Process of Aging. Manifestation of Estrogen and/or Androgen Loss: Symptoms Over Time. Estrogen Decrease and Its Impact on Sexual Functioning

Size: px
Start display at page:

Download "Process of Aging. Manifestation of Estrogen and/or Androgen Loss: Symptoms Over Time. Estrogen Decrease and Its Impact on Sexual Functioning"

Transcription

1 Impact of Vulvovaginal Atrophy on Quality of Life and Sexuality Process of Aging physical health sexual activity Sexual function and aging desire androgen levels Michael L. Krychman MD Executive Director of the Southern California Center for Sexual Health and Survivorship Medicine Associate Clinical Professor UCI Department of Gynecology Oncology NAMS Annual Meeting Dallas Texas 2013 Delayed orgasm Fear of sexual or anorgasmia relations Dyspareunia and vulvar/vaginal atrophy estrogen levels Sherwin BB et al. Psychosom Med. 1987;49: Sarrel PM et al. J Reprod Med. 1998;43: JL Alexander, 2 Manifestation of Estrogen and/or Androgen Loss: Symptoms Over Time Lila Nachtigall, M.D. Discussing Urogenital Atrophy Oncology Volume 13, 1999 Range of Estrogen secretion levels (pg/ml) Short-term symptoms Long-term symptoms Onset insidious with significant individual variability Mood, sleep, and/or Hot flushes acute cognitive changes Urogenital symptoms Decreased sexual activity Decreased arousal Decreased libido Among 2000 postmenopausal women in any given year: 20 will develop heart disease 11 will develop bone loss 6 will develop breast cancer 3 will develop endometrial cancer But nearly 100% will develop urogenital atrophy. Proceedings of a conference held in Charlottesville Virginia, September 21-23, Age (y). 3 4 Estrogen Decrease and Its Impact on Sexual Functioning Estrogen Has Effects on All Tissue Components of the Vulvovaginal Area Estrogen decrease impacts the integrity of the female reproductive tract tissues Dyspareunia Decreased vaginal lubrication Atrophic vaginitis Decreased blood flow to reproductive organs Diminished vasocongestion Blood flow to the vulva (as measured by Doppler ultrasound velocimetry) increased by 50% when estrogen was administered to postmenopausal women Sarrel PM. Obstet Gynnecol. 1990:75:4:26S-30S. Epithelia (skin, vaginal) Promotes epithelial maturation and proliferation Maturation index relates to estrogen levels Ratio of parabasal to intermediate to superficials cells Skin appendages Blood vessels Increases vascularity and blood flow Nerves Specialized glands Stimulates glandular secretions (eg, Bartholin s gland) Sarrel PM et al. Fertil Steril. 1997;68: JL Alexander, 5 Utian WH. Front Hormone Res. 1975;3:

2 7 Perivaginal Blood Flow During Estrogen Replacement Therapy Vulvovaginal Changes Can Lead to Sexual Symptoms Milliwatts (mw) Baseline 1 Month 3 Months 6 Months Increase in blood flow values in women estrogen-deprived at baseline, and then administered conjugated estrogens. Vaginal dryness Dyspareunia Reduced or absent pleasure from direct genital stimulation Urinary symptoms Urgency, frequency, and possibly incontinence Predisposition to vulvar, vaginal, and lower UTIs If atrophy severe Vaginal shortening and narrowing Possible introital stenosis Prevents penetration or causes significant pain and/or bleeding from attempted penetration Possibly frequent sexual arousal and activity promotes genital health Wilbur JE et al. Menopause. 1998;5: Semmens J et al. JAMA. 1982;248: Leiblum S et al. JAMA. 1983;249: What is Urogenital Atrophy (UA)? Dyspareunia & Bladder Symptoms UA is a condition of associated tissue and organ deterioration/dryness UA is due to estrogen depletion and is associated with urinary and vaginal symptoms UA is chronic and progressive UA contributes to atrophic vaginitis (AV) and sexual dysfunction in women Coital pain causes: Tightened, defensive myalgic pelvic floor Pelvic Floor Hypertonus Reflex inhibition of periurethral vascular arousal Mechanical urethral trauma Keil K. Current Women s Health Reports.2002,2: O Connell HE et al. J.Urol. 1998;159: D Amati G et al. J.Urol. 2002;60: Slide courtesy of A Graziottin, Clinical Symptoms of Urogenital Atrophy Symptoms That May Accompany Urogenital Atrophy Urethral Weak urinary stream Recurrent UTI Urge incontinence Urgency Frequency Urethral caruncle (lesions) Urethral erythema Friable urothelium Urinary Frequency Urgency Incontinence Frequent UTI Dysuria Vaginal Dryness with dyspareunia Burning Occasional bleeding Recurrent vaginitis or bacterial vaginosis Itching Pain Vaginal pressure Malodorous discharge Endocrine Aspects of Female Sexual Dysfunctin Workgroup. Second International Consultation on Erectile and Sexual Dysfunctions; Paris, France; June 28-July 1, UTI = urinary tract infection. Keil K. Current Women s Health Reports 2002,2: Bachmann GA et al. Am Fam Physician 2000;;1:

3 13 Pelvic Floor Hypoestrogenism VVA is strongly Associated with FSD among Sexually Active Postmenopausal Women Levine et al: Menopause 15;4: Decreased connective tissue Decreased elastic tissue Increased fatty infiltration Cellular atrophy Nerve degeneration Reduced smooth muscle tone Menopause Epidemiology Study is cross sectional population based study of women years of age. Arizona Sexual Experience Study used Cross-sectional, population-based study of 1,480 sexually active, postmenopausal women Prevalence of vulvovaginal atrophy (57%) & FSD( 55%) Women with FSD were 3.84 times more likely to have vuvlovaginal atrophy than women without FSD. Women with sexual dysfunction ~4X more likely to also have vulvovaginal atrophy Endocrine Aspects of Female Sexual Dysfunction Workgroup. Second International Consultation on Erectile and Sexual Dysfunctions; Paris, France; June 28-July 1, Conclusion: Reducing symptoms of one condition may also relieve symptoms of the other What Do Patient Surveys Tell Us about VVA and QOL. ReVeal Survey (2008) Pfizer ReVeal ( Revealing Vaginal Effects at Mid Life) Healthy Women NovoNordisk VIVA ( Vaginal Health Insight, Views and Attitudes) CLOSER ( Clarifying Vaginal Atrophy Impact on Sex and Relationships) Shionogi REVIVE (REal Women s VIews of Treatment Options for Menopausal Vulvar/Vaginal ChangEs) Consisted of a phone survey among a representative sample of 1,006 PMW and an online survey of 602 HCP who treat postmenopausal women While most PMW surveyed recognized the importance of their sexual health, about 50% agreed that they refrain from talking about their sexual health/ intimacy with others 1/4 PMW surveyed experience dyspareunia at least sometimes. Even though it is painful, approximately 3/4 of these women engage in sex at least once a month, and one out of three engage in painful sex at least once weekly Healthy Women (2011) 56% of the postmenopausal women surveyed indicated they have experienced vaginal dryness. Among those women who reported experiencing vaginal dryness, 82% reported that their vaginal dryness is bothersome, with 20% reporting that their vaginal dryness bothers them either a lot or a great deal. 17% of women reported that their vaginal dryness did not bother them at all Negative Impact On Sexual Health But even if women are not discussing them, vaginal symptoms are having a negative impact on their sexual health. 63% who reported experiencing painful intercourse indicated that they avoid intimate situations because of their symptoms 70% who reported experiencing painful intercourse indicated their condition puts at least some strain on their sexual relationship with their partner 64% who reported experiencing vaginal dryness or 62% painful intercourse said they have learned to live with vaginal dryness/painful intercourse and have come to accept it

4 The CLOSER (CLarifying Vaginal Atrophy's Impact On SEx and Relationships) Survey: Implications of Vaginal Discomfort in Postmenopausal Women and in Male Partners. Nappi RE, et al. JSM 2013: Sept 10 (9) % of the postmenopausal women surveyed who reported experiencing painful intercourse indicated they still engage in intercourse even though it is painful, 40% engaging in intercourse at least once a week. 73% said they engage in painful intercourse because of their partner 80% report that vaginal dryness impacted sexual frequency 70% are less sexual now as compared to before menopause Results: 28% percent of women did not tell their partners when they first encountered vaginal discomfort, Having sex less often (women: 58%, men: 61%), less satisfying sex (women: 49%, men: 28%), and putting off having sex (women: 35%, men: 14%) were the main effects of VA. Intimacy avoidance was attributed to painful sex (women: 55%, men: 61%) and women's reduced sexual desire (women: 46%, men: 43%). Conclusions: VA has an adverse emotional and physical impact on postmenopausal women and their partners. VVA and Impact VVA has a big impact on a woman s relationship with her significant other (Husbands sometimes force their wives to seek medical help) VVA is more about sexual intimacy than loss of youth Some women deal with VVA by doing everything they can to avoid intimacy (e.g. waking up early before husband, intentionally putting themselves in situations that are not sexually inducing) VVA takes away a woman s sense of sexual spontaneity VVA also affects women in partaking in physical activities, such as biking, walking and running VVA also impacts a woman s enjoyment of life and her temperament Enjoyment of sex Sexual spontaneity Ability to be intimate Relationship w/ partner Sleeping Temperament Enjoyment of life Seeking new relationship Traveling Athletic activities Everyday activities Social activities Ability to work Women without a partner are more impacted by VVA impacts a woman s Sex Life and non-sexual aspects of life 22 Therapy Benefits Is Local Really Local? Maintains lubrication through production and regulation of mucosal and glandular secretions Promotes organ and tissue integrity Mucosal and epithelial health Elasticity of connective tissues Smooth muscle function Blood flow and parenchymal perfusion ph control for flora-friendly environment Acidifies vaginal ph through uptake regulation of proton secretion via apical membrane of ectocervical epithelial cells Kendall et. al. cautions that vaginal estradiol is contraindicated in postmenopausal women on adjuvant aromatase inhibitors1. Labrie et. al. demonstrate that even small doses of vaginal preparations Vagifem 25 µg; Premarin Vaginal Cream result in significant systemic absorption through estrogen naive vaginas(2). Naessen et al showed that 7.5 µg/24h could improve the lipid profile and bone density without affecting the endometrium3-5. Bachmann GA et al. Am Fam Physician. 2000;61: Belchetz PE. N Engl J Med. 1994;330: Keil K. Current Women s Health Reports. 2002,2: Gorodeski G et al. Endocrinology. 2005;146; Kendall A, et. al. Ann Oncol 2006;17: Labrie F, et. al. Menopause 2009;16: Naessen T, et. al. J Clin Endocrinol Metab 2001;86: ; Am J Obstet Gynecol 1997;177: ; Am J Obstet Gynecol 2002;186:

5 25 VVA: Medical Need That Is Not Fully Addressed Premenopausal women taking anti-estrogens or who have medical/surgical conditions that result in decreased estrogen levels are susceptible Cancer Chemo/radiation therapies Surgery/Hysterectomy/Oophorectomy Breast cancer patients 54% of patients on tamoxifen report sexual dysfunction Increased incontinence and vaginal dryness, decreased sexual activity Atrophic Vaginitis: Chronic and Progressive Early detection of signs and symptoms of vaginal atrophy is important VVA will likely worsen if left untreated Dyspareunia may lead to sexual dysfunction VVA impacts sexuality and QOL Treatment is considered efficacious and is well documented Mortimer JE et al. J Clin Oncol ;17: Ganz PA et al. J Natl Cancer Inst ;94: ASK You cannot treat a problem if you do not know that one exists TELL Your health care professional cannot help you if he or she does not know there is a problem. 27

Year: Issue 1 Obs/Gyne The silent epidemic: Postmenopausal vaginal atrophy

Year: Issue 1 Obs/Gyne The silent epidemic: Postmenopausal vaginal atrophy Year: 2013 - Issue 1 Obs/Gyne The silent epidemic: Postmenopausal vaginal atrophy By: Dr David W Sturdee, Immediate past President International Menopause Society and Hon Consultant Gynaecologist, Solihull

More information

Southern California Center for Sexual Health and Survivorship Medicine Inc, Newport Beach, CA 3

Southern California Center for Sexual Health and Survivorship Medicine Inc, Newport Beach, CA 3 The WISDOM survey: Physicians Level of Comfort Prescribing Treatment for Vulvar and Vaginal Atrophy (VVA) Symptoms in Women with a Predisposition or History of Breast Cancer Lisa Larkin, MD 1 ; Michael

