Nurture Your Nature Inspiring Womens Sexual Wellness Association

Nurture Your Nature: Inspiring Women’s Sexual Wellness Association of Reproductive Health Professionals www. arhp. org National Women’s Health Resource Center www. healthywomen. org

Nurture Your Nature Audience Women and their health care providers (HCPs) Goals Encourage communication on sexuality issues Provide educational resources

Expert Medical Advisory Committee • Raquel Arias, MD • Gloria Bachmann, MD • Kirtly Parker Jones, MD (co-chair) • Susan Kellogg-Spadt, CRNP, Ph. D • Sheryl Kingsberg, Ph. D (co-chair) more…

Expert Medical Advisory Committee (continued) • Chris Knutson, MN, RNC • Sharon Schnare, RN, FNP, CNM, MSN • Lee P. Shulman, MD • Beverly Whipple, Ph. D, RN, FAAN

Learning Objectives • Describe two models of female sexual response • List four variables that affect female sexual function • Name two treatments for female sexual disorders more…

Learning Objectives (continued) • List two barriers that prevent effective HCP/patient communication about sexual health • List three questions to begin the assessment of sexual health during a clinical visit

Women’s Sexuality • Complex • Less studied, understood than male sexuality • Many theories and beliefs are inaccurate or outdated • Difficult to address for some Personal Issues Berman, L. Fertil Steril. 2003. Kingsberg, S. Sexuality, Reproduction & Menopause. 2004. Lack of training Time

Female Sexual Disorders: Prevalence Interest Laumann Bancroft Geiss Nazareth 31. 6% 7. 2% 28. 8% 16. 8% Lubrication/ Orgasm Total Arousal 20. 6% 25. 7% 43% 31. 2% 9. 3% 45% 23. 0% 17. 8% 48% 3. 6% 18. 9% 39. 6% Bancroft, J. Arch Sex Behav. 2003. Geiss, IM. Urology. 2003. Laumann, EO. JAMA. 1999. Nazareth, I. BMJ. 2003.

NHSLS: Sexual Difficulty is Prevalent 43% 31% Women Laumann, EO. JAMA. 1999. Men

Limitations of NHSL Survey Only yes or no answers elicited Cross-sectional design No women >60 years of age Did not measure personal distress Menopausal status not a factor Laumann, EO. JAMA. 1999.

Distress About Sex: Kinsey 2000 Survey 24% Women Bancroft, J. Arch Sex Behav. 2003. Best predictors of distress: • General emotional well -being • Emotional relationship with partner during sexual activity

Assessment of Female Sexual Problems individual Rosen, RC. Fertil Steril. 2002. Basson R. J Psychosom Obstet Gynecol. 2003.

Myths about Female Sexuality • Organic dysfunction can be meaningfully separated from psychogenic dysfunction • Awareness of internal feelings of sexual desire is primary trigger for sexual behavior • Sexual desire necessarily precedes sexual arousal more… Basson R. J Psychosom Obstet Gynecol. 2003.

Myths about Female Sexuality (continued) • Women’s arousal identified primarily by: ▪ Genital vasocongestion ▪ Vaginal lubrication ▪ Awareness of genital sensations • Women’s sexual response essentially stable and invariant across time/circumstance • All women experience distress about alterations or limitations in sexual response Basson R. J Psychosom Obstet Gynecol. 2003.

Female Genital Arousal Berman, JR. World J Urol. 2002. Kerner, I. She Comes First: The Thinking Man’s Guide to Pleasuring a Woman. 2004.

Human Sexual Response – Linear Orgasm Plateau (C) (A) lut ion (B) tion lu Reso A B C n Resolutio Excitement Re so Masters, WH. Human Sexual Response. 1966. ; Kaplan, HS. Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy. 1979.

Problems with the Linear Model Masters, WH. Human Sexual Response. 1966. ; Kaplan, HS. Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy. 1979.

Female Sexual Response - Circular Emotional Intimacy Spontaneous Sexual Drive Arousal and Sexual Desire Basson, R. Obstet Gynecol. 2001. Sexual Arousal Seeking Out and Being Receptive to Sexual Stimuli Biologic

Variables Affecting Female Response Past sexual experiences or sexual abuse Sexual self. Relationship with characteristics image and/or individual sexual partner of the risk presentation body image (male or female) Basson, R. Menopause. 2004.

