PMS and Sexual Dysfunction


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Dr. Owen Phillips

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PMS and Sexual Dysfunction

  2. 2. PMS <ul><li>Premenstrual syndrome or premenstrual tension syndrome </li></ul><ul><li>Common complaint in a private practice </li></ul><ul><li>Newly into practice have little experience in diagnosing and treating from a residency program </li></ul><ul><li>Why? </li></ul>
  3. 3. PMS: Objectives <ul><li>Diagnosis </li></ul><ul><li>Causes </li></ul><ul><li>Treatments </li></ul>
  4. 4. “ I seem to have PMS all the time; my husband wants to divorce me” <ul><li>Making the Diagnosis: </li></ul><ul><li>75% of all women of reproductive age have some symptoms </li></ul><ul><li>Irritability, tension, dysphoria, mood lability </li></ul><ul><li>Timing is everything </li></ul><ul><ul><li>Combination of symptoms that appears during the week prior to menstruation and resolves within a week of onset of menses </li></ul></ul>
  5. 5. PMS v. PMDD (premenstrual dysphoric disorder) <ul><li>3-8% of women have complaints that seriously interfere with lifestyle and relationships </li></ul><ul><li>If have the diagnosis of PMDD- they do not usually respond to conservative or conventional interventions </li></ul>
  6. 6. PMS- etiology <ul><li>True- to have PMS, must have normal ovarian function, menstrual cyclicity- the trigger is the ‘normal endocrine events of the ovarian cycle’ </li></ul><ul><li>False- that PMS has anything to do with an excess of estrogen or progestin or an imbalance or a deficiency </li></ul><ul><li>May be neurotransmitters- Serotonin </li></ul>
  7. 7. PMS- consider alternative diagnoses <ul><li>Rule out hypothyroidism/anemia </li></ul><ul><li>High prevalence of pre-existing depression </li></ul><ul><li>Women with pre-existing mood disorders may have exacerbations related to their menstrual phase </li></ul><ul><li>Women with PMS relate higher levels of stressors </li></ul><ul><li>If having PMS ‘all the time’- it is by definition NOT PMS </li></ul>
  8. 8. PMS- diagnosis <ul><li>Charting symptoms </li></ul><ul><li>The Daily Record of Severity of Problems </li></ul><ul><li>Premenstrual Record of Impact and Severity of Menstruation </li></ul><ul><li>Calendar of Premenstrual Experiences </li></ul><ul><li>Core mood indicators: </li></ul><ul><ul><li>Depressed mood, anxiety, lability, irritabilty </li></ul></ul>
  9. 9. PMS- treatment <ul><li>Refer patients you suspect have depression or PMDD (or be prepared to treat) </li></ul><ul><li>Common sense (with some evidence) </li></ul><ul><ul><li>Dietary and lifestyle changes </li></ul></ul><ul><ul><li>Reduce weight </li></ul></ul><ul><ul><li>Group therapy sessions </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Stress reduction </li></ul></ul>
  10. 10. PMS- treatment, low risk with evidence <ul><li>Calcium 1200 mg daily </li></ul><ul><li>Vitamin B6- 100 mg </li></ul><ul><li>Vitamin E 400 IU daily </li></ul><ul><li>Optivate (mineral/vitamin supplement)- up to 6 tabs daily </li></ul><ul><li>Anaprox 7 days prior to menses </li></ul><ul><li>Spironolactone 100 mg daily (last 14 days) </li></ul><ul><li>Primrose oil (no benefit) </li></ul>
  11. 11. PMS: pharmacotherapy <ul><li>Conservative methods first </li></ul><ul><li>Then consider SSRIs </li></ul><ul><ul><li>Fluoxetine 20 mg daily </li></ul></ul><ul><ul><li>Effexor 50-150 mg daily </li></ul></ul><ul><ul><li>Sertaline 50 -150 mg daily </li></ul></ul><ul><ul><li>Recent studies found some effect if taken just during the last 14 days of cycle </li></ul></ul>
  12. 12. PMS: Hormonal therapies <ul><li>Progestins only- may aggravate </li></ul><ul><li>OCs- suppress ovulation </li></ul><ul><ul><li>Most studies found that OCs do not influence premenstrual mood in most women </li></ul></ul><ul><li>Exception: OC containing drospirenone (Yasmin) effective in one report </li></ul>
  13. 13. PMS- summary <ul><li>With etiology unknown, treatment empiric </li></ul><ul><li>Try life-style changes before pharmacotherapies </li></ul><ul><li>Look out for underlying mood disorders </li></ul><ul><li>Try any therapy for 3 cycles before changing </li></ul><ul><li>How to define success? </li></ul><ul><li>Requires counseling with your patient to know </li></ul>
  14. 14. “ Doctor, I don’t seem to enjoy sex anymore” <ul><li>It is 4:15 PM and you have 6 patients waiting to be seen </li></ul><ul><li>What was on your schedule as an annual: the patient stops you to ask a question as you have your hand on the door- and then says </li></ul><ul><li>“ Doctor, I don’t seem to enjoy sex anymore” </li></ul>
