FEMALE SEXUAL DYSFUNCTION

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FEMALE SEXUAL DYSFUNCTION Melissa Ferrara, MS, FNP-BC Associate Medical Director, MAZE Women s Sexual Health Female Sexual Dysfunction (FSD) is comprised of four categories: 1.

1 FEMALE SEXUAL DYSFUNCTION Melissa Ferrara, MS, FNP-BC Associate Medical Director, MAZE Women s Sexual Health Female Sexual Dysfunction (FSD) is comprised of four categories: 1. FSDD Female Sexual Desire Disorder (Hypoactive Sexual Desire Disorder HSDD) 3. Orgasmic Disorder 2. FSAD Female Sexual Arousal Disorder 4. Pain Disorders DSM Changes DSM-IV-TR Diagnosis Changes DSM 5 Diagnosis Female Hypoactive Desire Disorder Female Arousal Disorder Female Orgasmic Disorder Dyspareunia Vaginismus Merged into: Female Sexual Interest/Arousal Disorder Unchanged Merged into Genito-Pelvic Pain/Penetration Disorder Ishak & Tobia: DSM-5 Changes in Diagnositc Criteria of sexual dysfunction, Reprod Sys Sexual Disorders,

2 Putting together the pieces. Pain Syndromes: Vaginismus/Genito-pelvic pain/penetration disorder (GPPPD) Vulvodynia (Vestibulodynia, Vulvar Vestibulitis) Dyspareunia MAZE 2018 Vaginismus defined: recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina which prevents the ability to have any object, finger or penis penetrate the vagina, despite the woman s expressed desire to do so. GPPPD Definition: the woman has recurrent and distressing difficulty with one (or more) of the following for at least 6 months: vaginal penetration during intercourse; marked vulvovaginal or pelvic pain during intercourse or attempted intercourse; marked fear or anxiety about the experience of vaginal or pelvic pain as related to vaginal penetration; marked tensing of the pelvic floor muscles during attempted vaginal penetration. May be primary or secondary Lahaie, M et al. Vaginismus: a review of the literature on classification/diagnosis, etiology and treatment. Women sheath (2010)6 (5)

3 Vaginismus Etiologies: Pelvic Floor Dysfunction: Involuntary muscular contraction vaginal spasms. Anatomical Factors thick hymen Psychological factors Anxiety, Fear/Phobia of penetration. May be secondary to vulvodynia. Usually a result of a combination of factors. Rarely caused by sexual abuse Watts G., Nettle D. The role of anxiety in vaginismus: a case-control study. J Sex Med. 2010;7: Reissing E.D., Binik Y.M., Khalifé S. Etiological correlates of vaginismus: sexual and physical abuse, sexual knowledge, sexual self-schema, and relationship adjustment. J Sex Marital Ther. 2003;29: Vaginismus Diagnosis: Exact location of pain. Lamont classification 1-4 (5). Diagnosis of primary vs. secondary. Assess muscle tension (if possible). Lamont J.A. Vaginismus. Am J Obstet Gynecol. 1978;131: Vaginismus Treatment: Vaginal Dilation: programmatic introduction of dilators of increasing diameter quality of dilators is important. Syracuse Medical dilators (hard plastic), Pure Romance (silicone) Topical Anesthetics: for introduction of dilators and to break the pain cycle, Lidocaine 2% gel, or Lidocaine 5% ointment Anti-anxiety medication (short acting or SSRI) as well as guided relaxation exercises Pelvic floor physical therapy Biofeedback for diagnosis and treatment of involuntary muscular contraction Diazepam suppositories Botox injections Lahaie, M et al. Vaginismus: a review of the literature on classification/diagnosis, etiology and treatment. Women sheath (2010)6 (5)

MAZE Botox Procedure Usually reserved for more severe cases of vaginismus Patient under general anesthesia Intravaginal Botox injections 100 Units Ropivicaine injections for immediate pain relief

