FEMALE : HOPE AND HELP FOR YOUR PATIENTS

Kris Christiansen, MD Park Nicollet Sexual and Male St. Louis Park, MN March 28, 2019 DISCLOSURES

• I have no financial disclosures to discuss. • Off-label use of will be discussed in this presentation. • The use of medications for conditions not approved by the FDA can be used by clinicians according to their discretion but needs to be disclosed to patients at the time of prescribing. OBJECTIVES

• Discuss effective examples of how to take a sexual history • Review common female sexual dysfunctions • Learn about treatment options for female sexual problems 94% of U.S. adults feel sexual pleasure adds to quality of life

• Brunk, Family Practice News & Internal Medicine News 5/10/2013. • C. Marwick, “Survey says patients expect little physician help on sex. • Laumann, A. Paik JAMA 1999; 281.

PRINCIPLES FOR SEXUAL HISTORY TAKING

• Patients prefer that health care provider initiate topic and advise (90%) • Use simple, direct language • Compassion, honesty, normalizing statements • Declare and demonstrate lack of embarrassment • Be aware of patient’s cultural background • Ensure confidentiality • Avoid judgement and assumptions

Athanasiadis L, Papaharitou S, Salpiggidis G et al. J Sex Med 2006;3(1):47-55. Sadovsky R, Nusbaum M. J Sex Med. 2006;3(1);3-11. HOW TO CONDUCT THE INTERVIEW

• Use words and body language that put the patient at ease • Open, non-defensive body posture • Sit and maintain eye contact • Avoid nervous gestures • Choose language appropriate to age, ethnicity, and culture of patients • Practice using sexual terminology • Ask open-ended questions • Use silences to allow patients to speak

Athanasiadis L, Papaharitou S, Salpiggidis G et al. J Sex Med 2006;3(1):47-55. Sadovsky R, Nusbaum M. J Sex Med. 2006;3(1);3-11.

WHEN TO TAKE A SEXUAL HISTORY

• Health related conditions/life events • Prenatal/postpartum, infertility, visit • Chronic illness follow-up • Urological or gynecologic surgery • New patient or annual well-woman exam

Basson R. Sexuality and sexual disorders. Clin UpdatWomen's Health Care. 2003;1:1-84 BIOPSYCHOSOCIAL MODEL MEDICAL CONDITIONS CONTRIBUTING TO SEXUAL DYSFUNCTION

• Cardiovascular • Neuromuscular disorders • • Prolactinoma • Thyroid disease • Malignancy/treatment • Chronic pain • , anal, bladder, colorectal, gynecologic • Urinary incontinence • Gynecologic problems • Spinal cord injury • Cystocele, rectocele, • endometriosis, fibroids, lichen sclerosis, uterine prolapse, vulvodynia/vestibulodynia MEDICATIONS ASSOCIATED WITH SEXUAL DYSFUNCTION

• :: , , • Cardiovascular medications: , beta blockers, channel blockers, clonidine, , • Hormonal medications: (, ), hormonal contraception ( pills, patches, and rings) • Pain relievers: NSAIDS (, etc.), opioids • Psychotropic meds: antipsychotics, anxiolytics, , • Chemotherapeutic agents, inhibitors • Drugs of abuse: , amphetamines, , heroin, marijuana

Kingsberg and Woodard. Obstet and Gynecol. 2015;125:477-86 Graziottin A and Lieblum SR. J Sex Med. 2005;2:133-145. Liu-Seifert H, et al. Neuropsychiatr Dis Treat. 2009;5:47-54. Clayton A. J Sex Med. 2007;4:260-268 NON-MEDICAL FACTORS CONTRIBUTING TO SEXUAL HEALTH CONCERNS

• Co-morbid psychiatric • Trauma history concerns (e.g., ; • Sexual performance anxiety anxiety; eating disorders; chemical dependency) • Fear with resultant muscle tension and/or anxiety • Body image struggles • Distress related to medical • What it means to be a factors (systemic impact) man/woman in our culture (e.g., bilateral mastectomy) • Maladaptive relationship dynamics Pfaus JG. Pathways of . J Sex Med. 2009;6:1506-1533 Bancroft J, Graham CA, Janssen E, Sanders SA. The dual control model: current status and future directions. J Sex Res. 2009;46(2- 3):121-142. Clayton AH. Epidemiology and neurobiology of female sexual dysfunction. J Sex Med. 2007;4(supplement 4):260-268. ANATOMY AND PATHOPHYSIOLOGY THE VESTIBULE

• Lateral border is Hart’s line • Medial border is the hymen and urethra • Openings of the Bartholin’s, Skene’s, and minor vestibular glands • Derived from the primitive urogenital sinus • Different blood supply from the • Rich in receptors (Androgen receptors > receptors)

