1. Sexual Function in the Geriatric Population Vinita J. Speir, MD

2. Sexual Biology: Physiologic changes with aging Men: require more direct stimulation, prostate pathology Women: lack of estrogen results in vaginal atrophy, urinary incontinence, vaginal prolapse Sexual Behavior Men: more concerned with pleasing partner; Equate sexuality with feelings of masculinity and being alive Women: no partner so no reason to be sexual, “past my time” Sexual Biology versus Sexual Behavior with Aging

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4. Rose 70 yo woman comes to your office for her 3 month follow up for HTN and osteopenia. She is up to date on her colonscopy and DEXA scan. As you are leaving the room she asks, doctor, don’t I need a pap smear this year?

5. Rose Past Surgical History: Supracervical Hysterectomy and Bilateral Salpingoophrectomy for fibroids at age 56 Ob/Gyn History : 3 vaginal deliveries, no post-menopausal bleeding SH: Widowed, but states she might have a new boyfriend. No history of sexual abuse or domestic violence. She smokes 2-3 cigarettes a day and has a glass of wine every night with dinner. She lives in an assisted living facility. FH: Diabetes and HTN, no breast, cervical, or endometrial cancer Medications: Norvasc, Fosamax, multivitamin Allergies : None

6. This reminds you that you had almost forgotten about her referral to the ob/gyn. Then she tells you that her insurance no longer covers a pap smear but she recently found someone who she “might get serious with.” How do you ask about her sexual history?

7. Details on any pain or discomfort Any previous treatment First sexual experience Early learning regarding sexuality History of sexual/domestic/psychological abuse Sexually transmitted diseases Pregnancies History of sexual problems Sexual History

8. Relationship quality Conflict Communication Sources of stress and/or anxiety Employment Children Embarrassment Psychosocial History

9. Helpful Hints when History Taking Open-ending style: Many women with _____ also have problems with sex, how about you? Many women your age report problems during sex… Do you have any sexual concerns that you would like to discuss? Key points: sexual trauma/abuse, horse-back riding, cycling, use of hormonal contraception, or HRT, relationship, status of the partner, surgical history (TAH/BSO)

10. Things to NOT do Be Judgmental Recommend a glass of wine Avoid slang as much as possible Forget gender identity & sexual orientation

11. Education PLISSIT Model Permission Limited Information Specific Suggestions Intensive Therapy

12. Rose So while getting your history, you learn that Rose had an active sex life with intercourse once a week until her husband got prostate cancer and passed away about 6 years ago. She does not masturbate and has not had any new partners since his death. He was also her first partner. She recently met someone and wants to become sexually active, but is worried that it will be painful. How can you help her?

13. As her physician what are you worried about? Heart attack? Sexually Transmitted Infections? Vaginal atrophy? Getting into a bad relationship? Talking at all about sex at all, she reminds you of your grandmother!

14. Cardiovascular Disease Overall regular sexual activity is beneficial to the cardiovascular system and overall quality of life Most clinicians agree sexual activity is safe after CV event Large meta-analysis showed with 1 hour a week of physical or sexual activity absolute risk 1-2/10,000 of heart attack Changing positions, behaviors, and expectations can result in more satisfying sexual function for both men and women JAMA. 2011 Mar 23;305(12):1225-33. Association of episodic physical and sexual activity with triggering of acute cardiac events: systematic review and meta-analysis. Dahabreh IJ, Paulus JK.

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16. Sexually Transmitted Infections HPV Herpes Syphilis HIV- 2007 CDC reported 16.8% of new diagnoses were in people > 50 yo Gonorrhea/Chlamydia- mostly still in young population Age Ageing. 2010 Sep;39(5):536-41. Epub 2010 Aug 4. The ageing of HIV: implications for geriatric medicine. Kearney F, Moore AR, Donegan CF, Lambert J.

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18. Vulvo-Vaginal Atrophy Contraindications: Endometrial hyperplasia or cancer, active thrombo- embolic disease, estrogen dependent tumors Controversial: history of Breast Cancer Can really help vaginaldryness, abnormal discharge, itching Exam : pH will be high, vagina is smooth, lacks rugae, may have punctate lesions or bleed easily Treatments: Vaginal Cream (Premarin/Estrace $$)- can help dyspareunia, stress incontinence, recurrent UTIs and sexual arousal Estring 7.5 ug/day very low dose Vagifem tablets (10 ug) daily for two weeks

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20. Sex is good medicine for your patient! Try to be objective and not bring your own personal biases or paradigm when counselling your patient You can make a big difference by addressing this issue Sexual Health and Intimacy are important parts of overall health and well-being Clin Geriatr Med. 2003 Aug;19(3):595-604. Counseling about sexuality in the older person. Szwabo PA.

21. WHO Statement Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. World Health Organization. (2011). Health topics: Sexual Health. Retrieved from: http://www.who.int/topics/sexual_health/en/