Sexual dysfunction among female patients with rheumatic diseases

To demonstrate the burden of sexual dysfunction (SD) among females with rheumatic diseases, we conducted a cross-sectional comparative study in patients with systemic sclerosis (SSc), systemic lupus erythematosus (SLE), and Behçet's syndrome (BS) along with suitable healthy controls (HCs). Age-matched female patients with SSc (n = 50), SLE (n = 49), and BS (n = 54), along with 52 female HCs were included in this study between April and October, 2021. Sociodemographic features were recorded, and psychometric tests, i.e., female sexual function index (FSFI), Beck depression inventory (BDI), body cathexis scale, and marital adjustment test (MAT) were performed. Scale scores were compared, and binary logistic regression was used to identify predictors for SD in the whole group. The total FSFI and body cathexis scores among the patient groups were significantly lower than those of the HCs (p < 0.001). Depression was significantly more frequent in the patient groups. MAT scores did not differ significantly between the study groups. Patients with SSc had the worst scores in each psychometric index, including MAT. Decreased body cathexis score [OR 0.974, 95% CI (0.957-0.991), p = 0.003] and low MAT score [OR 0.937, 95% CI (0.896-0.980), p = 0.005], and being diagnosed with SSc [OR 6.6, 95% CI (1.975-22.498), p = 0.002], SLE [OR 2.7, 95% CI (0.998-7.753), p = 0.050], and BS [OR 2.8, 95% CI (1.100-7.359), p = 0.031], were identified as independent predictors for SD. Body cathexis seems to be the most important independent predictor for SD, and the burden of SD appears heavier in patients with SSc, probably due to poor body image satisfaction.

Multi-Organ System Screening, Care, and Patient Support in Systemic Sclerosis

Systemic sclerosis (SSc) is a heterogenous systemic autoimmune disease of complex multi-organ manifestations with a disease-specific mortality of >50%. The patient journey is fraught with severe, diverse, and diffuse physical impairment, psychological burden, and diminishing health-related quality of life. SSc remains unfamiliar to many clinicians. Delayed/misdiagnosis, inadequate screening, and attention for common complications with potentially preventable disability/death contribute to patients feeling isolated and unsupported. We present actionable standards including screening, anticipatory guidance, and counseling in patient-centered SSc-care emphasizing psycho-social health as the central goal, whereas robust vigilance and efforts to improve biophysical health and survival are imperatives that support this goal.

Sexual dysfunction in women with systemic autoimmune rheumatic disorders: a systematic review and meta-analysis

OBJECTIVES

In women with systemic autoimmune rheumatic diseases (SARDs), female sexual dysfunction (SD) remains underestimated. We aimed to explore the prevalence and correlates of SD in females with SARDs.

METHODS

We performed a systematic review and meta-analysis of studies assessing the prevalence of SD and the pooled Female Sexual Function Index (FSFI) scores in this setting (PROSPERO: CRD42021287346). We searched PubMed, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases and grey literature until February 2022. We evaluated the quality of the selected records using the Hoy Risk of Bias tool. A random-effects meta-analysis of proportions with the double arcsine transformation was conducted. Subgroup and sensitivity analyses, as well as meta-regression of important correlates, were conducted.

RESULTS

We included 68 studies with 5457 females diagnosed with a SARD (mean age: 43.7 [12.9] years). The overall SD prevalence was 63% (95% CI: 56, 69%, I2 = 94%) and the overall FSFI total score was 19.7 points (95% CI: 18.4, 21, I2 = 97%). Including only sexually active females, the SD prevalence was estimated as 60% (95% CI: 53, 67%, I2 = 88%), whereas the FSFI total score was 22 points (95% CI: 20.8, 23.1, I2 = 93%). Across the different SARDs, women with Sjögren's syndrome and systemic sclerosis reported the highest levels of SD (74%, 95% CI: 58, 87%, I2 = 84% and 69%, 95% CI: 54, 83%, I2 = 94%, respectively).

CONCLUSION

Sexual function in females with SARDs seems to be severely impaired, irrespective of the type of SARD. Screening and treatment of SD in females with SARDs should become an integral part of healthcare clinical practice.

Clitoral blood flow using color Doppler ultrasonography in women with and without provoked vestibulodynia

INTRODUCTION AND HYPOTHESIS

To compare blood flow of the dorsal clitoral artery in women diagnosed with provoked vestibulodynia (PVD) and in healthy controls using color Doppler ultrasonography. We hypothesized that women with PVD would have a restricted blood flow compared to controls.

