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Updates in Female Sexual

Health

Brooke M. Faught,

MSN, WHNP-BC, IF Nurse Practitioner/Clinical Director

Women’s Institute for Sexual Health (WISH)

division of Urology Associates

Nashville, TN

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Disclosures

Speaker Shionogi

Actavis

Advisory Board Actavis

Female Health Company

Shionogi

Overview

Prevalence of female sexual dysfunction (FSD)

Updated diagnostic categories

ICD 10 coding

Screening tools

Updated treatment options

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FSD Review and Updates

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National Health and Social Life Survey

Prevalence of Sexual Dysfunction

Women 43% vs. Men 31%

Lauman, E. Paik, A. & Rosen, R. (1999). Sexual dysfunction in the United States: Prevalence and predictors. Journal of the American Medical Association, 281, 537-544.

44% vs. 12%

Shifren et al. (2008). Sexual problems and distress in United States women: prevalence and correlates. Obstetrics and Gynecology, 112(5), 970-8.

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Prevalence of Female Sexual Dysfunction

Female Sexual Dysfunction

Prevalence Range

Desire Disorder 16% - 75%

Orgasmic Difficulties 16% - 48%

Arousal Disorders 12% - 64%

Pain Disorders 7% - 58%

Hayes RD, Bennett CM, Fairley CK, Dennerstein L. What can prevalence studies tell us about female sexual difficulty and dysfunction? Journal of Sexual Medicine. 2006;3:589-595.

Female Sexual Dysfunction

Sexual Desire Disorders Hypoactive Sexual Desire Disorder Sexual Aversion Disorder

Sexual Arousal Disorders Female Sexual Arousal Disorder

Orgasmic Disorders Female Orgasmic Disorder

Sexual Pain Disorders Dyspareunia Vaginismus Noncoital pain

Basson R, et al. 2000. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. Journal of Urol.ogy; 163:888-893 / 1998 AFUD Consensus Panel

AFUD Consensus Panel

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DSM vs. ICD

“Mental, Behavioral and Neurodevelopmental Disorders”

vs

“Symptoms, Signs and Ill-Defined Conditions”

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Female Sexual Dysfunction: DSM-IV-TR Codes and Definitions

Sexual desire disorders

Hypoactive sexual desire disorder

302.71 or 799.81

Absence or deficiency of sexual interest and/or desire

Sexual aversion disorder 302.79 Aversion to and avoidance of genital contact with a sexual partner

Sexual arousal disorders

Female sexual arousal disorder 302.72 Inability to attain or maintain adequate lubrication-swelling response of sexual excitement

Orgasmic disorders

Female orgasmic disorder 302.73 Delay in or absence of orgasm after a normal sexual excitement phase

Pain disorders

Dyspareunia 302.76 or 625.0

Genital pain associated with sexual intercourse

Vaginismus 306.51 or 625.1

Involuntary contraction of the perineal muscles preventing vaginal penetration

Am Psych Assoc 2000; Buck, et al. 2008

Female Sexual Dysfunction: DSM-V Changes

•Female sexual interest/arousal disorder • Sexual aversion disorder removed

•Female orgasmic disorder

•Genito-pelvic pain/penetration disorder

SIGNIFICANT DISTRESS

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Hypoactive Sexual Desire Disorder

Absence of sexual fantasies, thoughts, and/or desire for, or receptivity to, sexual activity, which causes distress

Most common female sexual complaint

~10% of women = Low sexual desire with distress.

-Shifren et al. (2008). Obstetrics and Gynecology, 112(5), 970-8. -Basson R, et al. J Urol. 2000; 163:888-893.

ICD-9

Hypoactive Sexual Desire Disorder 302.71

Low libido 799.81

ICD-10 Hypoactive Sexual Desire Disorder F52.0

Low libido R68.82

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Sexual Aversion Disorder

Phobic aversion to and avoidance of sexual contact with a sexual partner, which causes distress

-Basson R, et al. J Urol. 2000; 163:888-893.

ICD-9

Psychosexual Dysfunction, NEC 302.71

ICD-10 Sexual Aversion Disorder F52.1

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Sexual Arousal Disorder

Inability to attain or maintain sufficient sexual excitement causing distress

May be expressed as a lack of subjective excitement,

or genital (lubrication/swelling) or other somatic responses

-Basson R, et al. J Urol. 2000; 163:888-893.

ICD-9

Inhibited Sexual Excitement 302.71 Symptoms Associated with Female Genital

Organs, NEC 625.8

ICD-10 Female Sexual Arousal Disorder F52.22*

Vaginal Dryness (other specified conditions a/w female genital organs) N94.89

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Orgasmic Disorder

Delay in or absence of attaining orgasm following sufficient sexual stimulation and arousal, which

causes distress

-Basson R, et al. J Urol. 2000; 163:888-893.

