Alessandra Graziottin1, 2 and Monika Ewa Lukasiewicz3
(1)
Center of Gynecology and Medical Sexology, H. San Raffaele Resnati, Via Enrico Panzacchi 6, 20123 Milan, Italy
(2)
Graziottin Foundation for the cure and care of pain in women, Milan, Italy
(3)
Department of Obstetrics and Gynecology, The Medical Center of Postgraduate Education, Bielanski Hospital, Warsaw, Poland
Alessandra Graziottin
Email: a.graziottin@studiograziottin.it
Email: segreteria@studiograziottin.it
URL: http://www.alessandragraziottin.it
URL: http://www.fondazionegraziottin.org
Keywords
Female sexual dysfunctionDesireArousalOrgasmDyspareuniaPremature ovarian failurePremature menopauseCouple’s sexualityInfertilityBody image
28.1 Introduction
Women are never too young to become menopausal, as a result of either a spontaneous or iatrogenic process of premature ovarian failure (POF) or insufficiency (POI ). Here the POF acronym will be preferred, while premature menopause (PM) will be used when issues are shared both in spontaneous and iatrogenic menopause. The earlier the menopause, the more severe and complex the impact on women’s sexuality can be [1–3]. Women report changes on their sexual identity, sexual function, and sexual relationships, the major contributors of women’s sexual well-being, which is modulated by life events, reproduction-related events, health, relationships, and sociocultural variables [1, 4, 5]. According to the POF etiology, body image [6–8] and body feelings may change dramatically.
The younger the woman, the less she realizes the different key goals of her life cycle (feeling sexy, seductive and attractive, falling in love, having a satisfying sexual life, forming a stable couple/getting married, having children) and, consequently, the more pervasive the impact on her sexual identity, sexual function, and sexual relationship can be [1–3].
Female sexual dysfunction (FSD) can occur at any age but it tends to increase with age, with an accelerated impairment after the menopause and beyond [8, 9]. Three important overlapping factors that affect female sexuality in women with PM are indeed the aging process, menopause, and the systemic inflammation. The latter being a critical component of the former two [10].
The number of women complaining of PM is increasing, mainly as a result of prolonged survival after cancer treatment. The paper will focus on key sexual issues at menopause with this special perspective and a prominent attention on biologically based sexual issues, maintaining the key areas of sexual identity, sexual function, and sexual relationships [1–19] while psychosocial variables will be only briefly addressed [2]. The goal is to empower physicians’ competence in addressing the many sexual issues triggered by PM.
28.2 Prevalence of PM
Spontaneous POF affects on average 1 % of women under 40 years of age [12–14, 20, 21]. Ethnicity is a contributor: the highest figure of spontaneous POF is reported among African American and Hispanic (both 1 and 4 %) and the lowest in Japanese (0 and 1 %) [20]. Iatrogenic menopause, for benign and malignant conditions, secondary to pelvic or gynecologic surgery, systemic chemotherapy, and pelvic or total body radiotherapy, affects 3.4–4.5 % [1–3, 22]. The latter figure is increasing worldwide due to the increased effectiveness of treatments and survival.
28.3 Etiology of PM
Heterogeneity is the hallmark of the PM etiology, which can be genetic, autoimmune, associated with chronic diseases, or iatrogenic in the context of benign or malignant diseases [1–3, 11–14, 21]. Leading etiologies of PM are summarized in Table 28.1.
Table 28.1
Etiology of premature menopause
|
• Premature ovarian failure (POF): |
|
Idiopathic |
|
Genetic: Turner’s syndrome |
|
Fragile X syndrome |
|
Mosaicism |
|
Deletion/inversion |
|
Galactosemia |
|
BRCA1 mutation |
|
Autoimmune, associated with: Celiac disease |
|
Lupus erythematosus |
|
Rheumatoid arthritis |
|
Associated with chronic disease: |
|
Chronic renal insufficiency |
|
Primary biliary cirrhosis |
|
• Iatrogenic for benign conditions: |
|
Endometriosis |
|
Bilateral dysgerminoma |
|
Ovariectomy concomitant to hysterectomy |
|
• Iatrogenic in women at risk of breast and/or ovarian cancer: |
|
BRCA1 and/or BRCA2 carrier |
|
• Iatrogenic for established malignant conditions: |
|
Bilateral oophorectomy |
|
Chemotherapy |
|
Pelvic radiotherapy |
|
Total body irradiation |
Modified from Graziottin and Basson (2004) [1]
PM impact on health and sexuality varies accordingly [23]. It may be limited in women affected by POF, who already have a family and are on optimal HRT or HT, as it is currently defined. It may be dramatic when the consequences of PM are superimposed to a serious medical condition which currently contraindicates HT, such as breast cancer and/or uterine adenocarcinoma in a childless younger woman and couple [1, 24, 25]. Multiple pathologies (and associated treatments) further increase the risk of systemic inflammation and accelerated aging, as exemplified when PM is associated to cancer or autoimmune diseases [12, 13, 21]. Neuroinflammation, a still neglected component of systemic inflammation associated with diseases, menopause, and aging, may contribute to sexual dysfunction through the associated physical and emotional depression, pain, loss of energy, and pervading fatigue [10, 26].
