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The multidimensionality and interpersonal dimension of human sexuality make the study of female sexual dysfunction (FSD) a challenge. The aspiration to pursue a patient-centered, holistic approach collides with the need to establish commonly accepted diagnostic criteria for different disturbances in sexual functioning, involving one or multiple phases of the sexual response cycle and pain associated with sexual activity. According to recently proposed classifications, which are continuously evolving, the most relevant FSDs include hypoactive sexual desire disorder, female arousal disorder, persistent genital arousal disorder, and female orgasm disorder. The present chapter aims to provide a clinical perspective on these disorders by reviewing the most recent evidence on the pathophysiology, definitions, prevalence, leading etiologies, diagnostic tools, and key therapeutic approaches. Sexual pain-related conditions will be reviewed in another chapter.It is evident that a gender bias still exists, with prominent biological etiologies of FSDs being neglected and understudied at the expense of psychodynamic and relational determinants. Moreover, classifications should serve to advocate the advancement of our knowledge of female sexual functioning. This process goes through the practical translation of the updated nosology in a language that is intelligible to primary healthcare providers all over the world, and ultimately, to women.

Vasomotor symptoms (VMSs) are the most common symptoms affecting women during the menopause. Besides, affective symptoms may share with VMS a common biological pathophysiology. The current multicenter quantitative research was based on an online survey aimed to evaluate the impact of VMS in peri- and post-menopausal Italian women and to identify the main barriers to seeking help. The most frequent bothersome VMSs were hot flashes (41%), night sweats (31%), and over-heating (31%). Almost 87% of women experienced three or more simultaneous symptoms. Emotions verbalized by women indicate how intensely hot flushes and neuro-vegetative symptoms impact life: embarrassment, confusion, depression, impact on social/personal relationships, and guiltiness. Up to 43% of all women suffering from VMS were not treating the symptoms. Although 92% of women reported prior knowledge of the VMS condition, only 12% do something about it straight away after the appearance of VMS. This survey provided real-life observational data from a large population of peri-menopausal women and highlighted the important impact of VMS, its neurovegetative comorbidities and its significant burden effect on social life. Physicians must be more adaptive and inquisitive to evaluate and detect incipient VMS, as this will indicate the vulnerability to severe symptomatology and pathological brain aging.

PURPOSE Laser-evoked potentials (LEPs) are useful neurophysiological tools for investigating the A-delta sensory peripheral fibers and the central nociceptive pathway. The current investigation aims to obtain normative values of LEPs via pudendal nerve stimulation in healthy adult volunteers. METHODS Laser-evoked potentials were recorded in 16 men and 22 women, 22 to 75 years of age, using neodymium and yttrium and aluminum and perovskite laser bilateral stimulation to the pudendal nerve-supplied skin and the dorsal surface of the hands and feet. We assessed the perceptive threshold, latency, and amplitude of the N1 component and main vertex N2-P2 complex. The relationship between gender, age, height, and site of stimulation was statistically analyzed. RESULTS Both in men and in women, laser perceptive threshold increased from genitalia to foot and from hand to foot (P ≤ 0.001). N1 and N2-P2 latencies progressively increased from pudendal area to hand to foot (P ≤ 0.008). N1 and N2-P2 complex LEP amplitudes progressively decreased from hand to genitalia to foot (P ≤ 0.04). The latencies of N1 component and N2-P2 complex of LEPs correlated with body height, whereas the amplitude of the N2-P2 complex correlated negatively with age; no correlations were observed between the latencies and amplitudes with gender. CONCLUSIONS This study provides normative data on pudendal LEPs versus hand and foot LEPs. Incorporation of pudendal LEPs into clinical practice could provide a valuable neurophysiological tool for the study of pelvic pain syndromes.

