Overview of Female Sexual Dysfunction for the Primary Care Physician WVU WOMENS HEALTH CURRICULUM – Revisions 9/2008
Stanley Zaslau, MD, MBA, FACS
Program Director & Associate Professor
Division of Urology
West Virginia University
Objectives - 1
In this lecture, participants will learn:
Incidence, epidemiology and pathophysiology of Female Sexual Dysfunction
Female pelvic anatomy
AFUD Classification of Female Sexual Disorders
Clinical Evaluation of the Female Sexual response
Objectives - 2
In this lecture, participants will learn:
Treatment of FSD
Oral agents
Neutraceuticals
Vacuum Clitoral Erection Device
Potential novel therapies
Incidence
30 million men with compromised erectile function
Paucity of epidemiologic data regarding incidence of female sexual dysfunction
multi-causal
multi-dimensional
age-related
progressive
highly prevalent
Incidence
National Health and Social Life Survey (1999)
1749 Women
33% of women lack sexual interest
25% of women do not experience orgasm
20% of women report lubrication difficulties
20% of women report sex is not pleasurable
Incidence
Sexuality in Older Women (Diokno, 1990 and Mooradian 1990)
448 women over the age of 60
66% are sexually inactive
12% of married women had difficulty with intercourse; 14% experienced dyspareunia
Sexuality positively correlated with marital status
Less likely to have sex if partners in poor health
Diokno AC, et al. Sexual function in the elderly. Archives of Internal Medicine 1990;150:197-200.
Incidence
Rosen (1993) Study
329 women age 18 to 73 years
Most common areas of dysfunction
38% lack of desire
16% lack of pleasure
Age and relationship status predict FSD
single and older women highest incidence
Rosen (1993) Journal of Sexual and Marital Therapy
Female Pelvic Anatomy
Vagina
Vascular supply, innervation and physiologic changes
Clitoris
Vascular supply, innervation and physiologic changes
Vestibular bulbs
Uterus
Pelvic Floor Muscles
Vagina-Anatomy & Blood Supply
Labia minora surrounds vagina; protected by outer labia majora
Labia minora enclose the vestibule which contains:
Clitoris
Vaginal opening
-- Urethral opening
Innervation
Autonomic
Somatic motor fibers of S2-S4 innervate bulbocavernosis and ischiocavernosus muscles
Pudendal nerve—sensory to introitus
Main arterial supply (extensive anastomosis)
Vaginal branches of the uterine arteries
Vaginal branches of the pudendal arteries
Ovarian arteries
Clitoris-Anatomy & Blood Supply
Erectile organ similar to the penis
Blood supply
Iliohypogastric-pudendal arterial bed
Internal pudendal artery branches to form common clitoral artery --> dorsal and cavernosal clitoral arteries
Consists of fused midline corpora cavernosa
Unable to trap venous blood
With sexual stimulation, engorgement, rather than erection occurs
Vestibular Bulbs
Paired, 3-cm structures along the vaginal orifice
Homologous to corpus spongiosum of the penis
Composed of vascular smooth muscle
Arterial supply: branches of internal pudendal artery
Sensory innervation: posterior branches of the pudendal nerve
Uterus
Uterine/cervical glands secrete mucus during sexual arousal
Uterine/pelvic procedures interrupt vaginal innervation --> negative impact on later sexual health
Disruption of uterosacral and cardinal ligaments can result in genital arousal and orgasm difficulties
Role for nerve sparing procedures as similar to those performed in men
Pelvic Floor Muscles
Pelvic diaphragm formed by:
Levator ani muscles
Urogenital diaphragm
Peroneal membrane, composed of
ischiocavernosus, bulbocavernosus and superficial transverse perinii muscles
Muscles pull rectum, vagina and urethra anteriorly towards pubic bone
Pelvic Floor Muscles
Non-voluntary spasm of pelvic floor=vaginismus
Laxity or hypotonia of pelvic floor, associated with
vaginal hypoanesthesia
anorgasmia
incontinence
Question all women with voiding dysfunction about their sexual function!!
