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Two situations found in everyday gynecological practice demonstrate how a trustworthy doctor-patient relationship is built. This relationship helps to uncover what is concealed behind physical symptoms, which can perturb daily life (couple, social, family life) beyond a purely medical approach. To understand what is really happening rarely leads to a rapid solution. A stable chronicity that does not involve too many treatments, including surgical ones, can already be considered a success., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Sexuality is a natural function, part of global health and has to be evaluated in every patient. When difficulties or dyfunctions happen in this domain, a specific mangement should be proposed. Sexual medicine is a « young » transversal discipline developping these last years in the french-speaking area of Switzerland. We present in this article a short history of sexual medicine in Lausanne and the recent activity in the Sexual Medicine Consultation of the Maternity in the CHUV., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

There is a growing interest in the field of neurobiology of sexual function. With the advent of advanced technologies such as fMRI or EEG, it was possible to investigate the neuronal and psychobiological bases of the various phases of sexual response and sexual desire. Recently, a new technique debuted in sexual medicine, eye tracking. Thus through this article, we will leave the definition of sexual desire, through various neuropsychological studies in this field to finish on the unique and very recent eye tracking study that highlighted the visual patterns of desire sexual.

Transsexualism or gender dysphoria is a disorder of sexual identity of unknown etiology. At the biological level, one assumes atypical brain development during certain periods of its formation (genesis) notably during embryogenesis, as a result of altered hormonal influence and a particular genetic polymorphism. This article summarizes the research conducted to date in these three areas only, excluding psycho-social and environmental factors.

In the last years, University Fund Maurice Chalumeau (FUMC) launched a dynamic of research designed to promote scientific excellence and the development of Sexology with particular interest regarding sexual desire. The FUMC has supported a research project entitled "Neurobiological, psychological and sociological approach to sexual desire and sexual satisfaction". This project, sampled on 600 people (300 men and 300 women) aged between 25 and 46 years, was structured around three studies: a broad sociological study and two more specific ones, focused on some psychological mechanisms and neurobiological factors involved in sexual desire. The results show how the secondary socialization, personal expectations, beliefs and values in sexuality, sexual motivations, body image, as well as the neurobiological foundations and visual patterns, are of vital importance in the dynamics of sexual desire.

Introduction: Female genital mutilation (FGM), the partial or total removal of the external genitalia for non-medical reasons, can affect female sexuality. However, only few studies are available, and these have significant methodologic limitations., Aim: To understand the impact of FGM on the anatomy of the clitoris and bulbs using magnetic resonance imaging and on sexuality using psychometric instruments and to study whether differences in anatomy after FGM correlate with differences in sexual function, desire, and body image., Methods: A cross-sectional study on sexual function and sexual anatomy was performed in women with and without FGM. Fifteen women with FGM involving cutting of the clitoris and 15 uncut women as a control group matched by age and parity were prospectively recruited. Participants underwent pelvic magnetic resonance imaging with vaginal opacification by ultrasound gel and completed validated questionnaires on desire (Sexual Desire Inventory), body image (Questionnaire d'Image Corporelle [Body Image Satisfaction Scale]), and sexual function (Female Sexual Function Index)., Main Outcome Measures: Primary outcomes were clitoral and bulbar measurements on magnetic resonance images. Secondary outcomes were sexual function, desire, and body image scores., Results: Women with FGM did not have significantly decreased clitoral glans width and body length but did have significantly smaller volume of the clitoris plus bulbs. They scored significantly lower on sexual function and desire than women without FGM. They did not score lower on Female Sexual Function Index sub-scores for orgasm, desire, and satisfaction and on the Questionnaire d'Image Corporelle but did report significantly more dyspareunia. A larger total volume of clitoris and bulbs did not correlate with higher Female Sexual Function Index and Sexual Desire Inventory scores in women with FGM compared with uncut women who had larger total volume that correlated with higher scores., Conclusion: Women with FGM have sexual erectile tissues for sexual arousal, orgasm, and pleasure. Women with sexual dysfunction should be appropriately counseled and treated., (Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

The peripheral sexual response is achieved by the the Clitoro-Urethro-Vaginal Complex who is responsible of the transmission of the sensitive stimulation to the CNS where this information is modulated by the different cerebral areas. These latter will send this message to the peripheral sexual organs using efferent somatic and autonomic pathways able to induce vaso congestive response of clitoridal area with contractions of pelvic floor muscles. Muscles stretch injuries after obstetrical or surgical trauma can decrease the quality of the sexual peripheral response. These modifications of peripheral sexual response have to be evaluated with a specific questionnaire and pelvic floor clinical examination and recently, with a new microsystem device able to record continuously intra-vaginal pressure modifications.