Objectives This study set out to investigate the epidemiological characteristics and comorbidities of chronic vulvar pain. Secondary goals were to identify the preferred approaches for managing vulvodynia in Italy. Study Design A cross-sectional study (the VuNet -Vulvodynia Network project) was performed in consecutive female patients with chronic vulvar pain attending 21 Italian medical centers (public hospitals, university clinics and private outpatient services) in the period December 2016 to November 2018. Study data were entered by healthcare professionals in a special web-based medical record system (PRIDE- Progetto Rete Italiana Dolore vulvarE). These data covered epidemiological aspects, demographic characteristics, obstetric and gynecological history, presence and duration of current and/or past symptoms, associated disorders, details of physical examination and treatment approaches. Results A total of 1183 subjects with a diagnosis of chronic vulvar pain were included in the study. The main reason for consultation was superficial dyspareunia, present in 64.2 % of the women. 43.4 % of the sample reported comorbid sexual disorders (of desire in 22.1 % and arousal in 21.3 %). 48.3 % of the patients reported prolonged pain lasting between one and five years. Factors associated with vulvar pain included a relatively high family history of diabetes mellitus (father = 8.6 %; mother = 8.4 %), recurrent vulvovaginal candidiasis (32 %), and urinary tract infections (37.4 %: recurrent cystitis in 19.5 % and post-coital cystitis in 17.9 %). Irritable bowel syndrome (28 %), constipation (23.5 %), headache (25.7 %: migraine in 18.0 % and menstrual headache in 7.7 %), allergies (17.5 %: food allergies in 10.1 %, respiratory allergies in 7.4 %), anxiety (15.0 %), dyschezia (11.7 %), invalidating dysmenorrhea/endometriosis (11.1 %), and major depression (7.6 %) were also reported. Vestibulodynia was diagnosed in 837 of the 1183 patients (70.8 %) and generalized vulvodynia in 323 (27.3 %). Notably, 69.1 % of the patients stated that previous therapies had not changed their pain. Conclusions The diagnoses of vestibulodynia and vulvodynia must be considered in patients with chronic vulvar pain. The VuNet study contributes to a more comprehensive reading of the predisposing, precipitating and maintaining factors that contribute to vulvar pain, and of the key comorbidities.

Hormone therapy use has undergone dramatic changes over the past 20 years. Widespread use of hormone therapy in the 1980s and 1990s came to an abrupt halt in the early 2000s after initial findings of the Women’s Health Initiative trial were published and the study was terminated. Since then, much has been learned about the characteristics of women most likely to benefit from hormone therapy. There is general agreement that women younger than 60 years or who initiate hormone therapy within 10 years of menopause onset gain short-term benefit in terms of symptomatic relief and long-term benefit in terms of protection from chronic diseases that affect postmenopausal women. Despite accumulating evidence in support of hormone therapy for symptomatic menopausal women, the slow response by the medical community has led to a ‘large and unnecessary burden of suffering’ by women worldwide. Greater efforts are clearly needed to educate physicians and medical students about the pathophysiology of menopause and the role of hormone therapy in supporting women through the transition. This article provides a brief historical perspective of events that led to the backlash against hormone therapy, explores the current position of guideline groups, and provides practical recommendations to guide first-line management of symptomatic menopausal women.

Erectile dysfunction (ED) has been well recognized as a marker of increased cardiovascular risk for more than 15 years, especially in younger men. Early detection of ED represents an opportunity to intervene to decrease the risk of future cardiovascular events and limit the progression of ED severity. Evidence suggests there is a window of opportunity of 3 to 5 years from the onset of ED to subsequent cardiovascular events. This opportunity is usually missed if the onus is placed on the patient to seek care for his sexual problems. Unfortunately, these clear messages have not been incorporated into routine cardiovascular care. The reasons for these disparities within specialties are discussed in this article, in addition to management algorithms. Lifestyle modification is usually recommended as the first-line treatment to correct ED and lessen cardiovascular risk, but evidence suggests that this might be effective only in men without established cardiovascular comorbidities. In men with type 2 diabetes mellitus and established cardiovascular disease, lifestyle modification alone is unlikely to be effective. Cardiovascular medications are often associated with sexual dysfunction but changes in medication are more likely to be beneficial in men with milder recent-onset ED. A balanced view must be taken related to medication adverse events, taking into account optimal management of established cardiovascular disease. Testosterone deficiency has been associated with different metabolic disorders, especially metabolic syndrome and type 2 diabetes mellitus. Testosterone deficiency syndrome has been associated with an independent burden on sexual function globally and increased cardiovascular and all-cause mortality. Testosterone replacement therapy has been shown to improve multiple aspects of sexual function and, in some studies, has been associated with a decrease in mortality, especially in men with type 2 diabetes mellitus. Recent studies have suggested that phosphodiesterase type 5 inhibitors, the first-line medications to treat ED, could decrease cardiovascular and all-cause mortality, through multiple mechanisms, predominantly related to improved endothelial function.Copyright (C) 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Introduction: The diagnosis, treatment, and survivorship of cancer have a profound effect on the quality of life and psychological well-being of men and women. Indeed, the perturbation of sexual function because of neoplasm has far-reaching implications. Aims: To explore the prevalence, pathophysiology, and treatment of sexual issues in persons with cancer and offer evidence-based recommendations regarding optimal prevention and treatment strategies. Methods: A committee of multidisciplinary specialists was formed as part of the larger International Sexual Medicine Consultation working with urologic and sexual medicine societies over a 1-year period to review the result of chronic-illness management on sexual function and satisfaction. The aims, goals, data collection techniques, and report format were defined by a central committee. Main Outcomes Measures: Expert consensus was based on evidence-based medical and psychosocial literature review, extensive group discussion, and an open presentation with a substantial discussion period. Results: This summary evaluates contemporary literature concerning the prevalence, pathophysiology, and psychological impact of cancer diagnosis and treatment on sexual dysfunction. Evidence-based recommendations and guidelines for evaluation and management are presented. Conclusion: The diagnosis and treatment of cancer have a significant negative impact on sexual function and satisfaction. Comprehension of baseline sexual function, role of psychological supports, and available treatment options could attenuate the heavy burden of decreased sexual function. Copyright (C) 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Vulvar pain is an “orphan” symptom in prepubertal children. When a child complains of acute or chronic pain in that area, pediatricians/clinicians refer to “genital pain”: certainly a comprehensive, yet not a specific nor a sensitive word.

