Journal of Women’s Health Clinical Update

What We know

Distressing sexual problems are common and can have negative health consequences. ¹ Thus, it is important for clinicians to be equipped with tools to both evaluate and treat sexual dysfunction. Many medical societies endorse that standardized sexual health curriculum be included in medical schools and beyond, ² however, the extent to which a standardized curriculum is being offered is unclear. Furthermore, it is unknown if students are being evaluated regarding their knowledge of and competency in sexual health topics.

Study results

This systemic review conducted between May—August 2023 across four databases assessed the sexual health education curriculum for health professional students including educational content and duration, as well as evaluation of the educational interventions. They identified 614 sources, and after a screening process, 36 studies of educational interventions met inclusion criteria. They utilized the Effective Public Health Project (EPHPP) tool to assess the quality of the studies.

Most of the studies were conducted in the United States and were done in medical schools. Few included nursing school educational interventions. Only two of the studies utilized a randomized controlled trial design, while four employed quasi-experimental designs, and the remainder used pre-posttest design. Only seven of the pre-posttest design had a follow-up period. The quality of the studies was poor due to study design, data collection procedures and selection bias, with most of the studies receiving a weak score (EPHPP = 3).

They found that there were three types of educational interventions described: workshops (n = 20), one-time interventions (n = 9), and semester courses (n = 9). They found intervention durations were inconsistent, with interventions that ranged from as little as 45 minutes to as long as a year-long course with hands-on training. Most of the one-time educational interventions reviewed lasted 2 hours in duration, and focused on sexual health of the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) population. There was no consistent way in which the curricula were evaluated. A majority evaluated success of the educational intervention by self-report, and few identified behavioral change as an outcome. Two studies used an Objective Structured Clinical Examination and chart review of patients seen by the students who underwent the education to evaluate the curriculum.

What this changes or adds

There is a lack of published, standardized sexual health curricula for health care professionals, not only in terms of content, but also in delivery format and duration. Furthermore, there is no consistent evaluation of sexual health education or assessment of competency of sexual health skills among health professional students. Clinicians need skills to be able to evaluate and manage sexual health concerns of their patient’s. Developing and adopting a standardized curriculum that can be evaluated on its ability to equip health care professionals with knowledge of and competency in sexual health topics is an opportunity for medical educators.

What we know

It is common for women to experience distressing sexual problems after cancer treatment. ³ Women value maintaining intimate relationships and sexual functioning after treatment. Clinicians and health care systems providing survivorship care need programs and resources to address women’s sexual health after cancer care. ⁴ Women of color (WOC) often are underrepresented in survivorship research and are known to experience significant cancer-related disparities and poorer outcomes. ^5–6 Understanding the current evidence regarding the sexual experiences of WOC after cancer treatment is critical to addressing sexual health concerns in this population.

Study results

This systematic review evaluated five databases in August 2019 looking for descriptive and interventional studies (published within the previous 15 years) that addressed sex and intimacy of U.S. WOC treated for cancer. The initial search revealed 5,629 records, but only 18 publications met inclusion criteria. Half of the studies had a specific aim regarding sex and intimacy, whereas the other half described general cancer survivorship. Ten of the included studies were qualitative studies, while the other 8 were quantitative intervention studies. Samples sizes ranged from 13 to 2,703. Overall, they found that WOC treated for cancer reported changes in intimacy and sex and these changes impacted their quality of life and relationships.

There were four themes that arose from the analyses of the studies: treatment impact on body image and sexual health, overcoming and the process of acceptance, the value of a supportive and engaged partner, and the current clinical practice and barriers to sexual health care. Within each of these themes there were subthemes that arose and were reviewed. For example, in the clinical practice and barriers to sexual health care theme, health care seeking behavior and health literacy were identified. WOC felt embarrassed to bring up sexual health concerns to their health care professionals because they felt it was a taboo topic or they indicated that they felt they did not have authority to ask questions of their health care professionals. A unique theme that arose for WOC, especially for Black and African American women, was the positive link between spirituality, body image, and sexual adjustment.