Introduction: Despite the high prevalence of hypoactive sexual desire disorder (HSDD), especially among women, this sexual disorder remains poorly understood. Among the multiple factors possibly involved in HSDD, particularities in the cognitive evaluations of social stimuli need to be better characterized. Especially, beauty and attractiveness judgments, two dimensions of interpersonal perception that are related but differ on their underlying motivational aspects, may vary according to the level of sexual desire., Aim: The main goal of this study was to investigate whether women with and without HSDD differ in their evaluations of beauty and attractiveness of men's faces and voices., Methods: Young women from the general population (controls, n = 16) and with HSDD (patients, n = 16) took part in the study. They were presented with a series of neutral/nonerotic voices and faces of young men from the GEneva Faces And Voices database., Main Outcome Measures: Ratings of beauty (i.e., assessments of aesthetic pleasure) and of attractiveness (i.e., assessments of the personal propensity to feel attracted to someone) and the frequency to which the participants pressed a key to see or listen to each stimulus again were the main outcome measures., Results: Ratings of attractiveness were lower than ratings of beauty in both groups of women. The dissociation between beauty and attractiveness was larger in women with HSDD than in control participants. Patients gave lower attractiveness ratings than the controls and replayed the stimuli significantly less often., Conclusion: These results suggest that women with HSDD are characterized by specific alterations of the motivational component of men's perception, very early in the process of interpersonal relationships. Our findings have significant implications, both in better understanding the specific cognitive processes underlying hypoactive sexual desire and more largely the evaluative processes involved in human mate choice., (© 2014 International Society for Sexual Medicine.)

Sexual disturbances in patients with severe mental disorders can be related to medication, to psychological issues such as self-stigma and anhedonia, but also to the social context. This research aims to gain knowledge of desire and sexual practices in women suffering from schizophrenia. Women outpatients suffering from schizophrenia were compared with healthy women. Contrary to previous research, women with schizophrenia featured dyadic and individual desire similar to women of comparable age. Yet, only half of women with psychosis had sexual practice, either alone or with a partner. They were less satisfied with their activity, both in terms of function and psychological issues such as sexual self-esteem. Keeping into account the fact that most clinicians avoid this topic, this finding underscores the stigmatization these women suffer from, which prevents the opportunity of a possible improvement in this important interpersonal domain.

Background: In 2002, by popular vote, Swiss citizens accepted to legalise termination of pregnancy (TOP), up to the 12th week of amenorrhoea (WA). As a result, the cantons formulated rules of application. In 2002, medical TOP was authorised. Health institutions then had to modify their procedures and practices., Questions Under Study/principles: What are the views of healthcare professionals on the modifications of procedures and practices implemented in French-speaking Switzerland?, Methods: Qualitative method: in-depth interviews with 77 healthcare professionals, including doctors, nurses and midwives, and sexual and reproductive health social workers. Voluntary participation. Thematic analysis with content analysis software., Results: Most professionals have a balanced point of view on their practices. There is no point of view specific to each different category of professionals interviewed. They are unanimous on the elimination of the need for a second opinion. The points of view diverge on the usefulness of imposed waiting time to think before TOP, minors' access to TOP without parental consent, access to medical TOP and the right to refuse to practice TOP for personal reasons in public hospitals., Conclusions: The professionals do not question women's right to have TOP up to 12 WA, but they do diverge over procedures and practices. Institutional and cantonal cultures are probably behind these differences.

Introduction: One of the most difficult dilemmas in relationship science and couple therapy concerns the interaction between sexual desire and love. As two mental states of intense longing for union with others, sexual desire and love are, in fact, often difficult to disentangle from one another., Aim: The present review aims to help understand the differences and similarities between these two mental states using a comprehensive statistical meta-analyses of all functional magnetic resonance imaging (fMRI) studies on sexual desire and love., Methods: Systematic retrospective review of pertinent neuroimaging literature., Main Outcome Measures: Review of published literature on fMRI studies illustrating brain regions associated with love and sexual desire to date., Results: Sexual desire and love not only show differences but also recruit a striking common set of brain areas that mediate somatosensory integration, reward expectation, and social cognition. More precisely, a significant posterior-to-anterior insular pattern appears to track sexual desire and love progressively., Conclusions: This specific pattern of activation suggests that love builds upon a neural circuit for emotions and pleasure, adding regions associated with reward expectancy, habit formation, and feature detection. In particular, the shared activation within the insula, with a posterior-to-anterior pattern, from desire to love, suggests that love grows out of and is a more abstract representation of the pleasant sensorimotor experiences that characterize desire. From these results, one may consider desire and love on a spectrum that evolves from integrative representations of affective visceral sensations to an ultimate representation of feelings incorporating mechanisms of reward expectancy and habit learning., (© 2012 International Society for Sexual Medicine.)

