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Introduction Sexual pleasure has been a neglected issue in sexual health policies. Emerging trends in public health, however, emphasize the importance of sexual pleasure in preventing negative sexual health outcomes. Methods Using data from the German Sexuality and Health Survey (GeSiD), we tested the assumption that sexual pleasure is associated with sexual health, including a special focus on the role of gender. Participants were interviewed about their sexual experiences and health between October 2018 and September 2019. The analytical sample included 3472 partnered and single women and men who had been sexually active with a partner in the past 12 months. We examined if sexual pleasure was associated with various sexual health indicators (i.e., communication about sexually transmitted infections (STIs), condom use, and absence of sexual problems). Results Women reported less sexual pleasure than men. Results further indicate that sexual pleasure was associated with more sexual health indicators in women than in men. Conclusions Supporting emerging trends in public health our results emphasize the importance of sexual pleasure in preventing negative sexual health outcomes. Policy Implications. To promote (especially women’s) sexual health, our results call for the implementation of comprehensive sexuality education programs that focus on more positive aspects of sex, such as sexual pleasure and agency.

Objective: To determine long-term outcomes of a randomized trial (BIOPEX) comparing biological mesh and primary perineal closure in rectal cancer patients after extralevator abdominoperineal resection and preoperative radiotherapy, with a primary focus on symptomatic perineal hernia. Summary Background Data: BIOPEX is the only randomized trial in this field, which was negative on its primary endpoint (30-day wound healing). Methods: This was a posthoc secondary analysis of patients randomized in the BIOPEX trial to either biological mesh closure (n = 50; 2 dropouts) or primary perineal closure (n = 54; 1 dropout). Patients were followed for 5 years. Actuarial 5-year probabilities were determined by the Kaplan-Meier statistic. Results: Actuarial 5-year symptomatic perineal hernia rates were 7% (95% CI, 0-30) after biological mesh closure versus 30% (95% CI, 10-49) after primary closure (P = 0.006). One patient (2%) in the biomesh group underwent elective perineal hernia repair, compared to 7 patients (13%) in the primary closure group (P = 0.062). Reoperations for small bowel obstruction were necessary in 1/48 patients (2%) and 5/53 patients (9%), respectively (P = 0.208). No significant differences were found for chronic perineal wound problems, locoregional recurrence, overall survival, and main domains of quality of life and functional outcome. Conclusions: Symptomatic perineal hernia rate at 5-year follow-up after abdominoperineal resection for rectal cancer was significantly lower after biological mesh closure. Biological mesh closure did not improve quality of life or functional outcomes.

Purpose Young adult cancer patients and survivors have age-specific care needs, but care needs related to sexual health are poorly understood. A systematic literature review was conducted to examine sexual health-related care needs among patients/survivors diagnosed with cancer during young adulthood (age: 18–39 years). The prevalence and types needs were assessed along with associated patient factors. Methods Four major databases were screened to identify relevant studies, which were also assessed for risk of bias; all following PRISMA guidelines. Results Identified studies (N = 35) often assessed sexual health-related care needs by whether participants experienced a generic need for support from providers. The prevalence of such needs ranged between 8 and 61.7% and was higher in female survivors and those with more health impairments. The type of diagnosis could also play a role in these varying prevalence rates, but was not systematically tested in included studies. Types of sexual health-related care needs were clustered into practical/emotional support needs (e.g., coping with physical side effects), information needs (e.g., more details), and communication needs (e.g., providers should initiate conversations, validate concerns, be empathetic/open). Needs should be addressed in-person and/or online. Conclusions The extent of needs related to sexual health varies among young adult patients and survivors, but types of needs center around improving provision of support and information by providers. Implications for Cancer Survivors Sexual health should routinely be addressed alongside other potential effects of cancer treatment to allow for constructive conversations between patients and providers. Referrals to (online) resources or specialists should be tailored to individual preferences.

Sexual pleasure is central to current understandings of sexual function, health, and wellbeing. In this article, we suggest that we lack a sufficiently specific, yet encompassing, definition of sexual pleasure and that we therefore lack comprehensive assessments of sexual pleasure. We introduce a definition of sexual pleasure and position it centrally in an adapted framework of the sexual response. In the framework, we include a taxonomy of rewards which can be retrieved from sex and thereby aim to capture the multifaceted nature of sexual pleasure. We arrive at the definition, framework, and taxonomy by integrating theories of sexual motivation and response with the literature on sexual pleasure and basic rewards. We position this literature within theories of affect and personality which allows us to differentiate between the experience of and the tendency to experience sexual pleasure (i.e., state versus trait sexual pleasure). We shortly discuss how this conceptualization of sexual pleasure could be reflected in self-report assessments to quantitatively assess sexual pleasure. The framework may aid to focus on the role of the diverse facets of sexual pleasure in sexual function, health, and wellbeing and contribute to giving sexual pleasure the center position it deserves in sex research and therapy. [The four manuscript versions have been (re)submitted on July 15 2021, March 19 2022, August 19 2022, and January 3 2023 respectively. The fourth version is currently under review.]

Objective: various sources of evidence suggest that men and women differ in their experience of sexual pleasure. Such gender differences have been attributed to men’s higher innate sex drive, supported by evolutionary psychology perspectives and gender differences in reproductive strategies.Method: this paper presents biopsychosocial evidence for gender similarities in the capacity to experience pleasure, and for substantial gender differences in opportunities for sexual pleasure.Results: we conclude that sexual activity, in most cultures, is less pleasurable and associated with greater cost for heterosexual women than for heterosexual men, even though they do not differ in the capacity for sexual pleasure.Conclusion: since gender differences in experienced sexual pleasure are not a biological given, a more critical discourse of sexual pleasure might create awareness of current inequalities, help lift restrictions for women’s opportunities for pleasure, and could reduce gender differences in the cost of sex. That would truly serve sexual justice around the globe.

Sexual motivation (desire) requires the simultaneous presence of an active central motive state and a stimulus with sexual significance. Once activated, sexual motivation leads to visceral responses and approach behaviors directed toward the emitter of the sexual stimulus. In humans, such behaviors follow cognitive evaluation of the context, including predictions of the approached individual’s response. After successful approach and establishment of physical contact, manifest sexual activities may be initiated. Sexual interaction is associated with and followed by a state of positive affect in most animals, whereas aversive consequences may be experienced by humans. The affective reactions may become associated with stimuli present during sexual interaction, and these stimuli may thereby alter their incentive properties. Here we show how the incentive motivation model can be used to explain the origins and possible treatments of sexual dysfunctions, notably disorders of desire. We propose that associations formed between negative outcomes of sexual interaction and the salient stimuli, for example, the partner, underlies hypoactive desire disorder. Highly positive outcomes of sexual interaction enhance the incentive value of the stimuli present, and eventually lead to hyperactive sexual desire. Treatments aim to alter the impact of sexual incentives, mainly by modifying cognitive processes.

