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Nurture Your Nature: Inspiring Women’s Sexual Wellness

Nurture Your Nature: Inspiring Women’s Sexual Wellness. Association of Reproductive Health Professionals www.arhp.org National Women’s Health Resource Center www.healthywomen.org. Nurture Your Nature. R equired Slide. Expert Medical Advisory Committee. Raquel Arias, MD

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Nurture Your Nature: Inspiring Women’s Sexual Wellness

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  1. Nurture Your Nature:Inspiring Women’s Sexual Wellness Association of Reproductive Health Professionals www.arhp.org National Women’s 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. Women’s Sexuality • Complex • Less studied, understood than male sexuality • Many theories and beliefs are inaccurate or outdated • Difficult to address for some Berman, L. Fertil Steril. 2003.Kingsberg, S. Sexuality, Reproduction & Menopause. 2004.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 43% 31% Women Men 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 24% Women 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) • Women’s arousal identified primarily by: • Genital vasocongestion • Vaginal lubrication • Awareness of genital sensations • Women’s sexual response essentially stable and invariant across time/circumstance • All women experience distress about alterations or limitations in sexual response Basson R. J Psychosom Obstet Gynecol. 2003.

  15. Female Genital Arousal Berman, JR. World J Urol. 2002. Kerner, I. She Comes First: The Thinking Man’s Guide to Pleasuring a Woman. 2004.

  16. Orgasm Plateau Resolution Excitement Resolution Resolution (B) (C) A B C (A) 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 Seeking Out and Being Receptive to Emotional Intimacy Sexual Stimuli Spontaneous Sexual Drive Arousal and Sexual Desire Sexual Arousal Biologic Basson, R. Obstet Gynecol. 2001.

  19. Variables Affecting Female Response Past sexualexperiences or sexual abuse Past sexual experiences or sexual abuse Sexual self-image and/or body image Sexual self-image and/or body image Relationship with sexual partner (male or female) 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 ofsexual 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 26% Other 36% Death of spouse 18% Spouse unable to perform 20% 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 Diminished sexual response Decreased desire Menopause Vaginal dryness and dyspareunia Decreased sexual activity Dysfunctional male partner Kingsberg, SA. Arch Sex Behav. 2002.Basson, R. Menopause. 2004.

  25. SWAN Study: Women Ages 42-52 79% 77% 42% Rated sex moderately to extremely important Engaged in sex in past 6 months Infrequent desire for sex (0-2x per month) Cain, VS. J Sex Res. 2003.

  26. MA Women’s Health Study II Postmenopausal Women More likely to agree sexual activity declines with age Less desire and arousal 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 15 0.5 Premenopause Postmenopause 10 Production rate (mg/day) 0.25 Production Rate (mg/day) 50% ------------------------------------------- 5 60% 50% 75% 0 0 DHEA-S Testosterone DHEA A4 Longcope, C. Ann NY Acad Sci. 1990.; van Lunsen, RHW. Menopause. 2004.Anastasiadis, AG. Curr Urol Rep. 2002.

  30. Neurologic Disorders Endocrine Disorders Vascular Disorders • Head/spinal cord injury • MS • Stroke • Diabetes • Hepatitis • Kidney disease • Hypertension • Leukemia • Sickle-cell disease 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 Professional’s Guide. 1997.

  31. Psychiatric Disorders Debilitating Diseases Voiding Disorders • Anxiety • Depression • Cancer • Degenerative disease • Lung disease • Overactive bladder • Stress urinaryincontinence 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; Professional’s Guide. 1997.

  32. Psychoactive medications Hormonal agents Cardiovascular medications Others Medications Causing Desire Disorders 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 (<40) • 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 woman’s health, greater her interest in sex • Marital status • Married women had lower libidos and reduced arousal Avis, NE. Menopause. 2000.

  37. Women’s 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. Women’s 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 Lack of training Personal issues Clinicianissues Lack of skills Belief sexualinterest declineswith age Lack of time Lack of treatmentsto offer Fear ofembarrassing patient Berman, L. Fertil Steril. 2003.; Kingsberg, S. Sexuality, Reproduction & Menopause. 2004.

  42. Common Biases to Avoid Sexual Orientation Relationship Status Cultural Issues Age

  43. Why Don’t Patients Bring Up Sexuality Issues? 100 68% 71% 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.

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