  15. 15. Sexual Dysfunction Issues <ul><li>What’s a general gynecologist to do? </li></ul><ul><li>No training in sexual medicine or counseling </li></ul><ul><li>We are advised to ask about sexual practices, but we hope no one ever tells us anything. </li></ul><ul><li>And our patients might assume that as ‘experts in women’s health’ wemight actually know something </li></ul>
  16. 16. Sexual Health Assessment <ul><li>Asking about sexuality should be a part of our conversation </li></ul><ul><li>The clinician must learn to initiate this conversation </li></ul><ul><li>The patient may be embarrassed, uncomfortable or fearful </li></ul><ul><li>Patients may have misperceptions and not know what to ask </li></ul>
  17. 17. Sexual Health Assessment <ul><li>The clinician may feel uncomfortable, especially if poorly trained in asking questions </li></ul><ul><li>May have strong personal values that might interfere with educating patients </li></ul><ul><li>More importantly, we don’t have time to get into it. </li></ul>
  18. 18. Women’s general experience <ul><li>We can save time by educating our patients </li></ul><ul><li>Only when a change occurs from their ‘perceived’ normal experience will women think to seek counseling and maybe not then </li></ul><ul><li>By then there is so much emotional overlay you may not get through </li></ul>
  19. 19. Patients should be educated <ul><li>Then inquire </li></ul><ul><li>Defining ‘normal’ </li></ul><ul><li>DSM-IV does define the normal phases of sexual response so as to identify sexual dysfunction </li></ul><ul><ul><li>Desire - Excitement </li></ul></ul><ul><ul><li>Orgasm - Resolution </li></ul></ul>
  20. 20. Educating about ‘normal’ <ul><li>97% women surveyed report penile-vaginal intercourse as the most frequent sexual activity </li></ul><ul><li>It results in orgasm in only 25% of the time </li></ul><ul><li>More than 2/3 of couples use oral-genital stimulation </li></ul>
  21. 21. Educating about ‘normal’ <ul><li>About 12% of female college students report having experienced anal sex </li></ul><ul><li>About 35% of women report masturbation alone </li></ul><ul><li>20% use regular fantasy as a part of their sexual experience- but 25% feel guilty </li></ul>
  22. 22. Survey of ‘normal couples’ <ul><li>Middle class educated couples </li></ul><ul><ul><li>80% happy marriages </li></ul></ul><ul><ul><li>40% males- trouble with erection </li></ul></ul><ul><ul><li>63% females- trouble with arousal or orgasm </li></ul></ul>
  23. 23. Survey <ul><li>Of those with no dysfunction </li></ul><ul><ul><li>50% males reported decreased satisfaction </li></ul></ul><ul><ul><li>77% females reported decreased sexual satisfaction </li></ul></ul><ul><li>If you share these facts, most patients begin to feel ‘normal’ </li></ul>
  24. 24. Taking a History <ul><li>Be comfortable for your patient to be comfortable. Give the confidence that the discussion is confidential </li></ul><ul><li>Recognize that there isn’t enough time to do a complete history in a busy office </li></ul><ul><li>But one can start with a screen </li></ul>
  25. 25. Screening questions <ul><li>Do you feel you have a good sex drive </li></ul><ul><li>Do you lubricate well </li></ul><ul><li>How frequently- and are you ok with that </li></ul><ul><li>Do you experience any pain </li></ul><ul><li>Are you able to reach orgasm- do you have any concerns </li></ul>
  26. 26. Screening <ul><li>How well do you get along with your partner </li></ul><ul><li>A lead in to begin a discussion about partner abuse, safety in relationships </li></ul>
  27. 27. Listening is treatment <ul><li>Listening with empathy </li></ul><ul><li>Answering questions a patient may have about what is typical </li></ul><ul><li>Relieve unnecessary concern </li></ul><ul><li>Debunk myths </li></ul><ul><li>Provide reading material, websites </li></ul>
  28. 28. Sexual History <ul><li>Chief complaint </li></ul><ul><ul><li>Is the problem </li></ul></ul><ul><ul><ul><li>Desire </li></ul></ul></ul><ul><ul><ul><li>Arousal </li></ul></ul></ul><ul><ul><ul><li>Orgasm </li></ul></ul></ul><ul><ul><ul><li>Pain </li></ul></ul></ul>
  29. 29. Sexual History <ul><li>Onset </li></ul><ul><ul><li>Gradual versus sudden </li></ul></ul><ul><ul><li>Lifelong or situational </li></ul></ul><ul><ul><li>All partners </li></ul></ul><ul><ul><li>I find that when patients answer these questions, they often diagnose themselves </li></ul></ul>
