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Endogenous sex globulin concentrations in adult normal weight and obese hormones and cardiovascular disease incidence in men. Circulation;1988;3:539-45 evidence for leptin contribution to reduced androgen 92. Longitudinal effects of aging on serum total and free cardiovascular mortality in men with prostate cancer. Adrenal androgens cancer not suitable for local treatment with curative intent: and testosterone as coronary risk factors in the Helsinki European organisation for Research and Treatment of Heart Study. Adverse events associated with between low levels of anabolic hormones and 6-year testosterone replacement in middle-aged and older men: mortality in older men: the aging in the Chianti Area a meta-analysis of randomized, placebo-controlled trials. Endogenous testosterone effects of testosterone in men with chronic heart failure. Low Serum acute testosterone on myocardial ischemia in men with Testosterone and Mortality in older Men. Circulation 1999; 99: 1666-70 hormones and progression of carotid atherosclerosis in 119. Lower testosterone levels predict inci-- preparation on myocardial ischemia and cardiac function dent stroke and transient ischemic attack in older in 62 elderly male coronary heart disease patients. Low dose S, Elwood P Cortisol, testosterone, and coronary heart transdermal testosterone therapy improves angina disease: prospective evidence from the Caerphilly study. Changes in in men with moderate severity heart failure: a double-blind bone mineral density and body composition during initial and randomized placebo controlled trial. Eur Heart J 2006; long-term ganadotropin-releasing hormone agonist treat-- 27: 57-64 ment for prostate carcinoma. Intramuscular testosterone esters and hormonal therapy for carcinoma of the prostate. Grinspoon S, Corcoran C, Parlman K, Costello M, cardiovascular disease during androgen deprivation Rosenthal D, Anderson E, Stanley T, Schoenfeld D, therapy for prostate cancer. A randomized, Hyperglycemia and insulin resistance in men with prostate controlled trial. De Pergola G, De Mitrio V, Sciarafia M, Pannacciulli N, Cancer 2006; 106:581-8 Minenna A, Giorgino F. Testosterone and blood pressure vascular cell adhesion molecule-1 expression in human regulation. Testosterone (T) enhances apoptosis- related damage in human vascular endothelial cells. Pulse pressure, an index of arterial stiffness, is associated with androgen deiciency 150. Nakamura y, Suzuki T, Igarashi K, Kanno J, Furukawa determinant of endothelial dysfunction in men. Hypertens T, Tazawa C, Fujishima F, Miura I, Ando T, Moriyama N, Res 2007;30:1029-34 Moriya T, Saito H, yamada S, Sasano H. Androgens stimulate endothelial progenitor cells through an androgen receptor-mediated parthway. Endocrinol 2008;68:284-9 Role of putative membrane receptors in the effect of androgens on human vascular cell growth. The brain, the 2004;180:97-106 penis and steroid hormones: clinical correlates with endothelial dysfunction. Signiicance of hypogonadism in 2008;14:3723-36 erectile dysfunction: World J Urol 2006, 24:657-67 140. Testosterone enhances low-mediated brachial with erectile dysfunction : clinical signiicance and cost- artery reactivity in men with coronary artery disease. Prevalence of androgen deiciency in men with of testosterone on brachial arterial vasoreactivity in men erectile dysfunction. Androgen deprivation regulate phosphodiesterase type 5 expression and is associated with enhanced endothelium-dependent functional activity in corpora cavernosa. Androgen levels and sex functions in meta-analysis of randomized placebo-controlled trials. Blood of hypogonadal patients with long-acting testosterone testosterone threshold for androgen deiciency symptoms. Carani C, Bancroft J, Granata A, Del Rio G, Marrama study of testosterone on sexual dysfunction and features P. Testosterone and erectile function, nocturnal penile of the metabolic syndrome using testosterone gel tumescence and rigidity, and erectile response to visual and parenteral testosterone undecanoate. Venous incompetence: critical study of the organic R, Dzekov C, Dzekov J, Sinha-Hikim I, Bhasin S. Dose- basis of high maintenance low rates during artiicial dependent effects of testosterone on sexual function, erection test. Int J Androl Therapy in Hypogonadal Men at High Risk For Prostate 1999; 22:385-92. Cancer: Results of 1 year of Treatment in Men with Prostatic Intraepithelial Neoplasia. Bioavailable testosterone undecanoate reverses erectile dysfunction testosterone with age and erectile dysfunction. Analysis relationship between pituitary-gonadal function and sexual of the impact of androgen deprivation therapy on sildenail behavior in healthy aging men. Androgens and penile erection: evidence for a direct relationship between free 191. Testosterone and erectile testosterone and cavernous vasodilation in men with function in hypogonadal men unresponsive to tadalail. Clin Endocrinol (oxf) Randomized study of testosterone gel as adjunctive 2003, 58:632-38. Is sildenail citrate Longitudinal changes in testosterone, luteinizing hormone, associated with an amelioration of the symptomatology and follicle-stimulating hormone in healthy older men. The decline of serum testosterone levels in and incidence of androgen deiciency in middle-aged and community-dwelling men over 70 years of age: descriptive older men: estimates from the Massachusetts Male Aging data and predictors of longitudinal changes. The relative contributions of aging, health history of symptomatic androgen deiciency in men : and lifestyle factors to serum testosterone decline in men. J Clin and symptomatic androgen deiciency in a population- Endocrinol Metab 1980; 50:251-7. Mech Ageing Dev ratio changes with long - term tadalail administration : a 1997; 6:219-82. The relationship between libido and testosterone in with insulin, glucose, and C-peptide levels, but negatively aging men : results from the Massachussetts Male Aging with testosterone levels. The age-related decline of between endogenous steroid hormone, sex hormone- testosterone is associated with different speciic symptoms binding globulin and lipoprotein levels in men: contribution and signs in patients with sexual dysfunction. The associations between serum sex hormones, erectile function, and sex drive: the olmsted County Study of 221. Aging of skeletal muscle: a 12-yr of the effects on insulin sensitivity and sexual function of longitudinal study. J Appl Physiol 2000; 88:1321-6 transdermal testosterone gel in hypogonadal men with 223. Role des hormones muscle strength, bone density, and body composition in dans les dysfonctions sexuelles, l’homosexualite, le elderly men. Low circulating levels of insulin-like growth factors and Contraception-Fertilite-Sexualite. Endogenous sex hormones and deprivation therapy for prostate cancer: effects on hand metabolic syndrome in aging men. Arch testosterone is associated with a reduced risk of amnestic Intern Med 2006; 166: 2124-31. Low testosterone levels and decline in physical performance and muscle strength in older men: indings 247. Age hormones and cognitive functioning among Pentecost C, Whyte M, McMillan C, Bradley C, Martin middle-aged and elderly men : cross-sectional evidence F. The effects of growth hormone and/or testosterone in from the Massachussetts Male Aging Study; Journal of healthy elderly men : a randomized controlled trial. Pisacane estradiol deiciency with osteoporosis and rapid bone loss N, Chiappelli M, Licastro F, Patterson C. J Clin Endocrinol Metab 1981; 10: 115- hormone expression colocalizes with neurons vulnerable 39 to Alzheimer’s disease pathology. Am J Med Sci 1995; 310:229-34 C ; Hypogonadism is associated with overt depres-- sion symptoms in men with erectile dysfunction.