Female Sexual Physiology: Normal
Physiological changes during arousal
Enlargement of clitoris
Dilation of arterioles, increased vaginal and clitoral blood flow
Seeping of vascular transudate across vaginal membrane ---> lubrication
Expansion and tenting of upper 1/2 of vagina
Response mediated by nitric oxide (role for sildenafil)
AFUD Classification and Definition of Female Sexual Disorders
Consensus classification (AFUD Consensus Panel, 1998)
Hypoactive Sexual Desire Disorder
Sexual Aversion Disorder
Orgasmic disorders
Sexual pain disorders
Dyspareunia
Vaginismus
Other sexual pain disorders
Hypoactive Sexual Desire Disorder
Hypoactive sexual desire disorder
Persistent or recurrent deficiency (or absence) of sexual fantasies/thoughts or desire for a receptivity to sexual activity
Causes personal distress
Differential diagnosis:
surgical or medical menopause
endocrine disorders
Sexual Aversion Disorder
Sexual Aversion Disorder
Persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner
Causes personal distress
Results from:
childhood trauma (physical or sexual abuse)
Sexual Arousal Disorder
Persistent or recurrent inability to attain or maintain sufficient sexual excitement
Causes personal distress
Differential diagnosis: medical causes, prior pelvic trauma, pelvic surgery, medications
May be expressed as
lack of subjective excitement or lack of genital lubrication/swelling
Orgasmic Disorder
Persistent or recurrent difficulty, delay in or absence of attaining orgasm following sexual stimulation
Causes personal distress
Primary (never attained orgasm)--emotional trauma or sexual abuse
Secondary
Surgery
Hormone deficiency
-- Trauma
Sexual Pain Disorders
Dyspareunia
Recurrent or persistent genital pain with sexual intercourse
Consider:
vestibulitis
vaginal atrophy
vaginal infection
Sexual Pain Disorders
Vaginismus
Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration.
Conditioned response to painful penetration (?psychological or emotional)
Other Sexual Pain Disorders
Herpes Simplex Virus
Vestibulitis
Prior genital mutilation
Trauma
Endometriosis
Interstitial cystitis
Interstitial Cystitis (IC) and Female Sexual Dysfunction (FSD)
Pain associated with intercourse
Entry dyspareunia
Deep dyspareunia
IC and FSD
100 patients with IC
FSFI administered
Assess 6 domains of sexual function
Desire
Arousal
Orgasm
Lubrication
Satisfaction
Pain
Zaslau, et al. WVMJ 2008
IC and FSD
Results:
Mean age 39 years
Impairment in all domains “50-75% of the time”
Conclusions
FSD in IC involves more than pelvic pain
Zaslau, S et al FSFF, Vancouver, BC 2002
FSD in IC: 1st 400 Patients
400 IC patients
FSFI administered on line at IC-Network
Compared to two groups
Controls (131)
Female sexual arousal disorder (129)
FSD in IC 1st 400 Patients
Results
Statistically significant decrease in all domains when compared to controls
Stastically significant decrease in all domains when compared to Arousal Disorder Group
Lowest scores: pain
Zaslau, et al AUA 2003, Chicago, IL.
Conclusions: IC and FSD
Global sexual dysfunction affecting all domains
May be age related and progressive
Pain domain has lowest scores
Treatment is multimodal and may involve counseling, sex therapy and physical therapy
Etiologies of Female Sexual Dysfunction
Vasculogenic
Neurogenic
Hormonal/Endocrine
Musculogenic
Psychogenic
Vasculogenic
Risk factors: hypertension, hypercholesterolemia, smoking, heart disease
Associated with ED in men and sexual dysfunction in women
Diminished vaginal and clitoral blood flow (atherosclerosis)
Results in symptoms of vaginal dryness and dyspareunia
Alteration of circulating estrogen levels: atrophy of vaginal and clitoral smooth muscle
Traumatic arterial disruption: pelvic fracture, blunt trauma, surgical disruption, chronic perineal pressure (bicycle riding)
Neurogenic
Spinal cord injury (SCI) to the central or peripheral nervous system
Diabetes mellitus
Complete upper motor neuron lesions of the sacral cord
Incomplete SCI: capacity for psychogenic arousal and vaginal lubrication
Hormonal/Endocrine
Disorders of the hypothalamic-pituitary axis
Medical or surgical castration
Premature ovarian failure
Chronic birth control use
Symptoms: decreased desire, vaginal dryness, lack of sexual arousal
Musculogenic
Lavator ani muscles
Perineal membrane
bulbocavernosus and ischiocavernosus muscle
Contraction contributes to arousal and orgasm
Hypertonicity ---> vaginismus or dyspareunia
Hypotonicity ---> vaginal hypoanesthesia, coital anorgasmia, urinary incontinence during sexual intercourse or orgasm