Variables Affecting Female Response individual characteristics of the risk presentation Basson, R. Menopause. 2004.

Aging and Female Sexual Response Aging ≠ end of sexual interest and activity individual risk presentation Avis, NE. Menopause. 2000. ; Hartmann, U. Menopause. 2004. Bancroft, J. Arch Sex Behav. 2003.

Reasons for Decline in Sexual Activity Other Spouse unable to perform 26% 36% Death of spouse 18% 20% Illness of spouse Pfeiffer, E. Am J Psychiatry. 1972. Pfeiffer, E. J Am Geriatr Soc. 1972.

Physical Effects of Aging • Clitoris and clitoral reaction time • Vascularization and vaginal lubrication • Vaginal elasticity • Vaginal mucosa • Sex drive, sexual response, orgasm Kingsberg, SA. Arch Sex Behav. 2002. ; Bachmann, GA. Menopause. 2004. ; Whipple, B. Slide presentation. 2004.

Effects of Menopause Diminished sexual response Decreased desire Vaginal dryness and dyspareunia Menopause Kingsberg, SA. Arch Sex Behav. 2002. Basson, R. Menopause. 2004. Decreased sexual activity Dysfunctional male partner

SWAN Study: Women Ages 42 -52 79% 77% 42% Engaged in sex in past 6 months Cain, VS. J Sex Res. 2003. Rated sex moderately to extremely important Infrequent desire for sex (0 -2 x per month)

MA Women’s Health Study II Postmenopausal Women Less desire and arousal Avis, NE. Menopause. 2000. Kingsberg, SA. Arch Sex Behav. 2002. More likely to agree sexual activity declines with age

Testosterone

Mean Steroid Levels in Women (pg/ml) Reproductive Age Natural Menopause Surgical Menopause Estradiol 150 10 -15 10 Testosterone 400 290 110 Androstenedione 1, 900 1, 000 700 DHEA 5, 000 2, 000 1, 800 3, 000, 000 1, 000 Steroid DHEA-S Lobo, R. Treatment of Postmenopausal Women: Basic and Clinical Aspects, 2 nd ed. 1999. Judd, HL. J Clin Endocrinol Metab. 1974.

Premenopause Postmenopause 0. 5 10 50% 5 60% 75% 0 DHEA-S DHEA A 4 0. 25 50% 0 Testosterone Longcope, C. Ann NY Acad Sci. 1990. ; van Lunsen, RHW. Menopause. 2004. Anastasiadis, AG. Curr Urol Rep. 2002. Production Rate (mg/day) 15 ---------------------- Production rate (mg/day) Androgen Production Rates

Disease and Female Sexual Response Neurologic Disorders Endocrine Disorders • Head/spinal cord • Diabetes injury • Hepatitis • MS • Kidney disease • Stroke Vascular Disorders • Hypertension • Leukemia • Sickle-cell disease Phillips, NA. Am Fam Physician. 2000. ; Whipple, B. In: Sexual Function in People with Disability and Chronic Illness: A Health Professional’s Guide. 1997.

Disease and Female Sexual Response Debilitating Diseases • Cancer • Degenerative disease • Lung disease Psychiatric Disorders • Anxiety • Depression Voiding Disorders • Overactive bladder • Stress urinary incontinence Phillips, NA. Am Fam Physician. 2000. ; Whipple, B. In: Sexual Function in People with Disability and Chronic Illness: A Health; Professional’s Guide. 1997.

Medications Causing Desire Disorders • Psychoactive medications • Hormonal agents • Cardiovascular medications • Others Med Lett Drugs Ther. 1992.

Medications Causing Arousal Disorders • Anticholinergics • Antihistamines • Antihypertensives • Psychoactive medications Med Lett Drugs Ther. 1992.

Medications Causing Orgasmic Disorder • Amphetamines and related anorexic drugs • Antipsychotics • Methyldopa • Narcotics • SSRIs • Trazodone • Tricyclic antidepressants Med Lett Drugs Ther. 1992.

National Health & Social Life Survey • Younger age (<40) • Unmarried • Poor health • Low sexual activity or interest • Deteriorating economic status • Negative sexual experiences • Emotional and stress-related problems Laumann, EO. JAMA. 1999.