The mechanism for wall but the slow waves and the intermittent action this dilatation has never been investigated but as the 00 comitte 22. All that these demand is in younger women [1], mirroring the contractions basal, just moist, lubricated and expandable vagina. More recently much higher level of lubrication is necessary and as rectal pressure changes during orgasm have been described previously this is obtained during sexual analysed by calculating the spectral power in various arousal by the agency of the neural release of the frequency bands [228]. The increased lubrication alpha band (8-13 Hz) identiied 94% of the orgasms would appear obviously to facilitate the pleasurable induced in normal women by clitoral masturbation aspects of coitus for both partners and this gener-- undertaken by their partners. The alpha luctuations ally is so in the western world where the evidence only occurred during orgasm and were not seen in of such vaginal lubrication is taken by most men as attempts to mimic orgasm or in failed attempts to a sign of their inducing successful female arousal. The authors proposed However, in other nations, especially sub-Saharan that the integrated spectral power in this 8-13 Hz countries, this vaginal lubrication is not appreciated band of rectal pressure was a speciic and sensitive by many of the male population and is regarded marker for attributing that an orgasm had taken as possible evidence of female infection, coldness place. While orgasm is a subjective experience it is normal-- ly accompanied by a number of physiological body the sexually induced increase in vaginal blood low changes. These changes can be classiied as [229]: and lubrication creates a vaginal lumen that is much more oxygenated than in the hypoxic basal state and i) Prospective – those changes that indicate an the neurogenic transudate partially neutralises the impending orgasm; acidity of the basal vaginal luid [233]. The that an orgasm had occurred partial neutralisation of the vaginal acidity by the See Table 4 for more details transudate [233] reduces the deleterious effect of the basal low vaginal pH on sperm function. Thus sexual arousal creates a more favourable and receptive vaginal milieu for sperm function and survival. The changes that occur in the female genitals and genital tract can the possible role(s) of orgasm and their importance be divided into those that serve procreation, those in the female have always been disputed. A recent that serve recreation and those that serve both book by Lloyd [234], a philosopher, examined critically procreation and recreation. This section will describe some 26 papers on the topic and she concluded briely those changes induced by sexual arousal that that there was little or no real evidence to show that have functional importance for reproduction (for orgasm was important for reproduction. The most signiicant and most important difference in spectral power between orgasm and both control motor tasks (imitation of orgasm and failed orgasm attempt) was found in the alpha band. All have to be induced by the orgasmic release of oxytocin) overlooked the crucial inluence of vaginal tenting on create a uterine ‘upsuck’ and hasten the transport of this putative facilitation. The initial basis for this scenario was the that there is indeed a fast transport of spermatozoa very early paper of Beck [236] who described a case in the female tract even in the sexually unstimulated of a patient with a pronounced vaginal prolapse of her woman. Spermatozoa present in liquiied semen, uterus making the cervical os easily observed. She when placed on the cervical os in women who are was also extremely sensitive to clitoral stimulation. In another digitally and observed that at orgasm the os made 5 study, sperm-sized spheres of albumin labelled with 99mTechnetium (surrogates for spermatozoa) when or 6 ‘gasps’. He suggested that such activity would suck sperm up into the uterus when immersed in the placed in the posterior vaginal fornix in conscious vaginal seminal pool. Dickinson [237], in fact, using women are found in the fallopian tube on the side a glass test tube as a surrogate penis and arousing of the ovulating ovary within 1- 2 minute of their women by clitoral vibration did not ind any evidence application [239]. The mechanism the proposed second supporting study was that of for this remarkably rapid transfer even in the basal Fox et al [226] who used radio-telemetric pressure state is surprisingly not contractions of the main pills to measured the intrauterine and intravaginal uterine myometrium (stratum supravasculare and pressures in a couple during coitus in the face-to- stratum vasculare) but that of the archimyometrium face position. They interpreted their recordings to (stratum subvasculare), a thin layer of mainly circular indicate that the intrauterine pressure fell below smooth muscle that lies beneath the endometrial cell that of the vagina during intromission and male lining of the uterus and extends from the lower part ejaculation and after female orgasm suggesting of the cervix into the uterus and at its upper part that uterine upsuck of semen could occur. The dividing into two and continuing into the muscular size of the pressure pill placed inside the uterus, layer of the fallopian tubes [241]. These cervico- however, was such that it would have expanded the fundal archimyometrial contractions create the rapid, intrauterine virtual cavity abnormally introducing the passive uptake of the spermatozoa and direct them inluence of an unphysiological intrauterine stimulus. They can be illustrative of a mechanism but they do not are at a maximum intensity and frequency prior necessarily verify it [238]. Thus, the foundations of to ovulation, are not blocked by high doses of an the upsuck hypothesis appear to rest on results from oxytocin inhibitor (atosiban) and are not enhanced a 134 year