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  1. 1. Female Sexual Dysfunction Kecia Smette, D.O.
  2. 2. Female Sexual Dysfunction (FSD)-Defined <ul><li>Involves any problem during any phase of the sexual response cycle that prevents an individual or couple from experiencing satisfaction from sexual activity 1 </li></ul><ul><li>Includes disorders involving desire, arousal and orgasm 8 </li></ul><ul><li>Also includes sexual pain disorders (dyspareunia, vaginismus) 2 </li></ul><ul><li>All recognized by the DSM-IV </li></ul>
  3. 3. Prevalence <ul><li>43% of women (ranges 19-50%) </li></ul><ul><li>most common in early adult and geriatric years 2 </li></ul><ul><li>31% of men 1 </li></ul><ul><li>From National Health and Social Life Survey of 1992 (included 1749 women and 1410 men ages 18-59) </li></ul><ul><li>Masters and Johnson estimate sexual dysfunction plagues 50% of all marriages 15 </li></ul>
  4. 4. Four Types of FSD <ul><li>1. Hypoactive Sexual Disorder </li></ul><ul><li>2. Sexual Arousal Disorder </li></ul><ul><li>3. Orgasmic Disorder </li></ul><ul><li>4. Sexual Pain Disorders </li></ul><ul><li>Dysparunia </li></ul><ul><li>Vaginismus </li></ul>
  5. 5. FSD-Hypoactive Sexual Disorder <ul><li>Persistent or recurrent deficiency (or absence) of sexual fantasies or thoughts and/or the lack of receptivity to sexual activity </li></ul><ul><li>Disorder of desire </li></ul><ul><li>Most common sexual dysfunction 15 </li></ul><ul><li>Individual libidinal drives differ </li></ul><ul><li>Low testosterone (?) </li></ul>
  6. 6. FSD-Sexual Arousal Disorder <ul><li>Female Sexual Arousal Disorder (FSAD)-patients have the desire to have sex, but their genital area fails to respond in the normal way, making sex painful or impossible </li></ul><ul><li>Is the female equivalent of impotence </li></ul><ul><li>Usually psychological </li></ul><ul><li>Estrogen deficiency (?) 2,15 </li></ul>
  7. 7. FSD-Orgasmic Disorder <ul><li>Female Orgasmic Disorder-unable to achieve orgasm despite sufficient desire and arousal </li></ul><ul><li>Unlike men, in women, orgasm is a learned, not an automatic response </li></ul>
  8. 8. FSD-Orgasmic Disorder <ul><li>5-15% of women never have an orgasm (anorgasmia) </li></ul><ul><li>Usually the result of sexual inexperience, performance anxiety or past experiences that have led to inhibition of the sexual response 8,15 </li></ul><ul><li>Hormones not implicated </li></ul>
  9. 9. Sexual pain disorders Dyspareunia <ul><li>Dyspareunia </li></ul><ul><li>Superficial-occurs with attempted penetration </li></ul><ul><li>usually due to anatomic or irritative condition. Actively find and treat condition </li></ul><ul><li>Vaginal –related to pain from friction </li></ul><ul><li>tx: lubrication </li></ul><ul><li>Deep- pain from thrusting </li></ul><ul><ul><li>Tx: r/o pelvic disease. Encourage relaxation </li></ul></ul>
  10. 10. Sexual pain disorders Vaginismus <ul><li>Vaginismus- involuntary contraction of the muscles of the outer one third of the vagina </li></ul><ul><li>Often related to sexual phobias or past abuse </li></ul><ul><li>Can be complete or situational </li></ul><ul><li>Tx: counseling and progressive relaxation </li></ul><ul><li>Vaginal dilators (worn 15 min bid) achieve success rates of 90% </li></ul>
  11. 11. Causes of FSD <ul><li>Risk Factors </li></ul><ul><li>Physical </li></ul><ul><li>Psychological / Psychosocial </li></ul><ul><li>Surgical (combination of effects) </li></ul>
  12. 12. FSD-Risk Factors 7 <ul><li>Hypertension </li></ul><ul><li>Smoking/substance abuse </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>Previous pelvic surgery </li></ul>
