1. Menopause & Sexual Health Clinic University of Iowa Hospitals
Presented by:
Dr. Veronika Kolder
Medical Director,
Menopause & Sexual Health Clinic
University of Iowa Hospitals
and Clinics
(319)
© 2012 Spirit Health Group. All rights reserved.

2. I do not have any financial ties or interests in the drugs mentioned in this talk

3. Relationships and Intimacy
Relationships are a balancing act of two people sharing their lives, providing each other with love and support while still maintaining their identities as separate individuals.
As years pass, the general stresses of life can interfere with a couple’s intimacy
So what can you do to keep that closeness and
maintain the va-va-voom in your relationship?
© 2012 Spirit Health Group. All rights reserved.

4. Keeping the Spark Alive
Maintain your interests
Establish meaningful conversation
Give importance to your sexual relationship
Don’t take your partner for granted
What can you do to keep that closeness and maintain the va-va-voom in your relationship?
Maintain your interests. When you first began your relationship, you each had separate friends, interests and ideas. Your individuality is part of what drew you to each other. Keep up your friendships and hobbies, and encourage your partner to do the same.
Establish meaningful conversation. Engage in conversations of substance and not just superficial small talk. Make eye contact. Carve out time to sit and listen to each other without judgment and with the same respect you would offer anyone else.
Give importance to your sexual relationship. Be flirtatious; it’s intimate and fun! Make time to be romantic; plan a date night. Pay attention to the sexual chemistry you have with your partner; this expression of love goes beyond what words can say.
Don’t take your partner for granted. Express your appreciation for your partner – for who they are and for the love and kindness they extend to you. Never underestimate their ability to surprise or delight you.
© 2012 Spirit Health Group. All rights reserved.

5. Set the Stage for Romance
There’s an old myth that says as people get older they aren't interested in intimacy. Try a few of these tips to help increase the intimacy in your relationship:
Take care of your appearance
Go to bed at the same time
No T.V. in the bedroom
A.M. affection
Take care of your appearance. Remember all that time you spent in front of the mirror when you first starting dating or were first married? While there is more to a relationship than looks, not caring at all about your appearance sends a negative message.
Go to bed at the same time. Bedtime needs to be “couple time.” When you don’t go to bed with your partner, it sends an “I’m not that excited anymore” message. If only one of you is a night owl, you may have to meet in the middle to create a bedtime that works for both of you.
No T.V. in the bedroom. Your bedroom should be used for only two things: sleep and sex. Any other activities, including a T.V., a computer or a treadmill, are distractions that encourage distance.
A.M. affection. If you hardly interact or show affection for each other during the day, how can you expect the passion to magically appear at night? Flirt over your morning coffee. Send you partner off to work with a big hug or kiss. Small reminders such as an or text throughout the day say “you’re on my mind.”
© 2012 Spirit Health Group. All rights reserved.

6. Staying in Sync
Successful relationships are those where the couple is in sync both in and out of the bedroom
Try doing some daytime activities together; these can help increase your connection before heading into the bedroom
Cooking class
Golf lessons
Dance lessons
© 2012 Spirit Health Group. All rights reserved.

7. Men vs. Women
Understanding how your partner’s mind and body reacts is essential to maintaining intimacy
A woman’s sex drive is associated with emotion and intellectual connection
A man’s sex drive is not typically driven by thoughts or feelings; they show more of a physical response
In order to overcome fading intimacy in a committed relationship, you have to attract each other over and over again. To do this, you must understand how your partner’s mind and body react. Women associate emotion and intellectual connection with their sex drive. They are often not as easily aroused. Men, on the other hand, display a more physical response, one that is not driven by thoughts and feelings.
© 2012 Spirit Health Group. All rights reserved.

