Etiology and diagnosis of sexual dysfunction in women

Etiology and diagnosis of sexual dysfunction in women

Author
Alan Altman, MD
Section Editor
Robert L Barbieri, MD
Deputy Editor
Kathryn A Martin, MD



Last literature review version 16.2: May 2008 | This topic last updated: October 24, 2007 (More)


INTRODUCTION — Female sexual dysfunction refers to persistent or recurring reduction in sex drive, aversion to sexual activity, difficulty becoming aroused, inability to achieve orgasm, or dyspareunia that causes distress. According to the National Health and Social Life Survey, a study of sexual behavior in a demographically representative cohort of American men and women, sexual dysfunction is more prevalent among women than men (43 versus 31 percent) [1] .

Sexual dysfunction can occur at any age in women, but "midlife" is a particularly common time for changes to occur. The transition to menopause impacts the lives of women in different ways. Many will notice little change, some may experience an improvement, while others will complain of diminished sexual function. These variations are understandable considering the multiple factors that may affect midlife sexuality:

• Erratic ovarian function and fluctuating hormone levels that define perimenopause and the more definite decline that follows the menopause
• Alterations in anatomical structure, neurologic function, vascular responsiveness, and psychosocial function that accompany the normal aging process
• Relationship dynamics and each individual's foundation of sexual beliefs, expectations, and prior sexual experiences


Caring for women at this stage of life presents a unique opportunity for the clinician to ask the appropriate questions, bring the problem out into the open, and offer counsel and guidance. This requires the ability to communicate comfortably with patients plus an understanding of the physiology of human sexual response, the normal effects of aging on sexuality, relationship dynamics, and the healthcare provider's own limitations.

The etiology and diagnosis of sexual dysfunction are discussed here, with a focus upon changes that occur in midlife. The treatment of sexual dysfunction in women and an overview of the approach to sexual dysfunction in both men and women are discussed separately. (See "Treatment of sexual dysfunction in women" and see "The sexual history and approach to the patient with sexual dysfunction").


MIDLIFE — The concept of "midlife" must be redefined as life expectancy grows longer. Women today experience "two midlives:" one is reproductive, the other chronological, and they do not necessarily coincide. In the past, with a life expectancy of 50 to 60 years, menopause generally appeared near the end of a woman's life, and midlife, chronologically, coincided with the reproductive changes in ovarian function beginning in the mid 30s.

Today life expectancy has increased and chronological midlife has been redefined as the 50s and 60s, while age at menopause remains unchanged. This discrepancy between a woman's reproductive midlife and her chronological midlife presents some problems. It is difficult for women in their 30s to think of themselves as entering midlife, even though decline in reproductive function begins at that age. In addition, when midlife occurs it will impact the kind of sexual changes that are experienced. The older midlife woman will tend to have more physiologic and anatomic problems compared with the younger midlife woman, in whom psychosocial problems might predominate. Women and men expect sexual interest and function to continue for decades beyond the point where women lose their natural reproductive capabilities. Fortunately, the clinician can do much to help patients in reproductive midlife maintain sexual function well into and beyond chronological midlife.

Midlife sexuality — While the host of hormonal and other changes that begin prior to the menopausal transition and continue beyond the menopause affect sexuality, the desire for an active sex life remains important for many men and women throughout midlife, as illustrated by the following surveys:

• One survey of 1879 women ages 45 to 55 (most of whom had partners) was designed to identify changes in sexual interest over the previous year [2] . Of the respondents, 62 percent noted no change, 31 percent reported a decline in interest, and 7 percent indicated an increase in interest; most of the last group had new partners.
• A 1999 survey asked responders ages 45 and older if they were more or equally satisfied with their current sex life when compared with their past levels of sexual activity [3] . Fifty-six percent of men and 51 percent of women were more or equally satisfied. In addition, 54 percent of the men and 38 percent of the women considered themselves "a better lover now than in the past."


Seventy percent of males and females with partners in this study had intercourse one or two times per week. Of those without regular partners, 6 percent of males had intercourse one or two times per week; women had considerably less. Women ages 45 to 59 years were more likely than men to approve of sex outside of marriage, oral sex, masturbation, and sex, as a normal part of aging. Age became a factor when the participants were asked, "What would improve your sex life?" Men and women age 45 to 59 cited less stress and more free time; men over 60, better health; women 60 to 74, better health for their partner; and women over 75 responded that just having a partner would improve their sex life.

