Iatrogenic Factors Precipitating Female Sexual Disorder in .NET

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Iatrogenic Factors Precipitating Female Sexual Disorder
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Clinicians may actively precipitate or worsen preexisting unrecognized FSD in their daily practice This negative effect may be due to the known but not completely avoidable side effects of necessary medical and surgical treatment, or to mistakes, negligence, and overall malpractice
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Pharmacologic effects
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Drug-induced sexual disorders have special characteristics: the effect dissipates with drug discontinuation or dose reduction; it is not explained by the ongoing disease or environmental stress; the onset tends to coincide with drug initiation or dose increase (although a delayed onset is possible); it is generalized, ie tends to be present in all sexual situations and reappears with the reintroduction of the drug [1] Drugs more frequently associated with FSD are listed in Table 261 As a note, it should be remembered that some drugs such as sexual
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26 Hormonotherapy: Estrogen receptor-positive breast cancer has been treated with tamoxifen for almost three decades Although reasonably well tolerated and used worldwide, this drug may speci cally affect sexual function A recent study indicates that during tamoxifen therapy the most frequent complaints were hot ushes (85%), disturbed sleep (55%), vaginal dryness and/or dyspareunia (47%), decreased sexual desire (44%), and musculoskeletal symptoms (43%) [11] Disturbed sleep correlated with hot ushes (p < 00005) and concentration problems (p < 005) Decreased sexual interest correlated with vaginal dryness (p < 00005) and/or dyspareunia (p < 00005) After discontinuation of tamoxifen, symptoms decreased signi cantly [11] More recent treatments with aromatase inhibitors such as anastrozole, which inhibit the conversion of androgens to estrogens, may also have a negative impact on sexual response
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hormones, in hormone therapy (see s 20 and 27), hypoprolactinemic drugs, dopaminergic drugs, bupropion, or vasoactive drugs, to mention a few may have a positive effect on women s sexuality [1,5,32,34] Among the drugs most widely used, a negative sexual impact is more frequently reported with: Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) are associated with loss of desire and central arousal and a speci c inhibiting effect on orgasm, which increases with increasing doses [1,36] Hormonal contraception: Biologic, psychosexual, and relational factors interact in modulating the nal effect of hormonal contraceptives on women s sexual response [1,6,37 39] From the biologic point of view, sexual desire may be reduced by: the inhibition of the ovulatory peak of testosterone; the increase of liver production of sex hormone binding globulin (SHBG), which reduces the free fraction of plasmatic testosterone; the speci c anti-androgenic effect of progestins such as cyproterone acetate, drospirenone or norgestimate and norelgestromine; the inhibiting effect, through a negative feedback, of vaginal dryness and dyspareunia, more frequent with ultra light pills, containing 15 g ethinyl estradiol [6,37 39] A positive motivation to control fertility and avoid unwanted pregnancy, and satisfaction with a rewarding cosmetic results obtained with anti-androgenic hormonal contraceptive combinations (to treat acne, hypertrichosis, or hirsutism) may nevertheless move the overall perception toward a neutral effect on sexual desire, or even a favourable one [38] Chemotherapy has a complex effect: in pre-pubertal or fertile women it may cause permanent ovarian damage, with respectively, primary hypergonadotropic amenorrhea or premature menopause [5,9,11] This prolonged deprivation of sexual hormones, especially in women with hormone-dependent cancers, where hormone therapy is currently contraindicated, may negatively affect the whole sexual response; the younger the woman, the worse the effect, both for the impact on menopause and the impossibility of reaching critical life-goals, such as having children, unless through ovodonation, where it is legal and feasible [5,9,11,34]
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Negative outcomes of surgery In oncology
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Surgical interventions more likely to be causally associated with FSD are those indicated in the treatment of different cancers
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Breast cancer (BC)
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Breast cancer (BC) is the most frequent cancer in women, affecting 8 to 10 women in 100 Diagnosis and treatment may modify the woman s body image and sexuality [8,9] Cancer-dependent, woman-dependent and context-dependent factors interact in contributing to the individual outcome [5,8,9] Iatrogenic factors speci cally relate to outcomes of breast surgery and lymphadenectomy [8] Mastectomy patients had signi cantly (p < 001) lower body image, role, and sexual functioning scores, and their lives were, overall, more disrupted than breast-conserving therapy patients [40] Importantly, body image, sexual functioning, and lifestyle disruptions did not improve over time [40] Breast-conserving therapy, when oncologically appropriate, should be encouraged in all age groups Body image issues and coping with change in appearance should be addressed in patient interventions However, Kenny et al [41] suggest that, because of the need for adjuvant therapies, women treated by
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