  13. 13. Physical Causes <ul><li>Diabetes, heart disease, neurological disorders, hormonal imbalances </li></ul><ul><li>Chronic disease (liver or renal) </li></ul><ul><li>Arthritis </li></ul><ul><li>Urinary incontinence </li></ul><ul><li>Substance abuse </li></ul><ul><li>Pregnancy and postpartum states (prolonged with lactation) </li></ul><ul><li>Medications 1 </li></ul>
  14. 14. Medications <ul><li>Never underestimate them!!! </li></ul><ul><li>Influence </li></ul><ul><ul><li>desire, </li></ul></ul><ul><ul><li>arousal, </li></ul></ul><ul><ul><li>ability to attain orgasm </li></ul></ul>
  15. 15. Medications affecting desire 2,15 <ul><li>Psychoactive </li></ul><ul><li>antipsychotics, barbiturates, benzodiazepines, SSRIs, Lithium, TCAs </li></ul><ul><li>Cardiovascular and antihypertensives </li></ul><ul><li>antilipid meds, Beta blockers, Clonidine, Digoxin, Spironolactone </li></ul><ul><li>Hormonal Preparations </li></ul><ul><li>Danazol, GnRh agonists, OCPs </li></ul>
  16. 16. Medications affecting desire 2 <ul><li>Others </li></ul><ul><ul><li>H 2 receptor blockers </li></ul></ul><ul><ul><li>Promotility agents </li></ul></ul><ul><ul><li>Indomethacin </li></ul></ul><ul><ul><li>Ketoconazole </li></ul></ul><ul><ul><li>Phenytoin Sodium (Dilantin) </li></ul></ul>
  17. 17. Medications affecting arousal 2 <ul><li>Anticholinergics </li></ul><ul><li>Antihistamines </li></ul><ul><li>Antihypertensives </li></ul><ul><li>Psychoactive meds (same plus, MAOIs) </li></ul>
  18. 18. Medications affecting orgasm 2 <ul><li>Methyldopa </li></ul><ul><li>Amphetamines </li></ul><ul><li>Antipsychotics, benzodiazepines, SSRIs, TCAs* </li></ul><ul><li>Trazadone </li></ul><ul><li>Narcotics </li></ul><ul><li>*also associated with painful orgasm </li></ul>
  19. 19. Psychological / Psychosocial Causes <ul><li>Stress, anxiety </li></ul><ul><li>Religious taboos 2 </li></ul><ul><li>Sexual performance concerns </li></ul><ul><li>Marital/ relationship problems </li></ul><ul><li>Depression </li></ul><ul><li>Guilt </li></ul><ul><li>Past sexual trauma 1 </li></ul>
  20. 20. Surgical Effects <ul><li>Combination of surgical and psychological effects </li></ul><ul><li>Gynecological malignancy </li></ul><ul><li>74% reported decreased desire </li></ul><ul><li>40% reported dyspareunia 2 </li></ul>
  21. 21. Surgical Effects <ul><li>Breast Cancer survivors </li></ul><ul><li>21-39% incidence of sexual dysfunction (believed to be secondary to chemo or hypoestrogenism from ovarian failure) 2 </li></ul><ul><li>Hysterectomy for Benign disease </li></ul><ul><ul><li>30% reported decreased responses </li></ul></ul>
  22. 22. Diagnosis <ul><li>Complete History and physical examination is critical and should include: </li></ul><ul><li>Pap and pelvic exams </li></ul><ul><li>Attitude toward sex </li></ul><ul><li>Past trauma/sexual abuse </li></ul><ul><li>Relationship problems </li></ul><ul><li>Sexual orientation </li></ul><ul><li>Substance abuse 1 </li></ul><ul><li>Medication History </li></ul>
  23. 23. Focused Physical Exam for the OB/GYN <ul><li>Examination to include: </li></ul><ul><li>1. External genitalia </li></ul><ul><li>2. Monomanual exam </li></ul><ul><li>3. Bimanual exam </li></ul><ul><li>4. Speculum exam </li></ul>
  24. 24. External genitalia <ul><li>Assess muscle tone (vaginismus) </li></ul><ul><li>Color and texture (vulvar dystrophy and dermatitis) </li></ul><ul><li>Skin turgor and thickness (atrophy) </li></ul><ul><li>Amount and distribution of pubic hair (atrophy) </li></ul>
