L’Evoluzione della Sensibilità
dopo il Confine Menopausale
LA SESSUALITA’
Modena, 26 Marzo 2010
Antonella Camera & Rossella E. Nappi
Endocrinologia Ginecologica e della Menopausa –
IRCCS Fondazione Maugeri, Università degli Studi di Pavia
Relational
Factors
(couple’s intimacy,
partner’s health,
family problems…)
LIFE
EVENTS
Psychological
Factors
(body image,
mood changes,
self-esteem…)
SEXUAL WELL-BEING
(function, identity, relationship)
Socio-Cultural
Factors
(sexual identity,
norms, work,
support…)
REPRODUCTIVE
EVENTS
Biological
Factors
(hormones,
general health,
drugs, aging…)
RE Nappi, 2007
SEXUALITY AROUND 50’S
Premenopause Partner’s health &
sexual problems
Dyspareunia
Sexual
Responsiveness
Good Physical
& Mental Health
Premenopausal
Sexual Activity
Feelings for
Partner
Low
Sex-Hormones
Stress
Desire
Postmenopause
adapted from Dennerstein et al, 2002
RELEVANCE OF SEXUAL ISSUES AT
MENOPAUSE
No periods for 1+ years
66%
Hot flushes
52%
Sleeplessness
43%
Irritability
37%
Mood swings or mood changes
37%
Reduced sex drive
36%
Headaches or migraines
28%
Depression
25%
Involuntary urine loss
21%
Vaginal pain, dryness or discomfort
21%
Very occasional periods
14%
Q2A Are you currently experiencing or have you experienced any of the following in the past
year?
Base: Total Sample (n=1805) of European menopausal women (age: 50-60 yrs) interviewed by
phone
RE Nappi & Nijland EA, 2008
SEX HORMONES-DEPENDENT
SEXUAL CIRCUITRIES AT MENOPAUSE
MOOD
Loss of Ovarian
Cyclicity
NEUROENDOCRINE
ADAPTATION
Rearrangement of
Neurotransmitters/
Neuromodulators
Estrogens, Progesterone
& Androgens Changes
VAGINAL/GENITAL
PLASTICITY
ENGORGEMENT
LUBRICATION
SENSITIVITY
Reduced epithelial cell proliferation
Vascular remodelling
Diminished smooth muscle content
Changes in innervation
Desire, Central Arousal,
Pleasure, Satisfaction
Peripheral Arousal, Orgasm
RE Nappi, 2006
ASSOCIATION OF VULVOVAGINAL
ATROPHY WITH FSD IN POSTMENOPAUSE
Sexually active postmenopausal women (N =1,480) from The Menopause
Epidemiology Study, a cross-sectional, population-based study of women
40 to 65 years old in the US chosen from a source population selected
by random digit dialing and probability sampling.
Vulvovaginal atrophy was defined as one or more of the following:
vaginal dryness, itching, irritation; pain on urination; or pain or bleeding
on intercourse.
The Arizona Sexual Experience Survey was used to define FSD.
Prevalence
vulvovaginal atrophy
female sexual dysfunction (FSD)
57%
55%
Women with female sexual dysfunction were 3.84 times more likely
to have vulvovaginal atrophy than women without female sexual
dysfunction (95% CI: 2.99-4.94).
Levine et al, 2008
VAGINAL DRYNESS & MENOPAUSE
Dyspareunia (D)
Dt=0.43 Dt-1 – 0.64 Log(E2)
Dennerstein
(R²=0.53)
et al, 2005
3 years
(n=31)
47%
Late
perimenopause
(n=106)
Premenopause
(n=172)
21%
2 years
(n=54)
1 year
(n=72)
32%
25%
3%
Premenopause
51
Perimenopause
Postmenopause
Dryness increased significantly in late perimenopause
and postmenopause (p < 0.001)
Dennerstein
et al, 2000
ITALIAN TRANSLATION OF THE FEMALE
SEXUAL FUNCTION INDEX (FSFI)
IN ROUTINELY GYNECOLOGICAL PRACTICE
FSFI FULL SCALE SCORE
40
35
30
*
25
*
Validated
cut-off
20
15
10
5
0
Min-Max
25%-75%
-5
FERTILE AGE OC
MENOPAUSE HRT
Median value
RE Nappi et al, 2008
Sexual Function & Dysfunction in Middle Aged Women
11–year prospective study of Australian born women, aged 45-55 years and menstruating at baseline.
