2Desire Disorder (HSDD) A New Frontiers Program onWomen’s HealthEmerging Perspectives on the Science and Medicine of Hypoactive SexualDesire Disorder (HSDD)The Internal Medicine and Primary Care PerspectiveProgram Chairman and ModeratorAnita H. Clayton, MDDavid C Wilson ProfessorDepartment of Psychiatry & Neurobehavioral SciencesProfessor of Clinical Obstetrics & GynecologyUniversity of VirginiaCharlottesville, VA
3Program Faculty PROGRAM CHAIRPERSON Anita H. Clayton, MD PROGRAM CHAIRPERSONAnita H. Clayton, MDDavid C Wilson ProfessorDepartment of Psychiatry &Neurobehavioral SciencesProfessor of Clinical Obstetrics &GynecologyUniversity of VirginiaCharlottesville, VAJennifer E. Frank, MD, FAAFPAssistant ProfessorDepartment of Family MedicineUniversity of Wisconsin School of Medicine and Public HealthAppleton, WisconsinSheryl Kingsberg, PhDDivision Chief, Behavioral Medicine ProgramUniversity HospitalsAssociate Professor of MedicineCase Western Reserve UniversityCleveland, OhioLori Brotto, PhDAssistant ProfessorDepartment of Obstetrics and GynecologyUniversity of British ColumbiaVancouver, BC
4Addressing Current Challenges in Female Sexual Disorders A New Frontiers Program onWomen’s HealthAddressing Current Challenges in Female Sexual DisordersWhat Internal Medicine Specialists Need to Know about HSDDProgram Chairman and ModeratorAnita H. Clayton, MDDavid C Wilson ProfessorDepartment of Psychiatry & Neurobehavioral SciencesProfessor of Clinical Obstetrics & GynecologyUniversity of VirginiaCharlottesville, VA
5A New Frontiers Program on Women’s HealthClinical focusPrevalence and pathophysiology of HSDDCommunication strategiesDifferential diagnosesIntervention and management
6Case Example26-year-old MWF presents with 1 year history of decreased libido, some problems with vaginal lubrication, and diminished orgasmic capacity. No pain with intercourse.Change in sexual function since marriage 4 years ago, but relationship still strong1 year post-partum with mild depressive symptoms since deliveryNo general health problemsOn oral contraceptives for birth control
7A New Frontiers Program on Women’s HealthHypoactive Sexual Desire Disorder Prevalence and Barriers to Recognition in the Primary Care SettingSheryl A. Kingsberg, Ph.DChief, Division of Behavioral MedicineUniversity Hospitals Case Medical CenterProfessor, Department of Reproductive BiologyCase Western Reserve University School of MedicineCleveland OH
8“Normal” Female Sexuality Defined by Cultural Norms Historically given little attentionVictorian era: discovery that female orgasm irrelevant to conception2008: women’s sexuality hits ‘Primetime’ but not quite its ‘Prime’
9Human Sexual Response: Classic Models DesireExcitementPlateauOrgasmResolutionDividedArousalWe improved this somewhat in the 1980’s when Helen Singer Kaplan divided Excitement into 2 separate phases, desire and arousal. Then we became even more sophisticated by including satisfaction as a necessary component to fulfill the cycle.Linear progressionMasters WH, Johnson VE. Human Sexual Response. Boston, Mass: Little Brown; 1966.Kaplan HS. The New Sex Therapy
10Female Sexual Response Cycle OrgasmExcitementPlateauOrgasmResolutionABC(C)(A)(B)PlateauExcitementSex response is a natural phenomenon in which sensory stimulation leads to increased peripheral blood flow and vasocongestion. Genital tissues and breasts are most obviously affected. With continuing stimulation, there is a build-up of muscle tension and the development of a “plateau” phase that leads to orgasm. During orgasm, there is a brain discharge, widespread muscle contraction, and increased cardiac output. Resolution follows orgasm with return to the unstimulated state. The essential components of sex response depend upon adequate functioning of nerves, arteries, and muscles.Adapted from Masters WH, Johnson VE. Human Sexual Inadequacy. Little Brown; 1970.
11Physical Satisfaction Female Sexual Response CycleEmotional IntimacySeeking Outand Being Receptive toEmotional andPhysical SatisfactionSpontaneousSexual DriveSexual StimuliFemale Sexual Response CycleAnd now Rosemary Basson offers an alternative model to understanding the sexual response cycle that suggests that for women, it is not so linear and that for many women, desire comes after arousal and that many women begin from a point of sexual neutrality. Arousal may come from a conscious decision or as a result of seduction or suggestion from a partner. This is extremely important to understand because you can then normalize this reality for your patients who have come to believe that because the initial drive has gone they are no longer sexual beings and to reassure their partners that it is not that they have lost desirability.(e.g analogy of going to the gym—)So, Sexual neutrality or being receptive to rather than initiating sexual activity is considered a normal variation of female sexual functioning. This is very important for you to keep in mind as I review the female sexual dysfunctions, particularly hypoactive sexual desire disorder.This slide graphically illustrates “normal” female sexual response. Women’s desire has a large responsive (receptive) component that is driven by intimacy and is circular in nature. When any one (or more than one) aspect or phase of the cycle is absent, the patient may experience one or more sexual dysfunctions. Satisfaction is an essential component of the sexual response cycle. Instead of a linear relationship with orgasm as the end point, a cyclic concept with satisfaction as the focus appears to be more appropriate in females.The cycle: A woman starts out desire-neutral. If the patient experiences adequate emotional intimacy with her partner, she may seek or be receptive to sexual stimuli. Receptivity to sexual stimuli allows the woman to move from sexual neutrality to arousal. If the mind continues to process the stimuli on to further arousal, sexual desire will encourage the woman to move forward to sexual satisfaction and orgasm. This positive outcome fosters intimacy and reinforces sexual motivation.Arousal andSexual DesireSexual ArousalBiologicPsychologicalBasson R. Med Aspects Hum Sex. 2001;1:41-42.
12Women’s Endorsement of Models of Female Sexual Response The Nurses’ Sexuality Study, N=133Equal proportions of women endorsed the Masters and Johnson, Kaplan, and Basson models of female sexual response as representing their own sexual experience.Women endorsing the Basson model had significantly lower FSFI domain scores than women who endorsed either the Masters and Johnson or Kaplan models.Michael Sand, PhD, MPH, and William A. Fisher, PhD, JSM, :
13Biopsychosocial Model of Female Sexual Response (e.g., physical health,neurobiology, endocrine function)(e.g., performance anxiety, depression)BiologyPsychology(e.g., upbringing, cultural norms and expectations)(e.g., quality of current and past relationships, intervals of abstinence, life stressors, finances)SocioculturalInterpersonalUnlike the other influential models, the biopsychosocial model of female sexual response takes into account multiple etiologic factors and determinants that include the interpersonal, psychological, physiological, or biological, as well as the sociocultural.1,2Examples of biological factors include physical health, neurobiology, and endocrine function; the psychological include performance anxiety and depression; the sociocultural include upbringing, cultural norms, and expectations; and the interpersonal, quality of current and past relationships, intervals of abstinence, life stressors, and finances.1,21. Rosen RC, Barsky JL. Obstet Gynecol Clin North Am. 2006;334:References:Althof SE, Leiblum SR, Chevret-Measson M, et al. Psychological and interpersonal dimensions of sexual function and dysfunction. J Sex Med. 2005;26:Rosen RC, Barsky JL. Normal response in women. Obstet Gynecol Clin N Am. 2006;334:SD66098(Previously used in SD64473, Slide#18)13
14US Adult Women Are Sexually Active* Breaking Through the Barriers: Understanding and Diagnosing Female Sexual DysfunctionRandom Digital Dialing Survey of Women Years Old (N=2000)†10070706665605046US Women Sexually Active (%)40302020In this survey, 2000 US women were randomly dialed by phone to assess their sexual practices and health behaviors.Questions on sexual practices and health behaviors during a typical 4-week period were included in the questionnaire as were questions on medical history, vaginal symptoms, and sociodemographic variables.Sexually active was defined as oral (active or receptive), vaginal, or anal intercourse in the past 3 months.The percentage of sexually active women per age group was66% of women aged years70% of women aged years65% of women aged years46% of women aged years, and20% of women aged years1018-2930-3940-4950-5960-94(n=362)(n=451)(n=473)(n=271)(n=443)Age Ranges*Sexually active was defined as oral (active or receptive), vaginal, or anal intercourse in the past 3 months. †Age-adjusted percentages.Patel D, et al. Sex Trans Dis. 2003;30(3):References:Patel D, et al. Sexual behavior of older women: results of a random-digit-dialed survey of 2000 women in the United States. Sex Trans Dis. 2003;30(3):SD6609814
15DSM-IV-TR Classification of FSDs Sexual Desire DisordersHypoactive Sexual Desire DisorderAbsence or deficiency of sexual interest and/or desireSexual Aversion DisorderAversion to and avoidance of genital contact with a sexual partnerSexual Arousal DisordersFemale Sexual Arousal DisorderInability to attain or maintain adequate lubrication-swelling response of sexual excitementOrgasmic DisordersFemale Orgasmic DisorderDelay in or absence of orgasm after a normal sexual excitement phasePain DisordersDyspareuniaGenital pain associated with sexual intercourseVaginismusInvoluntary contraction of the perineal muscles preventing vaginal penetrationSpeaker’s notes:Definitions of FSD from the Diagnostic and Statistical Manual of Mental Disorders are based on the linear model of human sexual response posed by Masters and Johnson. There are 6 FSDs across the sexual response cycle: hypoactive sexual desire disorder, sexual aversion disorder, female sexual arousal disorder, female orgasmic disorder, dyspareunia, and vaginismus. The presence of personal or relationship distress is a required criterion for a diagnosis of these sexual dysfunctions. This table outlines the definitions for each of the FSDs. This classification system has been criticized since it is based on the traditional linear model and may not apply as well to female sexuality. In addition the DSM IV-TR classification system has been criticized for its emphasis on physiologic causes of disorders. As such, it is expected that the categories and their definitions will continue to evolve.Keywords:DesireAversionArousalOrgasmPainDyspareuniaVaginismusReference:American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revision (DSM-IV-TR). Washington, DC; American Psychiatric Association; 2000.