Predictors of Problems with Female Sexual Response • Health • Better a woman’s health, greater her interest in sex • Marital status • Married women had lower libidos and reduced arousal Avis, NE. Menopause. 2000.

Women’s Sexual Disorders: DSM-IV • Sexual desire disorders ▪ ▪ Hypoactive sexual desire Sexual aversion disorder • Sexual arousal disorders ▪ Orgasmic disorders • Sexual pain disorders ▪ ▪ Dyspareunia Vaginismus more… American Psychiatric Association. DSM-IV: Diagnostic and Statistical Manual for Mental Disorders, 4 th ed. 1994.

Women’s Sexual Disorders: DSM-IV (continued) • Sexual dysfunction due to a general medical condition • Substance-induced sexual dysfunction • Sexual dysfunction not otherwise specified American Psychiatric Association. DSM-IV: Diagnostic and Statistical Manual for Mental Disorders, 4 th ed. 1994.

Sexual Disorders: CCFSD Categories • Sexual desire disorders ▪ ▪ Hypoactive sexual desire disorder Sexual aversion disorder • Sexual arousal disorder more… Basson R. J Urol. 2000.

Sexual Disorders: CCFSD Categories (continued) • Orgasmic disorder • Sexual pain disorders ▪ ▪ ▪ Dyspareunia Vaginismus Other sexual pain disorders Basson R. J Urol. 2000.

Midlife Sexuality and the Clinician Personal issues Belief sexual interest declines with age Lack of treatments to offer Lack of training Clinician issues Lack of skills Lack of time Fear of embarrassing patient Berman, L. Fertil Steril. 2003. ; Kingsberg, S. Sexuality, Reproduction & Menopause. 2004.

Common Biases to Avoid Age Sexual Orientation Relationship Status Cultural Issues

Why Don’t Patients Bring Up Sexuality Issues? 100 68% Marwick, C. JAMA. 1999. 71%

General Sexual History Assessment • Are you currently involved in a sexual relationship? • Do you have sex with men, women, or both? • Are you or your partner having any sexual difficulties or concerns at this time? • Do you have any questions or concerns about sex? • Are you satisfied with your current sexual relations? Kingsberg, S. Sexuality, Reproduction & Menopause. 2004.

Extensive Questioning – Sexual Health • Tell me about your sexual history • How often do you engage in sexual activity? • What kinds of activities do you engage in? • Do you have difficulty with desire, arousal, or orgasm? Kingsberg, S. Sexuality, Reproduction & Menopause. 2004.

Male Products

Life with ED Treatment • Sexual activity may depend on health of male partner • ED treatment has changed sex for midlife couples Pfeiffer, E. Am J Psychiatry. 1972. Pfeiffer, E. Am J Geriatr Soc. 1972. Avis, NE. J Gend Specif Med. 2000. Laumann, EO. JAMA. 1999.

Communicating with Midlife Patients • Encourage patients to talk about sexuality concerns • Be open and nonjudgmental • Address as couples issue more…

Communicating with Midlife Patients (continued) • If patient desires, schedule a follow-up visit to focus on sexuality issues • Make referral as necessary more… Kingsberg, S. Sexuality, Reproduction & Menopause. 2004.

Communicating with Midlife Patients (continued) • Educate patient, particularly about changes in sexual function with aging • Be a sympathetic listener • Reassure patient • Provide literature Kingsberg, S. Sexuality, Reproduction & Menopause. 2004.

New Definitions: Women’s Sexual Interest and Desire Disorder • Absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies, and lack of responsive desire • Motivations (reasons or incentives) for attempting to become sexually aroused are scarce or absent • Lack of interest considered beyond normative lessening with life cycle, relationship duration Basson, R. J Psychosom Obstet Gynecol. 2003.

U. S. Women – Low Libido and Distress 35 30 U. S. 25 Pop. (millions) 20 2005 15 10 5 0 Menopausal status With low libido & distress 1. 8 mil NM 1. 2 mil Hysterectomy 50+ SM (Hysterectomy + Bilateral Oophorectomy) Procter & Gamble Pharmaceuticals data on file 2003

Treating Desire Disorders Evaluate/manage relationship and personal issues Treat underlying medical problems Change medication if necessary Prescribe estrogen and/or testosterone Counsel and/or refer patient and partner Kingsberg, S. Sexuality, Reproduction & Menopause. 2004. Walton, B. Curr Wom Health Rep. 2003.

