SEXUAL HEALTH YEAR IN REVIEW
By: Cheryl B. Iglesia, MD FACOG
2020 A.D. is unforgettable for many reasons beyond the SARS-Cov-2 pandemic which has impacted global industries including small businesses, restaurants, travel, lodging and entertainment. Dating and sexual relations beyond one’s pod has proven particularly problematic. Early on in the pandemic, the New York City Health Department came out with the most practical guidelines related to Safer Sex and Covid-19, including promotion of masturbation (“you are your safest sex partner”), selective kissing, social distancing through sexting and web chat platforms, and creative use of barriers and positions to get intimate while wearing a mask.1
One of the most reassuring papers on sexual health this year was published by Antosh Antosh et al2 on behalf of the Systematic Review Group of the Society of Gynecologic Surgeons. In this comprehensive review of 67 original articles, sexual function after surgery for pelvic organ prolapse (a condition of sagging vaginal organs that is associated with a lifetime risk of surgery for 12.6% of US women ), sexual function improved or remained unchanged and there was no worsening after pelvic reconstructive surgery. The risk for new onset painful sex was low at less than 9% after surgery and did not differ between mesh and no mesh repairs.
Furthermore, two of the hottest topics related to sexual health are low libido (Hypoactive Sexual Desire Disorder or HSDD) and vaginal dryness (Genitourinary Syndrome of Menopause or GSM). In a well-written clinical review of early menopause, defined as menopause before age 45, and premature menopause (before age 40), Kingsberg et al3 list the negative physical and mental health effects of early and premature menopause including higher risk for cardiovascular disease and early death, osteoporosis, joint and muscle stiffness, dementia, depression, anxiety, female sexual dysfunction and sleep difficulties which can lead to worsening memory.
With respect to sexual function, the younger the onset of menopause (for example due to removal of ovaries for prevention of cancer or as a result of chemotherapy or genetic disorders) the worse the symptoms including decreased desire, inability to orgasm, vaginal dryness and pain with sex. Hormone therapy in patients with early menopause is generally indicated until a woman reaches the age of natural menopause (51 years on average) for prevention of severe health consequences and not just for symptom relief. For those with GSM not responding to hormone therapy, additional local treatment with estrogen tablets, rings, creams, or other hormonal formulations (prasterone and ospemifene) may also be indicated.
Finally, for HSDD, there are no FDA-approved testosterone formulations for women; however, there are two non-hormonal drugs approved for the treatment of HSDD in premenopausal women –flibanserin and bremelanotide—and these likely would show benefit in women with early menopause. Treatment with antidepressants and psychotherapy for associated mood and sleep disorders should be considered for improved quality of life.
In summary, this pandemic year has presented many challenges but there are some bright lights with respect to sexual health. Pelvic reconstructive surgery has a positive impact in sexual function among women with pelvic support problems. Many hormonal and non-hormonal therapies can prevent sexual and quality of life problems in women with early menopause.
Cheryl B. Iglesia, MD FACOG is a member of the Patty Brisben Foundation for Women’s Sexual Health Medical Advisory Board. Dr. Iglesia is a Professor in the Departments of OBGYN and Urology at Georgetown University School of Medicine. She is also Director of the Section of Female Pelvic Medicine and Reconstructive Surgery at MedStar Health in Washington, D.C.
- Covid-Sex-Guidance by New York City Health Department accessed on December 22, 2020. https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-sex-guidance.pdf
- Antosh, Danielle D. MD; Kim-Fine, Shunaha MD; Meriwether, Kate V. MD; Kanter, Gregg MD; Dieter, Alexis A. MD; Mamik, Mamta M. MD; Good, Meadow DO; Singh, Ruchira MD; Alas, Alexandriah MD; Foda, Mohamed A. MD; Balk, Ethan M. MD, MPH; Rahn, David D. MD; Rogers, Rebecca G. MD Changes in Sexual Activity and Function After Pelvic Organ Prolapse Surgery, Obstetrics & Gynecology: November 2020 – Volume 136 – Issue 5 – p 922-931 doi: 10.1097/AOG.0000000000004125
- Kingsberg, Sheryl A. PhD; Larkin, Lisa C. MD, FACP; Liu, James H. MD, NCMP Clinical Effects of Early or Surgical Menopause, Obstetrics & Gynecology: April 2020 – Volume 135 – Issue 4 – p 853-868 doi: 10.1097/AOG.0000000000003729