Sexual Desire and Pharmacologic Management.

Female sexual desire is a complex interplay of neurotransmitters and hormones. Diagnosis is based on clinical features and sexual distress. Treatments that affect neurotransmitters and hormones that may be out of balance can help improve sexual desire in women with hypoactive sexual desire disorder.

Sexual function remains persistently low in women after treatment for colorectal cancer and anal squamous cell carcinoma.

BACKGROUND: Women diagnosed with colorectal cancer (CRC) or anal squamous cell carcinoma (ASCC) are at high risk of sexual dysfunction after treatment, yet little is known about recovery and risk factors for chronic dysfunction. AIM: We aimed to describe sexual function and sexual activity among women who underwent definitive treatment for CRC or ASCC, examine relationships between time since treatment completion and sexual function, and explore factors associated with desire and changes in sexual desire over time. METHODS: As part of a prospective cohort study of patients with gastrointestinal cancer at the University of California San Francisco, female-identifying participants who finished definitive treatment for CRC or ASCC completed the Female Sexual Function Index (FSFI) at 6- to 12-month intervals. We used multivariable linear mixed models to explore factors associated with the FSFI desire subscale. OUTCOMES: Outcomes were rates of sexual activity, proportion at risk for sexual dysfunction (FSFI score <26.55), total FSFI score, and FSFI desire subscale. RESULTS: Among the 97 cancer survivors who completed at least 1 FSFI, the median age was 59 years, the median time since treatment end was 14 months, and 87% were menopausal. Fifty-five women (57%) had a history of colon cancer; 21 (22%), rectal cancer; and 21 (22%), ASCC. An additional 13 (13%) had a current ostomy. Approximately half the women were sexually active (n = 48, 49%). Among these 48 sexually active women, 34 (71%) had FSFI scores indicating risk for sexual dysfunction. Among the 10 sexually active women who completed a FSFI ≥2 years since end of treatment, the median total score was 22.6 (IQR, 15.6-27.3). None of the evaluated characteristics were associated with desire (age, tumor site, treatment, menopause status, or ostomy status). CLINICAL IMPLICATIONS: Consistent with prior studies, we found low desire scores after treatment for CRC or ASCC, with little recovery over time, suggesting that patients should not expect an eventual rebound of sexual function. STRENGTHS AND LIMITATIONS: Strengths of our study include longitudinal data and use of the validated FSFI. Women with ASCC composed 22% of our cohort, allowing for insight into this rare disease group. Limitations of this study include the small sample size, particularly for longitudinal analyses, and the enrollment of patients at variable times since treatment end. CONCLUSION: We observed a high prevalence of sexual health concerns, including low desire, after the treatment of CRC and ASCC that persisted for years after treatment was completed.

Multi-Disciplinary Management in Rectal Cancer Survivorship: A Clinical Practice Review.

Colorectal cancer (CRC) is the third most common cancer in the USA and worldwide. In the USA, nearly one-third of CRC cases are anatomically classified as rectal cancer. Over the past few decades, continued refinement of multimodality treatment and the introduction of new therapeutic agents have enhanced curative treatment rates and quality of life outcomes. As treatments improve and the incidence of young onset rectal cancer rises, the number of rectal cancer survivors grows each year. This trend highlights the growing importance of rectal cancer survivorship. Multimodality therapy with systemic chemotherapy, chemoradiation, and surgery can result in chronic toxicities in multiple organ systems, requiring a multi-disciplinary care model with services ranging from appropriate cancer surveillance to management of long-term toxicities and optimization of modifiable risk factors. Here, we review the evidence on these long-term toxicities and provide management considerations from consensus guidelines. Specific topics include bowel dysfunction from radiation and surgery, oxaliplatin-induced neuropathy, accelerated bone degeneration, the impact of fluoropyrimidines on long-term cardiovascular health, urinary incontinence, sexual dysfunction, and psychosocial distress. Additionally, we review modifiable risk factors to inform providers and rectal cancer survivors of various lifestyle and behavioral changes that can be made to improve their long-term health outcomes.

A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions.

