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Sexuality and sexual dysfunction Sexuality and sexual dysfunction Presentation Transcript

  • SEXUALITY AND SEXUAL DYSFUNCTION Prof . M.C.Bansal. MBBs. MD. MICOG. FICOG. Founder Principal & Controller; Jhalawar Medical College And Hospital,Jhalawar. Ex. Principal & Controller ; Mahatma Gandhi Medical College And Hospital Sitapura, Jaipur.
  • Sexuality “ Sexual rights include right of an individual to achieve the highest attainable standard of health in relation to sexuality and to pursue a satisfying, safe and pleasurable sexual life” Who Working Definition , 2002.
  • Factors Modulate women’s Sexual function
  • Women’s Sex Desire  There are different phases of sex response, including desire, arousal , orgasm followed by relation , felling of wellbeing and satisfaction.  In established relationship , women mostly initiate sex or accept their partner’s invitation without any marked her own sense of sexual desire at that time.  Qualitative research has classified many reasons a woman instigates or accepts sexual engagement such as enhancement of emotional closeness with her partner, finding herself more responding to romantic environment and more specifically , to erotic cues.  Other reasons include wanting to feel better and completeness about herself/ her partner , more normal more loved and lovable, more committed to relation ship, to conceive and some times for more nefarious reasons.  Sexual desire , as typified by sexual fantasizing , positively anticipating sexual experience and spontaneously crazy need of partner’s sex or her self stimulation , has a broad spectrum of frequency across women.  It is also clear that this overt desire is quite frequent in many sexually functional and self motivated craziness for sex.
  • Model of Woman’s Sexual response
  • Women’s sexual response cycle  Woman’s desire for sex or her motivation for sex by other reasons --- women deliberately attends sexual stimuli– subsequent subjective arousal( excitement ) --pleasure, intense felling to have sex are triggered.  Desire and arousal co-exhibit and compound each other; provided that the duration is sufficiently prolong , continue to attend stimuli , pleasure, sexual satisfaction with one many discrete orgasms there by fulfilling her recently required sexual need.  Response is circular with overlapping phases of variable order--- once triggering can increase the motivation to attend stimuli and to accept request to ---Psycho physical act of sex.  This desire –orgasm also simultaneously reflects male sexuality . Male usually has ignition of desire earlier and far more frequently than woman .
  • Physiology of Desire and sexual arousal Drive ---  Felling of sex desire can be triggered by (A) internal cues such     as pleasant memories of sexual experiences , positive feeling for partner , positive expectations for firm bondages and relationship. or by(B) external one as a romantic environment and are dependent on certain biologic mechanism( not yet fully understood). Multiple neurotransmitters, peptides and hormones modulate desire and subjective arousal: noradrenalin , dopamin ,melanocortin , oxytocin , PGs, serotonin and catecholamine's acting on some serotonin receptors are prosexual. Where as prolactin and serotonin acting on s5 Hydroxiyryptaminas 2 ,3 receptors glutamte and Gamma Amniobutric Acid (GABA) are inhibitory. There is also a complex interplay between environmental and neuro- endocrine factors. Study on animal models and human volunteers are unable to explain it.
  • Sexual Arousal  Women’s sexual arousal is complex and correlates positively with in sexual stimuli and its emotional context.  This subconscious reflex organized by ANS and processed by limbic system in response to mental and physical stimuli( generated desire and drive) that are recognized as sexual.  There are also affective response to sexual arousal , fulfilling of joy and affirmation of felling of fear / guilt and awkwardness serves as cognitive feed back and modulate arousal.
  • Physiological changes arousal of sexual  Physical changes of sexual arousal include rise in Bp, Hr , respiratory rate , temperature , perspiration , breast engorgement, nipple erection ,increased skin sensitivity to stimuli, mottling of skin e.g. sexual flush on face and upper chest along with increased congestion and lubrication of genital tract( increase sympathetic tone ).  ANS stimulation immediately increases blood flow in bloods paces and sinuses of genital tract ( clitoris, vagina, vulva , perineum .  There is increased relaxation of smooth muscles around arterioles .  It is hypothesitized that during intercourse , penile thrusting on cervix might result in dilatation of upper vagina and constriction of lower 3rd vaginal and pelvic and perineal muscles --- known as penile cervix reflex.  Neurotransmission of genital congestion ---- is brought by Nitrous Oxide (NO) released by parasympathetic along with VIP .
  • Physiological changes arousal--- of sexual  Simultaneously Acetylcholine (Ach) blocks sympathetic vaso constriction .  There are enough evidences regarding communication between NO containing Cavernous nerves to clitoris a branch of pudendal nerve.  Input from the gangalion of caudal sympathetic chain containing noradrenalin and neuro peptide Y produce vasoconstriction on one hand and hypo gastric nerve ( sympathetic pathway ) passing through ganglion relay stations in the pelvic plexus can produce vaso- dilatation .  In sexually functional women prior viewing of visuals triggers anxiety --- increases sexual arousal to subsequent erotic cues.
