• Nathan Riley, MD

Obgyno Wino Podcast Episode 24 - Female Sexual Dysfunction

Updated: Sep 14, 2019

"The position held by the Church and enforced by civic bodies — that women who practiced without appropriate study must die — had a catch, of course. Women, except for a dwindling enrollment at Salerno, were not allowed access to education. All women healers, therefore, were suspect. Any woman with exceptional talent was suspect; any woman who had acquired her knowledge through the oral tradition of woman’s domestic healing was suspect; any woman who had studied independently with a master healer (even a man) was suspect. Any woman who had the bad luck to be associated, by proximity or reputation, with a physician’s failure to cure his patient was suspect." - Jeanne Achterberg, 'Woman As Healer'

2017 Chardonnay from Chloe Wines

PB#213 - Published July 2019

Five Pearls

  1. Older models of female sexual dysfunction were linear; contemporary models are dynamic and non-linear

  2. DSM-V now includes four main categories of female sexual dysfunction: female sexual interest/arousal disorder, female orgasmic disorder, genito-pelvic pain/penetration disorder, substance/medication-induced sexual dysfunction

  3. Hypoestrogenism can lead to discomfort and decreased sexual interest in postmenopausal women; vaginal or systemic estrogen may be helpful; vaginal estrogen supplementation results in minimal systemic absorption

  4. Your training as an OB/GYN is likely insufficient to meet the often complex etiologies for female sexual dysfunction; ask for help

  5. Education about anatomy and normal sexual physiology as well as partner therapy should be mainstays of an approach to managing these disorders, as drugs are of limited utility

Function versus dysfunction

- normal sexual function: older models favor linear approach, but more contemporary models suggest more likely a non-linear, dynamic response

- estrogen plays a role: maintenance of genital tissue elasticity, sensitivity, secretions, pH, and microbiome

- estrogen also plays a role in bladder function/incontinence, muscle tone, and joint mobility

- testosterone also plays a role but it's poorly understood; some benefit is seen with supplementation but the serum level of androgens below which one might expect sexual dysfunction is unknown

Recall: androgens peak in women in their 20s, decline until the mid-30s, then level out around age 60

- dysfunction is wide-ranging (desire, arousal, orgasm, pain)

- 40% of American women affected, in 10-15% it's severe enough to cause personal distress

Classifying sexual dysfunction disorders

- first four are recognized in the newest edition of DSM (V)

- symptoms must persist for 6 months to make a diagnosis (according to the psychiatry geeks) apart from substance or medication-induced disorders AND that the disorder isn't better explained by a medical condition, mental health disorder, or severe relationship (life) stressor

Female Sexual Interest and Arousal Disorder

- replaces DSM-IV terms hypoactive sexual desire disorder and female sexual arousal disorder - fluctuations in interest can occur across a female's lifespan due to a variety of modifiable factors: partner/relationship factors, sleep, stress, body image, pregnancy, breastfeeding, sedentary lifestyle, alcohol

- most think a lot about sex, but they may shy away from initiating or engaging their partner to preserve their relationship or because they were judgment or disinterest in their partner

- often times all it takes is a conversation with their partner and for their partner to engage more often

- medications such as SSRI have been found to cause impairments in libido

Female Orgasmic Disorder

- absence of orgasm or diminished orgasmic sensations

- many women experience orgasms without realizing them as such

- usually normal levels of desire

- generally acquired in relation to the new-onset of a condition listed in Box 1

- rarely, it may be acquired secondary to underlying neurologic conditions, changes associated with genital or pelvic surgery, and radiation therapy or medication use

Genito-Pelvic Pain and Penetration Disorder

- vaginismus and dyspareunia are now combined into this single category

- may be lifelong or acquired

- includes either 1) tightening of the vaginal muscle with decreased ability or inability to accommodate penetration or 2) tension, pain, or burning with penetration attempts

Note: non-penetrative sex may also elicit extreme pain

- may be associated with intense phobia of intimacy due to the intensity of discomfort OR an utter lack of desire for sexual activity

- symptoms can generally be resolved with careful, patient medical and psychological intervention

Substance or Medication-Induced Sexual Dysfunction

- anticholinergic, hormonal, cardiovascular, and psychiatric agents as well as alcohol, marijuana, and opioids may all be linked with female sexual dysfunction

Pregnancy-related sexual dysfunction

- dysfunction before pregnancy is a significant risk factor for postpartum difficulties

- c-section, operative delivery, episiotomy, and perineal/vaginal lacerations can also result in trauma that leads to very real pain or arousal disorders

- breastfeeding can cause vaginal dryness

- these factors are compounded by sleep disturbance, relational issues, newborn health issues, body image issues, and psychological adjustment to parenthood

- don't forget to consider postpartum depression and intimate partner violence

- workup and treatment should be the same as you would outside of pregnancy, w/ special attention given to medical therapies that might be contraindicated in breastfeeding

Menopausal-related sexual dysfunction

- the abrupt drop in estrogen causes significant atrophy (but also a constellation of other genitourinary and sexual symptoms)

- burning, irritation, dryness, pain w/ intercourse, urinary urgency, dysuria, and recurrent UTI

How to identify and diagnose in clinic

- "Many women experience concerns about sex. Are you experiencing any issues?"