16DSM-IV TR Criteria for FSD REVISED PER FACULTY INPUT 12/14/200912/18/2009DSM-IV TR Criteria for FSDSexual complaint or problem in desire, arousal, orgasm, or sexual pain:Judgment of severity of sexual symptom is made by the clinician, talking into account factors that affect sexual functioning, such as age and the context of the person’s lifeThe disturbance causes marked distress or interpersonal difficultyThe 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, drug of abuse, medication) or a general medical conditionThese are the DSM criteria for the diagnosis of female sexual disorders .These are described as any sexual complaint or problem in desire, arousal, orgasm, or sexual pain: The judgment of the severity of the sexual symptom is made by the clinician, talking into account factors that affect sexual functioning, such as the patient’s age and the context of her life. [QUERY: example?]The DSM IV criteria specify that, to be classified as an FSD, the disturbance must cause marked distress or interpersonal difficulty.Finally, the sexual dysfunction is not explained by another primary psychiatric disorder (except another Sexual Dysfunction), and it is not due exclusively to the direct physiological effects of a substance, such as a drug of abuse or medication, or a general medical condition.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.16
17Overlap of FSDs Sexual Desire Disorders Sexual Arousal Disorder DyspareuniaOrgasmicDisorderSpeaker’s notes:One or more FSDs may coexist in a patient, and, in fact,it is common that there is overlap among disorders, complicating a diagnosis. It is important that the clinician determine the primary FSD and how comorbid FSDs evolved over time.Reference:Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J, Goldstein I, Graziottin A, Heiman J, Laan E, Leiblum S, Padma-Nathan H, Rosen R, Segraves K, Segraves RT, Shabsigh R, Sipski M, Wagner G, Whipple B. Report on the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and Classification. J Urol. 2000;163:VaginismusBasson R, et al. J Urol. 2000;163:
18Prevalence of FSD: A Historical Perspective Sexual Dysfunction in the United States*OBJECTIVES: Assess the prevalence and risk of experiencing sexual dysfunction in men and womenNOT ASSESSED: Distress or interpersonal difficultyPOPULATION: 1749 women and 1410 men years of ageRESULTS: 43% of women reported sexual dysfunction10050Prevalence of Sexual Dysfunction in Women by Latent Class434030Women (%)222014This population study by Laumann and colleagues, a substudy of the National Health and Social Life Survey, called the NHSLS, was conducted in 1992.The substudy is a probability sample among 1749 women and 1410 men aged 18 to 59 years in the United States and is based on face-to-face interviews conducted by trained interviewers.The population is similar to the US Census Bureau Current Population Survey, representative for age, education level, and marital status.Sexual problems were measured in this study. While NHLHS data on critical symptoms do not connote a clinical definition of sexual dysfunction, their prevalence does provide important information about their extent and differential distribution among the US population.The prevalence in women for all sexual dysfunctions in this study is 43%.Broken down according to specific sexual dysfunction (subsets of the total 43%), the prevalence of low sexual desire is 22%; problems with arousal, 14%; and sexual pain, 7%.710Total for SexualLow SexualArousalPainDysfunctionsDesireAssessedSubsets for Sexual Dysfunctions Assessed*Sexual problems were measured in this study. NHLHS data on critical symptoms do not connote a clinical definition of sexual dysfunction.Laumann E, et al. JAMA. 1999; 281(6):References:Laumann E, Paik A, Rosen RC. Sexual dysfunction in the United States. JAMA. 1999;281(6):SD66098
19Prevalence of FSD: PRESIDE OBJECTIVES: Estimate the prevalence of self-reported sexual problems (any, desire, arousal, and orgasm), the prevalence of problems accompanied by personal distress, and describe related correlatesNOT DETERMINED: Whether low desire with sexually related personal distress was primary or secondary to another illness; pain was not assessedPOPULATION: 31,581 US female respondents ≥18 years of age from 50,002 householdsRESULTS*: Response rate was 63% (n=31,581 / 50,002)Prevalence of Female Sexual Problems Associated With Distress1005043.14537.74035US Women (%)Sexual Problems3025.3This survey by Shifren and colleagues, called The Prevalence of Female Sexual Problems Associated With Distress and Determinants of Treatment Seeking, or PRESIDE, was a cross-sectional, population-based survey of 31,581 US women respondents ≥18 years that assessed the prevalence of sexual problems, problems accompanied by personal distress, and related correlates using validated, mailed questionnaires.Importantly, this survey has a considerably larger sample size than any comparable published population-based study as well as a very wide age range, years of age.The red bars indicate prevalence data for sexual problems WITHOUT sexually related distress: 37.7% for low desire, 25.3% for low arousal, 21.1% for low orgasm, and 43.1% for any sexual problem.In blue, we have data for the same sexual problems WITH sexually related distress: 9.5% for low desire, 5.1% for low arousal, 4.6% for low orgasm, and 11.5% for any sexual problem.Distressing Sexual Problems2521.120159.511.5105.14.6*All results are US population age-adjusted.5DesireArousalOrgasmAnyShifren JL, et al. Obstet Gynecol. 2008;112(5):References:Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008;112(5):SD66098(Previously used in SD64473, Slide#30)
20Prevalence of Sexual Problems Associated with Distress (PRESIDE) Age-stratifiedprevalenceDesire2868/28,447Arousal1556/28,461Orgasm1315/27,854Any3456/28,40318-4126.96.36.1990.845-64188.8.131.524.865 or older7.46.05.8Shifren J et al Obstetrics & Gynecology, 2008, 112(5).
