Management Of FSD
Ricardo Munarriz, MD, Rachel Pauls, MD, Noel N. Kim, PhD, Abdul Traish, PhD and Irwin Goldstein MD
excerpt from North American Clinics
Well-designed, random-sample, community-based epidemiologic investigations of women with sexual dysfunction are limited. Current data reveals that up to 76% of women have some type of sexual dysfuntion.7,35 U.S. population census data suggest that approximately 10 million American women ages 50-74 self-report complaints of diminished vaginal lubrication, pain and discomfort with intercourse, decreased arousal, and difficulty achieving orgasm. Recently, Laumann and Rosen13 found that sexual dysfunction is more prevalent in women (43%) than in men (31%) and is associated with various psychodemographic characteristics such as age, education, and poor physical and emotional health. More importantly, female sexual dysfunction is associated with negative sexual relationship experiences. Despite the high prevalence of sexual dysfunction in women, there are very few center world wide that practice a comprehensive and multidisciplinary investigation and management of sexual dysfunction in women
Management of patients with female sexual dysfunction begins with the identification and diagnosis of the problem relationships and is based on the patient self-report in conjunction with a clinical evaluation. Sexual Dysfunction in women is defined as disorders of sexual desire, arousal, orgasm and/or sexual pain, which results in significant personal distress and may have an impact on the quality of life. Although each specific condition can be separately defined in medical terms, clinically there is significant overlap in afflicted patients. The Report of the International Consensus Development Conference on Female Sexual Dysfunction classified and female sexual dysfunction into:
Hypoactive Sexual desire Disorder: persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context of the person’s life. The disturbance must cause marked distress or interpersonal difficulty to warrant a diagnosis.
Sexual Aversion Disorder: persistent or recurring phobic aversion to, and avoidance of sexual contact with a sexual partner, which causes personal distress.
Sexual Arousal Disorder: persistent or recurring inability to attain, or maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement, which causes marked distress or interpersonal difficulty. It may be experienced as lack of subjective excitement or lack of genial (lubrication/swelling) or other somatic responses.
Female Orgasmic Disorder: persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal, and causes personal distress.
Sexual Pain Disorders:
Dyspareunia: recurrent or persistent genital pain associated with sexual intercourse
Vaginismus: recurrent or persistent involuntary spasm of the musculature of the outer third the vagina that interferes with vaginal penetration, which causes personal distress.
Other sexual pain disorders: Recurrent or persistent genital pain induced by non-coital sexual stimulation.
In some cases, it may be necessary for physicians to carefully inquire about sexual functioning paying special attention to the sensitivity of the topic and to the patient’s comfort levels. Validated sexual questionnaires, such as the Female Sexual Function Index and the Sexual Distress Scale may be helpful tools in the evaluation of sexual function. The cornerstone of the patient evaluation is a comprehensive and detailed sexual, medical and psychosocial history, physical examination and focused laboratory testing. Specialized diagnostic tests such as biothesiometry or genital vascular studies (duplex Doppler ultrasound, although not always indicated, may corroborate the impressions discovered on the initial evaluation. It should be stressed that the secondary psychologic reaction to these organic factors must not be ignored.
Sexual, Medical and Psychosocial History
A detailed and comprehensive sexual history should include past and present assessment of sexual desire (libido), arousal and orgasmic capabilities. In addition to physiologic sexual responses, overall sexual satisfaction should also be assessed.
The medical history should include focused questions on the patient’s medical illness (chronic/medical illness (e.g. diabetes, anemia, renal failure), neurological illness (e.g. spinal cord injury, multiple sclerosis, lumbosacral disc disease), endocrinologic illness (e.g. hypogonadism, hyperprolactinemia, thyroid disorders), atherosclerotic vascular risk factors (e.g. hypercholesterolemia, hypertension, diabetes, smoking, family history), medications/recreational drug use (e.g. antihypertensives, antidepressants, alcohol, cocaine), pelvic/perineal/genital trauma (e.g. bicycling injury), surgical (e.g. hysterectomy, laminectomy, vascular bypass surgery) and psychiatric history (e.g. depression, anxiety).
Given the personal, interpersonal, social and occupational implications of sexual problems, a brief psychosocial history is mandatory in every patient. Current psychological state, self-esteem, history of sexual trauma/abuse as well as past and present relationships and social and occupational performance should be addressed.
Physical Examination
A Careful and systematic examination of the external genitalia using magnifying surgical loops and Q-tip evaluation of the external genitalia may confirm aspects of the medical history (e.g. vestibular adenitis and neuropathies), and occasionally reveal unsuspected physical findings such as para-clitoral neuromas responsible for the patient’s sexual dysfunction.
In addition, a detail vascular, and neurologic examination
Laboratory Testing
Laboratory testing is strongly recommended. Standard serum chemistries, CBC and lipid profiles may elucidate vascular risk factors such as hypercholesterolemia, diabetes, and renal failure. Serum TSH determination may be indicated in select cases.