Midlife can be a time of sexual freedom for many women; freedom from menstrual cycles, interruptions by small children, and unwanted pregnancy. These factors may enhance midlife sexuality, especially if sex was a positive experience earlier in life. On the other hand, some women see midlife as a loss of youth, femininity, and childbearing capacity, leading to a negative impact upon sexuality. Still others see midlife as a time when they can finally use these changes as a long anticipated excuse to avoid sex that was never enjoyable for them before. Absence of sexual activity is, in itself, not a problem; it should be viewed and treated as a problem only when a woman or her partner are bothered by it.

PHYSIOLOGY OF THE NORMAL HUMAN SEXUAL RESPONSE — Knowledge of the physiology of the normal sexual response can facilitate an understanding of what may go wrong. Two basic models have been proposed to illustrate the physiology of human sexual response: the Masters and Johnson model and the biopsychosocial model (see below). While they differ in many ways, both acknowledge that neurologic and vascular responses are essential to produce a sexual response.

The brain is the most important sex organ in the human body. Neurologic changes initiate the process as the brain reacts to an image, idea, fantasy, smell, or anything else that stimulates a response or triggers desire. This leads to changes in vascular blood flow. Sex hormones play key roles here. There are estrogen, androgen, and progesterone receptors in the brain [4,5] . Estrogen and androgen receptors are particularly dense in the hypothalamus, which controls sexual function and mood.

Testosterone is the primary precursor for estradiol biosynthesis in the brain; the testosterone concentration in the brain is 7 to 10 times higher than the estrogen concentration. Thus, the free circulating concentration of estrogen and testosterone does not necessarily correlate with what is occurring in the brain.

Estrogen increases blood flow to the brain. Estrogens also increase vibratory sensation peripherally and have a positive effect on neuronal growth and nerve transmission. Other hormones, including oxytocin and endorphins, influence sexuality in the brain as well, while prolactin may have a negative effect on sexual response.

Increased blood flow to the genitalia occurs with sexual stimulation. This marks the arousal phase, in which the additional blood flow produces peripheral responses that define the sexual response. Estrogens affect how blood flows: increased estrogen increases vaginal blood flow (VBF) while a decreased concentration diminishes VBF [6] . The mechanism by which this occurs is related to estrogen stimulation of the release of vasoactive substances such as nitric oxide by endothelial cells, which induces vasodilatation [7] .

Addition of androgens to estrogen increases VBF further. Testosterone may work directly in the artery or indirectly by increasing the availability of estrogen [8] . Progesterone, on the other hand, can diminish blood flow by down-regulating the estrogen receptor [9] . Blood flow can also be increased through any mechanism that provides the neurovascular stimulus, be it sexual activity, the use of sexual aids, masturbation, or fantasy.

Masters and Johnson — Masters and Johnson first detailed the phases of human sexual response as a linear progression from excitement to plateau to orgasm, followed by resolution [10] .

Excitement — Activation of the central nervous system (CNS) causes specific changes in blood flow. Ovarian hormones also play essential roles in this process, encouraging vasodilation and increased blood flow. Uterine and internal mammary arteries contain some of the highest density of estrogen receptors, hence their responsiveness in the excitement phase.

Genital vasocongestion occurs because of this increase in blood flow and smooth muscle relaxation. The vaginal wall becomes lubricated. The labia increase in size and spread open. The clitoris increases in size and the vagina expands while the uterus elevates. Other areas of the skin, including the face and breasts, demonstrate this increase in blood flow with the "sex flush."

Following Masters and Johnson, Kaplan replaced the excitement phase with two phases: desire, in which the neurologic stimulus occurs; followed by arousal, in which blood flow produces the peripheral response leading up to orgasm [11] .

Plateau — Masters and Johnson presented this as a separate phase, while Kaplan later blended it into the arousal phase. Actions associated with this phase include retraction of the clitoris and engorgement of the labia. Bartholin gland secretion occurs, as well as congestion of the outer third of the vagina and further expansion of the upper two thirds of the vagina. Muscle tension builds.

