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SEXUAL
HEALTH ISSUES
The information provided in this
presentation was developed through the joint sponsorship of Boston
University School of Medicine and the National Foundation for Sexual
Health Medicine. It was originally developed as a continuing medical
education activity for primary care physicians. Its purpose here is
to promote human sexual health by providing information to
individuals that may be experiencing sexual dysfunction and by
encouraging these individuals to seek medical attention as these
dysfunctions may be symptoms of underlying medical conditions. The
information provided here is not medical advice nor is it meant to
substitute for an evaluation by a licensed healthcare provider.
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of Contents
GOALS
OF THIS PRESENTATION OF SEXUAL HEALTH ISSUES:
Improve information/education regarding
sexual function and dysfunction
Improve open discussion on sexual health
Improve the diagnosis and management of male
and female sexual dysfunctions by providing information to
individuals and encouraging them to seek medical attention, as many
of the problems that will be discussed have effective and safe
medical treatment options.
Society’s view of the role of sexuality in
one’s life is rapidly evolving. Since the so-called sexual
revolution in the 1960’s, people have been discussing sexuality
and sexual relationships more openly. In 1975 The World Health
Organization (WHO) declared that sex is a fundamental human right.
Sexual health provides many benefits. These are physical, emotional,
and psychological. Primary care physicians and healthcare providers
are in the “first line” medical position to identify and
address these concerns.
Why the increased interest in sexual disorders? It
can be outlined by the following:
Advances in scientific understanding of
sexual responses in men and women
Changing attitudes from clinicians and
patients
Changing demographics: people are living
longer
Availability of safe and effective oral
medications (eg. Viagra TM, Levitra TM)
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Before HIV and
Hepatitis (Pre-1980)
Primary care physicians seldom asked about
their patient’s sexual behavior
Patients rarely introduced the topic
Evaluation and treatment were often provided
by urologists or mental health professionals
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HIV/ Hepatitis Era (1980- 1998)
Increased risks from “unsafe sex”
Increased screening for sexually transmitted
diseases
Clinicians started to talk about sex
Asking, “With whom?” and “what
do you do?”
But rarely asked, “Are you satisfied?”
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Viagra Era (Post-1998)
Primary care physicians can effectively treat
men with erectile dysfunction (ED)
Physicians
need to ask their patients specific questions about sexual
functioning and satisfaction
Fact: More women than men experience sexual
dysfunction
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OVERVIEW OF SEXUAL DYSFUNCTION
Highly prevalent
True dysfunction affects quality of life
Affects both partners
Effective treatments are available
Most people can and should be treated in a
primary care setting
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MALE SEXUAL DYSFUNCTION
Disorders of libido/desire
Disorders of arousal (ED)
Disorders of ejaculation/orgasm
Other
National Health and Social Life Survey (NHSLS)
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NHSLS RESULTS- MALE: Prevalence by age
Premature ejaculation was the most prevalent
(numerous) disorder
Prevalence of low sexual desire was
positively associated with age
Men 50 to 59 years old were about 3 times
more likely to report low sexual desire compared to men 18 to 29
years old
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NHSLS RESULTS- MALE: Quality of Life
ED and low sexual desire are most associated
with diminished quality of life
Premature ejaculation does not appear to
affect quality of life, compared to control subjects
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FEMALE SEXUAL DYSFUNCTION
Disorders of desire
Sexual arousal disorder
Orgasmic disorder
Sexual pain disorders
Dysparaunia (painful intercourse)
Vaginismus (vaginal spasm)
Noncoital (non intercourse) sexual pain
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NHSLS RESULTS- FEMALE: Prevalence by Age
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NHSLS RESULTS- FEMALE: Quality of Life
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PRESENTATION OF PARTICIPATING MEN AND WOMEN
Men participatin
Most with one-dimensional problem: erectile
dysfunction (ED)
Typically with vascular (circulatory) risk
factors
Mostly older age: mid 50’s
Women participating
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WHY IS SEXUAL HEALTH RELEVENT TO PRIMARY MEDICAL
CARE?
Sexual dysfunctions and concerns are common
in men and women of all ages
Sexual health is important to the overall
health and quality of life
Sexual dysfunction may signal the presence or
progression of underlying disease
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WHY SHOULD PHYSICIANS ASK PATIENTS ABOUT SEXUAL ISSUES?
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PATIENTS WANT TO TALK ABOUT SEXUAL ACTIVITY BUT HESITATE TO BEGIN
DISCUSSION
In a survey of patients published in JAMA,1999
85% of adults would like to discuss sexual
functioning with their doctors but…
71% believe their physician would not want
or have the time to deal with sexual problems
68% of adults are concerned about
embarrassing their doctor
76% thought no treatment was available for
problems
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RECENT POPULAR PUBLICATIONS SUPPORT PREVALENCE OF SEXUAL DYSFUNCTION
AND STRESS NEED FOR TREATMENT
Newsweek feature article June 30, 2003 “No
Sex, Please, We’re Married. Are Stress, Kids, and Work Killing
Romance?”
Harper’s Bazaar, November 2003 “Are
You Too Stressed for Sex?”
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COMMON RISK FACTORS FOR SEXUAL DYSFUNCTION (SD): LIFESTYLE ISSUES
Age over 40
Smoking
Excessive alcohol use
Excess weight or obesity
Substance abuse
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MEDICAL CONDITIONS COMMONLY ASSOCIATED WITH SD
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-Anemia
(sickle cell)
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-Perimenopause/postmenopause
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-Cancer
and its treatment
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-Hypertension
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(prostate
and breast)
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-hypogonadism
(low hormone levels)
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-Coronary
artery or peripheral
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-Hypothyroidism
(under active thyroid)
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vascular(circulatory)
disease
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-Hysterectomy
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-Depression
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-Peyronie’s
disease
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-Diabetes
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-Pregnancy
and postpartum recovery
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-Endocrine
disorders
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-Trauma
or surgery to spine or pelvis
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-Hyperlipidemia
(high cholesterol)
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-Vascular
surgery
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MEDICATION OFTEN CAUSES SEXUAL DYSFUNCTION
Some include:
Anticonvulsants
Antidepressants
Antihypertensives (blood pressure)
beta blockers, diuretics
Anti-acid medication
Anti-cholesterol medication
Sedatives
Progestin-dominant oral birth control pills
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DEPRESSION: A MAJOR CAUSE OF SEXUAL DYSFUNCTION
Depression and its treatment is a major cause
of sexual dysfunction
Antidepressants such as tricyclics, MAOIs,
and SSRIs
Very few patients will report drug-induced
dysfunction unless directly asked
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PHYSICAL DISABILITIES ASSOCIATED WITH SEXUAL DYSFUNCTION
Alzheimer’s disease
Epilepsy
Multiple sclerosis
Poststroke
Traumatic brain injury
Rheumatoid arthritis
Spinal cord injury
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PSYCHOSOCIAL / INTERPERSONAL ISSUES RELATED TO SEXUAL DYSFUNCTION
Stress and anxiety
Recent changes in socioeconomic status
Partner or relationship issues
Lack of communication or emotional closeness
Lack of sexual interest on part of partner
Abuse (domestic violence, childhood abuse,
etc.)
Gender identity and sexual orientation
conflicts
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MALE SEXUAL DYSFUNCTION
Normal Male Sexual Response
Excitement (libido and desire)
Arousal (tumescence/erection)
Plateau
Orgasm and ejaculation
Resolution (detumescence)
Satisfaction
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Causes of Male Sexual Dysfunction (MSD)
Disorders of libido/desire
Disorders of arousal (erectile dysfunction,
ED)
Disorders of ejaculation/orgasm
Other:
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Characteristics of Male Sexual Dysfunction (MSD)
Age alone is a risk factor
Normal physiologic changes may affect
libido, erectile response, and ejaculation
Testosterone levels decrease with age, and
this may decrease libido
Refractory period before re-arousal
lengthens
Direct tactile stimulation of penis may be
needed
Increase in average life expectancy leads to
increased incidence of sexual dysfunction
People often misunderstand normal changes
that occur with age and should be educated
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Risk Factors Associated With MSD
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-Alcohol
abuse
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-Hypertension
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-Anemia
(sickle cell)
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-Hypogonadism
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-Coronary
artery disease or
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-Obesity
and low levels of activity
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peripheral
vascular disease
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-Peyronie’s
disease
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-Depression
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-Smoking
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-Diabetes
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-Trauma
or surgery to the pelvis or spine
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-Drug
abuse
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-Vascular
surgery
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-Endocrine
disorders
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-Hyperlipidemia
(high cholesterol)
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Medications Are Associated With MSD
As many as 25% of cases of ED(erectile
dysfunction) are related to medication side effects
Antihypertensives
Alcohol
Antiandrogens
Illicit drugs
Psychiatric medications (antidepressants,
antipsychotics)
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Importance of Detecting MSD
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Decreased Libido/Desire Disorders
Diagnosis and Treatment
What is Libido/Desire?
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Causes of Low Desire
Low testosterone levels (<300 ng/dL),
elevated prolactin
Age-related (>50) or drug-induced
examples: SSRIs,
Also associated with:
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Decreased Libido: Diagnosis
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Decreased Libido: Treatment
If hypogonadal and testosterone replacement
is indicated
If loss of libido is caused by depression
If caused by ED (erectile dysfunction)
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Erectile Dysfunction: Diagnosis and Treatment
Male Sexual Dysfunction: ED
ED is defined as the inability to attain and
or maintain penile erection sufficient for satisfactory sexual
performance (NIH, 1993)
Up to 30 million men in the USA may be
affected (NIH,1993) and over 600,000 new cases annually
Can be successfully treated in virtually all
cases
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Psychogenic and Organic ED
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Psychogenic Causes of ED
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Signs of Psychogenic ED
Young age with abrupt onset
Partner-specific ED
Dysfunctional situation
Rigid nocturnal/morning erections
Normal self induced erections
Difficulty coping with stress
Depression, psychosis, or anxiety
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Treatment Options for ED
Medication and lifestyle changes
Psychosocial counseling
Hormone replacement
Oral medication: Sildenafil (viagra TM),
Vardenafil (levitra TM) Pending FDA approval Tadalafil (cialis TM)
Vacuum constriction devices
Injectable medication
Penile implants
Vascular surgery
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Please note both of these medications listed
above are now available by prescription
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Please note this medication is now
available by the registered name: Levitra
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Male
Sexual Dysfunction
Ejaculatory Disorders: Diagnosis and Treatment
MSD: Ejaculatory Disorders
Ejaculatory disorders: most common male
sexual dysfunction
Premature ejaculation: most common
ejaculatory disorder (70%)
Delayed ejaculation: unusual but not rare
(~8%); may be drug-induced
Inability to ejaculate/achieve orgasm: may be
drug-induced
Diminished ejaculate volume: commonly
age-related
Retrograde ejaculation
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Premature Ejaculation
Persistent or repeated ejaculation with
slight stimulation before, on, or shortly after vaginal penetration
and before he wishes it
Either life-long or acquired
Primarily psychologically/behavior based
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Premature Ejaculation: Role of Psychosexual Counceling
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Premature Ejaculation: Drug Treatment
Medication with side effects that retard
ejaculation
Topical anesthetics (lidocaine, herbs,
certain condoms)
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Delayed Ejaculation: Causes
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Delayed Ejaculation: Diagnosis
Determine cause
Psychological: fear of pregnancy, affection;
religious orthodoxy; sexual orientation issues
Medical: neurological disorder (multiple
sclerosis); alcoholism; medications
Unknown cause
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Delayed Ejaculation: Treatment
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Special Concerns with Special Populations
Prostate Cancer and MSD
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Depression and MSD
A bi-directional problem (one may cause the
other)
Significant numbers of untreated depressed
men experience sexual dysfunction(40%- decreased interest in sex;
50%- arousal difficulties; 20%- erectile difficulties)
Many commonly used antidepressants affect
sexual function and desire
Double-blind studies have established that
buspirone 60 mg daily or sildenafil 50mg per day can reverse SSRI
induced sexual dysfunction
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Sexual Functioning Post-Myocardial Infarction
After myocardial infarction patients
frequently have impaired sexual function
Psychological distress is a primary factor
often due to safety concerns
Few patients have specific cardiac reasons
for limiting sex
In
stable post-MI cases, most may resume sex after 6 weeks and
after consulting with
their doctor
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Evolving Concepts in Female Sexual Dysfunction
Female Sexual Response
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Female Sexual Dysfunction (FSD):INTRODUCTION
FSD is characterized as a disturbance in, or
pain during, the sexual response cycle
Female sexual dysfunction is a widespread
problem,affecting 25% to 63% of women in the US
More difficult to diagnose and to treat in
women than in men
Until recently, a well-defined, accepted
diagnostic framework for FSD did not exist
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Female Sexual Dysfunction (FSD): Classification (1)
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FSD: Classification (2)
Orgasmic Disorder
Sexual pain disorders
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FSD: Classification (3)
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FSD:
Subtypes
Lifelong versus acquired
Generalized versus situational
Organic, psychogenic, and mixed
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NHSLS Results: Female Sexual Dysfunctional
Prevelence of FSD by Age
Tends to decline with age, unlike prevalence
of sexual dysfunction in men
Lubrication difficulties exhibit age related
increase in women
Study limitations:
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NHSLS Results: FSD and Quality of Life
Quality of Life
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NHSLS Results: FSD
Marital status
Being married had a positive effect
on interest in sex and the ability to achieve orgasm
Lubrication was the only area in which
married women reported more problems than unmarried women
Response to pleasure in sex and pain during
intercourse
The never married women had the fewest
problems
Those who were divorced, widowed, or