Psychogenic
Emotional and relational issues
self esteem
body image
quality of the relationship with the partner
Medications
serotonin re-uptake inhibitors
Clinical Evaluation of the Female Sexual Response
Medical/Physiologic Evaluations
Psychosocial/Psychosexual Assessment
Medical/Physiologic Evaluations
Full history, physical exam, pelvic exam
Hormonal profile (FSH, LH, prolactin, free testosterone, SHBG, estradiol)
Evaluation of the sexual response
Genital blood flow (Duplex doppler ultrasound)
Vaginal pH
Vaginal compliance/elasticity
Genital sensation by vibratory perception threshold
Psychosocial/Psychosexual Assessment
Address emotional and relational issues
Subjective assessment of sexual function
Brief Index of Sexual Function (BISF-W)
Inventory of Female Sexual Function (IFSF)
Therapy
Sildenafil
Dehydroepiandesterone (DHEA)
Alprostadil (PGE1)
Apomorphine
L-arginine and Yohimbine
Vacuum Clitoral Therapy Device
Sildenafil and Female Sexual Dysfunction
33 post menopausal women in prospective study
Excluded: heart disease, uncontrolled psych disorder, poorly controlled DM, alcohol abuse, CVA, history of MI or concurrent nitrate therapy
Took sildenafil 50 mg 1 hour prior to planned sexual activity
Given a 9 item Index of Female Sexual Function Questionnaire
Sildenafil and Female Sexual Dysfunction
Results
3 patients dropped out because of adverse effects
Clitoral hypersensitivity in 7 (21%)
Headache, dyspepsia, dizziness
No differences in intercourse satisfaction and sexual desire after 3 months of therapy
Women on HRT had an increased overall score (not statistically significant)
Sildenafil and Female Sexual Dysfunction
Comments
No placebo arm
Raises several questions
What is the potential role for other oral agents such as phentolamine and apomorphine?
Would higher doses of sildenafil produce a better response?
Role for combination therapy?
Role for topical therapy?
Sildenafil in SCI Women with FSD
50% of women achieve orgasm regardless of injury type (complete vs. incomplete)
Sildenafil given to 19 women with SCI
Results in significant increases in
subjective arousal
sexual stimulation
heart rate and decreases in blood pressure
Sipski M, Grand Master Lecture #2, Female Sexual Function Forum, 2000
Sildenafil for FSD in Women with Depression
50% of patients on SSRI have some sexual dysfunction
Study: 10 women with depression on SSRI with FSD
50 mg sildenafil prior to sexual activity
Results: 9/10 had reversal of anorgasmia or delayed orgasm; most with 1st dose of sildenafil
Hensley et al. Sildenafil for Iatrogenic Seritonergic antidepressant medication induced sexual dysfunction. Female Sexual Function Forum, 2000.
Sildenafil after Hysterectomy?
35 women evaluated after hysterectomy
BISF-Q survey used for pre/post treatment assessment
100 mg sildenafil given for 6 weeks
Results:
“Improved” sensation
“Improved” ability to reach orgasm
“Decreased” pain and discomfort
Berman, et al. Hysterectomy and Sexual Function: A Role for Sildenafil?, Female Sexual Function Forum, 2000.
Dehydroepiandosterone (DHEA)
Adrenal gland hormone, precursor to sex steroids testosterone and estradiol
Given in daily doses of 50, 75 and 100 mg
Included women with sexual dysfunction for more than 6 months and low testosterone levels
Treatment duration 2 to 6 months
Results:
Increase in mean and free testosterone levels
Improvement in Sexual Distress Scale Scores
Suggests: DHEA may be useful for women with FSD and low testosterone
Munnariz, et al. Lowered Personal Sexual Distress Scale Scores Following DHEA Treatment for Multi-dimensional FSD and Low Testosterone. Female Sexual Function Forum, 2000.
Topical Alprostadil
1% alprostadil formulation (0.25 mL gel)
Placed on glans penis, allowed to dry, then vaginal intercourse
36 healthy volunteer couples (16 treatment; 16 controls). All men had Erectile Dysfunction
Results:
No changes in vital signs in either partner
Females: some noted improved clitoral/vaginal sensation
Taintor, et al. Tolerance of Topical PGE1 Gel as a Topical Treatment for Erectile Dysfunction during Vaginal Intercourse, Female Sexual Function Forum, 2000.
Alprostadil (PGE1) Pellets
2 women with vaginismus
Given 1000 mcg alprostadil pellets to insert vaginally prior to sex
Evaluated after for improvement in vaginal muscle spasm
Results:
both able to have intercourse without difficulty
Benet, A. Intravaginal Alprostadil Pellets for Treatment of Vaginismus, Female Sexual Function Forum, 2000.