Purpose The aim of the present study is to investigate the prevalence of body image distress among head and neck cancer (HNC) patients after treatment and to examine its association with sociodemographic and clinical factors, health-related quality of life (HRQOL), HNC symptoms, sexuality, self-compassion, and psychological distress. Second, we aim to explore daily life experiences of HNC patients regarding body image. Methods A cross-sectional survey among HNC patients investigated the prevalence of body image distress based on the Body Image Scale. Multivariable logistic regression analysis was applied to study associations with sociodemographic and clinical factors, HRQOL (EORTC QLQ-C30), HNC symptoms (QLQ-HN43), sexuality (FSFI-6; IIEF-5), self-compassion (SCS-SF), and psychological distress (HADS). Qualitative data from a body image writing intervention was used to explore experiences in daily life related to body image. Results Body image distress was prevalent in 13–20% (depending on cut-off scores) of 233 HNC patients. Symptoms of depression (p p p = 0.001), problems with wound healing (p = 0.013), and larger extent of surgery (p = 0.014) were associated with having body image distress. This model explained 67% of variance. Writing interventions of 40 HNC patients showed that negative body image experiences were related to appearance and function, with social functioning problems described most often. Conclusion Prevalence of body image distress in HNC patients, using different cut-off scores, is 13–20%. Younger patients, patients after extensive surgery, and patients who had wound healing problems are most at risk. There is a significant association between body image distress and depressive symptoms and social functioning.

Introduction Multidisciplinary management of women‐specific bleeding is important to preserve quality of life, healthy reproduction and social participation of women and girls with bleeding disorders (WBD). Aim To support appropriate multidisciplinary care for WBD in haemophilia treatment centres. Methods Two case examples are presented and management issues discussed from different health care perspectives, including the nurse, patient, psychologist, gynaecologist, geneticist, psychosexual therapist and haematologist. Results Woman with bleeding disorders may experience heavy menstruation from menarche onwards. This has a physical and psychosocial impact requiring a multidisciplinary approach. If a woman with an inherited bleeding disorder desires to become pregnant, preconception counselling is essential, to discuss genetic diagnosis, state of the art treatment options for the bleeding disorder in question and possible choices to prevent having an affected child, as well as maternal bleeding risks during conception, delivery and the post‐partum period. Conclusion Adequate management and good education of WBD requires a patient‐centred multidisciplinary approach with experienced specialists in a haemophilia treatment centre.

Sexual incentive stimuli activate sexual motivation and heighten the level of general arousal. The sexual motive may induce the individual to approach the incentive, and eventually to initiate sexual acts. Both approach and the ensuing copulatory interaction further enhance general arousal. We present data from rodents and humans in support of these assertions. We then suggest that orgasm is experienced when the combined level of excitation surpasses a threshold. In order to analyze the neurobiological bases of sexual motivation, we employ the concept of a central motive state. We then discuss the mechanisms involved in the long- and short-term control of that state as well as those mediating the momentaneous actions of sexual incentive stimuli. This leads to an analysis of the neurobiology behind the interindividual differences in responsivity of the sexual central motive state. Knowledge is still fragmentary, and many contradictory observations have been made. Nevertheless, we conclude that the basic mechanisms of sexual motivation and the role of general arousal are similar in rodents and humans.

Introduction Several studies demonstrated that genital arousal and enhanced positive affect toward neutral stimuli due to sexual conditioning did not extinguish during a brief extinction phase, but other studies showed contrasting results. Possible resistance to extinction of conditioned human sexual response has, however, not been studied using extensive extinction trials. Aim To study resistance to extinction of conditioned sexual response in men and women. Methods Healthy sexually functional men (N = 34) and women (N = 32) participated in a differential conditioning experiment, with neutral pictures as conditioned stimuli (CSs) and genital vibrostimulation as unconditioned stimulus. Only one CS (the CS+) was followed by the unconditioned stimulus during the acquisition phase. Main Outcome Measure Penile circumference and vaginal pulse amplitude were assessed, and ratings of affective value and subjective sexual arousal were obtained. In addition, a stimulus response compatibility task was included to assess automatic approach and avoidance tendencies. Results Men and women rated the CS+ as more positive than the CS− during all 24 extinction trials and demonstrated a slight tendency to approach the CS+ directly after the extinction procedure. Participants rated the CS+ as more sexually arousing than the CS− during 20 extinction trials. No evidence was found for conditioned genital sexual response. Clinical Implications Learned sexual evaluations may be difficult to modify through an extinction procedure; therefore, unwanted but persistent subjective sexual evaluations may be better targeted by interventions such as the deployment of emotion regulation strategies. Strength & Limitations Extensive extinction trials were used; however, only relatively short-term effects within one experimental session were studied and there was no (unpaired) control condition. Conclusion The results provide evidence that conditioned sexual likes are relatively persistent, also at the behavioral level.

Introduction The prevalence of polycystic ovary syndrome (PCOS) is 10–15% in women of reproductive age. Its characteristics are (i) clinical or biochemical hyperandrogenism, (ii) oligomenorrhea or amenorrhea, and (iii) polycystic ovaries on ultrasound. PCOS is associated with lower quality of life, depression, anxiety, diabetes, and cardiovascular disease. Treatment commonly entails oral contraceptive use to lower endogenous androgen levels. Androgen levels and comorbidities may affect sexual function. Previous studies have addressed a limited range of possible contributing factors. We will assess sexual function as well as genital and self-reported sexual arousal in a laboratory setting in women with PCOS compared to an age-matched healthy control group. Modulation by biopsychosocial factors mentioned will be studied. Methods This is a multicenter prospective case control study. The study population includes healthy women with and without PCOS, aged 18–40 years, in a stable heterosexual relationship for at least 6 months. Power is calculated at 67 participants in each group. Anticipating a drop out of 10%, 150 participants will be recruited. Main outcome measures The main outcomes measured are sexual function using the Female Sexual Function Index, Sexual Desire Inventory, and Female Sexual Distress Scale-Revised; genital sexual arousal measured as vaginal pulse amplitude; and self-reported sexual arousal in response to erotic stimuli in a laboratory setting. The mediators that will be investigated include testosterone, free androgen levels, oral contraceptive use, sensitivity to androgens (using CAG repeat length), body mass index, body image, mental health, and self-esteem. Conclusion Strengths of this study are the inclusion of a broad range of biopsychosocial outcome measures including DNA analysis, a healthy control group, and standardized assessment of genital and self-reported sexual arousal in a laboratory setting. With the design of this study we aim to provide an insight into which biopsychosocial factors associated with PCOS are related to sexual function, and how sexual function may be affected by treatment. These new insights may help to improve clinical management of PCOS while improving the quality of life.

OBJECTIVES: To investigate associations between testosterone and patient reported sexual problems and need for sexual care in head and neck cancer patients at time of diagnosis and 6 months after treatment.PATIENTS AND METHODS: Data and samples were used of 40 patients (20 men, 20 women) before and 6 months after treatment. Outcome measures were total testosterone level (TT) and free testosterone index (FTI), testosterone insufficiency (TI), the EORTC QLQ-HN35 Sexuality subscale, the subscales of the International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI), and the Sexuality subscale of the Short-Form Supportive Care Needs Survey (SCNS-SF34).RESULTS: In men, higher FTI before treatment was significantly associated with better IIEF Orgasm (p = 0.020) and at 6 months follow-up with IIEF Desire (p = 0.019). Before treatment, insufficient testosterone was present in 5 males (25%) and in 3 at follow-up (15%) (2 patients who had TI before treatment plus one). In women, higher TT at follow-up was significantly associated with better EORTC Sexuality (p = 0.031) and FSFI Satisfaction (p = 0.020); FTI at follow-up was associated with FSFI Satisfaction (p = 0.012). Before treatment, TI was present in 2 women (10%) and in 3 (15%) at follow-up (the same 2 patients plus one).CONCLUSION: This pilot study showed that testosterone seems to be associated with patient reported sexual outcomes among male and female head and neck cancer patients. It is estimated that 10-25% of HNC patients may have testosterone insufficiency before treatment and/or at 6 months after treatment.