  25. 25. External genitalia continued… <ul><li>Visualize clitoris (adhesions) </li></ul><ul><li>Ulcers (HSV) </li></ul><ul><li>Cotton swab test (vulvar vestibulitis) </li></ul><ul><li>Palpate Bartholin glands (bartholinitis) </li></ul><ul><li>Assess posterior forchette and hymenal ring (episiotomy scars and strictures) </li></ul>
  26. 26. Monomanual exam 2 <ul><li>Palpation of rectovaginal surface (rectal disease) </li></ul><ul><li>Palpate levator ani (levator myalgia, vaginismus) </li></ul><ul><li>Palpate bladder and urethra (urethritis, cystitis, UTI) </li></ul><ul><li>CMT (infection, peritonitis) </li></ul><ul><li>Vaginal depth (post op changes, post radiation changes, stricture) </li></ul>
  27. 27. Bimanual exam 2 <ul><li>Palpate uterus (retrogression, fibroids, endometriosis) </li></ul><ul><li>Adnexa (masses, cysts, endometriosis) </li></ul><ul><li>Rectovaginal exam (endometriosis) </li></ul><ul><li>Guaiac test (bowel disease) </li></ul>
  28. 28. Speculum exam 2 <ul><li>Evaluate discharge, pH (vaginitis, atrophy) </li></ul><ul><li>Vaginal mucosa (atrophy) </li></ul><ul><li>Papanicolaou smear (HPV, cancer) </li></ul><ul><li>Assess for prolapse (cystocele, rectocele, uterine prolapse) </li></ul>
  29. 29. Diagnosis <ul><li>If surgically or easily medically correctable (not hormonal)…correct the problem </li></ul><ul><li>If psychological/ psychosocial…refer to appropriate therapist </li></ul><ul><li>If hormonal in nature, use your history and physical exam to guide your treatment and remember your physiology… </li></ul>
  30. 30. Physiology of FSD <ul><li>The power players are… </li></ul><ul><li>Estrogens </li></ul><ul><li>Androgens </li></ul><ul><li>Testosterone (T) </li></ul><ul><li>Dihydrotestosterone (DHT) </li></ul><ul><li>Dehydroepiandrosterone Sulfate (DHEAS) </li></ul><ul><li>Dehydroepiandrosterone (DHEA) </li></ul><ul><li>Androstenedione (A) </li></ul><ul><li>Progestogens </li></ul>
  31. 31. Evils threatening the power players <ul><li>Menopause </li></ul><ul><li>Bilateral oophorectomy </li></ul><ul><li>Premature/Pharmacologically induced ovarian failure </li></ul>
  32. 32. Menopause <ul><li>Permanent cessation of menstruation caused by failure of ovarian follicular development and estradiol production in the presence of elevated gonadotropin levels </li></ul><ul><li>Average age of onset for perimenopause is 47.5 yrs with menopause occuring at 51-52 yrs 15 </li></ul>
  33. 33. “Evils” of Menopause <ul><li>Total estrogen production decreases by 80% as estrone and estradiol levels fall </li></ul><ul><li>Androgen production declines by 50% </li></ul><ul><li>Androstenedione (the primary ovarian androgen) declines 75% </li></ul><ul><li>DHEAS (the principal adrenal androgen) decreases by 50% 16 </li></ul><ul><li>Decreased estrogen to androgen ratio. More problematic in slim women. </li></ul>
  34. 34. Effects of Hypoestrogenism <ul><li>Postmenopausal women produce about 3000 ug of androstenedione (A) qd. </li></ul><ul><li>95% of this is adrenal in origin, the remaining 5% is ovarian </li></ul><ul><li>A is converted to estrone in peripheral body fat </li></ul><ul><li>A slim woman converts 1.5% of A, resulting in 40 ug of estrone/day </li></ul><ul><li>A heavier women converts 7% of A, resulting in 200 ug of estrone/day </li></ul>
  35. 35. Effects of Hypoestrogenism <ul><li>Hot flashes </li></ul><ul><li>Increased anxiety, depression, irritability, fatigue </li></ul><ul><li>Associated with declining cognitive function </li></ul><ul><li>Usually resolve in 5 yrs </li></ul><ul><li>Estrogen increases levels of beta endorphin and beta lipotrophin </li></ul><ul><li>Improves cognitive function, may delay onset of Alzheimer’s disease </li></ul><ul><li>Studies by Paganini-Hill and Kawas </li></ul>
