Dr. Stute

Transcription

Dr. Stute

Der weibliche Orgasmus
Physiologie und Pathophysiologie,
hormonelle Einflüsse und weibliche Orgasmusstörung
PD Dr. med. Petra Stute
Universitätsklinik für Frauenheilkunde
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Was muss ich wissen,
um „es“
nicht faken zu müssen?
P. Stute
2
Das äussere weibliche Genital
12: Preputium clitoridis
9: Vestibulum vaginae
2: Labia majora
8: Labia minora
P. Stute
3
Schwellkörper(muskeln) der Frau
17: Corpus clitoridis
18: Glans clitoridis
7: M. bulbospongiosus
20: M. ischiocavernosus
P. Stute
16: Crus clitoridis
13: Urethra
6: Bulbus vestibuli
(Schwellkörper)
4
Schwellkörper
Klitoriskörper
Glans
Klitorisschenkel
(Corpus cavernosum
dextrum)
P. Stute
Klitorisschenkel
(Corpus cavernosum
sinistrum)
5
„Cluster erektiler Gewebe“ bei der
Frau
•  Klitoris
•  Bulbus vestibuli
•  Labia minora
•  Corpus spongiosum der Urethra
Kontrovers: G-Punkt
Kontrovers: vaginaler Orgasmus.
P. Stute
Puppo V. Clinical Anatomy 2013
Jannini EA et al., J Sex Med 2012
6
Sexualreflex der Frau
Lendenmark
Sakralmark
P. Stute
7
reasons, sexual intercourse may become uncomfortable. However, these physiological alterations are
only related to the reproductive (i.e., internal) organs
of women because estrogen does not affect the clito-
Rhythmische Kontraktionen von ...
Chiarugi and Bucc, cervix; cl, clitoe; cu, carina urePawlik’s triangle.
he thin epithelial
nd the vestibule.
and of the vestithe urethral orient of orgasm in
an clitoral stimuimulation of the
he whole
female
1: M. bulbo-
3: M. levator ani
types spongiosus
of female
lly in terms of
by Masters and
is responds with
and psychogenic
and Fortenberry
4: M. sphincter
ically considered
ani externus
, orgasms occureen occasionally
8) revealed that
P. Stute
2: M. ischiocavernosus
M. transv. perinei
prof. et. superfic.
Puppo V. Clinical Anatomy 2013
Fig. 21. Perineal muscle contractions to the orgasm
and the female emission (from Puppo, 2011d). 1,
8
Meston CM & Frohlich PF. The neurobiology of sexual function. Arch Gen Psychiatry 2000.
Klitorale Schwellung
Sexuelle Stimulation
NO Produktion in
Nerven und Gefässen der Klitoris
NO aktiviert GTP
GTP > cGMP
cGMP relaxiert glatte Muskulatur
in Schwellkörper und Arteriolen
Inhibitor z.B. Sildenafil
cGMP > GMP
(Phosphodiesterase (PDE) Typ 5
Blutstau in Klitoris
P. Stute
9
PDE5-Hemmer bei Frauen
Fazit: objektiv positiv, aber subjektiv inkonsistente Ergebnisse.
P. Stute
10
Anatomie und Funktion der weiblichen
Neuro-Hormon-Chemie des
Orgasmus
Hormonachse:
HypothalamusHypophyse-Ovar
Hy
Gehirn
Hirnanhangsdrüse
(Hypophyse)
Vorderlappen
Wechselwirkung
Freisetzung von
Östrogen und
Progesteron und
Rückkoppelung
Freisetzung von
Gonadotropinen
(FSH, LH)
P. Stute
11
Serotonin und Dopamin
Neurotransmitter
NT-Level
(NT)
Sexuelle
Kohorte / Charakteristika
Funktion
Serotonin
•  Erregung
é
ê
MAO-Hemmer, SSRI
•  Orgasmus
é
ê
MAO-Hemmer, SSRI
é
é
Antidepressiva + Cyproheptadin
(reduziert 5HT-2-Rez. Aktivität)
Dopamin
•  Libido
é
é
Levodopa/Carbidopa (M. Parkinson)
•  Erregung
-
-
-
•  Orgasmus
é
ê
Antipsychotika
P. Stute
12
Adrenalin und Noradrenalin
Neurotransmitter
NT-Level
(NT)
Sexuelle
Funktion
Adrenalin
•  Libido
é
é
Frauen ohne FSD
•  Erregung
é
é
Frauen ohne FSD
é
ê
Erhöhter Sympathikotonus + FSD
é
é
Frauen ohne FSD
ê
ê
Antipsychotika
•  Libido
é