21Prevalence of Low Sexual Desire and Hypoactive Sexual Desire Disorder Nationally Representative Sample of US WomenCategoryLow DesireN%HSDDAll193636.219208.3Age 30-3945330.8Age 40-4954225.35399.0Age 50-5982437.88149.4Age 60-7011760.71145.8Surgical Menopausal63539.763112.5Natural Menopausal55152.45416.6Premenopausal75026.77487.7West SL et al Archives of Internal Medicine, 2008
22Decreased Sexual Desire With Distress Negatively Impacts Women’s Lives Breaking Through the Barriers: Understanding and Diagnosing Female Sexual DysfunctionDecreased sexual desire is associated with negative effects including:1,2Poor self-imageMood instabilityDepressionStrained relationships with partnersThese data were taken from two landmark prevalence studies:A survey by Shifren and colleagues, called The Prevalence of Female Sexual Problems Associated With Distress and Determinants of Treatment Seeking, or PRESIDE, which was a cross-sectional, population-based survey of 31,581 US women respondents ≥18 years that assessed the prevalence of sexual problems, problems accompanied by personal distress1A survey by Leiblum and colleagues called The Women’s International Study on Health and Sexuality, or WISHeS, which was a cross-sectional survey among a national population sample of 952 US women aged 20 to 70 with varying reproductive status conducted in 20002Decreased sexual desire with distress negatively impacts women’s lives.Decreased sexual desire with distress is associated with negative effects including poor self-image and mood instability, including depression,1,2 and strained relationships with partners.1,21. Shifren JL, et al. Obstet Gynecol. 2008;112(5): Leiblum SR. Menopause. 2006;13(1):46-56.References:Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women. Obstet Gynecol. 2008;112(5):Leiblum SR. Hypoactive sexual desire disorder in postmenopausal women: US results from the Women’s International Study of Health and Sexuality (WISHeS). Menopause. 2006;13(1):46-56.SD6609822
23Hypoactive Sexual Desire Disorder (HSDD) REVISED PER FACULTY INPUT 12/14/2009Hypoactive Sexual Desire Disorder (HSDD)12/18/2009Persistent or recurrent deficiency or absence of sexual thoughts, fantasies and/or desire for, or receptivity to, sexual activityCauses marked personal distress or interpersonal difficultiesNot better accounted for by another primary disorder, drug/medication, or general medical conditionThe criteria for a diagnosis of Hypoactive Sexual Desire Disorder are as follows:The persistent or recurrent deficiency or absence of sexual thoughts, fantasies and/or desire for, or receptivity to, sexual activity, which causes marked personal distress or interpersonal difficulties, and that is not better accounted for by another primary psychiatric disorder (except another Sexual Dysfunction), or due exclusively to the direct physiological effects of a substance (eg, drug of abuse, medication) or a general medical condition.23
24Components of Sexual Desire 12/18/2009Components of Sexual DesireDrive:Sex steroids and neurotransmitters play a role in modulating sexual desire, drive, and excitementExpectations, beliefs, and valuesMotivationThe first component of sexual desire is drive: the biological component based on neuroendocrine mechanisms and evidenced by spontaneous sexual interest. That is, a person’s body signals through sexual thoughts, fantasies, dreams or sensations such as genital tingling that it wants to be sexual. Patients know this as feeling “horny”. Drive is relative. Each one of us has a certain drive level, low, once a month or less, moderate, weekly, or high, daily or more. Regardless of what the baseline is, drive declines with age in both men and women. Although we still do not fully understand the exact neuroendocrine mechanisms that are responsible for drive, we do know that drive declines in both men and women as a function of aging.The second component is cognitive. This component reflects a person’s expectations, beliefs, and values about sex. For example, a 60-year-old happily married woman whose kids have finally left home and who adores her husband and believes that sex is healthy and fun will likely have more desire. On the other hand, a 60-year-old widow who believes that grandmothers aren’t supposed to be sexual and doesn’t believe in premarital sex is likely to have less desire based on these values.The third component is the emotional or interpersonal component of desire which is subsumed under the category of motive and characterized by the willingness of a person to engage in sexual activity. This is often the most important and is impacted by the quality of a relationship, psychologic functioning, worries about health, children etc. You can have all the drive in the world but if you hate your spouse or are suffering from clinical depression, your motivation will not be there.This distinction between drive and desire is absolutely essential for any physician assessing or treating sexual problems because treatment is vastly different based on which component or components of desire have declined. For example, a woman might have a very strong sexual drive but if she is not motivated to be sexual, say, if she is angry with her partner, dealing with a stressful work problem, or suffering from depression, she will not act on the drive. In fact, it is virtually wiped out. On the other hand, if a woman has lost some of her drive but remains motivated to be close and intimate with her partner, then despite having little physical cues or interest, she still enjoys the sexual experience. This differentiation of drive from desire is particularly important to the understanding of female sexuality and points out some of the gender differences in prevalence of particular sexual problems. It also underscores the relative gender differences in the sexual response cycle itself.Hypoactive sexual desire disorder is the sexual dysfunction that is often assumed to correspond to menopause due to the loss of testosterone that occurs with ovarian hormone decline.References:Hull EM, et al Hormone neurotransmitter interactions in the control of sexual behavior. Behav Brain Res. 1999;105:105–116.Perelman M. J Sex Med. 2007;4(suppl)Hull EM, et al. Behav Brain Res. 1999;105:105–116.Levine S. Sexual Life, 199424
25Social Psychology Theories: Understanding Psychosocial Aspects of Female Sexual Desire Self-Perception TheoryPeople make attributions about their own attitudes by relying on observations of external behaviors (Bem, 1965)Wundt's schema of sensory affect (aka Kingsberg’s Ice-Cream Analogy)Increases of stimulus intensity above threshold are felt as increasingly pleasant up to a peak value beyond which pleasantness falls off through indifference to increasing unpleasantness.
26Prevention and Treatment of Sexual Problems ASK!You cannot treat a problem if you don’t know it exists
27Type of Help-Seeking (n=3239) Breaking Through the Barriers: Understanding and Diagnosing Female Sexual DysfunctionIn PRESIDE About One-Third of Women With a Distressing Sexual Problem Sought Formal CareType of Help-Seeking (n=3239)14.5% Did not seek helpFormal34.5%9.1% AnonymousInformal 41.9%A subset of participants (n=3239) in the PRESIDE study was evaluated to determine how women with self-reported distressing sexual problems seek help.The Prevalence of Female Sexual Problems Associated With Distress and Determinants of Treatment Seeking, or PRESIDE, was a cross-sectional, population-based survey of 31,581 US women respondents ≥18 years that assessed the prevalence of sexual problems, problems accompanied by personal distress, and related correlates using validated, mailed questionnaires.Prior to this study, very little was known about treatment-seeking behavior of women with sexual problems. Sexual problems are defined as the presence of any of the 3 individual problems of desire, arousal, or orgasm.The data show that of the women with distressing sexual problems:42% sought help from informal sources, defined as someone other than a health care provider.35% sought help from a formal source, such as a health care provider.9% sought help from an anonymous source such as the Internet, television, radio, or printed material.And 15% did not seek help.Formal=HCP; informal=anyone other than an HCP.Shifren JL, et al. J Women’s Health. 2009;18(4)References:Shifren JL, Johannes CB, Monz BU, Russo PA, Bennett L, Rosen R. Help-seeking behavior of women with self-reported distressing sexual problems. J Women’s Health. 2009;18(4):SD66098(Previously used in SD64473, Slide#49)27
28Physician Questioning Increases Patient Reporting of Sexual Dysfunction 40302010Patients (%)19%Speaker’s notes:This study underscores the importance of physician-initiated questioning on sexuality. Gynecologic outpatients (n=887) were screened for sexual concerns and dysfunction by the inclusion of 2 questions in the medical history. Only 3% of the patients spontaneously offered sexual complaints. With direct inquiry, 19% of the patients acknowledged a complaint.References:1. Bachmann GA, Leiblum SR, Grill J. Brief sexual inquiry in gynecologic practice. Obstet Gynecol. 1989;73:3%Spontaneous Reporting AfterReporting Direct InquiryN=887.Bachmann GA, et al. Obstet Gynecol. 1989:73:
29Physician-Based Barriers Lack of training/Inadequate knowledge or skills1Lack of awareness of associated comorbid conditions“Improving quality of life” may not be considered a high priority2Time constraints3Underestimation of prevalenceNo FDA approved treatments for female sexual dysfunction1Broekman CPM, et al. Int J Impot Res. 1994;6:67-72.2Eid JF, et al. Cliniguide® to Erectile Dysfunction. Lawrence DellaCorte Publications, Inc; 2001.3Baum N, et al. Patient Care. Spring 1998(suppl):17-21.
30Training Is Not Preparing HCPs To Be Informed in the Area of FSD Breaking Through the Barriers: Understanding and Diagnosing Female Sexual DysfunctionTraining Is Not Preparing HCPs To Be Informed in the Area of FSDCurriculum Time (Hours) Dedicated to Human Sexual Health Education (N=101)*HCPs receive minimal training in FSD and are poorly prepared to address these issues.This cross-sectional survey by Solursh and colleagues assessed the amount of curriculum time allotted to human sexual health education in 101 medical schools in the United States (n=93) and Canada (n=8).Investigators found medical training for problems relating to human sexual health was minimal, with most medical schools providing only 3 to 10 hours of training.Only 15% of medical schools offered curriculum time of 20 hours or more pertaining to sexual health education.17% of schools offered between 11 and 19 hours.The majority of medical schools offered 10 training hours or fewer in the area of human sexual health.*Human sexual health education was not specifically defined in the survey but included: type of educational experiences, disciplines, subject and topics areas, clinical program, continuing medical education, total number of hours, amongst others.Solursh DS, et al. Int J Impot Res. 2003;15(suppl 5):S41-S45.References:Solursh DS, Ernst JL, Lewis RW, et al. The human sexuality education of physicians in North American medical schools. Int J Impot Res. 2003;15(suppl 5):S41-S45.SD66098(Previously used in SD64473, Slide#15)30
