M. Chantel Long, M.D. June 24, 2011

 Discuss and Define Sexual Dysfunction in Women  Review Causes  Provide Strategies to Improve Communication with Patients and Treatment

 Defined as the persistent or recurrent deficiency or absence of sexual thoughts, fantasies, and/or desire for sexual activity as per the Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition.  It is widely agreed that decreased receptivity is another contributing factor and often the key symptom

 It must cause marked personal distress or interpersonal difficulties for the patient to meet the diagnosis  It can not be associated with another psychiatric disorder, drug, medication side effect, or other medical condition as a primary cause  May occur in women of all ages

 Four categories of female sexual disorders  Six Sexual Disorders

Hypoactive Sexual Desire Disorder Sexual Aversion Disorder Sexual Desire Disorders Female Sexual Arousal Disorder Sexual Arousal Disorders Female Orgasmic Disorder Orgasmic Disorders Dyspareunia Vaginismus Pain Disorders

Masters and Johnson Kaplan and Lief Linear Models Biopsychosocial Basson Circular Models

Orgasm Resolution Plateau Excitement

ResolutionOrgasmDesire

Emotional Intimacy Sexual Stimuli Sexual Arousal Arousal and Sexual Desire Emotional and Physical Satisfaction

 Is usually multifactorial (not just medical or hormonal)  Often, women choose to be sexual for reasons other than desire, such as for emotional intimacy or to please their partner.

Emotional Intimacy Sexual Stimuli Sexual Arousal Arousal and Sexual Desire Emotional and Physical Satisfaction

 Biopsychosocial model differs from the linear models in that it shows there are multiple factors contributing to whether a woman will have a healthy sexual response  Biological  Pyschological  Social  Interpersonal

 Hormone Levels  Ongoing Disease Processes (Sjogren’s)  Medication Side Effects  Tagamet, Wellbutrin, Diuretics, SSRIs, Narcotics, Anticonvulsants, and Antihistamines

 Depression  Anxiety  Confidence/Self-Esteem  Performance Anxiety

 Religion  Cultural Factors

 Marriage Counseling  Relationship Issues

 More difficult to treat females due to the many factors, i.e. one can’t simply prescribe “a blue pill”  Must consider all the possible factors, including stress and fatigue  Common after having a baby due to hormone changes, breastfeeding, stress, lack of sleep, lack of privacy, and increase time pressures

 National Health and Life Survey  43% reported having a sexual problem 22% Low Sexual Desire 14% Arousal Issues 7% Pain Issues  PRESIDE Study  43% reported having a sexual problem 12% reported Distress 9.5 % Low Sexual Desire 5.0% Arousal Issues 4.6% Orgasm Issues

 The most prevalent sexual disorder across all ages  It is not a disorder that only occurs in older women

Prevalence of Sexual Problems Associated With Distress by Age Group DesireArousalOrgasmAny Valid Responses28,44728,46127,85428,403 With Distress2,8681,5561,3153,456 Age Stratified Prevalence Years8.9%3.3%3.5%10.8% Years12.3%7.5%5.7%14.8% >65 Years7.4%6.0%5.8%8.9%

 Those with underlying medical issues (depression, diabetes)  Postpartum (Natural or Surgical)  Age > 45

 Menopause – naturally or surgically induced  Hypotestosteronism  Associated Disease – Diabetes Mellitus, Sleep Apnea, DDD, and even Age  Depression – whether the cause or the consequence  Substance Abuse  Dyspareunia (lubrication, position, infections)

 Clinician Based  Gender  Time  Lack of Screening Tool Use  Lack of Training  Lack of Effective Treatment

 Decreased Sexual Desire Screener  Female Sexual Function Index  Brief HSDD Screener

1. In the past, was your level of sexual desire or interest good and satisfying to you? 2. Has there been a decrease in your level of sexual desire or interest? 3. Are you bothered by your decreased level of sexual desire or interest? 4. Would you like your level of sexual desire or interest to increase? 5. Which of the factors below do you feel may be contributing to your current decrease in sexual desire or interest? (Check all that apply) a. An operation, depression, injuries, or other medical condition? b. Medication, drugs, or alcohol that you are currently taking? c. Pregnancy, recent childbirth, or are you having any menopausal symptoms? d. Other sexual issues you may be having (pain, decreased arousal or orgasms)? e. Your partner’s sexual problems? f. Dissatisfaction with your relationship or partner? g. Stress or fatigue?  Y/N

 Antidepressants  Hormone Replacement (Estrogen, Progesterone, Testosterone)  Treatment of Ongoing Diseases  Counseling

 Permission  Limited Information  Specific Suggestions (keep the patient comfortable)  Intensive Therapy

 For postmenopausal women, there are many studies showing that testosterone may be effective.  Hypotestosteronism leads to decreased bone density and decreased libido  Some women may try DHEA which is OTC  Testosterone has 20 times the androgen potency of DHEA or DHEA Sulfate.  In premenopausal women, most circulating testosterone results from ovarian production, with the remainder from the adrenal gland.

 In postmenopausal women, ovaries contribute less to circulating levels.  Currently, there are no guidelines for androgen replacement in women, but making the diagnosis of hypoandrogenemia can be important.  Measurement of total testosterone is not useful because of variable levels of binding with serum hormone-binding globulin

 The free testosterone level and serum hormone-binding globulin levels are better indicators.  Excess oral androgen therapy can lead to an increase in LDL and decrease in HDL  Excess androgens cause unwanted facial hair growth, acne, and hair loss and can occur with elevations of testosterone levels to just slightly above normal  Liver damage possible with oral replacement, including cholestatic juandice, but not with transdermal replacement

 Pregnancy  Breastfeeding  Hyperandrogenic State  Presence of androgen-dependent tumors

 Further study is needed to determine the clinical significance of androgen deficiency in women  Specifically in post-menopausal women, physiologic low-dose androgen replacement therapy may result in improved bone density, enhanced libido, and increased satisfaction with life  Androgen preparations that avoid liver metabolism and produce physiologic serum androgen level will enhance treatment options  Routine screening is not recommended until such preparations are available

 Estratest  0.625/1.25mg or 1.25/2.5mg daily or cyclically  Methyltestosterone  1mg PO daily with blood levels every 1-2 months  Lozenges, patches, cream  Pellets last 3-6 months and are injected (75mg); slow release into the bloodstream  Progesterone 4% cream with 1mg testosterone/ml. Apply one ml to skin (not genitalia) qHS. Disp: 50 grams. Must be refrigerated.

 Once upon a time, a perfect man and a perfect woman met. After a perfect courtship, they had a perfect wedding. One snowy, stormy Christmas Eve, the perfect couple were driving their perfect car along a winding road and noticed someone in distress. On the roadside, there stood Santa Claus with a huge bundle of toys. The perfect couple picked up Santa and began helping him deliver the toys. Unfortunately, the driving conditions worsened and they had a car accident. Only one survived. Who was the survivor?