Yohimbin bei HSDD
•  Erregung
é
é
Frauen ohne FSD
•  Orgasmus
é
é
Frauen ohne FSD
•  Orgasmus
Noradrenalin
P. Stute
13
ACH, Histamin und Opioide
Neurotransmitter
NT-Level
(NT)
Sexuelle
Funktion
Acetylcholin
•  Erregung
ê
"
Atropin bei Frauen ohne FSD
•  Orgasmus
ê
"
Atropin bei Frauen ohne FSD
ê
ê
Cimetidin (Fallstudie)
é
êé
Langzeit-Opiode (z.B. Heroin)
ê
é
Naloxon
•  Erregung
ê
"
Naloxon
•  Orgasmus
é
ê
Langzeit-Opiode (z.B. Heroin)
Histamin
•  Libido
Opioide
•  Libido
P. Stute
14
Fazit: Neurotransmitter
Serotonin
(5HT-2-Rez.)
P. Stute
Dopamin
(D2 und D4-Rez.)
(Nor-)Adrenalin
15
P. Stute
16
Der weibliche Hormonhaushalt – schematische Darstellung
Abteilung für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Achsen
HypothalamusHypophysePeripherieAchsen
1. Ebene
Hormondrüse
2. Ebene
Hormon
Vasopressin
Hormondrüse
Hormon
a
TRH
Thyroideastimulierendes
Hormon (TSH)
b
PRH
(Dopamin)
Prolactin *
GHRH
Wachstumshormon
(HGH / STH)
Schilddrüse
Leber
Hypophyse
Adrenokortikotropes Hormon Nebennierenrinde
(ACTH)
CRH
Follikelstimmulierendes
Hormon (FSH)
e
GnRH
Eierstöcke
P. Stute
Epiphyse
Zirbeldrüse
Thyroxin
(T4)
IGF - 1
(insulin-like growth
factors)
Glukokortikoide
(Cortisol)
Sexualhormone
(Oestrogene, Gestagene,
Androgene)
Oestrogene
Luteinisierungshormon (LH)
f
Trijodthyronin
(T3)
Mineralokortikoide
(Aldosteron)
Vorderlappen
d
Hormon
Vasopressin
(Antidiuretisches
Hinterlappen Hormon - ADH)
(Speicherung)
Oxytocin
Hypothalamus
Hormondrüse
Periphere Organe
Hypophyse
Oxytocin
c
3. Ebene
Gestagene
Androgene
Melatonin
Nebenschilddrüsen
Parathormon
17
Androgene
Hormon
Hormon
Sexuelle
i.S.
Funktion
é
é
Natürliche Menopause
é
é
Operative Menopause
é
é
GV-Frequenz (keine FSD)
é
é
GV-Initiierung bei Adoleszentinnen
é
é
Masturbation-Frequenz (keine FSD)
ê
ê
Ovarektomie; Adrenalektomie
ê
ê
Transsexualität Mann > Frau
é
é
Objektiv: Vaginale Durchblutung
é
é
Subjektiv: DHEA postmenopausal
é

Subjektiv: DHEA prämenopausal
Testosteron
•  Libido
•  Erregung
P. Stute
18
Östrogen und Progesteron
Hormon
Hormon
Sexuelle
i.S.
Funktion
é
é
Frauen ohne FSD
é

Menopause

éê
Frauen mit vs. ohne HSDD
ê
ê
Menopause
é
é
HRT
é
ê
Progesteronimplantat
é
éê
Hormonale Kontrazeptiva
é
"
Prämenopause Progesterontherapie
é

Postmenopause Progesterontherapie
Östrogen
•  Libido
•  Erregung
Progesteron
•  Libido
P. Stute
19
Achsen
1. Ebene
Hormondrüse
2. Ebene
Hormon
Vasopressin
Hormondrüse
Hormon
a
TRH
Hormon (TSH)
b
PRH
(Dopamin)
Prolactin *
GHRH
Wachstumshormon
(HGH / STH)
Schilddrüse
Leber
Hypophyse
(ACTH)
CRH
Hormon (FSH)
e
GnRH
Eierstöcke
P. Stute
Epiphyse
Zirbeldrüse
Thyroxin
(T4)
IGF - 1
factors)
Glukokortikoide
(Cortisol)
Sexualhormone
Androgene)
Oestrogene
f
Trijodthyronin
(T3)
Mineralokortikoide
(Aldosteron)
Vorderlappen
d
Hormon
Vasopressin
(Antidiuretisches
(Speicherung)
Oxytocin
Hypothalamus
Hormondrüse
Periphere Organe
Hypophyse
Oxytocin
c
3. Ebene
Gestagene
Androgene
Melatonin
Nebenschilddrüsen
Parathormon
20
Cortisol
Hormon
Hormon
Sexuelle
i.S.
Funktion
•  Libido
é
ê
Cushing Syndrom
•  Erregung