Background: In 2002, Swiss citizens voted to accept new laws legalising the termination of pregnancy (TOP) up to 12th week of pregnancy. As a result the cantons formulated rules of implementation. Health institutions then had to modify their procedures and practices., Questions Under Study/principles: One of the objectives of these changes was to simplify the clinical course for women who decide to terminate a pregnancy. Have the various health institutions in French-speaking Switzerland attained this goal? Are there differences between cantons? Are there any other differences, and if so, which ones?, Methods: Comparative study of cantonal rules of implementation. Study by questionnaire of what happened to 281 women having undergone a TOP in French-speaking Switzerland. Quantitative and qualitative method., Results: The comparative legal study of the six cantonal rules of implementation showed differences between cantons. The clinical course for women are defined by four quantifiable facts: 1) the number of days delay between the woman's decision (first step) and TOP; 2) the number of appointments attended before TOP; 3) the method of TOP; 4) the cost of TOP. On average, the waiting time was 12 days and the number of appointments was 3. The average cost of TOP was 1360 CHF. The differences, sometimes quite large, are explained by the size of the institutions (large university hospitals; average-sized, non-university hospitals; private doctors' offices)., Conclusions: The cantonal rules of implementation and the size of the health care institutions play an important role in these courses for women in French-speaking Switzerland.

Introduction: Although there is an abundant debate regarding the mechanisms sustaining one of the most common sexual complaints among women, i.e., female hypoactive sexual desire disorder (HSDD), little remains known about the specific neural bases of this disorder., Aim: The main goal of this study was to determine whether women with HSDD showed differential patterns of activation within the brain network that is active for sexual desire in subjects without HSDD., Methods: A total of 28 right-handed women participated in this study (mean age 31.1±7.02 years). Thirteen out of the 28 women had HSDD (HSDD participants), while 15 women reported no hypoactive sexual desire disorder (NHSDD participants). Using event-related functional magnetic resonance imaging (fMRI), we compared the regional cerebral blood flow responses between these two groups of participants, while they were looking at erotic vs. non-erotic stimuli., Main Outcome Measure: Blood-oxygenation level dependent (BOLD) signal changes in response to erotic stimuli (compared with non-erotic stimuli). Statistical Parametric Mapping was used to identify brain regions that demonstrated significant differential activations between stimuli and between groups., Results: As expected, behavioral results showed that NHSDD participants rated erotic stimuli significantly higher than HSDD participants did on a 10-point desirable scale. No rating difference was observed for the non-erotic stimuli between NHSDD and HSDD participants. Our functional neuroimaging results extended these data by demonstrating two distinct types of neural changes in participants with and without HSDD. In comparison with HSDD participants, participants without HSDD demonstrated more activation in brain areas involved in the processing of erotic stimuli, including intraparietal sulcus, dorsal anterior cingulate gyrus, and ento/perirhinal region. Interestingly, HSDD participants also showed additional activations in brain areas associated with higher order social and cognitive functions, such as inferior parietal lobule, inferior frontal gyrus, and posterior medial occipital gyrus., Conclusion: Together, these findings indicate that HSDD participants do not only show a hypo activation in brain areas mediating sexual desire, but also a different brain network of hyper activation, which might reflect differences in subjective, social, and cognitive interpretations of erotic stimuli. Collectively, these data are in line with the incentive motivation model of sexual functioning., (© 2011 International Society for Sexual Medicine.)

