NAMS 2015 Annual Meeting

LAS VEGAS – Female desire and sexual function involve a complicated and interconnected cascade of hormones and neurotransmitters, each providing a potential target for modulation in cases of low desire or sexual dysfunction.

There are some pharmacologic options available now and more drugs in the pipeline, Dr. Roya Rezaee said at the NAMS 2015 annual meeting.

Dr. Rezaee, codirector of the Program for Sexual Health and Vulvovaginal Disorders at University Hospitals Case Medical Center, Cleveland, explained how each treatment acts in the chemical cascade of desire and sexual response.* Though much remains unknown, researchers have identified neurochemical pathways of desire and arousal that act on the brain stem, the hypothalamus, and the amygdala.

Among the neurotransmitters and neurohormones thought to promote female sexual function, dopamine and melanocortin are associated with attention and desire, while norepinephrine and oxytocin are more directly related to arousal. Estrogen and testosterone function as excitatory neurohormones. Serotonin, because it is associated with satiety, may be inhibitory, as are prolactin and the endogenous opioids and endocannabinoids.

In the peripheral tissues, the presence of sex hormones maintains general genital function. For example, estradiol not only promotes vaginal lubrication, but also helps maintain adequate blood flow to the vagina and clitoris. Exogenous testosterone can directly influence the amount of unbound estrogen as well as testosterone, said Dr. Rezaee. Higher testosterone levels downregulate sex hormone–binding globulin, increasing circulating levels of free estrogen and testosterone.

“For women, low testosterone does not always correlate with low desire, but testosterone administration has been shown to be efficacious for low desire,” Dr. Rezaee said. “People are still writing prescriptions for testosterone off label, because a lot of us believe in the data,” she said, adding that a 2009 Cochrane review showed a good safety profile for testosterone.

Targeting dopaminergic pathways to increase desire, an extended-release daily oral combination of trazodone and bupropion, to be marketed as Lorexys, is about to begin phase III clinical trials. Bupropion, a norepinephrine and dopamine reuptake inhibitor, has been known to have prosexual side effects, Dr. Rezaee said. Both ingredients in Lorexys are currently approved as antidepressants.

Increasing available norepinephrine may help with focus and attention, and increase subjective sexual excitement. However, the ADHD and antidepressant medications that increase norepinephrine carry significant side effects and should not be what physicians use to help their patients with low desire, Dr. Rezaee said.

“Serotonin may have a role in low desire by acting as a sexual satiety signal, and SSRIs are serotonergic agents that inhibit desire, arousal, and orgasm in the brain and in the tissue,” she said.

However, there are seven known families of serotonin receptors, and selective modulation specifically of the 5-hydroxytryptamine receptor 1A and 5-HT_2A receptors may have prosexual effects. The newly approved medication flibanserin (Addyi) is a selective agonist for 5-HT_1A and an antagonist for 5-HT_2A receptors. Flibanserin is also thought to produce upregulation in dopamine and norepinephrine in the prefrontal cortex, combating the satiety signals from serotonin and leading to increased desire.

Other medications that are 5-HT_1A agonists with potential prosexual effects include buspirone (Buspar) and trazodone (Desyrel, Oleptro).

Blockade of phosphodiesterase type 5 (PDE5) permits relaxation of smooth muscles in arterial walls and increases blood flow to erectile tissues. PDE5 inhibitors such as sildenafil (Viagra) may be of benefit to some women as well, said Dr. Rezaee, though they do not address low desire.

“Newer data support the use of PDE5 inhibitors with women who suffer from SSRI-induced orgasmic complaints of increased latency or decreased intensity, or anorgasmia,” she said. A dose of 25-50 mg of sildenafil 1 hour before sexual activity may help these patients, she advised.

Phase II trials have been completed for two other combination drugs to treat female sexual problems. Lybrido is a combination of testosterone and sildenafil, while Lybridos combines testosterone with buspirone. Both products are oral tablets, taken on demand.

Bremelanotide is a first-in-class drug in development as a melanocortin agonist. This drug, meant to be used on demand to activate an endogenous pathway that increases attention and desire, is in phase III clinical trials.

Dr. Rezaee reported having no relevant financial disclosures.

[email protected]
On Twitter @karioakes

 *Correction, 10/20/2015: An earlier version of this story misstated Dr. Rezaee's title. 

LAS VEGAS – Female desire and sexual function involve a complicated and interconnected cascade of hormones and neurotransmitters, each providing a potential target for modulation in cases of low desire or sexual dysfunction.

There are some pharmacologic options available now and more drugs in the pipeline, Dr. Roya Rezaee said at the NAMS 2015 annual meeting.

Dr. Rezaee, codirector of the Program for Sexual Health and Vulvovaginal Disorders at University Hospitals Case Medical Center, Cleveland, explained how each treatment acts in the chemical cascade of desire and sexual response.* Though much remains unknown, researchers have identified neurochemical pathways of desire and arousal that act on the brain stem, the hypothalamus, and the amygdala.

Among the neurotransmitters and neurohormones thought to promote female sexual function, dopamine and melanocortin are associated with attention and desire, while norepinephrine and oxytocin are more directly related to arousal. Estrogen and testosterone function as excitatory neurohormones. Serotonin, because it is associated with satiety, may be inhibitory, as are prolactin and the endogenous opioids and endocannabinoids.

In the peripheral tissues, the presence of sex hormones maintains general genital function. For example, estradiol not only promotes vaginal lubrication, but also helps maintain adequate blood flow to the vagina and clitoris. Exogenous testosterone can directly influence the amount of unbound estrogen as well as testosterone, said Dr. Rezaee. Higher testosterone levels downregulate sex hormone–binding globulin, increasing circulating levels of free estrogen and testosterone.

“For women, low testosterone does not always correlate with low desire, but testosterone administration has been shown to be efficacious for low desire,” Dr. Rezaee said. “People are still writing prescriptions for testosterone off label, because a lot of us believe in the data,” she said, adding that a 2009 Cochrane review showed a good safety profile for testosterone.

Targeting dopaminergic pathways to increase desire, an extended-release daily oral combination of trazodone and bupropion, to be marketed as Lorexys, is about to begin phase III clinical trials. Bupropion, a norepinephrine and dopamine reuptake inhibitor, has been known to have prosexual side effects, Dr. Rezaee said. Both ingredients in Lorexys are currently approved as antidepressants.

