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Introduction: Many women have doubts about the normality of the physical appearance of their vulvas. This study measured genital self-image in a convenience sample of college-educated women, and assessed whether exposure to pictures of natural vulvas influenced their genital self-image.Method: Forty-three women were either shown pictures of natural vulvas (N = 29) or pictures of neutral objects (N = 14). Genital self-image was measured before and after exposure to the pictures and two weeks later. Sexual function, sexual distress, self-esteem and trait anxiety were measured to investigate whether these factors influenced genital self-image scores after vulva picture exposure.Results: A majority of the participants felt generally positively about their genitals. Having been exposed to pictures of natural vulvas resulted in an even more positive genital self-image, irrespective of levels of sexual function, sexual distress, self-esteem and trait anxiety. In the women who had seen the vulva pictures, the positive effect on genital self-image was still present after two weeks.Discussion: The results of this study seem to indicate that even in young women with a relatively positive genital self-image, exposure to pictures of a large variety of natural vulvas positively affects genital self-image. This finding may suggest that exposure to pictures of natural vulvas may also lead to a more positive genital self-image in women who consider labiaplasty. [ABSTRACT FROM AUTHOR]

Introduction. Sexual dysfunction after ileo pouch anal anastomosis (IPAA) is common. The most systematic physical reaction to sexual stimulation is an increase in vaginal vasocongestion. Genital response can be assessed by vaginal pulse amplitude (VPA) using vaginal photoplethysmography. Aim. To assess whether restorative proctocolectomy with IPAA is associated with autonomic pelvic nerve damage and changes in subjective indices of sexual function in women. Methods. Female patients undergoing IPAA between April 2004 and January 2006 were included. During sexual stimulation (visual and vibrotactile) changes in vaginal vasocongestion were measured by vaginal photoplethysmography. Concurrently, quality of life (SF-36) and sexual functioning (FSFI, FSDS) were assessed using validated questionnaires. Main Outcome Measures. Primary endpoint was difference in VPA pre- and postoperatively. Secondary endpoints were differences in feelings of sexual arousal and estimated lubrication pre- and postoperatively and difference in psychological and sexual functioning pre-and postoperatively. Results. Eleven patients were included. For eight patients (median age 37 [22–49 years]) pre- and postoperative data were collected. VPA analysis showed a significant reduction in vaginal vasocongestion during sexual stimulation postoperatively, P = 0.012. Subjective sexual arousal and estimated lubrication during the experiment, reported psychological and sexual functioning pre- and postoperative were not different. Conclusions. Vaginal vasocongestion after IPAA was significantly reduced in this small study; indicating that IPAA in women might possibly be associated with autonomic pelvic nerve damage or partial devascularization of the vagina. Subjectively reported sexual arousal, estimated lubrication, psychological and sexual functioning were not diminished. Future research should focus on the possible advantage of a full close rectal dissection in these patients. Vlug MS, Laan ET, van Lunsen RHW, van Koperen PJ, Polle SW, and Bemelman WA. Genital and subjective sexual response in women after restorative proctocolectomy with ileal pouch anal anastomosis—A prospective clinical trial. J Sex Med 2010;7:2509–2520. [ABSTRACT FROM AUTHOR]

Introduction. Most pharmacological treatments that are currently being developed for women with sexual arousal disorder are aimed at remedying a vasculogenic deficit. Aim. This study investigated whether pre- and postmenopausal women with sexual arousal disorder are less genitally responsive to visual sexual stimuli than pre- and postmenopausal women without sexual problems. Method. Twenty-nine medically healthy women with sexual arousal disorder (15 premenopausal and 14 postmenopausal), diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria, and 30 age-matched women without sexual problems (16 premenopausal and 14 postmenopausal) were shown sexual stimuli depicting cunnilingus and intercourse. Main Outcome Measure. Genital arousal was assessed as vaginal pulse amplitude (VPA) using vaginal photoplethysmography. Results. Results showed no significant differences between the two groups in mean and maximum VPA, nor in latency of VPA response. Conclusion. Women with sexual arousal disorder diagnosed according to DSM-IV criteria were not less genitally responsive to visual sexual stimuli than women without such problems. These findings are in line with previous studies. The sexual problems these women report are clearly not related to their potential to become genitally aroused. We argue that the DSM-IV criteria for sexual arousal disorder are in need of revision. In medically healthy women, impaired genital responsiveness is not a valid diagnostic criterion. Laan E, van Driel EM, and van Lunsen RHW. Genital responsiveness in healthy women with and without sexual arousal disorder. J Sex Med 2008;5:1424–1435. [ABSTRACT FROM AUTHOR]

