Papers by Alessandra Graziottin
Journal of Sex & Marital Therapy, 2001
Abstract 1. This reprinted article originally appeared in The Journal of Urology, Vol 163, 88889... more Abstract 1. This reprinted article originally appeared in The Journal of Urology, Vol 163, 888893. In contrast to widespread interest in research and treatment of male sexual dysfunction (SD), few studies have investigated the psychological and physiological underpinnings of ...
Journal of Psychosomatic Research, 2003
Standard Practice in Sexual Medicine
Physicians and health care providers may contribute to sexual disorders, with a predisposing role... more Physicians and health care providers may contribute to sexual disorders, with a predisposing role, when they do not recognize and diagnose conditions that may prelude to, precipitate in or maintain a Female Sexual Disorder (FSD) [1-6]. They may act as precipitating factors, through the inappropriate prescription of medications that may negatively affect women's and couple' sexuality [1] (Tab.1), or through the negative outcome of surgery, obstetrics and/or of chemotherapy, hormonotherapy or radiotherapy [2-12]. A lack of respect of professional boundaries in the clinician-patient relationship is another neglected precipitating co-factor of FSD, especially for women who sought professional help in a vulnerable moment of their life [13,14] (see sub-chapter on Classification, etiology and key issues in FSD).They may behave as maintaining factors, through the most frequent mistake in the field of FSD: the diagnostic omission, which encompasses occasional or systematic diagnostic neglect, particularly in the area of biological/medical etiology of FSD [2,3,4-6,10-12] and/or comorbidity between medical conditions and FSD [1-3,4-6,11-12, 15,16]. This chapter will discuss these three major areas of iatrogenic disorders, to open a mental window on the sexual scenario we clinicians often do not consider. The role of post-traumatic FSD will be briefly reviewed with a focus on spinal cord injuries [17-20], and ritual female genital mutilation (FGM) [21-24]. Sexual abuse, which may cause both a physical and emotional trauma, may be related to post-traumatic stress disorder and long term sexual disorders [25].
Handbook of Clinical Neurology, 2015
This chapter discusses the all too common problem of sex-related pain in women. Pain is a complex... more This chapter discusses the all too common problem of sex-related pain in women. Pain is a complex perceptive experience, involving biologic as well as psychologic and relational meanings. They become increasingly important with the chronicity of pain. Neurologists are quite aware of the painful aspect of many neurologic disorders, but lifelong and acquired genital and sexual pain is still neglected in a consistent percentage of women. One reason is the view - still held by many - that psychologic factors play the most important role in sex-related pain complaints. The consequences of diagnostic delay can be dramatic. Persisting tissue inflammation induces pain to change from acute and "nociceptive," which indicates a "friendly signal," alerting one to ongoing tissue damage, to chronic and "neuropathic," a disease per se. Whilst the primary disease is progressing and neuroinflammation becomes a prominent feature, affected women have to bear years of pain and distress, huge quantifiable and non-quantifiable costs, and a progressive deterioration of personal and relational health and happiness. The scenario is even more dramatic when pain complicates an already disabling disease. The main aspects considered in this chapter include neuroinflammation as a key feature of pain; genital and sexual pain as part of neurologic diseases; and genital and sexual pain syndrome (dyspareunia and vaginismus) as primary problems, and their pelvic comorbidities (bladder pain syndrome, endometriosis, irritable bowel syndrome, provoked vestibulodynia/vulvodynia). Finally, we discuss iatrogenic pain, i.e., genital and sexual pain caused by ill-conceived medical, surgical, pharmacologic or radiologic therapeutic interventions.
Historically, recognition and treatment of the biological basis of female sexual health issues mi... more Historically, recognition and treatment of the biological basis of female sexual health issues mirrored the recognition and treatment of female urologic disorders . Both were poorly understood, and therefore, under diagnosed and under treated.
Patients affected by vulvar vestibulitis syndrome (VVS) suffer from symptoms typical of neuropath... more Patients affected by vulvar vestibulitis syndrome (VVS) suffer from symptoms typical of neuropathic pain such as allodynia and hyperalgesia. Because of the severe pain on vestibular touch or attempt- ed vaginal entry, intercourse is increasingly avoided. Pathophysiology of physical symptoms is related to the microscopic findings of prolifera- tion of pain fibers which are also superficialized within the vestibular tissue.