Vulvar pain is challenging for patients and healthcare providers. It can be acute, recurrent, chronic, and neuropathic with or without premenstrual flares. Patients may present with a variety of symptoms such as pain, burning, itching, irritation, soreness, and patterns continuous or intermittent localized or generalized). Some critically differential aspects are summarized in Box 10.1.

Vulvar pain is a very common problem that affects women of all age groups. Too often, women endure pain and sexual dysfunction for years without an adequate definitive diagnosis. They are desperate for help, looking for every type of medical and alternative treatment and regularly self-treat, wasting a lot of money a year in disappointing/frustrating consultations, anti-yeast creams, and other over-the-counter treatments.

Vulvar pain affects an area of the body that is hidden by taboo and fraught with misinformation. It is an area rich of secret and seducing pleasures but also a source of potential excruciating and invalidating pain (Graziottin and Gambini 2015). The vulvar organ, its erotic meaning, and the many symptoms that may affect it have been too long neglected by the medical establishment. Discussing vulvar symptoms may be perceived as very challenging both for patients and healthcare providers, as they seem to be “too intimate to be spoken of.”

Pregnancy is a special period in a woman’s life. The childbirth involves significant physical, hormonal, psychological, social, and cultural changes that may influence her own sexuality as well as the health of the couple’s sexual relationship.

Uncomplicated recurrent urinary tract infections (rUTIs) are common among reproductive-aged women. We aimed to assess the prevalence and predictors of sexual dysfunction (FSD) in a cohort of women with rUTIs and compare their psychometric scores to those of matched controls. Data from 147 rUTIs women and 150 healthy controls were analysed. Participants completed the International Prostatic Symptoms Score (IPSS), the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (SDS). Descriptive statistics and logistic regression models tested prevalence and predictors of distressful FSD. Women with rUTIs had lower FSFI scores (p

Vulvar pain is often multifactorial in origin. Therefore, a multimodal approach to treatment should be considered. Multimodal interventions include the use of more than one type of therapy for the care of patients with acute, chronic, or pathologic/neuropathic pain (Graziottin 2006; Graziottin and Murina 2011; Graziottin and Gambini 2015a; Graziottin et al. 2016).

Pain during intercourse (coital pain or “dyspareunia”) has been recently included under the new genito-pelvic pain/penetration disorder (GPPPD). With patients, “pain during intercourse” is the best wording to ease communication. GPPPD is a sexual disorder with a multifactorial etiology. It can be elicited at the entrance of the vagina (“introital dyspareunia”), deep in the vagina (“deep dyspareunia”), or both. In its comprehensive wording, it should include pain during anal intercourse (when women like/practice it) and clitoral pain during penetration and/or at orgasm. Leading etiologies are different among premenopausal and postmenopausal women. In premenopausal subjects, the most frequent biological etiologies of introital dyspareunia are vulvar vestibulitis/provoked vestibulodynia, with recurrent candida infections and/or an hyperactive pelvic floor in the background, and painful outcomes of delivery (either because of episiotomy/rraphy, or traumatic deliveries). Endometriosis, chronic pelvic pain, and pelvic inflammatory disease are leading contributors of deep dyspareunia in premenopausal subjects.

Physicians and healthcare providers (HCPs) can contribute to vulvar pain with different pathophysiologic pathways and responsibilities. They seem to be often unaware of a dramatic truth, valid in every field of medicine: doctors can be cofactors in the pathogenesis of a disease (Graziottin 2006; Norian and Stratton 2008; Esparaz et al. 2015). Specifically, HCPs may contribute to cause vulvar pain, acting as