Purpose The aim of this pretest–posttest study was to investigate the reach and effects of My Changed Body (MyCB), an expressive writing activity based on self-compassion, among head and neck cancer (HNC) survivors. Methods This pilot study had a pretest–posttest design. HNC survivors received an invitation to complete a baseline survey on body image-related distress. At the end of the survey, HNC survivors were asked if they were interested in the intervention study. This entailed the writing activity and a survey 1 week and 1 month post-intervention. The reach was calculated by dividing the number of participants in the intervention study, by the number of (1) eligible HNC survivors and (2) those who filled in the baseline survey. Linear mixed models were used to analyze the effect on body image-related distress. Logistic regression analysis was used to investigate factors associated with the reach and reduced body image-related distress. MyCB was evaluated using study-specific questions. Results The reach of MyCB was 15–33% (depending on reference group) and was associated with lower education level, more social eating problems, and fewer wound healing problems. Among the 87 participants, 9 (10%) showed a clinically relevant improvement in body image-related distress. No significant effect on body image-related distress was found. Self-compassion improved significantly during follow-up until 1 month post-intervention (p=0.003). Users rated satisfaction with MyCB as 7.2/10. Conclusion MyCB does not significantly improve body image-related distress, but is likely to increase self-compassion, which sustains for at least 1 month.

Introduction Now that HIV infection has become a chronic disease, optimizing health status is an important goal of care for HIV-infected patients. Testosterone insufficiency (TI) can compromise health status, but little is known about the prevalence of TI and possible related factors in HIV-infected women. Aim To investigate the prevalence of TI among HIV-infected women attending our HIV outpatient clinic, and to study the relationship between TI and sexual function, fatigue, health status, and depression. Methods 56 HIV-infected women aged ≥18 years who attended the HIV outpatient clinic of the Amsterdam University Medical Center, The Netherlands, were included. Blood samples were taken for endocrinologic testing and patients filled out 6 validated questionnaires measuring sexual function, fatigue, health, and depression. Main Outcome Measure TI, the Female Sexual Function Index, the Female Sexual Distress Scale-Revised, the Multidimensional Fatigue Inventory, the Medical Outcomes Studies Short Form 36-item health survey, and the Beck Depression Inventory were assessed. Results A relatively high prevalence of TI, 37%, was found. Plasma viral load and CD4 cell count did not differ between women with or without TI. Clinical fatigue, physical fatigue, and impaired cognitive function were significantly more prevalent in women with TI. Women with TI also tended to report decreased sexual desire, reduced physical activity, increased mental fatigue, reduced physical function, increased health distress, and clinical depression. Conclusion We recommend that in all HIV-positive women with complaints typical for TI, testosterone is measured, and that in women with TI, testosterone replacement be considered as a treatment option. However, given that complaints are also prevalent in HIV-positive women without TI, the approach to women with these complaints should include sexual and psychological evaluation.

STUDY QUESTION Do mental health and sexual function differ between women with or without polycystic ovary syndrome (PCOS) with comparable BMI and fertility characteristics? SUMMARY ANSWER Women with PCOS have a poorer mental quality of life than women without PCOS, but there were no differences in symptoms of depression, anxiety, physical quality of life or sexual function. WHAT IS KNOWN ALREADY Various studies suggest that women with PCOS have poorer mental health, such as higher symptoms of anxiety and depression with a lower quality of life, and have an impaired sexual function compared to women without PCOS. However, in most studies, BMI and infertility status differ between women with and without PCOS, which may hamper comparability. STUDY DESIGN, SIZE, DURATION This study is a cross-sectional analysis of a 5-year follow-up of a randomized controlled trial (RCT) among women with obesity and a history of infertility. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants in this follow-up study of an RCT were women with obesity and infertility randomized to a lifestyle intervention followed by infertility treatment or prompt infertility treatment (control), stratified by ovulatory status and trial centre. In total, 173 (30.0%) women of the 577 women randomized in the initial trial participated in this follow-up study, with a mean follow-up of 5.5 years (range 3.7–7.0 years); of these women 73 had been diagnosed with PCOS and 100 did not have PCOS. Participants completed questionnaires on symptoms of anxiety and depression (Hospital Anxiety and Depression scale (HADS)), quality of life (36-item Short Form Health Survey (SF-36)) and sexual function (McCoy Female Sexuality Questionnaire (MFSQ)). We also compared quality of life subscale scores in women with and without PCOS and compared them to an age-matched Dutch reference population with average BMI. Effect sizes were calculated to assess the differences. MAIN RESULTS AND THE ROLE OF CHANCE Symptoms of anxiety and depression, physical quality of life and sexual function did not differ significantly between obese women with and without PCOS. However, women with PCOS had a worse mental quality of life summary component score (−3.60 [95% CI −6.72 to −0.56]), mainly due to a lower score on the subscale ‘role limitations due to emotional problems’ (−12.41 [95% CI −22.78 to −2.28]), compared to women without PCOS. However, compared to an age-matched Dutch reference population, the obese infertile women with and without PCOS both scored lower on almost all physical and mental quality of life subscales. LIMITATIONS, REASONS FOR CAUTION These are secondary analyses of the follow-up study of the RCT. No power analysis was performed for the outcomes included in this analysis and, as our study had a relatively small sample size, the null findings could be based on insufficient power to detect small differences between the groups. Our study population had a high mean BMI (average total group 34.5 [SD ± 5.1]); therefore, our results may only be generalizable to women with obesity. WIDER IMPLICATIONS OF THE FINDINGS Our results indicate that PCOS status is associated with impaired mental quality of life. Anxiety and depression, physical quality of life and sexual function in obese infertile women with PCOS seem more related to the obesity than the PCOS status. STUDY FUNDING/COMPETING INTEREST(S) The initial study and follow-up were supported by grants from: ZonMw (50-50110-96-518), the Dutch Heart Foundation (2013T085) and the European Commission (633595). The Department of Obstetrics and Gynaecology of the UMCG received an unrestricted educational grant from Ferring pharmaceuticals BV, The Netherlands, outside the submitted work. A.H. reports consultancy for Ferring pharmaceuticals. B.W.J.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.J.M. reports consultancy for ObsEva, Merck Merck KGaA, iGenomix and Guerbet. All other authors declare no competing interests. TRIAL REGISTRATION NUMBER The initial trial was registered on 16 November 2008 in the Dutch trial register; clinical trial registry number NTR1530.

