Sexual dysfunction Flashcards
patient with decreased sexual desire.
what is your ddx
female sexual interest and arousal disorder
relationship concerns
stress/anxiety
hx of female genital mutilation
2/2 other PFD: genitourinary syndrome of menopause, UI, POP
premature ovarian failure
medication or substances
sexual desire is triggered in what part of the brain?
via which neurotransmitter?
hypothalamus
dopamine
which neurotransmitters are released during orgasm
endogenous opioids, serotonin, prolactin, oxytocin
how long does one need to have symptoms of female sexual interest and arousal disorder to officially make the dx
6 months
which drug classes can cause female sexual interest and arousal disorder?
SSRI
antihypertensives
antihistamines
hormonal medications
MOA of flibanserin
serotonin receptor agonist/antagonist which results in decreased serotonin and increased norepinephrine and dopamine
SE of flibanserin
syncope, dizziness, hypotension
Who can use flibanserin?
dosage
premenopausal women
100mg per day at bedtime
How many more sexually satisfying events can one expect on flibanserin?
increase of 0.4 to 1 sexually satisfying events per month from a baseline of 2-3 per month.
what are the alcohol limitations to flibanserin
no alcohol
if you hve 2 drinks, wait 2 hours
if you have 3 or more, then skip the dose
CYP3A4
What is the typical pH of the postmenopausal vagina?
> 5.5
Estring dose
7.5 mcg/ 90 days
dose of vaginal insert (vagifem)
10 mcg 1 tab x 2 week
dose of premarin
0.625mcg per gram
0.5 gram 2-3 times per week
dose of estrace
100mcg pre gram
0.5 gram nightly for 1-2 weeks,
2-3 times per week
Can women with a hx breast cancer use DHEA?
evidence is not strong for safety, use estrogn. better data
a post menopausal woman with dypsareunia due to genitourinary syndrome of menopause?
What can you give her?
prasterone or DHEA, vaginal insert 6.5 mg
Ospenmifine, oral
Ospenmifine MOA
Dose
Does it increase risk of breast or endometrial cancer?
SERM- estrogen antagonist/agonist in the vagina
60 mg daily orally
no evidence to suggest increased breast or endometrial cancer
SE of Ospenmifine
clots, hot flashes
what is the evidence regarding fractional CO2 laser for vulvovaginal atrophy
only for use in research setting
dyspareunia
whats your ddx?
48 years old
low libido
ddx?
female sexual interest and arousal disorder
depression
stress
interpersonal relationship problems
48 years old
low libido
History and physical exam?
smoking
prior BSO
menopausal sympotms-vaginal dryness, hot flashes
medications- SSRI, OCP, steroids,
stress level, exercise, relationship status, safety
visual inspection-atrophy
neuro exam looking for hypersensitivity, or asympetry in sensation
trigger points
masses
discharge, possible STI
48 years old
low libido
she is on an SSRI. How would you counsel this patient?
what are alternative meds she could try
depression and SSRIs both can lead to low libido
consider switching meds
bupropioin and desvenlafaxine have lower risk of low libido
48 years old
low libido
natural ways to boost libido?
couples therapy
date night,
exercise
lubricants
stimulation toys
stress management,
improve sleep
improving body image
48 years old
low libido
medicinal ways to improve this?
flibanserin (addyi)
bremelanotide (vyleesi)
prasterone
off label bupropion or busparone
bremelanotide MOA
SE?
melanocortin receptor agonist
nausea, increased pigmentation at the injection site
cautions with bremelanotide?
FDA approved for premenopausal women
not for High BP, naltrexone, or more than 8 times per month
your low libido patient wants Testosterone pellets. how do you counsel her?
- not FDA approved for this indication in women
- pellets can result in high doses bc we cannot control the bioavailability on a day to day basis
- risks include hirsuitism, acne, virulization, cardiovascular problems, possible breast cancer due to aromatization of excess testosterone
what labs should be done before starting testosterone?
LFTs
