Transcription:
Addressing Post Menopause Orgasmic Dysfunction

Melanie Cole (Host):  Welcome. Today we’re discussing postmenopause orgasmic dysfunction. Northwester Medicine has launched a first of it’s kind center dedicated to providing highly specialized and personalized care to women and with me today is Dr. Lauren Streicher. She’s the Medical Director of Northwestern Medicine’s Center for Sexual Medicine in Menopause. Dr. Streicher, what a pleasure to have you join us today. What a great topic but it’s also a topic that’s rarely discussed in the doctor’s office. Why is that?

Lauren Streicher, MD (Guest):  Well you’re right, this is at the top of taboo topics and there’s a number of reasons for that. First of all, as physicians, we all know how busy our appointments are and you just simply don’t have time and who wants to open that can of worms. But the other reason is that quite frankly, most physicians do not have adequate training in sexual medicine or menopause. So, a patient very rarely is going to bring it up but if a doctor brings up something like oh are you having difficulty having orgasms and the patient says yes and you have nothing to say but I’m sorry, well you’re not going to bring that up in the first place.

So, while there are many reasons in terms of time constraints et cetera, the number one reason is we are not – we are solution driven and we don’t have a solution for this too many times.

Host:  What a great explanation and so true. So, what exactly is orgasmic dysfunction? Tell us a little bit about it and how common it is in the menopause population.

Dr. Streicher:  Oh orgasmic disorder is defined specifically as the persistent or recurrent absence, reduced intensity or delay of orgasm following a sexual excitement phase. And it’s far more common than most people realize in the menopause population particularly and we know that roughly we are looking at 30-40% of women that are disturbed by this and that’s important. If you look at how many people actually have difficulty with orgasm; the numbers are very high 60 to 70%. But we have to have that element of are they bothered by it. That’s what makes it a dysfunction. If a patient says to you, I’m not able to have an orgasm but it really doesn’t matter to me, she does not have orgasmic dysfunction. She just has difficulty with orgasms.

Host:  Do we think that this is because a lack of estrogen? Speak a little bit about the etiology and pathophysiology and what you know about that because some women might discuss with their providers that it’s easier to have an orgasm when they masturbate but not when they are with a partner and there’s all kind of things that go along with menopause and vaginal dryness and self-esteem and anxiety.

Dr. Streicher:  The list is very long yes.

Host:  It is very long. So, speak about some of those things that we know.

Dr. Streicher:  Absolutely. Well let’s start just in the general population. We know that at best, at best 30% of women have orgasms during intercourse. So, what that means is we have to get rid of that idea that there’s an expectation that a woman is going to have an orgasm during intercourse. And a physician needs to bring that up because you brought up the fact that many women are able to have orgasms with masturbation, with self-stimulation, with vibrators and they think that there’s something wrong with them that they are not able to have an orgasm with intercourse. And it’s incumbent up on the physician to say no, actually you’re normal. Most women are not able to have orgasms during intercourse.

But in terms of what it takes in order to have an orgasm. What we are really looking at is vascular and neurologic function. Because at the ends of the day, most women require clitoral stimulation and the clitoris has 8000 nerve endings and those nerve endings are vascularized by capillaries. So, as we get into the postmenopause group; when we look at women who are having difficulty; it goes way beyond the fact that they don’t have estrogen. It’s really looking at the vascularization of those clitoral nerve endings.

So, that’s why comorbidities play into this so much. Women who have diabetes for example who have small vessel disease; they get a neuropathy in their feet; they can also have a clitoral neuropathy. When we look at women who have vascular problems because of cardiovascular disease. Just as men have difficulty with erectile dysfunction; women might have problems with clitoral function and with the ability to have an orgasm. So, when we look at the role of estrogen, it actually quite interesting because you don’t strictly speaking require estrogen in order to have an orgasm. But what you do require estrogen for is vaginal lubrication and vasodilation.

So, when I talk to physicians what I always tell them is, on the list of things that are required to have an orgasm; estrogen is not absolutely required but it sure helps a lot. And when we get into treatments for orgasmic dysfunction; one of the things that we look at is hormonal treatment particularly local vaginal estrogens which are going to not only increase vaginal lubrication and arousal and pleasure; but are vasodilators which there in turn will make the neurons have an increased vascular supply and function better.

Host:  Wow, what a great explanation. So, if a provider is working with their patient; what kinds of things would you like them to be asking when they are taking medical history.

Dr. Streicher:  First thing, they have to ask about this.

Host:  Well it’s true and I think that’s a great point that you just brought up is that if they don’t ask about it, the patient needs to bring it up, right?