Introduction A recent randomized controlled trial (RCT) in patients with head and neck cancer (HNC) with psychological distress showed that a stepped care (SC) program targeting psychological distress compared with care as usual (CAU), is (cost)effective in reducing psychological distress. Aim The aim of the present study was to investigate whether SC can coalleviate problems with sexual interest and enjoyment. A secondary aim was to investigate whether the presence of an unmet sexual health need and having a psychiatric disorder (depression or anxiety) at baseline moderated any effect of SC on these sexual variables until 1-year follow-up. Methods HNC survivors (N = 134), randomized to SC or CAU, were assessed regarding their sexual interest and enjoyment before and after the intervention and at 3, 6, 9, and 12 months follow-up. Linear mixed models were used to evaluate differences in the course of sexual interest and enjoyment between SC and CAU. Main Outcome Measure The “sexuality” symptom subscale, part of the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire, Head and Neck Cancer–specific module. Results Of all patients, 76.1% had an unmet sexual need at baseline, 24.6% had a psychiatric disorder (anxiety or depression). SC did not reduce problems with sexual interest and enjoyment at any of the follow-up measurements compared with CAU (P = .85). This was neither moderated by an unmet sexual health need at baseline (P = .64) nor by the presence of a psychiatric disorder at baseline (P = .59). Conclusion A substantial number of patients with HNC have unmet sexual health needs. SC targeting psychological distress does not reduce problems with sexuality in these patients. Interventions specifically targeting sexuality are recommended.

Objective Many healthcare professionals experience difficulties in discussing sexual health with their patients. The aim of this review was to synthesize results of studies on communication practices in interactions about sexual health in medical settings, to offer healthcare professionals suggestions on how to communicate about this topic. Methods We searched for studies using five databases. Reference lists and specialist bibliographies were searched to identify additional studies. We included discourse analytic studies that used recordings of medical consultations. Results We identified five studies that met the inclusion criteria. Findings were synthesized into seven categories of practices deployed by patients and healthcare professionals when talking about sexual health: avoiding delicate terms (1), delaying potentially delicate words and issues (2), using assumptive talk (3), generalized advice-giving (4), deploying patients’ talk (5), depersonalization (6), and patient-initiated advice (7). Conclusion Practices indicate the delicacy associated with discussing sexual health issues, but results also shed light on practices that can help professionals to deal with this delicacy, and to be responsive to patients’ needs and concerns. Practice implications Findings will assist healthcare professionals in broaching topics related to sexual health so they can help patients deal with challenges that affect their sexual health and overall well-being.

Background Sexual complaints are a widespread problem around the globe. Ethnicity and culture play a vital role in sexual complaints, in terms of presentation, treatment, etiology, meaning, help-seeking behavior, and treatment preferences. Aim This study investigates whether there are differences in the type of sexual complaints among Dutch people with various ethnic backgrounds, using a help-seeking sample from 16 outpatient clinics based in different regions in the Netherlands. Methods Differences in sexual complaints between various ethnic groups were analyzed separately for women and men, using logistic regression, controlling for age. Main Outcome Measures The primary outcome measures included sexual complaints determined as per the registered details of the Dutch Registry for Sexology Outpatient Clinics. Results Both similarities and differences were found between ethnic groups. Dyspareunia was an important complaint among women from all ethnic backgrounds, as were erectile problems among men. For most complaints, however, modest yet significant ethnic differences were found. Clinical Translation Health practitioners need to be aware of this ethnic and cultural variation, while acknowledging variety within groups as well. Strengths & Limitations This study is the first to include a help-seeking sample large enough to investigate ethnic differences in sexual complaints in this level of detail. An important limitation is the fact that this study pooled together diverse groups of people into ethnic categories. Conclusion The differences found were significant, yet modest. We can state that ethnic background does play a role in etiology and/or help-seeking in patients with sexual complaints, as long as we maintain an open stance and acknowledge similarities between ethnic groups as well.

Contains fulltext : 233788.pdf (Publisher’s version ) (Open Access) Women undergo important changes in sex hormones throughout their lifetime that can impact cardiovascular disease risk. Whereas the traditional cardiovascular risk factors dominate in older age, there are several female-specific risk factors and inflammatory risk variables that influence a woman's risk at younger and middle age. Hypertensive pregnancy disorders and gestational diabetes are associated with a higher risk in younger women. Menopause transition has an additional adverse effect to ageing that may demand specific attention to ensure optimal cardiovascular risk profile and quality of life. In this position paper, we provide an update of gynaecological and obstetric conditions that interact with cardiovascular risk in women. Practice points for clinical use are given according to the latest standards from various related disciplines (Figure 1).

STUDY QUESTION Can we develop a web-based sex education programme (programme running in a web browser) that addresses the needs of subfertile couples who are advised expectant management for at least 6 months? SUMMARY ANSWER The ‘Pleasure & Pregnancy’ programme addresses couples’ needs, is likely to improve couples’ sexual functioning, and is subsequently hypothesised to improve the chance of natural pregnancy. WHAT IS KNOWN ALREADY According to professional guidelines (e.g. the Netherlands and UK) couples with unexplained subfertility and a good chance of natural pregnancy, should be advised at least 6 months of expectant management. Adherence to expectant management is challenging as couples and gynaecologist prefer a more active approach. Targeting sexuality may be useful as subfertility is a risk factor for decreased sexual functioning. STUDY DESIGN, SIZE, DURATION A novel programme was developed according to the three steps of the Medical Research Councils’ (MRC) framework. First, relevant literature was explored. Second, an interdisciplinary expert panel developed a theory (based on a systematic literature review and patient interviews) on how the chance of natural conception can be improved. Third, the expected process and outcomes were modelled. PARTICIPANTS/MATERIALS, SETTING, METHODS Two licenced clinical sexologists, two gynaecologists, a clinical embryologist and two midwife-researchers, all from Belgium and the Netherlands, proposed components for the sex education programme. PubMed was searched systematically for randomised controlled trials (RCTs) evaluating the proposed components in different patient populations. The needs of 12 heterosexual Dutch or Belgian couples who were advised expectant management were explored with in-depth interviews. The content and delivery characteristics of the novel programme were described in detail with the aid of ‘Intervention Taxonomy’. To model the outcomes, a protocol for an RCT was designed, registered and submitted for publication. MAIN RESULTS AND THE ROLE OF CHANCE To help maintain or improve sexual functioning, mainly pleasure, and hence increase pregnancy rates, the web-based Pleasure & Pregnancy programme contains a combination of psychosexual education and couple communication, mindfulness and sensate focus exercises. Information on the biology of conception and interaction with fertility clinic staff and peers were added based on couples’ needs to increase potential acceptability. LIMITATIONS AND REASON FOR CAUTION This paper outlines the development phase of a sex education programme according to the MRC-framework. Whether the Pleasure & Pregnancy programme actually is acceptable, improves sexual functioning, increases pregnancy rates and is cost-effective remains to be determined. WIDER IMPLICATIONS OF THE FINDINGS No previous interactive web-based sex education programme has aimed to increase the natural pregnancy rate of subfertile couples by targeting their sexual pleasure. The Pleasure & Pregnancy programme addresses couples’ needs and its effect on sexual functioning and pregnancy rate is plausible but remains to be demonstrated by an RCT which is currently ongoing. STUDY FUNDING/COMPETING INTEREST(S) Funding was provided by The Netherlands Organisation for Health Research and Development (ZonMw), Flanders Research Foundation and the University of Amsterdam. C.B.L. is editor-in-chief of Human Reproductionbut was blinded to all parts of the peer review process. The remaining authors have no conflict of interest to report. TRIAL REGISTRATION NUMBER Not applicable.