BACKGROUND: Clitoral adhesions are characterized by adherence of preputial tissue to the glans clitoris and can be managed using a non-surgical approach in order to relieve symptoms of sexual dysfunction. AIM: To evaluate efficacy and patient satisfaction associated with the non-surgical lysis procedure in order to determine if it is an appropriate treatment for symptomatic clitoral adhesions. METHODS: The non-surgical lysis procedure is performed by using a fine Jacobsen mosquito forceps to separate the plane between the prepuce and the glans of the clitoris, removing smegma and/or keratin pearls from underneath the adhesions and allowing for visualization of the entire glans. A chart review of 61 women that were treated for clitoral adhesions using the non-surgical lysis procedure at 1 sexual medicine practice was performed and an online survey was sent to these patients. MAIN OUTCOME MEASURES: Encrypted survey responses were used to evaluate patient satisfaction as well as self-reported improvement in sexual functioning and pain before and after the procedure. RESULTS: 41 survey responses were received out of 61 eligible (67% response rate). A large majority reported improvement in pain (76%), sexual arousal (63%), and ability to achieve orgasm (64%) and no participants reported worsening in these symptoms. Of the 16 women that reported the inability to orgasm from external clitoral stimulation prior to the procedure, 6 (38%) were able to do so afterwards. Seventy-one percent of respondents reported improvement in their satisfaction with sex and 83% reported being satisfied with their decision to have the procedure. Ninety-three percent of participants reported that they would recommend this procedure to a friend with clitoral adhesions. CLINICAL IMPLICATIONS: The results of this study will help clinicians to recognize the non-surgical lysis procedure as a treatment option for clitoral adhesions. STRENGTHS & LIMITATIONS: This study is the first of its kind assessing a cohort of patients undergoing the non-surgical lysis procedure for clitoral adhesions. Its limitations include a small sample size from 1 clinic and lack of validated instrument to evaluate sexual function and pain before and after the procedure. CONCLUSION: Providers should regularly examine the clitoris of patients with symptoms of sexual dysfunction in order to determine if they have clitoral adhesions. The non-surgical lysis procedure may be a viable therapeutic option for these patients that has demonstrated both satisfaction and symptom relief. Myers MC, Romanello JP, Nico E, et al. A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions. J Sex Med 2022;19:1412-1420.

Awareness, Clinical Experience and Knowledge of Female Genital Mutilation/Cutting Among Female Pelvic Medicine and Reconstructive Surgeons in the United States.

OBJECTIVE: To promote the recognition and care of patients with female genital mutilation/cutting (FGM/C), we aimed to evaluate the awareness, clinical experience and knowledge of FGM/C among female pelvic medicine and reconstructive surgery (FPMRS) specialists. FGM/C is a cultural practice whereby there is removal of external female genitalia for non-therapeutic reasons. Despite the high prevalence of urogynecologic complications, there is a paucity of literature discussing FGM/C from the lens of urologists and urogynecologists. METHODS: By cross-sectional design, we distributed a 27-item survey via email to members of the Society of Urodynamics, Female Pelvic Medicine and Reconstructive Surgery. We collected variables pertaining to previous FGM/C education, clinical confidence, cultural and medical knowledge, and desire for future education. RESULTS: A total of 54 US-based, mostly urologists and FPMRS specialists, completed the survey. All providers had heard of FGM/C; however only 13% received formal education during medical training. Over 50% had encountered a patient with FGM/C in clinical practice. Only 19% and 13% felt completely confident recognizing and discussing FGM/C, respectively. Seventy percent believed religious doctrine informed FGM/C practice and 24% correctly identified FGM/C type on clinical representation. Finally, only 17% of respondents were aware of FGM/C guidelines, and providers expressed a desire for increased availability of multimodal resources. CONCLUSION: Education regarding FGM/C remains sparse and variable for US FPMRS specialists. Cultural and clinical knowledge is also lacking, which is a detriment to patient care. In order to strengthen awareness and knowledge, we must develop high-quality FGM/C educational resources for urologists and gynecologists.

Gaps and Opportunities to Improve Prevention of Human Papillomavirus-Related Cancers.

Human papillomavirus (HPV) infections cause more than 35,900 cancers annually in the United States. Although cervical cancer is the most prevalent HPV-related malignancy in women, the virus is also responsible for a significant percentage of anal, vaginal, and vulvar cancers. A comprehensive approach to mitigating cervical cancer includes HPV vaccination (primary prevention), screening and treatment of precancerous lesions (secondary prevention), and diagnosis and treatment of invasive cancer (tertiary prevention). Although a successful strategy, there are opportunities to innovate and increase access that can also be adapted to address the unique clinical care gaps that exist with the other anogenital cancers. The Society for Women's Health Research held a series of interdisciplinary meetings and events, during which expert researchers, clinicians, patient advocates, and health care policy leaders evaluated the current landscape of HPV-related cancers and their effects on women's health. This report summarizes the discussions of this working group and areas it identified in which to address gaps in primary and secondary prevention approaches to improve access and health outcomes for women with HPV-related anogenital cancers.

