DR SHARMILA MAJUMDAR:FEMALE SEXOLOGIST |
Female sexual
dysfunction- Involves any problem from any phase of sexual response cycle that
prevents an individual or couple from experiencing satisfaction from sexual
activity. Includes disorder of desire, arousal, orgasm and pain.
Definitions of female
sexual dysfunction (FSD) from the Diagnostic and Statistical Manual of
Mental Disorders are based on the linear model of human sexual response
posed by Masters and Johnson. This table provides a brief summary of the
definitions for each of 6 FSDs across the sexual response cycle: The presence of personal or relationship
distress is a required criterion for a diagnosis of these sexual dysfunctions.
DSM-IV-TR
Classification of Female Sexual Dysfunction:
Desire Disorders
|
|
Hypoactive Sexual
Desire Disorder
|
Absence or
deficiency of sexual interest and/or desire
|
Sexual Aversion
Disorder
|
Aversion to and
avoidance of genital contact with a sexual partner
|
Arousal Disorders
|
|
Female Sexual
Arousal Disorder
|
Inability to attain
or maintain adequate lubrication-swelling response of sexual excitement
|
Persistent Genital
Arousal Disorder*
|
Persistent
sensations of genital arousal that are felt to be unprovoked, intrusive, and
unrelieved by one or several orgasms.
|
Orgasmic Disorder
|
|
Female Orgasmic
Disorder
|
Delay in or absence
of orgasm after a normal sexual excitement phase
|
Pain Disorders
|
|
Dyspareunia
|
Genital pain
associated with sexual intercourse
|
Vaginismus
|
Involuntary
contraction of the perineal muscles preventing vaginal penetration
|
PREVALANCE:
Female Sexual
Dysfunction: An Ignored Epidemic
Masters and Johnson
estimated 50% of all marriages are plagued by sexual dysfunction. Roughly 1 out
of 3 women have some form of fsd. Most common sexual dysfunction is hypoactive
desire disorder. Sexual arousal disorder is female equivalent of impotence and
usually psychological in nature. Orgasmic disorder- unlike men, in women orgasm
is learned, not an automatic process.
43% of women suffer from some type of
sexual dysfunction . Female sexual dysfunction most commonly occurs in premenopausal women ages 25 - 50
Female Sexual Dysfunction Risk Factors :
Hypertension , Smoking & Substance
abuse, Hyperlipidemia, Previous Pelvic Surgery &Past Psychological Trauma
Several
Pharmacotherapies Can Increase the Risk of Female Sexual Dysfunction
Several pharmacotherapies may result in sexual side effects. For example, the SSRIs have been associated with delayed or absent orgasm, depending on the balance between serotonergic, noradrenergic, and dopaminergic activity and dose. Patients should be questioned on the use of these pharmacotherapies as well as use of over-the-counter and alternative medicines during the medical history.
Several pharmacotherapies may result in sexual side effects. For example, the SSRIs have been associated with delayed or absent orgasm, depending on the balance between serotonergic, noradrenergic, and dopaminergic activity and dose. Patients should be questioned on the use of these pharmacotherapies as well as use of over-the-counter and alternative medicines during the medical history.
Antidepressants
and mood stabilizers
|
SSRIs
SNRIs Tricyclics Antipsychotics |
Benzodiazepines
Antiepileptics MOAIs |
Antihypertensives
|
Beta-blockers
Alpha-blockers |
Diuretics
|
Cardiovascular
agents
|
Lipid-lowering
agents
Digoxin |
|
Hormones
|
Oral contraceptives
Estrogens Progestins |
Antiandrogens
GnRH agonists |
Others
|
Histamine
H2-receptor blockers
Narcotics Amphetamines Anticonvulsants |
Basson R, Schultz WW.
Lancet. 2007;369:409-424; Kingsberg SA, Janata JW. Urol Clin North Am.
2007;34:497-506
Certain Medical
Conditions Can Increase the Risk of Female Sexual Dysfunction
A complete medical history should be conducted in order to rule out a female sexual dysfunction (FSD) secondary to an underlying medical condition. Untreated depression is associated with decreased desire due to alterations in serotonergic activity. Diabetes impairs arousal and orgasm, possible due to uncontrolled hyperglycemia. Thyroid disease is often associated with decreased desire that resolves with treatment. Coronary artery disease or a history of myocardial infarction may negatively impact desire or arousal due to fear of causing another event. Neurologic disease such as multiple sclerosis and spinal cord injuries may impair arousal and orgasm due to injury in brain regions that process sexual stimuli. Androgen insufficiency resulting from oophorectomy may result in hypoactive desire. Estrogen deficiency in postmenopausal women is associated with vaginal atrophy, pain, and impaired arousal. Partner health issues may also contribute to an FSD.
