deliveries, there is little evidence for strategies to prevent most preterm births. Today’s U.S. preterm birth rate is similar to 30 years ago, and this is not for lack of effort. Many studies and public health campaigns have not solved this problem. Indeed, major funders including the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Wellcome Trust, the March of Dimes, and the Bill and Melinda Gates Foundation recently joined together to address the challenge of preventing preterm birth.1 We simply disagree with the author’s contention that “premature births are preventable in a majority of cases.” Major improvements have, however, occurred in the prevention and treatment of preterm birth complications, including antenatal corticosteroids, surfactant, continuous positive airway pressure, improved fluids and electrolyte management, and antibiotic therapy. Most preterm neonates born in high-resource countries now not only survive, but survive without disabilities. Reasons for the hiatus between the initial antenatal corticosteroids study in 1972 and widespread adoption of antenatal corticosteroids by obstetricians in the 1990s are unknown but likely included difficulty in knowing when to give antenatal corticosteroids—since the timing of delivery is often unknown—and who should receive antenatal corticosteroids. Concerns included potential harm of antenatal corticosteroids in the presence of preeclampsia and membrane rupture and disparities in antenatal corticosteroid effectiveness among racial groups. Results regarding longterm newborn outcomes were pending. Also, in the 1970s, the diethylstilbestrol story was unfolding; not only did diethylstilbestrol not improve pregnancy outcomes, it also caused vaginal cancer among offspring.2 This likely contributed to the obstetrician community’s caution in administrating yet another steroid hormone to mothers during pregnancy. With the Eunice Kennedy Shriver National Institute of Child Health and Human Development Consensus Development Conference on antenatal corticosteroids in 1994,3 not only did use of single-course antenatal corticosteroids increase substantially, but, despite no evidence of benefit, many obstetricians used weekly antenatal corticosteroids if the fetus remained unde-
livered. When it soon became apparent that multiple antenatal corticosteroid courses decreased fetal growth and head size, most practitioners, appropriately, halted this harmful practice.4 Dr. Semchyshyn, however, recommends adding a second unstudied intervention, aspirin, to correct the damage done by the first unstudied intervention, multiple courses of antenatal corticosteroids. What about, “First, do no harm?” Financial Disclosure: The authors did not report any potential conflicts of interest.
Elizabeth M. McClure, PhD Research Triangle Institute, Durham, North Carolina Robert L. Goldenberg, MD Columbia University Medical Center, New York, New York
REFERENCES 1. Lackritz EM, Wilson CB, Guttmacher AE, Howse JL, Engmann CM, Rubens CE, et al. A solution pathway for preterm birth: accelerating a priority research agenda. Lancet Glob Health 2013;1: 328–30. 2. Herbst AL, Ulfelder H, Poskanzer DC. Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearance in young women. N Engl J Med 1971;284:878–81. 3. Gilstrap LC, Christensen R, Clewell WH, D’Alton MD, Davidson EC Jr, Escobedo MB, et al. Effect of corticosteroids for fetal maturation on perinatal outcomes: NIH Consensus Development Statement. JAMA 1995;273:413–18. 4. National Institutes of Health Consensus Development Panel. Antenatal corticosteroids revisited: repeat courses—National Institutes of Health Consensus Development Conference Statement, August 17– 18, 2000. Obstet Gynecol 2001;98: 144–50.
