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SEXUAL DYSFUNCTION IN WOMEN

Bharti Kalra, Komal Chawla, Kusum Bhatia, Pooja Batra

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DEFINITION OF HEALTH

Physical well –being.

Mental

Social

SEXUAL

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Women and sexuality ď Ź

Being female no longer means being unable to express oneself; being unable to enjoy oneself

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BACKGROUND

SEXUAL DYSFUNCTION IS COMMONER IN WOMEN THAN IN MEN (Laumann EO et al, 1999)

The commonest disorders are orgasm and arousal in community surveys; desire and arousal in OPD surveys.

LITTLE ATTENTION IS PAID TO THIS ASPECT OF WOMEN’S HEALTH

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Talk plan        

Phases of sexual response Classification of disorders; Etiology Perception Diagnostic tools; Prevalence Counselling Treatment Specific conditions; Specific drugs Conclusion

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PHASES OF SEXUAL RESPONSE •

DESIRE

 Subjective feeling .  Motivation & inclination to be sexual.  Mediated by neuroendocrine changes.

AROUSAL

 Erotic feeling.  Vaginal lubrication.  Mediated by parasympathetic system.

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PHASES OF SEXUAL RESPONSE 

ORGASM

 Myotonic response.  Peak of sexual tension.  Sudden release of tension.  Mediated by sympathetic system.

RESOLUTION

 Complete relaxation.  Reversal of all changes.

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Contributory factors  

Ageing Illness-

• •

   

ENDOCRINE NON-ENDOCRINE

Drugs Alcohol Illicit drugs PARTNER

• • •

PHYSICAL HEALTH MENTAL HEALTH SEXUAL HEALTH

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DSM IV: CLASSIFICATION OF FEMALE SEXUAL DISORDERS

Orgasmic disorder

Desire disorder *hypoactive sexual desire

* dysparenia

disorder. *sexual aversion disorder

Arousal disorder

Sexual pain disorder * vaginismus * noncoital sexual pain disorder.

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DISORDER is that which causes personal distress/partner distress

Primary vs. secondary Persistent vs. recurrent Generalized vs. situational Organic vs.psychogenic vs. mixed vs. unknown

  

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Etiology      

Chronic medical illnesses Almost all endocrine deficiencies Hyperprolactinemia Infertility CA breast; gynae CA Oophorectomy

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STUDIES IN INDIA

WOMEN EXPECT, AND APPRECIATE, COUNSELLING REGARDING SEXUALITY AS A PART OF ROUTINE CARE (Kalra B et al, Diabetes, 2006; Kalra B et al, Diabetologia, 2006)

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PERCEPTION OF SEXUALITY 

89.26%:concerned about sexual health

44.63% felt diabetes lowered self esteem

71.18%: diabetes reduces physical attractiveness

56.49%: diabetes affects sexuality.

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ATTITUDES TOWARDS COUNSELLING 

89.26% WANTED DISCUSSION ON SEXUALITY AS PART OF ROUTINE DIABETES CARE

 

3.95%: sexuality had been discussed by an earlier doctor. 1.21%: willing to initiate discussion on sexuality

98.87%:expected doctor to initiate discussion

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KNOWLEDGE OF SEXUALITY     

9% patients aware of G spot . 15.81% aware of clitoris 67.79% understood orgasm / arousal 43.5% prefer use of non-direct words to describe sexual anatomy. Sources of knowledge • Friends: 22.1% • Relatives: 41.24%. • Print media: 13.55% • Television: 18.1% • Doctor: 1.69%

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Attributes of successful sexual counsellor: patient expectations         

100% expect confidentiality. 71.75% prefer counseling from a gynaecologist 10.16% from nurse educator 10.16% from clinical psychologist 7.9% from multipurpose diabetes worker 96.1% expect a successful sexual counselor to be married, 100% feel that she should speak local dialect 100% prefer the counselor to be female. 56.49% want a counselor of the same age.

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DIAGNOSTIC TOOLS 

FEMALE SEXUAL FUNCTION INDEX (Rosen R et al,2000; 2005)

Brief multidimensional self-reporting validated questionnaire Assesses domains of desire, arousal, lubrication, orgasm, satisfaction and pain. Validated in English, not in Indian languages

 

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SOUTH ASIAN TRANSLATIONS   

   

DESIRE AROUSAL ORGASM

  

SATISFACTION PAIN LUBRICATION PENETRATION

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   

‘iccha’ ‘uttejna’, ‘josh’ ‘sukoon’, ‘tripti’, ‘nasha’, ‘pani chootna’ ‘mazaa’,’santushti’ ‘dard’ ‘chiknapan’ ‘sambhog’

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INCIDENCE OF SEXUAL DISORDERS

DIABETES GROUP CONTROL GROUP N= 177 N= 100 Desire disorder

80 (47.05%)

33(33.00%)

Arousal disorder*

101(57.06%)

26(26.00%)

Orgasm disorder*

151(85.31%)

36(36.00%)

Pain disorder*

36(20.33%)

4(4.00%)

Pruritis vulvae*

18 (10.16%)

5(5.00%)

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DIABETES GROUP (n) %

CONTROL GROUP (n) %

Intercourse ≤ 1/mth.

(27) 15.25%

(9) 9.00%

Intercourse ≥ 2-3 /wk.