Seven percent of breast cancers are diagnosed in women younger than 40 years of age, who face a very demanding disease. Their sexuality is threatened in all its dimensions: sexual identity, sexual function and sexual relationship. Age (the younger the woman, the more serious the impact), lymphedema, side effects of surgery, radio- or chemotherapy and hormonotherapy, infertility, pregnancy-related problems during or after breast cancer and iatrogenic premature menopause with its cohort of symptoms secondary to the chronic loss of oestrogens on the brain, on the sensory organs, on the pathophysiology of sexual response and on the function of the pelvic floor may all affect the quality of sexuality after breast cancer. Body image issues may polarize the negative impact on women’s sexual identity. Female sexual disorders (FSD), namely, loss of sexual desire, arousal disorders, dyspareunia, anorgasmia and loss of sexual satisfaction, are progressively complained of, as sexual function goes worse over time. Sexual relationship is threatened most by sexual symptoms, loss of erotic intimacy and complicity and infertility-related issues. Women carriers of BRCA mutations, who might consider bilateral prophylactic mastectomy, may have a specific iatrogenic impact of surgery on their self-image and femininity. Attention to biological, systemic and genital factors that impair women sexuality after breast cancer is still limited. Treatment encompasses lifestyle interventions, breast self-massage, physiotherapy, pharmacologic hormonal and nonhormonal help and psychosexual short-term interventions. New drugs offer new effective treatment opportunities of FSD after BC: nonhormonal and topical drugs, including hyaluronic acid gel and colostrum gel, should be recommended soon after the diagnosis of breast cancer to prevent vaginal dryness and dyspareunia; nonhormonal and systemic drugs, such as ospemiphene, offer new opportunity to treat vaginal dryness and dyspareunia in women who have completed the adjuvant treatment for breast cancer. Testosterone, either systemic or topical, is receiving positive attention as antiproliferative on the breast and sexually boosting at the same time. Topical vaginal DHEA is under investigation. A multidisciplinary approach to sexual complaints of breast cancer survivors should be offered to women and couples who desire to get back a better sexual life. Now this is possible.

Women have a much longer life expectancy than men: around 80–85 years of age in the high-income countries. This means 30–35 years after the menopause. This translates into an incredible gain in life duration (30 years on average) in comparison to only 100 years ago, when the mean life expectancy for women, in Western Europe for example, was 48 years.

Women’s quality of sexual life is an urgent issue in gynecological oncology. The multifactorial etiology of gynecological cancers (GC) and the increasing prevalence of such cancers at younger ages require a comprehensive medical and psychosexual perspective, even more so when sexual rehabilitation is the ultimate goal. The high rate of long-term survival makes GC more of a chronic than a fatal disease. Premature iatrogenic menopause is an important factor to be considered.

Adolescence is the life period when vulvar pain of various etiologies, and specifically vestibulodynia/vulvodynia, begins to be diagnosed, investigated, and treated (Bachmann et al. 2006; Clare and Yeh 2011; Graziottin and Murina 2011; Reed et al. 2014).

Becoming a woman is a long path. Women’s sexual identity starts in parent’s dreams about the child to be. It is shaped during the prenatal life by chromosomic, genetic and endocrine factors and more subtle chemical and emotional interactions with the mother’s biochemistry. It is powerfully modulated in the postnatal life by biological, affective, psychosexual and contextual factors. Human sexuality encompasses three major dimensions: sexual identity, sexual function and sexual relationship. Gender identity, gender role and gender orientation are considered major contributors of sexual identity. Encompassing the concept of sexuality, a major focus is currently devoted to the gender issues, with three readings: gender identity (which overlaps with the concept of sexual identity), gender role (a subspecification of the sexual identity) and sexual (gender) orientation considered as three key aspects of human psychosexual differentiation in sex-dimorphic differences. Gender dysphoria (GD) may stem from biological, psychosexual and contextual disruptors of the gender identity developmental pathway. The biological reasons why female is the default programme and why and how gender dysphoria is increasing will be carefully discussed.

Objective This study assessed the effectiveness of alpha lipoic acid (ALA) plus omega-3 polyunsaturated fatty acids (n-3 PUFAs) in combination with amitriptyline therapy in patients with vestibulodynia/painful bladder syndrome (VBD/PBS). Methods Women with VBD/PBS were randomly assigned to receive amitriptyline or amitriptyline plus a commercially available preparation (ALAnerv Age; Alfa Wassermann, Bologna, Italy) containing, in 2 capsules, ALA 600 mg plus docosahexaenoic acid 250 mg and eicosapentaenoic acid 16.67 mg. Symptoms of burning and pain were assessed using a 10-cm visual analog scale and the short form of the McGill-Melzack Pain Questionnaire. Results Among 84 women who were randomized, the mean ± standard deviation dose of amitriptyline was 21.7 ± 6.6 mg/day, without statistical difference between the two groups. Pain, as assessed using both the pain rating index of the visual analog scale and the short-form McGill Pain Questionnaire, decreased significantly in both trial groups, with a greater effect seen with the addition of ALA and n-3 PUFAs. The addition of ALA/n-3 PUFAs to amitriptyline treatment was also associated with improvements in dyspareunia and pelvic floor muscle tone. The overall incidence of adverse events was low, and none led to treatment discontinuation. Conclusions The addition of ALA/n-3 PUFAs to amitriptyline treatment in patients with VBD/PBS appears to improve outcomes and may allow for a lower dosage of amitriptyline, which may lead to fewer adverse effects.