Female Sexual Dysfunction: Focus on Low Desire To the Editor: We welcome the expert review and recommendations by Kingsberg and Woodard,1 agreeing that obstetrician– gynecologists (ob-gyns) play a critical role in treating female sexual dysfunction, specifically low desire. Our profes-
sion has room to improve in this domain.2 We find one important gap. Routine gynecology practice includes cancer prevention and detection. As we learn more about cancer genetics, more women need our guidance in deciding on preventive medical (eg, aromatase inhibitors) and surgical (eg, salpingooophorectomy, mastectomy) procedures to reduce risk of future cancer, especially breast and gynecologic cancers. Concerns about future sexuality factor into women’s decision-making on risk-reducing therapies.3 Women with cancer seek our expertise on the consequences of treatments on sexual function. Cancer and therapies to prevent or treat it affect women’s sexual desire. Menopause-inducing therapies can dramatically impair libido through biological mechanisms. Pain and loss of sensation in erogenous zones, such as the breasts or clitoris, and exhaustion from treatments may decrease desire. Psychological ramifications, including anxiety, depression, altered body image, and role changes, are common and affect libido. We respectfully suggest that ob-gyns consider cancer and its prevention or treatment in the diagnosis and management of libido problems and include chemopreventive and chemotherapeutic treatments in reference lists of medications affecting desire. The authors provide useful resources for sexual dysfunction. We suggest adding the Scientific Network on Female Sexual Health and Cancer (cancersexnetwork.org), established in 2010 with the vision that all women and girls affected by cancer have timely access to evidence-based education and care promoting sexual well-being and optimal sexual outcomes. Financial Disclosure: The authors did not report any potential conflicts of interest.
Stacy Tessler Lindau, MD, MAPP University of Chicago, Chicago, Illinois Deborah Coady, MD New York University Langone Medical Center, New York, New York David Kushner, MD University of Wisconsin–Madison, Madison, Wisconsin
VOL. 125, NO. 6, JUNE 2015
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Letters
1495
REFERENCES 1. Kingsberg SA, Woodard T. Female sexual dysfunction: focus on low desire. Obstet Gynecol 2015;125:477–86. 2. Sobecki JN, Curlin FA, Rasinkski KA, Lindau ST. What we don’t talk about when we don’t talk about sex: results of a national survey of U.S. obstetrician/gynecologists. J Sex Med 2012;9: 1285–94. 3. Staton A, Kurian A, Cobb K, Mills MA, Ford JM. Cancer risk reduction and reproductive concerns in female BRCA1/2 mutation carriers. Fam Cancer 2008;7:179–86.
In Reply: The authors thank Lindau et al for bringing attention to the role that cancer and its prevention or treatment plays in women’ s sexuality and sexual wellbeing. Cancer-related sexual dysfunction is an important quality-of-life issue; sexual health is one of eight areas covered by the National Comprehensive Cancer Network Guidelines for survivorship, which recommend that providers screen patients for sexual problems at regular intervals from the time of cancer diagnosis through the balance of their lives.1 Indeed, cancer can affect all domains of sexual functioning in complex ways.2 This highlights the importance of asking all women about sexual concerns and being open-minded about the effects that coexisting medical conditions, including cancer, can have on sexual function. In addition to the biological and psychological factors that influence libido, women with cancer may also experience changes in relationship dynamics with an intimate partner (who is also often a caregiver) that might negatively affect desire.3 Our review4 is intended to provide a general overview of the diagnosis and treatment of low desire in women, and we agree that the potential consequences of cancer and its prevention and treatment should be considered when evaluating a woman with this complaint. Given the myriad ways that sexual function and well-being can be affected in women with any cancer type, we believe that this topic warrants a separate and more thorough review. Financial Disclosure: Dr. Kingsberg is a consultant or sits on advisory boards for Sprout, Palatin, Pfizer, Shionogi, Trimel, Apricus, Strategic Solutions Technology, Nuelle, NovoNordisk, Metagenics, Emotional Brain, Endoceutics, Sermonix, and Teva. The other author did not report any potential conflicts of interest.