METHODS

This cross-sectional study evaluated the function of the dorsal clitoral artery through the spectral wave analysis of color Doppler ultrasonography (US) in 20 women diagnosed with PVD according to Friedrich's criteria and 21 healthy controls. Participants were evaluated during their follicular phase and were asked to abstain from sexual activities 24 ho prior the examination. Assessment was performed by an assessor blinded to participant diagnosis, in the morning after a 10-min rest period in a supine lying position in a room with temperature set at 22 °C. Measurements of the peak systolic velocity (PSV), time-averaged maximum velocity (TAMX), end-diastolic velocity (EDV), pulsatility (PI) and resistance index (RI) were performed at rest considering the mean value of three consecutive waveforms.

RESULTS

Women with PVD and healthy controls did not present any statistically different baseline characteristics. Participants with PVD presented higher values of Doppler-US PSV, TAMX, EDV and RI compared to controls (p ≤ 0.05), which are suggestive of a decrease in blood flow. However, non-significant difference was found regarding PI values between the two groups (p > 0.05).

CONCLUSION

Our findings revealed decreased peripheral tissue perfusion in women with PVD compared to healthy controls using color Doppler US, based on the alteration of four of the five assessed data of US parameters.

Reproductive Issues and Pregnancy Implications in Systemic Sclerosis

Systemic sclerosis (SSc) is a rare systemic autoimmune disease that can influence reproductive health. SSc has a strong female predominance, and the disease onset can occur during fertility age in almost 50% of patients. Preconception counseling, adjustment of treatment, and close surveillance during pregnancy by a multidisciplinary team, are key points to minimize fetal and maternal risks and favor successful pregnancy outcomes. The rates of spontaneous pregnancy losses are comparable to those of the general obstetric population, except for patients with diffuse cutaneous SSc and severe internal organ involvement who may carry a higher risk of abortion. Preterm birth can frequently occur in women with SSc, as it happens in other rheumatic diseases. Overall disease activity generally remains stable during pregnancy, but particular attention should be paid to women with major organ disease, such as renal and cardiopulmonary involvement. Women with such severe involvement should be thoroughly informed about the risks during pregnancy and possibly discouraged from getting pregnant. A high frequency of sexual dysfunction has been described among SSc patients, both in females and in males, and pathogenic mechanisms of SSc may play a fundamental role in determining this impairment. Fertility is overall normal in SSc women, while no studies in the literature have investigated fertility in SSc male patients. Nevertheless, some considerations regarding the impact of some immunosuppressive drugs should be done with male patients, referring to the knowledge gained in other rheumatic diseases.

Female Sexual Dysfunction and Pelvic Floor Muscle Function Associated with Systemic Sclerosis: A Cross-Sectional Study

Only a few studies have addressed sexual health in patients with systemic sclerosis (SSc). This study aimed to compare female sexual function and pelvic floor muscle function in SSc patients with healthy controls (HC) matched by age, and to identify the potential implications of clinical features on sexual function. Our cohort included 90 women with SSc and 90 HC aged 18-70 years that completed six well-established and validated questionnaires assessing sexual function (Brief Index of Sexual Function for Women, Female Sexual Function Index, Sexual Quality of Life Questionnaire-Female, Sexual Function Questionnaire) and pelvic floor function (Pelvic Floor Impact Questionnaire-Short Form 7 and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire Short Form). Results from women with SSc and HC were contrasted and correlated with relevant clinical features. The prevalence of female sexual dysfunction was 73% in SSc patients (vs. 31% in HC). Women with SSc reported significantly worse pelvic floor function and sexual function than HC. Impaired sexual function was correlated with higher disease activity, the presence of dyspnea and interstitial lung disease, increased systemic inflammation, reduced physical activity, functional disability, more severe depression, more pronounced fatigue, and impaired quality of life. We demonstrate that sexual dysfunction is highly prevalent among women with SSc. This aspect of the disease deserves more attention both in clinical care and at the level of international research collaboration.

Effects of testosterone treatment on clitoral haemodynamics in women with sexual dysfunction

PURPOSE

To explore the effects of 6-month systemic testosterone (T) administration on clitoral color Doppler ultrasound (CDU) parameters in women with female sexual dysfunction (FSD).