Increasing available norepinephrine may help with focus and attention, and increase subjective sexual excitement. However, the ADHD and antidepressant medications that increase norepinephrine carry significant side effects and should not be what physicians use to help their patients with low desire, Dr. Rezaee said.

“Serotonin may have a role in low desire by acting as a sexual satiety signal, and SSRIs are serotonergic agents that inhibit desire, arousal, and orgasm in the brain and in the tissue,” she said.

However, there are seven known families of serotonin receptors, and selective modulation specifically of the 5-hydroxytryptamine receptor 1A and 5-HT_2A receptors may have prosexual effects. The newly approved medication flibanserin (Addyi) is a selective agonist for 5-HT_1A and an antagonist for 5-HT_2A receptors. Flibanserin is also thought to produce upregulation in dopamine and norepinephrine in the prefrontal cortex, combating the satiety signals from serotonin and leading to increased desire.

Other medications that are 5-HT_1A agonists with potential prosexual effects include buspirone (Buspar) and trazodone (Desyrel, Oleptro).

Blockade of phosphodiesterase type 5 (PDE5) permits relaxation of smooth muscles in arterial walls and increases blood flow to erectile tissues. PDE5 inhibitors such as sildenafil (Viagra) may be of benefit to some women as well, said Dr. Rezaee, though they do not address low desire.

“Newer data support the use of PDE5 inhibitors with women who suffer from SSRI-induced orgasmic complaints of increased latency or decreased intensity, or anorgasmia,” she said. A dose of 25-50 mg of sildenafil 1 hour before sexual activity may help these patients, she advised.

Phase II trials have been completed for two other combination drugs to treat female sexual problems. Lybrido is a combination of testosterone and sildenafil, while Lybridos combines testosterone with buspirone. Both products are oral tablets, taken on demand.

Bremelanotide is a first-in-class drug in development as a melanocortin agonist. This drug, meant to be used on demand to activate an endogenous pathway that increases attention and desire, is in phase III clinical trials.

Dr. Rezaee reported having no relevant financial disclosures.

[email protected]
On Twitter @karioakes

 *Correction, 10/20/2015: An earlier version of this story misstated Dr. Rezaee's title. 

LAS VEGAS – Female desire and sexual function involve a complicated and interconnected cascade of hormones and neurotransmitters, each providing a potential target for modulation in cases of low desire or sexual dysfunction.

There are some pharmacologic options available now and more drugs in the pipeline, Dr. Roya Rezaee said at the NAMS 2015 annual meeting.

Dr. Rezaee, codirector of the Program for Sexual Health and Vulvovaginal Disorders at University Hospitals Case Medical Center, Cleveland, explained how each treatment acts in the chemical cascade of desire and sexual response.* Though much remains unknown, researchers have identified neurochemical pathways of desire and arousal that act on the brain stem, the hypothalamus, and the amygdala.

Among the neurotransmitters and neurohormones thought to promote female sexual function, dopamine and melanocortin are associated with attention and desire, while norepinephrine and oxytocin are more directly related to arousal. Estrogen and testosterone function as excitatory neurohormones. Serotonin, because it is associated with satiety, may be inhibitory, as are prolactin and the endogenous opioids and endocannabinoids.

In the peripheral tissues, the presence of sex hormones maintains general genital function. For example, estradiol not only promotes vaginal lubrication, but also helps maintain adequate blood flow to the vagina and clitoris. Exogenous testosterone can directly influence the amount of unbound estrogen as well as testosterone, said Dr. Rezaee. Higher testosterone levels downregulate sex hormone–binding globulin, increasing circulating levels of free estrogen and testosterone.

“For women, low testosterone does not always correlate with low desire, but testosterone administration has been shown to be efficacious for low desire,” Dr. Rezaee said. “People are still writing prescriptions for testosterone off label, because a lot of us believe in the data,” she said, adding that a 2009 Cochrane review showed a good safety profile for testosterone.

Targeting dopaminergic pathways to increase desire, an extended-release daily oral combination of trazodone and bupropion, to be marketed as Lorexys, is about to begin phase III clinical trials. Bupropion, a norepinephrine and dopamine reuptake inhibitor, has been known to have prosexual side effects, Dr. Rezaee said. Both ingredients in Lorexys are currently approved as antidepressants.

Increasing available norepinephrine may help with focus and attention, and increase subjective sexual excitement. However, the ADHD and antidepressant medications that increase norepinephrine carry significant side effects and should not be what physicians use to help their patients with low desire, Dr. Rezaee said.

“Serotonin may have a role in low desire by acting as a sexual satiety signal, and SSRIs are serotonergic agents that inhibit desire, arousal, and orgasm in the brain and in the tissue,” she said.

However, there are seven known families of serotonin receptors, and selective modulation specifically of the 5-hydroxytryptamine receptor 1A and 5-HT_2A receptors may have prosexual effects. The newly approved medication flibanserin (Addyi) is a selective agonist for 5-HT_1A and an antagonist for 5-HT_2A receptors. Flibanserin is also thought to produce upregulation in dopamine and norepinephrine in the prefrontal cortex, combating the satiety signals from serotonin and leading to increased desire.

Other medications that are 5-HT_1A agonists with potential prosexual effects include buspirone (Buspar) and trazodone (Desyrel, Oleptro).

Blockade of phosphodiesterase type 5 (PDE5) permits relaxation of smooth muscles in arterial walls and increases blood flow to erectile tissues. PDE5 inhibitors such as sildenafil (Viagra) may be of benefit to some women as well, said Dr. Rezaee, though they do not address low desire.

“Newer data support the use of PDE5 inhibitors with women who suffer from SSRI-induced orgasmic complaints of increased latency or decreased intensity, or anorgasmia,” she said. A dose of 25-50 mg of sildenafil 1 hour before sexual activity may help these patients, she advised.

Phase II trials have been completed for two other combination drugs to treat female sexual problems. Lybrido is a combination of testosterone and sildenafil, while Lybridos combines testosterone with buspirone. Both products are oral tablets, taken on demand.

Bremelanotide is a first-in-class drug in development as a melanocortin agonist. This drug, meant to be used on demand to activate an endogenous pathway that increases attention and desire, is in phase III clinical trials.

Dr. Rezaee reported having no relevant financial disclosures.