(MWMH-Project) Comparison of SPEQ responses at 1st and 11 th year of follow up. n=257
Year 1
Year 11
50 (46-56)
60 (56-67)
Current sexual partner
81 %
77 %
Sexual inactivity
17 %
26 %
< 0.001
Sex >1-2 times a week
20 %
6%
< 0.001
Sexual thoughts < once a week
39 %
71 %
< 0.001
No enjoyment of sexual activity
6%
20 %
< 0.001
No arousal
6%
17 %
< 0.001
Anorgasmia
12 %
26 %
< 0.001
Dyspareunia
12 %
17 %
< 0.01
No passionate love for partner
6%
15%
< 0.001
Partner-performance problems
23 %
41 %
< 0.001
Mean age (range) years
* paired samples t-test
Dennerstein L et al. J Sex Med 2008; 5: 2291-2299
p-value*
MENOPAUSA & SINTOMI SESSUALI
355 donne in postmenopausa (range di età: 46-60 anni)
afferenti a centri per la Menopausa in tutt’Italia
%
100
Secchezza Vaginale
80
Scarsa Libido/
Deficit di Eccitazione
60
Dispareunia
45.9
45.1
40
20
22.0
29.8
Scarso Piacere Sessuale/
Soddisfazione
0
RE Nappi et al, 2002
EFFETTO “DOMINO”
SUL BENESSERE SESSUALE
Intensità
Tono Emotivo Negativo
(depressione, ansia,
panico, perdita di interesse…)
DISFUNZIONE
SESSUALE
Salute Fisica Scadente
(perdita di forma, fatica,
Aumento di peso, cefalea…)
Problemi Genito-Urinari
(infezioni vaginali ricorrenti,
Perdita involontaria di urina…)
RE Nappi et al, 2002
CORRELATES OF SEXUAL FUNCTION IN
ITALIAN MENOPAUSAL WOMEN
Cross-sectional study conducted in menopause clinics.
Interview about their current and past sexual activity.
Oral HT use (OR 0.43 for desire, 0.54 for orgasm and 0.56 for
overall sexual satisfaction, all p<0.001) and transdermal HT (OR
0.38, 0.53 and 0.53, respectively, all p<0.001) were significantly
associated with lower risk of poor sexual functioning.
Higher physical and mental component scores are inversely related
to poor sexual functioning (all p<0.001).
Pain during and symptoms after sexual intercourse were significantly
related to desire (OR 1.96 and 1.78, respectively), orgasm (OR
2.22 and 2.06, respectively) and sexual satisfaction (OR 2.02 and
1.79, respectively).
The partner's health problems were associated with low sexual
intercourse frequency (OR 4.18, p < 0.001) and absent/poor
overall satisfaction (OR 2.61, p < 0.001).
life,
Sexual function is associated with the quality of sexual life in
reproductive age, partner's health status, current quality of
HT and occurrence of pain with sex.
Donati Sarti et al, 2010
EPIDEMIOLOGIA DELLA DISFUNZIONE
ERETTILE (DE) IN ITALIA
DE parziale o completa (%)
PREVELANZA COMBINATA DI DE= 12.8%
50
40
30
20
Campione di uomini ≥ 18 anni non-istituzionalizzati
identificati random a mezzo di 143 medici di medicina
generale
DOMANDA: non soddisfazione dell’abilità di
raggiungere e mantenere un erezione
26,8
sufficiente per l’attività sessuale
RISPOSTA: 82% (n=2010)
15,7
10
0
48,3
2,1
1,9
18–29
30–39
4,8
40–49
50–59
Range di età (anni)
60–70
>70
F Parazzini et al, 2000
Women satisfaction with their sex life was improved by ED treatment
(sildenafil citrate).
The final ISL sexual life satisfaction score was dependant on women's
age and final IIEF scores.
Couple global caring seemed to amplify the well-known
effect of ED treatment for men.