8. Basson’s model

9. Aging Sexual activity with a partner 57-64 years old 65-74 years old
In the previous
12 months
61.6%
39.5%
16.7%
If sexually active, have sex more than 2 to 3 times per month
62.6%
65.4%
54.1%
These data are from a University of Chicago national probability sample of 3005 adults (1550 women) conducted by Stacy Lindau and colleagues in 2004.
Lack of a partner becomes the leading reason for cessation of sexual activity in aging women. Preventive health strategies need to improve opportunities for social interaction in senior living communities.
Recap objectives:
Take a life stages approach
Contemplate that being a gynecologist means advocating for women’s sexual health across the lifespan
Practice using sexual language
Link sexual health with heart-healthy lifestyle and exercise
Prevalence of sexual activity in women declines with age
However, even in the oldest age group, 54% of sexually active women have partner sex 2-3 times per month
Lindau et al, NEJM, 2007; 357:762-74

10. Intimacy During Your Golden Years
Use protection – age does not protect you from STDs (sexually transmitted diseases)
Sexuality can become challenging as health conditions change
eg.: cardiovascular or joint health issues
ergoerotics.com
Talk to your doctor about available options so you and your partner can continue to enjoy a healthy and active love life
Older people who are sexually active may be at risk for diseases such as syphilis, gonorrhea, chlamydia infection, genital herpes, hepatitis B, genital warts and HIV. Using protection shields both partners.
Conditions concerning our cardiovascular system such as diabetes or high blood pressure may inhibit arousal. Joint health, which can include various types of arthritis, may impair movement or cause pain. Older adults may suffer from a lower libido as well.
© 2012 Spirit Health Group. All rights reserved.

11. Exercise
Increases blood hormone levels of estrogen, progesterone, & prolactin
Increases secretion of pleasure and pain-relief chemicals in the brain, particularly β-endorphins
Has an antidepressant effect and may increased well-being, resulting in fewer midlife mood and sleep problems
Can reduce the sexual side effects of some anti-depressant medications
Serum concentrations of estrogen, progesterone, prolactin, LH, and FSH all increase during and after intense exercise, although resting values tend to be lower in atheletes
Physical activity increases secretion of endogenous opioid peptides, particularly B-endorphins
Exercise has an antidepressant effect and may increased well-being and fewer midlife psychological symptoms, including negative mood and change in sexual desire.

12. Menopause & Sexual Health Clinic
Elizabeth Graf, PA-C, NCMP
Veronika Kolder, MD, NCMP
Medical Director
Carole Long, MA
Eugenia Mazur, MD,
NCMP
Julie Youngblut, RN

13. The Web of Female Sexual Problems PAIN/PENETRATION DISORDERS
unsatisfying
encounter
painful
sex
Decreased
desire
Decreased
arousal
Decreased
orgasm
Principles of care
Establish collaborative relationship with client
Gather adequate psychosexual history
Ensure that mood and psychosocial function is stable
Give permission, help maintain motivation & resolve barriers to adherence
Female Sexual Dysfunction: Evaluation and Treatment
NANCY A. PHILLIPS, M.D., Wellington School of Medicine, University of Otago, Wellington, New Zealand
Am Fam Physician. 2000 Jul 1;62(1):
Cycle of sexual dysfunction. Example showing how a patient can enter the cycle of sexual dysfunction in one area (i.e., decreased orgasm) and proceed to another area (i.e., decreased desire) so that the presenting complaint may not represent the problem that actually requires evaluation and treatment.
Adapted with permission from Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res 1998;10(suppl 2):S117–20.
SSRI selective serotonin inhibitor
SNRI selective serotonin and norepinephrine inhibitor
Orgasm (verb or noun)
Orgasmic (adjective?)… : )
Implementation of biopsychosocial treatment, though mandated by process-of-care guidelines, may be limited in the field of sexual health owing to resource limitations, limitations in physician training curricula, and structural obstacles preventing interdisciplinary collaboration. Nonetheless, a number of current treatment developments are biopsychosocially integrative, and a number of established models are biopsychosocially informed. These models and concrete strategies may provide a way forward for developing further initiatives to advance BPS treatment. Berry MD and Berry PD. Contemporary treatment of sexual dysfunction: Reexamining the biopsychosocial model. J Sex Med 2013;10:2627–2643.
Consider adding PGAD, persistent genital arousal disorder.
Dr. mazur: original article
put sexual dyfunction/vaginismus
in this spot. Do you think adding
new terminology is too broad?
Should I limit to ‘sexual disorders
and vaginismus’?
SEXUAL DISORDERS
&
PAIN/PENETRATION DISORDERS
inadequate
stimulation
Adapted from Phillips. Am Fam Physician 2000;62(1):127-36

