FEMALE SEXUAL DYSFUNCTION

Question 1

Overview of Types of FSD

Answer 1

Desire
Hypoactive sexual desire (low libido)
Sexual aversion disorder; sexual aversion disorder, which is extreme disgust or anxiety at having any kind of sexual activity.

Arousal: in arousal disorders, there’s an inability to maintain any sexual excitement,
Subjective arousal disorders
Genital arousal disorders
Combined subjective and genital

Orgasmic
Women’s orgasmic disorders

Pain
Dyspareunia
Vaginismus: contractions or spasms when there is vaginal penetration, this can be very painful for the woman and it can make it very difficult to have sexual intercourse

Question 2

Female Sexual Response Cycle

Answer 2

• Traditional model
  a Masters and Johnson model. In this model, it’s a very linear model with discrete events. And so there was initially some desire, which goes into arousal, plateaus until the organsim happens, and then sometimes multiple organism and then there’s resolution.
• Newer models of sexual response, Basson model - more complex, xircular

Question 3

Neurotransmitters

Answer 3

Desire:
Testosterone
+
Estrogen +
Dopamine +
Prolactin –

Arousal:
Norepinephrine +
Dopamine +
Acetylcholine +
Nitric Oxide +
Serotonin –

Orgasm:
Norepinephrine+
Serotonin –
Dopamine +/-
Nitric Oxide +/-

for desire, testosterone, estrogen, and dopamine, all of positive effects on desire. Whereas prolactin has a negative effect

for arousal. Norepinephrine, dopamine, acetylcholine, and nitrous oxide all are positive effects on arousal, where serotonin has a negative effect.

because serotonin has a negative effect on orgasm as well as arousal. More commonly seen side effects, sexual side effects from SSRIs is the inability to have an orgasm

Question 4

Model for Addressing Sexual Function

Answer 4

PLISSIT model
involves 4 steps

. This model includes permission, giving patients permission to raising sexual issues. Limited information, giving patients limited information about sexual side effects of treatments. Specific suggestions, making suggestions after a full evaluation of the presenting problem. And intensive therapy referral to more intensive therapies for patients such as psychological treatments, sex therapy, or others

Question 5

Model for Addressing Sexual Function

Answer 5

The International Society for women’s sexual health came up with a process of care for assessing sexual concerns or problems in women
Step 1: Elicit the story, gather patient history
Step 2: Identify the problem
Step 3: Listen empathetically
Step 4: Referral or Assessment and
Treatment

Question 6

Treatment of FSD

Answer 6

• Treatment plan is tailored to:
• Cause of FSD
• Patient preference
• Comfort level
• Couple/relationship issues

Question 7

Treatment of FSD
Lifestyle Management
Modification of risk factors

Answer 7

Lifestyle Management:
* Balanced diet, sleep, exercise
Modification of risk factors
* Smoking cessation
* Limit alcohol intake
* Treat alcohol/illicit drug abuse
* Manage - Comorbid conditions (e.g. hypertension, DM, etc)
* Switch to drugs with less sexual side effects.

Alcohol can decrease inhibition, however, it can also affect normal function, sexual function, so limiting alcohol intake

Question 8

treatment of FSD
Psychological treatment:

Answer 8

• Cognitive behavior therapy
• Sex therapy
• Couples/relationship therapy
• Psychiatric counseling (e.g. for history of sexual abuse)
• Distraction techniques – fantasize, relaxation, etc.
  For history of sexual abuse or other traumatic events. Psychiatric counseling can be very beneficial. Distraction techniques such as fantasizing or relaxation techniques. Daydreaming can all be helpful, especially for women who may have a lot of stress or anxiety associated with their sexual function.

Mechanical devices
* Example vaginal dilators
t. This is especially helpful for women who have issues with any kind of penetration, vaginal penetration such as vaginismus

Question 9

Pharmacotherapy

Answer 9

• Vaginal estrogen therapy for
• Vaginal atrophy
• Dyspareunia
• Lubricants/moisturizers

Question 10

Testosterone Therapy in Women

Answer 10

• None of the testosterone products are approved by Health
  Canada for use in FSD.
• Transdermal testosterone patches and gels for females are
  currently being investigated.
• Transdermal patch – 150 – 300 μg/day, gel - 1%
• Generally safe and effective for up to 2 years
• Oral testosterone can lead to adverse effects on lipids (reduce
  HDL) and liver function (liver toxicity at high doses)
• Transdermal testosterone therapy preferred.

