Download Midlife Sex Therapy

10/12/2015
Making Midlife
Sex Fun Again:
strategies and solutions
Karen E. Adams MD, FACOG
Professor, Obstetrics and Gynecology
Director, Over 40 Clinic, Center for Women’s Health
Oregon Health and Sciences University
Disclosures
• I have no commercial interest in any products
discussed
• I have no commercial interest in sex
OHSU Center for Women’s
Health Over 40 Clinic
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10/12/2015
Percentage of Men and Women with Sexual Complaints
National Social Life, Health & Aging: Sexual
Dysfunction in the US
Laumann EO, et al. JAMA 1999-281(6):537-544
How Are We Doing?
• REVIVE (REal Women’s
Views of Treatment
Options for Menopausal
ChangEs) survey of
postmenopausal women
• Only 19% of health
professionals addressed
their sexual lives
• Only 13% specifically asked
about genitourinary
symptoms
• 40% expected their
provider to initiate the
discussion
J Sex Med 2013; 10:1790-1799
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Approach to the Patient
• TREAT PAIN
• EXPLAIN WHAT’S NORMAL FOR WOMEN
• ADDRESS LACK OF LIBIDO
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Cycle of dyspareunia
Inhibited desire /
sexual aversion
Pain with intercourse
Lack of lubrication
and expansion
Failure of excitement
Genitourinary Syndrome of
Menopause (GSM)
• New term that replaced “vulvovaginal atrophy” in 2014
• A collection of symptoms and signs associated with a decrease
in estrogen and other sex steroids
• Involve changes to the labia majora/minora, clitoris,
vestibule/introitus, vagina, urethra, and bladder
Genitourinary Syndrome of
Menopause
• SYMPTOMS
• Genital dryness
• Decreased lubrication with
sexual activity
• Discomfort or pain with
sexual activity
• Post-coital bleeding
• Decreased arousal,
orgasm, desire
• Irritation, burning, or
itching of vulva or vagina
• Dysuria
• Urinary frequency/urgency
• SIGNS
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Decreased moisture
Decreased elasticity
Labia minora resorption
Pallor/erythema
Loss of vaginal rugae
Tissue fragility/fissures
Urethral eversion or
prolapse
Loss of hymenal remnants
Prominent urethral meatus
Introital retraction
Recurrent UTIs
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Treatment of GSM
• Nonprescription therapies
• Vaginal moisturizers (Replens, Vagisil, Vit E oil)
• Herbal products (black cohosh, soy) not beneficial
• Prescription therapies
• Systemic ET used for other menopausal symptoms will often
provide relief for GSM as well (75%)
• Local ET more effective (80-90%)
• Systemic ET associated with an increase in stress incontinence
Local Estrogen
• Cochrane Review of 19 studies including 4000
PMP women using local estrogen
All delivery methods essentially equal in
relieving effects of GSM whether ring,
tablet or cream
Some safety concerns with cream
Suckling, Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001500
Local Estrogen
Preparation
Dosing
Regimen (by manufacturer)
Estring®
7.5mcg E2/day
90d ring
Ring inserted vaginally and
replaced/removed in 90d
Vagifem®
10mcg E2/tablet
QHS x 14d then 2x/week
Premarin® cream
0.625mg CEE/g
0.5g cream 2x/week
Estrace® cream
100mcg E2/g
2-4g QHS x 7-14d then 1g 1-3x/week
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Other Local Therapies
Ospemifene
• Only SERM approved in US for treatment of moderate to
severe dyspareunia
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Improved VMI, vaginal pH, dryness in 52-week study
60 mg per day orally
No VTEs or hyperplasia but small n = 180
Vasomotor sxs 2% placebo/7% ospemifene
• INVESTIGATIONAL
• Bazedoxifene 20 mg/Conjugated Estrogen 0.45 or 0.625 mg
• Intravaginal DHEA (“dietary supplement”)
• Both in phase 3 trials
Diff Dx of GSM: other sources
of pain
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Infectious diseases (candida, BV, trich, GC/CT)
Irritant or allergic vulvitis (soaps, perfumes, panty liners)
Vestibulodynia
Levator myalgia
Vulvar dermatoses
Desquamative inflammatory vaginitis
Painful bladder syndrome/interstitial cystitis
Sexual counseling
• Several studies show profound psychological, physical, and
emotional impact of vulvar pain
• Unique impact on intimacy
• CBT counseling alone improves pain
• 76 women x 12 sessions of group CBT
• Reported less coital pain, increased satisfaction, reduced overall
pain
Bergeron, Pain 2001, 91(3):297
Ter Kuile, J Sex Marital Ther 2006;32:199
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What’s Normal for Women?
Traditional Model of Sexual Response
Masters & Johnson/Singer Kaplan
Orgasm
Plateau
Sexual
Excitement/
Tension
Arousal
Reduction
Desire
Time
Basson 2001
“Basson Model” Female Sexuality
Orgasm
Emotional
Intimacy
+
+
Motivates the sexually
neutral woman
Emotional
and Physical
Satisfaction
To find/
be responsive to
Sexual
Stimuli
Psychological and
biological factors
govern “arousability”
Arousal &
Sexual
Desire
Sexual
Arousal
Basson 2001
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New Sexual Response
• Enhanced intimacy is a strong stimulus for women to seek
partnered sexual activity
• Positive sexual experiences motivate women to be sexual
again-therefore allowing sexual stimuli to move her from
neutral to an aroused sexual state
• Spontaneous desire is not a measure of sexual satisfaction
Basson. J Psychosom Obstet Gynecol 2003;24:221-29
Bancroft J. Clinics in Obstet Gynecol 1980;7:253-278
Seagraves. J Sex Med 2007;4:567-80.
How to Approach Lack of
Libido
Factors that Predict an Active
Sex Life for Women
• Overall psychological
health
• Overall physical
health/exercise
• A new relationship!
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Overall Psychological Health
• High correlation of
desire complaints
with:
• Low self image
• Weak or fragile selfesteem
• Mood instability
• Tendency toward
worry and anxiety
Overall Physical Health
• Having sex can feel like working out to someone
who is not connected to her body
• Routine exercise is helpful
• Start slowly! Just walking can be beneficial
A New Relationship
• “Hormone cocktail of romance”
• Dopamine
• Norepinephrine
• Phenethylamine
• Evolutionary anthropologists tell us this lasts only a
few years at best
• This is the psychologically healthy, reasonably fit
patient who says, “We love each other. Our
relationship is great, but we hardly ever have sex.”
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The Effect of Longevity
• University of Hamburg surveyed 2500 men and women
• In new relationships, women’s lust = men’s lust
• After 1-4 years in a relationship, women’s lust dives
• This drop continues over time, leaving male desire far higher
• Women who don’t live with their partners retain desire much
more than women who do
• Lesbian women fare no better, and are perhaps worse
The Effect of Novelty
• Queen’s University, Ontario measured vaginal and penile
blood flow of heterosexuals while they watched one-minute
pornographic sex scenes repeatedly
• Breaks in between to allow return to baseline
• Both women and men’s responses leaped at first
• Men’s responses typically stayed more constant while
women’s plummeted with repetition
• Both spiked again when researchers introduced new clips
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“Doctor, is there a pill I can
take?”
Testosterone
• 300 mcg transdermal patch
• Several studies showed a
small increase in “sexually
satisfying events” over
baseline in PMP women
• FDA rejected in 2004 citing
concerns re: off-label use and
safety
• At least one study showed
increased breast cancer rates
with patch, also CV concerns
Testosterone
• NAMS 2005 position statement on T therapy has been retired,
currently no official statement
• US Endocrine Society recommended against T therapy in
2006 due to lack of a well defined clinical syndrome and
normative data on free and total T levels in women across
their lifespan
• LibiGel transdermal T gel was rejected by the FDA in 2011
when results were no better than placebo, Phase 3 trials
continuing
• T dosing remains off-label in the form of cream or gel
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Testosterone is not the magic
bullet
What to tell your patient
1. Testosterone is considered experimental & is not
commercially available for women in the dose associated
with improved sexual outcomes
2. Long-term safety not established
3. Strong placebo effect repeatedly seen
4. Sexual outcomes not correlated with serum androgen levels
5. May be some risk for breast cancer & CVD
6. Trials are ongoing
Flibanserin: Politics and Science
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Flibanserin: Science
• 5-HT mixed receptor agonist and antagonist
• Increases downstream release of dopamine and
norepinephrine
• Reduces serotonin
• mediates symptoms of reduced sexual interest and desire
• FDA unanimously rejected the new drug application in 2009
• Drug increased satisfying sexual episodes by an average of 1.7
per month compared to 1.0 per month by placebo
• BASELINE
2.7
• PLACEBO
3.7
• FLIBANSERIN
4.5
Flibanserin is NOT “The Female Viagra”
Flibanserin: Science
• Viagra increases blood flow to the penis, Flibanserin works on
the brain
• Viagra works almost instantly, Flibanserin takes four weeks to
be effective and peak results seen at eight weeks
• Flibanserin estimated to be effective in 1 in 10 women vs. 1 in
3 that have arousal/desire disorders
• Viagra has a very robust response in men, Flibanserin’s effect
is modest at best in women
• SIDE EFFECTS/RISKS: nausea, dizziness, syncopal episodes
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Flibanserin: Science
• The drug manufacturer dealt with dizziness by designing
studies with a single nighttime dose
• Demonstrated that next-day driving skills were not affected
• Most worrisome side effect is syncope (loss of consciousness
due to sudden or substantial drop in blood pressure)
• Enhanced when drug combined with alcohol, esp in people
who do not normally drink, or when patient takes other drugs
that utilize the CP450 pathway
Flibanserin: Public Relations
• Sprout Pharmaceuticals acquired the rights to Flibanserin in
2010
• At that point had two unsuccessful FDA hearings
• Partnered with Even the Score, a campaign by 24 women’s
groups that list 26 drugs for men’s sexuality, 0 for women
Even the Score
• 30 patients brought in by Sprout to testify at a 2-day FDA
workshop on patient-focused drug development in female
sexual dysfunction
• Advocates say that critics minimize the suffering of women
• FDA advisory committee members voted 18-to-6 to approve
with a risk management plan for patients
• Many said it was a difficult choice between that vote and a
straight “no” vote but many voices are charging the FDA with
gender discrimination
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Controversy
• Dr. Adrien Fugh-Berman: “What we have here is a mild
aphrodisiac with scary side effects.”
• Dr. Susan Wood: “I find the gender bias charges not only not
persuasive but offensive…We have a product without
particularly high efficacy, [that] comes with risks, has to be
taken on a daily basis for weeks or months or years, and in my
view would be widely marketed off-label, putting women at
risk who would see no benefit at all.”
• Sprout said it would refrain from direct-to-consumer
advertising in the first 18 months after approval
• Approved Sept 2015
for premenopausal
women
• Sprout was sold the
next day!
• No current “to
market” date
• Provider certification
will be required to
prescribe
45
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“No pill?! Then what?”
Monogamy = death of desire?
• When you love
someone, how does it
feel?
• When you desire
someone, how is that
different?
• Does good intimacy =
good sex?
• Can you desire
something you already
have?
• Esther Perel Mating in
Captivity, 2006
Love and desire
• Love wants to know all about you
• Desire needs mystery
• Love wants to shrink the distance between us
• Desire is energized by it
• Intimacy grows through repetition and familiarity
• Eroticism is numbed by repetition and thrives on the
mysterious, the novel, the unexpected
• Love is about having
• Desire is about wanting
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“In this world there are only two tragedies. One is getting
what one wants, the other is not getting it.”—Oscar Wilde
The key to making midlife sex fun again is wanting what
you have, recognizing the separateness of the other
Moving to a drug without psychotherapy and behavioral
intervention is inappropriate
Summar Midlife Sex: Summary
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Start by treating sources of pain
Help women understand what is normal for them
There is no pharmacologic panacea for low libido
Mental and physical health contribute to a healthy sex life
The intimacy, companionship, and familiarity of a long term
relationship can stifle desire
• Desire thrives on mini-separateness and novelty
• Long term couples can bring the erotic home through active
engagement and intention
“Passion is for teenagers and foreigners”
--Marge Simpson
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