Transcript FEMALE-SEXUAL-DYSFUNCTIONS

FEMALE SEXUAL
DYSFUNCTIONS
FSD
Prof. IHAB YOUNIS
About 40% of women are affected by sexual
problems, with a higher prevalence of 50% in
perimenopausal and post-menopausal women
A woman’s sexual responsiveness is not the same as a
man’s. Ignoring its complexity
can make difference look like
dysfunction
Types & Definitions
1.Hypoactive sexual desire
disorder 27-52%
Persistent or recurrent deficiency or
absence of sexual fantasies and
desire for sexual activity
2.Sexual arousal disorder
11%-30% (<60 y)
Persistent or recurrent Inability to
attain, or to maintain adequate
lubrication-swelling response of
sexual excitement until completion of
the sexual activity
3.Orgasmic disorder
20%(Eur) -29%(Am)
Persistent or recurrent delay in, or
absence of, orgasm following a
normal sexual
excitement phase
4.Sexual pain disorders:
Vaginismus 6%
Involuntary vaginal spasms that
interfere with penetration
Dyspareunia17%24%(PM)
Pain during intercourse
HYPOACTIVE SEXUAL
DESIRE DISORDER
HSDD
• HSDD is the most common FSD
• Prevalence
ranged from
26.7% among
premenopausal
women to 52.4%
among naturally
menopausal
women
PATHOPHYSIOLOGY
• Dopamine is the key neurotransmitter in
the modulation of sexual desire
• Steroid hormones increase available
dopamine,
-Testosterone potentiates the synthesis
of nitric oxide, which controls dopamine
release
- Estradiol facilitates dopamine release
• Increasing levels of serotonin (e.g. as with
the, SSRIs) can diminish the effects of
dopamine on sexual function
• Endogenous opioids (e.g. Endorphin),
which give the sense of pleasure and
reward, also modulate the perceived
intensity of sexual desire in humans
• Following the experience of orgasm,
desire decreases and requires a certain
time span to be regained
• Therefore, they may have an inhibitory
effect on sexual desire
causes
1- Low Testosterone
• Low testosterone does not only cause low
libido, but also causes decreased sexual
receptivity and pleasure, fatigue, lack of
motivation, and an overall reduced sense
of well being
• It is common in menopausal women or
after bilateral oophorectomy
• It is not uncommon for pre-menopausal
women to experience HSDD. This may be
due to the fact that testosterone
concentrations begin to decline as early as
the late 20s in women and continue to fall
at a constant rate of about 50% of their
peak level by menopause
2-Low Estrogen
• Menopause can cause vaginal dryness,
inability to lubricate, or dyspareunia
• In this case, oral estrogen replacement is
often prescribed for the relief of hot flashes,
mood changes, and sleep disturbances to
improve quality of life
• The reason for this is that oral estrogen
increases circulating levels of sex
hormone binding globulin (SHBG) which
lowers the level of free testosterone
• Oral estrogen also suppresses FSH and
LH, reducing ovarian synthesis and
lowering total testosterone levels
3-Indirect hormonal effects
• Hormone imbalances related to
pregnancy, the postpartum phase and
lactation
• Menopause: Natural or surgical
• The use of certain medications e.g. antidepressants
4-Psychosocial factors
• Women with HSDD were 2.5 times more
likely to feel dissatisfied with their marriage
or partner than normal women
• 80% of patients with mood
(e.g.depression) or anxiety disorders
reported reduced sexual desire. However,
patients with depression often do not
appear to be distressed by their lack of
interest in sex
5-Medications
• SSRIs
• Antihypertensive agents are proposed to
affect sexual function via central
adrenergic inhibition and blockade of
adrenergic receptors
• Antipsychotics are dopamine blockers,
and may increase prolactin levels
• Oral contraceptives may have negative
effects in a minority of women. But
because of the wide variety of hormonal
medications available the results of
studies are not conclusive
6-Medical conditions
• Chronic illnesses e.g. diabetes mellitus,
and cancer
• Painful intercourse due vaginal/pelvic floor
conditions, such as vestibulitis, vulvodynia,
or endometriosis; or bladder conditions,
such as interstitial cystitis or urinary
incontinence
EVALUATION
Female Decreased Sexual Desire
Screener
1. In the past was your level of sexual desire or
interest good and satisfying to you? y/n
2. Has there been a decrease in your level of
sexual desire or interest? y/n
3. Are you bothered by your decreased level of
sexual desire or interest? y/n
4. Would you like your level of sexual desire or
interest to increase? y/n
5. Do you feel any of the following has contributed
to your current decrease in sexual desire or
interest?
An operation, depression, injuries, or other
medical condition? y/n
6. Medication, drugs or alcohol you are currently
taking? y/n
7. Pregnancy, recent childbirth, menopausal
symptoms? y/n
8. Other sexual issues you may be having (pain,
decreased arousal or orgasm)? y/n
9. Your partner’s sexual problems? y/n
10. Dissatisfaction with your relationship or
partner? y/n
11. Stress or fatigue? y/n
• If the answer is "no" to any of questions 14: patient may not qualify for the
diagnosis of HSDD
• If the answer is "yes" to all of 1-4
questions: patient may qualify for the
diagnosis of HSDD
• 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
• If the answer to question 10 is "yes" add:
You and your partner should consider
professional counseling
•
Screener is based on Validation of the DSDS, Clayton et al: J Sex Med
2009;6:730-738
TREATMENT
Testosterone
• Intrinsa skin patch
• Releases 300 µg/day
• It is worn just below
the umbilicus & changed
twice weekly
• Sexual activity increased by an average of
19% in placebo users, vs. a 73% increase
for Intrinsa patch postmenopausal users
Contraindications
• Breast cancer
• Pregnancy
• Breastfeeding
• Naturally menopausal women
Side effects
• FDA declined to approve it for lack of
information on long term side effects
• Irritation of skin at patch application site
• Acne
• Excessive facial hair growth
• Voice deepening
• Breast pain
• Weight gain
• Hair loss
Bupropion (Wellbutrin)
• It is an antidepressant and
smoking cessation aid
• Bupropion SR 150 mg daily is
given for 12 weeks
• The thoughts/desire score showed a
greater than twofold increase in patients
treated with bupropion compared to those
receiving a placebo
Contraindications
• Conditions that lower the seizure threshold
e.g. alcohol or benzodiazepine discontinuation, anorexia nervosa, bulimia, or
active brain tumors & individuals taking
MAO inhibitors
Side effects
• Seizure: It is highly dose-dependent
• Hypertension in less than 1% of patients
Flibanserin (Female Viagra)
• As with Viagra, the effects of
flibanserin were discovered
accidentally after it was trialed as an antidepressant
• The results of four Phase III studies
involving more than 2,000 pre-menopausal
women suffering from HSDD showed that:
• Women using the drug said that the
average number of times they had
"satisfying sexual experiences" rose from
2.8 to 4.5 times a month
• Women with the placebo said the number
of times rose to 3.7 times a month
• Flibanserin must be taken once a day and
takes up to 4 weeks to have an effect
Mechanism of action
• It may enhance dopamine actions and
reduce serotonin actions
• The FDA refused to license it
because the studies showing its
effectiveness were not enough
• A double blind, placebo-controlled, randomized
study of 80 married women with FSAD
demonstrated that bremelanotide 20 mg nasal
spray increased sexual arousal and intercourse
satisfaction when compared with the placebo
group. The manufacturer cited blood pressure
elevation with intranasal administration of
bremelanotide as a reason for not pursuing
approval for sexual dysfunction.
ANORGASMIA
• Orgasm is a variable, transient peak sensation
of intense pleasure creating an altered state of
consciousness, usually accompanied by
involuntary, rhythmic contractions of the pelvic
striated circumvaginal musculature, often with
concomitant uterine and anal contractions and
myotonia that resolves the sexually-induced
vasocongestion (sometimes only partially),
usually with an induction of well-being and
contentment
• Orgasms vary in intensity, and women
vary in the frequency of their orgasms and
the amount of stimulation necessary to
trigger an orgasm
• Although the clitoris and vagina are the
most common sites of stimulation that
result in an orgasm, stimulation of other
body sites (eg, breast, nipple, or mons)
can trigger an orgasm, as can mental
imagery, fantasy
• The G-spot is:
- An ill-defined region, located on the
anterior vaginal wall, in its upper outer
third, suggested by Grafenberg
- This area is sensitive to tactile touch,
which, when applied, is claimed to result in
an intense female orgasm and female
ejaculation during orgasm
- Debate regarding the existence
of the G-spot and female
ejaculation as true clinical
entities is still ongoing
How frequent is anorgasmia in
Egypt? (My Work)
• In all women
- 17% do not have orgasm at all
- 5% rarely have orgasm
• In genitally cut women
- 2% do not have orgasm at all
- 32% have orgasm infrequently
• In Non genitally cut women
- 8.5% have orgasm infrequently
• 70-80% of women achieve orgasm only
through direct clitoral stimulation. Clitoral
orgasms are easier to achieve because
the tip or glans of the clitoris alone has
more than 8,000 sensory nerve
• Copulatory vocalizations were reported to
be made most often before and
simultaneously with male ejaculation
• These data clearly demonstrate a
dissociation of the timing of women
experiencing orgasm and making
copulatory vocalizations and indicate that
there is at least an element of these
responses that are under conscious
control, providing women with an
opportunity to manipulate male behavior to
their advantage
Etiology
I- Biological Factors:
1.General medical conditions, such as heart
or kidney disease, can damage patients’
quality of life and are often associated with
depression
2. Atherosclerosis and its related risk factors
(smoking, diabetes, hypertension, and
peripheral vascular disease) affect genital
blood flow which is critical to the female
sexual response
3.Anorgasmia is often seen as a side
effect of using psychotropic medications:
- Anorgasmia is reported in at least onethird of patients who receive SSRI
- Also it is reported
with antipsychotics
and mood stabilizers
4. Heavy alcohol consumption and illicit
drugs can also interfere with orgasmic
ability
5.Hormonal changes due to menopause or
other disorders:
- Lower estrogen levels may cause a
weakening of the pelvic muscles, affect
the responsiveness of nerves that act as
receptors for external sexual stimuli, and
reduce vaginal lubrication
- Low testosterone has also been found to
be reduce arousal and experiences of
orgasm
6-Recently, studies investigating genetic
factors have been conducted. Dunn et al.
estimate the heritability for difficulty
reaching orgasm to be 34%. Furthermore,
a certain gene (GRIA1) has been found to
be associated with difficulty achieving
orgasm
II- Psychosocial Factors
1-Poor body image and genital image (the
way a woman feels about the size, shape,
odor, and function of her genitals) can
contribute to anorgasmia
2- Relationship problems and lack of proper
communication with the partner about
clitoral stimulation techniques
3- Anorgasmic women often demonstrate
negative attitudes toward sex and
masturbation, and tend to experience guilt
following sexual activities
4- The effect of past sexual abuse on
women’s orgasmic functioning is important
to examine
5-Additional psychosocial factors
associated with orgasm capacity include:
• Age: older women may experience
orgasm difficulty due to changes in their
body and the belief that, at an older age,
sexual desire and activity are improper
• Education: correlates with anorgasmia
• Social class: correlates with anorgasmia
• Shame about sexuality due to religious
beliefs or familial inhibitions:Increase
incidence of anorgasmia
TREATMENT
• There are no Food and Drug Administration
(FDA)-approved medications for this disorder
• First , treat the underlying medical conditions
e g in anorgasmia due to hormonal changes
associated with menopause, partial
androgen replacement (avoiding doses that
could cause masculinization) can restore
sexual responsiveness
• Tibolone, a selective tissue estrogenic
activity regulator with estrogenic,
progestogenic, and androgenic properties,
