INTRODUCTION — Exposure to blood or other bodily fluids can cause many serious infections, including the human immunodeficiency virus (HIV, the virus that causes AIDS). While most people are not exposed to these fluids, a number of situations can arise where exposures may occur, such as finding a syringe with needle, helping an injured person, or being the victim of an assault or rape.
Experts have worked to determine the best advice for these situations. It is important to note that the guidelines are based on studies of exposures within the healthcare system, from needlestick and other exposures of healthcare workers.
Although more than 200 different diseases can be transmitted from exposure to blood, the most serious infections are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Fortunately, the risk of acquiring any of these infections is low. This topic review discusses the definition of exposure, the risk of infection, and treatment and follow up recommendations for non-healthcare workers.
DEFINITION OF EXPOSURE — In order to be exposed to a bloodborne pathogen, an individual must have contact with blood, a visibly bloody fluid (eg, phlegm or urine containing blood), or another bodily fluid (eg, semen or vaginal secretions) that contain a virus. The blood or fluid must come in direct contact with some part of the person's body. A virus can enter the body through the bloodstream or mucous membranes, which include the eye, mouth, or genitals. Contact with skin that is intact (without new cuts, scraps, or rashes) poses little to no risk of infection.
Thus, exposure to a bloodborne pathogen is possible after: A percutaneous (through the skin) injury such as a needlestick or cut with a sharp object Contact with a mucous membrane (including exposure through sexual intercourse, especially if an ulcer is present or trauma to vaginal tissues occurs) or non-intact skin
INFECTION AFTER EXPOSURE
Needlestick — Of the viruses that may be transmitted through the blood or bodily fluids, hepatitis B virus (HBV) is the most infectious. A healthcare worker who sustains a needlestick with blood from a known HBV-infected patient has between a 6 and 30 percent chance of developing HBV. The risk of HCV and HIV in the same situation is 1.8 and 0.3, respectively. Other factors influence the risk of becoming infected, including the amount of blood or bodily fluid involved, the depth of penetration, and the amount of virus in the source's blood or body fluid.
Mucous membrane — The risk of becoming infected from a mucous membrane exposure is more difficult to define. When healthcare workers were followed after mucous membrane exposure to HIV, no cases of HIV were identified among those who had been exposed. However, no other explanation for HIV has been found in a few cases where mucous membrane exposure occurred in a work setting. This has led most experts to believe that the risk of acquiring HIV following a mucous membrane exposure is far less than 0.3 percent, but the risk is not zero.
One versus multiple exposures — There is also a difference in terms of risk if the individual has a one-time exposure or has multiple exposures. Thus, the risk of infection for the victim of a single sexual assault is far less than that of a regular sexual partner of an infected person.
POST-EXPOSURE RECOMMENDATIONS — The first and most important measure to take following exposure to blood or bodily fluids is to wash the area well with soap and water. Crime victims are exceptions to this rule since washing may destroy important evidence for criminal prosecution. Recommendations to prevent infection after exposure depend upon the risk of a specific virus being present:
Hepatitis B — The risk of becoming infected with hepatitis B is greater than the risk of other infections. Fortunately, there is an effective vaccine that can help to prevent infection.
Hepatitis B vaccine — The vaccine may be administered to individuals who are exposed to blood, even if the blood is not known to carry HBV. The vaccine should be given at the time of exposure, and repeated one month and six months later to achieve full protection. (See "Patient information: Hepatitis B").
Many people have previously been given the series of three HBV vaccines. In this case, some experts recommend a single booster dose of the vaccine.
Hepatitis B immune globulin — If the source of the blood is known to be positive for HBV, treatment with hepatitis B immune globulin (HBIG) is recommended. HBIG contains antibodies that provide temporary protection against the infection. HBIG is an injection, which should be given as soon as possible after exposure, preferably within 24 hours. The first dose of hepatitis B vaccine should be given at the same time. HBIG is not needed if a person was previously vaccinated with HBV vaccine.
Hepatitis C — HCV can cause a form of hepatitis that leads to chronic liver disease. There is no known way to prevent this infection following exposure. Blood tests should be done immediately after exposure to measure liver function and test for the presence of hepatitis C; the tests should be repeated after four to six weeks and again after four to six months, or sooner if symptoms of hepatitis develop. Symptoms of hepatitis C include loss of appetite, nausea, abdominal pain, darkening of urine, light stools, or jaundice (yellowing of the skin or whites of the eye). (See "Patient information: Hepatitis C").
Human immunodeficiency virus (HIV) — Treatments are available to reduce the risk of becoming infected with HIV after exposure. One retrospective study suggested that the use of an anti-HIV medication, zidovudine (ZDV), reduced the already low risk of healthcare workers becoming infected with HIV by about 81 percent. The risk of becoming infected with HIV as a result of other types of exposure (eg, trauma, rape) is probably even lower than that of a healthcare worker.
However, unlike in healthcare settings, it is often difficult after a rape or trauma if the blood or bodily fluid contains HIV. If the source of the exposure is known, an attempt can be made to test the person for HIV. However, treatment is available even if the source's HIV status cannot be determined.
The benefits of post-exposure treatment (eg, reduced risk of infection) must be weighed against the risks (eg, side effects of treatment, interactions with other medications, cost of treatment). All women of childbearing age should be tested for pregnancy before beginning treatment. Anyone who was exposed to potentially infected blood or bodily fluids should be tested for HIV at the time of exposure (baseline) and at six weeks, three months, and six months postexposure (show table 1).
Recommendations — Experts from the United States Center for Disease Control recommend use of medications to reduce the risk of HIV infection if all of the following criteria are met: Exposure occurred less than 72 hours previously One or more of the following areas were exposed: the vagina, rectum, eye, mouth, or other mucous membrane, open skin, through the skin (eg, from a sharp or needle) One or more of the following bodily fluids was involved in the exposure: blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood
However, the CDC also recommends that each situation be considered on an individual basis; preventive treatment may be recommended to people who do not meet these criteria in some situations. In all situations, regardless of whether treatment is used, it is important to follow strategies to prevent further spread of the potential infection (see "Protecting others after exposure" below).
The CDC recommends NOT using preventive treatment when: the exposure occurred more than 72 hours prior; when the exposure is to intact skin; or when the exposure fluid is urine, nasal secretions, saliva, sweat, or tears, and is not visibly contaminated with blood.
Anyone who is exposed to blood or bodily fluids should consult with a healthcare provider if symptoms of fever, swollen lymph nodes (glands), sore throat, skin lesions, muscle or joint pain, diarrhea, headache, nausea/vomiting, or weight loss develop. The usual time from HIV exposure to the first symptoms of HIV is two to four weeks. (See "Patient information: Symptoms of HIV infection").
Treatment regimen — Postexposure prevention treatment should be started as soon as possible after exposure, within a few hours rather than days. Animal studies suggest that the longer treatment is delayed, the less effective it is. Preventive treatment should not be given if more than 72 hours have elapsed since exposure.
The Centers for Disease Control and Prevention (CDC) recommends a combination of two or three medications to prevent developing HIV after exposure; the best regimen should be determined by a healthcare provider who is experienced with HIV prevention and treatment regimens (show table 2). The optimal length of preventive treatment is unknown, although four weeks is generally recommended.
It is important to be aware of the potential side effects of these drugs, possible interactions with other medications, and the proper timing of doses. Because there are a variety of medications and combinations, it is best to discuss these issues with the person who prescribes them. In all cases, it is crucial to take all of the medication exactly as directed.
FOLLOW-UP
Testing — Follow-up testing for HBV, HCV, and HIV should be performed after possible exposure (see above for specific recommendations on frequency of testing). For people receiving HBV vaccine, return appointments to complete the vaccine series are crucial.
People exposed to a bloodborne pathogen via sexual intercourse are often tested for other sexually transmitted diseases (STDs). In particular, blood tests for syphilis and cultures for gonorrhea and chlamydia are usually performed immediately after exposure and four to six weeks later (show table 1).
Anxiety — It is common to feel anxious or scared after being exposed to blood or bodily fluids.
These fears are normal but may interfere with a person's ability to concentrate on normal day to day responsibilities.
However, the risk of becoming infected with hepatitis B, C, and HIV is small in most cases. Following the steps outlined here and the advice provided by healthcare personnel can further decrease this risk. Counseling may be helpful for people who have difficulty coping, especially during the first few weeks and months after exposure.
PROTECTING OTHERS AFTER EXPOSURE — Anyone exposed to a bloodborne pathogen should understand how to prevent spreading their potential infection to others (for example, family, sexual partner or breastfeeding child) during the follow-up period, especially during the first six months after exposure; this is when most people who are infected with HIV become antibody positive.
Precautions should include abstaining from sexual intercourse or using condoms every time. Condoms reduce, but do not completely eliminate, the chances of transmitting HBV, HCV, or HIV infection to others. Women who have been exposed to blood or body fluids from a person known to be infected should avoid becoming pregnant during this time. In addition, individuals who have been exposed to HIV-infected fluids should not donate blood, plasma, organs, tissue, or semen during the follow-up period. Women who are breastfeeding may consider stopping temporarily. To maintain a supply of breastmilk, it is acceptable to pump milk and then dump it.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
[1-8]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Bamberger, JD, Waldo, CR, Gerberding, JL, Katz, MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med 1999; 106:323.
2. Beck-Sague, CM, Solomon, F. Sexually transmitted diseases in abused children and adolescent and adult victims of rape: review of selected literature. Clin Infect Dis 1999; 28 Suppl 1:S74.
3. Fong, C. Post-exposure prophylaxis for HIV infection after sexual assault: when is it indicated?. Emerg Med J 2001; 18:242.
4. Lurie, P, Miller, S, Hecht, F, Chesney, M. Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations. JAMA 1998; 280:1769.
5. Tokars, JI, Marcus, R, Culver, DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood: The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118:913.
6. Wiebe, ER, Comay, SE, McGregor, M, Ducceschi, S. Offering HIV prophylaxis to people who have been sexually assaulted: 16 months' experience in a sexual assault service. CMAJ 2000; 162:641.
7. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
8. Smith, DK, Grohskopf, LA, Black, RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep 2005; 54:1.
Monday, October 15, 2007
Chlamydia
INTRODUCTION — Chlamydia is the most common sexually transmitted infection in the United States [1]. Approximately four million cases of Chlamydia are estimated to occur annually in the United States, although only about one quarter of those people are tested and receive treatment. Chlamydia and gonorrhea (another sexually transmitted infection) cause similar signs and symptoms. However, chlamydia tends to have fewer symptoms and causes more significant long-term complications than gonorrhea. Infection rates are highest in adolescent women. (See "Patient information: Gonorrhea").
CAUSES — Chlamydia infections are caused by a bacterium known as Chlamydia trachomatis, a one-celled microorganism that is too tiny to be seen with the naked eye. This bacterium is usually transmitted during sexual intercourse. It is not possible to become infected by touching an object (eg, toilet seat).
A person can become infected when the bacterium invades mucous membranes of the mouth, throat, anus, urethra (where urine exits), or vagina. Ejaculation is not necessary to spread the infection. Risk factors for infection include multiple sexual partners, a recent new sex partner, or a history of a previous STD.
SYMPTOMS — Infection with Chlamydia can cause mild to severe symptoms. However, some infected individuals have no symptoms at all, which allows the disease to be spread from person to person before it is detected.
Women — The most common site of infection in women is the cervix (show figure 1). Only about 50 percent of women with cervical Chlamydia or cervicitis, experience symptoms, usually vaginal discharge, abnormal vaginal bleeding, or abdominal pain. Another common symptom is pain during sexual intercourse. Lower abdominal pain can be a symptom of early pelvic inflammatory disease (see below).
Cervicitis is often accompanied by infection of the female urethra, or urethritis. Urethritis can cause symptoms similar to a urinary tract infection (UTI), including a frequent urge to urinate, burning during urination, and low abdominal pain.
Men — Men with Chlamydia typically develop urethritis, which can cause pain during urination and discharge from the penis. However, up to 30 percent of men with chlamydial urethritis experience no symptoms. In a small number of cases, chlamydia can also cause infection of the epididymis, known as epididymitis, which can cause testicular pain and tenderness, swelling in the scrotum, and swelling of the epididymis itself (show figure 2). Chlamydia can also cause infection of the male prostate gland, or prostatitis.
Proctitis is an infection of the anus and/or rectum. Chlamydial proctitis occurs mainly in men who have sex with men (MSM). Symptoms are rare, but may include anal or rectal pain, discharge, a persistent desire to move the bowels, and constipation.
Related disorders — Lymphogranuloma venereum (LGV) is a chlamydial infection that affects the lymph glands. It is rare in developed countries such as the United States. It is more common in men who have sex with men.
Uncommonly, people with chlamydial urethritis develop a form of arthritis, known as reactive arthritis. This is usually associated with a rash, typically develops within one month of infection, and can cause symptoms for several months. It can cause a cluster of seemingly unrelated features, including arthritis, uveitis (an inflammation of the eye), and urethritis. (See "Patient information: Reactive arthritis (formerly Reiter syndrome)").
DIAGNOSIS — Chlamydia can be easily identified with testing. Testing may be done because infection is suspected or as a routine screening procedure. These tests are highly sensitive and can be used on direct swabs of the cervix or urethra, or urine samples. These tests may also be used on vaginal samples, which can be collected by the patient herself (self-administered vaginal swabs). However, testing has to be done in the laboratory, and results typically take about 24 to 48 hours to be processed.
Annual testing is recommended for all sexually active women younger than 25 years old.
Other sexually transmitted infections — A person who is found to have a sexually transmitted infection (STI) or has a partner with an STI should consider testing for other infections, including HIV, gonorrhea, hepatitis B, trichomoniasis, and syphilis. (See "Patient information: Testing for HIV" and see "Patient information: Hepatitis B").
Women are advised to have an annual cervical cancer screening (Pap smear), which can detect abnormal cervical changes associated with the human papillomavirus. (See "Patient information: Screening for cervical cancer").
Men or women who use intravenous drugs or have sexual intercourse with a partner who is at risk for hepatitis C should consider testing for this infection. (See "Patient information: Hepatitis C").
Testing is also available for herpes simplex virus, although this is not usually performed unless there are symptoms or risk factors. (See "Patient information: Genital herpes").
COMPLICATIONS — Chlamydia in women can lead to a serious infection known as pelvic inflammatory disease (PID). Approximately 30 percent of women with chlamydia infection will develop PID if untreated. PID can cause scarring of the fallopian tubes, which can lead to infertility and an increased risk of ectopic pregnancy (a pregnancy that develops in the fallopian tube rather than the uterus). (See "Patient information: Ectopic (tubal) pregnancy").
Infants infected during birth can develop an eye infection, which can potentially cause blindness or a lung infection. As a result, pregnant women are routinely tested for Chlamydia during pregnancy, and infants are routinely given a one-time eye treatment with an antibiotic ointment immediately after birth. This infection has nearly been eliminated as a result of testing and treatment during pregnancy.
TREATMENT — Treatment of Chlamydia is the same for women and men. For the treatment of uncomplicated cervical, urethral, or anorectal infection, most experts favor the use of a one-time antibiotic by mouth, azithromycin (show table 1). This helps to ensure that the treatment is completed and decreases the risk of treatment failure. Azithromycin is safe to take during pregnancy.
An alternate regimen is doxycycline 100 mg twice daily for 10 days. Doxycycline is not used in pregnant women because of the risk of harm to developing teeth and bones in the fetus.
Patients infected with Chlamydia are sometimes also infected with gonorrhea. For this reason, some clinicians will recommend treatment for both infections at once. (See "Patient information: Gonorrhea").
Sexual partner treatment — Current or recent sexual partners of a person diagnosed with Chlamydia should also be treated, especially since that person may not have any symptoms. Furthermore, an untreated partner can reinfect the patient. The traditional approach has been for the patient to notify their partner that a clinic visit is necessary to test for and treat sexually transmitted infections. In contrast, some clinics have a policy of offering two prescriptions - one for the patient and one for the partner.
Sexual contact should be avoided for one week after both partners have been treated and all symptoms have resolved. It is possible to become infected with Chlamydia more than once.
Test of cure — Patients who finish the recommended treatment regimen do not need to be retested. However, a person who continues to have symptoms should be reevaluated.
PREVENTION — The most effective way to prevent Chlamydia is to avoid sexual intercouse. Because this is not practical for many people, the following tips are recommended: Use a latex condom with every act of sexual intercourse. Discuss routine screening for sexually transmitted infections with a healthcare provider. Persons in a long-term, mutually monogamous relationship are at a lower risk of STIs than those with multiple sexual partners or multiple short-term relationships. See a healthcare provider if you have signs or symptoms of Chlamydia. Avoid sexual intercourse if either partner notes abnormal genital discharge, burning with urination, or a genital rash or sore.
SUMMARY Chlamydia is a sexually transmitted infection that can be transmitted during sex. Men do not have to ejaculate to spread the infection. It is not possible to become infected by touching an object (eg, toilet seat) (see "Causes" above). Some people with chlamydia have no symptoms. Some women have pain in the pelvis or abnormal vaginal bleeding (see "Symptoms" above). Men with Chlamydia can have pain during urination or discharge from the penis. Some men have no symptoms (see "Men" above). Chlamydia can be easily identified with testing. (see "Diagnosis" above). Untreated Chlamydia can lead to a serious complication in women, called pelvic inflammatory disease (PID). PID can lead to infertility (trouble becoming pregnant) and other serious health problems (see "Complications" above). A medication is needed to cure the infection. Anyone who is infected or who has had sex with someone who is infected should be treated. The person should not have sex until one week after treatment. (see "Treatment" above). A latex condom can reduce the risk of Chlamydia. Testing for infections like Chlamydia is recommended before having sex with a new partner. Do not have sex if either person has discharge from the penis or vagina, pain with urination, or a genital rash or sore (see "Prevention" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdclam.htm)
American Social Health Association
(www.ashastd.org/stdfaqs/chlamydia.html)
Centers for Disease Control and Prevention
(www.cdc.gov/std/Chlamydia/STDFact-Chlamydia.htm)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
2. Cook, RL, Hutchison, SL, Ostergaard, L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005; 142:914.
3. Golden, MR, Whittington, WL, Handsfield, HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676.
4. Miller, WC. Screening for chlamydial infection: are we doing enough?. Lancet 2005; 365:456.
CAUSES — Chlamydia infections are caused by a bacterium known as Chlamydia trachomatis, a one-celled microorganism that is too tiny to be seen with the naked eye. This bacterium is usually transmitted during sexual intercourse. It is not possible to become infected by touching an object (eg, toilet seat).
