#213 Female Sexual Dysfunction

Question 1

Approximately what % of American women report experiencing sexual problems? What % reports it leads to personal distress?

Answer 1

43%. 12% leads to personal distress

Question 2

How does prevalence of female sexual distress change with age?

Answer 2

Increases through middle age (peak of 15% at age 45-64) and then decreases again in older age

Question 3

What are common etiologies and risk factors for female sexual dysfunction?

Answer 3

Anxiety disorder, diabetes, depression, female genital mutilation, genitourinary syndrome of menopause, hx of sexual abuse, HTN, hysterectomy, IPV, meds, neg sex attitudes, neurologic disease, perfectionism and self-dislike, postpartum period (breastfeeding, ob trauma), premature ovarian failure, psych sequelae of gyn ca and breast ca, relationship discord, stress, SUI, substance use disorder

Question 4

When do androgen levels in women peak?

Answer 4

In mid 20s

Question 5

What are the 5 types of female sexual dysfunction?

Answer 5

Female sexual interest/arousal disorder; female orgasmic disorder; gentio-pelvic pain/penetration disorder; substance/medication-induced sexual dysfunction; other specified sexual dysfunction and other unspecified sexual dysfunction

Question 6

What is female sexual interest/arousal disorder?

Answer 6

Symptoms for 6+ months, cause significant distress in individual.
A lack of, or significant decrease in, at least 3:
- interest in sexual activity
- sexual or erotic thoughts or fantasies
- initiation of sexual activity and responsiveness to a partner’s initiation
- excitement or pleasure during all or almost all sexual activity
- genital or nongenital sensations during sexual activity in almost all or all sexual encounters

Question 7

What is the definition of female orgasmic disorder?

Answer 7

Marked delay in, marked infrequency of, or absence or orgasm, or markedly reduced intensity of orgasmic sensations, in almost all or all occasions of sexual activity. Symptoms for 6+ months and cause clinically significant distress in the individual.

Question 8

What is the definition of genito-pelvic pain/penetration disorder?

Answer 8

The persistent or recurrent presence of one or more of the following symptoms for 6+ months and cause clinically significant distress in individual:

• Difficulty having intercourse
• Marked vulvovaginal or pelvic pain during intercourse or penetration attempts
• Marked fear or anxiety about vulvovaginal or pelvic pain anticipating, during, or resulting from vaginal penetration
• Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration

Question 9

What is substance/medication-induced sexual dysfunction?

Answer 9

A disturbance in sexual function that has a temporal relationship with substance/medication initiation, dose increase, or substance/medication discontinuation and causes significant distress in the individual

Question 10

What is the definition of “other specified sexual dysfunction and other unspecified sexual dysfunction?”

Answer 10

Distressing symptoms characteristic of a sexual dysfunction that do not meet criteria of one of the defined categories. The major distinction between other specified sexual dysfunction and other unspecified sexual dysfunction is whether the clinician specifies the reason that the symptoms described do not meet the criteria for one of the other classes

Question 11

True or false: women with primary orgasmic disorder usually have normal levels of sexual desire?

Answer 11

True

Question 12

What medical (non psych) things can cause acquired orgasmic disorder?

Answer 12

Underlying neurological conditions, genital pelvic surgery, radiation, certain medications

Question 13

Can women who do not have penetration as part of their sexual activity still be diagnosed with genito-pelvic pain and penetration disorder?

Answer 13

Yes, if pain interferes with sexual function

Question 14

Can anticholinergic medications affect sexual function?

Answer 14

Yes

Question 15

Can psychiatric agents affect sexual function?

Answer 15

Yes

Question 16

Can cardiovascular agents affect sexual function?

Answer 16

Yes

Question 17

What intrapartum events are associated with postpartum genito-pelvic pain and penetration disorder and related sexual interest and arousal difficulties?

Answer 17

Trauma cased by cesarean delivery, instrumented delivery, episiotomy, and perineal tears

Question 18

Does breastfeeding cause genito-pelvic pain/penetration disorder?

Answer 18

No, can cause vaginal dryness and therefore cause symptoms of genito-pelvic pain/penetration disorder

Question 19

Is treatment of female sexual dysfunction different in postpartum women different than nonpostpartum women?

Answer 19

No, only in such that you need to avoid medications that are contraindicated in a woman who is breastfeeding

Question 20

True or false: if a woman does not meet DSM5 criteria for female sexual dysfunction, she does not need treatment?

Answer 20

False: may still be needed

Question 21

What % of menopausal women area affected by symptoms associated with genitourinary syndrome of menopause?

Answer 21

Estimated up to 50%

Question 22

What psychologic interventions are available for women suffering from female sexual dysfunction?

Answer 22

Sexual skills training, cognitive-behavioral therapy (w or w/o pharmacotherapy), mindfulness-based therapy, and couples therapy. Referral to mental health specialists (eg, sex therapists, psychologists, psychiatrists, and marriage/relationship counselors)

Question 23

What is the preferred hormonal treatment for female sexual dysfunction that is due to genitourinary syndrome of menopause?

Answer 23

Low-dose vaginal estrogen

Question 24

What estrogen receptor modulator therapy can be offered to women for management of dyspareunia caused by genitourinary syndrome of menopause?

Answer 24

Ospemifene

Question 25

Can estrogen or selective estrogen receptor modulator therapy be used to treat female sexual dysfunction not due to a hypoestrogenic state?

Answer 25

Not recommended

Question 26

What physical exam findings on pelvic exam support genitourinary syndrome of menopause?

Answer 26

Loss of labial fat pad, thinning of the labia minora, pale mucosa, and loss of vaginal folds

Question 27

What physical forms does vaginal estrogen come in? Is any form more effective than another?

Answer 27

Tablets, gel, creams, and rings. Equally effective

Question 28

Is low dose vaginal estrogen or low dose systemic estrogen (alone or with progestin) preferred for the treatment of women with only vaginal symptoms with menopause? Why?

Answer 28

Vaginal estrogen. Lower systemic absorption

Question 29

What is the effect (agonist/antagonist) on breast, uterus, vaginal tissues? Associated with increased risk of cancer at these sites?

Answer 29

Breast antagonist
Uterus agonist
Vagina agonist.
Not associated with endometrial cancer or hyperplasia when used continuously for 1 year

Question 30

Is vaginal estrogen contraindicated in women with estrogen-sensitive cancer?

Answer 30

Insufficient evidence to fully counsel this population about risks and benefits. Individualized patient plan based on pt preferences and prognosis and ideally inclue the input of the treating oncologist.

Question 31

Can testosterone be used as a treatment for postmenopausal women with sexual interest and arousal disorder?

Answer 31

short-term use of transdermal testosterone can be considered as a treatment option after appropriate counseling about potential risks and unknown long-term effects. [evidence insufficient to recommend for or against in premenopausal women]

Question 32

When using transdermal testosterone for postmenopausal women with sexual interest and arousal disorder how long should the initial trial be? When should you check a testosterone level and what range should the level be in?

Answer 32

3-6 month trial, discontinue at 6 months if no improvement. Testosterone test at baseline and after 3-6 weeks, should be within the normal range for reproductive-aged women

Question 33

Can systemic dehydroepiandrosterone (DHEA) be used as a treatment for women with sexual interest and arousal disorder?

Answer 33

Not effective, therefore, not recommended

Question 34

True or false: androgen use is contraindicated in pregnancy?

Answer 34

True, could be harmful to fetal development

Question 35

What is the dose of the transdermal testosterone patch that can be used to treat postmenopausal women with sexual interest and arousal disorder?

Answer 35

300mcg

Question 36

What are the main adverse effects associated with testosterone therapy in women?

Answer 36

Hirsutism, acne, virilization (voice deepening, clitoral enlargement)

Question 37

What are the long-term effects of testosterone therapy on cardiovascular risk?

Answer 37

Unknown

Question 38

What are the long-term effects of testosterone therapy on breast cancer risk?

Answer 38

Unknown

Question 39

For which patients with hypoactive sexual desire disorder has the FDA approved Flibanserin? What is the mechanism of action of Flibanserin?

Answer 39

Premenopausal women without depression. It is a serotonin receptor agonist/antagonist

Question 40

What is the black box warning for Flibanserin?

Answer 40

Black box warning about alcohol use during treatment because of an increased risk of syncope and hypotension.
Flibanserin is an SNRI that can be used for hypoactive sexual desire disorder

Question 41

What are the common side effects of Flibanserin?

Answer 41

Dizziness, somnolence, fatigue, nausea.

Flibanserin is an SNRI that can be used for hypoactive sexual desire disorder

Question 42

Can sildenafil citrate be used for female interest/arousal disorder?

Answer 42

No

Question 43

What are the most common adverse effects of sildenafil use in women?

Answer 43

Headache, flushing, dyspepsia, nasal congestion, and transient visual disturbances

Question 44

What is the mechanism of action of bupropion?

Answer 44

Norepinephrine-dopamine reuptake inhibitor

Question 45

In what context can buproprion be used for female sexual dysfunction disorder?

Answer 45

Can be used as supplementation for women with antidepressant-induced female sexual dysfunction

Question 46

How often is a vaginal moistutizer used?

Answer 46

2-3x per week

Question 47

Can food-grade oils be used vaginally to alleviate dryness?

Answer 47

Yes, such as coconut, olive, and vegetable oils. However, oils are not compatible with condoms!

Question 48

What types of lubricants are and are not compatible with condoms?

Answer 48

Water and silicone based lubricants are compatible. Oil is not compatible.

Question 49

Is vaginal carbon dioxide fractional laser treatment used for vulvovaginal atrophy?

Answer 49

Inadequately studied, expensive, not FDA approved. Some preliminary data show potential benefit, but not placebo controlled, and long-term outcomes have not been described

Question 50

True or false: vaginal or systemic hormone therapy for female sexual dysfunction related to genitourinary syndrome of menopause can be prescribed based on reported symptoms alone

Answer 50

False, you should do an exam to diagnose female sexual dysfunction related to genitourinary syndrome of menopause

Question 51

What medication options are available for postmenopausal women for the treatment of moderate-to-severe dyspareunia that is due to genitourinary syndrome of menopause?

Answer 51

Intravaginal prasterone (DHEA), low-dose vaginal estrogen, and ospemifene