  36. 36. Effects of Hypoestrogenism 15 <ul><li>Osteopenia and osteoporosis </li></ul><ul><li>Skin thins, collagen levels fall </li></ul><ul><li>Teeth fall out more easily </li></ul><ul><li>Bone formation is unchanged, but low levels of estrogen result in increased bone absorption rates. E replacement believed to block actions of PTH responsible </li></ul><ul><li>Manheux study shows increased skin thickness and collagen with E compared to placebo </li></ul>
  37. 37. Effects of Hypoestrogenism 15 <ul><li>Atrophy of urogenital tract </li></ul><ul><li>Topical estrogen helpful initally, but absorption is irregular. As epithelium thickens, systemic replacement is necessary to support the collagen content of the ligaments supporting the uterus (prevents descensus) and the facial tissue (prevents cystoceles, rectoceles, enteroceles) </li></ul>
  38. 38. Effects of Hypoestrogenism 15 <ul><li>E defiency at urinary tract leads to urge incontinence, frequency, dysuria and nocturia </li></ul>
  39. 39. Power Player #2… The Androgens 9, 13, 14 <ul><li>DHEA, DHEAS and A are considered proandrogens: they must be converted to testosterone (T) to express their effects </li></ul><ul><li>T is the most potent androgen </li></ul><ul><li>Plasma T levels range from 0.2 to 0.7 ng/mL </li></ul><ul><li>T is metabolized to DHT or E 2 </li></ul><ul><li>Some studies show an increase libido at supra physiolocial levels, but no consistent results on libido at physiologic levels 16 </li></ul>
  40. 40. The Androgens 9, 13, 14 <ul><li>DHEA benefits (at 50 mcg) </li></ul><ul><li>Increased bone density </li></ul><ul><li>Estrogenic stimulation of vaginal cytology </li></ul>
  41. 41. The Androgens 9, 13, 14, 16 <ul><li>Enhancement of immune system </li></ul><ul><li>Does not reliably increase libido. Those most likely to benefit are young women with bilateral oophorectomies. </li></ul>
  42. 42. Serum levels of T and SHBG 15 <ul><li>Premenopausal </li></ul><ul><li>Testosterone: </li></ul><ul><li>1.7+/- 0.49 nmol/l </li></ul><ul><li>SHBG: </li></ul><ul><li>4.3+/- 1.46 mg/l </li></ul><ul><li>Postmenopausal </li></ul><ul><li>Testosterone </li></ul><ul><li>1.3 +/-0.40 nmol/l </li></ul><ul><li>SHBG </li></ul><ul><li>3.4+/-1.41 ml/l </li></ul>
  43. 43. Effects of Hypoandrogenism 15 <ul><li>Decreases libido? </li></ul><ul><li>T is produced in ovarian stroma, and elevated levels of LH post menopausally continue to support T production. </li></ul><ul><li>More problematic for those with bilateral oophorectomies vs. menopausal women </li></ul>
  44. 44. Effects of Hypoandrogenism 15 <ul><li>Sherwin and Williams show IM T increased libido and coital activity </li></ul><ul><li>Myers, et al. oral T did not significantly alter libido or coital activity </li></ul><ul><li>Trial testing T patch vs. placebo found increases in libido and coitus </li></ul><ul><li>Gels and lozenges under investigation </li></ul><ul><li>Verdict: parenteral, but not oral, T seems to be effective for FSD with low desire/libido </li></ul>
  45. 45. Power Player #3 The Progestogens 9 <ul><li>Progestogens are synthetic molecules with progestinic activity </li></ul><ul><li>Protectors of endometrium </li></ul><ul><li>May mildly inhibit sexual desire </li></ul>