31Most HCPs Have Little or No Confidence in Screening for or Diagnosing HSDD Breaking Through the Barriers: Understanding and Diagnosing Female Sexual DysfunctionWeb-Based Survey Consisting of Residents and Faculty in an Academic Primary Care Clinic (N=53; 41.5% women, 58.5% men)Respondents who had not screened ordiagnosed patients with HSDD90HCPs who felt little or no confidence in91diagnosing HSDDHCPs who had little confidence in57ability to manage HSDDThe majority of health care providers have little or no confidence in their ability to effectively screen for or diagnose HSDD.This conclusion was reached in a web-based survey of 53 health care providers, 58% of whom were men and 41.5% were women, all of whom were practicing at the University of Virginia.The survey found:90% of respondents had not screened or diagnosed HSDD in any of their patients.91% did not feel confident in their ability to diagnose HSDD—more specifically, 38% felt little confidence and 53% felt no confidence.Similarly, 57% of health care providers reported they had little confidence in their ability to manage HSDD.20406080100HCPs (%)Harsh V, et al. J Sex Med. 2008;5(3):References:Harsh V, McGarney EL, Clayton AH. Physician attitudes regarding hypoactive sexual desire disorder in a primary care clinic: a pilot study. J Sex Med. 2008;5(3):SD66098(Previously used in SD64473, Slide#60)31
32HCPs Perceive Patients as Reluctant to Bring Up Sexual Issues Breaking Through the Barriers: Understanding and Diagnosing Female Sexual DysfunctionHCPs Perceive Patients as Reluctant to Bring Up Sexual IssuesPatient Barriers Identified by HCPs in the Management of Sexual Dysfunction (n=133 HCPs)Patients‘ reluctance/ reticence/embarrassmentPatient thinks it's “normal”/lack of knowledge and awarenessIndirect presentation (hidden by other symptoms)Difficult area to discussDoesn't want to wastedoctors' time184.108.40.206573.1Physicians report that there are numerous barriers to managing their patients' sexual dysfunction, the most prevalent of which is patient reluctance or embarrassment to discuss the sexual problem.In a survey mailed to general practitioners, Humphrey and colleagues asked about the specific barriers to assessment and management of sexual dysfunction.133 physicians responded, 59% of whom were male and only 6% of whom had a special interest in sexual health.In their responses, physicians characterized their patients' primary barriers to discussing their sexual problems.5% or fewer of physicians felt that:Patients do not want to waste their doctor's time.Sexual problems were a difficult area to discuss.The presentation was indirect and hidden by other symptoms.15% of physicians identified their patients' lack of knowledge as a barrier and the belief that their sexual dysfunction was normal.A vast majority of physicians, more than 73%, reported that their patients' embarrassment and reticence to discuss their sexual problem was the primary barrier to appropriate management of sexual dysfunction.20406080Total Number of Barriers (%)**Total number of patient barriers=93; most HCPs identified more than one barrier.Humphrey S, et al. Fam Pract. 2001;18(5):References:Humphrey S, Nazareth I. GPs’ views on their management of sexual dysfunction. Fam Pract. 2001;18(5):SD6609832
33HCP Comfort Level Impacted by Patient Gender Breaking Through the Barriers: Understanding and Diagnosing Female Sexual DysfunctionHCP Comfort Level Impacted by Patient GenderDifferences in Physician Comfort Level Influenced by Gender (N=69)50*Physician self-report of discomfort with male patients19Female physicians (n=29)Physician self-report of discomfort with female patients12*Male physicians (n=40)35Physician perception of male patient discomfort4540Gender is an integral factor in the comfort level of both the patient and physician when sexual problems are presented.Burd and colleagues generated a cross-sectional descriptive analysis from results of a questionnaire mailed to multipractice specialties. The survey assessed physicians' levels of discomfort when assessing patients with sexual problems. Responses came from 69 physicians, 58% of whom were male.In general, significantly more female physicians than male physicians felt discomfort discussing sexual problems with male patients (50% vs 19% respectively).Similar results were seen with male physicians who felt significantly greater discomfort than female physicians when discussing sexual dysfunction with female patients (35% vs 12% respectively).When asked about patient perception, no significant difference was found between male and female physicians' perception of discomfort by their male patients when speaking about sexual problems.A significant difference in physician perception of discomfort among female patients was seen, however. Fifty-three percent of male physicians perceived discomfort in their female patients when discussing sexual problems compared with 24% of female physicians.Physician perception of female patient discomfort24*5310203040506070*P<0.05.Physicians (%)Burd ID, et al. J Sex Med. 2006;3(2):References:Burd ID, Nevadunsky N, Bachmann G. Impact of physician gender on sexual history taking in a multispecialty practice. J Sex Med. 2006;3(2):SD66098(Previously used in SD64473, Slide#57)33
34Open-Ended QuestionsRequire narrative elaboration, not yes/no or short responseDirective open-ended questions focus the topic Open the door to context, understanding, & feelingsDoctors ask ≈1 question/min; >90% are closed-endedPhysicians can increase use open-ended questions & improveAssessment of functional impairmentAdherencePatient satisfactionOpen-ended dialog is efficient (≈ 90 seconds for impairment dialog)4 & effectively reveals syndromal symptomsLipton et al. JGIM 2008;23:Hahn et al. Curr Med Res Opin 2008;24:34
35The Challenges of the Differential Diagnosis Breaking Through the Barriers: Understanding and Diagnosing Female Sexual DysfunctionEnsure that sexual dysfunction IS NOT due exclusively to thePhysiological effects of a specified general medical condition (eg, neurological, hormonal, metabolic abnormalities)*In Order to Meet the Diagnostic Criteria for HSDD:Ensure that sexual dysfunction IS NOT due exclusively to thePhysiological effects of substance (prescribed or illicit) abuse†HSDD and concomitant sexual dysfunctions (both should be noted)Also, additional diagnosis of HSDD IS NOT made if low sexual desire is better accounted for by another Axis I disorder (eg, major depressive disorder, obsessive-compulsive disorder, posttraumatic stress disorder)HSDD diagnosis may be appropriate if low desire predates the Axis I diagnosisIn order to meet the diagnostic criteria for HSDD, other disorders/dysfunctions have to be excluded in order for a differentiation diagnosis to be made.First, ensure that the sexual dysfunction is not due exclusively to the physiological effects of a specified general medical condition (eg, neurological, hormonal, metabolic abnormalities).This determination is based upon patient history, lab findings, or physical examination.Second, ensure that sexual dysfunction is not due exclusively to the physiological effects of substance (prescribed or illicit) abuse.The clinician should inquire carefully about the nature and extent of the substance abuse, including medications.Symptoms that occur during or shortly after (within 4 weeks of) substance intoxication or after medication use may be especially indicative of substance-induced sexual dysfunction, depending on the type or amount of the substance or the duration of use.Commonly, if one sexual dysfunction is present, additional sexual disorders will also be present and should be noted.However, if low sexual desire is better accounted for by another Axis I disorder (eg, major depressive disorder, obsessive-compulsive disorder, posttraumatic stress disorder), HSDD should NOT be the diagnosis; HSDD diagnosis may be appropriate if low desire predates the Axis I diagnosis.*If it is, refer to the diagnosis: Sexual Dysfunction Due to a General Medical Condition.†If it is, refer to the diagnosis is Substance-Induced Sexual Dysfunction.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision, Washington, DC: American Psychiatric Press; 2000.References:American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision Washington, DC: American Psychiatric Press; 2000.SD66098(Previously used in SD64473, Slide#67)35
36The Challenges of Differential Diagnosis Breaking Through the Barriers: Understanding and Diagnosing Female Sexual DysfunctionThe Challenges of Differential DiagnosisPsychiatric Illnesses and General Health Factors May Affect Sexual FunctionMood disorders1Major depressionBipolar illnessAnxiety disorders2,3Psychotic illness4HypertensionNeurological disorders6Endocrine disorders7Diabetes, thyroid disorders, hyperprolactinemia7Urological problems8Sexually transmitted infections9Gynecological problemsPost-partum10Other chronic illnessRheumatoid arthritis11Psoriasis12Breast cancer13Many psychiatric illnesses, including major depression and bipolar illness, are associated with sexual dysfunction; loss of libido has been shown to be prevalent in patients suffering from major depressive disorder, following sleep disturbances and preceding appetite loss, and is strongly influenced by the severity of the illness.1A high prevalence of anxiety disorders has been demonstrated in sexually dysfunctional male and female subjects,2 and anxiety was shown to be associated with distressing problems of female sexual desire and related to increased odds of arousal problems.3 Psychosexual dysfunctions have been documented to be markedly more common among schizophrenic women, both pre- and postmorbidly.4There may be a greater tendency for some hypertensive women with or without treatment to have low libido compared with age-matched controls.5Injuries to regions of the brain that are recruited during sexual arousal, and to the spinal cord and peripheral nerves that link genitalia to limbic and cognitive centers, can profoundly influence sexual wellbeing. In epilepsy, expressions of hypersexuality and hyposexuality interact with the location of epileptogenic foci in the temporolimbic circuitry and are tempered by the sexual effects of drug treatments. Epilepsy, stroke, multiple sclerosis, Parkinson's disease, and other common neurological disorders have sexual consequences.6Endocrine disease frequently interrupts sexual function, and sexual dysfunction may signal serious endocrine disease. The effect of diabetes on women's sexual function is complex.7 Hypothyroidism is associated with fatigue, depression, and mood disorders that might contribute to sexual dysfunction in both sexes.7 Hyperprolactinemic women without depression or other hormonal disorders have reported lower scores for sexual desire, arousal, lubrication, orgasm, and satisfaction than have controls.7Urinary incontinence may reduce sexual function in premenopausal sexually active women. Sexual dysfunction is a prevalent and distressing problem in women with urinary incontinence and seems to affect the satisfaction rate and sexual quality of life of these patients.8Some primiparous women delivered vaginally by mediolateral episiotomy experience decreased levels of desire, arousal, lubrication, orgasm, satisfaction, and increased level of pain at 6 months postpartum compared to women who gave birth by elective cesarean section. Also, some women in the mediolateral episiotomy group experienced decreased level of desire 6 months after giving birth when compared to prepregnancy.91. Casper RC, et al. Arch Gen Psychiatry. 