Menopause & Female Sexual Dysfunction. Debra Muth ND, WHNP, BAAHP Serenity Health Care Center

Transcription

1 Menopause & Female Sexual Dysfunction Debra Muth ND, WHNP, BAAHP Serenity Health Care Center

2 Menopause & Female Sexual Dysfunction Part 1 Complexity of what women really want Part 2 Why women say no to sex Part 3 How hormonal imbalances effect sexual desire

3 What Women Really Want Many of my patient's tell me they would rather do something other than sex? They are afraid, scared and disappointed in what has happened to their sex drive. Many faces of desire: attractions, passion, love, energy, libido, and the all-consuming lust. Women still long for sensual touch!

4 Sex is everywhere 77% of network TV contains sexual material according to the Kaiser Family Foundation. Billboards Commercials Rap music and YouTube- its everywhere!

5 Experts Everywhere we look someone is an expert on the subject of sex. Articles written, psychotherapy, weekend retreats. It is now a medical syndrome or dysfunction. Accepted for men and treated. Not yet accepted or successful treatment for women.

6 Loss of Sexual Desire The truth is, fluctuations in desire do pose genuinely painful problems for many women and their partners. Sexual desire gets completely derailed for some, some completely loose it. Stress, boredom, and poor relationships can all cause a problem. Besides hormonal change, illness or surgeries also interfere with ones sex life.

7 Sexual Energy Physical Energy Moving the body and enjoying the physical connection. Emotional Energy Passion, compassion, love, empathy, caring, safety and power. Mental Energy Helps us make decisions about what we want, who I am, what do I enjoy.

8 Sexual Energy Spiritual Energy Helps us find meaning in our lives, affirms our love for each other, liberation or a sense of connection with nature. Merging all the Energy Allows us to bring all the energies together to feel sensual touch, kisses, hugs, and heated sexual connections. It allows to become with one another.

9 What is normal How often are you asked this question? Have you wondered what is normal? Do you have scripted answer for your patients?

10 Essential Questions in Sexual Assessment Female Decreased Sexual Desire Screener 1. In the past was your level of sexual desire or interest good and satisfying to you? 2. Has there been a decrease in your level of sexual desire or interest? 3. Are you bothered by your decreased level of sexual desire or interest? 4. Would you like your level of sexual desire or interest to increase? Do you feel any of the following has contributed to your current decrease in sexual desire or interest? 5. An operation, depression, injuries, or other medical condition? 6. Medication, drugs or alcohol you are currently taking? 7. Pregnancy, recent childbirth, menopausal symptoms? 8. Other sexual issues you may be having (pain, decreased arousal or orgasm)? 9. Your partner s sexual problems? 10. Dissatisfaction with your relationship or partner? 11. Stress or fatigue?

11 Essential Questions in Sexual Assessment If the answer is no to any of 1-4, answer: The screener determines that you may not qualify for the diagnosis of Hypoactive Sexual Desire Disorder. You may still find value in the program as a tool to increase your understanding of sexual desire, and to improve your relationship. If the answer is yes to all of 1-4, answer: The screener determines that you may qualify for the diagnosis of Hypoactive Sexual Desire Disorder. The program that is offered may be beneficial to you. If the answer to any question 5-8, or 11 is yes add: You should also seek consultation with your health care provider to determine if a medical condition or problem is contributing to your current decrease in sexual desire or interest. If the answer to question 9 is yes add: Your partner may need to seek consultation with his health care provider before starting the program. If the answer to question 10 is yes add: You and your partner should consider professional counseling instead of or in addition to this program. Screener is based on Validation of the DSDS, Clayton et al: J Sex Med 2009;6:

12 Medications Associated with FSD Antipsychotics Progestin's Orgasm Benzodiazepines Phenytoin Benzodiazepines Beta Blockers Reserpine Clonidine Barbiturates SSRIs Diazepam Clonidine Spirolactone Methadone Digoxin Tricyclic Antidepressants Methyldopa Danazol Arousal Narcotics H-2 Blockers Alcohol Phenelzine Indomethacin Anticholinergices SSRIs Ketoconazole Benzodiazepines Trazadone Lithium Beta blockers TCA;s Methyldopa SSRIs Metoclopramide TCAs Niacin Thiazide diuretics