é
Frauen ohne FSD
•  Orgasmus

é
Frauen ohne FSD
Cortisol
Der negative Effekt von Cortisol ist whs. eher indirekt auf eine
begleitende Depression als auf einen direkten Einfluss
zurückzuführen.
P. Stute
21
Achsen
1. Ebene
Hormondrüse
2. Ebene
Hormon
Vasopressin
Hormondrüse
Hormon
a
TRH
Hormon (TSH)
b
PRH
(Dopamin)
Prolactin *
GHRH
Wachstumshormon
(HGH / STH)
Schilddrüse
Leber
Hypophyse
(ACTH)
CRH
Hormon (FSH)
e
GnRH
Eierstöcke
P. Stute
Epiphyse
Zirbeldrüse
Thyroxin
(T4)
IGF - 1
factors)
Glukokortikoide
(Cortisol)
Sexualhormone
Androgene)
Oestrogene
f
Trijodthyronin
(T3)
Mineralokortikoide
(Aldosteron)
Vorderlappen
d
Hormon
Vasopressin
(Antidiuretisches
(Speicherung)
Oxytocin
Hypothalamus
Hormondrüse
Periphere Organe
Hypophyse
Oxytocin
c
3. Ebene
Gestagene
Androgene
Melatonin
Nebenschilddrüsen
Parathormon
22
Oxytocin
Hypothalamische oxytocinerge Neurone
•  Neurohypophyse > Blutbahn
•  Adenohypophyse > Modulation der ACTH Sekretion
•  Synapse zu anderen Neuronen (Hirnstamm und Rückenmark)
> Modulation der Exzitabilität anderer Neurone
Stimulation der Sekretion
•  Mamillenstimulation > Milchsekretion (z.B. Laktation)
•  Genitale Manipulation > Uteruskontraktion (z.B. postpartal)
P. Stute
23
Oxytocin
Hormon
Hormon
Sexuelle
i.S.
Funktion
•  Libido
é
é
Laktation
•  Erregung
é
é
Frauen ohne FSD
é
é
Laktation
é
é
Frauen ohne FSD
é
é
Orgasmus Intensität
Oxytocin
•  Orgasmus
P. Stute
24
Achsen
1. Ebene
Hormondrüse
2. Ebene
Hormon
Vasopressin
Hormondrüse
Hormon
a
TRH
Hormon (TSH)
b
PRH
(Dopamin)
Prolactin *
GHRH
Wachstumshormon
(HGH / STH)
Schilddrüse
Leber
Hypophyse
(ACTH)
CRH
Hormon (FSH)
e
GnRH
Eierstöcke
P. Stute
Epiphyse
Zirbeldrüse
Thyroxin
(T4)
IGF - 1
factors)
Glukokortikoide
(Cortisol)
Sexualhormone
Androgene)
Oestrogene
f
Trijodthyronin
(T3)
Mineralokortikoide
(Aldosteron)
Vorderlappen
d
Hormon
Vasopressin
(Antidiuretisches
(Speicherung)
Oxytocin
Hypothalamus
Hormondrüse
Periphere Organe
Hypophyse
Oxytocin
c
3. Ebene
Gestagene
Androgene
Melatonin
Nebenschilddrüsen
Parathormon
25
Prolaktin
Hormon
Hormon
Sexuelle
i.S.
Funktion
é
ê
Hyperprolaktinämie
é
ê
Sex. Aktivität bei Hyperprolaktinämie
é
ê
Laktation
ê
é
Dopaminagonist bei Hyper-PRL
é
é
Nach Orgasmus bei Frauen ohne
Prolaktin
•  Libido
•  Orgasmus
FSD
P. Stute
26
Grundzustand =
permanente hypothalamische Unterdrückung
der hypophysären PRL Sekretion
PIF = PRL inhibiting factor
Dopamin
GABA, Somatostatin, Calcitonin
PRF = PRL releasing factor
TRH, Oxytocin, VIP
AVP, Histidin-Isoleucin-Peptid (Stress)
Melmed, Williams Textbook of Endocrinology, 12th edition 2011
P. Stute
27
Fazit: Hormone
Cortisol
Prolaktin
P. Stute
Androgene
Oxytocin
(Östrogene)
28
Sexuelle Störungen bei der Frau
Der Begriff „Sexuelle Störungen der Frau“ (FSD) umschließt
4 Einzelstörungen, die mit Leidensdruck verbunden sind.
Störungen des sexuellen Verlangens
Vermindertes sexuelles Verlangen, sexuelle Aversion
Störungen der sexuellen Erregung
Störungen der Orgasmusfähigkeit
Störungen mit sexuell bedingten Schmerzen
Dyspareunie, Vaginismus
P. Stute
29
DSM-IV/V Kriterien der weiblichen
Orgasmusstörung (FOD)
1)  Persistent or recurrent delay in, or absence of, orgasm
following a normal sexual excitement phase. Women exhibit wide
variability in the type of intensity of stimulation that triggers orgasm.
The diagnosis of Female Orgasmic Disorder should be based on the
clinician‘s judgement that the woman‘s orgasmic capacity is less
than would be reasonable for her age, sexual experience, and the
adequacy of sexual stimulation she receives.
2)  The disturbance causes marked distress or interpersonal
difficulty.
3)  The orgasmic dysfunction is not better accounted for by another Axis
I disorder (except another sexual dysfunction) and is not due
exclusively to the direct physiological effects of a substance (e.g. a
drug of abuse, a medication) or a general medical condition.
P. Stute
30
260
FOD Prävalenz
Table 3 Prevalence of orgasm problems in selected epidemiological studies
Study
N of women
Country
Bancroft et al. (2003b)
987; all in heterosexual relationships United
States
Age
Method of assessment
20–65 Computer-assisted telephone
interviewing
Time period
Prevalence
Previous month
