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Disclosures

 Dr. Althof serves as a Principal Investigator, Consultant or A General Approach to Female Member of an Advisory Board to:  Allergan Sexuality and Assessment  Eli Lilly  Evidera  Ixchelsis  Palitan  Pfizer Stanley E. Althof, Ph.D.  Promescent Executive Director  Sprout  S1 Pharma Center for Marital and Sexual Health of South Florida  SSI Professor Emeritus  Vyrix Case Western Reserve University School of

Female Sexual Function and Dysfunction Observations About Female Sexuality

 In general, women are quite resilient and responsive‐ both physically and sexually

 Sexual problems occur along a continuum from dissatisfaction (with or without significant distress) to frank dysfunction (with or without significant distress)

 There exists tremendous individual variability across women in terms of , arousal, and orgasmic ease

 Women do report more sexual difficulties and complaints than do men in almost every survey or study

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Overlap of Female Sexual Disorders

Sexual Sexual Desire Arousal Disorders Disorder

Female : Definitions and Classifications

Orgasmic Dyspareunia Disorder

Vaginismus

Basson R, et al. J Urol. 2000;163:888-893.

Comorbidity of HSDD Female Sexual Dysfunction

With Other Sexual Disorders Sexual Hypoactive sexual desire disorder desire disorders Sexual aversion disorder

80 73 Genital disorder 69 69 70 Sexual Subjective sexual arousal disorder 60 60 arousal disorder Combined genital/subjective Persistent sexual arousal 50 <30 years old (n=11) 40 30-39 years old (n=12) 40 40-49 years old (n=16) 30 33 Sexual 30 >49 years old (n=13) Female orgasmic disorder

Patients (%) Patients orgasmic disorder 20 17 10 Dyspareunia 0 Sexual pain Additional Arousal Additional Orgasmic Disorder Disorders disorders

Hartmann U, et al. World J Urol. 2002;20(2):79-88. © Springer-Verlag 2002. Figure reproduced with permission from the publisher. Partner’s Dysfunction Basson R et al. J Sex Medicine 2004;1;40‐48

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Female Sexual Dysfunction: Diagnostic Criterion for FSIAD Changes from DSM‐IV‐TR to DSM‐5  Lack of, significantly reduced, or absent sexual interest/arousal as manifested by 3 of the following: 1. Interest in sexual activity Hypoactive Sexual Female Sexual Arousal 2. Sexual/erotic thoughts or fantasies Desire Disorder Disorder (FSAD) (HSDD) 3. Initiation of sexual activity and unreceptive to partner’s attempts to initiate 4. Sexual excitement/pleasure during sexual activity in almost all or all (75%-100%) sexual encounters 5. Sexual interest/arousal in response to any internal or Female Sexual external sexual/erotic cues (written, verbal, visual) Interest/Arousal 6. Genital or non‐genital sensations during sexual activity Disorder Symptoms persisted a minimum of 6 months and not better explained by a non‐sexual or (FSAID) consequence of severe relationship distress or other significant stressors and not due to the effect of a substance/ or other medical condition American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorder, 5th Edition, American Psychiatric Publishing, 2013

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Subtypes of FSDs Described by DSM‐IV‐TR

Defined by Onset Sexual dysfunction has been present since the onset of sexual Lifelong functioning Acquired Sexual dysfunction develops only after a period of normal functioning Female Sexual Dysfunction:

Defined by Context Epidemiology Sexual dysfunction is not limited to certain types of stimulation, Generalized situations, or partners

Sexual dysfunction is limited to certain types of stimulation, situations, Situational or partners

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC: American Psychiatric Press; 2000.