Intranasal Apomorphine
Acts centrally to facilitate erectile response
12 healthy women studied at 3 doses of Apomorphine
Pharmacokinetics, nasal tolerance well tolerated thus far.
Efficacy studies “at-home” currently underway
Khan, et al. Evaluation of Nasal Apomorphine for FSD and Male ED as a function of dose, Female Sexual Function Forum, 2000.
Neutraceutical Therapy
Contents: Gingko balboa, Korean ginseng, L-arginine, calcium, iron, zinc and multi-vitamins
93 women (age 22-73 years); 46 treatment and 47 controls
Subjects:
58 premenopausal women
16 perimenopausal women
19 post menopausal women
Neutraceutical Therapy
Results:
PERI:
73% improvement in sexual desire
73% improvement in clitoral sensation
73% improvement in sexual satisfaction
POST:
64% improvement in sexual satisfaction
PRE:
71% increase in sexual desire
68% increase in sexual satisfaction
Trant A. Clinical Study on a Nutritional Supplement for the enhancement of Female Sexual Function, Female Sexual Function Forum, 2000.
L-arginine & Yohimbine
6 g arginine and 6mg yohimbine
23 post menopausal women with female sexual arousal disorder
Physiological arousal measured by vaginal pulse amplitude
Subjective arousal measured by questionnaire
Erotic film shown after medication given
Results:
Increased VPA responses vs. placebo at 60 minutes but not 30 or 90 min.
Drugs reach peak plasma levels at 40 min
Meston CM. The effects of L-arginine and Yohimbine in Sexual Arousal in Postmenopausal Women with Female Sexual Arousal Disorder, Female Sexual Function Forum, 2000.
Vacuum Clitoral Therapy Device
Treatment designed to increase clitoral blood flow, enhance clitoral engorgement and improve arousal
32 subjects (20 with FSD and 12 without FSD)
Results:
Parameter FSD No FSD
Greater sensation 90% 58%
Increase lubrication 80% 33%
Ability to achieve orgasm 55% 42%
Increased sexual satisfaction 80% 25%
Vacuum Clitoral Therapy Device
Results:
No side effects noted with use of device
Study by same authors in 5 diabetic women with FSD
Parameter Diabetic with FSD
Greater sensation 4/5 (80%)
Increase lubrication 3/5 (60%)
Ability to achieve orgasm 3/5 (60%)
Increased sexual satisfaction 4/5 (80%)
Billups et al. Vacuum Induced Clitoral Engorgement for treatment of Female Sexual Dysfunction, female Sexual Function Forum, 2000.
Conclusions
An exciting area applicable to all physicians.
Physicians need to learn through research and patient care about:
Epidemiology
Diagnosis
Pathophysiology
Treatment
References
Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The female sexual function index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther . 2000;26:191-208.
Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J, et. al. Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and classifications. J Urol. 2000;163:888-893.
Nicolosi A, Laumann EO, Glasser DB, Moreira ED, Pail A, and Gingell C. Sexual Behavior Sexual Dysfunctions Age 40: The Global Study of Sexual Attitudes and Behaviours. Urology. 2004;54(5): 991-997.
References
Laumann EO, Paik A, Rosen RC: Sexual Dysfunction in the United States: Prevalence and Predictors. JAMA. Feb 10, 1999: Vol 281, No 6: 537-544.
Peters KM, Killinger KA, Carrico DJ, Ibrahim IA, Diokno AC, and Graziottin A: Sexual Function and Sexual Distress in Women with Interstitial Cystitis: A Case Control Study. Urology. 2007; 70(3): 543-547.
Zaslau S, Triggs J, Morgan L, Osborne J, Subit M, Riggs D: “Characterization of Female Sexual Dysfunction in Patients with Interstitial Cystitis.” Presented at the American Urological Society Meeting, Chicago, IL, April 27, 2003.
References
Zaslau S, Subit MJ, Mohseni HF, Riggs D, Jackson B, Kandzari S: “Sexual Dysfunction in Patients with Interstitial Cystitis.” Presented at the American Urogynecology Meeting, Hollywood, FL, September 12, 2003.
Zaslau S, Subit MJ, Mohseni HF, Riggs D, Jackson B, Kandzari S. “Sexual Dysfunction in Patients with Interstitial Cystitis: Initial Analysis of Under 40 Cohort.” Presented at the Mid-Atlantic Section of the American Urological Society Meeting, Boca Raton, FL, October 26-29, 2003.
