The pill could lower sex drive in young women

The pillThis month marks the 50th anniversary of the contraceptive pill, first approved by the FDA in 1960 and now the choice of contraception for more than 100 million women worldwide. By uncoupling sex from pregnancy, oral hormonal contraceptives finally allowed women to become agents of their own bodies.

Life isn’t all rosy on the pill though. The various different formulations have been associated with all sorts of side effects, the most issue being venous thromboembolism.

Now new research from female medical students in Germany has found that hormonal contraception such as the pill could also reduce sex drive.

Several previous studies have suggested that oral contraception might affect female sexual function, but overall the evidence as to whether they have a positive or negative effect is pretty mixed.

The researchers behind this study emailed female students at six medical schools in Germany and asked them to fill in an online questionnaire about their sexual function in the past four weeks and their usual means of contraception over the past six months.  A total of 1,086 women (15-20%) aged mostly under 25 years responded.

A total of 87.4% of women had used contraception in the previous 6 months, most of whom had used oral hormonal contraception (69.5%).

About a third (32.4%) of participants were considered at high risk of sexual dysfunction.  However, this figure actually isn’t too bad compared with a previous study of 78 female medical students in the US, which found that 63% were at high risk of sexual dysfunction.  Other larger studies put the rate at a more conservative 38% in Germany and 43% in the States.

When the sexual dysfunction data were analysed on the basis of single usual form of contraception (1,046 participants), women who used oral hormonal contraception or non-oral hormonal contraception were most at risk of having sexual dysfunction. Oral hormonal contraception was associated in particular with low desire and arousal compared with other forms of contraception and no contraception.

The authors suggest that the link between oral hormonal contraceptives and sexual dysfunction may be because oral contraceptives decrease the circulating levels of testosterone, “which is needed to (i) stimulate sexual desire and (ii) regulate genital blood flow and the structural and functional integrity of the genitals.”

Interestingly, smoking was associated with a lower risk of sexual dysfunction than not smoking, an effect the authors hilariously suggest might be down to the fact that “smokers might have greater ability to enjoy themselves.”

“This is a very important research investigation,” stated Dr Irwin Goldstein, Editor-in-Chief of Journal of Sexual Medicine, which published this study. “There are hundreds of millions of women, in particular young women at the beginning of their sexual lives, who regularly use hormonal contraception for many years. The irony is that these women are provided a medication that enables freedom from reproductive worries but these same women are not provided information that there are significant adverse sexual effects that may ensue.  Agents that interfere with the hormonal milieu of women may adversely affect their sexual lives.”

Don’t panic yet though, this study isn’t the final word and has various shortcomings, not least the possibly of participation bias – where women with perceived sexual problems might have felt more inclined to participate than women with no sexual problems – and reporting bias – where participants might have overestimated or underestimated the scale of their sexual difficulties.

Furthermore, the low response rate to the questionnaire (15-20%) means the study population probably isn’t a great reflection of all the female medical students at the eight schools studied, much less students worldwide, and, as the authors say, their stats suggest that “the factors considered can only explain a small fraction of the variability of total [female sexual function] scores.”

As it is, hormonal forms of contraception – both oral and non-oral – are the most successful forms around.  So I wouldn’t throw away your pills just yet.

  • Put off oral hormonal contraceptives? Nature Medicine has an article on the 50th anniversary of the pill that highlights some possible alternatives under development.

Wallwiener C et al. (2010) Prevalence of Sexual Dysfunction and Impact of Contraception in Female German Medical Students. Journal of Sexual Medicine DOI: 10.1111/j.1743-6109.2010.01742.x

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Viagra could help women too, but not how you think…

Metastatic Breast Cancer in Pleural FluidSince first coming on the market in 1998, the erectile dysfunction drug Viagra has improved the sex lives of countless men. Now new research has suggested that phosphodiesterase 5 (PDE5) inhibitors like Viagra could also help women – but not how you think.

