Der weibliche Orgasmus Physiologie und Pathophysiologie, hormonelle Einflüsse und weibliche Orgasmusstörung - PD Dr. med. Petra Stute
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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
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Das äussere weibliche Genital
12: Preputium clitoridis
9: Vestibulum vaginae
2: Labia majora
8: Labia minora
P. Stute 3
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Schwellkörper(muskeln) der Frau
17: Corpus clitoridis
18: Glans clitoridis
16: Crus clitoridis
7: M. bulbo-
spongiosus 13: Urethra
6: Bulbus vestibuli
20: M. ischio- (Schwellkörper)
cavernosus
P. Stute 4
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Schwellkörper
Klitoriskörper
Glans
Klitorisschenkel Klitorisschenkel
(Corpus cavernosum (Corpus cavernosum
dextrum) sinistrum)
P. Stute 5
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
„Cluster erektiler Gewebe“ bei der
Frau
• Klitoris
• Bulbus vestibuli
• Labia minora
• Corpus spongiosum der Urethra
Kontrovers: G-Punkt
Kontrovers: vaginaler Orgasmus. Puppo V. Clinical Anatomy 2013
Jannini EA et al., J Sex Med 2012
P. Stute 6
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern Sexualreflex der Frau Lendenmark Sakralmark P. Stute 7
reasons, sexual intercourse may become uncomfort-
able. However, these physiological alterations are
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
only related to the reproductive (i.e., internal) organs
of women because estrogen does not affect the clito-
Rhythmische Kontraktionen von ...
Chiarugi and Buc-
c, cervix; cl, clito-
e; cu, carina ure-
Pawlik’s triangle.
he thin epithelial
nd the vestibule.
and of the vesti-
the urethral ori-
ent of orgasm in
an clitoral stimu-
imulation of the
he whole female
3: M. levator ani
1: M. bulbo-
types spongiosus
of female
lly in terms of
by Masters and 2: M. ischiocavernosus
is responds with
and psychogenic M. transv. perinei
4: M. sphincter
and Fortenberry prof. et. superfic.
ically considered
ani externus
, orgasms occur-
een occasionally Puppo V. Clinical Anatomy 2013
Fig. 21. Perineal muscle contractions to the orgasm
8) revealed that
P. Stute and the female emission (from Puppo, 2011d). 1, 8
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
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
Inhibitor z.B. Sildenafil
GTP > cGMP
cGMP relaxiert glatte Muskulatur cGMP > GMP
in Schwellkörper und Arteriolen (Phosphodiesterase (PDE) Typ 5
Blutstau in Klitoris
P. Stute 9
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern PDE5-Hemmer bei Frauen Fazit: objektiv positiv, aber subjektiv inkonsistente Ergebnisse. P. Stute 10
Anatomie und Funktion der weiblichen
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Neuro-Hormon-Chemie des
Orgasmus Hormonachse:
Hypothalamus-
Hy
Hypophyse-Ovar
Gehirn
Hirnanhangsdrüse
(Hypophyse)
Vorderlappen
Freisetzung von
Östrogen und
Progesteron und
Wechselwirkung Rückkoppelung
Freisetzung von
Gonadotropinen
(FSH, LH)
P. Stute 11Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Serotonin und Dopamin
Neurotransmitter NT-Level Sexuelle Kohorte / Charakteristika
(NT) 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
Meston CM & Frohlich PF. The neurobiology of sexual function. Arch Gen Psychiatry 2000.
P. Stute 12Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Adrenalin und Noradrenalin
Neurotransmitter NT-Level Sexuelle Kohorte / Charakteristika
(NT) Funktion
Adrenalin
• Libido é é Frauen ohne FSD
• Erregung é é Frauen ohne FSD
é ê Erhöhter Sympathikotonus + FSD
• Orgasmus é é Frauen ohne FSD
ê ê Antipsychotika
Noradrenalin
• Libido é Yohimbin bei HSDD
• Erregung é é Frauen ohne FSD
• Orgasmus é é Frauen ohne FSD
Meston CM & Frohlich PF. The neurobiology of sexual function. Arch Gen Psychiatry 2000.
P. Stute 13Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
ACH, Histamin und Opioide
Neurotransmitter NT-Level Sexuelle Kohorte / Charakteristika
(NT) Funktion
Acetylcholin
• Erregung ê " Atropin bei Frauen ohne FSD
• Orgasmus ê " Atropin bei Frauen ohne FSD
Histamin
• Libido ê ê Cimetidin (Fallstudie)
Opioide
• Libido é êé Langzeit-Opiode (z.B. Heroin)
ê é Naloxon
• Erregung ê " Naloxon
• Orgasmus é ê Langzeit-Opiode (z.B. Heroin)
Meston CM & Frohlich PF. The neurobiology of sexual function. Arch Gen Psychiatry 2000.