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Stanley Zaslau, MD, MBA, FACS
Program Director & Associate Professor
Division of Urology
West Virginia University
Objectives - 1
In this lecture, participants will learn:
Incidence, epidemiology and pathophysiology of Female Sexual Dysfunction
Female pelvic anatomy
AFUD Classification of Female Sexual Disorders
Clinical Evaluation of the Female Sexual response
Objectives - 2
In this lecture, participants will learn:
Treatment of FSD
Oral agents
Neutraceuticals
Vacuum Clitoral Erection Device
Potential novel therapies
Incidence
30 million men with compromised erectile function
Paucity of epidemiologic data regarding incidence of female sexual dysfunction
multi-causal
multi-dimensional
age-related
progressive
highly prevalent
Incidence
National Health and Social Life Survey (1999)
1749 Women
33% of women lack sexual interest
25% of women do not experience orgasm
20% of women report lubrication difficulties
20% of women report sex is not pleasurable
Incidence
Sexuality in Older Women (Diokno, 1990 and Mooradian 1990)
448 women over the age of 60
66% are sexually inactive
12% of married women had difficulty with intercourse; 14% experienced dyspareunia
Sexuality positively correlated with marital status
Less likely to have sex if partners in poor health
Diokno AC, et al. Sexual function in the elderly. Archives of Internal Medicine 1990;150:197-200.
Incidence
Rosen (1993) Study
329 women age 18 to 73 years
Most common areas of dysfunction
38% lack of desire
16% lack of pleasure
Age and relationship status predict FSD
single and older women highest incidence
Rosen (1993) Journal of Sexual and Marital Therapy
Female Pelvic Anatomy
Vagina
Vascular supply, innervation and physiologic changes
Clitoris
Vascular supply, innervation and physiologic changes
Vestibular bulbs
Uterus
Pelvic Floor Muscles
Vagina-Anatomy & Blood Supply
Labia minora surrounds vagina; protected by outer labia majora
Labia minora enclose the vestibule which contains:
Clitoris
Vaginal opening
-- Urethral opening
Innervation
Autonomic
Somatic motor fibers of S2-S4 innervate bulbocavernosis and ischiocavernosus muscles
Pudendal nerve—sensory to introitus
Main arterial supply (extensive anastomosis)
Vaginal branches of the uterine arteries
Vaginal branches of the pudendal arteries
Ovarian arteries
Clitoris-Anatomy & Blood Supply
Erectile organ similar to the penis
Blood supply
Iliohypogastric-pudendal arterial bed
Internal pudendal artery branches to form common clitoral artery --> dorsal and cavernosal clitoral arteries
Consists of fused midline corpora cavernosa
Unable to trap venous blood
With sexual stimulation, engorgement, rather than erection occurs
Vestibular Bulbs
Paired, 3-cm structures along the vaginal orifice
Homologous to corpus spongiosum of the penis
Composed of vascular smooth muscle
Arterial supply: branches of internal pudendal artery
Sensory innervation: posterior branches of the pudendal nerve
Uterus
Uterine/cervical glands secrete mucus during sexual arousal
Uterine/pelvic procedures interrupt vaginal innervation --> negative impact on later sexual health
Disruption of uterosacral and cardinal ligaments can result in genital arousal and orgasm difficulties
Role for nerve sparing procedures as similar to those performed in men
Pelvic Floor Muscles
Pelvic diaphragm formed by:
Levator ani muscles
Urogenital diaphragm
Peroneal membrane, composed of
ischiocavernosus, bulbocavernosus and superficial transverse perinii muscles
Muscles pull rectum, vagina and urethra anteriorly towards pubic bone
Pelvic Floor Muscles
Non-voluntary spasm of pelvic floor=vaginismus
Laxity or hypotonia of pelvic floor, associated with
vaginal hypoanesthesia
anorgasmia
incontinence
Question all women with voiding dysfunction about their sexual function!!
