Let's move on to now discussing the guidelines. What tests are available, and what are the HPV testing and cervical cancer screening guidelines? Basically, we have 3 methods which are in use in the United States. One would be HPV testing alone. Another is co-testing using cytology and an HPV test. There are different guidelines for these. Some organizations recommend HPV primary screening beginning at age 35. Other recommend co-testing beginning at a later age. Could we comment on the specificity and sensitivity of those 3 testing methods: HPV, cytology, and co-testing? Mark, do you want to address sensitivity targets?

Dr Mark H. Stoler: Sure. What sensitivity basically means for the patient and for the clinicians, the sensitivity of the test is what drives the performance of screening. You're trying to reassure patients who are mostly negative. We do HPV testing in the United States with current FDA-approved tests, 10% to 15% of women are positive. Eighty-five percent are negative, and you want negative to mean safe. What we've learned in the last 10 to 20 years is that a negative pap which we used to think that's safe, only means you're safe for about a year or so. It doesn't really predict long-term in the future safety because it's not that sensitive, 50% to 70% sensitive for people who have precancer. HPV testing on the other hand dramatically increases sensitivity into 95%, less than a 5% chance that you have pre-cancer or cancer if you have a negative HPV test. The perplexing thing to me as someone who's been following this field in trying to provide data on the performance of primary screening vs co-testing is that adding the pap to the HPV test doesn't really add much in terms of sensitivity. In many studies, it's statistically insignificant, so why haven't we converted to primary HPV which gets you the sensitivity that drives screening by itself. Part of it is as alluded to laboratories offering primary testing which has to do with which HPV tests they're doing because not all the HPV tests on the market are FDA approved for primary screening, but I think more of it is just this lack of recognition by patients and clinicians that you don't need both tests to really have the screening performance that you want.

Dr Hill, do you agree with the fact that we don't need both tests to screen?

That's a complicated question. I think that HPV, like Dr Stoler said, is clearly where you're going to get your sensitivity with regard to identifying women at risk for cervical dysplasia or cervical cancer. I think where the challenge comes in is the specificity in that with HPV primary screening, especially focusing on that alone, especially in populations that haven't had as much of an uptake of HPV vaccination as we'd like, which the US is, unfortunately, 1 of those populations; you are going to find a lot of women, especially young women, especially if you go with some of the screening approaches where you're starting earlier like the ones that start at 25. You're certainly going to pick up a lot of women who are positive for HPV, but maybe transiently and then therefore not as high of a risk of having dysplasia. I think that's where potentially there is sometimes room for the cytology and/or other tests which I think we'll talk about a little bit later relating to p16 and Ki-67 helping us triage those women to who really needs colposcopy.

Dr Sheth, what does an HPV test tell doctors about a woman's risk of cervical cancer which is different than what you would get with cytology?

I think that that is the heart of the role of HPV testing because HPV tells us about the presence or absence of the risk factor for cervical dysplasia and cervical cancer. Whereas cytology is looking for already existing abnormalities of the cells of the cervix. We are more upstream when we're looking for HPV in looking for the risk factor itself. Then as we discussed earlier, then there's opportunity to look for the persistence of HPV infection and act on the persistence because so much of HPV infection does spontaneously clear.

Videos

Experts in obstetric and gynecologic management examine conventional cervical cancer screening strategies and consider their specificity and sensitivity targets. 

HPV and CC Screening Testing Considerations

Annals of Allergy, Asthma, and Immunology

, the scientific journal of the American College of Allergy, Asthma, and Immunology (ACAAI) examined the effect of a longer duration of exclusive breastfeeding and protection against childhood asthma.

The study used prospective pregnancy cohorts in the ECHO PATHWAYS consortium—more than 2000 mother-child pairs—including the Conditions Affecting Neurocognitive Development and Learning in Early Childhood (CANDLE) study, the Infant Development and Environment study (TIDES), and the Global Alliance to Prevent Prematurity and Stillbirth (GAPPS). By combining studies, study investigators achieved demographic distribution, including 38% of Black respondents and 6% of Hispanic/LatinX respondents.

