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Title: Nurture Your Nature: Inspiring Womens Sexual Wellness


1
Nurture Your NatureInspiring Womens Sexual
Wellness
Association of Reproductive Health Professionals
www.arhp.org National Womens Health Resource
Center www.healthywomen.org
2
Nurture Your Nature
Required Slide
3
Expert Medical Advisory Committee
  • Raquel Arias, MD
  • Gloria Bachmann, MD
  • Kirtly Parker Jones, MD (co-chair)
  • Susan Kellogg-Spadt, CRNP, PhD
  • Sheryl Kingsberg, PhD (co-chair)

Required Slide
more
4
Expert Medical Advisory Committee (continued)
  • Chris Knutson, MN, RNC
  • Sharon Schnare, RN, FNP, CNM, MSN
  • Lee P. Shulman, MD
  • Beverly Whipple, PhD, RN, FAAN

Required Slide
5
Learning Objectives
  • Describe two models of female sexual response
  • List four variables that affect female sexual
    function
  • Name two treatments for female sexual disorders

Required Slide
more
6
Learning Objectives (continued)
  • 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

Required Slide
7
Womens Sexuality
  • Complex
  • Less studied, understood than male sexuality
  • Many theories and beliefs are inaccurate or
    outdated
  • Difficult to address for some

Berman, L. Fertil Steril. 2003.Kingsberg, S.
Sexuality, Reproduction Menopause. 2004.
8
Female Sexual Disorders Prevalence
Bancroft, J. Arch Sex Behav. 2003. Geiss, IM.
Urology. 2003.Laumann, EO. JAMA. 1999. Nazareth,
I. BMJ. 2003.
9
NHSLS Sexual Difficulty is Prevalent
Laumann, EO. JAMA. 1999.
10
Limitations of NHSL Survey
Laumann, EO. JAMA. 1999.
11
Distress About Sex Kinsey 2000 Survey
  • Best predictors of distress
  • General emotional well-being
  • Emotional relationship with partner during sexual
    activity

Bancroft, J. Arch Sex Behav. 2003.
12
Assessment of Female Sexual Problems
individual
Rosen, RC. Fertil Steril. 2002. Basson R. J
Psychosom Obstet Gynecol. 2003.
13
Myths about Female Sexuality
  • 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

more
Basson R. J Psychosom Obstet Gynecol. 2003.
14
Myths about Female Sexuality (continued)
  • Womens arousal identified primarily by
  • Genital vasocongestion
  • Vaginal lubrication
  • Awareness of genital sensations
  • Womens sexual response essentially stable and
    invariant across time/circumstance
  • All women experience distress about alterations
    or limitations in sexual response

Basson R. J Psychosom Obstet Gynecol. 2003.
15
Female Genital Arousal
Berman, JR. World J Urol. 2002. Kerner, I. She
Comes First The Thinking Mans Guide to
Pleasuring a Woman. 2004.
16
Human Sexual Response Linear
Masters, WH. Human Sexual Response. 1966.
Kaplan, HS. Disorders of Sexual Desire and Other
New Concepts and Techniques in Sex Therapy. 1979.
17
Problems with the Linear Model
Masters, WH. Human Sexual Response. 1966.
Kaplan, HS. Disorders of Sexual Desire and Other
New Concepts and Techniques in Sex Therapy. 1979.
18
Female Sexual Response - Circular
Basson, R. Obstet Gynecol. 2001.
19
Variables Affecting Female Response
Past sexualexperiences or sexual abuse
Sexual self-image and/or body image
Relationship with sexual partner (male or female)
characteristics of the risk
individual
risk presentation
Basson, R. Menopause. 2004.
20
Variables Affecting Female Response
characteristics of the risk
individual
risk presentation
Basson, R. Menopause. 2004.
21
Aging and Female Sexual Response
  • Aging ? end of sexual interest and activity

individual
risk presentation
Avis, NE. Menopause. 2000. Hartmann, U.
Menopause. 2004. Bancroft, J. Arch Sex Behav.
2003.
22
Reasons for Decline in Sexual Activity
Other
Death of spouse
Spouse unable to perform
Illness of spouse
Pfeiffer, E. Am J Psychiatry. 1972. Pfeiffer, E.
J Am Geriatr Soc. 1972.
23
Physical Effects of Aging
  • Clitoris and clitoral reaction time
  • Vascularization and vaginal lubrication
  • Vaginal elasticity
  • Vaginal mucosa
  • Sex drive, sexual response, orgasm

