Sunday, June 20, 2010

Female Sexual Dysfunction and Hypothyroidism

The thyroid gland’s importance in the body is essentially related to its regulation of many aspects of the body’s functions. Dysfunction of the thyroid, either overactive or underactive, is a common problem experienced by many women. Low thyroid, or hypothyroidism, can occur after removing the thyroid, simply low functioning of the thyroid, or autoimmune diseases such as Hashimoto’s thyroiditis.

Low thyroid function can affect mood, metabolism, weight, heart rate, brain function, hair, and ovulation. It is therefore a stretch to hypothesize if hypothyroidism affects sexuality? In other words, is hypothyroidism linked to female sexual dysfunction (FSD)?

TSH (Thyroid stimulating hormone) is the common blood test used to screening for hypothyroidism. When TSH levels are abnormally high, this suggests low circulating thyroid hormone from an underactive thyroid. TSH production from the pituitary gland will increase to try to “rev up” the sluggish thyroid gland if it’s underactive in order to push it to produce more thyroid hormone. Usually, TSH above 5 is considered “high/abnormal”, but it’s important to note that if the patient “feels normal” and has a slightly elevated TSH, then thyroid hormone replacement may not necessarily be warranted. Conversely, if the TSH is within the “normal range” (less than 5), but the patient appears sluggish or "clinically hypothyroid", then thyroid hormone replacment may be warranted. This goes to the point of "treating the patient, no the number".

A study was recently published looking at four groups of women, comparing their thyroid status, to see if it links to female sexual dysfunction. The four groups were:

Women who were clinically hypothyroid

Women with a TSH less than 10, but overtly hypothyroid

Women with a TSH greater than 10 but not overtly hypothyroid

Control group of women with "normal thyroid"

FSD was diagnosed in 56% of women who were clinically hypothyroid, and 54.6% of women with a TSH greater than 10. By contrast, the control group of women, and the group of women with a TSH less than 10 reported 15% and 14.6% FSD, respectively. In addition, prolactin levels were also found to be higher in the clinically hypothyroid group, as well as the group with a TSH greater than 10, but no so in the other two groups of women. Other hormone levels, such as estradiol, free testosterone, FSH, and LH were all normal across the board.

As a sidebar, Prolactin is a pituitary hormone that is linked to lower sexual function as well. Lactating women post-pregnancy will have elevated prolactin levels, a “protective mechanism” to allow nurturing of the infant and avoidance of early sexual interest that may be a distraction during this time.

The importance of this study, which was quite simple and straightforward in design and results, should help us remember to screen for female sexual dysfunction in women with hypothyroidism. It may be simply overlooked when busy physicians are concerned with fixing one problem, to not neglect secondary conditions which may co-exist.

Tuesday, June 1, 2010

Cystocele (Bladder Lift) Surgery: Success Rates after First Surgery vs. Recurrent Surgery

Who has a more successful outcome from her bladder lift surgery? Is it the woman who is undergoing it for the first time, or is it the woman who is undergoing it for the second time? Reason would dictate that if a woman needs a corrective surgery for the second time because the first failed, the likelihood of success the second time would be lower. In addition, are there underlying risk factors that lead to bladder drop (cystocele) in the first place that may lead to recurrent bladder drop no matter how many times the surgery is done? If this is the case, is there anything that can be done to prevent or at least reduce recurrence rates to lower repeated surgeries?

To demonstrate this dilemma, a recent paper from Cleveland Clinic-Florida was published looking at the success rates of cystocele repair in women undergoing it for the first time, vs. those undergoing it for the second time. The “in-between-the lines” question to be asked from reading this research is how to try to prevent women from having a recurrence after theirfirst surgery so there is potentially no subsequent surgery.

The results from the study are a bit depressing. After one year, the group of women undergoing surgery for the second time (group I) and the group of women undergoing surgery for the first time (group II), had the following success rates at 1 yr:

Group I: 18/23 or 78.2% (“second timers”)

Group II: 17/21 or 81% (“first timers”)

You may say to yourself, these groups are nearly the same, without significant difference. That’s good, right? The real story here is why are 20% of women developing recurrence in either group just 1 year after reconstructive bladder surgery?

Now let’s evaluate their results at two years:

Group I (“second timers”) 9/21 (2 lost to follow up) or 42.8%

Group II (“first timers”) 15/21 or 71.4%

What are we to make of these worsening results?

These results are actually in line and consistent with published data about how bladder surgery commonly fails within the first 1-4 years post-operatively. In fact, failure rates are actually between 40-70%.

The authors of the study (rightly) conclude that if a woman has recurrence of her bladder drop and requires another surgery, then just “fixing it” again using the same technique that failed the first time will not give good results. A different technique would be required and is logical to prevent a second recurrence.

In addition, the real question is what can be done at the time of the first surgery in order to lower recurrence and avoid a second surgery in the first place?

These seem like obvious questions to be asked, but in terms of surgical success rates, the obvious needs to be often pointed out. What looks good at one year, may not be good at 2 years, and so forth. In addition, when we look back on surgical data and outcomes, we may only able to draw a conclusion retrospectively that we could not draw looking forward, prospectively. Our knowledge base grows as different procedures are developed and patient outcomes are followed over time. The ideal are the ones with the least risk going in, and good outcomes post-operatively. As any worker in the health care field can attest, there is no ideal, and failures always exist, even for well done cases.

The bladder is the most common site of recurrence of all vaginal/pelvic floor defects, whether it’s the bladder operated on, or another pelvic organ. This has to do with its position in the pelvis, where it’s most subject to repetitive force/pressure.

Developing an enduring repair is the “holy grail” of pelvic floor surgery, and many things have been introduced, such as tissue or mesh grafts, to strengthen these surgeries. These have been shown to have lower failure rates, but many factors go into proper use of these materials in patients, and come with their own inherent risks. These would include:

Is the intended surgery appropriate for the patient?

Is the intended graft (tissue or mesh) appropriate for the patient?

Is the surgeon knowledgeable about the material and experienced in its use?

Can the surgeon deal with any complications that may arise?

Are there patient factors that increase risk of recurrence after surgery?