Women reported duration of any and exclusive breastfeeding and childhood asthma outcomes during study follow-up at child aged 4 to 6 years. “Outcomes included current wheeze (last 12 months), ever asthma, current asthma (having ≥2 of current wheeze, ever asthma, medication use in past 12-24 months) and strict current asthma (ever asthma with current wheeze and/or medication use in past 12 to 24 months),” wrote study investigators.

They used multivariable logistic regression to assess associations (odds ratios [OR] and 95% confidence intervals [95CI]) comparing breastfeeding and asthma outcomes—adjusting for potential confounders. Additionally, effect modification by mode of delivery, infant sex, and maternal asthma was assessed, according to the study.

Study results showed that women reported a 33% (0<2 months), 13% (2 to 4 months), 9% (5 to 6 months), and 45% (>6 months) duration of breast feeding had a protective linear trend with ever asthma but no other outcomes, investigators wrote.

The protective association of exclusive breastfeeding, and child outcomes showed to be duration-dependent, noted investigators, highlighting an example of “current asthma adjusted OR [95% CI]: 0.64 [0.41, 1.02], 0.61 [0.38, 0.98], and 0.52 [0.31, 0.87] for durations of 2-4, 5-6, and >6-months respectively, compared to <2 months.”

Of note, the protective associations in exclusive breastfeeding were stronger in dyads with children born vaginally vs cesarean delivery, however, the study reported interactions were not statistically significant.

Based on these results, investigators concluded that a longer duration of exclusive breastfeeding showed protective qualities against child asthma.

This article was originally published on Contemporary Pediatrics®. 

Wilson K, Gebretsadik T, Adgent MA, et al. The association between duration of breastfeeding and childhood asthma outcomes. 

. Published online May 2022:S1081120622004008.

Articles

A new study examines the relationship between an extended duration of mother-child breastfeeding and protective associations to asthma.

Study finds association between longer duration of exclusive breastfeeding and childhood asthma protections

 to the U.S. Department of Justice asking for the establishment of a task force to investigate commercial health insurance companies in the Medicare Advantage program that it alleges are routinely denying patients access to service and denying payments to health care providers.

AHA points to the HHS report that found a random sample of denials from one week in 2019 with a denial rate 13% higher for 

 and 18% of payment denials for services that met Medicare criteria and should not have been denied as a basis for additional investigations.

Medicare Advantage is designed to cover the same services as original Medicare, and by law, Medicare Advantage Organizations may not impose additional clinical criteria that are more restrictive than original Medicare’s national and local coverage policies.

“In a program the size of Medicare Advantage — with 26.4 million beneficiaries, or 42% of the total Medicare population in 2021 — improper denials at this rate is unacceptable,” the letter reads in part. “Yet, as the report explained, because the government pays MAOs a roughly $1,000 per-beneficiary capitation rate, they have every incentive to deny services to patients or payments to providers in order to boost their own profits.”

The AHA also points to the several disturbing examples of patient suffering due to payer denials in the 

 report as reason enough to start a larger investigation.

“These harmful denials all occurred in a single week. Imagine what else the Justice Department might find if it conducted a more far-reaching investigation?” the letter states. “It is time for the Department of Justice to exercise its False Claims Act authority to both punish those MAOs that have denied Medicare beneficiaries and their providers their rightful coverage and to deter future misdeeds.”

The AHA says the problem is so entrenched in the system that only the fear of civil and criminal penalties can prevent fraud and protect patients. The letter, addressed to Brian M. Boynton, acting assistant attorney general, attempt to hold him accountable to remarks he made in 2021, when he said one of his priorities would be “schemes that take advantage of elderly patients by providing them poor or unnecessary health care – or too often no care at all.”

“Seniors are being regularly refused vital medical services, and the Department is well-equipped to use its sophisticated anti-fraud tools to go after this persistent misconduct by certain MAOs,” the letter reads. “As the HHS-OIG report makes crystal clear, a more sustained Justice Department commitment is needed to fully tackle this problem. And it is time for the Civil Division to focus more directly on the commercial insurers who commit this fraud.”