separated had the most problems
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Impact
of FSD
FSD has the potential for serious, lasting
negative effects on a woman's lifelong
Many women suffer in silence and do not
realize treatments are available
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FEMALE SEXUAL DYSFUNCTION
CAUSAL
FACTORS
Factors in the Female Sexual Response
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FSD: Vascular Causes
Iliohypogastric/pudendal
arterial bed circulation problems
Clitoral and vaginal insufficiency
(dysfunction)
Hypertension
Coronary artery disease
Previous myocardial infarction(heart attack)
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FSD: Neurogenic Causes
Pudendal sensory
and motor nerve problem/injury
Autonomic (involuntary) nervous system
dysfunction
Spinal cord injury, central and peripheral
nerve damage
Multiple sclerosis
Peripheral neurapathies (common in Diabetes)
Stroke
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FSD: Endocrine Causes
Endocrine disorders
Diabetes
Hyperprolactinemia
Thyroid disorders
Adrenal disorders
Hormone disorders
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FSD:Gynecological Causes
Recurrent
cystitis(urinary tract infections)
Sexually transmitted diseases
Postpartum (after pregnancy/delivery) states
and breastfeeding
Hysterectomy and oophorectomy
Perimenopausal and postmenopausal states
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FSD: Other Medical Causes
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FSD: Psychogenic Causes
Intrapersonal conflicts
Religious taboos, social or cultural
restrictions, guilt
Abandonment, trust, control,and safety
issues
Interpersonal conflicts
Relationship conflicts
Poor communication
Sexual history
Stressors
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FSD: Role of Androgens
Androgens (testosterone) appear to be
important in female sexuality
Decline in androgens parallels increasing age
in late reproductive years (30+)
Declining levels contribute to decline in
sexual desire, arousal, and orgasm
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FSD: Role of Estrogens
Estrogen deficiency leads to marked genital
atrophy (degeneration)over time,while difficulty with lubrication
occurs rapidly
Genital atrophy and decreased lubrication
lead to sexual dysfunction
Estrogen replacement therapy (ERT) correlates
positively with sexual activity and desire in postmenopausal women
Early administration of ERT may prevent
irreversible changes to the urogenital tract
ERT must
be discussed with a physician
before starting to evaluate risks (increased occurance of
breast cancer and possibly heart attack/stroke) versus benefits
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FEMALE SEXUAL DYSFUNCTION
ASSESSMENT
FSD Assessment: History
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FSD Assessment: Physical Exam
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FEMALE SEXUAL DYSFUNCTION
TREATMENT
Behavioral
Therapy
Sensation focus excersizes
Masterbation training
Use of dilators (“dildos”)
Kegel excersizes
Biofeedback
Direct pelvic floor massage (vibrators)
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Estrogen Replacement
May be indicated for postmenopausal women
Improves clitoral sensitivity, increases
libido, decreases pain with intercourse
Topical therapy relieves pain and dryness
(postmenopausal)
Estradiol ring
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Androgen Replacement
Androgen (testosterone) insufficiency
characterized by
May be indicated in postmenopausal women and
premature ovarian failure
Conflicting reports with younger
premenopausal women
May improve desire, pleasur, well-being
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Androgen Replacement:Potential Side Effects
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Therapy with DHEA
DHEA and DHEA-S: adrenal precursors to
testosterone
OTC DHEA 50-100mg
May be useful in pre and postmenopausal women
Positive response in small study
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Therapy with PDE Inhibitors( Viagra TM)
Promotes clitoral
and vaginal smooth muscle (involuntary) relaxation and vasodilation
Genital not subjective , arousal
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Therapy with EROS-CTD (Vacuum Clitoral Stimulator)
Vacuum therapy device by prescription
Hand-held, battery operated
Small, soft plastic cup over clitoris
Gentle vacuum creates increased genital
blood flow
Promotes engorgement and lubrication
Improves orgasmic response and sexual
satisfaction
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Prevalence of Sexual Dysfunction with SSRI'S (Antidepressants)
25% spontaneous report
Fluoxetine 54%
Sertraline 56%
Fluvoxamine59%
Paroxetine 65%
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SSRI-Induced Sexual Dysfunction: Management Options for
Physicians
Dose reduction
Wait for tolerance to medications
”Drug Holidays”:skip doses on
days sexual activity planned (Must be discussed with phyician
before initiating this option)
Sexual dysfunction-sparing medications
Buproprion
Nefazadone
Mirtazapine
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Orgasmic Disorder: Treatment Options
Counseling to:
Estrogen/androgen replacement in some
patients
If due to medication: consider changing
therapy
Consider referal to sex therapist
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Sexual Pain Disorders: Treatment Options
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The information provided in this
presentation was developed through the joint sponsorship of Boston
University School of Medicine and the National Foundation for Sexual
Health Medicine. It was originally developed as a continuing medical
education activity for primary care physicians. Its purpose here is
to promote human sexual health by providing information to
individuals that may be experiencing sexual dysfunction and by
encouraging these individuals to seek medical attention as these
dysfunctions may be symptoms of underlying medical conditions. The
information provided here is not medical advice nor is it meant to
substitute for an evaluation by a licensed healthcare provider.
Table
of Contents
|