We present the first systematic review and meta-analysis of sexual function in women with polycystic ovary syndrome (PCOS) compared with women without PCOS. Data on this topic are limited and often contradicting. Sexual function is influenced by endocrine, mental and social factors, which are often compromised in women with PCOS. The main outcome measures were validated sexual function questionnaires and visual analogue scales (VAS). We identified and assessed 1925 original articles; 18 articles were included. Significant small effect sizes were found on sexual function subscales (total score: P = 0.006; arousal: P = 0.019; lubrication: P = 0.023; satisfaction: P = 0.015; orgasm: P = 0.028), indicating impaired sexual function in women with PCOS. Large effect sizes for the effect of body hair on sex were shown on VAS (P = 0.006); social effect of appearance (P = 0.007); sexual attractiveness (P < 0.001). Satisfaction with sex life was impaired (P < 0.001), but sexual satisfaction was rated equally important in women with PCOS and controls. We conclude that a satisfying sex life is important for women with PCOS; however, sexual function and feelings of sexual attractiveness are impaired. The findings imply that sexual function, sexual satisfaction and psychosocial functioning need to be part of every clinical assessment of women with PCOS.

Background Provoked Vulvodynia (PVD) is the most common cause of vulvar pain. General practitioners (GPs) are insufficiently familiar with it, causing a delay in many women receiving correct diagnosis and treatment. Besides patients factors, this delay can partly be explained by the reluctance of GPs to explore the sexual context of PVD and by their negative emotional reactions such as helplessness and frustration when consulted by patients with medically unexplained symptoms like PVD. Objective To gain insight into how women with PVD perceive and evaluate condition management by their GP, in order to support GPs in the consultation of women with PVD. Methods We performed face-to-face in-depth interviews with women diagnosed with PVD. The interviews were recorded, transcribed verbatim and thematically analysed. The Consolidated Criteria for reporting Qualitative Research (COREQ-criteria) were applied. Results Analysis of the interviews generated four interrelated themes: Doctor-patient relationship, Lack of knowledge, Referral process and Addressing sexual issues. Empathy of the GP, involvement in decision-making and referral were important factors in the appreciation of the consultation for women with PVD who were referred to a specialist. Because women were reluctant to start a discussion about sexuality, they expected a proactive attitude from their GP. The communication with and the competence of the GP ultimately proved more important in the contact than the gender of the GP. Conclusion Women with PVD prefer a patient-centred approach and want GPs to acknowledge their autonomy and to address sexuality proactively.

Background: The lifetime prevalence of women suffering from provoked vestibulodynia (PVD) is estimated to be approximately 15%. The etiology of PVD is not yet clear. Recent studies approach PVD as a chronic multifactorial sexual pain disorder. PVD is associated with pain syndromes, genital infections, and mental disorders, which are common diseases in family practice. PVD, however, is not included in the International Classification of Primary Care. Hence, the vulvovaginal symptoms, which could be suggestive of PVD, are likely to be missed. Aim: To explore the relationship between specific vulvovaginal symptoms that could be suggestive of PVD (genital pain, painful intercourse, other symptoms/complaints related to the vagina/vulva), and related diseases such as pain syndromes, psychological symptom diagnoses, and genital infections in family practice. Methods: A retrospective analysis of all episodes from 1995 to 2008 in 784 women between 15 and 49 years were used to determine the posterior probability of a selected diagnosis in the presence of specific vulvovaginal symptoms suggestive of PVD expressed in an odds ratio. Selected comorbidities were pain syndromes (muscle pain, general weakness, irritable bowel syndrome [IBS]), psychological symptom diagnoses (anxiety, depression, insomnia), vulvovaginal candidiasis, and sexual and physical abuse. Results: Women with symptoms suggestive of PVD were 4 to 7 times more likely to be diagnosed with vulvovaginal candidiasis and 2 to 4 times more likely to be diagnosed with IBS. Some symptoms suggestive of PVD were 1 to 3 times more likely to be diagnosed with complaints of muscle pain, general weakness, insomnia, depressive disorder, and feeling anxious. Conclusion: Data from daily family practice showed a clear relationship between symptoms suggestive of PVD and the diagnoses of vulvovaginal candidiasis and IBS in premenopausal women. Possibly, family doctors make a diagnosis of vulvovaginal candidiasis or IBS based only on clinical manifestations in many women in whom a diagnosis of PVD would be more appropriate. Copyright (C) 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved

Importance In August 2015, the US Food and Drug Administration (FDA) approved flibanserin as a treatment for hypoactive sexual desire disorder (HSDD) in premenopausal women, despite concern about suboptimal risk-benefit trade-offs. Objective To conduct a systematic review and meta-analysis of randomized clinical trials assessing efficacy and safety of flibanserin for the treatment of HSDD in women. Data Sources Medical databases (among others, Embase, Medline, Psycinfo) and trial registries were searched from inception to June 17, 2015. Reference lists of retrieved studies were searched for additional publications. Study Selection Randomized clinical trials assessing treatment effects of flibanserin in premenopausal and postmenopausal women were eligible. No age, language, or date restrictions were applied. Abstract and full-text selection was done by 2 independent reviewers. Data Extraction and Synthesis Data were extracted by one reviewer and checked by a second reviewer. Results were pooled using 2 approaches depending on the blinding risk of bias. Main Outcomes and Measures Primary efficacy outcomes included number of satisfying sexual events (SSEs), eDiary sexual desire, and Female Sexual Function Index (FSFI) desire. Safety outcomes included, among others, 4 common adverse events (AEs): dizziness, somnolence, nausea, and fatigue. Results Five published and 3 unpublished studies including 5914 women were included. Pooled mean differences for SSE change from baseline were 0.49 (95% CI, 0.32-0.67) between 100-mg flibanserin and placebo, 1.63 (95% CI, 0.45-2.82) for eDiary desire, and 0.27 (95% CI, 0.17-0.38) for FSFI desire. The risk ratio for study discontinuation due to AEs was 2.19 (95% CI, 1.50-3.20). The risk ratio for dizziness was 4.00 (95% CI, 2.56-6.27) in flibanserin vs placebo, 3.97 (95% CI, 3.01-5.24) for somnolence, 2.35 (95% CI, 1.85-2.98) for nausea, and 1.64 (95% CI, 1.27-2.13) for fatigue. Women’s mean global impression of improvement scores indicated minimal improvement to no change. Conclusions and Relevance Treatment with flibanserin, on average, resulted in one-half additional SSE per month while statistically and clinically significantly increasing the risk of dizziness, somnolence, nausea, and fatigue. Overall, the quality of the evidence was graded as very low. Before flibanserin can be recommended in guidelines and clinical practice, future studies should include women from diverse populations, particularly women with comorbidities, medication use, and surgical menopause.

BackgroundObesity and infertility are associated with poorer sexual function. We have previously shown that a lifestyle intervention in women with obesity and infertility reduced weight and improved cardiometabolic health and quality of life, which may positively affect sexual function. We now report on sexual function 5 years after randomization.Methods and findingsIn total 577 women, between 18-39 years of age, with infertility and a BMI >= 29 kg/m(2) were randomized to a six-month lifestyle intervention targeting physical activity, diet and behavior modification or prompt infertility care as usual. Intercourse frequency and sexual function were assessed with the McCoy Female Sexuality Questionnaire (MFSQ), 5.4 +/- 0.8 years after randomization. 550 women could be approached for the follow-up study, of whom 84 women in the intervention and 93 in the control group completed the MFSQ. Results were adjusted for duration of infertility, polycystic ovary syndrome and whether women were attempting to conceive. The intervention group more often reported having had intercourse in the past 4 weeks compared to the control group (aOR: 2.3 95% CI 0.96 to 5.72). Among women reporting intercourse in the past 4 weeks, the intervention group (n = 75) had intercourse more frequently (6.6 +/- 5.8 vs. 4.9 +/- 4.0 times; 95% CI 0.10 to 3.40) and had higher scores for vaginal lubrication (16.5 +/- 3.0 vs. 15.4 +/- 3.5; 95% CI 0.15 to 2.32) and total 'sexual function' score (96.5 +/- 14.2 vs. 91.4 +/- 12.8; 95% CI 0.84 to 9.35) compared to the control group (n = 72). Sexual interest, satisfaction, orgasm and sex partner scores did not differ statistically between the groups. The intervention effect on sexual function was for 21% mediated by the change in moderate to vigorous physical activity.ConclusionA six-month lifestyle intervention in women with obesity and infertility led to more frequent intercourse, better vaginal lubrication and overall sexual function 5 years after the intervention.

Introduction: The aim of this prospective study was to investigate the course of sexual interest and enjoyment in relation to sociodemographic and clinical factors, health-related quality of life (HRQOL), and symptoms of psychological distress in head and neck cancer (HNC) patients treated with primary (chemo)radiotherapy. Methods: HNC patients (n = 354) completed patient-reported outcome measures (PROMs) on HRQOL (EORTC QLQ-C30 and QLQ-H&N35, including the sexuality subscale covering less sexual interest and enjoyment), and psychological distress (HADS) pretreatment, at 6-week follow-up and at 3-, 6-, 12-, 18-, and 24-month follow-up (i.e., after treatment). Linear mixed models were used to analyze the course of sexuality from pretreatment to 24-month follow-up, and to investigate its relation to sociodemographic and clinical factors, HRQOL, and psychological distress as measured at baseline, and to investigate the course of sexuality from 6- to 24-month follow-up in relation to these factors measured at 6-month follow-up. Results: Before start of treatment, 37% of patients reported having less sexuality, which increased to 60% at 6-week follow-up, and returned to baseline level from 12-month follow-up onwards. Older age (p = 0.037) and trouble with social contact (p < 0.001), weight loss (p = 0.013), and constipation (p = 0.041) before treatment were associated with less sexuality over time. Female gender (p = 0.021) and poor social functioning (p < 0.001) at 6-month follow-up were associated with less sexuality from 6- to 24-month follow-up. Discussion: Less sexuality is often reported in HNC patients treated with (chemo)radiotherapy. Using PROMs in clinical practice may help identify patients who might benefit from supportive care targeting sexuality.

Researchers have demonstrated that several dimensions of sexual functioning (e.g., sexual desire, arousal, orgasm) are associated with the sexual satisfaction of individuals in a committed mixed-sex (male-female) relationship. We extended this research by comparing a dyadic model that included both own (i.e., actor effect) and partner (i.e., partner effect) domains of sexual functioning to an individual model that included only actor effects. Participants were 124 mixed-sex couples who completed online measures of sexual functioning and sexual satisfaction. Data analysis using the actor-partner interdependence model (APIM) and structural equation modeling (SEM) indicated that the dyadic model had a better fit than the individual model. Women's sexual desire and orgasm and men's erectile functioning were significant positive predictors of both own and partner's sexual satisfaction. These results are discussed in terms of the importance of taking a dyadic approach to research and clinical work related to sexual satisfaction.

The objective was to evaluate the effect of combined oral contraceptives (OCs) on sexual function, either alone or together with dehydroepiandrosterone (DHEA).An exploratory randomized, double-blind, placebo-controlled, comparative, crossover study was conducted in 81 OC users. Subjects discontinued their OC for one cycle before being randomized for 10cycles to a 30-mcg ethinyl estradiol (EE)/levonorgestrel (LNG) OC or a 30-mcg EE/drospirenone (DRSP) OC, along with daily use of 50mg dehydroepiandrosterone (DHEA) or placebo during five OC cycles before crossing over from DHEA to placebo or the reverse for another fivecycles. First, the effect on sexual function of five OC cycles + placebo was compared to baseline. Then, the effect of five OC cycles + DHEA was compared to the OC+placebo. Results regarding endocrine changes have been published separately. Primary efficacy outcomes of the current study were genital response (measured by vaginal pulse amplitude [VPA]) and sexual feelings (measured by the subjective self-assessment questionnaire [SSAQ]) to self-induced erotic fantasy and visual sexual stimuli in a laboratory setting and measures of desire and arousability using a sexual function diary (SFD). Secondary efficacy outcomes were the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale Revised.Eighty-one women were enrolled, and 74 women completed the study. Five cycles of OC+placebo resulted in a significant decline compared to baseline of four out of six SFD self-ratings of sexual desire and arousability with both OCs. The LNG OC also resulted in significant declines in the FSFI scores (baseline vs. LNG OC+placebo: total score, 28.7±3.7 vs. 25.6±7.4; arousal, 5.0±0.7 vs. 4.5±1.4; lubrication, 5.2±0.9 vs. 4.6±1.7; pain, 4.9±0.9 vs. 4.5±1.4), but no changes were observed using the DRSP OC. In the laboratory setting, five cycles of OC+DHEA showed no significant differences with placebo except for a significant increase in genital sensations (SSAQ) during erotic fantasy (OC+placebo vs. OC+DHEA: 3.3±1.4 vs. 3.6±1.5; p.05). No significant changes were observed for genital response (VPA) and the other two variables of the SSAQ assessed after visual erotic stimulus exposure. Using the SFD, 5 out of 10 variables showed a significant improvement with DHEA. Partner's initiative was rejected less often with OC+DHEA compared to placebo (OC+placebo vs. OC+DHEA: 1.1±1.5 vs. 0.8±1.0; p.05). Women with free testosterone levels in the upper quartile during DHEA co-administration showed significantly better effects on sexual arousal and desire compared to the three lower quartiles (lower vs. upper quartiles: sexual arousability: 25.0±19.8 vs. 41.2±29.0; sexual desire: 5.6±3.7 vs. 9.6±8.0; desire for sex with partner: 4.9±3.1 vs. 8.6±7.4; number of sex fantasies: 3.0±3.2 vs. 5.5±4.4; all p.05).In this exploratory study, OC use was associated with decreases in some measures of sexual functioning, whereas others remained unchanged. Maintaining or restoring physiological testosterone concentrations by the co-administration of DHEA to the OC may prevent these effects on sexuality, particularly in women with relatively high but physiologic levels of free testosterone during DHEA co-administration.The results of this exploratory study warrant further testing of the hypothesis that restoration and/or preservation of physiologic testosterone levels during OC use by co-administration of DHEA has favorable effects on those aspects of sexual function compromised by OCs.