The AHA represents almost 5,000 hospitals and health systems, with more than 270,000 affiliated physicians.

This article was originally published on Medical Economics®. 

American Hospital Association requesting a task force from the justice department to investigate commercial health insurance companies in the Medicare Advantage program.

Hospital group says payers are inappropriately denying care and payments

 to 2021, but the percentage increase was lower than those for surgical and nonsurgical specialists.

Meanwhile, compensation for most physician specialties in 2021 reached or exceeded levels frm before the COVID-19 pandemic, “outstripping the mostly flat results achieved in a lockdown-heavy 2020,” according to the 

The association published “Provider Pay and the Pandemic: Realizing Recovery,” its report on findings in its 33rd annual 

. The analysis includes data from more than 192,000 health care providers across more than 7,700 organizations.

“As we continue to emerge from the pandemic, I’m pleased to announce that data trends are more than stable, despite the countless challenges the industry has experienced over the past two years,” MGMA President Halee Fischer-Wright, MD, MMM, FAAP, FACMPE, said in a press release. "Providing a more holistic view of the industry, the insightful and actionable data in this report is invaluable for healthcare practices — both today and for ongoing future planning.”

 for primary care physicians was $286,525 for 2021, up 2.13% from the year before. But the percentage increase was lower than the 3.89% increase for surgical specialists, whose median total compensation was $517,501, and lower than the 3.12% increase nonsurgical specialists, whose median total compensation topped $400,000 in 2021.

Compensation increases from 2019 to 2021 included:

Internal medicine – hospitalists: 2.55%

Primary care physicians coming out of residency and newly hired to practices in 2021 reported earning 7% to 10% more in guaranteed compensation than their counterparts who were hired in 2020, the report said.

As for patient encounters, 15% of medical practices reported volumes declined in summer 2021 due to the Delta variant spike, while 42% said patient volumes increased and 43% reported volumes stayed the same.

For 2022 so far, “medical groups are signaling some optimism, with 85% reporting their year-to-date visit volumes are at or above 2021 levels,” the report said.

This year’s productivity levels will depend on several issues, according to MGMA:

Ensuring appropriate staffing levels to handle greater volumes

Filling appointment slots previously used for COVID-19 testing and vaccinations as vaccine demand drops and patients use home test kits

Engaging patients who don’t visit due to growing financial concerns about high-deductible health plans, consumer costs and inflation

The MGMA report noted two issues that have received national attention in recent months: physician burnout at critical levels and doctors moving away from physician-owned practices.

In October 2021, an MGMA poll found one in three medical practices had physicians retire early or leave due to burnout in the last year. That stress “likely won’t subside just because the pandemic eases,” the report said.

Electronic health record fatigue, fighting with insurance companies over prior authorizations and staff shortages likely will continue without being addressed, the report said.

MGMA cited the American Medical Association 2020 report that noted for the first time, less than half of patient-care physicians (49.1%) reported working in a physician-owned practice. That was down almost 5% from 2018 and down 11% since 2012.

This article originally appeared on Medical Economics®. 

Despite challenges, management group says doctors’ compensation stabilizes last year.

Primary care physician pay up 2.13% in 2021, still lower than specialists

Local community needs for obstetric care trump financial viability and staffing challenges at rural hospitals, according to a national survey in 

“Rural hospitals and rural obstetric units have been closing at alarming rates over the last decade,” said study team member Lindsay Admon, MD, MSc, an assistant professor of ob-gyn at the University of Michigan in Ann Arbor. “Rural communities that have lost local access to obstetric care face reduced access to prenatal care and higher rates of preterm birth.”

Safely maintaining access to obstetric care is a clinical and policy priority, according to Admon. “We sought to understand rural hospital perspectives on criteria for maintaining safe provision of obstetric care,” she said of her work on the survey.

The investigators used the American Hospital Association Annual Survey to identify a national sample of rural hospitals that provided obstetric services in 2021. Obstetric unit managers or administrators at 93 rural hospitals with obstetric services were surveyed between March and August of 2021.