A complete medical history should be conducted in order to rule out a female sexual dysfunction (FSD) secondary to an underlying medical condition. Untreated depression is associated with decreased desire due to alterations in serotonergic activity. Diabetes impairs arousal and orgasm, possible due to uncontrolled hyperglycemia. Thyroid disease is often associated with decreased desire that resolves with treatment. Coronary artery disease or a history of myocardial infarction may negatively impact desire or arousal due to fear of causing another event. Neurologic disease such as multiple sclerosis and spinal cord injuries may impair arousal and orgasm due to injury in brain regions that process sexual stimuli. Androgen insufficiency resulting from oophorectomy may result in hypoactive desire. Estrogen deficiency in postmenopausal women is associated with vaginal atrophy, pain, and impaired arousal. Partner health issues may also contribute to an FSD.
Certain Medical
Conditions Can Increase the Risk of Female Sexual Dysfunction
Condition
|
Effects on Sexual
Function
|
Depression
|
Decreased desire
|
Diabetes
|
Impaired arousal and
orgasm
|
Thyroid disease
|
Decreased desire
|
Cardiovascular
disease
|
Impaired arousal
|
Neurologic diseases
|
Impaired arousal and
orgasm
|
Androgen
insufficiency
|
Decreased desire
|
Estrogen deficiency
|
Impaired arousal
|
Basson R, Schultz WW.
Lancet. 2007;369:409-424; Kingsberg SA, Janata JW. Urol Clin North Am.
2007;34:497-506
Causes of Female Sexual Dysfunction
In addition to the
biological factors that may contribute to FSD, psychological factors also play
a significant role. Stress, a history of sexual or substance abuse, and
sociocultural influences may have a negative impact on a woman’s sexual
function.
Organic Causes
Psychosocial Factors Can Increase the Risk of Female Sexual Dysfunction
In addition to the biological factors that may contribute to FSD, psychological factors also play a significant role. Stress, a history of sexual or substance abuse, and sociocultural influences may have a negative impact on a woman’s sexual function. Relationship Issues Can be the cause, effect, or both of fsd Which include Sexual boredom, Dislike of partner, Anger, Fear, Power differences, control issues, Fallen out of love, Lack of sexual attraction Infidelity , Disappointment, Perceived selfishness, Money, kids, in-laws, Different values or interests, Abuse, Partner’s psychological disturbance. Sexual performance concerns -an important issue is the understanding of the male partner, who often feels that, like him, his partner cannot fully enjoy sexual activity without orgasm. Hence, there is an enormous pressure on the woman to achieve orgasm.
In addition to the biological factors that may contribute to FSD, psychological factors also play a significant role. Stress, a history of sexual or substance abuse, and sociocultural influences may have a negative impact on a woman’s sexual function. Relationship Issues Can be the cause, effect, or both of fsd Which include Sexual boredom, Dislike of partner, Anger, Fear, Power differences, control issues, Fallen out of love, Lack of sexual attraction Infidelity , Disappointment, Perceived selfishness, Money, kids, in-laws, Different values or interests, Abuse, Partner’s psychological disturbance. Sexual performance concerns -an important issue is the understanding of the male partner, who often feels that, like him, his partner cannot fully enjoy sexual activity without orgasm. Hence, there is an enormous pressure on the woman to achieve orgasm.
Cultural
influences/religious taboos & negative upbringing may have instilled the
belief that sex is dirty and masturbation is unnatural and unhealthy education
n permission sud be given by the therapist to alter such misconception. Partner
sexual dysfunction(ED) may cause desire disorder in women. Alcohol & sub
abuse– Sexuality and partner relationships were found
to be more stressful and conflicting among women alcoholics and sub abusers.
Decrease in desire, impaired arousal, lubrication, delayed orgasm are
experienced by alcoholics n sub abusers
Depressive states
increases feeling of fatigue thereby diminishing desire for sex causing
inhibition of desire and arousal
Psychological/Psychosocial
Causes
Diagnosis / Evaluation
Non-judgemental,
direct questions are best use for evaluation. Clinicians should inquire about
sexual function in all patients. This screening should be carried out in
private, when the patient is fully clothed. Studies indicate that physicians’
characteristics, such as level of eye contact, seat positioning, and relaxed
nature, have an impact on patients’ comfort when discussing sexuality.
