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Women's health > Women's sexual disorders > Flashcards

Women's sexual disorders Flashcards

1
Q

Stages of Sexual Response

A
  • Stage 1 - Desire (Libido)
  • Stage 2 - Arousal
  • Stage 3 - Orgasm
  • Stage 4 - Resolution
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2
Q

Hormonal Excitatory Effects on female response

A
  1. Estrogen - Peri/Post-menopausal pts; Pre-ovulation surge
  2. Testosterone - At supraphysiologic levels
  3. Dopamine
  4. Norepinephrine
  5. Oxytocin
  6. Melanocortins
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3
Q

Hormonal Inhibitory Effects on female response

A
  1. Serotonin - At higher levels
  2. Prolactin - Nursing mothers; Hyperprolactinemia
  3. Opioids
  4. Endocannabinoids
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4
Q

avg puberty age for females

A

8-13 y

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5
Q

Expected variations of libido and sexual activity, based on…

A
  1. Mental health
  2. Relationship status
  3. Societal/cultural/family norms
  4. Phase of menstrual cycle
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6
Q

sexual changes during Puberty, Adolescence, Adulthood

A
  1. puberty
  2. Expected variations of libido and sexual activity
  3. Setting healthy expectations for sexual activity
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7
Q

sexual changes during Perimenopause and Postmenopause

A
  1. Fluctuating hormones influence sexual desire and satisfaction - Libido, VVA, chronic disease
  2. Insecurities about aging and transitioning to a new period of life
  3. Some women note increased sexual satisfaction and desire
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8
Q

Up to ?% of women report at least one sexual problem
Highest and lowest where?

A
  1. 43
  2. Highest - SE Asia; Lowest - N Europe
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9
Q

Encompasses problems with either low sexual desire or abnormal arousal response (emotional/mental or lubrication/swelling)

A

Female Sexual Interest/Arousal Disorder

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10
Q

2 General Risk Factors
for Sexual Dysfunction

A
  1. psychosocial
  2. medical conditions
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11
Q

Criteria for common female sexual disorders

A
  1. Must occur 75% of the time or greater
  2. Must have been occurring for 6+ months
  3. Must cause distress for the patient
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12
Q

Female Sexual Interest/Arousal Disorder must report at least 3 of the following 6 criteria:

A
  1. Reduced or absent interest in sex or sexual activities
  2. Reduced or absent fantasizing or sexual thoughts
  3. Reduced or absent initiation of sexual activities - Generally unreceptive to partner initiation
  4. Reduced or absent interest or arousal to stimuli (internal or external)
  5. Reduced or absent excitement or pleasure during sexual activity
  6. Reduced or absent genital/nongenitial sensations during sexual activity
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13
Q

Encompasses problems with either vaginismus (involuntary vaginal
spasm), vulvar pain/vestibulodynia, or dyspareunia (pain with
penetration or sexual activity)

A

Genitopelvic Pain/Penetration Disorder

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14
Q

which type of sexual disorder is MC?

A

any sexual dysfunction - 43%

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15
Q

criteria for Genitopelvic Pain/Penetration Disorder

A
  1. Marked vulvovaginal or pelvic pain during penetration attempts
  2. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or because of vaginal penetration
  3. Marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration
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16
Q

h/o of what is common in Genitopelvic Pain/Penetration Disorder

A

sexual or physical trauma or abuse

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17
Q

Encompasses problems with frequency, intensity, or achievement of orgasm response

A

Female Orgasmic Disorder

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18
Q

criteria for Female Orgasmic Disorder

A
  1. Delayed, infrequent, diminished, or absent orgasm response after a normal sexual arousal phase on all or almost all sexual encounters
  2. Distress or interpersonal problems due to orgasmic dysfunction
  3. Absence of disorder or substance that would explain the orgasmic dysfunction
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19
Q

For Female Orgasmic Disorder, always consider… (3)