1985;42: van Lankveld JJ, Grotjohann Y. Arch Sex Behav. 2000;29: Shifren J, et al. Obstet Gynecol. 2008;112: Friedman S, Harrison G. Arch Sex Behav. 1984;13: Okeahialam BN, Obeka NC. J Natl Med Assoc. 2006;98: Rees PM, et al. Lancet. 2007;369(9560): Bhasin S, et al. Lancet. 2007;369(9561): Aslan G, et al. Int J Impot Res. 2005;17: Smith EM, et al. Infect Dis Obstet Gynecol. 2002;10(4): Baksu B, et al. Int Urogynecol J. 2007;18: Abdel-Nasser A, Ali E. Clin Rheumatol. 2006;25: Sampogna F, et al. Dermatology. 2007;214:13. Mathias C, et al. Ann Oncol. 2006;17(12):References:1. Casper RC, et al. Somatic symptoms in primary affective disorder. Arch Gen Psychiatry. 1985;42: b.2. van Lankveld J, Grotjohann Y. Psychiatric comorbidity in heterosexual couples with sexual dysfunction assessed with the composite international diagnostic interview. Arch Sex Behav. 2000;29:3. Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women. Obstet Gynecol. 2008;112:4. Friedman S, Harrison G. Sexual histories, attitudes, and behavior of schizophrenic and “normal” women. Arch Sex Behav. 1984;13:5. Okeahialam BN, Obeka NC. Sexual dysfunction in female hypertensives. J Natl Med Assoc. 2006;98:6. Rees PM, Fowler CJ, Maas CP. Sexual function in men and women with neurological disorders. Lancet. 2007;369:7. Bhasin S, Enzlin P, Coviello A, Basson R. Sexual dysfunction in men and women with endocrine disorders. Lancet. 2007;17:369:8. Aslan G, Köseoğlu H, Sadik Ö, Gimen S, Cihan A, Esen A. Sexual function in women with urinary incontinence. Int J Impot Res. 2005;17:9. Baksu B, Davas I, Agar E, Akyol A, Varolan A. The effect of mode of delivery on postpartum sexual functioning in primiparous women. Int Urogynecol J. 2007;18:36SD66098
37The Challenges of Differential Diagnosis Breaking Through the Barriers: Understanding and Diagnosing Female Sexual DysfunctionThe Challenges of Differential DiagnosisNumerous Medications are Associatedwith Female Sexual ProblemsPsychotropic drug classes/agentsOther drug classesChemotherapeutic agents6Aromatase Inhibitors7Triglyceride-lowering agents8Histamine receptors (H2) blockers9Weight loss agents10Antiepileptics11Immunosuppresants12Central alpha-adrenergic agonists13Opioid antagonists14Antipsychotics1SSRIs2Lithium3SNRIs4Tricyclic antidepressants5Questions on medications being taken are an important diagnostic element, as several types of drug are known to cause or exacerbate iatrogenic dysfunctions in sexual desire, arousal, and orgasm.1 Iatrogenic dysfunction is often the result of the clinical pharmacology of the agents in consideration.As for all medications, the mechanism of action underlying iatrogenic sexual dysfunction induced by psychotropic medications varies by drug class.Antipsychotics as a class are dopamine blockers, have anticholinergic effects, may increase prolactin levels, and produce sedative effects.2 A recent study in patients with schizophrenia who had been treated with conventional antipsychotics or an atypical agent indicated that the majority of patients (59% of females and 60% of males) reported impairment of sexual function. In postmenopausal females, risk of impaired sexual interest was increased by 31% for every 10 ng/mL increase in prolactin.3Recent studies of antidepressant-associated sexual side effects have found rates of sexual dysfunction of 25% to 80%.4 Interestingly, analyses of physician perceived and patient reported prevalence revealed that physicians consistently underestimated the prevalence of sexual dysfunction.5Cancer treatment, especially chemotherapy, creates changes in the female body that affect sexual desire, sexual functioning, and emotional relationships. Studies show that breast cancer patients experience sexual problems soon after treatment and continue in follow-up.6 There is substantial evidence supporting the adjuvant usage of aromatase inhibitors (AIs) in the treatment of postmenopausal women with early breast cancer. However, the exacerbation of postmenopausal gynecological symptoms such as vaginal dryness and dyspareunia has been reported in several studies investigating the quality of life (QOL) of women taking AIs. If not managed appropriately, these symptoms may result in sexual dysfunction.7Sexual dysfunction has been associated with anticonvulsants that induce the hepatic p450 system. These antiepileptics progressively increase sex hormone-binding globulin and thus decrease free testosterone.8Importantly, medication effects on sexual dysfunction may also be mediated by associated quality of life challenges and worsening of self image.For example, side effects of immunosuppressants such as weight gain and hirsutism, may influence women’s feelings about their sexual attractiveness. Corticosteroid-associated fluid retention, hirsuitism, and buffalo hump with a cushionoid facies have a high potential to induce low sexual self-esteem.91. Liu-Seifert H, et al. Neuropsychiatr Dis Treat. 2009;5: Serretti A, Chiesa A. J Clin Psychopharmacol. 2009;29: Lithium carbonate [package insert] Venlafaxine hydrochloride [package insert] Imipramine hydrochloride [package insert]6. Fobair P, Spiegel D. Cancer J. 2009;15(1): Mok K, et al. Breast. 2008;17(5): Fenofibrate [package insert] Ranitidine hydrochloride [package insert] Sibutramine hydrochloride monohydrate [package insert] Rees PM, et al. Lancet. 2007;369: Muehrer RJ, et al. West J Nurs Res. 2006;28: Clonidine [package insert] Naltrexone hydrochloride [package insert]References:1. Graziottin A and Lieblum SR. Biological and psychosocial pathophysiology of female sexual dysfunction during the menopausal transition. J Sex Med. 2005;2:2. Clayton A. Epidemiology and neurobiology of female sexual dysfunction. J Sex Med. 2007;4:3. Liu-Seifert H, Kinon BJ, Tennant CJ, Sniadecki J, Volavka J. Sexual dysfunction in patients with schizophrenia treated with conventional antipsychotics or risperidone. Neuropsychiatr Dis Treat. 2009;5:47-54.4. Serretti A, Chiesa A. Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. J Clin Psychopharmacol. 2009;29:5. Clayton AH, Pradko JF, Croft HA, et al. Prevalence of sexual dysfunction among newer antidepressants. J Clin Psychiatry. 2002;63(4):6. Fobair P, Spiegel D. Concerns about sexuality after breast cancer. Cancer J. 2009;15:19-26.7. Mok K, Juraskova I, Friedlander M. The impact of aromatase inhibitors on sexual functioning: current knowledge and future research directions. Breast. 2008;17:8. Rees PM, Fowler CJ, Maas CP. Sexual function in men and women with neurological disorders. Lancet. 2007;369:9. Muehrer RJ, Keller ML, Powwattana A, Pornchaikate A. Sexuality among women recipients of a pancreas and kidney transplant. West J Nurs Res. 2006;28:SD6609837
39A New Frontiers Program on Women’s HealthPathophysiology of Decreased Desire in Premenopausal Women Psychological, Pharmacologic, and Neurobiological MechanismsProgram Chairman and ModeratorAnita H. Clayton, MDDavid C Wilson ProfessorDepartment of Psychiatry & Neurobehavioral SciencesProfessor of Clinical Obstetrics & GynecologyUniversity of VirginiaCharlottesville, VA
40ObjectivesAt the conclusion of this activity, participants should be able to:Describe the psychological, pharmacological and neurobiological factors affecting desire in premenopausal women
41What’s it all about anyhow? Psychological/social/emotionalPhysiological/biological: interactions of sex steroids and neurotransmittersCognitive: thoughts, fantasies, satisfactionCulturalAmerican Psychiatric Association, DSM IV, 1994
42Central Effects on Sexual Function -5-HT+progesteronetestosterone+/-++estrogenDESIRE++dopamine (DA)-+5-HTSUBJECTIVE EXCITEMENT-prolactinnorepinephrine (NE)-++oxytocinORGASMModified from Clayton AH. Psych Clin NA 2003; 26: Cohen AJ. AD-induced SD associated with low serum free testosterone
43Peripheral Effects on Sexual Function gonadsadrenals5-HTEstrogenTestosteroneProgestinmaintain genitalstructure andfunction}-NitricOxide (NO)Clitoral and penile tissue+5-HT2A-SENSATIONVASOCONGESTION+NE+-5-HT+Prostaglandin E+Cholinergic fibersClayton AH. Psychiatric Clinics of North America 2003; 26:
44Physiology of Sexual Function Desire:Excitatory: dopamine, norepinephrine, testosterone, estrogenInhibitory: serotonin, prolactinArousal:Excitatory: dopamine, norepinephrine, nitric oxide, acetylcholine, estrogen, testosteronePfaus JG. J Sex Med 2009;6:
45Influences on Sexual Functioning NeurobiologicalReproductive endocrinology (ie. anything that lowers testosterone such as hyperprolactinemia, opiates, menopause)General health status/illness (e.g. fatigue)1 and co-morbiditiesMedication/substance usePsychologicalBody image (e.g. obesity)Psychological/relationship issues, partner availability/aging1Fears (e.g. pregnancy, infertility, STD, history of sexual abuse/trauma, cultural practices)1Meston C. Western Journal of Medicine 1997;167(4):
46DSM-IV TR Criteria for HSDD Sexual complaint or problem in sexual desire and/or fantasiesThe judgement of severity of the sexual symptom is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context of the person’s lifeThe disturbance causes marked distress or interpersonal difficultyThe 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 (e.g., a drug of abuse, a medication) or a general medical conditionAmerican Psychiatric Association. DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision. Washington, DC: American Psychiatric Press; 2000
47FSD may be Multi-faceted Biological/PharmacologicalMedical diagnosesPsychiatric conditionsOther sexual disordersMedications/substancesHormonal changesSocio-culturalLower educationReligious restrictionsSocial taboosCultural conflictPsychologicalPrior sexual or physical abuseRelational (conflict, lack of partner, partner SD)Body image, sexual self-esteemNegative emotional statesStressballoon
48Relational Problems (not HSDD) Sexual dysfunction in partnerInterpersonal conflictExtra-marital affair by either partnerDesire discrepancyCultural differencesReproductive concernsHistory of sexual abuse
49Prevalence of Sexual Dysfunction COMPLAINTPROBLEMPROBLEM PLUS DISTRESSFSD WITHOUT DEPRESSIONDesire38.7%10%6.3 – 8.8%Arousal26.1%5.4%3.3 – 4.7%Orgasm20.5%4.7%2.8 – 4.1%Any Dysfunction44.2%12%7.6 – 10.7%N=31,581. Definition of depression: Self-reported depressive sx’s + AD use; AD use without current depressive sx’s; Depressive symptoms without AD useShifren J et al. Sexual problems and distress in United States women: Prevalence and correlates. Obstet Gynecol 2008;112: ; Johannes CB et al. Distressing Sexual Problems in United States Women Revisited: Prevalence after Accounting for Depression. J Clin Psychiatry 2009;70(12):
50Proportion of Partnered Women with HSDD By Age and Menopausal Status 30P=0.0022520P=0.067% of Patients15105PremenopausalSurgicallypostmenopausalNaturallypostmenopausalSurgicallypostmenopausalAge yearsAge yearsLeiblum SR et al.Hypoactive sexual desire disorder in postmenopausal women: US results from the Women’s International Study of Health and Sexuality (WISHeS). Menopause. 2006;13:46-56.