Orgasm during sexual activity with
partner (% of occasions)
None: 9.7%
\25: 11.4%
25–50: 23.1%
51–75: 20.1%
[75: 35.7%
Laumann et al. (1999)
1,749; all sexually active over last 12 United
months
States
18–59 Face-to-face interview
Several months or more
during past 12 months
Unable to experience orgasm: 25.7%
Lindal and Stefansson
(1993)
421
Iceland
55–57 Face-to-face interview; Diagnostic
Interview Schedule (DIS-III-A)
Lifetime prevalence
Inhibited orgasm (DSM-III criteria):
3.5%
Lindau et al. (2007)
479
United
States
57–85 Face-to-face interview and self-report
questionnaire
Several months or more
during past 12 months
Unable to experience orgasm: 34%
Mercer et al. (2003)
4,826; all had at least 1 heterosexual Britain
partner in last 12 months
16–44 Computer-assisted self-interview
Past 12 months
Unable to experience orgasm:
Lasted at least 1 month: 14.4%
Lasted at least 6 months: 3.7%
Najman, Dunne, Boyle,
Cook, and Purdie (2003)
908
Australia 18–59 Telephone interview
Oberg et al. (2004)
1,056, all sexually active during last Sweden
12 months
Richters et al. (2003)
9,134
18–65 Structured face-to-face
interview ? questionnaires
Several months in the past
12 months
Trouble reaching orgasm: 21–30%
(depending on age)
Past 12 months
Difficulties reaching orgasm:
Manifest: 22%; Mild: 60%
Australia 16–59 Computer-assisted telephone interview At least 1 month in the past Unable to experience orgasm: 28.6%
12 months
aber nur ca. 5% dadurch „gestresst“!
Spira, Bajos, and The ACSF 1,137
Group (1994)
France
18–69 Telephone interview
Lifetime
Unable to experience orgasm:
Ventegodt (1998)
Denmark 18–88 Postal questionnaire
Current experience
Unable to experience orgasm: 6.8%
Finland
Past month
Problems with orgasm (met FSFI
cut-off score of 3.75): 31%;
Often: 11%
Sometimes: 21%
(Shifren
Witting et al. (2008) et al.
5,4632008)
18–49 Questionnaires (FSFI ? FSDS)
Graham CA. Arch Sex Behav 2010
Met FSFI cut-off and reported
distress: 16%
Note: manifest = ‘‘quite often’’, ‘‘nearly all the time’’, and ‘‘all the time’’; mild = ‘‘hardly ever’’ and ‘‘quite rarely’’
FSFI
Female Sexual Function Index (Rosen et al., 2000), FSDS Female Sexual Distress Scale (Derogatis et al., 2002)
P. Stute
31
Arch Sex Behav (2010) 3
753
Diagnostik der sexuellen
Funktionsstörung
Sexualanamnese
•  Aktuelle Beschwerden
•  Sex. Verhalten
•  Sex. Beziehung
•  Kurze sex.- und
Beziehungsbiographie
Allgemeinmedizinische
Anamnese
•  Systemanamnese
•  CVD, DM, Psyche, Haut
•  Medikamente
Gynäkologische
Anamnese
•  Zyklus, OP
•  Kontrazeption, HT
Hormonanalysen
•  FSH
•  Östradiol
•  Prolaktin
•  TSH, T3 / T4
•  Androgene
Gesamttestosteron
SHBG
(freies Testo, DHEAS)
Körperliche Untersuchung
•  Gewicht, Blutdruck,
•  Behaarung
ggf. Fragebögen
•  FSFI (21 items)
•  B-PFSF (7 items)
Gynäkologische Untersuchung
•  Vulva und Vagina Veränderungen
•  Inneres Genitale
Bildgebung
•  US
Modifiziert nach J. Bitzer, UniMed 2008
P. Stute
32
Orgasmusstörung
Basisdiagnostik
Primär
Sekundär
Psychosoziale
Ursachen
Sexualhormonmangel
Einzeltherapie
Paartherapie
Vulvovaginale
Atrophie
Klimakterische
Beschwerden
Systemische oder
lokale HT
Östrogen
Testosteron
P. Stute
gesundheitl. u/o
sexuelle Probleme
des Partners
Prädisponierende
klinische Faktoren
Therapie klinisch
relevanter
Erkrankungen:
Depression
Angststörung
chronische,
hormonelle,
metabolische
Erkrankungen
Medikation
FSD Education Team, Cimacteric 2009
33
Medikamentöse Therapie der
weiblichen Orgasmusstörung
•  Keine Zulassung!
P. Stute
34
Bupropion SR, 150 mg PO BID
Randomized controlled trial in which women with major
Changes in Sexual Functioning
depressive disorder who experienced SSRI-associated
Questionnaire (CSFQ), orgasm
Abt. für Gynäkologische Endokrinologie
und Reproduktionsmedizin,
Frauenklinik Inselspital
Bern scale
sexual dysfunction
(n = 42) were treated with
completion
bupropion SR or placebo for 4 weeks
Bupropion, 150 mg PO daily or
Single-blind sequential treatment of 20 and 10
Satisfaction with intensity of orgasm
300 mg PO daily
non-depressed women and men, respectively, with
orgasmic delay or inhibition with placebo, bupropion
SR 150 mg/day, and bupropion SR 300 mg/day