Taken together, the results from the review supported the importance of a supportive romantic partner for psychosocial adjustment and sexual well-being during cancer recovery in WOC. Within the groups of women of each racial and ethnic group there was variability of experiences expressed and given the small sample sizes and diversity within each group, caution should be taken to generalize broadly. The review provided a summary of nuanced experiences of WOC that could be considered in current survivorship guidelines to facilitate culturally responsive survivorship care.

What this changes or adds

Survivorship guidelines include sexual health but do not address the cultural nuances of caring for WOC. Oncology clinicians and those specializing in survivorship can provide culturally responsive sexual health care to WOC surviving cancer by better understanding the unique aspects of their experience.

What we know

Androgens are known to play an important role in the sexual health of women. A recent systematic review and meta-analysis that included 36 randomized controlled trials involving nearly 8,500 women concluded that testosterone therapy significantly increased sexual function versus placebo or comparator (e.g., estrogen alone or in combination with a progestogen) in a number of sexual health domains, including sexual desire, pleasure, arousal, responsiveness, and orgasm, as well as sexually satisfying event frequency, body image, and personal sexual distress in postmenopausal women. ⁷ A Global Consensus Statement recommends the use of testosterone therapy for the treatment of hypoactive sexual desire disorder (HSDD) in postmenopausal women. ⁸ However, the lack of a government-approved testosterone product formulated for women in any country, apart from Australia, remains a significant barrier to treatment, and largely stems from the absence of long-term safety data, particularly with regard to cardiovascular disease and breast cancer risk.

Study results

This cohort analysis used electronic health records (EHR) sourced from the real-world data research network, TriNetX Diamond, which offers access to patient EMR data in addition to linked medical and pharmaceutical claims records and cancer registries, including approximately 200 million patients from more than 90 health care organizations across the globe. Investigators queried the database from 2009 to December 2022. The study and control cohorts comprised adult females ≥18 years of age. The study cohort included adult females who had received ≥3 injectable or topical testosterone prescriptions in a span of 1 month to 1 year, with the second prescription required to be issued from 1 month to 1 year after the first prescription, thus intentionally targeting individuals with adherence to therapy. Additionally, the first prescription had to be issued when the individual was ≥ age 18 years. Exclusion criteria for the control cohort included females who had ever been prescribed testosterone, those with diagnoses of androgen excess or polycystic ovary syndrome. Exclusion criteria for both the study and control cohorts included diagnoses of intersex surgery (female to male), history of sex reassignment or gender identity disorders, heart failure, or unstable angina.

A total of 16,783 females who had received ≥3 topical or injectable testosterone prescriptions prescribed within 1 month to 1 year of each other were identified, with an average of 8 topical or injectable prescriptions received over their lifetimes. In the study group, 88% had at least 36 months of follow-up data available; 95% of the control group (n = 3,058,619) had at least 36 months of follow-up data available. Propensity matching (for cardiovascular risk factors including hypertension, hyperlipidemia, diabetes, obesity, and tobacco use) compared 10,300 females who received ≥3 testosterone prescriptions (mean age of 43.9 years ±15.3 years) with an equal number of controls (mean age 44.4 ± 16.3 years). Results showed that compared with control females, those who received ≥3 testosterone prescriptions had significantly lower risks of major adverse cardiac events (MACE)-defined as heart attack, stroke, or death (RR, 0.64; 95% CI, 0.51–0.81), deep vein thrombosis (DVT) (RR 0.61; 95% CI, 0.42–0.90), pulmonary embolism (PE) (RR, 0.48; 95% CI, 028–0.82), and malignant breast neoplasm (RR, 0.48; 95% CI, 0.37–0.62) within 1 month to 3 years after receiving ≥3 testosterone prescriptions. However, those receiving ≥3 testosterone prescriptions had a higher risk of hirsutism versus matched controls (RR, 2.52; 95% CI, 1.59–4.00). Additionally, subgroup analysis of women ≥56 years of age (4,172 women receiving prescriptions for testosterone compared with an equal number of propensity matched controls) showed similar results with lower risks in women receiving testosterone prescriptions versus controls of MACE (RR, 0.84; 95% CI, 0.64–1.10), DVT (RR, 0.82; 95% CI, 0.50–1.36), and PE (RR, 0.52; 95% CI, 0.26–1.05) and breast cancer (RR, 0.51; 95% CI, 0.38–0.68). The differences in risk of hirsutism could not be calculated due to low patient counts.