old ‘single patho-physiological uterus by injected oxytocin [241]. The authors concluded and measurements in an over-distended normal that the contractions were independent of systemic one, hardly the irmest of experimental foundations oxytocin but probably sensitive to local endometrial- for the putative importance to reproduction of this synthesized oxytocin [242]. According to the indings of enhanced genital particle transport in women these authors, on the one hand they state systemic (patients suffering from primary or secondary oxytocin has no effect on the archimyometrial infertility) injected i. Fortunately, However, comparing the actions of bolus injections not all the spermatozoa are capacitated at the same of oxytocin with that released at orgasm may be a time and there is a continuous replacement of ca-- lawed procedure because the injections were in pacitated spermatozoa [245,246] from the semen women who were not sexually aroused, their genital pool. Sperm guidance in the female oviduct to the tracts are in a different receptive state and also may ovum is probably by thermotaxis (responding to a have different responses and the dose of intravenous thermal gradient) and chemotaxis (responding to a synthetic oxytocin used appears far greater than that chemo-attractant gradient). It is now known, however, that the process of As described previously, in the basal unaroused activating sperm to become capable of fertilisation is state the vagina is a potential space with the cervix far more complex than previously thought [247,248]. High currently include: sexual arousal then causes the contraction of the pelvic levator ani muscle followed by the smooth i) the activation of sperm motility by the en-- muscle in the connective tissue septa attached to hanced vaginal oxygen pressure and enzymic the uterus. The former, being a striated muscle, breakdown of sperm motility inhibitors in the fatigues quickly within seconds [209] but the latter semen [163], can maintain contraction for long periods without ii) enzymic decoagulation of the gelated semen fatigue [230]. The back cul-de-sac of the vagina iii) mixing and contact of the spermatozoa with (fornix) becomes ballooned out creating a receptacle activators and inhibitors present in the various for the ejaculate to come. This lifting of the cervix component luids of semen especially the and ballooning of the vagina was named ‘vaginal prostate (prostasomes) and seminal vesicle tenting’ by Masters & Johnson [1]. While Masters & Johnson [1] realised that this sion by irst messengers in the semen which tenting would remove the os cervix from the path of prevents spontaneous acrosome exocytosis the ejaculate thus greatly reducing the possibility reaction occurring before fertilisation thus of rapid sperm entry into the uterus they did not preserving fertilising functionality [247]. This may be to impart All these processes are needed to create sperma-- a delay in the transport of spermatozoa into the tozoa that are competent to fertilise an ovum when cervical canal and hence through the uterus to the they are transported from the vagina to the fallopian fallopian tube to fertilise the ovum. Rapid transport without the spermatozoa un-- why delaying sperm transport is of importance it is dergoing these changes would deliver incompetent irst necessary to describe the status of semen and spermatozoa unable to fertilise. Freshly ejaculated spermatozoa in semen in the va-- one possible criticism of the importance of vaginal gina are barely motile, are trapped in a gel formed by tenting to reproductive itness is that it will only be coagulation of semen protein and are incompetent most effective when coitus is performed in the face- to fertilise the ovum. Coitus with ejacula-- into a fertilising state (called capacitation) and liber-- tion in the rear entry would allow a greater likelihood ated from the trapping gel. According to Eisenbach of semen falling onto the cervix thus negating the [244-245], once capacitated they remain in this delay. However, the males ejaculate before women have their coital or-- missionary position is regarded by many, if not the gasms. Moreover, as the semen coagulates at ejacu-- most, as the basic one for achieving pregnancy. The lation the relative immotile spermatozoa are trapped answer to the critics is that ‘no evolved biological and uncapacitated so little effectual transport into the mechanism can be effective and can ensure repro-- cervix/uterus would occur. Biological adap-- coital scenario will be that of iii), female orgasm af-- tation can serve only one particular set of conditions ter ejaculation. There is evidence, admittedly in consciously reduce the amount of semen leaking a single case, that uterine motility is inhibited after from their vagina (termed ‘lowback’) thus controlling orgasm [250] and that genital muscular relexes are the amount of semen retained which would aid fertili-- suppressed [163,205]. The effect only lasted for 1 minute before ejaculation to the female orgasm can occur at three particular time 45 minutes after. These studies and the statistics points during coitus, these are: used have been heavily criticised by Lloyd [234] who i) before ejaculation occurs, does not think that they can be relied on. Baker & Bellis [251] proposed, however, Various postulated functions for the female orgasm without any experimental measurements, that such were collected by Levin [178]. Those that could an orgasm would upsuck the acidic vaginal luid have a bearing on reproduction were a) to create making the cervical luid hostile to sperm and could lassitude in order to keep the female horizontal thus thus inluence subsequent sperm uptake. Sexual arousal per se has no smooth muscle and to inhibit urination and thus effect on the pH of cervical luid it being unchanged any subsequent sperm loss from a need to urinate from the basal values [233]. Psychological/psychiatric problems may also be a longterm complication, As described above possible pathophysiological pro-- as depression, phobia, anxiety, depression and cesses may interact on several levels of the female somatization [258] secondary to the physical and physiology and have an impact on different phases psychological trauma. The pathophysiological changes can be at many lev-- All these complications may evidently have a els: the central or the peripheral physiology of the possible affect on womens’s sexuality, though only female sexual response and may, amongst many few studies have adressed this and the reports are factors, include pathophysiological changes in cell- conlicting. Besides the sexual problems induced to-cell communication, changes in endocrine milieu, by side effects as mentioned above the damaged disruption in homeostasis of neurotransmitters and or missing structures and tissues can have a signal