  46. 46. The Progestogens 9 <ul><li>Vary in activity from strongly antiandrogenic, to neutral, to androgenic depending upon their structure, the molecule the are derived from (progesterone vs. 19-nortestosterone) and their interaction with different hormonal receptors </li></ul><ul><li>Can interact with progestinic, estrogenic, androgenic glucocorticoid and mineralocorticoid receptors. THUS, the consequent metabolic and sexual profile is very different 12 </li></ul>
  47. 47. General Treatment Guidelines 1, 2 <ul><li>Education, Education, Education!! (anatomy, function, effects of aging) </li></ul><ul><li>Enhancing stimulation (erotic materials, masturbation) </li></ul>
  48. 48. General Treatment Guidelines 1, 2 <ul><li>Distraction techniques (fantasy, Kegel exercises with intercourse, backgound music or television) </li></ul><ul><li>Encouraging non-coital behaviors (massage) </li></ul><ul><li>Minimize pain (positional, lubricants, warm baths, biofeedback, NSAIDS prior to intercourse) 1,2 </li></ul>
  49. 49. Treatment of Hypoactive Sexual Disorders 2 <ul><li>Difficult </li></ul><ul><li>Often secondary to boredom, lifestyle factors, medications, or other sexual dysfunction </li></ul><ul><li>No (reliable, recognized) medical therapy available 2 </li></ul><ul><li>Estrogen therapy may help some, although this is not universal </li></ul><ul><li>Testosterone usage controversial </li></ul>
  50. 50. Estrogen for Treatment of Hypoactive Sexual disorders 2 <ul><li>Improves urogenital atrophy </li></ul><ul><li>Improves vasomotor symptoms </li></ul><ul><li>Improves menopausal mood disorders (depression) </li></ul><ul><li>Addition of progesterone believed to exhibit a negative impact by dampening mood and decreasing available androgens 2 </li></ul>
  51. 51. Testosterone for treatment of Hypoactive Sexual disorders 2 <ul><li>No treatment guidelines or consensus for “normal” or “therapeutic” levels </li></ul><ul><li>Lack of safety data </li></ul>
  52. 52. Testosterone for treatment of Hypoactive Sexual disorders 2 <ul><li>Numerous side effects (5-35% occurrence). Most reversible with discontinuation </li></ul><ul><li>acne </li></ul><ul><li>lowers HDL (10%) </li></ul><ul><li>clitorimegaly </li></ul><ul><li>voice deepening </li></ul><ul><li>hepatic carcinomas, hepatocellular damage 2 </li></ul>
  53. 53. Proposed Testosterone therapy protocol 2 <ul><li>Strictly recommendations; no evidence-based protocols available. </li></ul><ul><li>None of the mentioned medications are labeled by the FDA for the treatment of desire disorders. </li></ul>
  54. 54. Proposed Testosterone therapy protocol 2 <ul><li>Screening: </li></ul><ul><li>baseline testosterone levels (free and total) </li></ul><ul><li>Baseline lipid profile </li></ul><ul><li>hepatic enzyme levels </li></ul><ul><li>Mammogram </li></ul><ul><li>Pap smear </li></ul>
  55. 55. Proposed Testosterone therapy protocol 2 <ul><li>Initiation of therapy </li></ul><ul><li>Estratest </li></ul><ul><li>Methyltestosterone (Android), 1.25 to 2.5 mg daily </li></ul><ul><li>Micronized oral testosterone, 5mg PO bid </li></ul><ul><li>Testosterone propionate 2% in petroleum applied qod </li></ul><ul><li>Testosterone injections/pellets </li></ul>
  56. 56. Proposed Testosterone therapy protocol 2 <ul><li>Reevaluation at 3-4 months </li></ul><ul><li>Repeat testosterone levels </li></ul><ul><li>Repeat lipid profile </li></ul><ul><li>Repeat liver function tests </li></ul><ul><li>Assess symptoms and side effects </li></ul>
  57. 57. Proposed Testosterone therapy protocol 2 <ul><li>Continued therapy </li></ul><ul><li>Taper to lowest effective dosage </li></ul><ul><li>Monitor lipid levels and hepatic function once or twice each year </li></ul><ul><li>Routine pap and mammography schedules </li></ul>
