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Much has been made recently about the medicalisation of women’s sexual desire. Does low desire constitute a problem and, if it does for that individual, what forms of treatment are available? The first step must be for the woman to decide for herself whether decreased desire poses a difficulty for her personally or in her intimate relationship or, indeed, her motivation to form or sustain such relations. With more research being published, it is clear that many women value their sexuality well past the menopause, and when circumstances curtail their enjoyment, they are prepared to seek help. The causes of less than optimal function can be described as physiological due to ageing or psychological due to situations such as work, family or medical problems affecting the woman or her partner. Certainly, medications such as serotonin reuptake inhibitors, beta-blockers or hormone replacement therapy (HRT) need to be enquired about, but, to date, most recommendations are towards psychosocial or couple therapy rather than pharmacological agents. Heiman from the Kinsey Institute believes that insufficient funding has been forthcoming to research the problem (NEJM 2008;359:2047–9) and welcomes the work by Davis et al. (NEJM 2008;359:2005–17) as ‘all good news’. A large cohort of postmenopausal women in five countries participated in a randomised trial of placebo or two doses of testosterone delivered transdermally to establish whether their libido, arousal and number of satisfying sexual episodes improved over 6 months. The active patches were either 300 or 150 micrograms per day of testosterone applied twice weekly to the abdomen (Intrinsa®; Proctor & Gamble Pharmaceuticals). No woman was on HRT. At the end of the trial, those allocated to the 300 micrograms patches had significant improvements from baseline of desire, arousal, orgasm and the number of pleasurable sexual episodes per month. There was a clear placebo effect, but the efficacy of the higher dose of the active medication was still significant. Whether this ‘near doubling to two’ of episodes indicates a successful intervention or not must again be up to women with depressed desire to decide. Adverse effects were similar in the three groups with the only difference being a 20% increase in hair growth in the 300 micrograms group compared with 10% in the placebo group. A concern was that 4 women of the 800 participants developed breast cancer over the year’s surveillance 2 after 4 months of treatment and 1 whose disease probably predated the trial—and all received the active patches. Although possibly due to chance, a causal association must be considered. The authors suggest that these improvements are clinically valuable, offering relief for women with hypoactive sexual desire disorder and low estrogens, adding to the list of pharmacological agents available to older people to assist them enjoying their sex lives. This is the right time of year to be thinking about holidays. Take some leave, plan a complete break or resolve to work shorter hours. Why? Because doctors suffer from burn-out and are at risk of resorting to alcohol or drugs more commonly than other professionals, presumably to escape from caring too much about others. Generally, physicians do not make good patients. They seldom take the advice they liberally dispense about lifestyle, time off, stress prophylaxis, screening or seeking help. Maybe the Scandinavians can offer two examples of the correct way to do things. KMB experienced a depressive episode some 10 years ago but felt that he could not disclose his affliction because he feared that he might be ridiculed if his ‘mental illness’ became common knowledge. He considered resigning his job but did talk to a colleague who persuaded him to take a break, seek help and be upfront about his problem. He did, was successfully treated and returned to work a month later. His attitude won him many plaudits—especially as he was Prime Minister of Norway at the time (Owen BMJ 2008;337:1173). The second example is closer to home—about preventing stress in doctors. Again in Norway, there are programmes aimed at promoting mental health and strengthening professional awareness, which medical practitioners can volunteer to attend or have recommended to them. The programmes offer counselling to counter emotional exhaustion, stress and distress. They last 1 day for individuals or 1 week for group sessions and aim at motivating reflection and the acknowledgement of personal or situational needs (Isaksson Ro et al. BMJ;337:1146–9). Both personal and group participation resulted in less emotional exhaustion and less sick leave being taken—in other words, healthier doctors. From the other side of the Atlantic, a large study of American physicians shows falling numbers of trainees willing to work in primary care—a drop from 50% a decade ago to 25% currently. This reduction in general practitioners threatens the backbone of the profession. The reasons for less attraction to GP practice are similar to those given for dwindling recruitment to obstetrics and gynaecology—namely long and antisocial hours, dual loyalties to office and hospital patients and pressurised daily consultations with the administrative turbulence of ‘their rooms’ high on the agenda. Okie (NEJM 2008;359:2305–9) suggests