A person can become infected when the bacterium invades mucous membranes of the mouth, throat, anus, urethra (where urine exits), or vagina. Ejaculation is not necessary to spread the infection. Risk factors for infection include multiple sexual partners, a recent new sex partner, or a history of a previous STD.
SYMPTOMS — Infection with Chlamydia can cause mild to severe symptoms. However, some infected individuals have no symptoms at all, which allows the disease to be spread from person to person before it is detected.
Women — The most common site of infection in women is the cervix (show figure 1). Only about 50 percent of women with cervical Chlamydia or cervicitis, experience symptoms, usually vaginal discharge, abnormal vaginal bleeding, or abdominal pain. Another common symptom is pain during sexual intercourse. Lower abdominal pain can be a symptom of early pelvic inflammatory disease (see below).
Cervicitis is often accompanied by infection of the female urethra, or urethritis. Urethritis can cause symptoms similar to a urinary tract infection (UTI), including a frequent urge to urinate, burning during urination, and low abdominal pain.
Men — Men with Chlamydia typically develop urethritis, which can cause pain during urination and discharge from the penis. However, up to 30 percent of men with chlamydial urethritis experience no symptoms. In a small number of cases, chlamydia can also cause infection of the epididymis, known as epididymitis, which can cause testicular pain and tenderness, swelling in the scrotum, and swelling of the epididymis itself (show figure 2). Chlamydia can also cause infection of the male prostate gland, or prostatitis.
Proctitis is an infection of the anus and/or rectum. Chlamydial proctitis occurs mainly in men who have sex with men (MSM). Symptoms are rare, but may include anal or rectal pain, discharge, a persistent desire to move the bowels, and constipation.
Related disorders — Lymphogranuloma venereum (LGV) is a chlamydial infection that affects the lymph glands. It is rare in developed countries such as the United States. It is more common in men who have sex with men.
Uncommonly, people with chlamydial urethritis develop a form of arthritis, known as reactive arthritis. This is usually associated with a rash, typically develops within one month of infection, and can cause symptoms for several months. It can cause a cluster of seemingly unrelated features, including arthritis, uveitis (an inflammation of the eye), and urethritis. (See "Patient information: Reactive arthritis (formerly Reiter syndrome)").
DIAGNOSIS — Chlamydia can be easily identified with testing. Testing may be done because infection is suspected or as a routine screening procedure. These tests are highly sensitive and can be used on direct swabs of the cervix or urethra, or urine samples. These tests may also be used on vaginal samples, which can be collected by the patient herself (self-administered vaginal swabs). However, testing has to be done in the laboratory, and results typically take about 24 to 48 hours to be processed.
Annual testing is recommended for all sexually active women younger than 25 years old.
Other sexually transmitted infections — A person who is found to have a sexually transmitted infection (STI) or has a partner with an STI should consider testing for other infections, including HIV, gonorrhea, hepatitis B, trichomoniasis, and syphilis. (See "Patient information: Testing for HIV" and see "Patient information: Hepatitis B").
Women are advised to have an annual cervical cancer screening (Pap smear), which can detect abnormal cervical changes associated with the human papillomavirus. (See "Patient information: Screening for cervical cancer").
Men or women who use intravenous drugs or have sexual intercourse with a partner who is at risk for hepatitis C should consider testing for this infection. (See "Patient information: Hepatitis C").
Testing is also available for herpes simplex virus, although this is not usually performed unless there are symptoms or risk factors. (See "Patient information: Genital herpes").
COMPLICATIONS — Chlamydia in women can lead to a serious infection known as pelvic inflammatory disease (PID). Approximately 30 percent of women with chlamydia infection will develop PID if untreated. PID can cause scarring of the fallopian tubes, which can lead to infertility and an increased risk of ectopic pregnancy (a pregnancy that develops in the fallopian tube rather than the uterus). (See "Patient information: Ectopic (tubal) pregnancy").
Infants infected during birth can develop an eye infection, which can potentially cause blindness or a lung infection. As a result, pregnant women are routinely tested for Chlamydia during pregnancy, and infants are routinely given a one-time eye treatment with an antibiotic ointment immediately after birth. This infection has nearly been eliminated as a result of testing and treatment during pregnancy.
TREATMENT — Treatment of Chlamydia is the same for women and men. For the treatment of uncomplicated cervical, urethral, or anorectal infection, most experts favor the use of a one-time antibiotic by mouth, azithromycin (show table 1). This helps to ensure that the treatment is completed and decreases the risk of treatment failure. Azithromycin is safe to take during pregnancy.
An alternate regimen is doxycycline 100 mg twice daily for 10 days. Doxycycline is not used in pregnant women because of the risk of harm to developing teeth and bones in the fetus.
Patients infected with Chlamydia are sometimes also infected with gonorrhea. For this reason, some clinicians will recommend treatment for both infections at once. (See "Patient information: Gonorrhea").
Sexual partner treatment — Current or recent sexual partners of a person diagnosed with Chlamydia should also be treated, especially since that person may not have any symptoms. Furthermore, an untreated partner can reinfect the patient. The traditional approach has been for the patient to notify their partner that a clinic visit is necessary to test for and treat sexually transmitted infections. In contrast, some clinics have a policy of offering two prescriptions - one for the patient and one for the partner.
Sexual contact should be avoided for one week after both partners have been treated and all symptoms have resolved. It is possible to become infected with Chlamydia more than once.
Test of cure — Patients who finish the recommended treatment regimen do not need to be retested. However, a person who continues to have symptoms should be reevaluated.
PREVENTION — The most effective way to prevent Chlamydia is to avoid sexual intercouse. Because this is not practical for many people, the following tips are recommended: Use a latex condom with every act of sexual intercourse. Discuss routine screening for sexually transmitted infections with a healthcare provider. Persons in a long-term, mutually monogamous relationship are at a lower risk of STIs than those with multiple sexual partners or multiple short-term relationships. See a healthcare provider if you have signs or symptoms of Chlamydia. Avoid sexual intercourse if either partner notes abnormal genital discharge, burning with urination, or a genital rash or sore.
SUMMARY Chlamydia is a sexually transmitted infection that can be transmitted during sex. Men do not have to ejaculate to spread the infection. It is not possible to become infected by touching an object (eg, toilet seat) (see "Causes" above). Some people with chlamydia have no symptoms. Some women have pain in the pelvis or abnormal vaginal bleeding (see "Symptoms" above). Men with Chlamydia can have pain during urination or discharge from the penis. Some men have no symptoms (see "Men" above). Chlamydia can be easily identified with testing. (see "Diagnosis" above). Untreated Chlamydia can lead to a serious complication in women, called pelvic inflammatory disease (PID). PID can lead to infertility (trouble becoming pregnant) and other serious health problems (see "Complications" above). A medication is needed to cure the infection. Anyone who is infected or who has had sex with someone who is infected should be treated. The person should not have sex until one week after treatment. (see "Treatment" above). A latex condom can reduce the risk of Chlamydia. Testing for infections like Chlamydia is recommended before having sex with a new partner. Do not have sex if either person has discharge from the penis or vagina, pain with urination, or a genital rash or sore (see "Prevention" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdclam.htm)
American Social Health Association
(www.ashastd.org/stdfaqs/chlamydia.html)
Centers for Disease Control and Prevention
(www.cdc.gov/std/Chlamydia/STDFact-Chlamydia.htm)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
2. Cook, RL, Hutchison, SL, Ostergaard, L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005; 142:914.
3. Golden, MR, Whittington, WL, Handsfield, HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676.
4. Miller, WC. Screening for chlamydial infection: are we doing enough?. Lancet 2005; 365:456.
Blood and body fluid exposure
INTRODUCTION — Exposure to blood or other bodily fluids can cause many serious infections, including the human immunodeficiency virus (HIV, the virus that causes AIDS). While most people are not exposed to these fluids, a number of situations can arise where exposures may occur, such as finding a syringe with needle, helping an injured person, or being the victim of an assault or rape.
Experts have worked to determine the best advice for these situations. It is important to note that the guidelines are based on studies of exposures within the healthcare system, from needlestick and other exposures of healthcare workers.
Although more than 200 different diseases can be transmitted from exposure to blood, the most serious infections are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Fortunately, the risk of acquiring any of these infections is low. This topic review discusses the definition of exposure, the risk of infection, and treatment and follow up recommendations for non-healthcare workers.
DEFINITION OF EXPOSURE — In order to be exposed to a bloodborne pathogen, an individual must have contact with blood, a visibly bloody fluid (eg, phlegm or urine containing blood), or another bodily fluid (eg, semen or vaginal secretions) that contain a virus. The blood or fluid must come in direct contact with some part of the person's body. A virus can enter the body through the bloodstream or mucous membranes, which include the eye, mouth, or genitals. Contact with skin that is intact (without new cuts, scraps, or rashes) poses little to no risk of infection.
Thus, exposure to a bloodborne pathogen is possible after: A percutaneous (through the skin) injury such as a needlestick or cut with a sharp object Contact with a mucous membrane (including exposure through sexual intercourse, especially if an ulcer is present or trauma to vaginal tissues occurs) or non-intact skin
INFECTION AFTER EXPOSURE
Needlestick — Of the viruses that may be transmitted through the blood or bodily fluids, hepatitis B virus (HBV) is the most infectious. A healthcare worker who sustains a needlestick with blood from a known HBV-infected patient has between a 6 and 30 percent chance of developing HBV. The risk of HCV and HIV in the same situation is 1.8 and 0.3, respectively. Other factors influence the risk of becoming infected, including the amount of blood or bodily fluid involved, the depth of penetration, and the amount of virus in the source's blood or body fluid.
Mucous membrane — The risk of becoming infected from a mucous membrane exposure is more difficult to define. When healthcare workers were followed after mucous membrane exposure to HIV, no cases of HIV were identified among those who had been exposed. However, no other explanation for HIV has been found in a few cases where mucous membrane exposure occurred in a work setting. This has led most experts to believe that the risk of acquiring HIV following a mucous membrane exposure is far less than 0.3 percent, but the risk is not zero.
One versus multiple exposures — There is also a difference in terms of risk if the individual has a one-time exposure or has multiple exposures. Thus, the risk of infection for the victim of a single sexual assault is far less than that of a regular sexual partner of an infected person.
POST-EXPOSURE RECOMMENDATIONS — The first and most important measure to take following exposure to blood or bodily fluids is to wash the area well with soap and water. Crime victims are exceptions to this rule since washing may destroy important evidence for criminal prosecution. Recommendations to prevent infection after exposure depend upon the risk of a specific virus being present:
Hepatitis B — The risk of becoming infected with hepatitis B is greater than the risk of other infections. Fortunately, there is an effective vaccine that can help to prevent infection.
Hepatitis B vaccine — The vaccine may be administered to individuals who are exposed to blood, even if the blood is not known to carry HBV. The vaccine should be given at the time of exposure, and repeated one month and six months later to achieve full protection. (See "Patient information: Hepatitis B").
Many people have previously been given the series of three HBV vaccines. In this case, some experts recommend a single booster dose of the vaccine.
Hepatitis B immune globulin — If the source of the blood is known to be positive for HBV, treatment with hepatitis B immune globulin (HBIG) is recommended. HBIG contains antibodies that provide temporary protection against the infection. HBIG is an injection, which should be given as soon as possible after exposure, preferably within 24 hours. The first dose of hepatitis B vaccine should be given at the same time. HBIG is not needed if a person was previously vaccinated with HBV vaccine.
Hepatitis C — HCV can cause a form of hepatitis that leads to chronic liver disease. There is no known way to prevent this infection following exposure. Blood tests should be done immediately after exposure to measure liver function and test for the presence of hepatitis C; the tests should be repeated after four to six weeks and again after four to six months, or sooner if symptoms of hepatitis develop. Symptoms of hepatitis C include loss of appetite, nausea, abdominal pain, darkening of urine, light stools, or jaundice (yellowing of the skin or whites of the eye). (See "Patient information: Hepatitis C").
Human immunodeficiency virus (HIV) — Treatments are available to reduce the risk of becoming infected with HIV after exposure. One retrospective study suggested that the use of an anti-HIV medication, zidovudine (ZDV), reduced the already low risk of healthcare workers becoming infected with HIV by about 81 percent. The risk of becoming infected with HIV as a result of other types of exposure (eg, trauma, rape) is probably even lower than that of a healthcare worker.
However, unlike in healthcare settings, it is often difficult after a rape or trauma if the blood or bodily fluid contains HIV. If the source of the exposure is known, an attempt can be made to test the person for HIV. However, treatment is available even if the source's HIV status cannot be determined.
The benefits of post-exposure treatment (eg, reduced risk of infection) must be weighed against the risks (eg, side effects of treatment, interactions with other medications, cost of treatment). All women of childbearing age should be tested for pregnancy before beginning treatment. Anyone who was exposed to potentially infected blood or bodily fluids should be tested for HIV at the time of exposure (baseline) and at six weeks, three months, and six months postexposure (show table 1).
Recommendations — Experts from the United States Center for Disease Control recommend use of medications to reduce the risk of HIV infection if all of the following criteria are met: Exposure occurred less than 72 hours previously One or more of the following areas were exposed: the vagina, rectum, eye, mouth, or other mucous membrane, open skin, through the skin (eg, from a sharp or needle) One or more of the following bodily fluids was involved in the exposure: blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood
However, the CDC also recommends that each situation be considered on an individual basis; preventive treatment may be recommended to people who do not meet these criteria in some situations. In all situations, regardless of whether treatment is used, it is important to follow strategies to prevent further spread of the potential infection (see "Protecting others after exposure" below).
The CDC recommends NOT using preventive treatment when: the exposure occurred more than 72 hours prior; when the exposure is to intact skin; or when the exposure fluid is urine, nasal secretions, saliva, sweat, or tears, and is not visibly contaminated with blood.
Anyone who is exposed to blood or bodily fluids should consult with a healthcare provider if symptoms of fever, swollen lymph nodes (glands), sore throat, skin lesions, muscle or joint pain, diarrhea, headache, nausea/vomiting, or weight loss develop. The usual time from HIV exposure to the first symptoms of HIV is two to four weeks. (See "Patient information: Symptoms of HIV infection").
Treatment regimen — Postexposure prevention treatment should be started as soon as possible after exposure, within a few hours rather than days. Animal studies suggest that the longer treatment is delayed, the less effective it is. Preventive treatment should not be given if more than 72 hours have elapsed since exposure.
The Centers for Disease Control and Prevention (CDC) recommends a combination of two or three medications to prevent developing HIV after exposure; the best regimen should be determined by a healthcare provider who is experienced with HIV prevention and treatment regimens (show table 2). The optimal length of preventive treatment is unknown, although four weeks is generally recommended.
It is important to be aware of the potential side effects of these drugs, possible interactions with other medications, and the proper timing of doses. Because there are a variety of medications and combinations, it is best to discuss these issues with the person who prescribes them. In all cases, it is crucial to take all of the medication exactly as directed.
FOLLOW-UP
Testing — Follow-up testing for HBV, HCV, and HIV should be performed after possible exposure (see above for specific recommendations on frequency of testing). For people receiving HBV vaccine, return appointments to complete the vaccine series are crucial.
People exposed to a bloodborne pathogen via sexual intercourse are often tested for other sexually transmitted diseases (STDs). In particular, blood tests for syphilis and cultures for gonorrhea and chlamydia are usually performed immediately after exposure and four to six weeks later (show table 1).
Anxiety — It is common to feel anxious or scared after being exposed to blood or bodily fluids.
These fears are normal but may interfere with a person's ability to concentrate on normal day to day responsibilities.
However, the risk of becoming infected with hepatitis B, C, and HIV is small in most cases. Following the steps outlined here and the advice provided by healthcare personnel can further decrease this risk. Counseling may be helpful for people who have difficulty coping, especially during the first few weeks and months after exposure.
PROTECTING OTHERS AFTER EXPOSURE — Anyone exposed to a bloodborne pathogen should understand how to prevent spreading their potential infection to others (for example, family, sexual partner or breastfeeding child) during the follow-up period, especially during the first six months after exposure; this is when most people who are infected with HIV become antibody positive.
Precautions should include abstaining from sexual intercourse or using condoms every time. Condoms reduce, but do not completely eliminate, the chances of transmitting HBV, HCV, or HIV infection to others. Women who have been exposed to blood or body fluids from a person known to be infected should avoid becoming pregnant during this time. In addition, individuals who have been exposed to HIV-infected fluids should not donate blood, plasma, organs, tissue, or semen during the follow-up period. Women who are breastfeeding may consider stopping temporarily. To maintain a supply of breastmilk, it is acceptable to pump milk and then dump it.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
[1-8]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Bamberger, JD, Waldo, CR, Gerberding, JL, Katz, MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med 1999; 106:323.
2. Beck-Sague, CM, Solomon, F. Sexually transmitted diseases in abused children and adolescent and adult victims of rape: review of selected literature. Clin Infect Dis 1999; 28 Suppl 1:S74.
3. Fong, C. Post-exposure prophylaxis for HIV infection after sexual assault: when is it indicated?. Emerg Med J 2001; 18:242.
4. Lurie, P, Miller, S, Hecht, F, Chesney, M. Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations. JAMA 1998; 280:1769.
5. Tokars, JI, Marcus, R, Culver, DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood: The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118:913.