Handbook of Clinical Neurology, 2015
"Anatomy is destiny": Sigmund Freud viewed human anatomy as a necessary, althou... more "Anatomy is destiny": Sigmund Freud viewed human anatomy as a necessary, although not a sufficient, condition for understanding the complexity of human sexual function with a solid biologic basis. The aim of the chapter is to describe women's genital anatomy and physiology, focusing on women's sexual function with a clinically oriented vision. Key points include: embryology, stressing that the "female" is the anatomic "default" program, differentiated into "male" only in the presence of androgens at physiologic levels for the gestational age; sex determination and sex differentiation, describing the interplay between anatomic and endocrine factors; the "clitoral-urethral-vaginal" complex, the most recent anatomy reading of the corpora cavernosa pattern in women; the controversial G spot; the role of the pelvic floor muscles in modulating vaginal receptivity and intercourse feelings, with hyperactivity leading to introital dyspareunia and contributing to provoked vestibulodynia and recurrent postcoital cystitis, whilst lesions during delivery reduce vaginal sensations, genital arousability, and orgasm; innervation, vessels, bones, ligaments; and the physiology of women's sexual response. Attention to physiologic aging focuses on "low-grade inflammation," genital and systemic, with its impact on women sexual function, especially after the menopause, if the woman does not or cannot use hormone replacement therapy.
Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology, 2014
Inflammatory and neuroinflammatory processes are increasingly recognized as critical pathophysiol... more Inflammatory and neuroinflammatory processes are increasingly recognized as critical pathophysiologic steps in the development of multiple chronic diseases and in the etiology of persistent pain and depression. Mast cells are immune cells now viewed as cellular sensors in inflammation and immunity. When stimulated, mast cells release an array of mediators to orchestrate an inflammatory response. These mediators can directly initiate tissue responses on resident cells, and may also regulate the activity of other immune cells, including central microglia. New evidence supports the involvement of peripheral and central mast cells in the development of pain processes as well as in the transition from acute, to chronic and neuropathic pain. That behavioral and endocrine states can increase the number and activation of peripheral and brain mast cells suggests that mast cells represent the immune cells that peripherally and centrally coordinate inflammatory processes in neuropsychiatric di...
To evaluate female sexual dysfunction (FSD) in women with interstitial cystitis (IC) versus a con... more To evaluate female sexual dysfunction (FSD) in women with interstitial cystitis (IC) versus a control group. Specific areas of FSD in women with IC have not been reported. A mailed survey was sent to 5000 randomly selected women from the United States (controls) and 407 women with IC from a large referral center (cases). The Female Sexual Distress Scale and questions about sexual function, desire, orgasm, and pain were included. The Student t test was used to compare the mean values, and the chi-square test was used to compare the proportions between the cases and controls. During adolescence (the start of menstruation through age 18), having had intercourse, levels of sexual desire, and orgasm frequency did not differ significantly between the cases and controls. However, a significantly greater proportion of cases reported fear of pain (P = 0.018) and pain with intercourse (P = 0.001). In adulthood, a significantly greater proportion of cases reported having pelvic pain, fear of pain during intercourse, and dyspareunia (P <0.001 for all). Furthermore, after the diagnosis of IC, the number of cases reporting moderate to high desire (P <0.001) and orgasm frequently and very frequently declined significantly (P <0.001). The mean value of the Female Sexual Distress Scale was greater among established IC cases (18.5 +/- 14.3) compared with controls (8.3 +/- 10.2; P <0.001). A score of 15 or greater on the Female Sexual Distress Scale has been associated with sexual distress. Women with IC have significantly more FSD and sexual distress than women without IC. Additional study is needed to explore the multiple factors contributing to FSD in IC.
Urology, 2015
To assess the cross-cultural differences in women's perception of prematu... more To assess the cross-cultural differences in women's perception of premature ejaculation (PE). A total of 1463 sexually active women from 3 different countries—Mexico, South Korea, and Italy—reporting being or having been in a relationship with a man who suffers from PE were included in the study. A mix of self-constructed questions and questions taken from validated instruments were used, including the Female Sexual Function Index, the Female Sexual Distress Scale, and the Relationship Assessment Scale. Significant differences in importance of ejaculatory control and the degree of distress caused by PE were detected between the 3 countries (P < .001 for both). Lack of control was the most commonly reported reason for distress for Mexico, short latency for Italy, and lack of control for South Korea. Mexico reported the highest rates of previous relationship breakups due to PE (28.9%), whereas Italian women reported the lowest relationship satisfaction and South Korean women the highest. It is important to get a better understanding of which sexual issues are important for individuals across different cultures, and whether the same aspects of the problem are considered distressing. This can have implications on nosology, on types of treatments offered, and hence, the likelihood of their efficiency when a couple's sexual perspective is carefully considered.
Current Sexual Health Reports, 2004
Value in Health, 2006
A393 Abstracts dered difficult. Our aim was to develop a sensitive instrument to evaluate how SUI... more A393 Abstracts dered difficult. Our aim was to develop a sensitive instrument to evaluate how SUI patients cope with their handicap in everydaylife. METHODS: A list of potential efforts provoking stress urinary leakages was established from a systematic literature review and 30 clinician interviews. Eight clinician interviews allowed the listed efforts' relevance, common occurrence and ability to capture changes to be assessed. Clinicians also reported how patients control the risk of leakage in daily life. A questionnaire was developed and further tested by 20 SUI women for relevance, importance and applicability. The patients were invited to reword items and describe how they control the risk of leakage. The scale was subsequently finalised. RESULTS: Seventy-two efforts provoking leakages were listed from 15 SUIspecific scales and 21 studies from the literature review. Clinician interviews allowed a shortlist containing the most relevant efforts to be established. Answer choices covered leakage occurrence, and various behaviour adaptations (taking precautions, muscular control, avoiding situations). The questionnaire was revised 3 times: after the 6th, the 13th and the 20th patient interviews. The pilot questionnaire contains 13 efforts of daily life and 4 items on coping with the risk of leakage. CONCLUSION: This iterative approach enabled the necessary modifications to be made to produce an understandable and complete selfreported questionnaire accepted by patients. It measures three complementary criteria related to SUI severity: leakage occurrence in daily activities, avoidance of activities provoking leakages and control of leakage risk. This highly specific instrument will allow clinicians to better assess the real impact of SUI and therapeutics on patients' lives in both clinical research and practice. Scoring procedures and psychometric properties will be established after a validation study.
Women's Health, 2006
The assessment and then treatment of a change in libido, or a change in the desire to partake in ... more The assessment and then treatment of a change in libido, or a change in the desire to partake in sexual activity, during the menopausal transition and beyond has been a challenging and elusive area of clinical research. This is partly due to the multidimensional nature of female sexuality, the difficulties of measuring testosterone in women in a reliable and accurate manner, and the complexity of the neurobiology and neurobehavior of female sexual desire. In addition, there is a lack of evidence for diagnostic specificity of low free testosterone levels for the symptom of low libido in women for whom there are no confounding interpersonal or psychological factors; although, in the symptomatic population of surgically or naturally menopausal women, a low level of free testosterone often accompanies a complaint of reduced desire/libido. The randomized clinical trial research on testosterone replacement for naturally and/or surgically menopausal women with sexual dysfunction has been criticized for a high placebo response rate, supraphysiological replacement levels of testosterone, the perception of modest clinical outcome when measuring objective data such as the frequency of sexual intercourse relative to placebo, and the unknown safety of long-term testosterone replacement in the estrogen-replete surgically or naturally menopausal woman. A careful review of current evidence from randomized, controlled trials lends support to the value of the replacement of testosterone in the estrogen-replete menopausal woman for whom libido and desire has declined. The issue of long-term safety remains to be answered.
Urology, 2007
To evaluate female sexual dysfunction (FSD) in women with interstitial cystitis (IC) versus a con... more To evaluate female sexual dysfunction (FSD) in women with interstitial cystitis (IC) versus a control group. Specific areas of FSD in women with IC have not been reported. A mailed survey was sent to 5000 randomly selected women from the United States (controls) and 407 women with IC from a large referral center (cases). The Female Sexual Distress Scale and questions about sexual function, desire, orgasm, and pain were included. The Student t test was used to compare the mean values, and the chi-square test was used to compare the proportions between the cases and controls. During adolescence (the start of menstruation through age 18), having had intercourse, levels of sexual desire, and orgasm frequency did not differ significantly between the cases and controls. However, a significantly greater proportion of cases reported fear of pain (P = 0.018) and pain with intercourse (P = 0.001). In adulthood, a significantly greater proportion of cases reported having pelvic pain, fear of pain during intercourse, and dyspareunia (P <0.001 for all). Furthermore, after the diagnosis of IC, the number of cases reporting moderate to high desire (P <0.001) and orgasm frequently and very frequently declined significantly (P <0.001). The mean value of the Female Sexual Distress Scale was greater among established IC cases (18.5 +/- 14.3) compared with controls (8.3 +/- 10.2; P <0.001). A score of 15 or greater on the Female Sexual Distress Scale has been associated with sexual distress. Women with IC have significantly more FSD and sexual distress than women without IC. Additional study is needed to explore the multiple factors contributing to FSD in IC.
