Treatment Approaches to Sexual Dysfunction

Assessment & Counseling - Talk It Out

• Assessment Steps:
  • Comprehensive History: Medical, sexual, psychosocial details.
  • Physical Examination: Identify/exclude organic contributions.
  • Partner Involvement: Assess relationship dynamics, if applicable.
  • Standardized Tools: Use FSFI, IIEF for objective measures.
• Counseling Focus:
  • Psychoeducation: Normal sexual function, dispel common myths.
  • Communication Training: Enhance dialogue for patient & partner.
  • Anxiety Management: Address performance fears, stress.
  • Realistic Goal Setting: Collaborative and achievable targets.

⭐ The PLISSIT model (Permission, Limited Information, Specific Suggestions, Intensive Therapy) is a key framework guiding stepped-care in sexual counseling.

Female Pharmacotherapy - Her Helpful Meds

• Estrogen Therapy (Local/Systemic):
  • GSM (dyspareunia). Improves vaginal lubrication, elasticity.
  • Local (creams, rings) preferred for isolated VVA.
• Testosterone (Off-label):
  • HSDD in postmenopausal women.
  • Transdermal. May ↑ desire. Monitor side effects.
• Flibanserin (Addyi):
  • HSDD (premenopausal). 100 mg daily bedtime.

  ⭐ ⚠️ Avoid alcohol (severe hypotension/syncope risk).

• Bremelanotide (Vyleesi):
  • HSDD (premenopausal). 1.75 mg SC PRN (45 min prior).
  • SE: Nausea, transient ↑BP.
• Ospemifene (Osphena):
  • SERM for mod-severe dyspareunia (VVA). 60 mg PO daily.
  • Risk: VTE.
• Bupropion (Off-label):
  • Antidepressant-induced SD (↓libido).

Male Pharmacotherapy & Devices - His Go-To Gear

• Pharmacotherapy (Erectile Dysfunction - ED):
  • PDE5 Inhibitors (1st Line):
    • Sildenafil (25-100 mg), Tadalafil (10-20 mg PRN; 2.5-5 mg daily), Vardenafil, Avanafil.
    • MOA: Inhibit PDE5 → ↑cGMP → smooth muscle relaxation → erection.
    • ⚠️ C/I: Nitrates. S/E: Headache, flushing, visual changes (Sildenafil), myalgia (Tadalafil), priapism (rare).
  • Alprostadil (PGE1) (2nd Line):
    • Intracavernosal Injection (ICI): 5-40 mcg.
    • Medicated Urethral System for Erection (MUSE): 125-1000 mcg.
    • S/E: Penile pain, fibrosis (ICI), priapism.
  • Testosterone Replacement Therapy (TRT): For confirmed hypogonadism.
• Devices:
  • Vacuum Erection Device (VED): External cylinder & pump; constriction ring. Non-invasive.
  • Penile Prosthesis (Implants): Surgical (malleable/inflatable). For refractory ED.

⭐ Tadalafil has the longest duration of action among PDE5 inhibitors (up to 36 hours), earning it the nickname "the weekend pill" and allowing for more spontaneous sexual activity compared to shorter-acting agents like Sildenafil.

Hormonal & Other Tx - Body & Beyond

• Hormonal:
  • Estrogen: Local (preferred for isolated VVA) or systemic for GSM/VVA dyspareunia.
  • Testosterone (transdermal): Postmenopausal HSDD (off-label). Monitor virilization.
  • Ospemifene (oral SERM): Moderate-severe VVA dyspareunia.
  • Prasterone (intravaginal DHEA): Moderate-severe VVA dyspareunia.
• Non-Hormonal Pharma:
  • Flibanserin (daily oral): Premenopausal HSDD. ⚠️ Alcohol (hypotension/syncope).
  • Bremelanotide (SC, as-needed): Premenopausal HSDD.
• Other:
  • Pelvic Floor PT: GPPPD, vaginismus (myofascial release, dilators).
  • Lubricants/Moisturizers: Dryness-related dyspareunia.
  • Vaginal Dilators: GPPPD, progressive desensitization.

⭐ Flibanserin, for premenopausal HSDD, acts on serotonin receptors (5-HT1A agonist/5-HT2A antagonist) and requires daily dosing.

High‑Yield Points - ⚡ Biggest Takeaways

• Biopsychosocial model is key for diagnosis and holistic management of sexual dysfunction.
• Psychosexual counseling (CBT, sensate focus) is a cornerstone for many dysfunctions.
• Flibanserin and Bremelanotide are FDA-approved for HSDD in premenopausal women.
• Estrogen therapy (local/systemic) treats Genitourinary Syndrome of Menopause (GSM) and associated dyspareunia.
• Testosterone therapy may be considered for postmenopausal HSDD; monitor closely.
• Pelvic floor physiotherapy is effective for vaginismus and some dyspareunia.
• Address underlying medical issues and medication side effects first.