The article presents comments to the proposed changes in the diagnostic criteria for female sexual dysfunction (FSD) from the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM)-V committee. Most of the comments focused on the proposed merging of the current diagnostic categories of hypoactive sexual arousal disorder (HSDD) and female sexual arousal disorder (FSAD) into a single disorder named Sexual Interest Arousal Disorder (SIAD). The approaches to determining the categories that define phenomenological space are explained.

Introduction. There are some data to suggest that tibolone improves sexual function in postmenopausal women. However, evidence about the effects of tibolone on female sexual dysfunction is lacking. Aim. To compare the efficacy on sexual function of tibolone 2.5 mg to continuous combined transdermal estradiol (E2)/norethisterone acetate (NETA) (50 µg/140 µg) in naturally postmenopausal women with sexual dysfunction. Main Outcome Measure. Differences between treatment groups in the change from baseline for the composite subscore of the arousal, desire, and satisfaction domains of the self-reported Female Sexual Function Index (FSFI). Methods. A multicenter, double-blind, randomized, clinical trial was performed. Sexual function was assessed with the FSFI at baseline, week 12, and week 24. The outcomes of the Female Sexual Distress Scale (FSDS) and the frequency of satisfying sexual events (daily diaries) were secondary end points. Results. Four hundred three women, mean age 56, were included. Both therapies improved sexual function assessed by the FSFI. In the per protocol analysis, but not in the intent-to-treat analysis, the increase in FSFI scores was significantly larger in the tibolone group when compared with the E2/NETA patch group at week 24 ( P = 0.036 and P = 0.025 for the composite subscore and total FSFI score, respectively). The satisfying sexual event rate increased from three to four times per 28 days at week 24 ( P < 0.001 from baseline for both groups), with no difference between groups. The FSDS showed a significant decrease from baseline ( P < 0.001), which was comparable for both treatment groups. Conclusions. Both treatments resulted to improved overall sexual function, as determined by scores on the FSFI, an increase in the frequency of sexual events, and a reduction in sexuality-related personal distress. The statistically significant higher FSFI scores in the tibolone group, when compared to the E2/NETA group, may be because of tibolone's combined estrogenic and androgenic properties. Nijland EA, Schultz WCMW, Nathorst-Boös J, Helmond FA, Van Lunsen RHW, Palacios S, Norman RJ, Mulder RJ, and Davis SR for the LISA study investigators. Tibolone and transdermal E2/NETA for the treatment of female sexual dysfunction in naturally menopausal women: Results of a randomized active-controlled trial. J Sex Med 2008;5:646–656. [ABSTRACT FROM AUTHOR]

Summary of Committee. For the complete report please refer toSexual Medicine: Sexual Dysfunctions in Men and Women, edited by T.F. Lue, R. Basson, R. Rosen, F. Giuliano, S. Khoury, F. Montorsi, Health Publications, Paris 2004.Data concerning the biologic pathophysiology of desire, arousal, and orgasm in women are limited.To gain knowledge of biologic pathophysiology of female sexual function.To provide state-of-the-art knowledge concerning female sexual dysfunction, representing the opinions of seven experts from five countries developed in a consensus process over a 2-year period.An International Consultation in alliance with key urological and sexual medicine societies convened over 200 multidisciplinary specialists from 60 countries into 17 consultation committees. The aims, goals and intentions of each committee were defined. Expert opinion was based on grading of evidence-based medical literature, extensive internal committee dialogue, open presentation, and debate.Three critical physiologic requirements, including intact sex steroids, autonomic/somatic nerves, and arterial inflow/perfusion pressure to women's genital organs play fundamental roles in maintaining women's sexual function. Despite this, there are nominal data supporting a direct pathophysiologic involvement of abnormal sex steroid values, and/or damage/injury to neurologic and/or blood flow integrity in women with problems in sexual desire, arousal, and/or orgasm. This summary details the available literature concerning hormonal, neurologic, and vascular organic pathophysiologies of women's sexual dysfunctions.Additional research on clinical pathophysiologies in women's sexual dysfunction is needed. This chapter encompasses data presented at the 2nd International Consultation on Sexual Medicine in Paris, France, June 28–July 1, 2003. [ABSTRACT FROM AUTHOR]

