ORIGINAL RESEARCH–WOMEN'S SEXUAL HEALTH: Clinically Relevant Changes in Sexual Desire,Satisfying Sexual Activity and Personal Distress as Measured by the Profile of Female Sexual Function,Sexual Activity Log,and Personal Distress Scale in Postmenopausal Women with Hypoactive Sexual Desire Disorder

IntroductionTransdermal testosterone patch (TTP) treatment produced statistically significant improvements in a satisfying sexual activity (SSA), sexual desire, and personal distress in postmenopausal women suffering from hypoactive sexual desire disorder (HSDD), but clinical significance of these changes was not determined.AimTo quantify the magnitude of change in three principal outcomes measures determined by HSDD patients as associated with the perception of meaningful benefit with TTP therapy.MethodsThe criteria for defining responders were determined using anchoring methodology and receiver operating characteristics analysis to establish minimum important differences (MIDs) in a representative subsample of 132 patients in two randomized, controlled trials in surgically menopausal women with HSDD (N = 1,094). Perceived benefit was established based upon the question “Overall, would you say that you experienced a meaningful benefit from the study patches?”. These data defined responders and established MIDs for changes in sexual desire, SSA, and personal distress. The MIDs were applied to the two trials to establish responder rates in each treatment group.Main Outcome MeasuresChanges in score that correspond to the MID for sexual desire, SSA, and personal distress, and responder rates in each treatment group based upon these values.ResultsIncreases in frequency of SSA of greater than 1 activity/4 weeks, increases in sexual desire score of ≥8.9, and decreases in the personal distress score of ≥20.0 were identified as threshold improvements best able to differentiate responders and nonresponders. The responder rate was significantly higher (P < 0.001) in the testosterone group vs. placebo for all three outcomes measures (sexual desire, 50% vs. 34%; SSA, 44% vs. 30%; personal distress, 51% vs. 39%).ConclusionsChanges in sexual desire, SSA, and personal distress observed with TTP treatment in surgically menopausal women with HSDD were clinically significant and were associated with a meaningful treatment benefit. DeRogatis LR, Graziottin A, Bitzer J, Schmitt S, Koochaki PE, and Rodenberg C. Clinically relevant changes in sexual desire, satisfying sexual activity and personal distress as measured by the profile of female sexual function, sexual activity log, and personal distress scale in postmenopausal women with hypoactive sexual desire disorder. J Sex Med 2009;6:175–183.     

Sexuelle Störungen in der Peri- und Postmenopause

The importance of adequate estrogen levels in preserving vaginal health and preventing dyspareunia in postmenopausal women has long been established. Additionally, estrogens may play an indirect role by priming the brain to be selectively responsive to sexual stimuli. Androgens may also be important for sexual function. Conventional systemic or local vulvovaginal hormone therapy with estrogens may be helpful in restoring vaginal health and sexual function respectively; however it may not be enough as the sole therapeutic agent. Additional testosterone treatment in low-dose regimens may be beneficial, specifically in women with an established cause of androgen deficiency such as surgical menopause. Recent data support hypotheses that androgens may be beneficial also in naturally menopausal women. Local dehydroepiandrosterone (DHEA) appears to have beneficial effects on all the symptoms and signs of vaginal atrophy.     

Sexuality and the menopause

Sexual problems such as dyspareunia and decreased sexual desire are common after the menopause. Hypoactive sexual desire disorder is the diagnostic category applied to many women with loss or lack of sexual interest or desire. The principal components of assessment for sexual dysfunction in menopausal women are: a general, gynaecological, obstetric, psychiatric, psychosexual and relationship history; use of self-report questionnaires; physical examination; and hormonal evaluation. The use of low-dose vaginal estrogen tablets, rings, creams or pessaries may help to improve local genital response but does not necessarily improve sexual interest or motivation. An improvement in sexual function has been reported with tibolone and a combination of estrogen and androgen therapy, al though it remains unclear which groups of postmenopausal women with sexual problems will benefit most from such treatments. Where there is no response to estrogens or where there is premature or surgical menopause the addition of an androgen may be necessary, particularly if the free testosterone levels are low.     

