00:00
welcome to the APGO sexual health
00:02
video series in this first video we will
00:05
review how to counsel your patients
00:07
about issues pertaining to sexuality and
00:09
sexual health sexual health is important
00:13
to a woman’s overall health and
00:15
well-being and the American College of
00:18
Obstetricians and Gynaecologists ACOG
00:21
recommends that sexual health be
00:23
incorporated into every well-woman visit
00:26
across the lifespan
00:29
data suggests that most women want
00:32
providers to bring up the topic of
00:34
sexuality during their healthcare visits
00:37
discussion of sexual health can prevent
00:39
unnecessary sexual health related
00:41
outcomes such as HIV and other sexually
00:44
transmitted infections unintended
00:47
pregnancies and sexual assaults it can
00:52
also uncover sexual problems gynecologic
00:55
and medical conditions and sexual
00:58
dysfunctions
01:01
although female sexual dysfunction is
01:04
common estimated to affect 43% of women
01:07
most OBGYNs don’t spend much time on
01:10
sexual health a 2012 survey found that
01:15
although 63% of practicing OBGYNs
01:18
routinely asked their female patients
01:19
about the types of sexual activities
01:21
they engage in they didn’t usually ask
01:24
about other sexual issues such as sexual
01:27
dysfunction as a clinician you must be
01:31
open to the idea that your patient may
01:33
be heterosexual lesbian bisexual or
01:38
sexually fluid she may not be sexually
01:42
active or she may be active with one or
01:45
many partners she also may have other
01:48
thoughts about her sexual identity do
01:52
not assume that all women are in stable
01:54
loving relationships monogamous using
01:58
contraception if they are of
02:00
reproductive age and sexually active and
02:03
are not being abused or coerced into
02:06
sexual activity by their partner this is
02:08
why it is so important to proactively
02:10
ask your patients about sexuality and
02:12
sexual health there are a number of
02:16
identified barriers to healthcare
02:18
provider patient discussions about
02:20
sexual health and history one of the
02:23
most common barriers is provider
02:25
discomfort in discussing sexually
02:27
related topics it is important to
02:30
reflect upon your personal comfort level
02:33
and identify your biases about sexuality
02:35
to reduce your discomfort
02:38
by routinely engaging in sexuality
02:41
discussions with your patients you will
02:43
increase your confidence level in this
02:45
area just as you would with any other
02:47
skill other provider barriers are the
02:52
fear that screening will be too
02:53
time-consuming for a busy clinical
02:55
practice and the mistaken belief that
02:57
there are no or few safe yet effective
03:00
treatment options available another
03:03
barrier is the notion that you have
03:05
failed a patient if you have to refer
03:07
her to a specialist in fact you may help
03:10
her more by developing a referral
03:12
network of specialized providers who
03:14
have the skills to treat her to overcome
03:19
provider barriers consider scheduling
03:22
visits specifically for the purpose of
03:24
focusing on sexual health issues with
03:26
patients particularly if a patient
03:29
expresses a sexual concern it is also
03:33
helpful to offer and discuss handouts
03:35
and educational website information as
03:37
well as provide other resources on
03:40
sexuality topics to patients
03:43
specific practical conversation
03:46
techniques for overcoming provider and
03:48
patient barriers include asking
03:50
open-ended questions to solicit more
03:53
revealing answers beyond yes or no
03:56
examples include what sexual concerns
03:59
would you like to talk about instead of
04:02
do you have any sexual concerns you want
04:05
to discuss or how does your sexual
04:08
concern affect your relationship with
04:10
your partner instead of does your sexual
04:14
concern affect your relationship with
04:15
your partner you may also consider
04:19
pointed detailed questions thereafter to
04:22
better characterize our sexual problem
04:25
follow a pattern of asking an open-ended
04:28
question educating and then asking
04:32
another question
04:35
other effective communication techniques
04:38
include speaking and neutral and
04:40
inclusive terms meaning you are
04:42
non-judgmental and include all forms of
04:45
possible sexual expression heterosexual
04:48
lesbian etc for instance use the term
04:53
partner instead of husband or boyfriend
04:56
if you are uncomfortable you should
05:00
strive not to over react this requires
05:03
that you take care and what you say and
05:05
in how you communicate non-verbally in
05:08
terms of your body language and posture