Female Sexual Physiology: Normal
Physiological changes during arousal
Enlargement of clitoris
Dilation of arterioles, increased vaginal and clitoral blood flow
Seeping of vascular transudate across vaginal membrane ---> lubrication
Expansion and tenting of upper 1/2 of vagina
Response mediated by nitric oxide (role for sildenafil)
AFUD Classification and Definition of Female Sexual Disorders
Consensus classification (AFUD Consensus Panel, 1998)
Hypoactive Sexual Desire Disorder
Sexual Aversion Disorder
Orgasmic disorders
Sexual pain disorders
Dyspareunia
Vaginismus
Other sexual pain disorders
Hypoactive Sexual Desire Disorder
Hypoactive sexual desire disorder
Persistent or recurrent deficiency (or absence) of sexual fantasies/thoughts or desire for a receptivity to sexual activity
Causes personal distress
Differential diagnosis:
surgical or medical menopause
endocrine disorders
Sexual Aversion Disorder
Sexual Aversion Disorder
Persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner
Causes personal distress
Results from:
childhood trauma (physical or sexual abuse)
Sexual Arousal Disorder
Persistent or recurrent inability to attain or maintain sufficient sexual excitement
Causes personal distress
Differential diagnosis: medical causes, prior pelvic trauma, pelvic surgery, medications
May be expressed as
lack of subjective excitement or lack of genital lubrication/swelling
Orgasmic Disorder
Persistent or recurrent difficulty, delay in or absence of attaining orgasm following sexual stimulation
Causes personal distress
Primary (never attained orgasm)--emotional trauma or sexual abuse
Secondary
Surgery
Hormone deficiency
-- Trauma
Sexual Pain Disorders
Dyspareunia
Recurrent or persistent genital pain with sexual intercourse
Consider:
vestibulitis
vaginal atrophy
vaginal infection
Sexual Pain Disorders
Vaginismus
Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration.
Conditioned response to painful penetration (?psychological or emotional)
Other Sexual Pain Disorders
Herpes Simplex Virus
Vestibulitis
Prior genital mutilation
Trauma
Endometriosis
Interstitial cystitis
Interstitial Cystitis (IC) and Female Sexual Dysfunction (FSD)
Pain associated with intercourse
Entry dyspareunia
Deep dyspareunia
IC and FSD
100 patients with IC
FSFI administered
Assess 6 domains of sexual function
Desire
Arousal
Orgasm
Lubrication
Satisfaction
Pain
Zaslau, et al. WVMJ 2008
IC and FSD
Results:
Mean age 39 years
Impairment in all domains “50-75% of the time”
Conclusions
FSD in IC involves more than pelvic pain
Zaslau, S et al FSFF, Vancouver, BC 2002
FSD in IC: 1st 400 Patients
400 IC patients
FSFI administered on line at IC-Network
Compared to two groups
Controls (131)
Female sexual arousal disorder (129)
FSD in IC 1st 400 Patients
Results
Statistically significant decrease in all domains when compared to controls
Stastically significant decrease in all domains when compared to Arousal Disorder Group
Lowest scores: pain
Zaslau, et al AUA 2003, Chicago, IL.
Conclusions: IC and FSD
Global sexual dysfunction affecting all domains
May be age related and progressive
Pain domain has lowest scores
Treatment is multimodal and may involve counseling, sex therapy and physical therapy
Etiologies of Female Sexual Dysfunction
Vasculogenic
Neurogenic
Hormonal/Endocrine
Musculogenic
Psychogenic
Vasculogenic
Risk factors: hypertension, hypercholesterolemia, smoking, heart disease
Associated with ED in men and sexual dysfunction in women
Diminished vaginal and clitoral blood flow (atherosclerosis)
Results in symptoms of vaginal dryness and dyspareunia
Alteration of circulating estrogen levels: atrophy of vaginal and clitoral smooth muscle
Traumatic arterial disruption: pelvic fracture, blunt trauma, surgical disruption, chronic perineal pressure (bicycle riding)
Neurogenic
Spinal cord injury (SCI) to the central or peripheral nervous system
Diabetes mellitus
Complete upper motor neuron lesions of the sacral cord
Incomplete SCI: capacity for psychogenic arousal and vaginal lubrication
Hormonal/Endocrine
Disorders of the hypothalamic-pituitary axis
Medical or surgical castration
Premature ovarian failure
Chronic birth control use
Symptoms: decreased desire, vaginal dryness, lack of sexual arousal
Musculogenic
Lavator ani muscles
Perineal membrane
bulbocavernosus and ischiocavernosus muscle
Contraction contributes to arousal and orgasm
Hypertonicity ---> vaginismus or dyspareunia
Hypotonicity ---> vaginal hypoanesthesia, coital anorgasmia, urinary incontinence during sexual intercourse or orgasm