Bupropion, 150 mg, 300 mg or
Randomized placebo-controlled trial of premenopausal
CSFQ, orgasm completion scale
400 mg PO daily
women with hypoactive sexual desire disorder treated
with escalating doses of bupropion (150, 300, or
400 mg/day) (n = 31) vs. placebo (n = 35)
Bupropion SR, 150 mg PO daily
30 adults (both men and women) who had received
Arizona sexual experience (sexual
SSRIs for at least 6 weeks were currently euthymic,
dysfunction determined by score
and who had sexual dysfunction were randomly
greater than 19/30)
assigned to receive 150 mg/day of bupropion SR or
placebo for 3 weeks
Estradiol, 0.014 mg/day transdermal
Randomized controlled trial in which postmenopausal
Medical Outcomes Study Sexual
patch
women aged 60–80 years (n = 417) were treated with
Problems Index “Orgasm
placebo (n = 209) or a 0.014 mg/day transdermal
frequency and quality” measure
estradiol patch (n = 208) for 24 months
Conjugated equine estrogens,
57 hysterectomized women were randomized to receive
Personal interviews for sexual
0.625 mg PO or 0.0625 mg/1 g
either oral (0.625 mg of conjugated equine estrogens
symptoms using a validated
Table 1 Continued
vaginal cream daily
per tablet; n = 27) or topical (0.625 mg conjugated
questionnaire before and 3
equine
estrogens per 1 g vaginal cream; n = 30)
months after estrogen therapy
Treatment
Study
description
Measures
estrogen administered once daily
Estradiol (women with surgical
Randomized controlled trial in which healthy
FSFI orgasm domain
menopause), 0.625 mg/day or
postmenopausal women (n = 169) were divided into a
estradiol 1 mg/day + drospirenone
control group (n = 58), surgically induced menopausal
2 mg/day or Tibolone 2 mg/day
women were treated with oral estradiol (n = 23), and
natural menopausal women were treated with oral
estradiol + drospirenone (n = 22), oral tibolone (n = 42),
or vaginal estradiol (n = 24) for 6 months
Estradiol 0.1 mg patch daily or
Randomized controlled trial in which pharmacologically
Derogatis Interview for Sexual
progesterone 200 mg suppository
induced hypogonadic females with resultant decreased
Functioning (DISF) orgasm
BID
quality of orgasm who were otherwise healthy (n = 20)
subscale
were treated with estradiol and progesterone for 5
weeks each
Ethinylestradiol 15 mg PO daily and
Prospective trial in which 48 healthy females were
Personal Experiences Questionnaire
Gestodene 60 mg PO daily
treated with a low-dose oral contraceptive containing
(PEQ) orgasm item
15 mg ethinylestradiol and 60 mg gestodene and
assessed at 3, 6, and 9 months of use
Gingko biloba extract
68 women with sexual arousal disorder were randomized
Subjective and physiological
to placebo, gingko biloba extract, sex therapy, or sex
(vaginal photoplethysmography)
therapy plus gingko biloba extract
measures of sexual function
No significant improvement with bupropion SR
150 mg BID vs. placebo at week 2 or week 4
Significant improvement in satisfaction with intensity
of orgasm in females at 150 mg/day (P < 0.05) but
not 300 mg/day (P = 0.10)
Östrogene
Fazit: z.T. positiver Effekt, z.T. kein Effekt
Methyltestosterone 2 mg PO daily
+/- Conjugated estrogens
0.625 mg PO daily and
medroxyprogesterone acetate
2.5 mg PO
daily
P. Stute
Randomized controlled trial in which women with
postmenopausal sexual complaints(n = 60) were
treated with estrogen + progesterone hormone
replacement + placebo (n = 29) or hormone
replacement + methyltestosterone (2 mg/day) (n = 31)
Sexual Energy Change Scale,
monthly orgasm frequency diary
Significant improvement in orgasm completion
(P = 0.0057) at days 28, 56, 84, and 112 as
compared to placebo
There were no significant differences between the
bupropion SR and placebo groups
No significant improvement in estradiol group vs.
placebo at any time point
Anorgasmia decreased significantly in both groups
(P < 0.05)
Results
All hormonal treatments reported to improve orgasm
domain scores (P reported as “0.000”), with oral
tibolone achieving the highest improvement
Neither estradiol (0.1 mg patch/day) or progesterone
(200 mg suppository BID) significantly improved
orgasm subscale scores
No significant change in score at any time period