Of the hospitals in the study sample, 35.5% were critical access hospitals and 64.5% were located in micropolitan rural counties.

Overall, the hospitals had a median average daily census of 22 total inpatients. Half (52.2%) of hospitals reported a decline in births over the past 3 years and a median of 274 births in 2019.

Respondents reported that the minimum number of annual births needed to safely provide obstetric care was 200, which was the same number of births needed to ensure financial stability.

“A full 40% of participants reported they did not have enough births annually to breakeven financially, yet they continue to offer obstetric services,” Admon told 

When making decisions about maintaining obstetric care, 64.6% of hospitals cited meeting local community needs as their highest priority, compared to 16.5% that listed financial considerations and 12.7% that considered staffing as the most important factor.

Overall, 25% of hospitals were unsure they would continue providing obstetrics, or they expected to stop offering the service.

“Many rural hospitals continue to operate obstetric units, despite operating at a financial loss,” Admon said. “It is likely that the availability of rural obstetric care will continue to decline in coming years, and that this will exacerbate longstanding rural maternal and child health disparities.”

Rural hospitals that lack obstetric units often have births that occur in their emergency departments—along with unanticipated adverse birth outcomes, delays in urgent transport—and report the need for additional resources for emergency obstetrics.

Admon noted that urgent policy solutions are needed to continue the safe provision of obstetric care in rural America.

“To support rural hospitals in continuing to safely provide obstetric services, attention to financing of maternity care ought to include discussion of low-volume adjustments,” she said.

Medicaid is a major lever for policy change because its programs fund more than half of rural births. “Hence, Medicaid payment policies and reimbursement rates play a key role in the financial viability of rural obstetric care,” Admon said. “However, Medicaid pays substantially lower rates for childbirth than commercial insurance.”

Furthermore, pregnant Medicaid beneficiaries living in rural areas are less likely than those who are privately insured to give birth at an urban hospital or at a hospital with neonatal intensive care.

Rural representation in policy decision-making bodies is crucial for providing the distinct perspective of rural residents, communities and healthcare delivery systems, according to Admon. “This will help ensure that policy changes and safety resources are relevant and useful in rural settings,” she said.

Kozhimannil KB, Interrante JD, Admon LK, et al. Rural hospital administrators’ beliefs about safety, financial viability, and community need for offering obstetric care. 

. Published online March 25, 2022. doi:10.1001/jamahealthforum.2022.0204

Local community needs for obstetric care trump financial viability and staffing challenges at rural hospitals, according to a national survey in JAMA Health Forum.

Rural obstetric care continues to operate at financial loss

Burnout is a crisis hurting health care providers, other medical workers, patients and the U.S. health care system, and addressing it must become a top national priority, according to Surgeon General Vivek Murthy, MD, MBA.

 The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce.” The 76-page paper outlined challenges health care workers faced before the COVID-19 pandemic, and how the pandemic made things worse.

Murthy offered practices and policies that health care organizations, insurers, technology companies, lawmakers, academics, and communities can take to help the problem “so that health workers can thrive and better answer their call as healers.”

“The nation’s health depends on the well-being of our health workforce. Confronting the long-standing drivers of burnout among our health workers must be a top national priority,” Murthy said in a 

 about the advisory. “COVID-19 has been a uniquely traumatic experience for the health workforce and for their families, pushing them past their breaking point. Now, we owe them a debt of gratitude and action. And if we fail to act, we will place our nation’s health at risk. This Surgeon General’s Advisory outlines how we can all help heal those who have sacrificed so much to help us heal.”

Murthy offered topline recommendations to address health care worker burnout:

Transform workplace culture to empower health workers and be responsive to their voices and needs.

“We can begin by listening to health workers and seek their involvement to improve processes, workflows, and organizational culture,” Murthy said in the press release.

Eliminate punitive policies for seeking mental health and substance use disorder care.

Health care leaders must ensure on-demand counseling and after work hours care are more accessible to health workers to promote and preserve their well-being.