- comprehensive social, medical, substance use, and symptom history

- do your full gyn physical exam, working up infectious etiologies and taking biopsies as appropriate

- illustrate their anatomy so that they can best describe where they are feeling the discomfort

- in focalizing discomfort, light touching with a cotton swab can help with specifics; start external than move internal with a fingertip

What can be done?

- psychologic interventions: sexual skills training, cognitive-behavioral therapy, pharmacology, mindfulness-based therapy, and couples therapy (See Esther Perel's podcast) are all recommended

- these experts might help through:

  • instruction in masturbation

  • addressing beliefs related to guilt or shame around masturbating or other pleasurable experiences

  • leading exercises inter-relational communication with her partner

  • systematic desensitization

  • behavioral techniques to improve body perceptions

  • trauma-informed psychotherapy

Can estrogen therapy or estrogen receptor modulator therapy help?

- low-dose vaginal estrogen is preferred hormonal treatment for disorders secondary to menopause ("genitourinary syndrome of menopause")

- a physical exam is important to make sure you know what you're treating

- hypoestrogenism will be reflected as loss of the labial fat pad, thinning of the labia minor, pale mucosa, and loss of vaginal folds

- lubrication is first-line; try coconut oil or water-based lubes like Aloe Cadabra

- oil-based lubes can weaken condoms

- systemic estrogen alone (or with progestins if uterus is still in place) can help with both genitourinary syndrome of menopause AND vasomotor symptoms

Note: minimal systemic absorption occurs with vaginal estrogen supplementation

- RCTs have found that ospemifene (selective estrogen receptor modulator with agonist properties in the genital tract and antagonist properties in the breast) is effective for treatment of dyspareunia secondary to menopause

- it's also agonistic at the endometrium, but not associated with endometrial cancer when used continuously for 1 year

- for patients with estrogen-sensitive cancer (e.g. breast), evidence is insufficient to fully counsel this population about the risks and benefits of vaginal estrogen therapy (ask her oncologist) and the risk of cancer recurrence

- having said all of this, your patient may be suffering more from her sexual dysfunction than from the prospect of maybe developing breast cancer recurrence (in my training program, we generally considered that the benefits outweigh the risks) - as always, informed consent goes a long way

- Peter Attia did a great podcast interview on hormone replacement therapy (summary: the risks are likely completely negligible)

Can androgen supplementation help improve libido?

- evidence is mixed, but a 3-6 month trial of transdermal testo in postmenopausal women is reasonable if patient accept unknown long-term side effects

- RCT: 300-mcg transdermal patch compared to placebo in setting of menopause resulted in improved satisfaction with sexual episodes, sexual activity, orgasms, and sexual desire

- discontinue thereafter if no response (unlikely to help if it hasn't kicked in by 6 months)

- safety data for long-term use is limited (most studies haven't been conducted for longer than 6 months)

- main adverse effects: hirsutism, acne, and virilization (deeper voice, larger clitoris)

- Systemic DHEA is not effective

Pearl: Testosterone supplementation for sexual dysfunction related to genitourinary syndrome of menopause is likely safe and may be effective for up to 6 months

Any non-hormonal options to improve libido?

- Flibanserin: serotonin receptor agonist/antagonist was approved by the FDA in 2015 for premenopausal women, but there's no evidence to suggest that it helps

- Sildenafil: won't help (phosphodiesterase type 5 inhibitor - aka Viagra)

- Bupropion: anti-depressant that can be helpful if added to current antidepressant regimen that is causing the disorder in the first place

- No devices have been found to be effective

What can be done for genito-pelvic pain and penetration disorders?

- know your limitations and don't gaslight your patient; she's not crazy, and she's coming to you for help

- if you can't help or don't know what to do: refer her to somebody who does

- education: self-care counseling around elimination of common vulvovaginal irritants

- psychologic interventions: self-dilation + psychotherapy was shown by a 2013 RCT to increase ability of women to have intercourse; this study was not included in the 2013 Cochrane review, which found no benefit

- dilation: self-dilation can help alleviate vaginismus, release pelvic floor muscle trigger points, or correct vaginal stenosis after RT or other injury; scant evidence but, see the 2013 RCT mentioned above

- physical therapy: internal (vaginal and rectal) and external soft-tissue mobilization and myofascial release; trigger-point pressure, visceral, urogenital, and joint manipulation; electrical stimulation; therapeutic exercises; biofeedback; bladder and bowel retraining

- medications: intravaginal prasterone (a DHEA preparation) was approved by FDA in 2016 for treatment of dyspareunia in postmenopausal women after an RCT of around 500 women showed benefit; other medications like botilinum have been less promising

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