man looking out the window at a giant COVID-19 virus

man looking out the window at a giant COVID-19 virus

The World’s most significant recent public health crisis is the COVID-19 pandemic. The pandemic resulted in an estimated 90 million COVID-19 cases, and more than a million COVID deaths in the US. New highly transmissible coronavirus variants continue to emerge, with Omicron subvariants BA.5 and BA.4 being the dominant strains. These strains can evade older home tests and prior immunization, luckily causing mostly mild disease with few hospitalizations in vaccinated and boosted healthy individuals. 

Unfortunately, about 10% of women and men, will suffer non-infectious “Long-COVID”, an unwanted aftermath of their COVID-19 infection. Long-COVID refers to more than two hundred different signs and symptoms, and fifty associated conditions. Some Long-COVID symptoms are the direct effects of the virus, while others seem unrelated with no apparent causal link. Long-Covid is a severe enough public health problem that The Federal Government recently established a Long-COVID office within the Department of Health and Human Services (HHS) to tackle the crisis.

The five most common symptoms of Long-COVID in order of prevalence are: 1) anosmia (loss of the ability to smell), 2) hair loss, 3) sneezing, 4) ejaculation difficulty (men), and 5) reduced libido (men and women). Two different sexual problems…that really got my attention. 

As I thought about this further, it seemed to make sense, until it didn’t. At first, I thought: no one who is really fatigued or chronically ill (two known symptoms of Long COVID) would likely be interested in sex, so loss of sexual desire seemed consistent. But new-onset difficulty with ejaculation (orgasm) seemed weird. Clearly, ejaculatory disfunction is well known in men, but recent onset as one of the most common symptoms of long-COVID, well that screamed vascular AND neurologic dysfunction from this viral disease. Having just published a paper suggesting that the same dysfunctions in men also affect women, and in both men and women, these disorders are a harbinger of underlying cardiovascular disease, you can understand my concerns. 

So, if you or a woman you know, is suffering from a sexual dysfunction (lost desire, poor lubrication, sexual pain, weak or absent orgasm, etc.), whether related to Long-COVID or not, we are here to help. Call for an in person or virtual appointment today. (202-293-1000)

 

Subramanian, A., Nirantharakumar, K., Hughes, S. et al. Symptoms and risk factors for long COVID in non-hospitalized adults. Nat Med (2022). https://doi.org/10.1038/s41591-022-01909-w

Levine RL. Addressing the Long-term Effects of COVID-19. JAMA. Published online August 03, 2022. doi:10.1001/jama.2022.14089

August 5, 2022. Coronavirus Roundup: HHS is Establishing a New Office Focused on Long COVID

https://www.govexec.com/management/2022/08/

Cipriani S, Simon JA. Sexual Dysfunction as a Harbinger of Cardiovascular Disease in Postmenopausal Women: How Far Are We? J Sex Med. 2022 Jul 19:S1743-6095(22)01489-8. doi: 10.1016/j.jsxm.2022.06.007. Epub ahead of print. PMID: 35869024.

A banana spooning an eggplant with a light pink background.

A banana spooning an eggplant with a light pink background.Is penetration ever painful for you? Whether it’s with fingers, toys, or penises, you’re not alone: An estimated 50% of menopausal women with sexually active partners experience pain during vaginal penetration. And that’s just women in menopause. (Note: Here’s a Partner’s Guide to Menopause)

Dyspareunia is a very general term for pain with penetration during intimate sexual contact. Deep pelvic pain, or deep dyspareunia, usually emerges because of other existing disorders hidden in the pelvis—either adjacent to or touching the upper portions of the vagina.

There are a few different possible causes for this deep pelvic pain (or deep dyspareunia), which include:

  • fibroid tumors in the uterus
  • cysts in the ovaries
  • tumors on the ovaries
  • endometriosis
  • scarring from pelvic infections or prior surgery

While the disorders that we just listed above are relatively common, the deep pelvic pain that can result from them is not nearly as common. Most people with these disorders won’t have the correlating deep pelvic pain, but if you experience a new onset of deep pain during sex, which can be triggered by a new partner or experience, you should talk with a doctor or other health professional.

More common causes of both superficial and deep pelvic pain include:

  • Vaginal atrophy following menopause (AKA vulvovaginal atrophy, genitourinary syndrome of menopause, or GSM)
  • Vestibulodynia (vulvar vestibulitis)
  • Pelvic floor muscle dysfunction

Regardless of the cause, pain during penetration is not fun, and it certainly isn’t comfortable. To provide additional context, this typically happens when there’s any restriction of movement at the opening of, or at the top of the vagina.

The vagina is meant to slide on its neighboring organs (i.e., ovaries, tubes, uterus, intestines, rectum, etc.). When the top of the vagina (or the vaginal apex) is restricted or bumps up against a tender neighboring organ or disorder, like a fibroid or an ovarian cyst, during penetration, it can cause deep pain.

Other relevant factors include:

  • Depth of penetration
  • Sexual position

Let’s do some quick math—Depending on the length and girth of the fingers, penis, or toy that’s penetrating you + the length of your vaginal canal = deep pelvic pain may only occur intermittently, for example, only with sex in particular positions, with a particular partner, or with a particular partner in a particular position.

If you are experiencing deep pelvic pain from penetration, regular or otherwise, a diagnosis can usually be determined with a vaginal or abdominal ultrasound (sonogram). Vaginal ultrasounds are preferred since the probe that’s inserted into the vagina can be used to reproduce or simulate the pain that’s felt during penetrative sex—quickly demonstrating exactly where and how the pain is initiated.

If endometriosis is the cause, there are a couple of things to note:

  1. Endometriosis often goes undiagnosed for many years.
  2. Endometriosis can be difficult to diagnose.
  3. A complete evaluation may require a careful rectal exam; this is because endometriosis causing deep penetrative pain during sex may best be felt on a rectal exam.

Typically, treatment of deep pelvic pain is focused on any underlying disorder. It may be surgical (i.e., fibroids, ovarian cysts, endometriosis, or scarring) or responsive to medication (i.e., fibroids, ovarian cysts, endometriosis).

When surgery isn’t preferred or necessary, there are medical therapies to shrink the size of fibroid tumors and reduce the heavy menstrual bleeding associated with them, and other medical treatments have been developed to shrink endometriosis, and reduce the associated pain, including deep sexual pain. These treatments include oral contraceptives, and both the injectable GnRH agonists (i.e., Leuprolide, Triptorelin) and the oral GnRH antagonists (i.e., Elagolix, Relugolix, Linzagolix). These GnRH modulating drugs are used to temporarily create a menopausal hormone milieu, because menopause typically shrinks these pathologies and clears the way for unrestricted movement of the upper vagina.

Typically, medical approaches are favored initially, and surgery reserved as a last resort. However, exceptions to this rule are common. For example, if fibroid tumors are causing infertility or recurrent miscarriages and there is related deep pelvic pain during penetration, surgery may be the only choice that can address all three problems: the infertility, pregnancy loss, and deep pelvic pain.

Additional remedies include pelvic floor physical therapy, including treatments like trigger point injections and pelvic floor “Botox,” which can be helpful in reducing the reactive pain, and can help your pelvic muscles to unlearn the guarding they do related to these disorders.

A very simple and non-invasive at-home remedy for pain with deep penetration is reducing the depth of penetration. Testing various positions that shorten penetration can help to achieve this, as can the OhNut, a wearable device that allows you to customize the penetration depth of penises and/or toys.

What else have you found to help? Comment with any thoughts, questions, or concerns. Or you can always give us a call to setup a consult.

 

References:

Yong PJ. Deep Dyspareunia in Endometriosis: A Proposed Framework Based on Pain Mechanisms and Genito-Pelvic Pain Penetration Disorder. Sex Med Rev. 2017 Oct;5(4):495-507. doi: 10.1016/j.sxmr.2017.06.005. Epub 2017 Aug 1. PMID: 28778699.

Donnez J, Stratopoulou CA, Dolmans MM. Uterine Adenomyosis: From Disease Pathogenesis to a New Medical Approach Using GnRH Antagonists. Int J Environ Res Public Health. 2021 Sep 22;18(19):9941. doi: 10.3390/ijerph18199941. PMID: 34639243; PMCID: PMC8508387.

