2025 Urogynecology for the Advanced Practice Provider-Female Sexual Dysfunction (Low Libido, Possibly Anorgasmia)

Female Sexual Dysfunction (Low Libido, Possibly Anorgasmia)

Video Transcription

Jessica Bell to kind of give her a little talk on, well, not little, big talk, on female sexual dysfunction.  Okay, well, welcome back from lunch.  Hopefully this talk is exciting for you as you're finishing off, and feel free to still mingle and trickle in. We're gonna talk about female sexual dysfunction.  Advance the slide.  Oh, okay.  Okay, all righties. So again, what does urogynecology have to do with sexual dysfunction? Well, it has a lot to do with it. I work in urogynecology,  and the reason why I got into this is because patients were coming to me with these concerns, right? And I thought to myself, you know, if I had these concerns, I would think that,  if I was the person sitting in that chair, that I had all of the answers, right? That the gynecologist or the urogynecologist  would have the answers to evaluate and treat these concerns. And when I first started, I reached out to my supervising physician, and they didn't have any information for me.  They were still telling people to drink a glass of wine to help with their concerns. So that's when I got involved in the organizations and delved into the specialty.  But again, sexual dysfunction is common in women with incontinence. Approximately 46% of people report bothersome symptoms that have incontinence, so they go together.  The objectives are similar to the previous talk. We're gonna understand, again, what is female sexual medicine? How do we use the biopsychosocial approach?  But this time, we're going to learn about the differences between desire, arousal, and orgasm, and what occurs when dysfunction happens in those realms.  And remember that the patient's goals are your goals. We definitely live in a culture and a society that I would say pushes a lot on us as to what it should look like  to have a robust sexual experience, right? And that is not everybody's situation. And they don't need to meet a certain level of expectations of society or culture.  So I always kind of reiterate that with people. Your goals are my goals. There's no normal way. So again, this is important because we don't get this training.  So we literally have to go to conferences like this to get the training that we need to show up for patients. And they're coming to us.  I already talked about ish-wish for a moment. I did want to mention one more thing because during the lunch break, somebody presented a very interesting case to me.  One of the things that I loved about this membership is that it gives you access to an online posting board. So you can post your complex cases,  and then the brilliant brains of the nation, and honestly the world, will chat with you about that. And they talk back and forth between one another.  I think that instead of watching Netflix, they like watch the posting board to talk about complex cases, which is awesome.  Alrighty, so this is the Mayo Clinic proceedings for sexual dysfunction and identifying sexual concerns. So sexual dysfunction manifests as chronic symptoms  related to sexual pain and the three phases of the sexual response cycle, desire, arousal, and orgasm. There are normal variations. The normal variations are distinguished from FSD  by the presence of occurring for a minimum of three months. We'll talk about that too in a moment. And this should occur with at least 75%  of sexual experiences, and there needs to be distress associated with it as well. This can be lifelong or acquired. It can be situational or generalized, and the severity varies.  People can experience sexual dysfunction in multiple areas. So they can have arousal, desire, and orgasm dysfunction. Again, we'll see that a lot of the times  they go together, right? If you are having pain, you have vasoconstriction, reduced ability for physiological arousal, which will naturally decrease your desire  for an intimate experience if it's not pleasurable and painful.  So the cause is multifactorial, and that's why when we address this, I will reiterate over and over again the biopsychosocial approach.  And I would say again, another thing in my opinion is that pleasure is an important piece to this puzzle.  So here's that biopsychosocial approach. Again, I use this in everything that I do.  So to understand the differences between,  or we need to have kind of a baseline, right? What is the sexual response cycle? So we've got Masters and Johnson's model, and then we also have Rosemary Besson's nonlinear model,  and I would say that's the more updated model. So the differences here is that Rosemary Besson also considered what is the motivation, whereas Masters and Johnson's,  they just start with desire. But we know that a lot needs to maybe happen before we get to desire.  So, dysfunction. I feel like that is a strong word sometimes, right? But in medicine, we need diagnosis codes, right? So dysfunction serves for that.  But when I think of this measure of lasting more than three months, I can think of a lot of times in my life personally where maybe things of desire for a lot of things  have changed, you know? Postpartum, school, new job, if you've got roommates, if you've had surgery, I had a knee injury, right? There's just so many life things that can impact  our sexual function, definitely desire, that occurs for more than three months. We also see that there's definitely a lot of lack of education and maybe even realistic expectations.  