Sexual Health: Why It's Important and How to Help Patients Struggling with It

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Introduction

This document presents an insightful discussion led by Dr. Ashley Fuller, a board-certified gynaecologist specialising in sexual health, menopause, and complex vulvovaginal diseases. It highlights the critical importance of addressing female sexual health concerns, revealing that many women struggle with these issues but often feel uncomfortable discussing them.

The presentation delves into understanding conditions such as Hypoactive Sexual Desire Disorder (HSDD) and various forms of sexual pain, including genitourinary syndrome of menopause (GSM) and vulvodynia. Dr. Fuller offers a comprehensive approach to diagnosis and treatment, covering biopsychosocial factors, the role of sex therapy, and pharmacological interventions like FDA-approved medications (e.g., flibanserin, bremelanotide) and off-label testosterone therapy. The material also provides practical advice on patient communication, examination techniques, and resources for both patients and healthcare providers.

Sexual Health and its Importance

Dr. Fuller transitioned her practice focus to sexual health about five years ago, recognizing a substantial gap in patient care where women struggled with sex-related issues but often did not know who in healthcare would listen or help them. She found that general gynecology appointments lacked the time and specific knowledge required to adequately address these concerns. Sexual health is an important part of overall health, and patients are often eager to discuss it when invited by their doctor. If healthcare providers do not initiate these conversations, patients may turn to unreliable sources like social media or websites like goop.com, leading to misinformation.

A large population study in 2008 involving over 10,000 women aged 18 to over 80 revealed that 44% reported some sexual dysfunction, and 12% experienced sexual problems with associated distress (e.g., discomfort, guilt, embarrassment, anxiety). This indicates that at least one or two out of every ten annual patients likely have a distressing sexual problem. Sexual problems are common across age groups, with desire issues peaking in women in their 30s, 40s, and 50s.

Approaching the Topic of Sex with Patients Dr. Fuller recommends that healthcare providers proactively ask patients about their sex lives. Key strategies include:

• Using simple, direct, and compassionate language.
• Normalizing the conversation by explaining that many women face similar issues, such as postmenopausal sexual pain.
• Showing a lack of embarrassment and reassuring patients that they can discuss anything.
• Being aware of cultural backgrounds and ensuring confidentiality.
• Avoiding judgment or assumptions.
• Dr. Fuller suggests asking, "Are you having sex? Who do you have sex with?" as this open-ended question can encourage patients to share more about their sexual relationships, including multiple partners or polyamorous relationships. If a patient is in a sexual relationship, providers can ask about any concerns; if not, concerns related to not being in a sexual relationship can still be explored.

Hypoactive Sexual Desire Disorder (HSDD) is defined as a lack of motivation for sexual activity (reduced or absent spontaneous or responsive desire) or active avoidance of sexual activity for at least six months, combined with clinically significant personal distress (e.g., frustration, grief, loss, sadness). It is crucial that this distress is not due to an underlying medical issue like sexual pain. If patients are not bothered by a lack of sexual activity, it is not considered HSDD.

Female Sexual Response Models:

• The circular model, proposed by Rosemary Basson in 2001, challenges the traditional linear model (desire-arousal-orgasm). It suggests that women can enter sexual intimacy at various points, not necessarily requiring initial desire.
• Responsive desire is common in long-term relationships, where a woman might not spontaneously think about sex but can become aroused and enjoy it once initiated. This is likened to going to the gym: not wanting to go but enjoying the workout once started.
• The dual control model describes a sexual control center in the brain with both excitatory signals (accelerator, e.g., dopamine, oxytocin) and inhibitory signals (brake, e.g., serotonin, opioids). A book called "Come as you are" provides worksheets to help patients understand and influence these.

Factors Contributing to Low Desire: Sexual response is highly complex, influenced by a biopsychosocial model involving:

• Biology: Hormones, physical health.
• Psychology: Mood, stress, body image, relationship satisfaction.
• Interpersonal/Sociocultural factors: Relationship dynamics, fatigue, societal expectations, trauma history.
• Stress and fatigue are significant contributors, particularly for women in their 30s, 40s, and early 50s balancing careers, young children, and aging parents. These women often choose sleep over sex due to exhaustion.
• Medical conditions (e.g., depression, pain, other sexual issues), medications (e.g., SSRIs), hormonal changes (postpartum, menopause), and partner sexual problems can also play a role.
• Often, patients presenting with low libido have underlying issues like sexual pain, which must be addressed first.

Management of HSDD

The International Society for the Study of Women's Sexual Health (ISSWSH) provides a process of care management for HSDD. After obtaining permission and conducting a sexual history or screener (e.g., asking about desire satisfaction, decrease, distress, and desire for increase), the focus is on identifying and addressing biopsychosocial factors.

Education and Counselling:

• Educating patients about responsive desire and the accelerator/brake model is crucial.
• Sex therapy is always a good idea, though often expensive and difficult to access. Techniques like sensate focus can help couples rekindle intimacy by progressively reintroducing touch without immediate pressure for intercourse.
• Addressing trauma histories and referring to therapy is important.
• Pelvic floor physical therapy (PT) is highly recommended for patients with pelvic floor dysfunction.

Biological Approaches and Medications:

• Testosterone: Although not FDA-approved for women, it shows promising efficacy, with studies showing a two-fold increase in satisfying sexual episodes and improvements in desire, arousal, orgasm, pleasure, and self-image.
  • ISSWSH guidelines (2021) recommend:
    • Not using testosterone levels to diagnose HSDD; levels are only checked before starting treatment to assess candidacy and monitor.
    • Using men's FDA-approved testosterone formulations (e.g., Testim gel, 1/10th of a man's dose daily) due to consistent dosing, avoiding compounded or oral formulations, pellets, or injections, which can lead to unsafe super physiologic levels.
    • Targeting normal female range (e.g., 60 ng/dL or less).
    • Monitoring levels 4-6 weeks after initiation and then every six months.
    • It is generally effective for low libido but lacks strong data for fatigue or muscle mass.
    • While data is primarily for postmenopausal women, premenopausal and perimenopausal women may also benefit. Dr. Fuller does not monitor endometrial lining in patients on testosterone alone, especially if levels remain in the normal female range, as significant conversion to estrogen is unlikely. However, she generally does not prescribe testosterone alone if a patient is not a candidate for estrogen due to this conversion. Clitoromegaly can be an irreversible side effect of super physiologic testosterone levels.
• Flibanserin (Addyi): FDA-approved in 2015 for premenopausal HSDD.
  • A mixed serotonin agonist/antagonist that increases sexual desire.
  • Taken as 100 mg at night.
  • Initially had an alcohol warning, now recommends no more than two alcoholic beverages within two hours of taking.
  • Side effects include sleepiness, dizziness, and nausea.
  • Data shows a half to one increase in satisfying sexual events per month, an increase in daily desire, and a decrease in distress.
  • Its approval process was lengthy and rigorous compared to Viagra.
• Bremelanotide (Vyleesi): FDA-approved in 2019 for HSDD.
  • A first-in-class melanocortin receptor antagonist.
  • Administered as a subcutaneous injection 45 minutes before anticipated sexual activity.
  • Common side effect is nausea, especially for the first few doses, often requiring anti-nausea medication (e.g., Zofran).
  • Data shows an increase in satisfying sexual encounters.
  • Some patients prefer this on-demand medication over a daily pill.
• Neither Flibanserin nor Bremelanotide are easily covered by insurance, but companies offer patient assistance programs.
• Estrogen: Systemic estrogen does not directly fix libido but can improve overall well-being and help with symptoms like sexual pain, which can indirectly improve libido.

Sexual Pain (Dyspareunia) Sexual pain is a significant issue, often more prevalent than low libido in Dr. Fuller's practice, and it profoundly impacts relationships and self-confidence.

Psychological Aspects of Pain:

• Pain experiences can lead to a catastrophizing path. When sex becomes painful, the brain instinctively causes the pelvic floor to tense up, exacerbating the pain. This can lead to fear, anxiety, and a "cloud" over libido, making even thoughts of masturbation difficult as the brain tries to protect the individual from pain.

Genitourinary Syndrome of Menopause (GSM):

• Formerly known as vulvovaginal atrophy, GSM affects 50-60% or more of postmenopausal patients.
• Unlike early menopausal symptoms (e.g., hot flushes), GSM is progressive and worsens over time.
• Symptoms include dryness, itching, burning, changes in tissue, recurrent UTIs, and dyspareunia (painful intercourse). Dyspareunia often starts a few years before the last menstrual period and increases significantly post menopause.
• Early intervention is crucial, as prolonged periods of no penetration (e.g., two years) make treatment more challenging and prolonged.