[email protected]
On Twitter @karioakes

 *Correction, 10/20/2015: An earlier version of this story misstated Dr. Rezaee's title. 

LAS VEGAS – Though fertility declines precipitously as menopause nears, women in midlife may still conceive. Clinicians and patients need guidance to develop a rational plan for contraceptive management and a clear path to transition to menopausal symptom management, said Dr. Petra Casey at the NAMS 2015 Annual Meeting.

Dr. Casey, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., noted that the rate of infertility approaches, but does not reach, 100% by age 50, so women need a game plan to take them through the end of their fertile years. These needs are not always met, she said, noting that 75% of pregnancies in women over the age of 40 are unintended.

The rate of spontaneous abortion may exceed 50% by age 45, and chronic diabetes and hypertension are more likely to result after pregnancies in older women. The substantial increase in risk for undesirable outcomes means that an unexpected pregnancy in midlife may cause considerable distress.

No contraceptive method is contraindicated by a patient’s age alone, said Dr. Casey, though it may be wise to reserve combined hormonal contraception (CHC) for women without cardiovascular disease and thrombotic risk. Reminding the audience that risk stratification for CHC for those over 40 years of age is category 2, meaning that benefits generally outweigh the risks, Dr. Casey said, “ ‘What? So a 55-year-old can use combined hormonal contraception?’ Yes!”

Patients may also wish to consider a progestin-only contraception method, a choice that provides endometrial protection. This option allows the judicious addition of estrogen by the most appropriate method to manage symptoms. Choices include a contraceptive implant, a progestin-only pill, or a levonorgestrel-emitting intrauterine device. Depot medroxyprogesterone acetate (DMPA) may be less desirable because of the theoretical risk of bone loss, said Dr. Casey.

Transdermal estrogen delivery is preferred for menopausal doses of estrogen, according to the North American Menopause Society’s guidance for clinical care for midlife. If perimenopausal women are having cyclic vasomotor symptoms or headaches associated with estrogen nadir, transdermal estrogen therapy can be used during the menstrual week. With this option, a higher-dose patch of 0.1 mg will work better to replace endogenous estrogen.

For women who desire nonhormonal contraceptive and menopausal symptom management, a copper IUD, barrier contraception, or sterilization of the patient or her partner can be used in combination with a nonhormonal medication to manage vasomotor symptoms. Though the only Food and Drug Administration–approved nonhormonal option is paroxetine (Paxil) 7.5 mg/day, a variety of choices have been found effective in clinical trials. These include citalopram (Celexa) and escitalopram (Lexapro), venlafaxine (Effexor), desvenlafaxine (Pristiq), gabapentin (Neurontin), and pregabalin (Lyrica).

Contraception should be continued until the patient has experienced 12 months of continuous amenorrhea if over the age of 50 years, or 2 years of amenorrhea if she is younger than 50 years, said Dr. Casey. A predictive model for onset of menopause has been developed that takes age, smoking, bleeding patterns, and estrogen and follicle-stimulating hormone levels into account, but “further study is needed before applying this model clinically,” said Dr. Casey. The decision about when to discontinue contraception also depends on the impact it will have on the particular couple. “Shared decision making is of the utmost importance,” she said.

Dr. Casey disclosed that she is a certified Nexplanon trainer and has received research grant support from Merck.

[email protected]

On Twitter @karioakes

LAS VEGAS – Though fertility declines precipitously as menopause nears, women in midlife may still conceive. Clinicians and patients need guidance to develop a rational plan for contraceptive management and a clear path to transition to menopausal symptom management, said Dr. Petra Casey at the NAMS 2015 Annual Meeting.

Dr. Casey, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., noted that the rate of infertility approaches, but does not reach, 100% by age 50, so women need a game plan to take them through the end of their fertile years. These needs are not always met, she said, noting that 75% of pregnancies in women over the age of 40 are unintended.

The rate of spontaneous abortion may exceed 50% by age 45, and chronic diabetes and hypertension are more likely to result after pregnancies in older women. The substantial increase in risk for undesirable outcomes means that an unexpected pregnancy in midlife may cause considerable distress.

No contraceptive method is contraindicated by a patient’s age alone, said Dr. Casey, though it may be wise to reserve combined hormonal contraception (CHC) for women without cardiovascular disease and thrombotic risk. Reminding the audience that risk stratification for CHC for those over 40 years of age is category 2, meaning that benefits generally outweigh the risks, Dr. Casey said, “ ‘What? So a 55-year-old can use combined hormonal contraception?’ Yes!”

Patients may also wish to consider a progestin-only contraception method, a choice that provides endometrial protection. This option allows the judicious addition of estrogen by the most appropriate method to manage symptoms. Choices include a contraceptive implant, a progestin-only pill, or a levonorgestrel-emitting intrauterine device. Depot medroxyprogesterone acetate (DMPA) may be less desirable because of the theoretical risk of bone loss, said Dr. Casey.

Transdermal estrogen delivery is preferred for menopausal doses of estrogen, according to the North American Menopause Society’s guidance for clinical care for midlife. If perimenopausal women are having cyclic vasomotor symptoms or headaches associated with estrogen nadir, transdermal estrogen therapy can be used during the menstrual week. With this option, a higher-dose patch of 0.1 mg will work better to replace endogenous estrogen.

For women who desire nonhormonal contraceptive and menopausal symptom management, a copper IUD, barrier contraception, or sterilization of the patient or her partner can be used in combination with a nonhormonal medication to manage vasomotor symptoms. Though the only Food and Drug Administration–approved nonhormonal option is paroxetine (Paxil) 7.5 mg/day, a variety of choices have been found effective in clinical trials. These include citalopram (Celexa) and escitalopram (Lexapro), venlafaxine (Effexor), desvenlafaxine (Pristiq), gabapentin (Neurontin), and pregabalin (Lyrica).

Contraception should be continued until the patient has experienced 12 months of continuous amenorrhea if over the age of 50 years, or 2 years of amenorrhea if she is younger than 50 years, said Dr. Casey. A predictive model for onset of menopause has been developed that takes age, smoking, bleeding patterns, and estrogen and follicle-stimulating hormone levels into account, but “further study is needed before applying this model clinically,” said Dr. Casey. The decision about when to discontinue contraception also depends on the impact it will have on the particular couple. “Shared decision making is of the utmost importance,” she said.