Orr N, Wahl K, Joannou A, Hartmann D, Valle L, Yong P; International Society for the Study of Women’s Sexual Health’s (ISSWSH) Special Interest Group on Sexual Pain. Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev. 2020 Jan;8(1):3-17. doi: 10.1016/j.sxmr.2018.12.007. Epub 2019 Mar 28. PMID: 30928249.

Eid S, Loukas M, Tubbs RS. Clinical anatomy of pelvic pain in women: A Gynecological Perspective. Clin Anat. 2019 Jan;32(1):151-155. doi: 10.1002/ca.23270. Epub 2018 Dec 3. PMID: 30390350.

Image of couple riding in an orange Thunderbird convertible

Hypoactive sexual desire disorder (HSDD), which affects about 10% of women in the United States, is defined as the persistent or recurrent deficiency or absence of sexual desire accompanied by personal distress. There are treatments to help you deal with these symptoms, and it is possible to regain sexual desire and libido.

Image of couple riding in an orange Thunderbird convertible

Although HSDD impacts patient quality of life and interpersonal relationships, the disorder often goes unaddressed or untreated. Recent studies of the burden of illness in women with HSDD, especially pre-menopausal women, are limited.

I co-authored an article in the Journal of Women’s Health assessing the burdens that women face when they have HSDD, or lack of libido and desire. You can read the highlights of the study here:

Materials and Methods: A 45-minute web-based survey was designed to investigate the experience of women seeking treatment for HSDD and the impact of this disorder on several psycho-social aspects of women’s lives.

Women were recruited from an online panel of patients who participated in research studies for compensation. Validated questionnaires assessed sexual function and health-related quality of life, including mental and physical component scores.

Results: A total of 530 women, aged 18+ years, diagnosed with HSDD were included in the study. Pre-menopausal women indicated greater overall HSDD symptom burden compared with post-menopausal women. Patients with HSDD reported lower quality of life scores compared with the general population.

A multivariable regression analysis demonstrated that psycho-social factors influencing the burden of HSDD, including interference with relationships with their partner, mental and emotional well-being, and household and personal activities, negatively affected quality of life mental component scores.

Conclusions: In the current survey, HSDD had a significant negative impact on sexual and mental health, social relationships, and general well-being. The impact was greater among pre-menopausal women compared with post-menopausal women.

Read the full Journal of Women’s Health article, co-authored by Dr. Simon, here.

And if you’d like to discuss treatments to help you deal with HSDD symptoms, including an increase in sexual desire and libido, you can fill out an appointment request form.

Three women on the beach pier; they're leaning together and talking.

Three women on the beach pier; they're leaning together and talking.

There is so much misconception about hormone replacement therapy (HRT) and menopause. I was recently featured on #justASK, a healthcare podcast dedicated to providing evidenced-based information from a team of sexual health experts. #justASK is hosted by Tara Thompson and Heather Quaile.

It was great to break down some of those misconceptions, and dive into the importance of hormone replacement therapy, solutions to frustrating peri-menopause and menopause symptoms, and myths and taboos surrounding these topics.

Women’s health has been under-researched and under-funded for way too long, and that’s a large reason why there is such a lack of comprehensive information.

A few notes you’ll hear me address in the podcast:

  • One of the biggest problems around lack of access to hormones is that there’s an entire generation of practitioners (physicians, nurses, PAs) who heard hormones were risky and were never trained to administer HRT. The medical community is finally coming around to addressing this misinformation and are finally being trained to replace hormones safely.
  • Hormones fluctuate throughout our lives. Fun fact: The only time in a woman’s life when her hormones are the same level as they are after menopause is when she’s breastfeeding. In the context of breastfeeding, those low hormone levels are a good thing, whereas it can be incredibly harmful during menopause.
  •  Hormones prevent bone loss, and ultimately prevent fractures. Hormone therapy, and non-hormonal medications, can all help strengthen bones and prevent osteoporosis.
  • There tends to be an increase in sex drive around the middle of a menstrual cycle. These are the same hormones that can stimulate libido during menopause, and we can apply them so that they stimulate the brain and can help increase interest in sex beyond reproductive years.

Listen to the full podcast below, and feel free to comment with any questions. You can also make an appointment to figure out if hormones are right for your body.

Photograph of older couple cuddling in bed

Photograph of older couple cuddling in bed

How many times have you shuddered the moment someone mentions your parents or your grandparents having sex?

As a doctor specializing in sexual health, I’ve seen that inevitable gasp time and time again.  The mere mention of our parents, or worse, our grandparents, “rolling around in the hay” leads to grimaces followed by an expression of “really!?” “yuck” or “gross”. This reaction is natural in our often times sex-phobic, even puritanical culture, but these attitudes set too many people up for failure. A fear of aging and an inability to associate sex with aging undermines the many health benefits gained simply by continuing sexual activity through our 70s and beyond. These health benefits are often overlooked by healthcare practitioners as well. A recent NYT Magazine article, “The Joys (and Challenges) of Sex After 70” attempts to normalize sex in older adults.

Here are 5 important points we wanted to highlight for you:

  1. People frequently have sex up until the end of their life.
  2. Everything about sex after 70 usually takes longer, is slower, but generally still works.
  3. Sex is so much more than penetration. Too often we are taught that sex is only penis-in-vagina (PIV), but that’s incredibly limited. If PIV is your definition of sex, that may need to change as you age.
  4.  Communication is one of the most critical components when it comes to good sex, especially since pleasure and desire change as we age.
  5. There are effective medications and non-medical treatments for sexual problems related to aging, regardless of your sex or gender.

As men age there are plenty of medications approved to increase their sexual health—we’re sure you’ve heard of Viagra or Cialis? And there are many other brands designed to do the same thing, plus no fewer than 25 different testosterone formulations for men.

For women, on the other hand, there are just two FDA-approved options: Addyi (Flibanserin), and Vyleesi (Bremelanotide). And while they both work for women well beyond menopause, as of right now,  neither of the two have been approved by the FDA for postmenopausal women, simply because FDA requirements have not been satisfied. And while pharmacologic treatments are not for everyone, both Addyi and Vyleesi should work for women of any age. Data on Addyi’s benefits in menopausal women was published almost 8 years ago, and is approved by Health Canada for use in women up to age 60. Many of our patients at IntimMedicine Specialists find it to be beneficial regardless of their age.

It is extremely frustrating that there are currently no testosterone products approved for women’s sexual health in the US. This past year, off label use of male testosterone products and compounded testosterone treatments for women had become so prevalent that the International Society for the Study of Women’s Sexual Health (ISSWSH) developed a manifesto for healthcare practitioners.  This “how to” is a classic citation of safe and effective use of “male” testosterone products in women.

As emphasized in the NYT Magazine article,  people often face many physical challenges in the bedroom as we age. It is normal for bodies to change, and for the ways we access pleasure to shift. For example:

  • Vaginal dryness is a normal shift in the body.
  • Erections are often not as naturally hard, as reliable,  or as long-lasting.
  • Physical movements and positions may become more limited, but that doesn’t mean that adaptive positions can’t be just as pleasurable.

While pharmacologic options can be really helpful, they aren’t for everyone, and there are other resources that can help normalize and troubleshoot sexuality through the aging process. You should check out the following:

Next time you shudder at the mention of your parents or grandparents still enjoying sex, consider the age you want to stop having sex – our guess is that you don’t ever want that. So, if you (or that parent or grandparent) need a little help, let us help identify the problem and offer some solutions for your body (or theirs). We can help, just reach out.

a doctor hiking up a "mountain" which leads to a clitoris, labia, urethra, and vaginal opening - Illustration by Lori Malépart-Traversy

a doctor hiking up a "mountain" which leads to a clitoris, labia, urethra, and vaginal opening - Illustration by Lori Malépart-TraversyIllustration by Lori Malépart-Traversy

Women have the only organ in the human body exclusively dedicated to pleasure: the clitoris! This humorous, brief documentary gives an illustrated and educational history of the clitoris; it also reveals something very telling: the clitoris has long been ignored and hidden—by society, medical professionals, and educators. For many women, their early sexual partners provided them with their only sex education, with little knowledge or accuracy and much fumbling. Clitoral pleasure was discovered almost by accident. (More on that in The Clitoral Truth…)

Clitorologist?

Think about it. Have you ever been taught how to look at your clitoris? Has a doctor ever asked you about your clitoris or examined it? Medical professionals are not routinely taught the anatomy of the clitoris (Even some of the most famous textbooks don’t mention it!), and it is not considered part of the routine female pelvic exam. This poses a big problem: If doctors don’t know what a normal clitoris looks like, even how to properly examine it, how will they know what to do when questions or problems come up? What kind of doctor do you see if you have a problem with your clitoris? (Pssst: Unfortunately, there is no such thing as a clitorologist!)

Clitoral Pain

Pain in the clitoris (called “clitorodynia”) is considered a localized form of vulvodynia (vulvar pain) and is thought to occur in 5% of women who complain of painful intercourse. Given the lack of comprehensive research, it could be more.

Pain can be due to adhesions or scarring of the clitoris where the clitoral hood (aka the prepuce) gets stuck to the glans of the clitoris. This can lead to trapping and buildup of oils and dead skin cells which cause underlying irritation and infection.

Women describe the pain as burning, stinging, or sharp—some have likened it to the sensation of having a grain of sand in your eye. It can affect the whole pelvis and just feel like “pain down there,” or it can be very focal with pain at a small, targeted location.

Clitorodynia can make sexual experiences difficult, if not impossible. As well as potentially leading to sexual dysfunction, it can also make everyday life excruciating because the “pain down there” can be present all the time, even without sexual activity.

Help Exists

While there might not be a clitorologist, doctors trained in sexual medicine can diagnose and treat clitoral problems, we promise! With a specialized physical exam and several diagnostic tests, the underlying cause for your pain can be found. Luckily, successful medical and surgical treatment options are available. For example, clitoral adhesions can be removed in a minimally invasive, in-office, procedure using local anesthetics. In a high percentage of women with painful clitoral adhesions, such a procedure is curative.

Don’t Suffer

Sexual health is an important part of your general health. You deserve a pleasurable, pain-free sexual experience and life. If you have discomfort or pain, we are here to provide solutions. If any of the symptoms we mentioned sound familiar, our providers are trained to help. Let’s work together to improve your sexual health.

 

Pills sitting on pink counter surrounded by caution tape.

Actress Gwyneth Paltrow, founder of the wellness and lifestyle brand goop®, recently launched a new “sexual health supplement” marketed under the name DTF. According to advertisements, this product is intended to “support women’s sexual desire, arousal, and mood.” We believe this claim to be an example of a misleading campaign marketed to consumers that is unsupported by scientific evidence. 

Pills sitting on pink counter surrounded by caution tape.

As a member of the International Society for the Study of Women’s Sexual Health (ISSWSH), which is comprised of leading academics, researchers, clinicians, and educators in female sexuality, IntimMedicine supports and agrees with ISSWSH’s concern around frequent, unsubstantiated claims made about many over-the-counter (OTC) products marketed to women for sexual enhancement. goop®’s latest product, DTF, is one of these products that concerns us.

While we applaud the attempt to investigate herbal ingredients which are in use by consumers, the statement by goop® that the ingredients in DTF are “clinically studied to support female sexual health and function” is egregiously misleading. Here’s why:

According to their own website, DTF “hasn’t been evaluated by the FDA” and “is not intended to diagnose, treat, cure, or prevent.”

According to the goop® website, DTF contains three main ingredients: Libifem®, a fenugreek seed extract, shatavari root extract, and saffron stigma extract. While one small study published in Phytotherapy Research in 2017 appears to support some potential benefit of one ingredient in DTF specifically to women with the vasomotor symptoms of “hot flushes, night sweats and other associated symptoms,” which are typically associated with the menopause, we were unable to find any data to demonstrate safety, efficacy or tolerability of the combination of active ingredients in DTF for women of any age to whom goop® makes these claims on female desire, arousal and mood.

As experts in the sexual health field committed to the highest standards of scientific research and medical care of women’s sexual health, we are not only concerned about the lack of proven benefit from such supplements, but also the potential harm to individuals who choose to take these products.

43% of U.S. women report some type of sexual problem for a multitude of bio-psycho-social reasons.  Lumping all sexual problems together is unlikely to lead to an appropriate treatment and improvement, which is why qualified healthcare providers, like IntimMedicine staff, diagnose a sexual problem before recommending a relevant treatment.

Hypoactive sexual desire disorder (HSDD) is a diagnosable and treatable medical condition experienced by upwards of 10% of U.S. women.  In 2018, ISSWSH published an HSDD process-of-care to assist healthcare providers in the diagnosis and management of pre- and post-menopausal women with HSDD. This open access article is freely available online.

In order to properly address low libido and HSDD, women should avoid self-treating with OTC products, like DTF, without the guidance of a licensed healthcare provider. 

There are two FDA-approved treatment options (flibanserin and bremelanotide) available in the U.S. for pre-menopausal women with acquired, generalized HSDD with extensive safety and efficacy data. Flibanserin is also approved in Canada for pre-menopausal women and naturally post-menopausal women ≤60 years of age.

As a practice that is focused on the advancement of women’s sexual health, it is our mission, alongside ISSWSH, to promote the dissemination of evidence-based information. Women should know that the medical community has treatments approved by regulatory agencies and processes of care to guide their healthcare providers in the delivery of evidence-based medicine.

References

  1. O’Malley, K. Gwyneth Gwyneth Paltrow’s Goop just launched a supplement to boost female libido.
  2. Reilly, K. Do Gwyneth Paltrow’s new ‘DTF’ libido supplements really work? Doctors weigh in.
  3. Sydora BC, Fast H, Campbell S, Yuksel N, Lewis JE, Ross S. Use of the Menopause-Specific Quality of Life (MENQOL) questionnaire in research and clinical practice: a comprehensive scoping review. Menopause 2016;23:1038-1051.
  4. Steels E, Steele ML, Harold M, Coulson S. Efficacy of a proprietary Trigonella foenum‐graecum L. de‐husked seed extract in reducing menopausal symptoms in otherwise healthy women: a double‐blind, randomized, placebo‐controlled study. Phytotherapy Research 2017;31:1316-1322.
  5. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537-544.
  6. Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstetrics & Gynecology. 2008;112:970-978.
  7. Brotto LA. The DSM diagnostic criteria for hypoactive sexual desire disorder in women. Archives of Sexual Behavior 2010;39:221-239.
  8. Clayton AH, Goldstein I, Kim NN, Althof SE, Faubion SS, Faught BM, Parish SJ, Simon JA, Vignozzi L, Christiansen K, Davis SR. The International Society for the Study of Women’s Sexual Health process of care for management of hypoactive sexual desire disorder in women. Mayo Clinic Proceedings 2018;93:467-487.

Adapted from ISSWSH’s official statement.

Back in April 2020, an article in the Journal of Women’s Health prompted me to think about the differences between men and women’s life and death responses to COVID-19. That article illustrated what we’ve heard in the news over, and over, and over again. Namely, that men tend to fare much worse than women if hospitalized with coronavirus (sars-cov-2) related diseases. Since then, we have come to know that, in this context, men are clearly the weaker sex. But even more data has emerged around the why, demonstrating that reproductive hormones are, in fact, an important part of women’s resistance to severe COVID-19 disease and can possibly even prevent death.

For most postmenopausal women, whether currently using menopausal hormone therapy or not, hormone therapy in early menopause (i.e., started in the first 10 years since their last menstrual period) is of significant benefit. Menopause specialists strive to determine the risk-benefit ratio for any woman before starting hormone therapy. It’s now clear that early menopausal women without absolute contraindications should seriously consider utilizing hormone therapy for disease prevention (i.e., heart attack and osteoporosis) and now to help prevent severe COVID-19 infections and even death.

Prevention of severe cases of COVID-19 may not be a good enough single reason to start hormone therapy, particularly as vaccinations are becoming more readily available. However, recent evidence documents that in women who start on hormone therapy for its basic, well-established benefits (treatment of hot flashes and night sweats, vaginal dryness and pain with sexual activity, prevention of osteoporosis etc. etc. etc.), may also benefit from the protection it provides against COVID-19 disease.

So, if you or someone you know wants a consultation to evaluate the benefit/risk ratio of postmenopausal hormone therapy, factoring in the potential benefits against severe COVID-19 infections, make an appointment to talk with us about all the options. All staff at IntimMedicine Specialists are fully vaccinated and we maintain careful CDC precautions, though we are also available for virtual visits. Menopausal hormone therapy may not only be good for you, it may save your life!

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