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Sexual Dysfunctions and Treatment Options

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Sexual Dysfunctions and Treatment Options Osteopathic Overview Sexual Dysfunctions and Treatment Options By Laura Souders Dalton, DO lactinemia, breastfeeding and use of some lants—may decrease discomfort and help medications may also contribute. engorge the vaginal area. Zestra topical oil Diagnosing and treating sexual dysfunc- Some medications that may affect sex- has a small clinical trial that showed im- tions in your female patients is a complex ual desire include: antipsychotics, barbitu- provement in satisfaction and level of yet rewarding process. Fortunately, more rates, benzodiazepines, lithium selective arousal.3,4 Vaginal atrophy should be treat- media attention has led to an increased serotonin re-uptake inhibitors, tri-cyclic ed prior to using these products as they awareness of the problem and a readiness antidepressants, anti-lipid drugs, beta- may otherwise cause unpleasant burning. on the part of the patients to seek help. blockers, clonidine, digoxin, spironolac- Argin Max, a daily nutritional supple- Understanding the normal female sex- tone, danazol, estrogen therapy, GnRH an- ment has one study revealing increased de- ual response cycle has changed over recent tagonists, cort-icosteroids, H2 blockers, sire, satisfaction and number of orgasms.5 years. Basson’s nonlinear model more close- indomethacin, ketoconazole, phenytoin Evaluating placebo effect in the studies is ly explains the complexities of the female sodium, and oral contraceptives.2 difficult. There are multiple other herbal sexual experience. The cycle can be affect- Relationship problems or anger with a preparations claiming improved sexual ed by physical, social, relationship and psy- woman’s partner may also be factors. It is function, but most have no clinical trials. chological factors. Sexual satisfaction for important to help patients explore other One of the most common reasons for the female is not as easily defined as it is for problems and work on solving them to decreased desire is being in a relationship the male. Intimacy rather than orgasm may help restore her sexual desire. that is more than a year old. To help rekin- provide satisfaction. This is not an easily dle desire, couples may need to schedule measured endpoint and that makes evalu- dates. Using fantasy, erotic literature or ation of treatment options difficult. films can also be of benefit. Women with The Sexual Function Council of the compromised neurovascular supply to the American Foundation of Urologic Disease genital area may benefit from a clitoral updated the classification of female sexual therapy device, such as EROS, which has dysfunctions in 1998. The categories are received FDA approval. The EROS is a organized in a linear sequence of desire, small, battery-operated suction device—or arousal and orgasm with a category for sex- vacuum therapy—used three to four times ual and noncoital pain. per week to enhance arousal, subjective genital swelling and lubrication.6,7 HSDD Androgen therapy has been explored as Hypoactive sexual desire disorder, also re- a treatment for FSD since the 1940s. At ferred to as HSDD ICD 799.81 is the present there is no FDA-approved product most common of the disorders. It is de- on the market for women. An estrogen and fined as “the persistent or recurrent defi- methyl testosterone product is approved for ciency (or absence) of sexual fantasies, and menopausal vasomotor symptoms. Using desire for—or receptivity to—sexual activ- any androgen product currently approved ity, which causes personal distress.” The for men may give your female patients Princeton consensus diagnostic criteria Helping Your Patient super-physiologic doses, unwanted side ef- for HSDD have been and include appro- While there may be no aphrodisiac to pre- fects and even unknown long-term effects. priate symptomatology, adequate estrogen scribe, there are many ways osteopathic A transdermal testosterone patch for therapy in menopausal women and labo- physicians can help their patients, includ- women is currently awaiting FDA ap- ratory confirmation.1 ing a review of the female anatomy and proval. This patch has been shown to in- This problem may not occur in isola- normal sexual response. In addition, re- crease desire in both naturally and surgical- tion as the patient may have accompany- viewing the patient’s assessment of the ly menopausal women.8,9 ing arousal, orgasm or pain disorders. problem and her expectations for treatment Other problems such as depression, fa- are important. Arousal Disorders tigue, hypoestrogenic states, androgen Water-based lubricants and botanical Female sexual arousal disorder, or FSAD deficiency, chronic diseases, hyperpro- oils or gels—some with herbal stimu- ICD 302.72 is defined as the “inability to 4 attain or maintain adequate lubrication or arousal and sexual pleasure. Physical caus- 2. Phillips, NA et al Female sexual dysfunc- swelling with a lack of physiologic or sub- es may include vaginitis, atrophy, vulvar le- tion: Evaluation and treatment. Am Fam jective sexual arousal that causes personal sions, interstitial cystitis, PID, endometrio- Physician 2000; 62:127-36. distress.” Often, patients with FSAD have sis, perineal scarring from childbirth or an accompanying desire disorder due to anatomic alterations from pelvic surgery. 