#213 Female Sexual Dysfunction Flashcards
Approximately what % of American women report experiencing sexual problems? What % reports it leads to personal distress?
43%. 12% leads to personal distress
How does prevalence of female sexual distress change with age?
Increases through middle age (peak of 15% at age 45-64) and then decreases again in older age
What are common etiologies and risk factors for female sexual dysfunction?
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
When do androgen levels in women peak?
In mid 20s
What are the 5 types of female sexual dysfunction?
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
What is female sexual interest/arousal disorder?
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
What is the definition of female orgasmic disorder?
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.
What is the definition of genito-pelvic pain/penetration disorder?
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
What is substance/medication-induced sexual dysfunction?
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
What is the definition of “other specified sexual dysfunction and other unspecified sexual dysfunction?”
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
True or false: women with primary orgasmic disorder usually have normal levels of sexual desire?
True
What medical (non psych) things can cause acquired orgasmic disorder?
Underlying neurological conditions, genital pelvic surgery, radiation, certain medications
Can women who do not have penetration as part of their sexual activity still be diagnosed with genito-pelvic pain and penetration disorder?
Yes, if pain interferes with sexual function
Can anticholinergic medications affect sexual function?
Yes
Can psychiatric agents affect sexual function?
Yes
Can cardiovascular agents affect sexual function?
Yes
What intrapartum events are associated with postpartum genito-pelvic pain and penetration disorder and related sexual interest and arousal difficulties?
Trauma cased by cesarean delivery, instrumented delivery, episiotomy, and perineal tears
Does breastfeeding cause genito-pelvic pain/penetration disorder?
No, can cause vaginal dryness and therefore cause symptoms of genito-pelvic pain/penetration disorder
Is treatment of female sexual dysfunction different in postpartum women different than nonpostpartum women?
No, only in such that you need to avoid medications that are contraindicated in a woman who is breastfeeding
True or false: if a woman does not meet DSM5 criteria for female sexual dysfunction, she does not need treatment?
False: may still be needed
What % of menopausal women area affected by symptoms associated with genitourinary syndrome of menopause?
Estimated up to 50%
What psychologic interventions are available for women suffering from female sexual dysfunction?
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)
What is the preferred hormonal treatment for female sexual dysfunction that is due to genitourinary syndrome of menopause?
Low-dose vaginal estrogen
What estrogen receptor modulator therapy can be offered to women for management of dyspareunia caused by genitourinary syndrome of menopause?
Ospemifene
Can estrogen or selective estrogen receptor modulator therapy be used to treat female sexual dysfunction not due to a hypoestrogenic state?
Not recommended
What physical exam findings on pelvic exam support genitourinary syndrome of menopause?
Loss of labial fat pad, thinning of the labia minora, pale mucosa, and loss of vaginal folds
What physical forms does vaginal estrogen come in? Is any form more effective than another?
Tablets, gel, creams, and rings. Equally effective
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?
Vaginal estrogen. Lower systemic absorption
What is the effect (agonist/antagonist) on breast, uterus, vaginal tissues? Associated with increased risk of cancer at these sites?
Breast antagonist
Uterus agonist
Vagina agonist.
Not associated with endometrial cancer or hyperplasia when used continuously for 1 year
Is vaginal estrogen contraindicated in women with estrogen-sensitive cancer?
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.
Can testosterone be used as a treatment for postmenopausal women with sexual interest and arousal disorder?
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]
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?
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
Can systemic dehydroepiandrosterone (DHEA) be used as a treatment for women with sexual interest and arousal disorder?
Not effective, therefore, not recommended
True or false: androgen use is contraindicated in pregnancy?
True, could be harmful to fetal development
What is the dose of the transdermal testosterone patch that can be used to treat postmenopausal women with sexual interest and arousal disorder?
300mcg
What are the main adverse effects associated with testosterone therapy in women?
Hirsutism, acne, virilization (voice deepening, clitoral enlargement)
What are the long-term effects of testosterone therapy on cardiovascular risk?
Unknown
What are the long-term effects of testosterone therapy on breast cancer risk?
Unknown
For which patients with hypoactive sexual desire disorder has the FDA approved Flibanserin? What is the mechanism of action of Flibanserin?
Premenopausal women without depression. It is a serotonin receptor agonist/antagonist
What is the black box warning for Flibanserin?
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
What are the common side effects of Flibanserin?
Dizziness, somnolence, fatigue, nausea.
Flibanserin is an SNRI that can be used for hypoactive sexual desire disorder
Can sildenafil citrate be used for female interest/arousal disorder?
No
What are the most common adverse effects of sildenafil use in women?
Headache, flushing, dyspepsia, nasal congestion, and transient visual disturbances
What is the mechanism of action of bupropion?
Norepinephrine-dopamine reuptake inhibitor
In what context can buproprion be used for female sexual dysfunction disorder?
Can be used as supplementation for women with antidepressant-induced female sexual dysfunction
How often is a vaginal moistutizer used?
2-3x per week
Can food-grade oils be used vaginally to alleviate dryness?
Yes, such as coconut, olive, and vegetable oils. However, oils are not compatible with condoms!
What types of lubricants are and are not compatible with condoms?
Water and silicone based lubricants are compatible. Oil is not compatible.
Is vaginal carbon dioxide fractional laser treatment used for vulvovaginal atrophy?
Inadequately studied, expensive, not FDA approved. Some preliminary data show potential benefit, but not placebo controlled, and long-term outcomes have not been described
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
False, you should do an exam to diagnose female sexual dysfunction related to genitourinary syndrome of menopause
What medication options are available for postmenopausal women for the treatment of moderate-to-severe dyspareunia that is due to genitourinary syndrome of menopause?
Intravaginal prasterone (DHEA), low-dose vaginal estrogen, and ospemifene