05:11
also be aware of the effective use of
05:13
silence as it may take patients some
05:17
time to reveal awkward but salient
05:19
information about their sexuality
05:22
in order to effectively counsel and
05:25
educate patients it is important that
05:27
you understand the female sexual
05:29
response the traditional model of female
05:33
sexuality developed by William masters
05:35
in Virginia Johnson suggested that like
05:38
in men arousal and sexual desire
05:40
proceeded in a linear manner to plateau
05:43
orgasm and resolution it should be noted
05:48
that women can also experience
05:49
resolution without orgasm Kaplan added
05:53
the concept of desire to that model but
05:57
it’s clear that a woman’s sexual
05:58
response is much more dynamic and
06:00
multifactorial than a straight line
06:02
progression there are now multiple
06:04
different models and theories and there
06:06
is no one accepted model
06:10
dr. rosemary Bosson of the Center for
06:13
sexual medicine at Vancouver General
06:15
Hospital has developed a circular model
06:18
of female sexuality that incorporated
06:20
emotional components this model suggests
06:24
that female sexuality is multifactorial
06:27
and heterogeneous and that the desire
06:30
for sexual activity may be motivated
06:32
more by a desire for emotional intimacy
06:34
than for sexual release to put it
06:38
another way
06:39
this model demonstrates that women can
06:42
have a reactive libido they may start
06:45
off in a sexually neutral frame of mind
06:46
but become interested in sex if their
06:49
partner approaches them they may also
06:52
experience arousal before desire many
06:56
physical psychological societal cultural
07:00
and interpersonal factors impact sexual
07:03
health including changes in sexual
07:06
function throughout the lifecycle life
07:10
transitions such as divorce or death of
07:13
a partner chronic or acute illness
07:16
including gynecologic disorders and
07:18
long-term disability medications
07:24
sexually transmitted infections or sti’s
07:28
violence and trauma stigmas and
07:32
religious beliefs use of tobacco drugs
07:36
and alcohol work life family and
07:40
financial stress changes in sexual
07:44
self-esteem including body image and the
07:46
perception of oneself as a sexual being
07:50
although it is acknowledged that sexual
07:53
problems are common the definition of
07:56
sexual dysfunction hinges on whether or
07:59
not it causes quote clinically
08:02
significant distress in the individual
08:06
in other words a woman is unable to
08:09
participate in sexual activity as she
08:12
wishes without distress treatment for a
08:16
sexual problem may not be necessary
08:20
statistically speaking 43% of American
08:23
women report a sexual problem but sexual
08:27
dysfunction causing distress is less
08:29
common at around twenty two point eight
08:31
percent newer definitions of sexual
08:35
dysfunctions released with the
08:37
Diagnostic and Statistical Manual
08:38
Edition 5 in 2013 specify that a problem
08:43
should be present for a minimum duration
08:45
of six months to be diagnosed as a
08:48
sexual dysfunction the provider is also
08:52
advised to rule out other potential
08:54
reasons for the sexual problem again
08:57
many problems although distressing may
09:01
be transient and may not meet the
09:03
official definition for a sexual
09:05
dysfunction prior to the release of the
09:08
dsm-5 OBGYNs relied on the DSM fourth
09:12
edition text revision which had four
09:14
categories of sexual dysfunction for
09:16
women some providers find these older
09:20
categories more clinically useful than
09:22
the dsm-5 categories and terms used in
09:26
the DSM 40 are such as hypoactive sexual
09:29
desire disorder or HSDD are still used
09:33
today in the dsm-5 patterns of female
09:37
sexual dysfunction focus on chronic
09:39
symptoms involving interest arousal
09:42
orgasm and pain female sexual
09:47
dysfunctions are interrelated and
09:49
overlapping and the presenting
09:51
dysfunction may not be the primary
09:53
dysfunction for example decreased
09:58
arousal can lead to a lack of vaginal
10:00
lubrication and thus pain with
10:02
intercourse
10:03
which can decrease desire alternatively
10:07
decrease desire can lead to decreased
10:09
arousal which can lead to pain which is
10:12
the presenting dysfunction in the next
10:16
few slides we will review the dsm-5
10:18
categories low desire with distress is
10:23
the most frequent female sexual
10:25
dysfunction with 8 to 10 percent of
10:28
women meeting the diagnostic criteria
10:32
female sexual interest arousal disorder
10:35
is defined as lack of or significantly
10:38
reduced sexual interest arousal in 3 of
