M. Chantel Long, M.D.

June 24, 2011

Discuss and Define Sexual Dysfunction in Women

Review Causes Provide Strategies to Improve

Communication with Patients and Treatment

Defined as the persistent or recurrent deficiency or absence of sexual thoughts, fantasies, and/or desire for sexual activity as per the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition.

It is widely agreed that decreased receptivity is another contributing factor and often the key symptom

It must cause marked personal distress or interpersonal difficulties for the patient to meet the diagnosis

It can not be associated with another psychiatric disorder, drug, medication side effect, or other medical condition as a primary cause

May occur in women of all ages

Four categories of female sexual disorders

Six Sexual Disorders

Hypoactive Sexual Desire Disorder

Sexual Aversion Disorder

Sexual Desire

Disorders

Female Sexual Arousal Disorder

Sexual Arousal Disorder

s

Female Orgasmic Disorder

Orgasmic

Disorders

Dyspareunia

Vaginismus

Pain Disorder

s

Is usually multifactorial (not just medical or hormonal)

Often, women choose to be sexual for reasons other than desire, such as for emotional intimacy or to please their partner.

Biopsychosocial model differs from the linear models in that it shows there are multiple factors contributing to whether a woman will have a healthy sexual responseBiologicalPyschologicalSocial Interpersonal

Hormone Levels Ongoing Disease Processes

(Sjogren’s) Medication Side Effects

Tagamet, Wellbutrin, Diuretics, SSRIs, Narcotics, Anticonvulsants, and Antihistamines

Depression Anxiety Confidence/Self-Esteem Performance Anxiety

Religion Cultural Factors

Marriage Counseling Relationship Issues

More difficult to treat females due to the many factors, i.e. one can’t simply prescribe “a blue pill”

Must consider all the possible factors, including stress and fatigue

Common after having a baby due to hormone changes, breastfeeding, stress, lack of sleep, lack of privacy, and increase time pressures

National Health and Life Survey43% reported having a sexual problem

22% Low Sexual Desire 14% Arousal Issues 7% Pain Issues

PRESIDE Study43% reported having a sexual problem

12% reported Distress9.5 % Low Sexual Desire5.0% Arousal Issues4.6% Orgasm Issues

The most prevalent sexual disorder across all ages

It is not a disorder that only occurs in older women

Prevalence of Sexual Problems Associated With Distress by Age Group

Desire Arousal Orgasm Any

Valid Responses 28,447 28,461 27,854 28,403

With Distress 2,868 1,556 1,315 3,456Age Stratified Prevalence

18-44 Years 8.9% 3.3% 3.5% 10.8%

45-64 Years 12.3% 7.5% 5.7% 14.8%

>65 Years 7.4% 6.0% 5.8% 8.9%

Those with underlying medical issues (depression, diabetes)

Postpartum (Natural or Surgical) Age > 45

Menopause – naturally or surgically induced

Hypotestosteronism Associated Disease – Diabetes Mellitus,

Sleep Apnea, DDD, and even Age Depression – whether the cause or the

consequence Substance Abuse Dyspareunia (lubrication, position,

infections)

Clinician BasedGenderTimeLack of Screening Tool UseLack of TrainingLack of Effective Treatment

Decreased Sexual Desire Screener

Female Sexual Function Index Brief HSDD 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?

5. Which of the factors below do you feel may be contributing to your current decrease in sexual desire or interest? (Check all that apply)

a. An operation, depression, injuries, or other medical condition?

b. Medication, drugs, or alcohol that you are currently taking?

c. Pregnancy, recent childbirth, or are you having any menopausal symptoms?

d. Other sexual issues you may be having (pain, decreased arousal or orgasms)?

e. Your partner’s sexual problems?f. Dissatisfaction with your relationship or partner?g. Stress or fatigue?

Y/N Y/N Y/N Y/N

Antidepressants Hormone Replacement (Estrogen,

Progesterone, Testosterone) Treatment of Ongoing Diseases Counseling

Permission Limited Information Specific Suggestions (keep the

patient comfortable) Intensive Therapy

For postmenopausal women, there are many studies showing that testosterone may be effective.

Hypotestosteronism leads to decreased bone density and decreased libido

Some women may try DHEA which is OTC Testosterone has 20 times the androgen

potency of DHEA or DHEA Sulfate. In premenopausal women, most circulating

testosterone results from ovarian production, with the remainder from the adrenal gland.

In postmenopausal women, ovaries contribute less to circulating levels.

Currently, there are no guidelines for androgen replacement in women, but making the diagnosis of hypoandrogenemia can be important.

Measurement of total testosterone is not useful because of variable levels of binding with serum hormone-binding globulin

The free testosterone level and serum hormone-binding globulin levels are better indicators.

Excess oral androgen therapy can lead to an increase in LDL and decrease in HDL

Excess androgens cause unwanted facial hair growth, acne, and hair loss and can occur with elevations of testosterone levels to just slightly above normal

Liver damage possible with oral replacement, including cholestatic juandice, but not with transdermal replacement

Pregnancy Breastfeeding Hyperandrogenic State Presence of androgen-dependent

tumors

Further study is needed to determine the clinical significance of androgen deficiency in women

Specifically in post-menopausal women, physiologic low-dose androgen replacement therapy may result in improved bone density, enhanced libido, and increased satisfaction with life

Androgen preparations that avoid liver metabolism and produce physiologic serum androgen level will enhance treatment options

Routine screening is not recommended until such preparations are available

Estratest 0.625/1.25mg or 1.25/2.5mg daily or

cyclically Methyltestosterone

1mg PO daily with blood levels every 1-2 months

Lozenges, patches, cream Pellets last 3-6 months and are injected

(75mg); slow release into the bloodstream Progesterone 4% cream with 1mg

testosterone/ml. Apply one ml to skin (not genitalia) qHS. Disp: 50 grams. Must be refrigerated.

Once upon a time, a perfect man and a perfect woman met. After a perfect courtship, they had a perfect wedding. One snowy, stormy Christmas Eve, the perfect couple were driving their perfect car along a winding road and noticed someone in distress. On the roadside, there stood Santa Claus with a huge bundle of toys. The perfect couple picked up Santa and began helping him deliver the toys. Unfortunately, the driving conditions worsened and they had a car accident. Only one survived. Who was the survivor?