Key Point
Surgical menopause suddenly deprives the woman of total ovarian hormone production, with a rapid impact on her well-being and sexuality. POF, either spontaneous or iatrogenic, has a gradual, insidiousevolution over 2 or more years. Occasional ovulation, due to the last recruitment of primordial oocytes, is possible for 2–3 years and pregnancy may occur in up to 10 % of women after POF diagnosis [12, 21]. This opportunity must not be missed by “masking” the first menstrual irregularities with a pill, without thinking about diagnosing or excluding PM before!
28.4 Prevalence of FSD in PM
Systematic studies on prevalence of female sexual disorders (FSD) in women affected by PM are limited. The prevalence of low desire for younger surgically menopause (SM) women is significantly higher (32 %) than that found for premenopausal women of the same age (19 %) ([4, 27]). The probability of hypoactive sexual desire disorder (HSDD) increases with age, while the distress associated with the loss of desire is inversely correlated with age [27]. SM is associated with low sexual desire and distress in 35 % of women in the United Kingdom, 44 % in Italy, 16 % in Germany, and 56 % in France [4].
The majority of the papers on the subject focus on qualitative aspects of PM impact on women’s sexual function [1, 2, 8].
28.5 Women’s Wording of Sexual Feelings and Concerns at PM
Women’s wording is essential, to set the scenario, understand the key vulnerabilities in their sexuality, and perceive the overall sense of sexual loss they feel when PM occurs (Box 28.1). This is more important here as the paucity of studies specifically focused on sexual problems after PM may otherwise make this issue underappreciated.
Box 28.1 Women’s Wording on Sexual Issues at PM
· Sexual identity
“With all those hot flushes and sweating I feel like an old lady. And I’m only 35!”
“I do not sleep well any more, since my (early) menopause. And when I get up in the morning I feel more tired than the night before. I have no energy at all…”
“My skin is drier, I see more and more wrinkles every day. I cannot look at myself in the mirror.”
“My pubic hairs are getting white so early! I feel so ashamed!”
“I’m getting fatter, without having changed anything in my diet! And I have this horrible ‘menopausal look’ with all the fat going on my belly.”
“I have pain in all my joints. I feel stiff and rigid in the morning as if I were trapped in an armor of rust. I feel so old.”
“Without my ovaries (or my uterus) I do not feel I’m a woman anymore.”
“After my early menopause, nobody looks at me, nobody dates me! I feel sexually invisible.”
“I feel asexual.”
“I feel no more feminine since chemo caused the loss of my beautiful hair. They were my pride, and now I feel so ugly….”
· Sexual function
“I do not have any more sexual drive, for anybody.”
“Since I became menopausal too early, I had a worsening vaginal dryness. Sex is no longer a pleasure.”
“I had an early menopause at 32. Now, at 40, it takes ages to get aroused, my orgasm is fading and weak. I’m too young to feel so old!”
“My clitoris is dead.”
“My vagina is so tied and dry, I cannot make love any more. It hurts too much!
“Having sex is a nightmare now: I have a cystitis every time I have intercourse!”
· Sexual relationship
“My husband has lost interest in making sex with me, since I lost my periods.”
“My partner says that I have lost my scent of woman. He does not like to do oral sex with me anymore, while we both loved it before!”
“I feel so hurt. Since I got menopausal so early, he became interested only in looking at other women! But it denies and this gets me crazy of jealousy.”
“Why should I make love, if I cannot have children anymore?”