Dr. Casey disclosed that she is a certified Nexplanon trainer and has received research grant support from Merck.

[email protected]

On Twitter @karioakes

LAS VEGAS – Though fertility declines precipitously as menopause nears, women in midlife may still conceive. Clinicians and patients need guidance to develop a rational plan for contraceptive management and a clear path to transition to menopausal symptom management, said Dr. Petra Casey at the NAMS 2015 Annual Meeting.

Dr. Casey, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., noted that the rate of infertility approaches, but does not reach, 100% by age 50, so women need a game plan to take them through the end of their fertile years. These needs are not always met, she said, noting that 75% of pregnancies in women over the age of 40 are unintended.

The rate of spontaneous abortion may exceed 50% by age 45, and chronic diabetes and hypertension are more likely to result after pregnancies in older women. The substantial increase in risk for undesirable outcomes means that an unexpected pregnancy in midlife may cause considerable distress.

No contraceptive method is contraindicated by a patient’s age alone, said Dr. Casey, though it may be wise to reserve combined hormonal contraception (CHC) for women without cardiovascular disease and thrombotic risk. Reminding the audience that risk stratification for CHC for those over 40 years of age is category 2, meaning that benefits generally outweigh the risks, Dr. Casey said, “ ‘What? So a 55-year-old can use combined hormonal contraception?’ Yes!”

Patients may also wish to consider a progestin-only contraception method, a choice that provides endometrial protection. This option allows the judicious addition of estrogen by the most appropriate method to manage symptoms. Choices include a contraceptive implant, a progestin-only pill, or a levonorgestrel-emitting intrauterine device. Depot medroxyprogesterone acetate (DMPA) may be less desirable because of the theoretical risk of bone loss, said Dr. Casey.

Transdermal estrogen delivery is preferred for menopausal doses of estrogen, according to the North American Menopause Society’s guidance for clinical care for midlife. If perimenopausal women are having cyclic vasomotor symptoms or headaches associated with estrogen nadir, transdermal estrogen therapy can be used during the menstrual week. With this option, a higher-dose patch of 0.1 mg will work better to replace endogenous estrogen.

For women who desire nonhormonal contraceptive and menopausal symptom management, a copper IUD, barrier contraception, or sterilization of the patient or her partner can be used in combination with a nonhormonal medication to manage vasomotor symptoms. Though the only Food and Drug Administration–approved nonhormonal option is paroxetine (Paxil) 7.5 mg/day, a variety of choices have been found effective in clinical trials. These include citalopram (Celexa) and escitalopram (Lexapro), venlafaxine (Effexor), desvenlafaxine (Pristiq), gabapentin (Neurontin), and pregabalin (Lyrica).

Contraception should be continued until the patient has experienced 12 months of continuous amenorrhea if over the age of 50 years, or 2 years of amenorrhea if she is younger than 50 years, said Dr. Casey. A predictive model for onset of menopause has been developed that takes age, smoking, bleeding patterns, and estrogen and follicle-stimulating hormone levels into account, but “further study is needed before applying this model clinically,” said Dr. Casey. The decision about when to discontinue contraception also depends on the impact it will have on the particular couple. “Shared decision making is of the utmost importance,” she said.

Dr. Casey disclosed that she is a certified Nexplanon trainer and has received research grant support from Merck.

[email protected]

On Twitter @karioakes

LAS VEGAS – Physicians looking for more options for alleviating dyspareunia in postmenopausal women should consider vaginal dilators, specialized vibrators, and pelvic floor physical therapy, according to Susan Kellogg Spadt, Ph.D.

These approaches can prevent or overcome some of the changes in the pelvic anatomy that can occur with menopause or with prolonged periods without sexual activity, Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said at the NAMS 2015 Annual Meeting.

Along with the topical atrophy that can occur with the low estrogen state of menopause, hypertonus and foreshortening of the pelvic floor muscles can occur in some postmenopausal women. Multiparous women may experience significant muscle laxity. Some women, especially those who may have gone without intercourse for prolonged periods, may also have vaginal stenosis. These can all present barriers to sexual health for women in midlife, she said.

Pelvic floor physical therapy, said Dr. Kellogg Spadt, is critical to help with all of these physical changes. Clinicians can find physical therapists certified in women’s health through the website of the American Physical Therapy Association (www.apta.org).

With the guidance of a physical therapist, women can learn about home use of a series of graduated vaginal dilators. Beginning with a smaller size, patients typically insert a dilator several times a week (up to daily) for 5-10 minutes, changing size every 2-3 weeks. During the changeover week, patients can start with the smaller size for 5 minutes and then change to the larger dilator for the second half of the session. This consistent, but gradual, approach is well tolerated and produces good results, she said.

Physical therapists may also use a pelvic wand, such as the Therawand, for women who have hypertonus of the pelvic musculature. This S-shaped acrylic wand is inserted into the vagina and provides direct internal pressure on the pubococcygeus and puborectalis muscles, facilitating trigger point release. Pelvic wands can be used in physical therapy sessions, but patients can also learn how to use the devices at home, Dr. Kellogg Spadt said.

Vibrators are another tool in addressing dyspareunia. The Intensity exerciser/vibrator is intended for therapeutic use as well as sexual pleasure. The device is powered by four AA batteries and is known to produce very intense orgasms with powerful pelvic muscle contractions. This might be deleterious and even painful for patients with an already tight pelvic floor, but it can be helpful for women with muscle laxity, Dr. Kellogg Spadt said. It can also be an important part of sex therapy for some women, “bringing orgasms to the orgasmless,” she said.

Another device option is Fiera, a small hands-free device that provides a low level of vibration to the clitoris and anterior vulva. It’s not designed to produce an orgasm, but to assist with arousal, so tissues are lubricated and engorged by the time the woman is ready to engage in partner sex play, she said.

Dr. Kellogg Stadt reported being a consultant to or on the advisory board of Neogyn and Nuelle, which markets Fiera. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – Physicians looking for more options for alleviating dyspareunia in postmenopausal women should consider vaginal dilators, specialized vibrators, and pelvic floor physical therapy, according to Susan Kellogg Spadt, Ph.D.

These approaches can prevent or overcome some of the changes in the pelvic anatomy that can occur with menopause or with prolonged periods without sexual activity, Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said at the NAMS 2015 Annual Meeting.