P. Stute 14Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Fazit: Neurotransmitter
Dopamin
Serotonin (D2 und D4-Rez.)
(5HT-2-Rez.) (Nor-)Adrenalin
P. Stute 15Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern P. Stute 16
Der weibliche Hormonhaushalt – schematische Darstellung
Abteilung für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Achsen 1. Ebene 2. Ebene 3. Ebene
Hypothalamus- Hormon-
drüse
Hormon
Hormon-
drüse
Hormon
Hormondrüse
Periphere Organe
Hormon
Hypophyse-
Vasopressin
Vaso- Hypophyse (Antidiu-
pressin retisches
Hinterlappen Hormon - ADH)
Peripherie-
(Speicherung)
Oxytocin Oxytocin
Achsen a TRH
Thyroidea-
stimulierendes
Hormon (TSH)
Schilddrüse
Trijodthyronin
(T3)
Thyroxin
(T4)
PRH
b
(Dopamin) Prolactin *
Wachstums- IGF - 1
Hypothalamus
c GHRH hormon (insulin-like growth
Leber
(HGH / STH) factors)
Hypophyse
Mineralokortikoide
Vorderlappen (Aldosteron)
Adrenokortiko- Glukokortikoide
d CRH tropes Hormon Nebennierenrinde (Cortisol)
(ACTH)
Sexualhormone
(Oestrogene, Gestagene,
Androgene)
Follikelstim-
Oestrogene
mulierendes
Hormon (FSH)
e GnRH Eierstöcke
Gestagene
Luteinisierungs-
hormon (LH) Androgene
Epiphyse
f Melatonin
Zirbeldrüse
Nebenschilddrüsen Parathormon
P. Stute 17Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Androgene
Hormon Hormon Sexuelle Kohorte / Charakteristika
i.S. Funktion
Testosteron
• Libido 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
• Erregung é é Objektiv: Vaginale Durchblutung
é é Subjektiv: DHEA postmenopausal
é Subjektiv: DHEA prämenopausal
P. Stute 18Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Östrogen und Progesteron
Hormon Hormon Sexuelle Kohorte / Charakteristika
i.S. Funktion
Östrogen
• Libido é é Frauen ohne FSD
é Menopause
éê Frauen mit vs. ohne HSDD
• Erregung ê ê Menopause
é é HRT
Progesteron
• Libido é ê Progesteronimplantat
é éê Hormonale Kontrazeptiva
é " Prämenopause Progesterontherapie
é Postmenopause Progesterontherapie
P. Stute 19Der weibliche Hormonhaushalt – schematische Darstellung
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Achsen 1. Ebene 2. Ebene 3. Ebene
Hypothalamus- Hormon-
drüse
Hormon
Hormon-
drüse
Hormon
Hormondrüse
Periphere Organe
Hormon
Hypophyse-
Vasopressin
Vaso- Hypophyse (Antidiu-
pressin retisches
Hinterlappen Hormon - ADH)
Peripherie-
(Speicherung)
Oxytocin Oxytocin
Achsen a TRH
Thyroidea-
stimulierendes
Hormon (TSH)
Schilddrüse
Trijodthyronin
(T3)
Thyroxin
(T4)
PRH
b
(Dopamin) Prolactin *
Wachstums- IGF - 1
Hypothalamus
c GHRH hormon (insulin-like growth
Leber
(HGH / STH) factors)
Hypophyse
Mineralokortikoide
Vorderlappen (Aldosteron)
Adrenokortiko- Glukokortikoide
d CRH tropes Hormon Nebennierenrinde (Cortisol)
(ACTH)
Sexualhormone
(Oestrogene, Gestagene,
Androgene)
Follikelstim-
Oestrogene
mulierendes
Hormon (FSH)
e GnRH Eierstöcke
Gestagene
Luteinisierungs-
hormon (LH) Androgene
Epiphyse
f Melatonin
Zirbeldrüse
Nebenschilddrüsen Parathormon
P. Stute 20Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Cortisol
Hormon Hormon Sexuelle Kohorte / Charakteristika
i.S. Funktion
Cortisol
• Libido é ê Cushing Syndrom
• Erregung é Frauen ohne FSD
• Orgasmus é Frauen ohne FSD
Der negative Effekt von Cortisol ist whs. eher indirekt auf eine
begleitende Depression als auf einen direkten Einfluss
zurückzuführen.