1496
Letters
Sheryl A. Kingsberg, PhD University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio Terri Woodard, MD The University of Texas MD Anderson Cancer Center and Baylor College of Medicine, Houston, Texas
REFERENCES 1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: survivorship (version 1.2015). Available at: http:// www.nccn.org/professionals/physician_gls/ pdf/survivorship.pdf. Retrieved February 27, 2015. 2. DeSimone M, Spriggs E, Gass JS, Carson SA, Krychman ML, Dizon DS. Sexual dysfunction in female cancer survivors. Am J Clin Oncol 2014;37: 101–6. 3. Rolland J. In sickness and in health: the impact of illness on couples’ relationships. J Marital Fam Ther 1994;20: 327–47. 4. Kingsberg SA, Woodard T. Female sexual dysfunction. Focus on low desire. Obstet Gynecol 2015;125:477–86.
be their normal state. I believe that our failure to recognize that lack of desire can be a normal variant in the spectrum of sexual response leads to much of the personal distress creating the diagnosis of sexual dysfunction. Homosexuality was once considered a disorder by the DSM, with societal disapproval creating much “personal distress” in those “suffering from” this disorder. The Asexual Visibility and Education Network seeks to educate the public that there are individuals who do not experience sexual attraction and those who have little interest in sex (most for their entire lives) and that these individuals can still lead happy, productive lives and experience fulfilling relationships. Additionally, the fact that a phone survey by West et al3 revealed an incidence of low sexual desire of more than 50% in naturally postmenopausal women in 2008 emphasizes that decrease in sexual desire is a normal part of aging for women. It can be therapeutic to counsel that lack of desire is not necessarily pathologic. Financial Disclosure: The author did not report any potential conflicts of interest.
Female Sexual Dysfunction: Focus on Low Desire To the Editor: I appreciated Drs. Kingsberg and Woodard’s1 well-referenced summary of the new Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)2 definition of the sexual dysfunction of lack of sexual desire, their discussion of evaluation and treatment, and their emphasis on including sexual histories and screens in our visits. They point out that the key phrase in the new definition is low desire resulting in “personal distress.” It is very difficult to separate this personal distress from the distress that results from disparity of desire in relationships and from our hypersexualized society’s expectations of sexuality as an essential part of our lives and relationships. The authors alluded to the “affect (sic) of social factors on sexual desire,” but I would have appreciated more attention paid to the large number of women who experience low desire and seek help for a condition that may simply
Linda Harris, MD Medford, Oregon
REFERENCES 1. Kingsberg SA, Woodard T. Female sexual dysfunction: focus on low desire. Obstet Gynecol 2015;125:477–86. 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edition: DSM-5. Washington, DC: American Psychiatric Association; 2013. 3. West SL, D’Alosio AA, Agans RP, Kalsbeek WD, Borisov NN, Thorp JM. Prevalence of low sexual desire and hypoactive sexual desire disorder in a nationally representative sample of US women. Arch Intern Med 2008;168: 1441–9.
In Reply: We support Dr. Harris’s efforts to counsel her patients who present with concerns about sexual desire. We agree that women may experience periods of time when desire waxes and wanes; this is not hypoactive sexual desire disorder. We believe that her concern that
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
livered. When it soon became apparent that multiple antenatal corticosteroid courses decreased fetal growth and head size, most practitioners, appropriately, halted this harmful practice.4 Dr. Semchyshyn, however, recommends adding a second unstudied intervention, aspirin, to correct the damage done by the first unstudied intervention, multiple courses of antenatal corticosteroids. What about, “First, do no harm?” Financial Disclosure: The authors did not report any potential conflicts of interest.
Elizabeth M. McClure, PhD Research Triangle Institute, Durham, North Carolina Robert L. Goldenberg, MD Columbia University Medical Center, New York, New York
REFERENCES 1. Lackritz EM, Wilson CB, Guttmacher AE, Howse JL, Engmann CM, Rubens CE, et al. A solution pathway for preterm birth: accelerating a priority research agenda. Lancet Glob Health 2013;1: 328–30. 2. Herbst AL, Ulfelder H, Poskanzer DC. Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearance in young women. N Engl J Med 1971;284:878–81. 3. Gilstrap LC, Christensen R, Clewell WH, D’Alton MD, Davidson EC Jr, Escobedo MB, et al. Effect of corticosteroids for fetal maturation on perinatal outcomes: NIH Consensus Development Statement. JAMA 1995;273:413–18. 4. National Institutes of Health Consensus Development Panel. Antenatal corticosteroids revisited: repeat courses—National Institutes of Health Consensus Development Conference Statement, August 17– 18, 2000. Obstet Gynecol 2001;98: 144–50.
