Women’s Sexual Health in Midlife and Beyond

Nurture Your Nature Women’s Sexual Health in Midlife and Beyond Sponsored by the Association of Reproductive Health Professionals www.arhp.org In conjunction with the National Women’s Health Resource Center www.healthywomen.org Made possible by an unrestricted educational grant from Procter & Gamble ARHP Nurture Your Nature: Inspiring Women’s Sexual Wellness Sponsored by: Goals: • Encourage communication between ♀ and health care providers (HCPs) on sexuality issues • Provide educational resources to ♀ and HCPs ARHP www.nurtureyournature.org Nurture Your Nature Committee Members Kirtly Parker Jones, MD Professor, Department of Obstetrics/Gynecology (Ob/Gyn) University of Utah Health Sciences Center Salt Lake City, Utah Lee P. Shulman, MD Distinguished Physician and Professor, Department of Ob/Gyn Feinberg School of Medicine, Northwestern University Chicago, Illinois Sheryl Kingsberg, PhD Associate Professor of Reproductive Biology Case Western Reserve University School of Medicine Cleveland, Ohio Beverly Whipple, PhD, RN, FAAN Professor Emerita College of Nursing, Rutgers, The State University of New Jersey Newark, New Jersey ARHP Learning Objectives • Describe two models of female sexual response • List four variables that affect female sexual function • Name two treatments for female sexual disorders • List two barriers that prevent effective HCP/patient communication about sexual health • List three questions to begin the assessment of sexual health during a clinical visit ARHP Healthy Sexuality • Women’s sexuality is complex • It is less studied, understood than male sexuality • Many theories, beliefs about female sexuality are inaccurate or outdated Lack of Personal • Clinicians may find training issues topic difficult to address Time ARHP Berman Fertil Steril 2003 Kingsberg Sexuality, Reproduction & Menopause 2004 Female Sexual Disorders: Prevalence Interest Lubrication /Arousal Orgasm Total Laumann Bancroft Geiss Nazareth 31.6% 7.2% 28.8% 16.8% 20.6% 31.2% 23.0% 3.6% 25.7% 9.3% 17.8% 18.9% 43% 45% 48% 39.6% ARHP Bancroft Arch Sex Behav 2003 Geiss Urology 2003 Laumann JAMA 1999 Nazareth BMJ 2003 National Health and Social Life Survey (NHSLS) 100 90 80 % of respondents • In-person survey – sexually active – 18-59 years 43% 31% 70 60 50 40 30 20 10 0 Women • Asked if problems in any one of seven areas of sexual function Laumann JAMA 1999 Men ARHP Limitations of NHSLS Survey • • • • • Only yes or no answers elicited Cross-sectional design No women >60 years of age Menopausal status not a factor Did not measure personal distress ARHP Distress About Sex: Kinsey 2000 Survey 100 90 • Telephone survey – 987 white and black ♀ – 20–65 years old % of respondents 80 70 60 50 40 30 20 10 0 24.4% • Best predictors of distress: – General emotional wellbeing – Emotional relationship with partner during sexual activity Bancroft Arch Sex Behav 2003 Women reporting marked distress ARHP Assessment of Female Sexual Problems ARHP Myths About Women’s Sexual Response • Organic dysfunction can be meaningfully separated from psychogenic dysfunction • Awareness of internal feelings of sexual desire is primary trigger for sexual behavior • Sexual desire necessarily precedes sexual arousal ARHP Basson J Psychosom Obstet Gynecol 2003 Myths About Women’s Sexual Response (continued) • Women’s arousal identified primarily by: – genital vasocongestion – vaginal lubrication – awareness of genital sensations • Women’s sexual response essentially stable and invariant across time/circumstance • All women experience distress about alterations or limitations in sexual response ARHP Basson J Psychosom Obstet Gynecol 2003 Female Genital Arousal ARHP Linear Model of Female Sexual Response Orgasm Plateau Excitement (B) A B C ARHP (C) (A) Masters and Johnson Human Sexual Response 1966 Kaplan Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy 1979 Problems with the Linear Model ARHP Circular Model of Female Sexual Response Emotional Intimacy Emotional and Physical Satisfaction Spontaneous Sexual Drive Sexual Stimuli Seeking Out and Being Receptive to Arousal and Sexual Desire Sexual Arousal Biologic Psychological ARHP Basson Obstet Gynecol 2001 Variables Affecting Female Sexual Response: Physiologic & Psychosocial Past sexual experiences or sexual abuse Relationship with Sexual self-image and/or sexual partner body image (male or female) Basson Menopause 2004 ARHP Variables Affecting Female Sexual Response (continued) ARHP Aging and Female Sexual Response Aging ≠ end of sexual interest and activity Avis Menopause 2000 Hartmann Menopause 2004 Bancroft Arch Sex Behav 2003 ARHP Reasons for Decline in Sexual Activity Among Women other 26% death of spouse 36% spouse unable to perform 18% illness of spouse 20% Pfeiffer Am J Psychiatry 1972 Pfeiffer J AM Geriatr Soc 1972 ARHP Physical Effects of Aging on Female Sexual Response • Clitoral shrinkage, ↓ in perfusion and engorgement, delay in clitoral reaction time • ↓ vascularization and delayed or absent vaginal lubrication • ↓ vaginal elasticity, thinning of vaginal mucosa • ↓ sex drive, erotic response, tactile sensation, capacity for orgasm ARHP Kingsberg Arch Sex Behav 2002 Bachmann Menopause 2004 Whipple 2004 Effects of Menopause on Female Sexual Response • • • • • ↓ in desire Diminished sexual response Vaginal dryness and dyspareunia ↓ sexual activity Dysfunctional male partner ARHP Kingsberg Arch Sex Behav 2003 Basson Menopause 2004 SWAN Study: Sexual Behavior of Women Ages 42 to 52 100 90 80 70 60 50 40 30 20 10 0 Engaged in sex within past 6 months Rated sex moderately to extremely important Infrequent desire for sex (0-2x per month) 79% 77% % of respondents 42% ARHP Cain J Sex Res 2003 MWHS II: Menopause and Female Sexual Response • 200 pre-, peri-, postmenopausal ♀ • Menopause status had less impact on sexual functioning than health, marital status, mental health, smoking • Satisfaction with sex life, frequency of intercourse, pain during intercourse did not vary by menopausal status • Postmenopausal ♀: – less desire and arousal – more likely to agree sexual activity declines with age Avis Menopause 2000 Kingsberg Arch Sex Behav 2002 ARHP Testosterone ARHP Mean Steroid Levels in Women (pg/ml) Steroid Estradiol Testosterone Androstenedione DHEA DHEA-S ARHP Reproductive Age 150 400 1,900 5,000 3,000,000 Natural Menopause 10–15 290 1,000 2,000 1,000,000 Surgical Menopause 10 110 700 1,800 1,000,000 Lobo Treatment of Postmenopausal Women: Basic and Clinical Aspects, 2nd Ed. 1999 Judd J Clin Endocrinol Metab 1974 Androgen Production Rates: Pre- and Postmenopause 15 Premenopause Postmenopause 10 0.25 0.5 Production Rate (mg/day) Production rate (mg/day) 50% 5 60% 75% 0 DHEA-S DHEA A4 Testosterone 50% 0 A4 =androstenedione. % represents reduction from premenopausal level ARHP Longcope Ann NY Acad Sci 1990 Diseases Affecting Female Sexual Response • Neurologic Disorders – Head/spinal cord injury – MS – Stroke • Endocrine Disorders – Diabetes – Hepatitis – Kidney disease • Vascular Disorders – Hypertension – Leukemia – Sickle-cell disease Phillips Am Fam Physician 2000 Whipple Sexual Function in People with Disability and Chronic Illness 1997 ARHP Diseases Affecting Female Sexual Response (continued) • Debilitating Diseases – Cancer – Degenerative disease – Lung disease • Voiding Disorders – Overactive bladder – Stress urinary incontinence • Psychiatric Disorders – Anxiety – Depression ARHP Phillips Am Fam Physician 2000 Whipple Sexual Function in People with Disability and Chronic Illness 1997 Medications That Cause Disorders of Desire • Psychoactive Medications – – – – – – Antipsychotics Barbiturates Benzodiazepines Lithium SSRIs Tricyclic antidepressants • Hormonal Agents – Danazol – GnRh agonists – Oral contraceptives ARHP Med Lett Drugs Ther 1992 Medications That Cause Disorders of Desire (continued) • Cardiovascular Medications – – – – – Antilipid drugs Beta blockers Clonidine Digoxin Spironolactone • Others – – – – H2-receptor blockers Indomethacin Ketoconazole Phenytoin sodium ARHP Med Lett Drugs Ther 1992 Medications That Cause Disorders of Arousal • • • • Anticholinergics Antihistamines