4/18 Female sexual dsyfunction Flashcards
what is the linear model of the human sexual response?
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
what is the circular model of the human sexual response?
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)
what is the biopsychosocial model of the human sexual response?
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)
T/F sexual arousal is subjective and multifactorial
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)
∆ btwn genital and subjective arousal?
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)
what triggers desire?w
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”
what is arousal contingency? how does it work?
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.
3 Types of Sexual Dysfunction (as defined by DSM V)
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
Sexual Dysfunction (as defined by DSM V)
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
What history should you consider when evaluating Sexual Dysfunction?
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?
What aspects of the physical exam should you look for when evaluating Sexual Dysfunction?
Anatomy?
introitus examination -atrophy? scarring? dystrophy? pain?
Vaginal tone, voluntary contraction and relaxation
Tenderness
Bladder and urethral sensitivity
What labs should you obtain when evaluating Sexual Dysfunction?
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?
What is Female Sexual Interest/Arousal Disorder (DSMV)? When does this usually occur?
Lack of sexual interest or arousal for at least 6 months
Peaks age 40-60, surgical menopause (hysterectomy)
Treatment for Female Sexual Interest/Arousal Disorder (DSMV)?
What therapy has not been shown to make a difference?
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)
What is Female Orgasmic Disorder (DSMV)?
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)
What is the treatment for Female Orgasmic Disorder (DSMV)?
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
What are the 3 components of Genitopelvic Pain/Penetration Disorder (DSMV)?
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
Genitopelvic Pain/Penetration Disorder (DSMV)
what may account for Marked vulvovaginal or pelvic pain during attempts of vaginal intercourse or penetration (dyspareunia)?
may be due to Vulvovaginal atrophy (not well ubricated, or delicate/atrophic tissues)
Genitopelvic Pain/Penetration Disorder (DSMV)?
what may account for Vulvodynia/provoked vestibulodynia - vulvar discomfort (burning, dysuria) after penetration attempt?
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)
Genitopelvic Pain/Penetration Disorder (DSMV)
what may account for marked difficulty with vaginal intercourse or penetration?
fear, emotions, arousal associated with sex
treatment of Genitopelvic Pain/Penetration Disorder (DSMV)?
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”
why is it hard to ask about sexual dysfunction?
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
Recommendations in talking about sexual dysfunction with a patient?
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”
Basic Steps of treating sexual dysfunction
Education on sexual health, address misconceptions “ask, tell, ask”
Assess specific goals
Treat associated conditions, refer if needed
Non-pharmacologic Treatment Modalities of sexual dsyfunction?
Cognitive Behavioral therapy Mindfulness-based therapy Sex therapy Physical therapy Psychiatric services (depression or other problems may be causing it) Lifestyle changes Lubricants Devices
Pharmacologic Treatment Modalities of sexual dsyfunction?
what has been shown to work? not work?
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
