ORIGINAL RESEARCH—EPIDEMIOLOGY: Sexual Problems Among a Specific Population of Minority Women Aged 40–80 Years Attending a Primary Care Practice

Improving the identification of genitourinary syndrome of menopause through the utilization of the Day-to-Day Impact of Vaginal Aging questionnaire

OBJECTIVE

Genitourinary syndrome of menopause (GSM) affects nearly 50% of postmenopausal women. Yet women fail to recognize GSM as a chronic condition and are reluctant to discuss their vaginal or sexual complaints with a health care provider. This quality improvement project implemented the Day-to-Day Impact of Vaginal Aging (DIVA) questionnaire to improve the identification and diagnosis of GSM in women ≥ 45 years of age presenting for an annual wellness examination or a vulvovaginal/genitourinary complaint.

METHODS

From October 2019 to February 2020, the DIVA questionnaire was distributed in a large women's health practice setting to women ≥ 45 years of age, for completion before their annual wellness visit or for evaluation of a GSM-related complaint. GSM diagnosis rates during the implementation period were compared with diagnosis rates during a 4-month period immediately preceding the implementation. Data collected during the implementation period were examined to evaluate if GSM diagnosis was more likely in patients who completed the DIVA questionnaire when compared to those women who did not complete the questionnaire.

RESULTS

Of the 175 women who met the inclusion criteria, 113 completed the DIVA questionnaire. Completion of the DIVA questionnaire demonstrated a relative percentage increase in GSM diagnosis by 30.7% when compared to the 4-month preimplementation period (10.1% to 13.2%, P = 0.231). This change was not statistically significant. During the implementation period, a statistically significant difference in GSM diagnosis was observed for patients who completed the DIVA questionnaire when compared to those patients who did not complete the questionnaire (37.2% vs 9.7%, P < 0.001). When results were stratified by visit type, women presenting for an annual wellness visit who completed the DIVA questionnaire had a higher GSM diagnosis rate than those who did not complete the questionnaire (37.2% vs 10%, P < 0.001). When results were stratified by menopausal status, GSM diagnosis rates were also more likely for postmenopausal women who completed the DIVA questionnaire when compared to those who did not complete the questionnaire (44.2% vs 8.5%, P < 0.001).

CONCLUSIONS

The DIVA questionnaire is a brief, but comprehensive screening tool that can increase GSM identification and treatment, particularly for postmenopausal, and midlife women presenting for an annual wellness visit in a busy women's health practice setting. : Video Summary:http://links.lww.com/MENO/A655.

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.

Improving Sexual Satisfaction in Persons with Spinal Cord Injuries: Collective Wisdom

Sexuality is an important part of life, and it is necessary for clinicians to have a specific format in which to address sexual issues with their patients. A systematic approach to working with patients with spinal cord injury (SCI) to improve their sexual functioning and response is presented. Nonjudgmental communication about sexual concerns is followed by a detailed pre- and postinjury medical, psychosocial, and sexual history. If preexisting sexual issues are present, it is recommended that the patient be referred for assessment and treatment of these separate from the patient's SCI-related concerns. Physical examination, with special attention to issues that could impact the patient's sexuality, is followed by a detailed neurologic assessment with specific attention to the T11-L2 and S3-5 spinal segments. Education of the patient with regard to his or her sexual potential and the need to be flexible in his or her sexual repertoire is followed by self-exploration and practice. Routine follow-up is suggested after patient's initial sexual exploration. Treatment of confounding and iatrogenic factors related to SCI is followed by more sexual experience. Afterwards the clinician is encouraged to use simple techniques to treat sexual issues and follow-up with the patient to assess the outcome. A structured program utilizing vibratory stimulation with or without midodrine is described as a way to achieve ejaculation and potentially orgasm, and techniques for treating severe autonomic dysreflexia are discussed. If these interventions do not alleviate the patient's sexual concerns, the clinician should refer the patient for more specialized consultation.

Gendered sexual uses of alcohol and associated risks: a qualitative study of Nigerian University students

Background

Alcohol misuse among young people is a global phenomenon. In many countries, young people engage in heavy drinking and this exacerbates risky sexual behaviour. In Nigeria, alcohol held multiple roles in the traditional era but was mainly consumed by adult males for pleasure. Adult females and young people were culturally constrained from drinking in most communities. In contemporary Nigeria, young people’s drinking is increasing, and many engage in sexual intercourse under the influence of alcohol.

Methods

This study draws on the traditional gender and social sexual scripts to explore the factors that motivate young people to use alcohol for sexual purposes. In-depth interviews were conducted with 19 to 23-year old male and female undergraduate students from a Nigerian university. Thematic analysis was conducted with the aid of NVivo 10 software.

Results

Men drink to become confident to initiate sexual relationships, stimulate sexual urges, prolong erection, increase sexual satisfaction and become more aggressive during sexual intercourse. Women also drink to be bold in initiating sexual relationships, for sexual arousal and to increase satisfaction. Relatedly, not every brand of alcohol is used for sexual purposes. For example, while men use ‘herbal’ alcoholic beverages and a mixture of locally-produced gin and marijuana, women use champagne and other flavoured alcoholic beverages. The results also revealed that young people use alcohol or salt in a bid to prevent conception after sexual intercourse.

Conclusions

Adherence to the traditional gender (masculinity) and social sexual scripts amongst men and the enactment of what appears to be a new form of femininity script amongst women contribute to a culturally specific understanding of the motivations to use alcohol for sexual purposes. Evidence-based strategies should be employed to distribute information about the consequences of sexual intercourse under the influence of alcohol.

Let's talk about sex: older people's views on the recognition of sexuality and sexual health in the health-care setting

Objective

To report on the findings of a systematic review which examined the experiences and views of older people aged 65 years and over on health professionals’ recognition of sexuality and sexual health and whether these aspects of the person are incorporated into care.

Review methods

The review followed the methods laid out by the Joanna Briggs Institute. Eleven electronic databases were searched using the terms sexual*, aged, ageing/aging, attitudes and care in any health‐care setting. Only quantitative and qualitative research and opinion papers written in English and offering unique commentary published between January 2004 and January 2015 were eligible.

Results

A total of 999 papers were initially identified and of these, 148 were assessed by two reviewers. Eighteen studies – seven quantitative, eight qualitative and three opinion papers – met the inclusion criteria and were appraised. The importance of sexuality to well‐being, language used, expressing sexuality, discomfort discussing sexuality, inadequate sexuality health education and treatment and deficient communication with health‐care professionals were all identified as significant issues in a range of settings. Fourteen categories and five syntheses summarize the 43 findings.

Conclusions

Sexuality remains important for many older people; however, embarrassment, dissatisfaction with treatment, negative attitudes and seeming disinterest by health professionals can all inhibit discussions. Professionals and health‐care services need to adopt strategies and demonstrate characteristics which create environments that are more supportive of sexuality. Issues related to sexuality and sexual health should be able to be discussed without anxiety or discomfort so that older people receive optimal care and treatment.

Psychosocial pathways to sexual dysfunction among female inmates

Although health surveys on sexual issues during incarceration have shown that women report having engaged in sexual activities while in prison, studies on sexual functioning in female inmates have been largely dismissed. This study aimed to assess sexual functioning among incarcerated women and determine the psychometric and sociodemographic features that are possibly related to the risk of sexual dysfunction. This was a cross-sectional study conducted inside a penitentiary for women in São Paulo, Brazil. From June 2006 to June 2010, 315 inmates convicted of robbery or homicide were recruited. High risk of female sexual dysfunction (HRFSD) was measured using the Female Sexual Function Index and participants were also evaluated for alcohol and drug misuse, impulsiveness, depressive symptoms, and psychosocial features. Descriptive statistics and multivariate logistic regression were utilized to analyze the data. Among the participants, 253 (80.32 %) met the criteria for HRFSD. Older age, total time of imprisonment, and depressive symptoms were related to a higher risk, while the status of being married, being Black, having sexual relations with other inmates, and receiving conjugal visits were associated with a lower risk. As only 110 (34.92 %) inmates admitted to having sexual relationships inside prison, we evaluated this sub-sample separately. For this sub-sample, 61 (55.45 %) women met the criteria for HRFSD and the main factors associated with this risk were total time of imprisonment and depressive symptoms. Incarcerated women are uniquely vulnerable because they often have histories of deprivation and violence stemming from multiple sources and experience considerable psychological symptoms as a consequence of imprisonment. With the affected population rarely receiving psychosocial management for sexual dysfunction, service delivery efforts should be intensified to target this high-risk population.