4 MAZE Botox Procedure Usually reserved for more severe cases of vaginismus Patient under general anesthesia Intravaginal Botox injections 100 Units Ropivicaine injections for immediate pain relief post-op Vaginal Dilation - Large dilator in vagina when patient awakes from anesthesia Recovery room dilation exercises Extensive teaching and dilation exercises on Day 2 in office Pacik P.T. Vaginismus: review of current concepts and treatment using Botox injections, bupivacaine injections, and progressive dilation with the patient under anesthesia. Aesthetic Plast Surg. 2011;35: Vulvodynia Definition: Itching, irritation, burning, pain or any discomfort in vulvar area of at least three months duration. *Can be generalized or localized. *Primary or Secondary *Intermittent or Constant Most Common: Provoked Vestibulodynia: Severe burning/sharp pain that occurs in response to pressure localized to the vulvar vestibule. Bornstein, J, Goldstein A etal ISSVD, ISSWSh and IPPS Consensus Terminology and Classification of Persistant Vulvar pain and Vulvodynia, Obstet Gynecol. 2016; 127(4) Lev-Sagie, A, Witkin S Recent advanced in understanding provoked vestibulodynia F1000Res. 2016; 5: 2581 Vulvodynia Etiologies: Hormonally-Mediated Most commonly related to birth control pills Post-menopausal atrophy Genitourinary syndrome of Menopause (GSM) Pelvic Floor Dysfunction High tone Neuro-proliferative (secondary - allergic reaction, primary - congenital defect) Vulvar Dermatoses (i.e. lichen sclerosis, lichen planus, lichen simplex chronicus) Chronic Candidiasis 4

Vulvodynia Diagnosis: Visualization of vulva r/o lichen sclerosis, lichen planus, biopsy as appropriate. Use of colposcope ideal Q-Tip Test on vestibule.

5 Vulvodynia Diagnosis: Visualization of vulva r/o lichen sclerosis, lichen planus, biopsy as appropriate. Use of colposcope ideal Q-Tip Test on vestibule. * Begin by touching Labia majora, interlabial sulci and labia minora to establish baseline, * Touch lateral to Hart s line, and then just medial to Hart s line, 1, 11, 4, 8, 6 o clock. * Use a 1-10 pain scale * Hormonally-mediated and Neuro-proliferative PVD will elicit pain throughout vestibule * Pelvic Floor Dysfunction will elicit pain at 4, 6, 8, o clock * Chronic Candidiasis may also cause discomfort between interlabial sulci Assess pelvic muscle tone Cultures to rule out yeast, bacteria, STD. Vulvodynia Treatment Hormonally-mediated OCP related Stop OCPs (IUD better option for birth control) Also can see associated with Spironolactone use Topical compounded Estradiol 0.02%/Testosterone 0.1% in versabase or methylcellulose BID to vestibule Prasterone suppositories in addition if needed 50% improvement at 12 weeks Greenstein, A et al Vulvar vestibulitis syndrome and estrogen dose of oral contraceptive pills. J Sex Med Nov;4(6): Burrows LJ, Goldstein AT. Vulvodynia, J Sex Med 2008;5:5 J Sex Med 2008;5: Vulvodynia Treatment Hormonally-mediated Postmenopausal atrophy Estradiol vaginal cream daily to introitus, additional 1-2gm PV twice weekly or above compounded ET cream Vaginal dilation Additional intravaginal prasterone or estradiol suppositories Postmenopausal Atrophy- Hormones contraindicated Hyaluronic Acid cream Compounded (Hyaluronic Acid 5mg/gm w/vit A & Vit E in vaginal cream base)1 gm daily for two weeks, then decrease for maintenance Neogyn non prescription, available on-line Ospemifine 60mg daily SERM Prasterone vaginal suppositories daily Mona Lisa Touch CO2 Laser three treatments 6 weeks apart Femilift CO2 Laser three treatments 4 weeks apart Goldstein I, Alexander JL. Practical aspects in the management of vaginal atrophy and sexual dysfunction perimenopausal a aspects in the management of vaginal atrophy and sexual dysfunction perimenopausal, J Sex Med Sep; 2 Suppl 3: Cehn, J, Geng, L, Song, X et al. Evaluation of the efficacy and safety of Hyaluronic Acid vaginal gel to ease vaginal dryness: A multicenter, randomized controlled, open label, parallel group, clinical trial. J Sex Med 2013;10: Labrie, F etal. Efficacy of intravaginal DHEA on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy and of the genitourinary syndrome of menopause, Menopause, VOl23 No.3, Krychman, M.etal, Laser treatmen Safe for Vulvovaginal Atrophy. NAMS 2015; 11(3) 5

