FEMALE SEXUAL INTEREST / AROUSAL DISORDER & STRATEGIES TO OPTIMIZE SEXUAL DESIRE IN WOMEN Dr. Shauna Correia MDCM, FRCPC UBC Sexual Medicine Program SEACRUISES - Sexual Health & Urology - Mediterranean CME Cruise July 22 - August 03, 2017 Holland America m/s Westerdam
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DISCLOSURE Presenters Names: Shauna Correia I have received speakers honorarium for talks from Lundbeck in the past Please contact me (shauna.correia@vch.ca) with any questions or reference requests
OBJECTIVES How to understand women s presentation of low sexual desire as a potentially normal and easily addressed concern How to understand the Basson/Incentive Based Sexual Response Cycle and how it can help to identify sexual barriers and provide treatment rationales Appreciate the current lack of quick fixes to this concern
CASE Mary is a 35 year old female, G2P2 Married for 10 years, has a 5 year old and a three year old. She is a materials engineer that works for a well known yoga clothing company. Her husband 37 and is a physiotherapist. She was referred to the clinic with a chief complaint of decreased sexual desire for 8 years. She presents to her family doctor s in tears saying he really is going to leave me unless I get fixed its so unfair because I want to want to have sex
FEMALE SEXUAL DYSFUNCTION Very common problem, but only needs to be addressed if it causes personal distress: 1/3 of Women experience low desire lasting several months over the last year 7-10 % associated with personal distress Women will wait for you to ask about it 19% report a problem 3% initiated the discussion In another study only 6% of women with a distressing sexual issue made an appointment to be evaluated But approximately 80% of these women stated that the provider did not broach the issue, even though that was the reason for the visit
WHEN ASKED WHY PATIENTS DO NOT RAISE THE PROBLEM: 71% reported that they believed their doctor would dismiss their sexual concerns 68% believed that their doctor would be embarrassed 76% did not think that a solution/treatment would be available WE CAN DO BETTER THAN THIS!
FEMALE SEXUAL DYSFUNCTIONS Female Sexual Interest/Arousal Disorder includes: Reduced interest/incentives for sexual engagement Difficulties with becoming subjectively aroused and/or genitally aroused Difficulties in triggering desire during sexual engagement Female Orgasmic Disorder: denotes sexual experiences with high levels of arousal but absence of orgasm Genito-Pelvic Pain/Penetration Disorder: Dyspareunia secondary to Provoked Vestibulodynia +/- Vaginismus
What more information do you want to know? How do we start to assess for a complaint of low libido?
ASSESSMENT FRAMEWORK Current Contextual Factors: Biological Psycho-social Sexual Predisposing Precipitating Perpetuating/Maintaining
CORE ELEMENTS TO THE MEDICAL /PSYCHOSOCIAL HISTORY Current Sexual Context/Sexual Response Cycle History of sexual trauma/abuse and ensure full recovery from same (*) History of major depression, substance use disorders, anxiety disorders ensure all adequately addressed and treated Is there adequate and acceptable sexual stimulation/context with her partner and/or with masturbation? Is the degree of trust and safety she feels she needs present? Are orgasms wanted but absent and/or delayed? What is the sexual pay-off? Rule out dyspareunia/pain conditions Make sure there are no sex-unfriendly medications potentially contributing Excessive fatigue?
CASE PMHX PMHx: Healthy, G2P2 with uneventful pregnancies She did have some post partum anxiety which resolved (used sertraline 150 mg po daily for 1 year after each of her pregnancies which helped her +++ but she came off it as it resulted in difficulties with orgasm and worsened her lack of libido) Trains for half marathons, BMI of 20, non-smoker, drinks wine 2 times a week in moderate amounts No medications currently, other than a copper IUD No history of significant trauma/abuse
CHIEF COMPLAINT For 8 years she has stopped initiating sex and doesn't always accept her husband s invitations to be sexual Husband has started to feel rejected and resentful At the start of the relationship: equally initiate sex and everything seemed so effortless Meet in university and were sexually active every time they saw each other initially After graduating they moved in together and they continued to be sexually active twice a week (less than before but it was a comfortable frequency for both of them) 2 years after they were married, however, things started to gradually change for the worse: Mary was busy with work and her career was really starting to pick up She just stopped thinking about having sex with Brad After her pregnancies and the need to take an antidepressant things significantly worsened But she has been off the Sertraline for a year now and doesn t understand why she isn't getting better
CURRENT FREQ AND MOTIVATIONS Currently: Sexually active once every 3 months Brad initiates once a month his motivations for initiating: he misses Mary and longs to be close to her again, it feels good, and he is less irritable when they have had sex So she only accepts 1 in 3 attempts Mary states that she refuses because she does not have any desire but accepts: because she knows that it will make Brad happy and because she feels guilty for saying no the previous times She has not self-stimulated in last 6 months, and maybe does it once/twice a year she is not sure what motivates her to self-stimulate: maybe to help sleep?
