Download Diagnosis and Management of Sexual Problems

Diagnosis and Management of
Sexual Problems
27th Annual Pelham P. Staples Educational
Symposium
MAUREEN WHELIHAN MD FACOG
WEST PALM BEACH, FLORIDA
Disclosures

Advisory Board Shionogi Pharma

Speakers Bureau Shionogi Pharma

No relevant financial interests
Objectives

Identify the most common sexual dysfunctions in a GYN
practice

Develop techniques to focus on the underlying causes

Understand the differential diagnosis of the sexual
complaint

Educate the patient on the risks/benefits of treatment

Direct the patient on various avenues of management

Understand your personal limitations in managing these
patients
Prior to this meeting…..

You should have been advised that this is a new format called “Flip
Classroom” (don’t worry – it is new to me, too)

You should have received journal articles about the topic

You should have received three videos with “the lecture”
- Low Sexual Desire
- Sexual Pain
- Office Tips
Low Desire – CASE 1

KS 27yo G1P1 – c/o low desire
She was new to me at age 25yo – having painful sex, severe
menstrual cramps, vaginal dryness, extreme fatigue
MEDS: Bupropion XL 150mg, sertraline 50mg and Lo Loestrin
Sex improved with the mood management but then she had a
pregnancy and delivered 8 months ago
She went from sex 2x/daily to now less than 2x weekly –
Fiancée is unhappy
Thoughts….

A. It’s her mood disorder

B.

C. It’s her toddler’s fault

D. Her fiancée needs be a better lover

E.
It’s her birth control pill
Who cares – they are still having way more
sex than I am
Low Desire – CASE 2

AW 49yo G1P2 – complains of low desire
States she is pre-menopausal and wants hormones checked
Menses are regular but “severely” heavy flow (no anemia)
MEDS: levothyroxine, escitalopram, zolpidem ER, dexadrine “PRN
for concentration”
Wants testosterone (off-label), menorrhagia worked up and she
had an endometrial ablation
Thoughts….

A. She has anxiety and seems to want a
medication for everything

B. She is not getting enough attention at home

C. She should have her hormone levels
checked

D. She should be given testosterone off-label

E. Take more of her dextroamphetamine – it’s a
sex stimulant
Low Desire – CASE 3

BB 59yo psychologist
Presented for “hormone management” – she has been doing
compounding with another doctor but it is getting too expensive
Her current labs – Total testosterone 643ng/dl and E2 163pg/ml
I refused to refill her testosterone – she presented 8 mos later with
low desire
Requested STD testing for her and her spouse
Other issues include obesity, HTN – when her BP was 162/90, she got
it down with “raisins, nuts, bitter no sugar chocolate nibs, beans
and olive oil”
Thoughts…..

A. Compounding has added another dimension to the
GYN visit

B. Just give her the testosterone, she had a good sex
drive before

C. Encourage her to correct her diet (low sugar), and
blood pressure before embarking on pellet hormone
therapy she was inquiring about

D. Sex therapy definitely needed for this therapist and
her spouse
Painful Sex – CASE 1

BH 81yo with a h/o lichen sclerosus
Symptomatic improvement with clobetasol proprionate
0.05% ointment and conjugated estrogens cream –
able to have penetration without pain
Pt had a new diagnosis of breast cancer (stage 1)
Returned c/o painful sex – oncologist not allowing her to
use her vaginal cream – she is frustrated and wants to
resume sexual activity
Thoughts….

A. Topical estrogen therapy on the vulva is too
dangerous in the cancer patient

B. Just treat her lichen sclerosus – as the SCC risk is
more important

C. At 81yo shouldn’t she be tired of sex by now?

D. Penetrative intercourse throughout the decades
helps maintain intimacy in the relationship, emotional
well-being and supports the tissue in the pelvis including
the urinary tract and pelvic floor
Painful sex – CASE 2

SL 49yo c/o insertional dyspareunia
She is noted to have vulvar dystrophy not responding to
clobetasol and estradiol cream
MEDS: Nuvaring, Finacea topical gel, clobetasol,
estradiol cream
I started her on a compound of estradiol 0.02% and
testosterone 0.1% BID for 6 weeks in place of the other
two
Thoughts…..

A. Stop the Nuvaring – it may be contributing to her
symptoms

B. There are testosterone receptors in the vulvar area
which may help with the non-responding patient

C. This patient should not have ospemifene since she is
still at risk for conceiving and she is on estrogen

D. If I am not getting any sex, why should she?
Painful sex – CASE 3

EP is a 34yo married 7 years – unconsummated marriage
Healthy female with orthodox upbringing
Seen by two GYNs who diagnosed “vaginismus”
Believes she has a blockage in the vagina
After 2 – 10mg diazepam and 45min exam – a normal hymen,
normal vaginal caliber were noted
Note: husband is 6’6” with large hands – size mismatch a secondary
issue
Thoughts…

A. Strict orthodox upbringing and no sex education
created the initial fear

B. Significant size mismatch can create initial concern –
but the vagina DOES stretch to permit a baby’s head,
so…..

C. Shocking that a couple stays together having no
intercourse for seven years (is he getting it elsewhere?)

D. Sex therapy with continual “homework” assignments
can lead to successful penetration
Quick Tips

Don’t forget to address the male partner’s issues

Erectile dysfunction is common and manageable

Premature ejaculation can be primary (anxiety) or
secondary (rushing from ED)

Low testosterone (less than 450ng/dl) is common with
aging and can lessen the desire of men

I remind women that men NEED sex and that ignoring
this can lead to an unhappy end to the relationship
Orgasm

90% of my patients have had an orgasm

Many have them at least 50% of the time

90% require clitoral stimulation to achieve orgasm – manual,
oral or vibration

10% can have vaginal orgasm – a much deeper, whole-body,
endless orgasm that is difficult for most to achieve

The requirement for vaginal orgasm puts significant strain on a
relationship

Diabetes and CV disease can reduce orgasmic capability
Kissing

THIS is the key to getting women naked

I instruct (married) couples to have at least a 1 minute
kiss daily

Kissing signals a wanting or craving

Good oral hygiene is integral to good kissing! Advise
getting rid of the chewing tobacco and cigarettes
Children

Suck the life and energy from women

Recommend 2 nights a week that the partner is responsible
for “kid duty” all the way til bedtime. SHE has a free evening
to exercise, get her nails done or simply read a sexy novel

Instruct your patient to “desensitize” the kids by sneaking into
the bedroom with doors locked during awake hours – first 2
minutes, then 5 minutes, 15, etc….

Share babysitting duties with a couple with kids so each
couple has a free night without children at least once a
month (once every two weeks is preferable)
Medications

Don’t discount the negative effect of medication on sex drive

If necessary – switch them to an IUD or tubal ligation to
reduce the SHBG increase in OCPs

Choose an SNRI or an SSRI with less negative effect on
desire/orgasm

Reduce the opiates the patient is taking (inhibitory for sex)

Promote good sleep and good mood
Lubes

Sex is friction in an inappropriately aroused woman

Silicone lubes stay on the surface longer – Wet Platinum, Eros

Pre-Seed for the patient trying to conceive (no interference
with sperm motility)

Astroglide has a sweet taste if encountered orally

Coconut oil, olive oil, vegetable oil work fine – (especially for
sex on the kitchen counter)
Books

All encompassing – “The Guide to Getting it On” Paul Joannides

Female erotica - “Best of Best Women’s Erotica” Marcy Sheiner
“Stories to Make You Blush” Marie Gray

Books: “Mating In Captivity” Esther Perel
“101 Grrreat Quickies” Laura Corn
“How to be a Great Lover” Lou Paget
“Every Man Sees You Naked” David Matthews
“The Seven Principles for Making Marriage Work” John
Gottman
More Books

A Billion Wicked Thoughts by Ogi Ogas and Sai Gaddam
– to understand why women behave the way they do
and why men have certain turn-ons

Problem specific - Saving your Sex Life by John Mulhall
MD – a guide for men with prostate cancer
Educational Videos

Great educational videos from www.sinclairinstitute.com

Created by sex therapists and “teach” how to do various things

Favorites include: “The Joy of Erotic Message”
“32 Ways to Please Your Lover”
“101 Positions for Lovers”
“Better Sex for a Lifetime Series”
“Oral Pleasures for Him/Her”
“Sex in Pregnancy and Lactation”
“Expanding Your Sexual Boundaries”
Incorporating Technology

Websites: www.Kryzol.com is a self-help counseling tool for the busy
couple who cannot find time to see a therapist OR as an adjunct to
marital therapy

www.KimAnami.com is a site that is a bit more descriptive about sex
with less focus on the relationship

Podcasts: www.PleasureMechanics.com – “Speaking of Sex” Fun,
direct, informative and most importantly can be uploaded and sent
to your lover to let them know what is on your mind

Apps: “Pocket Kamasutra” gives ideas (visual cartoons) on sexual
positions and sex games. Upload to a text or email and let your
lover know what you want to try next. You can rate each one or
mark it as a favorite
Final Thoughts…

Let your patient know that you are interested in her
sexual concerns

Do not assume you know who is sexually active – I am
ALWAYS surprised

Promote sexual pleasure as another component of
overall wellness

Understand your limitations and have a team to refer to
in your region

Your patient will be forever grateful!