Along with the topical atrophy that can occur with the low estrogen state of menopause, hypertonus and foreshortening of the pelvic floor muscles can occur in some postmenopausal women. Multiparous women may experience significant muscle laxity. Some women, especially those who may have gone without intercourse for prolonged periods, may also have vaginal stenosis. These can all present barriers to sexual health for women in midlife, she said.

Pelvic floor physical therapy, said Dr. Kellogg Spadt, is critical to help with all of these physical changes. Clinicians can find physical therapists certified in women’s health through the website of the American Physical Therapy Association (www.apta.org).

With the guidance of a physical therapist, women can learn about home use of a series of graduated vaginal dilators. Beginning with a smaller size, patients typically insert a dilator several times a week (up to daily) for 5-10 minutes, changing size every 2-3 weeks. During the changeover week, patients can start with the smaller size for 5 minutes and then change to the larger dilator for the second half of the session. This consistent, but gradual, approach is well tolerated and produces good results, she said.

Physical therapists may also use a pelvic wand, such as the Therawand, for women who have hypertonus of the pelvic musculature. This S-shaped acrylic wand is inserted into the vagina and provides direct internal pressure on the pubococcygeus and puborectalis muscles, facilitating trigger point release. Pelvic wands can be used in physical therapy sessions, but patients can also learn how to use the devices at home, Dr. Kellogg Spadt said.

Vibrators are another tool in addressing dyspareunia. The Intensity exerciser/vibrator is intended for therapeutic use as well as sexual pleasure. The device is powered by four AA batteries and is known to produce very intense orgasms with powerful pelvic muscle contractions. This might be deleterious and even painful for patients with an already tight pelvic floor, but it can be helpful for women with muscle laxity, Dr. Kellogg Spadt said. It can also be an important part of sex therapy for some women, “bringing orgasms to the orgasmless,” she said.

Another device option is Fiera, a small hands-free device that provides a low level of vibration to the clitoris and anterior vulva. It’s not designed to produce an orgasm, but to assist with arousal, so tissues are lubricated and engorged by the time the woman is ready to engage in partner sex play, she said.

Dr. Kellogg Stadt reported being a consultant to or on the advisory board of Neogyn and Nuelle, which markets Fiera. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – Physicians looking for more options for alleviating dyspareunia in postmenopausal women should consider vaginal dilators, specialized vibrators, and pelvic floor physical therapy, according to Susan Kellogg Spadt, Ph.D.

These approaches can prevent or overcome some of the changes in the pelvic anatomy that can occur with menopause or with prolonged periods without sexual activity, Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said at the NAMS 2015 Annual Meeting.

Along with the topical atrophy that can occur with the low estrogen state of menopause, hypertonus and foreshortening of the pelvic floor muscles can occur in some postmenopausal women. Multiparous women may experience significant muscle laxity. Some women, especially those who may have gone without intercourse for prolonged periods, may also have vaginal stenosis. These can all present barriers to sexual health for women in midlife, she said.

Pelvic floor physical therapy, said Dr. Kellogg Spadt, is critical to help with all of these physical changes. Clinicians can find physical therapists certified in women’s health through the website of the American Physical Therapy Association (www.apta.org).

With the guidance of a physical therapist, women can learn about home use of a series of graduated vaginal dilators. Beginning with a smaller size, patients typically insert a dilator several times a week (up to daily) for 5-10 minutes, changing size every 2-3 weeks. During the changeover week, patients can start with the smaller size for 5 minutes and then change to the larger dilator for the second half of the session. This consistent, but gradual, approach is well tolerated and produces good results, she said.

Physical therapists may also use a pelvic wand, such as the Therawand, for women who have hypertonus of the pelvic musculature. This S-shaped acrylic wand is inserted into the vagina and provides direct internal pressure on the pubococcygeus and puborectalis muscles, facilitating trigger point release. Pelvic wands can be used in physical therapy sessions, but patients can also learn how to use the devices at home, Dr. Kellogg Spadt said.

Vibrators are another tool in addressing dyspareunia. The Intensity exerciser/vibrator is intended for therapeutic use as well as sexual pleasure. The device is powered by four AA batteries and is known to produce very intense orgasms with powerful pelvic muscle contractions. This might be deleterious and even painful for patients with an already tight pelvic floor, but it can be helpful for women with muscle laxity, Dr. Kellogg Spadt said. It can also be an important part of sex therapy for some women, “bringing orgasms to the orgasmless,” she said.

Another device option is Fiera, a small hands-free device that provides a low level of vibration to the clitoris and anterior vulva. It’s not designed to produce an orgasm, but to assist with arousal, so tissues are lubricated and engorged by the time the woman is ready to engage in partner sex play, she said.

Dr. Kellogg Stadt reported being a consultant to or on the advisory board of Neogyn and Nuelle, which markets Fiera. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – For postmenopausal women who don’t want a hormonal topical treatment, there are plenty of other nonhormonal options to ease the symptoms of vulvovaginal atrophy, according to Susan Kellogg Spadt, Ph.D.

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said many of these topical products are available over the counter.

Lubricants – a good first-line choice to decrease pain and increase pleasure during intercourse – are primarily designed to minimize friction and irritation around the clitoral area, the labia, and the introitus and vagina. They are meant to be applied immediately before sex play, on an as-needed basis, Dr. Kellogg Spadt said at the annual meeting of the North American Menopause Society.

“The take-home message: Apply to both partner’s genitals,” she said.

However, some of these products have been associated with significant contact dermatitis, often because of additives such as camphor or menthol that are intended to provide a warming or tingling sensation. When women experience contact dermatitis from these or other causes in the vulvovaginal region, Dr. Kellogg Spadt said, clinicians should recommend that they avoid overzealous hygiene and treat the tissues gently. They can use a neutral emollient such as Aquaphor and use sleep aids or antihistamines for sedation and comfort at night as needed for a few days.

Lubricants are hyperosmotic, hypo-osmotic, or iso-osmotic. Hypo-osmotic lubricants such as FemGlide and Slippery Stuff can reduce mucus production. Hyperosmotic lubricants such as Replens lubricant, KY, and Astroglide can be irritating for some users, though some of these products have devoted long-time users who have never had difficulty, said Dr. Kellogg Spadt. Pre-seed is an iso-osmotic lubricant designed especially for couples who are trying to conceive.