Orgasm — In the orgasm phase, 8 to 12 muscular contractions of the levator ani muscles occur at precise intervals. Vaginal and uterine contractions occur followed by massive release of muscle tension. Regularly orgasmic women will achieve orgasm 50 to 70 percent of the time and a satisfying prolonged plateau phase other times.

Resolution — The final phase, or culmination, is often characterized as a gradual, pleasant diminishment of sexual tension and response, differing in the time it lasts among individuals.

The biopsychosocial sexual response — An alternative model has also been proposed to describe the female sexual response. Proponents believe that a large component of women's sexual desire is responsive rather than spontaneous. They maintain the biopsychosocial nature of the female sexual response cycle is a result of the dynamic and mutable interaction of four components [12,13] :

• Biology
• Psychology
• Sociocultural influences
• Interpersonal relationships


If only the biological or physiological component is addressed, as with the use of pharmacotherapy, successful treatment will frequently not be achieved. In this model, emotional intimacy of some kind motivates the woman to seek out or become responsive to sexual stimuli, which in turn leads to arousal. Once arousal is achieved, sexual desire is then accessed, allowing continuation of the experience for sexual reasons. Hence, sexual desire can be responsive to arousal instead of preceding it. While spontaneous drive can occur, it is not essential. Thus, lack of spontaneous desire is not necessarily a dysfunction. In addition, satisfaction is the goal, which may or may not include orgasm.

SEXUAL CHANGES WITH AGING — Sexuality and sexual capacity evolve over a lifetime of development and change, based on personal experience, interest, cultural attitudes, interpersonal relationships, desires, behaviors, physiology, and other factors.

Epidemiology — Although many older adults remain sexually active, sexual problems become more common, and these problems are infrequently discussed with their health care providers. This was illustrated in a national probability sample study of 3005 men and women ages 57 to 85 years [14] . The prevalence of sexual activity decreased with age in both men and women, but women at all ages were less likely than men to be sexually active (62, 40, and 17 percent among women who were ages 57 to 64, 65 to 74, and 75 to 85 years, respectively). The most common sexual problems in women were low desire, vaginal dryness, and inability to achieve orgasm (43, 39, and 34 percent, respectively). Only 38 percent of men and 2 percent of women reported having discussed their sexual concerns with a health care provider since the age of 50.

Estrogen — Estrogen deficiency develops gradually as women near menopause. A more abrupt decline is seen with surgical menopause. This decline in estrogen can cause several changes that may affect sexual function.

Urogenital function — Estrogen sustains the structure and function of the cells of the vagina. Every woman with estrogen deficiency for a prolonged period of time will develop some degree of vaginal and genital atrophy. Epithelial changes in the vagina occur first within weeks to months of estrogen loss. This leads to a decrease in superficial cells, an increase in parabasal cells, and a progressive loss of elasticity and integrity of the epithelium. Along with this change comes an increase in vaginal pH, which promotes the growth of organisms and leads to more frequent vaginal infections [15] .

Later changes, over years, affect the deeper structures such as the underlying vascular, muscle, and connective tissue, leading to a decrease in vaginal blood flow, and both foreshortening and narrowing of the vagina. There is actual loss of blood vessels in the layers beneath the epithelium. This constellation of changes can lead to vaginal dryness, decreased or absent lubrication and, dyspareunia. (See "Clinical manifestations and diagnosis of menopause" and see "Approach to the woman with dyspareunia").

The bladder tissues also suffer from estrogen loss with mucosal changes that can lead to urinary frequency, urgency, nocturia, dysuria, and incontinence. Clitoral changes can occur, including a 50 percent decrease in perfusion and shrinkage of the structure [16] . Neurologic changes include decreased touch perception, a decline in vibratory sensation, and slowing of nerve impulses leading to a delay in reaction time [17] . Decreased androgen levels also affect some of these changes (see below).

Effect on sexual response — Changes in the vaginal and clitoral tissues due to estrogen deficiency can have a profound effect on sexual response. The decrease in genital blood flow will affect vasocongestion. Sexual arousal will be delayed or altered. More time and stimulation may be necessary to achieve lubrication, which may be significantly reduced or absent. The outer third of the vagina, including the labia and G-spot, demonstrate decreased or absent congestion, as does the clitoris. Vaginal expansion in length and transcervical width decreases. Elsewhere, there is a reduced incidence of skin flush, a lack of increase in breast and nipple size during stimulation, decreased tactile sensation, or worse, aversion to skin touch due to pain perception instead of pleasure in the clitoris, skin, and nipples, and a general decrease in muscle tension [18] .