Protect the health, safety, and well-being of all health workers.

 should provide workers with living wages, paid sick and family leave, rest breaks, evaluation of workloads and working hours, educational debt support, and family-friendly policies including childcare and care for older adults. They must ensure adequate staffing, including surge capacity for public health emergencies, that is representative of the communities they serve.

“This is critical to protect and sustain health workers and communities,” Murthy said.

Reduce administrative burdens to help health workers have productive time with patients, communities, and colleagues.

One study showed that on average, for every hour of direct patient care, a primary care provider will spend two hours a day on administrative tasks. “That is time that could be spent with patients, in the community, and building relationships with colleagues, which is essential to strengthening the health and well-being of both health workers and patients,” the press release said.

Prioritize social connection and community as a core value of the health care system.

This includes peer and team-based models of care to strengthen collaboration and create opportunities for social support and community.

Federal, state, local, and tribal governments should diversify and expand the public health workforce and improve disease surveillance systems to help address social determinants of health and health inequities, counter health misinformation, and strengthen partnerships across clinical and community settings.

The problem has potential to get even worse due to current and projected shortages of physicians and other medical workers, Murthy said, citing the U.S. Bureau of Labor Statistics and the Association of American Medical Colleges.

The nation will need 1.1 million nurses to replace those retiring at the end of 2022. Within five years, there is a projected shortage of more than 3 million low-wage health workers, and by 2033, there is a projected shortage of up to 139,000 physicians.

This article was originally published on Medical Economics.

Medical staff, pushed past their breaking point, say something has to change.

Surgeon general says addressing health care worker burnout Must be top priority

You can reach her a lcarr@mjhlifesciences.com.

Belgian study finds seasonal variance in Candida infections

The research published in the Journal of Clinical Medicine found women were more likely to have infections in the summer.

Body composition, obesity increase odds of developing PCOS

Data presented at the European Congress of Endocrinology detail genetic and observational associations between obesity, and markers of body composition on the likelihood of developing PCOS later in life.

Materna Medical discusses new vaginal dilator

Tracy MacNeal, president and CEO of Materna Medical, sits down to discuss the company's recently FDA-cleared Milli Vaginal Dilator for vaginismus and associated dyspareunia, as well as a potential new use for the device currently being studied.

Recent studies investigate Phexxi for various potential indications

Bassem Maximos, MD, MPH, FACOG, discusses 2 recent studies investigating nonhormomal contraceptive gel Phexxi (Evofem Biosciences) for the potential treatment of UTIs and improvement in sexual satisfaction.

What impacts a woman’s contraceptive decisions while breastfeeding?

Interviews with mothers in the immediate postpartum period revealed that most decisions on breastfeeding and contraception were based on the personal experiences of participants and their friends and family.

In case you missed it: May 23 to May 27

A recent study1 confirms this idea by investigating the quality of information regarding recurrent urinary tract infections (UTIs) that is posted on YouTube. In this interview, coauthors 

, discuss the findings of this study and why it is important for urologists to understand where the sources of misinformation are coming from. This study was presented at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction 2022 Winter Meeting. Huang is a urology resident and Kim is a clinical assistant professor of urology at Stony Brook Medicine in New York.

Please discuss the background for this study.

 As we all know, social media is becoming more and more important in everyone's life. There's TikTok, YouTube, Instagram, [and] really a wide array of medical information available out there on the social media. In the urology literature, we actually have quite a few studies looking at some of the urologic topics, such as prostate cancer, overactive bladder, [and] erectile dysfunction, to [investigate] the quality of those medical information on social media and found that some sources could present as a major source of misinformation for a lot of our patients. So, we turned our attention to urinary tract infections. It's fairly common in my patients, especially female patients. About 50% to 80% of female patients had a history of UTI, and up to 40% of them had recurrent UTIs. So, we were curious to look at the quality of the medical information on UTIs on YouTube. Hopefully, we can have a better understanding of what patients are learning from online materials before they come to the doctor's office. That's where the idea of this study was coming from.