Introduction: Brain imaging is becoming a powerful tool in the study of human cerebral functions related to close personal relationships. Outside of subcortical structures traditionally thought to be involved in reward-related systems, a wide range of neuroimaging studies in relationship science indicate a prominent role for different cortical networks and cognitive factors. Thus, the field needs a better anatomical/network/whole-brain model to help translate scientific knowledge from lab bench to clinical models and ultimately to the patients suffering from disorders associated with love and couple relationships., Aim: The aim of the present review is to provide a review across wide range of functional magnetic resonance imaging (fMRI) studies to critically identify the cortical networks associated with passionate love, and to compare and contrast it with other types of love (such as maternal love and unconditional love for persons with intellectual disabilities)., Methods: Retrospective review of pertinent neuroimaging literature., Main Outcome Measures: Review of published literature on fMRI studies of love illustrating brain regions associated with different forms of love., Results: Although all fMRI studies of love point to the subcortical dopaminergic reward-related brain systems (involving dopamine and oxytocin receptors) for motivating individuals in pair-bonding, the present meta-analysis newly demonstrated that different types of love involve distinct cerebral networks, including those for higher cognitive functions such as social cognition and bodily self-representation., Conclusions: These metaresults provide the first stages of a global neuroanatomical model of cortical networks involved in emotions related to different aspects of love. Developing this model in future studies should be helpful for advancing clinical approaches helpful in sexual medicine and couple therapy., (© 2010 International Society for Sexual Medicine.)

Recent advances in cognitive-social neuroscience allow a better understanding of the mechanisms underlying dyadic relationships. From a neuronal viewpoint, desire in dyadic relationships involves a specific fronto-temporo-parietal network and also a subcortical network that mediates conscious and unconscious mechanisms of reward, satisfaction, attention, self representation and self-expansion. The integration of this neuroscientific knowledge on the unconscious neurobiological activation for sexual desire in the human brain will provide physicians with new therapeutical and neuroscientific tools to apprehend sexual disorders in couple.

Background: Several case series and reports describe paraphilia as occurring after brain damage, mostly in the frontal lobes and diencephalic structures. Hypersexuality and paraphilic behaviors are also documented in a variety of other neurologic disorders, (e.g., Kluver Bucy syndrome, and more rarely in multiple sclerosis). In multiple sclerosis, hypersexual behavior and paraphilias have been associated with various focal brain lesions in the frontal and temporal lesions when inflammatory demyelination involves the hypothalamus and septal regions., Case Report: A case of a patient who developed a particular and progressive sexual deviant behaviour after a head trauma. This men felt sexually aroused from seeing sleeping women as well as from taking care of their hands and nails while they were asleep. The patient was diagnosed with a moderate dysexecutive syndrome characteristic of a frontal disorder and a very specific parietal-related bodily self image disorder characterized by an incomplete mental image of his hands. The clinical hypothesis was that the paraphilia might be related to his post-traumatic disturbed bodily self image and more specifically to its related impulsive needs to complete his hands representation., Conclusions: This case report highlights the potential link between paraphilia, deviant and aggressive sexual behaviour, neurological disturbance and self-representation. The treatment of paraphilias remains very complex, and requires taking into account not only the social and psychological aspects of the disease, but also its organic dimensions.

Introduction: Electroencephalogram (EEG) combined with brain source localization algorithms is becoming a powerful tool in the neuroimaging study of human cerebral functions., Aim: The present article provides a tutorial on the various EEG methods currently used to study the human brain activity, notably during sexual response., Main Outcome Measures: Review of published literature on standard EEG waveform analyses and most recent electrical neuroimaging techniques (microstate approach and two methods of brain source localization)., Methods: Retrospective overview of pertinent literature., Results: Although the standard EEG waveform analyses enable millisecond time-resolution information about the human sexual responses in the brain, less is clear about their related spatial information. Nowadays, the improvement of EEG techniques and statistical approaches allows the visualization of the dynamics of the human sexual response with a higher spatiotemporal resolution. Here, we describe these enhanced techniques and summarize along with an overview of what we have learned from them in terms of chronoarchitecture of sexual response in the human brain. Finally, the speculation on how we may be able to use other enhanced approaches, such as independent component analysis, are also presented., Conclusions: EEG neuroimaging has already been proven as a strong worthwhile research tool. Combining this approach with standard EEG waveform analyses in sexual medicine may provide a better understanding of the neural activity underlying the human sexual response in both healthy and clinical populations.