More information

New Treatments for Vaginal Health. Sarah Azad, MD El Camino Women s Medical Group

New Treatments for Vaginal Health. Sarah Azad, MD El Camino Women s Medical Group New Treatments for Vaginal Health There s Hope Sarah Azad, MD El Camino Women s Medical Group The Genitrourinary Syndrome of Menopause (GSM) Problems with genital health secondary to the changes that occur

More information

Laser CO2: una terapia ambulatoriale innovativa nel trattamento delle disfunzioni sessuali femminili

Laser CO2: una terapia ambulatoriale innovativa nel trattamento delle disfunzioni sessuali femminili Obstetrics and Gynaecology Unit Functional Unit of Urogynaecology Vita-Salute San Raffaele University and San Raffaele Hospital Milan Italy Laser CO2: una terapia ambulatoriale innovativa nel trattamento

More information

FemTouch Treatment for Improving Vulvovaginal Health

FemTouch Treatment for Improving Vulvovaginal Health FemTouch Treatment for Improving Vulvovaginal Health Dr. M. Marziali MD PhD in Gynecology and Obstetric Introduction Vulvovaginal atrophy (VVA) accompanies the natural aging of the vagina and affects up

More information

Innovations in the Management of Dyspareunia

Innovations in the Management of Dyspareunia Transcript Details This is a transcript of a continuing medical education (CME) activity accessible on the ReachMD network. Additional media formats for the activity and full activity details (including

More information

Vaginal atrophy is a common condition

Vaginal atrophy is a common condition original article Oman Medical Journal [2017], Vol. 32, No. 1: 15 19 Treatment of Vaginal Atrophy with Vaginal Estrogen Cream in Menopausal Indian Women Maitri Shah 1 *, Zalak Karena 1, Sangita V. Patel

More information

GP Education Series Women s cancers. GP Education Day 11 July 2016

GP Education Series Women s cancers. GP Education Day 11 July 2016 GP Education Series Women s cancers GP Education Day 11 July 2016 Sexual Consequences of Treatment for Women s Cancers Dr Isabel White Clinical Research Fellow in Psychosexual Practice The Royal Marsden

More information

SEXUAL PAIN Home messages, a summary from Presentations, moderated Posters and Podiums

SEXUAL PAIN Home messages, a summary from Presentations, moderated Posters and Podiums SEXUAL PAIN Home messages, a summary from Presentations, moderated Posters and Podiums María Luisa Banfi, MD Gynecologist, Sexologist Montevideo, Uruguay, South America CHICAGO 2012,SMS- ISSM, World Meeting

More information

Dr. Maliheh Keshvari

Dr. Maliheh Keshvari 1 Dr. Maliheh Keshvari Assistant professor of Urology Fellowship in Female Urology Mashhad University of Medical Sciences 2 Female Sexual Function and Dysfunction 3 It was not until recently that urologists

More information

There are a variety of ways to address VVA. Keep yourself healthy, avoid irritants to the vulva and vagina, and use moisturizers and lubricants.

There are a variety of ways to address VVA. Keep yourself healthy, avoid irritants to the vulva and vagina, and use moisturizers and lubricants. What is VulvoVaginal Atrophy? VulvoVaginal Atrophy, or VVA for short, is also called genitourinary syndrome of menopause. VVA is a condition where the skin of the vagina and vulva becomes thin, dry and

More information

Energy Based Therapies in Gynecology and Vaginal Health: Update on CO 2

Energy Based Therapies in Gynecology and Vaginal Health: Update on CO 2 Energy Based Therapies in Gynecology and Vaginal Health: Update on CO 2 Eric R. Sokol MD Associate Professor of Obstetrics and Gynecology Associate Professor of Urology, by Courtesy Co-Director, Urogynecology

More information

Sexual dysfunction: Is it all about hormones?

Sexual dysfunction: Is it all about hormones? Sexual dysfunction: Is it all about hormones? Angelica Lindén Hirschberg, MD, PhD, Professor Department of Women s and Children s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm,

More information

Learning Objectives. Peri menopause. Menopause Overview. Recommendation grading categories

Learning Objectives. Peri menopause. Menopause Overview. Recommendation grading categories Learning Objectives Identify common symptoms of the menopause transition Understand the risks and benefits of hormone replacement therapy (HRT) Be able to choose an appropriate hormone replacement regimen

More information

Sexual dysfunction in women with cancer: Navigating intimacy and intercourse between women and their partners

Sexual dysfunction in women with cancer: Navigating intimacy and intercourse between women and their partners Sexual dysfunction in women with cancer: Navigating intimacy and intercourse between women and their partners Don S. Dizon, MD, FACP Clinical Co-Director, Gynecologic Oncology Founder and Director, The

More information

Haelle T. Changing the conversation about hormone therapy in menopause. Medscape, 2017; accessed

Haelle T. Changing the conversation about hormone therapy in menopause. Medscape, 2017;   accessed Pelvic PT Distance Journal Club: November 2018 (Moderator: MJ Strauhal PT, DPT, BCB- PMD) Topic: Why should pelvic PT s be knowledgeable of menopausal changes in the urogenital region and the history of

More information

Disease (diabetic neuropathy, multiple sclerosis, tumors, and, rarely, tertiary syphilis)

Disease (diabetic neuropathy, multiple sclerosis, tumors, and, rarely, tertiary syphilis) COURSES ARTICLE - THERAPYTOOLS.US Individual Planning: A Treatment Plan Overview for Adult Men with Sexual Performance Problems Individual Planning: A Treatment Plan Overview for Adult Men with Sexual

More information

Erin E. Stevens, MD Chair, Department of Gynecologic Oncology Billings Clinic Cancer Center January 18, 2017

Erin E. Stevens, MD Chair, Department of Gynecologic Oncology Billings Clinic Cancer Center January 18, 2017 Erin E. Stevens, MD Chair, Department of Gynecologic Oncology Billings Clinic Cancer Center January 18, 2017 Objectives Define what's normal Define female sexual dysfunction Identify the causes of female

More information

Renewing Intimacy & Sexuality after Gynecologic Cancer

Renewing Intimacy & Sexuality after Gynecologic Cancer Renewing Intimacy & Sexuality after Gynecologic Cancer foundationforwomenscancer.org Over 90,000 women are diagnosed with a gynecologic cancer each year. The challenge for a woman with cancer and her healthcare