Androgen Therapy • Testosterone therapies ▪ ▪ ▪ Patch Gel Oral formulations in clinical trials • Oral therapies Alexander, JL. Menopause. 2004. ; USA Today. Dec. 3, 2004 Shifren, JL. Mayo Clin Proc. 2004.

INTIMATE Trials – Testosterone Patch Simon, JA. J Clin Endocrinol Metab. 2005. Buster, JE. Obstet Gynecol. 2005.

Total Satisfying Sexual Activity – 24 Weeks 4 -week frequency change from baseline (SEM) INTIMATE SM 1 INTIMATE SM 2 P = 0. 0003 74% P = 0. 001 51% 33% Simon, JA. J Clin Endocrinol Metab. 2005. Buster, JE. Obstet Gynecol. 2005. 23% Placebo TTS

Mean change from baseline (SEM)) Desire at 24 Weeks INTIMATE SM 1 P = 0. 0006 INTIMATE SM 2 P = 0. 0006 56% 49% 29% Simon, JA. J Clin Endocrinol Metab. 2005. Buster, JE. Obstet Gynecol. 2005. 18% Placebo TTS

Phase III Transdermal Testosterone Therapy • 549 ♀ with hypoactive sexual desire disorder • Mean 54 y/o naturally menopausal • On stable doses of oral ERT/HRT • Placebo vs. transdermal testosterone patch 300 mcg/day twice weekly • 24 weeks Shifren, J. Menopause. 2004.

Phase III Transdermal Testosterone Therapy Study: Desire Intent-to- PFSF Score: Treat Mean Population Change from Baseline Placebo 4. 0 Patch Shifren, J. Menopause. 2004. 9. 8 PFSF Score: Percent Change from Baseline 20 P Value 48 0. 0001

Phase III Transdermal Testosterone Therapy Study: Distress Intent-to. PDS Score: Treat Mean Change Percent Population from Baseline Change from Baseline Placebo -11. 5 -28 P Value Patch <0. 000 1 Shifren, J. Menopause. 2004. -20. 5 -52

Alternative Treatments • DHEA • Bupropion • Nutritional remedies Spark, RF. Fertil Steril. 2002. American College of Obstetricians and Gynecologists. 2000. ; Clayton, AH. J Clin Psychiatry. 2004. Ito, TY. J Sex Marital Ther. 2001.

New Definitions: Sexual Aversion Disorder “…Extreme anxiety/disgust at anticipation of or attempt to have any sexual activity [it is a…] lifelong or acquired conditioned response” Basson, R. J Psychosom Obstet Gynecol. 2003. ; Kingsberg, SA. Handbook of Clinical Sexuality for Mental Health Professionals. 2003.

New Definitions: Subjective Sexual Arousal Disorder “…Absence or markedly diminished feelings of sexual arousal from any type of sexual stimulation…Vaginal lubrication or other signs of physical response still occur” Basson, R. J Psychosom Obstet Gynecol. 2003.

New Definitions: Genital Sexual Arousal Disorder “…Absent or impaired genital sexual arousal…Self-report may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation, reduced sexual sensations from caressing genitals…Subjective sexual excitement still occurs from nongenital sexual stimuli” Basson, R. J Psychosom Obstet Gynecol. 2003.

New Definitions: Combined Genital and Subjective Arousal Disorder “…Absence or markedly diminished feelings of sexual arousal from any type of sexual stimulation… Complaints of absent or impaired genital sexual arousal” Basson, R. J Psychosom Obstet Gynecol. 2003.

Treating Arousal Disorders More focused or direct stimulation Avoid boring or short routines Arousal disorders Vaginally administered estrogen Regular penetration Bachmann, GA. Menopause. 2004. Vaginal lubricants

Treating Arousal Disorders PDE-5 Inhibitors Mechanical Devices Alternate therapy Bachmann, GA. Menopause. 2004. Mayor, S. BMJ. 2004. Billups, KL. J Sex Marital Ther. 2001. Munarriz, R. J Sex Marital Ther. 2003. Ferguson, DM. J Sex Marital Ther. 2003. Ito, TY. J Sex Marital Ther. 2001.

