This presentation is a case based, practical approach to evaluation and treatment of female sexual dysfunction.
St. David’s Healthcare CME program recognized the significance of ongoing clinical changes in medicine and how often new techniques and outcomes are introduced. We are proud to offer the library of courses available to you, however, cannot guarantee that all courses are presented with the most current information. The course shown above is no longer available for CME credit.
SANDEEP MISTRY: Thank you, guys, so much for giving me your lunch hour today. I get to talk about a subject that some of you have heard me talk about before, and it's something that I've had a strong interest in since starting the practice 10 years ago. Largely deriving from my perception that female sexual dysfunction as a disease and study entity had gotten very little interest in my training program. And I really felt like it would be a great area for me to make an impact in. I'm going to spend a few minutes going over the prerequisite slides on definition and classification. And then most of what I'm going to spend time with here is on case studies to demonstrate kind of both FDA on-label ways that we treat female sexual dysfunction, which is a limited subject material area. And then beyond that, areas in which we try to expand and treat patients who may not fit in traditional treatment categories. The diagnosis and treatment sexual dysfunction in women is complex and controversial, and that's made more controversial because it's difficult to agree on terminology and treatment outcomes. What is considered success? In men, it's fairly straightforward. Generally speaking, if you can get an erection, you win. In women it's a little harder to define success. And that's wherein, a lot of the research difficulties come into play. Because how do you decide if a drug works or not if you don't have a definition of what working or what normal is? In the community and in the literature, in the lay press, some people have suggested this is a manufactured condition. That there really is no such thing as female most sexual dysfunction. That this is something that has been invented by drug companies or doctors. But I would argue that those of us that take care of women and sexual problems in a common way, can see it is very common, very distressing. And that simply writing it off as something that's not to be believed, I think is a disservice to patients. In terms of the determinants of sexuality, it should be no secret that it's a multi-factorial process here. We have biology, psychology, interpersonal sociocultural issues that all interact to determine a person's sexuality. We, as physicians, are used to judging disease states by comparing to normal. We have normal lab values, we have a normal pathophysiologic, a normal physiologic response to judge pathology on. But when it comes to sexuality, what is normal? It's difficult to define, and so using diagnosing statistical manual techniques, really we rely on something causing distress to the patient to determine whether or not it's really a disease process. Are you too short? Well, only if it really bothers you, is the way that we've taken sexuality. I would argue that, in fact, that definition leaves on the table many, many patients who would benefit from a more expanded evaluation. And I'll get to that in some of what we're going to talk about today. So the beginning part here, just a little outline of what we're going to talk about. The simplest definition of female sexual dysfunction is the various ways in which a woman is unable to participate in a sexual relationship as she would wish. It's pretty broad. It would include she doesn't have a partner. It would include sexual dysfunction in her partner, but certainly it gets to the heart of what we want, which is that it's broad enough to include a variety of different sexual complaints. We classify it based upon the domain in which the deficit occurs, whether it's desire, arousal, orgasm and pain. These four classifications make it easy and kind of more of a portable way of defining what sexual dysfunction is. The duration, whether or not it's always been present or more recent. And whether or not it's generalized situational. So I can't orgasm with my husband is different than I could, I have never been able to orgasm with any partner. And it kind of gets more towards whether or not a biological or psychological disease state may be present, and may help direct which direction we go in terms of our initial treatments. In terms of prevalence, depending on the study you look at, up to 43% of women complain of some sexual difficulty. But somewhere between 8% and 10% of women complain of a distressing sexual difficulty. Now that may be an over call depending on the subject cohort. But even if you halved it, up to 5% of women have a distressing sexual condition, which means that it is certainly worthy of training and worthy of exploration in your visits if you take care of a large number of women. The problem with classification of sexual disorders is that there's such a great overlap. It would be very difficult to imagine a woman achieving orgasm regularly if she has severe pain. Similarly, it would be very difficult for her to have significant arousal if her desire were low. So there's oftentimes an overlap between these conditions, and as part of the history, it's important to try to understand where the primary issue might be. In men, it used to be said that impotence was psychological 90% of the time. And these were books that were published as late as the mid-1980s. Today we would find that to