Christopher R. Graber, MD Salina Women’s Clinic 20 May 2011

Overview Background Female sexual physiology Changes with aging, drugs Dysfunction Hypoactive desire Dyspareunia Vaginismus and vulvar vestibulitis Orgasmic dysfunction Sexual assault and abuse

Background Sexuality is important to women And the survey says… 2/3 women have concerns about sexuality 1/3 lack interest in sex 1/5 said sex was not always pleasurable 1/2 experienced difficulty with arousal 1/2 had difficulty reaching orgasm 1/4 unable to have orgasm

Female Sexual Physiology Linear (Masters and Johnson) or cyclical (Basson) Phases Desire Arousal (excitement and plateau) Orgasm Resolution

Phases of Female Sex Physiology Desire Internal and external Testosterone required Large psycho-social component Arousal Parasympathetics Vasocongestion Includes plateau phase Orgasm Sympathetics Release of tension Muscular contractions Resolution Relaxation, feeling of well-being Return to baseline in minutes

Differences between men and women

Changes With Aging Effect of aging on female sexual physiology Decreased desire Increased time requirement for arousal Longer time needed for lubrication Production of less lubrication Less intense orgasm Increased need for stimulation to have orgasms Less likely to be multiorgasmic

Changes With Medications Drugs that can interfere with sexual function HTN meds, diuretics Antidepressants, lithium Antipsychotics, barbituates Antihistamines Narcotics, amphetamines, cocaine, hallucinogens Anticonvulsants

Sexual Dysfunction Hypoactive sexual desire disorder (HSDD) Dyspareunia Vaginismus Vulvar vestibulitis Orgasmic dysfunction

Hypoactive Sexual Desire Disorder (HSDD) Recurrent deficiency or absence of sexual fantasies or thoughts or desire for sexual activity causing marked distress and interpersonal difficulty Often accompanied by another dysfunction Evaluate prolactin and testosterone Treatment with HRT and/or counseling

Dyspareunia Genital pain that occurs before, during, or after intercourse (without vaginismus) “difficult mating” Full history/physical Associated symptoms, when/where is the pain Screen for infection, allergy, abuse

Dyspareunia Organic causes Poor lubrication, urethritis, cystitis, poorly healed laceration, PID, endometriosis, vestibulitis, müllerian abnormality, atrophy No organic cause Psychosocial evaluation, treatment similar to vaginismus

Vaginismus Recurrent or persistent involuntary contraction of the perineal muscles when vaginal penetration is attempted Primary or secondary May be a conditioned response Treatment – help with familiarity of anatomy, relaxation techniques, Kegel exercises, graduated dilators

Vulvar Vestibulitis Constellation of symptoms with severe pain or burning on touching the vestibule and posterior forchette Exam – extreme sensitivity to light touch, diffuse or local erythema Treatment – treat infections/remove allergens, lidocaine gel, amitriptyline, lidocaine injection, vestibulectomy

Orgasmic Dysfunction Persistent or recurrent delay in or absence of orgasm following a normal sexual arousal Primary Most effective treatment is directed masturbation Secondary Treat underlying cause Psychosocial, medical reason, lack of estrogen, history of abuse

Sexual Assault and Abuse One of the fastest growing, most frequently committed, most underreported crimes in US Woman who have been sexually abused/ assaulted often experience sexual dysfunction If any chance for evidence collection and/or reporting, contact local SANE/SART staff for procedural details

Treatment for Victims Pregnancy prophylaxis Best within 72 hours Many available plans/medications STD testing, consider repeating over 6 months Optional treatment for gonorrhea, chalmydia, trichomonas, syphilis Hepatitis B vaccination Coordinate counseling, if desired

Questions?