Female Genital Self-Image and Modification.

There has been an increase in genital cosmentic surgeries over the past decade, with the most common procedure being labiaplasty. This trend has many origins, but a significant motivator is genital self image, which has been shown to be very culturally influenced. Furthermore genital self modification, by way of grooming also is felt to play a role in the desire to surgically alter one's genital appearance. Given the cultural aspect of these practices, sexual health proivders should be aware of the role of self image and self modification in the drive towards persuing surgical changes to the genitals. Schmidt CN, Rowen TS. Female Genital Self-Image and Modification. J Sex Med 2021;18:1945-1949.

Risk Factors for Sexual Pain Among Physically Active Women.

INTRODUCTION: Sexual pain is common among women but little is known about associations with exercise and physical activity. AIM: To determine the prevalence of sexual pain among physically active women and to evaluate cycling and other potential risk factors. METHODS: This is a secondary data analysis of a study on the urinary and sexual wellness of physically active women recruited through sporting clubs and targeted social media advertising. We used multivariable logistic regression to assess the role of cycling and exercise in reporting any, frequent, or severe sexual pain, controlling for demographic, relationship, and health risk factors. MAIN OUTCOME MEASURE: Sexual pain, including frequency and severity, was measured using the Female Sexual Function Index. RESULTS: A total of 2,039 women were included, with 1,097 (54%) reporting any level of sexual pain, 364 (18%) experiencing frequent pain, and 378 (19%) reporting severe pain. Less than 5% of women reported diabetes or hypertension, and the cohort had a median body mass index of 23.3 (interquartile range 21.4-25.7). Increasing age and body mass index were protective against any sexual pain, as was cycling (odds ratio [OR] 0.73 [95% CI 0.59-0.90]). Participants who reported being "moderately satisfied" (OR 0.53 [95% CI 0.31-0.91]) or "very satisfied" (OR 0.33 [95% CI 0.19-0.56]) with their emotional closeness to a sexual partner had decreased odds of any sexual pain. CONCLUSION: Experiencing any sexual pain is common in physically active women, with a prevalence of over 50%; however, weekly energy expenditure from exercise was not associated with sexual pain. Cycling participation and higher levels of emotional closeness and intimacy were associated with less pain. Patients between the ages of 18 and 30 years who were normal or underweight incurred the highest risk of sexual pain. Fergus KB, Cohen AJ, Cedars BE, et al. Risk Factors for Sexual Pain Among Physically Active Women. Sex Med 2020;8:501-509.

Methodological Challenges in Studying Testosterone Therapies for Hypoactive Sexual Desire Disorder in Women.

INTRODUCTION: Testosterone has been studied for its benefits on sexual health for decades. The research regarding testosterone in women has produced evidence that this is a potential treatment for women suffering from female sexual dysfunction. There are several limitations of the testosterone trials that can affect their interpretation and challenges posed by some regulatory agencies that have prevented approval of any testosterone treatment for women in several countries. AIM: To summarize the challenges of testosterone trials in terms of study populations, patient-reported outcomes, validated instruments in research, confounders, and regulatory barriers. METHODS: A thorough review of published data on testosterone for the treatment of women's sexual health problems was undertaken. A detailed evaluation of the limitations of these trials was conducted and incorporated with the published evidence on the regulatory processes involved in moving testosterone from clinical research to drug approval. MAIN OUTCOME MEASURE: Main outcome measures are assessment of clinical trial populations, survey tools, confounders, and regulatory barriers. RESULTS: There is some heterogeneity of study populations included in testosterone trials in women. Similarly, there have been differences in instruments used to assess patient-reported outcomes and often minimal control for potential confounders. The regulatory agency had posed a challenge to approve any testosterone treatment for women based on unproven concerns and a lack of regulatory guidance for drug developers. CLINICAL IMPLICATIONS: There is strong evidence that shows testosterone is effective for treating sexual health concerns in the women included in clinical trials. STRENGTH & LIMITATIONS: Strengths include thorough review of published literature and trial design for sexual health concerns. Limitations include being restricted to English Language publications and not having access to unpublished clinical trial data. CONCLUSIONS: Testosterone trials in women have been limited by homogeneity in the study populations and outcomes measured. Drug development has been hampered by inconsistent regulatory barriers. Rowen TS, Davis SR, Parish S, et al. Methodological Challenges in Studying Testosterone Therapies for Hypoactive Sexual Desire Disorder in Women. J Sex Med 2020;17:585-594.