6 Vulvodynia treatments cont. Pelvic Floor Dysfunction Pelvic Floor Physical Therapy Vaginal Dilation Diazepam 5-10 mg suppositories QHS PV or PR Botox injections Sex without Pain by Heather Jeffcoat, DPT Vulvodynia treatments cont. Neuro-proliferative Tricyclic Antidepressants: Amitriptyline 10 mg daily, titrate up as needed Gabapentin 100mg daily, titrate up as needed. Compounded Gapabentin 5% cream BID Capsaicin 0.025% cream apply to vestibule and wash off after 20 min, every night for 3 months Vestibulectomy removal of entire vestibule with vaginal advancement (93-99% effective) Low Level Light Laser Treatment Minimum 12 sessions, 2x/week, if no improvement after 6 sessions, discontinue Lev-Sagie, A, Witkin S Recent advanced in understanding provoked vestibulodynia F1000Res. 2016; 5: 2581 Lev-Sagie, etal, Low-Level Laser Therapy for the Treatment of Provoked Vestibulodynia-A Randomized, Placebo-Controlled Pilot TrialJ Sex Med Nov;14(11): doi: /j.jsxm Epub 2017 Sep 29.. Vulvodynia treatments cont. Chronic Candidiasis Fluconazole 150mg every 3 rd day for three doses, then weekly Nystatin 500,000U three times a day Probiotic (lactobacillus, acidophilus) 1-2 tablets daily Diet modification Consider yeast culture with sensitivity to rule of fluconazole resistance when no improvement in sx Alternatives to Fluconazole: Itraconazole, Voriconazole, Boric Acid Suppositories 600mg PV QDX14 then BIW Nyirjesy, P, Sobel, J Practical strategies for acute and recurrent vaginitis. OBG Management, 2005, Vol17, No 8 6

7 Vulvodynia treatments cont. Additional Treatments Vulvar Care Measures: avoid contact irritants. (no panty liners!) Education regarding positions and lubrication Liquid Silk, Sliquid silk, coconut oil Relaxation exercises and guided imagery Psychotherapy (primarily to learn to decatastrophize ). Dyspareunia Definition: Non-introital vaginal pain during sexual intercourse. Can be generalized or localized. MAZE 2018 Dyspareunia Etiologies: Atrophic Vaginitis/GSM Infection/Inflammation Involuntary Muscular Contraction Trauma Endometriosis Interstitial Cystitis Pelvic Adhesions Pelvic Malignancy Pudendal Neuralgia 7

product should be available 10/2018 . Duration of intercourse? Length/width of partner s penis? Lubricant? Exact localization of pain in the office use a dilator.

8 Dyspareunia cont.. Anatomy - collision dyspareunia Review positioning Make a spacer to place at the base of the penis cut down a masturbation sleeve Ohnut - New product find on kickstarter, product should be available 10/2018 Dyspareunia cont.. Duration of intercourse? Length/width of partner s penis? Lubricant? Exact localization of pain in the office use a dilator. Consider ultrasounds to rule out fibroids and ovarian cysts. Treatments vary widely dependant on etiology. Female Sexual Arousal Disorder (FSAD) Definition: Most common: Hypoactive Arousal Disorder Lack of sensation of arousal: Tingling, swelling and lubrication. Persistent Genital Arousal Disorder Overactive arousal. MAZE

May be stratified into: primary, secondary, situational, or universal.

9 FSAD ORGASMIC DISORDER Definition: Inability to achieve orgasm, delayed orgasm or weakening orgasm. May be stratified into: primary, secondary, situational, or universal. FSAD/Orgasm disorders Etiologies: Vascular Neurological Hormonal Psychological Medication SE (SSRI; OCP) Anatomical ignorance or misinformation 9

Orgasmic Disorder and Female Sexual Arousal Disorder Treatment : Diagnosis primarily based on history and biothesiometry Bupropion xl150 mg daily, increase if needed, max dosage up to 450mg daily.