Clinicians can increase their own level of comfort by practicing sexual
terminology.
Complete
history and physical examination is critical and should include:
• Pap and pelvic exams
• Attitude towards sex
• Past trauma/sexual abuse
• Relationship problems
• Sexual orientation
• Substance abuse
• Medical history
Elements of a Routine Medical
Assessment for Female Sexual Dysfunction
•
Past
medical history
•
Physical
examination
o
Inspection
of external genitalia
o
Mono- and
bi-manual examinations
•
Laboratory
tests
o
Thyroid
function tests
o
Hormone
profile
o
Fasting
glucose
Patients should be
queried on their past and present medical histories to identify any biological
factors that may contribute to female sexual dysfunction. A physical
examination, including a urogynecologic examination, should be performed to
identify anatomical abnormalities or pathologies that may compromise, mask, or
be masked by sexual function.
Comprehensive
Sexual Assessment
•
Nature of problem
•
Duration of problem
•
Primary or secondary
•
Situational or generalized
•
Relationship problems
•
Stressors
•
Sexual problems in partner
•
History of physical, emotional or sexual abuse
Information obtained from this assessment can be used to identify which domain(s) of sexual response are affected, determine the timeline, dissect the etiology of fsd, and provide information on the most appropriate treatment approach. Brief Screening for Female Sexual Dysfunction
Clinicians should inquire about sexual function in all patients. Assessment should be carried out in private, when the patient is fully clothed. Studies indicate that physicians’ characteristics, such as level of eye contact, seat positioning, and relaxed nature, have an impact on patients’ comfort when discussing sexuality.
Detailed sexual history that clinician can
collect when there is time to do so. Information from the assessment can be
used to dissect the etiology of female sexual dysfunction.
·
First
sexual experience
•
Approximate
number of partners
•
Gender and
orientation development
•
Sexually
transmitted infections
•
Pregnancies
•
Past
history of sexual problems
•
Current/past
history of physical or sexual abuse (domestic violence to be covered separately
but keep in mind)
•
Sexual messages received
growing up
•
Significant sexual experiences -
Both positive and negative, Particularly any abuse (psychological, physical,
sexual)
•
History of sexual relationship
with current partner
Algorithm for Establishing a Diagnosis of
Female Sexual Dysfunction
Basson R, et al. J Sex
Med. 2004;1:24-34.
Algorithm for
Establishing a Diagnosis of Fsd may
be helpful for a brief comparison of all the possible female sexual
dysfunctions and their key criteria and can be used for making a diagnosis of
sexual dysfunction.
General Treatment Guidelines
•
Education, Education,
Education!! (anatomy, sexual function, effects of pregnancy, menopause &
aging)
•
Enhancing stimulation (erotic
materials, encouraging communication during sexual activity,
masturbation)
•
Distraction techniques
(fantasy, Kegel exercises with intercourse, background music or television)
•
Encouraging non-coital
behaviours (massage, sensate focus exercise)
•
Minimize pain (positional,
lubricants, warm baths, biofeedback, NSAIDS prior to
intercourse)
•
Treatment depends on the cause,
if organic, appropriate medical/surgical interventions. Plus or minus sex
counselling. If psychogenic then
psychotherapy/sex therapy/ marital therapy/ behaviour therapy or CBT can be used.
•
lifestyle modification
counselling should be included in all
cases.
Holistic Approach For Management of FSD
Most successful treatments for female sexual dysfunction are
“Psychophysiological”, in that
physiological change circularly interacts with
psychological change. In the enthusiasm for new physiologic approaches,
there has been a strong tendency to overlook the evidence that does exist for
efficacious psychological treatments.
- The numerous psychological factors that motivate a woman to begin her sexual experience must always be kept in the forefront when pharmacotherapy is considered.
- Since a psychological treatment does impact sexual physiology,
we need to continue to develop psychological approaches both out of
intellectual interest
and out of respect for the choices of patients preference. - The prescription of a physiologic treatment which ignores the fact that human sexuality is infused with individual meaning may invite further interference with sexual functioning.
Psychological
Approaches To Female Sexual Dysfunction
Disorder
|
Psychological approaches
|
Hypoactive Sexual
Desire Disorder
|
•
The most common of disorders.
