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Flashcards in Sexual Dysfunction Deck (21):
1

Vaginal moisturizers

use 2-3x per weeks because they last 2-3 days

Replense - almost as effective as Estrace for vaginal dryness

Luvena - 2 enzymes: 1 anti-candida, 1 antibacterial

Hyalogen - attracts 60x its weight in water. Designed for Breast cancer survivors

Refresh - has a probiotic

2

Medications that can decrease sexual functioning

ANTIDEPRESSANTS/MOOD STABILIZERS
* Selective serotonin reuptake inhibitors (SSRIs)
* Serotonin-norepinephrine reuptake inhibitors (SNRIs)
* Tricyclics
* Antipsychotics
* Benzodiazepines
* Antiepileptics
* Monoamine oxidase inhibitors (MOAIs)

ANTIHYPERTENSIVES
* β-blockers
* α-blockers
* Diuretics

CARDIOVASCULAR AGENTS
* Lipid-lowering agents
* Digoxin

HORMONES
*** HORMONAL CONTRACEPTIVES!
* Estrogens
* Progestins
* Antiandrogens
* Gonadotropin-releasing hormone (GnRH) agonists

OTHER
* Histamine2-receptor blockers
* Narcotics
* Amphetamines
* Anticonvulsants

3

Female Orgasmic Disorder
DSM V criteria

Presence of either of the following on all or almost all (75%- 100%) occasions of sexual activity:

1) Marked delay in, marked infrequency of, or absence of orgasm.

2) Markedly reduced intensity of orgasmic sensations

Symptoms persisted a minimum of 6 months and not better explained by a nonsexual mental disorder or consequence of severe relationship distress or other significant stressors and not due to effects of substance/medication or other medical condition

4

Female Sexual Interest/Arousal Disorder
DSM V criteria

Lack of, or significantly reduced, sexual interest/arousal as manifested by 3 of the following:

1) Absent/reduced interest in sexual activity
2) Absent/reduced sexual/erotic thoughts or fantasies
3) No/reduced initiation of sexual activity and unreceptive to partner’s attempts to initiate
4) Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (75%-100%) sexual encounters
5) Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (written, verbal, visual)
6) Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (75%-100%) sexual encounters

Symptoms persisted a minimum of 6 months and not better explained by a nonsexual mental disorder or consequence of severe relationship distress or other significant stressors and not due to effects of substance/medication or other medical condition

5

Genito-Pelvic Pain/Penetration Disorder
DSM V criteria

Persistent or recurrent difficulties with 1 or more of the following:
1) Vaginal penetration during intercourse
2) Marked vulvovaginal or pelvic pain during intercourse or penetration attempts
3) Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration
4) Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

Symptoms persisted a minimum of 6 months and not better explained by a nonsexual mental disorder or consequence of severe relationship distress or other significant stressors and not due to effects of substance/medication or other medical condition

6

What neurotransmitters increase sexual arousal and desire for sexual activity?

Norepinephrine and Dopamine

7

What neurotransmitter signals sexual satiety or inhibition

Seretonin

8

What neurotransmitters are involved in attachment/bonding and are prosexual?

Oxytocin and melanocortins

9

Chronic diseases that negatively affect sexual functioning

MOOD DISORDERS - major depression, bipolar disorder

ANXIETY DISORDERS - generalized anxiety, specific phobia

PSYCHOTIC DISORDERS - schizophrenia

ENDOCRINE DISORDERS - diabetes, thyroid disorders, hyperprolactinemia, adrenal insufficiency

UROLOGIC - renal failure, urinary incontinence, UTI

CARDIAC AND VASCULAR - hypertension, CAD, MI

GYNECOLOGIC - STIs, Chronic Pelvic Pain/Endometreosis, Dyspareunia/Vulvar Pain Disorders, Vulvovaginal Atrophy, Chronic Vulvovaginal Candidiasis, Postpartum Physical/Hormonal Changes, Pelvic Organ Prolapse

CANCER/SURGICAL/CHEMO - Breast Cancer, Anal Cancer, Colorectal, Gynecological


DERMATOLOGIC - Eczema, Psoriasis. Paget’s, Vulvar Dystrophies

10

Psychosocial factors that affect sexual function

Relationship conflict
Major life stressor(s)
Boredom
Discrepant desire levels between partners
Cultural/religious prohibitions/guilt
Subclinical depression/anxiety/body image

11

What is the PLISSIT acronym for office based counseling?

Permission to talk about sexual issues, reassurance and empathy

Limited Information
e.g., education about genital anatomy or educational resources

Specific Suggestions
e.g., use of lubricants, altering position

Intensive Therapy
e.g., referral for psychotherapy

12

Distinguish cognitive behavioral therapy from sex therapy

Cognitive-behavioral therapy
* Alters dysfunctional emotions, behaviors and cognitions through systematic procedure

Sex Therapy
* Brief (5-20 session) solution-focused treatment
* Refocus patient/couple on motivation component of desire
* Restructure perceptions of partner and lovemaking

13

What is the "sensate focus" in sex therapy?

Most well-known technique and most frequently prescribed behavioral sex therapy

Series of progressive, in vivo (homework) desensitization exercises

Enhance partners’ awareness of pleasurable experiences, preferences for sexual touch

Reduces anxiety

14

Name some FDA approved therapies for FSD

OSPHENA - SERM used for primary dyspareunia (agonist in vagina, endometrium, bone)

PREMARIN CREAM - conjugated estrogen. 0.5 gram BIW for post-menopausal dyspareunia

INTRAROSA - intravaginal DHEA.
* Precursor of estrogen and testosterone. Acted on by intracellular enzymes to convert to estrogen/testosterone
* Talk to oncologist if cancer survivor
* Daily for post-menopausal dyspareunia. FDA approved for post menopause only. Used off-label for premenopausal PVD

ADDYI (FLIBBANSERIN)
* approved for hypoactive sexual desire disorder (HSDD)
* Transient decreases in serotonin/Increases levels of dopamine and norepinephrine → calm + increased desire
* Taken q day
* Black box warning: no alcohol → drop in BP
* SE: mild nausea, dizziness, fatigue, somnolence
* works in about 50% of people, d/c if no improvement in 8 weeks

15

Evidence based nutraceutical options for FSD

ARGINMAX: Oral L-Arginine (precursor to N.O), ginseng, gingko and damiana. Embedded in multivitamin, available at GNC.

STRONVIVO: L-arginine, L citraline, L carnitine, zinc, Magnesium. For arousal, orgasm, and pain

ZESTRA: Essential arousal oil: vasodilatory oil of angelica, coleus, evening primrose. Must massage into non-mucous membrane. Smells of Juicy Fruit

16

"Off label" options for FSD

Testosterone creams, gels and patches approved for
men(Testim)
* Don’t give unless calculated Free T is low (need 3 values). Must monitor levels, shouldn’t be on it for more than 6 months
Subcutaneous T pellets
DNRIs (Wellbutrin/Apomorphine)
PDE-5 Inhibitors (Viagra,Cialis,Levitra)

17

#1 cause of insertional pain in premenopausal women

Vestibulodynia (vulvar vestibulitis)

18

2 most common pelvic floor dysfunctions

Pubococcygeus (on either side of introitus)
Transverseperinei (right under introitus)

19

1st, 2nd, and 3rd line treatments for pelvic floor hypertonia

1ST LINE:
* Noninvasive, multidisciplinary tx.
* Psychobehavoiral rx - CBT, mindfullness, sex therapy
* Physical therapy: external, internal, biofeedback

2ND LINE:
* Botox for hypertonus

3RD LINE:
* Topical capcaisin cream
* Vestibulectomy

20

What is allodynia?

hypersensitivity to a stimulus that is not meant to be painful (ie tampon insertion)

21

Non-pharm therapy for vulvodynia

Vulvar hygiene: cotton underwear and sanitary products, avoid tight clothes, expose vulva to air regularly (no undies at night)

Decrease chemical irritation: avoid contact irritants like shampoos, bubble bath, perfumed soaps, fabric softener, chlorine in pools, etc. Rinse vulva after urination and pat dry

Decrease mechanical irritation: drink lots of water to ensure tissue hydration. Emollient (good oil, vaseline), water based lube. Dont scrub vagina

Pain relief: ice packs or cool witch hazel soaks

Yoga, acupuncture, hypnosis, meditation, Tai Chi, psycho/sex therapy
Kegels
Low oxalate (avoid caffeine, meat, fruit) diet?
Calcium citrate