JSM, 2009
“WHEN SEX HURTS YOU…”
Time
Effect
MENOPAUSE
Sexual
Activity
Couple’s
Dysfunction
FEAR OF
PAIN
SEX
HORMONES
Stressors
IMPAIRED
VULVO-VAGINAL
RECEPTIVITY
VAGINISMUS
Leader
Symptom
DYSPAREUNIA
LOW
LIBIDO
REDUCED
SATISFACTION
IMPAIRED
ORGASM
RE Nappi, 2002
“WHEN NOTHING TURNS YOU ON…”
Time Effect
LOW
LUBRICATION
IMPAIRED
ORGASM
SEX
HORMONES
Stressors
DYSPAREUNIA
REDUCED
AROUSAL
REDUCED
SATISFACTION
IMPAIRED
MOTIVATION
LOW
DRIVE
Leader
Symptom
POOR
EMOTIONAL INTIMACY
RELATIONAL
PROBLEMS
Sexual
Activity
Couple’s
Dysfunction
RE Nappi, 2002
LOW SEXUAL DESIRE, DISTRESS,
HSDD & AGING
WISHES –Study: cross sectional study (n=1998 European w, 20-79 yrs
…distress among women
with low desire
Low sexual desire…
HSDD
Hayes et al, 2007
MENOPAUSAL STATUS &
HYPOACTIVE SEXUAL DESIRE DISORDER
*
*
*
West et al, 2008
SEXUAL SYMPTOMS &
SURGICAL MENOPAUSE
VAGINAL DRYNESS
SEXUAL DESIRE
Q: After surgical menopause did you
noticed the appearance/worsening of…
Q: After surgical menopause did you
noticed a reduction of…
0.5%
0.9%
20.2%
22.4%
55.5%
46.8%
23.8%
29.9%
Yes
Most of the time
Sample: 568 women with
surgical menopause
No
No Answer
RE Nappi et al, 2009
VAGINAL DRYNESS & LOW SEXUAL DESIRE
COMORBIDITY IN SURGICAL MENOPAUSE
LOW SEXUAL DESIRE
%
VAGINAL DRYNESS
No
*
Yes
*
0
Sample: 568 women with
surgical menopause
20
40
Yes
60
80
100
Most of the time
No
RE Nappi et al, 2009
LOW SEXUAL DESIRE &
DISTRESS WITH THE PARTNER
Q: Whether sexual desire is reduced,
how much this has compromised the
relationship with the partner?
Sample: 436 women with
Q: Wheter sexual desire is reduced,
how do you live this condition?
low sexual desire
2.5%
12.4%
12.4%
12.4%
7.7%
8.7%
32.6%
39.4%
33.4%
RE Nappi
et al, 2009
Yes
I have no interest
Yes, very much
I am used to
Most of the time
I am sorry, I would like to be back as before
No
I am very much sorry, I would do everything to reverse it
No Answer
I am afraid of problems with the partner
38.6%
PERCEPTION OF PARTNER’S SEXUAL BEHAVIOUR
AFTER SURGICAL MENOPAUSE
Q: After surgical menopause,
what kind of reactions had your partner
from a sexual point of view?
No change
Reduction of sexual desire
2.6%
5.1%
Fears of giving pain/
lack of pleasure
Sexual Dysfunctions
28.3%
No Answer
46.1%
17.8%
Sample: 568 women
with surgical menopause
RE Nappi et al, 2009
PERCEPTION OF LOW SEXUAL DESIRE BY
SURGICAL MENOPAUSAL WOMEN
LOW SEXUAL DESIRE
Q: Do you believe that other women
have the same problem?
7.7%
Yes
Yes, many at any age
2.6%
Yes, only those in
natural menopause
8.5%
Yes, only those in
surgical menopause
2.5%
No
No Answer
24.3%
Sample: 568 women with
surgical menopause
54.4%
RE Nappi et al, 2009
IL DIALOGO DEL MEDICO STIMOLA LE DONNE
A PARLARE DELLE DISFUNZIONI SESSUALI
16%
Percentuale di pazienti*
20
18
16
14
12
10
8
3%
6
4
2
0
Riportano
spontaneamente
Riportano dopo
domanda diretta
* Pazienti screenati per disfunzioni sessuali mediante 2 domande nella storia medica (n=887)
Bachmann et al, 1989
HOW A SEXUAL SYMPTOM BECOMES
A SEXUAL DYSFUNCTION!
SYMPTOM PROBLEM DYSFUNCTION
Partner
Age
(young/ Onset/
old)
Duration
Stage
of life
Status
of health
(age/
health,
relationship )
RE Nappi, 2009
GLI UOMINI VENGONO DA MARTE,
LE DONNE VENGONO DA VENERE!
RE Nappi, 2005