FEMALE SEXUAL DYSFUNCTION:ALL YOU WANT TO KNOW

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.

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.

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. 

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