The prevalence of asthma is about 9,7 % in women and 5,5 % in men. Asthma can deteriorate during the perimenstrual period, a phenomenon known as perimenstrual asthma (PMA), which represents a unique, highly symptomatic asthma phenotype. It is distinguished from traditional allergic asthma by aspirin sensitivity, less atopy, and lower lung capacity. PMA incidence is reported to vary between 19 and 40 % of asthmatic women. The presence of PMA has been related to increases in asthma-related emergency department visits, hospitalizations and emergency treatment including intubations. It is hypothesized that hormonal status may influence asthma in women, focusing on the role of sex hormones, and specifically on the impact of estrogens’ fluctuations at ovulation and before periods. This paper will focus on the pathophysiology of hormone triggered cycle related inflammatory/allergic events and their relation with asthma. We reviewed the scientific literature on Pubmed database for studies on PMA. Key word were PMA, mastcells, estrogens, inflammation, oral contraception, hormonal replacement therapy (HRT), and hormone free interval (HFI). Special attention will be devoted to the possibility of reducing the perimenstrual worsening of asthma and associated symptoms by reducing estrogens fluctuations, with appropriate hormonal contraception and reduced HFI. This novel therapeutical approach will be finally discussed.

Objective The aim of this study was to evaluate the effectiveness of the application of 0.005% estriol gel to the vulvar vestibule in the management of postmenopausal dyspareunia. Study design Postmenopausal women with dyspareunia were enrolled in this study. Patients were instructed to use a fingertip to apply 0.25g of vaginal gel containing 25μg of estriol to the vulvar vestibule daily for three weeks and then twice weekly for up to 12 weeks. Results Assessment of symptoms (dyspareunia and cotton swab test) and signs of vestibular atrophy were performed, and changes between baseline and weeks 3 and 12 were assessed. Adverse events were recorded. A total of 63 women were included. Of the 63, 59 (93.6%) completed the 12-week treatment period, and four dropped out for vestibular burning. Dyspareunia improved or was cured (score ≤1) by week 12 in 81.4% of patients. The patients also showed a statistically significant reduction in vestibular atrophy and cotton swab test at the end of treatment. Conclusions Application of 0.005% estriol gel to the vulvar vestibule is effective in correcting menopausal coital pain. This suggests that reduction in sensory vestibular innervation sensitivity is likely to play a pivotal role in the relief of dyspareunia. One limitation of this study is the limited follow-up, but the therapy may be continued for as long as the patients are distressed by their symptoms without estrogen intervention.

The extraordinary progress in oncologic surgery has blessed patients with a “second life.” The minimally invasive surgery has the ambitious goal of maximizing the benefits in terms of health expectancy, a challenge far beyond the goal of increasing life expectancy.

Spontaneous premature menopause (PM) affects 1 % of women younger than 40. Iatrogenic PM affects other 5–7 %. PM may affect sexual identity, sexual function, and sexual relationships, the three major contributors of women’s sexuality. Body image and body feelings may change dramatically, as women’s wording indicate. The younger the woman, the lower the probability of fulfilling the different key goals of her life cycle (feeling sexy and attractive, falling in love, having a satisfying sexual life, forming a stable couple/getting married, having children). Modulators of PM that impact on women’s sexuality include: etiology of PM, current health and psychosexual status, possibility or not of using hormone replacement therapy (HRT), relational status (single versus couple), possibility or not to have access to infertility treatments, quality of the health-care providers, and relational support. Desire, arousal, and orgasm are usually reduced, while vaginal dryness and sexual pain disorders tend to increase, unless HRT is feasible and accepted. Systemic inflammation associated with menopause and the aging process may further contribute to a complex impairment of women’s sexuality. PM may affect the relationship and the partner’s sexuality through its impact on women’s body image and body feelings, desire and arousability, pheromone levels, and fertility. An effective and satisfactory treatment of PM should include women’s and couple’s sexuality.

Introduction Erectile dysfunction (ED) impacts on both members of the couple. Female partners of men with ED are more likely to report reduced sexual quality of life than women whose partners do not have ED. Aim To assess vardenafil efficacy in men with ED and determine the effects of treatment on their female partner's sexual quality of life. Methods Study participants comprised men aged 18–64 years with ED and their female partners. Eligible men had ED of ≥6 months' duration and a female partner who was motivated to support their ED treatment. Eligible women had a total Female Sexual Function Index score >23.55, indicating absence of significant sexual dysfunction. Following a 4-week screening period, men were randomized to treatment with vardenafil 10 mg or placebo, which could be titrated to 20 or 5 mg after 4 weeks. Main Outcomes Measures Primary efficacy variables were question 3 of the Sexual Encounter Profile questionnaire (SEP3) and the quality-of-life domain of the modified Sexual Life Quality Questionnaire (mSLQQ-QOL). Results The intent-to-treat population included 343 couples, with 168 and 175 men receiving vardenafil or placebo, respectively. Vardenafil treatment significantly improved both erection maintenance and the female partners' sexual quality of life. Least squares (LS) mean SEP3 overall success rates after 12 weeks of treatment were 9.5 (baseline) vs. 67.2 (week 12) and 12.4 (baseline) vs. 24.2 (week 12) in the vardenafil and placebo groups, respectively (P Conclusions Vardenafil treatment of men with ED improved both their erectile function and the sexual quality of life of their female partners.