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14 Female Sexual Dysfunction Decreased libido Female Sexual arousal disorder DSMII % Hormonal imbalance Female Orgasmic Dysfunction DSMII % Sexual pain disorders 3-46% Dyspareunia Vaginismus Hypoactive sexual desire disorder %

15 Female Sexual Dysfunction For women ages low sexual desire is present in 26% of surgically postmenopausal women vs. 14% of premenopausal women. For women ages was 14% for surgically postmenopausal women vs. 9% for those who are naturally postmenopausal. Younger women were 3 times more likely to report sexually related distress, compared with older women.

16 Clinical Evaluation History of Chief Complaint When the problem began, how it developed, and factors that make it better or worse. Sexual status examination: A detailed account of the patient's behavior, emotional reactions, and thoughts about the most recent sexual encounter. Complete medical history: Illness, trauma, surgery, mediations that may interfere with sexual functioning.

17 Clinical Evaluation Medical work-up Hormone panel, thyroid panel, A1c, prolactin, FSH. Psychiatric History Common disorders are linked to sexual dysfunction. Depression is often found in sexual dysfunction. Antidepressants further inhibit sexual functioning. Psychosexual history, family, and religious background. History of upbringing, sexual attitudes, cultural backgrounds,

18 Clinical Evaluation Relationship history Does the patient s romantic relationships follow a pattern, i.e. sexual abuse, verbal abuse, communication issues. Obstacles to identifying FSD occurs because only 20% of women report symptoms.

19 Female Sexual Dysfunction Characterized by: Decreased libido Vaginal dryness Pain and discomfort with intercourse Decreased genital sensation Decreased arousal Orgasmic dysfunction Dysfunctions are due to vasculogenic, neurogenic, hormonal or psychogenic etiologies. Berman J.R., L.A. Berman, T.J. Werbin and I. Goldstein. Female sexual dysfunction: anatomy, physiology, evaluation and treatment options. Curr. Opin. Urol. 9: , 1999

20 Female Sexual Dysfunction Primary Defined as a lifelong or acquired dysfunction Secondary Situational only occurs in certain circumstances or with certain partners

21 Female Sexual Response Cycle

22 Causes of Female Sexual Dysfunction Cause Examples Sexual Symptoms Hormone/Endocrine Hypothalamic-pituitary axis dysfunction, surgical/medical castration, menopause, chronic oral contraception, premature ovarian failure Decreased libido/desire, vaginal dryness, lack of arousal Musculogenic Hyper or hypotonicity of pelvic floor muscles Hypertonicity; sexual pain disorders, including Vaginismus Neurogenic Spinal cord injury; disorders of the central or peripheral nervous system Anorgasmy Psychogenic Relationship problems, poor body image, decreased self-esteem, mood disorders, adverse effect of psychotropic medications Decreased libido/desire, decreased arousal, hypoesthesia, Anorgasmy Vasculogenic Diminished blood flow to genitals secondary to atherosclerosis, hormonal influences, trauma Vaginal dryness, Dyspareunia Aafp.org/afp

23 Hormonal Imbalance Estrogen depletion Progesterone depletion Testosterone depletion Diminishing DHEA

24 Oxytocin Oxytocin is best known for roles in female reproduction Recent studies have begun to investigate oxytocin's role in various behaviors, including orgasm, social recognition, pair bonding, anxiety, and maternal behaviors.

25 Increases in plasma Oxytocin at orgasm in both men and women Oxytocin evokes feelings of contentment, reductions in anxiety, and feelings of calmness and security around the mate abccarmichael MS, Humbert R, Dixen J, Palmisano G, Greenleaf W, Davidson JM (January 1987). "Plasma oxytocin increases in the human sexual response". The Journal of Clinical Endocrinology and Metabolism 64 (1): doi: /jcem PMID Meyer, Dixie (2007). "Selective Serotonin Reuptake Inhibitors and Their Effects on Relationship Satisfaction".TheFamily Journal 15 (4): doi: /