Taken together, these changes can result in delayed arousal, delayed or absent orgasm, or diminished peak of orgasm. Fewer uterine contractions occur with orgasm and, in older women, particularly age 70 and older, painful uterine contractions can be associated with orgasm because of vasoconstriction that produces a reaction similar to ischemia [16] .

Androgens — All women produce some androgens, which may contribute to maintaining normal ovarian function, bone metabolism, cognition, and sexual behavior [19] . However, serum testosterone concentrations are not a good predictor of libido in women. Studies evaluating vaginal blood flow and vasocongestion of the clitoris and labia suggest that normal testosterone levels are necessary for arousal and orgasm to occur [20] . In women who undergo bilateral oophorectomy and subsequently develop hypoactive sexual desire disorder, exogenous testosterone therapy may be moderately effective for libido and sexual activity. (See "Androgen production and therapy in women").

Total testosterone and androstenedione (the major androgen in the serum of cycling women) gradually decline with increasing age in normal women. Androgen levels peak around age 25 and begin a gradual, age-related decline in the early to mid 30s, much earlier than the decline in estrogen levels [21] . There is also a midcycle testosterone surge that declines with age [22] . Some have argued that the sexual effects of reduced androgen levels can occur well before menopause and the onset of estrogen deprivation [23] .

Other suggested causes of androgen deficiency include:

• Oophorectomy (producing sudden 50 percent fall in levels within 24 hours of surgery)
• Premature ovarian failure
• GnRH agonist therapy
• Corticosteroid therapy suppressing ACTH secretion
• Adrenal insufficiency


Additional important causes include exogenous oral estrogens, such as oral contraceptives (OCs) and hormone replacement therapy (HRT), both of which increase sex hormone binding globulin (SHBG), resulting in reduced bioavailability of androgens as well as estrogens. Non-oral contraceptives, ie ring and patch, also increase SHBG, while non-oral postmenopausal therapy does not.

The menopausal transition (ie, perimenopause) results in a somewhat unique hormonal profile. Erratic ovarian function leads to estrogen levels that can be normal, elevated, or decreased at any given time, but in general, estrogen secretion is preserved. (See "Clinical manifestations and diagnosis of menopause"). Ultimately, lower estrogen levels predominate. The postmenopausal ovary is an androgen-producing organ. Ovaries continue to produce androgens well into the postmenopausal years [24] . (See "Androgen production and therapy in women").

Serum androgen concentrations — It has been proposed that serum androgen concentrations are an independent predictor of sexual desire and function in women. In a community-based, cross-sectional study of 1021 women aged 18 to 75 years, low serum concentrations of testosterone, free testosterone, or androstenedione were not significantly associated with a low score on the Profile of Female Sexual Dysfunction instrument [25] . Women with low sexual function were more likely to have a low DHEAS level, however, the majority of women with a low DHEAS level did not report low sexual function. This suggests that the measurement of serum androgens in women presenting with sexual dysfunction is not clinically useful.

Impact of male sexuality — One of the major factors that impacts female midlife sexuality is the spectrum of midlife sexual changes in men. It has been reported that 50 percent of men over 50, 60 percent of men over 60, and 70 percent of men over 70 have some degree of erectile dysfunction [26] . (See "Overview of male sexual dysfunction"). Other changes include a prolonged preorgasmic or plateau phase during which it can take considerably longer to achieve orgasm after arousal, and, as with women, orgasm may not always be achieved [27] . Finally, the ejaculate itself can be decreased or absent during sexual encounters.

Many couples adjust to these changes with more manual or oral stimulation to compensate for waning maintenance of erection and carry on normal sex lives. Sexual dysfunction occurs when either partner is bothered by the changes and the lack of successful activity. In men, however, these changes often lead to performance anxiety, one of the most significant psychosocial sexual problems. When the man experiences performance anxiety, he will frequently withdraw from intimacy at all levels of the relationship for fear of stimulating his partner to expect sexual activity that he believes he cannot provide. This withdrawal from other areas of intimacy has a most profound impact on the woman because of the major importance of intimacy to female desire and sexual response.