Researchers in California have shown that sildenafil (Viagra) and a similar drug called vardenafil can improve the delivery of the chemotherapeutic drug Herceptin (trastuzumab) in women with breast cancer that has spread to the brain. Their studies in mice have found that PDE5 inhibitors help Herceptin cross the blood vessels of brain tumours into the heart of the cancer, thus improving the therapeutic efficacy of Herceptin for brain metastases from primary tumors.

Although only about 22,000 patients in the US are diagnosed with a primary brain tumor each year, nearly 10 times that many people develop brain tumors from cancers that began elsewhere in the body. For example, one study found that 36% of women receiving Herceptin for breast cancer developed brain metastases.

These secondary brain tumours are very hard to treat thanks to the fact that chemotherapy drugs can’t cross the walls of the tumour’s blood vessels – the blood-brain tumor barrier – and into the cancer. “Mother Nature created this barrier to protect our brains from dangerous substances, but here we need to get through the barrier to deliver the drugs, and that’s a problem,” said study author Julia Y Ljubimova, a research scientist at the Cedars-Sinai Maxine Dunitz Neurosurgical Institute in Los Angeles.  This means that drugs that can kill the primary tumour in the breast or lung aren’t effective on secondary tumours in the brain.

Ljubimova and her colleagues looked at the effects of PDE5 inhibitors on drug delivery in mice whose brains had been implanted with human lung and breast tumors. Oral administration of vardenafil to such mice doubled the uptake of Herceptin by brain tumours. Importantly, vardenafil had no effect on the uptake of Herceptin in neighbouring healthy tissue, an unfortunate effect of many chemotherapy drugs that is responsible for making cancer patients feel so awful and lose their hair.

Furthermore, combination treatment of mice with vardenafil and Herceptin increased the survival time of these mice by 20% compared with those that received Herceptin only.  This effect was only seen in mice whose brain tumours were positive for HER2, the growth factor targeted by Herceptin, and not those that were HER negative, indicating that the survival benefit was indeed due to an increase in the amount of Herceptin reaching the tumors.

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“Now that we’ve demonstrated that big molecules can cross the blood-brain tumor barrier, we’re going to continue this strategy with other big molecule drugs, such as nanomedicine drugs” said Ljubimova. “This opens a new world for brain tumor treatments.”

Hu J et al. (2010) Phosphodiesterase Type 5 Inhibitors Increase Herceptin Transport and Treatment Efficacy in Mouse Metastatic Brain Tumor Models. PLoS ONE 5 (4). DOI: 10.1371/journal.pone.0010108

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Cash for kidneys might not necessarily be unethical

Meeting the demand for kidney transplants is a big problem worldwide. In the UK, for example, only 18% of patients waiting on the kidney transplant list and 28% on kidney/pancreas transplant list received a transplant during 2008-09.

Donations from living people only made up 37% of the total UK kidney transplant programme in the same period, and as such this approach represents a key method by which to increase the number of organs available.

But how do you convince someone to just give away a kidney?  One very controversial way is to pay donors. Given that kidneys from living donors work so much better than those from deceased donors, even giving donors pretty large payments (for example, $90,000/£58,600) is thought to be a cost-effective way to increase the supply of kidneys available for transplantation.

Unsurprisingly, this approach hasn’t really got off the ground because people are worried about donors blithely selling a kidney without adequately weighing up the risks just to get their hands on some “easy money” or payment disproportionally luring poorer donors. Also, there’s a chance that payments may dissuade altruistic donation or cause potential altruistic donors to request financial compensation.

A study of a hypothetical regulated US market for kidneys has addressed all three of these questions and concluded that “theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence.”

The authors surveyed 342 commuters on regional rail and urban trolley lines in Philadelphia County using 12 fictional scenarios in which the risk of subsequent kidney failure in the donor (0.1%, 1%, or 10%), the payment ($0, $10 000, or $100 000), and the recipient of the kidney (either a close family member or the next eligible patient on the waiting list) were varied. Participants responded to each scenario by stating their willingness to donate a kidney on a five-point scale ranging from “definitely would not donate” to “definitely would donate.”

