Female sexual function dysfunction

Female Sexual Function & Dysfunction
TEVFİK YOLDEMİR MD. BSc. MA. PhD.
tevfikyoldemir
profdrdrtevfikyoldemir

Female Sexual Function and Dysfunction ISBN 978-3-319-41716-5 (eBook)

Physiology of sexual desire/interest and central
arousal

Biopsychosocial model of sexual response

Sexual responsiveness by Basson

Sexual tipping point model of sexual excitation
and inhibition

Peripheral effects on sexual function

Sexual response -Excitation and inhibition

Management of Sexual Dysfunction in Men and Women
ISBN 978-1-4939-3100-2 (eBook)

EPOR – excitation, plateau, orgasm, resolution
Textbook of Female Sexual Function and Dysfunction
Diagnosis and Treatment ISBN 9781119266112 (pdf)

ICD-10 DSM-5
Management of Sexual Dysfunction in Men
and Women ISBN 978-1-4939-3100-2 (eBook)

DSM-5 criterion A
(symptomatology)

Proper evaluation of sexual function

Interview
• Physicians are often not accustomed with and poorly educated about
obtaining a complete sexual history even though this is an important
component of primary health care .
• There are a number of validated self-report and interview-based tools for
assessing female sexual dysfunction, but they are mainly used in research
settings .
• The brief sexual symptom checklist is a self-report tool that may be useful in
the primary care setting as in addition to a complete sexual history.
• The checklist includes basic questions to determine the patient’s
satisfaction with her sexual function, details about specific sexual problems,
and the willingness of the patient to discuss these problems with the
physician.

• Discussions about sexuality should begin with open-ended questions.
• If a sexual concern is identified, a detailed history that includes
menstrual, obstetric, reproductive, and sexual histories should be
done; status of current relationships and sexual activity should be
required, so as family and personal beliefs about sexuality, and
history of sexual trauma or abuse.
• Additional elements of the history include medical and surgical
history; medication use, including herbal supplements; alcohol,
tobacco, and illicit drug use; family history; and birth control method.
• Several medical conditions and medications are associated with
sexual dysfunction.

• The Permission, Limited Information, Specific Suggestions,
Intensive Therapy (PLISSIT)
• Ask, Legitimize, Limitations, Open up, Work together (ALLOW)
method
in order to facilitate discussions about sexual concerns and initiation of treatment.
ALLOW
• Ask the patient about sexual function and activity
• Legitimize problems, and acknowledge that dysfunction is a clinical issue
• Identify limitations to the evaluation of sexual dysfunction
• Open up the discussion, including potential referral
• Work with the patient to develop goals and a management plan
PLISSIT
• Obtain permission from the patient to discuss sexuality (e.g., “I ask all my patients about their sexuality, is that okay to do
with you now?”)
• Give limited information (e.g., inform the patient about normal sexual functioning)
• Give specific suggestions about the patient’s particular complaint (e.g., advise the patient to practice self-massage to
discover what feels good to her)
• Consider intensive therapy with a sexual health subspecialist

physical examination
• Although physical examination findings are often normal, a complete
inspection, including a focused pelvic check, can identify pathology and
provide patient education about normal anatomy and reassurance that
no abnormality is present.
• The pelvic examination can detect evidence of low hormone levels,
infection, hypo- or hypertonicity of pelvic floor muscles, adhesions, and
tenderness.
• The remaining physical examination focuses on mental status, blood
pressure, musculoskeletal, thyroid, breast, and neurologic abnormalities.
• Abnormal findings are more likely in older women, in women with
known gynecologic pathology or chronic systemic disease

Laboratory evaluation
• Laboratory evaluation is rarely helpful; however, a focused
evaluation is appropriate, particularly if the history or
examination suggests a medical condition.
• Although some experts advocate testing hormone levels in
postmenopausal women or in women with decreased desire or
arousal, there is no reliable correlation between hormone
levels and sexual function

medications
• Sexual dysfunction may be the manifestation of psychiatric illness or
an adverse effect of psychotropic medication use.
• If a woman has sexual complaints while taking a psychotropic
medication, a detailed history is necessary to identify the etiology.
• The use of selective serotonin reuptake inhibitors (SSRIs) is a
common cause of medication-induced female sexual dysfunction,
although all antidepressant classes can cause dysfunction.
• SSRIs most commonly cause delayed or absent orgasm and decreased
libido.
• The incidence of SSRI-induced sexual dysfunction is estimated to be
30–50 %.

