benefit of follow-up cervical cytology in women treated for gynecological cancer is unclear. This study was designed to assess the rate of success of cytological examinations in the detection of early vaginal recurrence of gynecological cancer in women found by other methods to have vaginal recurrence of cervical and endometrial cancer. DATA SOURCES: Records of cytological examinations. STUDY SELECTION: Thirty-three women treated for early and invasive cervical and endometrial cancer with recurrence in the vaginal vault were retrospectively analyzed. DATA EXTRACTION: Records from 1979 to 2010. DATA SYNTHESIS: Sixteen women (48.5%) had symptomatic vaginal recurrence associated with distant metastases, whereas 17 (51.5%) had vaginal recurrence only. Cytology was negative in 12 women (36.4%) with both symptomatic and asymptomatic recurrence and positive in the other 21 (63.6%). In 9 of these 21 women (42.9%), the disease was limited to the vaginal vault, whereas the remaining 12 (57.1%) presented with vaginal lesions associated with distant metastases. Cytology was positive in 9 of the 17 (52.9%) women whose recurrence was limited to the vaginal vault and negative in 8 (47.1%). CONCLUSION: Vaginal cytology yielded false-negative results in almost half of the women with vaginal recurrence of gynecological cancer. Patents of methods used for early diagnosis and detection of immortalization of cervical cancer are also reviewed in this article.

Treatment of orgasmic urinary incontinence with physical therapy and weight loss / Tratamento da incontinência urinária orgásmica com fisioterapia e redução de peso

Importance of the problem: Orgasmic urinary incontinence (OUI) is an uncommon finding among other types of urinary leakage. Treatment of this condition is not established. Aims: To describe the case of a patient who presented OUI and had a multidisciplinary treatment. Methods: An obese, 50-year patient complained of OUI with two sexual partners during her consultation. Pharmacological treatment with imipramine and anticholinergics were undertaken, without success. Results: Patient had an important subjective improvement after performing a treatment combination of biofeedback, electrostimulation, pelvic floor muscle training and behavioral measurements such as weight loss, improved after bariatric surgery. Comments: OUI is a complex disorder, without standard treatments and needs to be further investigated with larger, prospective samples. Combined physical therapy approaches should be considered when discussing treatment.

Importância do problema: Incontinência urinária orgásmica (IUO) é um tipo incomum dentre os tipos de perda urinária. O tratamento para esta condição ainda não está estabelecido. Objetivo: Descreve o caso de uma paciente que apresentou IUO e foi submetida ao tratamento multidisciplinar. Metodologia: Paciente obesa, 50 anos, relatando, durante a consulta, IUO com dois parceiros sexuais. Tratamento farmacológico com imipramina e anticolinérgicos foram realizados sem sucesso. Resultados: Paciente apresentou importante melhora subjetiva após a realização de uma combinação de tratamento debiofeedback, eletroestimulação, treinamento muscular do assoalho pélvico e medidas comportamentais, como perda de peso, incrementada após a cirurgia bariátrica. Comentários: IUO é uma doença complexa, sem tratamentos padrão e precisa ser mais bem investigada com amostras prospectivas maiores. Abordagens fisioterapêuticas combinadas devem ser consideradas quando se discute o tratamento.

Current research on how infertility affects the sexuality of men and women.

OBJECTIVE: To assess data published from 2000 to 2010 on the effect of infertility on the sexual function of men and women. DATA SOURCES: The PubMed, Lilacs and Embase databases were searched for scientific articles assessing the sexual response of couples during infertility treatment. STUDY SELECTION: Studies selected for this review were published in English and conducted in human beings; articles included meta-analyses and cross-sectional or cohort studies that used objective measurement tools to quantitatively assess the data. DATA EXTRACTION: Seven studies met the inclusion criteria for this review. DATA SYNTHESIS: Infertility is a major risk factor for sexual problems in both men and women. CONCLUSION: Infertile couples are at higher risk of sexual dysfunction than fertile couples. We also describe several recent patents.

Hormone therapy for sexual function in perimenopausal and postmenopausal women.

BACKGROUND: The perimenopausal and postmenopausal periods are associated with many symptoms, including sexual complaints. OBJECTIVES: To assess the effect of hormone therapy (HT) on sexual function in perimenopausal and postmenopausal women. SEARCH METHODS: We searched for articles in the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, ClinicalTrials.gov, Current Controlled Trials, WHO International Clinical Trials Registry Platform, ISI Web of Knowledge and OpenGrey. The last search was performed in December 2012. SELECTION CRITERIA: We included randomised controlled trials comparing HT to either placebo or no intervention (control). We considered as HT estrogens alone; estrogens in combination with progestogens; synthetic steroids (for example tibolone); or selective estrogen receptor modulators (SERMs) (for example raloxifene, bazedoxifene). Studies of other drugs possibly used in the relief of menopausal symptoms were excluded. We included studies that evaluated sexual function using any validated assessment tool. The primary outcome was a composite score for sexual function and the scores for individual domains (arousal and sexual interest, orgasm, and pain) were secondary outcomes. Studies were selected by two authors independently. DATA COLLECTION AND ANALYSIS: Data were independently extracted by two authors and checked by a third. Risk of bias assessment was performed independently by two authors. We contacted study investigators as required. Data were analysed using standardized mean difference (SMD) and relative risk (RR). We stratified the analysis by participant characteristics with regard to menopausal symptoms. The overall quality of the evidence for the primary outcome was evaluated using the GRADE criteria. MAIN RESULTS: The search retrieved 2351 records from which 27 studies (16,393 women) were included. The 'symptomatic or early post-menopausal' subgroup included nine studies: perimenopausal women (one study), up to 36 months postmenopause (one study), up to five years postmenopause (one study), experiencing vasomotor or other menopausal symptoms (five studies), or experiencing hot flushes and sexual dysfunction (one study). The 'unselected postmenopausal women' subgroup included 18 studies, which included women regardless of menopausal symptoms and permitted the inclusion of women with more than five years since the final menstrual period. No studies were restricted to women with sexual dysfunction. Only five studies evaluated sexual function as a primary outcome. Eighteen studies were deemed at high risk of bias, and the other nine studies were at unclear risk of bias. Twenty studies received commercial funding.Findings for sexual function (measured by composite score):For estrogens alone versus control, in symptomatic or early postmenopausal women the SMD and 95% CI were compatible with a small to moderate benefit in sexual function for the HT group (SMD 0.38, 95% CI 0.23 to 0.54, P < 0.00001, 3 studies, 699 women, I² = 55%, high-quality evidence). In unselected postmenopausal women, the 95% CI was compatible with no effect to a small benefit (SMD 0.16, 95% CI -0.02 to 0.34, P = 0.08, 2 studies, 478 women, I² = 44%, low-quality evidence). The subgroups were not pooled because of considerable heterogeneity.For estrogens combined with progestogens versus control, in symptomatic or early postmenopausal women the 95% CI was compatible with a small to moderate benefit for sexual function in the HT group (SMD 0.42, 95% CI 0.19 to 0.64, P = 0.0003, 1 study, 335 women, moderate-quality evidence). In unselected postmenopausal women, the 95% CI was compatible with no effect to a small benefit (SMD 0.09, 95% CI -0.02 to 0.20, P = 0.10, 3 studies, 1314 women, I² = 0%, moderate-quality evidence). The subgroups were not pooled because of considerable heterogeneity.For tibolone versus control, in symptomatic or early postmenopausal women the 95% CI was compatible with no effect to a small benefit for sexual function in the HT group (SMD 0.13, 95% CI 0.00 to 0.26, P = 0.05, 1 study, 883 women, low-quality evidence). In unselected postmenopausal women, the 95% CI was compatible with no effect to a moderate benefit (SMD 0.38, 95% CI 0.04 to 0.71, P = 0.03, 2 studies, 142 women, I² = 0%, low-quality evidence). In the combined analysis, the 95% CI was compatible with no effect to a small benefit (SMD 0.17, 95% CI 0.04 to 0.29, P = 0.008, 3 studies, 1025 women, I² = 20%).For SERMs versus control, in symptomatic or early postmenopausal women the 95% CI was compatible with no effect to a moderate benefit for sexual function in the HT group (SMD 0.23, 95% CI -0.04 to 0.50, P = 0.09, 1 study, 215 women, low-quality evidence). In unselected postmenopausal women, the 95% CI was compatible with small harm to a small benefit (SMD 0.04, 95% CI -0.20 to 0.29, P = 0.72, 1 study, 283 women, low-quality evidence). In the combined analysis, the 95% CI was compatible with no effect to a small benefit (SMD 0.13, 95% CI -0.05 to 0.31, P = 0.16, 2 studies, 498 women, I² = 2%).A comparison of SERMs combined with estrogens versus control was only evaluated in symptomatic or early postmenopausal women. The 95% CI was compatible with no effect to a small benefit for sexual function in the HT group (SMD 0.21, 95% CI 0.00 to 0.43, P = 0.05, 1 study, 542 women, moderate-quality evidence). AUTHORS' CONCLUSIONS: HT treatment with estrogens alone or in combination with progestogens was associated with a small to moderate improvement in sexual function, particularly in pain, when used in women with menopausal symptoms or in early postmenopause (within five years of amenorrhoea), but not in unselected postmenopausal women. Evidence regarding other HTs (synthetic steroids and SERMs) is of low quality and we are uncertain of their effect on sexual function. The current evidence does not suggest an important effect of tibolone or of SERMs alone or combined with estrogens on sexual function. More studies evaluating the effect of synthetic steroids, SERMS and the association of SERM + estrogens would improve the quality of the evidence for the effect of these treatments on sexual function in peri and postmenopausal women. Future studies should also evaluate the effect of HT solely among women with sexual complaints.