What were the notable findings of this study? Were any of them surprising to you or your coauthors?

 We looked at the top 200 most-viewed videos on YouTube. I think it was interesting that a lot of the videos had relatively poor quality, based on the standardized instruments that we used to evaluate the quality of the material. Only 11% of the videos featured a urologist, which is a very small portion. Less than half of the videos actually featured a medical provider, so a majority of videos are being produced by non-medical providers, commercial media, or individual YouTubers with no medical experience. Then, we found that, very importantly, videos produced by medical providers have better content quality compared to those that did not feature any medical professionals. I thought those were interesting findings. This is consistent with other similar studies looking at online materials on medical information. We found that those that come from a medical institution or medical source or [were] produced by a physicianhad a better quality, with more accurate information.

 And didn't our results also show that most of the videos were actually about home remedies for UTIs and not necessarily other medical advice?

 Absolutely. Another very interesting finding was that a majority of the videos were featuring some kind of homeopathic supplements, such as herbal supplements or certain dietary remedies, to prevent and treat urinary infection. Some of the regimens, such as vitamin C, probiotics, or cranberries, do have scientific evidence—especially cranberries—featured in the [American Urological Association (AUA)] guidelines, but a lot of the other supplements, such as the herbal supplements or certain random dietary remedies, did not really have much of the scientific 

 n the literature. Those can pose as potential misinformation for a lot of our patients who are seeking for treatments for UTIs.

With an increase in digital media use around the world, how can physicians combat misinformation?

 Ideally, if we can increase the presence of physicians on social media platforms, I think that can help deliver more accurate and more accessible information for the general public. I know that some physicians, some urologists in our field are making an effort to contribute to higher quality of online patient education material, but for those of us who are really busy with clinics, with the work in the hospital, I think another way to combat misinformation is to have a better idea of what is available on the internet so that we can provide better patient counseling when we see them in office.

 I'll add [that] every day when patients come to the office, everyone has done their "research" on urinary tract infections or other things, and we really need to understand where this information is coming from. I think this study shows us that a lot of the information out there isn't necessarily sound medical advice or given by non-medical professionals. So, I think it's essential to understand where information is coming from so that we can counsel the patients appropriately.

What is the take-home message for the practicing urologist?

 From my perspective, the main take-home message would be [that] social media is obviously very important, and it plays a very big role in impacting [the] patient’s decision to seek proper care and make their medical decision. So, as a urologist, as a practicing physician, we should be aware of the online content so we can properly guide our patients and provide proper care and counseling.

 I'll also add that I know all physicians are extremely busy, but I think it's very important to have a bigger social media presence with sound medical advice. I think it's tremendously helpful for patients, and also for counseling. So, I think in the future, physicians should try to take the time to invest some more energy in this realm. I think it's an area that we've done poorly in, and hopefully, if we increase our presence on social media, it'll help the patients and it'll help the physicians.

Is there anything else you feel our audience should know about this topic?

 I think some of these videos may actually lead to patient frustration, because they're giving some of these home remedies for UTIs. In some cases, they may work, but in a lot of cases they don't. Patients come in extremely frustrated, saying things like, "I don't know what's wrong with me. I've done my research on the internet, I've watched YouTube, and I've done everything they said, and nothing's working. What's wrong with me?" So, I think patients need to understand [that] they don't always work.

This article originally appeared on Urology Times. 

1. Huang Z, Jeong R, Lee E, et al. Urinary Tract Infection on Social media: Examining YouTube content as a source of patient educational information. Paper presented at: Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction 2022 Winter Meeting; San Diego, California. February 22-26, 2022. Poster #OM8

In today’s world, it is easy to find information on the internet, whether it be through search engines or social media. Much of that information, however, is not reliable.

YouTube spreads low-quality medical information on recurrent UTIs, study shows

® is celebrating its 50th anniversary in 2022. To mark the occasion, we are highlighting 50 of the top innovations and developments that have transformed the field of urology over the past 50 years. In this installment, 

 discusses the evolution in the treatment of female hypoactive sexual desire disorder (HSDD). Rubin is a board-certified urologist with fellowship training in sexual medicine. She is an assistant clinical professor in urology at Georgetown University and recently started a private practice in the Washington DC area.