More information

Sexological aspects of genital pain

Sexological aspects of genital pain Sexological aspects of genital pain Annamaria Giraldi, professor, MD, PHD Sexological Clinic, Psychiatric Centre Copenhagen 1 Disclosures Speaker: Eli Lilly, Pfizer Consultant: Eli Lilly,Palatin 2 Agenda

More information

Menopause Symptoms and Management: After Breast Cancer

Menopause Symptoms and Management: After Breast Cancer Menopause Symptoms and Management: After Breast Cancer An Educational Webinar for Patients and their Caregivers Wen Shen, MD, MPH Division of Gynecologic Specialties July 27, 2018 1 Disclosure I have a

More information

Original Article INTRODUCTION

Original Article INTRODUCTION Original Article A comparative study of vaginal estrogen cream and sustained-release estradiol vaginal tablet (Vagifem) in the treatment of atrophic vaginitis in Isfahan, Iran in 2010-2012 Pardis Hosseinzadeh,

More information

Body image and sexuality issues after surgery or cancer

Body image and sexuality issues after surgery or cancer Body image and sexuality issues after surgery or cancer Sharon L. Bober, Ph.D. Director, Sexual Health Program Perini Family Survivors Center Dana-Farber Cancer Institute June 26, 2010 Why doesn t sex

More information

Dyspareunia: Best Practices in Counseling, Diagnosis, and Therapy

Dyspareunia: Best Practices in Counseling, Diagnosis, and Therapy Transcript Details This is a transcript of a continuing medical education (CME) activity accessible on the ReachMD network. Additional media formats for the activity and full activity details (including

More information

Menopause Matters. Equity Office Staff Seminar 14 November 2018

Menopause Matters. Equity Office Staff Seminar 14 November 2018 Menopause Matters Equity Office Staff Seminar 14 November 2018 1 What to expect at menopause How to manage symptoms Support at work Dr Janice Brown Medical lead, The University of Auckland NZ representative,

More information

Women s Health: Managing Menopause. Jane S. Sillman, MD Assistant Professor of Medicine Harvard Medical School

Women s Health: Managing Menopause. Jane S. Sillman, MD Assistant Professor of Medicine Harvard Medical School Women s Health: Managing Menopause Jane S. Sillman, MD Assistant Professor of Medicine Harvard Medical School Disclosures I have no conflicts of interest. Learning Objectives 1. Apply strategies to help

More information

Prior disclosures past 3 years Consultant for Pfizer University of Virginia received Grants/research support from TherapeuticsMD

Prior disclosures past 3 years Consultant for Pfizer University of Virginia received Grants/research support from TherapeuticsMD Prior disclosures past 3 years Consultant for Pfizer University of Virginia received Grants/research support from TherapeuticsMD JoAnn V. Pinkerton, MD Professor of Obstetrics and Gynecology Director,

More information

Therapy and Sexual Health

Therapy and Sexual Health Menopausal hormone therapy and sexual health Earn 3 CPD Points online Menopausal Hormone Therapy and Sexual Health Key messages Dr Tobie De Villiers Consultant Gynaecologist Panorama MediClinic Department

More information

Use of vaginal estrogen in Danish women: a nationwide cross-sectional study

Use of vaginal estrogen in Danish women: a nationwide cross-sectional study AOGS ORIGINAL RESEARCH ARTICLE Use of vaginal estrogen in Danish women: a nationwide cross-sectional study AMANI MEAIDI 1,, IRINA GOUKASIAN & OEJVIND LIDEGAARD 1 1 Department of Gynecology, Rigshospitalet

More information

VVA : new therapeutic options? BMS october 2017 A Pintiaux

VVA : new therapeutic options? BMS october 2017 A Pintiaux VVA : new therapeutic options? BMS october 2017 A Pintiaux Disclosures Member of the european board of TEVA without personal gain No conflict of interest for this presentation VVA Vulvar and vaginal atrophy

More information

Leslie R. Schover, PhD Department of Behavioral Science

Leslie R. Schover, PhD Department of Behavioral Science Causes and Treatments of Low Sexual Desire in Breast Cancer Survivors Leslie R. Schover, PhD Department of Behavioral Science IMPORTANCE OF SEX TO BREAST CANCER SURVIVORS Livestrong 2006 Post-Treatment

More information

Dyspareunia Associated with Vulvovaginal Atrophy: Innovations in Counseling, Diagnosis, and Management

Dyspareunia Associated with Vulvovaginal Atrophy: Innovations in Counseling, Diagnosis, and Management SUPPLEMENT TO FREE 1 CME Credit To receive CME credit, please read the articles and go to www.omniaeducation.com/dysparenuia to access the posttest and evaluation or see the back of this supplement for

More information

A Non-Hormonal Approach to Preventing Vulvovaginal Atrophy from Aromatase Inhibitors (AIs)

A Non-Hormonal Approach to Preventing Vulvovaginal Atrophy from Aromatase Inhibitors (AIs) A Non-Hormonal Approach to Preventing Vulvovaginal Atrophy from Aromatase Inhibitors (AIs) Leslie R. Schover, PhD Department of Behavioral Science Funded by the Duncan Family Institute for Cancer Prevention

More information

Post-menopausal hormone replacement therapy. Evan Klass, MD May 17, 2018

Post-menopausal hormone replacement therapy. Evan Klass, MD May 17, 2018 Post-menopausal hormone replacement therapy Evan Klass, MD May 17, 2018 Are we really still talking about this? Are we really still talking about this? 1960-1975- estrogen prescriptions doubled. Pharma

More information

Women s Sexual Interest/Desire Disorder : Implications of New Definition

Women s Sexual Interest/Desire Disorder : Implications of New Definition Women s Sexual Interest/Desire Disorder : Implications of New Definition Rosemary Basson MD FRCP(UK) Vancouver General Hospital University of British Columbia Vancouver, Canada 1 New Model of Sex Response

More information

9/26/2016. Disclosures. Genitourinary Syndrome of Menopause: Novel Term for Common Conditions. Objectives ISSWSH NAMS CONSENSUS CONFERENCE

9/26/2016. Disclosures. Genitourinary Syndrome of Menopause: Novel Term for Common Conditions. Objectives ISSWSH NAMS CONSENSUS CONFERENCE Genitourinary Syndrome of Menopause: Disclosures Novel Term for Common Conditions Research, Consultant, and/or Speaker Risa Kagan, MD, FACOG, CCD, NCMP Clinical Professor, Department of Obstetrics, Gynecology,

More information

Atrophic Vaginitis. Mimi Clarke Secor CHAPTER 23

Atrophic Vaginitis. Mimi Clarke Secor CHAPTER 23 Atrophic Vaginitis CHAPTER 23 Mimi Clarke Secor I. Atrophic vaginitis explained. A. Statistics. 1. Statistics indicate that 45 million women are menopausal and that this number is growing as baby boomers

More information

2017 Position Statement of Hormone Therapy of NAMS: overview SHELAGH LARSON, MS, RNC WHNP, NCMP ACCLAIM, JPS HEALTH NETWORK

2017 Position Statement of Hormone Therapy of NAMS: overview SHELAGH LARSON, MS, RNC WHNP, NCMP ACCLAIM, JPS HEALTH NETWORK 2017 Position Statement of Hormone Therapy of NAMS: overview SHELAGH LARSON, MS, RNC WHNP, NCMP ACCLAIM, JPS HEALTH NETWORK WHI the only large, long-term RCT of HT in women aged 50 to 79 years, Drug trail

More information

FEMININE INTIMATE CARE

FEMININE INTIMATE CARE FEMININE INTIMATE CARE The role of the pharmacist Dr Trudy Smith Vaginal Health Vagina sensitive area Just like GIT, also contain flora Vaginal flora Maintain healthy ph (4.5) Lactobacilli (aerobic) Automatic

More information

NAMS in the News 2016

NAMS in the News 2016 NAMS in the News 2016 Menopause in the News This is great support showing that being sedentary is not only not good for your health, it is not good for your menopause symptoms, said Dr. JoAnn Pinkerton,

More information

Management of Menopausal Symptoms

Management of Menopausal Symptoms Management of Menopausal Symptoms Tammie Koehler DO, FACOG 1 Menopause Permanent cessation of menstruation that occurs after the loss of ovarian activity Determined to have occurred after 1 full year of

More information

Vulvar and Vaginal Atrophy: Physiology, Clinical Presentation, and Treatment Considerations

Vulvar and Vaginal Atrophy: Physiology, Clinical Presentation, and Treatment Considerations CLINICAL OBSTETRICS AND GYNECOLOGY Volume 58, Number 3, 476 491 Vulvar and Vaginal Atrophy: Physiology, Clinical Presentation, and Treatment Considerations AHINOAM LEV-SAGIE, MD Department of Obstetrics

More information

Management of Menopausal Symptoms in Patients with Breast Cancer. Mike Dixon Edinburgh Breast Unit

Management of Menopausal Symptoms in Patients with Breast Cancer. Mike Dixon Edinburgh Breast Unit Management of Menopausal Symptoms in Patients with Breast Cancer Mike Dixon Edinburgh Breast Unit Menopausal symptoms have a major impact on Quality of Life Variety of Symptoms associated with the Menopause

More information

Sex Cells The effect of hormones on peri- and post- menopausal female sexuality Dr. Cathy Caron November 24, 2011

Sex Cells The effect of hormones on peri- and post- menopausal female sexuality Dr. Cathy Caron November 24, 2011 Sex Cells The effect of hormones on peri- and post- menopausal female sexuality Dr. Cathy Caron November 24, 2011 Is sex over at menopause? Older adults are having sex 51% of women ages 50 to 59 report

More information

Women s Intimacy, Sexuality and Relationship Issues After Cancer

Women s Intimacy, Sexuality and Relationship Issues After Cancer Women s Intimacy, Sexuality and Relationship Issues After Cancer Sylvie Aubin, Ph.D. Segal Cancer Centre Jewish General Hospital McGill University Objectives Acknowledge changes in intimacy and sexuality

More information

Female Sexual Dysfunction: Clinical approach

Female Sexual Dysfunction: Clinical approach Female Sexual Dysfunction: Clinical approach - What Nurses want to know - Alessandra Graziottin MD Director, Center of Gynecology and Medical Sexology H.San Raffaele Resnati, Milano, Italy Co-Director,

More information

Presented by: Helena Green Clinical Sexologist/Counsellor.

Presented by: Helena Green Clinical Sexologist/Counsellor. Female Sexuality Presented by: Helena Green Clinical Sexologist/Counsellor helena@relate-sexology.com.au www.insyncforlife.com.au 02/05/2018 UWA IMED2208: Issues in women's reproductive health Clinical

More information

PAINFUL URINATION CAUSES & NATURAL REMEDY. Dr. Bestman Anyatonwu

PAINFUL URINATION CAUSES & NATURAL REMEDY. Dr. Bestman Anyatonwu LIBRACIN NATURAL MEDICINE IND. LTD PAINFUL URINATION CAUSES & NATURAL REMEDY Dr. Bestman Anyatonwu MEANING Painful urination is a broad term that describes discomfort during urination. This pain may originate

More information

LET S START WITH (AND REMEMBER WE ARE TALKING ABOUT LOCAL E2) THERAPUTIC AGENTS: ARE THEY SAFE? Systemic HT/ET. Ospemifene. Local Estrogen Therapy

LET S START WITH (AND REMEMBER WE ARE TALKING ABOUT LOCAL E2) THERAPUTIC AGENTS: ARE THEY SAFE? Systemic HT/ET. Ospemifene. Local Estrogen Therapy THERAPUTIC AGENTS: ARE THEY SAFE? Steven R. Goldstein, M.D. Professor of Obstetrics & Gynecology New York University School of Medicine Director of Gynecologic Ultrasound Co-Director of Bone Densitometry

More information

Voiding Diary. Begin recording upon rising in the morning and continue for a full 24 hours.

Voiding Diary. Begin recording upon rising in the morning and continue for a full 24 hours. Urodvnamics Your physician has scheduled you for a test called URODYNAMICS. This test is a series of different measurements of bladder function and can be used to determine the cause of a variety of bladder

More information

Low sexual desire: Appropriate use of testosterone in menopausal women

Low sexual desire: Appropriate use of testosterone in menopausal women Low sexual desire: Appropriate use of testosterone in menopausal women Low-dose testosterone treatment may be considered for HSDD in carefully selected menopausal women after standard therapies have been

More information

Summary of the risk management plan (RMP) for Senshio (ospemifene)

Summary of the risk management plan (RMP) for Senshio (ospemifene) EMA/736568/2014 Summary of the risk management plan (RMP) for Senshio (ospemifene) This is a summary of the risk management plan (RMP) for Senshio, which details the measures to be taken in order to ensure

More information

By Milena Mincigrucci*, Costante Donati Sarti**, Angelamaria Becorpi***, Massimo Milani, and Gianluca Botta

By Milena Mincigrucci*, Costante Donati Sarti**, Angelamaria Becorpi***, Massimo Milani, and Gianluca Botta Results of the VALYD* study A multicenter, epidemiological, observational, prospective study of vaginal atrophy and quality By Milena Mincigrucci*, Costante Donati Sarti**, Angelamaria Becorpi***, Massimo

More information

Menopausal Symptoms. Hormone Therapy Products Available in Canada for the Treatment of. Physician Desk Reference - 3rd Edition

Menopausal Symptoms. Hormone Therapy Products Available in Canada for the Treatment of. Physician Desk Reference - 3rd Edition Hormone Therapy Products Available in Canada for the Treatment of Menopausal Symptoms Physician Desk Reference - 3rd Edition A clinical resource provided to you by: The Society of Obstetricians and Gynaecologists

More information

Genitourinary Symptoms of Menopause (GSM) Effects on Sexual Function

Genitourinary Symptoms of Menopause (GSM) Effects on Sexual Function Genitourinary Symptoms of Menopause (GSM) Effects on Sexual Function Amanda Clark MD MCR NCMP Urogynecologist Co-authors: Joanna Bulkley PhD, Kate Beadle WHNP, NCMP, Michael Leo PhD, Ashley Stoneburner

More information

Understanding Women's Sexuality after Bladder Cancer webinar. Part I: The Physical Impact

Understanding Women's Sexuality after Bladder Cancer webinar. Part I: The Physical Impact Understanding Women's Sexuality after Bladder Cancer webinar Tuesday, December 1, 2015 Part I: The Physical Impact Presented by LaShon Day received her Masters of Science as a Physician s Assistant at

More information

Virtual Mentor Ethics Journal of the American Medical Association November 2005, Volume 7, Number 11

Virtual Mentor Ethics Journal of the American Medical Association November 2005, Volume 7, Number 11 Virtual Mentor Ethics Journal of the American Medical Association November 2005, Volume 7, Number 11 Clinical Pearl Post Women's Health Initiative Menopausal Women and Hormone Therapy by JoAnn V. Pinkerton,

More information

OBSTETRICS & GYNECOLOGY

OBSTETRICS & GYNECOLOGY JANUARY 2012 COMPOUNDING PHARMACY SOLUTIONS PRESCRIPTION COMPOUNDING WWW.CPSRXS. COM We customize individual prescriptions for the specific needs of our patients. INSIDE THIS ISSUE: Female Sexual Arousal

More information

Amy Siston, Ph.D. July 9, 2017

Amy Siston, Ph.D. July 9, 2017 Amy Siston, Ph.D. July 9, 2017 Prevalence of Sexual Dysfunction Non-Cancer Population Ovarian Cancer Population 43% 30-100% Common Sexual Issues DESIRE: 25-59% no/low sexual desire AROUSAL: 24-60% difficulty

More information

Resilient Intimacy. Richa Sood, M.D.

Resilient Intimacy. Richa Sood, M.D. Resilient Intimacy Richa Sood, M.D. Disclosures No financial conflicts My specialty is Female Sexual Dysfunction Common Questions What is normal sexuality, and how does it change with medical illness?

More information

Sexuality After the Diagnosis of Ovarian Cancer

Sexuality After the Diagnosis of Ovarian Cancer Sexuality After the Diagnosis of Ovarian Cancer June La Valleur, MD, FACOG, Sexual Health Counselor Associate Professor, Ret., University of Minnesota Medical School Sexual Health Consultant at Skyhill

More information

Lucy Guerra MD MPH FACP FHM Division Director & Associate Professor Internal Medicine

Lucy Guerra MD MPH FACP FHM Division Director & Associate Professor Internal Medicine Lucy Guerra MD MPH FACP FHM Division Director & Associate Professor Internal Medicine Disclosures I have no financial, personal, or familial associations to disclose. Learner Objectives Develop a basic

More information

Sexuality and Sexual Dysfunction in Women

Sexuality and Sexual Dysfunction in Women Sexuality and Sexual Dysfunction in Women Denise M.S. Willers, MD Associate Professor of Obstetrics and Gynecology Washington University School of Medicine Disclosures No financial disclosures to make

More information

Interventions to Address Sexual Problems in People with Cancer

Interventions to Address Sexual Problems in People with Cancer A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO) Interventions to Address Sexual Problems in People with Cancer L. Barbera, C. Zwaal, D. Elterman, K. McPherson,

More information

Female Sexuality Sheryl A. Kingsberg, Ph.D.

Female Sexuality Sheryl A. Kingsberg, Ph.D. Female Sexuality Sheryl A. Kingsberg, Ph.D. Professor of Reproductive Biology Case Western Reserve University School of Medicine Chief, Division of Behavioral Medicine Department of OB/GYN University Hospitals

More information

Sexuality. Renewing Intimacy and. After Gynecologic Cancer. Gynecologic Cancer Foundation. Women s Cancer Network Web Site:

Sexuality. Renewing Intimacy and. After Gynecologic Cancer. Gynecologic Cancer Foundation. Women s Cancer Network Web Site: Gynecologic Cancer Foundation 401 North Michigan Avenue Chicago, IL 60611 Tel: 312.644.6610 Fax: 312.527.6658 E-mail: gcf@sba.com Women s Cancer Network Web Site: www.wcn.org Toll-Free Gynecologic Cancer

More information

Sexual Health in Older Adults

Sexual Health in Older Adults Sexual Health in Older Adults Lauren Carpenter, MD UW Division of Gerontology and Geriatric Medicine VA Puget Sound Geriatrics & Extended Care Objectives > Identify barriers to addressing sexual health

More information

Opening the Door to Intimacy. Carolynn Peterson, RN, MSN, AOCN

Opening the Door to Intimacy. Carolynn Peterson, RN, MSN, AOCN Opening the Door to Intimacy Carolynn Peterson, RN, MSN, AOCN What is the largest sex organ in humans? Ways That Cancer or Its Treatment Can Affect Your Sexuality: Physical ability to give and receive