did improve orgasm domains in multiple
studies of postmenopausal women
• Trials are needed to assess whether
androgen therapy can treat disorders of
orgasm in women who are not
postmenopausal
• Changing medications that may be
causing anorgasmia(eg SSRI) can reverse
it eg the use of moclobemide(Aurorix)
instead of SSRI can improve anorgasmia
• Cabergoline(Cabergolobe tab), a
dopaminergic agent, was found helpful
when administered prior to intercourse
• Sildenafil showed mixed results and
appears to be effective in some
populations of women, but additional
large-scale studies are needed
• Oxytocin is another potential therapy for
anorgasmia that warrants further study
• Alprostadil(Prostaglandin E1), 400 mg
vaginal cream applied prior to intercourse
was found effective in a controlled trial
The use of medical devices :
1- The Eros-Clitoral Therapy Device($395)
• It is the only such treatment approved by the
FDA for FOD
• The device works by
applying a gentle vacuum
to the clitoris, which
increases its blood flow
• It increased lubrication in 70% and increased
ability to have orgasm in 60% of patients in a
small study
2-Slightest Touch(140$)
• It stimulates nerve pathways to the genital
area
• Electrode pads
are appllied above the
ankles
• It gently stimulates the
sexual nerve pathways taking the woman
to a pre-orgasmic plateau where she
swings on the edge of orgasm for as long
as she wants
Vaginismus
• Involuntary muscle spasm of outer third of
the vagina
• In severe cases, the adductors of the
thighs, the rectus abdominis, and the
gluteus muscles may be involved
• It may be 1ry or 2 ry
PC = Pubococcygeus
Variations of vaginismus
• Some women are unable to insert anything
at all
• Some women are able to insert a tampon
and complete a gynecological exam, yet are
unable to insert a penis
• Others are able to partially insert a penis,
although the process is very painful
• Some are able to fully insert a penis, but
tightness interrupts the normal
progression from arousal to orgasm and
bring pain instead
• Some women are able to tolerate years of
uncomfortable intercourse with gradually
increasing pain and discomfort that
eventually interrupts the sexual experience
ETIOLOGY
I-Psychological causes
1-Misinformation & ignorance (90%)
2- Fears of:
• Pain
• Not being completely healed following pelvic
trauma
• Tissue damage (ie. "being torn")
• Getting pregnant
3-Anxiety or stress :performance pressures,
previous unpleasant sexual experiences, guilt
4-Partner issues:Abuse, emotional
detachment, fear of commitment, distrust
5-Traumatic events:Past emotional/sexual
abuse, witness of violence or abuse
6-Childhood experiences:Overly rigid
parenting, unbalanced religious teaching,
exposure to shocking sexual imagery
7-Idiopathic
II- Physical Causes
1-Medical conditions:Urinary tract infections
or urination problems, yeast infections,
STDs, endometriosis, genital or pelvic
tumors, cysts, cancer, vulvodynia /
vestibulodynia, pelvic inflammatory disease,
lichen planus, lichen sclerosus, eczema,
psoriasis, vaginal prolapse, pain from
normal deliveries or c-sections
2-Age-related changes:Menopause and
hormonal changes causing vaginal atrophy
and inadequate lubrication
Treatment
• Vaginismus is highly treatable with high
success rates (75-100%)
1- Sex therapy
• Step 1- Sexual history review &counseling
• Step 2- Dilators insertion(Diameter 2-4cm)
• Step 3 - Sensate focus techniques
• Step 4 - Making the transition to
intercourse
2-Botox
• An analgesic (e.g.Voltaren) is administered i.m.
30 minutes before the injection
• 25 IU BT diluted in 1 ml of saline, is injected into
the bulbospongiosus muscle
• Satisfactory intromission on the 2nd day after
injection was reported
• The toxin has a long-duration of action of up to 6
months
Advantages
• It is usually the treatment of choice for
refractory cases
• It helps the dilation treatment and
consequently allows for coitus by training
the muscles that it's not painful to insert
something in the vagina
• Patients can go through the treatments
under sedation (general or local
anesthesia) so it can be painless (but add
risks associated with anesthesia)
Disadvantages
• The idea of having an injection inside the
vagina can be very scary and intolerable for
women with primary vaginismus
• Its effects are not permanent so you may
have to repeat the injections after a while but
its side effects instead will be permanent
• Botox is not yet licensed for use in the
treatment of vaginismus in Egypt
Side Effects
• The most serious one being the paralysis of
the wrong muscle
• An allergic reaction
• Urinary stress incontinence
• Flatus, and fecal incontinence intermittently
THANK YOU