Why IntimMed, Seattle specifically addresses the issue of female sexual dysfunction?
Female sexual dysfunction is a very important health issue for women, regretfully one not being addressed adequately by health care providers. This could be due to lack of expertise and experience, or bias – viewing such issues as unimportant or not being a “real medical problem” and thus not spending the time to sort things out. Unfortunately, many women also are hesitant to bring up the subject of sexual dysfunction or lack of sexual satisfaction due to embarrassment or thinking such is normal, acceptable, or untreatable. With 25 years plus experience practicing cosmetic vaginal surgery and gynecology, Dr. Lau at IntimMed aims to properly address the issue of sexual dysfunction for women. It is important to professionally help women to sort out the reasons for not having a satisfying sexual relationship and be able to offer appropriate medical or psychological support if needed.
Instead of reciting list of clinical symptoms, I prefer to give a narrative that women can readily identify with. The narrative draws heavily from:
“The Voice of the Patient – A series of reports from the U.S. Food and Drug Administration’s (FDA’s) Patient-Focused Drug Development Initiative on female sexual dysfunction, June 2015” (the Report).
It was somewhat surprising, but retrospectively made sense by drawing from personal professional experience, that reduction or loss of sexual interest ranked top as a sexual problem by women. Quoting from the Report:
“Reduction or loss of sexual interest was the most frequently discussed symptom by in-person and web participants. Participants used the terms desire (most frequently used), interest, libido, and sexual appetite when describing this aspect of their condition. Their comments focused on thinking about sex, the desire to have sex, and their response to (or avoidance of) their partner’s initiation, as illustrated below:
• “I don’t even think about sex.”
• “I knew I wanted to have sex but I had no desire. I refrained.”
• “In a beautiful place with the man I love, my body was like a shell with nothing inside.”
• “I am able to grit through [sex], but I do it for [my partner], not for me.”
Overall impact of female sexual dysfunction on daily life
Participants throughout the meeting described the larger impact sexual interest and arousal symptoms have on their lives and the lives of their partners and families, summarized below:
- Impact on relationships: Most participants discussed the strain that their FSD placed on their partners and their relationships. A few participants described their partner’s reluctance to initiate contact, because of their perceived failure to stimulate sexual response, their fear of rejection, or their fear of causing their partner physical or emotional pain. As one participant’s partner commented during the meeting, “It does have a huge impact when your lover, your soul mate, is no longer interested in having sex with you.” Another participant shared that her partner “has said to me that he feels stupid at times when he keeps getting shut down. I know he feels rejected.” Other participants commented on relationships that have failed because of their FSD. One participant explained, “I lost a major relationship to this issue, and I never want to go back there.” A few participants stressed that the negative impact of their condition affects not just the relationship with their partner, but alsomtheir relationships with family and friends.
- Impact on self-esteem and identity: Participants said that their loss of sexual functioning left them with feelings of low self-esteem and inadequacy. Many noticed a drop in their levels of confidence as it related to their sexuality, attractiveness, and femininity. One participant shared, “I had difficulty coping with my new reality and coming to terms with the discrepancy between who I was and who I became.” Another participant commented that her condition “affects things like my self-confidence and how I approach the world and how I feel about myself and what I project to other people.”
- Emotional impact: Several participants described the devastation they felt after they failed to regain sexual function and were unable to perform in intimate situations with partners. One participant shared, “I became so frustrated that any attempt to have sexual intercourse would end up in me crying.” Other participants discussed the guilt their difficulties caused them to feel when they said, “I can’t be the woman he married” and “I feel like I pulled a bait and switch with my poor husband, who is undoubtedly wondering where the old me has run off to.” Participants also linked the shame and stigma associated with their condition to the isolation they felt. They described being embarrassed and reluctant to talk about their issues. “- End of quote from the Report.