ICD-9

Female Orgasmic Disorder 302.73

ICD-10 Female Orgasmic Disorder F52.31*

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Sexual Pain Disorders

Dyspareunia: Genital pain associated with sexual intercourse that causes distress (Vestibulodynia, Atrophy, Infection)

Vaginismus: Involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, which causes distress

Noncoital Pain: Genital pain induced by noncoital sexual stimulation (vulvodynia)

-Basson R, et al. J Urol. 2000; 163:888-893.

ICD-9

Psychogenic Dyspareunia 302.76 Dyspareunia 625.0 Pelvic congestion syndrome 625.5

ICD-10 Dyspareunia not due to a substance or known physiological condition F52.6 Dyspareunia N94.1

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ICD-9

Vaginismus 625.1

ICD-10 Vaginismus not due to a substance or known physiological condition F52.5 Vaginismus N94.2

Additional Pain Codes

Vulvodynia 625.70 N94.818/9 Vulvar Vestibulitis 625.71 N94.810 Atrophic Vaginitis 627.3 N95.2 Pelvic/Perineal Pain 625.9 R10.2 Pain in joint, pelvic region and thigh 719.45 M25.559

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Assessment

Screening Tools

FSFI – Female Sexual Function Index (1) FSDS/FSDS-R – Female Sexual Distress Scale (Revised) (2) DSDS – Decreased Sexual Desire Screener (3) HSDD Hypoactive Sexual Desire Disorder Screener (HSDD)

(4) (postmenopausal women)

SFQ28 – Sexual Function Questionnaire (5) ASFQ – Abbreviated Sexual Function Questionnaire (6) SQOL-F – Sexual Quality of Life-Female (7)

(1) Quirk F, Haughie S, Symonds T. The use of the sexual function questionnaire as a screening tool for women with sexual dysfunction. J Sex Med. 2005;2:469-477

(2) Derogatis LR, Clayton A, Lewis-D’Agostino D, Wunderlich G, Fu Y. Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder. J Sex Med. 2008;5:357-364.

(3) Clayton AH, Goldfischer ER, Godstein I, et al. Validation of the Decreased Sexual Desire Screener (DSDS): a brief diagnostic instrument for generalized acquired female hypoactive sexual desire disorder (HSDD). J Sexual Med. 2009;6:730–738.

(4) Leiblum S, Symonds T, Moore J, Soni P, Steinberg S, Sisson M. A methodology study to develop and validate a screener for hypoactive sexual desire disorder in postmenopausal women. J Sex Med. 2006;3(3):455-464.

(5) Quirk FH, Heiman JR, Rosen RC, Laan E, Smith MD, Boolell M. Development of a sexual function questionnaire for clinical trials of female sexual dysfunction. J Womens Health Gend Based Med. 2002;11(3):277-289.

(6) Williams K, Abraham L, Symonds T. Psychometric validation of an abbreviated version of the sexual function questionnaire (ASFQ). Value in Health 2010; 13(7): A381.

(7) Symonds T, Boolell M, Quirk F. Development of a questionnaire on sexual quality of life in women. J Sex Marital Ther. 2005;31(5):385-397.

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3 Pages

1 Page

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Physical Assessment

•Vital Signs •General presentation (hygiene, psych state) •Gait and posture •Skin (including mucosal) •General neurologic exam •Complete urogenital/pelvic exam •Tanner Stage

Physical Assessment

•Vulvovaginal/Pelvic Exam •Skin/tissue integrity •Q-tip touch test •Neuro

•biothesiometry •Vaginal/pelvic muscle strength

•perineometry •Wet prep/pH

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Labs

•Estradiol/FSH/LH •Testosterone •DHEA-S •Dihydrotestosterone •Sex Hormone Binding Globulin (SHBG) •Prolactin •Thyroid panel

Causes of FSD

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Infertility/ Pregnancy

Loss

Pelvic/

Back

Trauma

Marital

Discord

Smoking/

Drinking/

Drug Use

Dermatologic

Conditions

Pregnancy/

Childbirth

Menopause/

Oophorectomy

Depression/

Anxiety

Medical

Conditions

Stress

Medications

FSD

Just to name a few…

Pharmaceuticals that can increase risk for Sexual Dysfunction

Antidepressants and mood stabilizers

SSRIs Benzodiazepines

SNRIs Antiepileptics

Tricyclics MAOIs

Antipsychotics

Antihypertensives Beta-blockers Diuretics

Alpha-blockers

Cardiovascular agents Lipid-lowering agents

Digoxin

Hormones Oral contraceptives Antiandrogens

Estrogens GnRH agonists

Progestins

Other Histamine H2-receptor blockers

Narcotics

Amphetamines

Anticonvulsants

Kingsberg, S. A. & Janata J. W. Urologic Clinics of North America. 2007;34:497-506, v-vi.

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Medical Conditions That Can Increase Risk for FSD

• Depression

• Diabetes

• Thyroid disease

• Cardiovascular disease

• Neurologic diseases

• Androgen insufficiency

• Estrogen deficiency

Treatment

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Treatment

1 FDA APPROVED TREATMENT FOR HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD)

2 FDA approved treatments for dyspareunia related to atrophy

0 FDA approved treatments for arousal/orgasmic dysfunction

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Viagra

Intrinsa

Flibanserin

Tibolone

Libigel

Bremelanotide

Sexual Response Models

Excitement

Plateau

Orgasm

Resolution

Sexual Neutrality

Emotional and Sexual Satisfaction

Emotional Intimacy

Receptivity to Sexual Stimuli

Sexual Arousal

Sexual Desire

Limbic Center Processing

Adapted from Basson, R. (2001) Obstetrics

and Gynecology, 98, 350-3

Adapted from Masters & Johnson. (1966)

Human Sexual Response

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Men

Women

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Flibanserin

Hypoactive Sexual Desire Disorder (HSDD)

Premenopausal women

Increases dopamine, NE and decreases serotonin

NOT Viagra

Approved August 2015, release October 2015

REMS program

100mg Qhs

Adverse Events

somnolence, dizziness, nausea

9.6% discontinuation rate flibanserin (3.7% placebo)

3rd phase 3 trial:

53% improvement in desire

29% reduction in distress

6-8 more satisfying sexual events (SSEs) per month

Katz, et. al., 2013 Efficacy of flibanserin in women with hypoactive sexual desire disorder: results from the BEGONIA trial. Journal of Sexual Medicine, 10(7);1807-15.

Flibanserin

BLACK BOX WARNING

ALCOHOL

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Clit Pumps

EROS, NuGyn $395 * No longer available

Womanizer rechargeable clitoral stimulator, $189 Goodvibes.com

Vibrating clit pump, $32 Goodvibes.com

Company Website, fiera.com: “Fiera was specifically created for “Before-

Play,” in comparison to vibrators, which are designed for orgasm.”

Goldstein, I., Goldstein, S. & Millheiser, L. (2015, October) The impact of a women’s sexual health product (Fiera) on genital engorgement as measured by thermography: A proof of concept study. Paper presented at the annual meeting of The North American Menopause Society, Las Vegas, NV.

• N – 12

• 15 minutes of Fiera use • 8/12 completed Fiera session

• 4/12 ended <15 min due to experiencing orgasm • Mean 4.5 min to experience “sexual arousal”

• Endorsement of feeling “in the mood” • All participants agreed with statement

• Statistically significant differences in scores across FSFI domains

• Sexual satisfaction, orgasm and arousal scored highest

• Statistically significant temperature increases from baseline

• Clitoris – 0, 2, 4, 6, 8, 10 min • Vestibule – 0, 2, 4, 6, 8, 10 min

• Labia - 0, 2 min only

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Off Label and non medicinal Treatment Options for Sexual Interest/Arousal/Orgasmic Disorders

ADD/ADHD meds Testosterone/DHEA-S replacement

Women use ~ 1/10 of male dose

Monitor closely and calculate FAI (Total T x 3.47/SHBG)

Herbs L-Arginine

Serotonin Antagonist Buspirone

Dopamine Agonists Bupropion, Capergoline, Ropinirole

Oxytocin Troches, spray, lozenge

PDE5 Inhibitors Topical arousal creams

aminophylline, L-arginine, sildenafil, nitroglycerin, phentolamine, zestra

Psychotherapy/Sex Therapy Erotica

Pain - GSM

Genitourinary Syndrome of Menopause (GSM) – AKA: Atrophic Vaginitis

Cream

Vaginal pill

Vaginal ring

Oral pill

CO2 laser

Alternative options

Coconut oil (lavender)

EmuAid

Acid

Triamcinolone/Marcaine injections with vaginal dilation

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Vulvovaginal Personal Care

The vagina is a self cleaning oven NO SELF TREATING

Glycerin free lubricant

No harsh scrubbing/soaps

No douching

Chlorine/bleach free hygiene products (including pads/Depends)

Coconut oil is a great natural vaginal moisturizer

Vulvovaginal Skin Care Guidelines Give to all appropriate female patients

Email bmfaught@ua-pc.com for copy of WISH document

Take Home

Comprehensive assessment

Individualized care

Holistic treatment plan

Counseling/patient education in a nonjudgmental manner

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Get involved:

ISSWSH – International Society for the Study of Women’s Sexual Health

ISSM – International Society for Sexual Medicine SMSNA – Sexual Medicine Society of North

America NVA – National Vulvodynia Association ISSVD - The International Society for the Study of

Vulvovaginal Disease AASECT – American Association of Sex Educators,

Counselors and Therapists SSTAR - Society for Sex Therapy and Research

References

Basson, R., Berman, J., Burnett, A., Derogatis, L., Ferguson, D., et al.(2000). Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. Journal of Urology, 163, 888-893.