Ginkgo biloba extract combined with sex therapy
produced a significant increase in sexual desire
and contentment beyond placebo alone. No
difference between placebo and ginkgo biloba
extract alone. Sex therapy alone enhanced orgasm
function when compared with placebo
Conjugated estrogens (0.625 mg/
day)
+ medroxyprogesterone
acetate2010
(2.5 mg/day)
Ishak
et al., J Sex Med
increased orgasm frequency (P < 0.001), but
methyltestosterone did not significantly improve
orgasm frequency beyond hormone replacement
35
Nijland et al., J Sex Med. 2008
Cayan et al., J Sex Med. 2008
Osmanağaoğlu et al., Climacteric 2006
Tibolon und HRT
Sexuelle Funktion in der Postmenopause
n
Intervention
403
•  Tibolon (Livial®)
•  50 mcg E2+140 mcg NETA
patch (z.B. Estalis®)
3
HRT = Tibolon
•  Zunahme sex. Fukntion
•  Zunahme sex. Kontakte
•  Abnahme Leidensdruck
169
• 
• 
• 
• 
• 
6
Sex. Funktion:
ê  * Kontrolle
é  * Hormontherapie
Tibolon: v.a. Orgasmus
Östrogene: v.a. Lubrikation,
Erregung
158
•  Tibolon (Livial®)
•  2 mg E2+2 mg DNG
6
Sex. Funktion:
Tibolon > orale HRT
Dyspareunie:
Tibolon = orale HRT
orales E2 (HE+OVX)
E2+DRSP (Angeliq®)
Tibolon (Livial®)
vaginales E2 (Vagifem®)
Kontrolle
(z.B. Lafamme)
•  Kontrolle
P. Stute
Dauer
[Mo]
Ergebnis
36
Androgene
•  Oral
–  10 Studien, max. 10 Monate, n = 8-218 post- > prämenopausale
Frauen, Methyltestosteron und Testosteronundecanoat
•  Intramuskulär
–  5 Studien, max. 2 Jahre, n = 17-53 postmenopausale Frauen,
Testosteron s.c. und i.m.
•  Transdermal
–  13 Studien, max. 1 Jahr, n = max. 562 post- > prämenopausale
Frauen, natürliche und chirurgische Menopause, Testosteron patch
> Gel, Creme, Spray
Woodis CB et al., Pharmacotherapy 2012
P. Stute
37
Androgentherapie
in der Postmenopause
•  Transdermales Testosteron (300 µg/Tag) erhöht bei
postmenopausalen Frauen (OVX und spontan) die monatliche
Anzahl befriedigender sexueller Kontakte. LoE A
•  In den gleichen Studien wurde eine signifikante Zunahme der
Libido, Erregbarkeit, Reaktivität (responsiveness),
Orgasmusfähigkeit und Zufriedenheit beobachtet. LoE A
•  Orales DHEA (50 mg/Tag) steigert nicht signifikant die
sexuelle Funktion bei postmenopausalen Frauen ohne
Östrogenersatz mit HSDD. LoE A
Santen RJ et al., THE JOURNAL OF CLINICAL ENDOCRINOLOGY & METABOLISM 2010
P. Stute
38
Androgentherapie
in der Prämenopause
•  Testosteron-Creme (10mg/Tag): erfolgreich.
Goldstat R et al., Menopause 2003
•  Testosteron-Spray (50-90µg/Tag): erfolgreich.
Davis S et al., Ann Intern Med 2008
•  Testosteronpropionat 2 mg bei Bedarf: nicht erfolgreich.
Apperloo M et al., J Sex Med 2008
Woodis CB et al., Pharmacotherapy 2012
P. Stute
39
für Gynäkologischetreatments
Endokrinologie
Reproduktionsmedizin,
Table 1Abt.Pharmacological
forund
disorders
of orgasm in Frauenklinik
women Inselspital Bern
Treatment
Study description
Measures
Results
Alprostadil, 400 mg vaginal cream
prior to intercourse
Randomized controlled trial in which 51 women with
FSAD were treated for 6 weeks with placebo or
alprostadil. Results were analyzed for women who
used at least six doses (n = 25)
Frequency of orgasm and score
changes from baseline using
Female Sexual Function Index
(FSFI) and Female Sexual
Distress Scale (FSDS) (secondary
measures)
Diary rating orgasm frequency and
quality, Interview Rating of Sexual
Function
Achievement of orgasm increased significantly
(P = 0.026)
Measures
Self-report
measures)
FSFI,
sexual events,
Diary total
ratingnumber
orgasmoffrequency
and
total
number
of orgasms,
personal
quality,
Interview
Rating of
Sexual
distress,
Functionand adverse drug effects
Results
73.5% of ArginMax group reported improved
satisfaction in
life compared
with 37.2%
Achievement
of overall
orgasmsex
increased
significantly
of(Pplacebo
= 0.026)group (P < 0.01). Other noted
improvements were in sexual desire, reduction of
vaginal dryness, frequency of sexual intercourse,
orgasm, and clitoral sensation. No significant side
effects noted
Pretreatment
orgasm nor
scores:
treatment
group orgasm
4.3,
Neither amantadine
buspirone
improved
control
group
4.2. Post-treatment
measures
compared
to placebo scores: treatment
group 5.3 (P = 0.01), control group 4.4 (P = 0.1).