Background Provoked vulvodynia (PVD) is a chronic vulvar pain condition affecting up to 8.3% of the female population. Despite many years of research, no clear cause for PVD has been identified. Several risk factors have been studied, including vulvovaginal candidiasis (VVC). However, to date, the role of Candida infections in PVD has remained unclear. VVC and PVD have an overlap of symptoms that may contribute to diagnostic inaccuracy and mistreatment. Aim To systematically review the literature on the relationship between VVC and PVD. Methods Cohort and case-control studies were included that compared women with PVD with healthy controls with respect to the presence of a history of Candida vulvovaginitis. PVD had to be diagnosed by Friedrich’s criteria or the International Society for the Study of Vulvovaginal Disease criteria. The inclusion process as well as the quality appraisal of the studies, using the Newcastle-Ottawa Quality Assessment Scale, were performed independently by 2 authors. Main Outcome Measure Outcomes of the population-based case-control studies were listed as odds ratio. Outcomes of the pathophysiological studies were based on local pro-inflammatory responses on Candida in vitro. Results We included a total of 14 studies, both population and clinic-based case-control, and pathophysiological research. 7 studies were of low methodological quality, and 7 studies were of medium methodological quality. The population-based case-control studies showed a significantly increased odds ratio for self-reported VVC in PVD cases compared with controls. The pathophysiological studies revealed a tendency for an increased local proinflammatory response on Candida in vitro in patients with PVD. Owing to the substantial heterogeneity of the studies, meta-analysis was not performed. Clinical Implications Health care providers may consider a diagnosis of PVD in women with self-reported VVC, and to act on this properly. Reiteration of antifungal prescriptions by physicians without a decent diagnosis, will lead to mistreatment. Women should be informed by their health care provider that intercourse during (or shortly after) the treatment of VVC might worsen the vulnerability of the vulvar skin. Strength and Limitations This is the first systematic review performed to describe the relation between VVC and PVD. An independently performed in- and exclusion process and quality appraisal, ensured optimal internal validity. However, there were important methodological limitations and the size of heterogeneity prevented establishing a meta-analysis. Conclusion This systematic review is unable to draw conclusions regarding a relationship between actual VVC and PVD because studies were based on self-reported VVC. Until new evidence becomes available, we advocate that PVD should be considered as an unexplained chronic pain condition. In women with recurrent or persistent VVC-like complaints, physicians should consider a diagnosis of PVD.

Background d -Cycloserine (DCS) enhances extinction processes in animals. Although classical conditioning is hypothesized to play a pivotal role in the aetiology of appetitive motivation problems, no research has been conducted on the effect of DCS on the reduction of context specificity of extinction in human appetitive learning, while facilitation hereof is relevant in the context of treatment of problematic reward-seeking behaviors. Methods Female participants were presented with two conditioned stimuli (CSs) that either predicted (CS+) or did not predict (CS−) a potential sexual reward (unconditioned stimulus (US); genital vibrostimulation). Conditioning took place in context A and extinction in context B. Subjects received DCS (125 mg) or placebo directly after the experiment on day 1 in a randomized, double-blind, between-subject fashion (Placebo n = 31; DCS n = 31). Subsequent testing for CS-evoked conditioned responses (CRs) in both the conditioning (A) and the extinction context (B) took place 24 h later on day 2. Drug effects on consolidation were then assessed by comparing the recall of sexual extinction memories between the DCS and the placebo groups. Results Post learning administration of DCS facilitates sexual extinction memory consolidation and affects extinction’s fundamental context specificity, evidenced by reduced conditioned genital and subjective sexual responses, relative to placebo, for presentations of the reward predicting cue 24 h later outside the extinction context. Conclusions DCS makes appetitive extinction memories context-independent and prevents the return of conditioned response. NMDA receptor glycine site agonists may be potential pharmacotherapies for the prevention of relapse of appetitive motivation disorders with a learned component.

Introduction Research has shown that acquired subjective likes and dislikes are quite resistant to extinction. Moreover, studies on female sexual response demonstrated that diminished genital arousal and positive affect toward erotic stimuli due to aversive classical conditioning did not extinguish during an extinction phase. Possible resistance to extinction of aversive conditioned sexual responses may have important clinical implications. However, resistance to extinction of aversive conditioned human sexual response has not been studied using extensive extinction trials. Aim This article aims to study resistance to extinction of aversive conditioned sexual responses in sexually functional men and women. Methods A differential conditioning experiment was conducted, with two erotic pictures as conditioned stimulus (CSs) and a painful stimulus as unconditioned stimuli (USs). Only one CS (the CS+) was followed by the US during the acquisition phase. Conditioned responses were assessed during the extinction phase. Main Outcome Measure Penile circumference and vaginal pulse amplitude were assessed, and ratings of affective value and subjective sexual arousal were obtained. Also, a stimulus response compatibility task was included to assess automatic approach and avoidance tendencies. Results Men and women rated the CS+ more negative as compared with the CS−. During the first trials of the extinction phase, vaginal pulse amplitude was lower in response to the CS+ than in response to the CS−, and on the first extinction trial women rated the CS+ as less sexually arousing. Intriguingly, men did not demonstrate attenuated genital and subjective sexual response. Conclusions Aversive conditioning, by means of painful stimuli, only affects sexual responses in women, whereas it does not in men. Although conditioned sexual likes and dislikes are relatively persistent, conditioned affect eventually does extinguish.

Middle-aged and elderly women constitute a large and growing proportion of the population. The peri and postmenopausal period constitutes a challenging transition time for women's health, and menopausal health is a crucial aspect in healthy and successful aging. Currently, no framework for the concept of healthy menopause exists, despite its recognized importance. Therefore, we aimed to: (i) characterize healthy menopause; (ii) identify aspects that contribute to it; and (iii) explore potential approaches to measure it. We propose healthy menopause as a dynamic state, following the permanent loss of ovarian function, which is characterized by self-perceived satisfactory physical, psychological and social functioning, incorporating disease and disability, allowing the attainment of a woman's desired ability to adapt and capacity to self-manage. The concept of healthy menopause applies to all women from the moment they enter the menopausal transition, up until they reach early and late postmenopause and includes women with spontaneous, iatrogenic, and premature menopause. This conceptualization can be considered as a further step in the maintenance and improvement of health in menopausal women from different perspectives, foremost the woman's own perspective, followed by the clinical, public health, and societal perspectives, and can be seen as a further step in delineating lines for future research. Furthermore, it could facilitate the improvement of adequate preventive and treatment strategies, guide scientific efforts, and aid education and communication to health care practitioners and the general public, allowing women the achievement of their potential and the fulfillment of their fundamental role in society. (C) 2015 Elsevier Ireland Ltd. All rights reserved.

Background Cognitive-affective factors contribute to female sexual dysfunctions, defined as clinically significant difficulties in the ability to respond sexually or to experience sexual pleasure. Automatic thoughts and affect presented during sexual activity are acknowledged as maintenance factors for these difficulties. However, there is a lack of studies on the influence of these cognitive-affective dimensions regarding female orgasm. Aim To assess the role of automatic thoughts and affect during sexual activity in predicting female orgasm occurrence and to investigate the mediator role of these variables in the relation between sexual activity and orgasm occurrence. Methods Nine hundred twenty-six sexually active heterosexual premenopausal women reported on frequency of sexual activities and frequency of orgasm occurrence, cognitive factors, and social desirability. Participants completed the Sexual Modes Questionnaire–Automatic Thoughts Subscale, the Positive and Negative Affect Schedule, and the Socially Desirable Response Set. Multiple linear regressions and mediation analyses were performed, controlling for the effect of covariates such as social desirability, sociodemographic and medical characteristics, and relationship factors. Outcomes The main outcome measurement was orgasm frequency as predicted and mediated by automatic thoughts and affect experienced during sexual activities. Results The presence of failure thoughts and lack of erotic thoughts during sexual activity significantly and negatively predicted female orgasm, whereas positive affect experienced during sexual activity significantly and positively predicted female orgasm. Moreover, negative automatic thoughts and positive affect during sexual activity were found to mediate the relation between sexual activity and female orgasm occurrence. Clinical Implications These data suggest that the cognitive aspects of sexual involvement are critical to enhancing female orgasm experience and can aid the development of strategies that contemplate the central role of automatic thoughts and of positive emotions experienced during sexual activity. Strengths and Limitations Data were not collected face to face, which constitutes a strength of this study, because it is known that social desirability is lower in self-administered online questionnaires compared with traditional paper-and-pencil questionnaires, particularly for more sensitive sexual issues. The fact that the sample was composed of heterosexual, premenopausal, and relatively young women demands some caution regarding generalization of the present results. Conclusion The findings support the contribution of cognitive and affective factors to female orgasmic functioning. It is recommended that future research confirm these findings with other samples, particularly clinical samples of women with orgasmic difficulties.

BackgroundA recent Dutch study in general practice showed a clear relationship between the diagnosis of vulvovaginal candidiasis (VVC) and symptoms suggestive of provoked vulvodynia (PVD). PVD accounts for the largest group of vulvar pains, but is often not recognised by GPs.AimTo investigate whether diagnostic uncertainty about VVC in general practice could also point to the diagnosis of PVD, and whether and how this diagnostic uncertainty affects management.Design & settingAn observational study in 2014 in Dutch general practices of the NIVEL Primary Care Database.MethodWomen with an uncertain diagnosis of VVC were distinguished from those with certain VVC based on the occurrence of recurrent episodes and persisting complaints, despite treatment. Factors known to be associated with PVD were hypothesised to be more prevalent in women with uncertain VVC. Data on symptom management by GPs were collected.ResultsIn total 7066 women with VVC or uncertain VVC were included. Uncertain VVC was found to account for 28% of these patients. Compared to VVC, the group uncertain VVC included significantly more women with female genital symptoms, tiredness, irritable bowel syndrome (all PPPP = 0.009), and higher mean numbers of prescriptions per patient (PConclusionThis study's findings indicate that uncertain VVC could be a marker of PVD. GPs might reconsider their diagnostics and management when women present recurrent and persistent vulvovaginal complaints, especially if accompanied by dyspareunia, functional syndromes, micturition symptoms, and psychological conditions.

Absent or reduced sexual desire and/or arousal is a prevalent and often distressing complaint. In general, women present this problem only when the gynecologist proactively inquires about possible sexual difficulties. Incentive motivation theories, the abundance of evidence that spontaneous sexual desire does not exist, and the knowledge that sexual desire is the result of competent sexual stimuli that activate the sexual response system have changed the way science defines arousal and desire. Desire for sexual activity is more determined by the expectation of rewarding experiences than by a biological “drive.” Biological factors—neurotransmitters and hormones—are not the source of sexual desire but mainly determine the sensitivity of the sexual system for sexual stimuli. Based on these changed views, in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5), the distinction between arousal and desire is abandoned. In women experiencing reduced sexual desire and/or arousal, the diagnosis female sexual interest/arousal disorder should not be made if the sexual difficulties are the result of inadequate sexual stimulation. If the problem is situational, a biological cause is most unlikely. Sexuality is a biopsychosocial phenomenon. Whatever may be the most important initial precipitating factors, there always are secondary psychological, relational, and contextual maintaining factors that must be taken into account in the diagnostic and therapeutic process as well. Treatment of sexual desire and arousal disorders therefore by definition is multidimensional, taking into account all these factors. Therapy might include psychoeducation, basic counseling, individual and couple psychosexual behavioral therapy, and hormonal and pharmacological treatment.

Introduction Vaginal mesh surgery in patients with pelvic organ prolapse (POP) has been associated with sexual dysfunction. Implantation of synthetic mesh might damage vaginal innervation and vascularization, which could cause sexual dysfunction. Aim We aim to evaluate the effects of vaginal mesh surgery on vaginal vasocongestion and vaginal wall sensibility in patients with recurrent POP. Methods A prospective study was performed among patients with previous native tissue repair, scheduled for vaginal mesh surgery. Measurements were performed before and 6 months after surgery, during nonerotic and erotic visual stimuli, using a validated vaginal combi‐probe. Main Outcome Measures The combi‐probe involves vaginal photoplethysmography to assess Vaginal Pulse Amplitude (VPA) (representing vaginal vasocongestion) and four pulse‐generating electrodes to measure vaginal wall sensibility (representing vaginal innervation). Sexual function was assessed using validated questionnaires (Female Sexual Function Index, Female Sexual Distress Scale‐Revised, and Subjective sexual arousal and affect questionnaire). Results Sixteen women were included, 14 completed the 6‐month follow‐up visit. Vaginal vasocongestion under erotic conditions did not significantly alter after mesh implantation. Vaginal wall sensibility of the distal posterior wall was significantly increased after mesh surgery (preoperative threshold 6.3 mA vs. postoperative 3.4 mA, P = 0.03). Sexual function as assessed with questionnaires was not significantly affected. Conclusions In women with a history of vaginal prolapse surgery, vaginal mesh surgery did not decrease vaginal vasocongestion or vaginal wall sensibility. Vaginal vasocongestion prior to mesh surgery appeared to be lower than that of women never operated on. Apparently, native tissue repair decreased preoperative vaginal vasocongestion levels to such extent that subsequent mesh surgery had no additional detrimental effect. Our findings should be interpreted cautiously. Replication of the findings in future studies is essential. Weber MA, Lakeman MME, Laan E, and Roovers JPWR. The effects of vaginal prolapse surgery using synthetic mesh on vaginal wall sensibility, vaginal vasocongestion, and sexual function: A prospective single‐center study. J Sex Med 2014;11:1848–1855.

Objective To investigate the risk of developing a depression after induced abortion. Methods A prospective cohort study conducted in Curacao which involved 92 women having an induced abortion and 37 women delivering after an unplanned or unwanted pregnancy, who served as controls. All participants completed the Center of Epidemiological Studies Depression (CES-D) scale before and two to three weeks after the abortion or delivery. Results Following the abortion, significantly fewer women were at risk of depression (30%) as compared to when still pregnant (60%). Mean depression scores were significantly lower after-than before the procedure. The likelihood of depression post-abortum (30%) was similar to that after delivery of an unplanned/unwanted child (22%). Even though women in the abortion group more often reported having suffered from depression in the past than controls, they were not at greater risk of depression after their pregnancy had ended. Conclusion Curacao women's risk of developing a depression following an (early) induced abortion is not greater than that after carrying to term an unplanned/unwanted pregnancy. We recommend that the results of this study be taken into account in case the Curacao government should consider legalisation of induced abortion in the near future