I once had a patient come into my clinic for female sexual dysfunction and her complaint was that she could not orgasm with penetrative intercourse alone.  We know that that is common. Three quarters of women cannot experience orgasm with penetrative intercourse alone, right? So that was not dysfunction, that was actually  some lack of education or understanding of how the anatomy and the body works. We also see sometimes that this dysfunction is derived from a heteronormative lens.  Sometimes we use male physiological arousal as our compass for female desire. There's some good papers on that.  We also need to consider pleasure and satisfaction, right? Is it dysfunction if it is not pleasurable? And also as we go through this, we will see that  if there's pain experience that that is actually not dysfunction.  Sometimes I think about some other words as well, right? Differences or difficulties. And then what about distress, right? I've had a patient say, you know,  if I wasn't in a relationship, I wouldn't have a problem at all. So that's also an interesting thing to consider.  So sexual desire disorders, female sexual dysfunction, concerns can overlap. Again, if you have pain, if it's not pleasurable, if you're not experiencing physiological response,  it is natural for desire to decrease. And it can definitely be a puzzle.  So here's some examples of sexual dysfunction. Hypoactive sexual desire disorder would be described as a lack of motivation, reduced or absent spontaneous desire,  reduced or absent responsive desire to cues, loss of desire to initiate or participate, and behavior is not secondary to sexual pain. And it needs to be combined with distress.  So they need to be distressed about this. And this should be occurring for more than six months. When relationships get into the mix, the distress thing, like I say,  it is definitely interesting, right? The amount of times that I have had a person say, you know, this wouldn't bother me if it wasn't for them.  And then there's female sexual arousal disorders. So that would be the inability to attain or maintain adequate genital response, lubrication, engorgement, sensitivity,  also needs to occur for more than six months. Persistent genital arousal disorder. This one just touches my heart because these people go dismissed.  They, yeah, so this is an experience where a person is having persistent, unwanted, distressing feelings of arousal, not associated with desire.  So again, that is the honoring that we can have a lot of desire for an intimate experience and not the physiological arousal to go along with it. And the reverse can be true.  You can be in a not desired situation but have a physiological response in the body of arousal and even orgasm.  And with PGAD, there are multiple regions involved. I will share a slide on that. That's pretty complex and definitely sometimes complicated too, but I love those patients.  Female orgasm disorders. So that would be a change in orgasm frequency or maybe quality, we say. Also occurring for more than six months. Female orgasm illness syndrome.  This is more rare, but this can be a scenario to where a person gets a flu-like symptoms after orgasm.  And then, of course, we have genital pelvic pain. So this can occur in a lot of different regions of the pelvis and there's a lot of different causes for that.  So again, where do we start? Well, we start by asking. We start by honoring that this is important  to many people and we need to ask. They're not going to always offer this, right? And that's why we do need to get comfortable with asking.  So when I think about the biopsychosocial approach, one of the things I also think about is just differences in the population, right? And differences between individuals, right?  Bioindividuality. Who is the person in front of you?  Sexuality can be a spectrum, definitely, right? So a person has a baseline and also that can change over time.  I often describe to my patients, you know, this is a bell curve, right? The middle is more common, but that's not necessarily more normal, right?  Also an interesting thing, maybe when you are in a partnered scenario to where some people are kind of higher on this bell curve for desire and somebody is on the lower end.  That's a discordance. So you asked, but now what are we going to do? Well, before we start, I'm going to be talking in detail about some of these biological responses.  We need to know what is the difference between desire and arousal, right? Desire is not arousal. Desire happens in the brain. Arousal happens in the body.  Arousal is a physiological response. Again, you can experience one without the other.  So I really like this because I also come from a bit of a social constructualist, female sexual medicine viewpoint, right? So Lori Brado is an amazing researcher.  She researches mindfulness and sexual dysfunction. And so we honor that, again, like I say, in medicine, we need diagnosis codes, right? So sometimes maybe what might be, again,  normal individuality within society, we might call dysfunction because we need a way to evaluate and treat it.  So desire.  There are some overgeneralized differences in desire. So when we think about desire, it is so important to maybe honor this.  So gender differences in desire can be an overgeneralization, but like I say, an important consideration. So spontaneous desire.  