Overview%20of%20Female%20Sexual%20Dysfunction%20for%20the%20Primary%20Care%20Physician%20WVU%20WOMENS%20HEALTH%20CURRICULUM%20 - PowerPoint PPT Presentation

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Title: Female Sexual Dysfunction Author: Stanley Zaslau, M.D. Created Date: 1/7/2001 3:30:40 PM Document presentation format: 35mm Slides Other titles – PowerPoint PPT presentation

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Title: Overview%20of%20Female%20Sexual%20Dysfunction%20for%20the%20Primary%20Care%20Physician%20WVU%20WOMENS%20HEALTH%20CURRICULUM%20

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

  • 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

  • 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

Laumann E, Paik A, Rosen R. Sexual dysfunction
in the United States Prevalence and predictors,
JAMA 1999281537-544.
  • 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
  • Less likely to have sex if partners in poor
  • Diokno AC, et al. Sexual function in the elderly.
    Archives of Internal Medicine 1990150197-200.

  • 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

Female Pelvic Anatomy
  • Vagina
  • Vascular supply, innervation and physiologic
  • Clitoris
  • Vascular supply, innervation and physiologic
  • 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
  • Clitoris
  • Vaginal opening
  • -- Urethral opening
  • Innervation
  • Autonomic
  • Somatic motor fibers of S2-S4 innervate
    bulbocavernosis and ischiocavernosus muscles
  • Pudendal nervesensory 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 --gt 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
  • Sensory innervation posterior branches of the
    pudendal nerve

  • Uterine/cervical glands secrete mucus during
    sexual arousal
  • Uterine/pelvic procedures interrupt vaginal
    innervation --gt negative impact on later sexual
  • Disruption of uterosacral and cardinal ligaments
    can result in genital arousal and orgasm
  • 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 floorvaginismus
  • Laxity or hypotonia of pelvic floor, associated
  • 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 ---gt lubrication
  • Expansion and tenting of upper 1/2 of vagina
  • Response mediated by nitric oxide (role for

AFUD Classification and Definition of Female
Sexual Disorders
  • Consensus classification (AFUD Consensus Panel,
  • 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

Orgasmic Disorder
  • Persistent or recurrent difficulty, delay in or
    absence of attaining orgasm following sexual
  • 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
  • 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

  • Risk factors hypertension, hypercholesterolemia,
    smoking, heart disease
  • Associated with ED in men and sexual dysfunction
    in women
  • Diminished vaginal and clitoral blood flow
  • Results in symptoms of vaginal dryness and
  • 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)

  • Spinal cord injury (SCI) to the central or
    peripheral nervous system
  • Diabetes mellitus
  • Complete upper motor neuron lesions of the sacral
  • Incomplete SCI capacity for psychogenic arousal
    and vaginal lubrication

  • 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

  • Lavator ani muscles
  • Perineal membrane
  • bulbocavernosus and ischiocavernosus muscle
  • Contraction contributes to arousal and orgasm
  • Hypertonicity ---gt vaginismus or dyspareunia
  • Hypotonicity ---gt vaginal hypoanesthesia, coital
    anorgasmia, urinary incontinence during sexual
    intercourse or orgasm

  • 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

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)

  • 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

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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 93 women (age 22-73 years) 46 treatment and 47
  • 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
  • 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
  • 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
  • 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.

  • An exciting area applicable to all physicians.
  • Physicians need to learn through research and
    patient care about
  • Epidemiology
  • Diagnosis
  • Pathophysiology
  • Treatment

  • 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 . 200026191-208.
  • 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. 2000163888-893.
  • 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. 200454(5)

  • 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.

  • 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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