What we know: Sexually competent stimuli are integral to a sexual response
Kissing Caressing Manual stimulation or hand to genital contact Oral stimulation Vaginal Penetration or intercourse Anal stimulation Use of Sex Toys/Vibrators WHAT'S ON THE SEXUAL MENU (PAST AND PRESENT) What are the favorites? What are the most reliable ways to achieve orgasm?
TELL US ABOUT THE SEXUAL ENCOUNTERS: WHERE, WHEN, HOW, AND WHAT?
TELL US ABOUT THE SEXUAL ENCOUNTERS: WHERE AND WHEN? In the bedroom, at night before bed. She goes to bed earlier than Brad to get up to run in the morning. So if he comes to bed when she does she knows he wants something... He usually starts by saying What about tonight? Do you think you could manage it?
TELL US ABOUT THE SEXUAL ENCOUNTERS: HOW AND WHAT? If she agrees: they start by touching each others genitals with their hands and then progress to vaginal intercourse once brad s erection is firm enough Mary does not experience any triggered desire and hopes that the experience ends quickly Brad will ejaculate inside Mary and then they will kiss each other good night and go to sleep Mary will not have an orgasm with vaginal penetration alone At the beginning of the relationship she would always include oral stimulation to Brad and Brad used to always try to provide oral stimulation to her Mary on occasion would allow Brad to provide oral stimulation to her if she was feeling confident and sexy enough and sometimes correlated with when she last showered or the type of underwear she had on They used to use a vibrator on occasion to spice things up but they no longer seem to remember to bring it out and Mary has wondered about anal stimulation but has been too shy to even dream of bringing it up with Brad Mary denies any pain with vaginal penetration, has adequate vaginal lubrication
COMPLETING THE ASSESSMENT Confirmed: - No comorbid depression, anxiety, or pain disorders - No medications A Focused Physical Exam: Not necessary for this particular chief complaint and history, but may be highly therapeutic for the patient to confirm/reassure vulvar health (if the patient understand reason for and agrees to the exam!) Would include examination of vulvar mucosa, brief neurological exam of the genitals (touch, temperature sensation, reflexes), pelvic floor muscle tone and control, rule out allodynia (PRN) Lab Work: Not needed per se in an otherwise healthy person, if needed should be guided by the general medical assessment (ie fasting blood glucose, TSH, Prolactin etc.) No hormone levels required in to be tested in a heathy woman
WHAT IS HER DIAGNOSIS? A) Female orgasmic disorder B) Female sexual interest/arousal disorder C) Missed diagnosis of depression due to reality that GP only has so long to spend screening D) Must have an undisclosed sexual abuse history E) Normative shift from primarily spontaneous to primarily triggered desire pattern
HOW TO DEVELOP A FRAME WORK TO EXPLAIN THE DIAGNOSIS AND TREATMENT TO HER? Masters and Johnson Sexual Response Cycle The Basson / Incentive Based Sexual Response Cycle
M&J SEXUAL RESPONSE CYCLE
BASSON INCENTIVE BASED SEXUAL RESPONSE MODEL Incentives/ Motivations Outcome: Emotional & physical Spontaneous desire/urge Sexual stimuli & context Responsive/ Triggered desire Physical/ANS arousal Mental arousal Bio Psych
REMEMBER Sexual arousal problems in medically healthy women (with adequately estrogenized vaginal mucosa) are more often related to inadequate sexual stimulation caused by personal, contextual, and/or relational variables then to somatic causes! Hence, the lack of efficacious biological interventions and need for more psychosocial interventions:
EVEN IN. Even in cases where there is a clear medical/biological cause for sexual dysfunction (ie DM, MS, GSM, etc) there are psychological and interpersonal repercussions plus sexual adaptions that may or may not be helpful SO medical management in those cases alone may be insufficient
SIAD TREATMENT OPTIONS Address common general psychosocial issues: Fear of letting go Inability to stay present in the moment Fear of negative outcomes Lack of or inaccurate information/ myths regarding womens sexual response (i.e. sex should only happen when I am spontaneously in the mood ) Review basic genital anatomy Address more specific concerns related to the patients case: Relationship issues Poor communication Fatigue Lack of privacy/time Change medications to more sex-friendly ones if possible/needed
Dr. Levent Efe from The Elusive Orgasm (2007).
DO NOT UNDERESTIMATE THE POWER OF SEXUAL MYTH BUSTING Sex intercourse It is normal for women in long term relationships to experience a decline in spontaneous sexual desire Good sex does not need to start with mutually simultaneously occurring spontaneous desire Talking about what you like/what feels good (or want to explore) will not kill the mood or make your partner feel like a bad lover It is normal for a woman to not able to orgasm easily with vaginal penetration alone Sexual arousal can be triggered???