  • Sexual Dysfunction
  • Cervix Uterus Cervical sex reflex ?—its absence do not decrease it. Removal of uterus --- no decreased sexuality—post hysterectomy psychology --+/Their removal / failure ---+/no decreased orgasm –Vegas takes the function. no definite point on anterior vaginal wall– its massage --massage of periurethral erectile tissue increase orgasm. -Androgen – estrogen precursors – converted in estrogen by aromatization ----+ ve role not clear. helps in maintenance of blood supply, thickness of epithelium and vaginal lubrication No role. excess --- takes away the sex performance. excess ---- decreases it. Dopaminergic drug therapy in Parkinson patient – improve it. Dopamine --? Hyperprolactinaemia --- decreased desire for sex. Decreased desire and arousal Factors affecting sex desire & Ovaries arousal Spinal cord Injury Below T 1o Graffinberg’s Spot Adrenals Testosterone (DHES) Estrogens Progesterone Alcohol cocaine Dopaminergic drugs(dopamine) Prolactin Hypothyroidism
  • Risk Factors  Mental Health  Depression , low self esteem ,frequent mood changes , lack of emotional wellbeing --- associated with decreased desire and sex arousal . Anti depressants ( SSRIs) also do the same in some women. Depressed woman may masturbate more frequently.  Sexual Relationship  decreased satisfaction with partner’s relationship. Most influencing factor is presence/ absence of partner’s sex dysfunction.  Partner’s Sex Function main reason to cease sexual activity is lack of sexual function or sex drive in partner.
  • Risk Factors-- Personality Factor  woman develops orgasmic disorders when body’s reaction / circumstances are not under her control . Fear of –ve evaluation by others , marked self criticism , somatization and catastrophized woman develops vulvar vestibulitis syndrome (VVS)--vaginismus –a phobic quality to their fear of vaginal penetration.  Duration of Partnership Ease for response and heightened desire is typically more for new partner, but it declines by the end of one year . Desire for tender care increases more in woman than man .Symptomatic heterosexual woman in long term reports that her partner is cold – less romantic to her --- reveal her feeling / hopes and fear.
  • Painful Sex Decreased Desire Decreased Arousal Sex Dysfunction Veganism's Unsatisfactory - encounters Decreased Orgasm Inadequate sex stimulatio n
  • Drugs Affecting Sexual Arousal
  • Overview of Medical And Psychological effects of chronic illness on sexual function
  • Influence of OB-GY Problems on Sexual Function  Infertility  The goal oriented sex while trying to conceive such as in induction ovulation , drugs –chlomiphene, GnRH antagonist / OCPs used in down regulation , ART / IVF /ICSI--- stress , waiting for multiple test reports and result --- disturb the emotional aspect of both partners . Even a semen collection / or its below standard report puts an emotional stress .
  • Influence of OB-GY Problems on Sexual Function---- *Endometriosis & PID  Dyspareunia—marked sexual disorder. * PCOD Low level of desire and sexual response – emotional , though increased androgens still sexual dysfunction is more frequent– treatment with anti androgens to treat hirsutism improves sex desire and drive. *STD  recent STD infection --- fear of spreading it , explanation and discussion with partner/ doctor / recurrence / chronicity / its sequelies/ emotion feeling of guilt / shin lead to decrease desire . * Vulval Dystrophy– particularly the Lichen sclerosis involving clitoral hood and clitoris --- loss of sexual sensitivity , dysparenia in perineal involvement – decreases desire and increased fear.
  • Influence of OB-GY Problems on Sexual Function--- Cancer Cervixits diagnosis, post coital bleeding / foul smelling discharge / fear of spread , death – emotional upsets , radical Hysterectomy ) damage to nerves and blood supply to vagina/ chemotherapy / radiotherapy / lack of psychotherapy ---- vaginal fibrosis dyspareunia --- loss of decreased desire and to some extend decreased sexual interest by partner.  Irregular acyclic bleeding in AUB  decrease available dry days for sex – emotional upset.
  • Influence of OB-GY Problems on Sexual Function--- Breast Cancer After its diagnosis, surgery / chemo – radiotherapy women develops emotional instability / induced premature menopause, --- sexual function may develop and continue for more than one year. Use of aromatase inhibitors ( litrazole ) leads to decreased peripheral production of estriole--- dyspareunia, dry vagina .  Diabetes --- increased chances of depression . Obesity , recurrent candidacies—prone to develop VVS – peripheral neuropathy- poor conduction of tactile sensation and tissue response.  Lower urinary tract diseases ---- urinary incontinence (stress /urge / true –Urinary fistula), TVT surgery / anterior and posterior colpoperineorrhaphy / Burch suspension for prolapsed --- de enervation of anterior wall / dyspariunia ( in 820 % women ) ---sexual dysfunction.
