OB
Obstetrics Gynecology

Sexuality and Sexual Dysfunction

April 21, 2014.
Andrea Bradford, PhD,

Educational Objectives

The goals of this program are to improve diagnosis and treatment of sexual dysfunction. After hearing and assimilating this program, the clinician will be better able to:

1. List the phases of the female sexual response.

2. Explore the biologic and social influences on sexual outcomes in a patient with a sexual disorder.

3. Treat common sexual disorders.

4. Manage a patient with a history of childhood sexual abuse.

5. Counsel a patient presenting with gender dysphoria about appropriate treatment options.

Summary

Overview: sex and gender viewed in biopsychosocial model; levels of hormones, such as free testosterone (T), do not predict sexual problems; history most important diagnostic tool; many sexual pain disorders due to underlying pathology

Sexual response: model proposed by Masters and Johnson — 4 sequential phases (ie, excitement, plateau, orgasm, and resolution); excitement correlated with genitovasal congestion, plus lubrication, expansion, and tenting of vagina; peak excitement may trigger orgasm; orgasm — variable, transient, peak sensation of intense pleasure, usually with involuntary rhythmic contractions, often occurring concurrently in uterus and anus; myotonia resolves vasocongestion

Female response: variable; women may skip plateau phase, have arousal but no orgasm, have multiple orgasms, or show different responses in different circumstances; 4-phase model of limited value for describing range of experiences; 3-phase model of Kaplan includes desire, arousal, and orgasm; Basson proposed other scenarios, since women sometimes motivated by reasons other than interest in sex; women sometimes receptive to partner’s advances even if feeling uninterested, or may engage in sex for emotional closeness; arousal or excitement may precede desire

Changes across lifespan: National Survey of Sexual Health and Behavior (NSSHB; 2010) included ≈3000 men, ≈3000 women, and some adolescents; peak frequency of sexual behaviors in women in mid to late 20s (vaginal intercourse in past month reported by <10% of 14- and 15-year olds, ≈10% of women over 70 yr of age, but 70% of those 25 to 29 yr of age); no difference seen in long-term sexual outcomes of women giving birth vaginally vs by cesarean delivery; evidence on long-term effects of episiotomy and instrumented delivery conflicting; midlife and menopause associated with declines in sexual activity and desire, and increased dyspareunia; age and menopause both contribute; women in midlife have variable sexual outcomes; psychosocial stressors also affect mood and sexual function; limitations of male partner become important with aging

Sexual dysfunction: defined as disruption in ≥1 phase of response cycle associated with significant distress or functional impairment; in Diagnostic and Statistical Manual of Mental Disorders (DSM), definitions of sexual disorders depend on patient perception; ascertain onset and course of symptoms, medical and interpersonal events, consequences of symptoms, reaction of partner, developmental and gynecologic history, age at first sexual activity, sex of partner(s), duration of present relationship, sexual response, and history of pain with sexual activity; conversation may reveal embarrassment, inhibition, or knowledge deficits; ask about history of sexual abuse, coercion, or domestic violence

Hypoactive sexual desire: most common presenting complaint; chronic deficiency or absence of sexual thoughts, fantasies, or desire; can be lifelong or acquired; can occur with all partners, or only one; commonly, patient previously experienced desire but now uninterested in, or averse to, sex; some women with low desire may still enjoy sex and experience orgasm; in some women, low desire due to pain or to sexual problem of partner; often multifactorial

Sexual aversion: fear of sex or extreme disgust; patients may display anxiety or avoidance in nonsexual situations, such as pelvic examinations, and many report abuse or assault; refer to psychologist with training in anxiety and phobias

Asexuality: lifelong history of low or absent interest in sex; patients may avoid relationships, or might have romantic or sexual partners, or masturbate, but report no attraction or desire for partners; characterized by boredom or disinterest in sex, but not anxiety or fear; sex steroid hormones play role in desire, but androgen levels not correlated with desire (possibly due to variability in sensitivity to androgens); treatment — challenging; no drug currently approved; psychosocial and behavioral treatments include education, training in sexual communication skills between partners, and experiential exercises at home

Sex therapy: in sensate focus exercises, partners engage in pleasurable touch without demand for performance; fosters awareness of feelings and communication between partners; exercises structured progressively; initial experiences sensual, and progress in steps to arousal or orgasm; relapse common after sex therapy; assumptions or beliefs about sex and feelings of fear, resentment, or inadequacy must also be addressed; interpersonal factors with partner may undermine interest in sex

Disorders of arousal: usually accompanied by low desire; many women do not distinguish between arousal and desire; defined as persistent or recurrent inability to attain or maintain genital response, causing significant distress or impairment; disorder lifelong or acquired; can occur generally or in specific situations; women may lack physiologic or psychologic arousal, or both; treatment — identify contributing factors; if onset sudden, consider sources of altered genital sensation or blood flow; cognitive distractions or performance anxiety related to sexual attractiveness or behaviors during sex may contribute; if lack of arousal due to inadequate stimulation, provide sexual education and skill exercises for couple; if partner resistant and relationship tense, refer to sex therapist

Persistent genital arousal disorder: uncommon syndrome of excessive, unwanted genitovasal congestion and tension in absence of sexual thoughts or stimulation; orgasm provides only temporary relief; cause unknown; some patients have antecedent pregnancy, or surgery or injury to pelvis, brain, or spine; also associated with selective serotonin reuptake inhibitors (SSRIs); refer to specialist

Female orgasmic disorder: persistent difficulty or delay in reaching orgasm despite adequate stimulation; affects 5% of women in United States (US); primary anorgasmia — patient has never experienced orgasm; secondary anorgasmia — difficulty in reaching orgasm through stimulation that previously triggered orgasm; some women reach orgasm only through masturbation; orgasmic disorders group of conditions caused by physiologic, interpersonal, or situational factors; women who reach orgasm through manual or oral stimulation but not vaginal penetration considered normal; causes — associated with low socioeconomic status, poor health, and psychiatric comorbidities; orgasmic function does not decrease with age; many secondary cases related to drugs, especially SSRIs and antipsychotics; other causes include fatigue, alcohol and other depressants, problem with desire or arousal, and interpersonal factors such as trust in partner; vaginal childbirth, pelvic surgery, and pelvic radiotherapy do not affect orgasmic function; minority of women notice changes in sexual response after simple hysterectomy, and majority experience changes after more radical surgery, especially vulvar surgery; women who easily experienced orgasm before surgery most likely to recover

Treatment: primary anorgasmia — first goal to reach orgasm via masturbation; educate patient on anatomy and physiology, and give guidance and permission for self-exploration; erotic aids such as vibrators helpful; once masturbation successful, apply techniques to partnered sexual activity; prognosis good whether group, individual, or self-help format used; orgasm only through masturbation — bridging exercises may be helpful; address anxiety or inhibition during sex; use sensate focus exercises; combine treatments within cognitive behavioral approach; Kegel exercises ineffective; secondary anorgasmia — assess physiologic and psychologic factors, changes in physical health, medication, quality of relationship, and nature of sexual activity; for medication-induced issue, try drug holiday, change of dose or medication, or add second drug in different class; consider bupropion

Sexual pain disorders: vaginismus — inability to engage in penetrative sex due to spasm or muscle tension; dyspareunia — persistent or recurrent genital pain associated with intercourse, not due to vaginismus; common; distinguish between pain provoked by deep penetration vs superficial penetration or touching vulva

Provoked vestibulodynia: common cause of superficial dyspareunia; presents as exquisite sensitivity of vestibule; associated with abnormal proliferation of nerves or recurrent yeast infections; some women report lifelong history of superficial dyspareunia and pain when using tampon, or develop problem after using hormonal contraceptives; secondary hypertonicity of pelvic floor and heightened neurologic and psychologic reactivity to pain may develop; treatment multidisciplinary

Vulvovaginal atrophy and dryness: can cause superficial and deep dyspareunia after menopause; onset often gradual; only reversible via hormonal treatment; topical estrogen more effective than systemic estrogen; ospemifene now approved for treatment of sexual pain in postmenopausal women; recommend long-lasting moisturizer plus lubricant during sex; risk for cancer due to topical estrogen unknown

Deep dyspareunia: if linked to endometriosis, fibroids, pelvic organ prolapse, interstitial cystitis, or bowel syndromes, manage underlying disease; otherwise, no role for medical management; for spasms of pelvic floor, refer to physical therapist; consider sexual counseling or psychotherapy; effective treatment depends on diagnosis of underlying problem and supportive care for physical, psychologic, or relational difficulties; other possible causes — infectious diseases; vulvar dermatoses; injury to pudendal nerve

Sexual expression: abuse and assault risk factors for sexual dysfunction and high-risk behavior; sexual abuse — exploitation of child for sexual gratification of another; includes sexual contact and other unwilling exposure to sexual activity; one-fourth to one-third of women in US have experienced abuse; psychosexual problems more likely if abuse involved physical contact, violence, anal or genital penetration, repeated episodes, or incest; woman may associate sex with danger or negative feelings, or become hypersexual, with many casual sex partners or risky sexual behaviors; chronic severe abuse associated with subsequent revictimization, unwanted pregnancy, and sexually transmitted infections; coping mechanisms include substance abuse, dissociation, and emotional numbing; abused women may experience problems even within safe, stable, and long-term relationships, and have difficulties with trust and emotional expression; women with associated posttraumatic stress disorder may have unwanted memories or flashbacks during sex, which may lead to avoidance or dissociation; treat with psychotherapy; consider abuse in any woman with sexual disorder

Depression: affected women engage in less sexual activity, but may masturbate more; associated with sexual dysfunction in women with chronic illnesses (eg, diabetes); in study of >1000 women with hypoactive desire, one-third met criteria for depression; of these, one-half taking antidepressants; screen all women with sexual dysfunction for depression

Partner factors: female partners of men with premature ejaculation or erectile dysfunction (ED) may develop sexual difficulties; ED may exacerbate dyspareunia during intercourse with partial erection; many women report reduced interest and arousal if partner masturbates frequently, has sex outside relationship, or views pornography; involve both partners; consider referral to sex or couples therapist

Sexual orientation: defined along continuum; attractions, partner preferences, behaviors, and fantasies may not align; for example, woman in monogamous, heterosexual marriage may experience sexual attractions and fantasies directed toward women, creating distress; some women identify as heterosexual, bisexual, or lesbian, but others prefer none of these terms; 7% of women in US identify as other than heterosexual, but many more have had same-sex sexual experiences; influence of genetics vs environment debated; some genetic basis for orientation likely (monozygotic twins more likely than dizygotic twins to have same sexual orientation); uterine environment and prenatal exposure to androgens might influence orientation and sex-typical behaviors; congenital adrenal hyperplasia associated with differences in sexual and gender experiences; sex steroid hormones probably do not influence sexual orientation after early critical period of brain development; biologic factors provide only partial explanation; sexual orientation in women more fluid than previously assumed; bisexuality more common in women than men, especially during adolescence; context and interpersonal relationships possibly more important than prenatal hormonal and genetic influences

Gender expression: refers to internal experience and outward presentation; sexual orientation and gender identity exist in several combinations; probably influenced by genetic and biologic factors, and by learning and socialization; in sexually undifferentiated human embryo, expression of testis-determining factor and secretion of T by fetal gonads required for masculinization; female development can result from disruption of masculinization process in XY fetus; XXY, XXX, and XYY karyotypes or XX/XY mosaicism can influence development; receptors for androgens and estrogens present throughout nervous system; influence of hormones on gender-typical behavior not fully understood

Gender dysphoria: refers to individuals not comfortable with assigned or birth gender over period ≥6 mo; patient feels own physical characteristics discrepant with internal experience of gender; 3-fold more common in people born as males; common in preschool children, but often resolves by puberty; girls with gender dysphoria more likely to have bisexual or homosexual orientation; gender-atypical behavior does not imply gender dysphoria unless patient uncomfortable with assigned gender; affected individuals may have strong desire to live as person of opposite sex; transgender refers to living with cross-gender identity

Treatment: in mid adolescence, suppress puberty with gonadotropin-releasing hormone analogues and progestins to halt development of secondary sex characteristics and allow time to decide about other interventions; few adolescents change minds, and psychosocial outcomes usually good; most treated with cross-sex hormones; most women present late in adolescence or attracted to other women as adults; treatment requires medical and psychosocial support; acceptance of original sex unlikely; sex reassignment — surgery not always desirable; for women, treatment with T often enhances mood and sexual desire; surgical interventions include mastectomy, chest reconstruction, vocal cord surgery, hysterectomy, salpingo-oophorectomy, and phalloplasty; rather than all-or-nothing approach, consider range of hormonal and surgical options; many female-to-male transgender individuals retain vagina and engage in penetrative sexual activity, but adopt masculine gender role; continue routine cancer screening if reproductive organs left intact

Readings

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Bradford is a consultant for Palatin Technologies. The planning committee reported nothing to disclose. In her lecture, Dr. Bradford presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

This lecture is from our newest continuing medical education program, the Audio-Digest Obstetrics and Gynecology Board Review Course, a comprehensive review with approximately 35 hours of lectures presented by faculty from prominent teaching institutions across the United States.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OB610801

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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