“We were looking for our first child with no success. My periods were delayed. The results of the hormonal exams were shocking: I was getting menopausal! My husband had always longed for a child and said he cannot accept remaining childless. I’ve lost him because he wants a natural pregnancy.”
“Please give me all the info on how I can get pregnant. Do I have a last chance with my ovary? Is ovum donation safe? Which problems would I or my child have?”
Women’s reported feelings explain why sexual identity , the sense of femininity and sexual attractiveness, as well as the potential for pregnancy, is perceived as definitely wounded or lost. Their wording about how they see themselves in the mirror and in their cognitive mind-set (body image) and how they perceive the changes in their physical and emotional feelings (body feelings) well indicates why PM may affect so dramatically their sexual identity. Body image concerns, such as skin and hair changes, changes in body shape, and tendency for weight gain and central adiposity, may impair the sense of personal attractiveness, contributing to loss of self-confidence and self-esteem, and a general sense of “feeling and looking older” [1, 3, 5, 6, 24, 25]. Sexual identity is more vulnerable when PM disrupts the process of psychosexual maturity, after peripubertal spontaneous POF or after iatrogenic POF, for childhood or adolescent cancers, for example, lymphoma [4, 5]. Body image issues may become prominent in women who underwent breast or gynecologic oncology surgery and associated treatments causing PM. POF after brain cancer surgery and chemo may cause even worse sexual damages. Chemotherapy may have a pervading impact on sexual identity when hair loss and skin, nail, and genital mucosal changes become prominent. The woman’s health, coping attitude, and quality of sexuality before PM may all affect the sexual outcome after PM. Women at higher risk of negative sexual outcome after PM are younger, single or in conflicting relationships, and childless, with lower education and socioeconomic status [1, 6, 24, 25].
Women’s wording on the impairment of their sexual function is more clear-cut and informative than pure statistics. Different etiologies of PM may independently contribute to FSD. For example, dysmetabolic diseases, such as diabetes, are at higher risk in overweight PM women and generally in obese menopausal subjects, and this further contributes to FSD. Corticosteroids, when needed to treat the leading autoimmune pathology, such as systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA), affect sexuality as well [28–30].
The report on the impact of PM on relationships suggests facts and nuances that are more frequently told to a physician with training in sexual medicine. Stage in life cycle may contribute to FSD, fertility being a major issue in childless women and couples [1–3, 15]. The partner’s reaction to the associated infertility and the quality of the relationships before and after PM modulate the individual and couple’s coping attitudes. Contextual factors—both relational and sociocultural, such as ethnicity—further contribute [15].
Women’s words well express the need for complex sexual help. They indicate how pervasive the discovery of PM can be for the three dimensions of women sexuality and how we must keep in mind the complexity, without limiting the listening and intervention to the sexual function. A multidisciplinary approach, medical, rehabilitative, and psychosexual, may offer the most comprehensive and satisfying outcomes for the woman and the couple (either hetero- or homosexual). However, no specific papers on the impact of PM on homosexual couples have been published in the author’s knowledge.
28.6 How to Diagnose PM
Impending PM should be considered when menstrual irregularities are complained of, more so if menopausal symptoms appear in women younger than 40 years of age. Predictors of PM include: raised basal FSH when the sample is performed in the third or fourth day after the beginning of period, low anti-Mullerian hormone (AMH) and inhibin B, and/or a poor response to ovarian stimulation. Definite diagnosis is based on FSH levels above 40 IU/L in two consecutive samples at 1-month distance. Echography may show small ovaries for the age, with no or a few residual oocytes. PM is implicit when bilateral oophorectomy is performed in women younger than 40 years of age [12, 13, 21, 31].
28.7 Premature Menopause: A Challenge for Sexuality
Progress in oncology has significantly increased the number of survivors of childhood and adolescent cancers. Unfortunately, the impact of chemotherapy and radiotherapy, pelvic or total body radiotherapy, on oocytes may precipitate a PM [1, 3]. The complexity of the clinical picture, the increased vulnerability to accelerated aging for the combined effect of PM and side effects of chemotherapy and/or radiotherapy, and the survivor’s expectations for a better quality of life (QoL), both in general and sexual terms, challenge the physician’s ability to tailor the more appropriate medical and psychosexual treatment [1, 3].