Psychogenic
Emotional and relational issues
self esteem
body image
quality of the relationship with the partner
Medications
serotonin re-uptake inhibitors
Clinical Evaluation of the Female Sexual Response
Medical/Physiologic Evaluations
Psychosocial/Psychosexual Assessment
Medical/Physiologic Evaluations
Full history, physical exam, pelvic exam
Hormonal profile (FSH, LH, prolactin, free testosterone, SHBG, estradiol)
Evaluation of the sexual response
Genital blood flow (Duplex doppler ultrasound)
Vaginal pH
Vaginal compliance/elasticity
Genital sensation by vibratory perception threshold
Psychosocial/Psychosexual Assessment
Address emotional and relational issues
Subjective assessment of sexual function
Brief Index of Sexual Function (BISF-W)
Inventory of Female Sexual Function (IFSF)
Therapy
Sildenafil
Dehydroepiandesterone (DHEA)
Alprostadil (PGE1)
Apomorphine
L-arginine and Yohimbine
Vacuum Clitoral Therapy Device
Sildenafil and Female Sexual Dysfunction
33 post menopausal women in prospective study
Excluded: heart disease, uncontrolled psych disorder, poorly controlled DM, alcohol abuse, CVA, history of MI or concurrent nitrate therapy
Took sildenafil 50 mg 1 hour prior to planned sexual activity
Given a 9 item Index of Female Sexual Function Questionnaire
Sildenafil and Female Sexual Dysfunction
Results
3 patients dropped out because of adverse effects
Clitoral hypersensitivity in 7 (21%)
Headache, dyspepsia, dizziness
No differences in intercourse satisfaction and sexual desire after 3 months of therapy
Women on HRT had an increased overall score (not statistically significant)
Sildenafil and Female Sexual Dysfunction
Comments
No placebo arm
Raises several questions
What is the potential role for other oral agents such as phentolamine and apomorphine?
Would higher doses of sildenafil produce a better response?
Role for combination therapy?
Role for topical therapy?
Sildenafil in SCI Women with FSD
50% of women achieve orgasm regardless of injury type (complete vs. incomplete)
Sildenafil given to 19 women with SCI
Results in significant increases in
subjective arousal
sexual stimulation
heart rate and decreases in blood pressure
Sipski M, Grand Master Lecture #2, Female Sexual Function Forum, 2000
Sildenafil for FSD in Women with Depression
50% of patients on SSRI have some sexual dysfunction
Study: 10 women with depression on SSRI with FSD
50 mg sildenafil prior to sexual activity
Results: 9/10 had reversal of anorgasmia or delayed orgasm; most with 1st dose of sildenafil
Hensley et al. Sildenafil for Iatrogenic Seritonergic antidepressant medication induced sexual dysfunction. Female Sexual Function Forum, 2000.
Sildenafil after Hysterectomy?
35 women evaluated after hysterectomy
BISF-Q survey used for pre/post treatment assessment
100 mg sildenafil given for 6 weeks
Results:
“Improved” sensation
“Improved” ability to reach orgasm
“Decreased” pain and discomfort
Berman, et al. Hysterectomy and Sexual Function: A Role for Sildenafil?, Female Sexual Function Forum, 2000.
Dehydroepiandosterone (DHEA)
Adrenal gland hormone, precursor to sex steroids testosterone and estradiol
Given in daily doses of 50, 75 and 100 mg
Included women with sexual dysfunction for more than 6 months and low testosterone levels
Treatment duration 2 to 6 months
Results:
Increase in mean and free testosterone levels
Improvement in Sexual Distress Scale Scores
Suggests: DHEA may be useful for women with FSD and low testosterone
Munnariz, et al. Lowered Personal Sexual Distress Scale Scores Following DHEA Treatment for Multi-dimensional FSD and Low Testosterone. Female Sexual Function Forum, 2000.
Topical Alprostadil
1% alprostadil formulation (0.25 mL gel)
Placed on glans penis, allowed to dry, then vaginal intercourse
36 healthy volunteer couples (16 treatment; 16 controls). All men had Erectile Dysfunction
Results:
No changes in vital signs in either partner
Females: some noted improved clitoral/vaginal sensation
Taintor, et al. Tolerance of Topical PGE1 Gel as a Topical Treatment for Erectile Dysfunction during Vaginal Intercourse, Female Sexual Function Forum, 2000.
Alprostadil (PGE1) Pellets
2 women with vaginismus
Given 1000 mcg alprostadil pellets to insert vaginally prior to sex
Evaluated after for improvement in vaginal muscle spasm
Results:
both able to have intercourse without difficulty
Benet, A. Intravaginal Alprostadil Pellets for Treatment of Vaginismus, Female Sexual Function Forum, 2000.