Background. Recurrent vulvovaginal candidiasis (RVC) is an increasing challenge in clinical practice. Objective. The purpose of this study was to reduce the episodes of RVC through the intake of fluconazole 200 mg/dose with a personalized regimen at growing administration intervals with a probiotic. Method. 55 patients received a 200 mg fluconazole as an induction dose for 3 alternate days. Symptoms resolution after 10–14 days made the patients eligible to continue with a maintenance therapy of fluconazole weekly for one month, followed by 200 mg after 10, 15, 20 and 30 days. Patients were allowed to move on to the next level of maintenance therapy only if they were symptom free. Patients were also given a probiotic with Beta Glucan and Echinacea Purpurea. Results. Among the 55 patients enrolled, four (7%) have withdrawn after the induction phase. 51 patients completed the whole therapeutic maintenance period, and eight (15,6%) experienced a recurrence before the end of the therapy. Five women (9,8%) relapsed (two after 2 months and three after 6 months). Conclusion. The positive results of our study prove the effectiveness of an individualized protocol for a rather short period, with a slowly decreasing administration of fluconazole + probiotic.

Chronic pain has been recognized as a major worldwide health care problem. Today, medical experts and health agencies agree that chronic pain should be treated with the same priority as the disease that caused it, and patients should receive adequate pain relief. To achieve good analgesia, patient adherence to a prescribed pain treatment is of high importance. Patients with chronic pain often do not use their medication as prescribed, but change the frequency of intake. This can result in poor treatment outcomes and may necessitate additional emergency treatment, which increases the overall costs. Factors that influence adherence include knowledge of the disease, realistic treatment expectations, perceived benefit from treatment, side effects, depression, dosing frequency, and attitudes of relatives/significant others toward opioids. Addressing all these factors should ensure a good treatment outcome. Good adherence to pain therapy is associated with improved efficacy in pain relief and quality of life. Opioids have become an integral part of the treatment of moderate to severe chronic noncancer pain. They may cause unpleasant side effects such as nausea, vomiting, and constipation. Patients should be informed adequately about side effects, which should be treated pro-actively to foster adherence to treatment. Signs of tolerance, hyperalgesia, and drug abuse should be monitored as these may occur in some patients. An individualized treatment algorithm with a clear treatment goal and regular treatment reassessment is key for successful treatment. Long-acting opioids offer sustained pain relief over 24 hours with manageable side effects—they simplify treatment thereby supporting treatment adherence.

Woman's sexuality encompasses sexual identity, sexual function, and sexual relationships. It is modulated throughout life by life and reproduction-related events, health, relationships, and sociocultural variables. The aging process and menopause are two potent contributors to female sexual dysfunction. The earlier the menopause, the more severe and complex the impact on sexuality is. The younger the woman, the less she realizes the different key goals of her life cycle (falling in love, having a satisfying sexual life, forming a stable couple, getting married, having a family) and the more pervasive the consequences on her sexual identity, sexual function, and sexual relationship can be. Premature menopause is an amplified paradigm of the complex impact menopause can have on women's and couple's sexuality. This paper will focus on biologically based sexual issues, namely desire, arousal, orgasm, and pain disorders, as well as key questions encountered in infertility. The concepts of "symptom inducer" and "symptom carrier" will also be addressed.

To investigate whether botulinum neurotoxin type A improves vaginismus and study its efficacy with repeated treatments.Outpatients were referred because standard cognitive-behavioral and medical treatment for vaginismus and vulvar vestibular syndrome failed. From this group, we prospectively recruited consecutive women (n=39) whose diagnostic electromyogram (EMG) recordings from the levator ani muscle showed hyperactivity at rest and reduced inhibition during straining. These women were followed for a mean (+/-standard deviation) of 105 (+/-50) weeks. Recruited patients underwent repeated cycles of botulinum neurotoxin type A injected into the levator ani under EMG guidance and EMG monitoring thereafter. At enrollment and 4 weeks after each cycle, women were asked about sexual intercourse; underwent EMG evaluation and examinations to grade vaginal resistance according to Lamont; and completed a visual analog scale (VAS) for pain, the Female Sexual Function Index Scale, a quality-of-life questionnaire (Short-Form 12 Health Survey), and bowel and bladder symptom assessment.At 4 weeks after the first botulinum neurotoxin type A cycle, the primary outcome measures (the possibility of having sexual intercourse, and levator ani EMG hyperactivity) both improved, as did the secondary outcomes, Lamont scores, VAS, Female Sexual Function Index Scales, Short-Form 12 Health Survey, and bowel-bladder symptoms. These benefits persisted through later cycles. When follow-up ended, 63.2% of the patients completely recovered from vaginismus and vulvar vestibular syndrome, 15.4% still needed reinjections (censored), and 15.4% had dropped out.Botulinum neurotoxin type A is an effective treatment option for vaginismus secondary to vulvar vestibular syndrome refractory to standard cognitive-behavioral and medical management. After patients received botulinum neurotoxin type A, their sexual activity improved and reinjections provided sustained benefits.III.

