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Home , Premature ejaculation

Sex Med Update 2017: What‘s COMING?

FMF Montreal Nov 2017 Who’s the real “dr j” ? Ted Jablonski MD CCFP FCFP

Associate, Crowfoot Village Family Practice, Calgary AB

Medical Lead Calgary Foothills PCN

Clinical Assistant Professor, University of Calgary, Department of Family Medicine

Clinical Associate - Men’s Sexual Health Clinic SAIU (Southern Alberta Institute of , RVH Calgary)

Medical Director Jablonski Sexual Health and Wellness CFPC CoI Templates: Slide 1 Faculty/Presenter Disclosure

Faculty: • Dr Ted Jablonski MD CCFP FCFP #91934 Conflict of Interest Declaration / Disclosure 2017

• Relationships with commercial interests: • Principal Investigator (2015 – 2017) Principal Investigator in Clinical studies funded by Pfizer, Lilly, Cortria

• Speaker’s Bureau, Advisory Board Honoraria, Media Abbott Laboratories, AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Edelman, Eli Lilly, GlaxoSmithKline, Janssen- Ortho, Lundbeck, Merck Frosst, Novartis, Paladin labs, Pfizer, Sanofi- Aventis, Schering, Servier, Shire, Solvay, Takeda, Valeant, Watson and media companies Antibody, CTC Communications, Edelman, mdBriefCase, MedPlan, Meducom, RxMedia , Science and Medicine CFPC CoI Templates: Slide 2 Disclosure of Commercial Support

• This program has not received financial support

• This program has not received in-kind support

• Potential for conflict(s) of interest Commercial products for companies that I have worked for on clinical studies, advisory boards, CHE development and CHE presentations will be mentioned including on, and some “off label” uses of pharmacotherapies CFPC CoI Templates: Slide 3 Mitigating Potential Bias

Within the discussion of any medical diagnosis I will mention non-pharmacologic and pharmacologic therapies that are of use, compare and contrast them and discuss the pros and cons of each, presenting the information in the most non- biased way possible. RELAX and ENJOY… (perchance to learn)

You have full access to this powerpoint presentation and there are notes attached which provide a lot of detail including many references / links OBJECTIVES

• Define an approach to in primary care / family medicine

• Manage key topics in Male / Female / LGBTQ + sexual health

• Describe a few unique or controversial sexual health issues of 2017

WHO says…… “Sexual health is a state of physical, emotional, mental and social wellbeing in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity.

Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.

For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” SEXUAL MEDICINE

• Definition

• Place in FP / role of FP

• What’s “NORMAL”?

• Is sometimes NOT that SEXY

• Can be challenging (ESL,religious beliefs, cultural differences)

MEN’S SEXUAL HEALTH NORMAL

Penile size Time to Latency phase Frequency of activity Normal Post vasectomy

• The average measurements were: • Flaccid length 9.16 cm (3.61 in.) • Flaccid stretched length 13.24 cm (5.21 in.) • Erect length 13.12 cm (5.17 in.) • Flaccid girth or circumference 9.31 cm (3.67 in.) • Erect circumference 11.66 cm (4.59 in.) MEN’S SEXUAL HEALTH

•Are you satisfied with your SEX LIFE? COMMON MALE SEXUAL DYSFUNCTIONS

LIBIDO EJACULATION

And other… PENIS PELVIC FLOOR NEUROENDOCRINE - T LOW LIBIDO LOW LIBIDO

PEARL 1. Low T 2. 3. HYPERSEXUAL DISORDER HYPERSEXUAL DISORDER

PEARL aka SEX ADDICTION 1. OCD/addictions 2. Counselling / rehab 3. Naltrexone /SSRI ERECTILE DYSFUNCTION

PEARL 1. ED = ED = ED 2. Psychogenic – situational / abrupt onset / “healthy” TREATMENT RESISTANT ED TREATMENT RESISTANT ED

PEARL 1.Pills,pills and more pills 2.Check T, ensure correct dx 3.Intracavernosal injection (Trimix) 4.Alprostadil gel (Vitaros) Still unavailable in Canada HOT in 2017 STEM CELLS

European Association of Urology. "Stem cells shown to restore erection capability in men with erectile dysfunction.”