10:42
the following aspects
10:50
female orgasmic disorder is the presence
10:53
of either of the following 75 to 100
10:57
percent of the time during sexual
10:59
activity
11:01
jeanna doe pelvic pain penetration
11:04
disorder is defined by persistent or
11:07
recurrent difficulties with one or more
11:10
of the following
11:16
for more information on counseling
11:18
sexual health response cycles and sexual
11:22
health dysfunctions please refer to the
11:24
references at the end of this video
11:28
continue on to the next video in this
11:30
series to learn more about how to take a
11:32
sexual history and assess and treat
11:34
female sexual dysfunctions
11:44
you

00:00
welcome to the second video in the APGO
00:03
sexual health video series this video
00:05
focuses on how to complete a
00:07
comprehensive sexual history and perform
00:09
a directed physical exam for sexual
00:11
concerns it will also briefly address
00:13
treatment strategies at the end of this
00:16
video or a list of resources mentioned
00:18
in this series incorporating a sexual
00:22
history into well woman care is a way to
00:24
increase your comfort level with
00:26
discussing sexual health with your
00:27
patients as well as identifying and
00:29
treating sexual problems or dysfunctions
00:31
early the sexual history can be included
00:34
in a review of systems in the section on
00:37
social history or in response to answers
00:40
on a waiting room questionnaire ideally
00:43
it should be conducted before the
00:44
physical exam while a woman is fully
00:46
clothed to reduce her feelings of
00:48
anxiety and vulnerability
00:52
this algorithm from the National
00:54
Coalition for sexual health could be
00:55
used as a starting point for the
00:57
conversation however a clinician should
00:59
tailor questioning to his or her
01:01
practice style and incorporate
01:03
open-ended questions if the patient has
01:05
a specific complaint then more specific
01:08
questions may be asked to better
01:09
understand her specific sexual concern
01:11
if needed a separate appointment can be
01:14
made to discuss sexual concerns the ACOG
01:18
opinion report number 706 titled sexual
01:21
health has a more detailed list of
01:23
questions to ask during the sexual
01:24
history including questions on the 4ps
01:28
partners practices protection from s-cis
01:31
and past history of esti is physical
01:37
examination should be performed as
01:39
necessary to evaluate for sexual
01:41
disorders this examination is usually
01:44
based on a patient’s complaints and
01:45
reproductive stage of life for instance
01:48
in a mature woman complaining a vaginal
01:51
dryness with dyspareunia pain during
01:53
intercourse you would perform a genital
01:55
pelvic assessment to evaluate for
01:57
genitourinary syndrome of menopause in a
02:00
younger woman complaining of discharge
02:01
in dyspareunia genital infections should
02:04
be ruled out in cases of dyspareunia the
02:07
genital exam should try to reproduce the
02:09
pain a detailed physical examination
02:12
should not be dismissed if the patient
02:14
is complaining of other symptoms
02:15
for instance if thyroid symptoms are
02:18
elicited during the history and may be
02:20
associated with decreased libido a
02:21
detailed thyroid evaluation should be
02:24
performed
02:27
consult this table from Kingsburg and
02:29
janata for a more comprehensive
02:30
description of the euro gynecologic exam
02:33
for conditions that can impair sexual
02:35
function and assist in diagnosis
02:37
referral for a full evaluation by a more
02:40
experienced clinician as an option if
02:42
you do not feel you have the skills to
02:43
do a more advanced physical exam for
02:45
sexual health issues a number of
02:49
interventions can be employed for all
02:51
forms of female sexual dysfunction we
02:54
will now review global interventions and
02:56
disorder specific interventions it can
03:00
be useful to remember the placet model
03:02
when discussing sexual health treatment
03:04
with patients it consists of giving
03:07
permission to raise sexual issues to use
03:09
suggestions and try new things
03:12
giving limited information about a
03:14
sexual concern including clarifying
03:17
misinformation dispelling myths and
03:19
providing limited factual information
03:22
making specific suggestions about the
03:25
problem in question and offering or
03:29
referring the patient for intensive
03:30
therapy for the problem Global
03:35
interventions for all dysfunctions
03:37
include ruling out underlying medical
03:39
illness or anatomical pathology or
03:41
conditions as well as medications that
03:43
may have direct sexual side-effects you
03:46
