Hi, good morning everyone. Pleasure to be here today. We're gonna talk about female sexual dysfunction. I'm gonna go through this with a really practical approach on how would you handle this in the office. No relevant disclosures. Learning objectives today. Describe the multiple factors potentially impacting women's sexual function. Discuss an appropriate assessment of sexual health concerns in women. And explain an approach to treatment of female sexual dysfunction. The prevalence of female sexual dysfunction was defined in the PRESIDE study, at least in the United States. This was published back in 2008. There were over 31,000 respondents. And what we found was that over 40% of women were reporting some sort of sexual health concern. And you can see the breakdown. Desire is by far the most common complaint. Arousal and orgasm are also in the range of 26 and 20% respectively. But when you put it in the context of does it cause distress, then that lowers significantly. So a total of 12% reported some sort of dysfunction associated with distress. And 10% of women reported low sexual desire that was distressing to them. So still a significant proportion. Here it is in graphic form according to age groups. And you'll see that midlife women have the most concerning sexual problems associated with distress. So the prevalence goes up in midlife. And although women in older ages tend to report more sexual problems, they have less distress associated with the sexual dysfunction. So the green line at the top is any sexual problem. The pink line under that is low sexual desire specifically. So again, that is the most common complaint. It is the most common in midlife women between 50 and 59 years of age goes down from there. It's important to put this in the context of the female sexual response cycle. And Rosemary Bichon first described this in 2001. But this model fits well in terms of women in long-term sexual relationships and women who age over time, which is all of us. So the cycle is such that if you start over on the right-hand side and you have a sexual stimulus that could be spontaneous, could be spontaneous sexual desire associated with that, or your partner initiating sex, there are many things that can get in the way, including biological and psychological factors, which we will discuss. But that leads, if everything goes according to plan, sexual arousal, increased desire, emotional and physical satisfaction. That's where orgasm may or may not come in. And emotional intimacy at the top you'll see as a facilitating factor. It's also a factor that when not present in a relationship, makes the woman less likely to be receptive to sexual stimulus in the future. That sexual, the spontaneous sex drive box in the middle is largely in pre-menopausal women. And often in post-menopausal women, that spontaneous sex drive decreases and women are left with responsive sexual desire, meaning right place, right situation, right partner. She's willing to respond to a sexual stimulus. The biopsychosocial model takes into account these factors. So biology is very important. Biology includes reproductive health. So in other words, menopausal status, does she have estrogen on board? It also includes physical health. Does she have fatigue, a sleep disorder? Does she have arthritis that's getting in the way and causing problems? The psychology, think of things like depression, anxiety, past experiences with sexual health. Interpersonal, very important, that's relationships. What is the communication like in the relationship? Are there life stressors? Are there things like finances that are getting in the way and causing stress? Sociocultural, also important, that's upbringing, cultural norms and expectations, religious factors, et cetera. The neurobiology of sexual, and it says dysfunction, but also sexual function, is really a balance between excitation and inhibition. And when you look over on the excitation side, the chemicals, the neurochemicals that promote excitation are dopamine, oxytocin, melanocortin, and norepinephrine, whereas on the inhibition side, serotonin, think about all the antidepressants, opioids, endocannabinoids, prolactin. On the excitation side, the psychological and interpersonal factors are the intimacy, like I just said, that emotional connection to the partner, shared values, romance, and experience and behavior, whereas the negative things could be relationship conflict, negative stress, negative beliefs about sex, et cetera. It's really important when we're talking about female sexual dysfunction to consider the partner relationship. In fact, you really can't talk about female sexual functioning if you're not considering the partner, and whether that's a male or female partner. But this is a dynamic relationship, so it's really important to inquire about sexual satisfaction, physical and mental health of the partner, sexual health of the partner. And the partner's role as a precipitating or maintaining factor has really been overshadowed by focusing on the individual herself, and we really need to back up and consider this as a complex interaction between