51Medical Conditions that may Impact Sexual Function Neurologic Spinal cord injury, neuropathy, herniated disc, MS, epilepsy Endocrine Hypothyroidism, adrenal dysfunction, hypogonadism, diabetes mellitus, menopause Vascular Hypertension, arteriosclerosis, stroke, venous insufficiency, sickle cell disorderGenitourinary Urinary incontinence, vaginitis, PID, endometriosis Systemic Illness Renal, pulmonary, hepatic diseases, advanced malignancies, infections Psychiatric Depression, anxiety disorders, psychotic illness, eating disorders, PTSDClayton & Ramamurthy in Sexual Dysfunction: The Brain-Body Connection. Ed: R Balon, Karger, Basel, Switzerland, 2008; Basson R, Schultz WW. Lancet. 2007;369: ; Kingsberg SA, Janata JW. Urol Clin North Am. 2007;34: ; Zemishlany & Weizman in Sexual Dysfunction: The Brain-Body Connection. Ed: R Balon, Karger Basel, Swithzerland 2008
52Pharmacotherapies and Risk of FSD PSYCHOTROPIC MEDICATIONSSSRIs/SNRIs/TCAsMood stabilizersAntipsychoticsBenzodiazepinesAntiepileptic drugsANTIHYPERTENSIVESBeta-blockersAlpha-blockersDiureticsCARDIOVASCULAR AGENTSLipid-lowering agentsDigoxinHORMONESOral contraceptivesEstrogensProgestinsAnt-iandrogensGnRH agonistsOTHERHistamine H2-receptor blockersNarcoticsNSAIDsClayton & Ramamurthy in Sexual Dysfunction: The Brain-Body Connection. Ed: R Balon, Karger, Basel, Switzerland, 2008; Basson R, Schultz WW. Lancet. 2007;369: ; Kingsberg SA, Janata JW. Urol Clin North Am. 2007;34:
53Correlates of Distress with HSDD: PRESIDE PsychologicalHaving a partner (OR 4.63)Demographics: Greatest age < 45 years; to lesser degree < 65 years; white raceNeurobiologicalUntreated depression > treated depressionPresence of anxietyUrinary incontinenceUse of hormonal contraceptives or HRTRosen RC, et al. Correlates of sexually related personal distress in women with low sexual desire. J Sex Med 2009;6:
55ConclusionsMultiple factors may affect sexual functioning in women across the life cycleAppropriate assessment is important in management
56Addressing Current Challenges in Female Sexual Disorders A New Frontiers Program onWomen’s HealthAddressing Current Challenges in Female Sexual DisordersWhat Internal Medicine Specialists Need to Know About HSDDLori Brotto, PhDAssistant ProfessorDepartment of Obstetrics and GynecologyUniversity of British ColumbiaVancouver, BC
58sexual function difficult? Why is inquiry aboutsexual function difficult?Topic not important enoughIt is a private experienceEmbarrassment“I don’t exactly know why I am asking”Lack of trainingAbsence of normsSexual behaviour is a topic only when it is deviant or when others are at riskIncorrect beliefs about the benefit of asking(last point): Research indicates brief sexual counseling for medical patients can have a significant impact on sexual recovery and functioningOne study found that inner-city physicians failed to assess sexual behavior to adequately assess HIV risk for self or partner in only 31% and 12% of 26 office visits, respectively. This reflects the profound barriers to discussing sexual information even when it is clearly medically relevant and even potentially life-saving.
59Is Marriage Good for Your Health? This was addressed recently in the NY Times. It has been long been known that marriage bestows effects on improvements in a number of health-related domains. However, more research suggests a more nuanced view in that it is good and happy relationships with such positive effects, not merely being married. Sexual health, because of its connection to happiness, can therefore exert such effects on general health.New York Times Magazine, April 12, 2010
60Complicating factors: Symptom or disorder? Factoring in distress, rates of low desire drop by half in all studiesNote, DSM-IV-TR criteria for HSDD and all sexual dysfunctions require distressLutfey et al., 2008, Arch Sex Behavn = 3,205; Black, Hispanic, White
61Complicating Factors: Low Desire Does Not Always Imply Dissatisfaction Oberg et al. (2004) found a prevalence of manifest distress despite the absence of any sexual symptoms of 12.4%Bancroft, Loftus, and Long (2003) found that 8% of women reported distress about the relationship and 5.4% reported personal distress despite absence of sexual symptomsLutfey, Link, Rosen, Wiegel, and McKinlay (2008) reported that 5.5% of women were dissatisfied or very dissatisfied despite not having any sexual symptoms.Cain et al. (2003) in the SWAN study found that 70% of women reported thinking about sex less than once/week but 86% remained sexually satisfied.King et al. (2007) found that 19% of women did not have an ICD-10 diagnosed sexual dysfunction but still reported significant low sexual satisfaction.Dunn et al. (2000) found that 79% of women were very sexually satisfied but 24% had no sexual activity in the past 3 months.Laumann et al. (2005) in the GSSAB found that 7.7% % of women reported not finding sex pleasurable/satisfying.
62Why assess sexual function? Sexual dysfunction is commonIntegral component of quality of life and general well-beingsexuality is a vital part of a relationshipEveryone has sexual thoughts, feelings, and experiences that are integral to their sense of selfSexual problems often manifest and mask themselves in the major symptoms that bring patients to treatment: dep, anx, failure to achieve, low self-esteem, inability to engage in intimate relationships
66Are physicians asking?53 primary care physicians (or internal medicine residents) at UVA completed questionnaire about their experience asking about HSDD86.3% had not screened for HSDD90% had not diagnosed HSDD53% felt not confident at all, 38% little confidenceHarsh et al., J Sex Med 2008
67Survey Participants and Patients who Initiate First Discussion of FSDs Percentage of survey participants providing estimateSurvey participants initiatingfirst discussion of FSDPatients initiatingfirst discussion of FSDJ Sex Med 2006;3:
68Who should I ask about sexuality? EVERYONE!Legitimizes the patient’s concerns with and interest in sexAllows the patient to ask questionsIdentifies the provider as a potential resource for sexual informationMaximizes the chances that patients will get help for sexual and relationship problemsUNLES The chief complaint is so specific or crisis-oriented, you should ask everyone about sexual functionHow will you know it’s a concern unless you ask the patient?Even ask older persons; therapists often reluctant due to a belief that older people do not experience sexualityCPA 1st principle: respect for the dignity of persons regardless of their nationality, ethnicity, colour, race, religion and keep in mind that different cultures may have different norms about sexuality than yours
70Screening questionsAre you satisfied with your sexual response (sex life)? If not, why not?Are you currently active with a sexual partner?Men, women or bothFrequency (activity including masturbation)How often do you have difficulty _________?What questions or problems related to sex would you like to discuss?These questions allow for brief assessment of sexual problems. They are comprehensive enough to rule out any sexual dysfunction where there is none, and also opens the door for future discussions.Any positive responses can be followed up with further detailed questions and a more complete sexual assessment.Physicians who used these questions routinely with gynecologic oncology patients as part of a research protocol found that it increased their understanding of patient’s psychosocial situation in 39% of cases and revealed information that was medically important in 26% (Capone, Good, Westie et al, 1980).