Kingsberg, SA. Arch Sex Behav. 2002.Bachmann,
GA. Menopause. 2004. Whipple, B. Slide
presentation. 2004.
24
Effects of Menopause
Kingsberg, SA. Arch Sex Behav. 2002.Basson, R.
Menopause. 2004.
25
SWAN Study Women Ages 42-52
Cain, VS. J Sex Res. 2003.
26
MA Womens Health Study II
  • Postmenopausal Women

Avis, NE. Menopause. 2000.Kingsberg, SA. Arch
Sex Behav. 2002.
27
Testosterone
28
Mean Steroid Levels in Women (pg/ml)
Lobo, R. Treatment of Postmenopausal Women Basic
and Clinical Aspects, 2nd ed. 1999.Judd, HL. J
Clin Endocrinol Metab. 1974.
29
Androgen Production Rates
Longcope, C. Ann NY Acad Sci. 1990. van Lunsen,
RHW. Menopause. 2004.Anastasiadis, AG. Curr Urol
Rep. 2002.
30
Disease and Female Sexual Response
Phillips, NA. Am Fam Physician. 2000. Whipple,
B. In Sexual Function in People with Disability
and Chronic Illness A Health Professionals
Guide. 1997.
31
Disease and Female Sexual Response
Phillips, NA. Am Fam Physician. 2000. Whipple,
B. In Sexual Function in People with Disability
and Chronic Illness A Health Professionals
Guide. 1997.
32
Medications Causing Desire Disorders
  • Psychoactive medications
  • Hormonal agents
  • Cardiovascular medications
  • Others

Med Lett Drugs Ther. 1992.
33
Medications Causing Arousal Disorders
  • Anticholinergics
  • Antihistamines
  • Antihypertensives
  • Psychoactive medications

Med Lett Drugs Ther. 1992.
34
Medications Causing Orgasmic Disorder
  • Amphetamines and related anorexic drugs
  • Antipsychotics
  • Methyldopa
  • Narcotics
  • SSRIs
  • Trazodone
  • Tricyclic antidepressants

Med Lett Drugs Ther. 1992.
35
National Health Social Life Survey
  • Younger age (lt40)
  • Unmarried
  • Poor health
  • Low sexual activity or interest
  • Deteriorating economic status
  • Negative sexual experiences
  • Emotional and stress-related problems

Laumann, EO. JAMA. 1999.
36
Predictors of Problems with Female Sexual Response
  • Health
  • Better a womans health, greater her interest in
    sex
  • Marital status
  • Married women had lower libidos and reduced
    arousal

Avis, NE. Menopause. 2000.
37
Womens Sexual Disorders DSM-IV
  • Sexual desire disorders
  • Hypoactive sexual desire
  • Sexual aversion disorder
  • Sexual arousal disorders
  • Orgasmic disorders
  • Sexual pain disorders
  • Dyspareunia
  • Vaginismus

more
American Psychiatric Association. DSM-IV
Diagnostic and Statistical Manual for Mental
Disorders, 4th ed. 1994.
38
Womens Sexual Disorders DSM-IV (continued)
  • Sexual dysfunction due to a general medical
    condition
  • Substance-induced sexual dysfunction
  • Sexual dysfunction not otherwise specified

American Psychiatric Association. DSM-IV
Diagnostic and Statistical Manual for Mental
Disorders, 4th ed. 1994.
39
Sexual Disorders CCFSD Categories
  • Sexual desire disorders
  • Hypoactive sexual desire disorder
  • Sexual aversion disorder
  • Sexual arousal disorder

more
Basson R. J Urol. 2000.
40
Sexual Disorders CCFSD Categories (continued)
  • Orgasmic disorder
  • Sexual pain disorders
  • Dyspareunia
  • Vaginismus
  • Other sexual pain disorders

Basson R. J Urol. 2000.
41
Midlife Sexuality and the Clinician
Berman, L. Fertil Steril. 2003. Kingsberg, S.
Sexuality, Reproduction Menopause. 2004.
42
Common Biases to Avoid
43
Why Dont Patients Bring Up Issues?
100
Marwick, C. JAMA. 1999.
44
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?

Kingsberg, S. Sexuality, Reproduction
Menopause. 2004.
45
Extensive Questioning Sexual Health
  • Tell me about your sexual history
  • How often do you engage in sexual activity?
  • What kinds of activities do you engage in?
  • Do you have difficulty with desire, arousal, or
    orgasm?

Kingsberg, S. Sexuality, Reproduction
Menopause. 2004.
46
Male Products
47
Life with ED Treatment
  • Sexual activity may depend on health of male
    partner
  • ED treatment has changed sex for midlife couples

Pfeiffer, E. Am J Psychiatry. 1972. Pfeiffer, E.
Am J Geriatr Soc. 1972. Avis, NE. J Gend Specif
Med. 2000.Laumann, EO. JAMA. 1999.
48
Communicating with Midlife Patients
  • Encourage patients to talk about sexuality
    concerns
  • Be open and nonjudgmental
  • Address as couples issue

more
49
Communicating with Midlife Patients (continued)
  • If patient desires, schedule a follow-up visit to
    focus on sexuality issues
  • Make referral as necessary

more
Kingsberg, S. Sexuality, Reproduction
Menopause. 2004.
50
Communicating with Midlife Patients (continued)
  • Educate patient, particularly about changes in
    sexual function with aging
  • Be a sympathetic listener
  • Reassure patient
  • Provide literature

Kingsberg, S. Sexuality, Reproduction
Menopause. 2004.
51
New Definitions Womens 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



Basson, R.J Psychosom Obstet Gynecol.
Basson, R. J Psychosom Obstet Gynecol. 2003.
52
U.S. Women Low Libido and Distress
(Hysterectomy Bilateral Oophorectomy)
Procter Gamble Pharmaceuticals data on file 2003
53
Treating Desire Disorders
Kingsberg, S. Sexuality, Reproduction
Menopause. 2004.Walton, B. Curr Wom Health Rep.
2003.
54
Androgen Therapy
  • Testosterone therapies
  • Patch
  • Gel
  • Oral formulations in clinical trials
  • Oral therapies

Alexander, JL. Menopause. 2004. USA Today. Dec.
3, 2004Shifren, JL. Mayo Clin Proc. 2004.
55
INTIMATE Trials Testosterone Patch
Simon, JA. J Clin Endocrinol Metab. 2005. Buster,
JE. Obstet Gynecol. 2005.
56
Total Satisfying Sexual Activity 24 Weeks
Simon, JA. J Clin Endocrinol Metab. 2005. Buster,
JE. Obstet Gynecol. 2005.
57
Desire at 24 Weeks
Simon, JA. J Clin Endocrinol Metab. 2005.Buster,
JE. Obstet Gynecol. 2005.
58
Phase III Transdermal Testosterone Therapy
  • 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

Shifren, J. Menopause. 2004.
59
Phase III Transdermal Testosterone Therapy Study
Desire
Shifren, J. Menopause. 2004.
60
Phase III Transdermal Testosterone Therapy Study
Distress
Shifren, J. Menopause. 2004.
61
Alternative Treatments
  • DHEA
  • Bupropion
  • Nutritional remedies

Spark, RF. Fertil Steril. 2002. American College
of Obstetricians and Gynecologists. 2000.
Clayton, AH. J Clin Psychiatry. 2004. Ito, TY. J
Sex Marital Ther. 2001.
62
New Definitions Sexual Aversion Disorder

  • Extreme anxiety/disgust at anticipation of or
    attempt to have any sexual activity it is a
    lifelong or acquired conditioned response

Basson, R.J Psychosom Obstet Gynecol.
Basson, R. J Psychosom Obstet Gynecol. 2003.
Kingsberg, SA. Handbook of Clinical Sexuality for
Mental Health Professionals. 2003.
63
New Definitions Subjective Sexual Arousal
Disorder

  • Absence or markedly diminished feelings of
    sexual arousal from any type of sexual
    stimulationVaginal lubrication or other signs of
    physical response still occur

Basson, R.J Psychosom Obstet Gynecol.
Basson, R. J Psychosom Obstet Gynecol. 2003.
64
New Definitions Genital Sexual Arousal Disorder

  • Absent or impaired genital sexual
    arousalSelf-report may include minimal vulval
    swelling or vaginal lubrication from any type of
    sexual stimulation, reduced sexual sensations
    from caressing genitalsSubjective sexual
    excitement still occurs from nongenital sexual
    stimuli

Basson, R.J Psychosom Obstet Gynecol.
Basson, R. J Psychosom Obstet Gynecol. 2003.
65
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

Basson, R.J Psychosom Obstet Gynecol.
Basson, R. J Psychosom Obstet Gynecol. 2003.
66
Treating Arousal Disorders
Bachmann, GA. Menopause. 2004.
67
Treating Arousal Disorders
Bachmann, GA. Menopause. 2004. Mayor, S. BMJ.
2004. Billups, KL. J Sex Marital Ther. 2001.
Munarriz, R. J Sex Marital Ther. 2003. Ferguson,
DM. J Sex Marital Ther. 2003. Ito, TY. J Sex
Marital Ther. 2001.
68
New Definitions Womens Orgasmic Disorder

  • Despite self-report of high sexual arousal and
    excitement, there is lack of orgasm, markedly
    ? intensity of orgasmic sensations, and a
    marked delay of orgasm from stimulation.

Basson, R.J Psychosom Obstet Gynecol.
Basson, R. J Psychosom Obstet Gynecol. 2003.
Anastasiadis, AG. Curr Urol Rep. 2002. Walton, B.
Curr Wom Health Rep. 2003.
69
Genetic Influence on Female Orgasmic Function
P 0.0001
Dunn, KM. Biol Lett. 2005. Basson, R. J Sex
Marital Ther. 2001.
70
Treating Orgasmic Disorders
Whipple, B. Sexual Function in People with
Disability and Chronic Illness. 1997. Phillips,
NA. Am Fam Physician. 2000. Anastasiadis, AG.
Curr Urol Rep. 2002.
71
New Definitions Dyspareunia

  • Persistent or recurrent pain with attempted or
    complete vaginal entry and/or penile vaginal
    intercourse.

Basson, R.J Psychosom Obstet Gynecol.
Basson, R. J Psychosom Obstet Gynecol. 2003.
72
New Definitions Vaginismus

  • Persistent difficulties to allow vaginal entry
    of penis, finger, or object, despite womans
    expressed wish to do sovariable involuntary
    pelvic muscle contraction and (phobic) avoidance
    in anticipation of fear and the experience of
    painstructural, other physical abnormalities
    must be ruled out or addressed.

Basson, R.J Psychosom Obstet Gynecol.
Basson, R. J Psychosom Obstet Gynecol. 2003.
73
Treating Sexual Pain Disorders
Hays, J. N Engl J Med. 2003. Walton, B. Curr Wom
Health Rep. 2003. Phillips, NA. Am Fam
Physician. 2000.
74
Summary
  • Healthy sexuality can persist into midlife

75
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

76
Recommendations
  • Recognize sexual problems may not need treatment
    if do not cause distress to woman
  • Adopt nonjudgmental attitude toward patients
    sexual disclosures/activities
  • Dont assume patient is in heterosexual
    relationship or not sexually active
  • View sexual problems as couples concern
  • Partner with other health professionals

77
For more information
  • Nurture Your Nature Inspiring Womens Sexual
    Wellness www.nurtureyournature.org
  • Association of Reproductive Health Professionals
    (ARHP) www.arhp.org
  • National Womens Health Resource Center (NWHRC)
    www.healthywomen.org

78
  • Appendix

79
Expert Medical Advisory Committee
Raquel Arias, MDAssociate Professor,
Ob/GynUniversity of Southern California, Womens
Childrens Hospital Los Angeles, CA
Gloria Bachmann, MD Chief, Division of General
Obstetrics and GynecologyRobert Wood Johnson
University Hospital New Brunswick, NJ
Kirtly Parker Jones, MD (co-chair)Professor,
Department of Ob/GynUniversity of Utah Health
Sciences Center Salt Lake City, UT
more
80
Expert Medical Advisory Committee (continued)
Sheryl Kingsberg, PhD (co-chair)Associate
Professor of Reproductive Biology Case Western
Reserve University School of Medicine Cleveland,
OH
Chris Knutson, MN, RNC Public Health Nurse
Consultant Family Planning Reproductive Health
Olympia, WA
Susan Kellogg-Spadt, CRNP, PhD Director of
Sexual MedicineThe Pelvic Sexual Health
Institute Philadelphia, PA
more
81
Expert Medical Advisory Committee (continued)
Sharon Schnare, RN, FNP, CNM, MSN Clinician and
Consultant Womens Health Care Olalla, WA
Lee P. Shulman, MDNorthwestern Memorial
Hospital Distinguished Physician and Professor
Department of Obstetrics and Gynecology Feinberg
School of Medicine Northwestern
University Chicago, IL
Beverly Whipple, PhD, RN, FAAN Professor
Emerita, Rutgers University Past-president,
Society for the Scientific Study of Sexuality
(SSSS) Past-president, American Association of
Sex Educators, Counselors and Therapists
(AASECT) Voorhees, NJ
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