6. Wiebe, ER, Comay, SE, McGregor, M, Ducceschi, S. Offering HIV prophylaxis to people who have been sexually assaulted: 16 months' experience in a sexual assault service. CMAJ 2000; 162:641.
7. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
8. Smith, DK, Grohskopf, LA, Black, RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep 2005; 54:1.
Experts have worked to determine the best advice for these situations. It is important to note that the guidelines are based on studies of exposures within the healthcare system, from needlestick and other exposures of healthcare workers.
Although more than 200 different diseases can be transmitted from exposure to blood, the most serious infections are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Fortunately, the risk of acquiring any of these infections is low. This topic review discusses the definition of exposure, the risk of infection, and treatment and follow up recommendations for non-healthcare workers.
DEFINITION OF EXPOSURE — In order to be exposed to a bloodborne pathogen, an individual must have contact with blood, a visibly bloody fluid (eg, phlegm or urine containing blood), or another bodily fluid (eg, semen or vaginal secretions) that contain a virus. The blood or fluid must come in direct contact with some part of the person's body. A virus can enter the body through the bloodstream or mucous membranes, which include the eye, mouth, or genitals. Contact with skin that is intact (without new cuts, scraps, or rashes) poses little to no risk of infection.
Thus, exposure to a bloodborne pathogen is possible after: A percutaneous (through the skin) injury such as a needlestick or cut with a sharp object Contact with a mucous membrane (including exposure through sexual intercourse, especially if an ulcer is present or trauma to vaginal tissues occurs) or non-intact skin
INFECTION AFTER EXPOSURE
Needlestick — Of the viruses that may be transmitted through the blood or bodily fluids, hepatitis B virus (HBV) is the most infectious. A healthcare worker who sustains a needlestick with blood from a known HBV-infected patient has between a 6 and 30 percent chance of developing HBV. The risk of HCV and HIV in the same situation is 1.8 and 0.3, respectively. Other factors influence the risk of becoming infected, including the amount of blood or bodily fluid involved, the depth of penetration, and the amount of virus in the source's blood or body fluid.
Mucous membrane — The risk of becoming infected from a mucous membrane exposure is more difficult to define. When healthcare workers were followed after mucous membrane exposure to HIV, no cases of HIV were identified among those who had been exposed. However, no other explanation for HIV has been found in a few cases where mucous membrane exposure occurred in a work setting. This has led most experts to believe that the risk of acquiring HIV following a mucous membrane exposure is far less than 0.3 percent, but the risk is not zero.
One versus multiple exposures — There is also a difference in terms of risk if the individual has a one-time exposure or has multiple exposures. Thus, the risk of infection for the victim of a single sexual assault is far less than that of a regular sexual partner of an infected person.
POST-EXPOSURE RECOMMENDATIONS — The first and most important measure to take following exposure to blood or bodily fluids is to wash the area well with soap and water. Crime victims are exceptions to this rule since washing may destroy important evidence for criminal prosecution. Recommendations to prevent infection after exposure depend upon the risk of a specific virus being present:
Hepatitis B — The risk of becoming infected with hepatitis B is greater than the risk of other infections. Fortunately, there is an effective vaccine that can help to prevent infection.
Hepatitis B vaccine — The vaccine may be administered to individuals who are exposed to blood, even if the blood is not known to carry HBV. The vaccine should be given at the time of exposure, and repeated one month and six months later to achieve full protection. (See "Patient information: Hepatitis B").
Many people have previously been given the series of three HBV vaccines. In this case, some experts recommend a single booster dose of the vaccine.
Hepatitis B immune globulin — If the source of the blood is known to be positive for HBV, treatment with hepatitis B immune globulin (HBIG) is recommended. HBIG contains antibodies that provide temporary protection against the infection. HBIG is an injection, which should be given as soon as possible after exposure, preferably within 24 hours. The first dose of hepatitis B vaccine should be given at the same time. HBIG is not needed if a person was previously vaccinated with HBV vaccine.
Hepatitis C — HCV can cause a form of hepatitis that leads to chronic liver disease. There is no known way to prevent this infection following exposure. Blood tests should be done immediately after exposure to measure liver function and test for the presence of hepatitis C; the tests should be repeated after four to six weeks and again after four to six months, or sooner if symptoms of hepatitis develop. Symptoms of hepatitis C include loss of appetite, nausea, abdominal pain, darkening of urine, light stools, or jaundice (yellowing of the skin or whites of the eye). (See "Patient information: Hepatitis C").
Human immunodeficiency virus (HIV) — Treatments are available to reduce the risk of becoming infected with HIV after exposure. One retrospective study suggested that the use of an anti-HIV medication, zidovudine (ZDV), reduced the already low risk of healthcare workers becoming infected with HIV by about 81 percent. The risk of becoming infected with HIV as a result of other types of exposure (eg, trauma, rape) is probably even lower than that of a healthcare worker.
However, unlike in healthcare settings, it is often difficult after a rape or trauma if the blood or bodily fluid contains HIV. If the source of the exposure is known, an attempt can be made to test the person for HIV. However, treatment is available even if the source's HIV status cannot be determined.
The benefits of post-exposure treatment (eg, reduced risk of infection) must be weighed against the risks (eg, side effects of treatment, interactions with other medications, cost of treatment). All women of childbearing age should be tested for pregnancy before beginning treatment. Anyone who was exposed to potentially infected blood or bodily fluids should be tested for HIV at the time of exposure (baseline) and at six weeks, three months, and six months postexposure (show table 1).
Recommendations — Experts from the United States Center for Disease Control recommend use of medications to reduce the risk of HIV infection if all of the following criteria are met: Exposure occurred less than 72 hours previously One or more of the following areas were exposed: the vagina, rectum, eye, mouth, or other mucous membrane, open skin, through the skin (eg, from a sharp or needle) One or more of the following bodily fluids was involved in the exposure: blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood
However, the CDC also recommends that each situation be considered on an individual basis; preventive treatment may be recommended to people who do not meet these criteria in some situations. In all situations, regardless of whether treatment is used, it is important to follow strategies to prevent further spread of the potential infection (see "Protecting others after exposure" below).
The CDC recommends NOT using preventive treatment when: the exposure occurred more than 72 hours prior; when the exposure is to intact skin; or when the exposure fluid is urine, nasal secretions, saliva, sweat, or tears, and is not visibly contaminated with blood.
Anyone who is exposed to blood or bodily fluids should consult with a healthcare provider if symptoms of fever, swollen lymph nodes (glands), sore throat, skin lesions, muscle or joint pain, diarrhea, headache, nausea/vomiting, or weight loss develop. The usual time from HIV exposure to the first symptoms of HIV is two to four weeks. (See "Patient information: Symptoms of HIV infection").
Treatment regimen — Postexposure prevention treatment should be started as soon as possible after exposure, within a few hours rather than days. Animal studies suggest that the longer treatment is delayed, the less effective it is. Preventive treatment should not be given if more than 72 hours have elapsed since exposure.
The Centers for Disease Control and Prevention (CDC) recommends a combination of two or three medications to prevent developing HIV after exposure; the best regimen should be determined by a healthcare provider who is experienced with HIV prevention and treatment regimens (show table 2). The optimal length of preventive treatment is unknown, although four weeks is generally recommended.
It is important to be aware of the potential side effects of these drugs, possible interactions with other medications, and the proper timing of doses. Because there are a variety of medications and combinations, it is best to discuss these issues with the person who prescribes them. In all cases, it is crucial to take all of the medication exactly as directed.
FOLLOW-UP
Testing — Follow-up testing for HBV, HCV, and HIV should be performed after possible exposure (see above for specific recommendations on frequency of testing). For people receiving HBV vaccine, return appointments to complete the vaccine series are crucial.
People exposed to a bloodborne pathogen via sexual intercourse are often tested for other sexually transmitted diseases (STDs). In particular, blood tests for syphilis and cultures for gonorrhea and chlamydia are usually performed immediately after exposure and four to six weeks later (show table 1).
Anxiety — It is common to feel anxious or scared after being exposed to blood or bodily fluids.
These fears are normal but may interfere with a person's ability to concentrate on normal day to day responsibilities.
However, the risk of becoming infected with hepatitis B, C, and HIV is small in most cases. Following the steps outlined here and the advice provided by healthcare personnel can further decrease this risk. Counseling may be helpful for people who have difficulty coping, especially during the first few weeks and months after exposure.
PROTECTING OTHERS AFTER EXPOSURE — Anyone exposed to a bloodborne pathogen should understand how to prevent spreading their potential infection to others (for example, family, sexual partner or breastfeeding child) during the follow-up period, especially during the first six months after exposure; this is when most people who are infected with HIV become antibody positive.
Precautions should include abstaining from sexual intercourse or using condoms every time. Condoms reduce, but do not completely eliminate, the chances of transmitting HBV, HCV, or HIV infection to others. Women who have been exposed to blood or body fluids from a person known to be infected should avoid becoming pregnant during this time. In addition, individuals who have been exposed to HIV-infected fluids should not donate blood, plasma, organs, tissue, or semen during the follow-up period. Women who are breastfeeding may consider stopping temporarily. To maintain a supply of breastmilk, it is acceptable to pump milk and then dump it.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
[1-8]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Bamberger, JD, Waldo, CR, Gerberding, JL, Katz, MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med 1999; 106:323.
2. Beck-Sague, CM, Solomon, F. Sexually transmitted diseases in abused children and adolescent and adult victims of rape: review of selected literature. Clin Infect Dis 1999; 28 Suppl 1:S74.
3. Fong, C. Post-exposure prophylaxis for HIV infection after sexual assault: when is it indicated?. Emerg Med J 2001; 18:242.
4. Lurie, P, Miller, S, Hecht, F, Chesney, M. Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations. JAMA 1998; 280:1769.
5. Tokars, JI, Marcus, R, Culver, DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood: The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118:913.
6. Wiebe, ER, Comay, SE, McGregor, M, Ducceschi, S. Offering HIV prophylaxis to people who have been sexually assaulted: 16 months' experience in a sexual assault service. CMAJ 2000; 162:641.
7. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
8. Smith, DK, Grohskopf, LA, Black, RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep 2005; 54:1.
Sexual problems in women
INTRODUCTION — Sexual problems can occur in women of any age. Sexual dysfunction is a term used to describe difficulties in libido (sex drive), arousal, orgasm, or pain with sex that is bothersome to an individual or their sexual partner. It can occur in men or women at any age, though women in midlife are at higher risk of changes that can cause sexual dysfunction. In this topic review, midlife refers to the middle part of a woman's chronological years, between 35 and 65 years.
For most women, the earliest changes begin when they are in their 30s and continue through the menopause. The years before menopause are commonly referred to as the perimenopause or menopausal transition, which can precede a woman's final menstrual period by 10 years (show figure 1).
A host of hormonal, vascular, and other changes occur prior to the menopausal transition and continue in postmenopause; these changes can affect sexuality in a number of ways. To describe these changes, it will be helpful to review the basic elements of the normal sexual response.
OVERVIEW OF THE NORMAL SEXUAL RESPONSE — Two models have been proposed to describe the human sexual response. While they differ in many ways, both acknowledge that the brain is the most important sex organ in the human body, and that nerves and blood vessels are critical components in initiating and maintaining the human sexual response.
Masters and Johnson model — Masters and Johnson first described the human sexual response as a linear progression through a series of phases. They describe the response as follows: Excitement — At the start of the excitement phase, the brain stimulates nerves in the body, which causes changes in blood flow. This increases flow to the genital area; in women, the vaginal wall becomes lubricated and expands, the labia increase in size and spread open, and the clitoris enlarges. Other areas of the skin may be affected by the increased blood flow, resulting in nipple erection and flushing of the skin, sometimes known as the "sex flush." Plateau — Changes in the genital area progress and an increase in muscle tension occurs. Blood flow to the labia increases, glands in the labia produce secretions, and the vagina elongates. Orgasm — In the orgasm phase, vaginal, uterine, and other muscle contractions occur. There is a massive release of muscle tension. Regularly orgasmic women will achieve orgasm 50 to 70 percent of the time; other times women may experience a satisfying prolonged plateau phase. Resolution — The final phase is often characterized as a gradual, pleasant diminishing of sexual tension and response, differing in the time it lasts among individuals.
The Masters and Johnson model was later altered by Kaplan. Excitement was divided into desire followed by arousal. This highlights the differences between a cerebral event (desire) and a peripheral event (arousal). Some questioned whether women followed this linear sequence of events. Newer theories have concluded that the female sexual response is quite different from the male response, and does not follow a linear progression.
Biopsychosocial sexual response model — Another way to think about the female sexual response focuses on the complex interplay among four major components in a woman's life, rather than the more linear phases described by Masters and Johnson. These components are: Biology Psychology Sociocultural influences Interpersonal relationships
Using this model, sexual function or dysfunction can be defined using a combination of components. Thus, using medication to treat a biological factor without addressing other factors is unlikely to be successful for a woman with sexual dysfunction.
Proponents of this model believe that a large component of a woman's sexual desire is "responsive" versus "spontaneous." That is, desire may not occur spontaneously, but rather in response to an interplay of the factors listed above. Spontaneous desire may occur for some women, but is not essential. Therefore, a woman who does not have spontaneous desire does not necessarily have sexual dysfunction. The goal of sexual activity is satisfaction for both partners, which may or may not include orgasm.
SEXUAL CHANGES IN MIDLIFE — Sexuality and sexual capacity evolve over a lifetime and are based on personal experiences, interests, cultural attitudes, interpersonal relationships, desires, behaviors, physiology, and other factors. As midlife approaches, this foundation of sexuality can be altered by changes that affect many aspects of sexuality and sexual function. In learning about these changes, it is important to remember that they do not occur in isolation; a change in one is likely to affect other areas.
Understanding how the changes in midlife affect sexual response is an important first step in the treatment of sexual dysfunction. This can help to eliminate the fear and embarrassment that might otherwise occur, and which sometimes causes further detrimental changes in the sexual response.
Changes in estrogen — Estrogen is a female hormone produced by the ovaries. During the perimenopause, erratic ovarian function leads to estrogen levels that fluctuate. After menopause, estrogen levels begin to decline, causing a decrease in blood flow to the genitalia. This can lead to changes that affect sexual function. These include: Changes in the vagina, including narrowing, dryness, an increase in pH (which can lead to infections), and a decrease in elasticity of the vaginal wall. Changes in the bladder, which can lead to increased frequency of urination and, in some women, predispose them to loss of urine (incontinence). (See "Patient information: Urinary incontinence"). Changes in the clitoris, with decreased blood flow to the area and shrinkage of the structure. Nerve changes such as decreased sensitivity to touch and delayed reaction time to physical stimulation.
Vaginal dryness and decreased elasticity can result in discomfort or pain during sex. The decrease in blood flow to the genital organs can lead to diminished vascular congestion in the vagina and clitoris, thereby contributing to delayed arousal, delayed or absent orgasm, or diminished intensity of orgasm.
Changes in androgens — Women make more testosterone than estrogen; all of the estrogen made by the ovary is a by-product of testosterone. It is known to be important for the development of libido in men, but its role in women is not well understood. For example, blood levels of testosterone are not a good predictor of libido in women.
Other things can decrease androgen levels, including medications, such as birth control pills and oral estrogen replacement therapy, which are taken by many women in midlife.
The impact of male sexuality — Midlife changes in a woman's male sex partner can affect her sexual response. Male sexual dysfunction, (erectile dysfunction, diminished libido, or abnormal ejaculation), first emerges as a problem for men in their early 40s and increases with advancing age (show figure 2).
Changes in libido — Decreased libido or sexual desire is a common problem among women in the perimenopause or menopausal transition, but women of any age may experience it. Decreased libido refers to a decrease in sexual appetite, drive, and fantasy. Sexual arousal is best understood in physiologic and vascular terms while libido is more psychosocial and behavioral and is impacted by a multitude of factors in daily life and relationships. A desire for intimacy can be diminished in spite of normal levels of testosterone. Many factors may be involved, including:
Partner availability — Women tend to live longer than men, resulting in a natural shortage of males 50 years of age and older. At the same time, many men seek out younger partners, further affecting the availability of partners for women in midlife and beyond.
Personal well-being — A woman's sense of personal well being is important to sexual interest and activity. A woman who does not feel her best physically or emotionally may experience a decrease in sex drive.
Health and socioeconomic circumstances — Studies have shown that sexual dysfunction is highest in women with poor health, low income, and a history of infrequent sexual interest. It is also more common among women and men with poor physical and emotional health.
Performance anxiety — Women may fear pain during sex because of vaginal dryness or other changes in the vagina. This fear can diminish lubrication, causing further pain. Women may also develop anxiety if they are not satisfied by a sexual experience or feel they have not satisfied their partner. Women may avoid sexual contact with their male partner if he has a history of sexual dysfunction; avoiding sex prevents his potential sexual failure and her perceived inability to arouse him.
Medical issues — A host of medical issues in midlife can impact a woman's sexual desire and responsiveness. Problems such as coronary artery disease and arthritis can diminish the physical ability to perform sex. Indeed, arthritis has been identified in some studies as the most common cause of sexual inactivity in the United States. Other conditions such as Parkinson's disease, complications of diabetes, or alcohol and drug abuse can impair arousal and ability to experience orgasm. A psychiatric or emotional problem may impact sexual function, either due to the disorder itself or its treatment (see below).
Medications — Both prescription and nonprescription medications can alter sexual desire, arousal, and orgasm. As an example, medicines that alter blood flow (such as blood pressure medicines), those that affect the nervous system (such as some psychiatric medicines), or those that dry the skin or mucous membranes (such as cold or allergy medicines) can affect sexual function. As mentioned before, birth control pills, patches, and rings, as well as oral hormone replacement therapy can affect testosterone levels in women and decrease sexual desire.
Antidepressants — Selective serotonin reuptake inhibitors, or SSRIs, which are commonly used to treat depression, premenstrual syndrome, and anxiety frequently cause sexual dysfunction in both men and women; side effects can include diminished sexual desire, arousal, and orgasm. Examples of SSRIs include fluoxetine (Prozac®) and paroxetine (Paxil®).
