Female Sexual Dysfunction
/What is normal sexual response?
Original landmark studies had a very linear model of “normal sexual response”
Excitement → plateau → orgasm → resolution
More contemporary model is non-linear and encompasses a variety of sequences of the original four stages of as well as other stages
Estrogen plays a significant role in female sexual response, including maintenance of genital tissue sensitivity, elasticity, secretions, pH, etc, as well as urinary continence, pelvic floor muscle tone, and joint mobility
Approximately 43% of American women report experiencing sexual problems, with higher prevalence in women aged 45-64
What are the different types of sexual dysfunction?
Based on the DSM-V - 5 specific types of female sexual dysfunction:
Female sexual interest and arousal disorder
Lack of or significant decrease in at least three of the following:
Interest in sexual activity
Sexual or erotic thoughts or fantasies
Initiation of sexual activity and responsiveness to a partner’s initiation
Excitement or pleasure during all or almost all sexual activity
Interest or arousal in response to internal or external sexual erotic cues
Genital or nongenital sensations during sexual activity in almost all or all sexuall encounters
Symptoms have persisted for a minimum of 6 months and cause clinically significant distress in individuals
Female orgasmic disorder
Marked delay in, marked infrequency of, or absence of orgasm, or markedly reduced intensity of orgamsic sensations in almost all or all occasions of sexual activity
Symptoms have persisted for a minimum of 6 months and cause clinically significant distress in individuals
Genito-pelvic pain/penetration disorder
The persistent or recurrent presence of one or more of the following symptoms:
Difficulty having intercourse
Marked vulvovaginal or pelvic pain during intercouruse or penetration attempts
Marked fear or anxiety about vulvovaginal or pelvic pain anticipating, during, or resulting from vaginal penetration
Symptoms have persisted for a minimum of 6 months and cause clinically significant distress in individuals
Substance/medication-induced sexual dysfunction
Disturbance in sexual function that has a temporal relationship with substance/ medication initiation, dose increase, or discontinuation and causes clinically significant distress in the individual
Other specified or unspecified sexual dysfunction
Distressing symptoms characteristic of sexual dysfunction that do not meet the criteria of one of the defined categories. The major distinction between specified and unspecified is whether the clinician specifies reason that the symptoms do not meet criteria for other classes
One specified reason: genitourinary syndrome due to menopause
How should we evaluate for FSD?
Ask about it!
During routine visits, can ask questions about sexual function
Ask broad, open-ended questions during routine history gathering
“Many women experience concerns about sex. Are you experiencing any issues?”
Initial approach if patient answers yes, or if FSD is a complaint
Comprehensive History
Should ask detailed history about patient’s sexual and gender identity
Nature, duration, and onset of symptoms - also if symptoms cause distress
If patient is using medications
Partner factors (ie. number of current partners, their gender, health problems, sexual function problems)
Relationship quality - communication about sexual concerns with partner, past and current abuse or violence experience
Pain/injuries/Body image
Physical Exam
Often, there are not specific physical exam findings
However, use of mirror and pointing out female anatomy for education is sometimes helpful
Can also identify if there are areas that are causing pain
How do we treat FSD?
Psychological Interventions
Relationship distress and partner sexual dysfunction can trigger sexual problems in other domains
Options include sexual skills training, cognitive-behavioral therapy, mindfulness-based therapy, and couples therapy
Sexual skills training: can include instructions in masturbation, other erotic stimulation, decrease feelings of guilt and shame with masturbation, as well as learning about anatomy (ie. clitoral stimulation)
Couples therapy: exercises to better communication with partner
History of trauma - may need trauma-based psychotherapeutic approach
Can consult or refer to mental health specialists with expertise in this area
Medical therapy
Estrogen
Low-dose vaginal estrogen therapy is the preferred hormonal treatment for FSD due to genitourinary syndrome of menopause
Low-dose systemic estrogen can be an alternative
Other alternatives include Ospemifene for management of dyspareunia due to genitourinary syndrome of menopause
Androgen Therapy
Short-term use of transdermal testosterone can be considered for treatment of postmenopausal women with sexual interest andd arousal disorders
Need to appropriately counsel that there are risks (ie. acne, increased hair growth, virilization - may be irreversible) and long-term side effects are not known
Can try for 3-6 months after baseline testosterone is tested and after 3-6 weeks of initial use
Should be discontinued if no effect after 6 months
Flibanserin
Addyi on the market
Serotonin receptor agonist/antagonist and was approved in 2015 by the FDA to treat hypoactive sexual desire disorder in premenopausal women without depression
However, systematic review and meta-analysis of existing studies showed that overall quality of evidence for efficacy and safety were low, and there was minimal to no improvement in hypoactive sexual desire disorder with use
Black box warning against alcohol use - increased risk of syncope and hypotension
Sildenafil (Viagra)
Not efficacious
Hypothesized that it may increase pelvic blood flow to clitoris and vagina, but has not been proven to work
Bupropion
If patient has antidepressant-induced female sexual dysfunction, supplementation with bupropion may improve symptoms
Other
For genito-pelvic pain and penetration disorders:
Education to help patient understand anatomy and etiology of their symptoms
Vaginal dilators
Physical therapy (Pelvic PT)
Intravaginal prasterone for treatment of postmenopausal women who have dyspareunia
Lubricants and moisturizers
Don’t cure the underlying cause, but may reduce or alleviate dyspareunia that is due to vaginal dryness
Coconut oil is a good option, but do not use with condoms
Tend to counsel more toward silicone-based lubricants because they do not dry out as quickly as water-based lubricants
Vaginal lasers
Became a hot topic while we were senior residents and some people raved about them; latest evidence suggesting they’re not effective.
Vaginal CO2 fractional laser is inadequately studied for treatment of vulvovaginal atrophy
Cost of treatment is rather high