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Ask Stanford Med: Director of Female Sexual Medicine Program responds to questions on sexual health

7058874009_eeff99aae6 (1)In some circles, the term "female sexual health" may elicit more blushing than productive conversation, even between a woman and her gynecologist. So for this installment of Ask Stanford Med, we invited Leah Millheiser, MD, director of Stanford's Female Sexual Medicine Program, to respond to readers' questions on the topic. Below are her answers, which we hope will generate more open discussion on a health subject important to both women and men.

Heather asks: Why are there no FDA-approved medications for female sexual disorders and several for men? Will there ever be a Viagra-type drug for women?

That’s an excellent question, Heather, and one that I am frequently asked by my patients. There are two drugs FDA-approved for the treatment of female sexual dysfunction (FSD) compared to the seven available for the treatment of male erectile dysfunction. Premarin vaginal cream has been around for many years for the treatment of vaginal atrophy in postmenopausal women. However, in 2008, the FDA approved Premarin for a new indication - the treatment of postmenopausal sexual pain (dyspareunia). Earlier this year, Osphena was also approved for the treatment of postmenopausal dyspareunia. Osphena is an oral pill taken on a daily basis that belongs to a class of drugs called Selective Estrogen Receptor Modulators (SERMs). Unfortunately, we still have a long way to go when it comes to closing the gap between FDA-approved treatments available to men vs. those available to women. Currently, many women are being treated for sexual dysfunction with off-label treatments. These are medications that have been shown in research to be safe and effective for the treatment of FSD (desire, arousal, orgasm, and pain disorders). The good news is that there are several drugs currently under investigation for the treatment of low libido and arousal disorders. Learn more about female sexual dysfunction here.

Emily asks: Is there any connection between female sexual health disorders and infertility?

There is definitely a connection between female sexual function issues and infertility, Emily. In a 2010 study (subscription required) published in Fertility and Sterility, we demonstrated that women with infertility were at a higher risk for sexual dysfunction compared to women without infertility. Specifically, the women with infertility had greater difficulty with sexual arousal and desire. On the flip side, when a woman is experiencing sexual dysfunction, she may limit or avoid sexual activity altogether. This limitation may prevent a woman from becoming pregnant. In fact, many patients are referred to me from infertility centers with a diagnosis of sexual pain, most commonly vaginismus. Vaginismus occurs when there is an involuntary contraction of the pelvic floor muscles during attempted or actual vaginal penetration. Oftentimes, partners of women with vaginismus will describe the sensation of “hitting a brick wall” whenever they try to enter the vagina. Individuals with this disorder may avoid seeing a gynecologist for yearly exams due to the fear of pain. The treatment for vaginismus is quite successful and, in the motivated patient, can be completed in a relatively short period of time. From a financial perspective, it is often more cost-effective to address the sexual dysfunction prior to embarking on what can end up being very expensive fertility treatments. Learn more about the relationship between infertility and female sexual dysfunction here.

Grace asks: What is the relationship between body image/low self-esteem and low sex drive in women?

When a woman comes to see me for a complaint of low sex drive, we focus on several areas of her health: general medical disorders, medications, surgeries, pregnancy history, mental health, relationship history, as well as psychosocial stressors. When taking a patient’s mental health history, I always screen for depression/anxiety and discuss body image and self-esteem. There are many reasons why a negative body image can affect a woman, including dissatisfaction with body image following pregnancy, menopause, or treatment for cancer (breast, gynecologic). In the case of pregnancy, the data shows that most couples resume intercourse after six weeks; however, the frequency is usually decreased compared to pre-pregnancy, which can be related to low body image. If a woman does not feel comfortable with her own body, she may avoid situations of intimacy with her partner. This avoidant behavior becomes associated with low sex drive. Following menopause, many women find that they gain weight easily, especially in the abdominal area, and have difficulty losing it. Additionally, they may develop low libido and vaginal atrophy, which can lead to painful intercourse. In many cases, women feel as though their bodies have “turned against them” following menopause and, as a result, their body image and sexual self-esteem are impacted. In the setting of breast cancer, women may experience negative body image as a result of chemotherapy-related hair loss or surgical treatment, including mastectomy or lumpectomy. In fact, data shows that premenopausal women who undergo mastectomy experience greater issues related to poor body image compared to postmenopausal women treated with the same surgery.

M. Johnson asks: I take a lot of spin classes and I was interested to get your perspective on a past study showing the bicycling can affect a women’s sexual health. Is this something that bike commuters, or avid spin class takers such as myself, should be concerned about?

I love this question, as it is so relevant to the population of woman I see in my office here in Northern California. We have an avid bike-riding community, and it is not uncommon to hear about vulvar sensation and orgasm difficulties, especially in those women who bike greater than 10 miles a day most days of the week. Several studies have shown that placing pressure on the perineum can lead to decreased vulvar sensation and numbness. As a result, sexual arousal and orgasm can be negatively impacted. Studies have also revealed that these symptoms are more prevalent in women using handlebars positioned lower than the saddle of their bike or by using a saddle that places direct pressure on the perineum. Although greater studies are warranted, it may be helpful for women to use a “noseless” saddle that only places pressure on the sit bones.

Carrie asks: Are there any herbal remedies that are effective for treating certain types of female sexual dysfunction, such as low sex drive?

There are currently two nutraceuticals available for the treatment of female sexual dysfunction that have been compared to a placebo in research studies and have been shown to be effective. The first one is Arginmax and the research study can be found here. Arginmax is a blend of L-arginine, ginkgo, damiana, ginseng, as well as calcium, iron, zinc and various vitamins. The data shows that Arginmax significantly improves sexual desire and sexual relationship with a partner, as well as satisfaction with sex life. The other nutraceutical is Zestra, which has been shown in two studies to significantly improve several domains of sexual functioning: desire, arousal and sexual satisfaction. The data can be found here. Zestra is a blend of botanical oils/extracts including Evening Primrose Oil, Borage Seed Oil, Coleus Extract, Angelica Extract, as well as vitamins C and E. It is applied topically to the vulva. Both Arginmax and Zestra are hormone-free and are available without a prescription.

Previously: Ask Stanford Med: Director of Female Sexual Medicine Program taking questions on sexual healthShining the spotlight on women’s sexual health and Birth control pill may lead to sexual problems for women
Photo by Francisco Osorio

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