  58. 58. Treatment of Sexual Arousal Disorders 2 <ul><li>Usually attributed to inadequate stimulation </li></ul><ul><li>Encourage foreplay </li></ul><ul><li>Encourage use of lubricants (vitamin E oil and mineral oil are options) </li></ul>
  59. 59. Treatment of Sexual Arousal Disorders 2 <ul><li>Most common cause is urogenital atrophy of the post menopausal woman </li></ul><ul><li>Often treated with estrogen </li></ul><ul><li>Intact uterus requires progesterone add back </li></ul><ul><li>Estring is option because it has little systemic absorption, and does not require progesterone add back. Many patients can achieve relief by only wearing the ring at night </li></ul>
  60. 60. Treatment of Sexual Arousal Disorders 2 <ul><li>Small vessel atherosclerotic disease of vagina and clitoris may contribute to arousal disorders. </li></ul><ul><li>This is the basis for evaluation of vasoactive medications such as viagra. </li></ul>
  61. 61. Treatment of Orgasmic Disorders 2 <ul><li>Responsive to therapy </li></ul><ul><li>Usually due to sexual inexperience or lack of sufficient stimulation </li></ul><ul><li>Treatment goal is to maximize stimulation and minimize inhibition </li></ul>
  62. 62. Treatment of Sexual Pain Disorders <ul><li>Vaginismus </li></ul><ul><li>counseling, relaxation, dilators </li></ul><ul><li>Dysparunia (superficial, vaginal, deep) </li></ul><ul><li>treat organic causes, lubrication, relaxation </li></ul>
  63. 63. When to refer 2 <ul><li>Longstanding dysfunction </li></ul><ul><li>Multiple dysfunctions </li></ul><ul><li>Current or past abuse </li></ul><ul><li>Psychological disorder or acute psychologic event </li></ul><ul><li>Unknown etiology </li></ul><ul><li>No response to therapy </li></ul>
  64. 64. Treatment Summary <ul><li>Difficult, but Education is key </li></ul><ul><li>Often secondary to lifestyle factors, medications, or other sexual dysfunction </li></ul><ul><li>No (reliable, recognized) medical therapy available 2 </li></ul><ul><li>Estrogen therapy may help some, although this is not universal </li></ul><ul><li>Testosterone usage controversial </li></ul><ul><li>Many prospects on the horizon </li></ul>
  65. 65. FSD-treatment options on the Horizon <ul><li>1. Androgens </li></ul><ul><li>2. Prostaglandins </li></ul><ul><li>3. Nitric oxide delivery systems </li></ul><ul><li>4. Dopaminergic agonists </li></ul><ul><li>5. Melanocortin stimulating hormone </li></ul><ul><li>6. Drugs useful for reducing pain in sexual pain disorders (ie-gabapentin) </li></ul>
  66. 66. Drug mechanism of action Probable indication Product Name Developing company (phase of development) Dopamine receptor agonist Desire Intranasal apomorphine Nasteck/Pharmacia (phase II) Nonselective a 1 - and a 2-adrenoceptor antagonist Arousal Oral phentolamine Zonagen (phase I)
  67. 67. Nitric oxide system Phosphodiesterase IV inhibitor Arousal Arousal Sildenafil Tadalafil Pfizer (phase II) Lilly/ICOS (phase II) Other nitric oxide donors Arousal Arginine + yohimbine NitroMed a -Melanocyte stimulating hormone analogue Desire and Arousal PT-141 Palatin (phase I) Prostaglandins (smooth muscle relaxant) Arousal Arousal Alprostadil topical gel Alprostadil topical Vivus (phase II) NexMed
  68. 68. Androgens Testosterone Desire Desire Transdermal testosterone Testosterone gel Watson/Proctor & Gamble (phase III) Cellegy Estrogen/androgen combination Desire Esterified estrogen/methyltestosterone Solvay Androgenic dietary supplements No claims for an indication (NRR) Multiple androgen substances Multiple sources
  69. 69. Thank you!