The integrity of the hypothalamic-pituitary-gonadal axis should be examined in every patient with sexual dysfunction. Adrenal and ovarian androgens, estrogens and FSH and LH testing are strongly recommended. It is unclear which testosterone assay (total, free and bioavailable) is the best; however there is a consensus that at least one of these assays should be performed. Total androgen production is best reflected by the total testosterone, but the available testosterone is best measure d by free testosterone value, as determined by equilibrium dialysis. Whenever total or free testosterone are measured, the value of circulating sex steroid binding globulin (SHBG) has to be taken into consideration. Testosterone values should be ideally determined in the morning and in mid-third of the menstrual cycle, but this recommendation makes clinical practice extremely difficult.
Although pituitary adenomas are a rare cause of sexual dysfunction, this potentially life-threatening disease and reversible cause of sexual dysfunction should not be forgotten.
Patient/Partner Education
Patient and partner education is a critical component in the diagnosis of female sexual dysfunction and should be carried out whenever possible. The results of the history, physical examination, laboratory testing, and the need for additional diagnostic testing should be reviewed in detail with the patient and her partner, and if indicated, appropriate referrals should be made. Patient and partner education not only facilitates physician-patient-partner communication, but also enhances patient compliance and treatment adherence.
Specialized Diagnostic Testing
Diagnostic modalities such as duplex Doppler ultrasound, vaginal and clitoral temperature and vibration sensory testing, selective pudendal arteriogram expand the physician and patient understanding of the pathophysiologic mechanisms, but disadvantages such as invasiveness, cost, the associated risks and complications, and lack of normative data have limited the use of specialized testing.
Vaginal and clitoral warm, cold, and vibratory sensory thresholds can be reliably measured with a Thermal Sensory Analyzer/Vibratory Sensory Analyzer system (TSA-3000 and VSA-3000; Medoc, Israel) and compared to currently available validated normograms, allowing quantitative neurologic assessment of the female genitalia. This non-invasive valuable diagnostic tool and has been proven helpful in the management of women with sexual dysfunction.
Non-invasive vascular testing of women with sexual dysfunction has been reported by several investigators. These include vaginal photoplethysmography and genital duplex Doppler ultrasound. Vaginal photoplethysmography, the most widely used vascular testing technique, measures vaginal mucosal engorgement and vaginal blood volumens providing quantitative data on the extent of vaginal vasocongestion. 31-34. The major drawbacks of this diagnostic tool is that it provides arbitrary rather than absolute units of measurement. In addition, it is susceptible to subject movement artifact and baseline drift.
The role of duplex Doppler ultrasonography in the management of women with sexual dysfunction remains to be determined. Although several investigators have reported small patient series using duplex Doppler ultrasound before and after stimulation (visual and vibratory) as a diagnostic tool in females with sexual dysfunction, there is no standardized ultrasonographic technique to maximize diagnostic information. We routinely obtained volumetric and hemodynamic data before and after audio-visual-sexual stimulation by placing an 11 MHz small parts probe on the side of the clitoris. Clitoral shaft diameter is measured from the medial tunica albuginea of the corpoal body across the septum to the lateral tunical albuginea of the contralateral corporal body. The angle of the clitoral shaft formed by the suspensory ligament is the sonographic landmark used for volumetric measurements. Maintaining this sonographic landmark, the small parts probe is then swept laterally to evaluate the hypoechoic, ill-defined, carrot-shaped corpus spongiosum that possesses a thin, occasionally-visualized tunica and a corpus spongiosun diameter is measured. Hemodynamic data (peak systolic, end diastolic and resistive index values) from the corpus spongiosum and cavernosal arteries are measured. We have found that the increase in pre- and post-arousal clitoral and corpus spongiosum diameters directly correlated with an increase in both the pre- and post-arousal clitoral and corpus spongiosum end diastolic velocity values suggesting that end-diastolic velocity values have an important physiologic implication as a direct determinant of genital engorgement. One of the limitations of the current ultrasonographic methodology is the lack of standardized use of topical vasoactive agents to maximize genital smooth muscle relaxation. Several investigators are performing genital duplex Doppler ultrasounds before and after audio-visual-sexual stimulation in combination with topical application of 2% alprostadil with more consistent hemodynamic and volumetric data.
Indications for Referral
Physicians with appropriate training in sexual medicine should manage the vast majority of women with sexual dysfunction. However, there are several indications for referrals:
1.- Young patients with presumed pure cavernosal artery secondary to pelvic/perineal trauma. These patients may be candidates for curative vascular reconstruction.
2.- Patients with anorgasmia due to traumatic pudendal neuropathy.
3.- Patients with genital pain due to neuromas, vestibular adenitis myofascial pain syndrome, etc
3.- Patients with aortic aneurysm or bulbosacral disc disease that requires vascular or neurosurgical intervention.
4.- Patients with complicated endocrinopathies such as hypogonadism and pituitary adenoma.