711. During routine inquiry When to ask?1. During routine inquiryInclude it in a standard set of questions during developmental and psychosocial periodsInclude it on self-report questionnaireworking it in may work well for adults but not children or teensBy bringing it up during assessment, this lets the pt know that its ok to talk about this so later when it is an issue is will be less embarassingFor teens may need to introduce the topic; ‘we’re going to talk about sexual health now’“you were telling me about your male friendshipsgrowing up…Do you remember when you firstbecame aware of sexual feelings?”
722. After direct presentation When to ask?2. After direct presentationPatient directly states problemAsk permission and collect information3. After indirect presentationPatient is indirect and vague, hoping the clinician will ask about sexual complaintse.g., medication non-complianceKnow about that particular condition and side-effect profiles of medicationsputting it off or waiting for the patient to bring it up only reinforces the taboo that this is a difficult topicBest place is during assmt of psychosocial and developmental information
73How to ask?Need clinical knowledge, a non-judgmental attitude, and fundamental interviewing skillsObserving and monitoringInterpreting skillsResponding skills
743. Use personalized language How to ask?2. Clarify the problemPatient: I’ve lost my natureClinician: Tell me what a nature is? I haven’t heard that expression before.3. Use personalized languageUse the correct term and allow the patient to pick up on itSometimes may be appropriate to use patient’s languageCommunication problemsAbrupt introduction/change of topicFractured language/leading questionsFailure to clarify vague information
754. Use open-ended questions How to ask?4. Use open-ended questionsUse: “to what extent…what…how…”Don’t use: “do you…did you…are you…have you…”“What were the circumstances that led you tobe sexual with him?”5. Be empathicIs an expression of professional understanding“that must have been really difficult for you…”
76How to ask? 6. Facilitate 7. Provide information Encourage the patient to continue by nodding, leaning forward, using “yes…go on.”7. Provide informationAnticipate worries and speculateConfirm understanding of the problem before proceeding
78Women’s Sexual Difficulties Comorbidity ofWomen’s Sexual DifficultiesDesiredifficultiesArousaldifficultiesdesire and lubrication – 65%desire and orgasm- 53%desire and vaginismus – 75%lubrication and orgasm – 28%lubrication and dyspareunia – 61%In reality most of the female sexual dysfunctions are highly comorbidOrgasmdifficultiesPainVaginismicdifficultiesBasson et al., 2003J Psychosom Obstet Gynaecol
81Use of Validated Questionnaires Decreased Sexual Desire Screener (DSDS)Clayton et al. 2009, J Sex MedFemale Sexual Function Index (FSFI)Rosen et al. 2000, J Sex Marital TherProfile of Female Sexual FunctionMcHorney et al. 2004, MenopauseFemale Sexual Distress Scale (FSDS)Derogatis et al. 2002, J Sex Marital TherPFSF – for menopausal women, natural or surgical, with low desire.
82Decreased Sexual Desire Screener Clayton, Goldfischer, Goldstein, DeRogatis, Lewis-D’Agostino, Pyke, J Sex Med 2009;6:In the past was your level of sexual desire or interest good and satisfying to you?Has there been a decrease in your level of sexual desire or interest?Are you bothered by your decreased level of sexual desire or interest?Would you like your level of sexual desire or interest to increase?Please check all the factors that you feel may be contributing to you current decrease in sexual desire or interest.5. List of factors. If patient lists “yes” to one of these, then the clinician needs to decide if the answers indicate a primary diagnosis other than generalized acquired HSDD. (e.g., stress or fatigue; dissatisfaction with relationship or partner, etc.)
83Use of a Validated Structured Interview Women’s Sexual Interest Diagnostic InterviewDeRogatis et al. 2008, J Sex Med*39 items assessing desire, arousal, orgasm, pain and distress, partner sexual dysfunction, relationship problems, depression* Permission to use the WSID can be obtained by contacting Solvay Pharmaceuticals, Inc. ( ,Sexual Interest and Desire Inventory-Female Version (SIDI)Clayton et al. 2005, J Sex Marital Ther*13-item clinician administered measure of sexual interest, desire and arousability
85PLISSIT Permission Limited Information Specific Suggestions Acceptance, empathy“I ask all my patients about sex. Is it OK to do so now?”Limited InformationBasic education regarding anatomy & sexual responseSpecific SuggestionsMedical-medication, procedures to relieve discomfortPsychological-behavioral strategies, communication skillsIntensive TherapyIndividual or couples therapy to manage sexual or relationship issuesSurgery (penile implants, vestibulectomy)Once you have taken a sexual history and determined what the problem is, how it has affected the patient and her relationship, and developed a hypothesis about etiology (hormonal, psychological, medical), you will be in a better position to intervene.The PLISSIT model is a helpful way of conceptualizing various levels of intervention.**something else to keep in mind is that techniques you might suggest could be considered immoral in some cultures while widely accepted in others (e.g., masturbation, sexual aids, pornography)**also involves explaining the risks and benefits of all treatments that you suggest – esp relevant for drug treatments
86ALLOWFacilitates completion of the sexual history and initiation of treatment or further evaluationASK the patient about sexual function and activityLEGITIMIZE problems, and acknowledge that dysfunction is a clinical issueIDENTIFY LIMITATIONS to the evaluation of sexual dysfunctionOPEN UP the disucssion, including potential referralWORK TOGETHER to develop goals and a management planSadovsky, 2002
87Goals of a Comprehensive Sexual History Identify the primary complaintDetermine patient’s perspective of their problemDevelop hypotheses about etiologyDecide on an appropriate course of treatment (including referral)So, what if the patient does express sexual concerns. Then you need to do a comprehensive sexual history; this is different from just screening
88Elements of a Comprehensive Sexual History Assess sexual functioningAssess medical/organic contributorsAssess relationship satisfaction and functioningAssess risk behavioursAssess partner statusAsk about history of childhood sexual or physical abuseAssess moodWhen taking a sexual history, it is helpful to use the biopsychosocial model as a guide and to think about possible predisposing, precipitating and maintaining factors. Thus you will want to ask about past and present sexual functioning.Begin by asking women about their actual experiences and satisfaction with these experiences. It is important to assess relationship function and to remember that conflict may be adversely impacting their sexual functioning or may be a result of sexual problems. As healthcare providers, you would want to assess risk factors such as sex with multiple partners, unprotected sex outside of a monogamous relationship, or sex with high risk individuals (IV drug users).When asking about partners, note sexual preference and whether or not there is any sexual confusion contributing to the problem.It is helpful to ask about sexual development in addition to abuse, but this is not always possible due to time constraints. History of childhood abuse does not result in sexual problems for all women, but it has been associated with decreased sexual and relationship satisfaction as well as increased risky sexual practices. CSA is also a marker for numerous psychological and physical problems including depression, PTSD, substance abuse, eating disorders, gastrointestinal problems and chronic pelvic pain. Although in some women it increases help-seeking, it is also associated with inconsistent gynecological exams.
89Sample Assessment Questions What is your sexual interest like? What factors enhance and/or inhibit your desire?Many people engage in self-stimulation. Is this part of your sexual experiences?Some people avoid sexual activity for any variety of reasons? Can you relate to this?Many women talk about difficulties with lubrication or sexual activity that is painful. What is your experience with this?Most men experience occasional difficulties with their erection. Has this been the case for you?
90Sample Assessment Questions Do you notice any difference between your erections during sexual intercourse, during masturbation, and those when you wake up?When you’re experiencing this difficulty, can you recall what you’re thinking or feeling at the time? How about right before?Of your last 10 sexual encounters, on how many of them did you experience this difficulty?What do you do in response to this difficulty? What does your partner do?Can you describe the sensation of the pain? Is it burning, throbbing, or sharp? When do you experience it?
91Problems to Avoid During the Sexual InterviewMeddling: always rationalize your questioningPreoccupation: focus on each responseIdentification: consult with a colleague if you’re not able to be objectiveSexual arousal: be aware of your own feelings
92Putting the Sexual History in Context What explanations does the patient have (their theory)?What have they done to try to resolve the problem?Are there problems in multiple areas of sexual functioning? What is the relationship between these?What have they discussed with their partner and what was the reaction?Point 1:It is not uncommon for their to be multiple complaints and for the pt to report a relationship between them. For example, a man might complain that he began having difficulty with ED that was followed by a lack of interest in and motivation for sex.Point 2: Assess the chronology of the problem in terms of all aspects of functioning as well as other life events. The impact of the problem is an important aspect of diagnosis since some individuals may report a significant change, but not consider it to something that warrants attention.Patients often try to manage the problem in ways that are not helpful and may even exacerbate the problem. It is not uncommon for men to “test out” their erectile function with erotica or a new partner, but if the problem is related to performance anxiety, the problem often follows them to these new situations, which may further increase their anxiety.Assessing the extent to which their partner is involved can provide information about their relationship functioning.At this point you should have a description of the pts problem in their own words as well as information about whether its global or situational and the chronology of related sexual concerns. You should also know the impact the problem has had on the pt and her relationships.
