WOMEN 'S HEALTH AND MENOPAUSE : - National Heart, Lung ...

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7. ASSESSING SEXUAL ACTIVITY Clinicians should routinely ask their patients about their sexual functioning. Many elderly couples wonder if it is still possible or safe to have coitus after the menopause or how long they can enjoy sex without harming their health. Sexual history questions particularly pertinent to postmenopausal patients include the following: • Are you satisfied with your sexual life? • Do you have any questions about sex? • Has there been a change in your sex drive, lubrication, or orgasm? • Do you have any sexual problems? Would you like help with the problem or problems? • Can you describe when the problem started, and how often it occurs? • Have you tried anything to correct the problem? Has it worked? • Does your partner have any sexual problems? It is important to be alert to the possible effects of aging, illness, or medical or surgical treatment on libido and sexual responsiveness. Sexual dysfunctions may have a negative influence on a woman’s self image, her physiologic response, or her partner’s response. One of the most controversial issues is whether hysterectomy impacts sexual function. If done for symptoms, such as pain or bleeding, a hysterectomy can result in improved sexual functioning. 37 Alternatively, some women view it as causing a loss of their female identity that negatively impacts sexual functioning. 38,39 Possible medical causes of sexual problems include the following: Illnesses: Any physical or emotional chronic disease—physical or emotional, including liver, renal, cardiac, anemia, hypertension, stroke, cancer, neurologic disease, colostomy, neostomy, bladder surgery, incontinence, herpes virus or HIV infection, venereal warts, and cystitis—may cause sexual dysfunction. 130 Medications: Hypoglycemic agents, antihypertensive drugs, vasodilator and other cardiac drugs, antineoplastic drugs, major or minor tranquilizers (depending on dose), diuretics, and antihistamines may cause sexual problems. (See table 7–2.) Some studies suggest antidepressants (including SSRIs) may reduce desire and delay orgasm. 40 Decreased libido occurs in 20 percent of patients on tricyclic antidepressants, and 30 percent have impaired orgasm. Treatments: Major surgery (hysterectomy, mastectomy, coronary artery bypass, organ transplant), dialysis, radiotherapy, and chemotherapy may cause sexual dysfunction. 8. TREATMENT FOR SEXUAL DYSFUNCTION Sexual function for any person at any age involves sexual thoughts, desires, feelings of arousal, potential for orgasm, and physical and mental relaxation. The treatment of sexual dysfunction is dependent adequate research showing efficacy of the treatment over another medication, a placebo or another treatment. Compared to with treatments for other mental health diagnoses, treatment for sexual dysfunction has lagged behind. The causes are multiple and include such issues as a lack of a standardized approach to therapy, the lack of control groups, and the dominance of the techniques described by Masters and Johnson. 30 However, one of the most probable causes for the lack of treatment options for sexual dysfunction has been the lack of research funding to study these disorders. Behavioral and medical treatments for sexual dysfunction are reviewed below, and where evidence exists, recommendations are made as appropriate. 8.1 Behavioral Therapy for Sexual Dysfunction A literature review of the application and outcome of sex therapy and other treatments for sexual dysfunction showed the format of effective conjoint sex therapy may be of significant benefit to couples with sexual dysfunction. 41 Sarwer and Durlak con-
TABLE 7–2 Medications Associated With Adverse Effects on Female Sexual Function and Response Antihypertensive drugs Antidepressants and anxiolytics (especially SSRIs) Anti-inflammatory drugs Antiparkinsonian drugs Antiseizure drugs Beta-blockers Bromocriptine (painful clitoral tumescence) Cimetidine Digoxin Diuretics Gemfibrozil Gonadotropin-releasing agents Methyldopa Psychoactive drugs Sleeping pills Tranquilizers ducted a field trial of behavioral sex therapy for 365 married couples presenting with a range of sexual dysfunctions at an outpatient sexual dysfunction clinic of a large medical center. 42 The number of sensate focus exercises completed in the last week of treatment was the strongest predictor of successful treatment. The results of this study confirmed that behavioral sex therapy is effective in the treatment of married couples with sexual dysfunction. 8.1.1 Anorgasmia The approach to treatment of primary anorgasmia utilizes the techniques of sensate focus, desensitization, and/or directed masturbation exercises. The primary elements of sensate focus developed by Masters and Johnson are physical caresses coupled with nonsexual progressing to sexual touching Abusive Drugs Associated with Abnormal Sexual Response Alcohol Narcotics Nicotine exercises. 30 The success rate was 84 percent in just over 1 year and 82 percent at 5 years. Desensitization is used when anxiety plays a major role in the dysfunction; however, it alone does not improve orgasmic capacity. 43 Directed masturbation exercises have had varying success in the treatment of primary anorgasmia. Kilmann et al. investigated the differential effectiveness of various treatments for 55 couples where the woman reported secondary orgasmic dysfunction. 44 Compared with women in the control group, a significantly greater number of treated women reached or exceeded the project’s 50percent criterion for coital orgasmic functioning. However, these differences were not significant at the followup visit. 131
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National Heart, Lung, and Blood Ins
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CHAIRS AND EDITORS Chair and Editor