26 Oxytocin Makes you more receptive to touch Helps increase vaginal lubrication Makes the climax better Compounded Tablet triturates (rapid dissolve) Nasal spray

27 Neurotransmitters/Sexual Dysfunction Neurotransmitter Sexual function Type of effect Comments affected Dopamine Desire, arousal Positive May promote willingness to continue sexual activity after initiated. Norepinephrine Arousal Positive Serotonin Arousal/Desire Positive/negative Inhibits Norepinephrine and dopamine; may facilitate uterine contractions during orgasm, but also may inhibit orgasm by different mechanisms. Berman JR, Berman LA, Toler SM, Gill J. Hughie S. Safety and efficacy of Sildenafil citrate for the treatment of female sexual arousal disorder a double blind, placebo controlled study J Urol. 2003:170 (pt 1)

28 Hormonal Imbalance Nitric Oxide (NO) is believed to be involved in decreased sexual desire and vaginal atrophy during menopause. Estrogen withdrawal appears to play a role in the regulation of vaginal (NO) synthase expression and apoptosis in nerves, smooth muscle, vascular endothelium and epithelium of the vagina, implying an NO-related mechanism in female sexual function.

29 Nitric Oxide The focus of female sexual dysfunction has been on Nitric Oxide and has been shown to be essential to sexual maturation in female sexual function. Nitric Oxide (NO) and PDE5 expression has been known to enhance the clitoral cavernosal artery blood-flow, allowing for the vaginal and clitoral vascular engorgement. D Amati G, di Gioia CRT, Bologna M et al. Type 5 phosphodiesterase expression in the human vagina. Urology 2002; 60:191-5

30 Treating Female Sexual Dysfunction Testosterone replacement 1-3mg daily in transdermal dosage. Estrogen supplementation with Estradiol and Estriol transdermal dosage 0.25mg-2mg daily dosage. Vaginal Estriol 0.5-1mg applied daily for 7 days then 1-2 times weekly after that as needed. Progesterone mg transdermal daily dosage. Pregnenolone mg transdermal daily dosage.

31 Tibolone A selective tissue estrogenic activity regulator. Metabolized in the GI tract to a 3a and 3B metabolite, which circulates predominantly into their sulfated inactive form. These metabolites become estrogenic when desulfated in target tissue. The global effect of Tibolone is estrogenic. It is suggested that it will have an increase effect of sexual desire to a greater effect of estrogen/progesterone. Kloosterboer H. Tibolone: a steroid with tissue-specific mode of action. J Steroid Biochem Mol Biol 2001: 76; 231-8

32 Sildenafil for FSD Sildenafil a PDE5 inhibitor can significantly increase genital blood flow and lubrication in ovariectomized animals. Rosen R. Brown C, Heiman J et al. The Female sexual function index a multidimensional self report instrument for the assessment of female sexual function. J. Sex Marital Therapy 2000; 26: 191-5

33 Sildenafil for FSD Sildenafil mg given to women with dysfunction secondary to multiple sclerosis showed significant improvement in vaginal lubrication, sensation. DasGupta R, Wiseman OJ, Kanabar G et al. Efficacy of Sildenafil in the treatment of female sexual dysfunction due to MS. J. Urol. 2004; 171:

34 Nutritional Supplement to Enhance FSD Ginseng, Ginkgo, Damiana, L-Arginine, multivitamins and minerals. After 4 weeks, 73.5% of the women treated reported improved satisfaction in their sex life. Journal of Sex & Martial Therapy, 27; , A Double-Blind Placebo Controlled Study of ArginMax, a nutritional supplement for Enhancement fo Female Sexual Function.