14. Multidisciplinary Approach
Behavior
modification
Alternative
medicine
Structured
sexual
tasks
Sexual
devices
Treat
systemic
illnesses
Sexual
pharmacology
Treatment
Evaluate
medications
Principles of care
Establish collaborative relationship with client
Gather adequate psychosexual history
Ensure that mood and psychosocial function is stable
Give permission, help maintain motivation & resolve barriers to adherence
Female sexual problems are best considered from a biopsychosocial perspective that includes biological, psychological, sociocultural, and interpersonal factors. Treatment also follows a biopsychosocial model and options include psychotherapy, pharmacotherapy, PT, and complementary approaches, alone or in combination (Krychman & Kingsberg, Contemp Ob Gyn Nov 2012, p
Consultations
Patient and
partner
education
Psycho-
therapy
Pain
management
Krychman

15. Interest/ Arousal Disorder
BEFORE
MENOPAUSE
AFTER
Cognitive behavioral therapy
Trial of discontinuing birth control pills or DepoProvera®
If on hormone therapy, switch to transdermal
Bupropion (Wellbutrin®)
? Bupropion
?On demand buspirone (BuSpar®)
? On demand buspirone
?On demand testosterone
only with effective contraception or after hystectomy
? Sildenafil (Viagra®) for women with diabetes, neurologic problems, or antidepressant-induced problems
Transdermal systemic testosterone
2010 Cochrane review of testosterone for peri and postmenopausal women
Authors’ conclusions
There is good evidence that adding testosterone to HT has a beneficial effect on sexual function in post-menopausal women. However,
the combined therapy is associated with a higher incidence of hair growth and acne and a reduction in HDL cholesterol. These adverse
events may differ by the different doses and route of testosterone administration. There is insufficient evidence to determine the effect
of testosterone in long term use.
For all:
Abstain from intercourse until pain problems have been addressed.
Regularly scheduled sex.
Exercise before sex.
Use a lubricant.
For pre-menopausal FSIAD: (Panzer 2006 and Grossman&Polan, 2013)
Cognitive behavioral therapy
 barriers to arousal of the mind
 arousability of the mind
Trial of discontinuing OCP’s/DepoMPA
Prospective studies needed to determine if use of OCPs leads to lasting  in gene expression of SHBG and how this affects long-term libido
Buproprion (Wellbutrin®)
RCTs suggest improved sexual satisfaction in non-depressed and depressed females
No increase in number of sexually satisfying events
On demand testosterone, buspirone (Buspar®)
Only with effective contraception
Need effective (preferably non-hormonal) contraception if adding T
Retrospective study of 124 females with sexual problems. SHBG levels in the OCP ‘discontinued user’ group did not decrease to the values of ‘never users’ (Panzer, 2006).
Possible role of OCP’s in etiology of provoked vulvodynia & dyspareunia
Bupropion Improves sexual function in non-depressed premenopausal women with HSDD and those with SSRI-associated sexual dysfunction
Panzer 2006
Grossman & Polan, 2013

