Female Sexual Dysfunction (FSD) Susan R Davis Chair of Women’s Health Women’s Health Research Program Monash University, Melbourne, Australia

WHO Definition Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed.

Sexual health is a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity

FSD is associated with significant decreases in health-related quality of life Large negative effects on mental health, vitality, social function Affected women are more likely to be depressed, dissatisfied with their home life, dissatisfied with emotional and physical relationship with their sexual partner. The overall effect of HSDD on quality of life is similar in magnitude to that of diabetes and back pain. Biddle et al 2009

Female Sexual Dysfunction (FSD) DSM-V released 2013 CLASSIFICATION OF Female Sexual Dysfunction (FSD) DSM-V released 2013 Sexual Interest/Arousal Disorder Orgasmic disorder Genito-Pelvic Pain/Penetration Disorder Persistent arousal disorder

The definition of FSD is evolving Agreement on main issues being: Desire; arousal; orgasm; sexual pain with personal distress being a criterion for dysfunction Need to consider other conditions: Dyspareunia Secondary to medical or psychiatric illness, medication/substance induced. Persistent sexual arousal disorder in women

Prevalence of FSD The most commonly reported sexual problems in women relate to sexual desire and interest, pleasure, and global satisfaction (Laumann 1999; Hayes 2008; Moreira 2008).

Prevalence of sexual problems associated with distress* in a cross-sectional study of American women Shifren et al Obstet Gynecol 2008 DESIRE AROUSAL ORGASM ANY Responses (n) 28,447 28,461 27,854 28,403 Distressing problem (n) 2868 1556 1315 3456 Age stratified prevalence (%) 18-44 YEARS 8.9 (8.4-9.4) 3.3 (2.9-3.6) 3.4 (3.1-3.8) 10.8 (10.2-11.3) 45-64 YEARS 12.3 (11.7-12.9) 7.5 (7.0-8.0) 5.7 (5.2-6.1) 14.8 (14.1-15.4) >64 YEARS 7.4 (6.7-8.2) 6.0 (5.3-6.7) 5.8 (5.1-6.4) (8.1-9.7) *Female Sexual distress score 15 or more

The Prevalence of Sexual Dysfunction in Malaysian Women Sidi et al J Sex Med. 2007 Mean age 39.2 (10.5); Prevalence of FSD : 29.6% (68/230) ( defined as score ≤55 on the MVFSFI )

Factors associated with sexual dysfunction: Obstet Gynecol 2006;2008 Factors associated with sexual dysfunction: Higher education level Poor health Being in a significant relationship Daily/ weekly urinary incontinence Depression Past sexual abuse

Important considerations Relationship stress Body Image/ self esteem Individual and partner’s understanding of anatomy and sexuality Lack of adequate sexual stimulation needs consideration Cultural and religious beliefs Concurrent medical conditions (& partner) Concurrent psychological conditions (eg: depression)

Female desire-arousal disorder To make this diagnosis, a lack of sexual interest/arousal for a minimum duration of approximately 6 months as manifested by at least 4 of the following indicators must be present: Absent/reduced frequency or intensity of interest in sexual activity sexual/erotic thoughts or fantasies of sexual excitement/pleasure during sexual activity on all or almost all (approximately 75%) sexual encounters of genital and/or nongenital sensations during sexual activity on all / almost all (approximately 75%) sexual encounters Absent/reduced frequency of initiation of sexual activity and is typically unreceptive to a partner's attempts to initiate Absent sexual interest/arousal or infrequently elicited by any internal or external sexual/erotic cues (e.g., written, verbal, visual)

Prevalence of low desire in postmenopausal women: consistent across western countries and between studies Low desire Low desire + distress (HSDD) Sweden, age 18-74 y 42% NM 46% SM 9% natural M 12% surgical M Fugl-Meyer 1999 4 EU Countries age 50-70 y 33% all women 14% all women Dennerstein 2006 USA 9.3% natural M 12.3% surgical M Rosen 2009