The Report found several key messages relating to female sexual dysfunction that the FDA became interested in as they have been investigating the “ideal” form of treatment for female sexual dysfunction. At IntimMed in Seattle, we take a more comprehensive approach, recognizing that most likely there is no one single ideal form of treatment that could cover all the many and varying causes for female sexual dysfunction, and that any treatment should be tailored to the needs and contributing factors of the problem for a given woman. The approach to address female sexual dysfunction could be psychological support, medical treatment, or surgical correction, or in combination, as indicated for that individual.
The services provided by IntimMed, Seattle would broadly comprise the following major categories:
Reduction or loss of sexual interest
Lack of sexual desire can be caused by multiple interrelated factors – relationship, emotional, psychological, hormonal, general physical or specific genital health issues, and so forth. Not all the causes for reduced sexual interest are medical. For example, social/religious/ethical factors play into sexual desire dysfunction but cannot be addressed by medical means. After identifying the key causes of the decrease in sexual desire – psycho-social, hormonal, drug induced (for example birth control pills), or others – through history, physical examination, and laboratory testing, then support and treatment can be recommended.
A multidisciplinary approach to low desire is critical. For medical treatment, flibanserin (Addyi) has been approved by FDA in 2015 for the treatment of low desire. Addiyi has to be taken daily and cannot be taken with alcohol, which causes fainting. The FDA approved Vyleesi for low sexual drive in 2019. It is an injection to be used 45 minutes before sex, but s 40% of users experienced nausea. For years, testosterone therapy has also been used for post-menopausal women with low desire, also with side-effects and risks associated with it. Most importantly, there are no documented increases in “sexually satisfying events” associated with these medical treatments. This assessment is certainly consistent with the notion that low sexual interest is far more complex than what one medication can treat.
It might be more rewarding to approach low sexual desire holistically, including addressing the psychology of sexual interest. This make good sense, since sexual desire is certainly initiated in the brain. Recently, Mindfulness Based Cognitive Therapy (MBCT) has been used to treat female low desire and low arousal sexual disorder with reported success. With the advantage of avoiding medication related side effects and risks, MBCT is being actively investigated at IntimMed in Seattle for the treatment of low desire or low arousal female sexual dysfunction.
The symptoms related to lack of lubrication or decrease in blood flow to the vaginal area as related to low arousal should be evaluated and treated using the multidisciplinary approach. There might be local causes in the areas involved in intimacy that have anatomical or functional defects, making arousal difficult – dryness, atrophy, over-sensitivity/pain, or low-sensitivity. These issues should be addressed by examination and clinical testing, followed by appropriate treatments. IntimMed, Seattle can certainly provide such medical services. However, the causation for low arousal could be as complex as that of low sexual interest. Therefore, a single medication treatment would likely be unsuccessful. A 2016 study of 86 women showed that they favored cognitive behavioral therapy (CBT) over phosphodiesterase inhibitor in treating low arousal. A holistic approach seems to make the most sense in addressing low arousal female sexual dysfunction. With the latest encouraging findings in using Mindfulness Based Cognitive Therapy (MBCT) for low desire or low arousal female sexual dysfunction, IntimMed, Seattle is actively investigating such treatment options.
For women distressed by the delayed or absence of orgasm, be it lifelong or acquired, medical and psychosocial evaluation are necessary. Medications such as SSRI for depression can cause orgasmic dysfunction, for example. Mindfulness exercise, sexual technique instruction, and sex therapy could be helpful. For IntimMed, a specialized service is provided to improve sexual function with cosmetic vaginal surgery. For examples, phimosis (covering) of the clitoris could be treated with clitoral hood reduction; or vaginal and introital (opening) relaxation can be improved with colpoperineoplasty (in other words, vaginoplasty, or surgical vaginal rejuvenation) with reconstructing the vagina for tightness and contour to enhance sexual function. Dr. Lau presented a paper at the 2018 International Society for Sexual Medicine/ European Society for Sexual Medicine meeting in Lisbon, Portugal describing the role of vaginal rejuvenation surgery to enhance sexual function.