ScienceDaily, 27 March 2017. . PREMATURE EJACULATION PREMATURE EJACULATION

PEARL 1.Most common dysfcn 2.Decrease anxiety 3.Increase 4. (Priligy) still unavailable in Canada HOT in 2017 Maxim magazine – “Gamers last longer!” • https://www.maxim.com/maxim-man/gamers-sex- research-2017-6

• The Journal of Sexual Medicine July 2017 • Volume 14, Issue 7, Pages 898–903

Less Premature ejaculation but lower sex drive……. DELAYED EJACULATION

PEARL 1.Least common 2.Decrease anxiety / serotonin 3.“personailty disorder” 4. stimulant med trial (dexedrine 5mg) PELVIC FLOOR PELVIC FLOOR

PEARL 1. Men have one… 2. “Chronic ” – think chronic pain syndrome ie pelvic floor dysfunction NEUROENDOCRINE - T NEUROENDOCRINE - T PEARL THINK Testosterone Deficiency Syndrome (TDS) Updated Canadian Guidelines CMAJ Dec 2015

1. TRT ONLY if consistently LOW and SYMPTOMATIC

2. Define primary vs Secondary HYPOGONADISM NEUROENDOCRINE - T Testosterone Deficiency Syndrome (TDS)

Updated Canadian Guidelines CMAJ Dec 2015 HOT in 2017 Testosterone Therapy Improves Cardiometabolic Function and Reduces Risk of Cardiovascular Disease in Men with Hypogonadism

• Journal of Cardiovascular Pharmacology and Therapeutics, 2017; 107424841769113

• But, but, but……. Main limitations in existing evidence

• CV safety of testosterone replacement therapy has not been proven.

• Theoretically, testosterone could possibly reduce the risk of CV events in men with proven testosterone deficiency

• Most studies are Incredibly underpowered for evaluation of clinical CV events (small sample size, short follow-up, patients at low risk of CVD)

WOMEN’S SEXUAL HEALTH

The biopsychosocial factors impacting sexual function

Mental Health Family Medical Beliefs History

Early Sexual Sexual Illness/ Function Experiences Medications

Partner Relationship Cognitions/ External Beliefs Stressors Partner’s Sexual Functioning EMOTIONAL INTIMACY

• Women are wired to need it more than men. Sex is a way of letting them express, and in fact, build intimacy

• Is important for men but is often more of a by-product of intercourse rather than a key motivator. HOT in 2017 SAPIOSEXUAL I love you for your mind………..

• Sapiosexual means getting “turned on by intelligence” so that intellectual conversation is a key part of dating and sex

• Demisexuality is when a person doesn’t feel physically and sexually attracted to another person unless they feel a deep, emotional connection to them

• http://thefederalist.com/2017/06/15/why-sexual-preferences-will-never-stop-racing-down-the-rabbit-hole/ WOMEN’S SEXUAL HEALTH

“Sexuality is such an important part of our overall health…. Do you have any concerns about your sexual health?” WOMEN’S SEXUAL HEALTH Recognizing, understanding, delineating and categorizing might be amongst the most important aspects ASK (carefully) and (carefully) LISTEN “NORMAL” • Only 25% of women consistently with penile vaginal intercourse (50% “sometimes..”)

• Relationship issues and mental health (particularly mood and anxiety disorders) contributes to

• Physically – chronic illness, medications, and menopause can have significant impact on sexual function

• Female sexual function can be ( is) very complex! Basic approach to counseling PLISSIT Model

• P: Permission – Normalize certain sexual practices • Li: Limited Information – Educate about normal aspects of arousal / need of – Medication side effects or medical illnesses • SS: Specific Suggestions – Use of topical estrogen, lubricant • IT: Intensive Therapy – Refer to Classifications of FSD

• Desire – Hypoactive sexual desire disorder - MOST COMMON – Sexual aversion disorder • Arousal – Decreased arousal • Orgasm – Difficulty achieving orgasm, • Pain – (introitus/vaginal/deep) – – non-coital pain (eg vuvlodynia) WOMEN’S SEXUAL HEALTH

1. FSIAD (combination – arousal and interest) WOMEN’S SEXUAL HEALTH

2. Orgasmic disorders WOMEN’S SEXUAL HEALTH

3. Painful disorders – female genital-pelvic pain disorder

PROVOKED / VS Unprovoked multi-disciplinary and complex Biopsycho-social construct WOMEN’S SEXUAL HEALTH PEARLS

Sexual complaints ARE COMMON occur in 40% of women (displeasure vs dysfunction)

Primary (lifelong) vs. Secondary (acquired)

Situational vs. generalized Hypoactive Sexual Desire Disorders Hypoactive Sexual Desire Disorders

PEARLS • Most common female sexual dysfunction (pervasive sexual aversion is rare) • / Relationship issues, MDD or meds (SSRIs / AAP) Hormonal / Endocrine (OCP,pregnancy,PP,BF, menopause) • Education / Counselling • Flibanserin (ADDYI)? HOT in 2017 SLEEP and SEX

• For Menopausal women - the better your sleep the better your sex • And the better your sex – the better you sleep

• http://www.cnn.com/2017/06/01/health/sex- sleep-kerner/index.html

• Menopause, January 2017 DOI: 10.1097/GME.0000000000000824 HOT in 2017 Guideline Support for Prescribing MHT Today