Impact of vulvovaginal health on postmenopausal women: a review of surveys on symptoms of vulvovaginal atrophy

Several recent, large-scale studies have provided valuable insights into patient perspectives on postmenopausal vulvovaginal health. Symptoms of vulvovaginal atrophy, which include dryness, irritation, itching, dysuria, and dyspareunia, can adversely affect interpersonal relationships, quality of life, and sexual function. While approximately half of postmenopausal women report these symptoms, far fewer seek treatment, often because they are uninformed about hypoestrogenic postmenopausal vulvovaginal changes and the availability of safe, effective, and well-tolerated treatments, particularly local vaginal estrogen therapy. Because women hesitate to seek help for symptoms, a proactive approach to conversations about vulvovaginal discomfort would improve diagnosis and treatment.

Is one question enough to detect female sexual dysfunctions? A diagnostic accuracy study in 6,194 women

INTRODUCTION

Literature shows that recognition of sexual dysfunctions in women is insufficient and existing instruments to aid detection are mostly too extensive to be used in routine practice.

AIM

To develop a brief and accurate screening instrument to detect female sexual dysfunctions in routine care.

METHODS

The initial item pool for the index test consisted of 15 items. In a 4-year period, a total of 12,957 persons filled out the test on a specifically designed web-site. Six thousand one hundred ninety-four complete data sets could be used for statistical analysis. The validated German version of the Female Sexual Function Index (FSFI-d) served as reference standard to estimate the accuracy of the screening test. In order to test several possible ways of combining items a multi-step procedure employing univariate analyses, multiple logistic regression, and classification and regression tree analysis was applied to a learning sample and cross-validated in a test sample.

MAIN OUTCOME MEASURES

Diagnostic performance (sensitivity, specificity, positive and negative predictive value, accuracy, diagnostic odds ratio as well as adjusted odds ratio) of the items and resulting models to discriminate women with sexual dysfunction from those without were calculated.

RESULTS

One dichotomous question for overall satisfaction proved to show high accuracy as a stand-alone instrument and played also a central role in multivariate models. It may be recommended as a one-question screening test (76.4% sensitivity and 76.5% specificity in the test sample). A hierarchical two-question test yielded higher sensitivity (93.5%) and lower specificity (60.1%). A slightly more extensive version consists of five questions (83.1% sensitivity and 81.2% specificity).

CONCLUSIONS

Despite some methodological limitations of our study all developed tests showed acceptable to good diagnostic performance, all are very short and could therefore be easily implemented into routine care. Further tests of psychometric properties in other settings are needed.

Sexuality during the climacteric period

BACKGROUND

Cultural, social, physiological and psychological factors may alter the course of sexual function in climacteric women.

OBJECTIVE

The objective of the present literature review is to survey the prevalence of sexual dysfunctions in the climacteric and to establish the association between the organic and psychic changes that occur during this phase and sexual dysfunction. We also discuss potential treatments.

METHODS

We evaluated the data available in PubMed (1982-2008). For each original article, two reviewers analyzed the data independently and considered a study to be of high quality if it had all three of the following characteristics: prospective design, valid data and adequate sample size. Both reviewers extracted data from each of the 99 studies selected: 34 cross-sectional studies, 25 cohort studies, 9 trials, 31 reviews related to sexuality in pre- and post-menopausal women.

RESULTS

Sexual dysfunction among climacteric women is widespread and is associated with bio-psychosocial factors. However, there is not enough evidence to correlate sexual dysfunction with a decrease in estrogen levels and biological aging. A strong association exists between climacteric genital symptoms and coital pain. There is, however, sufficient evidence demonstrating the benefits of local estrogen therapy for patients with genital symptoms.

CONCLUSION

A significant decline in sexual function occurs in climacteric women, although it is still unclear whether this is associated with the known decrease in estrogen levels or with aging, or both. Relational factors may interfere with sexual function during this phase. The climacteric genital symptoms improve with estrogen replacement therapy, and positively influence sexual function. Further studies are needed to establish the actual impact of the decrease in estrogen levels and of aging on the sex life of climacteric women.

