female sexual dysfunction across the life span PDF
Preview female sexual dysfunction across the life span
8/31/2017 FEMALE SEXUAL DYSFUNCTION ACROSS THE LIFE SPAN: HOW TOO ASSESS, DIAGNOSE AND MANAGE (A LEARNING LAB) WE GET TO TALK GUESS WHAT WE ABOUT SEX! GET TO DO TODAY FOLKS? Objectives Objectives continued: 1. Describe epidemiology female sexual 3. Discuss barriers to addressing female dysfunction sexual dysfunction. 2. Review basic anatomy and physiology of the 4. Review communication skills/tools as they female reproductive system and the female relate to addressing female sexual arousal system. dysfunction. 5. Dispel myths about female sexual dysfunction. 1 8/31/2017 Objectives Objectives continued: 6. Describe epidemiology of female orgasmic 8. Explain the options for treatment of these disorders through medications, counseling, disorder, female sexual interest/arousal disorder education on anatomy, lubricants, sex toys and and genito‐pelvic pain/penetration disorder referrals. 9. Review intimacy products and how each product 7. Discuss the diagnosis of female orgasmic disorder, can be used for female sexual dysfunctions. female sexual interest/arousal disorder and genito‐ pelvic pain/penetration disorder. 10.Discuss common conditions and stages of life that bring different concerns such as MS, the teen, and peri/postmenopause.. Objectives continued: National Health & Social Life Survey 11.Review resources available to women and health care providers. • Younger age (<40) • Unmarried • Poor health • Low sexual activity or interest • Deteriorating economic status • Negative sexual experiences • Emotional and stress‐related problems Laumann, EO. JAMA Predictors of Problems with Female NHSLS: Sexual Difficulty is Prevalent Sexual Response • Health 43% –Better a woman’s health, 31% greater her interest in sex • Marital status –Married women had lower libidos and reduced arousal Women Men Avis, NE. Menopause.. 2 8/31/2017 Distress About Sex: Kinsey 2000 Survey Limitations of NHSL Survey 24% Best predictors of Only yes or no answers elicited distress: •General emotional Cross-sectional design well-being No women >60 years of age •Emotional relationship with partner during Did not measure personal distress Women sexual activity Menopausal status not a factor Bancroft, J. Arch Sex Behav. . Laumann, EO. JAMA. 1999. Communication Concerns: Patient Fears Bias Limits Discussion of Vaginal Issues % Very or Somewhat Concerned Clinicians may have 76 difficulty discussing sexuality with patients 71 68 <50% 53% 37% Provide no Dismiss Uncomfortable of women comfortable of postmenopausal of women would either discussing vaginal women comfortable hesitate to discuss or treatment problem issues related to discussing vaginal not mention the subject contraceptives discomfort Marwick C. JAMA.. Nappi RE. Contraception. 2006; Nappi RE. Climacteric. 2012; Shindel AW. J Sex Med. 2013. Berman L, et al. Fertil Steril. . Communicating with Patients Initiating a Communication Framework about Sexuality Discuss the reality of sexual problems Be a Reassure Make a sympathetic the patient referral listener Evaluate a couple’s sexual knowledge and provide sex education as needed more… Wincze JP, Barlow DH. 3 8/31/2017 Initiating a Communication Framework The PLISSIT Model (Continued) Identify the individual goals of each partner Permission Limited Information Obtain a baseline history Specific Suggestions Intensive Therapy Gain the couple’s agreement to make quality time for each other Wincze JP, Barlow DH. 1997. Annon JS. J Sex Ed & Ther. 1976. PLISSIT Level One: Permission PLISSITLevel Two: Limited Information “…It is not at all uncommon for “…What you are doing is not men and women in their 60s and wrong or unusual.” 70s to have sexual intercourse on a regular basis.” Annon JS Annon JS J Sex Ed & Ther. 1976 J Sex Ed & Ther. 1976 Annon JS. J Sex Ed & Ther. 1976. Annon JS. J Sex Ed & Ther. 1976. PLISSITLevel Three: Communication (or lack of….) Specific Suggestions “…Some women aren’t aware of the “…Today there are a number problems that men face as they age and, of effective ways to treat _____ as a result, view their partner’s sexual dysfunction as a personal rejection…Many that you might want to consider.” men assume that if the woman is not getting lubricated, she’s no longer interested.” Annon JS J Sex Ed & Ther. 1976 Gretchen Lentz, MD Kaunitz, AM. Contemporary OB/GYN. 1998. Annon JS. J Sex Ed & Ther. 1976. 