As would be expected, people were more willing to donate to a family member than to a stranger. Lower risk and higher payment also encouraged donation, in particular when the scenario covered donating to a stranger.

More interestingly, incremental household income affected willingness to donate independent of payment – people with a household income of $20,000 a year or less were much more likely to donate than those who earned $100,000 or more. As such, “poorer persons may contribute disproportionately to the supply of organs with or without payment.”

The promise of hard cash didn’t affect people’s perception of the risk involved in living kidney donation: “the magnitude of reductions in willingness to donate associated with increased risk for renal failure was virtually identical across payment levels.” And the effect of a bigger paycheck on willingness to donate was the same across all income strata.

Finally, the introduction of payment for organs did not reduce the level of altruistic donation. “We found no evidence that any of the three main concerns with a regulated system of payments for living kidney donation would manifest if such a market were established,” the authors conclude.

Halpern SD et al. (2010) Regulated payments for living kidney donation: an empirical assessment of the ethical concerns. Annals of Internal Medicine 152 (6): 358-65. PMID: 20231566

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Election 2010: Do you know your health policies?

King's Fund election gamePrime minister Gordon Brown has finally announced the UK general election, which will take place on 6 May 2010. The main political parties have all since gone into overdrive promoting their policies on the campaign trail, trying to guarantee votes for what looks set to be a very uncertain election.

As well as pushing plans on the economy, immigration, the environment and such like, the parties are also making promises regarding health and the NHS. But do you know one party’s policy from the other?

Independent health think-tank the King’s Fund has launched a fun interactive “election check-up” game to test your knowledge of where the three main parties stand on health policy.

Rebecca Gray, director of communications at The King’s Fund, said: “We wanted to inject some fun into our election activities while at the same time promote the more heavy-weight work we do in shaping health and social care policy.

“When we came up with the concept we knew the game would need to be fun and witty, but not too frivolous and definitely hold some informative value. The aim is to hook people into the issues and prompt them to visit The King’s Fund’s site to access our more in-depth resources.”

With dancing, yabbering “bobble head” figures of the leaders of the three main parties, the quiz is certainly entertaining. The quiz also includes plenty of facts I didn’t know.  For example, according to a MORI political poll, health is the second most important issue to voters, coming after managing the economy but topping education, unemployment, and immigration.

Shockingly I did quite badly – only four out of seven.  Even more outrageously, I didn’t recognize Andy Burnham‘s sultry gaze, but did spot Andrew Lansley‘s steely glare.

How did you get on with the quiz?  Are you already fully informed on the Labour, Tory, and Lib Dem health policies?  Or, like me, do you need to do some serious swotting before 6 May?

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Trachea transplants and awful articulation: doing the BMJ podcast

Last week my colleague Sally Carter and I had a go at doing the news roundup for the BMJ podcast.

First, Sally spoke about the passing of the health reform bill in the US and all the BMJ‘s coverage of the legislation itself and the bill’s rocky passage. Then I covered a remarkable news story about a British boy who received fledgling trachea transplant built with his own stem cells that then grew into a fully functioning organ within his body.

I’ve always had trouble with public speaking and being articulate during presentations, so I was very nervous about doing my first podcast.  Despite our countless rehearsals, Sally and I both found it quite hard to simultaneously speak fluently and get all the facts into our segments.  The experience was a lot of fun though and I think the finished product turned out OK.  Have a listen and let me know what you think.

BMJ Podcast 26 March 2010: Variolae Vaccina

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Backpackers in Australia are a sexual health risk

Backpacker AustraliaYoung people, especially Brits, famously head to Australia in their droves in search of travel, adventure, and, crucially, some hot weather.  In 2009-09, 560,105 international backpackers visited Australia, representing 10.9% of all international visitors.

It seems that backpackers in Oz aren’t just looking for fun and sun though – according to a new study they’re also looking for flings, and are bringing sexually transmitted diseases with them.

Research published in the journal Sexually Transmitted Infections has found that international backpackers in Sydney had a higher number of sexual partners and drunk more alcohol than native Australians. Backpackers also had higher rates of chlamydia and more previous sexually transmitted infections than locals.