METHODS

81 women with FSD were retrospectively recruited. Data on CDU parameters at baseline and after 6 months with four different treatments were available and thus further longitudinally analyzed: local non-hormonal moisturizers (NH group), n = 37; transdermal 2% T gel 300 mcg/day (T group), n = 23; local estrogens (E group), n = 12; combined therapy (T + E group), n = 9. Patients underwent physical, laboratory, and genital CDU examinations at both visits and completed different validated questionnaires, including the Female Sexual Function Index (FSFI).

RESULTS

At 6-month visit, T therapy significantly increased clitoral artery peak systolic velocity (PSV) when compared to both NH (p < 0.0001) and E (p < 0.0001) groups. A similar increase was found in the T + E group (p = 0.039 vs. E). In addition, T treatment was associated with significantly higher FSFI desire, pain, arousal, lubrication, orgasm, and total scores at 6-month visit vs. baseline. Similar findings were observed in the T + E group. No significant differences in the variations of total and high-density lipoprotein-cholesterol, triglycerides, fasting glycemia, insulin and glycated hemoglobin levels were found among the four groups. No adverse events were observed.

CONCLUSION

In women complaining for FSD, systemic T administration, either alone or combined with local estrogens, was associated with a positive effect on clitoral blood flow and a clinical improvement in sexual function, showing a good safety profile.

TRIAL REGISTRATION NUMBER

NCT04336891; date of registration: April 7, 2020.

Prevalence of Sexual Dysfunction in People With Systemic Sclerosis and the Associated Risk Factors: A Systematic Review

INTRODUCTION

The association between systemic sclerosis (SSc) and sexual dysfunction was controversial.

AIM

To explore the impacts of SSc on sexual function, the prevalence of sexual dysfunction in patients with SSc and associated risk factors.

METHODS

A systematic review of all published studies was performed. Studies exploring the association between SSc and sexual function were retrieved from PubMed, Web of Science, and EBSCO. All retrieved papers were selected according to the inclusion and exclusion criteria.

MAIN OUTCOME MEASURE

The impacts of SSc on sexual function, the prevalence of sexual dysfunction in males and females with SSc and associated risk factors.

RESULTS

A total 12 studies were included in this study. The prevalence of sexual dysfunction in SSc males and SSc females were 76.9-81.4% and 46.7-86.6%, respectively. But the direct impacts of SSc on sexual function were controversial. EULAR SSc activity score ≥3, the number of complications ≥2, and the presence of anticardiolipin antibody and anti U1 ribonucleoprotein antibody in males and resistive index (RI) and the systolic/diastolic (S/D) ratio of clitoral blood in females have potential to be SSc-specific risk factors for sexual dysfunction.

CLINICAL IMPLICATIONS

Clinicians need to pay more attention to the impacts of SSc on sexual function of patients especially in those with risk factors.

STRENGTHS & LIMITATIONS

Systematically explored the prevalence of sexual dysfunction in SSc males and females, and the risk factors of sexual dysfunction for SSc were explored innovatively. However, there were some limitations in included studies prevented exploring the impacts of SSc on sexual function deeply.

CONCLUSION

Sexual dysfunction may be an important symptom of SSc, many risk factors may be associated with sexual dysfunction in males and females with SSc. Gao R, Qing P, Sun X, et al. Prevalence of Sexual Dysfunction in People With Systemic Sclerosis and the Associated Risk Factors: A Systematic Review. Sex Med 2021;9:100392.

Color Doppler Ultrasonography of digital arteries and digital ulcers development in systemic sclerosis

BACKGROUND

The aim of this study was to evaluate the role of Color Doppler Ultrasonography (CDUS) of proper palmar digital arteries (PPDA) as predictive marker of new digital ulcers (DUs) in systemic sclerosis (SSc) patients during 5 years follow-up.