Meston CM & Frohlich PF. The neurobiology of sexual function. Arch Gen Psychiatry 2000.
P. Stute 21Der weibliche Hormonhaushalt – schematische Darstellung
Abteilung für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Achsen 1. Ebene 2. Ebene 3. Ebene
Hypothalamus- Hormon-
drüse
Hormon
Hormon-
drüse
Hormon
Hormondrüse
Periphere Organe
Hormon
Hypophyse-
Vasopressin
Vaso- Hypophyse (Antidiu-
pressin retisches
Hinterlappen Hormon - ADH)
Peripherie-
(Speicherung)
Oxytocin Oxytocin
Achsen a TRH
Thyroidea-
stimulierendes
Hormon (TSH)
Schilddrüse
Trijodthyronin
(T3)
Thyroxin
(T4)
PRH
b
(Dopamin) Prolactin *
Wachstums- IGF - 1
Hypothalamus
c GHRH hormon (insulin-like growth
Leber
(HGH / STH) factors)
Hypophyse
Mineralokortikoide
Vorderlappen (Aldosteron)
Adrenokortiko- Glukokortikoide
d CRH tropes Hormon Nebennierenrinde (Cortisol)
(ACTH)
Sexualhormone
(Oestrogene, Gestagene,
Androgene)
Follikelstim-
Oestrogene
mulierendes
Hormon (FSH)
e GnRH Eierstöcke
Gestagene
Luteinisierungs-
hormon (LH) Androgene
Epiphyse
f Melatonin
Zirbeldrüse
Nebenschilddrüsen Parathormon
P. Stute 22Abteilung für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern 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
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Oxytocin
Hormon Hormon Sexuelle Kohorte / Charakteristika
i.S. Funktion
Oxytocin
• Libido é é Laktation
• Erregung é é Frauen ohne FSD
é é Laktation
• Orgasmus é é Frauen ohne FSD
é é Orgasmus Intensität
Meston CM & Frohlich PF. The neurobiology of sexual function. Arch Gen Psychiatry 2000.
P. Stute 24Der weibliche Hormonhaushalt – schematische Darstellung
Abteilung für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Achsen 1. Ebene 2. Ebene 3. Ebene
Hypothalamus- Hormon-
drüse
Hormon
Hormon-
drüse
Hormon
Hormondrüse
Periphere Organe
Hormon
Hypophyse-
Vasopressin
Vaso- Hypophyse (Antidiu-
pressin retisches
Hinterlappen Hormon - ADH)
Peripherie-
(Speicherung)
Oxytocin Oxytocin
Achsen a TRH
Thyroidea-
stimulierendes
Hormon (TSH)
Schilddrüse
Trijodthyronin
(T3)
Thyroxin
(T4)
PRH
b
(Dopamin) Prolactin *
Wachstums- IGF - 1
Hypothalamus
c GHRH hormon (insulin-like growth
Leber
(HGH / STH) factors)
Hypophyse
Mineralokortikoide
Vorderlappen (Aldosteron)
Adrenokortiko- Glukokortikoide
d CRH tropes Hormon Nebennierenrinde (Cortisol)
(ACTH)
Sexualhormone
(Oestrogene, Gestagene,
Androgene)
Follikelstim-
Oestrogene
mulierendes
Hormon (FSH)
e GnRH Eierstöcke
Gestagene
Luteinisierungs-
hormon (LH) Androgene
Epiphyse
f Melatonin
Zirbeldrüse
Nebenschilddrüsen Parathormon
P. Stute 25Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Prolaktin
Hormon Hormon Sexuelle Kohorte / Charakteristika
i.S. Funktion
Prolaktin
• Libido é ê Hyperprolaktinämie
é ê Sex. Aktivität bei Hyperprolaktinämie
é ê Laktation
ê é Dopaminagonist bei Hyper-PRL
• Orgasmus é é Nach Orgasmus bei Frauen ohne
FSD
P. Stute 26Abteilung für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
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 27Abteilung für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Fazit: Hormone
Androgene
Cortisol
Oxytocin
Prolaktin
(Östrogene)
P. Stute 28Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
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 29Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern 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
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
FOD Prävalenz
260
Table 3 Prevalence of orgasm problems in selected epidemiological studies
Study N of women Country Age Method of assessment Time period Prevalence
Bancroft et al. (2003b) 987; all in heterosexual relationships United 20–65 Computer-assisted telephone Previous month Orgasm during sexual activity with
States interviewing 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 18–59 Face-to-face interview Several months or more Unable to experience orgasm: 25.7%
months States during past 12 months
Lindal and Stefansson 421 Iceland 55–57 Face-to-face interview; Diagnostic Lifetime prevalence Inhibited orgasm (DSM-III criteria):
(1993) Interview Schedule (DIS-III-A) 3.5%