molecules, tissue damage, organ damage, impairing effect on sexual desire, arousal, orgasm, vascular chages and neurological changes central satisfaction and pain during intercourse. However it is important to keep in on which type of circumcision that is performed, mind that women with impaired physiology may have genital sensitivity and orgasmic response may be no sexual problems as well as women with no physi-- affected. In the study by Thabet & Thabet [259] ological changes can experience sexual problems. In the study of Elsashar [258] on gical procedures all have the potential to induce 200 circumcised women, they showed a signiicantly pathophysiological processes inluencing the sexual lower libido, arousal and satisfaction with husband function in women. They is not adressed in other chapters and a short section conclude that cultural factors in combination with is therefore added to this chapter. The most frequently cited moderator of concordance is gender, such that men show signiicantly greater concordance than women. Until now the chapter has focused on physiology and pathophysiology of women’s sexual response, but it First, agreement between actual genital arousal and is clear there is an interaction between physiology self-reported arousal in women is not zero; the aver-- and psychology in the sexual response, and recently age correlation reported by Chivers and colleagues growing evidence has shown a gender difference in was +. This of sexual response are examples of the relative suggests that women’s experience of sexual arousal independence between physiological, psychological, is not primarily related to experience of physiological and behavioral aspects of women’s sexuality.
The development of these evidence-based guidelines is therefore intended to assist primary care physicians as well as other healthcare professionals in the effective management of infertility at the primary healthcare level. I hope that these guidelines will be able to help couples seeking help for the treatment of infertility. Executive summary of recommendations Details of recommendations can be found in the main text at the pages indicated. Grade D, Level 3 D In women with advanced maternal age (>35 years), consultation with a reproductive specialist should be considered after 6 months of unsuccessful efforts to conceive (pg 22). Grade D, Level 4 D Sexual intercourse every 2 to 3 days is recommended to optimise the chance of pregnancy; this is less stressful than timing intercourse to coincide with ovulation, which is not recommended unless in circumstances preventing regular intercourse (pg 22). Grade D, Level 4 B Women trying to get pregnant should be advised against excessive alcohol consumption of more than 2 drinks a day and episodes of binge drinking can cause fetal harm (pg 23). Grade B, Level 2++ C Men should be warned that excessive alcohol intake is detrimental to semen quality (pg 23). Grade C, Level 2+ 1 B Women should be informed that smoking is likely to reduce their fertility (pg 23). Grade B, Level 1+ D Men who smoke should be informed that smoking is associated with reduced sperm parameters (pg 24). Grade B, Level 1+ B Couples seeking treatment for infertility should be routinely screened for usage of long term prescription medication, as some have been known to affect fertility (pg 25). Grade B, Level 2++ C Couples seeking treatment for infertility should also be routinely screened for occupational hazards and given appropriate advice (pg 25). Grade C, Level 2+ A Women intending to become pregnant should be informed that dietary supplementation with folic acid before conception and up to 12 weeks’ gestation reduces the risk of having a baby with neural tube defects. For women who have previously had an infant with a neural tube defect or who are receiving anti-epileptic medication, a higher dose of 5 mg per day is recommended (pg 25). Cervical screening should be offered in accordance with the national cervical screening programme guidance (pg 26). Grade D, Level 4 D At the initial consult, each couple should be assessed for factors that may optimise or contraindicate the planned pregnancy, possible underlying causes of infertility, and the impact of infertility on the individual and relationship (pg 27). Grade D, Level 4 D A detailed history-taking and clinical examination should be carried out for couples with fertility concerns. Grade D, Level 4 D Patients meeting these criteria should be referred to specialists: • Women aged <30 years who are unable to conceive after regular unprotected intercourse for 2 years without any known reproductive pathology. Grade D, Level 4 D Women with fertility concerns should have their menstrual history taken (pg 29). Grade D, Level 4 4 D Use of basal body temperature charts and home ovulation kits alone to predict ovulation should not be recommended to patients with fertility problems as these are not always reliable in predicting ovulation and leads to unnecessary anxiety and stress for the patient (pg 29). Grade D, Level 4 B Women with infertility should be offered a blood test to measure mid luteal serum progesterone levels (about 7 days before the expected menstrual cycle). If cycles are irregular or prolonged, this test may need to be repeated again weekly thereafter until the next menstrual period (pg 29). Grade B, Level 2++ B Follicle stimulating hormone and luteinizing hormone investigations should be done on day 2 to 3 of the menstrual cycle. Patients with high levels of gonadotrophins should be informed that they are likely to have reduced fertility (pg 29). Grade B, Level 2+ B Women with infertility should be offered screening for Chlamydia trachomatis before undergoing instrumentation (pg 29). Grade B, Level 2++ B If screening for Chlamydia trachomatis has not been carried out, prophylactic antibiotics should be given before uterine instrumentation (pg 29). Grade A, Level 1+ B Laparoscopy and dye hydrotubation should be offered for women with comorbidities, such as pelvic infammatory disease, previous ectopic pregnancy or endometriosis (pg 31). Grade B, Level 2+ C Fertiloscopy and transvaginal hydrolaparoscopy should not be offered routinely as an alternative to laparoscopy hydrotubation as their diagnostic accuracy still require further evaluation (pg 31). Grade C, Level 3 C When available, transvaginal ultrasound may be used as a screening test for the assessment of uterine cavity in subfertile women (pg 32). Grade C, Level 2+ B Operative hysteroscopy should not be offered as an initial investigation (pg 32). Grade B, Level 2++ Ovulatory dysfunction C For patients with functional hypothalamic pituitary failure who desire fertility, ovulation induction therapies may be indicated. However, the achievement of a healthy weight and modifcation of lifestyle should be tried frst (pg 34). Grade C, Level 2+ C Where amenorrhoea (which occurs in functional hypothalamic pituitary failure women) has occurred for longer than a year in duration, assessment of the bone mineral densities should be considered (pg 34). If the medication which causes anovulation cannot be altered or discontinued, referral to a reproductive medicine specialist for further management is indicated (pg 35). Grade C, Level 2+ C Women with spontaneous premature ovarian failure should be referred to an endocrinologist to investigate asymptomatic autoimmune adrenal insuffciency (pg 36). Grade C, Level 2+ A Dopamine receptor agonists are the frst line treatment for patients with idiopathic hyperprolactinaemia secondary to pituitary adenoma (pg 36). Grade A, Level 1+ C Surgical trans-sphenoidal resection of microadenomas should not be the primary therapeutic approach for patients with hyperprolactinaemia secondary to pituitary adenoma (pg 37). Grade A, Level 1+ A Patients with polycystic ovary syndrome should be informed that there is an increased risk of multiple pregnancy with ovulation induction using clomiphene citrate (pg 41). Grade B, Level 2++ B Low dose therapy with gonadotrophin is recommended as it offers signifcant lower risk of ovarian hyperstimulation in women with polycystic ovary syndrome (pg 42). Grade B, Level 2++ C the recommended third-line treatment for infertility in women with polycystic ovary syndrome is in vitro fertilization (pg 42). Grade D, Level 3 B There is currently insuffcient evidence to suggest improvement in live birth rates on treatment with metformin before or during assisted reproductive technique cycles and its routine use is not recommended (pg 43). Grade B, Level 1+ B Women diagnosed with polycystic ovary syndrome should be asked (or their partners asked) about snoring and daytime fatigue/ somnolence and informed of the possible risk of sleep apnoea, and offered investigation and treatment when necessary (pg 46). Grade B, Level 2++ B Clinicians should continue to identify cardiovascular risk factors (including blood pressure, cholesterol, triglycerides and high density lipoprotein cholesterol) in women with polycystic ovary syndrome and treat these accordingly (pg 46). Grade B, Level 2++ A Women diagnosed with polycystic ovary syndrome should be advised regarding weight loss through diet and exercise (pg 47). Grade A, Level 1+ B Combining metformin and lifestyle modifcation, including calorie restriction and exercise to facilitate weight loss and attenuate central adiposity is recommended for obese patients with polycystic ovary syndrome. Grade B, Level 1+ 11 D Ovarian electrocautery should only be reserved for slim women with anovulatory polycystic ovary syndrome (pg 48). Grade D, Level 3 B Women who have been diagnosed as having polycystic ovary syndrome before pregnancy, especially those requiring ovulation induction for conception, should be screened for gestational diabetes before 20 weeks of gestation, with referral to a specialist obstetric diabetic service if abnormalities are detected (pg 49). Grade C, Level 3 D When available, penile electrovibration and transrectal electroejaculation should be considered before embarking on surgical sperm retrieval and intracytoplasmic sperm injection (pg 54). After exclusion of medical illnesses, referral could be made to a sexual therapist who could help in education, counselling and instruction in revised sexual technique to maximise sexual arousal (pg 54). On demand use of topical anaesthtics and tramadol may prolong intravaginal ejaculatory latency (pg 54). Patients need to be educated that they require sexual stimulation for these medications to work (pg 56). Grade D, Level 4 15 C Vacuum devices and rings are suitable for men with erectile dysfunction who have contraindications for pharmacologic therapies. Grade C, Level 2+ D Hormone assays should be performed to test for androgen defciency. As there is diurnal rhythm in hormone secretion, blood samples for testosterone should be taken in the morning (pg 56). Therefore, clinical assessment (recent changes in sexual function, patterns of body hair and secondary sexual characteristics) is important to diagnose androgen defciency (pg 56). Grade B, Level 2++ Tubal-Infertility (Preventive strategies & treatment) C Women with high risk profles (early sexual debut, multiple partners, non-compliance with safe sexual advice, etc. Grade C, Level 2+ 16 C Partners of Chlamydia positive women should be tested and treated as well, to prevent re-infection of the treated women. Grade C, Level 2+ A Oral doxycycline (100mg twice daily for 7 to 14 days) and azithromycin (1gm stat dose) are recommended antibiotics against Chlamydia trachomatis (pg 58). Grade A, Level 1++ B High risk women who are scheduled for invasive instrumentation of the reproductive tract should be empirically treated for Chlamydia, to prevent ascending infection of the upper reproductive tract, or re- activation of past infection (pg 59). Grade B, Level 2++ Endometriosis C A detailed vaginal examination with bimanual palpation, and / or rectal examination is essential to detect nodular lesion on the uterosacral ligaments, rectovaginal septum, or other surfaces accessible digitally. Grade C, Level 2+ C Magnetic resonance imaging may be considered as an adjunctive investigation tool to laparoscopy in the diagnosis of deeply infltrating endometriosis (pg 61). Grade B, Level 2++ D Diagnosis of endometriosis should be made at laparoscopy unless disease is visible in the vagina or elsewhere (pg 61). Grade D, Level 4 C Diagnostic laparoscopy for endometriosis should not be undertaken within 3 months of ovarian suppressive treatment, as there is a high risk of missing the lesions and leading to a false negative result (pg 62).
Smoking cessation by 40 years of age reduces that loss reproductive effects are now found to be attributable to approximately 90%. However, reduc- the embryo implants in the Fallopian tube or elsewhere ing the number of cigarettes smoked per day is much less outside the uterus. Ectopic pregnancy is very rarely a sur- effective than quitting entirely for avoiding the risks of vivable condition for the fetus and is a potentially fatal premature death from all smoking-related causes of death. This report fnds that mater- Much of this 50th anniversary Surgeon General’s nal smoking during early pregnancy is causal for orofa- report is devoted to examining evidence on the myriad cial clefts in infants, and evidence suggests that smoking health effects, avoidable diseases, and all-cause mortal- could be associated with certain other birth defects. Chapters highlight fndings on specifc report also fnds that the evidence is now suffcient to con- health topics from previous Surgeon General’s reports in clude that there is a causal relationship between smoking addition to presenting current information. The macula is the most