4/18 Female sexual dsyfunction

Question 1

what is the linear model of the human sexual response?

Answer 1

Sexual response progress in 4 phases

1) Excitement – labia becomes engorged, clitoris enlongates, vagina begins to lubricate and length, uterus pulls up and away
2) Plateau – bartholin glands serete lubrication, labia minora turns bright red and increases in size (orgasm occurs 1-1.5min after red color appears), clitoris retracts under the hood and gets very sensitive (stimulating it may be quite uncomfortable), vaginal entrance contracts to produce a grasping effect “orgasmic platform”, vaginal barrel expands
3) Orgasm - rhythmic contractions of vagina and uterus
4) Resolution - cervix drops to allow sperm entry

Question 2

what is the circular model of the human sexual response?

Answer 2

Arousal stimulates sexual desire (not the other way around), which leads to sexual activity, which leads to emotional/physical satisfaction, which has a (+) reinforcing effect on emotional intimacy and drives someone to seek sexual stimuli

There is level of spontaneous sex drive, but often times, sexual desire is is driven more by emotional intimacy (very impt)

Question 3

what is the biopsychosocial model of the human sexual response?

Answer 3

Factors that affect sexual arousal

• Biology (physical health, neurobiology, endocrine functions)
• Psychology (performance, anxiety, depression)
• Social/cultural (upbringing, cultural norms, and expectations)
• Interpersonal (quality of current and past relationships, intervals of abstinence, life stressors, finances)

Question 4

T/F sexual arousal is subjective and multifactorial

Answer 4

True. It depends on:

Mental excitement
Vulvar/Vaginal congestion (variable awareness)
Pleasure from vulvar/vaginal stimulation or non-genital stimulation
∆s: Lubrication, smooth muscle relaxation
Other somatic changes (HR, BP, T, etc)

Question 5

∆ btwn genital and subjective arousal?

Answer 5

Genital arousal is a reflex - happens quickly; rarely perceived by women

Subjective arousal is slow and strongly modulated by cognition and emotion; can be derailed immediately (ie post-partum mom who is trying to become sexually active again, but the baby cries)

Question 6

what triggers desire?w

Answer 6

Arousal can trigger desire; many women never/infrequently sense desire – but can reliably access it once they are aroused; (+) experiences reinforce sexual motivation “Arousal contingency”

Question 7

what is arousal contingency? how does it work?

Answer 7

Positive experiences reinforce sexual motivation

positive experiences reinforce sexual motivations, negative experiences will not. The body remembers painful/unpleasant sexual encounters and the body remembers that and they will probably become less responsive
conclusion: sexual encounters must be pleasurable for both parties.

Question 8

3 Types of Sexual Dysfunction (as defined by DSM V)

Answer 8

Disorders may be lifelong or acquired, and are not better explained by other disorders

Female Sexual Interest/Arousal D/O

Female Orgasmic D/O

Genitopelvic pain/Penetration D/O

Question 9

Sexual Dysfunction (as defined by DSM V)

Answer 9

many but the ones she highlighted in bold are

Depression
Anxiety possible PTSD from process of giving birth
Sexual Abuse
Relationship discord
Stress –emotional or environmental

Question 10

What history should you consider when evaluating Sexual Dysfunction?

Answer 10

Think biopsychosocial – context of life when problems began:

Medical history (Depression? Anxiety? Chronic disease? Neurologic conditions? Endocrine conditions?)
Surgical history?
Post-hysterectomy, sex/orgasm may feel very different (uterine normally contraction during orgasm – part of experience)
Sexual history?
Partner dysfunction?
Sexual abuse?

Question 11

What aspects of the physical exam should you look for when evaluating Sexual Dysfunction?

Answer 11

Anatomy?
introitus examination -atrophy? scarring? dystrophy? pain?
Vaginal tone, voluntary contraction and relaxation
Tenderness
Bladder and urethral sensitivity

Question 12

What labs should you obtain when evaluating Sexual Dysfunction?

Answer 12

Estrogen status best assessed by history and exam
Testosterone levels only useful if signs of excess androgen
Prolactin if infertility or oligomehorrhea
Can suppress sexual desire
TSH?
STIs?

Question 13

What is Female Sexual Interest/Arousal Disorder (DSMV)? When does this usually occur?