Patients with sexual side effects from SSRIs should speak with their healthcare provider about trying a drug holiday or alternate medication to reduce or eliminate their symptoms. A drug holiday involves stopping the SSRI for two to three days, which decreases the amount of drug in the body and may improve a patient's ability to become aroused and experience orgasm. Drug holidays have not been proven to be consistently helpful for all patients and should only be tried after consulting with a healthcare provider.
Patients with sexual side effects may benefit from a change in dose or type of antidepressant medication, or from the addition of a second medication. Bupropion (Wellbutrin®) has been shown to have few or no sexual side effects, and may be used in addition to or in place of an SSRI in certain carefully selected patients.
Erectile dysfunction medications — The medications commonly used for men with erectile problems, including Sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®), do not improve sexual function for most women.
Surgery — Operations commonly performed on women at midlife may have an effect on sexual response. In particular, those affecting the breasts or the genital tract may have an impact related to altered body image and function, as well as the psychological impact of an underlying diagnosis such as cancer.
Hysterectomy — Contrary to popular belief, hysterectomy, or removal of the uterus, may result in improved sexual function. (See "Patient information: Vaginal hysterectomy" and see "Patient information: Abdominal hysterectomy"). Relief from symptoms such as bleeding or pain may spark a renewed interest in sex. One study followed over 1000 women for two years after hysterectomy. The percentage of women who engaged in sexual relations increased from about 71 percent before the surgery to 77 percent at one and two years after the operation. Before surgery, 19 percent of women reported painful sex; after surgery, only 4 percent reported this problem. The number of women who experienced orgasm increased from 92 to 95 percent; libido increased as well. However, some women note a decrease or total absence of orgasm after hysterectomy.
Oophorectomy — Removal of the ovaries during hysterectomy is not always necessary. After menopause, the ovaries continue to produce testosterone, though they no longer produce estrogen. In the past, women have been advised to have their ovaries removed since the uterus was also being removed, they were near or beyond menopause, and to avoid a future risk of ovarian cancer. Although there is a risk for ovarian cancer if the ovaries are not removed, this risk may be acceptable depending upon the woman's risk profile. The average woman's lifetime risk of ovarian cancer is small, approximately two percent.
Removal of the cervix — Hysterectomy does not necessarily require removal of the cervix. Supracervical hysterectomy removes the lower part of the uterus through an incision in the abdomen, but leaves the cervix in place. Some clinicians believe that leaving the cervix maintains the blood vessel and nerve supply to the top of the vagina, which actively participates in orgasm. By this theory, the cervix contributes to orgasmic response. However, studies have demonstrated that sexual satisfaction does not appear to differ between women with and without a cervix after hysterectomy. Patients should discuss plans for surgery with their doctor.
TREATMENT — A number of treatments are available for women with sexual dysfunction. Treatments that do not involve medications may be tried first. In some women, treatment with medicine may also be recommended.
Non-pharmacologic treatments — One of the major points to remember when sexual dysfunction occurs is that decreasing the frequency of sex is likely to make the problem worse. In their early work, Masters and Johnson discovered that regular sexual activity helps maintain a woman's sexual capacity because it actually affects the chemical balance in the vagina and maintains blood flow to the genitalia. If possible, a treatment plan should address the issue of regular sexual activity. The benefits of regular activity do not require a partner; similar benefits are seen with sexual activity of any kind, including masturbation or sexual fantasy, all of which increase blood flow.
Vaginal weights — In some women, vaginal weights are useful to help strengthen the muscles in and around the genital area. This may improve awareness of sexual response in some women with orgasmic disorders. Vaginal weights can also decrease or eliminate urine leakage during sexual activity. (See "Patient information: Urinary incontinence", section on vaginal pessaries).
Vaginal weights are usually available in sets of five weights. The woman inserts the lightest weight and remains upright for 15 minutes, twice a day. With the weight in place, she should feel the urge to hold it in. After a number of days, she should not longer feel the urge to hold in the weight because an improvement in muscle tone has occurred. She then moves up to the next weight.
Increased tactile stimulation — Men and women can have decreased blood flow to the genitals during midlife. Increasing manual and/or oral stimulation can be helpful to achieve or maintain an erection in the male or arousal in the female.
Sexual frequency — The "optimal" frequency for sexual contact is what each pair of partners finds comfortable. Women do not need to initiate contact to enjoy sex; many women can respond to their partner's sexual signals, become aroused, and enjoy a sexual experience that is initiated by their partner. Ejaculation and/or orgasm is not required with each sexual encounter.
Treatment with medications — Non-pharmacologic treatments may not be sufficient to provide sexual satisfaction in some women. Medications may be tried in these women, with the goal being to maintain hormone levels and increase blood flow to the genitals.
Estrogen — Estrogen may positively affect sexual function by helping to maintain normal lubrication and elasticity of the vagina. It can also improve mood and affect nerve growth and response, which may impact arousal. In one study, estrogen was shown to increase clitoral sensitivity, rate of orgasm, and sexual desire. In another, the rate of orgasm and sexual arousal were not affected, but women treated with estrogen reported an increase in satisfaction with the frequency of sexual activity, sexual fantasies, enjoyment of sex, vaginal lubrication, and the level of discomfort during sex.
In general, women with symptoms of vaginal dryness should use topical (vaginal) estrogen rather than oral estrogen since it is far more effective for the sexual symptoms. Treatment with oral estrogen can decrease testosterone levels; topical estrogen avoids this negative effect.
Progestogens — Progestogens are progesterone-like medications that are an important component of hormone replacement therapy in women with a uterus. A number of studies have shown that treatment with certain potent synthetic progestogens can increase sexual problems in women. Studies are underway to determine if various combinations of estrogens with synthetic progestogens alters sexual response.
Androgens — Although androgens (such as testosterone) may be important in the female sexual response, treatment with androgen replacement is highly controversial. Estratest®, a combination of estrogen and testosterone, is the only androgen therapy currently available. It is available for the treatment of hot flashes that do no respond to estrogen alone.
There are no adrogen products that are approved for use in women with sexual dysfunctions, thus use of androgen therapy remains investigational. Studies have shown mixed results; those that carefully select participants with sexual dysfunction have shown statistically significant but clinically modest improvements when compared to placebo. Of note, in all of the transdermal testosterone trials, clinical improvement is seen only with higher than normal blood levels of testosterone. The long-term risks of these higher testosterone levels are unknown.
Side effects remain a concern, as these medicines can decrease HDL (good cholesterol) levels significantly. Masculinizing effects, such as body hair growth, scalp hair loss, oily skin, and acne can also occur.
Studies on the use of DHEA (dehydroepiandrosterone), available as a nutritional supplement in the United States, is beneficial for improving libido in women with adrenal insufficiency. DHEA is not proven to be safe or effective for other patients, and is not generally recommended.
Herbal therapies — The literature on herbal therapies for the treatment of sexual dysfunction in women is sparse. A small number of studies have shown that treatment with St. John's wort, ginseng, or dong quai did not have a significant effect on sexual function. Herbal products such as yohimbine and ginkgo biloba have been reported to enhance desire, arousal, and orgasm in both women and men, but the data is limited. Sex creams that contain menthol are available for application to the clitoris, and are promoted for their ability to enhance sensation. However, there are no studies that show these creams to be effective. In addition, some have ingredients that can cause irritation of vulvar or vaginal tissues.
More studies are needed to ensure herbal therapies are safe and effective. The production of herbs is not regulated by the government, and it is not always possible to know that an herbal product contains the type and quantity of ingredient that the label indicates, or that it is free of potentially dangerous additives. Patients who wish to use herbal therapies are urged to do so with caution.
Surgical treatments — Surgery is very rarely necessary to make the vagina "better" for sex. Women with congenital abnormalities of the vagina, who have had female circumcision (also known as female genital mutilation), and those with traumatic injuries from childbirth are a few groups that may benefit from careful surgical treatment. All women should be wary of advertisements for "vaginal rejuvenation surgery"; these procedures can be costly and painful, are permanent, and are unlikely to improve a woman or her partner's sexual enjoyment.
Future directions — A number of products are undergoing research and development for use in women with sexual dysfunction: Tibolone, currently available in Europe and Australia, may gain FDA approval in the United States soon. It is taken by mouth as hormone replacement therapy and may also help improve sexual function. Use of Sildenafil (Viagra®) in women is also undergoing evaluation. Preliminary findings demonstrate positive effects in some women with adequate testosterone levels who have problems with arousal and orgasm.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Mayo Clinic
(www.mayoclinic.com)
The Hormone Foundation
(www.hormone.org)
American Academy of Family Physicians
(www.familydoctor.org, search for sexual problems)
[1-7]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Phillips, NA, Female sexual dysfunction: Evaluation and treatment. Am Fam physician 2000; 62:127.
2. Sarrel, PM. Sexuality and menopause. Obstet Gyenecol. 1990; 75:26S.
3. Nathorst-Boos, J, Wiklund, I, Mattsson, LA, et al. Is sexual life influenced by transdermal estrogen therapy? A double blind placebo controlled study in postmenopausal women. Acta Obstet Gynecol Scand 1993; 72:656.
4. Myers, LS, Dixen, J, Morrissette, D, et al. Effects of estrogen, androgen, and progestin on sexual pscychophysiology and behavior in postmenopausal women. J Clin Endocrinol Metab 1990; 70:1124.
5. Masters, WH, Johnson, VE. Human Sexual Response. Boston, Mass. Little, Brown, 1966.
6. Basson, R. Female sexual response: The role of drugs in the management of sexual dysfunction. Obstet Gynecol 2001; 98:350.
7. Rhodes, JC, Kjerulff, KH, Langenberg, PW, Guzinski, GM. Hysterectomy and sexual functioning. JAMA 1999; 282:1934.
For most women, the earliest changes begin when they are in their 30s and continue through the menopause. The years before menopause are commonly referred to as the perimenopause or menopausal transition, which can precede a woman's final menstrual period by 10 years (show figure 1).
A host of hormonal, vascular, and other changes occur prior to the menopausal transition and continue in postmenopause; these changes can affect sexuality in a number of ways. To describe these changes, it will be helpful to review the basic elements of the normal sexual response.
OVERVIEW OF THE NORMAL SEXUAL RESPONSE — Two models have been proposed to describe the human sexual response. While they differ in many ways, both acknowledge that the brain is the most important sex organ in the human body, and that nerves and blood vessels are critical components in initiating and maintaining the human sexual response.
Masters and Johnson model — Masters and Johnson first described the human sexual response as a linear progression through a series of phases. They describe the response as follows: Excitement — At the start of the excitement phase, the brain stimulates nerves in the body, which causes changes in blood flow. This increases flow to the genital area; in women, the vaginal wall becomes lubricated and expands, the labia increase in size and spread open, and the clitoris enlarges. Other areas of the skin may be affected by the increased blood flow, resulting in nipple erection and flushing of the skin, sometimes known as the "sex flush." Plateau — Changes in the genital area progress and an increase in muscle tension occurs. Blood flow to the labia increases, glands in the labia produce secretions, and the vagina elongates. Orgasm — In the orgasm phase, vaginal, uterine, and other muscle contractions occur. There is a massive release of muscle tension. Regularly orgasmic women will achieve orgasm 50 to 70 percent of the time; other times women may experience a satisfying prolonged plateau phase. Resolution — The final phase is often characterized as a gradual, pleasant diminishing of sexual tension and response, differing in the time it lasts among individuals.
The Masters and Johnson model was later altered by Kaplan. Excitement was divided into desire followed by arousal. This highlights the differences between a cerebral event (desire) and a peripheral event (arousal). Some questioned whether women followed this linear sequence of events. Newer theories have concluded that the female sexual response is quite different from the male response, and does not follow a linear progression.
Biopsychosocial sexual response model — Another way to think about the female sexual response focuses on the complex interplay among four major components in a woman's life, rather than the more linear phases described by Masters and Johnson. These components are: Biology Psychology Sociocultural influences Interpersonal relationships
Using this model, sexual function or dysfunction can be defined using a combination of components. Thus, using medication to treat a biological factor without addressing other factors is unlikely to be successful for a woman with sexual dysfunction.
Proponents of this model believe that a large component of a woman's sexual desire is "responsive" versus "spontaneous." That is, desire may not occur spontaneously, but rather in response to an interplay of the factors listed above. Spontaneous desire may occur for some women, but is not essential. Therefore, a woman who does not have spontaneous desire does not necessarily have sexual dysfunction. The goal of sexual activity is satisfaction for both partners, which may or may not include orgasm.
SEXUAL CHANGES IN MIDLIFE — Sexuality and sexual capacity evolve over a lifetime and are based on personal experiences, interests, cultural attitudes, interpersonal relationships, desires, behaviors, physiology, and other factors. As midlife approaches, this foundation of sexuality can be altered by changes that affect many aspects of sexuality and sexual function. In learning about these changes, it is important to remember that they do not occur in isolation; a change in one is likely to affect other areas.
Understanding how the changes in midlife affect sexual response is an important first step in the treatment of sexual dysfunction. This can help to eliminate the fear and embarrassment that might otherwise occur, and which sometimes causes further detrimental changes in the sexual response.
Changes in estrogen — Estrogen is a female hormone produced by the ovaries. During the perimenopause, erratic ovarian function leads to estrogen levels that fluctuate. After menopause, estrogen levels begin to decline, causing a decrease in blood flow to the genitalia. This can lead to changes that affect sexual function. These include: Changes in the vagina, including narrowing, dryness, an increase in pH (which can lead to infections), and a decrease in elasticity of the vaginal wall. Changes in the bladder, which can lead to increased frequency of urination and, in some women, predispose them to loss of urine (incontinence). (See "Patient information: Urinary incontinence"). Changes in the clitoris, with decreased blood flow to the area and shrinkage of the structure. Nerve changes such as decreased sensitivity to touch and delayed reaction time to physical stimulation.
Vaginal dryness and decreased elasticity can result in discomfort or pain during sex. The decrease in blood flow to the genital organs can lead to diminished vascular congestion in the vagina and clitoris, thereby contributing to delayed arousal, delayed or absent orgasm, or diminished intensity of orgasm.
Changes in androgens — Women make more testosterone than estrogen; all of the estrogen made by the ovary is a by-product of testosterone. It is known to be important for the development of libido in men, but its role in women is not well understood. For example, blood levels of testosterone are not a good predictor of libido in women.
Other things can decrease androgen levels, including medications, such as birth control pills and oral estrogen replacement therapy, which are taken by many women in midlife.
The impact of male sexuality — Midlife changes in a woman's male sex partner can affect her sexual response. Male sexual dysfunction, (erectile dysfunction, diminished libido, or abnormal ejaculation), first emerges as a problem for men in their early 40s and increases with advancing age (show figure 2).
Changes in libido — Decreased libido or sexual desire is a common problem among women in the perimenopause or menopausal transition, but women of any age may experience it. Decreased libido refers to a decrease in sexual appetite, drive, and fantasy. Sexual arousal is best understood in physiologic and vascular terms while libido is more psychosocial and behavioral and is impacted by a multitude of factors in daily life and relationships. A desire for intimacy can be diminished in spite of normal levels of testosterone. Many factors may be involved, including:
Partner availability — Women tend to live longer than men, resulting in a natural shortage of males 50 years of age and older. At the same time, many men seek out younger partners, further affecting the availability of partners for women in midlife and beyond.
Personal well-being — A woman's sense of personal well being is important to sexual interest and activity. A woman who does not feel her best physically or emotionally may experience a decrease in sex drive.
Health and socioeconomic circumstances — Studies have shown that sexual dysfunction is highest in women with poor health, low income, and a history of infrequent sexual interest. It is also more common among women and men with poor physical and emotional health.
Performance anxiety — Women may fear pain during sex because of vaginal dryness or other changes in the vagina. This fear can diminish lubrication, causing further pain. Women may also develop anxiety if they are not satisfied by a sexual experience or feel they have not satisfied their partner. Women may avoid sexual contact with their male partner if he has a history of sexual dysfunction; avoiding sex prevents his potential sexual failure and her perceived inability to arouse him.
Medical issues — A host of medical issues in midlife can impact a woman's sexual desire and responsiveness. Problems such as coronary artery disease and arthritis can diminish the physical ability to perform sex. Indeed, arthritis has been identified in some studies as the most common cause of sexual inactivity in the United States. Other conditions such as Parkinson's disease, complications of diabetes, or alcohol and drug abuse can impair arousal and ability to experience orgasm. A psychiatric or emotional problem may impact sexual function, either due to the disorder itself or its treatment (see below).
Medications — Both prescription and nonprescription medications can alter sexual desire, arousal, and orgasm. As an example, medicines that alter blood flow (such as blood pressure medicines), those that affect the nervous system (such as some psychiatric medicines), or those that dry the skin or mucous membranes (such as cold or allergy medicines) can affect sexual function. As mentioned before, birth control pills, patches, and rings, as well as oral hormone replacement therapy can affect testosterone levels in women and decrease sexual desire.
Antidepressants — Selective serotonin reuptake inhibitors, or SSRIs, which are commonly used to treat depression, premenstrual syndrome, and anxiety frequently cause sexual dysfunction in both men and women; side effects can include diminished sexual desire, arousal, and orgasm. Examples of SSRIs include fluoxetine (Prozac®) and paroxetine (Paxil®).
Patients with sexual side effects from SSRIs should speak with their healthcare provider about trying a drug holiday or alternate medication to reduce or eliminate their symptoms. A drug holiday involves stopping the SSRI for two to three days, which decreases the amount of drug in the body and may improve a patient's ability to become aroused and experience orgasm. Drug holidays have not been proven to be consistently helpful for all patients and should only be tried after consulting with a healthcare provider.
Patients with sexual side effects may benefit from a change in dose or type of antidepressant medication, or from the addition of a second medication. Bupropion (Wellbutrin®) has been shown to have few or no sexual side effects, and may be used in addition to or in place of an SSRI in certain carefully selected patients.
