Sexual Health Matters: Management of Female Sexual Dysfunction

Case History

A 54-year-old female presents with concerns about her sexual function. She went through natural menopause 2 years ago. She is happily married, and is in a monogamous relationship. She has no medical problems and is not on any medications. She reports a significant decline in her libido in the past year and is unable to have orgasms. She also reports vaginal dryness and mild dyspareunia, but denies any vaginal irritation or discharge. How would you treat her symptoms?

Female sexual dysfunction (FSD) is common but frequently underdiagnosed. ¹ In one survey, 94% of the patients surveyed reported that sexual enjoyment is important for their quality of life. In general, 43% of women and 31% of men in the United States experience sexual problems during their life time. Women are more likely than men at all ages to report sexual dysfunction. ² Left untreated, sexual problems are associated with decreased quality of life, depression, and interpersonal conflicts. ¹ The assessment of FSD should begin with a comprehensive history looking for medical, psychological, and emotional factors that might be contributing. Interpersonal relationship issues along with sociocultural factors should be assessed. ^1,3 Detailed sexual history taking is key to evaluating FSD and should be accomplished in a culturally sensitive, nonjudgmental manner, considering the patient's background and lifestyle. ⁴ Several validated questionnaires that address all domains of sexual function (desire, arousal, orgasm, and pain) are available to physicians. ^5,6 A thorough physical examination with particular attention to vulvovaginal conditions and an assessment of the pelvic floor provide important clinical information. Laboratory testing to assess hormone levels is generally not required, as low estrogen or low testosterone levels do not correlate with low libido. ^7,8

There are a few basic principles in managing FSD:

1. There are age-related changes in sexual function, and sexual activity declines with age, but sexual enjoyment and intimacy continue to be important at all ages. It is important to assess patients' goals and to set realistic expectations.

Genitourinary syndrome of menopause (GSM), previously termed vulvovaginal atrophy, is a common, chronic, often progressive condition experienced by more than 50% of postmenopausal women that leads to vaginal and urinary symptoms. ⁹ Unlike vasomotor symptoms, vaginal symptoms such as dryness, burning, and dyspareunia frequently worsen over time. Women who experience pain with every sexual encounter may develop a lack of interest in sexual activity. ⁹ Urinary symptoms of GSM include frequency, dysuria, urgency, and recurrent urinary tract infections. ^10,11 Genitourinary symptoms are associated with significant impairment of a woman's enjoyment of sex and her sexual relationship. ^10,12 Treatment of vaginal dryness related to hormone deficiency relieves dyspareunia, leading to improvements in sexual interest, arousal, and response. The use of vaginal moisturizers on a regular basis, several times per week, along with lubricants as needed for sexual activity is the initial step in managing symptoms related to GSM. ¹⁰ Women can choose from a number of commercially available lubricants that are either water based, mineral or plant oil based, or silicone based. Because lubricants differ in their pH, osmolality, and the presence of preservatives, familiarity with products is helpful in providing counseling and guidance to patients. ¹³

Other Treatment Options for GSM

Low dose vaginal estrogen therapy (available in cream, ring, or vaginal tablet) should be considered for women who do not respond to nonhormonal interventions in the absence of contraindications (e.g., a hormonally responsive cancer). Treatment with low dose vaginal estrogen therapy improves symptoms of vaginal dryness, dyspareunia, urinary frequency, and urgency, and prevents recurrent urinary tract infections. ¹² Despite the proven benefits and tolerability of low dose vaginal estrogen therapy, only 7% of women with symptomatic GSM receive prescription therapy. ⁹ In a recent committee opinion in March 2016, American College of Gynecologists (ACOG) encourages providers to consider low dose vaginal estrogen therapy, even for women who have been diagnosed with an estrogen-dependent cancer, if they fail nonpharmacological measures. The data do not show an increased risk for cancer recurrence in women with a prior or current history of estrogen-dependent cancer who use low dose vaginal estrogen therapy. Women should make an informed decision in consultation with their oncologist.

Ospemifene is a Selective Estrogen Receptor Modulator (SERM) and an estrogen agonist in the vagina. It is FDA approved for treatment of GSM in postmenopausal women, and improves the vaginal maturation index, pH, and symptoms of dryness. ¹¹ It is ideal for women who prefer not to use a vaginal preparation to treat their symptoms. The most common adverse effect is hot flashes.

Yttrium Aluminum Garnet (YAG), vaginal erbium laser, and, recently, fractional CO₂ laser treatments have been studied for the treatment of GSM. ¹⁴ Treatment with the fractional CO₂ laser usually consists of three sessions that are 6 weeks apart. Small studies have shown improvements in dyspareunia and all domains of sexual function in the Female Sexual Function Index. Studies regarding long-term safety and efficacy are lacking. ¹⁵

Pelvic floor muscle dysfunction may exacerbate dyspareunia related to GSM. Multimodal pelvic floor physical therapy including manual therapies, patient education, and sometime dilator therapy is highly effective. ^3,16

Testosterone Therapy for FSD

Currently, testosterone therapy is not FDA approved for use in women, but it is still widely used off-label for the treatment of FSD. Topical testosterone is associated with significant improvements in desire, arousal, orgasmic response, and satisfying sexual experiences in postmenopausal women, with or without concomitant estrogen therapy. ¹⁷ The Endocrine Society recommends a trial of testosterone therapy for 3–6 months in carefully selected postmenopausal women with properly diagnosed hypoactive sexual desire disorder (HSDD), with discontinuation if there is no therapeutic benefit after 3–6 months. ¹⁸ Common side effects are hirsutism and acne, which resolve upon discontinuation of therapy. However, clitoromegaly and voice changes may be irreversible. ¹⁹ Patients on testosterone therapy should have a periodic clinical and laboratory evaluation for hyperandrogenism. Testosterone levels should be measured at baseline and 3–6 weeks after initiating therapy, then every 6 months if therapy is continued. ¹⁸ Although studies have established the short-term safety of testosterone in women up to 24 months, long-term safety data are lacking. ^7,19,20

Flibanserin is a new FDA-approved medication for treatment of HSDD in premenopausal women. It is a 5-HT1A agonist and 5-HT2A antagonist. Women who are healthy with no medical, psychological, or relational issues that are contributing to FSD may be candidates for this medication. The use of flibanserin with alcohol increases the risk of hypotension and syncope. Before prescribing flibanserin, the patient's ability to abstain from alcohol should be assessed. ²¹ If there is no benefit after 8 weeks, flibanserin should be discontinued.

Answer: D

Answers A, B, and C are incorrect as nonpharmacological measures should be tried and maximized before providing prescription therapy for FSD. Given the patient's symptoms, the next step would be to add low dose vaginal estrogen if she failed to respond to nonpharmacological treatments.