93Multi-Factorial Model MaintainingFactorsPredisposingFactorsEarlyDevelopmentCurrentFunctioningPrecipitatingFactors
95Current and Emerging Therapies for Hypoactive Sexual Desire Disorder A New Frontiers Program onWomen’s HealthCurrent and Emerging Therapies for Hypoactive Sexual Desire DisorderJennifer Frank, MD, FAAFPAssistant ProfessorDepartment of Family MedicineUniversity of Wisconsin School of Medicineand Public Health
96Learning Objectives Describe a multimodal treatment approach to HSDD Identify components of nonpharmacologic treatment of HSDDDescribe current pharmacologic treatment options for HSDD in both postmenopausal and premenopausal womenIdentify emerging pharmacologic treatment options for HSDD
97HSDD Treatment Starts with Nonpharmacologic Approaches Foundation of therapyIncludes treatment initiated and managed by the primary care physicianMay include treatment by specialist partnersSex therapistPhysical therapistCognitive behavioral therapistMarital/relationship counselor
98Nonpharmacologic Treatment PCP basedSpecialist basedEducationDispelling mythsExerciseHealthy DietAdequate RestStress ReductionCBTSensate-focusControlled self-stimulationCouples counselingPhysical therapyVaginal dilatorsBiofeedbackBitzer J, Brandenburg U. Psychotherapeutic interventions for female sexual dysfunction. Maturitas 2009;63:160-3.
99Sex Therapy for the PCP Education Lubrication What is normal?Basics of anatomy and physiology?LubricationBasic familiarity with 3 or 4 different productsMaximize intimacy and opportunities for intimacyIntroduce novelty – different positions, venues, toys, etc.Getting into a sexual frame of mind“Men are like light switches, women are like ovens.”Patient focused readingT.L.C.Redistribution of childcare and household responsibilitiesImproving body imagePotter JE. A 60-year-old woman with sexual difficulties. JAMA 2007;297:UpToDate and
100Barriers to Nonpharmacologic Treatment Physician’s unfamiliarity with counseling and recommendationsPhysician’s discomfort with this rolePatient’s resistance to relationship workPatient’s perceived barriers to implementing changePatient’s unwillingness to changePatient’s belief in a “little blue pill”Lack of or paucity of hopeReward not worth the work
101Current Pharmacologic Treatment Options for FSD HormonalEstrogenTestosterone*Psychotropic medicationsBuproprion*Phosphodiesterase inhibitorsSildenafil**Not FDA approved for this indication
102Local Estrogen Therapy for Vaginal Atrophy (Level C) Postmenopausal women without a history of hormone-dependent breast cancerLow dose as long as symptoms persistNot indicated for HSDD but can be helpful if pain/dryness is contributing to low desireConsider if prescribing testosterone
103Consider Testosterone for Post-Menopausal Women with HSDD Good evidence (Level A) to support its use in estrogen replete women1-3300 mcg patch for 24 weeksBoth naturally4 and surgically1-3 menopausal womenImprovements seen in desire, orgasm frequency and total number of sexually satisfying encountersBraunstein et al. Safety and efficacy of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women. Arch Intern Med 2005;165: ,Buster et al. Testosterone patch for low sexual desire in surgically menopausal women: a randomized trial. Obstet Gynecol 2005;105: ,Davis et al. Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo-controlled trial. Menopause 2006;13:Shifren et al. Testosterone patch for the treatment of hypoactive sexual desire disorder in naturally menopausal women: results from the INTIMATE NM1 study. Menopause 2006;5:770-9.,
104Testosterone’s Role in Postmenopausal Women without ERT DBRCT of placebo vs. testosterone patchIncrease in SSEs/month at 300 mcg daily dose2.1 (active) vs. 0.7 (placebo)Increase in desireDecrease in distressTreatment effect similar in naturally and surgically menopausal women4 episodes of breast cancer in study participants (n=537)Davis et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med 2008;359:
105Testosterone for Premenopausal Women may Have a Role DBRPCT of 261 premenopausal womenNot depressedLow serum testosteroneTestosterone at 90 microliters/day (spray) daily x 16 weeksIncrease of 0.8 SSEs/month over placeboStrong placebo effectSSE not related to testosterone levelsLevels returned to baseline at 20 weeks (4 weeks after study) but SSEs did notDavis et al. Safety and efficacy of a testosterone metered-dose transdermal spray for treating decreased sexual satisfaction in premenopausal women. Ann Intern Med 2008;148:
106Testosterone Treatment Limitations Androgen levels not clearly associated with decreased desireDifficult to measure testosterone levels accuratelyRole in premenopausal women is not established1Off label indicationLong term efficacy/safety not known1-3Study population (definition of decreased desire)1Relationship between arousal and desire1Need for concomitant use of estrogen (?)11. Basson R. Pharmacotherapy for women’s sexual dysfunction. Expert Opin Pharmacother 2009;10:2. NAMS. The role of testosterone therapy in postmenopausal women: position statement of the North American Menopause Society. Menopause 2005;12:3. Wierman et al. Androgen therapy in women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2006;91:
107Buproprion has Limited Data to Demonstrate Efficacy in HSDD (Level B/C) Buproprion (300 mg/day) x 112 days in non-depressed premenopausal women with normal serum testosterone1Global improvement in sexual functioning and on subsets of arousal, orgasm completion and pleasure on one of the scales used(Level C)No statistically significant improvement in desire268 women ages diagnosed with HSDD (Level B)2Premenopausal, not depressed, normal testosterone12 weeks of buproprion SR 150 mg/dayImprovement in rating scale of sexual function (globally and specific subsets)Greatest improvement in frequency of sexual activity, thoughts/desire, and pleasure/orgasmDecrease in personal distress scoreAdd-on or substitute therapy for SSRI induced sexual dysfunction(Level B)3,4Segraves et al. Buproprion SR for the treatment of HSDD in premenopausal women. J Clin Psychopharm 2004;24:Safarinejad et al. A randomized, double-blind, placebo-controlled study of the efficacy and safety of buproprion for treating hypoactive sexual desire disorder in ovulating women. BJU International Feb 2010 [Epub].Safarinejad . Reversal of SSRI-induced female sexual dysfunction by adjunctive buproprion in menstruating women: a double-blind, placebo-controlled and randomized study. J Clin Psychopharm Jan 2010 [Epub].Seretti A, Chiesa A. Treatment-emergent sexual dysfunction and anti-depressants: a meta-analysis. J Clin Psychopharm ;29:
108Phosphodiesterase Inhibitors No demonstrable role in the treatment of HSDDUse in antidepressant associated FSD1Main effect on orgasmic capacityPotential use in women with neurovascular mediated sexual dysfunction2Primarily arousal, orgasmic dysfunctionNurnberg et al. Sildenafil treatment of women with antidepressant-associated sexual dysfunction. JAMA 2008;300:Brown DA et al. Assessing the clinical efficacy of sildenafil for the treatment of female sexual dysfunction. Ann Pharmacother 2009;43:
109Emerging Pharmacologic Therapies HormonalTestosteroneCentrally acting agentsFlibanserinPhosphodiesterase InhibitorsOthersProstaglandin gel
110Testosterone in the Future1 Premenopausal womenEffects of long term use are unknownSearch for an FDA approved preparationLibiGelIntrinsa2Tibolone3 - estrogenic, progestogenic, androgenic synthetic hormoneCombined with ERT?Krapf and Simon. The role of testosterone in the management of hypoactive sexual desire disorder in postmenopausal women. Maturitas 2009;63:213-9.Davis et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med 2008;359:Wylie and Malik. Review of drug treatment for female sexual dysfunction. Int J STD AIDS 2009;20:671-4.
111Centrally Acting Agents1 Bremelanotide3Melanocortin agonistFSADFlibanserin1Acts as a partial serotonin agonist/antagonistSpecifically being studied for HSDDWylie and Malik. Review of drug treatment for female sexual dysfunction. Int J STD AIDS 2009;20:671-4.Baldwin. Agomelatine in the treatment of mood and anxiety disorders. Brit J Hospital Med 2010;71:153-6.Safarinejad. Evaluation of the safety and efficacy of bremelanotide, a melanocortin receptor agonist, in female subjects with arousal disorder: a double-blind placebo-controlled, fixed dose, randomized study. J Sex Med 2008;
112Other Agents Phosphodiesterase inhibitors Role will likely be focused to specific populationsNo demonstrable effect on desireAlprostadil (Prostaglandin E1) in trials for FSAD (vasodilatory properties)
113ConclusionsThe foundation of HSDD treatment is nonpharmacologic including PCP directed and specialty directed modalities.Pharmacotherapeutic options are limited at this time.Most promising treatments for HSDD include hormonal (testosterone) and centrally acting agents (buproprion and flibanserin).Other medications may have role for different types of FSD.
114Case Example26-year-old MWF presents with 1 year history of decreased libido, some problems with vaginal lubrication, and diminished orgasmic capacity. No pain with intercourse.Change in sexual function since marriage 4 years ago, but relationship still strong1 year post-partum with mild depressive symptoms since deliveryNo general health problemsOn oral contraceptives for birth control
116Evaluation/Interventions Consider labs such as TSHConsider change from birth control pills to non-hormonal contraceptiveSpecific suggestionsConsider adding bupropion to treat depression and enhance sexual functioningIf no improvement, check testosterone levels before supplementing