Introduction Insufficient 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. Aim The 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. Methods Cross-sectional survey of a convenience sample of 427 SM women aged 20–70 years. Main Outcome Measures The 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. Results SM 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 Conclusions A 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.

Objective: To provide an expert review of the clinical management of hypoactive sexual desire disorder. Method: The importance of diagnosing and providing therapeutic management for hypoactive sexual desire disorder will be explained with a case scenario which is resolved by drawing on original trial publications and meta-analyses published in English. Results: Hypoactive sexual desire disorder (HSDD) is highly prevalent (9-16%) and has a strong impact on the quality of life of both women and their partners. Medical and sexual history, physical and laboratory examinations as well as validated questionnaires will help us make an accurate diagnosis. Treatment should begin by focusing on lifestyle and psychosexual therapy. Women randomized to oestrogen-testosterone transdermal patch combination or testosterone transdermal patch alone reported significantly increased frequency of satisfying sexual activity (p < 0.05). Hormonal treatment with oestrogen and testosterone or with testosterone alone should be personalised, as should follow-up. Conclusions: Guidelines for the medical management of hypoactive sexual desire disorder are now available and this starts by understanding the importance of this disorder and knowing that accurate diagnosis and treatment options exist.

Background Gender differences, related to varying sexual hormone levels and hormone secretion patterns across the lifespan, contribute to women's vulnerability to mood disorders and major depression. Women are more prone than men to depression, from puberty onwards, with a specific exposure across the menopausal transition. However, controversy still exists in considering fluctuation/loss of estrogen as a specific aetiologic factor contributing to depression in perimenopause and beyond. Aims To briefly review the interaction between changes in menopausal hormone levels, mood disorders, associated neuropsychological co-morbidities and ageing, and to evaluate the currently available therapeutic options for perimenopausal mood disorders: (a) treatment of light to moderate mood disorders with hormonal therapy (HT); (b) treatment of major depression with antidepressants; (c) the synergistic effect between HT and antidepressants in treating menopausal depression. Results Depression across the menopause has a multifactorial aetiology. Predictive factors include: previous depressive episodes such as premenstrual syndrome and/or postpartum depression; co-morbidity with major menopausal symptoms, especially hot flashes, nocturnal sweating, insomnia; menopause not treated with HT; major existential stress; elevated body mass index; low socioeconomic level and ethnicity. Postmenopausal depression is more severe, has a more insidious course, is more resistant to conventional antidepressants in comparison with premenopausal women and has better outcomes when antidepressants are combined with HT. Conclusion The current evidence contributes to a re-reading of the relationship between menopause and depression. The combination of the antidepressant with HT seems to offer the best therapeutic potential in terms of efficacy, rapidity of improvement and consistency of remission in the follow-up.

Mast cells play a key role in many sexual pain disorders including interstitial cystitis (IC), provoked vestibulodynia (PVD), and endometriosis. Mast cells are ubiquitous, present in virtually all organs and vascularized tissue where they work to modulate the immune response. In addition, mast cells are present in, and recruited to, sites of inflammation, where they orchestrate key steps in the inflammatory response. Granules released by mast cells contain angiogenic, proinflammatory, and neurotrophic factors. These granules are heterogenous and different substances are released depending on the type, location, and timing of the damaging event or agent. When persistently up-regulated, mast cells maintain chronic inflammation, leading to a shift between nociceptive and neuropathic pain. This chapter reviews the biochemical complexity of mast cells to illustrate their role in sexual pain disorders.

