Outline Definitions and Epidemiology Aging and sexuality: More than just menopause Physiology, Definitions, Dysfunction Tami Rowen MD MS Assistant Professor UCSF Department of ObGyn&RS Physiology of Female Sexual Response Female Sexual Dysfunction Classification Risk Factors Treatment March 23,2016 Sexual Health is A state of physical, emotional, mental and social wellbeing in relation to sexuality Not merely the absence of disease, dysfunction or infirmity Requires the possibility of safe and pleasurable experiences An important and integral aspect of human development and maturation A human right -WHO Tech Consultation Sex Health 2002 T9 Do Women Care about Sex? Largest study(13882 women, 29 countries) 65% women sexually active in last year 38% in last week(inverse age relationship) Agrees with US data 20-37% reported sex was very/extremely important to life 76% women felt satisfactory sex is essential to maintain a relationship Sexual well being significantly correlated to self perceived overall health Laumann et al, 2006; Nicolosi et al, 2004; Lindau 2007 1
Slide 4 T9 Pfizer Global Study of Sexual Attitudes and Behaviors 13,882 women in 29 countries(age 40-80) Tami, 1/8/2014
Do older patients want to discuss sex? While 85% of adults (40-80) want to discuss sexual functioning with their physicians 71% believe their physicians doesn t have the time 68% don t want to embarrass their physician 76% thought no treatment was available for their problems 22% of women over 50 report discussing sex with a physician Do Physicians ask about Sex? Only 25% of primary care physicians take a sex history Jonassen et al, 2002 How do gynecologists do stack up? 63% ask about sexual activity 40% ask about sexual function <30% ask about sexual orientation & satisfaction Sobeicki et al, 2012 Other Specialties that take care of women with sexual health concerns: Urology, Psychiatry, Oncology, General Surgery, Neurology, Internal Medicine. Marwick et al, 1993; Maurice et al 1999, Lindau et al 2007 Bottom Line Sexual activity is an integral part of overall health Women would like to discuss sex Many providers don t ask about it Unsure how to ask Uncertainty what to ask Unfamiliar with treatment options Case #1 A 51 year old woman comes to the office to discuss a change in her level of desire. She used to have very satisfying sex with her husband of 25 year but since the kids left the house last year she feels like her desire should have been higher to rekindle their sexual relationship She was seen by another doctor who told her this was a normal part of aging and to just get used to it 8 2
Questions Is this just a normal part of Aging? Are there any treatments that could help this woman? Is it even reasonable to see a doctor over something that is usually considered a social problem? Summary of Research on Aging/Sex Sexual interest slowly diminishes with advancing age There is a greater variability of virtually all sexual parameters with higher age Sexuality of midlife and older women is more dependent on basic conditions like general wellbeing, physical and mental health, quality of relationship, life situation Strength of sexual interest depends on past sexual experience and quality/meaning sexuality had in younger years Cessation of sexual activity can be an expression of emotional problems resulting from lack of tenderness, communication problems, and feelings of guilt or pain 9 Endocrinology of sexual function Testosterone: Maintenance neuronal integrity Sexual appetitive role Vestibular glands, periurethra, clitoral volume What happens to women as they age? Estrogen: Maintenance of vaginal epithelium, lubrication in women Associated with clitoral volume Associated with sexual desire, initiation, masturbation in women Rupp Arch Sex Beh 2008 3
So what are the basic treatments Hormone therapy Emerging data show that Estrogen likely most important hormone Controversy about how testosterone is linked However, best evidence shows combination fo Estrogen and Testosterone (+/-Progesterone) has best effects on libido Key to Treatment: start close to menopause Understand testosterone is not FDA approved, need close monitoring for its use What is the role of Aging and Sex? Filled circle =desire open triangle= arousal filled square= orgasm open diamond=any Shifren et al, 2008 Physical and Emotional Health status is #1 predictor! Laumann et al, 1999; Laumann et al, 2006; Nicolosi et al, 2004; Lindau et al, 2007 13 14 Why the Peak at age 50? Not just menopause but definitely related Case #2 A 65 year old woman presents complaining of decreased orgasms. She used to be able to orgasm from intercourse with her partner but in the last few years feels like it takes longer and longer She has tried to use a device on her own but still finds it s taking a long time Her medical history is notable for high blood pressure and a recent diagnosis of depression after her mother passed away, she is now on fluoxetine Her partner is very loving. She reports their relationship is solid and is with her in the office to show support 15 16 4