Spontaneous desire is desire that occurs out of the blue. A visual stimulus, a thought promotes desire. Often the stimulus initiates physiological arousal and the result is desire.  So I would say male people may more often experience what we call spontaneous desire. Again, though, that spontaneous desire is that arousal that causes desire. That's a question.  And then responsive desire is desire that evolves out of a context that is low in stress, high in energy, and pleasurable, right? Distractions are reduced, affection and attention  is expressed, and desire evolves. But again, it needs to typically evolve in a high energy, low stress, pleasurable state. Everyone's different, though.  Some people, I think we have, people have sex for 250 different reasons. Only one of those is to make a baby, for that matter, so.  So when we think about desire, we also need to think about the brakes and the accelerators. So there's a couple different models for this. There's the sexual tipping point  and the dual control model. Again, I would say in this society that we live in, there might be more of a conversation about putting accelerant on it, you know,  buy the lingerie, like, do the thing. That might be helpful sometimes, but most often what we need to look at is what are the brakes, right?  You know, what is coming up for a person?  Is there pain? Do they like their partner or their relationship, right?  Are they sharing a wall with their children and they just refuse to be intimate with kids on the other side of the wall, right? So we need to figure out what are those brakes.  And typically I find that we need to work on removing those brakes versus trying to put more accelerant on it.  So when it comes to desire, there's a lot of stressors that impact this. Some are modifiable and some are not. Cancer is a non-modifiable stressor.  The tissue issues associated with that diagnosis are modifiable. Children are a non-modifiable stressor. I have three of them.  Planning for intimacy when energy is high, stress is low. Reducing distraction and focusing on pleasure is modifiable, right? So maybe not choosing to be intimate at 10 p.m.  after you've worked a day and done dinners and bedtime routines and now we're expected to have a spontaneous desire. It doesn't really work like that.  Disability or injury is non-modifiable. But expanding sexual repertoire, inviting sexual aids is modifiable, right? I will sometimes talk to my patients  about mutual masturbation, right? So there's a lot of ways we can show up for that.  Hypoactive sexual desire disorder, I mentioned that already. Here's a little process for evaluating that that is by Dr. Erwin Goldstein.  So some of the treatments that we consider is mindfulness. So mindfulness is very helpful. It helps us attune to sensation in our body,  our thought processes without letting them interfere. Lori Brado is the person who studies mindfulness and sexual health, she's amazing.  Sensate focus, that was developed a long time ago and we still use it because we find that it works really well, right? So this was developed by Masters and Johnson.  This is a technique used to improve intimacy and communication between partners. Non-goal oriented intimacy, we sometimes can call it mutual massage. I would say it really can also,  I talk about this a lot with people, my cancer patients who have had changes, surgical changes, those kind of things, right? Sometimes we talk about inviting sensate focus  to reevaluate again, like what feels good in your body now? Or maybe somebody in a long-term relationship where they've kind of been, you know, they're okay  but they've been doing things the same way for a long time. Taking a step back and doing a stepwise approach with sensate focus to really discover  what is actually pleasurable and feels good in the body is very, very powerful. And you can go to ISSM, all of SMSNA, all of them have sensate focus on there.  It's, we start from like the waist up, it's a whole process. And no actual intercourse is allowed until the very end.  Education, right? So again, when it comes to desire difficulties or dysfunction, it's important to know what to expect, right, I think that we could do a better job  at talking about desire and how this can change throughout the lifetime, again, with stressors or just as we become different people as we continue on our journey.  So Emily Nagoski is one of my favorite authors. I often recommend the book Come As You Are. She just wrote another book called Come Together  which is about maintaining an intimate relationship and long-term relationships.  Come As You Are, I mean, hopefully you guys have heard of it before, but when I talk to my patients about this, I'm like, get this book, you will feel seen, you will feel heard.  It's like she's looking into your soul, I swear. And she also has a lovely podcast as well. At the end of her chapter, she has a TLDR, Too Long, Didn't Read, so you don't have  to read the whole book. There are some FDA-approved medications to treat female sexual dysfunction.  Flibanserin, brimalanotide, buspirone, bupronate testosterone can be considered, but again, remember what we are treating, desire in the brain versus physiological arousal  in the body, you need to know what's going on for your patient, oftentimes it's both.  