Instrument for the Assessment of Sexual Function
• Different types of questionnaires have been used in the last few
years to investigate sexual function and dysfunction.
• Studies of human sexuality are inclined to bias and have varied
confounding factors because of the large cultural framework as well
as psychosocial factors that distinguish this aspect of human
behavior.
• Due to its subjective and multifactorial nature and relationship with
emotional processes, sexual function needs adequate instruments
for assessment, like self-report questionnaires, investigating different
aspects of sexual life with high reliability and validity.

questionnaires
• Different types of questionnaires were used to investigate sexual dysfunction
of women, such as the Derogatis Sexual Functioning Inventory (DSFI), the
sexual function questionnaire (SFQ), the Female Sexual Function Index (FSFI),
the Female Sexual Distress Scale-Revised (FSDS-R), and the Sexual Health
Outcomes in Women Questionnaire (SHOW-Q).
• The questionnaires vary mainly in terms of their levels of comprehensiveness;
however, all have developed well against established psychometric criteria
and have appeared empirical evidence of reliability and validity.
• A good standardized instrument should evaluate and measure multiple
domains, should have internal consistency (α) of at least 0.70 for all domains,
and should demonstrate test–retest reliability into an interval of 2–4 weeks of
at least 0.50 for items that should display stability over time

Validated questionnaires and scales

The Brief Index of Sexual Functioning for Women
• BISF-W was developed in response to the lack of a brief, standardized self-report measure
of overall sexual function in women .
• Previous self-report measures have been either excessively limiting or inappropriate for
the use in large-scale clinical trials.
• The BISF-W consists of 22 items, assessing the major dimensions of sexual desire, arousal,
orgasm, and satisfaction .
• Several items were adapted from the CSFQ, particularly those assessing frequency of
sexual behavior, fantasy, masturbation, and sexual preference.
• Additional items were included to address specific issues supposed to concern women’s
sexual functioning and satisfaction, such as body image, partner satisfaction, and sexual
anxiety.
• Several items were designed to evaluate sexual performance difficulties in women, such
as diminished arousal or lubrication, pain or tightness during intercourse, and difficulties
in reaching orgasm.
• Items assessing the impact of health problems on sexual functioning are also included.

Changes in Sexual Functioning Questionnaire
• CSFQ was developed with specific versions for females and males to
assess sexual functioning in all the domains of the sexual response
cycle .
• It was developed to be used in both clinical and research settings.
• CSFQ-W is a 35-item instrument identifying five scales of sexual
functioning.
• The original CSFQ items were tested and revised on the basis of
conceptual content to ensure that five aspects of sexual functioning
(i.e., sexual desire, sexual frequency, sexual satisfaction, sexual
arousal, and sexual completion) were evaluated .

Changes in Sexual Functioning Questionnaire
• The CSFQ was used clinically and had the particularity to include a
section identifying the sexual pattern of the individual, which
permitted information about how much sexual change someone
experienced over time
• Information about changes could be correlated to the five domains
of sexual functioning, so that the clinician could better focus on
strategically targeted treatment for the cause of the problem, which
could be related to medication, illness, relationship problems, or a
combination of difficulties .
• In addition, the CSFQ addressed the need for an assessment
instrument that could differentiate current sexual dysfunction from
previous “normal” sexual function and/or lifelong sexual dysfunction

Derogatis Interview for Sexual Functioning
• DISF/DISF-SR is a coordinated set of brief matched instruments
designed to provide an estimate of the quality of an individual’s
current sexual functioning .
• The DISF is semi-structured interview comprised of 25 items and
reflects quality of sexual functioning in a multi-domain format.
• The DISF-SR is a matching self-report inventory designed to achieve
the same goal in a patient self-report mode.
• All instruments in the DISF series are designed to be interpreted at
three distinct levels: discrete items, functional domains, and
aggregate summary (total) score.

