Title: Nurture Your Nature: Inspiring Womens Sexual Wellness
1Nurture Your NatureInspiring Womens Sexual
Wellness
Association of Reproductive Health Professionals
www.arhp.org National Womens Health Resource
Center www.healthywomen.org
2Nurture Your Nature
Required Slide
3Expert 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
4Expert 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
5Learning 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
6Learning 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
7Womens 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outdated - Difficult to address for some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.
8Female Sexual Disorders Prevalence
Bancroft, J. Arch Sex Behav. 2003. Geiss, IM.
Urology. 2003.Laumann, EO. JAMA. 1999. Nazareth,
I. BMJ. 2003.
9NHSLS Sexual Difficulty is Prevalent
Laumann, EO. JAMA. 1999.
10Limitations of NHSL Survey
Laumann, EO. JAMA. 1999.
11Distress 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.
12Assessment of Female Sexual Problems
individual
Rosen, RC. Fertil Steril. 2002. Basson R. J
Psychosom Obstet Gynecol. 2003.
13Myths 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.
14Myths 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.
15Female Genital Arousal
Berman, JR. World J Urol. 2002. Kerner, I. She
Comes First The Thinking Mans Guide to
Pleasuring a Woman. 2004.
16Human 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.
17Problems 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.
18Female Sexual Response - Circular
Basson, R. Obstet Gynecol. 2001.
19Variables 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.
20Variables Affecting Female Response
characteristics of the risk
individual
risk presentation
Basson, R. Menopause. 2004.
21Aging 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.
22Reasons 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.
23Physical 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.
24Effects of Menopause
Kingsberg, SA. Arch Sex Behav. 2002.Basson, R.
Menopause. 2004.
25SWAN Study Women Ages 42-52
Cain, VS. J Sex Res. 2003.
26MA Womens Health Study II
Avis, NE. Menopause. 2000.Kingsberg, SA. Arch
Sex Behav. 2002.
27Testosterone
28Mean 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.
29Androgen Production Rates
Longcope, C. Ann NY Acad Sci. 1990. van Lunsen,
RHW. Menopause. 2004.Anastasiadis, AG. Curr Urol
Rep. 2002.
30Disease 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.
31Disease 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.
32Medications Causing Desire Disorders
- Psychoactive medications
- Hormonal agents
- Cardiovascular medications
- Others
Med Lett Drugs Ther. 1992.
33Medications Causing Arousal Disorders
- Anticholinergics
- Antihistamines
- Antihypertensives
- Psychoactive medications
Med Lett Drugs Ther. 1992.
34Medications Causing Orgasmic Disorder
- Amphetamines and related anorexic drugs
- Antipsychotics
- Methyldopa
- Narcotics
- SSRIs
- Trazodone
- Tricyclic antidepressants
Med Lett Drugs Ther. 1992.
35National 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.
36Predictors 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.
37Womens 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.
38Womens 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.
39Sexual Disorders CCFSD Categories
- Sexual desire disorders
- Hypoactive sexual desire disorder
- Sexual aversion disorder
- Sexual arousal disorder
more
Basson R. J Urol. 2000.
40Sexual Disorders CCFSD Categories (continued)
- Orgasmic disorder
- Sexual pain disorders
- Dyspareunia
- Vaginismus
- Other sexual pain disorders
Basson R. J Urol. 2000.
41Midlife Sexuality and the Clinician
Berman, L. Fertil Steril. 2003. Kingsberg, S.
Sexuality, Reproduction Menopause. 2004.
42Common Biases to Avoid
43Why Dont Patients Bring Up Issues?
100
Marwick, C. JAMA. 1999.
44General 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.
45Extensive 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.
46Male Products
47Life 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.
48Communicating with Midlife Patients
- Encourage patients to talk about sexuality
concerns - Be open and nonjudgmental
- Address as couples issue
more
49Communicating 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.
50Communicating 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.
51New 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.
52U.S. Women Low Libido and Distress
(Hysterectomy Bilateral Oophorectomy)
Procter Gamble Pharmaceuticals data on file 2003
53Treating Desire Disorders
Kingsberg, S. Sexuality, Reproduction
Menopause. 2004.Walton, B. Curr Wom Health Rep.
2003.
54Androgen 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.
55INTIMATE Trials Testosterone Patch
Simon, JA. J Clin Endocrinol Metab. 2005. Buster,
JE. Obstet Gynecol. 2005.
56Total Satisfying Sexual Activity 24 Weeks
Simon, JA. J Clin Endocrinol Metab. 2005. Buster,
JE. Obstet Gynecol. 2005.
57Desire at 24 Weeks
Simon, JA. J Clin Endocrinol Metab. 2005.Buster,
JE. Obstet Gynecol. 2005.
58Phase 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.
59Phase III Transdermal Testosterone Therapy Study
Desire
Shifren, J. Menopause. 2004.
60Phase III Transdermal Testosterone Therapy Study
Distress
Shifren, J. Menopause. 2004.
61Alternative 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.
62New 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.
63New 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.
64New 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.
65New 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.
66Treating Arousal Disorders
Bachmann, GA. Menopause. 2004.
67Treating 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.
68New 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.
69Genetic Influence on Female Orgasmic Function
P 0.0001
Dunn, KM. Biol Lett. 2005. Basson, R. J Sex
Marital Ther. 2001.
70Treating 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.
71New 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.
72New 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.
73Treating Sexual Pain Disorders
Hays, J. N Engl J Med. 2003. Walton, B. Curr Wom
Health Rep. 2003. Phillips, NA. Am Fam
Physician. 2000.
74Summary
- Healthy sexuality can persist into midlife
75Recommendations
- 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
76Recommendations
- 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
77For 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 79Expert 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
80Expert 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
81Expert 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