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Anne McTiernan, M.D., Ph.D. Associa
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Lenore Manderson, Ph.D. Director an
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Michael Mendelsohn, M.D. Director,
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TABLE OF CONTENTS Preface XIII 1 Ex
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PREFACE Women’s health and menopa
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CHAPTER 1: EXECUTIVE SUMMARY Nanett
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TABLE 1-1 Evidence Categories Evide
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TABLE 1-2 (continued) Possible Bene
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symptom measures, cultural factors,
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5. PHYSIOLOGICAL ROLE OF ESTROGEN A
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The atherogenic risk profile of old
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• Hormone replacement therapy: Fi
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tion of the remaining ridge in area
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9.3.1 Interventions • In many cas
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Parkinson’s disease, no overall p
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TABLE 1-3 (continued) Sexuality •
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CHAPTER 2: THE MENOPAUSE AND AGING
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oped and are less prepared to addre
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FIGURE 2-4 Diabetes Mellitus. Estim
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Sarcopenia, defined as reduced musc
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Perimenopause WHO The term “perim
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decrease about 2 years before the F
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4.3 Menstrually Defined Menopausal
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to be under stress and to hold part
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21 Brincat MP. Hormone replacement
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62 Orentreich N, Brind JL, Rizer RL
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CHAPTER 3: SYMPTOMS AND THE MENOPAU
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women who may have reached natural
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numb-tingling feelings, headaches,
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(47 percent), problems sleeping (39
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FIGURE 3-2 Proportion of Women Both
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tomized hypogonadotropic women expe
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5.1 Exercise It has been suggested
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to consume 20-150 mg/day of isoflav
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REFERENCES 1 Stewart AL, Hays RD, W
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48 Avis NE, Crawford SL, McKinlay S
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92 Albertazzi P, Pansini F, Bonacco
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Hällström wrote that the psycholo
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countries. Perhaps, as the authors
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Beyene used a systematic ethnograph
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ange of variables, such as genetic
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REFERENCES 1 Gannon L, Ekstrom B. A
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47 George T. Women in a south India
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9. Estrogen and inhibins produced b
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Page 98 and 99: a partial agonist. In contrast, wit
Page 100 and 101: 3. UROGENITAL TRACT ERα and ERβ a
Page 102 and 103: 4. BONE: DEVELOPMENT AND HOMEOSTASI
Page 104 and 105: in response to estrogen. 106,105 In
Page 106 and 107: lation of sleep, motor behavior, an
Page 108 and 109: 7. HORMONE REPLACEMENT THERAPY: TRA
Page 110 and 111: REFERENCES 1 Jensen EV, Jacobsen HI
Page 112 and 113: 40 Power RF, Mani SK, Codina J, Con
Page 114 and 115: 83 Oursler MJ, Pederson L, Fitzpatr
Page 116 and 117: 125 Gabrielsson BG, Carmignac DF, F
Page 118 and 119: 169 Renier MA, Vereecken A, Buytaer
Page 120 and 121: FIGURE 6-1 Structural features of E
Page 122 and 123: ound, the conformation of the recep
Page 124 and 125: with extremely potent estrogenic ac
Page 126 and 127: Its potency as an antiestrogen was
Page 128 and 129: The observation that the degree of
Page 130 and 131: findings were remarkable because a
Page 132 and 133: Recently, the use of phage display
Page 134 and 135: 20 Crawley G. Non steroidal estroge
Page 136 and 137: 65 Qu Q, Zheng H, Dahllund J, et al
Page 138 and 139: in their survey of postmenopausal w
Page 140 and 141: where over half the world’s popul
Page 142 and 143: The Danish study of Koster and Gard
Page 144 and 145: Many studies of sexual interest in
Page 148 and 149: None of these studies evaluated the
Page 150 and 151: estrogen-androgen group during the
Page 152 and 153: REFERENCES 1 Sarrel PM, Whitehead M
Page 154 and 155: 52 Utian WH. The true clinical feat
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Page 158 and 159: outes of administration and differe
Page 160 and 161: FIGURE 8-2 Change in Age-Adjusted D
Page 162 and 163: fied as overweight or obese. 32 The
Page 164 and 165: TABLE 8-1 148 Guide to Risk Reducti
Page 166 and 167: TABLE 8-1 (continued) 150 Recommend
Page 168 and 169: TABLE 8-1 (continued) 152 Recommend
Page 170 and 171: Interesting differences in atherosc
Page 172 and 173: similar effects in both patients wi
Page 174 and 175: a lowering of triglycerides, 140 an
Page 176 and 177: may account for a substantial propo
Page 178 and 179: associated with an independent prot
Page 180 and 181: eases preoperatively. Quality of li
Page 182 and 183: excess risk of 6-18 per 10,000 per
Page 184 and 185: REFERENCES 1 NHLBI Morbidity and Mo
Page 186 and 187: 36 Samaras K, Hayward CS, Sullivan
Page 188 and 189: 79 Collins P, Rosano GM, Jiang C, L
Page 190 and 191: 121 Mäkelä S, Savolainen H, Aavik
Page 192 and 193: 162 Clarke S, Kelleher H, Lloyd-Jon
Page 194 and 195: 201 Rahimtoola SH, Bennett AJ, Grun
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243 Varas-Lorenzo C, Garcia-Rodriqu
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7. A connection between menopausal
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3. PATHOGENESIS OF FRACTURE Fractur
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Diagnosis of osteoporosis according
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density and has a favorable effect
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How should this information be inco
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emergence of proved treatment alter
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Data on the relation between skelet
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REFERENCES 1 Osteoporosis Preventio
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42 Gluer CC. Quantitative ultrasoun
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85 Ettinger B, Pressman A, Silver P
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130 Jeffcoat MK, Lewis CE, Reddy M,
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1. INTRODUCTION Perimenopausal wome
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for breast cancer are at increased
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findings on biopsy in women with an
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thra. Patients typically describe l
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Biofeedback: Used in conjunction wi
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There has been one systematic revie
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ence in pelvic organ prolapse. The
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21 Ferenczy A. Endometrial carcinom
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65 Wyman JF, Fantl JA, McClish DK,
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222
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1. INTRODUCTION Worldwide, breast c
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difficult to compare because of com
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Although HRT has been related to an
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cyclic use and 2.9 (95 percent CI 2
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TABLE 11-3 Selected Studies on Horm
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TABLE 11-3 (continued) Thus, a stro
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TABLE 11-4 236 Cohort Studies on Ho
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TABLE 11-5 238 Case-Control Studies
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TABLE 11-5 (continued) 240 Adjustme
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When the same women in NSABP were r
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REFERENCES 1 Pisani P, Parkin DM, B
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47 Day NE. Epidemiology: the role o
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93 Rodriguez C, Patel AV, Calle EE,
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139 Parazzini F, La Vecchia C, Negr
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1. INTRODUCTION Menopause is associ
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inverse relation with nonverbal mem
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ease decreased significantly with i
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of households selected to be repres
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standard antipsychotic drugs increa
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5. FUTURE NEEDS • Explore the pos
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19 Berman KF, Schmidt PJ, Rubinow D
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64 Lerner A, Koss E, Debanne S, Row
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114 Smith R, Studd JW. A pilot stud
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162 Klein BE. Lens opacities in wom
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patients with strong personal convi
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Therefore, convincing evidence of t
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3.1.1 Risk Factors Many factors are
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278 lower dosages of estrogen will
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• Diabetes: Women with diabetes b
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Lipids and lipoproteins • LDL cho
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284 persists but is less steep in w
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5.2.3 Pharmacotherapy Breast Cancer
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• There is no clinical trial evid
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Sirtori CR, Pazzucconi F, Colombo L
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Hansson L, Zanchetti A, Carruthers
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Dementia and Mental Health Forette
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CRP C-reactive protein CT computed
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PTCA percutaneous transluminal coro
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U.S. DEPARTMENT OF HEALTH AND HUMAN
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