Derogatis Interview for Sexual Functioning
• DISF items are arranged into five primary domains of sexual functioning:
sexual cognition/fantasy, sexual arousal, sexual behavior/experience, sexual
orgasm, and sexual drive/relationship.
• In addition, an aggregate DISF total score is computed which summarizes
quality of sexual functioning across the five primary DISF domains .
• Both the DISF and the DISF-SR take approximately 12–15 min to administer.
Internal consistency reliabilities for measures of the DISF-SR are well within
acceptable ranges, as are test–retest temporal stability coefficients.
• The DISF/DISF-SR has demonstrated good discriminative validity and
sensitivity to treatment-induced changes and is currently available in 12
foreign languages

Female Sexual Function Index
• FSFI is made up of 19 items encompassing the six domains:
desire (items 1–2), arousal (items 3–6), lubrication (items 7–
10), orgasm (items 11–13), satisfaction (items 14–16), and pain
(items 17–19).
• The total FSFI score is the sum of all points, and the higher the
score, the better the sexuality.
• Sexual dysfunction was defined as an FSFI score < 26.55, based
on the published validation studies .
• A very good discriminate validity and ability to predict the
prevalence of sexual problems have been reported

Sexual function questionnaire
• SFQ is a self-report questionnaire designed to measure female sexual
function .
• It is comprised of 28 items reflecting all aspects of the sexual response
cycle—desire, arousal, and orgasm—as well as dyspareunia.
• Factor analysis produced seven domains of female sexual function: desire,
physical arousal–sensation, physical arousal–lubrication, enjoyment,
orgasm, dyspareunia, and partner relationship [41].
• The item content of the SFQ was reviewed by an external panel of clinicians
with expertise in psychology, physiology, gynecology, physical medicine, and
the treatment of FSD.
• Internal consistency of the domains ranged from 0.79 to 0.91 for all
domains except partner relationship, which was 0.65, and test–retest
reliability is in the acceptable range.

McCoy Female Sexuality Questionnaire
• MFSQ was developed from the questionnaire used in a longitudinal study of the
menopausal transition and designed to measure aspects of female sexuality likely to be
affected by changing sex hormone levels.
• The original questionnaire was revised to insure that questions were easy to understand
and that labels for the Likert scales described a continuum.
• The revised MFSQ contains 19 questions, 18 items using 7-point Likert scales with labels
at the center and endpoints, and one item requesting a frequency of activity.
• Seven studies involving both clinical and convenience samples and two with double-blind
randomized controlled trials used 7, 9, 10, or 17 MFSQ items and demonstrated
acceptable reliability, internal consistency, apparent face, and content validity as well as
considerable evidence of construct validity .
• Results showed selected MFSQ item ratings decreased as women progressed through the
menopausal transition, varied positively with endogenous estradiol and androgen levels,
were higher in postmenopausal women receiving hormone replacement therapy (HRT),
and differentiated between different types of oral contraceptives and the presence or
absence of ovaries.

The Pelvic Organ Prolapse/Urinary
Incontinence Sexual Questionnaire
• PISQ-12 is a validated and reliable short form that evaluates sexual function
in heterosexual women with urinary incontinence and/or pelvic organ
prolapse and predicts long-form scores [45].
• The PISQ-12 was able to distinguish between women with low or high
sexual functioning scores as measured by the SHF-12, a validated sexual
function questionnaire that serves as a gold standard.
• Short forms are useful in the clinical setting because they reduce the time
and burden to the patient and provide the clinician with objective means of
evaluating functional outcomes of either medical or surgical interventions.
• In the research setting, a short form is useful when quality-of-life analysis is
part of the armamentarium used to evaluate outcomes and compare
results.