New Definitions: Women’s Orgasmic Disorder “…Despite self-report of high sexual arousal and excitement, […there is] lack of orgasm, markedly ↓ intensity of orgasmic sensations, […and a] marked delay of orgasm from stimulation. ” Basson, R. J Psychosom Obstet Gynecol. 2003. Anastasiadis, AG. Curr Urol Rep. 2002. Walton, B. Curr Wom Health Rep. 2003.

Genetic Influence on Female Orgasmic Function Pairs ICC for Frequency of Orgasm During Intercourse Masturbation Monozygotic (n = 683 pairs) Dizygotic (n = 714 pairs) 31% 39% 10% 17% P = 0. 0001 Dunn, KM. Biol Lett. 2005. Basson, R. J Sex Marital Ther. 2001.

Treating Orgasmic Disorders Consider options if SSRIS Educate about/ encourage appropriate arousal Treat dyspareunia Orgasmic disorder Explain orgasms may be situational Counsel or refer to sex and relationship therapy Whipple, B. Sexual Function in People with Disability and Chronic Illness. 1997. ; Phillips, NA. Am Fam Physician. 2000. ; Anastasiadis, AG. Curr Urol Rep. 2002.

New Definitions: Dyspareunia “…Persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse. ” Basson, R. J Psychosom Obstet Gynecol. 2003.

New Definitions: Vaginismus “Persistent difficulties to allow vaginal entry of penis, finger, or object, despite woman’s expressed wish to do so…variable involuntary pelvic muscle contraction and (phobic) avoidance in anticipation of fear and the experience of pain…structural, other physical abnormalities must be ruled out or addressed. ” Basson, R. J Psychosom Obstet Gynecol. 2003.

Treating Sexual Pain Disorders Lubricants Vaginal or oral estrogen Treatment of medical conditions Sexual pain disorder Regular penetration (when/if possible) Hays, J. N Engl J Med. 2003. ; Walton, B. Curr Wom Health Rep. 2003. ; Phillips, NA. Am Fam Physician. 2000. Counseling/ education Vaginal dilators

Summary Healthy sexuality can persist into midlife

Recommendations • Place literature about sexual/marital concerns in waiting/exam rooms • Include inquires and assessment of sexual concerns in routine exams • Educate patients about common sexual problems that occur with aging • Reassure patients that sexual concerns are common

Recommendations • Recognize sexual problems may not need treatment if do not cause distress to woman • Adopt nonjudgmental attitude toward patients’ sexual disclosures/activities • Don’t assume patient is in heterosexual relationship or not sexually active • View sexual problems as couple’s concern • Partner with other health professionals

For more information • Nurture Your Nature: Inspiring Women’s Sexual Wellness: www. nurtureyournature. org • Association of Reproductive Health Professionals (ARHP): www. arhp. org • National Women’s Health Resource Center (NWHRC): www. healthywomen. org

Appendix

Expert Medical Advisory Committee Raquel Arias, MD Associate Professor, Ob/Gyn University of Southern California, Women’s Children’s Hospital Los Angeles, CA Gloria Bachmann, MD Chief, Division of General Obstetrics and Gynecology Robert Wood Johnson University Hospital New Brunswick, NJ Kirtly Parker Jones, MD (co-chair) Professor, Department of Ob/Gyn University of Utah Health Sciences Center Salt Lake City, UT more…

Expert Medical Advisory Committee (continued) Sheryl Kingsberg, Ph. D (co-chair) Associate Professor of Reproductive Biology Case Western Reserve University School of Medicine Cleveland, OH Chris Knutson, MN, RNC Public Health Nurse Consultant Family Planning & Reproductive Health Olympia, WA Susan Kellogg-Spadt, CRNP, Ph. D Director of Sexual Medicine The Pelvic & Sexual Health Institute Philadelphia, PA more…

Expert Medical Advisory Committee (continued) Sharon Schnare, RN, FNP, CNM, MSN Clinician and Consultant Women’s Health Care Olalla, WA Lee P. Shulman, MD Northwestern Memorial Hospital; Distinguished Physician and Professor; Department of Obstetrics and Gynecology; Feinberg School of Medicine Northwestern University Chicago, IL Beverly Whipple, Ph. D, RN, FAAN Professor Emerita, Rutgers University; Past-president, Society for the Scientific Study of Sexuality (SSSS); Past-president, American Association of Sex Educators, Counselors and Therapists (AASECT) Voorhees, NJ