SIAD TREATMENT Sex therapy strategies shown to improve sexual function in 57-65% of couples Sensate focus for touch/communication work Explore techniques that encourage arousal including enhancing the context (environment, lighting) and stimuli (fabrics, toys, scents) CBT strategies: Behavioral skills training: to improve communication, increase sexual skills, reduce sexual and performance anxiety; anxiety reduction techniques; and cognitive challenging skills A 2013 meta-analysis found that CBT had a large effect size (d=0.91) on low desire endpoint and moderate effect size on improving sexual satisfaction Group CBT improves sexual desire disorder in 74% of couples and the effect was maintained at 64% one year out
SIAD TREATMENT Group Mindfulness-based CBT (developing present moment awareness of ones thoughts and body sensations in a nonjudgmental accepting manner) has been shown to have statistically significant improvements on sexual desire and overall sexual function and less distress More studies needed however in comparison with other strategies
BUT WHAT ABOUT TESTOSTERONE??? But the serum levels might come back so low it was off the scale?!? Most current assays are set up according to the male range so only high levels of testosterone production will be of significance And they measure serum testosterone... BUT intracrine testosterone accounts for >50% (but can measure via metabolites)
Outcome measures in controls and sexual dysfunction groups Outcome Measure Control Group (n = 124) Clinical Group (n = 121) p-value 1 with age adjustment ADT-G: ng/ml Average (SD) 24.65 (17.27) 21.09 (17.46) 0.33 Min, Max 2.42, 109.38 0.36, 103.00 5%, 95% percentile 7.52, 53.88 5.35, 56.79 Testosterone: ng/ml Average (SD) 0.21 (0.10) 0.19 (0.11) 0.19 Min, Max 0.02, 0.54 0.03, 0.68 5%, 95% percentile 0.08, 0.40 0.06, 0.37 By Dr. Basson 1 ANCOVA comparing the control and sexual dysfunction groups
NO EVIDENCE OF T DEFICIENCY AND LOW SEXUAL DESIRE Whether studies exam sexual dysfunction and serum testosterone Or sexual dysfunction and serum ADT-G (metabolite) Even if using the gold standard mass spectrometry THERE IS NO EVIDENCE OF LOW T AND SEXUAL DYSFUNCTION BUT isnt it available in Europe as a patch?? Study was on women reporting low desire since their surgical menopause 300μg transdermal testosterone daily At baseline they had 2, or usually 3 sexually satisfying events/ month * with the T patch it increased to 5 events a month vs 4 events with placebo (but not with 150 ug or 450 ug patches) HOWEVER no longer produced and sold due to a lack of demand for the product...
Would testosterone benefit women unable to have ANY sexually satisfying events? These are the women in need of further study Safety data for long term (co) therapy???? No safety data beyond 3 years: high endogenous T/ low SHBG linked to increased risk of CVD, increased upper abdominal obesity, and?breast ca risk? Potential for permanent clitoromegaly and voice deepening
?VIAGRA FOR WOMEN? PDE5-inhibitors do work on female genital tissue like in men ie will allow for more NO effect on the smooth muscle relaxation and increased genital engorgement HOWEVER... Most healthy women do not correlate this effect with increased sexual desire or even sexual arousal And studies found to have no benefit over placebo
OK BUT WHAT ABOUT FLIBANSERIN?? Flibanserin (Addyi) is a 5-HT1A agonist/5-ht2a antagonist originally developed as an antidepressant, while failing as an antidepressant in studies was noted to have some pro-sexual side effects Failed in the first two studies to show statistically significant benefit on the primary endpoint of desire Sprout pharmaceuticals then re tested with a different endpoint (retrospective desire over 4 weeks) and failed then tried again using sexually satisfying events (SSE) Results showed that in women with 2-3 SSE a month when taking daily flibanserin experience 0.5-1 extra SSE a month
OK BUT WHAT ABOUT FLIBANSERIN?? Meanwhile, clinically significant risk of dizziness, somnolence, nausea and fatigue and comes with a complete contraindication with alcohol use* JAMA 2015 Meta-analysis: Treatment with flibanserin, on average, resulted in one-half additional SSE per month while statistically and clinically significantly increasing the risk of dizziness, somnolence, nausea, and fatigue. Available in the US since Oct 2015 but in the same amount of time that Viagra (sildenafil) sold half a million prescriptions Addyi has only sold a few hundred
https://youtu.be/qdt8h9yv7bu
SUMMARY This case can be addressed by identifying psychosocial/sexual barriers to her Incentive Based Sexual Response Cycle We normalized her decline in spontaneous desire Then using evidence based techniques including sex therapy strategies, CBT, and/or mindfulness based strategies we can: help her tune into and communicate about the optimal stimulation desired ( in an ideal sexual context) to allow for subjective feelings of arousal to develop which can trigger a desire for more sexual experiences/the feelings to last longer There are no evidence based medications indicated/available at this point to help address her sexual concerns
QUESTIONS?