  70. 70. References <ul><li>1. Modelska K. Female Sexual Dysfunction in postmenopausal women: systematic review of placebo-controlled trials; Am J of Ob/Gyn . Jan 2003; 188(1): 286-93 </li></ul><ul><li>2. Phillips N. Female sexual dysfunction: evaluation and treatment. American Family Physician. 2000. http://www. aafp .org </li></ul><ul><li>3. Marwick C. Survey says patients expect little physician help on sex. JAMA. 1999;281:2173-4 </li></ul>
  71. 71. References <ul><li>4. Sullivan M. Alprostadil, vacuum decice oppose sexual dysfuntion in women. http://natural-hrt.com </li></ul><ul><li>5. Davis S. Female Sexual Dysfunction-androgens and female sexuality. http://natural- hrt .com </li></ul><ul><li>6. Grayson C. Sexual problems in women. http://my.webmd.com </li></ul><ul><li>7. Vannerson J. Female Sexual </li></ul><ul><li>Dysfunction-Questions and Answer Up to Date </li></ul>
  72. 72. References <ul><li>8. Female Sexual Dysfuntion. Http://news.bbc.co.uk/1/hi/health/medical_notes </li></ul><ul><li>9. Graziottin A. Is there enough evidence for the pharmacologic treatment of female sexual dysfunction. www.medscape.com/viewarticle/494297/ </li></ul><ul><li>10. Striar S, Bartlik B. Stimulation of the libido: the use of erotica in sex therapy. Psychiatr Ann . 1999;29:60-62. </li></ul>
  73. 73. References <ul><li>12 . Graziottin A Basson R. Management of sexual dysfunctions after premature menopause. Menopause 2004. (in press) </li></ul><ul><li>13. Guay A, Jacobsen J, Munarriz R et al. Serum androgen and androgen precursor hormone levels in women with and without sexual dysfunction. Int J Imp Res . 2004; 16: 121-129. </li></ul>
  74. 74. References <ul><li>14. Goldstat R. Briganti E, Tran J, et al. Transdermal testosterone therapy improves well-being, mood and sexual function in premenopausal women. M enopause . 2003;10: 390-398 </li></ul><ul><li>15. Stenchever, Droegemueller, Herbst, Mishell. Comprehensive Gynecology-4 th ed. 185-190. </li></ul>
  75. 75. References <ul><li>16. 2004 Compendium. ACOG Committee on Gynecologic Practice. Nov 2000; 24 :7-8. </li></ul><ul><li>17. Berman, JR. Female Sexual Dysfunction. Urology Clinics of North America. 01-May-2001: 28(2): 405-416 </li></ul><ul><li>18. Oelke M, Walkirch E et al. New research in female sexual dysfunction. Cyclic AMP and cyclic GMP phospodiesterase isoenzymes in the human vagina-relation to NOS isoforms and VIP-positive nerves. http:// medscape .com </li></ul>
  76. 76. References <ul><li>19. Masters EH, Johnson VE. Human Sexual Response. Boston, Little, Brown, 1966. 20. Kaplan HS. The New Sex Therapy: Active Treatment of Sexual Disorders. London, Bailliere Tindall, 1974. </li></ul><ul><li>21. Bachman GA, Phillips NA. Sexual dysfunction. In: Steege JF, Metzger DA, Levy BS, eds. Chronic Pelvic Pain: an integrated approach. Philadelphia: WB Saunders, 1998:77-90. </li></ul>