Erectile dysfunction medications — The medications commonly used for men with erectile problems, including Sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®), do not improve sexual function for most women.
Surgery — Operations commonly performed on women at midlife may have an effect on sexual response. In particular, those affecting the breasts or the genital tract may have an impact related to altered body image and function, as well as the psychological impact of an underlying diagnosis such as cancer.
Hysterectomy — Contrary to popular belief, hysterectomy, or removal of the uterus, may result in improved sexual function. (See "Patient information: Vaginal hysterectomy" and see "Patient information: Abdominal hysterectomy"). Relief from symptoms such as bleeding or pain may spark a renewed interest in sex. One study followed over 1000 women for two years after hysterectomy. The percentage of women who engaged in sexual relations increased from about 71 percent before the surgery to 77 percent at one and two years after the operation. Before surgery, 19 percent of women reported painful sex; after surgery, only 4 percent reported this problem. The number of women who experienced orgasm increased from 92 to 95 percent; libido increased as well. However, some women note a decrease or total absence of orgasm after hysterectomy.
Oophorectomy — Removal of the ovaries during hysterectomy is not always necessary. After menopause, the ovaries continue to produce testosterone, though they no longer produce estrogen. In the past, women have been advised to have their ovaries removed since the uterus was also being removed, they were near or beyond menopause, and to avoid a future risk of ovarian cancer. Although there is a risk for ovarian cancer if the ovaries are not removed, this risk may be acceptable depending upon the woman's risk profile. The average woman's lifetime risk of ovarian cancer is small, approximately two percent.
Removal of the cervix — Hysterectomy does not necessarily require removal of the cervix. Supracervical hysterectomy removes the lower part of the uterus through an incision in the abdomen, but leaves the cervix in place. Some clinicians believe that leaving the cervix maintains the blood vessel and nerve supply to the top of the vagina, which actively participates in orgasm. By this theory, the cervix contributes to orgasmic response. However, studies have demonstrated that sexual satisfaction does not appear to differ between women with and without a cervix after hysterectomy. Patients should discuss plans for surgery with their doctor.
TREATMENT — A number of treatments are available for women with sexual dysfunction. Treatments that do not involve medications may be tried first. In some women, treatment with medicine may also be recommended.
Non-pharmacologic treatments — One of the major points to remember when sexual dysfunction occurs is that decreasing the frequency of sex is likely to make the problem worse. In their early work, Masters and Johnson discovered that regular sexual activity helps maintain a woman's sexual capacity because it actually affects the chemical balance in the vagina and maintains blood flow to the genitalia. If possible, a treatment plan should address the issue of regular sexual activity. The benefits of regular activity do not require a partner; similar benefits are seen with sexual activity of any kind, including masturbation or sexual fantasy, all of which increase blood flow.
Vaginal weights — In some women, vaginal weights are useful to help strengthen the muscles in and around the genital area. This may improve awareness of sexual response in some women with orgasmic disorders. Vaginal weights can also decrease or eliminate urine leakage during sexual activity. (See "Patient information: Urinary incontinence", section on vaginal pessaries).
Vaginal weights are usually available in sets of five weights. The woman inserts the lightest weight and remains upright for 15 minutes, twice a day. With the weight in place, she should feel the urge to hold it in. After a number of days, she should not longer feel the urge to hold in the weight because an improvement in muscle tone has occurred. She then moves up to the next weight.
Increased tactile stimulation — Men and women can have decreased blood flow to the genitals during midlife. Increasing manual and/or oral stimulation can be helpful to achieve or maintain an erection in the male or arousal in the female.
Sexual frequency — The "optimal" frequency for sexual contact is what each pair of partners finds comfortable. Women do not need to initiate contact to enjoy sex; many women can respond to their partner's sexual signals, become aroused, and enjoy a sexual experience that is initiated by their partner. Ejaculation and/or orgasm is not required with each sexual encounter.
Treatment with medications — Non-pharmacologic treatments may not be sufficient to provide sexual satisfaction in some women. Medications may be tried in these women, with the goal being to maintain hormone levels and increase blood flow to the genitals.
Estrogen — Estrogen may positively affect sexual function by helping to maintain normal lubrication and elasticity of the vagina. It can also improve mood and affect nerve growth and response, which may impact arousal. In one study, estrogen was shown to increase clitoral sensitivity, rate of orgasm, and sexual desire. In another, the rate of orgasm and sexual arousal were not affected, but women treated with estrogen reported an increase in satisfaction with the frequency of sexual activity, sexual fantasies, enjoyment of sex, vaginal lubrication, and the level of discomfort during sex.
In general, women with symptoms of vaginal dryness should use topical (vaginal) estrogen rather than oral estrogen since it is far more effective for the sexual symptoms. Treatment with oral estrogen can decrease testosterone levels; topical estrogen avoids this negative effect.
Progestogens — Progestogens are progesterone-like medications that are an important component of hormone replacement therapy in women with a uterus. A number of studies have shown that treatment with certain potent synthetic progestogens can increase sexual problems in women. Studies are underway to determine if various combinations of estrogens with synthetic progestogens alters sexual response.
Androgens — Although androgens (such as testosterone) may be important in the female sexual response, treatment with androgen replacement is highly controversial. Estratest®, a combination of estrogen and testosterone, is the only androgen therapy currently available. It is available for the treatment of hot flashes that do no respond to estrogen alone.
There are no adrogen products that are approved for use in women with sexual dysfunctions, thus use of androgen therapy remains investigational. Studies have shown mixed results; those that carefully select participants with sexual dysfunction have shown statistically significant but clinically modest improvements when compared to placebo. Of note, in all of the transdermal testosterone trials, clinical improvement is seen only with higher than normal blood levels of testosterone. The long-term risks of these higher testosterone levels are unknown.
Side effects remain a concern, as these medicines can decrease HDL (good cholesterol) levels significantly. Masculinizing effects, such as body hair growth, scalp hair loss, oily skin, and acne can also occur.
Studies on the use of DHEA (dehydroepiandrosterone), available as a nutritional supplement in the United States, is beneficial for improving libido in women with adrenal insufficiency. DHEA is not proven to be safe or effective for other patients, and is not generally recommended.
Herbal therapies — The literature on herbal therapies for the treatment of sexual dysfunction in women is sparse. A small number of studies have shown that treatment with St. John's wort, ginseng, or dong quai did not have a significant effect on sexual function. Herbal products such as yohimbine and ginkgo biloba have been reported to enhance desire, arousal, and orgasm in both women and men, but the data is limited. Sex creams that contain menthol are available for application to the clitoris, and are promoted for their ability to enhance sensation. However, there are no studies that show these creams to be effective. In addition, some have ingredients that can cause irritation of vulvar or vaginal tissues.
More studies are needed to ensure herbal therapies are safe and effective. The production of herbs is not regulated by the government, and it is not always possible to know that an herbal product contains the type and quantity of ingredient that the label indicates, or that it is free of potentially dangerous additives. Patients who wish to use herbal therapies are urged to do so with caution.
Surgical treatments — Surgery is very rarely necessary to make the vagina "better" for sex. Women with congenital abnormalities of the vagina, who have had female circumcision (also known as female genital mutilation), and those with traumatic injuries from childbirth are a few groups that may benefit from careful surgical treatment. All women should be wary of advertisements for "vaginal rejuvenation surgery"; these procedures can be costly and painful, are permanent, and are unlikely to improve a woman or her partner's sexual enjoyment.
Future directions — A number of products are undergoing research and development for use in women with sexual dysfunction: Tibolone, currently available in Europe and Australia, may gain FDA approval in the United States soon. It is taken by mouth as hormone replacement therapy and may also help improve sexual function. Use of Sildenafil (Viagra®) in women is also undergoing evaluation. Preliminary findings demonstrate positive effects in some women with adequate testosterone levels who have problems with arousal and orgasm.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Mayo Clinic
(www.mayoclinic.com)
The Hormone Foundation
(www.hormone.org)
American Academy of Family Physicians
(www.familydoctor.org, search for sexual problems)
[1-7]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Phillips, NA, Female sexual dysfunction: Evaluation and treatment. Am Fam physician 2000; 62:127.
2. Sarrel, PM. Sexuality and menopause. Obstet Gyenecol. 1990; 75:26S.
3. Nathorst-Boos, J, Wiklund, I, Mattsson, LA, et al. Is sexual life influenced by transdermal estrogen therapy? A double blind placebo controlled study in postmenopausal women. Acta Obstet Gynecol Scand 1993; 72:656.
4. Myers, LS, Dixen, J, Morrissette, D, et al. Effects of estrogen, androgen, and progestin on sexual pscychophysiology and behavior in postmenopausal women. J Clin Endocrinol Metab 1990; 70:1124.
5. Masters, WH, Johnson, VE. Human Sexual Response. Boston, Mass. Little, Brown, 1966.
6. Basson, R. Female sexual response: The role of drugs in the management of sexual dysfunction. Obstet Gynecol 2001; 98:350.
7. Rhodes, JC, Kjerulff, KH, Langenberg, PW, Guzinski, GM. Hysterectomy and sexual functioning. JAMA 1999; 282:1934.
Sexual problems in women
INTRODUCTION — Sexual problems can occur in women of any age. Sexual dysfunction is a term used to describe difficulties in libido (sex drive), arousal, orgasm, or pain with sex that is bothersome to an individual or their sexual partner. It can occur in men or women at any age, though women in midlife are at higher risk of changes that can cause sexual dysfunction. In this topic review, midlife refers to the middle part of a woman's chronological years, between 35 and 65 years.
For most women, the earliest changes begin when they are in their 30s and continue through the menopause. The years before menopause are commonly referred to as the perimenopause or menopausal transition, which can precede a woman's final menstrual period by 10 years (show figure 1).
A host of hormonal, vascular, and other changes occur prior to the menopausal transition and continue in postmenopause; these changes can affect sexuality in a number of ways. To describe these changes, it will be helpful to review the basic elements of the normal sexual response.
OVERVIEW OF THE NORMAL SEXUAL RESPONSE — Two models have been proposed to describe the human sexual response. While they differ in many ways, both acknowledge that the brain is the most important sex organ in the human body, and that nerves and blood vessels are critical components in initiating and maintaining the human sexual response.
Masters and Johnson model — Masters and Johnson first described the human sexual response as a linear progression through a series of phases. They describe the response as follows: Excitement — At the start of the excitement phase, the brain stimulates nerves in the body, which causes changes in blood flow. This increases flow to the genital area; in women, the vaginal wall becomes lubricated and expands, the labia increase in size and spread open, and the clitoris enlarges. Other areas of the skin may be affected by the increased blood flow, resulting in nipple erection and flushing of the skin, sometimes known as the "sex flush." Plateau — Changes in the genital area progress and an increase in muscle tension occurs. Blood flow to the labia increases, glands in the labia produce secretions, and the vagina elongates. Orgasm — In the orgasm phase, vaginal, uterine, and other muscle contractions occur. There is a massive release of muscle tension. Regularly orgasmic women will achieve orgasm 50 to 70 percent of the time; other times women may experience a satisfying prolonged plateau phase. Resolution — The final phase is often characterized as a gradual, pleasant diminishing of sexual tension and response, differing in the time it lasts among individuals.
The Masters and Johnson model was later altered by Kaplan. Excitement was divided into desire followed by arousal. This highlights the differences between a cerebral event (desire) and a peripheral event (arousal). Some questioned whether women followed this linear sequence of events. Newer theories have concluded that the female sexual response is quite different from the male response, and does not follow a linear progression.
Biopsychosocial sexual response model — Another way to think about the female sexual response focuses on the complex interplay among four major components in a woman's life, rather than the more linear phases described by Masters and Johnson. These components are: Biology Psychology Sociocultural influences Interpersonal relationships
Using this model, sexual function or dysfunction can be defined using a combination of components. Thus, using medication to treat a biological factor without addressing other factors is unlikely to be successful for a woman with sexual dysfunction.
Proponents of this model believe that a large component of a woman's sexual desire is "responsive" versus "spontaneous." That is, desire may not occur spontaneously, but rather in response to an interplay of the factors listed above. Spontaneous desire may occur for some women, but is not essential. Therefore, a woman who does not have spontaneous desire does not necessarily have sexual dysfunction. The goal of sexual activity is satisfaction for both partners, which may or may not include orgasm.
SEXUAL CHANGES IN MIDLIFE — Sexuality and sexual capacity evolve over a lifetime and are based on personal experiences, interests, cultural attitudes, interpersonal relationships, desires, behaviors, physiology, and other factors. As midlife approaches, this foundation of sexuality can be altered by changes that affect many aspects of sexuality and sexual function. In learning about these changes, it is important to remember that they do not occur in isolation; a change in one is likely to affect other areas.
Understanding how the changes in midlife affect sexual response is an important first step in the treatment of sexual dysfunction. This can help to eliminate the fear and embarrassment that might otherwise occur, and which sometimes causes further detrimental changes in the sexual response.
Changes in estrogen — Estrogen is a female hormone produced by the ovaries. During the perimenopause, erratic ovarian function leads to estrogen levels that fluctuate. After menopause, estrogen levels begin to decline, causing a decrease in blood flow to the genitalia. This can lead to changes that affect sexual function. These include: Changes in the vagina, including narrowing, dryness, an increase in pH (which can lead to infections), and a decrease in elasticity of the vaginal wall. Changes in the bladder, which can lead to increased frequency of urination and, in some women, predispose them to loss of urine (incontinence). (See "Patient information: Urinary incontinence"). Changes in the clitoris, with decreased blood flow to the area and shrinkage of the structure. Nerve changes such as decreased sensitivity to touch and delayed reaction time to physical stimulation.
Vaginal dryness and decreased elasticity can result in discomfort or pain during sex. The decrease in blood flow to the genital organs can lead to diminished vascular congestion in the vagina and clitoris, thereby contributing to delayed arousal, delayed or absent orgasm, or diminished intensity of orgasm.
Changes in androgens — Women make more testosterone than estrogen; all of the estrogen made by the ovary is a by-product of testosterone. It is known to be important for the development of libido in men, but its role in women is not well understood. For example, blood levels of testosterone are not a good predictor of libido in women.
Other things can decrease androgen levels, including medications, such as birth control pills and oral estrogen replacement therapy, which are taken by many women in midlife.
The impact of male sexuality — Midlife changes in a woman's male sex partner can affect her sexual response. Male sexual dysfunction, (erectile dysfunction, diminished libido, or abnormal ejaculation), first emerges as a problem for men in their early 40s and increases with advancing age (show figure 2).
Changes in libido — Decreased libido or sexual desire is a common problem among women in the perimenopause or menopausal transition, but women of any age may experience it. Decreased libido refers to a decrease in sexual appetite, drive, and fantasy. Sexual arousal is best understood in physiologic and vascular terms while libido is more psychosocial and behavioral and is impacted by a multitude of factors in daily life and relationships. A desire for intimacy can be diminished in spite of normal levels of testosterone. Many factors may be involved, including:
Partner availability — Women tend to live longer than men, resulting in a natural shortage of males 50 years of age and older. At the same time, many men seek out younger partners, further affecting the availability of partners for women in midlife and beyond.
Personal well-being — A woman's sense of personal well being is important to sexual interest and activity. A woman who does not feel her best physically or emotionally may experience a decrease in sex drive.
Health and socioeconomic circumstances — Studies have shown that sexual dysfunction is highest in women with poor health, low income, and a history of infrequent sexual interest. It is also more common among women and men with poor physical and emotional health.
Performance anxiety — Women may fear pain during sex because of vaginal dryness or other changes in the vagina. This fear can diminish lubrication, causing further pain. Women may also develop anxiety if they are not satisfied by a sexual experience or feel they have not satisfied their partner. Women may avoid sexual contact with their male partner if he has a history of sexual dysfunction; avoiding sex prevents his potential sexual failure and her perceived inability to arouse him.
Medical issues — A host of medical issues in midlife can impact a woman's sexual desire and responsiveness. Problems such as coronary artery disease and arthritis can diminish the physical ability to perform sex. Indeed, arthritis has been identified in some studies as the most common cause of sexual inactivity in the United States. Other conditions such as Parkinson's disease, complications of diabetes, or alcohol and drug abuse can impair arousal and ability to experience orgasm. A psychiatric or emotional problem may impact sexual function, either due to the disorder itself or its treatment (see below).
Medications — Both prescription and nonprescription medications can alter sexual desire, arousal, and orgasm. As an example, medicines that alter blood flow (such as blood pressure medicines), those that affect the nervous system (such as some psychiatric medicines), or those that dry the skin or mucous membranes (such as cold or allergy medicines) can affect sexual function. As mentioned before, birth control pills, patches, and rings, as well as oral hormone replacement therapy can affect testosterone levels in women and decrease sexual desire.
Antidepressants — Selective serotonin reuptake inhibitors, or SSRIs, which are commonly used to treat depression, premenstrual syndrome, and anxiety frequently cause sexual dysfunction in both men and women; side effects can include diminished sexual desire, arousal, and orgasm. Examples of SSRIs include fluoxetine (Prozac®) and paroxetine (Paxil®).
Patients with sexual side effects from SSRIs should speak with their healthcare provider about trying a drug holiday or alternate medication to reduce or eliminate their symptoms. A drug holiday involves stopping the SSRI for two to three days, which decreases the amount of drug in the body and may improve a patient's ability to become aroused and experience orgasm. Drug holidays have not been proven to be consistently helpful for all patients and should only be tried after consulting with a healthcare provider.
Patients with sexual side effects may benefit from a change in dose or type of antidepressant medication, or from the addition of a second medication. Bupropion (Wellbutrin®) has been shown to have few or no sexual side effects, and may be used in addition to or in place of an SSRI in certain carefully selected patients.
Erectile dysfunction medications — The medications commonly used for men with erectile problems, including Sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®), do not improve sexual function for most women.