Treatment group reported greater intercourse
satisfaction
(P = 0.001)
more drug-related
73.5%
of ArginMax
groupand
reported
improved
adverse
effects;
5% (2 sex
subjects)
had to discontinue
satisfaction
in overall
life compared
with 37.2%
therapy
of placebo group (P < 0.01). Other noted
No improvements
significant improvement
with bupropion
SR
were in sexual
desire, reduction
of
150
mg BID
vs. placebo
at week
2 or week
4
vaginal
dryness,
frequency
of sexual
intercourse,
Amantadine, buspirone
fluoxetine-induced
sexualof
dysfunction
treated with
Table 1 Pharmacological treatments
for disorders
orgasmwere
in women
amantadine (n = 18), buspirone (n = 19), or placebo
(n = description
20) for 8 weeks
Treatment
Study
ArginMax (proprietary nutritional
supplement
interest in improving
treated
Alprostadil,
400containing
mg vaginalginseng,
cream
Randomized
controlled sexual
trial in function
which 51were
women
withfor 4
ginkgo,
damiana, L-arginine,
weeks were
with ArginMax
prior
to intercourse
FSAD
treated foror6placebo
weeks with placebo or
multivitamins, and minerals)
Psychopharmaka
Ishak et al., J Sex Med 2010
Neither amantadine nor buspirone improved orgasm
measures compared to placebo
Buspiron (Angststörung): Agonist an 5-HT1A-Rezeptoren, Antagonist an D2-Rezeptoren.
Amantadin (Influenza-A-Grippe, Parkinson Syndrom): u.a. Dopamin Agonist
Bremelanotide,
20 mg intranasal
Amantadine,
buspirone
spray 45–60 minutes prior to
attempted intercourse
supplement containing ginseng,
ginkgo, damiana, L-arginine,
Bupropion
SR, 150
PO BID
multivitamins,
andmg
minerals)
80 married, menstruating
women
(mean
age with
31 years)
Randomized
controlled trial
in which
women
with female sexual sexual
arousaldysfunction
disorder were
treated
with
fluoxetine-induced
were
treated
with
placebo
or
intranasal
bremelanotide
45–60
minutes
prior
to attempted
intercourse
(n
= 20)
for 8 weeks
interest in improving sexual function were treated for 4
weeks with ArginMax or placebo
sexual dysfunction (n = 42) were treated with
80 married, menstruating women (mean age 31 years)
with female sexual arousal disorder were treated with
placebo or intranasal bremelanotide 45–60 minutes
prior to attempted intercourse
Single-blind
sequential
placebo for
3 weeks treatment of 20 and 10
non-depressed
women
and
with
Randomized
controlled
trial
in men,
whichrespectively,
postmenopausal
orgasmic
delay
or
inhibition
with
placebo,
bupropion
SR
150 mg/day,
SR 300
mg/day
placebo
(n = 209)and
or abupropion
0.014 mg/day
transdermal
Randomized
placebo-controlled
trial
of
premenopausal
with hypoactive
sexual
disorder
treated
57women
hysterectomized
women
were desire
randomized
to receive
with
escalating
doses
of
bupropion
(150,
300,
or
either oral (0.625 mg of conjugated equine estrogens
400
mg/day)
= 31)
vs. placebo
= 35)
per tablet;
n =(n27)
or topical
(0.625(nmg
conjugated
Self-report
Bupropion (Depression): Dopamin-, Noradrenalin-, Serotonin-Reuptake-Hemmer
Bremelanotide, 20 mg intranasal
300 mg PO daily
400 mg PO daily
300 mg PO
daily
Estradiol,
0.014
mg/day transdermal
completion scale
FSFI, total number of sexual events,
total number of orgasms, personal
distress, and adverse drug effects
completion scale
greater than 19/30)
effects noted
Pretreatment orgasm scores: treatment group 4.3,
control group 4.2. Post-treatment scores: treatment
not 300 mg/day (P = 0.10)
satisfaction (P = 0.001) and more drug-related
(P = 0.0057) at days 28, 56, 84, and 112 as
adverse effects; 5% (2 subjects) had to discontinue
compared to placebo
therapy
orgasm in
females at 150
mg/daygroup
(P < 0.05)
No of
significant
improvement
in estradiol
vs. but
not
300
mg/day
(P
=
0.10)
Fazit: positiver Effekt, wenn keine SSRI parallel
kein Effekt, wenn SSRI parallel
patch
400 mg POequine
daily estrogens,
Conjugated
0.625 mg PO or 0.0625 mg/1 g
vaginalP.cream
Stutedaily
symptoms using a validated
questionnaire before and 3
(P = 0.0057)
at days significantly
28, 56, 84, and
112groups
as
Anorgasmia
decreased
in both
compared
to
placebo
(P < 0.05)
40
Table 1
Pharmacological treatments for disorders of orgasm in women
Treatment
Study description
Measures
Results
Alprostadil, 400 mg vaginal cream