Percentage of Men and Women with Sexual Complaints FSD Prevalence By Decade National Health and Social Life Survey 45 20 40 35 43 15 Any 30 Desire 31 10 25 Arousal Women 20 Men Orgasm Prevalence (%) Prevalence

Percent 5 15 10 0 5 18-20 20-29 30-39 40-49 50-59 60-69 70-80 Above 0 Age Band (Years) 80 Women Men *Sexual pain was not measured in this survey. Shifren JL, et al. Sexual problems and distress in United States Women. Obstet Gynecol. 2008;112(5);970-978. Figure reproduced with permission from the publisher. Laumann EO, et al. JAMA 1999‐281(6):537‐544

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Fifty Shades of Maxine Prevalence From the PRESIDE Study

 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 correlates  NOT DETERMINED: Whether low desire with sexually related personal distress was primary or secondary to another illness; pain was not assessed  POPULATION: 31,581 US female respondents ≥18 years of age from 50,002 households  RESULTS*: Response rate was 63% (n=31,581 / 50,002) Prevalence of Female Sexual Problems Associated With Distress 100 50 45 43.1 40 37.7 35 Sexual Problems 30 25.3 Distressing Sexual Problems 25 21.1

US Women(%) 20 15 9.5 11.5 10 5.1 4.6 5 0 *All results are US population age-adjusted. Desire Arousal Orgasm Any Shifren JL, et al. Obstet Gynecol. 2008;112(5):970-978. 17

Age at Menopause has Remained Constant Sexual Life in Older Adults While Life Expectancy Has Increased (USA)  Included U.S. adults (1550 women and 1455 men) Life Expectancy 80 57 to 85 years of age

60  The prevalence of sexual activity declined with age (Years)

73% among respondents who were 57 to 64, 40 Age of Menopause

Age 53% among respondents who were 65 to 74 As the population ages women will live 26% among respondents who were 75 to 85 20 longer portions of their lives in postmenopause

0  Women were significantly less likely than men at 1850 1900 1950 2000 all ages to report sexual activity Date Lindau ST, et al. A study of sexuality and health among older adults in the United States. N Soules MR, et al. J Am Geriatr Soc. 1982;30:547‐561. Engl J Med. 2007; 357: 762‐74.

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Sexual Life in Older Adults

 Men and women who rated their health as being poor were less likely to be sexually active and, among respondents who were sexually active, were more likely to report sexual problems

 A total of 38% of men and 22% of women reported having discussed sex with a physician since the age The Role of the Partner of 50 years.

Lindau ST, et al. A study of sexuality and health among older adults in the United States. N Engl J Med. 2007; 357: 762‐74.

Sexual Problems Do Not Occur in a Vacuum Interpersonal Dimension “There is no such thing as an uninvolved partner in a marriage where sexual dysfunction exists.”

Masters & Johnson, 1970

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The Partner As a Precipitating Factor Male and Female Sexual Dysfunctions for Sexual Dysfunction Women Men  The partner’s role as a precipitating or maintaining Hypoactive Sexual Hypoactive Sexual factor has been overshadowed by focusing on Desire Disorder Desire Disorder individual medical, psychological, or interpersonal factors upon sexual function Female Sexual Male Arousal Disorder Erectile Disorder

 There is a dynamic and reciprocal relationship of one Female partner’s sexual function, sexual satisfaction, physical Orgasmic Disorder and mental health to the other partner’s sexual health and satisfaction Sexual pain Sexual pain Althof, S. et al. (2010) Psychological and Interpersonal Dimensions of Sexual Function and disorders disorders Dysfunction. In : Sexual Dysfunctions in Men and Women. Edited by, F. Montorsi, R. Basson, G. Adaikan, E. Becher, A. Clayton, F. Giuliano, S Khory & I. Sharlip. Pairs, Editions 21, pg. 121‐182

The Paradox of Sexuality Assessment Reconciling passion and intimacy, or the erotic and domestic, is about bringing  Overview of sexual life together two sets of human fundamental needs: the need for safety and security with  History and course of presenting sexual problem the need for adventure and novelty  Assess all phases of function  Desire, arousal, orgasm and satisfaction Love and Desire‐ they relate and they conflict  Why is the patient presenting now?  In‐depth review of last sexual encounter Security Adventure  Partner’s response • Safety and reliability • Novelty, mystery, unexpected  Quality of relationship • Permanence and grounding • Risk, quest for the unknown • Love seeks closeness • Freedom  Life stresses\Contextual issues • Predictability • Difference‐ otherness • Knowing your beloved • Passion and uncertainty  Biomedical factors  Mental health screen  , anxiety, , prior MH contacts Perel, E., Mating in Captivity, Harper, 2006