. Transdermal testosterone is preferred over oral. As the oral testosterone and woman can negatively affect lipids by reducing HDL and could cause liver toxicity, especially at higher doses.

Question 11

Testosterone Therapy in Women
* Examples of current products used

Answer 11

• Compounded transdermal testosterone
• Dose: 5 mg per day (often compounded as 0.5% or 1% creams/gels)
• Different bases used depending on compounding pharmacy
• Apply to any skin surface such as arms, abdomen or thigh
• Androgel®, Testim® - are also options, need to calculate out
  correct dose for women (5 mg/day)
• Do NOT use patches approved for men.

Question 12

Monitoring Testosterone Therapy

Answer 12

• Monitoring testosterone levels – controversial
• May be insensitive and inaccurate in females
• Most professional organizations (e.g. NAMS) do not
  recommend testosterone levels in females for efficacy
• Testosterone levels may be recommended to monitor for
  toxicity (baseline, then 4 – 6 weeks after starting)
  Free Androgen Index (FAI) = total testosterone/SHBG x 100
• Total testosterone – 0.6 – 2 nmol/L
• Free testosterone – 0.4 – 23 pmol/L

What’s most important is the free testosterone level, the amount of testosterone that is available to cause effect. And so a lot of times we would do both the total testosterone as well as the free testosterone. Number of labs will calculate out the free androgen index, which is a representation of the free testosterone. This is the total testosterone over sex hormone binding globulin. Just remember that testosterone is bound to the sex hormone binding globulin 100 times

There’s also a test called the bioavailable testosterone. And in this test they do both the free as well as the albumin bound testosterone. Remember that albumin bound testosterone is also active. So by capturing both at, captures, a better representation of the active testosterone. We don’t often do bioavailable testosterone as a woman usually have to pay for this

Question 13

Testosterone Therapy
Side effects:

Answer 13

• acne,
• hair growth,
• anger/irritability,
• deepening of the voice (not common with small doses used
  for females)

Question 14

Phosphodiesterase (PDE-5) Inhibitors

Answer 14

• Blocks PDE-5 activity: leads to accumulation of cGMP in
  clitoral corpus cavernosa smooth muscle relaxation -
  arousal
• Most studies in females have been with sildenafil (Viagra).
• Inconsistent results in studies
• Most studies have been in females with SSRI-induced
  dysfunction
• Doses: 25 – 100 mg day, overall well tolerated
• May be helpful for females with spinal cord injury
• Data with vardenafil and tadalafil are limited

Question 15

Bupropion
Dihydroepiandrosterone (DHEA)

Answer 15

• Increases sexual interest and
  arousal
• Improves SSRI-induced sexual
  dysfunction when switched to
  bupropion
• Precursor to testosterone –
  “pro-androgen” supplement
• Some efficacy data with
  adrenal insufficiency
• Not enough conclusive data
  in other populations

Question 16

Flibanserin (Addyi®)

Answer 16

• Hypoactive sexual desire disorder (low desire)
• Serotonin 1A receptor agonist and a serotonin 2A receptor 7antagonist
• The exact mechanism of how it improves sexual desire is not known.

Indicated for premenopausal women with hypoactive sexual desire
disorder
* Recently approved for postmenopausal women
* Dose: 100 mg qhs, if no response in 8 weeks then discontinue. Woman should respond within eight weeks. If there is no response, then it’s probably not gonna be effective and should be discontinued.
* Adverse effects: drowsiness, dizziness, fatigue, nausea,
hyperthermia
* Limit alcohol consumption with flibanserin – increased risk
syncope, hypotension, depression
* Drug interactions: avoid use with moderate/strong CYP3A4
inhibitors (increases flibanserin levels, can lead to hypotension,
syncope)

Question 17

CAM for FSD

Answer 17

l-arginine - produces clitoral relaxation
- often topical creams in mixture with
menthol, applied to vulva
- may cause irritation
and it may actually be the menthol that’s causing the effect, not the large adenine, but often these are done together. The only issue is that it could cause irritation.

gingko biloba - may enhance bloodflow to genitalia
- inconsistent results

yohimbine - not considered a NHP in Canada as
schedule F
- antagonizes α2-adrenergic receptors –
efficacy inconclusive
- can cause hypertension, renal failure

Multiple-ingredient products:
* Oral products
* Topical creams, massage oils