Sexual Interest and Desire Inventory-Female
• (SIDI-F) is a clinician-administered instrument that was developed to measure severity
and change in response to treatment of HSDD .
• Seventeen items were included in a preliminary version of the SIDI-F, including 10 items
related to desire and seven items related to possible comorbid factors (e.g., other kinds
of sexual dysfunction, general relationship satisfaction, mood, and fatigue).
• It is a brief, clinician-administered rating scale designed to assess severity of HSDD
symptoms in women.
• Analyses show that majority of the items of the SIDI-F function well in discriminating
individual differences in HSDD severity .
• The validity of the SIDI-F as a measure of HSDD severity was confirmed by a number of
observations. Women with a clinical diagnosis of HSDD had significantly lower SIDI-F
scores than women not meeting diagnostic criteria for any subtype of female sexual
dysfunction and women diagnosed with female orgasmic disorder.
• There was a high correlation between scores on the SIDI-F and scores on the FSFI and an
interactive voice response version of the CSFQ. A cutoff score of 33 was proved to
indicate the presence of HSDD

Sexual Quality of Life-Female• SQOL-F questionnaire is a short instrument that specifically assesses the relationship
between female sexual dysfunction and quality of life.
• The basis for the generation of the SQOL-F questionnaire was Spitzer’s Quality of
Life (QOL) model that involved physical, emotional, psychological, and social
components.
• Validity of the SQOL-F questionnaire first was assessed in the UK and the USA.
• In the UK setting, studying a sample of 1296 women aged 18–65 years, internal
consistency was found to be 0.95, and the questionnaire discriminated well
between depressed and not depressed women .
• In the USA setting, studying three groups of women (women with spinal cord injury,
women with sexual dysfunction, and a sample of healthy women), the SQOL-F was
lower among women with sexual dysfunction as expected lending support to its
discriminate validity.
• In addition, intraclass correlation coefficient was reported to be 0.85, which showed
an appropriate stability for the questionnaire

Sexual Satisfaction Scale for Women
• (SSS-W) represents a brief, 30-item, multifaceted measure of women’s
sexual satisfaction [52].
• It exhibits sound psychometric properties and has a demonstrated ability to
discriminate between clinical and nonclinical populations.
• The final SSS-W consists of five domains (two relational, three personal) of
six items each: communication, compatibility, contentment, relational
concern, and personal concern.
• Items in the communication, compatibility, and contentment domains were
written to reflect themes relating to sexual satisfaction noted in prior
literature.
• The SSS-W was developed to provide a comprehensive measure of sexual
satisfaction and sexual distress that would benefit researchers and clinicians
interested in further understanding what constitutes sexual satisfaction in
women and how it relates to levels of sexual functioning

Female Sexual Distress Scale-Revised
• FSDS-R is a screening instrument consisting of 13 items for
measuring sexually related personal distress.
• The fixed choice response format offered the five increments:
“never,” “rarely,” “occasionally,” “often,” and “always.” Sexual
distress was defined as a FSDS-R score > 11, based on the
published validation studies.
• The higher the score, the greater the distress.
• A very good discriminate validity and ability to predict the
prevalence of sexual problems have been shown for this
instrument

Sexual Health Outcomes in Women Questionnaire
• SHOW-Q is formed by 12 items organized conceptually to include 2–3
items per domain: satisfaction with sex, orgasm frequency, sexual
desire, and pelvic problem interference with sex.
• Factor analysis demonstrated a 12-item scale with high internal
consistency reliability (Cronbach’s α=0.86) and four reliable subscales
(α=0.73 to 0.84).
• SHOW-Q involves women of diverse sociodemographic and clinical
background, including women in same-sex relationships and women
who are sexually active without a partner as well as sexually inactive
women.
• SHOW-Q investigates also different aspects of sexual life and pelvic
problem interference with sex.

Conditions associated with low testosterone
in women

Conditions and medications associated with
low sexual desire

Low sexual desire- contributing factors

Decreased sexual desire screener

Hypoactive sexual desire disorder
HSDD presents with any of the following characteristics for a minimum period
of at least six months:
● Lack of motivation for sexual activity characterized by:
–– decreased or absent spontaneous desire (i.e. sexual thoughts or fantasies);
–– decreased or absent responsive desire to erotic cues or stimulation or
inability to maintain desire or interest through sexual activity.
● Loss of desire to initiate or participate in sexual activity, including
behavioral responses such as avoiding situations that could lead to sexual
activity that is not secondary to sexual pain disorders.
The manifest characteristic(s) must be accompanied by clinically significant
personal distress that includes frustration, grief, guilt, incompetence, loss,
sadness or worry.

