Questions About Sex That You Are Too Embarrassed to Ask Denise Rizzolo, PhD, PA-C What percent of people over the age of 45 are satisfied with their sex life? • 19% • 31% • 51% • 61% And the answer is….

• 51% are either somewhat or extremely satisfied • 31% are neither satisfied nor dissatisfied • 23% of men and 14% of women say they are dissatisfied What Women Say About Sex…

“Is this the way it’s supposed to be?”

“I have very little interest or desire for sex anymore.”

“I wait for my husband to fall asleep before I get into bed because he wants to have sex and all I want when we turn out the lights is to go to sleep.”

“I never achieve orgasm and it used to be so easy and natural.”

“Intercourse is just plain painful.” As you get older, it’s normal to want less sex? • True • False And the answer is …..

• True, as people age, their sexual desire usually decreases. • This is true for men and women, although women are two to three times more likely than men to see their sex drive decline. • Lower hormone levels in women may be responsible for decline. Statistics

• Most studies suggest a normative and gradual decline in desire with age. • The prevalence of sexual activity: • 73% of respondents 57-64 years of age • 53% of respondents 65-74 years of age • 26% of respondents 75-85 years of age Decline vs Dysfunction vs Problems

• Women admit to a gradual decline sexual desire and activity with age. • Normal sexual decline becomes dysfunction when sexual difficulty persists over time and causes the patient distress for which she requests evaluation and intervention. • Need to differentiate between a true “dysfunction” compared to a “problem” or “decline” • Dysfunctions are much more difficult to treat • No two women are the same! • Matter of interpretation ……. Overview

• Sexual Dysfunctions • Persistent or recurrent difficulties in becoming sexually aroused or reaching orgasm. • People with Dysfunctions • Often avoid sexual opportunities • Feel inadequate or incompetent • Find it difficult to talk about Overview

•Sexual Problems •Tend to be due to , personal issues, etc. •Usually easier to identify, discuss and treat. Types of - Old Model

DESIRE AROUSAL/EXCITE Hypoactive sexual MENT desire disorder Female sexual Sexual aversion arousal disorder disorder

ORGASM PAIN Female orgasmic disorder (inhibited orgasm) Vaginismus Types of Sexual Dysfunction- New Model

Female sexual Interest/Arousal Disorder Hypoactive sexual desire disorder Combined the top Sexual aversion disorder two into one Female

Gentiopelvic ORGASM Pain/penetration Female orgasmic Disorder disorder Dyspareunia (inhibited orgasm) Vaginismus Sexual Desire Disorders: Female sexual Interest/Arousal Disorder

• Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context of the person's life. • Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner. • Persistent or recurrent inability to attain, or to maintain typical arousal responses until completion of the sexual activity, an adequate lubrication response of sexual excitement. • The disturbance causes marked distress or interpersonal difficulty. Orgasmic Disorder

• Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. • Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm. • The diagnosis of Female Orgasmic Disorder should be based on the clinician's judgment that the woman's orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives. • The disturbance causes marked distress or interpersonal difficulty. Gentiopelvic Pain/Penetration Disorder Dyspareunia Vaginismus

• Recurrent or persistent genital pain • Recurrent or persistent associated with involuntary of the in either a male or a female. musculature of the outer third of • The disturbance causes marked the that interferes with distress or interpersonal difficulty. sexual intercourse. • The disturbance is not caused • The disturbance causes marked exclusively by Vaginismus or lack of distress or interpersonal lubrication difficulty.

(www.behavenet.com, 2004) As you get older, it takes longer to get aroused ? • True • False And the answer is….

• True- as individuals age, sexual response time gets slower. • Lubricants and hormone creams can help women. • Couples can also focus more on foreplay. Menopause and Sexuality

• Majority of women continue to engage in sexual activity and enjoy it. • Some decline in sexual functioning at menopause. • Vaginal dryness contributes to decline in sexual functioning. • Women's sexual desire may decline as levels of ovarian testosterone decline . Psychological Causes

• Sexual or Emotional Abuse • Depression • Relationship Issues •Stress • Self Esteem Sexual or Emotional Abuse

•Sexual abuse as a child/adult •Emotionally abusive partner • All lead to a lack of interest in sex Depression

• Can reduce a woman’s interest in desire- lack of desire • Unable to feel aroused/excited • Some also can decrease interest in sex (Catch 22) Relationships

• Fighting, disagreeing, bickering • LACK of COMMUNICATION • Should feel comfortable with partner • Decrease in desire= decrease in arousal=decrease in sex Stress and the Impact on Sexual Desire

• High stress factors include workplace stress, social, financial crises or CHILDREN! • Especially during infancy- up all night. • When some women have decreased desire to have sex, it will become more difficult to become aroused and to have an orgasm. • Many women complain of being to exhausted to have sex. • When they are in the “mood” the partners are usually not home. • When their partners are in the “mood” women are usually ready to go to sleep. Stress and

Stress = Infertility Or Infertility = Stress Self Esteem

• Weight gain after pregnancy • Stretch marks • Sagging skin • Feeling uncomfortable about oneself = lack of sexual interest Only 35% of PCP’s reported taking a sex history routinely or often Let’s Talk about Sex…..