Postoperative Opioid Use Using Enhanced Recovery After Surgery Guidelines for Benign Gynecologic Procedures.

STUDY OBJECTIVE: To evaluate opioid use after benign gynecologic surgery after implementation of Enhanced Recovery After Surgery (ERAS) opioid prescribing recommendations. DESIGN: A prospective cohort study. SETTING: An academic tertiary care hospital. PATIENTS: All patients undergoing elective benign gynecologic surgery at a large academic institution between August 2017 and December 2017, 1 year after ERAS postoperative opioid prescribing recommendations were implemented for the benign gynecologic surgery department. INTERVENTIONS: A chart review determining opioid prescription quantity and a patient telephone survey 7 days after surgery were both performed. Total opioid use was calculated. Physician adherence to the institution's ERAS postoperative opioid prescribing recommendations after benign gynecologic surgery was then determined. Patients were classified as either in the physician adherent to ERAS group or the physician nonadherent to ERAS group. After this stratification, patients' total opioid use within each group was then compared. MEASUREMENTS AND MAIN RESULTS: A total of 241 consecutive benign gynecologic surgical procedures were reviewed. Opioids were prescribed for outpatient postoperative pain management in 186 (77.2%) of these procedures. Physician adherence to the ERAS postoperative opioid prescribing recommendations occurred in 150 (62.2%) of all surgical cases. The telephone survey was completed by 144 (59.8%) patients 7 days after their surgery. Among survey participants, a total of 13 783.5 morphine milligram equivalents (MMEs) or 64.7% of all opioids prescribed were unused 7 days after surgery. This is equivalent to 1838 oxycodone 5-mg tablets unused by the end of the study period. For all surgical procedure types, the ERAS-nonadherent group was prescribed statistically significantly more opioids per patient than the ERAS-adherent group (246.2 ± 22.8 MME vs 81.1 ± 6.2 MME, p < .005), resulting in more opioids unused among the ERAS-nonadherent group. Consequently, the ERAS-nonadherent group contributed 63.5% (8747.5 MMEs) of the total unused opioids by the end of the study period despite only making up 39.6% of the completed patient surveys. CONCLUSION: Patients require significantly less opioids after benign gynecologic surgery than they are being prescribed. Physician adherence to the ERAS postoperative opioid recommendations is suboptimal and contributes significantly to the quantity of unused opioids after surgery for benign gynecologic indications. Almost two thirds of all opioids prescribed are not used by 1 week after benign gynecologic surgery.

A multi-disciplinary model of survivorship care following definitive chemoradiation for anal cancer.

Following definitive chemoradiation for anal squamous cell carcinoma (ASCC), patients face a variety of chronic issues including: bowel dysfunction, accelerated bone loss, sexual dysfunction, and psychosocial distress. The increasing incidence of this disease, high cure rates, and significant long-term sequelae warrant increased focus on optimal survivorship care following definitive chemoradiation. In order to establish our survivorship care model for ASCC patients, a multi-disciplinary team of experts performed a comprehensive literature review and summarized best practices for the multi-disciplinary management of this unique patient population. We reviewed principle domains of our survivorship approach: (1) management of chronic toxicities; (2) sexual health; (3) HIV management in affected patients; (4) psychosocial wellbeing; and (5) surveillance for disease recurrence and survivorship care delivery. We provide recommendations for the optimization of survivorship care for ASCC patients can through a multi-disciplinary approach that supports physical and psychological wellness.

Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from The North American Menopause Society and The International Society for the Study of Women's Sexual Health.

The objective of The North American Menopause Society (NAMS) and The International Society for the Study of Women's Sexual Health (ISSWSH) Expert Consensus Panel was to create a point of care algorithm for treating genitourinary syndrome of menopause (GSM) in women with or at high risk for breast cancer. The consensus recommendations will assist healthcare providers in managing GSM with a goal of improving the care and quality of life for these women. The Expert Consensus Panel is comprised of a diverse group of 16 multidisciplinary experts well respected in their fields. The panelists individually conducted an evidence-based review of the literature in their respective areas of expertise. They then met to discuss the latest treatment options for genitourinary syndrome of menopause (GSM) in survivors of breast cancer and review management strategies for GSM in women with or at high risk for breast cancer, using a modified Delphi method. This iterative process involved presentations summarizing the current literature, debate, and discussion of divergent opinions concerning GSM assessment and management, leading to the development of consensus recommendations for the clinician.Genitourinary syndrome of menopause is more prevalent in survivors of breast cancer, is commonly undiagnosed and untreated, and may have early onset because of cancer treatments or risk-reducing strategies. The paucity of evidence regarding the safety of vaginal hormone therapies in women with or at high risk for breast cancer has resulted in avoidance of treatment, potentially adversely affecting quality of life and intimate relationships. Factors influencing decision-making regarding treatment for GSM include breast cancer recurrence risk, severity of symptoms, response to prior therapies, and personal preference.We review current evidence for various pharmacologic and nonpharmacologic therapeutic modalities in women with a history of or at high risk for breast cancer and highlight the substantial gaps in the evidence for safe and effective therapies and the need for future research. Treatment of GSM is individualized, with nonhormone treatments generally being first line in this population. The use of local hormone therapies may be an option for some women who fail nonpharmacologic and nonhormone treatments after a discussion of risks and benefits and review with a woman's oncologist. We provide consensus recommendations for an approach to the management of GSM in specific patient populations, including women at high risk for breast cancer, women with estrogen-receptor positive breast cancers, women with triple-negative breast cancers, and women with metastatic disease.

Characteristics of Genital Dissatisfaction Among a Nationally Representative Sample of U.S. Women.

BACKGROUND: Female genital self-image is an important aspect of psychosocial and sexual health. The Female Genital Self-Image Scale (FGSIS) is a validated instrument that has been used to characterize women's level of genital dissatisfaction. AIM: In this report, we assess genital dissatisfaction using the FGSIS in a nationally representative sample of U.S. women. METHODS: We conducted a nationally representative survey of non-institutionalized adults aged 18-65 years residing in the United States. The survey included questions about demographics, sexual behavior, and the FGSIS. OUTCOMES: Demographic characteristics were found to significantly correlate to women's perceived genital dissatisfaction. RESULTS: In total, 3,372 women completed the survey and 3,143 (93.2%) completed the FGSIS. The mean age was 46 years, and there was broad representation across the United States in terms of age, education, and location. On bivariate analysis, women's genital dissatisfaction was significantly correlated to their age, race, location, and education. Women who were sexually active were less likely to report genital dissatisfaction than women who were not sexually active (76% vs 62%, respectively, P < .001). The frequency of sexual activity was negatively correlated with genital dissatisfaction (P = .002). Women who reported genital dissatisfaction were less likely than those who reported satisfaction to engage in receptive vaginal sex (83% vs 88%, respectively, P = .03). There were no other significant associations between genital dissatisfaction and types of sexual activity. On multivariate analysis, women were less likely to report genital dissatisfaction if they were older, of black race, had an education level of high school or above, and/or lived in the Northeastern or Midwestern United States. There was no association between genital dissatisfaction and relationship status or gender of sexual partner. CLINICAL TRANSLATION: Female genital dissatisfaction may be related to age, race, education, and geography. CONCLUSIONS: This is the first nationally representative sample of U.S. women focusing on genital and self-image and dissatisfaction. These data may not apply outside the United States. These data may help providers who provide information for women and manage concerns related to genital self-image. Rowen TS, Gaither TW, Shindel AW, et al. Characteristics of Genital Dissatisfaction Among a Nationally Representative Sample of U.S. Women. J Sex Med 2018;15:698-704.

Uterine artery pseudoaneurysm in the setting of deep endometriosis: an uncommon cause of hemoperitoneum in pregnancy.

Uterine, ovarian, and placental pathologies are among the differential considerations for a pregnant woman presenting with abdominal and pelvic pain. Imaging plays a key role in the initial work-up of these patients. Sonography is often the first line test; however, evaluation of pelvic pathology can be limited in the gravid state, especially in mid- or late-term pregnancy. We present a case of a pregnant woman who came to the emergency room at 25 weeks with acute abdominal and pelvic pain. Both ultrasound and MR imaging findings revealed intraperitoneal hemorrhage, initially of unknown origin, as well as endometriomas and deep endometriosis. Only postpartum imaging confirmed a uterine artery pseudoaneurysm (PSA) presumably due to decidual reaction in deep endometriosis. We speculate the intraperitoneal hemorrhage was subsequently due to the PSA. This case demonstrates that if hemorrhage is not recognized promptly, it can lead to hemodynamic instability, as well as premature labor and delivery.

Urinary Incontinence and Associated Female Sexual Dysfunction.

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