The authors of this study retrospectively looked through the medical records at the Sydney Sexual Health Centre and identified 5,702 backpackers – people who had been born outside of Australia and been in the country for less than two years – and 7256 comparison patients – natives or people who had lived in the country for longer than 2 years. The average age of the backpacker group was 25 and almost half had come from the UK.

Backpackers were twice as likely to report drinking alcohol at hazardous levels than were comparison patients. More than a quarter (27%) of female backpackers reported drinking more than 17.5 units of alcohol a week, equivalent to about eight glasses of wine, whereas only 14% of comparison women drank at this level. A total of 17% of male backpackers drank more than 35 units of alcohol a week, roughly 15 pints of beer, compared with 5% of comparison men.

About 40% of backpackers reported having had two or more sexual partners in the previous 3 months, compared with 30% of comparison patients.  Interestingly, condom use was low in both the backpacker group and the comparison group: two thirds of each group reported having had unprotected sex.

When it came to rates of sexually transmitted infections, backpackers were more likely to be diagnosed with chlamydia (7% vs 5%) and have a history of sexually transmitted infections (15% vs 10%).  However, locals were more likely to have genital warts.

The authors point out the public health implications of their findings – international backpackers are a potential risk population for either acquiring sexually transmitted diseases or transmitting them to other travellers or local residents.  “Although we could not determine the extent of the risk of transmission to local residents from our study,” they say, “it has been demonstrated that being born overseas or having a partner from overseas was a risk factor for chlamydia infection in Sydney women.”

McNulty A et al. (2010) The behaviour and sexual health of young international travellers (backpackers) in Australia. Sexually Transmitted Infections DOI: 10.1136/sti.2009.038737

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News reports on cancer don’t give the full story

NewspapersCancer stories seem to make the news on a daily basis.  For example, just today in the UK there are stories about a gene that could predispose non-smokers to lung cancer, how infertile men are at raised risk of prostate cancer, and how testing for the HPV virus during cervical screening doesn’t help pick up women who might go on to develop cervical cancer.

But it’s not just a case of “all publicity is good publicity.” Research published recently in Archives of Internal Medicine has shown that newspaper and magazine stories on cancer tend to focus on survival and aggressive treatments but steer clear of covering treatment failure, side effects of treatment, end of life care, and death.

The authors of this study looked at 436 500-word articles from top American newspapers and magazines, such as Chicago Tribune, New York Times, Newsweek, and Time. The 312 newspaper articles and 124 magazine pieces largely covered breast cancer (35.1%) and prostate cancer (14.9%), two of the most common types of cancer in the US.

Articles were more likely to focus on people who had survived or been cured of cancer than on people who had died of the disease (32.1% vs 7.6%).  In fact, those articles that covered individual patients (173 articles; 216 individuals), more than three quarters covered success stories and only a fifth told the story of someone who had died of cancer.

Few articles (13.1%) pointed out that aggressive treatments such as chemotherapy can fail or that late stage cancer can be incurable. Moreover, less than a third highlighted the side effects associated with such treatments, like pain, hair loss, and nausea.

Only two articles (0.5%) exclusively covered palliative or hospice care for when treatment options had run out, whereas more than half (57.1%) instead focused solely on aggressive treatment.

Given that one in every two men and one in every three women in the US will be diagnosed with cancer in their lifetime, half of whom will die from their cancer or related complications, this optimistic skew in media reporting of cancer is somewhat misleading.

Cancer news coverage is known to affect the beliefs and behaviours of patients; for example, media coverage of mammography screening is known to increase the use of mammography in women. As such, “The tendency of the news to report on aggressive cancer treatments and survival but not on alternatives is also noteworthy given that unrealistic information may mislead the public about the trade-offs between attempts at heroic cures and hospice care,” say the authors.