Patient-provider communication and cancer screening among unmarried women

OBJECTIVES

Unmarried women are less likely than married women to receive recommended cancer screenings. Patient-provider communication is a consistent predictor of cancer screening among women. The purpose of this study was to investigate the relationship between patient and provider communication, barriers to cancer screening, and on-schedule breast and cervical cancer screening (BCCS) among unmarried women.

METHODS

Data were from the Cancer Screening Project for Women, a 2003-2005 survey examining cancer screening practices. We computed polytomous logistic regression models to examine the relationship between communication (communication about tests, communication about sexual and intimate relationships), barriers to screening, and on-schedule BCCS among unmarried women.

RESULTS

A total of 630 women were enrolled, and 605 women completed the baseline questionnaire. Overall, more than 60% reported on-schedule BCCS. More than half reported that their providers communicated about BCCS most or all of the time. Fewer than half communicated about sexual history and intimate relationships. Women who reported that their providers communicated about screening tests and their sexual and intimate relationships were more likely to be on-schedule for BCCS.

CONCLUSION

Patient-provider communication about multiple topics may encourage women to remain on-schedule for their recommended cancer screenings. Longitudinal research should be conducted to examine whether communication predicts BCCS, and to examine how patient and provider characteristics may influence communication in order to promote adherence to screening guidelines for unmarried women.

PRACTICE IMPLICATIONS

Comprehensive communication that goes beyond information about screening tests may impact adherence to cancer screening guidelines.

RETRACTED: Evaluation of the safety and efficacy of bremelanotide, a melanocortin receptor agonist, in female subjects with arousal disorder: a double-blind placebo-controlled, fixed dose, randomized study

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief. Following the retraction of Dr. Safarinejad's work by other journals, The Journal of Sexual Medicine has undertaken an extensive re-review of all papers Dr. Safarinejad published with the journal. Following an intensive re-evaluation and close scrutiny of the manuscripts, our expert reviewers raised multiple concerning questions about the methodology, results, and statistical interpretation as presented in this article. Dr. Safarinejad was contacted to provide his original data and offer explanations to address the concerns expressed by the reviewers. Dr Safarinejad chose not to respond. Consequently, we can no longer verify the results or methods as presented and therefore retract the article.

Premenopausal women with sexual dysfunction: the need for a bladder function history

INTRODUCTION

Despite the high prevalence of both female sexual problems and bladder dysfunction in the premenopausal population, sexual history forms used in primary care offices rarely include questions about the impact of bladder dysfunction on sexual health.

AIM

To provide a review of the literature that illustrates the relationship between bladder problems and sexual performance of premenopausal women.

MAIN OUTCOME MEASURES

To objectively support by a review of the literature the need for a complete bladder history in when evaluating premenopausal women with female sexual dysfunction.

METHODS

Pubmed was searched for all articles (from November 1980 to June 2007) that reported on the effect bladder dysfunction has on premenopausal female sexual function.

RESULTS

The scant literature available strongly suggested that bladder dysfunction is a contributor to sexual dysfunction and that this medical concern should be considered in all women, regardless of age who present with sexual complaints.

CONCLUSION

Further studies need to be conducted in order to solidify a direct causal relationship between bladder dysfunction and premenopausal female sexuality. These studies should include a larger sample size, clearly defined types of sexual dysfunction and bladder dysfunction, and appropriate follow-up of patient responses using validated objective and subjective outcome modalities to confirm that the patient responses are factual.

The Prevalence and Causes of Sexual Problems among Premenopausal Turkish Women

INTRODUCTION

Sexual dysfunction in females is an important public health problem worldwide. It is suggested that sexual problems among women are more common than the number of diagnosed female sexual dysfunction (FSD) cases indicates.

AIM

To determine the frequency and causes of sexual problems among premenopausal and married women who attend primary healthcare facilities.

METHODS

This study was conducted at the Mother and Child Health and Family Planning Center. All women who attended this center during a 3-month period were included in the study. Sexual problems were evaluated via questionnaire and a standardized scale known as the Golombok Rust Inventory of Sexual Satisfaction (GRISS). MAIN OUTCOME MEASURE. A cross-sectional study.

