Women's sexual disorders Flashcards
Stages of Sexual Response
- Stage 1 - Desire (Libido)
- Stage 2 - Arousal
- Stage 3 - Orgasm
- Stage 4 - Resolution
Hormonal Excitatory Effects on female response
- Estrogen - Peri/Post-menopausal pts; Pre-ovulation surge
- Testosterone - At supraphysiologic levels
- Dopamine
- Norepinephrine
- Oxytocin
- Melanocortins
Hormonal Inhibitory Effects on female response
- Serotonin - At higher levels
- Prolactin - Nursing mothers; Hyperprolactinemia
- Opioids
- Endocannabinoids
avg puberty age for females
8-13 y
Expected variations of libido and sexual activity, based on…
- Mental health
- Relationship status
- Societal/cultural/family norms
- Phase of menstrual cycle
sexual changes during Puberty, Adolescence, Adulthood
- puberty
- Expected variations of libido and sexual activity
- Setting healthy expectations for sexual activity
sexual changes during Perimenopause and Postmenopause
- Fluctuating hormones influence sexual desire and satisfaction - Libido, VVA, chronic disease
- Insecurities about aging and transitioning to a new period of life
- Some women note increased sexual satisfaction and desire
Up to ?% of women report at least one sexual problem
Highest and lowest where?
- 43
- Highest - SE Asia; Lowest - N Europe
Encompasses problems with either low sexual desire or abnormal arousal response (emotional/mental or lubrication/swelling)
Female Sexual Interest/Arousal Disorder
2 General Risk Factors
for Sexual Dysfunction
- psychosocial
- medical conditions
Criteria for common female sexual disorders
- Must occur 75% of the time or greater
- Must have been occurring for 6+ months
- Must cause distress for the patient
Female Sexual Interest/Arousal Disorder must report at least 3 of the following 6 criteria:
- Reduced or absent interest in sex or sexual activities
- Reduced or absent fantasizing or sexual thoughts
- Reduced or absent initiation of sexual activities - Generally unreceptive to partner initiation
- Reduced or absent interest or arousal to stimuli (internal or external)
- Reduced or absent excitement or pleasure during sexual activity
- Reduced or absent genital/nongenitial sensations during sexual activity
Encompasses problems with either vaginismus (involuntary vaginal
spasm), vulvar pain/vestibulodynia, or dyspareunia (pain with
penetration or sexual activity)
Genitopelvic Pain/Penetration Disorder
which type of sexual disorder is MC?
any sexual dysfunction - 43%
criteria for Genitopelvic Pain/Penetration Disorder
- Marked vulvovaginal or pelvic pain during penetration attempts
- Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or because of vaginal penetration
- Marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration
h/o of what is common in Genitopelvic Pain/Penetration Disorder
sexual or physical trauma or abuse
Encompasses problems with frequency, intensity, or achievement of orgasm response
Female Orgasmic Disorder
criteria for Female Orgasmic Disorder
- Delayed, infrequent, diminished, or absent orgasm response after a normal sexual arousal phase on all or almost all sexual encounters
- Distress or interpersonal problems due to orgasmic dysfunction
- Absence of disorder or substance that would explain the orgasmic dysfunction
For Female Orgasmic Disorder, always consider… (3)
- Psychiatric and social contributing factors
- Patient position, arousal, and adequate stimulation
- Medical conditions, including menopause
May affect desire, arousal, orgasm, or any other parameter of normal sexual function
- May be associated with onset or titration of medication
- May be associated with changes in use of a substance (increase or decrease)
- Must cause distress for the patient
Substance/Medication-Induced
Sexual Disorder
criteria for Substance/Medication-Induced
Sexual Disorder
- Significant disturbance in sexual function
- Disturbance occurred during or soon after exposure to a medication, or substance intoxication/withdrawal
- no other s/s better explains dysfunction
- No sx prior to substance/medication use or withdrawal
- sx do not persist beyond acute withdrawal or severe intoxication