2013 2014 2016 2017

MHT: menopausal hormone therapy Arousal Disorders Arousal Disorders

PEARLS • Subjective (mental) and genital /physical can be a disconnected • ETOH/MEDICATION / SURGERIES • MDD / chronic illness / mp • Stress / Relationship issues • Education / Counselling Orgasmic Disorders Orgasmic Disorders • PEARLS • Stress / relationship • Penile / vaginal intercourse stats • SSRIs • Education / Counselling • Open minded / creative Pain Disorders Pain Disorders

PEARLS • Nomenclature can be confusing – Dyspareunia (introitus/vaginal/deep) – Vaginismus – non-coital pain (eg vuvlodynia) • EXAMINATION (particularly introital) • Vaginal – Atrophic / Hormornal (P only, BF, menopause) • Lubrication / Pelvic PHYSIO • Local specialists if complex HOT in 2017 RU Ready??

• Slow introduction of 2 step medical abortion pill combination (mifepristone and misoprostol) known as Mifegymiso (previously known as RU-486)

• New Brunswick, Ontario and Alberta to cover $300 private • Day #1 mifepristone, Misoprostol day#2 – expulsion 2 -3 days • Only recently available in Canada (used in 60 countries around the world for 30+ years) • MDs to take “additional training” • In Canada 95% abortion services are surgical • (prior MTX / Misoprostol off-label accounted for 4% of abortions) HOT in 2017 CE 0.45/BZA 20 (DUAVIVE)

• Pairing of conjugated estrogens (CE) and SERM bazedoxifene achieves unique pharmacologic results based on their blended tissue-selective activity profile

• Significant reduction in VMS frequency and severity, improvement in genitourinary symptoms (vulvovaginal atrophy), and significant increase in bone mineral density

• Low risk of endometrial hyperplasia, VTE, and stroke without the need for a progestin. STI / CONTRACEPTION / SEXUALITY www.sexualityandu.ca

LGBTQ HOT in 2017

HOT in 2017 Physicians vastly underestimate patients' willingness to share

• 80% of HCP believed patients would refuse to disclose • Only 10% reported they would refuse • Closing disclosure gap for lesbian, gay and bisexual community should improve care

Lau. Et al Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and . JAMA Internal Medicine, 2017; DOI: 10.1001/jamainternmed.2017.090 Do you think of yourself as: • Lesbian, gay or homosexual • Straight or heterosexual • Bisexual • Anything else? Please Specify ______• Questioning / don’t know / unsure How would you describe your sexual orientation ? HOT in 2017 LGBTQQIP2SAA HOT in 2017 Trans • TRANS MEN getting pregnant is increasing reality

• “I’ve known other transgender men who have been through this process,” he says. “I always knew it was possible … I just didn’t know if this was something I wanted to do until I met [my partner].”

• http://globalnews.ca/news/3523130/trans-dad-pregnant/ HOT in 2017 GENDER “X” on Canadian Passports

• The Ministry of Immigration, Refugees and Citizenship announced that a new gender designation, “X,” for those who don’t identify as male or female, will be available starting Aug. 31 / 2017 HOT in 2017 May 17 2016 The Trudeau government introduced on Tuesday federal legislation that would guarantee legal and human rights protection to transgender people across Canada, casting it as the latest in a Liberal tradition of human rights advancements. Passed Oct 18, 2016. passed by senate 16/06/17, royal assent 19/06/17 BILL C-16 The purpose of this Act is to extend the laws in Canada to give effect, within the purview of matters coming within the legislative authority of Parliament, to the principle that all individuals should have an opportunity equal with other individuals to make for themselves the lives that they are able and wish to have and to have their needs accommodated, consistent with their duties and obligations as members of society, without being hindered in or prevented from doing so by discriminatory practices based on race, national or ethnic origin, colour, religion, age, sex, sexual orientation, gender identity or expression, marital status, family status, disability or conviction for an offence for which a pardon has been granted or in respect of which a record suspension has been ordered Gender vs Sexuality

97 Gender identity

What is your current gender identity? (Check all that apply) • Male • Female • Female-to-Male (FTM)/Transgender Male/Trans Man • Male-to-Female (MTF)/Transgender Female/Trans Woman • Genderqueer, neither exclusively male nor female • Additional Gender Category/(or Other), please specify ______• Decline to Answer

• What sex were you assigned at birth on your original birth certificate?

(Check one)  MALE  FEMALE  Decine to answer 

98 LGBTQ+

• Lesbian, gay, bisexual, and transgender patients are at increased risk of suicide, eating disorders, substance misuse, and breast and anal cancer

• Fear and lack of knowledge by both providers and patients can lead to suboptimal or no provision of health care

• Practitioners need to improve awareness and take steps to create an open, nonhostile environment

• Community outreach, education, and research are necessary to attain optimum health care for this population Q+A THANKS [email protected]