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Techniques for Discussing Patient’s Sexual History Variety of Validated Tools Can Be Used for Assessing FSD Examples of Validated Tools Available to Assess FSD

Inquiry techniques include Tool Assessment Area  Starting with general questions Female Sexual Function Index (FSFI)1,2 Desire, arousal, orgasm, and pain Profile of Female Sexual Function (PFSF)3,4 Desire in postmenopausal women

about sexual activity then Brief Profile of Female Sexual Function Self-screener for low desire in surgically postmenopausal women becoming more specific (B-PFSF)5 Sexual Interest and Desire Inventory-Female Severity of symptoms in women with HSDD (SIDI-F)6,7 Female Sexual Distress Scale-Revised Distress  Using 2 types of questions: (FSDS-R)8  Direct: “Do you have any problems Sexual Quality of Life-Female (SQoL-F)9 Quality of life in women with FSD Golombok Rust Inventory of Sexual Quality of sexual relationship related to sex?” Satisfaction (GRISS)10,11  Ubiquity style: “Many women over Decreased Sexual Desire Screener 12,13 Brief diagnostic tool for HSDD age __ note some problems with (DSDS) 1. Meston CM. J Sex Marital Ther. 2003;29(1):39-46. 8. DeRogatis L. J Sex Med. 2008;5(2):357-364. 2. Rosen R, et al. J Sex Mar Ther. 2000;26:191-208. 9. Symonds T, et al. J Sex Marital Ther. 2005;31(5):385-397. sexual activity” 3. Derogatis L, et al. J Sex Marital Ther. 2004;30(1):25-36. 10. Rust J, Golombok S. Br J Clin Psychol. 1985;24(Pt.1):63-64. 4. McHorney CA, et al. Menopause. 2004;11(4):474-483. 11. Rust J, et al. Arch Sex Behav. 1986;15(2):157-165. 5. Rust J, et al. Gynecol Endocrinol. 2007;23(11):638-644. 12. Clayton AH, et al. J Sex Med. 2009;6:730-738. 6. Clayton AH, et al. J Sex Marital Ther. 2006;32(2):115-135. 13. Clayton AH, et al. Poster Presentation. ISSWSW. 2007. Sadovsky R, et al. J Sex Med. 2006;3(5):795-803. 7. Sills T, et al. J Sex Med. 2005;2:801-818.

Office Based Counseling for Sexual Questions/Comments Problems: Follow PLISSIT Model Permission to talk about sexual issues, reassurance and empathy

Limited Information e.g., educational resources, partner dysfunction, resources, realistic expectations

Specific Suggestions e.g., use of lubricants, altering position, date night, novelty, plan sexual activity when energy is highest and pain is lowest.

Intensive Therapy e.g., referral for psychotherapy/ Annon, 1976

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Multiple Models of Female Sexual Response

Linear Model1,2,3* Circular Model3†

Emotional Orgasm intimacy Plateau Emotional and Seeking out and physical satisfaction being receptive to Spontaneous sexual drive

Arousal Arousal and Sexual stimuli sexual desire

Resolution Biological Sexual arousal Desire

Sexual Excitement/ Tension Excitement/ Sexual Psychological Time

* † Called the Masters & Johnson Model with Kaplan Modifier (Desire). Called the Basson Model.

1. Masters WH and Johnson VW. Human Sexual Response. Boston:Little Brown;1966. 2. Kaplan HS. Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy. New York:Brunner/Mazel;1979. 3. Basson R. Female sexual response: the role of drugs in the management of sexual dysfunction. Obstet Gynecol. 2001;98(2):350-353. Figures reproduced with permission from the publisher.

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