A
  1. Psychiatric and social contributing factors
  2. Patient position, arousal, and adequate stimulation
  3. Medical conditions, including menopause
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20
Q

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
A

Substance/Medication-Induced
Sexual Disorder

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21
Q

criteria for Substance/Medication-Induced
Sexual Disorder

A
  1. Significant disturbance in sexual function
  2. Disturbance occurred during or soon after exposure to a medication, or substance intoxication/withdrawal
  3. 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
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22
Q

MCC of Substance/Medication-Induced
Sexual Disorder

A

Psychiatric medications

  1. antidepressants (SSRIs, TCAs)
  2. Anxiolytics - BZDs lower libido and arousal; buspirone not associated
  3. Anticonvulsants - dec libido
  4. Lithium or Barbiturates - any type of sexual dysfunction
23
Q

which antidepressants are not as associated with sexual dysfunction

A

Dopaminergic or selective serotonergic (mirtazapine, bupropion, venlafaxine, duloxetine)

24
Q

other causes of Substance/Medication-Induced Sexual Disorder

A
  1. Anticholinergics - can reduce genital arousal and lubrication (Antihistamines, Antispasmodics)
  2. Antihypertensives - BBs, clonidine, methyldopa
  3. Hormonal agents - GnRH agonists/antagonists, SERMs, aromatase inhibitors
    - Contraceptives - mixed data; no strong evidence for/against
25
Q

Substances of Abuse that can impact sexual function include…

A
  1. Nicotine - limits sexual arousal
  2. Alcohol - hypogonadotropic state; impaired overall function
  3. Opiates - hypogonadotropic state; impaired overall function
  4. Marijuana - does not harm function but negative impact on sperm, fetus

Most follow a dose-response relationship

26
Q
  • 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
A

Other Female Sexual Disorders

27
Q

gynecologic conditions that causes other female sexual disorders

A
  1. Pregnancy and Postpartum - physical discomfort, life stressors, fatigue
    - No impact of type of delivery or number of parity noted
  2. Infertility - sex becomes a “chore” and associated with disappointment
  3. Endometriosis - due to adhesions and scarring; especially with deep/forceful penetration, but can be with most types of sexual activity
  4. Uterine fibroids - dyspareunia, fatigue secondary to anemia
  5. Pelvic organ prolapse / Incontinence - dyspareunia, discomfort, embarrassment
  6. GU syndrome of menopause - hormonal changes, atrophy
28
Q

medical conditions that causes other female sexual disorders

A

Anything that leads to hormone, vascular, or neurologic changes

  1. Endocrine - DM, hyperthyroid, hyperprolactinemia
  2. Vascular - HTN esp associated with sexual dysfunction; Unclear as to how much is from disease vs. medication
  3. Neurologic - DM neuropathy, MS, Parkinson, epilepsy; Epilepsy may be contributed to by medications
  4. Urinary - Interstitial cystitis, CKD
29
Q

lab testings for female sexual disorder

A
  • CBC if anemia suggested
  • STI screening if indicated
  • Hormone levels not usually helpful
30
Q

how to assess if you and the patient on the same page?

Approaching Treatment of Sexual Disorders

A
  1. Assess patient goals
  2. Counsel the patient - Very common conditions; Multifactorial tx
  3. Address partner issues
  4. Address other conditions - Choose meds with minimal sexual SE
31
Q

General Interventions for Sexual Disorders

A
  1. Counseling - Sex therapy; Couples counseling; General psychotherapy
  2. Lifestyle changes - Relieving stress/fatigue; Renewed emotional intimacy
  3. Improving body image
  4. Pelvic floor dysfunction
32
Q

T/F: There is a set management to use to treat all patients the same

A

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!
33
Q
  • Hormonal Rx - most helpful for patients with menopausal VVA
  • Can improve libido, arousal response, pain secondary to vaginal atrophy
  • Improves clitoral sensitivity
A

Estrogen

34
Q

SE & CI of estrogen

A
  • SE - liver disease, endometrial hyperplasia and cancer, VTE events; premenstrual-type sx
  • CI - unexplained genital bleeding, pregnancy, hx or increased risk of clotting
35
Q

dose considerations for estrogen

A
  • local > systemic, transdermal > oral
  • Not indicated for sexual dysfunction alone, but may help if sexual dysfunction occurs alongside menopausal symptoms
36
Q

5 androgens?
which ones are the most potent?