Female Sexual Dysfunction: Focus on Low Desire To the Editor: We welcome the expert review and recommendations by Kingsberg and Woodard,1 agreeing that obstetrician– gynecologists (ob-gyns) play a critical role in treating female sexual dysfunction, specifically low desire. Our profes-
sion has room to improve in this domain.2 We find one important gap. Routine gynecology practice includes cancer prevention and detection. As we learn more about cancer genetics, more women need our guidance in deciding on preventive medical (eg, aromatase inhibitors) and surgical (eg, salpingooophorectomy, mastectomy) procedures to reduce risk of future cancer, especially breast and gynecologic cancers. Concerns about future sexuality factor into women’s decision-making on risk-reducing therapies.3 Women with cancer seek our expertise on the consequences of treatments on sexual function. Cancer and therapies to prevent or treat it affect women’s sexual desire. Menopause-inducing therapies can dramatically impair libido through biological mechanisms. Pain and loss of sensation in erogenous zones, such as the breasts or clitoris, and exhaustion from treatments may decrease desire. Psychological ramifications, including anxiety, depression, altered body image, and role changes, are common and affect libido. We respectfully suggest that ob-gyns consider cancer and its prevention or treatment in the diagnosis and management of libido problems and include chemopreventive and chemotherapeutic treatments in reference lists of medications affecting desire. The authors provide useful resources for sexual dysfunction. We suggest adding the Scientific Network on Female Sexual Health and Cancer (cancersexnetwork.org), established in 2010 with the vision that all women and girls affected by cancer have timely access to evidence-based education and care promoting sexual well-being and optimal sexual outcomes. Financial Disclosure: The authors did not report any potential conflicts of interest.
Stacy Tessler Lindau, MD, MAPP University of Chicago, Chicago, Illinois Deborah Coady, MD New York University Langone Medical Center, New York, New York David Kushner, MD University of Wisconsin–Madison, Madison, Wisconsin
VOL. 125, NO. 6, JUNE 2015
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Letters
1495
REFERENCES 1. Kingsberg SA, Woodard T. Female sexual dysfunction: focus on low desire. Obstet Gynecol 2015;125:477–86. 2. Sobecki JN, Curlin FA, Rasinkski KA, Lindau ST. What we don’t talk about when we don’t talk about sex: results of a national survey of U.S. obstetrician/gynecologists. J Sex Med 2012;9: 1285–94. 3. Staton A, Kurian A, Cobb K, Mills MA, Ford JM. Cancer risk reduction and reproductive concerns in female BRCA1/2 mutation carriers. Fam Cancer 2008;7:179–86.
In Reply: The authors thank Lindau et al for bringing attention to the role that cancer and its prevention or treatment plays in women’ s sexuality and sexual wellbeing. Cancer-related sexual dysfunction is an important quality-of-life issue; sexual health is one of eight areas covered by the National Comprehensive Cancer Network Guidelines for survivorship, which recommend that providers screen patients for sexual problems at regular intervals from the time of cancer diagnosis through the balance of their lives.1 Indeed, cancer can affect all domains of sexual functioning in complex ways.2 This highlights the importance of asking all women about sexual concerns and being open-minded about the effects that coexisting medical conditions, including cancer, can have on sexual function. In addition to the biological and psychological factors that influence libido, women with cancer may also experience changes in relationship dynamics with an intimate partner (who is also often a caregiver) that might negatively affect desire.3 Our review4 is intended to provide a general overview of the diagnosis and treatment of low desire in women, and we agree that the potential consequences of cancer and its prevention and treatment should be considered when evaluating a woman with this complaint. Given the myriad ways that sexual function and well-being can be affected in women with any cancer type, we believe that this topic warrants a separate and more thorough review. Financial Disclosure: Dr. Kingsberg is a consultant or sits on advisory boards for Sprout, Palatin, Pfizer, Shionogi, Trimel, Apricus, Strategic Solutions Technology, Nuelle, NovoNordisk, Metagenics, Emotional Brain, Endoceutics, Sermonix, and Teva. The other author did not report any potential conflicts of interest.