Orgasm: Some physiology Transient peak sensation of intense pleasure-includes rhythmic contractions of pelvic floor muscles not related to cervix or uterus Leads to sudden release of endogenous opioids, serotonin, prolactin and oxytocin Generally, orgasm is subjectively similar between men and women No difference in vaginal or clitoral orgasm Puppo Clin Anat 2013, Mession 2004 So what can affect orgasm? (as well as desire) Medications Medical Conditions SSRIs Antipsychotics Opiates Hormonal contraception Chemotherapy Diabetes Multiple Sclerosis Nerve injuries Chronic pain Genital syndrome of menopause Genital dermatoses 18 So what can affect orgasm? Non medical Depression Anxiety Lack of stimulation Relationship difficulty How to manage our patient? Thorough history and exam Most likely culprit is fluoxetine However important to think about her other risk factors, especially age Changes in genital sensation can be directly related to decrease in estrogen at time of menopause-decreases epithelial cells, lactobacilli, increase ph 19 20 5
How to manage our patient? Make sure to consult with psychiatrist before changing any medication Buproprion known to have less sexual AE Can consider off label use of sildenafil Shown in RCT to improve FSD from SSRIs If GSM found, can consider: Topical moisturizers Vaginal lubricants water./glycerin based Silicone Oil More on Sexual Function Models What is considered dysfunction How to talk to your provider 21 22 Models of Sexual Function Male Models of Sexual Function Female Female Masters & Johnson 1964 Masters & Johnson 1964 6
T10 Female model of Basson Classification of Female Sexual Dysfunction: DSM IV Responsive Desire Basson et al 2004 Rewards: Sexual and nonsexual Sexual Arousal Innate Sexual Desire? Numero us Incentive s for Sex Sexual Stimuli Sexual Receptiv e-ness Persistent or recurrent, causing personal distress Desire Disorders Hypoactive Sexual Desire Disorder Sexual Aversion Disorder Sexual Arousal Disorder Genital Subjective Mixed Anorgasmia Sexual Pain Disorders Dyspareunia Vaginismus Non-coital sexual pain disorders DSM V Updates Must have 6 months of symptoms HSDD, sex aversion and arousal disorders replaced by Sexual Desire/Arousal Disorders Vaginismus and dyspareunia are combined into Genito-pelvic Pain/Penetration Disorder Still includes Orgasmic Disorder Sexual Arousal/Desire Disorder Lack of, or significantly reduced sexual interest, manifested by 3 of the following: Absent/reduced interest in activity Absent or reduced sexual thoughts/fantasies No/reduced initiation of sexual activity Absent/reduced excitement/pleasure Absent/reduced response to cues Absent/reduced genital sensations 5.3-13.6% prevalence Shifren et al, 2008; Seagraves & Woodard, 2006 7
Slide 25 T10 Does it apply to women only? Dismissive of intrinsic desire Implies ulterior/secondary motive is norm Tami, 1/8/2014
Sexual Pain Disorders Genital pain associated with sexual stimulation Etiology Vulvar Vestibulitis Endometriosis Fibroids Surgery Psychosocial Vaginal Atrophy Inadequate lubrication Prevalence: 14% among women 40-80 Laumann et al, 1999; Laumann et al, 2005; Walton et al, 2003 Why are Guidelines Helpful for Patients and Providers New definitions take into account that pathogenesis of sexual dysfunction is not precise Multiple psychologic, interpersonal, and organic contributions are involved New guidelines also draw attention to the frequent overlapping or comorbidity of female sexual dysfunction More on Aging/Female Sexual Health Role of Relationships There is a big difference between sexual motivation in women in new vs. long-term relationships Spontaneous sexual thoughts are infrequent in the majority of sexually healthy women in longer-term relationships Sexual fantasies in women help focus on sexual feelings/avoid distraction during sexual activity Reasons motivating sexual interaction include many that are not genuinely sexual Can include tenderness, emotional closeness, appreciation, and confirmation of one s desirability Bancroft J et al 2003.; Basson et al 2000 How to Address Sex Health with your Health Provider Use questions related to change in health over last year as opportunity Be as specific as possible about your symptoms Think about desire, lubrication, pain, partner status etc. When did they start, any associated factors(medications, illnesses etc) Describe any treatments you have already tried Allow for a physical exam, esp if any pain sx If your provider is not comfortable discussing your concerns, ask for a referral 8
