24th Annual Family Medicine Potpourri

Transcription

1 24th Annual Family Medicine Potpourri The Spectrum of Female Sexual Dysfunction in Primary Care Jennifer Frank, MD Theda Care Physicians

2 Disclosure Statement I have no relevant financial relationships with any commercial interest. I will be discussing the off-label use of medications.

3 Learning Objectives Identify the underlying physiological and psychological factors that can influence female sexual function and dysfunction. Educate and counsel patients on sexuality and the disorders that can arise from sexual dysfunction and make referrals as necessary. Analyze symptoms and conduct a thorough medical and sexual history to determine when sexual dysfunction may be a symptom of an underlying illness and recommend additional testing as necessary. Describe treatment options.

4 The World According to M&J

5 Kaplan adds Desire

6 Human Response Cycle

7 Image: Salvatore Vuono / FreeDigitalPhotos.net

8 Types of Female Sexual Dysfunction Disorders of Desire Disorders of Arousal Disorders of Orgasm Disorder(s) of Pain

9 Sexual Desire Arousal/Excitement Orgasm and Resolution

10 Complaints vs Disorders Sexual concern We only have sex once a day. Sexual complaint (expression of discontent) My viagra isn t working anymore. Sexual dysfunction (disturbance in sexual function) I ve never had an orgasm. Sexual disorder (dysfunction plus distress) My relationship is really strained with my husband because I just don t want to have sex anymore.

11 Contextualizing Sexual Dysfunction Is it new or old? Lifelong 24 year old newly married female who has never experienced orgasm Acquired 24 year old female who recently gave birth and has decreased sexual desire Is it always or sometimes? Generalized 28 year old female who has pain with intercourse, insertion of a tampon, speculum exam, etc. Situational 28 year old female able to orgasm with masturbation but not during intercourse with her boyfriend

12 DSM V Changes Recognition of responsive desire (vs spontaneous desire) Combining interest/arousal disorder Defining a normal frequency of orgasm Combining pain disorders

13 Prevalence of FSD

14 Dysfunction & Distress 5463 women ages years 36% had distress but not all with distress had dysfunction Type Sexual dysfunction (FSFI score) Dysfunction plus Distress (FSD) Desire 55% 23% Arousal 18% 12% Orgasm 32% 16% Pain 21% 11%

15 Prevalence of Dysfunction/ Distress Dysfunction Age Des Ar Org Dysfunction + Distress Age Des Ar Org % 10% 10% % 3% 3% % 24% 17% % 8% 6% % 65% 55% 65+ 7% 6% 6%

16 Female Orgasmic Disorder 2 nd most common disorder Dysfunction in about 25% of women (not necessarily distress) 20-30% of women report an inability to experience orgasm during sexual intercourse Prevalence estimates vary widely In part due to differences in definition (never/ almost never, etc) and part due to differences in how data is obtained Range of 6.8% to 34%

17 Zietsch et al. J Sex Med 2011;8:2305

18 Increased prevalence of FSD is observed in certain populations

19 Sexual incompatibility with partner

20 Concurrent depression or anxiety Image: David Castillo Dominici / FreeDigitalPhotos.net

21 Self-reported difficulty sleeping Image: photostock / FreeDigitalPhotos.net

22 Increasing age of woman and partner Image: Ambro / FreeDigitalPhotos.net

23 Increasing length of relationship Image: renjith krishnan / FreeDigitalPhotos.net

24 Presence of medical illness Image: markuso / FreeDigitalPhotos.net

25 Relationship Partner s skill Substance use Physical Health Sexual knowledge Age Life stage BMI Sexual beliefs Female Sexual Function Medications Mental Health Past experiences Hormonal influences Genetic characteristics Religion Personality traits Culture Society

26 Medications and FSD Antiandrogens Spironolactone Anticonvulsants Anticholinergics Antiestrogens Raloxifen Tamoxifen Antihistamines Antihypertensives Beta blockers CCBs Diuretics Drugs of Abuse Alcohol Opioids Sedatives/Hypnotics Metoclopramide Metronidazole Oral contraceptives Sympathomimetic amines Amphetamines Pseudoephedrine Phenylephrine

27 Treatment Emergent FSD One-third (or higher) of women experience anorgasmia Increased with increased dose May be partially reversed by decreasing dose Response to SSRI/SNRI may predict FSD (inverse relationship) Accupuncture may help treatment-emergent FSD

28 Clinicians rarely ask women rarely seek

29 Sexual Health Screening and Assessment

30 Why patients may not seek help Age (consistent factor but variable effects) Distinction between sexual problems and medical problems Sexuality not seen as a health issue Normal aspect of aging Embarrassment Problem may go away on its own Gender (men more likely to seek help) Sexual beliefs

31 Why clinicians may not ask Lack of training Lack of practice Fear of opening the flood gates Covert presentation of the problem Lack of time Lack of effective treatments Associated stigma Embarrassment of doctor, patient, or both Sensitive and difficult subject Gender, age, or culture bias

32 Who do we screen for FSD? Image: renjith krishnan / FreeDigitalPhotos.net

33 Presence of medical conditions Diabetes Renal failure CAD CVD Neurologic disease Adrenal dysfunction Infertility Endometriosis Multiple Sclerosis Hormonal Transitions Antenatally Postnatally Perimenopause Postmenopause Screening for FSD Use of medications Antidepressants SSRIs Antihypertensives Antipsychotics Antiepileptics Antiandrogens Narcotics Combined oral contraceptive pills

34 Screening Patients the How To History-taking What to ask Screening tools* Interviewing How to ask Maurice WL. Sexual Medicine in Primary Care, 1999.