Reprinted with permission from Andrew Goldstein, MD, FACOG, IF THE CLITORIS

COTTON SWAB TEST

• Use a moistened cotton swab • Apply uniform pressure around the entire vestibule. • Outside Hart’s line • Inside labia minora • Around “clock face”(6:00 posterior) • Esp. glands and where pt. indicates pain in history COMMON FEMALE SEXUAL DYSFUNCTION PROBLEMS COMMON FEMALE SEXUAL DYSFUNCTION PROBLEMS

• Low Desire • Hypoactive sexual desire disorder • Pain with sexual activity • Female genital-pelvic pain disorder • Vulvodynia, vestibulodynia • Vaginismus/Pelvic floor dysfunction • Genitourinary syndrome of menopause • Female arousal disorder • Female orgasm disorder Johannes CB, Clayton AH, Odom DM, et al. J Clin Psychiatry. 2009;70:1698-1706.

HYPOACTIVE SEXUAL DESIRE DISORDER

Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Obstet Gynecol 2008;112: 970-978. Mayo Clin Proc. 2018;93(4):467-487. Clayton AH, Goldfischer ER, Goldstein I, Derogatis L, Lewis-D’Agostino DJ, Pyke R. J Sex Med. 2009;6:730-738.

TREATMENT OPTIONS TREATMENT OPTIONS FOR WOMEN WITH FEMALE SEXUAL DYSFUNCTION (GENERALIZED TREATMENT APPROACH)

• Address any contributing factors • Depression, anxiety, meds • , stress • Relationship problems: refer for counseling • Optimize diabetes and chronic medical conditions • Treat sexual pain if present • Lubricants that do not contain , glycerin, or propylene glycol • Vaginal Moisturizers (Luvena, Yes VM, Sylk Natural Intimate) • Localized • Lifestyle, exercise, Mediterranean diet • Refer for sex therapy Giugiano et al. J Sex Med. 2010 May:7(5):1883-90. Wing et al. Diabetes Care. June 11, 2013 LIFESTYLE AND HEALTH-RELATED FACTORS ASSOCIATED WITH SEXUAL ACTIVITY

• Increased • Decreased • Mediterranean diet • Smoking • Exercise/walking • Depression/ Somatization • Resilience • SSRI/SNRIs • Normal weight/BMI • CAD/ Inactivity • Social support • /M. Synd. (↑TGs) • Diabetes (psychosocial • Social activity factors) SSRI/SNRI= selective serotonin reuptake inhibitor/serotonin norepinephrine • Sleep difficulties reuptake inhibitor CAD= coronary artery disease • Vasomotor symptoms TG= triglycerides Met S= metabolic syndrome TREATMENT OPTIONS FOR HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD) Clayton AH et al. Mayo Clin Proc. 2018;93(4):467-487. BIOLOGICAL APPROACHES FOR LOW DESIRE

• Increase (locally and systemically) • Increase dopamine • Increase norepinephrine • Modulate serotonin • Melanocortins TREATMENT OPTIONS FOR HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD)

• Psychotherapy/sex therapy • Central nervous system agents • Flibanserin (Addyi®) for premenopausal women • (off label) • Buspirone (off label) • Hormonal agents for late peri- and postmenopausal women • Estrogen/ • (off label) • Shifren J. Menopause 2006;Davis SR. NEJM 2008, Wierman ME et al., Androgen Therapy in Women: A Reappraisal: An Endocrine Society Clinical Practice GuidelineJCEM 2014; 99(10):3489–3510

Caruso et al. J Sex Med 2012;9:2057-2065. Caruso et al., Fertil Steril 2006. Clayton, A, Hamilton D. Female Sexual Dysfunction. Obstet Gynecol Clin N Am 2009; 36. 861-876. Sayuk et al. Diabetes Care 2011 Feb; 34 ADDYI® (FLIBANSERIN)

• Indicated for the treatment of hypoactive sexual desire disorder (HSDD) in premenopausal women. • Studied in > 11,000 women • Action: • 5-HT1A and 5-HT2 • Increases norepinephrine and dopamine • Decreases serotonin • Side effects: drowsiness, , , low BP, and syncope ADDYI® (FLIBANSERIN)

• Contraindications • Alcohol – increased risk of severe and syncope • Strong or moderate CYP3A4 inhibitors (eg, , , atazanavir, etc.) • Hepatic impairment • Providers and pharmacies must be REMS certified to prescribe and dispense Addyi®. • Patients and prescribers must sign an agreement form acknowledging the risks of hypotension and syncope and that alcohol is contraindicated when taking Addyi ®. • Cost: $400+ for 1 month supply BUPROPION AND PDE-5 INHIBITORS (OFF LABEL USE)

• Bupropion increases norepinephrine/dopamine which appears to improve: , arousal, orgasm and satisfaction

