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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