Treatment must be individualized to the factors that is inhibiting sexual
interest.
•
Some couples require marital
therapy prior to focusing directly on enhancing sexual activity. Declining
sex is sometimes one of the few areas where someone who feels dominated in
most other areas of a marriage may still exert control.
•
Many couples will need to
direct focus on the sexual relationship through education and couple
assignments they expand the variety and time devoted to sexual activity plus
bridge the gap in their sexual expectations.
•
Some couples will also need to focus on how
they may sexually approach their partner in more interesting and desirable
ways, and how to more gently and
tactfully decline a sexual invitation.
|
Aversion Disorder
|
•
Cognitive-behaviour therapy
with systematic desensitization and relaxation skills as a focal component
•
Couples therapy including
communication, relationship, and negotiation skills
•
Group therapy to teach sexual
function skills, should be included.
|
Disorder
|
Psychological approaches
|
Arousal Disorder
|
•
The
psychological component should be addressed with individual psychotherapy
& couples therapy.
•
The psychological portion of
treatment is directed at teaching how to focus on pleasurable thoughts and
feelings about sex, i.e. sensate focus.
•
Strategies
to alleviate anxiety by employing distraction techniques(spectatoring),
fantasizing or listening to music are helpful.
•
Treating communication and
other relationship issues believed to cause or maintain the disorder .
|
Persistent Genital
Arousal Disorder
|
•
Also
attributed to psychological / stress related causes. Psycho-education, stress
reduction techniques, identification of triggers is often helpful.
|
Disorder
|
Psychological
approaches
|
Sexual Orgasmic Disorder
|
•
Unlike
men, in women orgasm is a learned and not an automatic process, 5-15% have
never had an orgasm, anorgasmia, usually result of sexual inexperience,
performance anxiety or past experiences that have let to inhibition
•
The
goals such treatment relies on decreasing anxiety; minimizing distraction & inhibition and
maximizing stimulation.
•
Methods
to minimize inhibition include spectatoring (observing oneself from a third
party perspective), fantasizing or listening to music. Stimulation may
include masturbation and or use of vibrator as needed.
•
Individual
and couple counseling sessions and sex therapy may be effective for treatment
of orgasmic disorder. Usually responsive to therapy.
•
Occurs usually due to sexual inexperience or
lack of sufficient stimulation.
|
Disorder
|
Psychological
approaches
|
Pain Disorder
|
•
Vaginismus – Treatment consists of
progressive muscle relaxation and vaginal dilation exercises using plastic
dilators. It is important that the use of dilators proceeds in a systematic
progression under the direction of a professional and should actively involve
the woman's sexual partner. The treatment include gradually more intimate
contact eventually culminating in successful and pain free intercourse. Sex
education about physiology, sexual response cycle and myths about sex is also
very important to counter sexual naivety and dispel any misinformation.
•
In cases
where there is a strong phobic avoidance component, the use of hypnosis and
relaxation may be useful.
•
Dyspareunia
– Progressive muscle relaxation exercises may help a woman regain control
over vaginal muscles, reducing pain and making sexual intercourse more
pleasurable in deep dyspareunia.
•
In long
term pain disorder psychotherapy, pain control strategies and systematic
desensitization are helpful.
|
Pharmacotherapeutic
Approaches To Female Sexual Dysfunction
Disorder
|
Pharmacotherapeutic approaches
|
Hypoactive Sexual
Disorders
|
•
Transdermal
Testosterone gel (phase 3 trial underway), inhaled sprays and vaginal ring
containing testosterone under research
•
Estrogen
therapy may help some
|
Sexual Arousal
Disorder
|
•
Vacuum device which increases clitoral and
external genitalia blood flow
•
Local
application of a vasodilator is another approach to increase blood flow
•
Number
of centrally acting agents are also under investigation
|
Orgasmic Disorder
|
•
There are no pharmacotherapeutic approaches of treating orgasmic disorder
but the vacuum device which increases genitalia blood flow is also approved.
•
EROS
Therapy
|
Pain Disorder
|
•
Dyspareunia - vaginal lubrication gel and variety of local or systemic hormone
therapies can be used (post menopausal women)
•
Vaginismus
- Dilators can be used
|
Referral for Female Sexual Dysfunction
Clinicians with a low
level of comfort or expertise in treating patients with female sexual
dysfunction (FSD) may wish to refer their patient to a specialist to improve
outcomes. Patients with complex FSD or accompanying relationship problems may
also benefit from specialized treatment. Options for referral include Sexologist,
sex therapists or an OB/GYN, primary care practitioner specializing in FSD.