10 Orgasmic Disorder and Female Sexual Arousal Disorder Treatment : Diagnosis primarily based on history and biothesiometry Bupropion xl150 mg daily, increase if needed, max dosage up to 450mg daily. Hormonal Treatments (same as FSDD) Modification of medications SSRI OCP Education Vibrators Fantasy/Erotica Moisturizers MAZE 2017 Modell JG1, May RS, Katholi CR. Effect of bupropion-sr on orgasmic dysfunction in nondepressed subjects: a pilot study J Sex Marital Ther Jul- Sep;26(3): Orgasmic Disorder and Female Sexual Arousal Disorder Treatment cont: PDE-5 Inhibitors Sildenafil (Viagra, Levitra, Cialis) Sex therapy Oxytocin 80 IU min prior to sex PRP injection - O-Shot Behnia, B et al. Differential effects of intranasal oxytocin on sexual experiences and partner interactions in couples Horm Behav Mar;65(3): doi: /j.yhbeh Epub 2014 Feb 3 Magon, N, Kalra, S. The orgasmic history of oxytocin: Love, lust, and labor Indian J Endocrinol Metab Sep; 15(Suppl3): S156 S161. PGAD Persistent Genital Arousal Syndrome Definition: Throbbing and irritation of vulvar/clitoral area which feels pre-orgasmic but which is not relieved by 4 or more orgasms. Etiologies still somewhat unknown: Neurological Dorsal Clitoral Nerve, or Pudendal nerve involvement Vascular Anxiety Urological secondary to IC Jackowich R, Pink L, Gordon A Pukall CF, Persistent Genital Arousal Disorder: A Review of Its Conceptualizations, Potential Origins, Impact, and Treatment Sex Med Rev Oct;4(4):

PGAD Treatment: Gabapentin Chantix Cymbalta TENS Unit Topical lidocaine Psychotherapy (primarily to learn to decatastrophize ) SSRI Nerve blocks Physical Therapy Jackowich R, Pink L, Gordon A Pukall

Female Sexual Desire Disorder (FSDD) Hypoactive Sexual Desire Disorder (HSDD) Definition: Decreased interest in sex. Can range from mild (able to respond to sexual overtures) to the aversive.

11 PGAD Treatment: Gabapentin Chantix Cymbalta TENS Unit Topical lidocaine Psychotherapy (primarily to learn to decatastrophize ) SSRI Nerve blocks Physical Therapy Jackowich R, Pink L, Gordon A Pukall CF, Persistent Genital Arousal Disorder: A Review of Its Conceptualizations, Potential Origins, Impact, and Treatment Sex Med Rev Oct;4(4): Female Sexual Desire Disorder (FSDD) Hypoactive Sexual Desire Disorder (HSDD) Definition: Decreased interest in sex. Can range from mild (able to respond to sexual overtures) to the aversive. Please note that this can exist separately from FSAD. FSDD Etiologies: Diagnosis primarily based on history. Hormonal Androgen (Testosterone and DHEA-S) deficiency. Estrogens deficiency. Thyroid abnormalities Pituitary abnormalities. Medications (SSRI; OCP) Psychological or relationship issues MAZE

FSDD cont. Helpful Questionnaires: Female Sexual Function Index, Sexual Desire Inventory, Female Sexual Distress Scale Masters and Johnson Linear Model (Desire Arousal Orgasm Resolution) vs.

experimental use in women, no FDA approved testosterone products for women Testosterone gel 1% - 50mg tubes or packets, Starting dosage 5mg daily, one packet over 10 days, titrate up as needed