35 Screening for Sexual Dysfunction Are you currently in a sexual relationship? Do you have any problems with desire, arousal, orgasm or sexual pain? If you are not currently sexually active, are there any particular problems contributing to your lack of sexual activity? Do you have any concerns or questions about your sex life? Please feel free to ask in the future. Jha S, Thakar R. Female sexual dysfunction. Eur J Obstet Gynecol (2010).

36 The How of Interviewing Initiative Language Ubiquity technique ( Many or most ) Privacy, confidentiality, security Delay sensitive questions Nonjudgmental attitude Explanation Feelings Optimism

37 Taking the Initiative Image: Simon Howden / FreeDigitalPhotos.net

38 Use their language

39 Ubiquity Image: Master isolated images / FreeDigitalPhotos.net

40 Image: suphakit73 / FreeDigitalPhotos.net

41 It s nothing to be embarassed about Image: Stuart Miles / FreeDigitalPhotos.net

42 Be Nonjudgmental Image: David Castillo Dominici / FreeDigitalPhotos.net

43 Explain what you mean Libid o Image: Stuart Miles / FreeDigitalPhotos.net

44 Focus on Feelings Image: Idea go / FreeDigitalPhotos.net

45 Image: basketman / FreeDigitalPhotos.net HOPE

46 PLISSIT model Permission Limited Information Specific Suggestions Intensive Therapy I ask about sexual health as part of my general health review. Is it okay to ask those questions? It is very common for people who take an antidepressant to experience difficulty achieving orgasm. Many postmenopausal women find that intercourse is more comfortable if they use lubrication. To fully treat your vaginismus, I will need to have you see a therapist who specializes in sexuality. Would you be willing to do this? Annon, 1976

47 PLISSIT in action LW is a 58 year old female in whom decreased sexual desire is elicited during a general ROS performed in the context of a CPX. She reports significantly decreased interest and difficulty focusing during sexual activity since undergoing menopause and which was exacerbated after her sister s death. She is asked to follow up on this issue in addition to a couple of other issues that were raised during her CPX.

48 Permission JF: Linn, thanks for coming in today. I wanted to discuss a few things that were brought up at your last visit. One of those was your sexual desire. You had mentioned that you thought it was decreased. Can we talk about that today? LW: Yeah, I just feel like things have changed since menopause and I don t know if it is normal to feel this way.

49 Limited Information JF: Decreased sexual desire is common in women who are postmenopausal and also in women who are in long-term relationships where the concept of desire may change. Are any other areas of your sexual functioning a concern, such as vaginal dryness or pain? LW: No, once we start, I really get into it. I just have heard that 60 is the new 30 and it seems no one else has this problem. JF: Well, I see it pretty frequently in my clinic, especially in women who are postmenopausal. Part of the reason might be because you lose some testosterone after menopause and testosterone is a hormone that promotes sexual desire.

50 Specific Suggestions JF: Have you heard the phrase men are like light switches and women are like ovens? A lot of women need some time to get ready for sexual activity. I would recommend that you plan for a sexual encounter with your husband and spend the 30 minutes prior getting ready whether that is having a glass of wine, taking a bath, getting rid of mental clutter, or lighting candles and putting on soft music.

51 Intensive Therapy LW: That makes sense. I can do that. JF: How distressing is this for you? LW: Not that much, I think I just am concerned because I have always been raring to go. I am not sure why this is all of a sudden a problem. JF: After trying some of these things, if you are still concerned about your level of desire, we can talk about other treatments that are available.

52 A revelation LW: Okay. I just hate to see my fat body and don t feel so comfortable being naked. Hmmm I wonder if that is what s wrong. You know, I think it is. I feel like a fat pig. No wonder I don t want to get naked. JF: Certainly if you don t feel good about how you look, it can affect your desire. LW: Well, now that I am going to lose weight, let me see if things are better by June.

53 The role of physical exam in FSD assessment Image: Suat Eman / FreeDigitalPhotos.net

54 Physical Exam and Lab Evaluation Physical exam rarely makes the diagnosis Most helpful for disorders of pain Educational benefit Lab evaluation rarely makes the diagnosis No agreed upon standard lab work up Recommend focused labs Checking hormone levels not demonstrated to be beneficial

55 Laboratory Test Clinical significance Hemogram TSH FSH/LH Estradiol Anemia is common, consider postpartum or with heavy menses Hypothyroidism is common, look for other s/sx of thyroid dysfunction Consider evaluation for POF or PCOS with oligomenorrhea Rarely helpful no clear link b/w level and sexual function, treat signs of estrogen def. Testosterone Limited benefit unless androgenizing features. Normal not established.