  • Influence of OB-GY Problems on Sexual Function--- Pregnancy  her physiological changes – emotional versatility/ social restrictions / her own sexual value system folklore . Religious taboos/ fear of repetition of events of previous confinement / abortion APH preterm labour / PROM in cases of incompetent os ---- can lead to decreased interest in sexual activity.  Post partum period --- associated with reduced motivation for sexual activity--- contributory factors may be ---mood swings / fatigue fear of waking of baby . Continuous discharge from vagina/ painful perineal repair or episiotomy / sore breast / decrease vaginal lubrication due to decrease estrogen levels and increased prolactin levels and many more .
  • Assessment Of Sexual Dysfunction  Interview assessment  * It is better and always fruitful to assess bith partners alone and together. * Partner’s insight is helpful and recommendations for changes in behavior both asexual and sexual are difficult if another partner is assessed and his opinion is not heard.
  • Assessment by interview of Both Partners ---
  • Quick Assessment of Assessment
  • Physical Examination
  • Psychological therapy
  • Treatment modalities of Female Sexual Dysfunctions
  • Reasoning for combined Therapy  Central brain studies have recently shown that Serotonin , Norepinehrin ,and dopamine are implicated in sexual function.  Melanocyte stimulating hormone ( MSH ) agonists have also been investigated as possible modulator of sexual function .  Estrogen and Testosterone are helping in vulvalvaginal health --- epithelium , blood vessels . Neurosensitivity and lubrication.  Biological , psychological . Physical and sociocultural factors do influence widely and in variable way the sexual interplay between two partners.
  • Methods of therapy        Sex Re education– about structures / functions of sex organs and reproductive systems of both sexes---- their role in sexual arousal , provocation of desire , sex play and achievement of sexual satisfaction. Psycho therapy--- psycho analysis , moral boost up , regeneration of self esteem , hope and winning the goal --- removal of depression / clearing all doubts about oneself sexual capability and capacity and so also about the sex partner too. Motivation to follow the instructions and stick to treatment with full hope. Slides show session about --- making mood , alteration of environment and surroundings . Learning care and respect for feeling of each other , amusement , enjoyable breaks in the routine hectic life schedules , fore play .body massage and identify / discovery of erotic points on the partners body to stimulate her / his sexual desire and orgasm . Eros clitoral stimulators --- FDA approved ---2000. Conjugate Equine estrogen for moderate to severe dyspareunia. Drugs --Estrogens , testosterone , DHEA , Vaginal Lubrications , Lybridos and lybroidos, Dopamine agonists , MSH analog s and Viagra etc.
  • Slides Show
  • Sexual Un satisfaction
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  • Never To Blame The Partner
  • Viewing Romantic Scenes And enjoying together in Bed
  • Going out Together And Improving Relations
  • Develop Your own games and ways to improve understanding and Love
  • Ankhon Hi Ankhon Main Fore play
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  • sex_drive_killers_s8_ woman_looking_at_b ehind_in_mirror Viewing self body image in mirror on 3rd party ‘s comments and developing Negative thoughts about her own figures
  • sex_drive_killers_s12 _woman_consoled_b y_man
  • Sexual Dysfunction ----- Husbands disappointment ---Takes sleeping Pills
  • Treatment Of Sexual Arousal disorder  Lyriana ---A little sex pill for woman – it revokes the libido, it addresses the lowe Dopamine level --- it provides precursor L-Dopy. Body is able to convert it in     to Dopamine – increase biological Trigger that control sex . Tibolone ---Phospho diesterase inhibitors . Zestra , T oil for gentle massage of genital Pvt parts , Vacuum therapy – battery operated device increase blood supply of clitoris and increase nerve sensitivity. Self designed sex games. Erotic massage. Fellatio Tips pressing your lips / mouth to partners genitalia . Cognitive behavior ---approach.
  • Treatment Of Sexual Arousal disorder  Commercial Available --vaginal Lubricants, Vit.E and       mineral oils. Encouraging adequate fore play . Use of clitoral/ anterior vaginal wall and perineal vibrators. Scented (aromatic smell)Warm water bath before sex. Eliminate anxiety by engaging in distraction techniques . Treat urogenital atrophy --- post menopausal / oophrectomized women – with estradiol vaginal cream, ERT wit 5mg medroxy progesterone. Est ring , sidenophil – tab 1-2 hr before sex?