Sexuality,pelvic floor/vaginal health and contraception at menopause

A multitude of biopsychosocial factors influences sexual health at midlife, a common concern in daily practice along with vaginal and pelvic health. Health-care providers (HCPs) need to be proactive in dealing with possible symptoms because in most cases early management prevents distress and improves quality of life. Female sexual dysfunctions (FSDs) may have a complex etiology but sexual history is not difficult implementing basic knowledge of risk factors and some skills helping women to cope with hormonal and age-related changes.This work summarizes key points to approach sexual symptoms in midlife women, providing principles to diagnose and manage hypoactive sexual desire disorder (HSDD) and genitourinary syndrome of menopause (GSM)/vulvovaginal atrophy (VVA), as well as manage contraceptive needs.     

The Prevalence of Hypoactive Sexual Desire Disorder in Surgically Menopausal Women: An Epidemiological Study of Women in Four European Countries

IntroductionInsufficient documentation exists regarding the prevalence of hypoactive sexual desire disorder (HSDD) in surgically menopausal (SM) women in European countries. Women who have undergone hysterectomy and bilateral oophorectomy experience a loss of ovarian hormones. Inclusion of these women in an epidemiological study provided the opportunity to study biological and cultural impacts on sexual function.AimThe aim of this study was to compare the prevalence of HSDD among SM women in France, Germany, Italy, and the United Kingdom, as well as the relationship between low sexual desire and sexual activity or behavior, and sexual or partner relationship satisfaction.MethodsCross-sectional survey of a convenience sample of 427 SM women aged 20–70 years.Main Outcome MeasuresThe desire domain of the Profile of Female Sexual Function (PFSF) to identify women with low sexual desire, Personal Distress Scale (PDS) to measure distress caused by low sexual desire, and a sexual activities measure. Women with low sexual desire who were distressed were classified as having HSDD.ResultsSM women having low sexual desire ranged from 35% (United Kingdom) to 44% (Italy); of these women, 16% (Germany) to 56% (France) were distressed because of their low sexual desire. Overall, SM women classified with HSDD ranged from 7% (Germany) to 22% (France). A strong positive correlation was observed between sexual desire and arousal, orgasm, and sexual pleasure in all countries (P < 0.001). Low sexual desire leads to less sexual activity, more dissatisfaction with sex life and partner relationship, and more negative emotional or psychological states, than normal desire in each country.ConclusionsA similar percentage of SM women with low sexual desire were found across countries suggesting the role of biological factors (i.e., losing ovarian hormones) in determining sexual desire. Differences in the percentage of SM women with HSDD suggest a role for cultural factors in determining how low sexual desire is perceived. Graziottin A, Koochaki PE, Rodenberg CA, and Dennerstein L. The prevalence of hypoactive sexual desire disorder in surgically menopausal women: An epidemiological study of women in four European countries. J Sex Med 2009;6:2143–2153.     

Sexual Desire in Trans Persons: Associations with Sex Reassignment Treatment

IntroductionSex steroids and genital surgery are known to affect sexual desire, but little research has focused on the effects of cross‐sex hormone therapy and sex reassignment surgery on sexual desire in trans persons.AimThis study aims to explore associations between sex reassignment therapy (SRT) and sexual desire in a large cohort of trans persons.MethodsA cross‐sectional single specialized center study including 214 trans women (male‐to‐female trans persons) and 138 trans men (female‐to‐male trans persons).Main Outcome MeasuresQuestionnaires assessing demographics, medical history, frequency of sexual desire, hypoactive sexual desire disorder (HSDD), and treatment satisfaction.ResultsIn retrospect, 62.4% of trans women reported a decrease in sexual desire after SRT. Seventy‐three percent of trans women never or rarely experienced spontaneous and responsive sexual desire. A third reported associated personal or relational distress resulting in a prevalence of HSDD of 22%. Respondents who had undergone vaginoplasty experienced more spontaneous sexual desire compared with those who planned this surgery but had not yet undergone it (P = 0.03).In retrospect, the majority of trans men (71.0%) reported an increase in sexual desire after SRT. Thirty percent of trans men never or rarely felt sexual desire; 39.7% from time to time, and 30.6% often or always. Five percent of trans men met the criteria for HSDD. Trans men who were less satisfied with the phalloplasty had a higher prevalence of HSDD (P = 0.02).Trans persons who were more satisfied with the hormonal therapy had a lower prevalence of HSDD (P = 0.02).ConclusionHSDD was more prevalent in trans women compared with trans men. The majority of trans women reported a decrease in sexual desire after SRT, whereas the opposite was observed in trans men. Our results show a significant sexual impact of surgical interventions and both hormonal and surgical treatment satisfaction on the sexual desire in trans persons. Wierckx K, Elaut E, Van Hoorde B, Heylens G, De Cuypere G, Monstrey S, Weyers S, Hoebeke P, and T'Sjoen G. Sexual desire in trans persons: Associations with sex reassignment treatment. J Sex Med 2014;11:107–118.     

