ESSM Newsletter # 40

12 ESSM Today The fourth International Consultation on Sexual Medicine (ICSM) established that the prevalence of women who report a Female Sexual Disorder (FSD) is approximately 40– 50%, irrespective of age. Compared with male sexuality, biologic de- terminants of female sexual response, in particu- lar cardiovascular risk (CV) factors, have received scant attention. Erectile dysfunction is recognized as an opportunity for preventing CV events, and assessing the impairment of penile vascular flow by Color Doppler Ultrasound (CDU) is an important tool to ascertain CV risk. Conversely, the role of car- diovascular disease (CVD)-related genital vascular impairment remains unclear in female population. In literature, there is an increasing interest to answer to this question and in this brief report, we try to elucidate some aspects of this issue. Endothelial dysfunction and FSD The peripheral sexual response in women is manifested by increased blood flow leading to swelling of genital tissues, clitoral engorgement, and production of lubricating fluid transudate in the vagina; the hemodynamic mechanisms that underpin these processes are basically regulated by the tone of the vascular and non-vascular smooth muscle. Preclinical studies have con- stantly indicated that the nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) path- way plays a key role in modulating clitoral and vaginal blood flow. Essentially, clitoral and penile tissues share the same pattern of expression of molecular markers involved in the relaxant and contractile pathways. These data support the notion that metabolic insults could impair genital vascular function in women as observed in men. In accordance with this view, the existence of organic vasculogenic FSD syndromes has been postulated. In 1997 Park et al. defined these syndromes, typically presenting with symptoms such as vaginal discomfort with coitus, dryness and diminished sexual arousal, as “vaginal en- gorgement insufficiency” and “clitoral erectile insufficiency”. They hypothesized that such conditions consist of impaired hemodynamic responses to sexual efferent autonomic pelvic nerve stimulation in women with CV risk factors similar to those contributing to ED in men. So, transposing our knowledge from one gender to the other, it was hypothesized that endothelial dysfunction contribute to vascular insufficiency even in female genital tissue. In particular, when damaged or dysfunctional, the endothelium can produce increased amounts of contracting fac- tors and decreased amounts of relaxing fac- tors. Metabolic syndrome and its components can contribute to these endothelial alterations. However, the relations between MetS and its single components with vasculogenic FSD and the pathologic mechanisms underpinning these relations, have yet to fully understood. Sex steroids and FSD The sex steroid milieu also is a pivotal regulator of the female genital response. Both estrogens and testosterone are critical for maintaining the structure and function of vaginal and clitoral tis- sue. Menopause-associated decrease in estro- gen contributes to decreased pelvic blood flow, causing vaginal dryness and hypo-lubrication: This condition is known as Genitourinary Syn- drome of Menopause. An overall age-related decrease in androgens also is observed in women, particularly in those with history of surgical menopause. Local estrogen therapy is a universally recog- nized tool for contrasting vaginal dryness and at- rophy. With regard to androgen therapy, a recent meta-analysis of randomized controlled trials on the effects of systemic testosterone therapy in postmenopausal women demonstrated that the use of testosterone alone or in combination with hormonal replacement therapy significantly improved multiple domains of sexual functioning, including the peripheral response. Male vs female The clitoris and the penis share many anatomic and histo-morphologic features. Although genital changes from increased blood flow in women are not as externally pronounced as in men, it has been demonstrated that all compartments of the vulva contain a substantial amount of erectile and non-erectile vascular tissue, with a variable, but unified, response to sexual arousal. As in penis, clitoral corpora cavernosa show smooth muscle, sinuses, and a deformable albuginea that opposes the pressure of blood flow, thus limiting the swelling and rigidity of the organ; indeed the elongation is moderate, because it does not have the same purpose as penile erection for coitus, but it is present. Then, compared with men, the vessels supplying fe- male genitalia differ only in their smaller diameter owing to a lower hemodynamic demand. Sex steroids probably play a pivotal role in modulating gender-related characteristics of Cardiomatebolic risk and female sexual dysfunction: A gender issue by Vincenza di Stasi, Elisa Maseroli and Linda Vignozzi Vincenza di Stasi, MD Sexual Medicine and Andrology Unit, Dept. Experimental and Clinical Biomedical Sciences University of Florence Florence, Italy Elisa Maseroli, MD Sexual Medicine and Andrology Unit, Dept. Experimental and Clinical Biomedical Sciences University of Florence Florence, Italy elisameseroli@gmail.com Linda Vignozzi, MD Sexual Medicine and Andrology Unit, Dept. Experimental and Clinical Biomedical Sciences University of Florence Florence, Italy linda.vignozzi@unifi.it