Management of the patient with desire
disorder The European Society for Sexual Medicine (ESSM)

Treatments for Hypoactive Sexual Desire
Disorder - Central Nervous System Agents
• Flibanserin , 100 mg bedtime
• When the drug is taken during the daytime, with concomitant use of
cytochrome P‐450 3A4 inhibitors (i.e. someantiretroviral drugs,
antihypertensive drugs, antibiotics, and fluconazole) increases systemic
exposure to flibanserin by a factor of 4.5–7,
• and with significant alcohol use.
• Bupropion, doses of 300–400 mg/d
• Trazodone

Testosterone Tx
• Methyltestosterone is available in doses of 1.25 or 2.5 mg per day
and is usually prescribed in combination with conjugated
estrogens (0.625 mg/ day or 1.25 mg/day) as Estratest ® (Solvay).
• Transdermal testosterone delivered by matrix patch ( Intrinsa ® ,
300 ug/day, Procter and Gamble) has been the most extensively
studied formulation in women with HSDD.
• Androderm ® and Testoderm ® are testosterone matrix patches
FDA approved for use in men.
• Cutting them down to size 1/5th to 1/10th doses.Management of Sexual Dysfunction in Men

Testosterone Tx
• AndroGel ® and Testim ® are testosterone transdermal gels that are
FDA approved in the United States for use in men.
• Reducing the amount applied to about 1/5th to 1/10th doses.
• PLO gel testosterone is available in 10 cc syringes or small pumps
(testosterone in PLO gel, 32 mg/cc dosed at 1 cc given in the evening)
• Intramuscular testosterone injection products are approved for use
in men. Testosterone can be injected in a slow-release form as a
testosterone ester (cypionate, propionate, and enanthate).
• Doses are 25–50 mg every 2–4 weeks
• This treatment requires frequent dosing and testosterone levels are
not consistent

Testosterone Tx
• DHEA (prasterone) cream inserted nightly for 12 weeks
increased sexual desire, arousal, organism, and dyspareunia in
a time- and dose-dependent fashion
• Testosterone 0.5 mg and PDE5i (sildenafil 50 mg)
• Participants were permitted to use the medication up to 14
times during a 4-week period with a minimum of 48 h between
doses.
• It is important to keep women’s free testosterone in a range of
0.6– 0.8 ng/dl. Management of Sexual Dysfunction in Men

• Flibanserin is a nonhormonal therapy that acts on the brain to
increase sexual desire.
• single daily dose at bedtime of 100 mg
• Bremelanotide (BMT) is a cyclic melanocortin peptide that acts
as a melanocortin receptor 4 (MCR4) agonist.
• subcutaneous injection, 1.25 and 1.75 mg BMT

Treatments of sexual desire disorders

Sex steroid
hormone
function in
regulating
vaginal function

Psychological Factors that Impact Sexual Arousal
• Depresssion
• Anxiety
• Body image
• Environmental stresses
• Culture and religion
• Relational factors
• Relationship commitment and duration
• Childhood sexual abuse

Common female sexual health assessment
instruments and arousal‐related items

Health and Lifespan Considerations
• Pregnancy
• Infertility
• Diabetes
• Aging and menopause
• Metabolic syndrome
• Cancer

Management of the patient with arousal
disorder

Psychological Treatment
• Cognitive Behavioral Therapy identify
• The cognitive schema or beliefs for better understanding of the
psychological processes.
• This implies: approach and revision of thoughts, identification and
elimination of undesirable behaviors, and their substitution for desirable
ones and positive communication.
• Mindfulness Therapy
• awareness and acceptance of sensations, emotions, and thoughts,
focusing one’s complete attention on the present
• Couples’ and Individual TherapyTextbook of Female Sexual Function and Dysfunction

Medical Management of Female Genital
Arousal Disorder
• Vaginal Lubricants and/or Vaginal Moisturizer Strategies
• Device Strategies
• Vibrator devices generate vibration stimuli, via a series of pulses of
electromagnetic waves of variable amplitude and frequency, to the
peripheral dorsal, perineal, and/or external hemorrhoidal nerves, branches
of the pudendal nerve that pass afferent sensory information to sacral roots
S2, 3, 4.
• A‐beta fibers, are the largest fibers within the peripheral nerves that mediate
touch, mild pressure, sensation of joint position, and vibration.
• A dildo is a nonvibrating device that is used for sexual stimulation of
the vagina and/or anus.