Treatments for Sexual Concerns Treat underlying disorders Address relationship/ psychosexual issues Recalibrate expectations Sexual Enhancement treatments: gels and devices Pharmacotherapy Role of Ancillary Providers Sex Therapists Variety of training backgrounds/therapy types Psychologists, psychiatrist, social worker, marriage and family therapist Sexologist: interdisciplinary training Physical Therapist Life Coach Group Therapy 34 Sexual Enhancement Treatments Gels Need to go outside of traditional supermarkets Specialty sex stores have variety of gels Include non glycerine, organic, silicone based, etc Vibrators Fiera: specific for FSD Variety of device types Clitoral, vaginal Accessories Drugs: Sildenefil Evidence equivocal for sildenafil use in women with arousal/hypoactive desire disorder Possible role of sildenafil for FSD associated with SSRI use, also for vascular causes of FSD Adverse Effects of sildenafil are: congestion, flushing, headache, dyspepsia, myalgias Can t take with nitrates(hypotension) No significant adverse events reported in studies on women 35 9
Flibanserin Mixed post-synaptic 5HT1A agonist and 5HT2A antagonist 5HT1A agonists could have pro-sexual effects. Stimulating 5HT2A receptor has been associated with decreased sexual behavior (male rodents) Also has activity at dopamine D4 receptors Precise mechanism of action of for HSDD is not fully understood Thought to produce region-specific elevations in dopamine and norepinephrine, and may help to offset inhibitory serotonergic activity impacting desire pathways Flibanserin only FDA approved tx for FSD only premenopausal women needs REMS to rx Hormones Estrogens Demonstrated effect on vaginal vascularity/moisture Regular use associated with increased sex activity May improve other sexual health measures Can use Cream (Estrace/Premarin) Estring Vagifem SERMs Ospemafine: only FDA approved tx for FSD Tibolone: has Progesterone, Estrogen, & Testosterone activity Not approved in US Gass et al, 2011; Kovalevsky 2005, Lobo 2003, Basson 2004, Shifren 2000, Davis 2006, Nappi 2006 T12 Testosterone No single androgen level predictive of sexual response Multiple studies have shown improvement in FSD with testosterone can use as patch, gel, cream Common Adverse Effects Major AE: hirsutism, acne, lowering of HDL (with oral T) over 1-2 year time frame Braunstein 2007; Davis 2012 Data very equivocal for CVD and breast/uterine CA Summary of Known Safety Data Common Adverse Effects Major AE: hirsutism, acne, lowering of HDL (with oral T) over 1-2 year time frame Braunstein 2007; Davis 2012 CVD? 297 F-M Transsexuals given T for 2 mo-41 years No difference in CAD rate compared to control Van Kesternen et al 1997 Breast Cancer? 70,444 post-menopausal women in Nurses Health Study taking E, E+P, E+T, or no hormones over 24 years Multivariate RR for breast CA was 1.77 for E+T, 1.15 for E, 1.58 for E+P Tamimi et al 2006: 31842 women in WHI, E+T vs no HRT and Br Ca No difference Ness et al 2009 10
Slide 39 T12 There is abundant evidence that testosterone plays important roles for women, including sexual appetitive behavior, maintenance of genital tissue integrity, and sexual arousal responses. Testosterone levels may also play a modulatory role in CNS systems dependent on arousal memory formation are related to androgens.{laan, 2001 #164} Higher endogenous serum androgen levels has been associated with increased sexual desire in women, increased masturbation{van Goozen, 1997 #387} and coital intercourse. {Bachmann, 1991 #241;Riley, 2000 #388} Low androgen levels have been associated with declines in sexual activity and desire. {Appelt, 1986 #391;Bachmann, 1991 #241} However, several recent large population studies have not confirmed a consistent relationship between female sexual function and serum testosterone levels. Tami, 1/8/2014
Testosterone Bottom Line Data insufficient to demonstrate sig AE, incl breast ca Off-label use: what obgyn societies say NAMS (2005): Postmenopausal women with decreased sexual desire associated with personal distress may be candidates for testosterone therapy. Testosterone treatme nt without concomitant estrogen therapy cannot be recommended because of a lack of evidence ACOG: Practice Bulletin (2012) : Transdermal Testosterone has been shown to be effective for the short term tx of hypo-active sexual desire disorder, with little evidence to support long term use (longer than 6 months) Level A Developing and Alternative Therapies Zestra for Women L-arginine Bremelanotide Lybrido(s) Compounded combinations 42 For Review Sexual Health is very important to women Female Sexual Health changes over time Multiple factors affect women s sex lives as they age Sexual dysfunction can have a broad range of causes Any treatment should be both physiologic and psychosocial There are few FDA approved therapies to treat FSD, but MANY treatments are available Questions? 11
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