• https://www.youtube.com/watch?v=sw6UetyUuD0 Medical Professional Reported Barriers

• Lack of training in taking a sexual history • Insufficient knowledge of about sexual function and dysfunction • Inadequate communication skills • Discomfort with sexual language • Lack of information about treatment options • Time constraints • Embarrassment

Sallie Foley Question for audience

• How often do you talk to your patients (adult/elderly) about sex? • Is it part of your history taking? Patient Reported Barriers

• Although 85% of adults want to discuss sexual functioning with their physicians… • 71% believe their physicians doesn’t have the time • 68% don’t want to embarrass their physician • 76% thought no treatment was available for their problems • They also report… • Non-empathic and/or judgmental responses • Physician discomfort • Concern about privacy and/or confidentiality • Lack of cultural sensitivity Common Complaints from Women

• Low/no desire • Inability to lubricate • Low arousal • Illness—e.g. diabetes, breast cancer • Pain on touch of genitals or penetration • Changing body image/vulvar structures • Delayed orgasm/absent orgasm Taking a Sexual History

• The chance of a female expressing sexual concerns is influenced by her perception of the health care professional’s level of comfort in discussing the subject. • When diagnosing sexual dysfunction, a sexual function questionnaire can be completed or ask open ended questions? • How often do you have sex? • How do you feel your sex life is? • Do you have trouble with lubrication? • Do you feel dry constantly? • Is sex pleasurable? Painful? • Do you believe you have difficulty with penetration? Physiologic Changes - Women

• Labia lose some of their firmness. • The walls of the vagina become less elastic. • The vagina itself becomes drier. • The can become highly sensitive, even too sensitive. • Uterine contractions with orgasm may at times be painful. • Due to loss of elasticity- penetration can become more difficult. Female Sexual Response Cycle

• characterized cycle with four phases: • Excitement • Plateau • Orgasmic • Resolution

• Kaplan proposed idea of “desire” and a three-phase model. • Desire • Arousal • Orgasm

(Berman et. al, 1999) How many older people say treatments for sexual problems have improved their sex life? • 22% • 44% • 64% • 82% And the answer is…..

• 64% say that medications, hormones or other treatments have improved their sex lives. • About half the people with a regular partner said treatments for sexual problems had a good effect on their relationship. What about medication side effects? • Fluoxetine vs Sertraline vs Trazodone • 195 patients who met the DSMIV-IR criteria for MDD were enrolled (102 men and 93 women) • Baseline – normal sexual function; + for major depressive disorder • Fluoxetine had the most impairment in desire/drive items (43%–51% and 44%–50%, respectively), while patients receiving trazodone had the least impairment in these items (12%–18% and 23%–24%, respectively). • Sertraline was in the middle (intermediate decrease in desire/drive)

Khazaie H, Rezaie L, Payam NR, Najafi F. -induced sexual dysfunction during treatment with fluoxetine, sertraline and trazodone; a randomized controlled trial. General hospital . 2015 Jan 1;37(1):40-5. Medication Side effects continued • 160 women (18–60 years) with mild or moderate hypertension, randomized to a once-daily treatment with felodipine combined with irbesartan or metoprolol for 48 weeks. Patients’ sexual function was evaluated using a female sexual function index (FSFI) questionnaire at baseline and after 24 and 48 weeks of therapy. Additionally measured were hormone levels. • After 48 weeks, in felodipine–irbesartan group, total scores of FSFI improved Items showing improvement in scores corresponded to desire, arousal and orgasm • Levels of estradiol increased under treatment with felodipine–irbesartan (P = 0.003) and decreased under felodipine–metoprolol treatment (P < 0.001)

Ma R, Yu J, Xu D, Yang L, Lin X, Zhao F, Bai F. Effect of felodipine with irbesartan or metoprolol on sexual function and oxidative stress in women with essential hypertension. Journal of hypertension. 2012 Jan 1;30(1):210-6. Potential Medication for Hypoactive Sexual Desire

• Flibanserin (fly ban ser in)– mixed 5-HT1A agonist and 5-HT2A antagonist –FDA approved • One table at bedtime for Premenopausal women • Violet Trial: Shown to improve number of satisfying sexual events in a 24 week period • 40% improvement in patients using 50 mg daily • 50% improvement in patients using 100 mg daily • 30% in the placebo • Adverse effects reported: dizziness, nausea, fatigue and dry mouth What Patient’s Wish We Would Talk About

https://static1.squarespace.com/static/569e771a0e4c1148e6c49fe6/t/57c87694e3df2817f3287e41/1472755348360/ Vulvovaginal+Care+++Moisturize+Lubricate+Stretch+%28MLS%29Foley.pdf Moisturize

• Without estrogen, the mucous membrane of the inner labia and vagina can get thin and too dry. • Most women moisturize their skin daily, the vagina should be no different. • Should occur 2-3 times a week. Moisturize – Prescription

• Vagifem- small vaginal suppository • Estring- ring place over the opening of the • Estradiol cream- cream applied to vulva and vaginal walls • The doses are small and the estrogen stimulates normal lubricating activity in the vagina • Side effects? • Some report increased urethral comfort and decreased urinary leakage Moisturize – Over the Counter

• Luvena (www.luvenacare.com) is hormone free, glycerin free, and paraben free • Replens, KY Liquibeads • Vitamin E suppositories • Take regular Vitamin E capsules, slice them open and use oil • Make sure it is pure Vitamin E oil • Extra virgin olive oil can be used in replace of Replens. Use a Replens applicator, fill top portion with olive oil and insert in vagina 2-3 times a week • Prone to UTIs and yeast infections or have diabetes- should not use regular olive oil • No other food oils should be used as these can trap bacteria Lubrication

• The process of lubrication is stimulated in part by the presence of estrogen in the body. • Lubrication not only helps during sexual activity.- it protects the vulva and vagina from getting too dried up, itching, feeling painful, or experiencing tiny cracks from all the dryness. • The normal process of perimenopause and menopause can cause vaginal dryness. • Medications: antihistamine medications, some antidepressants or other psychopharmacologic medications, any medications that dry- will dry the vaginal mucosa as well. • Lubrication reduces the burning, itching, irritation feel inside the vagina during or after penetration Lubrication

• Lubricate when dilating/stretching the vagina or when engaging in sexual activity. • Lubricate both the inner labia, introitus, and inside the vagina. • Find glycerin free lubricants. • Although not well researched, glycerin has been shown to increase the production of yeast and irritation in the vagina for some women. • https://goodcleanlove.com/ • http://sliquid.com/full-width/sliquid-naturals/naturals- silver/?gclid=CjwKCAjwk4vMBRAgEiwA4ftLs4iwYQsFFXNZ7vZE1DM0c UVE-YVzFUiNvsgHBXnL1me0kKNIfLutdBoCIIAQAvD_BwE Stretch

• We stretch other parts of our bodies- vagina should not be neglected. • The skin/membrane of the opening to the vagina and the inside of the vagina will respond to gentle stretching/dilating, several times a week. • Regular stretching makes penetration possible without pain • Make stretching part of a routine • Even after menopause or treatment, the walls of the vagina can relearn to stretch and through regular dilating, once or twice a week, stay stretched. • Even if a woman thinks she will not be engaging in any penetrative sexual activity, the vagina remains an important part of her body and in need of attention as part of her general physical health. Stretch

• Some women practice regular dilating/stretching of the vagina so that penetration can occur without pain, spasm or tightness. • Dilators can be purchased www.vaginismus.com • 2 things to keep in mind when discussing with patients: • Gradual, insertion should occur; may be uncomfortable, but not painful – hold for 2 minutes gently pressing it in. Overtime- more of the length of the dilator can be inserted as the vagina learns to re-stretch. • Move the dilator in and out of the vagina gently- vigorous motion is not necessary. • Can refer to Physical Therapist that are trained in this area. Sex Toys

• There is nothing wrong with using sex toys! • Can help with arousal and orgasm. • Vibrators • Clitoral stimulators • Be thoughtful when purchasing them- may have to try more than one. Other treatments

• Yoga • Meditation • Supplements- mixed reviews • Acupuncture 5 weeks – 2 times a week (25 minutes) of acupuncture therapy was associated with significant improvements in sexual function, particularly desire • The list goes on……..

Mazaro‐Costa R, Andersen ML, Hachul H, and Tufik S. Medicinal plants as alternative treatments for female sexual dysfunction: Utopian vision or possible treatment in climacteric women? J Sex Med 2010;7:3695–3714. Oakley S, Walther-Liu J, Crisp CC, Pauls RN. Acupuncture in Premenopausal Women with Hypoactive Sexual Desire Disorder: A Prospective Cohort Study. Journal of Minimally Invasive Gynecology. 2015 Mar 1;22(3):S37-8. When all else fails…refer to specialist What Else Can Women Do for Sexual Health? • Healthy diet, exercise, sleep • Positive experiences of connection/attachment • Acknowledge limits in time and be realistic • Date night • Sex does not have to be at night- have it anytime that works for the couple • Use it or lose it – is not necessarily a joke for women • Try to have regular sex • Sex toys can be an option for some women Physical Therapy

• Physiotherapy (e.g., hands-on techniques, , pelvic floor electrical stimulation, use of vaginal dilators) is a treatment option for sexual pain disorders such as vulvar vestibulitis and vaginismus. • Must me a trained physical therapist in this discipline.

Mohapatra, S., Rath, N., Agrawal, A., & Verma, J. (2014). Management of female sexual dysfunction. Delhi Pschyhiatry Journal, 17(2), 243-247. References • Marwick C. JAMA 1993; 281:2 173-4 • Maurice WI, Bowman MA, in Primary Care 1999:1-41 • http://www.salliefoley.com/ • Foley, S. 2015. “Older adults and sexual health: A review of current literature.” Current Sexual Health Reports. June, 2015:7:2; 70-79. DOI: 10.1007/s11930-015-0046-x • Foley, S. 2015. “Biopsychosocial Assessment and Treatment of Sexual Problems in Older Age. Current Sexual Health Reports. June, 2015;7:2; 80-88. DOI: 10.1007/s11930-015-0047-9 • Berman, J.R., Berman, L., and Goldstein, I. (1999). Female Sexual Dysfunction: incidence, Pathophysiology, evaluation, and treatment options.Urology, 45, 385-391. • Brassil, D.F, Keller, M. (2002). Female Sexual Dysfunction: Definitions, Causes, and Treatment. Urologic Nursing, 22, 237- 242. • Laumann, E.O, Paik, A., Rosen, R.C. (1999). Sexual Dysfunction in the United States. Journal of the American Medical Association, 281, 537-544. • Sarwer, D.B, Durlak, J.A. (1996). Childhood Sexual Abuse as a Predictor of Female Sexual Dysfunction: A Study of Couples Seeking . Child Abuse & Neglect, 20, 963-972. • McCabe MP, Sharlip ID, Lewis R, Atalla E, Balon R, Fisher AD, Laumann E, Lee SW, Segraves RT. Risk factors for sexual dysfunction among women and men: a consensus statement from the Fourth International Consultation on Sexual Medicine 2015. The journal of sexual medicine. 2016 Feb 1;13(2):153-67. • McCabe MP, Sharlip ID, Lewis R, Atalla E, Balon R, Fisher AD, Laumann E, Lee SW, Segraves RT. Incidence and prevalence of sexual dysfunction in women and men: a consensus statement from the Fourth International Consultation on Sexual Medicine 2015. The journal of sexual medicine. 2016 Feb 1;13(2):144-52. • Wincze JP, Weisberg RB. Sexual dysfunction: A guide for assessment and treatment. Guilford Publications; 2015 May 18. • Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J, Goldstein I, Graziottin A, Heiman J, Laan E, Leiblum S. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. The Journal of urology. 2000 Mar 1;163(3):888-93. References

• Lewis RW, Fugl‐Meyer KS, Corona G, Hayes RD, Laumann EO, Moreira Jr ED, Rellini AH, Segraves T. Definitions/epidemiology/risk factors for sexual dysfunction. The journal of sexual medicine. 2010 Apr 1;7(4pt2):1598-607. • Isidori AM, Pozza C, Esposito K, Giugliano D, Morano S, Vignozzi L, Corona G, Lenzi A, Jannini EA. Outcomes assessment: Development and validation of a 6‐item version of the Female Sexual Function Index (FSFI) as a diagnostic tool for female sexual dysfunction. The journal of sexual medicine. 2010 Mar 1;7(3):1139-46. • Millheiser LS, Helmer AE, Quintero RB, Westphal LM, Milki AA, Lathi RB. Is infertility a risk factor for female sexual dysfunction? A case-control study. Fertility and sterility. 2010 Nov 1;94(6):2022-5. • McCabe M, Althof SE, Assalian P, Chevret‐Measson M, Leiblum SR, Simonelli C, Wylie K. Psychological and interpersonal dimensions of sexual function and dysfunction. The journal of sexual medicine. 2010 Jan 1;7(1pt2):327-36. • Khazaie H, Rezaie L, Payam NR, Najafi F. Antidepressant-induced sexual dysfunction during treatment with fluoxetine, sertraline and trazodone; a randomized controlled trial. General hospital psychiatry. 2015 Jan 1;37(1):40-5. • Ma R, Yu J, Xu D, Yang L, Lin X, Zhao F, Bai F. Effect of felodipine with irbesartan or metoprolol on sexual function and oxidative stress in women with essential hypertension. Journal of hypertension. 2012 Jan 1;30(1):210-6. • Mohapatra, S., Rath, N., Agrawal, A., & Verma, J. (2014). Management of female sexual dysfunction. Delhi Pschyhiatry Journal, 17(2), 243-247.