Surgery — Operations commonly performed on women at midlife may have an effect on sexual response. In particular, those affecting the breasts or the genital tract may have an impact related to altered body image and function, as well as the psychological impact of an underlying diagnosis such as cancer.
Hysterectomy — Contrary to popular belief, hysterectomy, or removal of the uterus, may result in improved sexual function. (See "Patient information: Vaginal hysterectomy" and see "Patient information: Abdominal hysterectomy"). Relief from symptoms such as bleeding or pain may spark a renewed interest in sex. One study followed over 1000 women for two years after hysterectomy. The percentage of women who engaged in sexual relations increased from about 71 percent before the surgery to 77 percent at one and two years after the operation. Before surgery, 19 percent of women reported painful sex; after surgery, only 4 percent reported this problem. The number of women who experienced orgasm increased from 92 to 95 percent; libido increased as well. However, some women note a decrease or total absence of orgasm after hysterectomy.
Oophorectomy — Removal of the ovaries during hysterectomy is not always necessary. After menopause, the ovaries continue to produce testosterone, though they no longer produce estrogen. In the past, women have been advised to have their ovaries removed since the uterus was also being removed, they were near or beyond menopause, and to avoid a future risk of ovarian cancer. Although there is a risk for ovarian cancer if the ovaries are not removed, this risk may be acceptable depending upon the woman's risk profile. The average woman's lifetime risk of ovarian cancer is small, approximately two percent.
Removal of the cervix — Hysterectomy does not necessarily require removal of the cervix. Supracervical hysterectomy removes the lower part of the uterus through an incision in the abdomen, but leaves the cervix in place. Some clinicians believe that leaving the cervix maintains the blood vessel and nerve supply to the top of the vagina, which actively participates in orgasm. By this theory, the cervix contributes to orgasmic response. However, studies have demonstrated that sexual satisfaction does not appear to differ between women with and without a cervix after hysterectomy. Patients should discuss plans for surgery with their doctor.
TREATMENT — A number of treatments are available for women with sexual dysfunction. Treatments that do not involve medications may be tried first. In some women, treatment with medicine may also be recommended.
Non-pharmacologic treatments — One of the major points to remember when sexual dysfunction occurs is that decreasing the frequency of sex is likely to make the problem worse. In their early work, Masters and Johnson discovered that regular sexual activity helps maintain a woman's sexual capacity because it actually affects the chemical balance in the vagina and maintains blood flow to the genitalia. If possible, a treatment plan should address the issue of regular sexual activity. The benefits of regular activity do not require a partner; similar benefits are seen with sexual activity of any kind, including masturbation or sexual fantasy, all of which increase blood flow.
Vaginal weights — In some women, vaginal weights are useful to help strengthen the muscles in and around the genital area. This may improve awareness of sexual response in some women with orgasmic disorders. Vaginal weights can also decrease or eliminate urine leakage during sexual activity. (See "Patient information: Urinary incontinence", section on vaginal pessaries).
Vaginal weights are usually available in sets of five weights. The woman inserts the lightest weight and remains upright for 15 minutes, twice a day. With the weight in place, she should feel the urge to hold it in. After a number of days, she should not longer feel the urge to hold in the weight because an improvement in muscle tone has occurred. She then moves up to the next weight.
Increased tactile stimulation — Men and women can have decreased blood flow to the genitals during midlife. Increasing manual and/or oral stimulation can be helpful to achieve or maintain an erection in the male or arousal in the female.
Sexual frequency — The "optimal" frequency for sexual contact is what each pair of partners finds comfortable. Women do not need to initiate contact to enjoy sex; many women can respond to their partner's sexual signals, become aroused, and enjoy a sexual experience that is initiated by their partner. Ejaculation and/or orgasm is not required with each sexual encounter.
Treatment with medications — Non-pharmacologic treatments may not be sufficient to provide sexual satisfaction in some women. Medications may be tried in these women, with the goal being to maintain hormone levels and increase blood flow to the genitals.
Estrogen — Estrogen may positively affect sexual function by helping to maintain normal lubrication and elasticity of the vagina. It can also improve mood and affect nerve growth and response, which may impact arousal. In one study, estrogen was shown to increase clitoral sensitivity, rate of orgasm, and sexual desire. In another, the rate of orgasm and sexual arousal were not affected, but women treated with estrogen reported an increase in satisfaction with the frequency of sexual activity, sexual fantasies, enjoyment of sex, vaginal lubrication, and the level of discomfort during sex.
In general, women with symptoms of vaginal dryness should use topical (vaginal) estrogen rather than oral estrogen since it is far more effective for the sexual symptoms. Treatment with oral estrogen can decrease testosterone levels; topical estrogen avoids this negative effect.
Progestogens — Progestogens are progesterone-like medications that are an important component of hormone replacement therapy in women with a uterus. A number of studies have shown that treatment with certain potent synthetic progestogens can increase sexual problems in women. Studies are underway to determine if various combinations of estrogens with synthetic progestogens alters sexual response.
Androgens — Although androgens (such as testosterone) may be important in the female sexual response, treatment with androgen replacement is highly controversial. Estratest®, a combination of estrogen and testosterone, is the only androgen therapy currently available. It is available for the treatment of hot flashes that do no respond to estrogen alone.
There are no adrogen products that are approved for use in women with sexual dysfunctions, thus use of androgen therapy remains investigational. Studies have shown mixed results; those that carefully select participants with sexual dysfunction have shown statistically significant but clinically modest improvements when compared to placebo. Of note, in all of the transdermal testosterone trials, clinical improvement is seen only with higher than normal blood levels of testosterone. The long-term risks of these higher testosterone levels are unknown.
Side effects remain a concern, as these medicines can decrease HDL (good cholesterol) levels significantly. Masculinizing effects, such as body hair growth, scalp hair loss, oily skin, and acne can also occur.
Studies on the use of DHEA (dehydroepiandrosterone), available as a nutritional supplement in the United States, is beneficial for improving libido in women with adrenal insufficiency. DHEA is not proven to be safe or effective for other patients, and is not generally recommended.
Herbal therapies — The literature on herbal therapies for the treatment of sexual dysfunction in women is sparse. A small number of studies have shown that treatment with St. John's wort, ginseng, or dong quai did not have a significant effect on sexual function. Herbal products such as yohimbine and ginkgo biloba have been reported to enhance desire, arousal, and orgasm in both women and men, but the data is limited. Sex creams that contain menthol are available for application to the clitoris, and are promoted for their ability to enhance sensation. However, there are no studies that show these creams to be effective. In addition, some have ingredients that can cause irritation of vulvar or vaginal tissues.
More studies are needed to ensure herbal therapies are safe and effective. The production of herbs is not regulated by the government, and it is not always possible to know that an herbal product contains the type and quantity of ingredient that the label indicates, or that it is free of potentially dangerous additives. Patients who wish to use herbal therapies are urged to do so with caution.
Surgical treatments — Surgery is very rarely necessary to make the vagina "better" for sex. Women with congenital abnormalities of the vagina, who have had female circumcision (also known as female genital mutilation), and those with traumatic injuries from childbirth are a few groups that may benefit from careful surgical treatment. All women should be wary of advertisements for "vaginal rejuvenation surgery"; these procedures can be costly and painful, are permanent, and are unlikely to improve a woman or her partner's sexual enjoyment.
Future directions — A number of products are undergoing research and development for use in women with sexual dysfunction: Tibolone, currently available in Europe and Australia, may gain FDA approval in the United States soon. It is taken by mouth as hormone replacement therapy and may also help improve sexual function. Use of Sildenafil (Viagra®) in women is also undergoing evaluation. Preliminary findings demonstrate positive effects in some women with adequate testosterone levels who have problems with arousal and orgasm.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Mayo Clinic
(www.mayoclinic.com)
The Hormone Foundation
(www.hormone.org)
American Academy of Family Physicians
(www.familydoctor.org, search for sexual problems)
[1-7]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Phillips, NA, Female sexual dysfunction: Evaluation and treatment. Am Fam physician 2000; 62:127.
2. Sarrel, PM. Sexuality and menopause. Obstet Gyenecol. 1990; 75:26S.
3. Nathorst-Boos, J, Wiklund, I, Mattsson, LA, et al. Is sexual life influenced by transdermal estrogen therapy? A double blind placebo controlled study in postmenopausal women. Acta Obstet Gynecol Scand 1993; 72:656.
4. Myers, LS, Dixen, J, Morrissette, D, et al. Effects of estrogen, androgen, and progestin on sexual pscychophysiology and behavior in postmenopausal women. J Clin Endocrinol Metab 1990; 70:1124.
5. Masters, WH, Johnson, VE. Human Sexual Response. Boston, Mass. Little, Brown, 1966.
6. Basson, R. Female sexual response: The role of drugs in the management of sexual dysfunction. Obstet Gynecol 2001; 98:350.
7. Rhodes, JC, Kjerulff, KH, Langenberg, PW, Guzinski, GM. Hysterectomy and sexual functioning. JAMA 1999; 282:1934.
For most women, the earliest changes begin when they are in their 30s and continue through the menopause. The years before menopause are commonly referred to as the perimenopause or menopausal transition, which can precede a woman's final menstrual period by 10 years (show figure 1).
A host of hormonal, vascular, and other changes occur prior to the menopausal transition and continue in postmenopause; these changes can affect sexuality in a number of ways. To describe these changes, it will be helpful to review the basic elements of the normal sexual response.
OVERVIEW OF THE NORMAL SEXUAL RESPONSE — Two models have been proposed to describe the human sexual response. While they differ in many ways, both acknowledge that the brain is the most important sex organ in the human body, and that nerves and blood vessels are critical components in initiating and maintaining the human sexual response.
Masters and Johnson model — Masters and Johnson first described the human sexual response as a linear progression through a series of phases. They describe the response as follows: Excitement — At the start of the excitement phase, the brain stimulates nerves in the body, which causes changes in blood flow. This increases flow to the genital area; in women, the vaginal wall becomes lubricated and expands, the labia increase in size and spread open, and the clitoris enlarges. Other areas of the skin may be affected by the increased blood flow, resulting in nipple erection and flushing of the skin, sometimes known as the "sex flush." Plateau — Changes in the genital area progress and an increase in muscle tension occurs. Blood flow to the labia increases, glands in the labia produce secretions, and the vagina elongates. Orgasm — In the orgasm phase, vaginal, uterine, and other muscle contractions occur. There is a massive release of muscle tension. Regularly orgasmic women will achieve orgasm 50 to 70 percent of the time; other times women may experience a satisfying prolonged plateau phase. Resolution — The final phase is often characterized as a gradual, pleasant diminishing of sexual tension and response, differing in the time it lasts among individuals.
The Masters and Johnson model was later altered by Kaplan. Excitement was divided into desire followed by arousal. This highlights the differences between a cerebral event (desire) and a peripheral event (arousal). Some questioned whether women followed this linear sequence of events. Newer theories have concluded that the female sexual response is quite different from the male response, and does not follow a linear progression.
Biopsychosocial sexual response model — Another way to think about the female sexual response focuses on the complex interplay among four major components in a woman's life, rather than the more linear phases described by Masters and Johnson. These components are: Biology Psychology Sociocultural influences Interpersonal relationships
Using this model, sexual function or dysfunction can be defined using a combination of components. Thus, using medication to treat a biological factor without addressing other factors is unlikely to be successful for a woman with sexual dysfunction.
Proponents of this model believe that a large component of a woman's sexual desire is "responsive" versus "spontaneous." That is, desire may not occur spontaneously, but rather in response to an interplay of the factors listed above. Spontaneous desire may occur for some women, but is not essential. Therefore, a woman who does not have spontaneous desire does not necessarily have sexual dysfunction. The goal of sexual activity is satisfaction for both partners, which may or may not include orgasm.
SEXUAL CHANGES IN MIDLIFE — Sexuality and sexual capacity evolve over a lifetime and are based on personal experiences, interests, cultural attitudes, interpersonal relationships, desires, behaviors, physiology, and other factors. As midlife approaches, this foundation of sexuality can be altered by changes that affect many aspects of sexuality and sexual function. In learning about these changes, it is important to remember that they do not occur in isolation; a change in one is likely to affect other areas.
Understanding how the changes in midlife affect sexual response is an important first step in the treatment of sexual dysfunction. This can help to eliminate the fear and embarrassment that might otherwise occur, and which sometimes causes further detrimental changes in the sexual response.
Changes in estrogen — Estrogen is a female hormone produced by the ovaries. During the perimenopause, erratic ovarian function leads to estrogen levels that fluctuate. After menopause, estrogen levels begin to decline, causing a decrease in blood flow to the genitalia. This can lead to changes that affect sexual function. These include: Changes in the vagina, including narrowing, dryness, an increase in pH (which can lead to infections), and a decrease in elasticity of the vaginal wall. Changes in the bladder, which can lead to increased frequency of urination and, in some women, predispose them to loss of urine (incontinence). (See "Patient information: Urinary incontinence"). Changes in the clitoris, with decreased blood flow to the area and shrinkage of the structure. Nerve changes such as decreased sensitivity to touch and delayed reaction time to physical stimulation.
Vaginal dryness and decreased elasticity can result in discomfort or pain during sex. The decrease in blood flow to the genital organs can lead to diminished vascular congestion in the vagina and clitoris, thereby contributing to delayed arousal, delayed or absent orgasm, or diminished intensity of orgasm.
Changes in androgens — Women make more testosterone than estrogen; all of the estrogen made by the ovary is a by-product of testosterone. It is known to be important for the development of libido in men, but its role in women is not well understood. For example, blood levels of testosterone are not a good predictor of libido in women.
Other things can decrease androgen levels, including medications, such as birth control pills and oral estrogen replacement therapy, which are taken by many women in midlife.
The impact of male sexuality — Midlife changes in a woman's male sex partner can affect her sexual response. Male sexual dysfunction, (erectile dysfunction, diminished libido, or abnormal ejaculation), first emerges as a problem for men in their early 40s and increases with advancing age (show figure 2).
Changes in libido — Decreased libido or sexual desire is a common problem among women in the perimenopause or menopausal transition, but women of any age may experience it. Decreased libido refers to a decrease in sexual appetite, drive, and fantasy. Sexual arousal is best understood in physiologic and vascular terms while libido is more psychosocial and behavioral and is impacted by a multitude of factors in daily life and relationships. A desire for intimacy can be diminished in spite of normal levels of testosterone. Many factors may be involved, including:
Partner availability — Women tend to live longer than men, resulting in a natural shortage of males 50 years of age and older. At the same time, many men seek out younger partners, further affecting the availability of partners for women in midlife and beyond.
Personal well-being — A woman's sense of personal well being is important to sexual interest and activity. A woman who does not feel her best physically or emotionally may experience a decrease in sex drive.
Health and socioeconomic circumstances — Studies have shown that sexual dysfunction is highest in women with poor health, low income, and a history of infrequent sexual interest. It is also more common among women and men with poor physical and emotional health.
Performance anxiety — Women may fear pain during sex because of vaginal dryness or other changes in the vagina. This fear can diminish lubrication, causing further pain. Women may also develop anxiety if they are not satisfied by a sexual experience or feel they have not satisfied their partner. Women may avoid sexual contact with their male partner if he has a history of sexual dysfunction; avoiding sex prevents his potential sexual failure and her perceived inability to arouse him.
Medical issues — A host of medical issues in midlife can impact a woman's sexual desire and responsiveness. Problems such as coronary artery disease and arthritis can diminish the physical ability to perform sex. Indeed, arthritis has been identified in some studies as the most common cause of sexual inactivity in the United States. Other conditions such as Parkinson's disease, complications of diabetes, or alcohol and drug abuse can impair arousal and ability to experience orgasm. A psychiatric or emotional problem may impact sexual function, either due to the disorder itself or its treatment (see below).
Medications — Both prescription and nonprescription medications can alter sexual desire, arousal, and orgasm. As an example, medicines that alter blood flow (such as blood pressure medicines), those that affect the nervous system (such as some psychiatric medicines), or those that dry the skin or mucous membranes (such as cold or allergy medicines) can affect sexual function. As mentioned before, birth control pills, patches, and rings, as well as oral hormone replacement therapy can affect testosterone levels in women and decrease sexual desire.
Antidepressants — Selective serotonin reuptake inhibitors, or SSRIs, which are commonly used to treat depression, premenstrual syndrome, and anxiety frequently cause sexual dysfunction in both men and women; side effects can include diminished sexual desire, arousal, and orgasm. Examples of SSRIs include fluoxetine (Prozac®) and paroxetine (Paxil®).
Patients with sexual side effects from SSRIs should speak with their healthcare provider about trying a drug holiday or alternate medication to reduce or eliminate their symptoms. A drug holiday involves stopping the SSRI for two to three days, which decreases the amount of drug in the body and may improve a patient's ability to become aroused and experience orgasm. Drug holidays have not been proven to be consistently helpful for all patients and should only be tried after consulting with a healthcare provider.
Patients with sexual side effects may benefit from a change in dose or type of antidepressant medication, or from the addition of a second medication. Bupropion (Wellbutrin®) has been shown to have few or no sexual side effects, and may be used in addition to or in place of an SSRI in certain carefully selected patients.
Erectile dysfunction medications — The medications commonly used for men with erectile problems, including Sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®), do not improve sexual function for most women.
Surgery — Operations commonly performed on women at midlife may have an effect on sexual response. In particular, those affecting the breasts or the genital tract may have an impact related to altered body image and function, as well as the psychological impact of an underlying diagnosis such as cancer.
Hysterectomy — Contrary to popular belief, hysterectomy, or removal of the uterus, may result in improved sexual function. (See "Patient information: Vaginal hysterectomy" and see "Patient information: Abdominal hysterectomy"). Relief from symptoms such as bleeding or pain may spark a renewed interest in sex. One study followed over 1000 women for two years after hysterectomy. The percentage of women who engaged in sexual relations increased from about 71 percent before the surgery to 77 percent at one and two years after the operation. Before surgery, 19 percent of women reported painful sex; after surgery, only 4 percent reported this problem. The number of women who experienced orgasm increased from 92 to 95 percent; libido increased as well. However, some women note a decrease or total absence of orgasm after hysterectomy.
