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FEMALE SEXUAL DYSFUNCTIONS FSD. Prof. IHAB YOUNIS. About 40% of women are affected by sexual problems, with a higher prevalence of 50% in perimenopausal and post-menopausal women.
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FEMALE SEXUAL DYSFUNCTIONSFSD Prof. IHAB YOUNIS
About 40% of women are affected by sexual problems, with a higher prevalence of 50% in perimenopausal and post-menopausal women A woman’s sexual responsi-veness is not the same as a man’s. Ignoring its complexity can make difference look like dysfunction
HSDD is the most common FSD • Prevalence ranged from 26.7% among premenopausal women to 52.4% among naturally menopausal women
Dopamine is the key neurotransmitter in the modulation of sexual desire • Steroid hormones increase available dopamine, -Testosterone potentiates the synthesis of nitric oxide, which controls dopamine release - Estradiol facilitates dopamine release
Increasing levels of serotonin (e.g. as with the, SSRIs) can diminish the effects of dopamine on sexual function • Endogenous opioids (e.g. Endorphin), which give the sense of pleasure and reward, also modulate the perceived intensity of sexual desire in humans • Following the experience of orgasm, desire decreases and requires a certain time span to be regained • Therefore, they may have an inhibitory effect on sexual desire
1- Low Testosterone • Low testosterone does not only cause low libido, but also causes decreased sexual receptivity and pleasure, fatigue, lack of motivation, and an overall reduced sense of well being • It is common in menopausal women or after bilateral oophorectomy
It is not uncommon for pre-menopausal women to experience HSDD. This may be due to the fact that testosterone concentrations begin to decline as early as the late 20s in women and continue to fall at a constant rate of about 50% of their peak level by menopause
2-Low Estrogen • Menopause can cause vaginal dryness, inability to lubricate, or dyspareunia • In this case, oral estrogen replacement is often prescribed for the relief of hot flashes, mood changes, and sleep disturbances to improve quality of life
The reason for this is that oral estrogen increases circulating levels of sex hormone binding globulin (SHBG) which lowers the level of free testosterone • Oral estrogen also suppresses FSH and LH, reducing ovarian synthesis and lowering total testosterone levels
3-Indirect hormonal effects • Hormone imbalances related to pregnancy, the postpartum phase and lactation • Menopause: Natural or surgical • The use of certain medications e.g. anti-depressants
4-Psychosocial factors • Women with HSDD were 2.5 times more likely to feel dissatisfied with their marriage or partner than normal women • 80% of patients with mood (e.g.depression) or anxiety disorders reported reduced sexual desire. However, patients with depression often do not appear to be distressed by their lack of interest in sex
5-Medications • SSRIs • Antihypertensive agents are proposed to affect sexual function via central adrenergic inhibition and blockade of adrenergic receptors • Antipsychotics are dopamine blockers, and may increase prolactin levels • Oral contraceptives may have negative effects in a minority of women. But because of the wide variety of hormonal medications available the results of studies are not conclusive
6-Medical conditions • Chronic illnesses e.g. diabetes mellitus, and cancer • Painful intercourse due vaginal/pelvic floor conditions, such as vestibulitis, vulvodynia, or endometriosis; or bladder conditions, such as interstitial cystitis or urinary incontinence
Female Decreased Sexual Desire Screener 1. In the past was your level of sexual desire or interest good and satisfying to you? y/n 2. Has there been a decrease in your level of sexual desire or interest? y/n 3. Are you bothered by your decreased level of sexual desire or interest? y/n 4. Would you like your level of sexual desire or interest to increase? y/n 5. Do you feel any of the following has contributed to your current decrease in sexual desire or interest? An operation, depression, injuries, or other medical condition? y/n
6. Medication, drugs or alcohol you are currently taking? y/n 7. Pregnancy, recent childbirth, menopausal symptoms? y/n 8. Other sexual issues you may be having (pain, decreased arousal or orgasm)? y/n 9. Your partner’s sexual problems? y/n 10. Dissatisfaction with your relationship or partner? y/n 11. Stress or fatigue? y/n
• If the answer is "no" to any of questions 1-4: patient may not qualify for the diagnosis of HSDD • If the answer is "yes" to all of 1-4 questions: patient may qualify for the diagnosis of HSDD • If the answer to any question 5-8, or 11 is "yes" add: You should also seek consultation with your health care provider to determine if a medical condition or problem is contributing to your current decrease in sexual desire or interest
If the answer to question 9 is "yes" add: Your partner may need to seek consultation with his health care provider • If the answer to question 10 is "yes" add: You and your partner should consider professional counseling • Screener is based on Validation of the DSDS, Clayton et al: J Sex Med 2009;6:730-738
Testosterone • Intrinsa skin patch • Releases 300 µg/day • It is worn just below the umbilicus & changed twice weekly • Sexual activity increased by an average of 19% in placebo users, vs. a 73% increase for Intrinsa patch postmenopausal users
Contraindications • Breast cancer • Pregnancy • Breastfeeding • Naturally menopausal women
Side effects • FDA declined to approve it for lack of information on long term side effects • Irritation of skin at patch application site • Acne • Excessive facial hair growth • Voice deepening • Breast pain • Weight gain • Hair loss