Vaginal moisturizers have a different mode of action. These products use bioadhesive polymers that attach to mucin and the epithelial cells on the vaginal wall. These products can carry up to 60 times their weight in water, and will leave the water in place on the vulvovaginal epithelial surface until the product is eventually sloughed off, Dr. Kellogg Spadt said.

Vaginal moisturizers are meant to be used regularly – not necessarily every day, but at least two or three times weekly. They do not need reapplication before intercourse. Though studies on the efficacy of these products have generally been lacking, Replens is a vaginal moisturizer that, in one study, was found to improve vulvovaginal health with findings of normalized vaginal cytology and a return to premenopausal vaginal pH (Fertil Steril. 1994 Jan;61[1]:178-80.).

These changes in the vaginal environment, said Dr. Kellogg Spadt, won’t treat yeast or bacterial vaginal infections, but they may help prevent recurrent infections.

Some vaginal moisturizers use hyaluronic acid, and one in particular, Hyalogyn, is 100% hyaluronic acid. This product has been found to be as efficacious as local estrogen in a randomized clinical trial (J Sex Med. 2013 Jun;10[6]:1575-84).

Juvagyn is a hybrid lubricant-moisturizer with hyaluronic acid that can be applied with a fingertip. This allows more selective application to the external structures, where much of the discomfort of intercourse can occur, Dr. Kellogg Spadt said. Most other products use an intravaginal applicator to deliver a premeasured amount.

Another option is Neogyn, which is marketed as an external vulvar soothing cream and is also meant to be applied to the introitus and external vulvar tissue. It has been shown to reduce vulvar pain significantly, she said.

For patients who still have pain despite these measures and desire to have intercourse, over-the-counter lidocaine gel can be used. Patients should be warned that the lidocaine – 1% topical gel is available over the counter – will burn on application before numbing. It should be washed off after intercourse, she said.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Nuelle and of Neogyn, which also markets Juvagyn. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – For postmenopausal women who don’t want a hormonal topical treatment, there are plenty of other nonhormonal options to ease the symptoms of vulvovaginal atrophy, according to Susan Kellogg Spadt, Ph.D.

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said many of these topical products are available over the counter.

Lubricants – a good first-line choice to decrease pain and increase pleasure during intercourse – are primarily designed to minimize friction and irritation around the clitoral area, the labia, and the introitus and vagina. They are meant to be applied immediately before sex play, on an as-needed basis, Dr. Kellogg Spadt said at the annual meeting of the North American Menopause Society.

“The take-home message: Apply to both partner’s genitals,” she said.

However, some of these products have been associated with significant contact dermatitis, often because of additives such as camphor or menthol that are intended to provide a warming or tingling sensation. When women experience contact dermatitis from these or other causes in the vulvovaginal region, Dr. Kellogg Spadt said, clinicians should recommend that they avoid overzealous hygiene and treat the tissues gently. They can use a neutral emollient such as Aquaphor and use sleep aids or antihistamines for sedation and comfort at night as needed for a few days.

Lubricants are hyperosmotic, hypo-osmotic, or iso-osmotic. Hypo-osmotic lubricants such as FemGlide and Slippery Stuff can reduce mucus production. Hyperosmotic lubricants such as Replens lubricant, KY, and Astroglide can be irritating for some users, though some of these products have devoted long-time users who have never had difficulty, said Dr. Kellogg Spadt. Pre-seed is an iso-osmotic lubricant designed especially for couples who are trying to conceive.

Vaginal moisturizers have a different mode of action. These products use bioadhesive polymers that attach to mucin and the epithelial cells on the vaginal wall. These products can carry up to 60 times their weight in water, and will leave the water in place on the vulvovaginal epithelial surface until the product is eventually sloughed off, Dr. Kellogg Spadt said.

Vaginal moisturizers are meant to be used regularly – not necessarily every day, but at least two or three times weekly. They do not need reapplication before intercourse. Though studies on the efficacy of these products have generally been lacking, Replens is a vaginal moisturizer that, in one study, was found to improve vulvovaginal health with findings of normalized vaginal cytology and a return to premenopausal vaginal pH (Fertil Steril. 1994 Jan;61[1]:178-80.).

These changes in the vaginal environment, said Dr. Kellogg Spadt, won’t treat yeast or bacterial vaginal infections, but they may help prevent recurrent infections.

Some vaginal moisturizers use hyaluronic acid, and one in particular, Hyalogyn, is 100% hyaluronic acid. This product has been found to be as efficacious as local estrogen in a randomized clinical trial (J Sex Med. 2013 Jun;10[6]:1575-84).

Juvagyn is a hybrid lubricant-moisturizer with hyaluronic acid that can be applied with a fingertip. This allows more selective application to the external structures, where much of the discomfort of intercourse can occur, Dr. Kellogg Spadt said. Most other products use an intravaginal applicator to deliver a premeasured amount.

Another option is Neogyn, which is marketed as an external vulvar soothing cream and is also meant to be applied to the introitus and external vulvar tissue. It has been shown to reduce vulvar pain significantly, she said.

For patients who still have pain despite these measures and desire to have intercourse, over-the-counter lidocaine gel can be used. Patients should be warned that the lidocaine – 1% topical gel is available over the counter – will burn on application before numbing. It should be washed off after intercourse, she said.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Nuelle and of Neogyn, which also markets Juvagyn. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – For postmenopausal women who don’t want a hormonal topical treatment, there are plenty of other nonhormonal options to ease the symptoms of vulvovaginal atrophy, according to Susan Kellogg Spadt, Ph.D.

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said many of these topical products are available over the counter.

Lubricants – a good first-line choice to decrease pain and increase pleasure during intercourse – are primarily designed to minimize friction and irritation around the clitoral area, the labia, and the introitus and vagina. They are meant to be applied immediately before sex play, on an as-needed basis, Dr. Kellogg Spadt said at the annual meeting of the North American Menopause Society.

“The take-home message: Apply to both partner’s genitals,” she said.

However, some of these products have been associated with significant contact dermatitis, often because of additives such as camphor or menthol that are intended to provide a warming or tingling sensation. When women experience contact dermatitis from these or other causes in the vulvovaginal region, Dr. Kellogg Spadt said, clinicians should recommend that they avoid overzealous hygiene and treat the tissues gently. They can use a neutral emollient such as Aquaphor and use sleep aids or antihistamines for sedation and comfort at night as needed for a few days.