Dr. Streicher:  Well it’s interesting. Because I talk to a lot of consumer audiences and very often, I’ll say to the audience, raise your hand if your doctor ever asked you about sexual function. And maybe a handful of people will raise their hand and then I’ll say, and now keep your hand up if your doctor ever asks if you are able to have an orgasm. Every single hand goes down. So, part of what I do when I teach medical students and residents and lecture to physicians is talk about how you bring up that conversation. And it’s easier than you think. You can simply say to someone many women with diabetes have difficulty with sexual function whether it’s loss of libido, pain during intercourse or difficulty with orgasm. Are any of those problems for you? And what you are immediately doing is saying, A, you are willing to discuss it, B, this is not an isolated or strange thing and that this is a normal thing to be talking about in the doctor’s office. So, before you can even get into what causes it, what are the solutions; you have to have the conversation and there are also surveys that we use for doctors or other providers who just say I’m not comfortable bringing it up and we have very brief questionnaires which you can get online which ask a few simple questions about are you having difficulty with your sexuality.

The most common question that doctors are taught to ask is are you sexually active. And that’s really not helpful. Because what does sexually active mean? Why does the patient think you are asking that? They think you’re asking because you want to know if they need contraception. No, we’re asking because we want to know if you are having sexual issues that are problematic to you, that you would like to be addressed.

So, once you ask the question, and once you have the discussion; the first thing I look at then during the history is what are the possible comorbidities? What are the medical problems that can be impacting such as diabetes, cardiovascular disease, chemotherapy, prior pelvic surgery, all of that. Then you have to take a very close look at medications. The SSRIs are very often one of the number one culprits for orgasmic dysfunction and the treatment of a patient who has orgasmic dysfunction from an SSRI is different than the patient who it’s a sequalae of diabetes. So, you really need to look at that.

You mentioned painful sex. We know that painful sex is an enormous, enormous problem in terms of women with orgasmic dysfunction because you need to be aroused in order to have an orgasm. You notice in the definition I mentioned the fact that after a sexual excitement phase. Well, if intercourse is excruciatingly painful, not only are you going to avoid it but it’s very difficult to become aroused. So, we look at that. Certainly I’m not ignoring the fact that we look at history of trauma, substance abuse, relationship, I’m not ignoring relationship, I’m not a therapist. It’s very interesting when someone says I have orgasmic problems with my regular partner but with my boyfriend it’s just fine. Then you know that they don’t need your help, they need someone else’s help.

But certainly those are the kind of things we look at. But the big one, the big one the postmenopause population are the comorbidities, diabetes, multiple sclerosis, spinal cord injury, hypothyroidism; anything that’s going to impact on neurologic function or vascular function can impact on orgasmic function.

Host:  Well then let’s talk about some of the treatment options and solutions. What are some current issues in medical management? Assess for us Dr. Streicher, somethings specific that you would try once you detect what’s going on when you first find this out?

Dr. Streicher:  Absolutely. There’s really two approaches to nerve endings that are just not responding optimally. You either increase stimulation or you increase sensitivity. Very simple. So, let’s talk about increasing stimulation. How do you increase stimulation? If someone says I was always able to have an orgasm and now they have acquired orgasmic dysfunction which is what we are primarily looking at. And what that tells you is that the nerve endings are not as sensitive as they used to be, so they have to be stimulated more. So, it may be that this is where you incorporate vibrator therapy, that you talk about oral sex, that you talk about digital, things that someone may not be doing.

This is where a sex therapist comes into play who can do talk therapy along those lines and we are very lucky at the Center for Sexual Medicine in Menopause at Northwestern because we have an entire staff of sex therapists who are physically here in the center and that is incredibly helpful.

But then we also look at increasing blood flow. If the blood flow is poor, how do you make it better? Well that’s where we look at things like local vaginal estrogen, local vaginal DATA, optimizing diabetes care, optimizing things such as blood pressure, cardiovascular care. Do we do pharmacotherapy? Absolutely. Beyond local hormone therapy sometimes we will give a phosphodiesterase type five inhibitor just and this is off label, completely off label but we know that just as it’s going to increase penile blood flow in men that the PDE5 inhibitors are going to increase blood flow to the clitoris and the vagina and therefore are going to improve general sexual function particularly in women who have orgasmic issues. Again, off label, I tell women it’s off label, but we do have good literature and I mention the population that has orgasmic dysfunction from using an SSRI. The good news is, that sometimes this is temporary. Sometimes it will reverse on its own. Sometimes they do better with a different SSRI. But having said that, we know that the woman who is most likely to respond to a phosphodiesterase type 5 inhibitor is going to be the woman who has acquired orgasmic dysfunction specifically because of an SSRI.

There are a lot of things that again, off label but there’s good data to show that L-arginine is very helpful. I don’t want to get into the cannabinoids too much because there is no data but certainly anecdotally there is a lot of anecdotal information that using a topical CBD oil and the reason is, is because we know that CBD is a vasodilator. But we do not have good data to back it up. We also really look towards our pelvic floor physical therapists. Because people think in terms of referring to pelvic floor physical therapists for things like urinary incontinence and fecal incontinence, but the reality is, is that the same population that has urinary incontinence has incredibly high rates of orgasmic dysfunction and we know that pelvic floor physical therapy is going to help for two reasons. Number one, it’s going to increase that pelvic floor contraction which is such an important part of the orgasm experience and the second is pelvic floor physical therapy is going to increase blood flow to the genitals which in turn will increase sensitivity neurologically.

Host:  Wow. You are a ball of energy. What an amazing physician you are Dr. Streicher. What is a physician doesn’t feel comfortable or equipped to treat orgasmic dysfunction. Tell other providers what you’d like them to know about referral to the Center for Sexual Medicine and Menopause at Northwestern Memorial Hospital.

Dr. Streicher:  Exactly. And we see so many referrals from all over the country. People will travel for this trust me. They will travel to get their sex lives back and very often we only need to see these people once and then refer back to their physicians and we write letters back to the referring physician so that they can feel comfortable continuing the plan that we have started. So, the best way to get to us is through our website which is www.sexmedmenopause.nm.org. www.sexmedmenopause.nm.org. There is a lot of information on there on our programs. Not only our sexual medicine program and our menopause program but we have a vulvar and vaginal health program, we have a bone program. We are very involved in treating post cancer patients because we know that in terms of other sexual dysfunctions, libido, painful sex in addition to orgasmic dysfunction; that it’s 90% of women who are going through cancer treatments or cancer survivors have difficulty, so we are looking at the impact of radiation, chemotherapy, pelvic surgery, all of those things.

So, we are happy to get those referrals. I also find that a lot of doctors would like to know more about this. Certainly there are conferences. There’s a wonderful organization called ISWISH on NAMS the North American Menopause Society is another wonderful resource. I do have a consumer book that I want to mention because my book is called Sex Rx, Hormones, Health and Your Best Sex Ever and many physicians find that if the patient reads that book, first of all, they may not need their help anymore. But also, they come to them really being far more informed so that they can walk in the door and say I read this book and I know that a local vaginal estrogen is going to help me, and I would like a prescription. So, it really is a short cut for you.

And then the other thing that I want to emphasize is there are many doctors who and providers who are very comfortable talking about this and want to, but they think how can I possibly do this during this annual exam that gives me 15 minutes to cover an insane amount of areas. And the answer is you tell them to make another appointment. We don’t do that enough. It is important to say to the patient to validate that this is important to say this is a big deal. I appreciate the fact that this is important to you and I would like to help you, but this is going to take some time. So, I’m going to give you some resources to read and then I would like you to make a return appointment so we can sit down and really do the deep dive into what is going on and how I can help you. And your patient will really appreciate that.

Host:  Well they certainly would, and do you have any final thoughts what you would like to tell other physicians about the Center for Sexual Medicine and Menopause at Northwestern Memorial Hospital and why you feel it’s important that they refer.

Dr. Streicher:  What we have found since we opened this center a little bit over two years ago is that there is this enormous unmet need. And the number one thing that patients say when they come in is, I’m so glad I found you. No one else has been able to help me. And they are grateful to physicians that refer them and particularly because we do send them back and what I always tell people when I’m out there talking publicly to consumers is just because someone hasn’t given you a solution, doesn’t mean that the solution doesn’t exist.

And I think as a physician, it is so important to say to your patient, you know, this isn’t an area of expertise for me, but I know that there are experts out there and I’m going to give you a referral. And then you send them to our website www.sexmedmenopause.nm.org and if you tell our coordinator when you call, I’m coming from out of town; that means we will go that extra mile to make sure that we have the records from your physician, we have everything we need so that when you come for your visit we will sometimes spend an hour or two hours with someone so that when they walk out the door, they will be going back to their referring physician feeling like they have really come to a special place that is going to help them with these very specific problems.

Host:  Wow Dr. Streicher, what a great segment. Thank you so much for joining us and sharing your expertise. And that wraps up this episode of Better Edge a Northwestern Medicine Podcast for physicians. To refer your patient or for more information on the latest advances in sexual medicine and the Center for Sexual Medicine and Menopause at Northwestern Memorial Hospital head on over to our website at www.sexmedmenopause.nm.org for more information and to get connected with one of our providers. If you found this podcast as interesting and informative as I did, please share with other providers, share with your patients, share on social media. That way we can all learn from the experts together and be sure not to miss all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole.