Therapeutic options for postmenopausal female sexual dysfunction.

BACKGROUND: Female sexual dysfunction (FSD) is a multidimensional problem combining biological, psychological and interpersonal elements of multiple etiologies. Menopause-related sexual dysfunction may not be reversible without therapy. Hormonal deficiency does not usually decrease in severity over time. Many options are available for the successful treatment of postmenopausal FSD. OBJECTIVE: To review the pharmacological and non-pharmacological therapies available for postmenopausal FSD, focusing on practical recommendations for managing postmenopausal women with sexual complaints, through a literature review of the most relevant publications in this field. PSYCHOSOCIAL THERAPY: This type of therapy (basic counselling, physiotherapy and psychosexual intervention) is considered an adaptable step-by-step approach for diagnostic and therapeutic strategies, normally combined with biomedical interventions to provide optimal outcomes. PHARMACOLOGICAL THERAPY: For postmenopausal FSD, many interventional options are now available, including hormonal therapies such as estrogens, testosterone, combined estrogen/testosterone, tibolone and dehydroepiandrosterone. CONCLUSIONS: Menopause and its transition represent significant risk factors for the development of sexual dysfunction. FSD impacts greatly on a patient's quality of life. Consequently, it is receiving more attention thanks to the development of effective treatments. Non-pharmacological approaches should be used first, focusing on lifestyle and psychosexual therapy. If required, proven effective hormonal and non-hormonal therapeutic options are available.

[Psychogenic amenorrhea]. / Aménorrhées psychogènes.

Any amenorrhoea noticed outside pregnancy, lactation and menopause periods might be of organic or functional origin. Today, non organic amenorrhoea are either called hypothalamic amenorrhoea, more exactly supra hypothalamic amenorrhoea; functional amenorrhoea--this definition being characterized by its lack of any anatomic substratum; or, psychogenic amenorrhoea--an etiologic definition. Like any amenorrhoea, functional or psychogenic amenorrhoea is the consequence of either anovulation or endometrial hypotrophy. Neuroendocrine sciences do open new exciting research perspectives but other ways all the more promising since hormonal mechanics would not be the explanation. Work on the unconscious is indeed the other road leading to these psychogenic amenorrhoea. The term "psychogenic"--of psychological origin--does not mean of unknown origin, provided we recognize the strong link between psyche and soma. Treatment for this kind of amenorrhoea is twofold: medical and psychotherapeutic. Even though psychological etiology is obvious, clinical examination must be rigorous and completed by complementary exams which will guide the therapeutics. This is reassuring to the patient for the gynaecologist she chose to consult is implied, and not the psychotherapist. This reassures us too, because what we care for, as doctors, is first of all the body. Psychotherapeutic support can be provided by the general practitioner or the gynaecologist, both with psychosomatics training, but a multidisciplinary approach must often be worked out.

[Erectile dysfunction, sexuality and sociocultural aspects]. / Dysfonction érectile, sexualité et influence socioculturelle.

Perception of sexuality varies considerably from population to population and their cultural inheritance, depending on whether you consider occidental, oriental or African cultures. In a wider concept of environment, worries, anxiety or stress induced by work, family, social and economic factors may have a negative impact on sexual functions. Quantitative surveys on sexuality try to measure the incidence of love feelings on sexual behaviour but they cannot determine the close overlaps between mind and body. To give his partner satisfaction, men do not always need performing well. Men also have right to love women, their own ways and according to their means. Impotence or erectile dysfunction (ED) is nowadays a subject that is more and more studied on conceptual, epidemiological as much as clinical levels. Taking this trouble into consideration is relatively new for the general public and seems to coincide with the launching towards the end of the last decade of the first real effective oral treatment, the phosphodiesterase 5 (PDE5) inhibitors and of the communication developed around this event. Demand for sexual problems management seems to be on the increase.

[Couple, sexuality and sexual health]. / Couple, sexualité et santé sexuelle.

Sexuality remained for a long time in the intimacy domain, judged worthy of a consultation reason only and yet as an illness cause or a male failure. Besides, dyspareunia and various women's illnesses took more time to be worthy of interest and care. And now it seems almost as if a turnaround were taking place. This mutation will probably induce some cultural changes. This paper focuses on the fifty-year-old man, in a world in which sexuality, from a universal right, becomes an obligation with the need for means and results, a requirement for performance. In order to discover how to approach these old problems with nowadays tools, we carried out a Medline review on sexuality and impotence, or erectile dysfunction (ED), which is a real problem in public health policy concerning more than 150 million men all over the world and more than 2 million in France. The analysis of the main papers associated with our own experience, allows us to better understand the changes in men/women relationship and the disclosure of male fragility, visible in the management of their well-being, their state of anxiety fowards this new women's control which probably influences their attitude in front of ageing and its consequences.

[Erectile dysfunction drugs and women]. / Les médicaments de la dysfonction érectile et les femmes.

Erectile dysfunction (ED) is no more a taboo and the number of patients who are consulting a physician and asking for some help in this domain is growing every day. The quality of life of men presenting an ED and having access to treatments is continually improving. But what can be said concerning the partners' quality of life? Patients as much their partners clearly prefer lesser invasive therapeutics and the new oral drugs available present some advantages for the couples, and surely for a majority of female partners, willing to improve the spontaneity and the frequency of intercourse. It seems now obvious that the partner's help is one of the key points for a successful treatment. How will women facing this recovered virility react? What will they say in the secret of the consulting room? What could be exactly the role of the gynaecologist in assuming the female partner of a man treated for an ED? That is the object of the present article, dealing with quite an important matter.

[Place of persistence trouble during oral contraception and subsequent use of emergency contraception]. / Place des troubles de la persistance contraceptive dans les situations à risque de grossesse, utilisation subséquente de la contraception d'urgence.

OBJECTIVE: In order to improve the understanding of hormonal contraceptive failures, this study evaluates the persistence of oral contraception and the use of emergency contraception (EC) during persistence incidents. We made the hypothesis of the existence of a strong link between the risk of unplanned pregnancies and these two parameters. In this study, we also evaluated women's perception of EC in order to elucidate the reasons of EC insufficient use. METHODS: One survey was carried out on Internet on a representative sample of women, aged 16-45. RESULTS: In this survey, 3775 French women were interviewed (source-population). We defined a target population of 2415 fertile women who had heterosexual intercourse during the last 12 months, and a population of 760 women at risk of unintended pregnancy who had unprotected sexual intercourse during the last 12 months(risk-population). A little more than 30% of the target population, meaning 20% of the source-population (n=745) stopped their contraceptive method temporarily for an average time of two months. Almost 60% of women had a risk of unwanted pregnancy during this period without contraception, which is 59% of the risk-population. Only 20% of women among the population at risk used EC. The main reasons given for EC insufficient use were the misperception of the risk of pregnancy, the lack of knowledge about EC and its way of use. CONCLUSION: For the first time, this survey shows that 13% of women (of the source population) decide to stop temporarily their contraceptive method for an average time of two months per year. Fifty-nine percent of unplanned pregnancy situations are due to this poor contraception persistence. Although there is a need to reduce the risk of women being at risk, it seems also highly desirable to overcome the consequences of this poor persistence. Giving information about EC and a systematic prescription during contraception consultations would lead to an increased use of EC.

[Body remodeling, or the quest of the desire]. / Les remodelages du corps ou la quête du désir.

A few thoughts about the passing of time, woman's times, and times of youth: the very youth our society, afraid of its new longevity, refuses to lose at least its visible features. How to be lovable and desirable, or rather how to stay so: there is the prescription our patients expect from our tender loving care. This was inspired by a round table on "Time lost and regained" at the January 2002 JTA meeting, [in Punta Cana].

[Psychosomatic gynaecology or gynaecology and psychosomatics?]. / Gynécologie psychosomatique, gynécologie et psychosomatique ?

Such an interrogation might well seem vain or even absurd, although one cannot deny that it does mean a different vision of medicine, if not an entirely different conception of it. Considering the sick person as a whole and not only the sickness of one organ means practicing a true holistic approach, far from a limited somatic medicine addressing the psyche only in case of failure, as a last resort. Rather than artificially applying to the soma some would-be psychological recipes, let us try and take up that bet: a simultaneous use, in time and space, of body and mind medicine. Psychosomatic gynaecology certainly requires will and training, disponibility and curiosity, but it might well be the best protection against boredom and routine, as well as a true source of pleasure. Can such a satisfying way of practicing our art be anything else than a bonus for our patients?

[Sexual abuse: what gynaecologists hear]. / Abus sexuels : ce qu'en entendent les gynécologues.

For the last decade, it has become impossible for us to ignore the reality, frequency and psychopathological consequences of sexual abuses, even if those seldom constitute the official motive of patients' consultation. Many victims still hold to their secret. Hints such as behavior in our consultation rooms, way of expressing gynecological problems and certain sexual troubles should enable us to perceive their suffering. As for its cause, some patients, given enough time and empathy, will be able to open up and reveal it. It will take a long time as well as the help of other specialists to find the path towards repairing the damage.

[Improving oral contraception compliance. The "ringing card": memory aid or new ritual?]. / Améliorer l'observance de la contraception orale. La "carte qui sonne": aide-mémoire ou nouveau rituel?

Forgetting to take pills is frequent and induces an avoidable risk of unwanted pregnancy. The integration of the daily use of the pill into a ritual allows to improve compliance. Nine hundred and seventy-five women were retrospectively asked by 180 gynecologists about missed pills in the last three and six months. More than nine out of ten women declare having forgotten at least one pill in the last six months. In 39% of the cases the pill was missed during the first week of 'cycle' in which the risk of pregnancy is theoretically increased. In this survey, 485 women used the compliance card for an average time of 3.5 months. The compliance card is a device that reminds the user to take the pill daily. It is the size of a credit card and can be programmed to ring daily at the same time 21 days out of 28. The efficacy of this device is attested by the great number of women who think that it allowed them avoid forgetting at least one pill in the last three months. Regardless of the age of the women, 91% of the users of the compliance card acknowledged that it allowed them to decrease the number of missed pills. Eighty-four percent think avoided forgetting at least one pill in the last three months, 34% between two and three pills and 17% more than three pills. In practice, 41% of the compliance card users didn't have any failure in taking the pill in the last three months versus 19% among nonusers (P = 0.001). Although women aware of their poor compliance more often think that they benefit from the compliance card, 83% of women who declare themselves as compliant share this opinion. The number of avoided missed pills by the compliance card is greater among women who often fail to take their pill. The mean number of missed pill during the three months preceding the use of the compliance card was 1.6 +/- 1.7 versus 0.9 +/- 1.3 during the three months of use. Among users of the compliance card, 98% think that it is easy to use and 97% like the way it works. The compliance card is an easy and reliable device that improves the compliance of women using oral contraceptives by helping them to establish a ritual.

[Who should treat the endometriosic infertile patient? The ART technician, the surgeon, or the psychiatrist?]. / Qui doit traiter la patiente endometriosique infertile : le fiviste, le chirurgien, ou le psy ?

The answer is simpler than the question ! Endometriosis and infertility, a heavy burden: psychological and physical pains do not simply add but potentialise each other, especially when hard life-events have already darkened the past. All the more difficult for these women who have long felt they were considered as nervous and "hysterical", and not as "real" patients, despite their effective and now well-known painful symptoms. They will recover their dignity if we, health practitioners, recognize their right and their need to be taken in charge by a multidisciplinary team, in a psychosomatic approach. Every specialist will, each with his own means, work for their health, meaning the present and future well-being of those endometriosic infertile women.

Estrogen therapy: from women's choice to women's preference.

The climacteric is not an illness, but the menopause is an event that troubles a woman's present life and puts her future life at risk. One would like to think that, for the woman of the new millennium, the menopause has simply become what it is: a feminine milestone that marks the transition and path to another period of life. She appears younger than her mother was at her age, she has given birth when she decided to, she has had the number of children she wanted, and her social and professional roles are well defined. Nevertheless, none of this makes much difference--the 'change of life' is still something difficult to live through, a bend to negotiate, each woman going at her own pace, using her own means, with the cards that life has already dealt her. Where do we gynecologists come in, what part have we to play in our patients' lives? Sometimes, we need to be less discreet and ask some of those questions women may have trouble voicing aloud. Let us try to help them to talk about their mood changes, the changes in their body, and their anxiety about osteoporosis and aging. Shame or fear of ridicule are still often among the ideas on the menopause and, by preventing honest answers from being given, often modify the scientific statistics on menopausal women--especially as women are often at a loss to know which of the different opinions to believe. The media air their news, the medical community offers its dissent, while friends recount frightening stories. Between the danger of offending Mother Nature and the risk of missing out on the progress of science, what is the right modus operandi that helps to add quality to the quantity of life still there to be enjoyed after the menopause? The doctor-patient relationship is of the utmost importance here, since an atmosphere of confidence and trust is the basis of mutual comprehension. By understanding the patient's needs, her desires, and her ways of coping with the situation, the physician will enable her to accept the proposed prescription. The mode of administration should be proposed and not imposed, offered first as one of many possibilities, and should take into account the lifestyle, the private and professional situation of the particular woman, and her habits and tastes, allowing her a true role in the decision-making process. Observance and compliance will therefore naturally follow, with a woman feeling she has been listened to and understood as a mature adult, and not as a stupid individual or a child. After all, there are not very many medical situations where both patients and physicians have such an array of products and routes of administration available to them. This was the way patients in the Aerodiol studies were considered, and it was also the way that they responded, after the initial surprise factor which opened the road to interesting exchanges. Local acceptability was graded as good to excellent by the spray users. While the Kupperman score was as significantly reduced in both the group that received the Aerodiol spray and the group treated via the transdermal route, mastalgia, one of those side-effects known to dramatically reduce the acceptability of a treatment, was significantly less frequent and user satisfaction was similarly greater at week 16 in the Aerodiol group. The approach, as well as the drug itself, seems to have been well appreciated, as a great number of patients (66% versus 34% for the transdermal route) wanted to continue the treatment after the end of the protocol. How else do our patients express their satisfaction if not by their compliance (which is, after all, our aim)? Compliance was not a problem with the pulsed estrogen therapy and nasal administration of it. The woman's preference could well be the doctor's choice, meaning true informed consent from both parties.

[Words]. / Les mots.

Society and our modern world are changing, and so does our language and its words, those carriers of our different trains of thought. Heavy or lightweight, last but not least, simple or pompous, easygoing or sophisticated, words can fail and cheat us, we can play with them or simply use them, they live their own life but we cannot live without them. They disappear or reappear, they sometimes don't have the same meaning for our patients as for us, and we have to strive and hear what they say and do not say... in so many words. Maybe the real change in our brave new world of high-tech communication would be to restore its true value to the patient-doctor relationship in a verbal and non-verbal exchange. Of course this goes without saying, but so much better when said!

[STD, sterility, contraception -- or influence on sexuality]. / MST, sterilite, contraception, etc. ou le sexe sous influence.

PIP: The author of this article, a gynecologist, argues that medicine and especially gynecology are by their nature intrusive and do violence to the sex and sexuality of the patient. Although gynecologists believe their daily practice to be devoid of aggressiveness, their words and gestures are actually filled with aggression against the modesty and physical intimacy of the woman and the couple. Gynecological consultation for contraception, sexually transmitted diseases, sterility, or pregnancy all concern some aspect of sex. It is a truism to say that the practitioner should be comfortable with his own sexuality before considering that of another person, but it is difficult to listen without judging or advise without moralizing. The words of the practitioner if not carefully chosen can do permanent damage to the patient. The resurgence of sexually transmitted diseases creates a favorable climate for latent aggressiveness against patients. It is necessary for gynecologists and other physicians to be aware of the impact of their own attitudes and words and to be sensitive to the feelings of the patient.^ieng

[Chronicle of functional pain: chronic pelvic pains]. / Chronique d'une douleur fonctionnelle: les pelvialgies chroniques.

Chronic pelvic pains are one of the most frequent complaints in our daily gynecological practice, motivating at least a quarter of our consultants. As it usually puts the practitioner ill at ease in a difficult situation, we will try to understand the meaning of those particular pains, thus defined: a duration outlasting 6 months and the absence or the ineffective suppression of any organic--somatic--substratum. But every alleged pain is real and true, and we must work on that. To validate such suffering, to accept such repetitive complaints, can also be a therapeutic medical approach, even if it is less gratifying for the gynecologist, and certainly less customary.