Estradiol (E) Testosterone (T) Progesterone Prolactin Oxytocin Endogenous hormones potentially influencing female sexual desire/arousal Estradiol (E) Testosterone (T) Progesterone Prolactin Oxytocin Endorphins Melanocortins Davis 2003

Effect of hysterectomy on hormones and sexual function Most studies suggest hysterectomy alone does not generally adversely affect sexual functioning Bilateral oophorectomy lowers testosterone levels in pre- and postmenopausal women Decline in libido greater after oophorectomy than after hysterectomy alone Nathorst-Boos et al 1992

Anorgasmia The second most frequently reported sexual dysfunction in women. 20-30% of women report inability to achieve orgasm (Simon JS et Arch Sex Behav 2001; Harris JM J Sex Med 2008) Anorgasmia is rarely addressed in the clinical setting of a general practice. A study of 170 patients presenting at a general practice clinic found that only 2% of all sexual dysfunctions reported were being documented Anorgasmia can be - lifelong (has never achieved orgasm) or - acquired (has achieved orgasm in the past but is no longer able), - generalized or situational, and - due to physical, psychological, or combined factors

Orgasmic disorders in women To make this diagnosis, at least 1 of the 2 following symptoms must have been present for a minimum duration of approximately 6 months and be experienced on all or almost all (approximately 75%) occasions of sexual activity: ■ Marked delay in, infrequency or absence of orgasm ■ Markedly reduced intensity of orgasmic sensation

Orgasmic dysfunction associated with The Prevalence of Orgasmic dysfunction in Malaysian Women Sidi et al Asia Pac J Public Health 2008 20: 298 136 scored ≤4 on the orgasmic domain Malay Version of FSFI (0-10) = prevalence of orgasmic difficulties 59.1% Orgasmic dysfunction associated with - > 45 years of age (p < .001), - Non-Malay (P = .042), - lower academic status (P = .001), - married >14 years ( P < .001), - > 4 children (P < .001), - married to an older husband (aged >55 years) (P <001) - having sexual 1 to 2 times a week (P < .001), - Menopausal (P = .001)

Anorgasmia is associated with Relationship issues Past sexual abuse Bartoi et al J Sex Marital Ther 1998;24:75–90. Chronic disease - Multiple Sclerosis Zorzon M et al Mult Scler 1999;5:418–27. - Cardiovascular disease risk: hypertension, and peripheral vascular disease, smoking, diabetes - Renal failure Urinary incontinence Psychotrophic medications: antidepressants, antipsychotics and mood stabilizers- up to 1/3 of women on SSRIS Stimmel GL et al. CNS Spectr 2006;11:24–30. Pelvic disorders - post Sx; irradiation; trauma…

Sexual pain disorders Dyspareunia - etiology can be difficult to diagnose vaginal atrophy, vaginismus, vulvodynia, vestibulitis,

Genito-Pelvic Pain/Penetration Disorder Persistent or recurrent difficulties for a minimum duration of approximately 6 months with one or more of the following: Marked difficulty having vaginal intercourse/penetration Marked vulvovaginal or pelvic pain during vaginal intercourse/penetration attempts Marked fear or anxiety either about vulvo-vaginal or pelvic pain on vaginal penetration Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration

Persistent genital arousal disorder in women First described in 2001 Characterized by excessive and unrelenting sexual arousal in the absence of desire. Associated with restless legs syndrome, overactive bladder syndrome, and urethra hypersensitivity MRI shows pelvic varices of different degree in the vagina (91%), labia minora and/or majora (35%), and uterus (30%) Hyperesthesia sensory neuropathy of the pudendal nerve and dorsal nerve of clitoris Waldinger et al J Sex Med. 2009 Oct;6(10):2778-87.