Could you provide an overview of the historical view and approach to female HSDD and discuss some of the misconceptions that surround this condition?

Even in 2022, there are a lot of misconceptions surrounding HSDD, mostly because we are not trained to think of it as a medical problem. Many people think libido is all a psychosocial construct and is not something that can be improved with medications. But this goes against our understanding that antidepressants and other hormonal medications have a clear impact on libido. As urologists, we discuss and treat concerns surrounding male libido all the time. It's very easy for us to talk about libido and testosterone and different ways to boost dopamine in men's brains. Unfortunately we have not been equal in our treatment strategies regarding female libido and HSDD.

HSDD was first described several decades ago by Helen Singer Kaplan[, PhD]. What makes it different than just low libido is that the patient must be bothered by their symptoms. About 40% of all women will say they have low libido, but only about 10% are reportedly bothered by it. Think of BPH. When a man has BPH symptoms but is not bothered by it, it's not really a medical problem. He has to say, "Doctor, I want to do something for my BPH symptoms; I'm bothered." That's why we ask a "bother" question. Now in 2022, we have several solutions that can help us approach HSDD in women and treat our patients in a biopsychosocial construct, very similar to how we treat our male patients.

What treatments currently exist for female HSDD?

When we treat HSDD in women, we take a biopsychosocial approach. What's really important, just like with our male patients, is to do a history and physical exam and really try to understand what's happening. In addition to sex therapy, which is wonderful but often expensive and not covered by insurance, we now have biologic treatment options.

Education and Sex therapy will always be important when managing any issues in sexual health. We know sex therapy works for all of our patients. I always say: Nobody is so good at sex that they can't get better, right? Improving sex education, improving communication with our partners. How many sex lives can we fix if we just explain how our body parts work? Getting our patients to truly understand the biomechanics of that can be wonderful for improving HSDD in a relationship.

There is also quite a bit of data on mindfulness and certain cognitive behavioral therapy approaches in helping people with low libido.

The new thing that has happened in this space is medications. Now, we've been using some medications off lable for years in our male and female patients. Medications like testosterone, bupropion and buspirone have been used for a long time to help improve libido.

As of 2022, we have 2 FDA-approved medications for HSDD specifically in premenopausal women. The first one that came to market in 2015 is called flibanserin [Addyi]. It’s a nightly medication. It takes about 2 to 3 months to know if you’re a responder, and it helps improve desire. Studies have also found that it improves arousal, orgasm, lubrication, and satisfaction as well. It’s a nightly medication; it makes you sleepy, and often can replace any other sleep aids.

The second one to the market is called bremelanotide [Vyleesi], which is an auto injector that you take an hour before you “want to want,” so it’s more of an on-demand medication. It’s a subcutaneous auto injector; you put it in your belly or your thigh. It works on the melanocortin receptors and gives the brain a boost of dopamine. The biggest side effect is nausea, and you don't want to give it to someone who has uncontrolled hypertension.

Those are the 2 biggest things that have come to market in the past decade. Of course, testosterone is a big conversation starter. We know testosterone works for libido in women much the same way as it works for men. But we have many FDA-approved products for men and no FDA-approved products for women. In 2019, a global position statement about the use of testosterone in women was put out by a number of societies that stated that testosterone works, it's safe, and should be considered in post menopausal women with HSDD. It is approved in Australia for use in postmenopausal women. But due to some FDA challenges and costs, it hasn't been able to come to market in the United States. But it works quite well.

What makes the evolution of treatment for female HSDD an innovation in urology?