Fishman, J., Ten Have, T., & Casarett, D. (2010). Cancer and the Media: How Does the News Report on Treatment and Outcomes? Archives of Internal Medicine, 170 (6), 515-518 DOI: 10.1001/archinternmed.2010.11

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Winter getting you down? It might also be making you unhealthy

Do the long nights and shoddy weather over the winter months make you feel low? If so, you could also be at raised risk of cardiovascular disease and being overweight, according to new research in PLoS ONE.

This study of 11,545 Norwegian adults found that people who were classified as having considerable variations in mood across the seasons had a higher BMI and waist to hip ratio, and higher levels of fat in their blood, than people who were less affected by the seasons.

In addition, women who had “high seasonality” tended to do less exercise and were more likely to smoke daily than their “low seasonality” counterparts. All these factors add up to an elevated risk of cardiovascular disease, according to the study authors.

The most well known variant of seasonal mood changes is seasonal affective disorder (SAD), which is characterised by severe episodes of depression that only occur during a particular time of year. SAD affects an estimated 7% of the UK population every winter between September and April, in particular during December, January, and February. Seasonality is distinguished by milder variations in mood rather than major lows, although high seasonality combined with a propensity for depression is thought to be a risk factor for SAD.

People with SAD or high seasonality tend to eat more, gain weight, and feel more sleepy during episodes. This could be advantageous from an evolutionary point of view, because it could facilitate energy storage and promote reproductive potential in the seasons optimal for conception, gestation, and lactation. In the modern world, however, we have access to resources all year round and don’t have to worry about energy storage, so seasonality may conversely be a stress factor.

In the new PLoS ONE study, all individuals in Hordaland county, Norway, born between 1953 and 1957 (i.e. aged 40–45 years) were invited to participate, 63% of whom said yes. These 8,598 men and 9,983 women filled in questionnaires about their seasonal fluctuations in mood and behaviour and about their health behaviours. Blood samples were taken and height, weight, waist circumference, hip circumference, and blood pressure were measured.

In both men and women, weight, BMI, waist-hip ratio, and blood levels of triglycerides increased as the level of seasonality increased. For example, the average BMI for men with low seasonality was 25.9, a touch overweight but otherwise fine, but for men with high seasonality to the point of having SAD the average BMI was 27.1, definitely overweight.

Women with high seasonality were about 20% less likely to do at least three hours of exercise a week than their less affected counterparts, and tended to drink and smoke more. Furthermore, the association between seasonality and BMI in women was affected by when the researchers took their measurements: BMI increased over autumn and winter in women with high seasonality.

Given the high BMI, weight, and blood fat levels in people with high seasonality, the authors state that “Overall it seems to be fair to conclude that subjects with high seasonality have an elevated risk for cardiovascular disease.” They do point out that a cross-sectional study such as theirs can’t pinpoint causation though: we don’t know whether high seasonality causes poor health or whether poor health is responsible for high seasonality.

Øyane N et al. (2010) Increased Health Risk in Subjects with High Self-Reported Seasonality. PLoS ONE 5 (3). DOI: 10.1371/journal.pone.0009498

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A healthy life leads to a healthy sex life

Being in good or excellent health increases the quality and quantity of sex for middle aged and older people, according to a big study that delved into the sex lives of 6,000 American adults aged 25-85.  Plus being fit can keep you sexually active into a ripe old age, unlike your unhealthy peers.

The study also had a whole raft of other expected findings, some rather expected (e.g. men are more interested in sex) and others maybe less so (such as more than a third of men aged 75-85 are sexually active, as are 17% of women the same age).

The cross sectional study, published in the BMJ, looked at two large American health surveys: the national survey of midlife development in the United States (MIDUS), which assessed in 1995-6 adults aged 25-74, and the national social life, health and aging project (NSHAP), which in 2005-06 looked at people aged 57-85.

Overall, men were more likely than women to be sexually active and be interested in sex. Between 69% and 87% of men of all ages reported being sexually active in the past six months, compared with 43% to 76% of women, and men were significantly more likely to report being interested in sex than were women (66% versus 53% among those aged aged 25-74 and 62% versus 21% in those aged 57-85). These gender differences increased with age and were greatest in people aged 75-85 years: 38.9% of men compared with 16.8% of women were sexually active.