Antihypertensives Psychoactive medications – Benzodiazepines – MAO inhibitors – SSRIs – Tricyclic antidepressants ARHP Med Lett Drugs Ther 1992 Medications That Cause Orgasmic Disorders • • • • • • • Amphetamines and related anorexic drugs Antipsychotics Methyldopa Narcotics SSRIs Trazodone Tricyclic antidepressants Med Lett Drugs Ther 1992 ARHP Predictors of Problems with Female Sexual Response: NHSLS • • • • • • • Younger age (<40) Unmarried Poor health Low sexual activity or interest Deteriorating economic status Negative sexual experiences Emotional and stress-related problems Laumann JAMA 1999 ARHP Predictors of Problems with Female Sexual Response: MWHS II • Health – Better a woman’s health, greater her interest in sex • Marital status – Married women had lower libidos and reduced arousal ARHP Avis Menopause 2000 Women’s Sexual Disorders: DSM-IV Categories • Sexual desire disorders – Hypoactive sexual desire – Sexual aversion disorder • Sexual arousal disorders • Orgasmic disorders • Sexual pain disorders – Dyspareunia – Vaginismus ARHP American Psychiatric Association 1994 Women’s Sexual Disorders: DSM-IV Categories (continued) • Sexual dysfunction due to a general medical condition • Substance-induced sexual dysfunction • Sexual dysfunction not otherwise specified ARHP American Psychiatric Association 1994 Women’s Sexual Disorders: 1999 CCFSD Categories • Sexual desire disorders – Hypoactive sexual desire disorder – Sexual aversion disorder • Sexual arousal disorder • Orgasmic disorder • Sexual pain disorders – Dyspareunia – Vaginismus – Other sexual pain disorders ARHP Basson J Urol 2000 Sexuality and the Midlife Woman: Clinician Issues • • • • • • • Personal issues Lack of training Lack of skills Lack of time Fear of embarrassing patient Lack of treatments to offer Belief that sexual interest declines with age ARHP Sexuality and the Midlife Woman: Common Biases to Avoid • Age • Sexual orientation – Heterosexual – Lesbian or bisexual • Relationship status – Patient may be at risk for STIs • Cultural issues ARHP Why Patients Don’t Bring Up Sexuality Issues with Providers 100 90 80 % of respondents 70 60 50 40 30 68% 71% 20 10 0 Fear of embarrassing provider Believe provider will dismiss concerns ARHP Marwick JAMA 1999 General Sexual History Assessment • Are you currently involved in a sexual relationship? • Do you have sex with men, women, or both? • Are you or your partner having any sexual difficulties or concerns at this time? • Do you have any questions or concerns about sex? • Are you satisfied with your current sexual relations? ARHP Kingsberg Sexuality, Reproduction & Menopause 2004 More Extensive Questioning About Sexual Health • Tell me about your sexual history • How often do you engage in sexual activity? • What kinds of activities do you engage in? – Ask about specific forms of sex – If lesbian, ask if she has ever had penetrative sex with a man to assess risk of cervical cancer and STIs • Do you have difficulty with desire, arousal, or orgasm? ARHP Kingsberg Sexuality, Reproduction & Menopause 2004 Male Products ARHP Impact of Male Sexual Functioning on Midlife Women • Sexual activity may depend on health of ♂ partner • ED treatment has changed sex for midlife couples • Common complaints of midlife ♀ resuming sexual intercourse after abstinence – Vaginal dryness – Dyspareunia and vaginismus – Urinary tract infections – Lack of desire ARHP Pfeiffer Am J Psychiatry 1972 Pfeiffer Am J Geriatr Soc 1972 Avis J Gend Specif Med 2000 Laumann JAMA 1999 Communicating with Midlife Patients about Sexuality • Encourage patients to talk about sexuality concerns • Be open and nonjudgmental • Address as couples issue ARHP Communicating with Midlife Patients about Sexuality (continued) • If patient desires, schedule a follow-up visit to focus on sexuality issues • Make referral as necessary – www.aasect.org ARHP Kingsberg Sexuality, Reproduction & Menopause 2004 Communicating with Midlife Patients about Sexuality (continued) • Be a sympathetic listener • Reassure patient • Educate patient, particularly about changes in sexual function with aging • Provide literature – www.healthywomen.org – www.twshf.org – www.nurtureyournature.org ARHP Kingsberg Sexuality, Reproduction & Menopause 2004 New Definitions: Women’s Sexual Interest and Desire Disorder • Absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies, and lack of responsive desire • Motivations (reasons or incentives) for attempting to become sexually aroused are scarce or absent • Lack of interest considered beyond normative lessening with life cycle, relationship duration ARHP Basson J Psychosom Obstet Gynecol 2003 U.S. Women with Low Libido and Distress 35 30 Menopausal status With low libido With low libido & distress U.S. ♀ Population 20 (millions) 15 2005 10 5 1.8 mil NM Hysterectomy 50+ 1.2 mil SM (Hysterectomy + Bilateral Oophorectomy) 25 0 ARHP NM= natural menopause SM = surgical menopause Procter & Gamble Pharmaceuticals data on file 2003 Treating Disorders of Desire • Evaluate, manage relationship, psychological, situational issues • Treat underlying medical problems, depression, anxiety • Change medication if necessary (e.g., SSRIs) • Prescribe estrogen and/or testosterone • Counsel or refer patient and partner ARHP Kingsberg Sexuality, Reproduction & Menopause 2004 Walton Curr Wom Health Rep 2003 Androgen Therapy • Testosterone therapies – Patch, gel, oral formulations in clinical trials – FDA application for patch withdrawn in 2004 • Appears to be effective alone or in combination with estrogen/progestin therapy • Possible risks: hirsutism, acne, lowering of voice – Oral: liver dysfunction, adverse lipid changes Alexander Menopause 2004 USA Today, Dec. 3, 2004 Shifren Mayo Clin Proc 2004 ARHP Testosterone Patch ARHP INTIMATE SM 1 and 2 Trials: Transdermal Testosterone for Low Sexual Desire • Two 24-week, randomized, double-blind, multicenter phase III clinical trials • 533 and 562 surgically menopausal ♀ w/ hypoactive sexual desire disorder • Placebo vs. testosterone patch 300 mcg twice weekly • Primary endpoint: Change from baseline at week 24 in Sexual Activity Log ARHP Simon J Clin Endocrinol Metab 2005 Buster Obstet Gynecol 2005 Increases in Total Satisfying Sexual Activity at 24 Weeks from SAL 3 4-week frequency change from baseline (SEM) 2.5 2 INTIMATE SM 1 P = 0.0003 INTIMATE SM 2 P = 0.001 Placebo TTS 1.5 1 0.5 0 33% 74% % increase from baseline ARHP Simon J Clin Endocrinol Metab 2005 Buster Obstet Gynecol 2005 23% 51% Increase in Desire at 24 Weeks from Profile of Female Sexual Function INTIMATE SM 1 Mean change from baseline (SEM) INTIMATE SM 2 P = 0.0006 14 12 10 8 6 4 2 P = 0.0006 Placebo TTS 0 29% 56% 18% 49% % increase from baseline ARHP Simon J Clin Endocrinol Metab 2005 Buster Obstet Gynecol 2005 Phase III Transdermal Testosterone Therapy w/ Naturally Menopausal Women 549 ♀ with hypoactive sexual desire disorder Mean 54 y/o naturally menopausal On stable doses of oral ERT/HRT Placebo vs. transdermal testosterone patch 300 mcg/day twice weekly • 24 weeks • • • • ARHP Shifren Menopause 2004 Phase III Transdermal Testosterone Therapy Study: Desire Intent-toPFSF Treat Score: Population Mean Change from Baseline Placebo 4.0 Patch ARHP PFSF Score: Percent Change from Baseline 20 48 P Value 9.8 0.0001 Shifren Menopause 2004 PFSF = Profile of Female Sexual Function Phase III Transdermal Testosterone Therapy Study: Distress Intent-toPDS Score: Treat Mean Population Change from Baseline Placebo -11.5 PDS Score: P Value Percent Change from Baseline -28 Patch ARHP -20.5 -52 <0.0001 Shifren Menopause 2004 PDS = Personal Distress Scale Treating Disorders of Desire: Alternative Treatments • DHEA • Bupropion • Nutritional remedies – ArginMax™ ARHP New Definitions: Sexual Aversion Disorder • Extreme anxiety/disgust at anticipation of or attempt to have any sexual activity • Lifelong or acquired conditioned response • Treatment – Desensitization therapy with psychologist or sexologist ARHP Basson J Psychosom Obstet Gynecol 2003 Kingsberg Handbook of Clinical Sexuality for Mental Health Professionals 2003 New Definitions: Subjective Sexual Arousal Disorder • Absence or markedly diminished feelings of sexual arousal from any type of sexual stimulation • Vaginal lubrication or other signs of physical response still occur ARHP Basson J Psychosom Obstet Gynecol 2003 New Definitions: Genital Sexual Arousal Disorder • Absent or impaired genital sexual arousal • Self-report may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation, reduced sexual sensations from caressing genitals • Subjective sexual excitement still occurs from nongenital sexual stimuli ARHP Basson J Psychosom Obstet Gynecol 2003 New Definitions: Combined Genital and Subjective Arousal Disorder • Absence or markedly diminished feelings of sexual arousal from any type of sexual stimulation • Complaints of absent or impaired genital sexual arousal – Vulval swelling – Lubrication Basson J Psychosom Obstet Gynecol 2003 ARHP Treating Arousal Disorders • • • • • Avoid boring and short routines More focused and direct stimulation Vaginal lubricants Regular penetration Vaginally administered estrogen ARHP Bachmann Menopause 2004 Treating Arousal Disorders (continued) • PDE-5 inhibitors – Off-label use – Trial results mixed • Mechanical devices – EROS Therapy™ • Alternative treatments – Zestra™ – ArginMax™ ARHP Bachmann Menopause 2004 Mayor BMJ 2004 Billups J Sex Marital Ther 2001 Munarriz J Sex Marital Ther 2003 Ferguson J Sex Marital Ther 2003 Ito J Sex Marital Ther 2001 New Definitions: Women’s Orgasmic Disorder • Despite self-report of high sexual arousal and excitement: – Lack of orgasm – Markedly ↓ intensity of orgasmic sensations – Marked delay of orgasm from stimulation ARHP Basson J Psychosom Obstet Gynecol 2003 Genetic Influence on Female Orgasmic Function Pairs ICC for Frequency of Orgasm During Intercourse 31% 10% ICC for Frequency of Orgasm During Masturbation 39% 17% P = 0.0001 ARHP Monozygotic (n = 683 pairs) Dizygotic (n = 714 pairs) ICC = intraclass correlation coefficient Dunn Biol Lett 2005 Treating Orgasmic Disorders • Encourage, educate about appropriate arousal techniques, duration • Educate that orgasm may be situational • If SSRIs associated w/ orgasmic disorder, consider alternatives • Treat dyspareunia • Counsel or refer Whipple Sexual Function in People with Disability and Chronic Illness 1997 Phillips Am Fam Physician 2000 Anastasiadis Curr Urol Rep 2002 ARHP New Definitions: Dyspareunia • Persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse ARHP Basson J Psychosom Obstet Gynecol 2003 New Definitions: Vaginismus • Persistent difficulties to allow vaginal entry of penis, finger, or object, despite woman’s expressed wish to do so • Variable involuntary pelvic muscle contraction and (phobic) avoidance in anticipation of fear and the experience of pain • Structural, other physical abnormalities must be ruled out or addressed ARHP Basson J Psychosom Obstet Gynecol 2003 Treating Sexual Pain Disorders • • • • • • Vaginal or oral estrogen Lubricants Treatment of medical conditions Psychological counseling, education Vaginal dilators to increase vault caliber Regular penetration (if and when possible) Hays N Engl J Med 2003 Walton Curr Wom Health Rep 2003 Phillips Am Fam Physician 2000 ARHP Summary Healthy sexuality can persist into midlife ARHP Recommendations • Place literature about sexual/marital concerns in waiting/exam rooms • Include inquires and assessment of sexual concerns in routine exams • Educate patients about common sexual problems that occur with aging • Reassure patients that sexual concerns are common ARHP Recommendations (continued) • Recognize sexual problems may not need treatment if do not cause distress to woman • Adopt nonjudgmental attitude toward patients’ sexual disclosures/activities • Don’t assume patient is in heterosexual relationship or not sexually active • View sexual problems as couple’s concern • Partner with other health professionals ARHP For more information… • Nurture Your Nature: Inspiring Women’s Sexual Wellness: www.nurtureyournature.org • Association of Reproductive Health Professionals (ARHP): www.arhp.org • National Women’s Health Resource Center (NWHRC): www.healthywomen.org ARHP