Parole chiave: distonia cervicale, vaginismo, vestibolite, dolore cronico, stipsi La distonia cer... more Parole chiave: distonia cervicale, vaginismo, vestibolite, dolore cronico, stipsi La distonia cervicale è spesso associata ad altre distonie focali . Osservando una paziente di 32 anni con distonia cervicale idiopatica, vaginismo primario di quarto grado complicato da vestibolite e stitichezza, gli Autori hanno ipotizzato che il vaginismo primario possa essere una forma di distonia.
Obstetrics & Gynecology, 2009
To investigate whether botulinum neurotoxin type A improves vaginismus and study its efficacy wit... more To investigate whether botulinum neurotoxin type A improves vaginismus and study its efficacy with repeated treatments. Outpatients were referred because standard cognitive-behavioral and medical treatment for vaginismus and vulvar vestibular syndrome failed. From this group, we prospectively recruited consecutive women (n=39) whose diagnostic electromyogram (EMG) recordings from the levator ani muscle showed hyperactivity at rest and reduced inhibition during straining. These women were followed for a mean (+/-standard deviation) of 105 (+/-50) weeks. Recruited patients underwent repeated cycles of botulinum neurotoxin type A injected into the levator ani under EMG guidance and EMG monitoring thereafter. At enrollment and 4 weeks after each cycle, women were asked about sexual intercourse; underwent EMG evaluation and examinations to grade vaginal resistance according to Lamont; and completed a visual analog scale (VAS) for pain, the Female Sexual Function Index Scale, a quality-of-life questionnaire (Short-Form 12 Health Survey), and bowel and bladder symptom assessment. At 4 weeks after the first botulinum neurotoxin type A cycle, the primary outcome measures (the possibility of having sexual intercourse, and levator ani EMG hyperactivity) both improved, as did the secondary outcomes, Lamont scores, VAS, Female Sexual Function Index Scales, Short-Form 12 Health Survey, and bowel-bladder symptoms. These benefits persisted through later cycles. When follow-up ended, 63.2% of the patients completely recovered from vaginismus and vulvar vestibular syndrome, 15.4% still needed reinjections (censored), and 15.4% had dropped out. Botulinum neurotoxin type A is an effective treatment option for vaginismus secondary to vulvar vestibular syndrome refractory to standard cognitive-behavioral and medical management. After patients received botulinum neurotoxin type A, their sexual activity improved and reinjections provided sustained benefits. III.
Menopause, 2007
To determine patterns of symptoms across age groups, identify symptom groups associated with ovar... more To determine patterns of symptoms across age groups, identify symptom groups associated with ovarian hormonal depletion or other variables, and develop a prediction model for each symptom. This was a cross-sectional survey of 4,517 women ages 20 to 70 years recruited from market research panels in the United States, United Kingdom, Germany, France, and Italy using a self-report questionnaire that included general health information and a checklist of 36 symptoms. Stepwise regression was used to determine for each symptom how prevalence varied with age, indicators of menopausal hormonal changes, and the effects of other explanatory variables, including body mass index, morbidity, and country. Hierarchical clustering was used to group symptoms. Six groups of symptoms were found, of which two groups, with seven symptoms in total, were related to markers of menopausal hormonal change: a group consisting of hot flashes and night sweats and a second group including poor memory; difficulty sleeping; aches in the neck, head, and shoulders; vaginal dryness; and difficulty with sexual arousal. Physical and mental morbidity affected estimates of the prevalence of all symptoms. Psychological symptoms declined with age from a maximum prevalence before age 40. Certain physical symptoms increased with age and body mass index. Clustering identified three country groups: (1) US and UK women; (2) French and Italian women; and (3) German women. There were marked differences in prevalence between countries for certain physical and psychological symptoms. The seven symptoms most linked to menopausal hormonal change should form part of any future menopause symptom list. Physical and mental morbidity affect symptom prevalence and should be measured.