A

testosterone, DHT, DHEA, DHEAS, androstenedione

37
Q

androgens are not generally recommended, but has some evidence for ___ and ____ patients

A
  • perimenopausal and postmenopausal patients
  • May help with libido, arousal response
38
Q

SE & CI of androgens

A
  • 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
39
Q

dose considerations for androgens

A
  1. Dosed much lower < male patient ranges
  2. 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
  3. Trial of 6 months
40
Q
  • 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
A

Flibanserin (Addyi)

41
Q

SE & CI of Flibanserin (Addyi)

A
  1. SE - HoTN, dizziness, fainting
    - worse w/ alcohol - abstain
    - May also cause nausea, fatigue, sleepiness or insomnia
  2. CI - alcohol, HoTN, hypersensitivity
42
Q
  • off-label use for sexual dysfunction
  • NOR and dopamine reuptake inhibitor
  • May have similar effects to flibanserin
  • Thought to help sexual pleasure, arousal, orgasm
A

Bupropion (Wellbutrin, Zyban)

43
Q

SE and CI Bupropion (Wellbutrin, Zyban)

A
  • 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
44
Q

dose considerations for Bupropion (Wellbutrin, Zyban)

A
  • 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
45
Q
  • 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
A

PDE Inhibitors (sildenafil, tadalafil, vardenafil)

46
Q

SE & CI of PDE Inhibitors (sildenafil, tadalafil, vardenafil)

A
  1. SE - headache, flushing, nausea/diarrhea
    - Can cause severe hypotension if taken with nitrates
  2. CI - nitrate use, hx of non-arteritic anterior ischemic optic neuropathy, hypersensitivity to rx
47
Q

dose considerations for PDE inhibitors

A
  • 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
48
Q
  • approved for premenopausal patients with
  • low sexual desire/libido
  • agonist on melanocortin receptors in the brain
  • Unknown how this improves hypoactive sexual desire
A

Bremelanotide (Vyleesi)

49
Q

SE & CI of Bremelanotide (Vyleesi)

A
  1. SE - N/V, flushing, HA, hyperpigmentation
    - No known interaction with alcohol
    - May cause harm in the developing fetus
  2. CI - HTN or Cv disease, liver disease, hypersensitivity
50
Q

Other Tx Options for Female Orgasmic Disorder

A
  1. Sexual Devices
  2. 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
  3. Genital Cosmetic Procedures - Collagen injection, clitoral hood reduction, PRP injection
    - No scientific evidence to support, costly, risk of tissue damage
51
Q

GU syndrome of menopause - most pain is secondary to ?
tx?

A

hypoestrogenism and subsequent atrophy of GU tissues

  1. Other than vaginal estrogen therapy: Vaginal lubricants and moisturizers, Vaginal DHEA or testosterone, Oral ospemifene
  2. Vaginal laser/radiofrequency - Very limited evidence and costly
  3. Pelvic Floor PT - vaginal dilators and other PT may be helpful for patients with advanced atrophy who have failed conservative tx
52
Q

mgmt for Vaginismus

A

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
53
Q

mgmt for Vulvodynia

A

Removal of irritating agent + good vulvar hygiene is the initial approach to improvement

  1. Pelvic PT - myofascial release
  2. Topical Therapies - lidocaine, estrogen +/- testosterone, DHEA
  3. Oral Meds (not first-line) - TCAs or SNRIs, gabapentin, ospemifene
    - If evidence of fungal infection - itraconazole x 5-8 weeks

Women's health (15 decks)

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