12 FSDD cont. Helpful Questionnaires: Female Sexual Function Index, Sexual Desire Inventory, Female Sexual Distress Scale Masters and Johnson Linear Model (Desire Arousal Orgasm Resolution) vs. Rosemary Basson Non-linear Model (emotional intimacy, sexual stimuli, and relationship satisfaction) Female Sexual Desire Disorder (FSDD)Treatment: Hormonal Treatment Options Testosterone off-label, experimental use in women, no FDA approved testosterone products for women Testosterone gel 1% - 50mg tubes or packets, Starting dosage 5mg daily, one packet over 10 days, titrate up as needed Testosterone pellets 75 mg/pellet, each pellet lasts three months, starting dosage 1 pellet, titrate up as needed Compounded testosterone - easiest was to start really low dosage, can compound 1mg per day and work up Slow process, can take 4-8 months to see changes, goal is Free testosterone ng/dL, or Free androgen Index nmol/L DHEA-S over the counter, can have compounded Starting dosage: mg daily Estrogen Therapy (with progesterone, if applicable.) Choose bioidenticals: patches, ring, gels, compounded Goldsteinet al Hypoactive Sexual Desire Disorder: ISSWSH Expert Consensus Panel Review Mayo Clinic Proceedings, Volume 92, Issue 1, 2017, pp Davis SR, Worsley R.Androgen treatment of postmenopausal women. J Steroid Biochem Mol Biol Jul;142: Glaser, R et al, Testosterone implants in women: Pharmacological dosing for a physiologic effect, Maturitas 74 (2103) Khera, M. Testosterone Therapy for Female Sexual Dysfunction. Sex Med Rev Jul;3(3):

Female Sexual Desire Disorder (FSDD)Treatment Flibanserin 100mg 1st FDA approved medication for HSDD, only FDA approved for premenopausal women Bupropion 150mg daily, increase if needed off label use

13 Female Sexual Desire Disorder (FSDD)Treatment Flibanserin 100mg 1st FDA approved medication for HSDD, only FDA approved for premenopausal women Bupropion 150mg daily, increase if needed off label use Buspirone 15mg BID, increase if needed off label use Oxytocin Troche/Nasal Spray compounded 80U, 30 min prior to sex, can also try daily dosage of 25 U Psychotherapy/ Behavior Modification Scheduling Sex, Daily Erotica, Sensate Focus learning to touch your partner again Clayton AH, Kingsberg SA, Goldstein I. Evaluation and Management of Hypoactive Sexual Desire Disorder.Sex Med Jun;6(2): Behnia, B et al. Differential effects of intranasal oxytocin on sexual experiences and partner interactions in couples Horm Behav Mar;65(3): doi: /j.yhbeh Epub 2014 Feb 3 Good Sex should be forever References Basson R., Althof S., Davis S. Summary of the recommendations on sexual dysfunctions in women. J Sex Med. 2004;1: Behnia, B et al. Differential effects of intranasal oxytocin on sexual experiences and partner interactions in couples Horm Behav Mar;65(3): Bolour S, Braunstein G. Testosterone therapy in women: a review. Int J Impot Res Sep-Oct;17(5): Bornstein, J, Goldstein A et al ISSVD, ISSWSh and IPPS Consensus Terminology and Classification of Persistant Vulvar pain and Vulvodynia, Obstet Gynecol. 2016; 127(4) Cehn, J, Geng, L, Song, X et al. Evaluation of the efficacy and safety of Hyaluronic Acid vaginal gel to ease vaginal dryness: A multicenter, randomized controlled, open label, parallet goup, clinical trial. J Sex Med 2013;10: Clayton AH, Kingsberg SA, Goldstein I. Evaluation and Management of Hypoactive Sexual Desire Disorder.Sex Med Jun;6(2): Davis SR, Worsley R.Androgen treatment of postmenopausal women. J Steroid Biochem Mol Biol Jul;142: Goldstein I, Alexander JL. Practical aspects in the management of vaginal atrophy and sexual dysfunction perimenopausal a aspects in the management of vaginal atrophy and sexual dysfunction perimenopausal, J Sex Med Sep; 2 Suppl 3: Glaser, R et al, Testosterone implants in women: Pharmacological dosing for a physiologic effect, Maturitas 74 (2103) Glaser R, Dimitrakakis C. Testosterone therapy in women: myths and misconceptions. Maturitas Mar;74(3): Greenstein A, Ben-Aroya Z, Fass O, Militscher I, Roslik Y, Chen J, Abramov L. IsHak WW, Tobia G J Sex Med Nov;4(6): Vulvar vestibulitis syndrome and estrogen dose of oral contraceptive pills. DSM-5 Changes in Diagnostic Criteria of Sexual Dysfunctions. Reprod Sys Sexual Disorders 2:122. Irwin Goldstein, Noel N. Kim, Anita H. Clayton, Leonard R. DeRogatis, Annamaria Giraldi, Sharon J. Parish, James Pfaus, James A. Simon, Sheryl A. Kingsberg, Cindy Meston, Stephen M. Stahl, Kim Wallen, Roisin WorsleyHypoactive Sexual Desire Disorder: International Society for the Study of Women's Sexual Health (ISSWSH) Expert Consensus Panel ReviewMayo Clinic Proceedings, Volume 92, Issue 1, 2017, pp Jackowich R, Pink L, Gordon A Pukall CF, Persistent Genital Arousal Disorder: A Review of Its Conceptualizations, Potential Origins, Impact, and Treatment, Sex Med Rev Oct;4(4): Khera, M. Testosterone Therapy for Female Sexual Dysfunction. Sex Med Rev Jul;3(3): Krychman, M.etal, Laser treatment Safe for Vulvovaginal Atrophy. NAMS 2015; 11(3) Labrie, F etal. Efficacy of intravaginal DHEA on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy and of the genitourinary syndrome of menopause, Menopause, VOl23 No.3, Lahaie, M et al. Vaginismus: a review of the literature on classification/diagnosis, etiology and treatment. Women sheath (2010)6 (5) Lamont J.A. Vaginismus. Am J Obstet Gynecol. 1978;131: Lev-Sagie, A, Witkin S Recent advanced in understanding provoked vestibulodynia F1000Res. 2016; 5: 2581 Lev-Sagie, etal, Low-Level Laser Therapy for the Treatment of Provoked Vestibulodynia-A Randomized, Placebo-Controlled Pilot TrialJ Sex Med Nov;14(11): doi: /j.jsxm Epub 2017 Sep 29. Magon, N, Kalra, S. The orgasmic history of oxytocin: Love, lust, and labor Indian J Endocrinol Metab Sep; 15(Suppl3): S156 S