Oophorectomy — Removal of the ovaries during hysterectomy is not always necessary. After menopause, the ovaries continue to produce testosterone, though they no longer produce estrogen. In the past, women have been advised to have their ovaries removed since the uterus was also being removed, they were near or beyond menopause, and to avoid a future risk of ovarian cancer. Although there is a risk for ovarian cancer if the ovaries are not removed, this risk may be acceptable depending upon the woman's risk profile. The average woman's lifetime risk of ovarian cancer is small, approximately two percent.
Removal of the cervix — Hysterectomy does not necessarily require removal of the cervix. Supracervical hysterectomy removes the lower part of the uterus through an incision in the abdomen, but leaves the cervix in place. Some clinicians believe that leaving the cervix maintains the blood vessel and nerve supply to the top of the vagina, which actively participates in orgasm. By this theory, the cervix contributes to orgasmic response. However, studies have demonstrated that sexual satisfaction does not appear to differ between women with and without a cervix after hysterectomy. Patients should discuss plans for surgery with their doctor.
TREATMENT — A number of treatments are available for women with sexual dysfunction. Treatments that do not involve medications may be tried first. In some women, treatment with medicine may also be recommended.
Non-pharmacologic treatments — One of the major points to remember when sexual dysfunction occurs is that decreasing the frequency of sex is likely to make the problem worse. In their early work, Masters and Johnson discovered that regular sexual activity helps maintain a woman's sexual capacity because it actually affects the chemical balance in the vagina and maintains blood flow to the genitalia. If possible, a treatment plan should address the issue of regular sexual activity. The benefits of regular activity do not require a partner; similar benefits are seen with sexual activity of any kind, including masturbation or sexual fantasy, all of which increase blood flow.
Vaginal weights — In some women, vaginal weights are useful to help strengthen the muscles in and around the genital area. This may improve awareness of sexual response in some women with orgasmic disorders. Vaginal weights can also decrease or eliminate urine leakage during sexual activity. (See "Patient information: Urinary incontinence", section on vaginal pessaries).
Vaginal weights are usually available in sets of five weights. The woman inserts the lightest weight and remains upright for 15 minutes, twice a day. With the weight in place, she should feel the urge to hold it in. After a number of days, she should not longer feel the urge to hold in the weight because an improvement in muscle tone has occurred. She then moves up to the next weight.
Increased tactile stimulation — Men and women can have decreased blood flow to the genitals during midlife. Increasing manual and/or oral stimulation can be helpful to achieve or maintain an erection in the male or arousal in the female.
Sexual frequency — The "optimal" frequency for sexual contact is what each pair of partners finds comfortable. Women do not need to initiate contact to enjoy sex; many women can respond to their partner's sexual signals, become aroused, and enjoy a sexual experience that is initiated by their partner. Ejaculation and/or orgasm is not required with each sexual encounter.
Treatment with medications — Non-pharmacologic treatments may not be sufficient to provide sexual satisfaction in some women. Medications may be tried in these women, with the goal being to maintain hormone levels and increase blood flow to the genitals.
Estrogen — Estrogen may positively affect sexual function by helping to maintain normal lubrication and elasticity of the vagina. It can also improve mood and affect nerve growth and response, which may impact arousal. In one study, estrogen was shown to increase clitoral sensitivity, rate of orgasm, and sexual desire. In another, the rate of orgasm and sexual arousal were not affected, but women treated with estrogen reported an increase in satisfaction with the frequency of sexual activity, sexual fantasies, enjoyment of sex, vaginal lubrication, and the level of discomfort during sex.
In general, women with symptoms of vaginal dryness should use topical (vaginal) estrogen rather than oral estrogen since it is far more effective for the sexual symptoms. Treatment with oral estrogen can decrease testosterone levels; topical estrogen avoids this negative effect.
Progestogens — Progestogens are progesterone-like medications that are an important component of hormone replacement therapy in women with a uterus. A number of studies have shown that treatment with certain potent synthetic progestogens can increase sexual problems in women. Studies are underway to determine if various combinations of estrogens with synthetic progestogens alters sexual response.
Androgens — Although androgens (such as testosterone) may be important in the female sexual response, treatment with androgen replacement is highly controversial. Estratest®, a combination of estrogen and testosterone, is the only androgen therapy currently available. It is available for the treatment of hot flashes that do no respond to estrogen alone.
There are no adrogen products that are approved for use in women with sexual dysfunctions, thus use of androgen therapy remains investigational. Studies have shown mixed results; those that carefully select participants with sexual dysfunction have shown statistically significant but clinically modest improvements when compared to placebo. Of note, in all of the transdermal testosterone trials, clinical improvement is seen only with higher than normal blood levels of testosterone. The long-term risks of these higher testosterone levels are unknown.
Side effects remain a concern, as these medicines can decrease HDL (good cholesterol) levels significantly. Masculinizing effects, such as body hair growth, scalp hair loss, oily skin, and acne can also occur.
Studies on the use of DHEA (dehydroepiandrosterone), available as a nutritional supplement in the United States, is beneficial for improving libido in women with adrenal insufficiency. DHEA is not proven to be safe or effective for other patients, and is not generally recommended.
Herbal therapies — The literature on herbal therapies for the treatment of sexual dysfunction in women is sparse. A small number of studies have shown that treatment with St. John's wort, ginseng, or dong quai did not have a significant effect on sexual function. Herbal products such as yohimbine and ginkgo biloba have been reported to enhance desire, arousal, and orgasm in both women and men, but the data is limited. Sex creams that contain menthol are available for application to the clitoris, and are promoted for their ability to enhance sensation. However, there are no studies that show these creams to be effective. In addition, some have ingredients that can cause irritation of vulvar or vaginal tissues.
More studies are needed to ensure herbal therapies are safe and effective. The production of herbs is not regulated by the government, and it is not always possible to know that an herbal product contains the type and quantity of ingredient that the label indicates, or that it is free of potentially dangerous additives. Patients who wish to use herbal therapies are urged to do so with caution.
Surgical treatments — Surgery is very rarely necessary to make the vagina "better" for sex. Women with congenital abnormalities of the vagina, who have had female circumcision (also known as female genital mutilation), and those with traumatic injuries from childbirth are a few groups that may benefit from careful surgical treatment. All women should be wary of advertisements for "vaginal rejuvenation surgery"; these procedures can be costly and painful, are permanent, and are unlikely to improve a woman or her partner's sexual enjoyment.
Future directions — A number of products are undergoing research and development for use in women with sexual dysfunction: Tibolone, currently available in Europe and Australia, may gain FDA approval in the United States soon. It is taken by mouth as hormone replacement therapy and may also help improve sexual function. Use of Sildenafil (Viagra®) in women is also undergoing evaluation. Preliminary findings demonstrate positive effects in some women with adequate testosterone levels who have problems with arousal and orgasm.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Mayo Clinic
(www.mayoclinic.com)
The Hormone Foundation
(www.hormone.org)
American Academy of Family Physicians
(www.familydoctor.org, search for sexual problems)
[1-7]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Phillips, NA, Female sexual dysfunction: Evaluation and treatment. Am Fam physician 2000; 62:127.
2. Sarrel, PM. Sexuality and menopause. Obstet Gyenecol. 1990; 75:26S.
3. Nathorst-Boos, J, Wiklund, I, Mattsson, LA, et al. Is sexual life influenced by transdermal estrogen therapy? A double blind placebo controlled study in postmenopausal women. Acta Obstet Gynecol Scand 1993; 72:656.
4. Myers, LS, Dixen, J, Morrissette, D, et al. Effects of estrogen, androgen, and progestin on sexual pscychophysiology and behavior in postmenopausal women. J Clin Endocrinol Metab 1990; 70:1124.
5. Masters, WH, Johnson, VE. Human Sexual Response. Boston, Mass. Little, Brown, 1966.
6. Basson, R. Female sexual response: The role of drugs in the management of sexual dysfunction. Obstet Gynecol 2001; 98:350.
7. Rhodes, JC, Kjerulff, KH, Langenberg, PW, Guzinski, GM. Hysterectomy and sexual functioning. JAMA 1999; 282:1934.
Polycystic ovary syndrome (PCOS)
DEFINITION — Polycystic ovary syndrome (PCOS) is a chronic condition that causes irregular menstrual periods and elevated levels of androgens (male hormones) in women. The elevated androgen levels can sometimes cause excessive facial hair growth, acne, and/or male-pattern hair thinning. The condition occurs in about 5 to 10 percent of women.
Although PCOS is not completely reversible, there are a number of treatments that can reduce or minimize bothersome symptoms. Most women with PCOS are able to lead a normal life without significant complications.
CAUSE — The cause of PCOS is not completely understood. It is believed that abnormal levels of the pituitary hormone LH and high levels of male hormones (androgens) interfere with normal function of the ovaries. To explain how these hormones cause symptoms, it is helpful to understand the normal menstrual cycle.
The brain (including the pituitary gland), ovaries, and uterus normally follow a sequence of events once per month; this sequence helps to prepare the body for pregnancy. Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH), are made by the pituitary gland. Two other hormones, progesterone and estrogen, are made by the ovaries.
During the first half of the cycle, small increases in FSH stimulate the ovary to develop a follicle (cyst) that contains an egg (oocyte). The follicle produces rising levels of estrogen, which cause the lining of the uterus to thicken and the pituitary to release a very large amount of LH. This midcycle "surge" of LH causes the egg to be released from the ovary (called ovulation, show figure 1).
After ovulation, the ovary produces both estrogen and progesterone, which prepare the uterus for possible implantation and pregnancy. In women with PCOS, multiple follicles (cysts) may develop. The follicles are unable to grow to a size that would trigger ovulation. Therefore, small follicles (4 to 9 mm in diameter) accumulate in the ovary, hence the term polycystic ovaries. None of these small follicles are capable of initiating ovulation nor can they release an egg. As a result, the levels of estrogen, progesterone, LH, and FSH become imbalanced.
Androgens are normally produced by the ovaries, the adrenal gland, and probably from other sources as well. Examples of androgens include testosterone, androstenedione, dehydroepiandrosterone (DHEA), and DHEA sulfate (DHEA-S). It is thought that androgens (male-type hormones) become increased in women with PCOS because of the high levels of LH, but also because of high levels of insulin that are usually seen with PCOS (see "Insulin abnormalities" below).
SIGNS AND SYMPTOMS — The changes in hormone levels, described above, cause the classic symptoms of PCOS, including absent or irregular menstrual periods, abnormal hair growth or loss, acne, weight gain, and difficulty becoming pregnant. (See "Patient information: Hair loss in men and women (androgenetic alopecia)").
Signs and symptoms of PCOS usually begin around the time of puberty, although some women do not develop symptoms until adulthood. Because hormonal changes vary from one woman to another, patients with PCOS may have mild to severe acne, facial hair growth, or scalp hair loss.
Menstrual irregularity — If ovulation does not occur, the lining of the uterus (called the endometrium) does not uniformly shed and regrow as in a normal menstrual cycle. Instead, the endometrium becomes thicker and may shed irregularly, which can result in heavy and/or prolonged bleeding. Irregular or absent menstrual periods can increase a woman's risk of endometrial overgrowth (called endometrial hyperplasia) or even endometrial cancer.
Women with PCOS usually have fewer than six to eight menstrual periods per year. Some women have normal cycles during puberty, which may become irregular as weight gain occurs.
Weight gain and obesity — PCOS is associated with gradual weight gain and obesity in about one-half of women. For some women with PCOS, obesity develops at the time of puberty.
Hair growth and acne — Male-pattern hair growth (hirsutism) may be seen on the chin, neck, sideburn area, chest, and upper abdomen. Acne is a skin condition that causes oily skin and blockages in hair follicles, leading to pimples.
Insulin abnormalities — PCOS is associated with elevated levels of insulin in the blood. Insulin is a hormone that is produced by specialized cells within the pancreas; insulin regulates blood glucose levels. When blood glucose levels rise (after eating, for example), these cells produce insulin to help the body use glucose for energy. If glucose levels do not decline in response to normal levels of insulin, the pancreas produces additional insulin. Excess production of insulin is called hyperinsulinemia. When increased levels of insulin are required to maintain normal glucose levels, a person is said to be insulin resistant. When the blood glucose levels are not completely controlled with increased amounts of insulin, the person is said to have impaired glucose tolerance. If blood glucose levels continue to rise despite increased insulin levels, the person is said to have type 2 diabetes.
These conditions are diagnosed with blood tests. (See "Patient information: Diabetes mellitus, type 2").
Insulin resistance and hyperinsulinemia can occur in both normal-weight and overweight women with PCOS. Among women with PCOS, up to 35 percent of obese women develop impaired glucose tolerance by age 40, while up to 10 percent of obese women develop type 2 diabetes. The risk of these conditions is much higher in women with PCOS compared to women without PCOS.
Infertility — If a woman with PCOS has difficulty becoming pregnant after six to 12 months of trying to conceive, an evaluation of both partners is needed to determine the cause of infertility. (See "Patient information: Evaluation of the infertile couple").
Heart disease — Women who are obese and who also have insulin resistance or diabetes have an increased risk of coronary artery disease, the narrowing of the arteries that supply blood to the heart. Both weight loss and treatment of insulin abnormalities can decrease this risk. Other treatments (eg, cholesterol lowering medications, treatments for high blood pressure) may also be recommended. (See "Patient information: High cholesterol and lipids (hyperlipidemia)" and see "Patient information: High blood pressure treatment").
Sleep apnea — Sleep apnea is a condition that causes brief spells where breathing stops (apnea) during sleep. Patients with this problem often experience fatigue and daytime sleepiness. In addition, there is evidence that people with untreated sleep apnea have an increased risk of cardiovascular problems such as high blood pressure, heart attack, abnormal heart rhythms, or stroke. This risk may be due to the wide fluctuations in heart rate and blood pressure that occur in people with sleep apnea.
Sleep apnea may occur in up to 30 percent of women with PCOS. The condition can be diagnosed with a sleep study, and several treatments are available. (See "Patient information: Sleep apnea").
DIAGNOSIS — There is no single test for diagnosing PCOS. A woman may be diagnosed with PCOS based upon her signs and symptoms and blood tests. Expert groups have determined that a woman must have all of the following to be diagnosed with PCOS: Irregular menstrual periods caused by anovulation or irregular ovulation Evidence of elevated androgen levels. The evidence can be based upon signs (hirsutism, acne, or male pattern balding) or blood tests (high serum androgen concentrations) No evidence of other causes of elevated androgen levels or irregular periods (eg, congenital adrenal hyperplasia, androgen-secreting tumors, or hyperprolactinemia)
Blood tests are usually recommended to determine if another condition is the cause of a person's signs and/or symptoms. Blood tests for pregnancy, prolactin level, thyroid stimulating hormone (TSH), and follicle stimulating hormone (FSH) may be recommended.
If PCOS is confirmed, the blood glucose level and cholesterol levels are usually measured; these tests are best done before the first meal of the day. Other glucose tests, called oral glucose tolerance testing and hemoglobin A1C, may also be recommended. In women with moderate to severe hirsutism (excess hair growth), blood tests for testosterone and DHEA-S may be recommended.
All women who are diagnosed with PCOS should be monitored by a healthcare provider. Symptoms of PCOS may seem minor and annoying and treatment may seem unnecessary. However, untreated PCOS can increase a woman's risk of other health problems over time.
TREATMENTS
Oral contraceptives — Oral contraceptives (OCs) are the most commonly used treatment for establishing normal menstrual periods in women with PCOS. OCs protect the uterine lining from a precancerous or cancerous condition by inducing a monthly menstrual period, and are also effective for treating hirsutism and acne.
Women with PCOS occasionally ovulate, and oral contraceptives are useful in providing protection from pregnancy. Although an OC allows for bleeding once per month, this does not mean that the PCOS is "cured"; irregular cycles generally return when the OC is stopped. (See "Patient information: Menstrual cycle disorders (Absent and irregular periods)").
Oral contraceptives decrease the body's production of androgens, and anti-androgen drugs (such as spironolactone) decrease the effect of androgens. Both treatments can lessen and slow hair growth. Oral contraceptives and antiandrogens can also reduce acne, although some women should consult a healthcare provider about the need for prescription skin treatments (eg, medicated lotions) or oral antibiotics. (See "Patient information: Acne").
Before prescribing an oral contraceptives, a clinician will perform an examination or a blood test to be certain that a woman is not pregnant. If a woman hasn't had a period for six weeks or longer, her clinician may first prescribe a hormone (eg, Provera®) to induce a menstrual period. Side effects — Some women who take oral contraceptives (not just those with PCOS) may notice amenorrhea (lack of monthly bleeding) or breakthrough bleeding (bleeding that occurs at the irregular time of the month). Breakthrough bleeding usually resolves after a few menstrual cycles.
Many women worry that they will gain weight on the pill. This is not a concern with the currently available low-dose pills. Some women develop nausea, breast tenderness, and bloating after beginning the pill, but these symptoms usually resolve after two or three months.
The pill is safe and effective, although it slightly increases the risk of blood clots in the legs or lungs, although this is a rare complication in young, healthy women who do not smoke. The risk is higher in women older than 35 years and in smokers. (See "Patient information: Hormonal methods of birth control").
Progestin — Another method to treat menstrual irregularity is to take a hormone called progestin (eg, Provera®) for 10 to 14 days every one to three months. This will cause a period in almost all women with PCOS, but it does not help with the cosmetic concerns (hirsutism and acne) and does not prevent pregnancy. It does reduce the risk of uterine cancer.
Hair treatments — Excess hair can be removed by shaving or use of depilatories, electrolysis, or laser therapy. Many women worry that these treatments cause hair to grow faster, although this is not true. (See "Patient information: Causes and treatment of hirsutism"). Hair loss can be treated with medications in some situations, although medications are not usually as effective in women with hormonally-related hair loss as they are in men. Other options include hair replacement and wigs. (See "Patient information: Hair loss in men and women (androgenetic alopecia)").