can and should also educate the patient
03:48
about the specific sexual dysfunction
03:50
and provide appropriate literature or
03:52
handouts for her to review at her
03:53
discretion
03:54
you may also prescribe medications for
03:57
certain underlying sexual medical issues
04:01
structured sexual tasks such as
04:03
masturbation self-stimulation using a
04:05
vibrator as well as simple sense 8 focus
04:08
and mindfulness exercises may be helpful
04:10
recommendations these are typically
04:12
included in marital and sex therapy
04:14
counseling sessions under a form of
04:16
cognitive behavioral therapy sense8
04:19
focus exercises eliminate orgasm as the
04:22
goal of sexual encounters and instead
04:24
focus on body awareness and the types of
04:26
stimulation that makes a woman feel good
04:28
these exercises also initially avoid any
04:31
erotic stimulation and promote good
04:34
communication with a partner mindfulness
04:37
is a technique to help a woman focus on
04:39
what is happening and what she is
04:40
feeling in the present moment and not
04:42
judge her experience in the next section
04:46
of this video we will review disorder
04:48
specific interventions the dsm-5
04:52
combines desire and arousal disorders
04:54
here we will review them separately as
04:57
lack of or low desire with distress is
04:59
the most common female sexual
05:00
dysfunction and the term hypoactive
05:03
sexual desire disorder or HSDD is still
05:06
commonly used one intervention for lack
05:09
of desire is to educate patients that
05:11
their experience is normal and that
05:13
there are safe effective treatments
05:14
available the knowledge that a woman may
05:18
not feel spontaneous desire or may be
05:20
motivated more by a desire for emotional
05:22
intimacy with her partner than for
05:23
sexual release may be all that is needed
05:26
to improve her sex life books and other
05:29
resources may also be helpful
05:32
prescribing medication for lack of
05:34
desire is another option there is
05:36
emerging data on the value of medication
05:39
and a woman should be offered medication
05:41
without judgment as part of her
05:42
treatment paradigm flibanserin is
05:47
currently the only fda approved drug for
05:49
generalized acquired HSDD and is
05:51
indicated for pre menopausal women it is
05:54
a non hormonal agent that affects
05:55
neurotransmitters that influence sexual
05:57
desire clinical data suggests that
06:00
approximately half of women with HSDD
06:02
may respond to flibanserin adverse
06:05
events include dizziness somnolence and
06:07
nausea the risk of hypotension and
06:10
syncope increase when flibanserin is
06:11
taken with certain other drugs or
06:13
alcohol
06:14
women should discontinue drinking
06:15
alcohol at least two hours before taking
06:18
flibanserin at bedtime
06:19
the drug is only available under a risk
06:22
evaluation and mitigation strategy REMS
06:24
and clinicians must be certified to
06:26
prescribe it testosterone therapy is
06:29
another option for some women with HSDD
06:31
but currently is not fda-approved for
06:33
treatment in either pre or
06:34
postmenopausal women interventions for
06:39
arousal issues include educating a woman
06:41
about the mechanics of arousal and
06:43
genital engorgement and conducting an
06:45
instructional pelvic examination to help
06:47
a woman identify the clitoris clinicians
06:51
can also recommend reading materials and
06:52
resources mindfulness exercises directed
06:56
masturbation to help a woman identify
06:57
what kinds of stimulation arouse her and
06:59
sense8 focus exercises increasing
07:04
stimulation with longer directed
07:05
foreplay or use of a vibrator during
07:07
partnered sexual encounters may also be
07:09
suggested another simple practical
07:13
recommendation is use of
07:14
over-the-counter topical arousal creams
07:16
these creams which are wrapped into the
07:19
genital area are reported to increase
07:21
blood flow to the clitoris and genitals
07:22
and may result in improved genital and
07:24
gorge mint although there is limited
07:27
data on these products they can be used
07:29
successfully in some women skin
07:32
irritation may develop in some so an
07:35
initial trial with a small amount even
07:37
in a non genital location as prudent
07:40
women with female orgasmic disorder may
07:43
lack body awareness about how to have an
07:45
orgasm or may have misperceptions that
07:47
they should be having vaginal orgasms
07:49
during intercourse or simultaneous
07:52
orgasms with their partner both in fact
07:54
occur rarely they may benefit from basic
07:58
sex education accompanied by an
08:00
instructional pelvic exam to identify
08:02