• One RCT showed benefit of sildenafil in premenopausal women with type 1 DM and Cialis 5 mg qd to help with arousal, orgasm, enjoyment and decreased pain

Caruso et al. J Sex Med 2012;9:2057-2065. Caruso et al., Fertil Steril 2006. Clayton, A, Hamilton D. Female Sexual Dysfunction. Obstet Gynecol Clin N Am 2009; 36: 861-876. Sayuk et al. Diabetes Care 2011 Feb;34 ZESTRA

• Zestra (OTC) botanical oils and extracts. • “clinically proven” to improve sexual desire, arousal, and sexual satisfaction • Directions indicate to apply to the clitoris and labia 5 -10 minutes before SA. • Recommend applying to mons pubis to avoid burning sensation (14.6%, experienced mild to moderate genital burning)

Ferguson et al.Randomized, -controlled, double-blind, parallel design trial of the efficacy and safety of Zestra in women with mixed desire/interest/arousal/orgasm disorders. J Sex Marital Ther. 2010;36(1):66-86 EROS THERAPY DEVICE

• Hand held clitoral vacuum device cleared by the FDA for the treatment of female arousal and orgasm dysfunction • Designed to increase blood flow to the clitoris, enhance clitoral engorgement, and improve sexual arousal. • Works by applying a gentle vacuum to the clitoris, which increases blood flow to the area. SEXUAL PAIN

• Vulvodynia • Chronic pain or discomfort of the vulva commonly described as burning, stinging, irritation, or rawness • Localized: vestibulodynia, clitorodynia • Causes: infectious, inflammatory, neoplastic, trauma, hormonal deficiencies, iatrogenic • Pain with penetration • Pelvic floor dysfunction (vaginismus) • Increased muscle tone • Results in decreased blood flow and oxygen to the muscles of the pelvic floor • Symptoms: generalized muscle pain or burning • Genitourinary syndrome of menopause (vulvovaginal atrophy) • Vulvar disorders • Lichen sclerosus, lichen planus

TREATMENT OF VESTIBULODYNIA WITH TOPICAL AND TESTOSTERONE

Goldstein AT, Burrows L. Vulvodynia (CME). J Sex Med. 2008;5(1):5-15. TREATMENT OPTIONS FOR GENITOURINARY SYNDROME OF MENOPAUSE (AKA VULVOVAGINAL ATROPHY)

• Non-hormonal treatments • Vaginal moisturizers • Sexual lubricants • Vaginal estrogen • Vaginal DHEA (Intrarosa®) • (Osphena®)

• CO2 Vaginal laser NON-HORMONAL TOPICAL TREATMENT OF VULVOVAGINAL ATROPHY

• Vaginal Moisturizers may have similar effect as topical estrogen: • Good for women trying to avoid hormonal therapy • Rehydrates vaginal tissue • Must use regularly to be effective • Improves vaginal elasticity in mild to moderate cases - Decreases atrophy • ie. Luvena, Sylk, or Yes VM (3 times a week, takes 2-3 months) • Use lubricants for sexual activity to assist with vaginal dryness and protect against (use with vaginal moisturizer) • Recommend lubricants which do not contain propylene glycol, parabens or glycerin • i.e. Slippery Stuff, Pjur, Good Clean Love, Sutil, UberLube

VIBRATORS VAGINAL AVAILABLE FOR POSTMENOPAUSAL USE

1. Goldstein I. J Womens Health (Larchmt). 2010;19:425-432. 2. www.eMPR.com. 3. North American Menopause Society. Menopause. 2007;14:357-369 DON’T FORGET TO TREAT THE VULVA OTHER TREATMENT OPTIONS FOR GSM

• Ospemiphene (Osphena®) • A selective modulator that has favorable effects on the vulva and vagina • (Intrarosa®) • Intravaginal DHEA that is converted into active androgens and/or estrogens for intracellular activity

• Fractional CO2 Laser

• CO2 laser used to revitalize the vaginal mucosa of women with vaginal dryness. • removes damaged skin • heats upper dermis and promotes collagen growth FRACTIONAL CO2 LASER

MonaLisa Touch Laser Cleared by the FDA in December of 2014 for use in gynecologic procedures ( 2008)

CO2 laser used to improve the vaginal mucosa of women with vaginal dryness. • removes damaged skin • heats upper dermis and promotes collagen growth • Series of 3 treatments, 6 weeks apart, then yearly treatments for maintenance No/Minimal side effects MULTI-DISCIPLINARY APPROACH WORKS BEST

• Psychologists (and patients) need medical providers to address the biological components • Medical providers (and patients) need psychologists to address the psychological and social variables • If we fail to address any variable that is a significant contributing factor to sexual dysfunction, progress will be limited • Even in cases where primary initial cause is biological • A multi-disciplinary approach is essential Thank you!

If questions, please email me: [email protected]