Receptors for sexual hormones are present in virtually all organs and tissues. Estrogen receptor alpha is mainly located in the breast, genitals, and hypothalamus (“the reproductive system”). They modulate the proliferative actions of estrogens. Estrogen receptor beta is present in all the organs (brain, lung, bowels, bone, joints): they mediate antiproliferative and reparative actions. PM causes a dramatic loss of sexual hormones: distribution of receptors explains why it is associated with an increased risk of accelerated aging—the younger the woman, the higher the risk, unless appropriate HT, when feasible, is initiated and adequately maintained at appropriate doses [1, 11, 14, 32, 33]. Morbidity and mortality from cardiovascular disease, stroke, accelerated brain aging, and osteoporosis present a greater risk in PM women compared to controls [34–37]. Some observational studies indicate that effects of estrogens on the brain (neuroprotective or harmful) depend on age of onset of the menopause [36, 38, 39]. In a recent study Bove et al. showed that an earlier age of surgical menopause is associated with decline in global condition and increase burden of Alzheimer’s disease [39]. Rocca et al.’s study on the effect of mono- or bilateral oophorectomy, without subsequent HT, indicates an odds ratio of 1.46 of accelerated brain aging and an odds ratio of 1.68 of Parkinsonism (with borderline significance for Parkinson disease) in women who underwent this surgery in the fertile age. The data strongly indicate that the younger the woman, the more vulnerable the brain [14]. The dramatic vulnerability of both the cognitive and motor systems well indicates how pervasive the brain damage and the associated neuroinflammation are, when the consequences of PM are neglected.
Sexual dysfunctions are reported with higher frequency and more significant personal distress after surgical menopause [4]. Overall sense of well-being and achievements of life goals are variably affected.
28.8 Hormones and the Pathophysiology of Sexual Dysfunction After PM
Estrogens and androgens modulate the neurobiology of brain aging. Their trophic role in neuronal membrane repair, in promoting neuronal sprouting and interneuronal connectivity as well as the levels of neurotransmitters, is gaining increasing evidence [1, 4, 40]. They also modulate sexual desire and mental arousal and the neurovascular cascade of events leading to genital arousal, lubrication, and orgasm. Estrogens are modulators of sexual response and “permissive” factors for the vasoactive intestinal polypeptide (VIP), which “translates” desire and central arousal into vaginal congestion and lubrication (reference).
Testosterone has an initiating role on desire and central arousal, acting on the dopaminergic appetitive-seeking pathway, and a modulator role of the peripheral response, as a permissive factor for nitric oxide (NO), the main mediator of clitoral and cavernosal body congestion [1, 4, 40].
Loss of estrogens and androgens contributes to impaired brain aging, as exemplified by increased and anticipated neurovegetative, affective, cognitive, and motor disorders in PM women (reference). It reduces sexual desire, central and peripheral arousal, with vaginal dryness, and causes/worsens orgasmic difficulties and dyspareunia, causing loss of self-confidence and self-esteem, and increases anxiety and concerns (reference). Loss of estrogens and androgens (particularly of testosterone and DHEA) increases the vulnerability to neuroinflammation, a still underappreciated aspect of brain aging (reference). Sexual hormone loss may as well contribute to the neurobiological etiology of depressed mood that coexists so often with acquired loss of desire and potentiates the depressive feelings (reference) consequent to the many losses that PM—and menopause in general—implies [5]. Comorbidity of FSD is frequent. The issue of FSD cannot be separated from the impact on sexuality of concomitant medical comorbidities associated with or consequent to different etiologies of PM [1].
28.9 Clinical Features Contribute to FSD After PM
Premature menopause is strongly connected with vasomotor symptoms (more severe after surgical menopause), sleep disturbances, insomnia, depression, anxiety, lack of concentration, and fatigue, more prominent when HH is not feasible, not offered, or inadequate in terms of quality and duration.
Vaginal symptoms, urinary symptoms, and comorbid disorder further contribute to the sense of accelerated sexual aging [12, 13, 21, 23]. They include vaginal atrophy, reduced vaginal secretion, delayed time of vaginal lubrication during sexual intercourse, vaginal dryness, and loss of vaginal rugae, elasticity, and transudate. Urinary symptoms as dysuria, urge or stress incontinence, and recurrent postcoital cystitis can have a further detrimental effect on QoL and sexual health.
Joint pain, sarcopenia, and accelerated osteopenia further impair women’s general health and sense of vital energy and strongly influence QoL [12, 13, 21, 23].