5.- Patients with complicated psychiatric or psychosexual disorders (e.g. refractory depression, transsexualism).
6.- Patient or physician request for specialized evaluation.
7.- Medico-Legal reasons (occupational or iatrogenic injuries)
Modifying Reversible Causes
Health professionals should work with patients to modify reversible causes of female sexual dysfunction such as psychogenic FSD, hormonal imbalances, hyperprolactinemia, specific drug-related FSD (e.g. SSRIs), cavernosal artery insufficiency secondary to blunt perineal trauma and anorgamia due to pudendal neuropathy
Androgen insufficiency in women with sexual dysfunction is characterized by diminished libido, arousal and orgasmic capabilities, in the presence of adequate estrogen values and androgen values either below or in the lower quartile of the physiologic range. These women should undergo androgen therapy (formerly known as androgen replacement therapy or androgen supplementation) where the clinical goal is to restore androgen values to the upper half of the physiologic range. Unfortunately, there are no FDA approved androgen preparations for the management of androgen insufficiency in women with sexual dysfunction and the currently available testosterone preparations for men are associated with supra-physiologic androgen levels and significant side effects in women. We replace androgens in women with sexual dysfunction and androgen insufficiency with 50 mg of dehydroepiandrosterone. This treatment modality is capable of improving sexual desire, arousal, and orgasmic capabilities in 50 to 70 of women with sexual dysfunction and androgen insufficiency. Women with sexual dysfunction and androgen insufficiency who desire to undergo androgen therapy should undergo routine breast examination and mammograms if indicated. In addition, hematocrit, liver function tests and a lipid profile should also be determined prior to androgen replacement therapy and repeated periodically.
The treatment of hyperprolactinemia in women with sexual dysfunction consist of 1) the cessation of medication causing hyperprolactinemia (e.g., estrogens, _-methyldopa), 2) the administration of bromocryptine, or 3) the surgical ablation or extirpation of a pituitary prolactin-secreting tumor.
Psychotropic agents such as SSRIs, neuroleptics, and antipsychotics, have been associated with sexual dysfunction in women. In addition, LH-RH agonist and anti-androgens, commonly used in the treatment of endometriosis, infertility, uterine fibromas, are also associated with sexual dysfunction.
Patients with destructive behaviors, alcoholism, cigarette smoking, and recreational drug use, should be counseled on the potential etiologic role of these factors in FSD.
Although cavernosal artery insufficiency due to blunt perineal trauma is a reversible cause of erectile dysfunction in men, we have not yet made this diagnosis in woman with sexual dysfunction. It may be that because clitoral rigidity is not necessary for sexual activity, women.
Genital pain is a highly prevalent, incapacitating and devastating condition associated with significant personal distress and diminished quality of life. Careful genital examination may allow for surgical correctable pathology such as neuromas, vestibular adenitis, etc.
FIRST LINE THERAPY
First-line interventions, characterized by ease of administration, reversibility, non-invasive nature, and low cost, include oral erectogenic agents (e.g. sildenafil, apomorphine, oral phentolamine), vacuum erection devices, and psychosexual or couples therapy.
Oral Vasoactive Agents
The introduction of sildenafil in 1998 revolutionized the management of men with erectile dysfunction 38and empowered women with sexual dysfunction to seek medical attention. This potent and selective PDE 5 inhibitor, which blocks the hydrolysis of cGMP, enhances the accumulation of cGMP, and potentiates the relaxant effects of NO in the clítoris , it is not currently FDA-approved for use in women. Sildenafil has been utilized in the treatment of women with sexual arousal disorders with mixed results 4,11 Clinical studies evaluating efficacy and safety of this drug in women are currently in progress.
Phentolamine is a 1 and 2 adrenergic antagonist which decreases adrenergic tone, thus facilitating vasocongestion and delaying detumescence. Topical application of phentolamine increases vaginal blood flow and subjective responses of sexual arousal in postmenopausal women with arousal disorders and on hormonal replacement therapy. (Rubio et al.)
Apomorphine is a central dopamine agonist known to induce mild to moderate penile erection in men. 139.
PGE1: the simplicity, noninvasiveness, and safety of topical administration of vasoactive agents is ideal for the treatment of women with sexual dysfunction. Preliminary reports on the use of topical alprostadil is encouraging, but further research is needed before this agent can be established as a first line therapy agent.
Vacuum constrictive devices
Sexual Therapy: Individual or Couples
Sexual therapy addressing relationship distress, sexual performance concerns, and dysfunctional communication patterns is likely to enhance sexual functioning. It is recommended to involve both patient and partner in the sexual therapy.
Sexual therapy is also indicated and beneficial in patients or couples who desire to resume sexual activity after a prolonged period of abstinence. Lastly, sexual therapy is effective in addressing psychological reactions to the medical or surgical treatment.
Unfortunately, there are no second or third line therapies available for the management of women with sexual dysfunction.