prior to intercourse
FSAD were treated for 6 weeks with placebo or
measures)
Diary rating orgasm frequency and
quality, Interview Rating of Sexual
Function
Achievement of orgasm increased significantly
(P = 0.026)
Self-report
73.5% of ArginMax group reported improved
satisfaction in overall sex life compared with 37.2%
of placebo group (P < 0.01). Other noted
improvements were in sexual desire, reduction of
vaginal dryness, frequency of sexual intercourse,
effects noted
Pretreatment orgasm scores: treatment group 4.3,
control group 4.2. Post-treatment scores: treatment
satisfaction (P = 0.001) and more drug-related
adverse effects; 5% (2 subjects) had to discontinue
therapy
Bremelanotid
Amantadine, buspirone
fluoxetine-induced sexual dysfunction were treated with
(n = 20) for 8 weeks
interest in improving sexual function were treated for 4
weeks with ArginMax or placebo
Neither amantadine nor buspirone improved orgasm
measures compared to placebo
Agonist an Melanocortinrezeptor-1 (Hautbräunung) und
Melanocortinrezeptor-4 (u.a. Libido)
supplement containing ginseng,
ginkgo, damiana, L-arginine,
multivitamins, and minerals)
Bremelanotide, 20 mg intranasal
80 married, menstruating women (mean age 31 years)
with female sexual arousal disorder were treated with
placebo or intranasal bremelanotide 45–60 minutes
prior to attempted intercourse
FSFI, total number of sexual events,
total number of orgasms, personal
distress, and adverse drug effects
placebo for 3 weeks
Randomized controlled trial in which postmenopausal
placebo (n = 209) or a 0.014 mg/day transdermal
57 hysterectomized women were randomized to receive
completion scale
Fazit: positiver Effekt, aber zu viele Nebenwirkungen,
Daher (noch) keine Weiterentwicklung.
300 mg PO daily
400 mg PO daily
Estradiol, 0.014 mg/day transdermal
patch
P. Stute
Conjugated equine estrogens,
not 300 mg/day (P = 0.10)
(P = 0.0057) at days 28, 56, 84, and 112 as
compared to placebo
greater than 19/30)
Ishak improvement
et al., J Sex
Med group
2010
No significant
in estradiol
vs.
41
Anorgasmia decreased significantly in both groups
Ishak et al., J Sex Med 2010
•  Mianserin = tetrazyklisches Antidepressivum
positiv (15mg/die) bei SSRI induzierter FSD
•  Gingko biloba extract
positiv nur in Verbindung mit Sexualtherapie
•  Yohimbin = Antagonist an α2-Adrenozeptoren
Positiv (12-20mg/die) bei SSRI-induzierter FSD
•  Zestra = botanisches Massageöl (auf Vulva)
positiv (Frauen mit / ohne FSD), wenn Applikation vor GV
•  Oxytocin Nasenspray ?
P. Stute
42
Fazit - I
•  Der Orgasmus ist das Ergebnis des Zusammenspiels von
–  adäquater Stimulation
–  intakten Genitalorganen inkl. deren Gefässe und Nerven
–  (Beckenboden-)Muskulatur
–  Gehirn und Rückenmark
–  Neurotransmittern und -modulatoren
–  Hormonen
•  Die weibliche Orgasmusstörung (FOD) gemäss DSMKriterien ist selten (5%).
P. Stute
43
Fazit - II
•  Die FOD Therapie ist multidisziplinär.
•  Es sind keine Medikamente zur Behandlung der FOD
zugelassen.
•  Positive Effekte wurden beschrieben für
– 
– 
– 
– 
– 
– 
– 
– 
P. Stute
z.T. Östrogene (postmenopausal)
Testosteron (v.a. postmenopausal)
Tibolon (postmenopausal)
Bremelanotid (prämenopausal)
Bupropion
Mianserin und Yohimbin (SSRI-induzierte FSD)
Gingko (in Kombination mit Sexualtherapie)
Zestra topisch
44
DANKE!
P. Stute
45
Orgasmustypen
•  Online-Befragung von 225 Frauen
•  Typ I (tiefer Ursprung)
–  Schwebegefühl (floating sensation)
–  Apnoe
–  Selbstverlust (loss of self)
–  Sucking sensation
–  Partnercharakteristika: guter Geruch, dominantes und
gleichzeitig rücksichtsvolles Verhalten, kraftvolle Penetration (aber
nicht Aggressivität, „Muckis“ und Maskulinität)
•  Typ II (oberflächlicher Ursprung)
–  eher lokalisiert
–  entspannender
P. Stute
King R & Belsky J, Arch Sex Behav 2012
46

Dr. Stute

Transcription

Similar documents

Patientin mit Hyperandrogenämie

Eine sprudelnde Quelle der Lust

des Programmheftes hier

Mediaeval cattle from Bern (Switzerland): An archaeozoological

Die Polyneuropathie – immer eine diagnostische Herausforderung

Inhaltsverzeichnis - Institut für Sexualpädagogik

Dateien anzeigen - Heinrich-Heine

Lehrerinformation Fachbereichsarbeit