sensitive part of the retina and is the part of the eye that supplies sharp vision. The evidence is suffcient to infer that nicotine acti- not appear for 20 or more years after smoking cessation. The evidence is suffcient to infer that nicotine expo- Prostate Cancer sure during fetal development, a critical window for 1. The evidence is suggestive of no causal relationship brain development, has lasting adverse consequences between smoking and the risk of incident prostate for brain development. The evidence is suggestive of a higher risk of death adversely affects maternal and fetal health dur- from prostate cancer in smokers than in nonsmokers. In men who have prostate cancer, the evidence is sug- gestive of a higher risk of advanced-stage disease and 5. The evidence is suggestive that nicotine exposure less-well-differentiated cancer in smokers than in during adolescence, a critical window for brain devel- nonsmokers, and—independent of stage and histo- opment, may have lasting adverse consequences for logic grade—a higher risk of disease progression. The evidence is inadequate to infer the presence or absence of a causal relationship between exposure to 1. The evidence is suggestive but not suffcient to infer Chapter 6: Cancer a causal relationship between tobacco smoke and breast cancer. The evidence is suggestive but not suffcient to infer of developing adenocarcinoma of the lung from ciga- a causal relationship between active smoking and rette smoking has increased since the 1960s. The evidence is suggestive but not suffcient to infer a increased risk of adenocarcinoma of the lung in causal relationship between exposure to secondhand smokers results from changes in the design and com- tobacco smoke and breast cancer. The evidence is not suffcient to specify which design and Survivors changes are responsible for the increased risk of ade- 1. In cancer patients and survivors, the evidence is suf- nocarcinoma, but there is suggestive evidence that fcient to infer a causal relationship between ciga- ventilated flters and increased levels of tobacco-spe- rette smoking and adverse health outcomes. In cancer patients and survivors, the evidence is suf- carcinoma follows the trend of declining smoking fcient to infer a causal relationship between cigarette prevalence. In cancer patients and survivors, the evidence is suf- ship between smoking and hepatocellular carcinoma. The evidence is suffcient to infer a causal relation- ship between smoking and colorectal adenomatous polyps and colorectal cancer. In cancer patients and survivors, the evidence is sug- Tuberculosis gestive but not suffcient to infer a causal relation- 1. The evidence is suffcient to infer a causal relation- ship between cigarette smoking and (1) the risk of ship between smoking and an increased risk of Myco- recurrence, (2) poorer response to treatment, and (3) bacterium tuberculosis disease. The evidence is suffcient to infer a causal relationship between smoking and mortality due to tuberculosis. The evidence is suggestive of a causal relationship Chronic Obstructive Pulmonary Disease between smoking and the risk of recurrent tubercu- losis disease. The evidence is suffcient to infer that smoking is the dominant cause of chronic obstructive pulmonary 4. The evidence is inadequate to infer the presence or absence of a causal relationship between exposure to 2. The evidence is suffcient to infer that severe a causal relationship between cigarette smoking and ?1-antitrypsin defciency and cutis laxa are genetic idiopathic pulmonary fbrosis. The evidence is suggestive but not suffcient to infer a causal relationship between active smoking and the 1. The evidence is suffcient to infer a causal relation- incidence of asthma in adolescents. The evidence is suggestive but not suffcient to infer a causal relationship between active smoking and exac- 2. The estimated increase in risk for stroke from expo- erbation of asthma among children and adolescents. The evidence is suffcient to infer a causal relation- a causal relationship between active smoking and the ship between the implementation of a smokefree law incidence of asthma in adults. The evidence is suffcient to infer a causal relation- ship between active smoking and exacerbation of 4. The evidence is suggestive but not suffcient to infer Spontaneous Abortion a causal relationship between the implementation of 1. The evidence is suggestive but not suffcient to infer a a smokefree law or policy and a reduction in other causal relationship between maternal active smoking heart disease outcomes, including angina and out-of- and spontaneous abortion. The evidence is suffcient to infer a causal relation- Chapter 9: Reproductive Outcomes ship between smoking and erectile dysfunction. The evidence is suffcient to infer a causal relation- Chapter 10: Other Specifc ship between maternal smoking in early pregnancy and orofacial clefts. The evidence is suggestive but not suffcient to infer Eye Disease: Age-Related Macular Degeneration a causal relationship between maternal smoking in 1. The evidence is suffcient to infer a causal relation- early pregnancy and clubfoot, gastroschisis, and atrial ship between cigarette smoking and neovascular and septal heart defects. The evidence is suggestive but not suffcient to infer a that smoking cessation reduces the risk of advanced causal relationship between maternal prenatal smok- age-related macular degeneration. The evidence is insuffcient to infer the presence or causal relationship between active cigarette smoking absence of a causal relationship between maternal and dental caries. The evidence is suggestive but not suffcient to infer a causal relationship between exposure to tobacco 3. The evidence is insuffcient to infer the presence or smoke and dental caries in children. The evidence is suggestive but not suffcient to infer a causal relationship between cigarette smoking and 4. The evidence is suffcient to infer that cigarette smok- absence of a causal relationship between maternal ing is a cause of diabetes. The risk of developing diabetes is 30–40% higher for active smokers than nonsmokers. The evidence is suffcient to infer a causal relation- the number of cigarettes smoked and the risk of devel- ship between maternal active smoking and ectopic oping diabetes. The evidence is suggestive but not suffcient to infer cigarette smoke impact components of the immune a causal relationship between cigarette smoking and system. The evidence is suffcient to infer that cigarette smok- causal relationship between cigarette smoking and a ing compromises the immune system and that altered protective effect for ulcerative colitis. The evidence is suffcient to infer that cigarette smoke Chapter 11: General Morbidity and compromises immune homeostasis and that altered immunity is associated with an increased risk for sev- All-Cause