4 8/31/2017 PLISSITLevel Four: Intensive Therapy DESIRE 101 “…I would like to refer you to someone else who I believe is better qualified to help you solve this problem.” Annon JS J Sex Ed & Ther. 1976 Annon JS. J Sex Ed & Ther. 1976. “A” Ask FSD Intermediate General: “annual exam” question Specific: Lead-in Questions “An Important aspect hoef aylothu…r o”verall health is sexual “thMeairn sye oxfu maly r epsayptoioeunn’dst ewli.k itAehr te-o- -y -toaeulkx peaxebproieeurntie?cne cailntegr aantiyotnhsin ign Currently in a sexual relationship? Yes No Male/Female/Both Any concerns? “C” Clarify/Normalize/Validate Discuss overlap of FSD’s + Practice Elicit more info limitations Refer “TOepll emne e mndoerde…?” Assess Monbitoodry s lealnf gaunadg oether Meds, etc. Illness Psych/Cultural/Context/ Relationship Sexual Factors Summarize Concerns DSDS, etc Differential Diagnosis Pelvic exam if needed RD/eOp rAensxsiieotny CICoDd-e9s Diagnosis pCroiDonerfifitirinmzea tdfiooisrnt rpfeaostrsi ec naatnred Developed by Susan Kellogg Spadt, PhD, CRNP and Michael Krychman, MD (2010). “E” Educate Available at www.SexualHealthFundamentals.org. Handouts Verbal Website Basic Cx Refer specialists Treatment Counseling Couples About Counseling Couples About Sexual Communication Sexual Communication (continued) • Two basic needs: • Discuss confidentiality •To be happy • Non‐discrimination policy •To be free from suffering • Make time for discussion • Let patients be themselves • Have resources and referrals available more… 5 8/31/2017 Recommendations Recommendations • Place literature about sexual/marital • Recognize sexual problems may not need concerns in waiting/exam rooms treatment if do not cause distress to woman • Include inquires and assessment of sexual • Adopt nonjudgmental attitude toward concerns in routine exams patients’ sexual disclosures/activities • Educate patients about common sexual • Don’t assume patient is in heterosexual problems that occur with aging relationship or not sexually active • Reassure patients that sexual concerns are • View sexual problems as couple’s concern common • Partner with other health professionals Women’s Sexuality R/T Anatomy of Female Sexuality Health Professional –Pelvic floor muscles (like a well organized light • Complex show) • Less studied, understood –External genitalia than male sexuality Personal Lack of • Clitoris Issues training • Mons pubis • Many theories and beliefs • Labia minora and majora are inaccurate or outdated –Internal genitalia • Difficult to address for • Vagina Time • Cervix some Berman, L. Fertil Steril.2003. Kingsberg, S. Sexuality, Reproduction & Menopause.2004. Assessment of Female Sexual Myths about Female Sexuality Problems •Organic dysfunction can be meaningfully separated from psychogenic dysfunction •Awareness of internal feelings of sexual desire is primary trigger for sexual behavior •Sexual desire necessarily precedes sexual individual arousal more… Rosen, RC. Fertil Steril. 2002. Basson R. J Psychosom Obstet Gynecol. 2003. Basson R. J Psychosom Obstet Gynecol. 2003. 6 8/31/2017 Myths about Female Sexuality Female Genital Arousal (continued) •Women’s arousal identified primarily by: ▪Genital vasocongestion ▪Vaginal lubrication ▪Awareness of genital sensations •Women’s sexual response essentially stable and invariant across time/circumstance •All women experience distress about alterations or limitations in sexual response Basson R. J Psychosom Obstet Gynecol. 2003. Berman, JR. World J Urol. 2002. Kerner, I. She Comes First: The Thinking Man’s Guide to Pleasuring a Woman. 2004. Human Sexual Response – Linear Problems with the Linear Model Orgasm Plateau Excitement (B) A B C (C) (A) Masters, WH. Human Sexual Response. 1966.; Kaplan, HS. Disorders of Sexual Masters, WH. Human Sexual Response. 1966.; Kaplan, HS. Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy. 1979. Desire and Other New Concepts and Techniques in Sex Therapy. 1979. Female Sexual Response ‐ Circular Medicalization of FSD Seeking Out Does…. Emotional and Being Intimacy Receptive to Spontaneous Sexual Sexual Drive Stimuli Arousal and Sexual Sexual Biologic Desire Arousal Basson, R. Obstet Gynecol. 