Female Sexual Dysfunction

Educational Objectives

The goal of this program is to improve the management of female sexual dysfunction. After hearing and assimilating this program, the clinician will be better able to:

1. Identify the 3 main categories of female sexual dysfunction classified in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition).
2. Optimize appropriate use of flibanserin in female patients with sexual dysfunction.

Summary

Definition: normal sexual activity is negatively impacted ≥75% of the time, present for ≥6 mo, and causes significant distress; excludes sexual inactivity and lack of sexual interest that does not cause distress

Epidemiology: incidence of Female Sexual Dysfunction (FSD) is ≈43%; sexual dysfunction is more prevalent in women vs men, with an earlier onset; FSD has a significant correlation with depression and is common during pregnancy, breast-feeding, and peri- and postmenopause; associated with psychological factors such as sexual abuse, intimate partner violence, a history of female genital mutilation, certain religious beliefs, and substance abuse

Female sexual response: includes autonomic and somatosensory innervation, mainly through the pudendal nerve; tenderness on pelvic examination or pain (eg, from pelvic trauma) can affect pudendal nerve function and cause FSD; hormones (mainly estrogen, but also testosterone) and neurotransmitters (dopamine and norepinephrine are excitatory and serotonin is inhibitory) can affect the female sexual function, as do vasculogenic and psychosocial factors

Classification of FSD: the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition; DSM-5) classifies FSD into 3 main categories, including 1) Female Sexual Interest/Arousal Disorder (FSIAD; previously Hypoactive Sexual Desire Disorder [HSDD]), 2) disorders of orgasm, and 3) Genito–pelvic Pain/Penetration Disorder (GPPPD; previously Vaginismus and Dyspareunia)

Female Sexual Interest/Arousal Disorder: absence of sexual interest, sexual thoughts, or sexual fantasies, resulting in failure to initiate or respond to sexual activity; may be acquired or lifelong, and generalized or situational; treatment — includes addressing underlying disorders, sex therapy, and counseling; for peri- and postmenopausal women and those undergoing treatment for cancer, estrogen replacement therapy may be considered

Flibanserin: the first treatment approved by the Food and Drug Administration (FDA) for HSDD in premenopausal women; decreases serotonin; in a phase 3 study (Katz et al [2013]), significant improvement in the number of satisfying sexual events (SSE; by 1 or 2), improved level of sexual desire, and a reduction of distress related to sexual dysfunction were observed with use; contraindicated in patients with hepatic impairment and those who consume large quantities of alcohol; common side effects include nausea, dizziness, somnolence, and fatigue

Bremelanotide: approved by FDA for HSDD in premenopausal women; requires administration by subcutaneous injection 45 min prior to sexual activity; in 2 randomized trials (Kingsberg et al [2019]), 25% of patients had increase in sexual desire score vs 17% with placebo; no difference in number of SSEs was observed

Testosterone: off-label use; long-term safety data is lacking; contraindicated in breast and endometrial cancer and thromboembolic and cardiovascular disease

Female Orgasmic Disorder: marked delay in, marked infrequency of, or absence of orgasm following a normal phase of sexual excitement; prevalence is ≈47%; cognitive behavioral therapy, sensory focus, and directed masturbation are effective in younger, emotionally healthy women

Genito–pelvic Pain/Penetration Disorder: relatively new diagnosis; diagnosis requires difficulty with vaginal penetration, genito-pelvic pain during vaginal intercourse, associated fear or anxiety, or tightness of pelvic floor muscles during vaginal penetration; etiology may be psychological (eg, sexual trauma, abuse), social, cultural, or relationship-related; pelvic-floor physical therapy is recommended; vaginal topical treatments and cognitive therapy may help

Drugs associated with FSD: antidepressants, hormonal medications, anticancer drugs (especially for breast cancer), and opioids

Other treatment options: sildenafil citrate (eg, Revatio, Viagra), which increases blood flow, and vibrators are other options

Questions and answers: vaginal rejuvenation surgery — vaginal fractional CO₂ laser causes microscopic damage, resulting in regrowth of epithelium; increase in the epithelial lining enhances stretching and lubrication; supplementation of dehydroepiandrosterone — estrogen is better than intravaginal suppositories, but it can be useful; supplemental estrogen — the risk for recurrence is negligible for vaginal estrogen in breast cancer population; concentration in biogenicals or compounded creams may be high, and systemic absorption may occur; lower-dose vaginal estrogen is safe for patients with deep vein thrombosis; cervical cancer has no hormonal influence, and higher doses may be prescribed after radiation; the speaker prefers to be aggressive with vaginal estrogen and dilation in these patients; concomitant antipsychotic therapy — not all patients have sexual dysfunction; stopping antipsychotic therapy may not be an option without consulting the psychiatrist and is not considered on a routine basis

Readings

American College of Obstetricians and Gynecologists' Committee on Practice Bulletins — Gynecology. Female Sexual Dysfunction: ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician-Gynecologists, Number 213. Obstet Gynecol. 2019; 134(1):e1-e18. doi:10.1097/AOG.0000000000003324; Katz M, DeRogatis LR, Ackerman R, et al. Efficacy of flibanserin in women with hypoactive sexual desire disorder: results from the BEGONIA trial. J Sex Med. 2013; 10(7):1807-1815. doi:10.1111/jsm.12189; Kingsberg SA, Clayton AH, Portman D, et al. Bremelanotide for the treatment of hypoactive sexual desire disorder: Two randomized phase 3 trials. Obstet Gynecol. 2019; 134(5):899-908. doi:10.1097/AOG.0000000000003500; Deeks ED. Flibanserin: First global approval. Drugs. 2015; 75(15):1815-1822. doi:10.1007/s40265-015-0474-y.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Eilber is a consultant for Boston Scientific Corporation and Coloplast; and is on the Speaker’s Bureau for Abbvie. Members of the planning committee reported nothing relevant to disclose. Dr. Eilber's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Eilber was recorded at the 2022 What's New in Urology: A Primer for the Primary Care Provider, held virtually on April 23, 2022, and presented by Cedars-Sinai. For more information about upcoming CME activities from this presenter, please visit Cedars.cloud-cme.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

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 0.50 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 0.50 CE contact hours.

Lecture ID:

UR451501

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.