Last but not least, severity of vasomotor symptoms predicts and increases the vulnerability to depression and Alzheimer’s and Parkinson diseases [32, 36, 38, 39]. They gradually undermine the sense of self-confidence and self-esteem, when the feeling of a progressively incompetent memory threatens the basis of the social and professional role (reference).
28.10 Diagnosis of FSD After PM
FSD may be antecedent to PM, concomitant to PM, and/or specifically caused and/or maintained by PM. Diagnosis should consider the multifactorial etiology of FSD (with special attention to predisposing, precipitating, and maintaining factors, biological and psychosexual), the disorder being generalized or situational, lifelong, or acquired, as well as the level of distress it causes.
In stable relationships, counseling to both partners is a crucial part of the diagnosis and management. Accurate physical examination is mandatory, given the importance of biological factors associated to PM, with focus on trophism and appearance of external genitalia, vagina and vaginal pH, pelvic floor tonicity, and “pain map,” in case of dyspareunia [1, 41]. A poor quality of genital sexual feedback is usually an underevaluated contributor of loss of sexual desire/interest in all women, more so in PM and menopausal women for the additional aging and hormone-deprivation contributing role.
Key Point
Hormone samples should be included in diagnosis of POF as well as vaginal pH. Specific exams should be considered according to the clinical history and etiology of PM.
28.11 Medical Management of FSD Associated with PM
The first-line intervention should be focused on improving lifestyles as major contributors of health, body image, and body shape, of a better sense of femininity, and of a (still) fulfilling sexual life [8]. Daily physical exercise to feel fitter; appropriate food choice and intake; avoidance of smoking, alcohol, and leisure drugs; and better care of hairs, nails, skin, all are subtle and substantial changes that should be encouraged. The woman should fully understand her sense of loss after PM and then be positively encouraged to move across the mourning and the sense of having lost something essential to get a “reconquered” life. Empowering her feeling of being an even more aware protagonist of her own life is a key step in the counseling pathway. Specifically, treatment of POF should be etiologically based on hormonal (replacement) therapy (HT), when medically/oncologically feasible, in order to avoid the consequences of estrogen and androgen insufficiency [1, 2, 5, 8, 16–19, 33]. HT may minimize the impact of PM on general health, menopausal symptoms and signs, and couple dynamics. Interdisciplinary approach is sometimes indicated to offer the best opportunity to tailor treatment according to the woman’s clinical situation and to optimize the treatment choices to her and her partner’s sexual needs [42, 43].
Options include bioidentical estradiol and progesterone at individualized doses: 25, 50, or 75 pg/mL of plasmatic estradiol should be obtained according to age and individual vulnerabilities, particularly in younger patients, when specific somatic concerns (early onset osteopenia and sarcopenia, among others) are in play [1, 2, 8, 37]. Estrogens’ and testosterones’ anti-inflammatory properties on the brain are of increasing interest [26]. Route of administration can be oral, vaginal, and transdermal, according to the woman’s preferences. When the uterus is present, 12 days of progesterone or progestins/month should be prescribed [1, 8, 33]. Women without uterus can use estradiol alone, with the good news that it does significantly decrease the risk of breast cancer. Topical testosterone cream, compounded by the pharmacist with the medical prescription, may improve the clitoral and genital responsiveness to sexual stimulation. Systemic testosterone, previously available with the transdermal patch [16–19], is now administered through bioidentical compounds, but no study on these treatments have been performed in the authors’ knowledge, in spite of their increasing use. DHEA (10 or 25 mg/day, orally) is increasingly considered as a critical and yet underevaluated part of a well-tailored HT.
However, no guidelines are available on the optimal dose and schedule treatment for PM patients in the authors’ knowledge. The sentence “lowest hormone dose for the shortest period of time,” currently used for the HT after natural menopause around 50 years of age is a biological nonsense for women who have to face 20, 30, or more years hormoneless at a very young age. Consensus exists that they should be offered treatment at least until the age of 51, in absence of major contraindications [1, 8].
Management of FSD due to POF differentiates according to the most important sexual issues: (1) age, physical and psychological impact of PM or natural menopause; (2) effects of estrogen and androgen loss on general and sexual health; (3) severity of menopausal symptoms; and (4) loss of fertility and its meaning to both partners [1].
The focus here will be on treatment of FSD associated to PM or natural menopause. An updated critical review of available treatment for menopausal FSD has been published by Al-Azzawi et al. [33].