Menopause, 2004
To discuss assessment and management of sexual dysfunctions associated with premature menopause. ... more To discuss assessment and management of sexual dysfunctions associated with premature menopause. Literature review plus clinical observations. Studies on assessment and management of sexual dysfunctions associated with premature menopause are minimal. Premature menopause affects sexual identity, sexual function, and sexual relationship. Major modulating factors include etiology, life cycle stage, factors personal to the woman, and family and societal influences. Loss of ovarian function in adolescence may delay psychosexual maturity via psychological and biological mechanisms. Maternity becomes impossible, unless ovodonation is feasible, accepted, and legally available. Loss of sexual desire, subjective and genital arousal, and orgasm may be highly distressing. Reduction of sex hormones and psychological reactions of both partners to the prematurity and infertility are etiologically important. Estrogen therapy is usually indicated, but long-term safety data in this population are lacking. Testosterone therapy, also lacking in safety data and mainly investigational, may be needed to restore sexual arousability. Presence, age, and sexual health of the partner, having children, and quality of intimacy in previous and present relationships modulate coping attitudes and clinical outcome. An interdisciplinary medical and psychosexual approach comprises individualized hormone therapy and specific psychosexual treatment(s). Research into optimal management of sexual dysfunction with premature menopause is urgently needed.
Menopause, 2005
To obtain data on sleep quality in women attending menopause clinics in Italy. A cross-sectional ... more To obtain data on sleep quality in women attending menopause clinics in Italy. A cross-sectional study was conducted on the sleep quality of postmenopausal women attending a network of first-level outpatient menopause clinics in Italy for general counseling about menopause or treatment of its symptoms. Eligible for the study were women observed consecutively during the study period with natural or spontaneous menopause. All participating centers enrolled women into the study who had never used hormone therapy (HT) (group 1, 819 women), current users of transdermal estrogens with or without progestins (group 2, 819 women), and current users of oral estrogens with or without progestins (group 3, 790 women). The women were asked about their quality of sleep using the Basic Nordic Sleep Questionnaire, their quality of life using the Short Form-12 questionnaire, and the intensity of hot flushes using a visual analogue scale. Women in groups 2 and 3 tended to report difficulties in sleeping less often than those in group 1. For example, never users of HT more frequently reported sleeping poorly and needed more time to sleep or had problems falling asleep; these differences were significant (P < 0.05). Otherwise, no difference emerged from the Basic Nordic Sleep Questionnaire between women in groups 2 and 3. This study gives support to the suggestion that HT improves the quality of sleep. The effect was similar in women taking oral or transdermal therapy with or without progestins.
Menopause International, 2009
Gender differences, related to varying sexual hormone levels and hormone secretion patterns acros... more Gender differences, related to varying sexual hormone levels and hormone secretion patterns across the lifespan, contribute to women's vulnerability to mood disorders and major depression. Women are more prone than men to depression, from puberty onwards, with a specific exposure across the menopausal transition. However, controversy still exists in considering fluctuation/loss of estrogen as a specific aetiologic factor contributing to depression in perimenopause and beyond. To briefly review the interaction between changes in menopausal hormone levels, mood disorders, associated neuropsychological co-morbidities and ageing, and to evaluate the currently available therapeutic options for perimenopausal mood disorders: (a) treatment of light to moderate mood disorders with hormonal therapy (HT); (b) treatment of major depression with antidepressants; (c) the synergistic effect between HT and antidepressants in treating menopausal depression. Depression across the menopause has a multifactorial aetiology. Predictive factors include: previous depressive episodes such as premenstrual syndrome and/or postpartum depression; co-morbidity with major menopausal symptoms, especially hot flashes, nocturnal sweating, insomnia; menopause not treated with HT; major existential stress; elevated body mass index; low socioeconomic level and ethnicity. Postmenopausal depression is more severe, has a more insidious course, is more resistant to conventional antidepressants in comparison with premenopausal women and has better outcomes when antidepressants are combined with HT. The current evidence contributes to a re-reading of the relationship between menopause and depression. The combination of the antidepressant with HT seems to offer the best therapeutic potential in terms of efficacy, rapidity of improvement and consistency of remission in the follow-up.
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Papers by Alessandra Graziottin