the clitoris reading materials and
08:05
resources can be helpful to increase
08:07
understanding of anatomy and dispel
08:08
myths clinicians should discuss methods
08:11
of increased stimulation such as
08:13
vibrators as well as where and how to
08:16
obtain them this is an example of using
08:19
the P implicit permission to try new
08:22
things
08:25
many women have pelvic floor problems
08:27
such as laxity prolapse or poor muscle
08:31
contraction for these women instructions
08:34
on how to perform pelvic floor exercises
08:35
often referred to as kegels can help
08:38
strengthen and improve control of these
08:40
muscles in other cases referral to a
08:43
genital pelvic floor physical therapists
08:45
for therapy may be appropriate
08:47
of course the clinician should evaluate
08:49
all medications the patient is taking
08:51
that may be inhibiting her orgasmic
08:53
response and inquire about relationship
08:56
psychosexual issues that may be
08:57
impacting her sexual function there is
09:01
emerging data on laser and
09:02
radiofrequency however these new
09:05
technologies are not currently approved
09:07
or indicated for treatment of female
09:08
orgasmic disorder
09:12
genital pelvic pain penetration
09:14
disorders include dyspareunia and
09:16
vaginismus treatments for dyspareunia
09:19
caused by vaginal a traffic changes part
09:22
of the genitourinary syndrome of
09:24
menopause include non prescription
09:26
moisturizers which must be used on a
09:28
regular basis to improve the elasticity
09:30
and pliability of genital tissues
09:33
moisturizers maintain vaginal health
09:35
independent of coitus in addition there
09:38
are many types of lubricants which are
09:40
used to reduce friction during sexual
09:41
activity patients should be advised to
09:45
read labels carefully as lubricants have
09:47
different bases only water-based
09:49
lubricants should be combined with
09:50
condom use for women who do not find
09:54
adequate relief with over-the-counter
09:55
products prescription products may be
09:58
added approved medical prescription
10:00
products for dyspareunia such as
10:02
estrogen cream ring tablets or soft gel
10:05
caps may be considered along with sex
10:08
steroid vaginal suppositories DHEA
10:10
vaginal inserts or the oral Surma spam
10:13
afine for women who are estrogen
10:16
deficient these products may also aid in
10:18
lubrication and arousal
10:22
new terminology now considers vaginismus
10:25
part of GP PPD it is the involuntary
10:28
spasm of the musculature of the outer
10:30
third of the vagina that interferes with
10:32
sexual intercourse treatment typically
10:35
involves systematic desensitization a
10:38
combination of cognitive and behavioral
10:40
psychotherapy counseling to help a woman
10:42
overcome anticipatory anxiety about pain
10:44
on penetration and progressive vaginal
10:46
dilation for complicated or
10:51
long-standing sexual problems or
10:52
dysfunctions you may wish to refer
10:55
patients to a sexual health therapist or
10:57
a couples counselor for individual
10:59
couples or sex therapy or a gynecologist
11:02
who specializes in sexual disorders
11:05
pelvic floor therapy from a qualified
11:07
physical therapist may also be
11:09
beneficial you may decide to refer
11:13
because you feel you lack the technical
11:14
expertise to adequately manage the
11:16
patient or because the sexual problem is
11:19
best served by a multidisciplinary team
11:20
approach when referring be sure to
11:25
normalize the nature of the patient’s
11:26
problem and the commonality of referrals
11:28
to gain the patient’s acceptance and
11:30
follow-through with the referral you can
11:33
also recommend books or other resources
11:35
for patients to consult about their
11:37
sexual dysfunction there are many
11:40
excellent consumer books on the market
11:42
some recommended books are listed here
11:44
and at the end of the video in
11:47
conclusion female sexual dysfunction is
11:50
a common problem in the United States
11:52
and sexual health is an important
11:54
component of well woman care across the
11:56
lifespan that can reduce the incidence
11:58
of risky sexual practices sti’s
12:01
unintended pregnancies and sexual
12:04
assaults gaining confidence and
12:07
overcoming discomfort in discussing and
12:09
diagnosing sexual concerns is critical
12:11
to your competence as a gynecologist in
12:13
the 21st century you may wish to manage
12:16
simple sexual problems or you may prefer
12:19
to refer all cases of sexual dysfunction
12:21
to specialists either approach is
12:24
acceptable as long as a woman receives
12:26
the help she needs to improve her sexual
12:28
and overall health and quality of life
12:39
you