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41 Cards in this Set
- Front
- Back
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What are normal initial female sexual physiological responses?
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1) Vaginal lubrication w/ transudate from vaginal walls 2/2 vasoconstriction
2) Expansion of upper 2/3 of vaginal walls 3) Cervix and uterus elevate 4) Clitoris and labia enlarge 5) Breast size increases & nipples become erect |
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What are physiological changes seen in the female "orgasmic platform"?
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1) Lower 3rd of vagina vasoconstricts
2) Vaginal lubrication slows 3) The shaft and glans of clitoris contracts 4) Sex flush along chest wall and back (50-75% of women) |
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What is prevalence of female sexual dysfunction?
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10-63%
Average is 41% |
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What factors are associated with increased risk for sexual dysfunction?
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Low income
Lower educational level Unmarried Prior h/o emotional or psychological stressors |
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What are main types of disorders seen in female sexual dysfunction?
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1) Sexual desire disorders
2) Sexual arousal disorders 3) Orgasmic disorders 4) Sexual pain disorders |
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What are subtypes of disorders seen in female sexual dysfunction?
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1) Lifelong vs acquired
2) Generalized vs situational 3) Specific etiologies |
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What are types of sexual desire disorders?
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1) Hypoactive: deficiency of sexual thoughts &/or desire for or receptivity to sexual activity
2) Sexual aversion: phobia w/ avoidance of sexual activity + severe anxiety associated w/ thinking about sexual activity These pts have normal physiological sexual response |
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What is sexual arousal disorder?
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Can't generate or keep sufficient sexual excitement (anatomical and physiological).
Decreased vasoconstriction Lack of lubrication Subjective diminution of excitement Examples: pts w/ pelvic floor dysfunction + incontinence |
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What is orgasmic disorder?
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Absence of or difficulty attaining orgasm despite sufficient sexual stimulation & arousal
Can be primary or situational |
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What are types of sexual pain disorders? (2)
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1) Dyspareunia: genital pain associated w/ intercourse. Often a/w vaginal atrophy, dryness, pelvic adhesions, endometriosis, myomas, vaginitis, vulvitis, & vestibulitis. Can also be impacted by prior abuse, lack of enough stimulation time, & cultural perceptions about female sexuality
2) Vaginismus: Pt w/ normal physiologic sexual response but can't psychologically engage in penetration. Muscles of lwr 1/3 of vagina + introitus constrict. May be 2/2 h/o sexual trauma or abuse |
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What are the etiologies of sexual dysfunction?
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Multifactorial! (organic & psychosocial)
1) Decreased vascularity 2/2 heart dz, HXOL, smoking, DM 2) Neurogenic: injury, hormonal (POF) 3) Underlying depression/anxiety disorder 4) Meds: antidepressants (SSRI or TCAs), H2 blockers, beta blockers, thiazides, spironolactone 5) Psychosocial: religious, cultural issues; prior h/o abuse or trauma; fear of rejection, fear of intimacy, body images issues |
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Which antidepressant increases sexual desire?
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Trazodone
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How to eval sexual dysfunction?
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Perform sexual history routinely, after rapport has been established.
Ask: sexual orientation, type & freq of sexual activity, partners past & present, sexual satisfaction Pt must feel that complete confidentiality will be kept at all times!! |
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What meds to treat sexual dysfunction?
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1) PO and intravaginal estrogen for vaginal dryness, atrophy, dyspareunia
2) Estrogen + methyltestosterone for libido decrease 3) Sildenafil: help increase genital blood flood & smooth muscle relaxation (for pts w/ sexual arousal disorder) |
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What devices to treat sexual dysfunction?
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Clitoral vacuum device (enhances blood flow in sexual arousal disorder)
Vibrators? |
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What other treatments for female sexual dysfunction?
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Correct underlying conditions
Treat adhesions or endometriosis Antifungals, steroid creams Therapist referral Usually include pt's partner in the therapy process |
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What is menopause?
What is "natural" menopause vs premature ovarian failure? |
1) Permanent cessation of menses resulting from loss of ovarian follicular activity
2) Natural = 12 months of amenorrhea w/o pathologic cause; avg age = 51.4 POF: Menopause <40y/o |
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What is perimenopause?
What is avg age & how long it lasts? |
Period immediately prior to menopause & after 1st yr of menopause
Avg age = 47.5, lasts ~4yrs |
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What is the climacteric?
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Phase that makes transition btw reproductive and non-reproductive state in women
Includes decreased fertility & extends beyond menopause |
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What endocrine changes are seen in menopause?
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1) Declining inhibin levels from granulosa cells -> increased FSH form pituitary
2) This accelerates follicular phase 3) See high E2 levels during menses +/- follicular cysts 4) Granulosa cells gradually lose ability to make E2 + increased FSH & LH 5) Post mp: androgen levels decline by 50%, but still androgen>estrogen so can get hirsutism & alopecia |
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Which form of estrogen is dominant after menopause?
