#118 Female Sexual Problems with Stacy Lindau MD

October 8, 2018 | By Matthew Watto, MD

Houston, we have a female sexual dysfunction problem. Female sexual problems, which can affect women of all ages, are underdiagnosed and undertreated–in part because clinicians are not the best at asking about sex in primary care visits. In the course of this episode, learn about how to have that sex talk you’ve (maybe) been avoiding, what to ask when working up sexual problems in women, and find the words to talk to patients about sex. Today, we’re lucky to have the female sexual health expert of experts, Dr. Stacy Lindau, MD, MA, Professor of Obstetrics and Gynecology and Medicine-Geriatrics at the University of Chicago Medicine, on the show to teach us the best “sex talk” language, the differential for female sexual problems, and explore therapies. Sadly, there’s no sildenafil-like magic bullet, but a multidisciplinary team can make real impact on female sexual problems. Don’t forget to check out http://womanlab.org .

Credits

Written and produced by: Nora Taranto MS4

Hosts: Leah Witt MD and Matthew Watto MD

Infographic: Leah Witt MD

Editor: Matthew Watto MD

Guest: Stacy Lindau MD

Clinical Pearls

1. The DSM V has specific criteria for defining female sexual problems. The main categories for dysfunction are female sexual interest and arousal disorders, female orgasmic disorders, and female genital pain/penetration disorders.
2. Sexual problems are not a “normal part” of aging. The prevalence of sexual function problems is largely stable across age groups in women. [Lindau et al. N Engl J Med 2007]
3. When a female patient, with comorbidities, brings up a sexual complaint in the midst of a clinic visit, thank her for sharing this information with you. Then ask whether it would be alright to schedule a follow-up appointment (of at least 30 minutes) to take a full biopsychosocial history. It is wise to routinely screen patients via the Review of Systems for sexual problems.
4. While severe mental illness is a risk factor for developing sexual dysfunction, the majority of women with sexual problems DO NOT have psychiatric disorders. We need to be careful, as physicians, to avoid suggesting that the source of the problem is in a woman’s head. Instead, reiterate that the problem is in the vagina, and in atrophy or muscle spasm etc.
5. In taking the history of the sexual problem, always ask about the partner. Most sex occurs between two people. The origin of the problem may very well lie in a problem the partner is facing.
6. If a woman comes to clinic with a partner or family member, make it a matter of routine to request several minutes with just the patient. It is never wise to ask about abuse of any kind in front of her partner. You can say: “I request, as a matter of routine, to have a few minutes alone with all of my patients.”
7. It is important to differentiate between deep pain versus pain around the opening of the vagina. New onset deep pain points more towards an organic pathology that ought to be worked up with thorough gynecologic exam and possibly pelvic ultrasound.
8. Medications that can contribute to sexual dysfunction: systemic antihistamines (they dry out everything…), antidepressants (SSRIs especially can lower libido),  anti-hormonal therapy (which you’ll see most often in patients with cancer)
9. If you are treating a woman for sexual dysfunction, you need to take a look down there. Do an external exam to look at the vulva, do an internal speculum exam to examine the vagina and cervix, and often perform an internal bimanual exam. Do not presumptively treat with topical Estrogen without examining the patient.
10. The best medication available for treatment is local Estrogen therapy, though its efficacy (obviously) depends on the etiology of the problem. Flibanserin is not all it’s cracked up to be.  

In-Depth Show Notes

Definitions

Female Sexual Dysfunction: The DSM V has very specific criteria for defining female sexual dysfunction. The main categories for dysfunction are female sexual interest and arousal disorders, female orgasmic disorders, and female genital pain/penetration disorders. There are a few others, but the main way to break it down is: problems with arousal, problems with orgasm, and problems with pain/penetration. [APA 2013. DSM-V]

A tip from Dr. Lindau: it may be more useful to think about female sexual problems, not dysfunction as defined by the DSM-V. People may come to clinic with problems that don’t meet criteria for an official disorder, and we don’t have to label someone as having a dysfunction in order to understand and help alleviate the problem.

Some fascinating stats about sex and aging:  

Dr. Lindau’s work, examining sexuality in a nationally representative sample over adults 57-85 years old: Approximately half of both male and female respondents reported at least one sexual problem that was bothering them, across age groups. The prevalence is pretty stable Among women, most of these problems arose from low desire (43%), problems with vaginal lubrication (39%), or inability to climax (34%). (Among men, erectile difficulty was most prevalent).  Only 38% of men and 22% of women reported having discussed sex with a physician since the age of 50 years. [Lindau et al. N Engl J Med 2007]

7 Minutes: It’s not enough.   

Time is the enemy of the primary care physician. Especially with complex, chronically ill patients many physicians see in their clinics, the seven minute clinic visit isn’t enough time to manage sexual problems in addition to the Diabetes, Hypertension, and sleep issues (an under-appreciated cause of sexual dysfunction) that are essential to tackle as well.

One framework to consider: First, acknowledge and thank the patient for sharing their concern. Say that difficulties with sexual function are legitimate health problems, which many people experience. Sexual problems are not your age-related destiny. They can be addressed, but it will take time. So ask to schedule a follow-up appointment, where the focus will be the sexual problem specifically. Schedule at least 30 minutes. This will give you the time to take an appropriate biopsychosocial history.

Taking The Biopsychosocial History:   

Bio: A patient’s health conditions, and how well they’re managed.  

Psycho: What psychological, mental health issues and life stressors (divorce, job, etc.) are present in the patient’s life?

Social: What relationship dynamics are at play? Is there a new partner, are things not going well?  

You’ve got to remember to ask about the partner. Most sex occurs between two people. If we focus only on the woman, we may miss the problem that other issues (e.g. erectile dysfunction issues with a male partner or poor sexual communication between partners). Ask about the biopsychosocial aspects, and Age, health conditions of the partner.

You can go through much of the detailed sexual history with the partner in the room.

But It is important, however, to make sure that you have several minutes alone with the patient. You could frame it this way: I request as a matter of routine to have a few minutes alone with the patient without the partner. This needs to be a matter of routine, because it is never wise to ask questions about physical, sexual, or emotional abuse with the partner in the room, and these are essential questions to ask in taking the history.  –Dr. Lindau

How to ask about abuse: Reiterate that these are questions that you ask everyone. You can ask them couched by other questions that are routinely asked–about exercise, body weight, body image–and then ask about any history of physical, emotional, sexual abuse/trauma.  It is also important to ask the following question: Do you have any history of abuse where you were not the victim directly but where you were the witness to abuse? (Witnessing abuse can be as traumatic as being the person abused directly) [Russell et al. Child Abuse & Neglect, 2010]

Questions to ask in the Sexual History:

When’s the last time you had sex? (A lot of patients will have attempted sex recently so that they can explain what’s going on in the appointment). If there is pain on intercourse, is the pain deep or around the opening of the vagina?  (Usually, the pain is superficial. Deep pain is concerning, especially if new onset, and in post-menopausal women. This warrants a thorough gynecologic evaluation and maybe a pelvic ultrasound to rule out an organic problem). Who initiated sex, the last time you had it? Are you still masturbating? (You’ve got to ask. It’s like riding a horse, it gets easier with time). Are you using any soaps or douching? (If so, recommend against).

Are you taking any of the following medications? Medications that could cause or contribute to sexual dysfunction: Systemic antihistamines (every day, can cause vaginal dryness), Antidepressants (SSRIs can cause low libido. But sexual dysfunction and depression are often in tension, you can also have sexual problems if depression isn’t managed appropriately—Dr. Lindau’s expert opinion), Anti-hormonal therapy (patients with cancer, especially on aromatase Inhibitors, which inhibit estrogen synthesis and can cause extreme vaginal atrophy).

Repeat after me (and repeat to the patient): vaginal dryness and painful interourse is not in the patient’s head, it’s physiologically in her vulva and her vagina, or in her bulbocavernosus muscle spasm.  Anxiety, stress, a history of abuse and psychiatric illness CAN cause sexual dysfunction, and there’s a definite role for getting these evaluated and treated. [Van Lankvelt et al. Arch Sex Behav 2000]; [Lutfey et al. Fertil Steril. 2008]

BUT the majority of women who experience painful intercourse or decreased libido have NO history of mental illness or abuse. And yet, so many women think that the problem is in their head, because they’ve been told that.

Labs?

Dr. Lindau’s expert opinion.  No estradiol or testosterone level would change her management, except in tracking a cancer’s natural history. Consider checking a thyroid stimulating hormone and STD testing, including HIV. Overall, most female sexual dysfunction isn’t caused by hormone “levels” and can be treated without extensive labs. Even androgen levels, the most commonly cited hormone labs, aren’t particularly useful. [Dennerstein et al. Maturitas. 1997]; [Davis et al. JAMA. 2005]

Dr. Lindau’s overall philosophy: We need to identify what’s working. How do we leverage those assets to help restore function, and to help you get you back to where we want you to be. Let’s look at your partner and optimize there as well. If we need tests or drugs, we’ll use them, but let’s see if we can get you back to where you want to be without those interventions. There may be people who choose not to come back to see me, but most of my patients would prefer not to have more blood drawn, and not to take more medicines if they don’t need to.

If you’re treating a woman for sexual dysfunction, you need to do a pelvic exam.  

Do not presumptively treat with estrogen in an attempt to avoid doing an external and internal pelvic exam. You need to look “down there.” The exam should focus on signs of skin irritation, atrophy, and dryness. You can treat some of these–dryness, atrophy–with estrogen, or lubricants/moisturizers. And then, you’ve got to do an internal speculum exam to look at the vaginal mucosa. Finish the exam with a bimanual to assess for pelvic masses

All you didn’t know about Pelvic PT:  

The treatment approach to female sexual problems is multi-pronged and multidisciplinary. Some patients should also see a psychologist, a sex/couples therapist, and/or pelvic floor physical therapist (PT).  Physical therapists can obtain specialized training in pelvic floor PT, which uses biofeedback to treat some forms of urinary incontinence and sexual problems.

A classic case in which pelvic floor PT can be extremely useful: high tone pelvic floor dysfunction is a very common cause of sexual function problems. High muscle tone of the levator ani or bulbocavernosus can lead to a decrease in blood flow and nerve strangulation. This initially can present as difficulty with penetration, and later, difficulty with arousal. If we can retrain the bulbocavernosus muscle, this will improve blood flow and oxygenation.  Pelvic floor PT provides manual, biofeedback-based, therapy to treat this condition. Pelvic floor PTs will conduct a history focusing on straddle injuries and injuries to the low back/coccyx, thorough musculoskeletal evaluation, and pelvic exam.

Pharmacologic Management: There is no magic pill.

Flibanserin (the flipside): It received FDA approval a few years ago, for libido improvement among premenopausal women. But the medication has to be taken nightly, and it has some side effects that can be problematic. You cannot drink alcohol while taking it. Insurance hasn’t routinely covered it. The FDA has in place a risk evaluation mitigation strategy that requires training by the physician, the pharmacist, and consent by the patient.

Estrogen: Estrogen can provide significant relief to many patients. Most often used in local formulations, either as a cream in the vulva or vagina, or a tablet/ring. The cream can be used more widely though.

Screening

There is no evidence to support profiling based on age, relationship status, health status, or anything else, in helping decide who to ask about sexual function. Screen all of your patients, with the genitourinary review of systems questions (validated Single Item Screeners on sexual function that can also be used) [Flynn et al. J Gen Intern Med 2015]

Men relay their concerns about sexual function to their doctors more frequently than women do. This may be because sildenafil can provide men with relief from their sexual problems, which most commonly are related to erectile dysfunction. [Lindau et al. N Engl J Med 2007]  

1. In a survey study of 2073 women in military medical clinics in the early 1990s, >98% of surveyed women reported one or more sexual concerns (concerns varied across age ranges). Most women had not had the topic ever brought up by their physicians. [Nusbaum et al. Maturitas 2004]
2. In another population-based, nationally representative sample, only about ⅓ of women with a distressing sexual problem had sought formal care, and 80% of the time, they initiated the discussion about their sexual health, instead of their physician. Only 6% had scheduled the visit specifically for the sexual problem. [Shifren et al. J Womens Health (Larchmt) 2009]

Take home points

1. Don’t profile people. Assume everyone cares about sexual function until proven otherwise.
2. Sexual problems are not “all in a woman’s head”. Avoid suggesting to women that if they’re having a sexual function problem, it’s just in their head.
3. Approach sexual function for women and men in a biopsychosocial manner. Most sex happens with a partner, so it’s important to assess if the issue lies with your patient, the partner, or both. Treatments will be different.
4. Talking about sex is not comfortable for everyone. Practice your “sex talk” so that it is comfortable for you. Patients will follow your lead. If you can ask questions in a nonjudgmental manner, people will be honest. And if you initiate these conversations, even when patients aren’t complaining of sexual problems, then patients will know that you are the kind of doctor they can come to if they do eventually have a problem.
5. Refer your patients, colleagues, friends, and even family to the Woman Lab Website: a resource that Dr. Lindau’s lab has been putting together the last two years to disseminate everything they know about women, sex, dysfunction, and disease: http://womanlab.org/

Picks of the week

1. Leah: Womanlab.org, and the Aspen Ideas Episode about the Bulbocavernosus Muscle featuring Dr Lindau
2. Stacy: Invisible Man (book) by Ralph Ellison; Letter from Birmingham Jail by Martin Luther King Junior; Mountains Beyond Mountains (book) by Paul Farmer

Goals and Learning Objectives

Goal

Listeners will define, classify, and diagnose female sexual dysfunction and develop a practical approach nonpharmacologic and pharmacologic management of this condition.

Learning objectives

After listening to this episode listeners will…

1. Define, classify and diagnose female sexual dysfunction
2. Identify risk factors for female sexual dysfunction (e.g. medications, comorbidities, etc.)
3. Counsel patients and set expectations after a diagnosis of female sexual dysfunction
4. Utilize nonpharmacologic therapy for female sexual dysfunction
5. Counsel patients about potential side effects and limitations with currently available pharmacologic therapy for female sexual dysfunction
6. Comprehend the controversy behind the approval of flibanserin
7. List available resources to for women with female sexual dysfunction
8. Recognize which patients with female sexual dysfunction need a referral and where to refer them

Disclosures

Dr Lindau reports no relevant financial disclosures. The Curbsiders report not relevant financial disclosures.

Time Stamps

• 00:00 Disclaimer
• 00:35 Intro and guest bio
• 03:30 Guest one liner, book recommendations, favorite failure, career advice and picks of the week
• 12:57 Clinical Case of female sexual dysfunction and some definitions
• 15:08 Are sexual problems a normal part of aging?; How to take a sexual history; Etiology of sexual dysfunction; “Diagnostic sex”; Red flags
• 27:54 Medications that contribute to sexual dysfunction
• 31:00 Labs
• 34:45 Treatment: pelvic PT, medications, counseling, flibanserin, herbal supplements
• 49:05 Screening for female sexual problems
• 51:58 Take home points; WomanLab.org
• 55:19 Outro

Links

Links from the show are included in the text above.

Extra Credit Reading!

1. A manifesto on the preservation of sexual function in women and girls with cancer
2. Female Sexual Dysfunction: Focus on Low Desire
3. A Study of Sexuality and Health among Older Adults in the United States
4. Hypoactive Sexual Desire Disorder: International Society for the Study of Women’s Sexual Health (ISSWSH) Expert Consensus Panel Review.
5. Flibanserin Ineffective for Hypoactive Sexual Desire Disorder in Women.
6. Efficacy and Safety of Flibanserin in Women with Hypoactive Sexual Desire Disorder: A Systematic Review and Meta-Analysis.
7. Efficacy and Safety of Flibanserin for the Treatment of Hypoactive Sexual Desire Disorder in Women: A Systematic Review and Meta-analysis.