(96) 54.24%

(61) 61.00%

Pre/extra marital contact

(6) 3.38%

(4) 4.00%

Painful intercourse

(36) 20.38%

(4) 4.00%

Pruritis vulvae

(18) 10.17%

(5) 5.00%

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INCIDENCE OF SEXUAL DISORDERS

90 80 70 60 50 diabetes control

40 30 20 10 0 desire

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arousal

orgasm

pain

pruritis

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AGE-WISE INCIDENCE OF SEXUAL DISORDERS IN DIABETIC WOMEN

Age< 40 n=92

Age >40 n=85

Desire disorder *

17 (18.47%)

63(74.11%)

Arousal disorder*

38(41.30%)

63(74.11%)

Orgasm disorder*

73(79.34%)

78(91.76%)

Pain disorder*

10(10.87%)

26(30.58%)

Pruritis vulvae*

3(3.26%)

15(17.64%)

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Counselling       

Begin thinking Ask Active listening Empathy Anatomy/physiology/sociology/psychology Non-pharmacological therapy Pharmacological treatment

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Improve familiarity about internal organs

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History taking    

Time Privacy Confidentiality External environment

• Noise • Ambient temperature • Doors and windows/curtains

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History taking      

From general to specific From non-threatening to threatening From non-genital to genital From non-penetrative to penetrative From adolescence to pre- to post-marital From fantasy to reality

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In whom ?        

Direct chief complaint Chronic medical/endocrine illness INFERTILITY Lower abdominal symptoms Recurrent urinary symptoms Anxiety Depression Asthenia Vague somatic complaints

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By whom ? For whom ?  

  

Single counsellor/doctor Paired counsellors Single patient Couple therapy Family therapy

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Drugs     

Antidepressants Antihypertensives Statins Antiandrogens Antiestrogens

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Anorgasmia       

Directed masturbation Erotic fantasisation Vibrators/massagers Manual clitoral stimulation with partner BRIDGE technique Biothesiometry Sesame oil with camphor

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Vaginismus     

Graduated dilators Propranolol Anti-anxiety drugs Kegel’s exercises with dilators in-situ Coconut oil

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Dyspareunia 

Diagnose stage:

• pain at external genitalia stimulation, • penile entry, • midvaginal pain, • deep vaginal stimulation

 

Physical examination Treatment of cause

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Dyspareunia     

Antibiotics KY jelly Benzocaine gel Estrogen tablets/gel NSAIDs

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Desire disorder       

Identify sexual orientation Individual needs Religion vs. practicality Relationship with partner Help achieve orgasm Cinnamon bark Nicotinic acid

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Yohimbine     

Indole alkylamine alkaloid Bark of tree Pausinystalia yohimbe Root of Rauwolfia structure resembles that of reserpine; actions are opposite to those of clonidine Competitive selective Alpha-2 adrenergic receptor antagonist

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Yohimbine  

Shotgun approach Profound effect on sexual behaviour

• Post-synaptic α2 adrenoceptor antagonist • central noradrenergic activity • serotoninergic potentiation • Readily enters CNS • Has peripheral and central actions • Encourages sympathetic outflow

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Use of yohimbine   

 

Max 200 mg/d Average dose 6 to 10 mg/d Tolerance: initial enhanced response followed by decline in effect t½ = 35 mins h.s. vs. t.d.s vs p.r.n

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Estrogens    

Oral IM Local Mild improvement in symptoms, esp. desire Marked improvement in lubrication, pain

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Androgens 

     

Recommended in low doses for post-, perimenopausal women Improves desire disorder No low dose preparation in India Inj Mixogen Inj Aquaviron 25 mg Testospray 1 to 2 actuations Use cautiously only after documenting low T

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DHEA-S     

Adrenal corticosteroid Endogenous anabolic hormone Produces both androgens and estrogens Age-related decline Investigate in women with asthenia

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AVERAGE DOSE/LEVELS OF DHEA 

The average dose of DHEA required to correct DHEAS levels was 24.31 ± 10.75 mg at 3 months and 30.40 ± 13.67 mg at 6 months.

The average level at baseline was 40.86 ± 23.40 μg/ml in the AADS cohort. It rose to 81.39 ± 51.71 μg/ml at 3 months and 89.53 ± 51.50 μg/ml at 6 months

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ď Ź

DHEA-S levels rose significantly after supplementation with oral DHEA .

ď Ź

Most patients felt the maximum benefit of therapy within 4-6 weeks.

16.00% study patients and 4.00% controls reported a

subjective improvement in libido.

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Sulbutiamine (Arcalion) 

  

Selectively binds to excitatory area of reticular formation Increases acetylcholine receptor density Resets the control Perception of less physical fatigue, improved sexual performance Effective in desire disorder

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Sulbutiamine   

Dose 1 to 2 tabs o.d. with breakfast Treat for 1 month Effects are long-lasting

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Sildenafil   

Varying results May improve blood flow if used locally Not recommended for use in women

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Treat the partner 

Male sexuality is equally important Ensure that the partner is healthy Ensure financial,emotional, social health

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Conclusion    

Sexuality is an indispensible domain of health Targeting optimal sexual health is an integral part of medical care Female sexual medicine helps the patient, her spouse, her society. Female sexual medicine opens a new dimension in our practice

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Thank you

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SEXUAL DYSFUNCTION IN WOMEN