research. While the presence of penile SCC in two men with history of Prince Albert piercing may lead to excitement about a possible correlation between penile carcinoma and piercing, further evidence is necessary. Other bodily piercings are much more pervasive in the United States. If chronic manipulation and inflammation from piercing plays a role in the development of SCC as the authors hypothesize, then there should be a similar association between cancer and piercings on more common piercing sites, such as the ear or nose. In fact, there are no documented reports of piercings elsewhere on the body correlating with squamous cell cancer. The few cases of piercing-associated cancer that exist in the lit- erature report findings of basal cell carcinoma with the ear and nose [3–5]. Co-infection with HCV and HIV was another hypothesis introduced as a risk factor for development of penile cancer in the Prince Albert series. Again there is an absence of data linking these conditions to the development of piercing-related SCC. The authors are to be commended for presenting an intriguing hypothesis relating genital piercings with carcinogenesis, however, if an association did exist, a similar correlation with other bodily piercings would be expected. Further population based investiga- tions are necessary to investigate the reports of Edlin et al. For example, a national piercings registry could help determine if the rates of cancers are different than those expected for the general population. Until such evidence exists, concern for developing penile cancer should not preclude men from Prince Albert piercings. Catherine R. Harris, MD University of California San Francisco—Department of Urology San Francisco, California, USA Michael L. Eisenberg, MD Baylor College of Medicine—Department of Urology Male Reproductive Medicine and Surgery Houston, Texas, USA Conflict of Interest: None. References 1 Edlin RS, Aaronson DS, Wu AK, Blaschko SD, Yang G, Erickson BA. Squamous cell carcinoma at the site of a prince albert’s piercing. J Sex Med 2010;7:2280–3. 2 Hernandez BY, Barnholtz-Sloan J, German RR, Giuliano A, Goodman MT, King JB, Negoita S, Villalon-Gomez JM. Burden of invasive squamous cell carcinoma of the penis in the United States, 1998–2003. Cancer 2008;113:2883–91. 3 Khundkar R, Wilson PA. Basal cell carcinoma at the site of a nasal piercing. J Plast Reconstr Aesthet Surg 2009;62:557–8. 4 Ng MF, Clarkson JH, Hogg FJ. Basal cell carcinoma arising from nasal piercing: Cause or coincidence. J Plast Reconstr Aesthet Surg 2010;63:e153–4. 5 Brouard M, Kaya G, Vecchietti G, Chavaz P, Harms M. Basal cell carcinoma of the earlobe after auricular acupuncture. Dermatology 2002;204:142–4. Comment for Summary of the Recommendations of Sexual Dysfunction in Women: R Basson, M Wierman, J Van Lankveld, L Brotto. J Sex Med 2010;7:314–26 DOI: 10.1111/j.1743-6109.2010.01889.x We would like to commend the authors for an excellent review and summary of female sexual dysfunction in women. However, we feel compelled to point out that the chart on page 325 is incomplete. Under the heading of vulvar vaginal atrophic changes, local estro- gen is discussed and described as formulated as a vaginal ring or tablet. The omission of local vaginal creams is unfortunate for many reasons. Creams, both Premarin ® (New York, NY, USA) and Estrace cream (Warner Chicott; Rockaway, NJ, USA), have been the primary form of local estrogen treatment for vulvar vaginal atrophic change for almost a century. Further, in November 2009, Premarin vaginal cream became the first and only Food and Drug Administration (FDA)-approved medication for the treatment of moderate to severe dyspareunia. This landmark approval, the first FDA-approved treatment for a female sexual disorder, was not cited in major headlines or publicity. However, for those of us who provide female sexual health care, the approval is remarkable. Women’s sexual health care and pharmacologic treatments to address female sexual disorders are finally gaining financial support in the form of research dollars. It is not so clear that women’s sexual health, particularly for postmenopausal women, is faring as well with regard to social support. Dyspareunia, dryness, and atrophy all have the potential for signficantly impairing sexual function and overall sexual satisfaction. A review of the results from the recent REVEAL (REvealing Vaginal Effects At mid-Life) Survey confirms the difficulties with societal support and the impact of vaginal atrophy on sexual health. The REVEAL Survey is available for public review at http://www.revealsurvey.com and a formalized manuscript is in the process of review. The data were presented in abstract form at the recent ISSWSH annual meeting [1]. 1. The REVEAL Survey of 1,006 postmenopausal women not on hormone therapy found that roughly half of all postmenopausal women surveyed (47%) strongly or somewhat agreed that it is still taboo in society to acknowledge they are experiencing vulvar and vaginal dryness or painful intercourse. 2. Less than half of postmenopausal women surveyed who expe- rienced dyspareunia (44%) have initiated a conversation with their health care professionals about this condition. 3. Eighty percent of postmenopausal women surveyed who expe- rienced pain during sex strongly or somewhat agreed that they have learned to live with the vulvar and vaginal symptoms of menopause such as dryness as a normal part of getting older. The introital area and vulvar region are often the culprits in pain and sexual discomfort that typically are not able to be treated with the pill or ring, which only reach the intravaginal areas. In a recent case series, minimally absorbed local estrogen placed on the clito- ral tissue improved arousal and orgasmic response in postmeno- pausal women [2]. The data for minimally absorbed local vaginal estrogens, regardless of preparation type, support safety and efficacy [3]. In addition, women on low-dose systemic hormone therapy will often still complain of vulvar distress and its affects on personal comfort 332 Letters to the Editor J Sex Med 2011;8:331–333