individuals. There's overlap between female sexual disorders. In other words, it's important to note that if a woman has pain with sexual activity, she's not gonna have arousal, she's not gonna have orgasm, and she's gonna have low sexual desire. So these things often really overlap with each other, and when you get a woman in the office, it's important to disentangle and see what the primary issue is, because if you can't address the primary issue, you're not gonna get at the overall problem. Hypoactive sexual desire disorder. Let's talk about what does that mean. I recently was at the International Consultation on Sexual Medicine in Madrid this last June, and one of the groups set out to redefine and in fact confirm the diagnosis of what hypoactive sexual desire is. And it's manifestation of any of the following for a minimum of six months. It's a lack of motivation for sexual activity. It could be decreased or absent spontaneous sexual desire, but also decreased or absent responsive desire. So in other words, if you're in the right place, the right situation with the right partner, it's an inability to maintain desire or interest through sexual activity. A loss of desire to initiate or participate in sexual activity, including avoidance behaviors, and it has to be combined, and this is important, with significant personal distress. If it's not combined with any sort of distress, it's not a sexual dysfunction. But what does distress really mean? It can be frustration, it can be grief, it can be guilt, it can be a feeling of incompetence, loss, sadness, sorrow, or worry. So all of those things manifest as distress. What is the treatment for female sexual dysfunction? We use a lot of things. Our toolbox has a lot of things in it, and psychotherapy is one of them, and that includes cognitive behavioral therapy, mindfulness treatments, but we also have some pharmacotherapeutic options in our toolbox, and I'll discuss those, or it's a combination of these things. What is sex therapy? I will say that we have a sex therapist that we work with on a regular basis, and it's hard to do sexual medicine without having a partnership with a sex therapist. Sex therapy is psychotherapy that draws on an array of evidence-based cognitive behavioral interventions to treat sexual dysfunction. It focuses on improving awareness and recognition of positive and negative emotions related to sexual interaction, reframing the negative cognitions, and providing tools to reduce distracting thoughts. Often I'll ask women, she says I have low sexual desire, and I'm like, what's going through your head when you're having sex, and often women are going, well, it's my to-do list for the day. I've got this, and this, and this, and this going on, and I've got these things to do, and the bottom line is if you're focused on everything else you've got to do today and not tuned into the moment, you are not going to feel desire or feel response to sexual activity. So it's really offering insights as to what's going on and what's happening during the moment. Altering maladaptive behaviors, improving communication. I put desire discrepancy there because it's really important to note that if a woman comes in saying I would like to have sex once a month, that's fine for me, and the partner says I would like to have sex three times a week, that's fine for me, that's not a sexual dysfunction, but it's a desire discrepancy and something that has to be addressed. So that's something that a sex therapist can really help with. These sessions may be five to 20 sessions. They may include some between-session homework. It can be done remotely, and in the United States we have sex therapists who are licensed in most every state who can do telehealth visits with our patients. Mindfulness, it targets the relationship between awareness of sexual stimuli and response of sexual desire, and this just makes you tune into the moment again, encourages increased attention to sexual cues, reducing judgment. Many women come in saying I've gained a lot of weight during midlife and I have concerns about my body and what I look like during sex. Well, if you're just, you know, the only thing that's in your head is what do I look like during sex, then you're not, again, tuned into the moment and you're gonna have less awareness. It also increases compassion to your own suffering, and it alleviates suffering through kindness. All right, we do have some pharmacologic options approved in the United States for hypoactive sexual desire disorder. They are only approved in pre-menopausal women, not post-menopausal women, although you'll see flibanserin, the first one, is approved in women in Canada up to the age of 60 years. So flibanserin is a non-hormonal CNS agent. It's a five, it acts on serotonin receptors, and it basically has two parts to it. A 5-HT1A receptor agonist and a 5-HT2A receptor antagonist. Basically what it does is it reduces serotonin, it increases dopamine and norepinephrine. So again, back to the neurobiology, serotonin is inhibitory, dopamine and norepinephrine are excitatory. It's taken orally every night at bedtime. It was approved in the US in 2015. There was an alcohol warning on it initially, but that was taken off, and I can talk more about that. Premelanotide, approved in 2019. This is an on-demand injection. It's a melanocortin receptor modulator. A little bit more on flibanserin. It's approved for acquired, generalized, hypoactive sexual desire disorder in premenopausal women, not caused by anything else. So I will tell you that for sexual medicine consultations, we spend an hour with patients going through what is contributing to sexual dysfunction, and it's rare to find someone who actually has no medical or psychiatric condition, no relationship issues, and no effect of a medication. So in essence, that's not most of the women we see. It's 100 milligrams at bedtime. Their administration during waking hours increases risk of hypotension. I will say this is somewhat funny. They did an alcohol study in the United States and then put an alcohol warning on it, but the alcohol study was done in 25 patients, 23 of whom were men, for a drug approved in women, and they had them drink the equivalent of a half a bottle of wine on an empty stomach first thing in the morning, and a couple of people passed out, which was not exactly surprising. So they eventually took the warning off, and they just say, you know, be careful with alcohol and don't take it within a couple of hours of drinking. But they also say don't take a second pill if you miss one, so don't, a missed dose should be skipped. Remelanatide, so this is a melanocortin receptor agonist. It has an affinity for the type four melanocortin receptor. It was originally developed intranasally, but they found that subcutaneous administration improved the tolerability profile. I think about 45% of women reported nausea with this, but at the same time, no one stopped using it because of that, which I found interesting. Inject it subcutaneously in the abdomen 45 minutes before anticipated sexual activity. All right, let's talk about testosterone a little bit. So there was a global consensus position statement on use of testosterone for women published in Climacteric in 2019. I think it was also simultaneously published in JCEM. This was following a very nice systematic review and meta-analysis that was done on the impact of testosterone in women. And what they found was testosterone, the literature shows that it's effective for sexual dysfunction and almost every aspect of sexual function improves with testosterone in women. The only recommendation for use of testosterone, and it's not government approved anywhere except in Australia, but the only recommendation is for hypoactive sexual desire disorder. And going back through the literature, just because I know you all have patients who ask you about this all the time, no evidence for sarcopenia, no evidence for maintenance of bone density, no evidence for well-being, no evidence for mood, in fact, nothing else. There's no evidence for anything except sexual functioning in women. All right. So there's an international guideline on practice guideline on how to use it that was published in Journal of Sex Med in 2021. And basically what they, the key messages from this are proper dosing should attain and maintain testosterone levels in the normal pre-monopausal range. So women should not be getting into the male range, and that is the main goal with monitoring, is that you're not trying to get them up to a certain level except for the normal pre-menopausal level, which is pretty low, but certainly not into the male level. Again, there's no approved female formulation except for Australia, so what people, what they recommended is one-tenth of a standard male dose of 1% transdermal testosterone or about 5 milligrams a day, can go up to 10 milligrams a day if needed, and that's enough to usually achieve that normal pre-menopausal physiologic range. Compounded testosterone pellets, IM injections, and oral formulations are not recommended. And let me just say that the main reason it is not government approved is the fact that we do not have long-term safety data on testosterone in women. The data only go out about two years, and I will say that there is no signal for increased cardiovascular disease in two years. There's no increased signal for increased breast cancer risk in two years, but nonetheless, that's all we have is about two years of safety data. Monitoring and follow-up. So, check a baseline testosterone level, the total, T, measured before therapy, repeat at about three to six weeks. Check after about six weeks if you change the dose at all. Check after two to three weeks if you have a super physiologic level and you're trying to get it down. Obviously you're monitoring for clinical response. Did it do what it's supposed to do? Did desire increase? If it didn't increase by six months, it's not going to, and you should stop therapy. Screen for overuse and androgenic consequences, so the most common adverse effects in the normal range are going to be hair growth and acne. But if you get into the male range, you can have hair loss, you can have irreversible changes of the voice, you can have irreversible clitoromegaly. So there are some irreversible changes that go along with high levels, and we recently, we were just talking about this, had a woman present at Mayo Clinic, and she was worked up many times for voice changes. She had evaluations in GI for gastroesophageal reflux disease and had a scope in ENT because she had these voice changes. It turned out to be her testosterone level was chronically in the 400 range. If it results in improvement, you can consider ongoing therapy, monitoring every six to 12 months. You may want to also see if the woman can take a drug holiday to see if further treatment is required. I also really have very few patients that have chosen to continue with long-term therapy. Most of my patients try it, they say, hmm, it did a little bit, but I'm not sure it did a whole lot. I also have patients coming in thinking it's going to solve the world's problems for them, and you know, sometimes it's worth it just to say, all right, go on it for three months because they're not really willing to discuss the fact that they need to have some relationship counseling or whatever else I'm recommending, so sometimes a three-month trial of testosterone just to prove my point is often enough to get the patient to listen. Genitourinary syndrome and menopause, and I would like to mention this because this is such a common problem, and if you don't address this, women are not going to have sexual desire if it feels like razor blades every time they have sex. This impacts about 50 to 70% of postmenopausal women, more common in survivors of any cancer, particularly breast cancer, but any woman who has had cancer therapy is at increased risk for sexual dysfunction. It's substantially undertreated. Only about 9% of affected women actually receive any type of therapy. The symptoms are both vaginal, but also they really report a lot of vulvar discomfort, irritation, itching, but also urinary symptoms. Don't forget about the urinary part of this. It's chronic and progressive, meaning if you don't treat it, it's going to get worse. Here are some of the treatments that are available, so there's vaginal creams, vaginal inserts, and the inserts include estradiol and prasterone, so DHEA, at least in the United States. There's a low-dose vaginal ring called Estring, but not to be confused with FemRing, which is a full hormone therapy dose of estradiol. There's also an oral CIRM, selective estrogen receptor modulator, ospemiphene. You'll note that the serum estradiol levels are typically well in the postmenopausal range, so less than 10 picograms per mL, but vaginal creams, depending on the dose, you can get a full systemic hormone therapy dose. Keep in mind that in the United States, these low-dose estrogen products come with a big black box warning on the package insert, and that's because we have class labeling of estrogen in the U.S., so many women are therefore quite afraid because it says this project causes dementia and breast cancer and everything else, which is not true, and we continue to work with the FDA to try to get that removed. All right, there are a lot of provider barriers to addressing sexual health in the office, and there's been multiple publications on this, but providers feel it takes too long to discuss, and again, I just told you we have an hour-long consultation to go over sexual health concerns, so it does take a long time, but I would say if a woman brings it up, then it should be, even if you don't have time that day, say, this is really important, we'll bring you back on another day to discuss this. There are a few government-approved treatments. There are other issues that might be considered higher priority, so if you're in the office with somebody who's got obesity and diabetes and heart disease and everything else you're trying to manage, then sexual health might be lower on the list. Providers may be embarrassed to discuss this, that you might fear embarrassing your patient, and it's pretty clear that none of us had training in this when we were in our medical training programs. All right, I'm going to go over just a couple of cases to say how we might address this in the office. This is Nora. She's 59. Her last period was at 52, and she says, I have low sexual desire. What you already know about her, she has type 2 diabetes. It's well-managed with metformin and diet. She had hot flashes for a few years after menopause, but really not now. She's had three vaginal births. She's been married for 35 years. What else should you know or ask about? All right, well, one, you could think about using a biopsychosocial approach, as we've talked about. Ask about biological factors, psychological factors, sociocultural factors, interpersonal factors that might be contributing. Does she have pain with sexual activity? How important is sexual activity to her and to her partner? And is she able to experience pleasurable genital sensations and orgasm? All right, so you go back and ask her these questions. She says she does have some vaginal discomfort with some dryness and feels like her vaginal tissues are tight, but her husband's very careful to avoid causing pain with penetration. Sometimes she's anxious about having pain. She anticipates having pain with sex. What are the factors related to decreased desire? Well, she said, now that my kids are out of the house, I would like to be more sexual, but I feel a little conflicted, and I feel guilty because I'm not supposed to enjoy sex as a woman. I can't tell you this is a common complaint in the United States. She rarely reaches orgasm, but this is really unchanged over time. Sexual activity is very important to her partner. All right, so what do you do with this? What's the diagnosis? How do you treat her? Would you call this hypoactive sexual desire disorder? Yeah? No? No. Genitourinary syndrome and menopause, well, I would say yes, she's got that. Is it both? Does she have a little bit of both? Or does she have no diagnosable sexual dysfunction? All right, think about what treatment you would give her. Are you going to give her off-label testosterone? I would say probably not. Local vaginal estrogen therapy, I would say yes, for sure. And just a point here, when you give someone local vaginal estrogen therapy, it takes eight to 12 weeks for full effect. You need to tell them that. That is not going to happen in two weeks, and they shouldn't stop it after two weeks because it's not going to work that fast. Pelvic floor PT, couples therapy, individual therapy. She may need pelvic floor physical therapy because she may be having some spasm of the pelvic floor muscles. And if the vaginal estrogen alone doesn't take care of it after a couple of months, I would consider pelvic floor PT. Her thoughts about sexual functioning and her feelings of guilt might be best addressed with individual therapy. All right, second case here, Mila. She's 56, gravida 1, para 1. She has a BRCA1 mutation. Her ovaries were removed 10 years ago. No breast cancer history. She used an estradiol patch for a while but really didn't help her hot flashes. She's happily married. What would you ask her about her sexual health and functioning? One, I would use a ubiquity statement and follow up with asking questions about desire, arousal, orgasm, pain. Two, I wouldn't bring up sexual health. If she had a concern, she certainly would bring it up to me. Three, I avoid the topic of sex at all costs. It takes way too much time to screen. Or four, I would ask her if she's afraid to use vaginal hormone therapy because of her gene mutation. All right, so importance of normalizing and universalizing the conversation about sexual health. You can start with a ubiquity-style question, and this is what we recommend when talking with patients about sexual functioning. Normalize it for them. Say many women fill in the blank with diabetes after menopause with a history of breast cancer. Fill in the blank. Have sexual problems such as pain with sex or loss of interest. Do you have any sexual health concerns? Has that affected you? Maintain an open, non-defensive body posture. Follow up with directed questions about desire, arousal, orgasm, and pain. All right, so when you asked her about these questions, she said, I have moderate to severe dryness with pain on penetration. She reports a moderate vulvar irritation and discomfort even after wiping, after urinating. Does she have desire? No, she doesn't have interest in sex because it's painful. It makes her not want to engage in sexual activity. So what's the diagnosis and what's the treatment option? Is this low sexual desire first, then GSM? Is it GSM, then low sexual desire? I would say probably that. Is it low sexual desire and GSM simultaneously? Or I wouldn't treat her. I would refer her to a colleague more comfortable treating sexual dysfunction, which, by the way, is never a bad answer if you don't want to do it. So what treatments might you suggest to her with shared decision making? Local vaginal estrogen therapy, I would say, is an option for her. Use of lubricants and moisturizers. And we can talk about this more in the question and answer period, but lubricants are for sexual activity. Moisturizers are used to maintain vaginal moisture and used on a regular basis. For her, I would not use off-label bromelanotide or flavancerin. So quickly, I know my time is up, the POSIT model is a good model for behavioral health in the office. So you're giving permission for the patient to talk. You're offering limited information like education. You're making some specific suggestions like use a lubricant. And you would recommend intensive therapy if needed. So here's a summary, we can go through this later, of what's available for the different sexual health concerns. The summary is sexual health is important to women of all ages. Most women want and expect their health care professionals to ask about their sexual health. Treatment options are available and a multidisciplinary approach may be needed. All right. With that, I will turn it over to my colleague. Thank you very much.

female sexual dysfunction

biopsychosocial model

treatment approaches

genitourinary syndrome of menopause

psychotherapy and pharmacology

healthcare communication