be ridiculous. We know that it's physiologic and hormonal in many and most cases, in fact. And so if we were to assume that sexual dysfunction in women is primary psychologic, I think that's a mistake. That there's a psychological component is obvious. There isn't an impotent man out there who you wouldn't say also has a psychological component to what's going on with him. Similarly, there is likely to be a psychological component regardless of what the underlying FSD domain might be. There are many barriers to treatment. Time, being number one and primary. There is restricted availability to therapy resources. I've got four sex therapists that are going to be here that we work with, they're going to have cards today for you to visit with and hopefully have availability for your patients. Many physicians don't believe the patients want to discuss it. And a lot of the patients don't think the doctor wants to discuss it. When in fact, both groups should want to be able to discuss this. Patients feel the provider would be uncomfortable or doesn't care, because they don't ask follow-up questions or try to delve into the issue. And then doctors, if haven't been educated in it, you're going to feel a lack of confidence in the diagnosis and management the condition. And these are all understandable barriers. But as I spoke in the beginning, there's let relatively limited research because we can't agree on terms to use. And we don't have very good consensus on what treatment outcomes look like. So I'm going to try to give us a treatment outcome, and that is to go back to embryology and talk about how men and women are the same. OK, we all start off the same embryologically and then we differentiate. But there are male and female analogs, and those of you that went to medical school, we had tests on this. What is the male and female analog of the labia majora, the clitoris, the labia minora? What does the penile shaft in the woman? You know biologically, these areas function and respond very similarly to arousal, to testosterone, to estrogen and testosterone balance. And so to say that one group, one gender is primarily anatomic and physiological and may have sexual dysfunction, and another group is primarily psychological, I think really discounts how similar genital sensation and sexual response will be in both sexes. And so when we have a disease state that we don't know how to deal with in a woman, like someone who has arousal difficulties, one of the first things that I try to do is think about them, what would I say about the same complaint in a man. So if I find, if I have woman in my office and I ask her if she's sexually active, she says no, if I had the same man, a 35-year-old man, who by all rights seems biologically intact, I usually ask him again. Have you ever been sexually active? Are you having any problem? What's going on? Is it your upbringing? He'll give me an answer. But we tend not to do that in women. And I think that leaves a lot of people who potentially have issues that they may not feel initially comfortable with, on the table. And that's kind of my approach. And that's where we get at some of the second and third step treatments that I'll be discussing in the case-based studies. The elements of my sexual history will include, are you currently involved in a sexual relationship. I never assume is it with men, women, or both. And do you have any pain or concerns? Now a lot of times the answer will be are you currently involved in a sexual, the answer is no. And do you have any concerns? No. But if you don't ask any questions beyond that, you will miss the entire swath of women and men that have sexual aversion disorder. Because they're really not bothered by the fact that they don't want to have sex. When in fact, I think that it could be argued that a disgust of sex or disgust of discussing genital sensation would be considered something that is not normative. Some of the aspects of the sexual history that we want to make sure we get on in patients that do have troubles, of course, the obvious ones, like abuse. We also would like to know what their views on masturbation. If they aren't sexually active, are they masturbating. If not, why not? Is there a libido issue that's uncovered that's not distressing to them? You also want to get an idea about specific sexual preferences, if possible. And you want to assess whether there are sexual difficulties in the partner. Many men come to us and you ask them if they're having sex, they say no. And the answer is because their wife doesn't want to have sex, their wife has a medical condition that prevents sex. Those are other opportunities for us to intervene as well. In terms of a physical exam, besides height, weight and BMI, as BMI has a significant impact on both hormonal function, as well as self-esteem, it's important in some of the treatment paradigms that we'd decide to use. I'm going to talk about a vestibular and vulvar examination that we do that's specifically geared towards sexuality. Pelvic force strength and tenderness is an important part of what we deal with. Pain is the most common presenting symptom of sexual dysfunction to a provider, despite the fact that desire is the most commonly experienced. So we see a lot of pain in our practice. A bi-manual vaginal examination, and if, in patients who have a history of breast cancer, I think it's important to look at the breast reconstruction and understand how anatomically things have changed. In terms of specialized testing, we do testing in a woman with sexual dysfunction just like we would a man. We want to make sure their lipids are normal, we want