How is is produced? |
E1
Made by aromatization of androstenedione in adipose tissues |
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What are major symptoms of menopause?
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1) Irregular menses - shorter cycle then missed periods 2/2 anovulation
2) Hot flashes (~70% of pts) 3) Sleep disturbances 4) Mood disturbances 5) UG atrophy: dyspareunia, vulvar pruritis, in continence |
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How to treat irregular menses at menopause?
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1) Low dose OCPs (20ug ethinyl E2) in nonsmokers w/o HTN/vascular dz
2) Monthly withdrawal progestins 3) Combo OCPs |
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What is a hot flash?
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Sudden sensation of warmth + flushed sensation of upper body + face
Usually 1-5 mins Can occur 5-7 yrs after mp |
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What is etiology of hot flashes?
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2/2 alterations in hypothalamic thermoregulation 2/2 steroid & peptide hormone level fluctuations
A/w increases in serum LH, but this doesn't seem to be causative |
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What is osteopenia?
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2.5 > bone mineral density <1.0 SD below T score (young adult mean)
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What is a T score in assessing bone mineral density?
A Z score? |
1) BMD compared to young adult mean
2) BMD compared to pt's own age group |
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What is osteoporosis?
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BMD >/= 2.5 SD below young adult mean
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How to assess bone mineral density (BMD)?
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Via dual-energy x-ray absorptiometry (DEXA)
Can also look at bone remodeling markers (osteocalcin, bone-specific ALkP, precollagen extension peptides) and urinary markers of bone resorption (pyridinoline cross-link peptides, N telopeptides, OH-proline, OH-lysine) -> increased usu means increased bone turnover |
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How common is osteoporosis?
How many fractures/yr does it account for? |
1) 25 million in U.S.; 15% females >50y/o have osteoporosis (~50% >65y/o have osteopenia)
2) 50% of women over age 65 -> 25% lead to death in 1yr, 25% stay bedridden |
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Where do fractures of osteoporosis occur in old people?
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Vertebrae (spinal compression)
Hip (at femur) Distal radius (Colles) |
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What is primary osteoporosis (type 1)?
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2/2 estrogen deprivation, advancing age, xs smoking and EtOH, poor nutrition, not enough wt-bearing exercise, & hereditary factors (Asian or Caucasian)
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What is secondary osteoporosis (type 2) owing to? (3)
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2/2 another factor:
1) endocrine abnormalities, e.g., PTH, TH, and cortisol xs; DM, hypogonadism 2) GI abnormalities (malabsorption, anorexia) 3) Meds: anticonvulsants, cyclosporine, GCs, GnRH agonists, heparin, isonizaid, Li, MTX, Thyroid hormone |
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What treatments are available for osteoporosis? (10)
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1) Wt-bearing exercise
2) Stop smoking/drinking EtOH 3) Calcium (500mg if on E2, 1000mg if not) 4) Vit D (esp if ltd sunlight exposure) 5) E or P replacement 6) Bisphosphonates 7) Calcitonin 8) SERMs 9) Tibolone 10) PTH |
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Is Sodium Fluoride recommended from treatment of osteoporosis?
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No - increases BMD< but may increase fracture risk.
Slow release formulations may be better. |
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What are benefits of HRT in menopause? (6)
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1) 70-80% improvement in vasomotor sx & UG atrophy
2) 2-5% BMD increase 3) 25-50% decrease in vertebral and hip fractures 4) Possible 20% decrease in CRC & AD 5) 25% reduction in tooth loss risk 6) Possible reduction in age-related macular degeneration |
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What are risks of HRT in menopause?
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1) Elevated risk of cardiac and stroke risk
2) Thromboembolic events 3) Breast cancer |
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What are recommendations in HRT nowadays?
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Risk outweighs benefits for any given woman
Reserve HRT treatment for menopausal symptoms for as short a time as possible |
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What are currently available HRT estrogen preparations (generally)? (7)
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1) 17β E2 (PO, vaginal, transdermal)
2) Ethinyl E2 (PO) 3) Conjugated Equine (PO, IV, vaginal) 4) Synthetic conjugated 5) Estropipate (PO and vaginal) 6) Esterified 7) Others: estrogen combos, E3 valerate, black cohash extract |
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What are currently available HRT progesterone preparations (generally)?
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MPA
Norethindrone Micronized progesterone Note: use these for women with uteri. |
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What are advantages of SERMs in treatment of osteoporosis?
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Have differential agonistic and antagonistic properties.
Raloxifene is approved for osteoporosis; does not promote endometrial hyperplasia, may reduce risk of breast neoplasms. |