Decreased libido or sexual desire — Decreased libido or sexual desire, termed hypoactive sexual desire disorder (HSDD), has increasingly become one of the more common complaints of women in the menopausal transition and in midlife in general [28] . Sexual desire includes sexual appetite, drive, and fantasy. While sexual arousal leading to orgasm is predominantly a physiological event dependent upon neurovascular responses to stimuli within the appropriate hormonal milieu, libido or sexual desire is more psychosocial and behavioral, impacted by a multitude of factors in daily life and relationships.

The desire for sexual intimacy can be diminished in spite of normal levels of testosterone and estrogen. Many factors affect sexual drive and its expression in midlife and should be evaluated when patients present with decreased libido.

A number of instruments exist for the measurement of female sexual function, but only one has been validated for use in evaluation of treatment response (Profile of Female Sexual Function [PFSF]) in women with HSDD in international clinical trials [29] . Of note, androgen deficiency is not one of the criterion for the diagnosis of HSDD. Revised definitions of female sexual disorders have been proposed that reflect the importance of subjective sexual arousal and the concept of a circular sex-response cycle rather than a linear model (Masters and Johnson) [30] . In this model, a woman may access desire only after she becomes aroused by her partner, in which case lack of spontaneous desire is not a sexual dysfunction.

Partner availability — Women tend to live longer than men, resulting in a natural shortage of males ages 50 and older. At the same time, many men seek out younger partners, further affecting the availability of partners for women in midlife and beyond.

Personal well-being — A woman's sense of personal well-being is important to sexual interest and activity. Low perceived levels of physical and emotional satisfaction and a sense of unhappiness correlate with low sexual desire, resistance to arousal, and pain during sex [1] . Women who experience premenopausal physical or emotional problems, particularly disorders of sexual desire, sexual response, and sexual behavior, tend to experience a worsening of these conditions after menopause [16] .

Overall health and socioeconomic circumstances — Analysis of data from the National Health and Social Life Survey of 1749 women and 1410 men indicated that sexual dysfunction is highest in women with poor health, low income, and a history of infrequent sexual interest. Sexual dysfunction is also more common among women and men with poor physical and emotional health [1] .

Other — Other predictors of decreased libido have been described in women in their late reproductive years. In a four-year prospective cohort study of 326 women ages 35 to 47 (27 percent of whom reported a decreased libido), depression, vaginal dryness, and children living at home were associated with an increased risk of low libido [31] . Mean serum testosterone concentrations (measured every eight months in the early follicular phase) were not associated with libido. However, women with the greatest variability in serum testosterone concentrations reported the greatest declines in libido.

In a second report of 341 peri- and postmenopausal women, common menopausal symptoms, including depression, sleep disturbances, and night sweats, were associated with diminished libido [32] .

Medical issues — Chronological midlife may be associated with medical issues that impact sexuality in either the woman or her partner. These problems can diminish the physical ability to perform sexually, such as with coronary artery disease or arthritis (the most prevalent cause of sexual inactivity in the United States), or can affect arousal and orgasm capability as with neurologic disorders such as multiple sclerosis, Parkinson's disease, or sequelae of diabetes [1] . Alcohol and substance abuse may have a disabling affect on performance by altering erectile capability in the male and arousal in the female. Psychiatric or emotional problems can impact sexual function due to the particular disorder or to the treatment.

Medications — Both prescription and over-the-counter medications have the capability to alter desire, arousal, and orgasm. Any medication that alters blood flow (eg, antihypertensives), affects the CNS (eg, psychotropics), or dries the skin or mucous membranes (eg, antihistamines), may disrupt normal sexual function. As previously mentioned, both oral estrogens in HRT and oral asl well as non-oral contraceptives can adversely affect levels of bioavailable androgens. Non-oral estrogens, however, used peri or postmenopausally, do not diminish bioavailable androgens.

One of the major classes of medications that impacts sexuality is the selective serotonin reuptake inhibitors (SSRIs), frequently used to treat depression in the perimenopausal woman. (See "Antidepressant medication in adults: SSRIs and SNRIs"). The risk/benefit ratio with use of these agents is based on individual need and response. When depression is severe, SSRI's may allow for increase in sexual activity by treating the underlying process. However, in many patients, therapy can diminish sexual desire and alter or eliminate arousal and orgasm. Changing to a different antidepressant may help; the addition of bupropion to ongoing therapy also has been shown to improve sexual function [33] . (See "Sexual dysfunction associated with selective serotonin reuptake inhibitor (SSRI) antidepressants").