METHODS

36 SSc patients were examined using nailfold videocapillaroscopy (NVC) and CDUS of PPDA.

RESULTS

Fourteen (38.9%) patients had chronic or acute occlusions (C and D pattern) on CDUS evaluation. Using a cut-off of 0.70, 21 (58.3%) patients had a Resistive Index (RI) ≥0.70. Nineteen (52.8%) patients developed new DUs during the follow-up. The median value of RI was higher in SSc patients with DUs than in SSc patients without DUs [0.73 (IQR 0.70-0.81) vs 0.67 (IQR 0.57-0.70), p < 0.0001]. The Kaplan-Meier analysis showed a free survival from new DUs higher (p < 0.01) in SSc patients with Pattern A and B than SSc patients with Pattern C and D. The Kaplan-Meier curves showed that free survival from new DUs is lower (p < 0.001) in SSc patients with increased RI (≥0.70) than in SSc patients with normal RI. In multivariate analysis with two co-variates, RI ≥ 0.70 [HR 5.197 (1.471-18.359), p < 0.01] and NVC late scleroderma pattern [HR 7.087 (1.989-25.246), p < 0.01] were predictive markers of new DUs.

CONCLUSIONS

RI of PPDA in association with NVC could be used to evaluate SSc patients with increased risk of new DUs development.

Late Gadolinium Enhancement in Cardiac Magnetic Resonance Imaging Is Associated with High Renal Resistive Index in Patients with Systemic Sclerosis

INTRODUCTION

Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by microvascular damage and fibrosis of the skin and internal organs. The major complications are lung fibrosis, pulmonary artery hypertension, scleroderma renal crisis, and cardiac involvement.

OBJECTIVE

The aim of this study was to assess renal and cardiac involvement in asymptomatic SSc patients using renal Doppler ultrasound (RDU) and cardiac magnetic resonance (CMR).

MATERIALS AND METHODS

We enrolled 26 consecutive SSc patients (21 female) according to 2013 ACR/EULAR criteria. Biochemical analysis, clinical evaluation, RDU with intrarenal hemodynamic parameters (renal resistive index [RRI], pulsatility index [PI], systolic/diastolic [S/D] ratio), and CMR with late gadolinium enhancement (LGE) were investigated at the time of enrollment.

RESULTS

The median PI value was significantly (p = 0.007) higher in SSc patients with LGE than in SSc patients without LGE (1.37 [1.28-1.58] vs. 1.12 [1.06-1.26]). The median RRI value was significantly (p = 0.002) higher in SSc patients with LGE than in SSc patients without LGE (0.68 [0.65-0.73] vs. 0.64 [0.63-0.65]). The median S/D ratio was significantly (p = 0.02) higher in SSc patients with LGE than in SSc patients without LGE (3.12 [2.83-3.76] vs. 2.78 [2.64-2.84]).

CONCLUSIONS

Our study, although performed on a small SSc population, showed RRI and LGE as markers of vascular and fibrotic damage. Early detection of cardiorenal involvement in SSc patients without symptoms is important to avoid further complications.

Ultrastructural Study of Clitoral Cavernous Tissue and Clitoral Blood Flow From Type 1 Diabetic Premenopausal Women on Phosphodiesterase-5 Inhibitor

BACKGROUND

The effects of phosphodiesterase-type 5 (PDE5) inhibitors on the in vivo clitoral structure of women with diabetes have never been investigated.

AIM

To study the in vivo structural and hemodynamic changes of the clitoris in premenopausal women with type 1 diabetes on PDE5 inhibitors.

METHODS

38 premenopausal women with type 1 diabetes aged 36 -46 years. A randomized 1:1 study design was used: Study Group (group A) on Tadalafil 5 mg daily, and control group (group B). Blood samples were taken from each woman to measure HbA1c, testosterone, and Free Androgen Index. The women underwent microbiopsy of the clitoral body by means of semiautomatic gun during total anesthesia for surgery therapy of a benign gynecological pathology. The tissue removed was processed for electron microscopy. Translabial color Doppler ultrasound was used to measure the peak systolic velocity (PSV), the end diastolic velocity (EDV), and the pulsatility index (PI) of clitoral arteries.

MAIN OUTCOME MEASURES

Micro-ultrastructure observation of clitoral tissue and color Doppler sonography of clitoral blood flow.

RESULTS

Of the 38 women, 13 (68.4%) of group A and 15 (78.9%) of group B completed the study. Group A showed a mean PSV and EDV increase, and a mean PI decrease with respect to baseline (P < .001). Group B did not show any change in both the parameters (P = NS). By a quantitative study in both groups a variable degree of ultrastructural abnormalities of smooth muscle cells (SMCs) was observed, consisting in increased glycogen and lipoic deposits, cytoplasmic vacuoles, and focal increase of electron density of SMCs. Moreover, the mean SMC thickness of group A (1.83 ± 0.68 µm) was larger than that of group B (1.3 ± 0.41 µm) (P = .02).

CLINICAL IMPLICATIONS

PDE5 inhibitors could be used to treat diabetic women with genital arousal disorder.

STRENGTHS & LIMITATIONS

The study shows a clear effect of PDE5 inhibitors on clitoral SMCs. However, a limit was to not have investigated the sexual function/behavior of women of both groups, this was because of the short time of the study.

CONCLUSION

This study could help to understand in what way PDE5 inhibitors act on the ultrastructural pathophysiological clitoral cavernous tissue of women with diabetes. It could support PDE5 inhibitor usage in women with genital sexual arousal disorder due to metabolic diseases. Caruso S, Cianci A, Cianci S, et al. Ultrastructural Study of Clitoral Cavernous Tissue and Clitoral Blood Flow From Type 1 Diabetic Premenopausal Women on Phosphodiesterase-5 Inhibitor. J Sex Med 2019;16:375-382.

Female sexual dysfunction in systemic sclerosis: The role of endothelial growth factor and endostatin

INTRODUCTION

Since female sexual dysfunction in systemic sclerosis women is multifactorial, we can assume that vascular damage may play a role in pathogenesis. The aim of the study was to evaluate the clitoral blood flow, by Echo color Doppler, and to correlate it whit serum levels of vascular endothelial growth factor and endostatin.

METHODS

A total of 15 systemic sclerosis women and 10 healthy controls matched for sex and age were enrolled in this study. Serum VEGF165 and endostatin levels were determined in systemic sclerosis patients by commercial enzyme-linked immunosorbent assay kit. Clitoral blood flow was measured by Doppler indices of clitoral artery: pulsatile index, resistive index, and systolic/diastolic ratio were measured. Sexual dysfunction was assessed by Female Sexual Function Index.

RESULTS

Vascular endothelial growth factor (pg/mL) and endostatin (ng/mL) median values were significantly higher in systemic sclerosis women than healthy controls. Resistive index and systolic/diastolic ratio median values were significantly higher in systemic sclerosis women than healthy controls. Negative correlation exists between serum levels of vascular endothelial growth factor and resistive index (r = -0.55, p < 0.05). Positive correlation was observed between serum levels of endostatin and resistive index (r = 0.70, p < 0.01) and systolic/diastolic ratio (r = 0.77, p < 0.01).

DISCUSSION

We can suppose that clitoral blood flow in systemic sclerosis women is reduced not only for macro- and microvascular damage but also for impaired angiogenesis.

The Physiology of Female Sexual Function and the Pathophysiology of Female Sexual Dysfunction (Committee 13A)

INTRODUCTION

The article consists of six sections written by separate authors that review female genital anatomy, the physiology of female sexual function, and the pathophysiology of female sexual dysfunction but excluding hormonal aspects.

AIM

To review the physiology of female sexual function and the pathophysiology of female sexual dysfunction especially since 2010 and to make specific recommendations according to the Oxford Centre for evidence based medicine (2009) "levels of evidence" wherever relevant.

CONCLUSION

Recommendations were made for particular studies to be undertaken especially in controversial aspects in all six sections of the reviewed topics. Despite numerous laboratory assessments of female sexual function, genital assessments alone appear insufficient to characterise fully the complete sexual response.

The clinical relevance of sexual dysfunction in systemic sclerosis

Systemic sclerosis is a chronic multi-organ autoimmune disease, leading to important clinical and psychological implications. Among organ complications, sexual dysfunction is a major issue for both male and female gender, with high prevalence and great impact on quality of life, although frequently not addressed by both clinicians and patients. While erectile dysfunction is the most common cause of sexual problems in males, genital tract and general physical changes are major contributors to sexual impairment in females. This review presents current state of the art on this topic, discussing published data on presentation, evaluation and therapeutic options.

Psychosexual Aspects of Vulvar Disease

Physically, the vulva is an anatomic location of convergence, which includes vascular, neural, hormonal, reproductive, dermatologic, and musculoskeletal systems. Psychosocially, the vulva represents privacy, femininity, sexuality, and intimacy. Because of this intertwined relationship, vulvar disease and dysfunction can significantly impact a woman's physical health as well as her relationships. This article elucidates the impact of vulvar disease on the individual psyche, sexual functioning, and intimate relationships. Psychological concepts are explained, psychological interventions are reviewed, and integrative approaches addressing psychological factors in the clinic are introduced.