14 References Modell JG1, May RS, Katholi CR. Effect of bupropion-sr on orgasmic dysfunction in nondepressed subjects: a pilot study J Sex Marital Ther Jul-Sep;26(3): Nyirjesy, P, Sobel, J Practical strategies for acute and recurrent vaginitis. OBG Management, 2005, Vol17, No 8 Pacik P.T. Vaginismus: review of current concepts and treatment using Botox injections, bupivacaine injections, and progressive dilation with the patient under anesthesia. Aesthetic Plast Surg. 2011;35: Pacik PT. Open label, single center, pilot study of the use of Botox injections, Sensorcaine injections and progressive dilation under anesthesia for the treatment of primary vaginismus. Available at: Processed March 10, Reissing E.D., Binik Y.M., Khalifé S. Vaginal spasm, pain, and behavior: an empirical investigation of the diagnosis of vaginismus. Arch Sex Behav. 2004;33:5 17. Reissing E.D., Binik Y.M., Khalifé S. Etiological correlates of vaginismus: sexual and physical abuse, sexual knowledge, sexual self-schema, and relationship adjustment. J Sex Marital Ther. 2003;29:47 59 Schwenkhagen A1, Studd J. Role of testosterone in the treatment of hypoactive sexual desire disorder. Maturitas Jun 20;63(2): Watts G., Nettle D. The role of anxiety in vaginismus: a case-control study. J Sex Med. 2010;7: MAZE Women s Sexual Health Westchester, NY New York, NY Great Neck, NY Medical Director: Michael A. Werner MD Clinical Director: Bat Sheva Marcus LMSW, MPH, PhD Associate Medical Director: Melissa Ferrara, FNP MAZE

Sexological aspects of genital pain

Sexological aspects of genital pain Annamaria Giraldi, professor, MD, PHD Sexological Clinic, Psychiatric Centre Copenhagen 1 Disclosures Speaker: Eli Lilly, Pfizer Consultant: Eli Lilly,Palatin 2 Agenda