The simulation theory assumes we understand actions and intentions of others through a direct matching process. This matching process activates a complex brain network involving the mirror neuron system (MNS), which is self-related and active when one does something or observes someone else acting. Because social psychology admits that mutual intention's understanding grows in close relationship as love grows, we hypothesize that mirror mechanisms take place in love relationships. The similarities between the mirror matching process and the mutual intention's understanding that occurs when two persons are in love suggest that exposure to love might affect functional and neural mechanisms, thus facilitating the understanding of the beloved's intentions. Congruent with our hypothesis, our preliminary results from 38 subjects strongly suggest a significant facilitation effect of love on understanding the intentions of the beloved (as opposed to control stimuli). Based on these phenomenological, and neurofunctional findings we suggest that the mirror mechanisms are involved in the facilitation effects of love for understanding intentions, and might further be extended to any types of love (e.g., passionate love, maternal love). Love experiences are important not only to the beloved himself, but also to any societal, cultural, and institutional patterns that relate to love. Yet, concerning its subjective character, love experiences are difficult to access. The modern procedures and techniques of socio-cognitive neuroscience make it possible to understand love and self-related experiences not only by the analysis of subjective self-reported questionnaires, but also by approaching the automatic (non-conscious) mirror experiences of love in healthy subjects, and neurological patients with a brain damage within the mirror neuron system. Although the psychology of love is now well admitted, the systematic study of the automatic facilitation effect of love through mirror mechanisms might open a new avenue towards the social mind and also self consciousness.

Recent neuroimaging research suggests that human sexual desire (SD) recruits both the limbic system and higher-order cognitive brain areas. Because of the temporal limitation of this technique, the chronoarchitecture of SD remains however unresolved. Here, we investigated the spatio-temporal dynamics of SD by combining a behavioral desire decision task with high-density visual event-related potential (VEP) recordings and brain source estimations. VEPs were recorded from thirteen healthy participants when presented with pictures from two different stimulus categories (i.e., high and low desirability). In agreement with the literature, behavioral results showed that participants were faster to rate non-desired stimuli than desired stimuli (p=0.028). Electrophysiological results extended these behavioral data. Group-averaged VEPs peaked at 90 to 140 ms (P100), at 142 to 220 ms (N200), and at 222 to 360 ms (P300). Desired stimuli (DS) were distinguished from non-desired stimuli (NDS) over the N200 period, notably from 142 to 187 ms. Over this time period, DS processing was characterized by a significant scalp potential field. Although both conditions (DS and NDS) showed the recruitment of the occipito-temporal region (including the extrastriate body area, EBA), LAURA source estimation of the DS scalp potential field revealed a more right-lateralized current source density maximum in the posterior superior temporal sulcus (STS) extending to the temporo-parietal junction (TPJ). The recruitment of STS and TPJ for desired stimuli indicates that these brain areas, known to be respectively involved in social cognition, attention, integration of body-related information and self-processing, play a crucial role for the coding of desirability of visual sexual human stimuli within the first 200 ms after stimulus onset. These findings support the hypothesis that complex cognitive processing for desire occurs much faster than previously thought and open new perspectives with respect to the role of both bottom-up and top-down mechanisms in visual processing of sexual stimuli.

We update the epidemiology, diagnostic process, significant clinical features as well as main treatment and prevention issues in the field of antepartum depression, a widespread condition with significant relevance to primary care. During pregnancy, one forth women exhibit clinical symptoms of depression and such maternal depression may have disruptive effects on infants attachment process, marital relationships, family cohesion and work adjustment. Strenghts and limitations of psychotherapy, antidepressant medication and psychiatric hospitalisation are reviewed with a special accent on the specific ethical and scientific issues associated with the clinical dilemma of risks balance evaluation and medication treatment choice with these patients.

The way women experience orgasm is of interest to scientists, clinicians, and laypeople. Whereas the origin and the function of a woman's orgasm remains controversial, the current models of sexual function acknowledge a combined role of central (spinal and cerebral) and peripheral processes during orgasm experience. At the central level, although it is accepted that the spinal cord drives orgasm, the cerebral involvement and cognitive representation of a woman's orgasm has not been extensively investigated. Important gaps in our knowledge remain. Recently, the astonishing advances of neuroimaging techniques applied in parallel with a neuropsychological approach allowed the unravelling of specific functional neuroanatomy of a woman's orgasm. Here, clinical and experimental findings on the cortico-subcortical pathway of a woman's orgasm are reviewed and compared with the neural basis of a man's orgasm. By defining the specific brain areas that sustain the assumed higher-order representation of a woman's orgasm, this review provides a foundation for future studies. The next challenge of functional imaging and neuropsychological studies is to understand the hierarchical interactions between these multiple cortical areas, not only with a correlation analysis but also with high spatio-temporal resolution techniques demonstrating the causal necessity, the temporal time course and the direction of the causality. Further studies using a multi-disciplinary approach are needed to identify the spatio-temporal dynamic of a woman's orgasm, its dysfunctions and possible new treatments.