Treatments for GSM:

• Lubricants and Moisturizers:
  • Lubricants reduce friction during sex. Water-based can be absorbed and become sticky; silicone-based and oil-based are often preferred.
  • Moisturizers (e.g., Replens, Revaree, hyaluronic acid-based) are used regularly to hydrate tissue.
• Dilators:
  • Help stretch tissues that have become less elastic due to lack of use or estrogen deficiency. Silicone dilators (e.g., Soul Source) are often preferred over hard plastic.
  • They also aid in retraining the brain to reduce tension and pain, re-establishing a mind-body connection. Patients are encouraged to use them regularly, even in the shower, to make it part of their routine.
• Vaginal Estrogen:
  • Crucial for restoring tissue health, especially the vestibule (the area at the vaginal opening), which has many estrogen receptors and is often the site of pain.
  • Products like Estradiol 10 microgram gel cap (Imvexxy) or Estradiol vaginal cream are effective when applied directly to the vestibule. Dr. Fuller advises patients to use a finger to apply cream directly to the opening, not just deep inside the vagina.
• Other Medications:
  • Ospemifene: An oral SERM (Selective Estrogen Receptor Modulator) that increases estrogen receptors in the vagina without affecting the uterus.
  • DHEA (Intrarosa): A nightly vaginal insert that converts to estrogen and testosterone within vaginal cells; thought to be localized and non-systemic.
• CO2 Laser: Conflicting data on its efficacy; some patients report benefit, but it is not universally recommended.

Vulvodynia:

• Defined as chronic vulvar pain or discomfort lasting at least three months without an identifiable cause, where the vulva appears normal on examination.
• Classified by location (localized, generalized, mixed), whether it's provoked or spontaneous, onset (primary/congenital vs. secondary/acquired), and timing.
• Localized provoked vestibulodynia (LPV) is the most common form of sexual pain, affecting 10-15% of premenopausal women. It is localized to the vestibule and occurs only with touch or pressure.
  • Two common presentations: patients who have never had penetrative sex or used tampons without pain, or those who developed it after an inflammatory insult (e.g., recurring infections, allergic reaction). It is often associated with hormonal birth control.
  • Underlying theories include congenital extra nerve endings or an upregulated inflammatory response.
• Clinical Examination for Dyspareunia: Involves a thorough vulvar exam, assessment of clitoral hood mobility, and a Q-tip test on the vestibule to map pain points. A small speculum or finger exam is used carefully to avoid adding to trauma.

Treatments for Vulvodynia/LPV:

• Topical Neuromodulators: Dr. Fuller often starts with topical gabapentin (6% in a white petroleum base), which she finds helpful for about 50% of patients, despite mixed data, due to minimal systemic side effects. Other topical mixtures with amitriptyline may also be used.
• Pelvic Floor PT.
• Topical Estrogen and Testosterone: Can be helpful for some.
• Therapy: Especially for patients with trauma histories.
• Vestibulectomy: Surgical removal of the vestibule for severe cases.
• Management is often complex and requires a multi-layered approach.

Clitoral Adhesions:

• Often overlooked during routine exams, Dr. Fuller stresses the importance of a thorough clitoral examination.
• Adhesions occur when the clitoral hood sticks to the clitoris, causing a buildup of dead skin cells and keratin pearls.
• They can affect sensation, orgasm, and cause clitoral pain.
• Clitoral adhesion takedown is a simple in-office procedure using topical numbing medicine and a narrow instrument to gently open the adhesions and remove keratin pearls.
• Patients often tolerate this well and report improvements in pain, ability to orgasm, arousal, and sexual satisfaction.
• However, recurrence is common, ranging from quickly to within a year or two, but many patients find the procedure so beneficial they are willing to repeat it.

Conclusion

Dr. Fuller's overarching message is the crucial need for healthcare providers to engage in conversations about sexual health with their patients. Even if time is limited, simply asking opens the door for patients to express concerns they often feel too embarrassed or uncertain to bring up themselves. Examining the vulva and clitoris thoroughly is also essential for comprehensive care.

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