On the other hand, overall, sexual satisfaction was similar in the two genders: among sexually active respondents, about two thirds of men and women reported a good quality sex life. These proportions also changed as women aged though, so that only half women aged 57-85 who were sexually active reported a good quality sex life compared with nearly three quarters of men.

A novel aspect of this study was the use of a new measure devised by the authors called “sexually active life expectancy” – that is, the average number of remaining years a person could expect to remain sexually active.

At the age of 30, men had a sexually active life expectancy of 34.7 years (i.e., to within 10 years of the average life expectancy of 74.8 years) and women had 30.7 years (to 20 years less than their life expectancy of 80.6 years). This means that men spend 78% of their lives sexually active, compared with 61% for women. At 55, these figures changed to 14.9 remaining years for men and 10.6 years for women.

For me the most interesting finding was the link between good health and good sex. Men aged 25-74 who were in very good or excellent health were more than twice as likely to be sexually active than their less healthy counterparts, whereas women of the same age were 60% more likely to be sexually active.

Of those people who were sexually active, men and women who were in very good or excellent health were 70% more likely to report having a good quality sex life than those who were in less good shape, and were 40-80% more likely to be interested in sex.

Good health also increased how long people would remain sexually active compared with people reporting fair or poor health: men in very good health at age 55 were projected to gain on average 5-7 years of life as sexually active, whereas women were projected to gain 3-6 years.

It seems like good health keeps people keeping on in more way than one…
Lindau S & Gavrilova N (2010) Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageing. BMJ 340 (mar09 2). DOI: 10.1136/bmj.c810

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A picture is worth a thousand words: comic books for medical and patient education

Patient communicationThe BMJ has just published an interesting feature about comics in medicine – the history, the approaches, and their use in medical and patient education.

The authors Michael J Green and Kimberly R Myers call such comics “graphic pathographies”: illness narratives in graphic form. “These graphic pathographies can be helpful to patients wanting to learn more about their illness and find a community of similarly affected people,” they say. “Graphic pathographies also provide doctors with new insights into the personal experience of illness and misconceptions about disease and treatment that could affect compliance and prognosis.”

Mom's cancerThe two examples they discuss are Marisa Acocella Marchetto’s Cancer Vixen, in which Marchetto describes her experiences as “a shoe-crazy, lipstick-obsessed, wine-swilling, pasta-slurping, fashion-fanatic big-city girl cartoonist” with breast cancer, and Brain Fies’ Mom’s Cancer, which documents Fies’ mother’s metastatic lung cancer. Both provide actually quite moving and at times subtle personal accounts of illness, and in a more succinct and engaging way than the same tale in prose form.

Medikidz diabetesMedical comics are proving particularly useful in patient education, both to promote public awareness and to help patients and their families understand what to expect from a disease. Apparently, combining pictures and text enhances understanding because reading and viewing activate different information processing systems within the brain. “This combination also fosters connections between new information and existing knowledge,” say the authors, “thereby increasing recall of health information, especially among those with low literacy.”

The series Medikidz is a prime example of the latter approach. Medikidz comics provide quite complex medical information for kids about a variety of different diseases, such as osteosarcoma, scoliosis, and type 1 diabetes.

The “Medikidz” are a group of five larger-than-life superheroes who journey around Mediland, a planet shaped like the human body. These heroes battle against villainous characters representing aspects of disease. For example, Chi is the Medikidz lungs specialist whose secret power is hypnotic relaxation, whereas her nemesis is Anna Phalaxis.

Comics can also be used to educate medical students and doctors. For example, personal patient stories in comic book form could reinforce to junior doctors that fact that healing a patient entails more than treating a body. Also, as the authors point out, “In keeping with research in medical education showing that visual art improves students’ diagnostic skills, reading graphic stories may likewise enhance students’ observational and interpretive abilities.”

I find these comic fun to read, and they certainly seem a novel and creative way to communicate patients experiences and information about diseases.

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