Urologists are incredible at separating reproduction from sexual health. We train our doctors to know that male reproduction and male sexual health are two different things and that quality of life is so important. We love teaching and talking about erectile dysfunction, ejaculatory dysfunction, hormones, libido, and orgasm when it comes to male sexual health. And now, for the female side of the population, we have the tools to say it's no different—women are not just reproductive beings, right? They deserve sexual health quality of life. And it is not just in the purview of an OB/GYN to do those things. We as urologists are board certified to take care of all genders. We are really good sexual medicine doctors, and we need to apply what we know about sexual medicine, not just for our male patients, but for all of our patients. And the interesting thing here is by caring about female sexual medicine, it will improve many of our male patient's quality of life. We always complain that we have all these tools for men, and we have no tools for our female patients. But we have so many more tools than we realize when it comes to medications for HSDD.

In this installment of Urology Times' 50th Anniversary Innovation Celebration, Rachel S. Rubin, MD, discusses the evolution in the treatment of female hypoactive sexual desire disorder.

The evolution in the treatment of female hypoactive sexual desire disorder

Dr Hill, what are the current US guidelines? We now have some discrepancies. You've got a set from the American Cancer Society, which are not very long ago and now we have the ASCCP which joined together with the ACOG and SGO to come up with another set of guidelines. What are the differences?

 I think these do frankly get confusing for people because there are different sets, and some of the recommendations have similarities, and there are some differences, and sometimes it's hard to tease that out. I feel for myself, especially when I'm teaching learners that there's constantly a new evolution of this, which is appropriate, that it'd be updated and recommendations and data changes. In my lectures, I almost never put actual specifics, especially with medical students because it changes so much. I think one of the big differences is that the American Cancer Society guidelines really embrace that primary HPV screening as a preferred option. They have no screening actually up until the age of 25 with screening starting at 25, which is later than the ASCCP guidelines which still recommend starting at 21 for pap screening. With the American Cancer Society, again, you're starting at 25, and it's really primary HPV screening alone as the preferred option for women after that age of 25, whereas the ASCCP guidelines have the 21 to 29 year old age group still cytology alone, done every 3 years, I believe. Hopefully, I'm not getting them wrong myself.

 Then basically at 30, it's starting to do the co-testing with HPV and cytology. I think the reason for that is the prevalence of the frequency of high-risk HPV being a lot higher in that younger age group, but they are less likely to actually develop precancer and cancer. I think that's the big difference. It is a pretty big difference, and as a provider, you have to pick which guideline you're gonna go with. Again, some of that right now might be your availability of primary HPV screening, but I think part of it also is it's just a change in our practice, and I think patients struggle with it too because they're told for years, get your pap every year; this pap is super important. Then the transition to a screening system where you're either not having Pap until you're 25 or you're only doing HPV screening can be hard for patients too, and explaining that to patients and reassuring them that it's a safe approach takes some finesse.

Now, you were part of the ASCCP committees which developed the joint or which adopted the guideline with the SGO and ACOG. The ASCCP really adopted the previous US Preventative Services guidelines. What were the discussions around not doing HPV primary screening in women 25 to 30 or 29?

 It's not that they don't support those American Cancer Society guidelines because there is support, I think, in general endorsement that they're a reasonable, acceptable screening strategy. I think one of the big things was just implementation issues, worrying that if we went right to that as the clearly preferred method, but it's not available to the majority of providers in the US. That is problematic, and there's just so much that has to change in FDA approval of primary HPV screening tests being widely available, cost, workflow, billing, insurances. There's just a lot of complexity there. I think the lack of uptake in HPV vaccination in our US population is problematic too because, again, if you're using primary HPV screening for this younger age group, you're gonna get a lot of positive tests, and you have to figure out the negatives to that of which there are several. I think the hope being that in 5 years or a few years, shouldn't put a number on it that maybe we'll have better vaccination rates, so the younger women moving forward will have higher protection from that reason. Then the age of HPV screenings becomes a little, I don’t know if easier is the right word. Then I think the other concern is that a lot of the studies that have been done did not necessarily have great representation from some underserved and minority populations in the US, so there is concern about different HPV strains in different groups of women and that potentially some of the data on the primary HPV screening hasn't properly extended to those patients or those women. There is some concerns about that. I think all of that weighed into the choice to support the US Preventative Services guidelines for now.