Arousal Disorder
• Clitoral engorgement, which plays a vital function in sexual arousal in
many women, can also be facilitated by use of mechanical vacuum
clitoral engorgement devices. Such vacuum clitoral engorgement devices
provide negative pressure suction to the glans clitoris, acting to enhance
clitoral blood inflow and achieve a non‐neurogenic mechanical clitoral
engorgement.
• Local and Systemic Vasodilation Agents
• Application of prostaglandin E1 can be predicted to result in local genital
vasodilation and enhanced vestibular and vaginal lubrication.
• Local and Systemic Hormone AgentsTextbook of Female Sexual Function and Dysfunction

Arousal Disorder
• ospemifene, a selective estrogen receptior modulator (SERM) as a safe and
effective treatment for moderate to severe dyspareunia in menopause.
• Concerning the use of systemic testosterone hormonal agents as treatment
of female genital arousal disorder, discussion should ensue as to the
carefully monitored use of biologically‐identical testosterone.
• Off‐label use of FDA‐approved testosterone products for men dosed at
approximately one‐tenth of the intended male dose or off‐label use of
compounded testosterone products.
• An ideal goal of testosterone therapy is a calculated free testosterone value
of 0.6–0.8 ng/dl.
• Follow‐up blood tests for total testosterone, sex hormone binding globulin,
and dihydrotestoserone should initially be made at three‐month intervals
and then as needed, such as every 6–12 months if stable.

Arousal Disorder
• Systemic Agonists to CNS Excitatory Neurochemicals and
CNS Antagonists to Inhibitory Neurochemicals
• bupropion 75 mg/d in the morning; cabergoline 0.5 mg each Monday and
each Thursday; ropinirole 0.25 mg one to three times a day; oxytocin
lozenges 250 U sublingually – one hour prior to sexual activity; and/or
amphetamine, dextroamphetamine mixed salts, 2.5–10 mg taken 30
minutes prior to sexual activity, but if taken after 2:00 p.m., difficulty with
sleep should be considered.
• the use of flibanserin at a dose of 100mg/night

Persistent genital arousal disorder
• psychosocial issues resulting in stress, worry, anxiety and/or panic
• psychiatric disorders including anxiety, panic and/or depressive
disorders
• increased sexual excitatory processes in the central nervous system
that involve dopamine, oxytocin, melanocortin, and norepinephrine,
as well as decreased sexual inhibitory processes in the central
nervous system that involve opioids, endocannabinoids, and
serotonin
• pelvic floor dysfunction, specifically hightone pelvic floor dysfunction

Persistent genital arousal disorder
• vestibulodynia, clitorodynia or genitourinary syndrome of
menopause; injury to or irritation of the pudendal nerves that
transmit pain and other sensations; abnormal response of
tissues to Candida infection or allergy; dermatologic conditions
such as lichen sclerosus or lichen planus; vulvar granuloma
fissuratum; pathology of the peri‐urethral glans; and bladder or
rectal prolapse or rectal diverticulum

Diagnosis of Women with PersistentGenital Arousal
Disorder
• psychological assessment
• psychiatric assessment
• pelvic floor physical therapy assessment
• full history of medication use
• vulvoscopy, cotton swab (Q‐tip) testing, and vaginal wet mount and
smear testing
• thyroid stimulating hormone (TSH), free triiodothyronine (free T3),
total triiodothyronine (total T3), free thyroxine (free T4), and total
thyroxine (total T4);
• pelvic ultrasound studies, CT or MRI examinations of the pelvis, and
venography or selective arteriographyTextbook of Female Sexual Function and Dysfunction

• Clitorodynia: consider therapeutic release of clitoral adhesions or
dorsal slit surgery with removal of keratin pearls
• Hormonally‐mediated vestibulodynia: consider therapeutic hormonal
intervention such as systemic testosterone and/or local
administration of testosterone/estradiol cream to the vestibule
• Lichen sclerosus or lichen planus: consider therapeuticuse of
ultrapotent steroids.
• High‐tone pelvic floor dysfunction: consider therapeutic pelvic floor
physical therapy strategies with or without local skeletal muscle
relaxants or onabotulinum toxin A injections.