3. Foutcrouy, JL Female Sexual Dysfunc- frustration and recurrent unsatisfactory Pain on initial entry may also be due to tion: Potential for Pharmacotherapy sexual encounters. decreased lubrication or vulvodynia. Deep Drugs (2003) 63(14): 1445-1457. Sildenafil citrate has been shown in penetration pain may also be related to the some studies to improve smooth muscle re- partner’s thrusting technique. Any chronic 4. Ferguson, DM Randomized, Placebo- laxation and vasocongestion of the clitoris pelvic pain syndromes should also be treat- controlled Double-blind Crossover Design and vagina. Sexual function was improved ed with medications, physical therapy, Trial Of the Efficacy and Safety of Zestra in patients with FSAD without HSDD. relaxation techniques and possible counsel- for Women* in women with and without The dose was 50 mg one hour prior to sex- ing. There is often a history of physical and Female Sexual Dysfunction J of Sex and ual activity. This is not an FDA-approved sexual abuse in women with chronic pelvic Marital Therapy (2003) 29(s): 33-44. therapy for women and has the same side pain. effects found in male patients. Heart dis- 5. Das, AK; Thomas, Y et al A Double- ease and nitrate use are contraindications Final Notes blind Placebo-controlled Study on Argin- to using this medication.10,11 Understanding of the female sexual re- Max*, a nutritional Supplement for En- Arousal difficulties may also be helped sponse and definitions of the related disor- hancement of Female Sexual Function J with vibratory or static massagers, self- or ders has certainly improved over recent Sex and Marital Therapy (2001) partner clitoral stimulation. Patients often years. The next few years should bring a look to their physicians for information whole new spectrum of treatment options 6. Billups, KL; Berman, L et al A New and “permission “ to explore these options. for FSD. Non-pharmacologic Vacuum Therapy for We all should encourage open commu- Female Sexual Dysfunction J of Sex and Orgasmic Disorders nication and offer nonjudgmental support Marital Therapy (2001) 27: 435-441. Female orgasmic disorder (ICD 302.73) is and education. Develop a team approach the “persistent delay or absence of orgasm to treatment including physicians and sex- 7. Wilson, SK; Delk, JR et al Treating following a normal arousal phase.” ual counselors. Recognize there may be Symptoms of Female Sexual Arousal Dis- Patients with female orgasmic disorder available treatments for your patients that order with the Eros- Clitoral Therapy De- tend to have more sexual guilt and negative will not have FDA approval due to the vice JGSM (2001) 4 (2): 54-58. sexual attitudes, and they fear a loss of con- complex nature of studying FSD. trol. Some of the treatments already de- 8. Shifren, JL, Braunstein, GD et al Trans- scribed may help these patients along with Note: Brand names are used only when no dermal Testosterone Treatment in Women psychotherapy or sexual therapy. Adjust- generic name is available. with Impaired Sexual Function After Oo- ment in medication type or dose may be pherectomy NEJM (2000) 343(10): 682- especially important in patients on psy- Laura Souders Dalton, DO, practices gyne- 688. choactive or neurotropic medications. cology and gynecologic surgery at Methodist Hospital Division of Thomas Jefferson Uni- 9. Simon, JA Emerging treatment strategies Aversion Disorder versity Hospital in Philadelphia, Pa. She is a for menopausal women with HSDD: the Female sexual aversion disorder (ICD clinical instructor at Thomas Jefferson Uni- role of testosterone therapy Contem ObGyn 302.9) is characterized by a phobic aver- versity and volunteer faculty for the Univer- (Suppl) 2004: 18-23. sion, generalized or situational, in sexual sity of Medicine and Dentistry of New Jersey situations. The phobic nature of this disor- School of Osteopathic Medicine. She serves on 10. Basson, R Female Sexual Response: der usually demands counseling that may the Board of Trustees of ACOOG and has The Role of Drugs in the Management of be outside the realm of the primary care presented sexuality topics at national and Sexual Dysfunction Ob Gyn (2001) 98(2): physician, so referral is appropriate. regional meetings. 350-353. Pain Disorders References 11. Rosen, RC; Roger, ML et al Effects of Sexual pain disorders include dyspareunia 1. Bachmann G, Bancroft J, Braunstein G, SSRI’s on Sexual Function: A Critical Re- (ICD 625.0), vaginismus (ICD 625.1), et al. Female Androgen Insufficiency: The view J of Clin Psychopharmacology (1999) and noncoital sexual pain (ICD 625.9). Princeton consensus statement on defini- 19(1): 67-85. ❙ ww Physiologic factors may play a large role in tion, classification and assessment. Fertil these disorders. The pain may affect desire, Steril 2002; 77: 660-665. 5.
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