More information

Scream Cream. Ingredients: Aminophylline 15-mg, Ergoloid mesylate 0.25-mg, Pentoxifylline 25-mg and L-Arginine 30-mg

Scream Cream. Ingredients: Aminophylline 15-mg, Ergoloid mesylate 0.25-mg, Pentoxifylline 25-mg and L-Arginine 30-mg At LifeCare Pharmacy we understand that women have different needs at different stages of their lives. Maintaining a healthy and balanced lifestyle can be a difficult struggle. The chronic stress of overly

More information

Breast cancer is the most common malignant tumor in

Breast cancer is the most common malignant tumor in Menopause: The Journal of The North American Menopause Society Vol. 23, No. 10, pp. 1108-1113 DOI: 10.1097/GME.0000000000000672 ß 2016 by The North American Menopause Society Fractional microablative CO

More information

The Mona Lisa Touch, a microablative fractionated CO2 laser for vaginal atrophy

The Mona Lisa Touch, a microablative fractionated CO2 laser for vaginal atrophy The Mona Lisa Touch, a microablative fractionated CO2 laser for vaginal atrophy VVA Lasers basics The MLT treatment Evidence Indications,cautions etc Summary Vulvovaginal Atrophy The new term is GSM- Genitourinary

More information

An Evidence-based Review of Clinical Trial Data

An Evidence-based Review of Clinical Trial Data An Evidence-based Review of Clinical Trial Data Karen K. Miller, MD Massachusetts General Hospital Harvard Medical School Boston, MA 1 Rationale for Investigating Androgen Administration in Women: Data

More information

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved. 28 The Nurse Practitioner Vol. 41, No. 7 www.tnpj.com 2.0 CONTACT HOURS 1.0 CONTACT HOURS Genitourinary syndrome of menopause: A new name for an old condition Abstract: Genitourinary syndrome of menopause

More information

Sexuality. The Pharmacologic Treatment of Female Sexual Dysfunction: Future Reality or Wishful Thinking? Risks of Opening the Medicine Cabinet

Sexuality. The Pharmacologic Treatment of Female Sexual Dysfunction: Future Reality or Wishful Thinking? Risks of Opening the Medicine Cabinet 5 th Annual Meeting of the North American Menopause Society October 5, 4 Washington, DC Low Libido at Midlife: Will the Answer Ever Be in Our Medicine Cabinets? The Pharmacologic Treatment of Female Sexual

More information

The impact of cancer and cancer treatments on sexuality and what can help. Trish Lymburner, MSW, RSW Lisa Roelfsema, MSW, RSW

The impact of cancer and cancer treatments on sexuality and what can help. Trish Lymburner, MSW, RSW Lisa Roelfsema, MSW, RSW The impact of cancer and cancer treatments on sexuality and what can help Trish Lymburner, MSW, RSW Lisa Roelfsema, MSW, RSW 1 Presenter Disclosure Presenters: Lisa Roelfsema, MSW, RSW and Trish Lymburner,

More information

Urinary Tract Infections

Urinary Tract Infections Urinary Tract Infections Introduction A urinary tract infection, or UTI, is an infection of the urinary tract. Infections are caused by microbes, including bacteria, fungi and viruses. Microbes are organisms

More information

Evaluation of Systemic Effects of a Vaginal Estradiol Softgel Capsule Insert (TX-004HR) in Menopausal Women with Moderate to Severe Dyspareunia

Evaluation of Systemic Effects of a Vaginal Estradiol Softgel Capsule Insert (TX-004HR) in Menopausal Women with Moderate to Severe Dyspareunia Evaluation of Systemic Effects of a Vaginal Estradiol Softgel Capsule Insert (TX-4HR) in Menopausal Women with Moderate to Severe Dyspareunia Lisa Larkin, MD 1 ; Andrew M Kaunitz, MD 2 ; James Liu, MD

More information

Menopause management NICE Implementation

Menopause management NICE Implementation Menopause management NICE Implementation Dr Paula Briggs Consultant in Sexual & Reproductive Health Southport and Ormskirk NHS Hospital Trust Why a NICE guideline (NG 23) Media reports about HRT have not

More information

Presentation 10 Feb 2, 2019

Presentation 10 Feb 2, 2019 Addressing Sexual Relationship Concerns for the Patient Treated for Cancer 2019 BREAST HEALTH: A TEAM APPROACH 2/2/2019 SARAH JAX, MA, APRN, AOCNP MINNESOTA ONCOLOGY - PLYMOUTH Objectives Discuss causes

More information

Women's Cancer & Sexuality Diljeet K. Singh, MD, DrPH CANCER SURVIVOR DAY

Women's Cancer & Sexuality Diljeet K. Singh, MD, DrPH CANCER SURVIVOR DAY Women's Cancer & Sexuality Diljeet K. Singh, MD, DrPH CANCER SURVIVOR DAY Explicit diagrams & anatomy drawings will be used in this lecture Specific treatment techniques will be discussed for sexual problems

More information

Research Article The Treatment with Hormone Replacement Therapy and Phytoestrogens and The Evolution of Urogenital Symptoms in Postmenopausal Women

Research Article The Treatment with Hormone Replacement Therapy and Phytoestrogens and The Evolution of Urogenital Symptoms in Postmenopausal Women Cronicon OPEN ACCESS PHARMACEUTICAL SCIENCE Research Article The Treatment with Hormone Replacement Therapy and Phytoestrogens and The Evolution of Urogenital Symptoms Bungau S 1, Tit DM 1 *, Fodor K 1

More information

RAISING THE AWARENESS OF GYNAECOLOGICAL CANCER. Penny Bognuda CNS Gynaecologic Oncology ADHB. June 2015.