Intranasal Apomorphine
Acts centrally to facilitate erectile response
12 healthy women studied at 3 doses of Apomorphine
Pharmacokinetics, nasal tolerance well tolerated thus far.
Efficacy studies “at-home” currently underway
Khan, et al. Evaluation of Nasal Apomorphine for FSD and Male ED as a function of dose, Female Sexual Function Forum, 2000.
Neutraceutical Therapy
Contents: Gingko balboa, Korean ginseng, L-arginine, calcium, iron, zinc and multi-vitamins
93 women (age 22-73 years); 46 treatment and 47 controls
Subjects:
58 premenopausal women
16 perimenopausal women
19 post menopausal women
Neutraceutical Therapy
Results:
PERI:
73% improvement in sexual desire
73% improvement in clitoral sensation
73% improvement in sexual satisfaction
POST:
64% improvement in sexual satisfaction
PRE:
71% increase in sexual desire
68% increase in sexual satisfaction
Trant A. Clinical Study on a Nutritional Supplement for the enhancement of Female Sexual Function, Female Sexual Function Forum, 2000.
L-arginine & Yohimbine
6 g arginine and 6mg yohimbine
23 post menopausal women with female sexual arousal disorder
Physiological arousal measured by vaginal pulse amplitude
Subjective arousal measured by questionnaire
Erotic film shown after medication given
Results:
Increased VPA responses vs. placebo at 60 minutes but not 30 or 90 min.
Drugs reach peak plasma levels at 40 min
Meston CM. The effects of L-arginine and Yohimbine in Sexual Arousal in Postmenopausal Women with Female Sexual Arousal Disorder, Female Sexual Function Forum, 2000.
Vacuum Clitoral Therapy Device
Treatment designed to increase clitoral blood flow, enhance clitoral engorgement and improve arousal
32 subjects (20 with FSD and 12 without FSD)
Results:
Parameter FSD No FSD
Greater sensation 90% 58%
Increase lubrication 80% 33%
Ability to achieve orgasm 55% 42%
Increased sexual satisfaction 80% 25%
Vacuum Clitoral Therapy Device
Results:
No side effects noted with use of device
Study by same authors in 5 diabetic women with FSD
Parameter Diabetic with FSD
Greater sensation 4/5 (80%)
Increase lubrication 3/5 (60%)
Ability to achieve orgasm 3/5 (60%)
Increased sexual satisfaction 4/5 (80%)
Billups et al. Vacuum Induced Clitoral Engorgement for treatment of Female Sexual Dysfunction, female Sexual Function Forum, 2000.
Conclusions
An exciting area applicable to all physicians.
Physicians need to learn through research and patient care about:
Epidemiology
Diagnosis
Pathophysiology
Treatment
References
Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The female sexual function index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther . 2000;26:191-208.
Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J, et. al. Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and classifications. J Urol. 2000;163:888-893.
Nicolosi A, Laumann EO, Glasser DB, Moreira ED, Pail A, and Gingell C. Sexual Behavior Sexual Dysfunctions Age 40: The Global Study of Sexual Attitudes and Behaviours. Urology. 2004;54(5): 991-997.
References
Laumann EO, Paik A, Rosen RC: Sexual Dysfunction in the United States: Prevalence and Predictors. JAMA. Feb 10, 1999: Vol 281, No 6: 537-544.
Peters KM, Killinger KA, Carrico DJ, Ibrahim IA, Diokno AC, and Graziottin A: Sexual Function and Sexual Distress in Women with Interstitial Cystitis: A Case Control Study. Urology. 2007; 70(3): 543-547.
Zaslau S, Triggs J, Morgan L, Osborne J, Subit M, Riggs D: “Characterization of Female Sexual Dysfunction in Patients with Interstitial Cystitis.” Presented at the American Urological Society Meeting, Chicago, IL, April 27, 2003.
References
Zaslau S, Subit MJ, Mohseni HF, Riggs D, Jackson B, Kandzari S: “Sexual Dysfunction in Patients with Interstitial Cystitis.” Presented at the American Urogynecology Meeting, Hollywood, FL, September 12, 2003.
Zaslau S, Subit MJ, Mohseni HF, Riggs D, Jackson B, Kandzari S. “Sexual Dysfunction in Patients with Interstitial Cystitis: Initial Analysis of Under 40 Cohort.” Presented at the Mid-Atlantic Section of the American Urological Society Meeting, Boca Raton, FL, October 26-29, 2003.
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