Download Female Sexual Dysfunction Lecture

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
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Incidence
30 million men with compromised erectile
function
 Paucity of epidemiologic data regarding
incidence of female sexual dysfunction
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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

Laumann E, Paik A, Rosen R. Sexual dysfunction in the United States:
Prevalence and predictors, JAMA 1999;281;537-544.
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
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Vagina
– Vascular supply, innervation and physiologic
changes
Clitoris
– Vascular supply, innervation and physiologic
changes
Vestibular bulbs
Uterus
Pelvic Floor Muscles
Vagina-Anatomy & Blood Supply
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Labia minora surrounds vagina; protected by outer labia majora
Labia minora enclose the vestibule which contains:
– Clitoris
– Vaginal opening
-- Urethral opening
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Innervation
– Autonomic
– Somatic motor fibers of S2-S4 innervate bulbocavernosis and
ischiocavernosus muscles
– Pudendal nerve—sensory to introitus
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Main arterial supply (extensive anastomosis)
– Vaginal branches of the uterine arteries
– Vaginal branches of the pudendal arteries
– Ovarian arteries
Clitoris-Anatomy & Blood
Supply
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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
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Consists of fused midline corpora cavernosa
– Unable to trap venous blood
– With sexual stimulation, engorgement, rather than
erection occurs
Vestibular Bulbs
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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
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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
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Pelvic diaphragm formed by:
– Levator ani muscles
– Urogenital diaphragm
– Peroneal membrane, composed of
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ischiocavernosus, bulbocavernosus and superficial
transverse perinii muscles
Muscles pull rectum, vagina and urethra
anteriorly towards pubic bone
Pelvic Floor Muscles
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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
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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
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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
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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
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Sexual Aversion Disorder
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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
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– lack of subjective excitement or lack of genital
lubrication/swelling
Orgasmic Disorder
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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
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Dyspareunia
– Recurrent or persistent genital pain with sexual
intercourse
– Consider:
vestibulitis
 vaginal atrophy
 vaginal infection
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Sexual Pain Disorders
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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
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Interstitial Cystitis (IC) and Female
Sexual Dysfunction (FSD)
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Pain associated with intercourse
– Entry dyspareunia
– Deep dyspareunia
IC and FSD
100 patients with IC
 FSFI administered
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– Assess 6 domains of sexual function
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Desire
Arousal
Orgasm
Lubrication
Satisfaction
Pain
Zaslau, et al. WVMJ 2008
IC and FSD
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Results:
– Mean age 39 years
– Impairment in all domains “50-75% of the
time”
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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
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– Controls (131)
– Female sexual arousal disorder (129)
FSD in IC 1st 400 Patients
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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
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Etiologies of Female Sexual
Dysfunction
Vasculogenic
 Neurogenic
 Hormonal/Endocrine
 Musculogenic
 Psychogenic
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Vasculogenic
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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
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Hormonal/Endocrine
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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
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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
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Emotional and relational issues
– self esteem
– body image
– quality of the relationship with the partner
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Medications
– serotonin re-uptake inhibitors
Clinical Evaluation of the
Female Sexual Response
Medical/Physiologic Evaluations
 Psychosocial/Psychosexual Assessment
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Medical/Physiologic Evaluations
Full history, physical exam, pelvic exam
 Hormonal profile (FSH, LH, prolactin, free
testosterone, SHBG, estradiol)
 Evaluation of the sexual response
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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
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– 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
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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
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Sildenafil and Female Sexual
Dysfunction
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Results
– 3 patients dropped out because of adverse
effects
Clitoral hypersensitivity in 7 (21%)
 Headache, dyspepsia, dizziness
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– 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
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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?
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Sildenafil in SCI Women
with FSD
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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
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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?
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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)
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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
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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
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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
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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
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Contents: Gingko balboa, Korean ginseng, Larginine, 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
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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
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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
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Treatment designed to increase clitoral blood flow,
enhance clitoral engorgement and improve arousal
32 subjects (20 with FSD and 12 without FSD)
Results:
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Parameter
Greater sensation
Increase lubrication
Ability to achieve orgasm
Increased sexual satisfaction
FSD
90%
80%
55%
80%
No FSD
58%
33%
42%
25%
Vacuum Clitoral Therapy
Device
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Results:
– No side effects noted with use of device
– Study by same authors in 5 diabetic women
with FSD
Parameter
Greater sensation
Increase lubrication
Ability to achieve orgasm
Increased sexual satisfaction
Diabetic with FSD
4/5 (80%)
3/5 (60%)
3/5 (60%)
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:
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Epidemiology
Diagnosis
Pathophysiology
Treatment
References
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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
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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
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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 2629, 2003.