So we know that there's a hypoactive sexual desire. Some people may experience a hypersexuality, right? So that would be an inability to regulate  one's behavior, causing personal distress.  So here's a desire case, so Desi is a 37-year-old who presents with low libido. She's postpartum, six months, she's breastfeeding. Her cycle hasn't returned.  She resumed intercourse at the period the doctor said she could, and it's been painful. She's a pelvic floor physical therapist,  so she has a lot of knowledge. Her relationship with her husband is great. She's having some sleep disturbances, body integrity changes, but she's distressed about this  before she had a high libido, and she's really seeking to get that back because she wants that physical intimacy with her husband as they're navigating being new parents.  So what's going on? Well, on exam, because it hurts, she has a low estrogen effect. This occurs in lactating women. Ashley Winters, when she was pregnant and breastfeeding,  I think she's the one that coined the term genitourinary syndrome of lactation.  And you can use vaginal estrogen cream in patients that are breastfeeding. Again, it is not systemically absorbed.  Her other concerns are sleep disturbances and body integrity changes. These changes are expected. We should talk to her about responsive desire, right?  It's okay to not have desire at 11 o'clock after your day. Maybe she needs to plan for intimacy when energy is high and stress is low. I talk to my patients about this all the time.  Flip the script, be intimate in the morning.  Maybe they can try some sensate focus, and definitely non-intimate time spent together. It's not all about planning for intimate time. Honestly, planning to go do the pickleball  or to go on the hike can be so helpful. And in sex med spaces, we often don't recommend just going out to dinner. That's when you get to sit down and talk about all the stuff  you didn't have time to talk about. It's actually not usually a sexy time when you do that. At the end of the dinner, you're like, okay, so now we talked about our finances  and all the stuff with the kids, and that's not what we thought we were gonna do tonight. So yeah, consider the sexual tipping point  and the dual control model. Figure out what are the breaks for her. It's also good to know what the accelerators are. Give her the book, Come As You Are.  I order these and give them to people sometimes when I'm like, you're the one that needs this and you might not buy it. And then also, this is not HSDD because there's pain, right?  So we can validate and support her goals with treatment and refer if needed. Definitely make a plan to follow up to make sure that she's getting better.  So biological differences. So again, there's just differences between humans. I love that about humans. And then medication side effects.  We see that birth control can definitely decrease desire. The statistic is 15%. So systemic contraceptives, pill, patch, ring, deponexplanon by mechanism of action  can decrease testosterone. and 15% of people may experience a new decrease in desire as a result. Of course though they may also need their reproductive rights and birth  control so but we should tell our patients this right. If we if there was a side effect of 15% for any other medication we put somebody on we would  definitely tell them that potential. So other medications can cause side effects as well. Again biologically pain is a huge one. GSM like in sclerosis decreases  blood flow to the tissues causes a vasoconstriction inhibiting the ability for vasodilation physiological arousal. A person can also have those tense  hypertonic pelvic floor right and that cycle is just so big if you have tissue issues if you have pain then even the intimacy approaching you you will have  pain. Hormones and medical conditions. Hormones can impact desire arousal and orgasm. Other conditions can as well. We'll talk about hormones here in a bit.  Well here's one here we go. Okay so testosterone there's a lot of talk about testosterone I feel like in the media and social media in particular.  Testosterone is definitely not a gendered hormone. It declines slowly over time unless the ovaries are removed. This can be impacted by medication so  again we see that some people on systemic contraceptives may have had their testosterone lowered by mechanism of action and then we see when we take  them off of the medication it doesn't always go back up. We see that when a person feels good hormonally this can create a context that is higher in  energy lower in stress and pleasurable right. So I do I have my menopausal hormone specialist and so I do a lot of that and that's one of the things that I  talk to my patients about a lot when they're going through hormonal changes. Perimenopause and menopause is not a high energy low stress pleasurable state  right. So that is where we can address that there right. So when we address somebody's hormones when they are sleeping better when they feel better  about themselves when their mood is even keel you know when the musculoskeletal joint pains are coming up when their hip pain at night when  they're trying to be intimate isn't occurring anymore right. This can create a context that is higher in energy lower in stress than pleasurable for a desire  to evolve from. And estrogen can do that too though so this slide is about testosterone. I don't start with testosterone I start with estrogen and  progesterone if needed and then I follow up. So if a person comes to me