Bupropion (Wellbutrin) • It is an antidepressant and smoking cessation aid • Bupropion SR 150 mg daily is given for 12 weeks • The thoughts/desire score showed a greater than twofold increase in patients treated with bupropion compared to those receiving a placebo
Contraindications • Conditions that lower the seizure threshold e.g. alcohol or benzodiazepine disconti-nuation, anorexia nervosa, bulimia, or active brain tumors & individuals taking MAO inhibitors Side effects • Seizure: It is highly dose-dependent • Hypertension in less than 1% of patients
Flibanserin (Female Viagra) • As with Viagra, the effects of flibanserin were discovered accidentally after it was trialed as an anti-depressant • The results of four Phase III studies involving more than 2,000 pre-menopausal women suffering from HSDD showed that:
Women using the drug said that the average number of times they had "satisfying sexual experiences" rose from 2.8 to 4.5 times a month • Women with the placebo said the number of times rose to 3.7 times a month • Flibanserin must be taken once a day and takes up to 4 weeks to have an effect
Mechanism of action • It may enhance dopamine actions and reduce serotonin actions • The FDA refused to license it because the studies showing its effectiveness were not enough
A double blind, placebo-controlled, randomized study of 80 married women with FSAD demonstrated that bremelanotide 20 mg nasal spray increased sexual arousal and intercourse satisfaction when compared with the placebo group. The manufacturer cited blood pressure elevation with intranasal administration of bremelanotide as a reason for not pursuing approval for sexual dysfunction.
Orgasm is a variable, transient peak sensation of intense pleasure creating an altered state of consciousness, usually accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions and myotonia that resolves the sexually-induced vasocongestion (sometimes only partially), usually with an induction of well-being and contentment
Orgasms vary in intensity, and women vary in the frequency of their orgasms and the amount of stimulation necessary to trigger an orgasm • Although the clitoris and vagina are the most common sites of stimulation that result in an orgasm, stimulation of other body sites (eg, breast, nipple, or mons) can trigger an orgasm, as can mental imagery, fantasy
The G-spot is: - An ill-defined region, located on the anterior vaginal wall, in its upper outer third, suggested by Grafenberg - This area is sensitive to tactile touch, which, when applied, is claimed to result in an intense female orgasm and female ejaculation during orgasm - Debate regarding the existence of the G-spot and female ejaculation as true clinical entities is still ongoing
How frequent is anorgasmia in Egypt? (My Work) • In all women - 17% do not have orgasm at all - 5% rarely have orgasm • In genitally cut women - 2% do not have orgasm at all - 32% have orgasm infrequently • In Non genitally cut women - 8.5% have orgasm infrequently
70-80% of women achieve orgasm only through direct clitoral stimulation. Clitoral orgasms are easier to achieve because the tip or glans of the clitoris alone has more than 8,000 sensory nerve • Copulatory vocalizations were reported to be made most often before and simultaneously with male ejaculation
These data clearly demonstrate a dissociation of the timing of women experiencing orgasm and making copulatory vocalizations and indicate that there is at least an element of these responses that are under conscious control, providing women with an opportunity to manipulate male behavior to their advantage
Etiology I- Biological Factors: 1.General medical conditions, such as heart or kidney disease, can damage patients’ quality of life and are often associated with depression 2. Atherosclerosis and its related risk factors (smoking, diabetes, hypertension, and peripheral vascular disease) affect genital blood flow which is critical to the female sexual response
3.Anorgasmia is often seen as a side effect of using psychotropic medications: - Anorgasmia is reported in at least one- third of patients who receive SSRI - Also it is reported with antipsychotics and mood stabilizers 4. Heavy alcohol consumption and illicit drugs can also interfere with orgasmic ability
5.Hormonal changes due to menopause or other disorders: - Lower estrogen levels may cause a weakening of the pelvic muscles, affect the responsiveness of nerves that act as receptors for external sexual stimuli, and reduce vaginal lubrication - Low testosterone has also been found to be reduce arousal and experiences of orgasm
6-Recently, studies investigating genetic factors have been conducted. Dunn et al. estimate the heritability for difficulty reaching orgasm to be 34%. Furthermore, a certain gene (GRIA1) has been found to be associated with difficulty achieving orgasm
II- Psychosocial Factors 1-Poor body image and genital image (the way a woman feels about the size, shape, odor, and function of her genitals) can contribute to anorgasmia 2- Relationship problems and lack of proper communication with the partner about clitoral stimulation techniques
3- Anorgasmic women often demonstrate negative attitudes toward sex and masturbation, and tend to experience guilt following sexual activities 4- The effect of past sexual abuse on women’s orgasmic functioning is important to examine
5-Additional psychosocial factors associated with orgasm capacity include: • Age: older women may experience orgasm difficulty due to changes in their body and the belief that, at an older age, sexual desire and activity are improper • Education: correlates with anorgasmia • Social class: correlates with anorgasmia • Shame about sexuality due to religious beliefs or familial inhibitions:Increase incidence of anorgasmia