35 Ginkgo Biloba Facilitates microvascular circulation that may physiologically lead to improvement in sexual function. Evidence shows that Ginkgo may directly elucidate smooth muscle relaxation, likely based on the (NO) Nitric Oxide pathway. Average dosage 60mg/day of extract. Welt, K., J Weiss, S. Koch and G. Fitzl. Protective effects of Ginkgo biloba extract EGb 761 on the myocardium of experimentally diabetic rats. II. Ultrastructual and immunohistochemical investigation on microvessels and interstitum. Exp. Toxicol. Pathol. 51: , 1999

36 Ginseng Ginseng is commonly used for the treatment of sexual desire. American and Asian Ginseng enhances libido and copulatory performance. These effects of ginseng may not be due to changes in hormone secretion, but to direct effects of ginseng, or ginsenoside components on the central nervous system on gonadal tissues. Attele, A.S., J.A. Wu and C.S. Yuan. Ginseng pharmacology: multiple constituents and multiple actions. Biochem. Pharmacol. 58: , 1999

37 Tribulus Terrestris plan Tribulus has been clinically proven to improve sexual desire and enhance erection via the conversion of protodioscin to DHEA. Tribulus 50mg a day is the typically dosage. Tribulus has been proven to reduce hot flashes and menopausal symptoms. Moeloek, N., W. Pangkahila, T.D. Tanojo and A. Adimoelja. Trials on Tribulus Terrestris on idiopathic ologasthenoteratozoosperms. In: 6 th National Congress Indonesian Society of Andrology and 3 rd International Symposium of Andrology, Manado, Indonesia, 1994.

38 Damiana Damiana has been used traditionally as a tonic for central nervous system and hormonal system in Latin America. It has been shown that damiana has progestin receptor-binding activity and is considered a phytoprogestin. Animal studies show that damiana increases the copulatory performance. Arletti, R., A. Benelli, E. Cavazzuti, G. Scarpetta and A. Bertolini. Stimulating property of Turnera diffusa and Pfaffia paniculata extracts on the sexual behavior of male rats. Psychopharmacology 143; 15-19, 1999

39 Libido Many agents when applied topically may enhance sensation Scream Creams Aminophylline Arginine Ergoloid Mesylates Naltrexone Nifedipine Papaverine Sildenafil better known as Viagra Testosterone/DHEA

40 Vaginal Dryness Creams and Suppositories Lubricant like base Containing: Estriol DHEA Progesterone Testosterone Vitamin E Hydrocortisone

41 Sex Therapy Techniques Sexual fantasy training Masturbation Identifying & overcoming cultural inhibitions Improving communication Sensual massage Flexible partners Use of sexual stimulators

42 Arousal Disorder Eros Clitoral Therapy Device manufactured by UroMetric. FDA approved and designed to improve arousal by increasing blood flow to the clitoris with gentle suction. Billups KL, Berman L, Berman J, Metz ME, Glennon ME, Goldstein I.A new non-pharmacological vacuum therapy for female sexual arousal disorder. J Sex Martial Ther. 2001; 27(5)

43 The American Sex Diet Adapted from the book The Great American Sex Diet by Laura Corn.

44 Step One: Commitment If you really want to achieve great sex, then you need to agree and commit to wanting better sex. First is to be more mental and emotional than physical. Sounds easy, Right!

45 Step Two: Frequency Research indicates that couples who have sex frequency tend to have better sex. This means you should schedule sex. Frequent, regular sex. Scheduling means it is a priority in your life; and it is going to happen; meaning you are going to get some! Set a goal with your partner! Chose a target for the diet. Think of this as motivation

46 Step Three: Anticipation With any diet you need spice, surprise, power of suggestions and seduction without this you will get predictability, even boring. Anticipation keeps a lovers curiosity, keep them guessing, give each other something to look forward to. Think about big events that you plan for Christmas, Halloween, Hanukkah, Valentine s Day, do you count down the days?

47 Step Four: Variety The key to turning predictable into passionate and seductive is in His and Hers Spice Menus.. Variety Dessert First Love Slave Massage Find a forbidden zone 300 hot seconds (Quickie)

48 Schedule Sexual Fun

49 Romantic Diet S-SS-SS-SmOOOOth!! Remember to write those little love notes to each other, invite each other to a romantic dinner. Place a love not inside a red balloon and place it next to the bed she will melt when you tell her she can open after you make love.

50 Foreplay Remember It Go back to what was off limits, tease, Feed each other their favorite treat Red light district Use a finger vibrator to massage the body without touching the genitals

51 Your patient s are ready to reclaim love, intimacy, confidence, and sexuality- if you are willing to work with them not only medically but life-style changes. Your spicy new life can start tonight!