Sexual Dysfunction in Women Lauren Pallis PGY-1September 2015

Female Sexual Cycle

A.Desire or libido*B.Arousal - subjective sense of pleasure plus physiologic changes

C.Orgasm - peak and release with rhythmic contractions of perineal/reproductive muscles*

D.Resolution - muscular relaxation and “general sense of well-being”

Epidemiology

- About 40% of women worldwide complain of sexual dysfunction1

- prevalence highest in Southeast Asia, lowest in Northern Europe

- PRESIDE study (2008) - largest US study, surveyed >30,000 women to estimate prevalence of self-reported sexual issues, presence of problems that went along with personal distress

- low desire was most commonly reported (39%) with 10-14% of these women reporting some kind of personal distress in their lives2

Role of Hormones in Sexual Cycle

Estrogen - decreasing levels of estrogen are associated with decline in libido and sexual responsivity - Lower E levels lead to reduction in vulvovaginal lubrication, vasocongestion during arousal; also leads to tissue atrophy, increases likelihood of pain with intercourse

Role of Hormones in Sexual Cycle

Androgens - likely play a role in female sexual function

- Conflicting evidence- Data out of Europe supporting use of testosterone in treatment of sexual dysfunction in surgically menopausal women

Role of Neurotransmitters in Sexual Cycle

Dopaminergic system - increases sexual desire and excitement

Norepinephrine system - affects arousal and orgasm

Imbalance between these two systems can cause an inability to begin sexual response cycle

Serotoninergic system - if overactive, can decreased desire and orgasm

Risk Factors/Comorbidities

Gynecologic- Pelvic floor dysfunction - 26-47% of women with

this report low sexual desire3

- common issue is urination with sex- Endometriosis - dyspareunia with penetration is

very common- Uterine fibroids can cause dyspareunia- Parity is NOT associated with sexual dysfunction

Risk Factors/Comorbidities

Menopause- lower levels of estrogen known to cause certain

physiological changes related to female sexual function

- lower estrogen levels alone may not directly account for all changes in sexual function

- study of 341 peri- and postmenopausal women, common menopausal symptoms, including depression, sleep disturbances, and night sweats, were associated with diminished libido4

Risk Factors/Comorbidities

PsychosocialConflict within relationshipFatigue or stressLack of privacyIssues surrounding prior physical or sexual abusePartner’s sexual dysfunction Relationship factors

- study of over 1800 men and women between the ages of 19 to 32 years in stable relationships sexual activity and satisfaction declined as the duration of partnership increased5

Risk Factors/Comorbidities

Depression- 17-26% of women with low sexual desire also have depression2

- Initially can be difficult to distinguish if dysfunction 2/2 depression or side effects of medications

Risk Factors/Comorbidities

Substance Use/Abuse● Chronic alcohol use - can lead to

hypogonadotropic state○ Alcohol lowers physiological signs of

arousal

● Nicotine - can inhibit arousal

Risk Factors/Comorbidities

Medical ConditionsMSHTN*Epilepsy - particularly patients on antiepileptics

Cancer - especially those treated with endocrine therapies

Risk Factors/Comorbidities

MedicationsSSRIs - can decrease desire, cause difficulty with orgasm benzodiazepinesantipsychoticsbeta-blockers*gabapentinlamotriginetopiramatearomatase inhibitors - profound hypoestrogenemia

Diagnostic Evaluation

- Obtain complete history, assess for risk factors

- When discussing sexual health history ask about:

menopausal status pregnancy/parityhistory of pelvic injury, cancer, surgeryvulvovaginal/pelvic painpruritus, dryness, dischargeabnormal bleedingincontinence

Diagnostic Evaluation

Potential labs/studies:- Transvaginal pelvic ultrasound- CG and chlamydia- Complete blood count- Prolactin levels - hyperprolactinemia causes

gonadal suppression- TSH

Making the diagnosis

DSM-V criteria:- present 75-100% of the time

exception with of substance/medication induced disorders

- present for at least 6 months- disorder must cause “significant distress”

DiagnosesFrom DSM-V

Female Sexual Interest/Arousal Disorder

Female Orgasmic Disorder Genito-pelvic Pain/Penetration Disorder

Lack of, or significantly reduced sexual interest/arousal, demonstrated by 3 or more:

- absent/reduced interest in sex- absent/reduced sexual

thoughts- absent/reduced initiation of

sex, generally uninterested when partner initiates

- absent/reduced sexual excitement

- absent/reduced genital/non genital sensations during sex

Presence of either symptoms, experienced all or almost all of the time:

- marked delay in/infrequency of orgasam, or complete absence

- markedly reduced intensity of oragasm

Persistent or recurrent difficulties with one or more:

- penetration - vulvovagianl or pelvic

pain during sex- fear/anxiety about pain

during sex- tensing or tightening of

pelvic floor muscles during attempted penetration

Diagnoses

Substance or medication- induced dysfunction

Other sexual dysfunction, specified

Other sexual dysfunction, unspecified

Clinically significant disturbance in sexual function predominates

- symptoms develop during or soon after intoxication/withdrawal or after taking med

- substance or medication is known to be capable of producing symptoms

- disturbance not better explained by another cause of sexual dysfunction

- does not occur solely during delirium

Patient presents with sexual dysfunction that causes distress, but presentation does not fully meet diagnostic criteria of other disorders, and physician chooses to specify specific reason that criteria are not met

Same, but clinician does not or cannot specify reason that criteria are not met (i.e. presentations where there is not enough information to make diagnosis)

Management

- Should combine pharmacological therapy to maximize biological factors of sexual response as well as individualized therapy or counseling to overcome personal/relationship difficulties

- principal predictors of sexual satisfaction are physical and mental health, and the quality of the relationship with the partner

Non-pharmacologic Treatments

- Sex and couples therapy- Pelvic physical therapist - subspeciality trained in

pelvic anatomy- Psychotherapy - for women with comorbid

psychiatric disorders- Lifestyle changes - reduce stress, fatigue; if

possible make changes to living situation to improve privacy

- Improving body image- EROS-Clitoral Therapy Device (clitoral suction

vacuum device)- may improve arousal

Hormonal Therapy

Estrogen and estrogen-progesterone therapy- First line therapy in treating symptoms of menopause

- Systemic and local estrogen can treat tissue atrophy, improve dyspareunia

- NO consistent increase in sexual desire or activity

Hormonal Therapy

Androgens- Role of testosterone therapy in female sexual function has

been studied since 1950s - Two recent Cochrane reviews examined benefit of T + EP

therapy vs EPT alone in treating sexual dysfunction in peri- and postmenopausal women

- Addition of T to hormone therapy regimens improved sexual function scores and number of satisfied sexual episodes in postmenopausal women

Hormonal Therapy

Androgen Safety- Major side effects of testosterone therapy include hirsutism, acne, decreased HDL

- Seen with oral T therapy- Side effects do not occur with transdermal T

(bypasses hepatic metabolism)- Data on long term use is limited

Hormonal Therapy

Androgen Use- T patch approved in Europe for surgically menopausal women on concurrent ET

- Androgen therapies not approved by FDA

- Off-label use for treating sexual dysfunction is increasing

Pharmacologic Treatments

Flibanserin (Addyi)- Increases DA and NE levels and induces transient decreased in 5-HT levels in some areas of

brain- Most commonly reported side effects are

dizziness, nausea, fatigue, sleepiness, trouble sleeping

Neurotransmitters

Dopaminergic system - increases sexual desire and excitement

Norepinephrine system - affects arousal and orgasm

Imbalance between these two systems can cause an inability to begin sexual response cycle

Serotoninergic system - if overactive, can decreased desire and orgasm

Flibanserin

VIOLET trial- In premenopausal women with sexual dysfunction, flibanserin was associated with significant improvements in satisfying sexual events, sexual desire, overall sexual function, as well as reduction of sexual distress versus placebo

Conclusions

- Lots to take into consideration when making diagnosis

- Take FULL history, including sexual history- Optimize therapy - both pharmacologic

agents and behavioral therapies often used concurrently

- Focusing on patients’ wellness and happiness with themselves is key

Resources1. Laumann EO et al. Sexual problems among women and men aged 40-80 y: prevalence and

correlates identified in the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res. 2005;17(1):39

2. Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008;112(5):970

3. Salonia A et al. Sexual dysfunction is common in women with lower urinary tract symptoms and urinary incontinence: results of a cross-sectional study. Eur Urol. 2004;45(5):642.

4. Reed SD, Newton KM, LaCroix AZ, Grothaus LC, Ehrlich K. Night sweats, sleep disturbance, and depression associated with diminished libido in late menopausal transition and early postmenopause: baseline data from the Herbal Alternatives for Menopause Trial (HALT). Am J Obstet Gynecol. 2007;196(6):593.e1

5. Klusmann D. Sexual motivation and the duration of partnership. Arch Sex Behav. 2002;31(3):2756. Nappi RE et al. Management of hypoactive sexual desire disorder in women: current and emerging

therapies. Int J womens health. 2010: 1(2); 167-75.7. DeRogatis LR et al. Treatment of hypoactive sexual desire disorder in premenopausal women:

efficacy of Flibnaserin in the VIOLET study. Journal of sexual medicine. 2012: 9(4); 1074-85.DOI: 10.1111/j.1743-6109.2011.02626.x

8. Stahl SM, Sommer B, Allers KA. Multifunctional pharmocology of Flibnaserin: possible mechanism of therapeutic action in hypoactive sexual desire disorder. Journal of sexual medicine. 2011: 9(1); 15-27. DOI: 10.1111/j.1743-6109.2010.02032.x

Resources9. Bachmann G. Strategies for recognition and management of sexual dysfunction in menopausal women. Medscape 2015.