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Microsoft powerpoint - adams - making midlife sex fun again

Making MidlifeSex Fun Again:strategies and solutionsKaren E. Adams MD, FACOGProfessor, Obstetrics and GynecologyDirector, Over 40 Clinic, Center for Women's HealthOregon Health and Sciences University • I have no commercial interest in any products • I have no commercial interest in sex OHSU Center for Women's Health Over 40 Clinic

Percentage of Men and Women with Sexual Complaints National Social Life, Health & Aging: Sexual Dysfunction in the US Laumann EO, et al. JAMA 1999-281(6):537-544
How Are We Doing? • REVIVE (REal Women's
Views of Treatment Options for Menopausal ChangEs) survey of postmenopausal women • Only 19% of health
professionals addressed their sexual lives • Only 13% specifically asked
about genitourinary symptoms • 40% expected their
provider to initiate the
discussion
J Sex Med 2013; 10:1790-1799

Approach to the Patient • TREAT PAIN
• EXPLAIN WHAT'S NORMAL FOR WOMEN
• ADDRESS LACK OF LIBIDO
Cycle of dyspareunia Pain with intercourse Inhibited desire /sexual aversion Lack of lubrication Failure of excitement Genitourinary Syndrome of Menopause (GSM) • New term that replaced "vulvovaginal atrophy" in 2014 • A collection of symptoms and signs associated with a decrease in estrogen and other sex steroids • Involve changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra, and bladder Genitourinary Syndrome of Menopause • SYMPTOMS
• SIGNS
• Genital dryness • Decreased moisture • Decreased lubrication with • Decreased elasticity • Labia minora resorption • Discomfort or pain with • Pallor/erythema • Loss of vaginal rugae • Post-coital bleeding • Tissue fragility/fissures • Decreased arousal, • Urethral eversion or • Irritation, burning, or • Loss of hymenal remnants itching of vulva or vagina • Prominent urethral meatus • Introital retraction • Urinary frequency/urgency • Recurrent UTIs • Nonprescription therapies
• Vaginal moisturizers (Replens, Vagisil, Vit E oil) • Herbal products (black cohosh, soy) not beneficial
• Prescription therapies
• Systemic ET used for other menopausal symptoms will often
provide relief for GSM as well (75%) • Local ET more effective (80-90%)
• Systemic ET associated with an increase in stress incontinence
• Cochrane Review of 19 studies including 4000 PMP women using local estrogen All delivery methods essentially equal in
relieving effects of GSM whether ring,
tablet or cream
Some safety concerns with cream
Suckling, Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001500 Regimen (by manufacturer)
Ring inserted vaginally and replaced/removed in 90d QHS x 14d then 2x/week 0.5g cream 2x/week 2-4g QHS x 7-14d then 1g 1-3x/week Other Local Therapies • Only SERM approved in US for treatment of moderate to severe dyspareunia • Improved VMI, vaginal pH, dryness in 52-week study • 60 mg per day orally • No VTEs or hyperplasia but small n = 180 • Vasomotor sxs 2% placebo/7% ospemifene • INVESTIGATIONAL
• Bazedoxifene 20 mg/Conjugated Estrogen 0.45 or 0.625 mg
• Intravaginal DHEA ("dietary supplement") • Both in phase 3 trials Diff Dx of GSM: other sources of pain • Infectious diseases (candida, BV, trich, GC/CT) • Irritant or allergic vulvitis (soaps, perfumes, panty liners) • Vestibulodynia • Levator myalgia • Vulvar dermatoses • Desquamative inflammatory vaginitis • Painful bladder syndrome/interstitial cystitis Sexual counseling • Several studies show profound psychological, physical, and
emotional impact of vulvar pain • Unique impact on intimacy • CBT counseling alone improves pain
• 76 women x 12 sessions of group CBT • Reported less coital pain, increased satisfaction, reduced overall Bergeron, Pain 2001, 91(3):297 Ter Kuile, J Sex Marital Ther 2006;32:199 What's Normal for Women? Traditional Model of Sexual ResponseMasters & Johnson/Singer Kaplan as o
s n 2
0
2 0
0 1
"Basson Model" Female Sexuality Motivates the sexually
and Physical
be responsive to
Arousal &
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001
New Sexual Response
• Enhanced intimacy is a strong stimulus for women to seek
partnered sexual activity • Positive sexual experiences motivate women to be sexual again-therefore allowing sexual stimuli to move her from neutral to an aroused sexual state • Spontaneous desire is not a measure of sexual satisfaction
Basson. J Psychosom Obstet Gynecol 2003;24:221-29Bancroft J. Clinics in Obstet Gynecol 1980;7:253-278Seagraves. J Sex Med 2007;4:567-80.
How to Approach Lack of Libido Factors that Predict an Active Sex Life for Women • Overall psychological • Overall physical • A new relationship! Overall Psychological Health • High correlation of desire complaints with: • Low self image • Weak or fragile self- • Mood instability • Tendency toward worry and anxiety Overall Physical Health • Having sex can feel like working out to someone who is not connected to her body • Routine exercise is helpful • Start slowly! Just walking can be beneficial A New Relationship • "Hormone cocktail of romance" • Norepinephrine • Phenethylamine • Evolutionary anthropologists tell us this lasts only a few years at best • This is the psychologically healthy, reasonably fit patient who says, "We love each other. Our
relationship is great, but we hardly ever have sex."
The Effect of Longevity • University of Hamburg surveyed 2500 men and women • In new relationships, women's lust = men's lust
• After 1-4 years in a relationship, women's lust dives
• This drop continues over time, leaving male desire far higher
• Women who don't live with their partners retain desire much
more than women who do • Lesbian women fare no better, and are perhaps worse The Effect of Novelty • Queen's University, Ontario measured vaginal and penile
blood flow of heterosexuals while they watched one-minute
pornographic sex scenes repeatedly
• Breaks in between to allow return to baseline • Both women and men's responses leaped at first
• Men's responses typically stayed more constant while women's plummeted with repetition
• Both spiked again when researchers introduced new clips "Doctor, is there a pill I can take?" • 300 mcg transdermal patch • Several studies showed a small increase in "sexually
satisfying events" over
baseline in PMP women
• FDA rejected in 2004 citing concerns re: off-label use and safety • At least one study showed increased breast cancer rates
with patch, also CV concerns
• NAMS 2005 position statement on T therapy has been retired, currently no official statement
• US Endocrine Society recommended against T therapy in
2006 due to lack of a well defined clinical syndrome and normative data on free and total T levels in women across their lifespan • LibiGel transdermal T gel was rejected by the FDA in 2011
when results were no better than placebo, Phase 3 trials continuing • T dosing remains off-label in the form of cream or gel Testosterone is not the magic bullet What to tell your patient Testosterone is considered experimental & is not commercially available for women in the dose associated with improved sexual outcomes Long-term safety not established Strong placebo effect repeatedly seen Sexual outcomes not correlated with serum androgen levels May be some risk for breast cancer & CVD Trials are ongoing Flibanserin: Politics and Science Flibanserin: Science • 5-HT mixed receptor agonist and antagonist • Increases downstream release of dopamine and • Reduces serotonin • mediates symptoms of reduced sexual interest and desire • FDA unanimously rejected the new drug application in 2009 • Drug increased satisfying sexual episodes by an average of 1.7
per month compared to 1.0 per month by placebo Flibanserin is NOT "The Female Viagra" Flibanserin: Science • Viagra increases blood flow to the penis, Flibanserin works on • Viagra works almost instantly, Flibanserin takes four weeks to be effective and peak results seen at eight weeks • Flibanserin estimated to be effective in 1 in 10 women vs. 1 in 3 that have arousal/desire disorders • Viagra has a very robust response in men, Flibanserin's effect is modest at best in women • SIDE EFFECTS/RISKS: nausea, dizziness, syncopal episodes Flibanserin: Science • The drug manufacturer dealt with dizziness by designing studies with a single nighttime dose • Demonstrated that next-day driving skills were not affected • Most worrisome side effect is syncope (loss of consciousness due to sudden or substantial drop in blood pressure) • Enhanced when drug combined with alcohol, esp in people who do not normally drink, or when patient takes other drugs that utilize the CP450 pathway Flibanserin: Public Relations • Sprout Pharmaceuticals acquired the rights to Flibanserin in • At that point had two unsuccessful FDA hearings • Partnered with Even the Score, a campaign by 24 women's groups that list 26 drugs for men's sexuality, 0 for women • 30 patients brought in by Sprout to testify at a 2-day FDA workshop on patient-focused drug development in female sexual dysfunction • Advocates say that critics minimize the suffering of women • FDA advisory committee members voted 18-to-6 to approve with a risk management plan for patients • Many said it was a difficult choice between that vote and a straight "no" vote but many voices are charging the FDA with gender discrimination • Dr. Adrien Fugh-Berman: "What we have here is a mild aphrodisiac with scary side effects." • Dr. Susan Wood: "I find the gender bias charges not only not persuasive but offensive…We have a product without particularly high efficacy, [that] comes with risks, has to be taken on a daily basis for weeks or months or years, and in my view would be widely marketed off-label, putting women at risk who would see no benefit at all." • Sprout said it would refrain from direct-to-consumer advertising in the first 18 months after approval • Approved Sept 2015 for premenopausal women • Sprout was sold the • No current "to • Provider certification will be required to prescribe "No pill?! Then what?" Monogamy = death of desire? • When you love
someone, how does it feel? • When you desire
someone, how is that different? • Does good intimacy = • Can you desire something you already have? • Esther Perel Mating in • Love wants to know all about you
• Desire needs mystery
• Love wants to shrink the distance between us
• Desire is energized by it
• Intimacy grows through repetition and familiarity
• Eroticism is numbed by repetition and thrives on the
mysterious, the novel, the unexpected • Love is about having
• Desire is about wanting
"In this world there are only two tragedies. One is getting what one wants, the other is not getting it."—Oscar Wilde The key to making midlife sex fun again is wanting what
you have, recognizing the separateness of the other
Moving to a drug without psychotherapy and behavioral intervention is inappropriate Summar Midlife Sex: Summary • Start by treating sources of pain
• Help women understand what is normal for them
• There is no pharmacologic panacea for low libido
• Mental and physical health contribute to a healthy sex life
• The intimacy, companionship, and familiarity of a long term
relationship can stifle desire
• Desire thrives on mini-separateness and novelty
• Long term couples can bring the erotic home through active
engagement and intention
"Passion is for teenagers and foreigners" --Marge Simpson

Source: http://www.oregonpa.org/resources/2015CME/Speaker%20Presentations/Adams%20-%20Making%20Midlife%20Sex%20Fun%20Again%20-%20BW.pdf