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Transcript
FEMALE SEXUAL DISORDERS:
Enhancing Communication Skills
Faculty Disclosure
Linda Burdette, MPAS, PA-C, serves as a
consultant for Novo Nordisk, Wyeth, and
Boehringer Ingelheim.
Learning Objectives
 Upon completion of the activity,
participants will be better able to:
– Describe the prevalence and importance
of female sexual disorders (FSDs)
– Define FSDs, including hypoactive
sexual desire disorder (HSDD), and
explain their physiological and
psychological components
– Outline communication techniques that
identify sexual concerns, overcome
barriers, and increase patient and
clinician comfort level in discussing
sexual health
Program Overview
 Importance of Screening
 Prevalence and Definitions
 Etiology of Female Sexual Disorders
 Effective Communication Techniques
 Next Steps
IMPORTANCE OF
SCREENING FOR FEMALE
SEXUAL DISORDERS
PATIENT SCENARIO 1: Postmenopausal Woman
Patient Scenario 1: Mrs. Parker
 Postmenopausal woman
with well-controlled
diabetes
– Increased risk for yeast
and bladder infections
– Potential for vascular disease
– Also raises risk for arousal
disorder
 If concerns are beyond
scope of current visit,
arrange follow-up or
referral for counseling
Why Take a Sexual History?
 Sexuality is important to quality of life
 Sexual health is a basic human right
– World Health Organization (WHO)
encourages clinicians to help patients
achieve this
 Patients may be hesitant to bring up
the topic on their own: It is up to
YOU!
http://www.who.int/reproductivehealth/en/
When Should a Sexual History/
Assessment Be Taken?
 Initial evaluation/written patient
intake (eg, part of review of systems)
 Consultation before and follow-up
after surgery/medical procedure
 Routine visit for care of chronic illness
 Major life events (puberty,
postpartum, menopause)
Is Sexual Health the Last
Taboo?
 Many clinicians recognize the
importance of sexual health, but
perceive potential barriers:
– Embarrassment
– Inadequate knowledge/skills
• Lack of awareness of comorbid conditions
– Consider other issues as higher priorities
– Assume reimbursement is poor
Women Believe Clinicians Do Not
Care About Their Sexual Problems
Patient experience of provider reactions: N=3,807
Patients (%)
100
87
Did Not Give
Diagnosis
(n=1907/2218)
No Follow-up
About Complaint
(n=1896/2179)
75
80
60
85
52
40
20
0
Did Not Want
to Hear
About Problem
(n=1216/2339)
Did Not Thoroughly
Examine Patient
Complaint
(n=1696/2232)
Berman L, et al. Fertil Steril. 2003;79:572-576.
Only One-third of Women With
Distressing Sexual Problems Seek
Formal Care
Type of help-seeking for problems of desire,
arousal, or orgasm: N=3,239/31,581
14.5%
Did not
seek help
9.1%
Anonymous
Formal
34.5%
Formal = clinician
Informal = anyone
other than clinician
Informal
41.9%
PRESIDE = Prevalence of Female Sexual Problems Associated With Distress and
Determinants of Treatment Seeking; HCP = health care provider
Shifren JL, et al. J Womens Health (Larchmt). 2009;18:461-468.
Clinician Questioning Increases
Patient Reporting of Sexual
Problems
Gynecologic outpatients: N=887
25
19
Patients (%)
20
15
10
5
3
0
Spontaneous
Reporting
Bachmann GA, et al. Obstet Gynecol. 1989;73:425-427.
Reporting After
Direct Inquiry
PREVALENCE AND
DEFINITIONS OF FEMALE
SEXUAL DISORDERS
DSM-IV-TR Designates Four
Categories of Female Sexual
Disorders
1. Sexual Desire Disorders (Billing Codes: 302.71; 302.79; or 799.81)
Hypoactive Sexual Desire Disorder
Absence or deficiency of sexual interest and/or
desire (302.71 or 799.81)
Sexual Aversion Disorder
Aversion to and avoidance of genital contact with
a sexual partner (302.79)
2. Sexual Arousal Disorders (Billing Code: 302.72)
Female Sexual Arousal Disorder
Inability to attain or maintain adequate
lubrication-swelling response of sexual excitement
3. Orgasmic Disorders (Billing Code: 302.73)
Female Orgasmic Disorder
Delay in or absence of orgasm after normal sexual
excitement phase
4. Pain Disorders (Billing Codes: 625.0; 625.1; 302.76; or 306.51)
Dyspareunia
Genital pain associated with sexual intercourse
(625.0 or 302.76)
Vaginismus
Involuntary contraction of the perineal muscles
preventing vaginal penetration (625.1 or 306.51)
DSM-IV-TR. American Psychiatric Association; 2000.
DSM-IV-TR Criteria for
Diagnosis of FSD
 Sexual complaint or problem in desire,
arousal, orgasm, or sexual pain:
– Severity of symptom made by clinician,
taking into account factors that affect
sexual functioning, such as age and the
context of the person’s life
 Disturbance causes marked distress
or interpersonal difficulty
DSM-IV-TR. American Psychiatric Association; 2000.
DSM-IV-TR Criteria for
Diagnosis of FSD (Cont’d)
 Sexual dysfunction is NOT:
– Better accounted for by another primary
psychiatric disorder (except another
sexual dysfunction)
– Due exclusively to the direct physiological
effects of a substance (eg, medication or
abuse of a drug) or a general medical
condition
DSM-IV-TR. American Psychiatric Association; 2000.
Additional Considerations
in Diagnosis of FSDs
 Second International Consensus of
Sexual Medicine further defines FSDs
– May or may not be associated with distress
– Lifelong vs acquired
– Situational vs generalized
Basson R, et al. J Sex Med. 2004;1:24-34.
Overlap of Female Sexual
Disorders
Sexual
Desire
Disorders
Sexual
Arousal
Disorder
Orgasmic
Disorder
Dyspareunia
Vaginismus
Basson R, et al. J Urol. 2000;163:888-893.
How Common Is FSD in Your
Practice?
PRESIDE survey: N = 31,581; response rate = 63.2%
Sexual Problem
Problem Plus Distress
50
Patients (%)
40
44.2
38.7
30
26.1
20.5
20
10
0
12
10
Desire
5.4
4.7
Arousal
Orgasm
Shifren JL, et al. Obstet Gynecol. 2008;112:970-978.
Any
complaint
Prevalence of Sexual Problems
Associated With Distress
PRESIDE: Age-stratified prevalence
Patients (%)
Desire (2868/28,447)
16
Arousal (1556/28,461)
14
Orgasm (1315/27,854)
12
Any (4356/28,403)
10
8
6
4
2
0
18-44 yrs
45-64 yrs
≥65 yrs
Shifren JL, et al. Obstet Gynecol. 2008;112:970-978.
DSM-IV-TR Criteria for Hypoactive
Sexual Desire Disorder (HSDD)
 Persistent or recurrent deficiency or
absence of sexual thoughts, fantasies,
and/or desire for, or receptivity to,
sexual activity
– Causes marked personal distress or
interpersonal difficulties
– Not better accounted for by another
primary disorder, drug/medication, or
general medical condition
DSM-IV-TR. American Psychiatric Association; 2000.
Components of Sexual Desire
 Biological drive
– Sex steroids and neurotransmitters play
a role in modulating sexual desire, drive,
and excitement1
 Cognitive
– Expectations, beliefs, and values2
 Motive
– Emotional and/or interpersonal factors2
1. Hull EM, et al. Behav Brain Res. 1999;105:105-116.
2. Levine SB. Sexual Life: Clinician’s Guide. 1992.
ETIOLOGY OF FEMALE
SEXUAL DISORDERS
PATIENT SCENARIO 2: Perimenopausal Woman
Patient Scenario 2:
Mrs. Andrews
 Perimenopausal woman,
otherwise healthy, but
with features of HSDD
– Possibly related to
menopause and/or
psychosocial factors
 Vasomotor symptoms often
occur before cessation of
menses
– Disturbed sleep, fatigue, and
behavioral changes may alter
sexual desire
Possible Causes of FSDs
Cause
Hormonal/endocrine
Sexual Symptoms
Decreased libido/desire, vaginal dryness,
lack of arousal
Hypertonicity: sexual pain
Musculogenic
Hypotonicity: vaginal hypoesthesia,
anorgasmia, urinary incontinence
associated with sexual activity
Neurogenic
Anorgasmia
Psychogenic
Decreased libido/desire, decreased arousal,
hypoesthesia, anorgasmia
Vasculogenic
Vaginal dryness, dyspareunia
Berman JR. Int J Impot Res. 2005;17(suppl 1):S44-S51.