Riassunto Premesse Le donne, dalla puberta in poi, sono piu vulnerabili degli uomini alla depressione. Le modificazioni endocrine durante la transizione menopausale possono contribuire a una “finestra di vulnerabilita” specifica. Fattori predittivi della depressione postmenopausale sono: precedenti episodi depressivi in eta fertile, sindrome premestruale e/o depressione post partum; comorbilita con sintomi menopausali maggiori, in particolare vampate, sudorazioni notturne, insonnia; menopausa non trattata con terapia ormonale sostitutiva; stress esistenziali maggiori; elevato indice di massa corporea; basso livello socioeconomico. Scopo dello studio 1) Analizzare le interazioni tra modificazioni ormonali menopausali, modificazioni dell’umore, comorbilita neuropsichiche associate e invecchiamento; 2) discutere le opzioni terapeutiche oggi disponibili: a) trattamento con terapia ormonale dei disturbi dell’umore lievi-moderati; b) trattamento con antidepressivi di alcuni sintomi menopausali; c) sinergia tra terapie ormonali e antidepressivi nell’anticipare la risposta terapeutica e ottimizzare gli outcome clinici. Discussione e conclusioni Le crescenti scoperte sulle interazioni tra ormoni sessuali e basi neurobiologiche del comportamento e delle emozioni richiedono una piu stretta collaborazione tra psichiatra e ginecologo. L’obiettivo e aumentare la diagnosi precoce e la terapia dei fattori disendocrini predisponenti, precipitanti e di mantenimento che contribuiscono alla depressione perimenopausale e alle comorbilita associate.

Introduction Transdermal 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.

Background and Objective Botulinum neurotoxin (BoNT), now commonly used for reducing muscular spasms in other neuromuscular disorders, is now increasingly proposed also for treating pelvic floor disorders, including chronic pelvic pain syndromes, vaginismus, vulvodynia and vulvar vestibulitis syndrome. To provide up-to-date information on these advances we reviewed the literature about Bunt injections for pain and spasms related to pelvic floor disorders. Methods We conducted a Medline search using the terms botulinum neurotoxin, pelvic floor disorders, levator ani myalgia, vaginismus, vulvar vestibulitis , vulvodynia, dyspareunia, interstitial cystitis, recurrent cystitis, and postcoital cystitis. We sought information on the indications and techniques used for Bunt treatment for pelvic floor dysfunctions, and related pain syndromes in women. Results Our search identified 12 studies for review (including a randomized controlled trial) showing that Bunt effectively reduces pain in chronic genital pain syndromes associated with pelvic floor spasm. Before Bunt trials, patients with idiopathic lifelong vaginismus and dyspareunia, associated with hyperactive pelvic floor muscles, had no effective treatment options. Bunt injected under electromyographic (EMG) guidance in pelvic floor muscles improves vaginismus, helping to restore a normal sexual life. Bunt injections also seem to improve vulvodynia and vulvar vestibulitis. Though some patients need periodic injections, in about 65% of affected women BoNT achieves permanent benefit. Conclusions These encouraging evidence-based results suggest that BoNT injected intramuscularly should extend treatment options for women with lifelong or acquired pelvic floor disorders and genital pain.

Dyspareunia and vaginismus are sexual pain disorders that partially overlap and are neglected in clinical practice. The etiology of sexual pain disorders is multifactorial. Pain may be perceived at vaginal entry (introital dyspareunia) or deep in the pelvis (deep dyspareunia). It may be lifelong, acquired, generalized, or situational and cause personal and interpersonal distress. Dyspareunia has a solid biological etiology. Comorbidity is frequent with lower urinary tract symptoms, sex-associated and recurrent cystitis, vulvodynia, recurrent Candida infections, vaginal dryness, obstructive constipation, myalgia of the levator ani, endometriosis, and disorders of desire and arousal disorders. Vaginismus has a psychosexual etiology with a variable myogenic component. Dyspareunia and vaginismus affect the patient on many levels: sexual, medical, emotional, and relational. The aim of the paper is to share with physicians the key steps of a focused clinical history and physical examination for a comprehensive diagnosis and effective multimodal treatment of sexual pain disorders.

Somatic symptoms characterized by arthralgias, bodily aches and pains, musculoskeletal pain and joint pain have been investigated in a number of menopause and depression studies. Although depression is one of the most common causes of bodily aches and pains, and arthralgias, these same symptoms are also commonly associated with a natural menopause, surgical menopause and menopause induced by chemotherapy in breast cancer treatment. Somatic symptoms in the absence of definitive medical diagnoses result in these patients receiving various diagnoses and labels--'medically unexplained symptoms', 'worried well', as well as various Diagnostic and Statistical Manual of Mental Disorders (4th edition) somatoform diagnoses. Osteoarthritis and joint pain increase in prevalence from premenopausal- to menopausal-aged women with hormonal change implicated in their etiology. The current research on the relationships among menopause, depression, nociceptive mechanisms, perception and pain in the distressed midlife patient is discussed. The amelioration and management of pain symptoms in the menopausal and postmenopausal woman, with or without comorbid depression, have been elusive and difficult problems for clinicians. Familiarity with the differential diagnosis, pathophysiology and evidence-based treatment for such patients is crucial to their proper care.