1. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Sexuality Ch 28 2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study

2. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Case Study 42 yo G4P4 presents to gyn clinic with c/o decreased libido. She states that she is happily married for 14 years. After further discussion, she confides that she rarely has orgasm and worries that her husband will leave her if she does not have more interest in their sex life.

3. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies APGO Educational Topic 56: A. Obtain a basic sexual history, including sexual function and sexual orientation. B. Describe the physiology of female sexual response. C. Discuss female sexuality across the lifespan. D. Categorize common patterns of female sexual dysfunction. E. Identify physical, psychological and societal contributions to female sexual dysfunction.

4. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Basic History (Page 356) Are you sexually active? Are there any problems with your sexual function? (Can preface with “Many people experience sexual dysfunction…”) What is our sexual orientation? What age did you first have intercourse? How many partners have you had? Do you use birth control? How do you protect yourself from STD’s (if multiple partners)?

5. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Sexual Orientation Heterosexual –Engage in sexual activity with opposite sex Homosexual –Engage in sexual activity with same sex Bisexual –Engage in sexual activity with both sexes at same or different times of their life

6. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Sexual Response Cycle Excitement Phase –Stimulation Plateau Phase –Continuation of physiologic changes Orgasmic Phase –Release of sexual tension Resolution Phase –Return to baseline physiologic state

7. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Excitement Phase Chest sex flush Nipples become erect Breasts enlarge Uterus elevates Vaginal lubrication starts Clitoris enlarges Labia enlarges HR increases BP increases Muscles become tense

8. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Plateau Phase Uterus tents (allows easier sperm passage Vagina enlarges Clitoris elevates, retracts under hood Labia enlarges HR increases BP increases RR increases Muscles become tense Bartholins glands lubricate introitus

9. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Orgasmic Phase ***Clitoris, Vagina, and Uterus Vaginal muscles contract Uterus contracts Lower abdominal muscles contract Anal muscles contract HR peaks BP peaks RR peaks Muscles – loss of voluntary tone (Toes curl) **Women can have Multiple orgasms Before next phase!!!

10. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Resoluton Phase Chest sex flush disappears Nipples decrease in size Breasts decrease in size Uterus returns to normal size Vagina returns to normal size Clitoris returns to normal size HR normalizes BP normalizes RR normalizes

11. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Lifespan - Sexuality Increasing age associated with decreased frequency and satisfaction of intercourse. Decreased estrogen –Vaginal atrophy and dryness –Dypareunia –Difficulty in achieving orgasm

12. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Female Sexual Dysfunction Sexual dysfunction –Failure of 1 or more of the phases of the sexual response cycle (desire, aousal, orgasm) or pain disorders. Primary –Realistic expectations have never been met. Secondary –All phases have functioned in past, but 1 or more no longer functions. Situational –Response cycle functions in some situations, but not other situations.

13. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Sexual Response Cycle Disorders Sexual Function Disorders Desire Phase Excited by Dopamine Inhibited by Serotonin Hypoactive Sexual Desire Disorder Decreased / absent desire Stress, lack of privacy, external disease Sexual Aversion Disorder Prior trauma, personal aversion Arousal Phase Estrogen Decreased subjective or somatic response Orgasmic Phase Difficulty or absence of orgasm Insufficient sexual stimulation/arousal

14. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Pain Disorders Dyspareunia Genital pain assoc with intercourse Pain with intromission Vestibulitis Vaginismus Fissures Vulva lesions Mid-Vaginal Pain Lack of lubrication Surgical scars Urethral diverticulosis Deep Thrust Dyspareunia Endometriosis Interstitial cystitis Pelvic adhesions Neoplasms Vaginismus – severe pain +/- involuntary muscle spasm of distal vaginal and pelvic floor muscles during attempted penetration.

15. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Physical, Psychological and Societal contributions to female sexual dysfunction Society Expectations What is socially or culturally acceptable Physical Secondary sexual function d/o’s External disease (cancer, hysterectomy) Medications (SSRI’s) Genital infections Diabetes Psychological Primary sexual function d/o’s Depression Anxiety

16. 2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Treatment Hormonal therapy ONLY in women with hormonal deficits. Clitoral vacuum device approved by FDA –Improves clitoral blood flow and engorgement. –Tricare will authorize treatment. Fantasy therapy Exogenous lubricants Sildenafil – better results in men http://health.zaobao.com