Current multidimensional models of women's sexual function acknowledge the implicit impact of psychosocial factors on women's sexual function. Interaction between human sexual function and intensity of love has been also assumed, even if love is not an absolute condition. Yet, whereas great insights have been made in understanding the central mechanisms of the peripheral manifestations of women's sexual response, including orgasm, the cerebral correlates sustaining the interaction between women's sexual satisfaction and the unconscious role of the partner in this interpersonal experience remain unknown. Using functional imaging, we assessed brain activity elicited when 29 healthy female volunteers were unconsciously exposed to the subliminal presentation of their significant partner's name (a task known to elicit a partner-related neural network) and correlated it with individual scores obtained from different sexual dimensions: self-reported partnered orgasm quality (ease, satisfaction, frequency), love intensity and emotional closeness with that partner. Behavioral results identified a correlation between love and self-reported partnered orgasm quality. The more women were in love/emotionally close to their partner, the more they tended to report being satisfied with the quality of their partnered orgasm. However, no relationship was found between intensity of love and partnered orgasm frequency. Neuroimaging data expanded these behavioral results by demonstrating the involvement of a specific left-lateralized insula focus of neural activity correlating with orgasm scores, irrespective of dimension (frequency, ease, satisfaction). In contrast, intensity of being in love was correlated with a network involving the angular gyrus. These findings strongly suggest that intimate and sexual relationships are sustained by partly different mechanisms, even if they share some emotional-related mechanisms. The critical correlation between self-reports of orgasm quality and activation of the left anterior insula, a part of the partner-related neural network known to play a pivotal role in somatic processes, suggests the importance of somatic information in the integration of sexual experience. On the other hand, the correlation between activation of the angular gyrus and love intensity reinforces the assumption that the representation of love calls for higher order cognitive levels, such as those related to the generation of abstract concepts. By highlighting the specific role of the anterior insula in the way women integrate components of physical satisfaction in the context of an intimate relationship with a partner, the current findings take a step in the understanding of a woman's sexual pleasure.

The frequent interaction and synergy between sexual arousal and sexual desire occuring during a sexual experience explains the difficulty in disentagling these two phenomena in the human sexual response. Sexual desire is defined as a goal-directed motivational state integrating the other in one's personal sphere on the basis of intentionality, rather than by instinct only. Sexual arousal includes physical manifestations and subjective perception of excitement. Interest in sexual arousal has engendered a growing body of research concerning its nature and function as well as the biological basis of the mechanisms sustaining it. Recent functional imaging has played a key role in seeking to isolate brain regions specific to sexual arousal. This field may represent a new challenge for social neuroscience.

Over the last decades a debate on the psychological and psychiatric consequences of the right to abortion took place. Abortion is a word-wide phenomenon linked to different aspects of public health. Although negative consequences are assumed to occur after abortion, most of the women who decide to terminate their pregnancy show several signs of relief. For instance, a decrease of signs of anxiety and depression may occur during the first month after abortion. Actually, the critical moment is the pre-abortion period. In this phase, most of the psychiatric and psychologic manifestations take place. Moreover, recent studies reinforce the importance to address the consequences of abortion with a multidisciplinary approach integrating somatic and psychologic components.

Objective: We studied maternal health 18 years postpartum in women having sustained an anal sphincter tear and controls., Study Design: We assessed symptoms with the short form of the urogenital distress inventory, the female sexual function index, and physical and mental health with the Short Form-12 summary scales., Results: Women with a sphincter tear had no increased risk of urinary symptoms (54 of 251, 22%, versus 51 of 273, 19%, risk ratio 1.2, 95% confidence interval 0.8 to 1.6) or sexual symptoms (84 of 223, 38%, versus 90 of 230, 39%, risk ratio 1.0, 95% confidence interval 0.8 to 1.2). Their physical health was also similar to controls (mean score +/- SD, 47 +/- 7 versus 47 +/- 6), whereas their mental health was slightly lower (score 45 +/- 6 versus 46 +/- 6, difference 1, 95% confidence interval 0 to 2, P = .05)., Conclusion: Women who sustained an anal sphincter tear have no more urinary or sexual symptoms 18 years after delivery.

Perimenopause (and not the entire postmenopausal period) is a period at risk for depression. Menopause is a psychosocial and physiologic reality whose neurobiological aspects are often under-estimated. Various disturbances, such as hot flushes and, at least in part, depressive disorders, are related to this neurobiological dimension. When the depression is minor, hormone replacement therapy may be an adequate treatment. Keeping in mind the complex interactions that may occur between endogenous and exogenous progestins at the neuronal level, we would recommend a physiologic replacement using transdermal estradiol and vaginal progesterone. When the depression is major, present data do not support the possibility of using hormone replacement therapy instead of antidepressants.

Aromatase inhibitors (AI) block the last enzymatic step of estrogen production, the aromatization of the A-cycle of aromatizable androgens and particularly, androstenedione (delta4) and testosterone (T). Molecules designed for interfering with aromatase activity have existed for many years. Yet the activity of products of the aminogluthetimide era was unspecific and these substances carried too many side effects for being used clinically. Newer third generation AIs, however, are highly specific and essentially devoid of side effects. These molecules have recently been approved for treating breast cancer in postmenopausal women either, in advanced forms or, as part of adjuvant therapy. In women whose ovaries are active, a temporary inhibition of E2 production will raise gonadotropins and in turn, stimulate follicular growth. In cancer patients, this property precludes the use of AIs in women whose ovaries are still active, unless gonadotropins are blocked. But in infertility patients, this property of AIs has been put to play for inducing ovulation. AIs have been used both in women who do not ovulate but whose hypothalamo-pituitary-gonadal (HPG) axis is active (oligo-anovulators of PCOD type) and those who ovulate regularly but in whom multiple ovulation is sought for treating unexplained infertility or as part of IVF. Like clomiphene citrate (CC), AIs are not usable in women whose gonadotropins are suppressed, as in the case of hypothalamic amenorrhea. The sum of data available on the use of AI for inducing ovulation remains however meager to this date and is mainly constituted of pilot and non-randomized trials. Yet mounting evidence tends to support AIs' advantages over CC for induction of ovulation. Hence, we think that the likelihood that these drugs will play a key role in induction of ovulation in the future is high. AIs appear particularly interesting for treating unexplained infertility because AI-FSH/hMG regimens are lighter than FSH-only regimens while retaining the high pregnancy rates of these latter treatments.

Sexual dysfunction is defined as a disturbance in the sexual response cycle or as a pain with sexual intercourse. The prevalence of sexual dysfunctions is approximately 40% in the female population. The disorders affecting sexual desire are the most common sexual dysfunctions encountered in women. Whereas recent studies have demonstrated clear influences of hormones on sexual dysfunctions, no pharmacological treatment has been approved for that indication. We will review here several pharmacological treatment strategies proposed in case of sexual dysfunction, underlying the fact that they are effective only to treat specific cases of sexual disorders but cannot replace the sex therapies.

This is the first report of a patient who experienced a recurrence of PTSD repeatedly after 2 attempts to initiate antiretrovirals including efavirenz for HIV infection. After recurrence of PTSD, the patient showed an important decrease in viral load and a higher CD4 level despite a bad compliance to antiretrovirals.

In the long history of controlled ovarian hyperstimulation (COH), two steps stand out as being the most important ones for providing the high efficacy of current treatments: the introduction of GnRH agonists for the prevention of premature ovulation and the widespread use of pretreatment with oral contraceptives before COH for in vitro fertilization. Interestingly, the benefits of both measures resulted largely from pure serendipity, as the discovery of these advantages was mostly fortuitous and/or unintended. Today, we believe that two areas of research have the highest potential for further improving the efficacy of COH: (1) switching the follicle-stimulating hormone stimulus to that of luteinizing hormone (or small amounts of hCG) in the last stages of COH; and (2) using the benefit of the new third-generation aromatase inhibitors that have recently become available. The effects of the latter products are to enhance the endogenous production of gonadotropins (mostly FSH). This article reviews the background data and rationale that justifies each of these two new developments and summarizes data currently available.