Lubricants are hyperosmotic, hypo-osmotic, or iso-osmotic. Hypo-osmotic lubricants such as FemGlide and Slippery Stuff can reduce mucus production. Hyperosmotic lubricants such as Replens lubricant, KY, and Astroglide can be irritating for some users, though some of these products have devoted long-time users who have never had difficulty, said Dr. Kellogg Spadt. Pre-seed is an iso-osmotic lubricant designed especially for couples who are trying to conceive.

Vaginal moisturizers have a different mode of action. These products use bioadhesive polymers that attach to mucin and the epithelial cells on the vaginal wall. These products can carry up to 60 times their weight in water, and will leave the water in place on the vulvovaginal epithelial surface until the product is eventually sloughed off, Dr. Kellogg Spadt said.

Vaginal moisturizers are meant to be used regularly – not necessarily every day, but at least two or three times weekly. They do not need reapplication before intercourse. Though studies on the efficacy of these products have generally been lacking, Replens is a vaginal moisturizer that, in one study, was found to improve vulvovaginal health with findings of normalized vaginal cytology and a return to premenopausal vaginal pH (Fertil Steril. 1994 Jan;61[1]:178-80.).

These changes in the vaginal environment, said Dr. Kellogg Spadt, won’t treat yeast or bacterial vaginal infections, but they may help prevent recurrent infections.

Some vaginal moisturizers use hyaluronic acid, and one in particular, Hyalogyn, is 100% hyaluronic acid. This product has been found to be as efficacious as local estrogen in a randomized clinical trial (J Sex Med. 2013 Jun;10[6]:1575-84).

Juvagyn is a hybrid lubricant-moisturizer with hyaluronic acid that can be applied with a fingertip. This allows more selective application to the external structures, where much of the discomfort of intercourse can occur, Dr. Kellogg Spadt said. Most other products use an intravaginal applicator to deliver a premeasured amount.

Another option is Neogyn, which is marketed as an external vulvar soothing cream and is also meant to be applied to the introitus and external vulvar tissue. It has been shown to reduce vulvar pain significantly, she said.

For patients who still have pain despite these measures and desire to have intercourse, over-the-counter lidocaine gel can be used. Patients should be warned that the lidocaine – 1% topical gel is available over the counter – will burn on application before numbing. It should be washed off after intercourse, she said.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Nuelle and of Neogyn, which also markets Juvagyn. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – The first step is to ask. A menopausal woman may be struggling with a female sexual disorder (FSD), but unless her clinician asks, the patient may never volunteer information about her sexual health.

Susan Kellogg Spadt, Ph.D., offered that advice, along with a toolkit of tips, treatments, and pearls for physicians and others caring for the menopausal woman’s sexual health.

Clever Cupcakes/Flickr/CC BY-SA 2.0/No changes

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, addressed FSD in the context of the complicated psychosocial landscape of midlife.

Women at this stage of life may be experiencing life stress as children move out, retirement looms, and aging parents require time and attention. Also, as women age, they are more likely to require medications that can negatively affect sexual health. Body image issues, depression, anxiety, and discrepancy with partner desire levels can all be prevalent in women aged 45-64 years, the group most likely to experience distress from sexual problems, she said at the NAMS 2015 annual meeting.

This is important in the context of a relationship, said Dr. Kellogg Spadt. She pointed out that “when sex is good, it adds a little bit – like icing on the cupcake – to a good relationship.” But when sex is bad or nonexistent, she said, it plays an inordinately negative role, reducing the quality of the relationship by 50%-70% in some studies.

Dr. Kellogg Spadt said a good opening approach should confirm the ubiquity of sexual problems in midlife and normalize concerns. Clinicians can ask: “With menopause, many women have changes in their sexual response. These concerns are very common. Tell me – are you feeling well and complete in your sex life?”

If questioning reveals unsatisfying or nonexistent sex, many problems can be addressed in the office. First, careful questioning and an exam can tease out the extent to which dyspareunia and vaginal dryness may be limiting sexual pleasure. In that case, lubricants, moisturizers, and topical estrogen can be considered.

Office sessions with physical therapists certified in pelvic issues, combined with home use of dilators, can help overcome physical contributors to an uncomfortable sexual experience, she said.

Clinicians can also provide brief office-based counseling using the “PLISSIT” model, which. gives permission for the patient to speak openly about sexual issues; provides limited information to educate the patient about her anatomy and resources available; offers specific suggestions, for example, positioning tips or moisturizer recommendations; and offers intensive therapy, when indicated, such as referring for adjunctive psychotherapy.

Dr. Kellogg Stadt concluded with her top clinical pearls for sexual health in menopausal women:

• Add moisture daily. Using a water-based, bioadhesive lubricant several times a week regardless of sexual frequency can significantly ease comfort and satisfaction with sex and make it easier to have an orgasm.

• Nourish. A Mediterranean diet has been shown to promote sexual function, and regular exercise improves mood and overall health.

• Talk. Partners can use “I” language to talk about sex honestly and in a nonaccusatory way. Clinicians can help provide the vocabulary and communication tips to facilitate this.

• Prioritize pleasure. Intimate time together won’t just happen; even a 20-minute block of time, scheduled weekly, for touching and intimate conversation can clear the way to better sex.

• Think. Reading or watching erotica, being mindful of erotic thoughts as they occur, and focusing on sensation rather than distractions during arousal are all important.

• Stimulate. After menopause, some women need more intense stimulation to reach orgasm, so vibrators can be incorporated into sex play. Women who are uncomfortable with this can use the “doctor’s orders” approach with their partners.

• Try. Just opening up and talking about sex problems shows that a woman is committed to her partner, and taking action shows her level of care and concern for the relationship.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Neogyn and Nuelle, and on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – The first step is to ask. A menopausal woman may be struggling with a female sexual disorder (FSD), but unless her clinician asks, the patient may never volunteer information about her sexual health.

Susan Kellogg Spadt, Ph.D., offered that advice, along with a toolkit of tips, treatments, and pearls for physicians and others caring for the menopausal woman’s sexual health.

Clever Cupcakes/Flickr/CC BY-SA 2.0/No changes

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, addressed FSD in the context of the complicated psychosocial landscape of midlife.