16. On Demand Treatment http://charcoalpencilart.com/tag/spock/

17. On Demand Treatment Brain insensitive to cues

18. STOP On Demand Treatment Brain insensitive to cues
Automatic brain inhibition
STOP
Per emotionalbrain website, there are at least two causes of female arousal/interest disorder:
In some women, the brain is relatively insensitive to sexual stimuli. For example, the partner’s sexual advances are not recognized as important or interesting sexual stimuli in the brain of these women. As a results, they rarely or never result in a desire for sex.
Other women have an overactive inhibition system in the brain in response to sexual stimuli. Their system is sensitive to sexual stimuli, but as soon as the stimulus occurs, an automatic inhibition occurs. As a result, the sexual response is insufficient or absent.
Speroff recommends Androgel titrated to blood level, baseline measure. Not as guide to Rx
Br Menop Soc 2013 recommends off label use of testosterone gel licenced for males
Get reference for benefits of combined t-ET + vag ET over either alone for sexual function.
Lybrido®
0.5 mg T sublingual & 50 mg sildenafil (Viagra®) po
For females with low sensitivity to sexual cues
Lybridos®
0.5 mg T sublingual & 10 mg buspirone (BuSpar®) po
For females with maladaptive activation of sexual inhibition
Intrinsa® T patch; LibiGel®
300 mcg T patch; 300 mcg T gel
Serum levels _____ in phase III trials of Intrinsa
Lybrido(s) phase ? Trials now
Intrinsa and LibiGel turned down by FDA in recent years.
T inceases sexual desire/motivation
PDE5 inhibitor increases genital sensitivity
Buspirone is approved, in the US, by the FDA for the treatment of anxiety disorders and the short-term relief of the symptoms of anxiety.[
Buspirone counters the sexual inhibition mechanism in the prefrontal area of the brain. It is a 5HT(1A) agonist
Both of these combinations are associated with a window of effectiveness from 3-6 hrs after use.
Consider PDE5 (phosphodiesterase) inhibitor in:
diabetics
neurologic disorders
SSRI-associated sexual dysfunction
2006 NAMS position statement
APHRODITE study with 300 μg T/d patch showed modest but meaningful improvement in postmenopausal women without ET
Gel: 1 fingertip-sized dab/d rub into thigh/shoulder
Androgel 1.62%
Testim 1%. One 5-g or two 5-g tubes of Testim contains 50 mg or 100 mg of testosterone, respectively, to be applied daily to the skin's surface. Approximately 10% of the applied testosterone dose is absorbed across skin of average permeability during a 24-hour period.
(from Basson, Expert Op Pharmacother 2009;10(10): )
The role of oestrogen in women’s central sexual physiology
There is no conclusive evidence for a role for oestrogen in central sexual physiology. Nevertheless, some research links sexual higher endogenous estradiol (not the major oestrogen post menopause, but the one most readily measured), to less decline in overall sexual enjoyment as women age [77]. There are few human data to confirm that any sexual effect of testosterone is actually through the androgen receptor versus the oestrogen receptor (oestrogen formed from intracellular aromatisation of testosterone). Early research suggests marked differences in brain function between oestrogen replete or deficient women as they view erotic stimuli [78]. It is not yet known if areas of the human female brain having large numbers of androgen receptors also possess high aromatase activity, as is the case in the rodent brain. It remains possible that clinical benefit from testosterone may be owing to the increased availability of oestrogen owing to the lowering of sex hormone binding globulin (SHBG). However, one study of women benefiting from transdermal testosterone showed continued benefit when an aromatase inhibitor was added, suggesting the benefit was from testosterone itself [79].