RAISING THE AWARENESS OF GYNAECOLOGICAL CANCER. Penny Bognuda CNS Gynaecologic Oncology ADHB. June 2015. RAISING THE AWARENESS OF GYNAECOLOGICAL CANCER Penny Bognuda CNS Gynaecologic Oncology ADHB. June 2015. AIMS AND OBJECTIVES OF THE NEXT ½ HOUR. Brief overview of the different types of gynaecological cancers

More information

DHEA, a superior treatment option for vaginal atrophy and menopause symptoms in women

DHEA, a superior treatment option for vaginal atrophy and menopause symptoms in women DHEA, a superior treatment option for vaginal atrophy and menopause symptoms in women Dr. Anna Cabeca With aging, menopause, and hormonal changes some 75% of post-menopausal women suffer from vaginal atrophy

More information

Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women:

Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Irwin Goldstein MD Director, Sexual Medicine, Alvarado Hospital, San Diego, California Clinical Professor of Surgery, University

More information

One Day Hormone Check

One Day Hormone Check One Day Hormone Check Patient: EMILY TEST DOB: January 18, 1948 Sex: F MRN: 0000000004 Order Number: J5070009 Completed: March 07, 2014 Received: March 07, 2014 Collected: March 07, 2014 Alec Smart, ND

More information

MENOPAUSAL HORMONE THERAPY 2016

MENOPAUSAL HORMONE THERAPY 2016 MENOPAUSAL HORMONE THERAPY 2016 Carolyn J. Crandall, MD, MS Professor of Medicine David Geffen School of Medicine at UCLA NICE provides the National Health Service advice on effective, good value healthcare.

More information

Management of Urogenital Prolapse of Women in Primary Care. Lizzie McManus MBE RGN RMN Practice nurse Womens health practitioner

Management of Urogenital Prolapse of Women in Primary Care. Lizzie McManus MBE RGN RMN Practice nurse Womens health practitioner Management of Urogenital Prolapse of Women in Primary Care Lizzie McManus MBE RGN RMN Practice nurse Womens health practitioner Primary Care Womens Health Forum www.pcwhf.org.uk Useful websites RCN genital

More information

Menopause and Post Gynecological Reproductive Care

Menopause and Post Gynecological Reproductive Care Menopause and Post Gynecological Reproductive Care Nguyet-Cam Vu Lam, MD, FAAFP Associate Program Director St. Luke s Family Medicine Residency 1 Disclosure Dr. Nguyet-Cam Vu Lam has no conflict of interest,

More information

MENOPAUSE. I have no disclosures 10/11/18 OBJECTIVES WHAT S NEW? WHAT S SAFE?

MENOPAUSE. I have no disclosures 10/11/18 OBJECTIVES WHAT S NEW? WHAT S SAFE? MENOPAUSE WHAT S NEW? WHAT S SAFE? I have no disclosures Sara Whetstone, MD, MHS OBJECTIVES To describe risks of HT by age and menopause onset To recommend specific HT regimen for women who undergo early

More information

Northwest Rehabilitation Associates, Inc.

Northwest Rehabilitation Associates, Inc. Pelvic Health Patient Intake Form Name: Date: Please answer the following questions as honestly and thoroughly as you can. Your responses will help us better understand your condition and provide the best

More information

5/3/2016 SEXUALITY: KNOWLEDGE OPENS THE DOOR OBJECTIVES DEFINITIONS CONT. DEFINITIONS

5/3/2016 SEXUALITY: KNOWLEDGE OPENS THE DOOR OBJECTIVES DEFINITIONS CONT. DEFINITIONS SEXUALITY: KNOWLEDGE OPENS THE DOOR TO COMMUNICATION JILL LIBBESMEIER BSN, RN, OCN OBJECTIVES Understand the differences between sexuality, intimacy, sexual health, and sexual dysfunction Identify how

More information

Sexuality in Later Life

Sexuality in Later Life National Institute on Aging AgePage Sexuality in Later Life Many people want and need to be close to others as they grow older. This includes the desire to continue an active, satisfying sex life. But,

More information

Sexual Concerns. Mental Health Topics

Sexual Concerns. Mental Health Topics Sexual Concerns A lot of people have concerns about their sex life. Common concerns and problems that affect one or both sex partners Talk to your partner about your include: sexual concerns. n Little

More information

-TherapeuticsMD will host a conference call at 8:00 AM EDT today-

-TherapeuticsMD will host a conference call at 8:00 AM EDT today- FOR IMMEDIATE RELEASE TherapeuticsMD Announces FDA Approval of TX-004HR: IMVEXXY TM (estradiol vaginal inserts), the Lowest Dose Vaginal Estrogen Product Approved for the Treatment of Moderate to Severe

More information

Definition/Epidemiology Approach to premenopausal and postmenopausal women A couple tricky cases DISCLOSURES. No financial relationships to disclose.

Definition/Epidemiology Approach to premenopausal and postmenopausal women A couple tricky cases DISCLOSURES. No financial relationships to disclose. DISCLOSURES RECURRENT URINARY TRACT INFECTIONS No financial relationships to disclose. Anna C. Kirby, MD, MAS Acting Assistant Professor University of Washington Division of Urogynecology Department of

More information

genitourinary syndrome of menopause Objectives: To evaluate the safety and long-term efficacy of fractional CO2 laser

genitourinary syndrome of menopause Objectives: To evaluate the safety and long-term efficacy of fractional CO2 laser Safety and long-term efficacy of fractional CO2 laser treatment in women suffering from genitourinary syndrome of menopause Abstract Objectives: To evaluate the safety and long-term efficacy of fractional

More information

Urogynecology ICD-9 to ICD-10 Crosswalks

Urogynecology ICD-9 to ICD-10 Crosswalks 1100 Wayne Ave, Suite 825 Silver Spring, MD 20910 301.273.0570 Fax 301.273.0778 info@augs.org www.augs.org Urogynecology ICD-9 to ICD-10 Crosswalks ICD 9 ICD 9 Description ICD 10 Code ICD 10 Description

More information

One Day Hormone Check

One Day Hormone Check One Day Hormone Check DOB: Sex: F MRN: Order Number: Completed: Received: Collected: Salivary Hormone Results Estradiol pmol/l >3330.0 Testosterone pmol/l

More information

Postmenopausal women may experience genitourinary

Postmenopausal women may experience genitourinary Menopause: The Journal of The North American Menopause Society Vol. 23, No. 1, pp. 000/000 DOI: 10.1097/gme.0000000000000485 * 2015 by The North American Menopause Society Quality of life and sexual function

More information

Therapeutic Cohort Results

Therapeutic Cohort Results Patient: SAMPLE PATIENT DOB: Sex: MRN: Menopause Plus - Salivary Profile Therapeutic Cohort Results Hormone Average Result QUINTILE DISTRIBUTION 1st 2nd 3rd 4th 5th Therapeutic Range* Estradiol (E2) 8.7

More information