LAUSR

Sexual symptoms are common, affecting nearly half of all women in their lifetime. However, personal or relationship distress, which is a key element to diagnose female sexual dysfunctions (FSD), is much less prevalent, especially in the elderly [1]. Despite intensive research over the last two decades, we are far away from having an effective management of FSDs in clinical practice. Sexual health is an important quality-of-life issue, but age, education, and marital and socioeconomic status, including a gender-equal sexual regime, are significant deterrents to discussing this topic. Women should consult anytime they do not feel satisfied by their sexual response due to either difficulties with drive, arousal, or orgasm or with painful intercourse. Sadly, embarrassment, poor awareness, misconceptions, and fears of social stigma are still barriers to effective communication with health-care providers (HCPs). Thus, sexual problems may remain untreated [2]. In most cases, women expect to discuss sexual health in routine family planning, antenatal, and menopause care programs. Provision of individualized care has the aim to prevent, diagnose, and treat a broad range of conditions with a significant impact on the well-being associated with sexual and reproductive function. Unfortunately, HCPs face the challenge of making a diagnosis that revolves around a very sensitive issue in a short timeframe, even though these dysfunctions usually involve a multitude of factors, ranging from organic determinants to intrapersonal and interpersonal components. Knowledge and confidence are key elements for conducting a proactive assessment of clinically significant sexual dysfunctions [3]. Given the multifactorial origin of FSDs and the frequent overlapping of sexual symptoms, HCPs may find it hard to formulate a treatment plan from a biopsychosocial perspective. This step is rather complex, and it may be time consuming, resulting in low-profit margins. It requires a multidisciplinary approach or the ability to refer to another specialist when appropriate. Nonetheless, HCPs must rule out any underlying medical conditions, recognize situations in which it may be normal to have a sexual impairment, and select the most effective strategy to reach the therapeutic goal [4]. Reproductive stages and hormonal interventions (hormonal contraception, fertility treatment, and menopausal hormone therapy) are strong influencers in FSD because sex hormones play a role in the physical, emotional, and cognitive domains of the sexual response. They modulate neural, vascular, muscular, and other organic substrates of desire, arousal, and orgasm. In postmenopausal women, pharmacotherapy has the primary aim to reverse hormonal deficiency associated with FSDs. Other biological and psychosocial causes can be treated with nonhormonal compounds and cognitive and behavioral strategies. In premenopausal women, instead, the main organic therapeutic target is the vast array of substances such as neuromodulators and vasoactive molecules likely involved in the occurrence of FSDs [2]. The chronic progressive condition formerly known as vulvovaginal atrophy (VVA) was recently renamed genitourinary syndrome of menopause (GSM) to indicate the constellation of urogenital signs and symptoms associated with aging and hormonal changes. It is a clear example of the beneficial role hormone therapy can play in reversing FSDs. Local estrogen therapy is a first-line and well-established strategy to relieve VVA/GSM symptoms, whereas ospemifene oral tablets (Osphena/Senshio, Shionogi & Co, Ltd., London, UK), an estrogen selective receptor modulator, and dehydroepiandrosterone (DHEA) vaginal inserts (Intrarosa, Endoceutics, Inc., MSH, Québec Canada), a prohormone with both estrogenic and androgenic activity, were approved only recently for the treatment of dyspareunia and other symptoms associated with VVA/GSM [5]. These drugs effectively ameliorate sexual function in postmenopausal women, when treating sexual pain associated with VVA/GSM. Their positive effect against placebo is evident during the first three months of treatment, and it is supported by a significant improvement in objective parameters, such as vaginal pH and maturation index. Safety data are currently available for the first year of therapy [5–7]. Differently from VVA/GSM, in which signs associated with symptoms are visible and can be monitored through a gynecological examination, the assessment and manage-