19. Sexual Pain/Penetration Disorders
Example: vulvar pain with penetration
Mechanism(s)?
Vestibular
Tissue Changes
inflammation
cytokine changes
mast cell degranulation
oxidative nerve damage
increased blood flow
hormone receptor changes
Vestibular Nerve
Fiber Proliferation
PNS Sensitization
Pelvic Floor Muscle
Dysfunction
Triggering Factors
infection
allergy
vulvar trauma
childbirth
birth control pills
CNS Changes
‘Central
Sensitization’
Pain Feedback Loop
Alternate models are available from
Basson J Sex Med 2012;9:
Zolnoun et al. Ob Gyn Surv 2006;61:395-40
Fugl-Meyer et al. Standard operating procedures for female genital sexual pain. J Sex Med 2013;10: Modified from Zolnoun et al. Ob Gyn Surv 2006;61:395-40
Sexual pain problems may be primary (present at first intercourse) or secondary (pain developing after previous pain-free sexual activity), ma be complete (with each sexual experience) or situational.
From Sociey of Reproductive Health Professionals
TREATING DYSPAREUNIA
Dyspareunia is often viewed as a specific pain disorder with independent psychologic and biologic contributors with context-dependent etiologies. Physical examination may be required to rule out underlying anatomic pathology. Specific testing, including pelvic sonogram and vulvoscopy, may be useful in certain situations.
Differential diagnosis: introital dyspareunia, vaginismus, vulvovaginal atrophy, inadequate lubrication, vulvodynia, deep dyspareunia, endometriosis, pelvic inflammatory disease
Assess/consider concurrent psychologic or behavioral contributions via sexual history
Treatment options include treating the underlying physiologic or psychologic source of the pain:
Anti-irritant hygiene program
Vulvovaginal atrophy
Topical/local estrogen preparations (tablets, creams, rings)
Premarin® Vaginal Cream is FDA-approved to treat moderate-to-severe postmenopausal dyspareunia
Burning pain (indicative of neuroproliferation)
Low-dose tricyclic antidepressants (e.g., amitriptyline), SSRIs (e.g., duloxetine), or anticonvulsants (e.g., gabapentin)
Pelvic floor myofascial pain and guarding of pelvic floor muscle
Refer for manual pelvic floor muscle physical therapy (visit for qualified and trained pelvic floor specialist/provider)
Low-dose muscle relaxing agent (e.g., cyclobenzaprine, diazepam)
Anxiety management and coping
Refer for cognitive behavioral therapy
Referral for couples sexual counseling/therapy to explore non-penetrating pleasuring techniques (as appropriate)
TREATING VAGINISMUS
Vaginismus is persistent difficulty to allow vaginal entry of a penis, finger, or any object despite the express wish to do so.
Important considerations during assessment:
Vaginismus may be limited to sexual activity and may not be seen during a pelvic examination
Vaginismus may occur due to fear of pelvic examinations, but not impact sexual activity
Treatment is based on a combination of cognitive and behavioral psychotherapeutic approaches to desensitize the woman to her anxiety/panic and help achieve a sense of control over a sexual encounter or a pelvic examination, and an understanding that she is no longer in danger of experiencing pain. Treatment options may include:
Cognitive behavioral therapy
Pelvic floor physical therapy
Relaxation training with systemic desensitization using graduated vaginal dilators to help gain control over and relax muscles and stretch the vagina

Borg C, Georgiadis JR, Renken RJ, Spoelstra SK, Weijmar Schultz W, et al. (2014) Brain Processing of Visual Stimuli Representing Sexual Penetration versus Core and Animal-Reminder Disgust in Women with Lifelong Vaginismus. PLoS ONE 9(1): e doi: /journal.pone
2012 Cochrane Review. Melnik et al. Interventions fro vaginismus.
Background:
Vaginismus is an involuntary contraction of the vaginal muscles which makes sexual intercourse difficult or impossible. It is one of the more common female psychosexual problems. Various therapeutic strategies for vaginismus, such as sex therapy and desensitisation, have been proposed, and uncontrolled case series appear promising. Objectives:
To assess the effects of different interventions for vaginismus.
Search strategy:
We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) to August This register contains relevant randomised controlled trials from: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We searched reference lists and conference abstracts. We contacted experts in the field regarding unpublished material.
Selection criteria:
Controlled trials comparing treatments for vaginismus with another treatment, a placebo treatment, treatment as usual or waiting list control.
Data collection and analysis:
The review authors extracted data which we verified with the trial investigator where possible.
Main results:
Five studies were included, of which four with a total of 282 participants provided data. No meta-analysis was possible due to heterogeneity of comparisons within included studies as well as inadequate reporting of data. All studies were considered to be at either moderate or high risk of bias. The results of this systematic review indicate that there is no clinical or statistical difference between systematic desensitisation and any of the control interventions (either waiting list control, systematic desensitisation combined with group therapy or in vitro (with women under instruction by the therapist) desensitisation) for the treatment of vaginismus. The drop-out rates were higher in the waiting list groups.
Authors' conclusions:
A clinically relevant effect of systematic desensitisation when compared with any of the control interventions cannot be ruled out. None of the included trials compared other behaviour therapies (e.g. cognitive behaviour therapy, sex therapy) to pharmacological interventions. The findings are limited by the evidence available and as such conclusions about the efficacy of interventions for the treatment of vaginismus should be drawn cautiously.
This record should be cited as:
Melnik T, Hawton K, McGuire H. Interventions for vaginismus. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD DOI: / CD pub2
Assessed as up to date:
August 30, 2012
- See more at:
Predisposing / perpetuation factors
(eg. genetic & environmental factors)
CNS central nervous system
PNS peripheral nervous system
National Vulvodynia Association-supported CME, slide 19,