the following innovations to stay ahead of burn-out: A huge part of job satisfaction is having some control over your working environment. Receptionists and managers must stick to their boss’s agreed schedules without squeezing in extras. Extras can be diverted to telephone visits—calls by the doctor to patients carried out during ring-fenced time, so the person knows when to expect a call from the doctor. Email encounters that have increased by 40% in the last year. Patient’s queries are dealt with by dictated responses—again during time allocated for the purpose. Electronic medical records. Doctors have been slow to embrace the electronic capturing and storage of results and records. Administrative staff can assemble data for on-screen or hard copy availability for the consultation—and prescription relaying. The aim was to work smarter not harder to ensure more satisfying patient contact time. Doctors who do become addicted to substances rather than work are likely to indulge in the abuse of alcohol (50%), opiates (35%) or stimulants (10%), and it seems about one in ten of us will fall into this category of impairment or dependence during our professional lives. Encouraging to note is the high percentage of doctors who have favourable outcomes from programmes that exist to help them. Reports from Canada and the USA show that the majority of participants (75–80%) successfully complete the courses offered with good long-term follow up (McLellan et al., BMJ 2008;337:1154–6 and Brewster et al., BMJ 2008;337:1156–8). And while on the subject of excess, one of the evils of alcohol is the increasing predisposition to pancreatitis of rising intake. The risk association has been well known, but now Kristiansen et al. have quantified the problem and shown that women are at the same risk as men (Am J Epidemiol 2008;168:932–7). The higher the intake, the greater the risk with hazard ratios approximately as follows—drinks per week first—1–10 = 1.1, 10–20 = 1.2, 20–50 = 2.5 and more than 50 = 3. Excessive beer drinking seemed to be the most risky. Virus researchers have won this year’s Nobel Prize for medicine. It was shared between two French scientists who discovered HIV and a German pathologist who proved the link between the human papillomavirus (HPV) and cervical cancer. The HIV award was controversial as the recipients, Barre-Sinonssi and Montagnier had been embroiled in an acrimonious dispute with the American Gallo about who had actually identified the virus. The BMJ report (Watts, BMJ 2008;337:a2023–833) sides with the French saying the accolade was well deserved while acknowledging the part played by the US contributors. The purse of 1 million Euros will be split between them and zur Hanson from Germany who diligently pursued HPV as the causative agent of cervical cancer, while others had put their money on other viruses like Herpes. His meticulous documentation of the subtypes and their recovery from preserved specimens was virological detective work of the highest order without which the vaccines now available would not have been defined and developed. A worthy winner. But then, there are the Ig-Nobel prizes. These are organised by the Annals of Improbable Research at Harvard University and have become quite an institution in themselves and honour work that ‘first makes you laugh and then makes you think’. Many of the awards are handed out by genuine Nobel laureates, and examples of the fine art are as follows: Nutrition: it is difficult to swallow, but an Oxford don and an Italian researcher showed that potato crisps that were accompanied by loud crackling sounds tasted 15% better than those eaten with quieter crackles (J Sensory Studies 2004:19:347–63). Medicine: some electrifying work from Massachusetts Institute of Technology concerned research into painkillers. It involved scientists shocking volunteers with increasingly greater intensity of current. They gave the subjects various analgesics to alleviate the pain without disclosing the nature of the substances they were receiving—but they did tell them the price and the country of origin. There were four substances tested—two American (one cheap and one expensive) and two Chinese, again one cheap and one expensive. They had to rate the analgesic efficacy of each agent. The fact that they were all placebos allowed the effects of price and faith in the products’ of the country of origin to be assessed (Tanne, BMJ 2008;337:838–9 or Waber et al., JAMA 2008;299:1016–17). With true patriotic fervour, these brave souls rated the expensive American placebo best, the cheap American one second, the expensive Chinese placebo third and the cheap Chinese one fourth. Economics: but of far more interest to gynaecologists, is the definitive study on the earnings of lap dancers in the fleshpots of Albuquerque (Miller et al., Evolution & Human Behaviour 2007;28:375–87). In carefully controlled but certainly not blinded circumstances, these intrepid academics looked at what these outstanding ladies earned in takings at various stages of their menstrual cycle. Those on oral contraceptives showed no cyclical patterns, but those with natural cycles got bigger tips around ovulation time. They say that the women felt themselves more attractive then and the men obviously agreed and responded accordingly.

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