Clayton, A. H., Goldfischer, E. R., Goldstein, I., Derogatis, L., Lewis-D’Agostino, D., et al.(2009). Validation of the decreased sexual desire screener (DSDS): a brief diagnostic instrument for generalized acquired female hypoactive sexual desire disorder (HSDD). Journal of Sexual Medicine, 6, 730-738.

Derogatis, L. R., Rosen, R., Leiblum, S., Burnett, A. & Heiman, J. (2002). The female sexual distress scale (FSDS): initial validation of a standardized scale for assessment of sexually related personal distress invisual women. Journal of Sexual and Marital Therapy, 28(4), 317-330.

Derogatis, L. R., Clayton, A., Lewis-D’Agostino, D., Wunderlich, G .& Fu, Y.(2008). Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder. Journal of Sexual Medicine, 5(2), 357-364.

Goldstein, I., Goldstein, S. & Millheiser, L. (2015, February) The impact of a women’s sexual health product (Fiera) on genital engorgement as measured by thermography: A proof of concept study. Paper presented at the annual meeting of the International Society for the Study of Women’s Sexual Health, Austin, TX

Guay, A., Munarriz, R., Jacobson, J., Talakoub, L., Traish, A., et al.(2004). Serum androgen levels in healthy premenopausal women with and without sexual dysfunction: part a: serum androgen levels in women aged 20–49 years with no complaints of sexual dysfunction. International Journal of Impotence Research, 16, 112-120.

Haboubi, N. & Lincoln, N.(2003). Views of health professionals on discussing sexual issues with patients. Disability and Rehabilitation, 25(6), 291-296.

Hayes, R. D., Bennett, C. M., Fairley, C. K. & Dennerstein, L.(2006). What can prevalence studies tell us about female sexual difficulty and dysfunction? Journal of Sexual Medicine. 3, 589-595.

Katz M, DeRogatis LR, Ackerman R, Hedges P, Lesko L, Garcia M Jr, Sand M; BEGONIA trial investigators. Efficacy of flibanserin in women with hypoactive sexual desire disorder: Results from the BEGONIA trial. J Sex Med. 2013 Jul;10(7):1807-15.

Kingsberg, S. A. & Janata J. W. Urologic Clinics of North America. 2007;34:497-506, v-vi.

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References page 2

• Laumann, E. O., Paik, A. & Rosen, R. C. (1999). Sexual dysfunction in the united states: prevalence and predictors. Journal of the American Medical Association, 281(6), 537-544.

• Leiblum, S., Symonds, T., Moore, J., Soni, P., Steinberg, S., et al.(2006). A methodology study to develop and validate a screener for hypoactive sexual desire disorder in postmenopausal women. Journal of Sexual Medicine, 3(3), 455-464.

• Masters, W. H. , & Johnson, V. E. (1966). Human sexual response. Boston, MA: Little, Brown and Company.

• Parish, S. J. & Rubio-Aurioles, E.(2006). Education in sexual medicine: Proceedings from the international consultation in sexual medicine. Journal of Sexual Medicine, 7, 3305-3314.

• Quirk, F. H., Heiman, J. R., Rosen, R. C., Laan, E., Smith, M. D., et al.(2002). Development of a sexual function questionnaire for clinical trials of female sexual dysfunction. Journal of Women’s Health and Gender Based Medicine, 11(3), 277-289.

• Quirk, F., Haughie, S. & Symonds, T.(2005). The use of the sexual function questionnaire as a screening tool for women with sexual dysfunction. Journal of Sexual Medicine, 2(4), 469-477.

• Shifren, J. L., Monz, B. U., Russo, P. A., Segreti, A. & Johannes, C. B. (2008). Sexual problems and distress in United States women: prevalence and correlates. Obstetrics and Gynecology, 112(5), 970-978.

• Symonds, T., Boolell, M. & Quirk, F.(2005). Development of a questionnaire on sexual quality of life in women. Journal of Sexual and Marital Therapy, 31(5), 385-397.

• Wamock, J. K., Clayton, A. H., Yates, W. R., Bundren, J. C.(2001). Sexual Energy Scale (SES): a simple valid screening tool for measuring of sexual dysfunction. Poster presented at North American Society for Psychosocial Obstetrics and Gynecology; Waikoloa, Hawaii.

• Williams, K., Abraham, L. & Symonds, T.(2010). Psychometric validation of an abbreviated version of the sexual function questionnaire (ASFQ). Value in Health, 13(7), A381.

•