20. Sexual Pain/Penetration Disorders
Example: Vaginal dryness
FDA-approved
Estrogen
creams
Estrace Vaginal Cream®
Premarin Vaginal Cream®
tablets (Vagifem®)
vaginal ring (Estring®)
Ospemifene (Osphena®)
Compounded
DHEA vaginal ovules
Alternate models are available from
Basson J Sex Med 2012;9:
Zolnoun et al. Ob Gyn Surv 2006;61:395-40
Fugl-Meyer et al. Standard operating procedures for female genital sexual pain. J Sex Med 2013;10: Modified from Zolnoun et al. Ob Gyn Surv 2006;61:395-40
Sexual pain problems may be primary (present at first intercourse) or secondary (pain developing after previous pain-free sexual activity), ma be complete (with each sexual experience) or situational.
From Sociey of Reproductive Health Professionals
TREATING DYSPAREUNIA
Dyspareunia is often viewed as a specific pain disorder with independent psychologic and biologic contributors with context-dependent etiologies. Physical examination may be required to rule out underlying anatomic pathology. Specific testing, including pelvic sonogram and vulvoscopy, may be useful in certain situations.
Differential diagnosis: introital dyspareunia, vaginismus, vulvovaginal atrophy, inadequate lubrication, vulvodynia, deep dyspareunia, endometriosis, pelvic inflammatory disease
Assess/consider concurrent psychologic or behavioral contributions via sexual history
Treatment options include treating the underlying physiologic or psychologic source of the pain:
Anti-irritant hygiene program
Vulvovaginal atrophy
Topical/local estrogen preparations (tablets, creams, rings)
Premarin® Vaginal Cream is FDA-approved to treat moderate-to-severe postmenopausal dyspareunia
Burning pain (indicative of neuroproliferation)
Low-dose tricyclic antidepressants (e.g., amitriptyline), SSRIs (e.g., duloxetine), or anticonvulsants (e.g., gabapentin)
Pelvic floor myofascial pain and guarding of pelvic floor muscle
Refer for manual pelvic floor muscle physical therapy (visit for qualified and trained pelvic floor specialist/provider)
Low-dose muscle relaxing agent (e.g., cyclobenzaprine, diazepam)
Anxiety management and coping
Refer for cognitive behavioral therapy
Referral for couples sexual counseling/therapy to explore non-penetrating pleasuring techniques (as appropriate)
TREATING VAGINISMUS
Vaginismus is persistent difficulty to allow vaginal entry of a penis, finger, or any object despite the express wish to do so.
Important considerations during assessment:
Vaginismus may be limited to sexual activity and may not be seen during a pelvic examination
Vaginismus may occur due to fear of pelvic examinations, but not impact sexual activity
Treatment is based on a combination of cognitive and behavioral psychotherapeutic approaches to desensitize the woman to her anxiety/panic and help achieve a sense of control over a sexual encounter or a pelvic examination, and an understanding that she is no longer in danger of experiencing pain. Treatment options may include:
Cognitive behavioral therapy
Pelvic floor physical therapy
Relaxation training with systemic desensitization using graduated vaginal dilators to help gain control over and relax muscles and stretch the vagina