Answer 13

Lack of sexual interest or arousal for at least 6 months

Peaks age 40-60, surgical menopause (hysterectomy)

Question 14

Treatment for Female Sexual Interest/Arousal Disorder (DSMV)?

What therapy has not been shown to make a difference?

Answer 14

Consider the circular cycle:

1) Sex therapy, focus exercises (focus on what feels good/pleasurable)
2) Sensate focus exercises

Caution with hormonal therapy (no great evidence that it makes a difference)

Question 15

What is Female Orgasmic Disorder (DSMV)?

Answer 15

Marked delay in, infrequency of, or absence of orgasm
Markedly reduced intensity of orgasmic sensation
Must be generalized
(Note: it is probably not an orgasmic d/o if it varies by partner – ie if you can orgasm w one partner but not with another)

Question 16

What is the treatment for Female Orgasmic Disorder (DSMV)?

Answer 16

SSRIs – sexual benefits of treating depression far outweigh these side effects of delayed or absence of orgasm with decreased desire; ADD wellbutryn or buproprion because these tends to be slightly more stimulating or “pro-orgasmic”

Behavioral therapy can be highly effective

Exercises that help people figure out what is pleasurable for them

Mindfulness? Sari?

Focus on being present

Question 17

What are the 3 components of Genitopelvic Pain/Penetration Disorder (DSMV)?

Answer 17

Marked difficulty with vaginal intercourse or penetration

Marked vulvovaginal or pelvic pain during attempts of vaginal intercourse or penetration (dyspareunia)

Marked Vulvodynia or vestibulodynia - vulvar discomfort (burning, dysuria) after penetration attempt

Question 18

Genitopelvic Pain/Penetration Disorder (DSMV)

what may account for Marked vulvovaginal or pelvic pain during attempts of vaginal intercourse or penetration (dyspareunia)?

Answer 18

may be due to Vulvovaginal atrophy (not well ubricated, or delicate/atrophic tissues)

Question 19

Genitopelvic Pain/Penetration Disorder (DSMV)?

what may account for Vulvodynia/provoked vestibulodynia - vulvar discomfort (burning, dysuria) after penetration attempt?

Answer 19

may be due to increased # of nerve endings

Marked fear or anxiety regarding pain on vaginal penetration

Marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration (vaginismus)

Question 20

Genitopelvic Pain/Penetration Disorder (DSMV)

what may account for marked difficulty with vaginal intercourse or penetration?

Answer 20

fear, emotions, arousal associated with sex

Question 21

treatment of Genitopelvic Pain/Penetration Disorder (DSMV)?

Answer 21

Treat underlying gyn condition (or lack of arousal) Ie if they’re not well lubricated, address that

Explain effect on sexual response cycle

Importance of removing pain from sexual experience – not “just for her partner”

Question 22

why is it hard to ask about sexual dysfunction?

Answer 22

Not sure what to do when you get an answer
Unfamiliar with treatments, uncertainty about next questions
Fear of offending patient
Lack of obvious justification
Generational obstacles
Fear of sexual misconduct charge
Sometimes perceived irrelevant
Unfamiliarity with some sexual practices

Question 23

Recommendations in talking about sexual dysfunction with a patient?

Answer 23

adjust your language:

• Don’t assume medical/technical terms will be understood; provide definitions
• Avoid being overly superficial
• Slang – may be understood but may be alienating
• Educational opportunities
• “Ubiquity technique” “I ask this of everyone”

Question 24

Basic Steps of treating sexual dysfunction

Answer 24

Education on sexual health, address misconceptions “ask, tell, ask”
Assess specific goals
Treat associated conditions, refer if needed

Question 25

Non-pharmacologic Treatment Modalities of sexual dsyfunction?

Answer 25

Cognitive Behavioral therapy
Mindfulness-based therapy
Sex therapy
Physical therapy
Psychiatric services (depression or other problems may be causing it)
Lifestyle changes
Lubricants
Devices

Question 26

Pharmacologic Treatment Modalities of sexual dsyfunction?

what has been shown to work? not work?

Answer 26

Topical estrogen

Systemic hormone replacement

Androgens (not FDA-approved) - little evidence to support

Phosphodiesterase inhibitors - generally not helpful for women (ie viagra)

DHEA? (not shown to be helpful)

Psychotropic agents – little specific evidence