they're perimenopausal menopausal they've got a full constellation of  symptoms and decline and desire is one of those. First of all I think there's also an honoring that that decline and desire for a lot of us is not just  desire for intimacy it can be desire to do anything right. When we're going through perimenopause or menopause it can be like a decline in desire to hang  out with friends or to like do other stuff let alone be intimate. And so that is where hormone therapy can sometimes be helpful when we feel like ourselves  again. And so yeah estrogen can do this. So I start with estrogen first I prescribe a good amount of testosterone in my practice. When I'm prescribing  testosterone I always get a baseline level first reassess after 12 weeks. I use the FDA approved formulation androgel at one-tenth a dose for women  that's the ish wish recommendations and there is specific recommendations on that never pellets never ever ever ever ever pellets that no societies recommend  pellets they can cause supra physiological levels of testosterone that do not occur with the FDA approved formulations and some of the  complications that occur could be endometrial hyperplasia if it converted to estrogen at the uterus. So that is why I check a baseline initiate treatment  with the FDA approved medications recheck at 12 weeks to assess for absorption and also discuss if they're noticing anything from it. And I have to  say when I'm talking to my patients about what they're noticing from desire or from testosterone they are not coming back saying that they have a new sexual  desire. Honestly what most of those people are describing is just kind of a new zest right. It's kind of this nuance like yeah I feel like I I'm going on the  hike without convincing somebody to come with me or you know when I go to the gym  I feel like I'm not looking at the clock at the 30 minute mark as much when I'm supposed to be there for an hour. Right. So again it's not nuanced and maybe that  zest that increase in energy right and feeling good relates to desire again desire for anything like hanging out with friends or intimacy.  OK. So here's a list of some of the contributing factors to sexual dysfunction. So this is a list of medical conditions and a list of medications.  It's pretty long but these are some of the things that I consider in my evaluations.  Anatomy. We already did this a few times which is like so exciting. But the vestibule is definitely important when I'm assessing for sexual pain. The  vestibule is oftentimes the location and also often the times that maybe gets missed by other people. So assess the vestibule. Anatomy. So the clitoris has  a flaccid and an erect state. This pictures are from the vulva gallery. I love their work but the picture on the left is about the size of the clitoris  under the pelvis there. And then the picture on the right is it's swapped for you guys isn't it. Yeah. Anyway is the cross section of the clitoral anatomy.  OK. So again arousal happens in the body.  One of the things that I'm hearing a lot is that there are more medications to treat male sexual dysfunction than female sexual dysfunction which is true.  But again let's consider what is being treated. Oftentimes when we are treating male sexual dysfunction we are treating arousal erection and we are treating  physiological arousal or erection. Right. And that is not what the medications used to treat female sexual dysfunction work on. They work on desire and we  don't necessarily see that there's a lot of significant results there. These data shows that the sexually satisfying event may increase by one event a month.  I some and in my community finances are limited. I live in Oregon. I would say people also are really seeking actually a more holistic approach and holistic  conversation. And so I don't prescribe a lot of the FDA approved medications for  low desire. I would say a lot of those patients feel like they might be kind of expensive and they might be able to you know plan for that one additional event  each month and spend that money on something together.  And remember the pleasure is important. Right. There is no magical pill for pleasure. So without pleasure it can be difficult for arousal to occur.  There are some oral medications for arousal. Actually sildenafil can be considered. But again it does not work in the same way in women as it does in  men. Bupropion is also helpful sometimes. There's also some topical medications for arousal. So there's often arousal scream creams. These have vasodilators in  them and it's applied topically about 30 to 50 minutes prior to use. I would say most compounding pharmacies have like their own little formulation of scream  cream. They often have a topical sildenafil and L-citrulline and perimenopause brain I don't know. And a few others. But the first scream cream  that I came across I had like 10 things in it. One of them was oxytocin and it needed to be refrigerated. And so I had patients coming to me saying like I  don't want to apply this cold cream this refrigerated cream to my body before so I actually ended up working with a compounding pharmacist and we really  geeked out on like what are all of these things in this cream doing and how can we minimize them. So my arousal cream that I use sometimes just has four  ingredients in it. It does not have topical testosterone in it. It does not have oxytocin in it like some of the other formulations