Background: The purpose of this study was to assess whether the detection of atherosclerotic aortic plaques by transoesophageal echocardiography (TEE) could be used as a marker of coronary artery disease (CAD), relying on their number, cross-sectional surface, depth and localisation., Methods: The thoracic aortas of 102 consecutive patients (77 men, mean age 67 +/- 12 years) undergoing elective cardiac surgery were assessed by TEE. Atherosclerotic plaques were defined as > or = 5 mm thick focal hyperechogenic zones of the aortic intima and/or lumen irregularities with mobile structures or ulcerations. All patients had undergone prior coronary angiography., Results: Thoracic aortic plaques were present in 73 patients, 66 of whom had CAD. The presence of aortic plaques detected by TEE identified significant coronary artery disease with a sensitivity of 90% and a specificity of 76%. The maximum transverse cross-sectional plaque area, the maximum plaque depth and the total plaque number all correlated significantly with the presence of CAD, but not with its severity. Multivariate regression analysis showed that aortic plaques, hypertension and hypercholesterolaemia were significant predictors of CAD, but aortic plaques were the most significant predictor regardless of age and sex., Conclusions: This study suggests that detection of atherosclerotic aortic plaques is a useful marker of significant coronary artery disease. Absence of plaques in the patients aged over 70 identified a subgroup with a very low probability of CAD.

This study is part of a larger prospective research program focusing on termination of pregnancy (TOP). One hundred and three women requesting TOP were interviewed before the intervention and 6 months later using open and closed questions and psychological tests. This paper focuses on contraceptive practices before and after abortion. The analysis took into account specific aspects of contraceptive practices and patients' behaviors. The aims were to assess: the level of women's knowledge and practice of contraception at the time of request for a TOP; the behavioral modifications following professional counseling 6 months after TOP; the influence of psychological and sexual factors, and those linked to the women's use of contraception. Most women (n = 101) had already used recommended contraception. During the cycle that had resulted in pregnancy, more than half (n = 58) had used recommended contraception and one third had not used any contraception. Six months later, 86 women used recommended contraception, and 17 did not. The majority of women reported changes in their contraceptive methods (n = 82). Most changes were within recommended methods. The women (n = 10) who continued to practice unprotected intercourse post-TOP were slightly older, satisfied with their sexual relations with their partner, often involved in a long-term and good relationship. During post-TOP period, it is essential to take into account the psychological dynamics involved in the choice of contraceptive methods. Counseling should emphasize not only protection against an unwanted pregnancy but also protection against sexually transmitted diseases, which is often perceived as a less important issue following TOP.

Objective: Premenstrual dysphoric disorder (PMDD), also referred to as premenstrual syndrome (PMS), is a recurrent luteal-phase condition involving regular occurrence, prior to the onset of menstrual bleeding, of a cluster of symptoms of sufficient severity to result in the deterioration of interpersonal relationships and normal activity. Several treatment options for PMDD with varying degrees of efficacy have been proposed. The literature is reviewed and treatments of proven efficacy are reported., Study Design and Methods: A MEDLINE/Cochrane Library search for all studies on PMS and PMDD published between 1983 and 2001 was performed. Only randomised trials were included., Results: Several treatments appear to be effective. Among these are increased physical activity, dietary change, mineral salt supplementation and ovulation inhibitors. The most effective seems to be administration of selective inhibitors of serotonin reuptake (SSRIs)., Conclusion: Therapy should begin with nonmedicated approaches and pharmacological treatment should only be envisaged if symptoms persist.

Objective: Study the impact of termination of pregnancy on women sexuality, contraceptive behaviour and couple relationship., Design: Prospective qualitative and quantitative study., Subjects: 103 women requiring induced abortion by vacuum aspiration who were interviewed one to three weeks before the operation and again six months later. The interview was performed by a questionnaire including open and closed questions and psychological tests (Locke-Wallace and Horowitz' IES)., Results: A majority of women (n = 101) had already used contraception. During the cycle that had resulted in pregnancy, more than a half (n = 58) had actually used contraception and 1/3 had not use any contraception at all. Six months later, the majority (n = 86) used contraception, while only 16 did not. Condom was only rarely used (n = 11). After termination of pregnancy, 14 couples of 84 separated. The majority of women (n = 72) did not report changes in their sexual behaviour. On the other hand, 1/5 of women presented a decrease in sexual desire and orgasm troubles. About 1/3 described psychosomatic symptoms, but a majority (n = 92) was not traumatised., Conclusions: The great majority of women seems to tolerate well the termination of pregnancy. A minority presents sexual dysfunction, psychosomatic symptoms, which persist six months after intervention. As per contraception, the majority of women does protect herself from pregnancy but a percentage still does not protect itself at all or only in a noneffective or less effective way. After termination of pregnancy, the issue of protection from AIDS and sexuality-transmitted diseases seems to be less important.