Surgery — Surgery related to cancers of the breast or female genital tract can have a profound effect on sexuality in midlife, as can prostate surgery in men. This occurs as a result of the extensive surgery affecting body image and function, as well as the psychological sequelae of the cancer diagnosis and prognosis on patient and partner. Many of these malignancies preclude the use of hormonal therapies, leading to even further problems involving genital function. Referral for counseling is critical in these patients.

Contrary to public perception, sexual function often improves with hysterectomy. Seriousness of pathology along with level of annoyance of bleeding, pain, or pressure preoperatively, affect satisfaction with sexual activity postoperatively. A two year prospective study assessed measures of sexual functioning in over 1000 women prior to hysterectomy and at 6, 12, 18, and 24 months, after the procedure [34] . The percentage of women who engaged in sexual relations increased from approximately 71 percent before hysterectomy to 77 percent at 12 and 24 months after hysterectomy; the rate of frequent dyspareunia dropped from 19 to 4 percent; the rate of experiencing orgasms increased from 92 to 95 percent; and libido increased. Overall, the frequency of sexual activity increased and problems with sexual functioning decreased postoperatively.

There remain, however, women who note a decrease or total absence of orgasm after hysterectomy. Preoperative counseling can help to prepare and assist the patient and partner by reviewing the risks of surgery, as well as the risks of not having the surgery, and potential sexual changes, better or worse, that might follow. Preservation of the ovaries and cervix, if not contraindicated and surgically possible, may help to avoid major changes in sexual response. (See "Abdominal hysterectomy", section on Outcome).

DIAGNOSIS OF SEXUAL DYSFUNCTION — The diagnosis of sexual dysfunction should begin with use of the non-threatening question, "Are you sexually active?" If the answer is affirmative, the second question can be, "Do you have any questions, problems, or concerns about your sexual activity that you would like to discuss?" If, instead, the patient indicates that she is not sexually active, the next and most important question should be, "Does that bother you or your partner?"

There are two common reasons that these questions are not asked. First, because the clinician may feel uncomfortable with the questions or with his or her level of knowledge of the subject and, second, the amount of time needed for discussion once the patient senses sincere interest and feels comfortable beginning a dialogue with the provider. After initiating the discussion, a separate consultation can be scheduled at a later date so that more uninterrupted time can be spent, and also to allow the patient to gather all her thoughts on the topic she now knows is open for discussion. Presence of the partner may also be useful later, once the patient has covered her own concerns. (See "The sexual history and approach to the patient with sexual dysfunction").

A teaching session should occur during the second consultation, in which the clinician describes normal sexual response as well as the physiological changes in sexuality that are common in midlife. Frequently little or no therapy is needed once patients realize so many of these changes are a normal part of the aging process and learn how to cope with them effectively.

The point at which the physiologic changes of aging become sexual dysfunction is best defined within the context of each individual relationship, based on the effect these changes have on the couple. The need for referral to a specialized counselor, therapist, or sexologist, should be made when more detailed consultation is necessary or when the clinician is unable to provide the service.

A detailed gynecologic examination is an important component of the evaluation. Careful assessment of the vulva, clitoris, introitus, and vagina, for atrophic changes, loss of elasticity, inflammation, scarring, infection, or genital prolapse, is paramount. Any tenderness to palpation, superficial or deep, must be evaluated. The pelvic structures, including the bladder, should be evaluated for pathology that might interfere with successful sexual activity, such as masses, endometriosis, or urinary incontinence. Routine breast and cervical cancer screening should be updated.

Laboratory testing is guided by the history and physical examination. No specific tests are universally recommended in all women. Assessment of the serum free and total testosterone concentrations are often done in women considering androgen therapy. However, many currently available methods for measurement of total and free testosterone lack the sensitivity and accuracy necessary for determining androgen deficiency in women [35] .

It is also important to note that the type and dose of androgen replacement therapy for women has not been well established. (See "Androgen production and therapy in women").

INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients. (See "Patient information: Sexual problems in women"). We encourage you to print or e-mail this topic review, or to refer patients to our public web site, www.uptodate.com/patients, which includes this and other topics.