Mortality eral disorders with an underlying immune diathesis. The evidence is suffcient to infer a causal relation- ship between smoking and diminished overall health. The evidence is suffcient to infer a causal relationship smokers include self-reported poor health, increased between cigarette smoking and rheumatoid arthritis. The evidence is suffcient to infer that cigarette smok- ing reduces the effectiveness of the tumor necrosis 2. Section 3: Tracking and Ending the Epidemic the fnal section of the 50th anniversary Surgeon economic waste that have fowed from the manufacture, General’s report on smoking and health covers the human marketing, sale, and consumption of combustible tobacco and economic costs of the smoking epidemic in the United products. In this half-century, nearly 25 trillion cigarettes States, current trends in tobacco use and tobacco control, have been consumed, despite a signifcant drop in con- the status of interventions and programs that address the sumption per smoker (Figure 2). The annual costs attrib- smoking epidemic, and a vision for a future that is free of uted to smoking in the United States are between $289 death and disease caused by tobacco use. Accumulated data from the past 50 years billion for lost productivity from premature death due to graphically illustrate the devastating loss of life and the exposure to secondhand smoke (Chapter 12). Executive Summary 11 Surgeon General’s Report 12 Executive Summary the Health Consequences of Smoking—50 Years of Progress Despite decades of warnings on the dangers of smok- prevalence of current smoking among high school-aged ing, nearly 42 million adults (Chapter 13) and more than youth has declined, the total number of youth and young 3.
Such overconfidence in driving ability has been shown to be associated with young men engaging in more frequent reckless driving (Sarker & Andreas, 2004; Farrow & Brissing, 1990); being less likely than young women to consider speeding, drunk driving or distracted driving as dangerous driving behaviours (Sarker & Andreas, 2004), and being less likely to expect a negative consequence to result from such driving behaviour (Farrow & Brissing, 1990). These findings are borne out by a recent Eurobarometer (2010) survey on road safety which found that men were less likely than women to identify as a ‘major problem’ (i) not wearing a seat belt; (ii) driving under the influence of alcohol; (iii) exceeding speed limits; and (iv) driving while talking on a mobile phone (Fig. In Denmark, for example, the rate of accidents involving male drink drivers aged 18–24 is still approximately three times that of 25 to 64 year-olds (Bernhoft et al. Similarly in Ireland, men account for 90% of drink driving offences during the period 2003-2007 (Mongan at al. Luxembourg, Office for Official Publications There are considerable variations between countries, with the highest number of fatal accidents occuring in Italy and Germany (Fig. It is acknowledged that such differences are, to a large extent, the result of methodological differences in surveillance of workplace accidents. Construction, manufacturing and transport, storage and communication account for the highest proportion of fatal accidents (Fig. Approximately two-thirds (68%) of non-fatal accidents occurring among craft and related trade workers, machine operators, 37 or workers employed in an elementary occupation. Over 70% of non fatal accidents injuries arising from non fatal accidents are sustained as wounds and superficial injuries, dislocations, sprains and strains. Luxembourg, Office for Official Publications Advances in occupational health and health and safety have resulted in reductions in the rate of accidents at work. Between 1997 and 2007, there has been a decline in the standardised incidence rate of fatal accidents at work, with Ireland having achieved the most notable reduction (Fig. Although a large proportion of accidents entailed fewer than 14 days of absence (45. Workplace accidents and occupational injuries pose a considerable economic burden to employers, employees and to society as a whole. In addition to the personal costs in terms of pain and disability to the individual and lost income, workplace accidents are associated with decreased productivity, staff replacement costs and increased demands on public services, such as healthcare and social security (European Agency for Safety and Health at Work, 2005). Estimated Member State costs due to work accidents vary from 1–3 % of gross national product (ibid). Notwithstanding the clear progress that is being made in reducing workplace injuries, it is noteworthy that there has been little questioning or conceptualisation as a health issue, of the disproportionate incidence of work- related injuries and fatalities among men, particularly working-class men (Schofield at al. As men continue to dominate those industries that 276 have high levels of occupational injury and death – the construction industry, work involving heavy machinery and dangerous tools, most transport work, and most work in heavily polluted environments – this continues to be taken for granted as normal and expected masculine practice, as ‘men’s work’ (Connell, 1995). Future policy directed at reducing workplace injuries needs to take account of the gendered patterns of workplace accident and injury and the wider cultural and institutional masculine ideologies within workplaces in which accidents are more prevalent. Home & leisure accidents refer to a diverse category that comprises all accidents other than transport and workplace accidents. The diversity implies also various legal and administrative responsibilities, imposing a challenge for coordinated prevention efforts. It is beyond the scope of this report to cover all aspects of this category, therefore the following discussion of falls, poisoning & sport injuries should be seen as merely exemplary. There is also large variability between countries, ranging from a rate of approximately 2 for males in Portugal to 25 for males in Slovenia (Fig. Over the last available 3 years of the study period, accidental falls accounted for the majority of unintentional injury deaths (51%). There was also great variability across countries, with rates (per 100,000 person-years) ranging from =15 (Spain and Greece) to >150 (Hungary and Czech Republic). The authors hypothesised that the inter-country injury 278 variability could be related to the prevalence of osteoporosis linked to climate and nutritional differences; variations in the sources used for coding the cause of death among different countries; and differences in coding with respect to the role of falls in conjunction with leading chronic causes of death at older ages. It is estimated that approximately 6 in 1000 unintentional fatal injuries can be attributed to sports such as rock