Patients should be reminded that referral is a common procedure in order to
alleviate any fears or feelings of rejection by their clinician.
Basic Treatment
Strategies for ‘FSD’
·
Estrogen replacement therapy has been shown to correlate positively with
sexual activity, enjoyment and desire, although the findings are not universal.
·
Testosterone
Therapy for Treatment of Disorders of Desire
Ø Screening
o
Baseline testosterone levels (free and total),
o
baseline lipid profile,
o
baseline liver enzyme levels,
o
mammography,
o
Papanicolaou smear
Ø Initiate therapy
o
Combination product (Estratest or Estratest hs)
o
Methyltestosterone (Android), 1.25 to 2.5 mg daily
o
Micronized oral testosterone, 5 mg twice daily
o
Testosterone proprionate 2 percent in petroleum applied daily to every
other day
o
Testosterone injectables/pellets
Ø Reevaluation at three to four months
o
Repeat testosterone levels, lipid profile, liver enzyme levels
o
Monitor symptoms, side effects
Ø Continued therapy
o
Taper to lowest effective dosage
o
Monitor lipid levels, liver enzyme levels once or twice yearly
o
Routine Papanicolaou smear and mammography schedules
KEGEL EXERCISES
Ø Potential uses
o
Increased
pubococcygeal tone
o
Improved
orgasmic intensity
o
Correction
of orgasmic urine leakage
o
Distraction
technique during intercourse
o
Improved
patient awareness of sexual response
Ø Teaching Kegel exercises
o
Instructional
examination with examiner's finger in vagina
o
Initial
patient home exercise with patient's finger in vagina
v Slow count to 10, with movement directed
"in and up"
v Hold for count of 3
v Slow release to count of 10
v Repeat 10 to 15 times daily
o
Consider
vaginal weights, biofeedback clinics
Ø Maintaining Kegel exercises
o
Advise
repetitions during routine activities (standing in line, at stop lights, etc.)
o
Schedule
follow-up appointments to discuss progress
DEVICES/VIBRATORS/
LUBRICANTS can be used as a basic
treatment strategy for FSD
APPROVED- EROS
THERAPY
Ø The Eros Therapy device is the first clinically
proven prescription device cleared to market for women with arousal and
orgasmic disorders
Ø A Non-
Pharmacological Method to Increase Vaginal Blood Flow in Patients with Sexual
Arousal Disorder
Ø A Prospective Duplex Doppler Ultrasonographic
Study in Women with Sexual Arousal Disorders to Objectively Assess Genital
Engorgement Following Therapeutic Use with Eros Therapy.
Original
Clinical Study (EROS)
Results after
Using Eros
|
Sensation
|
Orgasm
|
Lubrication
|
Satisfaction
|
More than Before
Eros
|
90%
|
55%
|
80%
|
80%
|
Same as Before
Eros
|
10%
|
45%
|
20%
|
20%
|
Original clinical trial results as published
by: Billups, K; Berman, J; Berman, L;, Metz, M; Glennon, M; Goldstein, I "A
new Non-Pharmacological Vacuum Therapy for Female Sexual Dysfunction" Journal
of Sex & Marital Therapy: 27: 2001.
FSD-Treatment Option On the Horizon
•
Androgens
•
Prostaglandins
•
Nitric
oxide delivery systems
•
Dopamenergic
agonist
•
Flibanserin - is a drug
produced by Boehringer
Ingelheim.
It is currently being investigated as a drug for women suffering from decreased
sexual desire. It is a 5-HT1A serotonin
receptor agonist and 5-HT2a serotonin receptor antagonist that had
initially been developed as an anti-depressant.
•
Disorders
of Desire are an area of great interest
and research- neuropeptide oxytocin, which affects sexual motivation in
animals, may have a role in treating disorders of this phase
•
Apomorphine
may be used in treating FSD as it is centrally acting through hypothalamus,
& also through peripheral organ response -
disorders of desire and arousal.
•
Drugs
useful for reducing pain in sexual pain
disorder (gabapentin)
All
Women’s Problems Start With Men
•
MEN tal illness
•
MEN stural cramps
•
MEN opause
•
HIS terectomy
•
Fe MALE Sexual Dysfunction
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