Women at this stage of life may be experiencing life stress as children move out, retirement looms, and aging parents require time and attention. Also, as women age, they are more likely to require medications that can negatively affect sexual health. Body image issues, depression, anxiety, and discrepancy with partner desire levels can all be prevalent in women aged 45-64 years, the group most likely to experience distress from sexual problems, she said at the NAMS 2015 annual meeting.

This is important in the context of a relationship, said Dr. Kellogg Spadt. She pointed out that “when sex is good, it adds a little bit – like icing on the cupcake – to a good relationship.” But when sex is bad or nonexistent, she said, it plays an inordinately negative role, reducing the quality of the relationship by 50%-70% in some studies.

Dr. Kellogg Spadt said a good opening approach should confirm the ubiquity of sexual problems in midlife and normalize concerns. Clinicians can ask: “With menopause, many women have changes in their sexual response. These concerns are very common. Tell me – are you feeling well and complete in your sex life?”

If questioning reveals unsatisfying or nonexistent sex, many problems can be addressed in the office. First, careful questioning and an exam can tease out the extent to which dyspareunia and vaginal dryness may be limiting sexual pleasure. In that case, lubricants, moisturizers, and topical estrogen can be considered.

Office sessions with physical therapists certified in pelvic issues, combined with home use of dilators, can help overcome physical contributors to an uncomfortable sexual experience, she said.

Clinicians can also provide brief office-based counseling using the “PLISSIT” model, which. gives permission for the patient to speak openly about sexual issues; provides limited information to educate the patient about her anatomy and resources available; offers specific suggestions, for example, positioning tips or moisturizer recommendations; and offers intensive therapy, when indicated, such as referring for adjunctive psychotherapy.

Dr. Kellogg Stadt concluded with her top clinical pearls for sexual health in menopausal women:

• Add moisture daily. Using a water-based, bioadhesive lubricant several times a week regardless of sexual frequency can significantly ease comfort and satisfaction with sex and make it easier to have an orgasm.

• Nourish. A Mediterranean diet has been shown to promote sexual function, and regular exercise improves mood and overall health.

• Talk. Partners can use “I” language to talk about sex honestly and in a nonaccusatory way. Clinicians can help provide the vocabulary and communication tips to facilitate this.

• Prioritize pleasure. Intimate time together won’t just happen; even a 20-minute block of time, scheduled weekly, for touching and intimate conversation can clear the way to better sex.

• Think. Reading or watching erotica, being mindful of erotic thoughts as they occur, and focusing on sensation rather than distractions during arousal are all important.

• Stimulate. After menopause, some women need more intense stimulation to reach orgasm, so vibrators can be incorporated into sex play. Women who are uncomfortable with this can use the “doctor’s orders” approach with their partners.

• Try. Just opening up and talking about sex problems shows that a woman is committed to her partner, and taking action shows her level of care and concern for the relationship.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Neogyn and Nuelle, and on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – The first step is to ask. A menopausal woman may be struggling with a female sexual disorder (FSD), but unless her clinician asks, the patient may never volunteer information about her sexual health.

Susan Kellogg Spadt, Ph.D., offered that advice, along with a toolkit of tips, treatments, and pearls for physicians and others caring for the menopausal woman’s sexual health.

Clever Cupcakes/Flickr/CC BY-SA 2.0/No changes

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, addressed FSD in the context of the complicated psychosocial landscape of midlife.

Women at this stage of life may be experiencing life stress as children move out, retirement looms, and aging parents require time and attention. Also, as women age, they are more likely to require medications that can negatively affect sexual health. Body image issues, depression, anxiety, and discrepancy with partner desire levels can all be prevalent in women aged 45-64 years, the group most likely to experience distress from sexual problems, she said at the NAMS 2015 annual meeting.

This is important in the context of a relationship, said Dr. Kellogg Spadt. She pointed out that “when sex is good, it adds a little bit – like icing on the cupcake – to a good relationship.” But when sex is bad or nonexistent, she said, it plays an inordinately negative role, reducing the quality of the relationship by 50%-70% in some studies.

Dr. Kellogg Spadt said a good opening approach should confirm the ubiquity of sexual problems in midlife and normalize concerns. Clinicians can ask: “With menopause, many women have changes in their sexual response. These concerns are very common. Tell me – are you feeling well and complete in your sex life?”

If questioning reveals unsatisfying or nonexistent sex, many problems can be addressed in the office. First, careful questioning and an exam can tease out the extent to which dyspareunia and vaginal dryness may be limiting sexual pleasure. In that case, lubricants, moisturizers, and topical estrogen can be considered.

Office sessions with physical therapists certified in pelvic issues, combined with home use of dilators, can help overcome physical contributors to an uncomfortable sexual experience, she said.

Clinicians can also provide brief office-based counseling using the “PLISSIT” model, which. gives permission for the patient to speak openly about sexual issues; provides limited information to educate the patient about her anatomy and resources available; offers specific suggestions, for example, positioning tips or moisturizer recommendations; and offers intensive therapy, when indicated, such as referring for adjunctive psychotherapy.

Dr. Kellogg Stadt concluded with her top clinical pearls for sexual health in menopausal women:

• Add moisture daily. Using a water-based, bioadhesive lubricant several times a week regardless of sexual frequency can significantly ease comfort and satisfaction with sex and make it easier to have an orgasm.

• Nourish. A Mediterranean diet has been shown to promote sexual function, and regular exercise improves mood and overall health.

• Talk. Partners can use “I” language to talk about sex honestly and in a nonaccusatory way. Clinicians can help provide the vocabulary and communication tips to facilitate this.

• Prioritize pleasure. Intimate time together won’t just happen; even a 20-minute block of time, scheduled weekly, for touching and intimate conversation can clear the way to better sex.

• Think. Reading or watching erotica, being mindful of erotic thoughts as they occur, and focusing on sensation rather than distractions during arousal are all important.

• Stimulate. After menopause, some women need more intense stimulation to reach orgasm, so vibrators can be incorporated into sex play. Women who are uncomfortable with this can use the “doctor’s orders” approach with their partners.

• Try. Just opening up and talking about sex problems shows that a woman is committed to her partner, and taking action shows her level of care and concern for the relationship.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Neogyn and Nuelle, and on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes