Sexual Function Across Life Cycle In Women

Sex Across the Lifecycle: Constants, Changes, and Problems Anita H. Clayton, M.D. Professor and Vice Chair Department of Psychiatric Medicine University of Virginia Health System

What’s it all about anyhow?  

 

Psychological/Social/Emotional Physiological/biological: interactions of sex steroids and neurotransmitters Cognitive: thoughts, fantasies, satisfaction Cultural

APA, DSM IV, 1994

Phases of the Sexual Response Cycle     

Desire Arousal Orgasm Resolution Other areas to consider  satisfaction  pain

APA, DSM-IV 1994

Central Effects on Sexual Function estrogen (permissive) +

+

testosterone (initiation)

+

5-HT progesterone (receptivity)

+

+

Dopamine (DA)

-

DESIRE

+

5-HT

prolactin

oxytocin

-

+

SUBJECTIVE EXCITEMENT

+

Norepinephrine (NE)

ORGASM

Modified from Clayton AH. Psychiatric Clinics of North America 2003; 26:673-682

Peripheral Effects on Sexual Function gonads adrenals

• • •

}

Estrogen Testosterone Progestin

5-HT

-

maintain genital structure and function

Nitric Oxide (NO)

+ -

Clitoral and penile tissue SENSATION

5-HT

VASOCONGESTION

?

NPY Substance P

5-HT2A

+

+

Clayton AH. Psychiatric Clinics of North America 2003; 26:673-682

+ + +

NE VIP

Prostaglandin E Cholinergic fibers

Changes Over the Life Cycle     

Puberty Reproductive years Pregnancy and the postpartum period Perimenopausal period Postmenopausal years

Puberty 

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1

Development of regular menstrual cycles (monthly fluctuations in estrogen, progesterone, and testosterone) Rise in testosterone linked to increasing sexual desire, perhaps mediated by social variables1 Sexual self image as a “woman” Recognition of body image

Halpern, Udry & Suchindran, 1997

Reproductive Years   



Regular sexual activity regulates menstrual cycles and reduces anovulatory cycles1 Fear of or desire for pregnancy, and infertility affect sexual experience Triphasic oral contraceptives are associated with more sexual thoughts, fantasies, and sexual interest than monophasic oral contraceptives2 Premenstrual symptoms diminish desire, frequency of sexual activity, ability to achieve orgasm, and satisfaction with orgasm in the late luteal phase3

Cutler, Garcia & Krieger 1979; Cutler, Perth, Huggins, Erickson & Garcia 1985; 2 McCoy & Matyas 1996; 3Clayton, Clavet, McGarvey Warnock, & Weihs 1999 1

Pregnancy and the Postpartum Period 

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

Pregnancy may be associated with dramatic changes in desire, pain on intercourse, or decreased ability to achieve orgasm1 Restoration of sexual functioning following delivery parallels restoration of hormonal cycling (delayed with breastfeeding),2 but this is a common period for the onset of HSDD Possible change in body image (“shape” of pregnancy, full expression of being a woman, weight gain, etc.)

Oruc, Esen, Lacin, Adiguzel, Uyar, Koyuncu 1999; 2Glazener 1998; Visness & Kennedy 1996 1

Perimenopausal Period  



Dramatic fluctuations in sex hormones “Change of life” with physical symptoms, freedom from constraints (children leaving home, no longer fertile, etc.), change in body/self image1 Low levels of estrogen and testosterone may lead to decreased libido2, dyspareunia associated with vaginal dryness1, diminished sexual response, etc.

Kingsberg 1998; 2Chiechi, Granieri, Lobascio, Ferrer, Loizzi 1997

1

Postmenopausal Years 



1

Aging: general health decline, medication use including hormone replacement therapy, illnessrelated factors1 Relationship/partner factors: emotional, physical changes in partner

Meston 1997

Factors with Potential Sustained Effects   

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Partner availability/Issues with self stimulation Fear of sexually-transmitted diseases History of childhood sexual abuse, or history of sexual assault Cultural practices ie. female circumcision

Problems in Sexual Functioning 

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

43% of 1749 US women reported sexual dysfunction in the 1992 National Health and Social life Survey (NHSLS) Younger women complain of low sexual desire, and difficulty achieving orgasm Sexual problems decrease as we age, except for diminished lubrication, and unmarried women have 1.5 the rate of problems seen in married women

Laumann, Paik, Rosen 1999

Cultural Differences in Sexual Functioning 

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Hispanic women report the lowest rates of sexual problems African-American women report lower sexual desire and satisfaction White women describe more sexual pain

Laumann, Paik, Rosen 1999

More Problems in Sexual Functioning 

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1

Negative effects on sexual functioning1  Declining social status (ie. divorce)  History of sexual trauma  Lower education attainment Marital difficulties are associated with:2  arousal, orgasmic, and enjoyment difficulties  anxiety and depression Poor physical health is correlated with sexual pain1

Laumann, Paik, Rosen 1999; 2Dunn, Croft, Hackett 1999

Primary Sexual Disorders  

   

Disorder = dysfunction + distress Desire:  Hypoactive sexual desire disorder (HSDD)  Sexual aversion disorder Female sexual arousal disorder (FSAD) Female orgasmic disorder Pain disorders: dyspareunia, vaginismus Subtypes:  May be due to psychological factors, general medical conditions, be substance-induced, or a combination  Context: generalized or situational type  Onset: lifelong or acquired

APA, DSM-IV 1994

Known Causes of Sexual Dysfunction 

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Psychosocial/situational factors: interpersonal relationships, body image, sexual self-esteem, prior psychosexual adjustment Medical conditions: endocrine, psychiatric, cardiovascular, neurological, genitourinary Substance-induced: medications, alcohol, drugs of abuse Combination of factors

Desire 



Sexual desire includes:  Physiologic  Cognitive  Behavioral components manifested by:  sexual thoughts and fantasies  interest in participation in sexual activity  initiation of sexual activity  receptivity to partner approach

Kornstein & Clayton (eds.), 2002

Influences on Libido 

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Reproductive endocrinology (ie. anything that lowers testosterone such as hyperprolactinemia, opiates, menopause) Body image (ie. obesity) General health status/illness (ie. fatigue) Medication/substance use Psychological/relationship issues Fears (ie. pregnancy, infertility, STD, history of sexual abuse, cultural practices)

Reproductive-Related Periods of Low Libido  

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Pre-puberty Late luteal phase in women with premenstrual symptoms1 Monophasic oral contraceptive users2 Pregnancy3 Postpartum4 Perimenopause Menopause5

Clayton, Clavet, McGarvey, Warnock, Weihs 1999; 2McCoy & Matyas 1996; 3 Oruc, Esen, Lacin, Adiguzel, Uyar, Koyumcu 1999; 4Glazener 1998; Visness & Kennedy 1997; 5Chiechi, Granieri, Lobascio, Ferrer, Loizzi 1997 1

Biology of Libido 

Physiologic 

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Primary sex steroid is testosterone: progesterone may influence sexual receptivity1 Neurotransmitters: dopamine and serotonin

Chronobiology 

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Estrogen plus androgen replacement enhances desire in postmenopausal women2 Testosterone levels in premenopausal women inconclusively linked to desire,3 but higher testosterone levels linked to increased response to bupropion SR in SSRI-induced SD4 Supplemental testosterone cypionate injections (100 mg/month IM) improved sexual desire to normal levels despite no difference in testosterone levels at baseline between women with HSD and aged-matched women without sexual complaints5

Frye, Rhodes, Walf, Petralia 2001; 2Sherwin 1991; 3Persky et al. 1978; Udy et al. 1986; 4 Clayton, McGarvey, Warnock, Kornstein 2001; 5van Anders SM, Chernick AB, Chernick BA, et al 2005. 1

Arousal 

Phase of sexual excitement manifested by pelvic vasocongestion, vaginal lubrication, and swelling of the external genitalia

Physiology of Arousal 

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1

Hormones  Estrogen  Vasoactive intestinal peptide (VIP) may mediate autonomic effects on pelvic blood flow1 Neurotransmitters:  Central dopamine stimulation2  Modulation of cholinergic-adrenergic balance2  Alpha-1 adrenergic agonism2  Presence of nitric oxide3