Evaluation of the Sexual Desire Relationship Distress Scale (SDRDS) in Women with Hypoactive Sexual Desire Disorder

IntroductionThe Sexual Desire Relationship Distress Scale (SDRDS) was developed to address the need for a patient‐reported outcome (PRO) measure of sexual distress associated with hypoactive sexual desire disorder (HSDD). The SDRDS is a 17‐item PRO that includes items related to personal distress and distress related to relationship with partner.AimThe aim of this article was to evaluate the psychometric properties of the SDRDS among women with HSDD.MethodsPre‐ and post‐menopausal women with HSDD or with no sexual dysfunction completed the SDRDS, Sexual Activity Questions, Female Sexual Distress Scale‐Revised (FSDS‐R), and desire domain of the Female Sexual Function Index (FSFI) at baseline and 2 and 4 weeks later.Main Outcome MeasuresThe main outcome measures of this article were item performance, internal consistency, test–retest reliability, construct validity, known groups validity, and responsiveness of the SDRDS.ResultsData from 260 women were analyzed: 101 in each of the pre‐ and post‐menopausal HSDD groups and 29 in each of the pre‐ and post‐menopausal control groups. No differences emerged between pre‐ and post‐menopausal women. Least‐squares mean (±standard errors [SE]) SDRDS score was higher in women with HSDD than in women with no sexual dysfunction (43.1 ± 0.9 vs. 6.1 ± 1.7; P < 0.0001), supporting known groups validity. Individual item scores correlated with total scores (r = 0.7–0.9; P < 0.0001). Internal consistency was high, with a Cronbach's alpha of 0.973 at baseline. Test–retest reliability was good, with an intraclass correlation coefficient of 0.89. SDRDS scores correlated strongly with other measures of sexual distress and sexual function including the FSDS‐R and FSFI desire domain items. Preliminary analyses suggested that the SDRDS was sensitive to changes in clinical status.ConclusionsThe SDRDS provides a comprehensive and reliable assessment of distress due to decreased sexual desire in women with HSDD and may be a useful measure of treatment effects in clinical trials in women with this condition. Revicki DA, Margolis MK, Fisher W, Rosen RC, Kuppermann M, Hanes V, and Sand M. Evaluation of the Sexual Desire Relationship Distress Scale (SDRDS) in women with hypoactive sexual desire disorder. J Sex Med 2012;9:1344–1354.     

Women's perception of sexuality around the menopause: outcomes of a European telephone survey

OBJECTIVE: Women's attitudes and experience towards sexuality around the menopause were investigated in Europe by a telephone survey. In addition, it was qualified to what extent reduced sex drive and vaginal dryness affect personal life, taking into account cultural differences. STUDY DESIGN: A survey on 1,805 post-menopausal women (age range: 50-60 years), experiencing at least one menopausal symptom (hot flushes or sleeplessness) or not menstruating for at least 1 year, was conducted in six European countries (United Kingdom, France, Germany, Italy, The Netherlands, Switzerland) by computer-assisted telephone interviewing. A structured interview analysed menopausal profile, sexuality-related menopausal symptoms, mental well-being and attitudes towards sexuality. RESULTS: Apart from hot flushes or sleeplessness, women particularly experienced sexual symptoms, such as reduced sexual desire and vaginal pain/dryness during the menopausal transition: one third (34%) of the women mentioned experiencing a reduced sex drive whereas one half (53%) of the women noticed that they became less interested in sex in spite of the majority of the sample reporting finding it important to maintain an active sex life (71%). Sex is experienced as an important part of the relationship with a partner, especially for Italian and Swiss women and ageing seems to play a critical role in sexual functioning, particularly for Italian and Dutch women. A general positive attitude toward sex was supported by the evidence that almost half of the study sample reported having sexual contact at least four times a month. Mental and sexual well-being interfered with self-worth and enjoyment of life, as did vaginal discomfort. CONCLUSIONS: These data suggest that European middle-aged women experience the menopause as a process that brings about mood and sexual changes able to impair their personal life. However, cultural values and health beliefs influence perception of sexuality at the time of the menopause and will also influence the need for treatment.     

Female sexual dysfunction and use of hormone therapy in postmenopausal women

Sexual dysfunction is a common problem for women of all ages and remains an important aspect of women's health following menopause. For postmenopausal women, the evaluation and management of sexual dysfunction differs from that of younger women because the etiology is often linked to the diminished levels of sex hormones. Female sexual function is highly complex and deeply influenced by nonhormonal factors such as emotional intimacy and culture. Our understanding of this important area of women's health remains inadequate, and much more research needs to be performed before definitive conclusions can be made. Existing data allow for some preliminary observations. It appears that lack of estrogen may lead to sexual dysfunction primarily by causing vaginal atrophy and dyspareunia. These symptoms may be treated by systemic or local estrogen therapy. Conversely, androgen deficiency appears to be most strongly linked to diminished sexual desire. Growing evidence indicates that administration of androgens may be beneficial in such situations. Other agents that use sex hormone receptors, such as selective estrogen receptor modulators and tibolone, also may affect sexual function.     

Actualización sobre el trastorno del deseo sexual hipoactivo femenino

Hypoactive sexual desire disorder (HSDD) is the most common type of female sexual dysfunction (FSD). A diagnosis of HSDD requires evidence of personal distress or interpersonal difficulty associated with low sexual desire that cannot be better accounted for by another psychiatric condition and is not due exclusively to a medical condition or substance. HSDD can have a major impact on women's emotional wellbeing and relationships and occurs in both pre- and post-menopausal women. Until recently, diagnosis of HSDD required an extensive diagnostic interview conducted by a clinician with experience in the diagnosis of FSD. The decreased sexual desire screener (DSDS) is a brief diagnostic instrument that has been developed to aid clinicians who are not experts in FSD to diagnose generalized acquired HSDD in women. There is a need for greater understanding of the etiology of HSDD and for more therapeutic options.     

Prevalence and Predictors of Low Sexual Desire,Sexually Related Personal Distress,and Hypoactive Sexual Desire Dysfunction in a Community-Based Sample of Midlife Women

BackgroundLow desire is the most common sexual problem in women at midlife. Prevalence data are limited by lack of validated instruments or exclusion of un-partnered or sexually inactive women.AimTo document the prevalence of and factors associated with low desire, sexually related personal distress, and hypoactive sexual desire dysfunction (HSDD) using validated instruments.MethodsCross-sectional, nationally representative, community-based sample of 2,020 Australian women 40 to 65 years old.OutcomesLow desire was defined as a score no higher than 5.0 on the desire domain of the Female Sexual Function Index (FSFI); sexually related personal distress was defined as a score of at least 11.0 on the Female Sexual Distress Scale–Revised; and HSDD was defined as a combination of these scores. The Menopause Specific Quality of Life Questionnaire was used to document menopausal vasomotor symptoms. The Beck Depression Inventory–II was used to identify moderate to severe depressive symptoms (score ≥ 20).ResultsThe prevalence of low desire was 69.3% (95% CI = 67.3–71.3), that of sexually related personal distress was 40.5% (95% CI = 38.4–42.6), and that of HSDD was 32.2% (95% CI = 30.1–34.2). Of women who were not partnered or sexually active, 32.4% (95% CI = 24.4–40.2) reported sexually related personal distress. Factors associated with HSDD in an adjusted logistic regression model included being partnered (odds ratio [OR] = 3.30, 95% CI = 2.46–4.41), consuming alcohol (OR = 1.48, 95% CI = 1.16–1.89), vaginal dryness (OR = 2.08, 95% CI = 1.66–2.61), pain during or after intercourse (OR = 1.63, 95% CI = 1.27–2.09), moderate to severe depressive symptoms (OR = 2.69, 95% CI 1.99–3.64), and use of psychotropic medication (OR = 1.42, 95% CI = 1.10–1.83). Vasomotor symptoms were not associated with low desire, sexually related personal distress, or HSDD.Clinical ImplicationsGiven the high prevalence, clinicians should screen midlife women for HSDD.Strengths and LimitationsStrengths include the large size and representative nature of the sample and the use of validated tools. Limitations include the requirement to complete a written questionnaire in English. Questions within the FSFI limit the applicability of FSFI total scores, but not desire domain scores, in recently sexually inactive women, women without a partner, and women who do not engage in penetrative intercourse.ConclusionsLow desire, sexually related personal distress, and HSDD are common in women at midlife, including women who are un-partnered or sexually inactive. Some factors associated with HSDD, such as psychotropic medication use and vaginal dryness, are modifiable or can be treated with safe and effective therapies.Worsley R, Bell RJ, Gartoulla P, Davis SR. Prevalence and Predictors of Low Sexual Desire, Sexually Related Personal Distress, and Hypoactive Sexual Desire Dysfunction in a Community-Based Sample of Midlife Women. J Sex Med 2017;14:675–686.     

Hormones and Sexuality in Postmenopausal Women: A Psychophysiological Study

Sexual function, including vaginal atrophy, and hormonal status, were studied in 42 naturally postmenopausal women. Vaginal pulse amplitude and subjective sexual responses during self-induced erotic fantasy and during erotic films were compared with responses of a small number of premenopausal women. As predicted, vaginal atrophy was related to estrogens but not to complaints of vaginal dryness and dyspareunia. No significant relationship was found between hormones and sexual function. Unexpectedly, most of the few correlations that did reach significance involved prolactin. The fact that prolactin was negatively associated with sexual desire, sexual arousal and vaginal lubrication during sexual activity, suggests that psychosocial factors are more important titan hormone levels in postmenopausal sexual function. Comparisons with a number of premenopausal women revealed that although postmenopausal women displayed lower vaginal pulse amplitude responses prior to erotic stimulation than the premenopausal women, this difference disappeared during subsequent erotic stimulation. We argued that this finding can be interpreted as being supportive of the notion that complaints of vaginal dryness and dyspareunia should not be attributed to vaginal atrophy associated with menopause. Rather, vaginal dryness and dyspareunia seem to reflect sexual arousal problems.     

Hypoactive sexual desire disorder, HSDD

Hypoactive Sexual Desire Disorder (HSDD) is the most common Female Sexual Dysfunction (FSD) affecting adult women of any age, including postmenopausal women. HSDD may have significant effects on the relationships and emotional balance of women and constitutes the most common form of FSD observed in clinical practice. HSDD is characterised by a deficiency or lack of sexual fantasies and desire for sexual activity, causing serious distress or interpersonal difficulties, and it is not exclusively caused by the effects of another psychiatric disorder, pathology or substance (such as medication). HSDD pathophysiology is not yet well understood, but it is thought to involve an imbalance between factors controlling inhibition and excitation of sexual desire in the brain. Many physicians are reluctant to discuss sexual desire problems with their patients for various reasons, such as insufficient knowledge of the field, an absence of efficient treatments and time constraints. Even though current treatment options are limited, a better understanding of the physiopathology behind HSDD may help develop new therapies.     

绝经激素治疗与乳腺癌风险

众所周知,乳腺癌是激素依赖性肿瘤,也是全球范围内女性患病率最高的恶性肿瘤。绝经虽然是一种人体自然现象,但也会引起很多病理性结果,严重影响女性的生活质量,增加各种慢性病发生的风险。绝经激素治疗（MHT）是治疗更年期症状最有效的方法,但很多女性最恐惧激素与乳腺癌风险。关于激素与乳腺癌的关系近几十年来争议不断,最初的妇女健康倡议（WHI）结果于2002年发表后,报告了乳腺癌的总体风险增加;最近研究表明：除了阴道雌激素外,每一种MHT都与额外的乳腺癌风险相关,且这种风险随着应用时间的增加而稳步升高;与雌激素相比,雌激素-孕激素的风险更大。文章主要讨论MHT与乳腺癌风险。     

Androgen and menopause

PURPOSE OF REVIEW: Androgen therapy is being increasingly used in the management of postmenopausal women. The most common indication is to improve sexual function. The aim of this review is to evaluate current knowledge pertaining to testosterone and sexual function in postmenopausal women. RECENT FINDINGS: The change of testosterone levels during the menopause transition remains controversial. A correlation of endogenous testosterone levels and sexual function is still inconclusive. A Cochrane Review and recent randomized control trials have, however, consistently demonstrated that short-term testosterone therapy in combination with traditional hormone therapy regimens improves sexual function in postmenopausal women, particularly surgically menopausal women with hypoactive sexual desire disorder. An adverse effect on the lipid profile has been identified which appears to be mostly associated with oral methyltestosterone. Data for other effects of testosterone and long-terms risks are lacking. Testosterone may act in a variety of ways in different tissues. This is, however, an area that requires further investigation. SUMMARY: Testosterone therapy is a promising option for treating women with hypoactive sexual desire disorder after surgical menopause. Two remaining questions need to be answer: who is most likely to benefit from testosterone therapy and what are the long-term health risks?     

绝经激素治疗与绝经相关症状

绝经期是女性生命必经的过程,绝经后由于卵巢功能减退而引起的雌激素缺乏将导致女性出现血管舒缩症状、神经精神症状、泌尿生殖道萎缩等症状以及绝经晚期发生骨质疏松、心血管疾病和老年痴呆等疾病。这些症状和绝经相关的疾病严重影响绝经后女性的生活质量和身心健康,而绝经激素治疗（MHT）是治疗绝经相关症状及预防相关疾病最有效的方法。文章对绝经相关症状作一阐述,并进一步探讨MHT的价值。     

Guideline No. 422d: Menopause and Sexuality

ObjectiveProvide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.Target PopulationPerimenopausal and postmenopausal women.Benefits, Harms, and CostsTarget population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.EvidenceDatabases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended Audiencephysicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.SUMMARY STATEMENTS

• 1Low sexual desire in combination with distress is most common in women in mid-life (high).
• 2Vaginal atrophy is a common cause of sexual pain in menopausal women (high).
• 3Sexual dysfunction in menopausal women can be categorized as disorders involving desire, arousal, pain, and orgasm. These categories often overlap (high).
• 4A brief sexual history is part of the evaluation of menopausal women (moderate).
• 5The treatment of sexual dysfunctions involves a multifaceted approach that addresses medical, psychological, and relationship issues (high).
• 6Local estrogen therapy treats genitourinary syndrome of menopause (high).
• 7Pelvic physiotherapy is an excellent adjuvant treatment for hypercontracted pelvic floor muscles (often referred to as vaginismus) and genito-pelvic pain (low).
• 8Flibanserin has been shown to improve desire in women (moderate).
• 9Transdermal testosterone has been shown to increase desire, arousal, and satisfying sexual events, and to decrease personal distress (high).
• 10Psychological therapies, including cognitive behavioural therapy, mindfulness-based therapy, couples’ therapy, and sexual therapies, are useful for treating sexual dysfunctions (moderate).
• 11Sexual dysfunction is common in patients with depression, those on selective serotonin reuptake inhibitors (SSRIs), women with primary ovarian insufficiency, and those with a history of breast cancer (high).

RECOMMENDATIONS

• 1The patient's problem should be categorized as related to desire, arousal, pain, or orgasm, in order to facilitate treatment and to triage care (strong, moderate).
• 2Health care providers should include a sexual screening history and physical examination in the initial evaluation of menopausal women (strong, low).
• 3Vaginal estrogens, lubricants and moisturizers, vaginal dehydroepiandrosterone, and ospemifene may be used as treatments for vaginal atrophy related to menopause (strong, high).
• 4For postmenopausal women with hypoactive sexual desire disorder, the best current options include managing pain, addressing any biopsychological factors, counselling, and prescribing transdermal testosterone (off-label) or flibanserin (strong, moderate).
• 5Patients with breast cancer and symptomatic genitourinary syndrome of menopause can be offered local vaginal estrogen if local lubricants and moisturizers are ineffective, after consulting with the patient's oncologist (conditional, moderate).

     

绝经激素治疗与乳腺癌风险

众所周知,乳腺癌是激素依赖性肿瘤,也是全球范围内女性患病率最高的恶性肿瘤。绝经虽然是一种人体自然现象,但也会引起很多病理性结果,严重影响女性的生活质量,增加各种慢性病发生的风险。绝经激素治疗（MHT）是治疗更年期症状最有效的方法,但很多女性最恐惧激素与乳腺癌风险。关于激素与乳腺癌的关系近几十年来争议不断,最初的妇女健康倡议（WHI）结果于2002年发表后,报告了乳腺癌的总体风险增加;最近研究表明：除了阴道雌激素外,每一种MHT都与额外的乳腺癌风险相关,且这种风险随着应用时间的增加而稳步升高;与雌激素相比,雌激素-孕激素的风险更大。文章主要讨论MHT与乳腺癌风险。     

Asexuality: An Extreme Variant of Sexual Desire Disorder?

IntroductionHuman asexuality is defined as a lack of sexual attraction to anyone or anything. Various theories have been proposed to explain how asexuality should best be classified, and some have maintained that asexuality is an extreme variant of hypoactive sexual desire disorder (HSDD)—a sexual dysfunction characterized by a lack of interest in sex and significant distress. To date, this has never been empirically examined.Aim and MethodUsing measures of sexual desire and behavior, sex‐related distress, personality, and psychopathology, the aim of the current study was to compare individuals scoring above the cutoff for asexuality identification (AIS >40) (n = 192) to sexual individuals (n = 231). The sexual group was further divided into a control group (n = 122), a HSDD group (n = 50), and a group with symptoms of low desire that were nondistressing (n = 59).ResultsAnalyses were controlled for age. Individuals in the AIS >40 group had a greater likelihood of never previously engaging in sexual intercourse, fantasies, or kissing and petting than all other groups and a lower likelihood of experiencing sex‐related distress than those with HSDD. For women, those in the HSDD and AIS >40 groups had significantly lower desire than the subclinical HSDD and control groups. Men in the AIS >40 group had significantly lower desire than the other three groups. Symptoms of depression were highest among those with subclinical HSDD and HSDD, whereas there were no group differences on alexithymia or desirable responding. A binary logistic regression indicated that relationship status (long‐term dating/married), sexual desire, sex‐related distress, and lower alexithymia scores were the best predictors of group membership (HSDD vs. AIS >40).ConclusionTaken together, these results challenge the speculation that asexuality should be classified as a sexual dysfunction of low desire. Brotto LA, Yule MA, and Gorzalka BB. Asexuality: An extreme variant of sexual desire disorder? J Sex Med 2015;12:646–660.     

The Safety of Testosterone Therapy in Women

Hypoactive sexual desire disorder (HSDD), a subset of female sexual dysfunction, causes personal distress for surgically and naturally postmenopausal and premenopausal women. HSDD has a multifactorial etiology, including psychosocial factors such as relationship issues and medical factors such as medications, chronic illnesses, and hormonal effects. Although no androgen therapies for female sexual dysfunction are currently approved for use in Canada, clinical trials support the efficacy and short-term safety of testosterone therapy for HSDD. We review the scientific evidence for the safety of testosterone therapy for HSDD.