Weight loss — Weight loss is one of the simplest, yet most effective, approaches for managing insulin abnormalities, menstrual irregularities, and other symptoms of PCOS. For example, many overweight women with PCOS who lose 5 to 10 percent of their body weight notice that their periods become more regular. Weight loss can often be achieved with a program of diet and exercise.
There are a number of options available for obesity. These options are identical to those recommended for women without PCOS, and include diet and exercise, weight loss medications, and weight loss surgery. (See "Patient information: Diet and health" and see "Patient information: Weight loss treatments").
Weight loss surgery may be an option for severely obese women with PCOS. Significant amounts of weight can be lost after surgery, which can restore normal menstrual cycles, reduce high androgen levels and hirsutism, and reduce the risk of type 2 diabetes. (See "Patient information: Weight loss surgery").
Metformin — Metformin (Glucophage®) is medication that improves the effectiveness of insulin produced by the body. It is sometimes used to treat the insulin abnormalities associated with PCOS. This medication can decrease the ovary's production of androgens and reestablish the body's normal hormone balance. The end result is that some signs and symptoms of PCOS improve.
Metformin is usually prescribed for the treatment of diabetes. In preliminary studies, metformin helps restore normal menstrual cycles in approximately 50 percent of women with PCOS. Blood androgen levels sometimes decrease, but there may not be much improvement in hirsutism or acne. In addition, metformin does not prevent pregnancy. In fact, it can stimulate ovulation; another method of pregnancy prevention is recommended to women who do not want to become pregnant.
Metformin may also help with weight loss. Although metformin is not a weight-loss drug, some studies have shown that women with PCOS who are on a low-calorie diet lose more weight when metformin is added. If metformin is used, it is essential that diet and exercise are also part of the recommended regimen because the weight that is lost in the early phase of metformin treatment may be regained over time.
Treatment of infertility — If tests determine that lack of ovulation is the cause of infertility, several treatment options are available, including clomiphene and gonadotropin therapy. These treatments work best in women who are not obese. A summary of treatment options is shown in table 1 (show table 1).
The primary treatment for women who are unable to become pregnant and who have PCOS is weight loss. Even a modest amount of weight loss may cause the woman to begin ovulating normally. In addition, weight loss can improve the effectiveness of other infertility treatments.
Clomiphene is a medication that stimulates the ovaries to release one or more eggs. It triggers ovulation in about 80 percent of women with PCOS, and about 50 percent of these women will become pregnant. (See "Patient information: Infertility treatment with clomiphene (Clomid® or Serophene®)").
Several studies have shown that metformin increases the effectiveness of clomiphene in producing ovulation. However, it is unknown if this drug is safe during pregnancy, so the current recommendation is to stop metformin once pregnancy is achieved.
If a woman does not ovulate or is unable to conceive with clomiphene, gonadotropin therapy may be recommended. Gonadotropins are hormones (LH and FSH) that are given as a daily injection under the skin for 7 to 10 days. Ovulation occurs in almost all women with PCOS who use gonadotropin therapy; approximately 60 percent of these women become pregnant.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
From UpToDate — This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
From other sources — A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
The Hormone Foundation
(www.hormone.org/public/polycystic.cfm, available in English and Spanish)
U.S. Department of Health and Human Services
(www.4woman.gov/faq/pcos.htm)
American Academy of Family Physicians
(www.familydoctor.org)
The Nemours Foundation
(http://kidshealth.org/teen/sexual_health/girls/pcos.html)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ehrmann, DA, Cavaghan, MK, Barnes, RB, et al. Prevalence of impaired glucose tolerance and diabetes in women with Polycystic Ovary Syndrome. Diabetes Care 1999; 22:141.
2. Adams, J, Polson, DW, Franks, S. Prevalence of polycystic ovaries in women with anovulation and idiopathic hirsutism. BMJ 1986; 293:355.
3. Huber-Buchholz, MM, Carey, DG, Norman, RJ. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: Role of insulin sensitivity and luteinizing hormone. J Clin Endocrinol Metab 1999; 84:1470.
4. Nestler, JE, Jakubowicz, DJ, Evans, WS, Pasquali, R. Effects of metformin on spontaneous and clomiphene-induced ovulation in the polycystic ovary syndrome. N Engl J Med 1998; 338:1876.
Although PCOS is not completely reversible, there are a number of treatments that can reduce or minimize bothersome symptoms. Most women with PCOS are able to lead a normal life without significant complications.
CAUSE — The cause of PCOS is not completely understood. It is believed that abnormal levels of the pituitary hormone LH and high levels of male hormones (androgens) interfere with normal function of the ovaries. To explain how these hormones cause symptoms, it is helpful to understand the normal menstrual cycle.
The brain (including the pituitary gland), ovaries, and uterus normally follow a sequence of events once per month; this sequence helps to prepare the body for pregnancy. Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH), are made by the pituitary gland. Two other hormones, progesterone and estrogen, are made by the ovaries.
During the first half of the cycle, small increases in FSH stimulate the ovary to develop a follicle (cyst) that contains an egg (oocyte). The follicle produces rising levels of estrogen, which cause the lining of the uterus to thicken and the pituitary to release a very large amount of LH. This midcycle "surge" of LH causes the egg to be released from the ovary (called ovulation, show figure 1).
After ovulation, the ovary produces both estrogen and progesterone, which prepare the uterus for possible implantation and pregnancy. In women with PCOS, multiple follicles (cysts) may develop. The follicles are unable to grow to a size that would trigger ovulation. Therefore, small follicles (4 to 9 mm in diameter) accumulate in the ovary, hence the term polycystic ovaries. None of these small follicles are capable of initiating ovulation nor can they release an egg. As a result, the levels of estrogen, progesterone, LH, and FSH become imbalanced.
Androgens are normally produced by the ovaries, the adrenal gland, and probably from other sources as well. Examples of androgens include testosterone, androstenedione, dehydroepiandrosterone (DHEA), and DHEA sulfate (DHEA-S). It is thought that androgens (male-type hormones) become increased in women with PCOS because of the high levels of LH, but also because of high levels of insulin that are usually seen with PCOS (see "Insulin abnormalities" below).
SIGNS AND SYMPTOMS — The changes in hormone levels, described above, cause the classic symptoms of PCOS, including absent or irregular menstrual periods, abnormal hair growth or loss, acne, weight gain, and difficulty becoming pregnant. (See "Patient information: Hair loss in men and women (androgenetic alopecia)").
Signs and symptoms of PCOS usually begin around the time of puberty, although some women do not develop symptoms until adulthood. Because hormonal changes vary from one woman to another, patients with PCOS may have mild to severe acne, facial hair growth, or scalp hair loss.
Menstrual irregularity — If ovulation does not occur, the lining of the uterus (called the endometrium) does not uniformly shed and regrow as in a normal menstrual cycle. Instead, the endometrium becomes thicker and may shed irregularly, which can result in heavy and/or prolonged bleeding. Irregular or absent menstrual periods can increase a woman's risk of endometrial overgrowth (called endometrial hyperplasia) or even endometrial cancer.
Women with PCOS usually have fewer than six to eight menstrual periods per year. Some women have normal cycles during puberty, which may become irregular as weight gain occurs.
Weight gain and obesity — PCOS is associated with gradual weight gain and obesity in about one-half of women. For some women with PCOS, obesity develops at the time of puberty.
Hair growth and acne — Male-pattern hair growth (hirsutism) may be seen on the chin, neck, sideburn area, chest, and upper abdomen. Acne is a skin condition that causes oily skin and blockages in hair follicles, leading to pimples.
Insulin abnormalities — PCOS is associated with elevated levels of insulin in the blood. Insulin is a hormone that is produced by specialized cells within the pancreas; insulin regulates blood glucose levels. When blood glucose levels rise (after eating, for example), these cells produce insulin to help the body use glucose for energy. If glucose levels do not decline in response to normal levels of insulin, the pancreas produces additional insulin. Excess production of insulin is called hyperinsulinemia. When increased levels of insulin are required to maintain normal glucose levels, a person is said to be insulin resistant. When the blood glucose levels are not completely controlled with increased amounts of insulin, the person is said to have impaired glucose tolerance. If blood glucose levels continue to rise despite increased insulin levels, the person is said to have type 2 diabetes.
These conditions are diagnosed with blood tests. (See "Patient information: Diabetes mellitus, type 2").
Insulin resistance and hyperinsulinemia can occur in both normal-weight and overweight women with PCOS. Among women with PCOS, up to 35 percent of obese women develop impaired glucose tolerance by age 40, while up to 10 percent of obese women develop type 2 diabetes. The risk of these conditions is much higher in women with PCOS compared to women without PCOS.
Infertility — If a woman with PCOS has difficulty becoming pregnant after six to 12 months of trying to conceive, an evaluation of both partners is needed to determine the cause of infertility. (See "Patient information: Evaluation of the infertile couple").
Heart disease — Women who are obese and who also have insulin resistance or diabetes have an increased risk of coronary artery disease, the narrowing of the arteries that supply blood to the heart. Both weight loss and treatment of insulin abnormalities can decrease this risk. Other treatments (eg, cholesterol lowering medications, treatments for high blood pressure) may also be recommended. (See "Patient information: High cholesterol and lipids (hyperlipidemia)" and see "Patient information: High blood pressure treatment").
Sleep apnea — Sleep apnea is a condition that causes brief spells where breathing stops (apnea) during sleep. Patients with this problem often experience fatigue and daytime sleepiness. In addition, there is evidence that people with untreated sleep apnea have an increased risk of cardiovascular problems such as high blood pressure, heart attack, abnormal heart rhythms, or stroke. This risk may be due to the wide fluctuations in heart rate and blood pressure that occur in people with sleep apnea.
Sleep apnea may occur in up to 30 percent of women with PCOS. The condition can be diagnosed with a sleep study, and several treatments are available. (See "Patient information: Sleep apnea").
DIAGNOSIS — There is no single test for diagnosing PCOS. A woman may be diagnosed with PCOS based upon her signs and symptoms and blood tests. Expert groups have determined that a woman must have all of the following to be diagnosed with PCOS: Irregular menstrual periods caused by anovulation or irregular ovulation Evidence of elevated androgen levels. The evidence can be based upon signs (hirsutism, acne, or male pattern balding) or blood tests (high serum androgen concentrations) No evidence of other causes of elevated androgen levels or irregular periods (eg, congenital adrenal hyperplasia, androgen-secreting tumors, or hyperprolactinemia)
Blood tests are usually recommended to determine if another condition is the cause of a person's signs and/or symptoms. Blood tests for pregnancy, prolactin level, thyroid stimulating hormone (TSH), and follicle stimulating hormone (FSH) may be recommended.
If PCOS is confirmed, the blood glucose level and cholesterol levels are usually measured; these tests are best done before the first meal of the day. Other glucose tests, called oral glucose tolerance testing and hemoglobin A1C, may also be recommended. In women with moderate to severe hirsutism (excess hair growth), blood tests for testosterone and DHEA-S may be recommended.
All women who are diagnosed with PCOS should be monitored by a healthcare provider. Symptoms of PCOS may seem minor and annoying and treatment may seem unnecessary. However, untreated PCOS can increase a woman's risk of other health problems over time.
TREATMENTS
Oral contraceptives — Oral contraceptives (OCs) are the most commonly used treatment for establishing normal menstrual periods in women with PCOS. OCs protect the uterine lining from a precancerous or cancerous condition by inducing a monthly menstrual period, and are also effective for treating hirsutism and acne.
Women with PCOS occasionally ovulate, and oral contraceptives are useful in providing protection from pregnancy. Although an OC allows for bleeding once per month, this does not mean that the PCOS is "cured"; irregular cycles generally return when the OC is stopped. (See "Patient information: Menstrual cycle disorders (Absent and irregular periods)").
Oral contraceptives decrease the body's production of androgens, and anti-androgen drugs (such as spironolactone) decrease the effect of androgens. Both treatments can lessen and slow hair growth. Oral contraceptives and antiandrogens can also reduce acne, although some women should consult a healthcare provider about the need for prescription skin treatments (eg, medicated lotions) or oral antibiotics. (See "Patient information: Acne").
Before prescribing an oral contraceptives, a clinician will perform an examination or a blood test to be certain that a woman is not pregnant. If a woman hasn't had a period for six weeks or longer, her clinician may first prescribe a hormone (eg, Provera®) to induce a menstrual period. Side effects — Some women who take oral contraceptives (not just those with PCOS) may notice amenorrhea (lack of monthly bleeding) or breakthrough bleeding (bleeding that occurs at the irregular time of the month). Breakthrough bleeding usually resolves after a few menstrual cycles.
Many women worry that they will gain weight on the pill. This is not a concern with the currently available low-dose pills. Some women develop nausea, breast tenderness, and bloating after beginning the pill, but these symptoms usually resolve after two or three months.
The pill is safe and effective, although it slightly increases the risk of blood clots in the legs or lungs, although this is a rare complication in young, healthy women who do not smoke. The risk is higher in women older than 35 years and in smokers. (See "Patient information: Hormonal methods of birth control").
Progestin — Another method to treat menstrual irregularity is to take a hormone called progestin (eg, Provera®) for 10 to 14 days every one to three months. This will cause a period in almost all women with PCOS, but it does not help with the cosmetic concerns (hirsutism and acne) and does not prevent pregnancy. It does reduce the risk of uterine cancer.
Hair treatments — Excess hair can be removed by shaving or use of depilatories, electrolysis, or laser therapy. Many women worry that these treatments cause hair to grow faster, although this is not true. (See "Patient information: Causes and treatment of hirsutism"). Hair loss can be treated with medications in some situations, although medications are not usually as effective in women with hormonally-related hair loss as they are in men. Other options include hair replacement and wigs. (See "Patient information: Hair loss in men and women (androgenetic alopecia)").
Weight loss — Weight loss is one of the simplest, yet most effective, approaches for managing insulin abnormalities, menstrual irregularities, and other symptoms of PCOS. For example, many overweight women with PCOS who lose 5 to 10 percent of their body weight notice that their periods become more regular. Weight loss can often be achieved with a program of diet and exercise.
There are a number of options available for obesity. These options are identical to those recommended for women without PCOS, and include diet and exercise, weight loss medications, and weight loss surgery. (See "Patient information: Diet and health" and see "Patient information: Weight loss treatments").
Weight loss surgery may be an option for severely obese women with PCOS. Significant amounts of weight can be lost after surgery, which can restore normal menstrual cycles, reduce high androgen levels and hirsutism, and reduce the risk of type 2 diabetes. (See "Patient information: Weight loss surgery").
Metformin — Metformin (Glucophage®) is medication that improves the effectiveness of insulin produced by the body. It is sometimes used to treat the insulin abnormalities associated with PCOS. This medication can decrease the ovary's production of androgens and reestablish the body's normal hormone balance. The end result is that some signs and symptoms of PCOS improve.
Metformin is usually prescribed for the treatment of diabetes. In preliminary studies, metformin helps restore normal menstrual cycles in approximately 50 percent of women with PCOS. Blood androgen levels sometimes decrease, but there may not be much improvement in hirsutism or acne. In addition, metformin does not prevent pregnancy. In fact, it can stimulate ovulation; another method of pregnancy prevention is recommended to women who do not want to become pregnant.
Metformin may also help with weight loss. Although metformin is not a weight-loss drug, some studies have shown that women with PCOS who are on a low-calorie diet lose more weight when metformin is added. If metformin is used, it is essential that diet and exercise are also part of the recommended regimen because the weight that is lost in the early phase of metformin treatment may be regained over time.
Treatment of infertility — If tests determine that lack of ovulation is the cause of infertility, several treatment options are available, including clomiphene and gonadotropin therapy. These treatments work best in women who are not obese. A summary of treatment options is shown in table 1 (show table 1).
The primary treatment for women who are unable to become pregnant and who have PCOS is weight loss. Even a modest amount of weight loss may cause the woman to begin ovulating normally. In addition, weight loss can improve the effectiveness of other infertility treatments.
Clomiphene is a medication that stimulates the ovaries to release one or more eggs. It triggers ovulation in about 80 percent of women with PCOS, and about 50 percent of these women will become pregnant. (See "Patient information: Infertility treatment with clomiphene (Clomid® or Serophene®)").
Several studies have shown that metformin increases the effectiveness of clomiphene in producing ovulation. However, it is unknown if this drug is safe during pregnancy, so the current recommendation is to stop metformin once pregnancy is achieved.
If a woman does not ovulate or is unable to conceive with clomiphene, gonadotropin therapy may be recommended. Gonadotropins are hormones (LH and FSH) that are given as a daily injection under the skin for 7 to 10 days. Ovulation occurs in almost all women with PCOS who use gonadotropin therapy; approximately 60 percent of these women become pregnant.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
From UpToDate — This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
From other sources — A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
The Hormone Foundation
(www.hormone.org/public/polycystic.cfm, available in English and Spanish)
U.S. Department of Health and Human Services
(www.4woman.gov/faq/pcos.htm)
American Academy of Family Physicians
(www.familydoctor.org)
The Nemours Foundation
(http://kidshealth.org/teen/sexual_health/girls/pcos.html)
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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ehrmann, DA, Cavaghan, MK, Barnes, RB, et al. Prevalence of impaired glucose tolerance and diabetes in women with Polycystic Ovary Syndrome. Diabetes Care 1999; 22:141.
2. Adams, J, Polson, DW, Franks, S. Prevalence of polycystic ovaries in women with anovulation and idiopathic hirsutism. BMJ 1986; 293:355.
3. Huber-Buchholz, MM, Carey, DG, Norman, RJ. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: Role of insulin sensitivity and luteinizing hormone. J Clin Endocrinol Metab 1999; 84:1470.
4. Nestler, JE, Jakubowicz, DJ, Evans, WS, Pasquali, R. Effects of metformin on spontaneous and clomiphene-induced ovulation in the polycystic ovary syndrome. N Engl J Med 1998; 338:1876.
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