climbing, boating sports or horse related sports (Baur & Steiner, 2009). When drowning (in natural water and swimming pools) and non- traffic bicycle accidents are included, 36 in 1,000 unintentional injuries can be attributed to sporting activities. Adolescents/young people are over-represented in most categories of sports-related injuries. For example, in an audit of sports injuries in children (n=238) attending an Accident & Emergency department in Scotland, the incidence of injury was much higher in boys (71%) than in girls, with football (39%) and rollerblading (14%) accounting for the highest proportion of injuries (Boyce & Quigley, 2003). Team ball 280 sports account for approximately 40% of all hospital-treated sports injuries (ibid). The overall incidence of sports-related injuries is higher in men (67%) than in women, reflecting, in part, men’s higher participation levels in sport (Eurobarometer, 2010). For example, in a review of sports injuries (n=2270) over a one year period in the Accident and Emergency Department at the Royal Infirmary, Edinburgh, 88. In a review of 152 accidental deaths associated with mountain tourism and sports in the Republic of Kabardino-Balkaria, most of the victims were found to be male under the age of 30 (Mechukaev & Mechukaev, 2006). For men, taking risks and foregoing safety through sport, have long been regarded as masculine defining, and are practices that are valorised and sustained through wider gendered systems and structures within sporting organisations (Sabo, 1995; Messner, 1992, Connell, 1995). There has been an increasing focus on sports-related violence as a form of interpersonal violence (Fields et al. Violence and intimidation are more common in heavy-contact and collision sports, giving rise to a tendency to tolerate sports-related violence ‘as part of the game’ (Shields, 1999). Nevertheless, sports-related violence has been found to result in serious physical and psychological injuries to its victims (Campo et al. It has also been proposed that the focus in the sports media on personal rivalry, conflict, and fierce competition reinforces the social attitude that violence and aggression are normal and natural expressions of masculine identity (Children Now, 1999). From a sex and gender differences perspective, such distinctions are important, since women have been found to be over- represented among victims of intimidation and psychological violence, while men are more at risk of physical violence and assault (European Foundation for the improvement of living and working conditions, 2003). Measuring violence presents a number of challenges, not least being the inconsistencies that are to be found in defining and collecting data on violence across different countries. A German study that explored men’s experiences of interpersonal violence noted that: “Certain forms of violence are so normal in men’s lives that the men themselves do not perceive them as violence and therefore have only limited memory of them. Children who are exposed to violence are also more likely to become a violent offender themselves in later life (Moses, 1999). In addition to the more obvious physical effects, interpersonal violence can have severe repercussions on mental health. This can include feelings of dissociation, post-traumatic stress disorder-like symptoms, anger and depression (Buka at al. It should also be acknowledged that interpersonal violence data derived from mortality and hospitalisation data is likely to represent a mere fraction of the overall incidence of interpersonal violence, with only a small minority of physical assaults resulting in death or severe injury requiring hospitalisation (Harrison & Tyson, 1993; Voukelatos & Mitchell, 2009). Connell (1995) highlights the prevalence of violence in maintaining what he describes as the ‘patriarchal dividend’, and that it is predominantly men who hold and use violence to sustain their dominance. A number of studies (see Hong, 2002) have linked traditional male gender roles and hegemonic masculinity with violence, and with a much greater propensity for men to be perpetrators and victims of violence: 284 “The motivation for all male violence is related to males attempting to reinforce and render incontestable their heterosexual masculinity. The sense of obligation to uphold ‘honour’ or to reciprocate violence can be magnified considerably in the context of drinking (Brooks, 2001). Meuser (2002) differentiates between two forms of male violent action, emphasizing that both are gendered in specific ways: ‘reciprocal’ versus ‘asymmetrical’. Reciprocal violence, though directly targeting other men and not women, contributes to the reproduction of hegemonic masculinity and the masculine habitus. Whereas male violence against women solely degrades its victims, thus reinforcing women’s subordinated position in the gender order. Reciprocal violence allows for mutual acknowledgement within the competitive relations between men, related to notions of male honour. According to Meuser (2002), male violence should not be viewed as a case of disorder or deviance, but rather as a resource: a means of reproducing the gender order and male dominance. Like Meuser, Whitehead (2005) distinguishes two forms of male violence, though giving them different names: ‘inclusive’ and ‘exclusive’ violence. By acts of inclusive violence, men position themselves and their opponents as either ‘Heroes’ or ‘Villains’, mutually affirming their status as men and ‘worthy’ rivals. Exclusive violence, in contrast, degrades the attacked to the position of the ‘Non-Man’: Thus, through violence, he [the perpetrator] excludes the victim from the category ‘man’ as unworthy of belonging there. Such violence in its extreme, overt form, is characterised by overwhelming force, removing any pretence of competition, and humiliation on a sexual level. Such violence may manifest itself, for example, in a vigilante attack on a man who is perceived by the perpetrators as a ‘paedophile’, or in an attack against a gay man. In a study of antigay behaviours among young adults, Franklin (2000) found that many young adults believed that antigay harassment and violence was socially acceptable, particularly in response to inferred sexual innuendos or gender norms violations. With antigay behaviours being culturally normative and 285 mostly going unreported, the study concluded that educational outreach to adolescents and preadolescents is likely to be a more effective prevention strategy than a criminal prosecutions approach. Schuck (2009) extends Whitehead’s category of ‘exclusive violence’ to include violence against women, not just men; and he further subdivides the ‘exclusive violence’ into the categories of ‘disciplinary exclusive violence’ and ‘eliminatoric exclusive violence’.
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