have. And when I talk  to patients about the arousal scream creams I talk about it as being like just like a funsy tool in the toolbox for some people. It can bring good  blood flow to the anatomy allow for vasodilation which may help kind of bridge that gap between physiological arousal and orgasm or in a partnered  situation. Some people might find it to be beneficial to maybe apply before anticipated intimacy. That way there's some vasodilation and engorgement before  they maybe encounter a partnered situation. And then of course education. So understanding how arousal works and how your body works is helpful right. So  and I often talk to people about again you know if they're comfortable with it evaluating their body for themselves right. I always show up for people in  regards to any limitations with religious or cultural kind of aspects but sometimes I use the analogy of like you need to know how to play your own  instrument before you join a band right. And so understanding how your body works how physiological arousal works in your body how orgasm works for you  individually before you're in a partnered situation can be very helpful. Sexual aids can be helpful as well. Those bring blood flow to the area. It can help  with purposeful clitoral stimulation. The Kiwi is developed by the Onut company. It allows for vibration to the vestibule and vulva prior to penetration that can  help with decreasing pain with intimacy and improves improving arousal. So I'm not going to go into this in depth because goodness gracious a lot of this  talk we could you know spend days on but you need to know that PGAD exists. It is a real diagnosis. It is very and yeah patients are very bothered by this. So I  I've had some patients hear from other clinicians about well that doesn't sound too bad doesn't sound too bad just you know having persistent arousal. But when  patients describe this and one of our patients in the community is an artist right and she has this picture of it's like a giant spider coming from the  pelvis and just engulfing her body right. So you feel like your body is taking over and you don't have that consent. So this is how we might evaluate that.  Again it's complex and it is actually this one is complicated. OK so arousal tissue issues definitely inhibit physiological arousal. So low estrogen  effect like in sclerosis like in plainness radiation changes vulvitis but most commonly low estrogen. Again birth control pills lactation fertility  treatments menopause euphorectomy breast cancer trans males on high dose testosterone low estrogen states for other reasons as well. So when I'm  assessing for pain here is Dr. Andrew Goldstein's algorithm for evaluating vestibulodynia. Again it's complex and it's complicated.  Genital urinary syndrome of menopause. We talked about this a little bit already but people need good estrogen effect for vasodilation and for physiological  arousal. And I am more aggressive with my prescribing of estrogen cream for prevention because I've just seen the amount of times in my practice that  person that comes in they it started with pain with intercourse just a little low level tissue discomfort that then resulted in a hypertonic pelvic floor  that then resulted in relationship issues right. And so when they come to me and I let them know that we can treat this with vaginal estrogen that it is  safe for basically all people to use that it is economical particularly when you prescribe the generic and that it will treat their symptoms and may have  prevented that from occurring. They're upset right. I mean they're actually upset that wait you mean these tissue changes happen in almost everybody with  perimenopause and menopause and nobody told me this right. And so they want to be treated sooner because by the time they come in to talk to you about it if  they are honest with you there might be bigger issues like relationship issues. So we don't really need to wait to prescribe we can prevent. Here's that  cost savings analysis again when we think about prevention I mean I think about preventing sexual pain and again urinary tract infections. So we do have  good robust data on how vaginal estrogen can prevent urinary tract infections and I heard from Rachel Rubin that they are going to be updating UTI prevention  recommendations pretty soon and Oggs has agreed that vaginal estrogen is first line. All right here's a mention on lichen sclerosis. We had great lichen  sclerosis talk so I'm not going to talk about this in any detail really. But again of course lichen sclerosis can cause pain with intimacy and and female  sexual dysfunction. I use mirrors in my practice. I've got a mirror at the bottom of my drawer and so I always ask a patient if they would be up for taking a  look with me. Most often they are like so grateful that I asked and they are very enthusiastic to do so. For somebody with lichen sclerosis honestly it's pretty  important. They need to have an understanding of their anatomy so that they can do their own vulvar checks once monthly for changes. We talked about this  a little bit too. So clinical pearls when it comes to pain that can contribute to female sexual dysfunction again consider the vestibule. If you have patients on  vaginal estrogen tablets that are talking about sexual pain and you think well it can't be low estrogen effect. They're on hormones. Do the exam and take  a look. Is the clitoris atrophic or the labia atrophic? Is the vestibule atrophic and erythematous? And also and this all came out of clinical experience. In the  beginning I had patients on systemic hormone therapy and they would come into my practice talking about pain with intimacy, pain with intercourse, arousal  changes, orgasm changes. And I thought well it can't be low estrogen. They're on systemic hormone therapy. And then we do the exam and the vulva is atrophic, right?  They have diminished sensation and vasoconstriction and pain and irritation. So here's a pharmacological list of treatments for a female sexual  dysfunction. So you can have the different dosages there. The clitoris. The clitoris is also a very important part of female sexual function, right? And one  of our presenters already talked about clitoral femosis. When you are doing a pelvic exam we need to do a good detailed vulvar exam. Oftentimes it's  like speculum, pap smear, get in get out. But we need to take a look at the vulva. We need to see if the clitoral hood is retractable. Look at the labia minora,  the perineum, the vestibule. Some people will have complete clitoral femosis and this can contribute to sensation changes. And there are some procedures  for this. Dr. Rachel Rubin is the one that studies I would say clitoral femosis most or at least her team does. We also believe again education is  important. It is very common to teach uncircumcised little boys to pull down their tissue so that they don't get penile femosis, right? And we actually  need to be teaching young women about anatomy as well and pulling back the clitoral hood. That is also something that I would say my patients get very  frustrated about. The amount of times that I have seen somebody who has complete clitoral femosis with a buried clitoral glands and they've seen  multiple gynecologists before and in none of their exams is there any mention of these clitoral changes, right? They're upset and they wonder why  nobody has said anything to them. So here's another case. So this is Desi. She's got diminished arousal. Okay so she's menopausal. We're going to put her  on some hormone therapy. We'll start with estrogen progesterone. We'll consider testosterone and vaginal estrogen. We're also going to talk about expected  changes. And I've got short on time so I'm going to buzz through a little bit. So orgasm. This is another place where sexual dysfunction can occur. The  definition of orgasm varies between specialists, right? So this is Nicole Prowse's definition of orgasm and she studies orgasm in the lab. There's really  people may feel like they experience orgasm in different places but it's kind of just the same thing. Three-quarters of women do not experience orgasm  without purposeful clitoral stimulation. However that is can be achieved with penetration because the clitoral legs are can be stimulated internally. This is  new. I don't know that it's out there in the world much but this was presented at ish wish recently. So when we're considering dysfunction in the orgasm  it's important to understand what phase. So pre-orgasm phase, during orgasm, or post orgasm. Fluids. Incontinence with intimacy or ejaculate. This is also a  concern that comes up for patients. So we do incontinence. It's important to differentiate between incontinence during intercourse. If it occurs  spontaneously throughout intercourse that would be a stress urinary incontinence picture. If this only occurs with orgasm that would be more of a fluid ejaculate  picture. And here's some details about that. It is true that there is a female prostate. It's kind of a silly thing to think that that was just selected out.  Everybody is different. Everybody's anatomy is completely different but when we stain that tissue we do see that there are some it stains positive for  PSA. And that is a space where some people can collect or some people do collect fluid. And then with that pressure gradient that occurs during  orgasm some of that fluid can be emitted. And that is not all urine. When we assess the chemistry of that there is some urine in there but there's also urine  and semen by the way. So here are the different types of orgasm dysfunction. And again we assess this by phase. So post orgasmic illness syndrome that's a  fairly rare one. Again that's when a person feels like they've got the flu. Here are some different options for treatment. So hormones. Hormones have a  biological and psychological impact. Female sexual dysfunction increases during perimenopause and menopause. Women make up 50% of the population. Mean age  of menopause is 51. We live about 40% of our lives postmenopausally. So again this is not a drop in the bucket. And this full constellation of symptoms is one of  the primary drivers of the decrease in desire. Psychosocial. Again I also consider everything else. Family, religion, culture, society, friends,  relationships, mental health and stress. It is definitely true that our lack of education contributes to our lack of understanding. Masturbation is a normal  experience. Culture and religion can impact sexual health and discussing this and supporting patients where they are at is important. Ask the questions, take a  thorough history and again meet the patients where they're at. So here's a little summary of female sexual medicine, the biopsychosocial approach, arousal,  desire, orgasm, clitoris and hormones and my references. Thank you.  Thank you Jessica for a great talk.