• use of perineal small soft tissue balls or internal vaginal
dilators/accommodators to stretch larger areas of tissue in the
absence of pain.
• an awareness of training for actively relaxing the pelvic floor.

FSAD Tx
• Vasoactive agents including phosphodiesterase inhibitors
(PDEi’s) have been investigated in several studies for treatment
of FSAD
• Bupropion , which is a noradrenaline and dopamine reuptake
inhibitor with nicotinic antagonist properties originally
marketed as an antidepressant, may have a beneficial effect on
women with sexual arousal disorder.
• Low-dose bupropion at 75 mg twice a day can achieve an
optimal improvement in sexual arousal potentialManagement of Sexual Dysfunction in Men

FSAD Tx
• Cabergoline administered at 0.5 mg up to three times per week
and ropinirole 0.25 mg administered daily.
• Oxytocin lozenges, linked to improved arousal and desire, are
administered at 250 IU sublingually 30 min to 1 h before sexual
activity.
• Flibanserin is a 5-HT1A receptor agonist and 5-HT2A receptor
antagonist that was initially investigated as an antidepressant.

Female orgasm disorder
• Female orgasm disorder is characterized by a persistent or recurrent,
distressing compromise of orgasm frequency, intensity, timing,
and/or pleasure, associated with sexual activity for a minimum of six
months .
• Frequency: orgasm occurs with reduced frequency (diminished
frequency of orgasm) or is absent (anorgasmia).
• Intensity: orgasm occurs with reduced intensity (muted orgasm).
• Timing: orgasm occurs either too late (delayed orgasm) or too early
(spontaneous or premature orgasm) than desired by the woman.
• Pleasure: orgasm occurs with absent or reduced pleasure (anhedonic
orgasm, pleasure dissociative orgasm disorder).

Female orgasm disorder
• Brain central nervous system neurotransmitter imbalances in
excitatory and inhibitory critical nuclei
• Associated with pelvic floor dysfunction, both high‐tone and
low‐tone pelvic floor dysfunction
• Endocrine disorders, such as low testosterone, low estradiol states
including menopause and genitourinary syndrome of menopause,
prolactinoma, or hypothyroidism
• Genital dermatologic conditions such as lichen plannus, lichen
sclerosus, or
• vestibulodynia conditions such as hormonally‐mediated
vestibulodynia, neuro‐proliferative vestibulodynia, vulvar granuloma
fissuratum, and/or desquamative inflammatory vaginitisTextbook of Female Sexual Function and Dysfunction

Diagnosis of Women with Female Orgasm
Disorder
• Psychosocial assessment
• Certain medications negatively affect orgasm, such as selective
serotonin reuptake inhibitors, antipsychotics, antihypertensives,
benzodiazepines, histamine 2 receptor antagonists, and
anticonvulsants
• Partner sexual dysfunction assessment
• Pelvic floor physical therapy assessment
• Distracting and bothersome genital medical conditions : lichen
plannus, lichen sclerosus, vulvar granuloma fissuratum, and
desquamative inflammatory vaginitis

Investigation
• total testosterone, sex hormone binding globulin,
dihydrotestosterone, luteinizing hormone, follicle stimulating
hormone, prolactin, thyroid stimulating hormone, estradiol and
progesterone
• quantitative sensory testing, sacral dermatome testing,
bulbocavernosus reflex latency testing, and urodynamic testing
• Cardiovascular disease or metabolic syndrome: duplex Doppler
ultrasonography or clitoral/vulvar thermography

Management of the patient with orgasmic
disorder

FOD Tx
• 300 mg of testosterone patch
• 10 mg of testosterone gel
• phosphodiesterase type 5 inhibitors (PDE5is)
• low-dose bupropion at 75 mg twice a day
• cabergoline, administered at 0.5 mg up to three times per
week, and ropinirole 0.25 mg administered daily
• Oxytocin lozenges, 250 IU sublingually 30 min to one hour
before sexual activity

Treatment of Women with Female Orgasm
Disorder
• Modification Treatment Strategies
• sensate focus therapy, cognitive behavior therapy, and/or mindfulness
therapy, typically focusing on modifying feelings, attitudes, actions,
sentiments, and relationship communication/ behaviors that may be
causatively related to the female orgasm disorder condition
• Pelvic floor physical therapy strategies
• Adjunctive use of trigger point injections, vaginal or rectal
diazepam or baclofen, and/ or intramuscular onabotulinum
toxin A

FOD Tx
• An ideal goal of testosterone therapy is a calculated free testosterone
values of 0.6–0.8 ng/dl. Follow‐up blood tests for total testosterone,
sex hormone binding globulin, and dihydrotestosterone should
initially be made at three‐month intervals and then as needed, such
as every 6–12 months if stable.
• The ideal goal of estradiol therapy is a value of approximately 35–50
pg/ml, the usual upper value of normal for many reference
laboratories in menopause and values consistent with 8–10% of peak
estradiol values in the reproductive years. Follow‐up blood tests for
estradiol should initially be made at three‐month intervals and then
as needed, such as every 6–12 months if stableTextbook of Female Sexual Function and Dysfunction

FOD Tx
• The ideal goal of cabergoline therapy is a normal prolactin value of
4–23 ng/ml. The typical starting dose of cabergoline is 0.5 mg twice a
week on Monday and Thursday. Follow‐up blood tests for prolactin
should initially be made at three‐month intervals and then as
needed,such as every 6–12 months if stable.
• The ideal goal of thyroid therapy is a thyroiod stimulating hormone
value of 1–2 μU/ml. The typical starting daily dose of thyroid
hormone is 25 μg/d. Follow‐up blood tests for thyroid stimulating
hormone, free triiodothyronine, total triiodothyronine, free
thyroxine, and total thyroxine should initially be made at
three‐month intervals and then as needed, such as every 6–12
months if stable.

FOD Tx
• bupropion 75 mg/d in the AM; cabergoline 0.5 mg q Monday
and q Thursday; ropinirole 0.25 mg qdaily – TID; oxytocin
lozenges 250 U sublingually – one hour prior to sexual activity;
and/or amphetamine, dextroamphetamine mixed salts, 2.5–10
mg taken 30 minutes prior to sexual activity, but if taken after
2:00 p.m. difficulty with sleep should be considered.
• Use of flibanserin at a dose of 100 mg/night.

Useful questions when obtaining a sexual pain
history

Conditions associated with dyspareunia

PE of dyspareunia

Vulvodynia Tx
• combined estradiol 0.01 % and testosterone 0.1 %
• an oral medication, ospemifene.
• Lidocaine may be applied using a 2 % jelly or 5 % ointment as
needed prior to intercourse.
• long-term use of overnight topical lidocaine 5 %
• 2–6 % gabapentin for at least 8 weeks
• topical amitriptyline 2 % cream, apply a pea-size amount of
amitriptyline cream to the vulvar vestibule twice daily
• topical capsaicin 0.025 % applied 20 min daily for 12 weeks

Vulvodynia Tx
• Classes of oral medications used include tricyclic
antidepressants (TCAs) (amitriptyline, desipramine), selective
norepinephrine reuptake inhibitors (venlafaxine, duloxetine),
and anticonvulsants (gabapentin, lamotrigine).

Vulvodynia Tx
• vulvar vestibulectomy with vaginal advancement
• excision of a semicircular segment of perineal skin, the mucosa
of the posterior vulvar vestibule,and the posterior hymeneal
ring. Three centimeters of the vaginal mucosa was then
undermined and approximated to the perineum.
• Pelvic floor physical therapy can be augmented with
biofeedback, vaginal dilators, home pelvic fl oor relaxation
exercises, rectal or vaginal diazepam suppositories, oral muscle
relaxants, trigger point injections, and botulinum toxin type A
injections Management of Sexual Dysfunction in Men

Female sexual function dysfunction

Female sexual function dysfunction

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