1496
Letters
Sheryl A. Kingsberg, PhD University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio Terri Woodard, MD The University of Texas MD Anderson Cancer Center and Baylor College of Medicine, Houston, Texas
REFERENCES 1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: survivorship (version 1.2015). Available at: http:// www.nccn.org/professionals/physician_gls/ pdf/survivorship.pdf. Retrieved February 27, 2015. 2. DeSimone M, Spriggs E, Gass JS, Carson SA, Krychman ML, Dizon DS. Sexual dysfunction in female cancer survivors. Am J Clin Oncol 2014;37: 101–6. 3. Rolland J. In sickness and in health: the impact of illness on couples’ relationships. J Marital Fam Ther 1994;20: 327–47. 4. Kingsberg SA, Woodard T. Female sexual dysfunction. Focus on low desire. Obstet Gynecol 2015;125:477–86.
be their normal state. I believe that our failure to recognize that lack of desire can be a normal variant in the spectrum of sexual response leads to much of the personal distress creating the diagnosis of sexual dysfunction. Homosexuality was once considered a disorder by the DSM, with societal disapproval creating much “personal distress” in those “suffering from” this disorder. The Asexual Visibility and Education Network seeks to educate the public that there are individuals who do not experience sexual attraction and those who have little interest in sex (most for their entire lives) and that these individuals can still lead happy, productive lives and experience fulfilling relationships. Additionally, the fact that a phone survey by West et al3 revealed an incidence of low sexual desire of more than 50% in naturally postmenopausal women in 2008 emphasizes that decrease in sexual desire is a normal part of aging for women. It can be therapeutic to counsel that lack of desire is not necessarily pathologic. Financial Disclosure: The author did not report any potential conflicts of interest.
Female Sexual Dysfunction: Focus on Low Desire To the Editor: I appreciated Drs. Kingsberg and Woodard’s1 well-referenced summary of the new Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)2 definition of the sexual dysfunction of lack of sexual desire, their discussion of evaluation and treatment, and their emphasis on including sexual histories and screens in our visits. They point out that the key phrase in the new definition is low desire resulting in “personal distress.” It is very difficult to separate this personal distress from the distress that results from disparity of desire in relationships and from our hypersexualized society’s expectations of sexuality as an essential part of our lives and relationships. The authors alluded to the “affect (sic) of social factors on sexual desire,” but I would have appreciated more attention paid to the large number of women who experience low desire and seek help for a condition that may simply
Linda Harris, MD Medford, Oregon
REFERENCES 1. Kingsberg SA, Woodard T. Female sexual dysfunction: focus on low desire. Obstet Gynecol 2015;125:477–86. 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edition: DSM-5. Washington, DC: American Psychiatric Association; 2013. 3. West SL, D’Alosio AA, Agans RP, Kalsbeek WD, Borisov NN, Thorp JM. Prevalence of low sexual desire and hypoactive sexual desire disorder in a nationally representative sample of US women. Arch Intern Med 2008;168: 1441–9.
In Reply: We support Dr. Harris’s efforts to counsel her patients who present with concerns about sexual desire. We agree that women may experience periods of time when desire waxes and wanes; this is not hypoactive sexual desire disorder. We believe that her concern that
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