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. Laan ETM, Prins JM, van Lunsen RHW, et al. Testosterone Insufficiency in Human Immunodeficiency Virus-Infected Women: A Cross-Sectional Study. Sex Med 2019;7:72-79., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The objective was to evaluate the effect of combined oral contraceptives (OCs) on sexual function, either alone or together with dehydroepiandrosterone (DHEA)., Study Design: 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., Results: 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)., Conclusions: 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., Implications: 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., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: A literature analysis on the effects of female genital mutilation (FGM) on sexual and psychological well-being., Design: Narrative systematic review., Method: In March 2016 we performed a search for relevant literature in the Cochrane Library, Embase, PubMed, PsycINFO and CINAHL. Inclusion criteria were studies (a) of women who had undergone FGM and with a control group of women who had not undergone FGM; (b) published since 2010; (c) in Dutch, English, French or German; and (d) in which use was made of sexological and/or psychological questionnaires., Results: We included 14 studies from African, Arabic or European countries. In 3 studies psychological well-being was assessed, in 5 studies sexual well-being, and in 6 studies both were assessed. Women with FGM reported more symptoms of post-traumatic stress, anxiety and depression. FGM had negative effects on self-confidence, quality of life and marital satisfaction. Women with FGM were less satisfied with their sex life. They reported less sexual desire, less arousal and lubrication and fewer orgasms and more often had dyspareunia., Conclusion: Women with FGM have an increased risk of reduced psychological and sexual well-being.

Objective: To determine whether adding dehydroepiandrosterone to combined oral contraceptives (COCs) maintains physiological levels of free testosterone., Study Design: A randomized, double-blind, placebo-controlled, two-way crossover study conducted in 81 healthy women (age range: 20-35 years; Body mass index (BMI) range: 18-35 kg/m 2 ) using oral contraceptives. Androgens, sex hormone-binding globulin (SHBG), estradiol (E2) and estrone (E1) were measured, and free testosterone and the free testosterone index were calculated. Subjects discontinued oral contraceptive use for at least one menstrual cycle before being randomized to receive five cycles of ethinyl estradiol (EE) combined with either levonorgestrel (EE/LNG group) or drospirenone (EE/DRSP group) together with either dehydroepiandrosterone (DHEA) (50 mg/day orally) or placebo. Subsequently, all subjects crossed over to the other treatment arm for an additional five cycles., Results: Both COCs decreased the levels of all androgens measured. Significant decreases (p<.05) were found with EE/LNG and EE/DRSP for total testosterone (54.5% and 11.3%, respectively) and for free testosterone (66.8% and 75.6%, respectively). Adding DHEA to the COCs significantly increased all androgens compared to placebo. Moreover, including DHEA restored free testosterone levels to baseline values in both COC groups and total testosterone levels to baseline in the EE/LNG group and above baseline in the EE/DRSP group. SHBG concentrations were significantly higher with EE/DRSP compared to EE/LNG (p<.0001). The addition of DHEA did not affect the levels of SHBG., Conclusions: Taking COCs reduces total and free testosterone levels and increases SHBG concentrations. By coadministration with DHEA, physiological levels of total and free testosterone are restored while using EE/LNG. With EE/DRSP, only the free testosterone level is normalized by DHEA coadministration., Implications: A daily oral dose of 50-mg DHEA maintains physiological free and total testosterone levels in women who are using an EE/LNG-containing COC., (Copyright © 2016 Pantarhei Bioscience. Published by Elsevier Inc. All rights reserved.)