Video Summary

The talk by Jessica Bell focused on female sexual dysfunction, particularly the connection to urogynecology and the importance of addressing these issues through a biopsychosocial approach. Bell emphasized that sexual dysfunction is a common concern among women, especially those experiencing incontinence. She highlighted the importance of understanding the distinctions between desire, arousal, and orgasm, and the different causes of dysfunction in these areas. Bell discussed the need for a cultural shift in understanding sexual dysfunction, emphasizing that there is no standard of "normal" and individual goals are paramount. The talk also covered various aspects such as hormonal influences, the role of mindfulness, education, and exploring conditions such as hypoactive sexual desire disorder and persistent genital arousal disorder. Bell stressed the importance of proper medical training to better assist patients and the need for conferences to improve knowledge and treatment strategies. The talk concluded with a focus on the impact of hormones and the significance of personalized care to meet the unique needs of individual patients.

Asset Subtitle

Sexual Dysfunction, Difficulty, Difference or Disorder? Sexual dysfunction is common in women with incontinence, approximately 46% of people report bothersome concerns.

Sexual dysfunctions manifest as chronic sexual symptoms related to sexual pain and the 3 phases of the sexual response cycle: desire, arousal, and orgasm.
Desire, arousal and orgasm: a detailed explanation.
How do you determine what is difficulty vs. difference vs. a disorder or dysfunction? Where does distress come in?
The ISSWSH 4 step model.
What is the biopsychosocial approach and how do you use it in a 30min visit?
Fluids. Incontinence with intimacy or ejaculate?
Resources. Resources. Resources.

Speaker - Jessica Bell PA-C, MSCP, IF

Keywords

female sexual dysfunction

urogynecology

biopsychosocial approach

incontinence

hypoactive sexual desire disorder

persistent genital arousal disorder

hormonal influences

personalized care