56 Management Approaches for Patients with FSD Image: Stefano Valle / FreeDigitalPhotos.net

57 Sexual Tipping Point Treatment with SSRI No history of abuse/trauma Strong relationship with partner Turn On Hot Postmenopausal vulvovaginal atrophy Turn off Not

58 Nonpharmacologic treatment plays a role in almost every patient PCP based Education Dispelling myths Exercise Healthy Diet Adequate Rest Stress Reduction Specialist based CBT Sensate-focus Controlled selfstimulation Couples counseling Physical therapy Vaginal dilators Biofeedback

59 Specific Suggestions (sex therapy for the PCP) Education What is normal or natural given length of relationship, quality of relationship, other stressors or distraction, hormonal changes or lifestage Lubrication (if needed) Particularly good products include slippery stuff (especially for a history of vaginal irritation/pain disorders), astroglide, liquid silk, etc Maximize intimacy dates, weekend getaways Introduce something new: experimentation with different positions, venues, toys if open to that Promoting relaxation beforehand (time to unwind, warm bath, massage) Focused reading list Promote overall well being exercise, sleep, healthy diet Redistribution of childcare and household responsibilities Improving body image through communication, exercise, weight loss, etc.

60 Approach to Vulvodynia Avoid irritants Soap, perfume, deodarants, douching Dietary changes Low oxalate diet Few simple carbohydrates Supplementation with calcium citrate Wear cotton underwear Consider use of a peri-bottle after urination

61 Nonpharmacologic treatment - Vulvodynia Relaxation techniques CBT or group counseling Pelvic floor physical therapy Surgical excision of the vulvar tissue (vestibulectomy) Success rates of 65-90% Long-term data lacking Laser ablation of the vulvar epithelium Success rates of 62% (complete response) to 92% (improvement) At 2 year follow up, 68% reported decreased pain

62 Image: Nutdanai Apikhomboonwaroot / FreeDigitalPhotos.net

63 PHARMACOLOGIC TREATMENT

64 Pharmacologic treatment is limited, but can be helpful in specific cases Hormonal Estrogen Testosterone* Psychotropic medications Bupropion* Mirtazapine* Phosphodiesterase inhibitors* *Off label indication

65 Local estrogen therapy for vaginal atrophy Postmenopausal women No history of hormone-dependent breast cancer Low dose as long as symptoms persist Consider lower dose, less frequent dosing Not indicated for HSDD but can be helpful if pain/dryness is contributing to low desire

66 Testosterone Good evidence (Level A) to support its use in naturally and surgically menopausal estrogen replete women 300 mcg patch for 24 weeks+ Improvements seen in desire, orgasm frequency and total number of sexually satisfying encounters Postmenopausal women without ERT Increase in SSEs/month at 300 mcg daily dose (2.1 vs. 0.7) Increase in desire, Decrease in distress 4 episodes of breast cancer in study participants (n=537) Non-depressed premenopausal women with low test Increase of 0.8 SSEs/month over placebo SSE not related to testosterone levels Levels returned to baseline at 20 weeks (4 weeks after study) but SSEs did not

67 Bupropion has limited data to demonstrate efficacy Bupropion (300 mg/day) x 112 days in non-depressed premenopausal women with normal serum testosterone Global improvement in sexual functioning and on specific subsets No statistically significant improvement in desire 268 women ages diagnosed with HSDD Premenopausal, not depressed, normal testosterone 12 weeks of bupropion SR 150 mg/day Improvement in rating scale of sexual function (globally and specific subsets) Greatest improvement in frequency of sexual activity, thoughts/ desire, and pleasure/orgasm Decrease in personal distress score Add-on or substitute therapy for SSRI induced sexual dysfunction

68 Mirtazapine and other psychotropics SSRIs and venlafaxine tend to have highest rate of sexual side effects Mirtazapine, bupropion least side effects Mirtazapine may improve desire or cause decreased desire (in up to 20% of women as an early SE). Busprione and roporinole may have some benefit (not well-studied) in treatmentemergent SD

69 Phosphodiesterase-inhibitors no little blue pill for women Studies in small groups of women with neurovascular disease show modest benefit Possible role in anti-depressant associated (treatment-emergent) sexual dysfunction Overall, limited use in FSD PDE inhibitors may help with objective arousal (genital vasocongestion) but not subjective arousal

70 Pharmacologic Treatment - Vulvodynia Topical Gel anesthetics (lidocaine) Estrogen cream (perimenopause, postpartum) Oral/systemic Approach mirrors approach to any chronic pain syndrome Neuromodulators (gabapentin/pregabalin, TCAs, other anti-depressants) Limited use of opioids Ventolini G. J Clin Med Res 2011;3:59.

71 Questions?