to make sure they're not diabetic, we want to make sure their liver function is normal. We check their hormones, testosterone, their sex hormone binding globulin, which is a protein made by the liver that can rise up in patients with certain medical conditions and a certain history of exposure to hormones that will reduce their free testosterone. We want to look at their prolactin level. Even people with quote unquote normal prolactin levels, that are on the high level, the high end of the normal range, can have a libido suppressing effect from that prolactin. In select patients we like to do endothelium testing, the machine that's called EndoPAT. Talks about vasculogenic response. And then the piece of equipment that we have that has been very informative is a vibratory and temperature nerve testing device. They sell them for diabetic foot kind of issues, but it has a vibratory sense and a temperature sense. And this gives a lot of information in regards to genital sensation, especially in men and women who have orgasmic or arousal disorders. So as I go into the case presentations, I want everybody to be warned, OK? Virtually everything we're going to talk about here is going to be off-label. And that's because there's only three on-label drugs, OK? So we have topical estrogen, which I don't need to educate anybody on. Addyi or flibanserin is a relatively newer agent. It's a dopamine agonist used for low sexual desire disorder, which I'll talk about more as we go through. And then Osphena, which is an oral serum that's used for vaginal dryness. So it was easier to list all the things that are FDA approved and then everything else is not FDA approved for the use that we're going to use. Now some of the drugs that we're going to use, they've all kind of been put on the slide as bullet points. I don't want you to think that they're very cavalierly used. Some of them are very, very much out of off-label from what they're intended for. And this is, we usually give them to patients who are severely distressed and in whom things haven't worked. Obviously, we want to use interventions that have higher success rates before we go on things that have lower success rates. But I thought it would be valuable for you to understand the things that we've used in the past that have been successful. So the first case study is going to be a 28-year-old woman with severe pain with penetration that persists after intercourse. All these cases are actual patients that we've had. She had a 10-year history of oral contraceptive use. The pain developed over time, so it was an acquired condition, not generalized. She has occasional discomfort with tight clothing, unable to achieving orgasm, and her physical exam revealed severe tenderness along the entire vestibule, especially periurethrally. In terms of our physical exam that we do, the sexual physical exam when it comes to vestibulodynia is going to be focused right at the vestibule, which is going to be internal the labia minora and at the hymen and externally. This area, especially the periurethral glands and posteriorally affords us a lot of information and its tenderness there that we define as provoked vestibulodynia or vestibulitis. Vaginitis internal to the vestibule, vulvodynia external to the vestibule. And that's an important demarcation for us in terms of how we decide our next treatment. This is just a graphical description of where the pain is, for just a little information on what could be the cause of it. When pain is at the entire vestibule, we think of things like hormonally mediated vestibulodynia or proliferative vestibulodynia. Now this is a very busy slide. The slide deck will be available for anybody that wants it. And I'll just kind of go through it. Many of you have come across patients with penetrative sexual pain. VVS or vulvar vestibulitis syndrome is one term that's given to it. Provoked vestibulodynia is another one. In this patient we would consider the anorgasmia secondary to the pain. And we would also consider the oral contraceptive use to be the major risk factor for the pain. It's not that all women on oral contraceptives will have a problem, but some do. If they've been having the pain for less than six months, we will use a topical Triamcinolone or an injected Triamcinolone into the vestibule, which we can do in the office. And the data shows about a 20% reduction in symptoms. We use Neogyn, which is a vulvar soothing cream that's available commercially in these patients. When you do biopsies in patients with provoke vestibulodynia that's less than six months in duration, there will be an increase in mass cells before you get an increase in proliferative response. And so oral Singulair may have a role. And studies in patients with less than six months of symptoms showed a 52% improvement. Vestibular alpha-interferon injections are also something that we do, and you get about a 50% reduction in symptoms if it's less than six months. If it's more than six months, we start with a combination cream of lidocaine, elavil, occasionally gabapentin. And then we include testosterone or estrogen. The hormonal response of the vestibule has been widely published, so this area of the body does often respond to testosterone in a way that perhaps intravaginally it may not. Oral amitriptyline in some studies has shown that 60% response rate. And just anecdotally, people have used topical clindamyson. Now that process works I would say 60%, 70% of the time going through that algorithm for provoked vestibulodynia. We use pelvic floor physical therapy almost in all these cases, because just like having sexual pain often causes orgasmic problems, having penetrative pain often will lead to pelvic floor spasticity and deeper pain. So to just completely disconnect these, I think is a mistake. And many times women will just say they're having pain with intercourse and it would be difficult for them to really verbalize at what area the discomfort is. We use vaginal or Valium suppositories. It is debatable whether or not the Valium is actually helping locally with muscle relaxation, or the use of some type of device going into the vaginal introitus that's causing a reflexive relaxation. Either way, it tends to work in a subgroup of patients. Dilators I think is, proper instruction and use of dilators is something that you'll see used very often in this talk for a number of different conditions. We use silicone dilators that are easy to clean. They can be warmed safely. And they don't, they're available in a variety of different sizes. And we use dilators quite a bit. Botox into the vestibule, because I'm going to talk about Botox into the pelvic floor musculature later, but Botox into the vestibule has been able to see up to a 95% ability of some patients to resume intercourse. And 30% of patients with vestibulodynia had no pain at three months. Oral gabapentin and cymbalta, and then in select cases, vestibulectomy. Now vestibulectomy appears is a surgery that's generally reserved for people that have always had, that have always had vestibulodynia, not necessarily patients who acquire it with age. So it generally works better in a primary case. We consider those patients to have had some type of nerve proliferative process from early on, and that's why perhaps removing that nerve tissue is a benefit. The next one is going to be a fairly straightforward one, and that is a 60-year-old woman with pain with intercourse due to severe vaginal dryness. A diminished libido is reported and labs consistent with menopause. Now vulvovaginal atrophy related to estrogen deficiency is something that almost all of us will come across as we treat women who are aging, whether it's due to natural menopause or surgical menopause. In these cases, we usually try to address the pain of the vulvovaginal atrophy prior to addressing the libido loss, which we believe is also primarily hormonally driven. For us, topical estrogen preparation, that's a no-brainer. However, compliance rates with Estrace or Premarin cream is very low after a year. And so trying to understand what are those barriers to compliance I think is important. It's messy. People don't remember. So trying to come up with alternative ways I think is valuable. The Vagifem suppositories I think have seen a slightly better compliance rate. Maybe it's a little less messy. And Osphena, which I think that we don't push hard enough, certainly has a very good success rate and potentially better compliance rate. Now when you're using these creams, a lot of patients will come to you and say that they're sensitive to the creams. And so what do you do then? So it's usually the base. Whether it be in your vulvovaginal atrophy patients or your provoked vulvodynia patients who are not tolerating the creams that you might be putting them on, coming up with a more inert cream base is something that all compounding firms can be made available to you. We use an emu oil base as our first one. I don't know how they squeeze the oil out of that emu, but somehow they do it. And then we also use a petrolatum gel. Many times, what you can get from the compounding pharmacies, and we'll be happy to share what we do, is they will send a little sample pack of four different bases to the patient,-- Which they'll try them all and then see which one is the most inert for them. And then make the creams out of that one. So that's how we get past that. Many of you may be providing the MonaLisa or the fractional micro ablative CO2 therapy, which has a very high success rate and high patient satisfaction. Now in some patients who estrogen's not working, DHEA, whether done topically or done through vaginal suppository, has shown very good rates of success. 84% in the 6.5 milligram daily ovule. A topical testosterone preparation for vaginal dryness has also been shown to be successful. And then a variety of lubricants. We're kind of a lubricant house, so there are silicone-based, oil-based, water-based lubricants. It's probably easiest just to kind of know the names of one of each and then kind of go with it, so that way you at least have something to recommend to your patients. Many of them available on Amazon, some of them are available at CVS or Walgreens or any other pharmacy. What you want to encourage them to do, of course, is to not use something that has-- Something like a glycerin in it, or some kind of warming gel or any kind of taste or anything like that, because with preexisting vaginal discomfort, these things tend to make things worse. Number three, we're going to talk about the 42-year-old divorcee. I think many of us know this particular patient. Inability to achieve orgasm with a new partner with no trouble previously. And then she's doing all the other things. She started exercising and now has lower back pain. She started a diet program after she was found to be diabetic. And when we checked her temperature and vibratory sensation, we found her to have decreased temperature sensitivity. Now this decreased temperature sensitivity is potentially related to her history of diabetes, which we would say the same thing for a man. So similarly, again going back to my original point, if you have a man with decreased arousal it's easy to identify that man because he doesn't get erections. If you had a 48-year-old man without erections, you would naturally think that checking and treating his diabetes more aggressively would be an important first course of action. Similarly in women with diminished sensation, anorgasmia, even diminished libido, an aggressive treatment of their underlying medical conditions I think should be our very first inclination. This particular patient is at risk for pelvic floor spasticity, which may inhibit relaxation allowing for an orgasm. And there may be a psychological impact of restarting a sexual relationship after getting divorced. What do we do? Directed masturbation and mindfulness therapy. That's where our sex therapy colleagues are so important. We have an in-house pelvic floor physical therapist. And if you guys don't have one that deals with sexuality, you should have one, because they're exceptional adjuncts to your therapy program. And then we want to do things that may improve temperature sensitivity. A topical capsaicin cream, as bad as that may seem, in fact, or as painful as that may seem, it is in fact very successful and tends not to be burning. A topical alprostodil in men. We use alprostodil as a erectile agent. We would use it in this case as well. Warming lubricants. this would be an example if in case she does not already have any type of vaginal discomfort. I still mispelled Sildenafil, I don't know how I got away with that one, I'm sorry about that. A topical, Sildenafil, we're part of a research study in our practice where we're using a topical Sildenafil. I don't know how they're going make any money, since you can just compound it easily in a cream anyway, but it's not my problem. But a topical Sildenafil may also help in this case. We use yohimbine. We use yohimbine a lot in hypo-orgasmic and anorgasmia patients. Yohimbine, it's an extract that comes from a tree bark. It was known as an aphrodisiac for many years. And it even touted or tested as an erectile aid. What it really does is it gives many patients a better orgasm. It's an excitatory alpha agonist, and so it raises your heart rate, it makes you sweat, gives you the jitters. And hopefully makes it easier to orgasm. And so we use it both in men and women for that particular purpose. Oxytocin intranasal through an intranasal or through sublingual troches is something that we use. And, of course, again in an off-label manner, Viagra 12.5 milligrams, at times trading up to 100 milligrams. Taken in the way that I've put here on an empty stomach an hour before intercourse. All right, so next we're going to talk about our hypoactive sexual desire patient. She's 42 years old, mother of two, married for 10 years and she's come to us because she's distressed from an absence of sexual desire and absence of sexual fantasies for the last five years. She has used oral contraceptives in the past. Otherwise, her exam's normal. Her laboratory exam did find a decreased free testosterone. So hypoactive sexual desire disorder generally requires that no other domain of sexual difficulty exists. So predominantly pain. You can't have pain and have hypoactive sexual desires disorder. The laboratory evaluation is generally normal, although I mentioned an abnormality here in this particular patient. That is not considered a contraindication. That particularly [INAUDIBLE] not considered a contraindication to this diagnosis. Our treatment algorithm. I think psychotherapy is a very important component. Because to keep going on the medical field and not having uncovered a significant relationship issue I think would have you spinning your wheels for a long time. We're going to talk about flibanserin and its efficacy, but that I think has to be very much on the top of your mind as a treatment option. Transdermal testosterone has been shown to be effective in this particular patient population, those with free testosterone levels that are low and hypoactive sexual desire disorder. Wellbutrin, this is one area in which some studies will show no efficacy. But the study that I've cited showed a 71% increase, reported increased in libido. Requip is a medicine that's used for restless leg syndrome. If you ever hear the ad for Requip, they will tell you about the potential side effect of hypersexuality and a desire to gamble. And so we use that side effect to our benefit in this case. And so it's not a home run, but it's certainly a potential bullet in your armamentarium. And then both Dostinex and bromocriptine are both medications that will act to reduce prolactin. This is going to be a better drug in patients who have a prolactin level say in the to to 30 range, less effective than somebody with a prolactin in five to 10 range. When it comes to sexual desire, there are excitatory and depressive neurotransmitters. Dopamine, oxytocin, melanocortin and norepinephrene are all kind of excitatory. That's why in all those movies when the hero and heroine get together, their norepinephrene levels are high and now everbody's all horny. Depressive-type neurotransmitters includes serotonin, which is why SSRIs will, in some patients, cause low sexual desire. Opioids, important in patients on chronic pain management. And then prolactin. So what Addyi is, it's a dopamine agonist. And so it went through three studies, thousands of women, really to find a change in baseline sexual events that amounted to about one more sexual event a month. And so there again lies the difficulty in getting drugs approved and thinking about what we're going to do for sexual desire. Because that may or may not sound like a really big win. However, if you look at the patients that were on the medication, many of them reported that they had increased sexual desire, even though they didn't have sex more often. And so a willingness to understand these kind of softer targets of perceived libido, I think is an important message from this study. Because you're not always going to get more sex. Because when you define, we would never do that in a man. We would never say you have erectile dysfunction, this drug better make you have more sex this month. Because we know just cognitively that there's probably a lot of things that get in the way of that. Whether you have a partner, whether the partner is mad at you, I mean there's lot of things they can get in the way of you actually having sex. So being able to get an erection, especially for those that don't get an erection when they're not aroused or not being sexually stimulated, that may also not be a one, that may not be a good test for men. How many spontaneous erections did you get in a month. That may not be a good test. But hardness of erections, your satisfaction with how you could perform sexually is a potential outcome and I think that would be a good outcome to potentially analogously use in women. There is a big drawback with flibanserin is that they can't drink alcohol. Because 17% of those on Addyi develop syncope or hypotension requiring some kind of intervention. They had to go into a Trendelenburg position or get smelling salts. That seems like a pretty big number. But one thing I would like to caution you about is that once you hear this, the room goes silent. Like nobody's interested anymore. And I would urge, you don't use, you don't transfer. Don't use your willingness to stop drinking on the patient. That's not fair. Not you, Dr. Seeger. Don't do that, OK? If she's coming to you because of a distressing amount of low sexual desire and you tell her she can't drink, let her try it out for a month. Don't transfer, because I think that is a bigger hurdle than them not drinking, is you thinking to yourself, man, nobody's going to want this. I've heard it 1,000 times. Nobody's ever going to agree to that. Well I mean, if you understand that the problem is really the patient with the disease, if you understand that it's their condition that they're opening up to you about, please make sure that you understand this is an FDA-approved treatment, it works. Anecdotally, I'll tell you that works in a revolutionary way for many women. And certainly make sure you put it into your armamentarium. All right, case study number five, one of my favorite patients that my sex therapist isn't here about, but she was a 24-year-old, she's a lesbian with lifelong hypo-orgasmia. She's unable to achieve orgasm with clitoral stimulation. She came was complaining that she could only orgasm with vaginal stimulation, which when you do this long enough, you'll see that most women complain of the opposite, which is why she sticks out as a case study. Upon deep, deep questioning, and only really after we found a decreased vibratory sensation, did she admit to a bad straddle injury from bicycle accident when she was a child. So what are our treatments for it? Well, we think that she probably had a pelvic trauma. She has measured decreased vibratory sensation in her clitoral region. And I think it's important in this particular patient, to understand how does she want to orgasm. She doesn't participate in intercourse with her partner. So if the only way she can orgasm is through intercourse, then her and her partner cannot share that sexual, and that's why it was distressing to her. Directed masturbation, pelvic floor physical therapy. Ultimately yohimbine and alprostadil worked on her. And I think we ended up using sildenafil on her also with some success. But really, I put this case in there to show you this, OK? The Hitachi Magic Wand. So Time magazine rated in 2016 in May the top 50 gadgets of all time. Number nine was the iPod. OK? Number 10 is the Hitachi Magic Wand. That is no kidding. OK? And it's not because it's a back massager. It is hands down, the most powerful sexual aid that you can buy. And it comes with a ton of accessories. So you go online, you can get the Rabbit, you can get this thing, you can get that thing. You can get chains, and a lot of things that go with it, but that seem a little bit off the rails. But a lot of things that are very much geared towards particular conditions that patients may want to explore. Things that are just specifically clitoral, specifically vaginal. But this is it, especially for those patients that have diminished vaginal sensation or clitoral sensitivity. All right, my next case is a 38-year-old decreased desire, decreased genital sensation. She has a history of depression and she has a 10-year history of Zoloft. So that SSRI use has now reduced her sexual arousal and her desire. Our treatments for her first focused on trying to find a way to reduce her use of the SSRI. Now a 10-year history of a stable patient, a lot of times you don't necessarily want to do that. Viagra, that is one of the, it's a JAMA study that was published that showed that Viagra, starting at the 12.5 milligram dose is effective in 75% of women who have low arousal and were on SSRIs. Wellbutrin, also 150 milligrams bid has also been shown effective. We'll use yohimbine and an alprostadil in that grouping as well. And pelvic floor physical therapy, especially if you think relaxation or an anxiety component could be conpounding the issue. My next one is of a three year, of a woman with a three-year history of persistent, non-enjoyable clinical engorgement. Has anybody here ever seen a PGD patient? You have. They really break your heart, because it's such a confusing condition. So they will come to you with complaints generally of genital engorgement that's non-enjoyable. This particular woman, she couldn't wear pants, she couldn't even sit for prolonged periods of time. She was having to masturbate several times a day just to get some kind of relief that would only last for like an hour. She was asexual, was unable to have relationships because partners could never understand why they she didn't really actually want to have sex. She had a history of Paxil use, which she had stopped. And a history of an open hysterectomy. This particular patient ended up completely resolving with just myofascial release of her hysterectomy scar. But additional treatments for that condition are available. I would say that if you don't do a lot of it, then find somebody that some of it, because it's not very common. Causes can include cessation of the SSRI, a pudendal nerve entrapment, or pelvic floor spasticity. And we've seen people that presented with this with every single one of these different underlying conditions. Generally-- What did you say about the hysterectomy scar in connection with this? For reasons that are unclear to me, there must have been some aspect of the scar that was causing pelvic floor spasticity, that was leading to this continued feeling of engorgement. And what did you do to relieve that? Myofascial release. It's a very intense physical therapy program that whether it quote unquote breaks the scar or relaxes the pelvic musculature, is unclear to me, but certainly the relaxation of the pelvic musculature is what ultimately worked for her. But we've had patients who you had put back on the SSRI. And then these are other things. Pudendal nerve blocks, there have been reports of pudendal nerve releases, in fact, and then a TENS unit can sometimes overload those nerve impulses and allow some benefit. My next patient is a 32-year-old Indian woman who presented with her husband. They've been married for seven years, never had sex, and now they're coming to us because they want to have children. So I think a lot of us, when we speak anecdotally, have seen this particular patient. She was never able to use a tampon, unable to tolerate a speculum exam, and now she's interested in having a child, which is why she presented to us. So vaginismus is either one of the worst forms of dyspareunia or a separate entity altogether. I think that those that have taken care of it would agree there's a significant psychological component to the vaginismus patient. And it needs to be done in a multi-modal way. What's interesting is, pelvic floor physical therapy, psychotherapy, and medicine, they all think that this is their condition to deal with. And so oftentimes referral out comes after you do whatever you were going to do. When that's backwards. Really, it's everybody's condition and we should all be dealing with it from the initial get-go. So then the question is, well, what can the doctor do? If you think that it's primarily psychological or you think it's primarily pelvic floor, you may not know what your role is. Well, you need to make sure there's nothing else wrong. You need to make sure it's not provoked vestibulodynia. You need to make sure that it is a pelvic floor, an involuntary pelvic floor contraction that this patient suffering from. You may want to try things, like vaginal Valium. You may want to initiate a dialator therapy program from the beginning. Amitriptyline can have an impact. And there's even some role for either a target, a trigger point infiltration, which can be difficult because the patient has to be awake for the trigger point injection of either lidocaine or a steroid. And then just getting them pregnant, because ultimately if many times, they're unwilling to go through a multi-modal kind of intense program. And when that's the case, just giving them what they want without too much difficulty I think is something that you should consider. This is an example of how not asking past the no, I don't have a sexual problem that bothers me, runs into trouble. An 18-year-old with no sexual desire probably came to see us for a kidney stone or something unrelated. Through the asking of this history, no relationship seeking inclination, considers intercourse dirty and concerned about pregnancy and STDs. Is that normal? Maybe, right? Maybe sex is dirty. Maybe she doesn't really want to get pregnant or get an STD. Is that normal? So then I say, OK, what about that 18-year-old college guy? he just went to UT, lacrosse scholarship, ready to go. He doesn't want to have sex because he thinks it's dirty. I would definitely say I need to ask this guy some more questions. If he tells me that he was raised in a religious upbringing and he wants to remain chaste, that's, now I understand where he's coming from. If he thinks that genitals are dirty and he feels that his epididymis is separated from his body or some other kind of genetic-centric kind of dysfunction in his mentality,-- Then it's something that I would explore more thoroughly, especially through the use of a psychotherapist, which is really what is the primary modality of treatment with sexual aversion. The last couple of cases that I want to talk about are specific ones. This first one has to do with cervical cancer and sexuality preservation. So if you wait until after radiation to start sexual preservation, you are going to be well behind the curve. Because 80% of them have dysfunction. 60% of them stop having sex, and 65% of them develop vaginal shortening or stenosis. However, if you initiate a vaginal preservation program early, most of these women can maintain a healthy sexual relationship afterwards. What does that require? It requires teaching them how to use dilators. If you give them the website to buy the dilators, they will not know how to use it and they will not use it properly. That is why referring to a appropriately trained pelvic floor physical therapist will enhance the use, the compliance and the outcomes of these patients. We want to use a vaginal moisturizer therapy. We use Replens as a vaginal moisturizer and they need to use that at least three times a week. Again, if you want these slides later, these are the actual guidelines that are published in the nursing literature about how these dilators should be used in a vaginal preservation program for pelvic radiation therapy. Breast cancer patients with sexual dysfunction. Oftentimes women go through a ton. They go through this near-death experience and now we have to deal with survivorship issues. So what are some of the things that challenge us? Well, most all of them are menopausal now. So they're going to have hormone deficiencies. Many of them have severe vulvovaginal atrophy. Some of them have gone through bilateral mastectomy where there was nipple sparing or not. And a lot of them are on current treatment. So what are things that we can do? Well, there's a vaginal hygiene program that has been proven to maintain the sexual function of women in about 70% when initiated early. It involves the use of Replens, used three times a week, a olive oil type, olive oil as an actual lubricant during intercourse. And pelvic floor muscle relaxation exercises. That last one is important. Having them learn how to relax their pelvic floor will allow them to not respond to the painful stimulus as significantly. There have been some studies on the use of Mona Lisa in the breast cancer patient subgroup. And for those that are getting particularly kind of aggressive, the DHA topical or the DHA suppository has been shown on pico milligram levels not to increase testosterone or estrogen levels in the blood. Psychotherapy, because the partner often suffers from some degree of sexual problems just going through that survivorship. A lot of times there's guilt, a lot of times there's this hesitancy to approach their wife for sex. And so that's where sex therapy and survivorship-type therapy has a big, big role. I think looking at the reconstruction's important. I mean if it really, if you can tell that it doesn't look right, then she's not going to feel like it looks right. And she's not going to want to take her shirt off and is going to have a big self-esteem issue. If she had a nipple sparing, she may have very high expectations of what those nipples are supposed to feel like. And there's loss of nipple sensitivity often, even in a nipple sparing situation. And, of course, complete absence of nipple sensitivity if they're tattooed on. 82% of women report increased sexual around nipple stimulation, and about 12% of women can only orgasm with nipple stimulation. So if she has decreased arousal and decreased desire and ability to orgasm, and she doesn't have her nipples anymore,-- Trying to teach her how to overcome that and how to use these other adjuncts that we have for hypo-orgasmia, I think becomes an important tool in our belt. Other women, BMI has been shown to be a direct, have a direct relationship to women who are breast cancer survivors. So I just put that in mind. And of course, don't forget that she's a diabetic and she has other medical conditions. It may not just be the breast cancer treatments that have caused her sexual dysfunction. All right, and the final case study here is going to be about the infertile woman. Now they come to us oftentimes as the partner for the men they get referred to us. And this has to do with what impact does prolonged infertility treatments have on a woman's sexuality. So there are medical conditions that cause infertility that can also cause sexual dysfunction, and the medications. But there's really a huge psychosocial component. There's marital stress, there's self-doubt and blame. Sex becomes about conception without pleasure and sex becomes on demand. I see this in men, too. I have a bunch of men that were referred to me only because they cannot ejaculate when their wife is ovulating. I mean there's the stress and they can't get erections when their wife is ovulating, and this is an actual thing that we see quite often. Problems can persist after fertility treatment, which is the real point. Which is that although the fertility treatments may only last a limited amount of time, the impact on the relationship and how that couple develops a sexual habit pattern, is going to change. And so understanding early on that it's going to have an impact, I think is the only way that you can make any kind of effect. There can be self-esteem issues, depression, and of course, anxiety. For us, it's critical to discuss the impact of fertility with couples early. And then reassure them through the process that it is normal to have some sexual difficulties through the process. It is normal. And that when they feel they need to see somebody, please make sure you have a pocketful of cards of therapists that you can send your patients to. So in conclusion, sexual difficulties in women are highly common and we play an important role in validating their concerns and helping to direct treatment. And having that multi-disciplinary team available to you is very important when addressing these sexual concerns. And I left my email address up here if anybody would like this slide here. Thank you guys very much. [APPLAUSE]