RESULTS

Although a total of 422 women aged 19-51 years were eligible for inclusion in the study, the participation rate was 27%. Nearly two-thirds of the women were aged 20-34 years, and of this group, 84.3% were unemployed. According to self-reports, 15.7% (18) of the women had sexual problems, whereas the prevalence of sexual dysfunction using GRISS was 26.1%. Vaginismus (41.7%), infrequent intercourse (39.1%), and nonsensuality (38.3%) were the most common complaints of the women with sexual problems. The rate of sexual dissatisfaction was found to be 7%. Sexual problems among women who had a long-term marriage (more than 11 years) and who were sexually inexperienced at the time of their marriage were significantly higher (P = 0.036, P = 0.034, respectively). It was found that discussing sexual problems with husbands and healthcare professionals did not reduce sexual problems.

CONCLUSIONS

According to GRISS, nearly one-quarter of the women were suffering from sexual problems. The most common sexual problem was vaginismus, followed by infrequent intercourse. It is suggested that inadequate knowledge and the attitudes of spouses and health workers in primary healthcare settings are the important causes of FSD in this population.

A Pilot Survey of Sexual Functioning and Preferences in a Sample of English-Speaking Adults from a Small South Indian Town

INTRODUCTION

There is a dearth of recent information on sexual functioning and preferences from an Indian population.

AIM

To study sexual functioning and preferences in a sample of English-speaking adults in a small town in South India.

METHOD

Responses were obtained through a postal questionnaire method and were analyzed. Study document included an explanation of the study, sociodemographic details, a sexual functioning questionnaire, a semistructured sexual preference questionnaire, and meanings of terms used in the questionnaires.

MAIN OUTCOME MEASURE

Frequency of various sexual functions, difficulties, and preferences over a period of 1 month.

RESULTS

Sixty-one subjects out of 200 English-speaking persons from a south Indian town returned the questionnaire. Common sexual difficulties included decreased interest in sex (16.4%), arousal difficulties (21.3%), orgasmic difficulties in females (28.6%), and premature ejaculation in males (15.2%). Masturbation was considered wrong by 18% of respondents; with almost 40% of females and 6% of males reported to have never masturbated. There were many differences in the sexual functioning of married compared to unmarried persons and other sociodemographic groups. Practice of various sexual preferences was reported: voyeurism (41.0%), fetishism (18.0%), frotteurism (11.5%), homosexuality (11.5%), telephone scatology (9.8%), and incest (8.2%) being more common. In a small minority, telephone scatology (3.3%), voyeurism (1.6%), and fetishism (1.6%) were reported to be the only method of sexual gratification.

CONCLUSIONS

Sexual difficulties were similar to other reports in different cultures. Varieties of preferences were practiced, and there were variations among different sociodemographic groups.

Overactive bladder and women's sexual health: what is the impact?

INTRODUCTION

Overactive bladder (OAB) is quite prevalent and significantly affects health-related quality of life and daily functioning.

AIM

The impact of OAB on sexual health is currently not known. This qualitative study was conducted to gain a thorough understanding of OAB's impact.

METHODS

Sexually active women with continent or incontinent OAB were recruited from urology and urogynecology clinics. Six focus groups of women (three continent and three incontinent) were conducted to assess the sexual health of women with OAB. Data were analyzed descriptively and qualitatively.

MAIN OUTCOME MEASURES

Qualitative data, Sexual Quality of Life Questionnaire-Female, Overactive Bladder Questionnaire.

RESULTS

Thirty-four women (11 continent; 23 incontinent) participated; mean age was 48.4 years; 76% were white, 67% postmenopausal, and 88% in a long-term relationship. Continent women reported more frequent sexual activity than incontinent women; 91% reported intercourse >or=1-3 times per month vs. 50% of incontinent women. Half of the incontinent women reported a reduction in sexual desire related to OAB, aging, and menopause. Over half of continent women experienced pain with intercourse, and the majority complained of having to interrupt intercourse to void. Although not all incontinent women reported incontinence during intercourse, the majority were embarrassed by their incontinence and OAB with resulting loss of self-image. Both continent and incontinent women reported difficulty achieving orgasm because of pain, fear of incontinence, or anxiety related to intercourse. Approximately a third of the women would not initiate discussion of sexual issues with their physicians, but all women expressed concern about the impact of OAB on their sexual life.

CONCLUSION

Overactive bladder with or without incontinence negatively affects women's sexual health, reducing sexual desire and ability to achieve orgasm. Given the impact of OAB on sexual health, sexual health should be routinely assessed by clinicians and addressed by researchers.