Introduction: Lichen sclerosus (LS) of the vulva can profoundly affect sexual interaction because of painful fissures and narrowing of the vaginal introitus. Successful surgical treatment is usually defined as restoration of (pain-free) penetrative sexual activity., Aims: To evaluate the impact of surgery on (dyadic) sexual functioning and pleasure and psychological well-being., Methods: Nineteen women with anogenital LS participated in audiotaped, qualitative, individual interviews after surgery to re-enable sexual intercourse., Main Outcome Measures: Physical, sexual, and psychological experiences were analyzed using the constant comparative method., Results: Vulvar surgery resulted in a decrease of sexual pain in 13 of 19 patients (68%). Of these 13 patients, 4 were completely free of pain and the other 9 patients expressed a shift from preoperative sexual pain to postoperative sexual discomfort. These women reported improved sexual functioning, increased sexual activity and intimacy with the partner, and reinstated feelings of being an adequate woman and sexual partner. In 1 of the 19 patients (5%), surgery did not result in decreased sexual pain, yet she continued to have intercourse. Five of the 19 patients (26%) stopped having intercourse because of pain; one woman had secondary vaginismus and another woman, in retrospect, had premorbid generalized unprovoked vulvodynia. Four of these women were unable to communicate with their partner about sexual matters and to change their sexual repertoire (satisfactorily) once they had ceased intercourse (attempts). Eighteen women (95%) reported a decrease of LS symptoms in daily life., Conclusion: Vulvar surgery seems an effective treatment for most women with LS who experience sexual pain owing to anatomic or epithelial changes and who wish to resume intercourse. To assess whether women might benefit from such surgery and/or whether (additional) sexual counseling is indicated, preoperative sexological couple-based consultation is needed. This consultation should exclude comorbid vaginismus and generalized unprovoked vulvodynia and index the couple's pre-existing sex life, including sexual communication skills, and the ability to incorporate non-coital pain-free sexual activities., (Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the most appropriate cutoff value for the Sexual Interest and Desire Inventory-Female (SIDI-F) score to discriminate between women with hypoactive sexual desire disorder (HSDD) and those with no female sexual dysfunction (FSD). The SIDI-F is a clinician-rated instrument consisting of 13 items designed to assess HSDD severity in women. The total score ranges from 0 to 51, with higher scores indicating better sexual function., Methods: Data from patients enrolled in a North American nontreatment study and a European nontreatment study were analyzed. Both studies were 4-week, prospective, multicenter trials designed to assess the reliability and validity of the SIDI-F. Only patients with HSDD or no FSD were included in this analysis. Receiver operating characteristics (ROC) analysis was used to determine the ability of the SIDI-F to differentiate between patients with HSDD and those with no FSD at baseline., Results: A total of 428 women were included in this analysis: 174 from North America (HSDD 113, no FSD 61) and 254 from Europe (HSDD 130, no FSD 124). In the North American study, a SIDI-F cutoff score of 33 minimized the difference between sensitivity (94.7%) and specificity (93.4%). In the European study, SIDI-F cutoff scores of both 33 and 34 minimized the difference between sensitivity (95.2%) and specificity (94.4%)., Conclusions: In appropriately screened women, a SIDI-F score of ≤33 indicates the presence of HSDD.

Recently the Dutch College of General Practitioners issued a revised practice guideline 'The intrauterine device' (IUD). This should help women considering intrauterine contraception to choose between a conventional copper IUD and a levonorgestrel-releasing intrauterine system (LNG-IUS). This guideline states that two aspects of these IUDs are important determinants of the decision, namely reliability and expected bleeding patterns. We argue that women deserve more detailed information than the practice guideline provides, especially about bleeding patterns. We introduce 'tailor-made bleeding' as one of the aspects of contraceptive counselling that is very much determining levels of compliance and patient satisfaction. A table reviewing different aspects of possible bleeding patterns for all intrauterine and hormonal contraceptive methods is presented as an important counselling tool.