  • EROS-Clitoral-Therapy-DeviceFor-Female-Sexual-Dysfunctionc-pz It is hand operated with rechargeable battery --produce radio-frequency vibrations to stimulate clitoris
  • Treatment Of Sexual Arousal disorder- For Woman Only ---A Revolutionary Guide to overcome Sexual dysfunction and recover your Sex Life ---by L Bussens, J Burma , etal New York Herrittoolt. 2001.  How to have Magnificent Sex . ---The 7 Dimensions of vital connection by L .Hostein New york, Harmony books 2oo1.  Resource of prone pictures / tapes, music ,and general information about sexuality and spirituality ---WWW. Tantra .com
  • Treatment of orgasmic disorders  Androgenic substances --- testosterone / DHEs are quite effective in few cases but there side effe3cts are likely to be troublesome after a prolong use or use in higher doses .Maximizing stimulation and minimizing inhibitions simultaneously can also help .  Stimulation with masturbation , clitoral vibrator , gentle massage of anterior vaginal wall with lubricated finger ( self / partner ), Kegal exercise training , touching at vulva with lips / whole face while woman is standing or lying in bed naked by the partner , kissing of nipples and there gentle e tickling with lips and fingers, kissing from head to toe , rubbing the organ at her back ( lumbo sacral spine and buttocks
  • Treatment Of Orgasmic disorders--- Kegal exercise—Its prudential uses are ---increase pubococcygeal tone , increase orgasm intensity ,correction of orgasmic urine leakage, one of distraction technique during coitus , improves patient awareness of sexual response. It’s proper training by consultant is helpful .  Decrease inhibition  distraction by “ Spectoring “ e.g. observing oneself from a 3rd party perspective. Fantasizing / listening erotic music and dialogues . Viewing romantic videos  No response in given period of 3-4 months refer her to specialist and multi disciplinary approach.
  • Newer Drugs --- In Pipe Line  Flibanserin –5HT (1A) agonist / 5HT-2 antagonists for hypo sexual desire disorder --- 100 mg at bed time was associated with clinical meaningful and significant improvement.  Librido And lybroidons are in pipe line for Hyposexual desire disorder( HSDD). Libridos contain testosterone with Phospho diastrase inhibitor ( PDE5 inhibition ) Lybroidons --- testosterone with alpha 5HT(1A) agonists (Buspirone) . Testosterone increase desire and sexual motivation . PDE5 is inhibitors increase genital sensitivity to sexual afferent signals. Buspirone converts the inhibition generated in fr5ontal area of brain . - Librigel – low dose 300ug testosterone topical cream --- helpful in VVS and post menopausal women . - TB s-2 –Tefrin –TBS -2 is an intra nasal gel preparation of low dose testosterone for women with orgasmic disorder .
  • Newer Drugs In Pipe line -- Alprostedil ( Femprox ) – PGE -1 , a potent vasodilator . It is      alprostatil based cream marketed for Rx of FSAD. , 900 ug dose showed improvement in arousal and sexual performance / satisfaction out come . MSH Analogs – Bremalanotick – a melano cortin receptor 4 agonist (MCR4 agonist ) for Rx of HSDD and FSAD. It has adverse effect on BP and cardiovascular system , hence it is on trial in low dose to minimize the side effects . Apomorphine– a dopamine agonist used as oral preparation help in Rx of orgasmic problems. Intra Vaginal suppositories of DHEA in low dose for VVS case --has promising effect on HSDD. Osperifene– Estrogen specific receptor modulator with agonist and antagonist action --- for VVS with sexual pain --increased improvement. VIVENE Therapy – mono polar radio-frequency thermal therapy for laxity of vagina and its introitus and improves sexual satisfaction of both partners.
  • Functional Sexual Disorders ( FSD)  When to refer? Long standing sexual dysfunction . Multiple dysfunction. Current / past Sex abuse. Psychological disorders of acute onset with unknown etiology . No sufficient response to therapy till given.
  • Sex Pain ( Dyspareunia)  Progressive muscle relaxation and vaginal dilatation to accommodate      the penetrating male organ facilitate the sex performance and satisfaction to both during normal sexual act. It is seldom painful. But when the pain is felt by women at her introitous or deep in pelvis , the sex is no more completed and causes a chronic sexual disorder called Dyspareunia. Vaginismis / a synonym of Dyspareunia is mainly associated with voluntary contraction / spasm of muscles around lower 3rd of vagina as soon as vaginal penetration by penis / examining fingers of doctor and even the tampon by herself. It is an intense type of phobia culminating in physical act and sexual disorder / marital disharmony . Past experience of sexual abuse (rape/ an attempt ) , disliking with husband precipitates it while she may be comfortable with lover. It may be complete / situational .