2001. Bancroft J. Arch Sex Behav. 2002. 7 8/31/2017 Variables Affecting Female Response Variables Affecting Female Response Past sexual experiences or sexual abuse Relationship with Sexual self- sexual partner image and/or (male or female) body image Basson, R. Menopause. 2004. Basson, R. Menopause. 2004. Disease and Female Sexual Response Disease and Female Sexual Response Neurologic Disorders Endocrine Disorders Debilitating Diseases Psychiatric Disorders •Head/spinal cord •Diabetes •Cancer •Anxiety injury •Hepatitis •Degenerative disease •Depression •MS •Kidney disease •Lung disease •Stroke Vascular Disorders Voiding Disorders •Hypertension •Overactive bladder •Leukemia •Stress urinary •Sickle-cell disease incontinence Phillips, NA. Am Fam Physician. 2000.; Whipple, B. In: Sexual Function in People Phillips, NA. Am Fam Physician. 2000.; Whipple, B. In: Sexual Function in People with Disability and Chronic Illness: A Health Professional’s Guide. 1997. with Disability and Chronic Illness: A Health; Professional’s Guide. 1997. Effects of Depression on Sexual Psychology & FSD Function • Can and does impact sexual physiology • Continue to develop and test psychological Derangement of: approaches Desire • Combination of pharmacologic plus psychological approaches best Arousal • Comprehensive evaluation of woman and Orgasm partner before formalizing treatment plan Heiman JR. Arch Sex Behav. 2002. Leiblum SR, et al. World J Urol. 2002. 8 8/31/2017 Female Sexual Disorders: Prevalence What we know • Multiple factors related to aging of Interest Lubrication/ Orgasm Total Arousal the patient and her partner biologic Laumann 31.6% 20.6% 25.7% 43% and possibly medical Bancroft 7.2% 31.2% 9.3% 45% • Medical and psychiatric disorders are Geiss 28.8% 23.0% 17.8% 48% closely associated with sexual Nazareth 16.8% 3.6% 18.9% 39.6% dysfunction in men and women. Bancroft, J. Arch Sex Behav.2003. Geiss, IM. Urology. 2003. Laumann, EO. JAMA. 1999. Nazareth, I. BMJ. 2003. Medications Causing Desire Disorders Medications Causing Arousal Disorders •Psychoactive medications • Anticholinergics •Hormonal agents • Antihistamines •Cardiovascular medications • Antihypertensives •Others • Psychoactive medications Med Lett Drugs Ther. 1992. Med Lett Drugs Ther. 1992. Medications Causing Orgasmic Causes of Dyspareunia Disorder • Amphetamines and related Viagra Sex in the post‐ era… anorexic drugs • Antipsychotics • Methyldopa • Narcotics • SSRIs • Trazodone • Tricyclic antidepressants Med Lett Drugs Ther. 1992. 9 8/31/2017 Male Products Contextual Descriptors • Negative upbringing/losses/trauma, past interpersonal relationships, cultural/religious restrictions • Current interpersonal difficulties, partner sexual dysfunction, inadequate stimulation, unsatisfactory sexual and emotional contexts • Medical conditions, psychiatric conditions, medications or substance abuse Basson R, et al. J Psychosom Obstet Gynecol. 2003. Other Considerations We Still Avoid the Word “Vagina” • “Vagina” • Lifelong or acquired disorder ▪ Originally meant “sheath” or “scabbard” (a protective covering • Situational or generalized disorder for a sword) • Degree of distress felt by woman as a result of ▪ Adopted in 17th century to refer to female genitalia dysfunction • 21st century—insufficient clear, accurate info available for public • Perceptions are slowly changing STAND UP PLEASE Basson R, et al. J Psychosom Obstet Gynecol. 2003. Blackledge C. 2003. Misinformation About the Vagina Is The V‐Word: A Brief US History Also Common • Patients report that they: 2001“The Vagina •Lack basic knowledge about vaginal Monologues,” V-Day health, including during/after Edition menopause Silence . . . •Have discomfort with touching •Misunderstand anatomy and/or 1997 “The Vagina 2004 “The placement Monologues” Vagina •Are uncertain whether partner will opens Memoirs” perceive the presence of a vaginal insert therapy University of North Carolina. 2001; Associated Students of Western Washington University. Raine TR. J Adolesc Health. 2009; Morris E. Menopause Int. 2011; Nappi RE. Climacteric. 2013; Hyde M. 2011. 2012. 10
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