  30. 30. Fact <ul><li>Asking and Listening </li></ul><ul><li>80% of sexual complaints can be successfully treated by primary care doctors </li></ul><ul><li>The time, knowledge base, willingness and empathy are the limiting factors for doctors </li></ul><ul><li>Part of good doctoring is to ask and to educate </li></ul>
  31. 31. Dyspareunia <ul><li>Pain during intercourse </li></ul><ul><li>Nearly 2/3 women have experienced dyspareunia </li></ul><ul><li>Can be associated with vaginal or vulvar pathology such as infections, insufficient lubrication, child-birth injuries </li></ul><ul><li>Vestibular vaginitis </li></ul>
  32. 32. Dyspareunia <ul><li>Where and when it hurts exactly </li></ul><ul><li>If superficial, </li></ul><ul><ul><li>vestibular adenitis, lack of lubrication, infectious vaginitis </li></ul></ul><ul><li>If deep, intraperitoneal pathology possible </li></ul><ul><ul><li>Endometriosis, pelvic inflammation </li></ul></ul><ul><li>If no pathology found </li></ul><ul><ul><li>psychological overlay </li></ul></ul><ul><ul><li>particularly sexual abuse as a child </li></ul></ul>
  33. 33. Male sexual dysfunction <ul><li>31% men have sexual dysfunction </li></ul><ul><li>Erectile dysfunction increases with age </li></ul><ul><ul><li>More than 50% in men from 40-70 </li></ul></ul>
  34. 34. Males <ul><li>Expect doctor to help </li></ul><ul><li>“ Many people have sexual concerns, I wonder what yours might be” </li></ul><ul><li>37% male FPs raised the question to males </li></ul><ul><li>17% of female FPs </li></ul>
  35. 35. Asking about sexuality <ul><li>The usual questions in gynecology: </li></ul><ul><li>Are you sexually active? </li></ul><ul><ul><li>Answer: YES </li></ul></ul><ul><li>What are you using for birth control? </li></ul><ul><ul><li>Answer: NOTHING </li></ul></ul><ul><li>OK then </li></ul>
  36. 36. Asking about sexuality- Ask men and women <ul><li>ACOG: “Do you sleep with men, women or both?” </li></ul><ul><li>Sexual practice may be different from sexual orientation. The patient may not respond to being asked about being a lesbian, gay or homosexual. These may be considered lifestyles. </li></ul>
  37. 37. Another way to ask <ul><li>Are you in a sexual relationship you would like to disclose? </li></ul><ul><li>Gives the patient the option to volunteer </li></ul><ul><li>Are they comfortable enough to disclose? </li></ul>
  38. 38. LGBT <ul><li>Clinician’s interest is what health risks the patient is predisposed to </li></ul><ul><li>One exception is in the adolescent where the suicide rate is higher. </li></ul>
  39. 39. Health risks for LGBT <ul><li>For women </li></ul><ul><ul><li>No increased risk for breast, lung or ovarian cancer </li></ul></ul><ul><ul><li>Increase in risk factors </li></ul></ul><ul><ul><ul><li>Smoking </li></ul></ul></ul><ul><ul><ul><li>Increase in body mass index </li></ul></ul></ul><ul><ul><ul><li>Fewer pregnancies </li></ul></ul></ul><ul><ul><ul><li>More alcohol use </li></ul></ul></ul>
  40. 40. Health risks for LGBT <ul><li>For women who report sex with women </li></ul><ul><ul><li>When they do have heterosexual sex, it is likely with a risky male partner </li></ul></ul><ul><li>Find a bookstore in your town to recommend to your patient about health issues </li></ul>
  41. 41. Consider: Medical disorders associated with hypoactive sexual desire <ul><li>Anemias CBC </li></ul><ul><li>Autoimmune disorders sed rate, ANA </li></ul><ul><li>Diabetes fasting glucose </li></ul><ul><li>Thyroid disorders TSH, T4 </li></ul><ul><li>Hormones?? </li></ul>
  42. 42. Medications and their sexual side-effects <ul><li>Alcohol Initially increases sexual arousal, higher doses impair </li></ul><ul><li>Antibiotics Vaginitis </li></ul><ul><li>Antihistamines Decreases lubrication </li></ul><ul><li>Benzodiazepines Decrease desire and orgasm </li></ul><ul><li>Beta-blockers Decreases lubrication </li></ul>
  43. 43. Medications and their sexual side-effects <ul><li>Lithium Decreased desire </li></ul><ul><li>Ocs Decreased desire </li></ul><ul><li>SSRIs Decreased desire </li></ul><ul><li>Antihypertensives in men and women </li></ul><ul><ul><ul><ul><ul><li> Arousal problems </li></ul></ul></ul></ul></ul>
  44. 44. Summary of Treating Sexual Complaints <ul><li>Educate </li></ul><ul><li>Ask </li></ul><ul><li>Listen </li></ul>
  45. 45. Identifying problems <ul><li>When a problem is identified, an indepth sexual assessment is indicated </li></ul><ul><li>That may not be done by you- </li></ul><ul><li>A qualified sex therapist (or psychologist with interest) is needed to assess and treat sexual disorders and dysfunction </li></ul>