What this changes or adds

These results provide some, albeit limited, reassurance about the relative safety of short-term testosterone therapy in women, including among those aged 56 years and older. The strengths of the study include the size and scope of the dataset, but limitations of the study are several and include lack of information about the indication for the use of testosterone or the dose of testosterone used and whether the therapy was actually used. Additionally, no detailed information about aspirin, antihypertensive, statin, or aromatase inhibitor therapy use was available at the individual patient level which would have provided more information on cardiovascular and breast cancer risk. Further, health outcomes were assessed at 36 months, which is short for outcomes such as breast cancer and cardiovascular disease and may not accurately reflect true longer-term risks associated with testosterone use. Finally, a healthy user bias cannot be excluded such that it is possible that women who elected to use testosterone were healthier at baseline than those who did not use testosterone. Questions about the long-term safety of testosterone therapy in women remain. However, testosterone therapy may be helpful for select women diagnosed with HSDD after a well-informed discussion of the potential risks and benefits and with regular follow-up.

What we know

Polycystic ovary syndrome (PCOS), the most common endocrine disorder among reproductive age women, has the potential to impact female sexual function via multiple mechanisms. The comorbidities and components of PCOS—obesity, infertility and subfertility, depression and anxiety, poor body image, and self-esteem—have all been shown to have a detrimental effect on female sexual function. ⁹ Nevertheless, the association between PCOS and female sexual function has not been adequately studied, and the evidence is sparse and somewhat contradictory. The authors had previously conducted the first meta-analysis on sexual function in women with PCOS. ¹⁰ The goal of the current systematic review and meta-analysis was to update that evidence, which served as the basis for the 2023 International Evidence Based Guideline for the Assessment and Management of PCOS.

Study results

In this review, 8 electronic databases were searched through June 1, 2023. Studies were included that either utilized validated questionnaires for assessment of female sexual function, or those that used visual analog scales (VAS) in PCOS patients. Thirty-two studies were included for the final analysis, of which 28 had used validated questionnaires, and the rest had used VAS for assessment of female sexual function.

The pooled Female Sexual Function Index (FSFI) scores revealed worse sexual function spanning multiple domains in women with PCOS: arousal (Hedges’s g [Hg] [95% CI] ¼ −0.35 [−0.53, −0.17], I 2 ¼ 82%, p < 0.001), lubrication (Hg [95% CI] ¼ −0.54 [−0.79, −0.30], I 2 ¼ 90%, p < 0.001), orgasm (Hg [95% CI] ¼ −0.37 [−0.56, −0.19], I 2 ¼ 83%, p < 0.001), pain (Hg [95% CI] ¼ −0.36 [−0.59, −0.13] I 2 ¼ 90%, p < 0.001), total sexual function (Hg [95% CI] ¼ −0.75 [−1.37, −0.12], I 2 ¼ 98%, P ¼ 0.02), and sexual satisfaction (Hg [95% CI] ¼ −0.31 [−0.45, −0.18], I 2 ¼ 68%, p < 0.001). Participant stratification by fertility status and body mass index did not alter the results. The meta-analysis on the studies that utilized the VAS brought out the negative impact of hirsutism on sexual function including poorer sexual satisfaction in PCOS patients, compared to controls. Because none of the studies assessed sexual distress, the formal diagnosis of female sexual dysfunction could not be assessed.

What this changes or adds

PCOS impacts the psychosocial well-being and sexual function of women via multiple mechanisms. It is important to recognize and quantify the negative impact of this common condition on female sexual function. Health care professionals should proactively evaluate for the presence of sexual dysfunction, assess for potential contributors, and offer women appropriate lifestyle interventions and prescription therapies in their patients with PCOS.