28.12 Desire/Interest and Central Arousal Disorders
Reduced libido is observed in about 7–22 % of women with POF [4]. Desire and central arousal overlap. Although some clinical studies have failed to demonstrate a direct correlation between testosterone level and FSD [44], there is evidence that women with POF demonstrate reduced total and free testosterone level compared to control group [45, 46]. Randomized controlled trials (RCT ) indicate the positive effect of testosterone in estrogen-repleted women after surgical menopause, when etiology of FSD appears to be hormone dependent. RCT have shown that treatment with 300-μg/day testosterone patches on estrogen-repleted women significantly increased sexual desire, frequency of satisfying sexual activity, and reduced sexual distress and was well tolerated [16–19]. Two systematic reviews of RCT indicate a positive effect of testosterone on all dimensions of sexual function and some psychological benefits as well [24, 29]. According to a Cochrane Review and a high-quality RCT, sexual function of postmenopausal women given testosterone therapy in addition to standard hormone therapy was improved [47, 48].
Secondary outcomes indicate a significant improvement of arousal and orgasm and of self-image and self-esteem and a significant reduction in anxiety and concerns. The testosterone patch treatment has been approved by the European Agency for the Evaluation of Medicinal Products (EMEA) in July 2006. However, controversy still exists on the indication of androgen therapy in women [49]. In spite of its clear-cut efficacy on all dimensions of sexual function, the testosterone patch has been withdrawn from the market by Warner Chilcott, the company that held the rights to market Intrinsa, in October 2012. The real truth being it proved to be an economic failure as only a small percentage of physicians did prescribe it.
Tibolone and HT with estradiol and norethisterone are other options to improve sexual desire [50]. Bupropion is a nonhormonal drug that may as well improve it when HT is not feasible [51].
28.13 Genital Arousal Disorders
Vaginal estrogenic treatment is indicated when the genital arousal disorder causes and/or is associated with vaginal dryness, dyspareunia, postcoital cystitis, urogenital atrophy, and/or urinary incontinence, mostly of the urge type. Accelerated urogynecological comorbidity will be delayed with appropriate HT [1, 8, 33, 41, 52, 53]. Safety of vaginal estrogen therapy has been documented in RCT and in observational studies; however, controversy about using vaginal estrogens in breast cancer patients still exists [6, 7, 25].
To minimize the impact of radiotherapy on vaginal tissue, it is crucial to start vaginal estrogenic treatment, pelvic floor stretching, and vaginal molds as early as possible. The proper, early treatment may maintain vaginal elasticity, optimal length, and “habitability” during pelvic or vaginal radiotherapy for cervical cancer [54, 55].
In 2013 ospemifene (an estrogen agonist/antagonist) was approved by the US Food and Drug Administration (FDA) for the treatment of moderate-to-severe dyspareunia associated with vulvovaginal atrophy [56].
Intravaginally administered dehydroepiandrosterone (DHEA) on daily basis improves symptoms of vaginal atrophy in postmenopausal women and reduces burning, itching, and dryness [57].
Testosterone applied daily on the vulva and vaginal introitus may anecdotally improve vulvovaginal trophism, clitoral sensitivity, genital arousal, and erotic response. It may therefore improve the genital feedbacks that may contribute to maintain sexual desire/interest and central arousal. However, more studies are needed [58, 59].
28.14 Orgasmic Disorder
True orgasmic disorder acquired subsequent to PM may benefit from HT. Increasing evidence supports a positive role of testosterone in restoring orgasmic potential [5, 16–19, 47]. Pelvic floor rehabilitation is indicated when (a) hypotonia is diagnosed as contributing to reduced orgasmic sensations and (b) hyperactive pelvic floor causes introital dyspareunia and vaginal dryness, preventing the genital engorgement (“orgasmic platform,” according to Masters and Johnson [60], thus impairing the coital component of orgasm). Comorbid stress or urge incontinence with fear of leakage, respectively, with thrusting or with orgasm is to be appropriately addressed [1].
28.15 Sexual Pain Disorders (Dyspareunia )
Dyspareunia, introital and/or deep, requires a careful pathophysiologic understanding of its complex biological etiology (cutaneous, muscular, endocrine, vascular, nervous, immune, iatrogenic) and meaning to design an effective treatment [41]. Friction introital dyspareunia, secondary to vaginal dryness, may benefit from vaginal ET. Reflexive pelvic muscle tightening (“hyperactivity of the levator ani,” secondary to pain) may benefit from self-massage and stretching, electromyographic biofeedback, and/or physiotherapy [1, 8, 61].
28.16 Treatment of PM and Associated Fertility Issues
Prevention of infertility in women facing impending POF is critical in childless women. Three lines of research are currently raising new hopes in the pursuit of fertility protection in young women [1, 8, 62]: (a) Cryopreservation of oocytes or ovarian tissue before cancer therapy is an option in women with impending POF. (b) Cryopreservation of embryos is feasible in women with a partner, when both are committed to have a baby, but requires a cycle of in vitro fertilization (IVF): time before cancer treatment may be a key limiting factor. (c) Cryopreservation of ovarian tissue is very promising, also in the prepubertal years [1, 8, 62]. Ovarian suppression with GnRHa during chemotherapy can be also an option [7]. However, with an impending PM, the current possibility of having a child is very rare. An honest disclosure of current limits of all these techniques should be clearly acknowledged in counseling with patients and their partner. Referral to a reproductive specialist should be offered to patients who are interested in fertility preservation. Ovodonation can be considered, if accepted by the woman and the couple, in countries where it is legal or abroad [62].
28.17 Couple Issues After PM
In women with either POF or natural menopause, appropriate listening to the sexual concerns and to the real personal motivation to treatment is essential for treatment planning and psychosexual management of FSD (Box 28.2). Specific concerns triggered by body image issues, loss of fertility, or menopausal symptoms that cannot be hormonally treated (i.e., in breast cancer patients) should be considered also with the couple perspective, when indicated [7, 63]. After the natural menopause, 48 % of women [4] report low desire, but only a minority feel distressed because of it and motivated to seek for treatment. Moreover, the older the woman, the higher the probability that the partner himself may have concomitant personal sexual problems, i.e., male sexual disorders (MSD) , that may preexist to menopause, be concomitant to it, or consequent to the many FSD menopausal women may complain about [2]. The partner can be the symptom inducer, when, for example, his persistent or worsening erectile deficit may cause or contribute to her loss of desire or when his inadequate personal care or hygiene precipitates her loss of sexual interest; or he can be the symptom carrier, when his loss of desire is consequent to her avoidant behavior toward any form of sexual intimacy; when her vaginal atrophy, with dyspareunia and introital narrowing, “precipitates” his erectile deficit, while erection could have been still acceptable, although not perfect, with a well-lubricated vagina; or when the many physical changes induced by PM, including the reduction of sexual pheromones, may precipitate a loss of desire and interest in the partner.
Key Point
Evaluate and treat, when indicated, both partners, to have a comprehensive diagnosis of his/her contribution to the current sexual complaint after PM
Box 28.2 Psychosexual Management in Case of FSD
· Individual behavioral therapy
· In case of dyspareunia:
· Behavioral therapy with vaginal inserts/molds and progressive rehabilitation of the pelvic floor
· Pharmacological treatment for any associated intense phobic avoidance.
· Psychotherapy to cope with the many losses PM and its e tiology have caused on health and sexuality
· Couple therapy to address sexual and/or nonsexual couple issues, such as conflicts, poor erotic skills, or communication inadequacies
28.18 Conclusions
PM accelerates general health and sexual aging, unless appropriate HT, when non-contraindicated, is initiated and maintained over time, at least until the age of 51. FSD reporting after PM increases. Women with PM are at higher risk for distressing sexual disorders. RCT indicate that HT, with estrogen and testosterone, may have positive effects on all domains of sexual function, especially after surgical PM. Attention to sexuality may be essential and welcomed for POF women in spite of the difficulty to raise sexual issues. Simple and open question may ease the dialogue between patient and gynecologist. The questions “How’s your sexual life?,” “Is there any sexual concern you’d like to discuss?,” or “Would you like to improve your sexual life, if you are not currently satisfied?” show the women that the health-care provider is at ease with this issue. She will be listened to and counseled would she be willing to raise her concerns to get a proper diagnosis and treatment. In sexual medicine a well-tailored, integrated medical and psychosexual approach may offer POF women and couples a long-lasting satisfying sexual season. The best outcome is obtained when a well-tailored HT, when feasible and oncologically appropriate, is combined with healthy lifestyles. Psychotherapy, of either the woman or couples, may prove useful when specific issues are not addressed by simply restoring the hormonal equilibrium.
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