Borg C, Georgiadis JR, Renken RJ, Spoelstra SK, Weijmar Schultz W, et al. (2014) Brain Processing of Visual Stimuli Representing Sexual Penetration versus Core and Animal-Reminder Disgust in Women with Lifelong Vaginismus. PLoS ONE 9(1): e doi: /journal.pone
2012 Cochrane Review. Melnik et al. Interventions fro vaginismus.
Background:
Vaginismus is an involuntary contraction of the vaginal muscles which makes sexual intercourse difficult or impossible. It is one of the more common female psychosexual problems. Various therapeutic strategies for vaginismus, such as sex therapy and desensitisation, have been proposed, and uncontrolled case series appear promising. Objectives:
To assess the effects of different interventions for vaginismus.
Search strategy:
We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) to August This register contains relevant randomised controlled trials from: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We searched reference lists and conference abstracts. We contacted experts in the field regarding unpublished material.
Selection criteria:
Controlled trials comparing treatments for vaginismus with another treatment, a placebo treatment, treatment as usual or waiting list control.
Data collection and analysis:
The review authors extracted data which we verified with the trial investigator where possible.
Main results:
Five studies were included, of which four with a total of 282 participants provided data. No meta-analysis was possible due to heterogeneity of comparisons within included studies as well as inadequate reporting of data. All studies were considered to be at either moderate or high risk of bias. The results of this systematic review indicate that there is no clinical or statistical difference between systematic desensitisation and any of the control interventions (either waiting list control, systematic desensitisation combined with group therapy or in vitro (with women under instruction by the therapist) desensitisation) for the treatment of vaginismus. The drop-out rates were higher in the waiting list groups.
Authors' conclusions:
A clinically relevant effect of systematic desensitisation when compared with any of the control interventions cannot be ruled out. None of the included trials compared other behaviour therapies (e.g. cognitive behaviour therapy, sex therapy) to pharmacological interventions. The findings are limited by the evidence available and as such conclusions about the efficacy of interventions for the treatment of vaginismus should be drawn cautiously.
This record should be cited as:
Melnik T, Hawton K, McGuire H. Interventions for vaginismus. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD DOI: / CD pub2
Assessed as up to date:
August 30, 2012
- See more at:

21. Osphena® Taken by mouth ‘Selective Estrogen Receptor Modulator'
For moderate to severe sexual pain due to menopause
‘Selective Estrogen Receptor Modulator'
Same drugs group as Tamoxifen® and Clomid®
Boxed warning: can thicken the uterine lining
May increase risk of
blood clots to the legs or lungs
stroke
May cause or increased hot flashes
Contraindications same as estrogen therapy
Discontinuation rate for hot flashes was 1.6%.
January 2014, the Journal of Sexual Medicine published an additional study about ospemifene.  This research involved three double-blind, placebo-controlled clinical trials.  In two trials, women were also given lubricants to try on an as-needed basis. The researchers found that ospemifene 60 mg/day was associated with an improvement in VVA. 
Boxed warning
risk of endometrial cancer in women with a uterus
consider adding a progestogen
(Interesting: Ospemifene and 4-hydroxyospemifene effectively prevent ad treat breast cancer in Mtag. TG Transgenic mouse)
Biological actions mediated through binding to estrogen receptors.
60 mg sig: 1 po daily with food.
Contraindications:
undiagnosed abnormal bleeding
known or suspected E-dependent neoplasia
active DVT, PE, or hx of these conditions
active arterial thromboembolic disease (stroke, MI, or hx of either of these conditions
known or suspected pregnancy
Warnings and precautions: VTE, breast ca, severe hepatic impairment
Adverse reactions (> or = 1%): hot flush (7.5% vs 2.6% in placebo grp), vag discharge (3.8% vs 0.3% in placebo grp), muscle spasmn(3.2% vs. 0.9% in placebo grp), hyperhidrosis(1.6% vs. 0.6% in placebo grp).
Do not use concomitantly with E, fluconazole, or rifampin.
The use of progestins with ospemifene was not evaluated in the clinical trials.
In the trials, no endometrial cancer was seen with exposure for up to 52 mo.
There was a single case of simple hyperplasia without atypia.
Endometrial stripe thickness of > or = 5 mm was seen in 60/1000 females treated with Ospemifene and 21/1000 females on placebo.
Incidence of any type of proliferative (weakly plus active plus disordered) endometrium was 86/1000 for ospemifene vs 13/1000 for placebo.
Uterine polyps occurred at an incidence of 5.9/1000 females with ospemifene vs. 1.8/1000 for placebo.
Ospemifene was shown to be an antagonist of "ERE-mediated transactivation on MCF-7 cells," which the authors concluded indicates "anti-estrogenic activity in breast cancer cells.” However, it is contraindicated in women with known or suspected breast cancer.
Should be discontinued 4-6 weeks before surgery or in case of immobilization to reduce risk of VTE.
Long-term safety trial:
52-weeks, RCT 426 postmenopausal women with intact uterus.
Kaunitz AM. Ob Gyn Mgmt. 2013;25(5) Ospemifene may be of particular appeal for symptomatic women who prefer not to use estrogen vaginal cream, tablets, or the vaginal ring. However, in contrast to vaginal estrogen therapy, ospemifene increases hot flushes and may (like tamoxifen and raloxifene) increase the risk of VTE. As with vaginal estrogen, package labeling does not specifically recommend the use of progestin with ospemifene to prevent endometrial neoplasia in women with an intact uterus. However, and again, as with vaginal estrogen, endometrial monitoring should be considered in long-term users, and any vaginal bleeding occurring in users should be evaluated.
Use of vaginal or systemic estrogen is contraindicated in women with a history of breast cancer. As the package labeling indicates, “Osphena [ospemifene] 60 mg has not been adequately studied in women with breast cancer…”3 Accordingly, the FDA’s guidance is that, as with vaginal estrogen, ospemifene “…should not be used in women with known or suspected breast cancer or with a history of breast cancer.”1
Treatment with ospemifene (at various dosages of 25–200 mg/day) for 3 months [17–19] or 52 weeks [31] was associated with a dosage-dependent decrease in serum follicle stimulating hormone (FSH) levels [17–19] and a dosage-dependent increase in serum sex-hormone-binding globulin (SHBG) levels [18, 19]; there was an inconsistent effect on serum luteinizing hormone levels after 3 months [17–19], but a decrease was seen after 52 weeks [31]. Ospemifene had no effect on serum estradiol levels [17, 19, 31] or free testosterone levels [31], but decreased serum insulin-like growth factor I levels [17, 19] and increased total testosterone levels [31]. The decrease in serum FSH levels was significantly greater with ospemifene 90 mg/day than with raloxifene 60 mg/day, and the increase in serum SHBG levels was significantly greater with ospemifene 30–90 mg/day than with raloxifene 60 mg/day [19].
Ospemifene 30–90 mg/day for 3 months [35] or 52 weeks [12, 31] generally had no effect on lipid or lipo- protein levels relative to placebo. Total cholesterol levels decreased significantly (p \ 0.05) more with raloxifene 60 mg/day than with ospemifene 30–90 mg/day, but otherwise the lipid profiles were similar [19].
In general, ospemifene 30–90 mg/day for 3 months [35] or 52 weeks [31] caused no major changes on endothelial markers or coagulation parameters, with the exception of a decrease in fibrinogen levels. Ospemifene had no effect on fasting or fed glucose levels, or baseline insulin levels [35].

22. www.uihealthcare.org/spirit-of-women to download the Frisky Business
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What Do Women Want? By Daniel Bergner.
‘Good enough sex’, Men’s Sexual Health by McCarthy & Metz, 2008, Routledge
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