MCC of Substance/Medication-Induced
Sexual Disorder
Psychiatric medications
- antidepressants (SSRIs, TCAs)
- Anxiolytics - BZDs lower libido and arousal; buspirone not associated
- Anticonvulsants - dec libido
- Lithium or Barbiturates - any type of sexual dysfunction
which antidepressants are not as associated with sexual dysfunction
Dopaminergic or selective serotonergic (mirtazapine, bupropion, venlafaxine, duloxetine)
other causes of Substance/Medication-Induced Sexual Disorder
- Anticholinergics - can reduce genital arousal and lubrication (Antihistamines, Antispasmodics)
- Antihypertensives - BBs, clonidine, methyldopa
-
Hormonal agents - GnRH agonists/antagonists, SERMs, aromatase inhibitors
- Contraceptives - mixed data; no strong evidence for/against
Substances of Abuse that can impact sexual function include…
- Nicotine - limits sexual arousal
- Alcohol - hypogonadotropic state; impaired overall function
- Opiates - hypogonadotropic state; impaired overall function
- Marijuana - does not harm function but negative impact on sperm, fetus
Most follow a dose-response relationship
- May affect desire, arousal, orgasm, or any other parameter of normal sexual function
- May be associated with a medical diagnosis known to affect endocrine, vascular, or neurologic function, especially if new or uncontrolled
- May be a complaint of sexual-related distress that doesn’t fit other criteria
- Must cause distress for the patient
Other Female Sexual Disorders
gynecologic conditions that causes other female sexual disorders
-
Pregnancy and Postpartum - physical discomfort, life stressors, fatigue
- No impact of type of delivery or number of parity noted - Infertility - sex becomes a “chore” and associated with disappointment
- Endometriosis - due to adhesions and scarring; especially with deep/forceful penetration, but can be with most types of sexual activity
- Uterine fibroids - dyspareunia, fatigue secondary to anemia
- Pelvic organ prolapse / Incontinence - dyspareunia, discomfort, embarrassment
- GU syndrome of menopause - hormonal changes, atrophy
medical conditions that causes other female sexual disorders
Anything that leads to hormone, vascular, or neurologic changes
- Endocrine - DM, hyperthyroid, hyperprolactinemia
- Vascular - HTN esp associated with sexual dysfunction; Unclear as to how much is from disease vs. medication
- Neurologic - DM neuropathy, MS, Parkinson, epilepsy; Epilepsy may be contributed to by medications
- Urinary - Interstitial cystitis, CKD
lab testings for female sexual disorder
- CBC if anemia suggested
- STI screening if indicated
- Hormone levels not usually helpful
how to assess if you and the patient on the same page?
Approaching Treatment of Sexual Disorders
- Assess patient goals
- Counsel the patient - Very common conditions; Multifactorial tx
- Address partner issues
- Address other conditions - Choose meds with minimal sexual SE
General Interventions for Sexual Disorders
- Counseling - Sex therapy; Couples counseling; General psychotherapy
- Lifestyle changes - Relieving stress/fatigue; Renewed emotional intimacy
- Improving body image
- Pelvic floor dysfunction
T/F: There is a set management to use to treat all patients the same
F:
- Many patients have complex, multifactorial cases.
- A multifaceted approach combining psychological interventions, nonpharmacologic therapies, medication, and relationship support is typically needed.
- It may take trials of different treatments to find what is right for your patient!
- Hormonal Rx - most helpful for patients with menopausal VVA
- Can improve libido, arousal response, pain secondary to vaginal atrophy
- Improves clitoral sensitivity
Estrogen
SE & CI of estrogen
- SE - liver disease, endometrial hyperplasia and cancer, VTE events; premenstrual-type sx
- CI - unexplained genital bleeding, pregnancy, hx or increased risk of clotting
dose considerations for estrogen
- local > systemic, transdermal > oral
- Not indicated for sexual dysfunction alone, but may help if sexual dysfunction occurs alongside menopausal symptoms
5 androgens?
which ones are the most potent?