Impact of FSD

WOMEN WITH FSD CONTINUE TO BE SEXUALLY ACTIVE Number of sexual events/month according to sexual satisfaction and menopausal status Davison et al J. Sex Med 2009 n, sexual events per month *p<0.001 * * PREMENOPAUSAL POSTMENOPAUSAL

DYSPAREUNIA increases across the menopause frequency of intercourse is constant * * Avis et al Menopause 2009

Wellbeing is lower in pre- and postmenopausal women with low sexual satisfaction * * p<0.001 * * * * Davison at J Sex Med 2009

Assessment Biopsychological assessment current circumstances partner status employment Sexual experiences adequacy of sexual stimulation, both contextural and physical Health history, medications, drug use Medical examination including genital and pelvic examination particularly for loss of sensitivity or pain disorders

Laboratory investigations Menstrual irregularity/amenorrhoea E2, FSH, prolactin ? Androgen profile Fatigue Thyroid function Iron stores fasting glucose Others as indicated – e.g. for STIs

Management of low libido Management of psychosocial issues Review medications (anti-depressants) Treatment of vaginal atrophy Tibolone (see management of menopause) Androgen EVIDENCE OF EFFICACY LIMITED NO JUSTIFICATION FOR USE TESTOSTERONE

Management Current circumstances Individual psychological factors Relationship issues Sexual health knowledge Individual psychological factors Body image and self-esteem Experience of sexual abuse/trauma Negative attitudes, inhibitions and anxieties Health related factors Mental health Physical health Medication side effects particularly antidepressants and antipsychotics

Treatment of vaginal atrophy Local application of oestrogen alleviates vaginal dryness and lowers vaginal pH Oestradiol pessaries Oestriol cream/pessaries Vaginal Moisturizers The polycarbophil-based water insoluble compounds (Replens®)carry multiple times their weight in water. When used intra-vaginally 2x/week they lower vaginal pH and alleviate itching and dryness. Hyaluronic acid-based preparations also provide good symptom relief and objective evidence of improved vaginal health Vaginal lubricants alleviate vaginal dryness and prevent dyspareunia during sexual activity Only effective when used i.e. no benefit between applications

Testosterone therapy Physiology of testosterone Indications for use

Testosterone declines with age, not menopause Davison et al JCEM 2005

Other causes of low testosterone Use of the oral contraceptive pill: switches off ovarian testosterone production and increases sex hormone binding globulin levels so free testosterone levels lower Systemic oral glucocorticoid therapy- suppresses adrenal androgen production Panhypopituitism Anti-androgen therapy

surgically postmenopausal women on estrogen EFFICACY OF TESTOSTERONE FOR HYPOACTIVE SEXUAL DESIRE DISORDER DEMONSTRATED IN LARGE studies of: surgically postmenopausal women on estrogen naturally postmenopausal women on estrogen + progestin postmenopausal women on no hormone therapy premenopausal women Studies consistently show benefits of transdermal testosterone vs placebo for sexual satisfaction, desire, arousal, pleasure AND orgasm

Primary indication for testosterone therapy for women: Treatment of persistent low libido that profoundly impairs quality of life testosterone improves sexual desire, arousal and sexual satisfaction in premenopausal and postmenopausal women presenting with loss of sexual desire NOTE- substantial overlap between desire and arousal in women

Deciding who not to treat Treatment is a TRIAL so rather than exclude women from a trial decide who not to treat Women unlikely to benefit: Young women with normal ovarian function- other issues Women in poor relationships Need to understand if the relationship stress is 1’ or 2’ to FSD Women on high dose oral estrogen therapy- high SHBG Women with other sexual difficulties Women who have never experienced satisfactory sexual function

Contraindications androgenic alopecia/hirsutism/acne hormone dependent malignancy potential contraindication very low SHBG levels - need to be very judicious in dosing

International Menopause Society Guidelines There is no diagnosis of “androgen sufficiency syndrome” There is evidence that testosterone therapy will improve sexual outcomes for women diagnosed with hypoactive sexual desire disorder (HSDD) Women can be considered candidates for a trial of treatment after full clinical assessment Testosterone formulations for men should NOT be used Compounded testosterone not advisable There is no evidence for a benefit of DHEA in women with intact adrenal function (adrenal fatigue is not a diagnosis)