Variety of Medications Associated
With Sexual Problems
 Antidepressants/mood
stabilizers
– Selective serotonin reuptake
inhibitors (SSRIs)
– Serotonin-norepinephrine
reuptake inhibitors (SNRIs)
– Tricyclics
– Antipsychotics
– Benzodiazepines
– Antiepileptics
– Monoamine oxidase inhibitors
(MOAIs)
 Antihypertensives
 Cardiovascular agents
– Lipid-lowering agents
– Digoxin
 Hormones
– Oral contraceptives
– Estrogens
– Progestins
– Antiandrogens
– Gonadotropin-releasing
hormone (GnRH) agonists
 Other
– Histamine2-receptor blockers
– β-blockers
– Narcotics
– α-blockers
– Amphetamines
– Diuretics
– Anticonvulsants
Basson R, et al. Lancet. 2007;369:409-424.
Kingsberg SA, et al. Urol Clin North Am. 2007;34:497-506.
Psychosocial Risk Factors
for FSDs
 Relationship quality/conflict
 Partner’s sexual health
 Prior sexual, physical, or emotional
abuse
 Stress, anxiety, depression
 Alcohol/substance abuse
 Cultural/religious influences
EFFECTIVE
COMMUNICATION
TECHNIQUES
PATIENT SCENARIO 2: Perimenopausal Woman
Ineffective Approach
Set a Positive Atmosphere
 Quiet, private, no
interruptions
 Introduce yourself
 Assure confidentiality
 Respect patient’s dignity
 Use an interpreter if needed
 Avoid assumptions or judgments
Set a Positive Atmosphere
 Quiet, private, no
interruptions
 Introduce yourself
 Assure confidentiality
 Respect patient’s dignity
 Use an interpreter if needed
 Avoid assumptions or judgments
How to Conduct the Interview
 Use words and body language
that put the patient at ease
– Open, non-defensive body posture
– Sit and maintain eye contact
– Avoid nervous gestures
 Choose language appropriate
to the age, ethnicity, and culture
of patients
– Practice using sexual terminology
 Ask open-ended questions
– Use silences to allow the patient
to speak
How to Bring Up the Topic
 Generic:
– “Many of my patients have
concerns or questions about
their sexuality. I’m going to ask
you a few questions about this,
and would be pleased to discuss
these issues with you.”
 Illness-specific:
– “Many women notice a change
in their sexual desire following
(illness). Have you noticed any
changes that concern you?”
 Consider use of the Brief Sexual
Symptom Checklist1
1. Hatzichristou D, et al. J Sex Med. 2004 Jul;1:49-57.]
Brief Screening for FSD
• Legitimize importance of assessing sexual function
• Normalize as part of the usual history and physical
“What concerns or questions do you
have about your sexual functioning?”
“Are you currently in a sexual
relationship?”
“Are you having difficulty with
desire, arousal, or orgasm?”
“If you are not currently sexual,
are there any particular problems
that are contributing to your lack
of sexual behavior?”
None
“Please feel free to
ask in the future.”
Adapted from Kingsberg SA, Janata JW. Urol Clin North Am. 2007;34:497-506.
PATIENT SCENARIO 3: Woman in Mid-twenties
Patient Scenario 3: Rebecca
 Woman in mid-twenties with
features of HSDD
– Possibly related to antidepressant
medication and/or psychosocial/
interpersonal factors
 Lesbian women share same
risks for FSD as heterosexual
women
– Vulvodynia and vestibulitis often
neglected in this population
– Body-image problems and
depression also may be present
 Communication techniques
include postural echoing
PATIENT SCENARIO 3: Woman in Mid-twenties
Ineffective Approach
Patient Scenario 3: Ineffective
Interview
 Clinician’s unreceptive
manner indicated
discomfort about
patient’s sexual status
 Clinician’s actions
were distracting
and dismissive
A Few Routine Questions Help
Define the Problem
 “How would you describe the
problem?”
– “On a scale of 1 to 10, how would you
rate…?”
 “How long have you been aware of the
problem?”
– “Did it begin suddenly or gradually?”
– “Do you associate its appearance with any
particular event or circumstance?”
– “Does it only happen in certain situations,
or with certain partners?”
Kingsberg SA, et al. Urol Clin North Am. 2007;34:497-506.
Variety of Screening Tools
for FSD
Tool
1.
2.
3.
4.
5.
Assessment Area
Female Sexual Function Index1
Desire, arousal, orgasm, and
pain
Profile of Female Sexual Function2
Desire in postmenopausal
women
Female Sexual Distress Scale—
Revised3
Distress
Sexual Quality of Life—Female4
Quality of life in women with
FSD
Decreased Sexual Desire Screener5
Brief diagnostic tool for HSDD
Wiegel M, et al. J Sex Marital Ther. 2005;31:1-20.
Derogatis L, et al. J Sex Marital Ther. 2004;30:25-36.
Derogatis L, et al. J Sex Marital Ther. 2008;5(2):357-364.
Symonds T, et al. J Sex Marital Ther. 2005;31(5):385-397.
Clayton AH, et al. J Sex Med. 2009;6:730-738.
Decreased Sexual Desire Screener
(DSDS): Validated Diagnostic Tool
for Generalized Acquired HSDD
1. In the past, was your level of sexual desire/interest good
and satisfying to you?
No
Yes
NO to Q1, 2, 3, or 4
2. Has there been a decrease in your level of sexual
desire/interest?
No
Yes
NOT generalized
acquired HSDD
3. Are you bothered by your decreased level of sexual
desire/interest?
No
Yes
4. Would you like your level of sexual desire/interest to
increase?
No
5. Please check all the factors that you feel may be
contributing to your current decrease in sexual desire/
interest:
A. An operation, depression, injuries, or other medical
condition
B. Medications, drugs, or alcohol you are currently taking
C. Pregnancy, recent childbirth, menopausal symptoms
D. Other sexual issues you may have (pain, decreased
arousal, orgasm)
E. Your partner’s sexual problems
F. Dissatisfaction with your relationship or partner
G. Stress or fatigue
Yes
YES to all Q1–4 and
clinician-verified NO
to all Q5 factors
Generalized
acquired HSDD
No
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
YES to all Q1–4 and
YES to any Q5 factor
Clinician to use best
judgment to
determine diagnosis
Clinical assessment of patient answers is required.
• On average, the DSDS took <15 minutes to complete in a clinical study (N = 921).
• DSDS had a sensitivity of 0.836 (84%) and a specificity of 0.878 (88%) (N = 263).
Clayton AH, et al. J Sex Med. 2009;6:730-738.
NEXT STEPS
Basic Counseling
 Female sexual disorders (FSD) are
highly prevalent in clinical practice
 NP/PAs are optimally positioned to:
– Identify FSD, including hypoactive sexual
desire disorder
– Integrate sexual history and basic
counseling into routine clinical practice
“PLISSIT” Model
P
Permission to talk
about sexual issues
LI
Limited Information
SS
Specific Suggestions
IT
Intensive Therapy
Annon J. J Sex Ed Ther. 1976;Spring-Summer:1-15.
General Recommendations
 Bibliotherapy (erotic reading; instruction)
 Date night
 Mediterranean diet
 Moderate exercise
 Self-stimulation
 Mindfulness/identifying sexuality cues
 Communicating needs
 Goal setting
 Identity
“Oh, by the way….”
Problem Solving
 What to say when the patient has
concerns that cannot be addressed
in the allotted time
– Validate the patient’s concerns
– Emphasize your desire to help
– Schedule a follow-up visit
 Be flexible about what you spend
time on
– Focus on patient priorities
– Refer as appropriate
When to Refer to a Specialist
 Sexual problems have occurred as a
result of trauma
 Sexual problems have been chronic
– (“I’ve always had this problem”)
 Underlying medical or psychiatric
problem is out of your scope of
practice
 You are uncomfortable working with
the client or the situation
Types of Interventions
 Psychotherapy
 Physical therapy
 Pharmacologic therapies
 Adjunctive and alternative therapies
Kingsberg SA, et al. Urol Clin North Am. 2007;34:497-506.
Simon JA, et al. Fertil Steril. 2008;90:1132-1138.
On the Horizon: Selected
Investigational Agents
 Flibanserin for HSDD
–P3 clinical trials in >5,000 women
–lIn June, the FDA Advisory Committee
voted that data failed to prove efficacy and
to show that benefits outweighed risks1
 Melanocortin receptor agonists
–BBrelanocortin trials were discontinued due
to concerns about elevated blood pressure
LibiGel (testosterone gel, 300 mcg/d)
–Phase 3 clinical trials including women
at risk for breast cancer and CV disease
Summary
 FSDs can be treated successfully
 FSDs are highly prevalent
– Lack of desire is the most common
complaint
– FSDs do not always cause distress
 Effective communications help
patients discuss concerns
Handout Materials
 Selected information resources for
clinicians
 Selected Web resources for locating
therapists
 Recommended reading
 “Pocket card” (see Web link to
downloadable PDF file)
– Definitions and billing codes for FSD
– Brief Screening for FSD
– Strategies for Brief Office Assessment
– DSDS questions
Available Online
 Patient scenario video clips
 “Pocket card” (downloadable PDF file)
 Starting September 30
 To access, go to:
www.mycme.com