testosterone, DHT, DHEA, DHEAS, androstenedione
androgens are not generally recommended, but has some evidence for ___ and ____ patients
- perimenopausal and postmenopausal patients
- May help with libido, arousal response
SE & CI of androgens
- SE - liver disease and low HDL (oral), skin irritation, hirsuitsm, acne
- CI - unexplained genital bleeding, pregnancy, unable to take estrogen - Failure to exhaust other methods
dose considerations for androgens
- Dosed much lower < male patient ranges
- MC transdermal patch/gel or as topical genital cream
- PO combo estrogen/testosterone pill available, but more SE noted
- Injections and pellets not typically used - Trial of 6 months
- approved for premenopausal patients with low sexual desire/libido
- 5HT-1a agonist / 5HT-2a antagonist
- Causes transient decrease in 5HT and increase in norepinephrine/dopamine in certain regions of the brain
Flibanserin (Addyi)
SE & CI of Flibanserin (Addyi)
-
SE - HoTN, dizziness, fainting
- worse w/ alcohol - abstain
- May also cause nausea, fatigue, sleepiness or insomnia - CI - alcohol, HoTN, hypersensitivity
- off-label use for sexual dysfunction
- NOR and dopamine reuptake inhibitor
- May have similar effects to flibanserin
- Thought to help sexual pleasure, arousal, orgasm
Bupropion (Wellbutrin, Zyban)
SE and CI Bupropion (Wellbutrin, Zyban)
- SE - agitation, insomnia, anxiety, tachycardia, triggering mania, seizure, weight loss, acute angle-closure glaucoma; Possible risk of suicide if 18-24 y/o
- CI - seizures, anorexia/bulimia, hypersensitivity, MAOI in last 14 d
dose considerations for Bupropion (Wellbutrin, Zyban)
- sustained release form may help reduce sx
- Dose in AM may be more helpful due to SE profile
- Longer-term studies and lower cost compared to flibanserin
- primary benefit seen in women with SSRI-induced sexual dysfunction (off-label use)
- Potential benefit to women with neuro disorders - DM, MS, spinal cord injury
- inhibits enzyme phosphodiesterase-5
- Leads to smooth muscle relaxation in the vasculature of the genitalia and lungs
PDE Inhibitors (sildenafil, tadalafil, vardenafil)
SE & CI of PDE Inhibitors (sildenafil, tadalafil, vardenafil)
- SE - headache, flushing, nausea/diarrhea
- Can cause severe hypotension if taken with nitrates - CI - nitrate use, hx of non-arteritic anterior ischemic optic neuropathy, hypersensitivity to rx
dose considerations for PDE inhibitors
- 50-100 mg orally, taken 1 hr prior to sexual activity
- Sildenafil is the only version studied for female sexual disorders, but other PDE-5s thought to have similar benefit
- approved for premenopausal patients with
- low sexual desire/libido
- agonist on melanocortin receptors in the brain
- Unknown how this improves hypoactive sexual desire
Bremelanotide (Vyleesi)
SE & CI of Bremelanotide (Vyleesi)
- SE - N/V, flushing, HA, hyperpigmentation
- No known interaction with alcohol
- May cause harm in the developing fetus - CI - HTN or Cv disease, liver disease, hypersensitivity
Other Tx Options for Female Orgasmic Disorder
- Sexual Devices
-
Directed Masturbation
- Home exercises done alone, then with a partner if desired
- Weekly sessions x 5-6 wks usually effective
- Sensate focus exercises - done with partner from get-go - may be less effective -
Genital Cosmetic Procedures - Collagen injection, clitoral hood reduction, PRP injection
- No scientific evidence to support, costly, risk of tissue damage
GU syndrome of menopause - most pain is secondary to ?
tx?
hypoestrogenism and subsequent atrophy of GU tissues
- Other than vaginal estrogen therapy: Vaginal lubricants and moisturizers, Vaginal DHEA or testosterone, Oral ospemifene
- Vaginal laser/radiofrequency - Very limited evidence and costly
- Pelvic Floor PT - vaginal dilators and other PT may be helpful for patients with advanced atrophy who have failed conservative tx
mgmt for Vaginismus
PT + treating any underlying psychological cause is the mainstay of treatment
- Pelvic PT - vaginal dilators, myofascial release
- Other tx - sex therapy, relaxation exercises, desensitization
- Medications - gabapentin, TCAs, cyclobenzaprine, botulinum toxin injection
mgmt for Vulvodynia
Removal of irritating agent + good vulvar hygiene is the initial approach to improvement
- Pelvic PT - myofascial release
- Topical Therapies - lidocaine, estrogen +/- testosterone, DHEA
-
Oral Meds (not first-line) - TCAs or SNRIs, gabapentin, ospemifene
- If evidence of fungal infection - itraconazole x 5-8 weeks