Levin 1992; 2Segraves 1989; 3Burnett, Lowenstein, Bredt, Chang, Snyder 1992

Orgasm 

Process of physiologic release of sexual tension, associated with rhythmic contractions of perineal and reproductive organ structures with cardiovascular and respiratory changes

Physiologic Mechanism of Orgasm 



1

Hormones:  Estrogen  Oxytocin1 Unclear neurotransmitters involved: Can disrupt orgasm with stimulation of 5-HT2 receptors1, or with alpha-adrenergic antagonism2

Watson & Gorzalka 1992; 2Segraves 1989

Etiology of Sexual Dysfunction Medical  Primary (eg. HSDD)  Secondary: psychiatric, neurological, endocrine, genitourinary  Situational/Psychosocial  Substance-induced: psychotropics, nonpsychotropics, drugs of abuse 

Medical Conditions & Sexual Dysfunction      

Neurological illness Endocrine disorders Genitourinary conditions Infectious processes Cardiovascular disease Autoimmune disorders

Secondary Sexual Disorders: Psychiatric   

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70% of patients with MDD report diminished libido1 41% of women with hypomania experienced increased sexual intensity2 Decreased sexual interest seen in women with eating disorders3, and women with histrionic personality disorder4 60% of women with schizophrenia report never experiencing an orgasm vs. 13% of normal volunteers5

Casper, Redmond, Katz, Schaffer, Davis, Koslow 1985; 2Goodwin & Jamison 1990; 3Morgan, Wiederman, Pryor 1995; 4Apt & Hurlbert 1994; 5Friedman & Harrison 1984 1

Antidepressant Effects on Sexual Functioning 

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Diminished desire and/or function  SSRIs1  Venlafaxine1  TCAs2  MAOIs2 Few negative effects on desire or function  Bupropion-SR1  Mirtazapine3  Nefazodone1  Selegiline transdermal system4

Clayton, Leadbetter, Bass, Bolden-Watson, Donahue, Jamerson, Metz, DeVeaughGeiss 2000; 2Segraves 1992; 3Boyarsky, Haque, Rouleu, Hirschfeld 1999; 4Clayton, Campbell, Favit, et al. 2007 1

Assessment of Sexual Dysfunction     

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Sexual history Assessment of current level of sexual functioning Documentation of medical and psychiatric history/diagnosis Identification of substances with effects on sexual functioning Endocrine measures as indicated: free and total testosterone, sex hormone binding globulin, TFTs, Hgb A1C , prolactin, estradiol, FSH, and LH levels, lipid profile Neurological and/or genitourinary exam

Treatment of Primary Sexual Dysfunctions   

Psychotherapy, especially with history of negative sexual experiences Use of erotica in sex therapy1 Insure adequate levels of sex hormones ie. low libido  In postmenopausal women, with adequate estrogen replacement, if free testosterone < 2.0 pg/ml, consider testosterone supplementation to physiologic androgen levels2  Oral micronized methyl-T (0.25 mg, 0.50 mg, or 0.75 mg tablets) compounded  Soon to be available, testosterone gel and/or patch

Striar & Bartlik 1999; 2Warnock 2001

1

Treatment of Sexual Disorders 

Hypoactive Sexual Desire Disorder1 

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66 women with HSDD were randomized to bupropion SR (n=31) or placebo (n=35) for 3 months Receptivity to partner initiation was significantly greater with bupropion SR; CSFQ desire scores were also greater Bupropion SR also significantly increased measures of sexual arousal, orgasm/completion, and sexual satisfaction as measured by the CSFQ1

Testosterone levels in the upper half of the normal range may enhance response to bupropion2 For FSAD, consider sildenafil3 +/- hormones (estrogen or SERMs) in peri- and postmenopausal women

Segraves, Clayton, Croft, Wolf, Warnock 2004; 2Clayton, McGarvey, Warnock, Kornstein 2001; 3Warnock 2001 1

Conclusions Multiple factors may affect sexual functioning in women across the life cycle  Appropriate assessment is important to direct treatment  Some recent successes in the management of sexual dysfunction in the context of physiologic, psychosocial, cognitive, and cultural factors 