Lindau et al. (2007) 479 United 57–85 Face-to-face interview and self-report Several months or more Unable to experience orgasm: 34%
States questionnaire during past 12 months
Mercer et al. (2003) 4,826; all had at least 1 heterosexual Britain 16–44 Computer-assisted self-interview Past 12 months Unable to experience orgasm:
partner in last 12 months Lasted at least 1 month: 14.4%
Lasted at least 6 months: 3.7%
Najman, Dunne, Boyle, 908 Australia 18–59 Telephone interview Several months in the past Trouble reaching orgasm: 21–30%
Cook, and Purdie (2003) 12 months (depending on age)
Oberg et al. (2004) 1,056, all sexually active during last Sweden 18–65 Structured face-to-face Past 12 months Difficulties reaching orgasm:
12 months interview ? questionnaires Manifest: 22%; Mild: 60%
Richters et al. (2003) 9,134 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 France 18–69 Telephone interview Lifetime Unable to experience orgasm:
Group (1994) Often: 11%
Sometimes: 21%
Ventegodt (1998) 753 Denmark 18–88 Postal questionnaire Current experience Unable to experience orgasm: 6.8%
(Shifren
Witting et al. (2008) et al.
5,4632008)
Arch Sex Behav (2010) 3
Finland 18–49 Questionnaires (FSFI ? FSDS) Past month Problems with orgasm (met FSFI
cut-off score of 3.75): 31%;
Met FSFI cut-off and reported
distress: 16%
Graham CA. Arch Sex Behav 2010
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 31Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Diagnostik der sexuellen
Funktionsstörung
Allgemeinmedizinische Hormonanalysen
Anamnese • FSH
• Systemanamnese • Östradiol
• CVD, DM, Psyche, Haut • Prolaktin
Sexualanamnese • Medikamente • TSH, T3 / T4
• Aktuelle Beschwerden Gynäkologische • Androgene
• Sex. Verhalten Anamnese Gesamttestosteron
• Sex. Beziehung • Zyklus, OP SHBG
• Kurze sex.- und • Kontrazeption, HT (freies Testo, DHEAS)
Beziehungsbiographie ggf. Fragebögen
Körperliche Untersuchung
• Gewicht, Blutdruck, • FSFI (21 items)
• Behaarung • B-PFSF (7 items)
Gynäkologische Untersuchung Bildgebung
• Vulva und Vagina Veränderungen • US
• Inneres Genitale
Modifiziert nach J. Bitzer, UniMed 2008
P. Stute 32Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Orgasmusstörung gesundheitl. u/o
sexuelle Probleme
Basisdiagnostik des Partners
Primär Sekundär
Psychosoziale Prädisponierende
Sexualhormonmangel
Ursachen klinische Faktoren
Einzeltherapie
Paartherapie Therapie klinisch
relevanter
Erkrankungen:
Vulvovaginale Klimakterische Depression
Atrophie Beschwerden Angststörung
chronische,
hormonelle,
Systemische oder metabolische
lokale HT Erkrankungen
Östrogen Medikation
Testosteron FSD Education Team, Cimacteric 2009
P. Stute 33Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern 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 No significant improvement with bupropion SR
depressive disorder who experienced SSRI-associated Questionnaire (CSFQ), orgasm 150 mg BID vs. placebo at week 2 or week 4
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin,
sexual dysfunction Frauenklinik Inselspital
(n = 42) were treated with Bern scale
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 Significant improvement in satisfaction with intensity
Medikamentöse Therapie der
300 mg PO daily non-depressed women and men, respectively, with of orgasm in females at 150 mg/day (P < 0.05) but
orgasmic delay or inhibition with placebo, bupropion not 300 mg/day (P = 0.10)
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 Significant improvement in orgasm completion
weiblichen Orgasmusstörung
400 mg PO daily women with hypoactive sexual desire disorder treated (P = 0.0057) at days 28, 56, 84, and 112 as
with escalating doses of bupropion (150, 300, or compared to placebo
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 There were no significant differences between the
SSRIs for at least 6 weeks were currently euthymic, dysfunction determined by score bupropion SR and placebo groups
Östrogene and who had sexual dysfunction were randomly
assigned to receive 150 mg/day of bupropion SR or
placebo for 3 weeks
greater than 19/30)
Estradiol, 0.014 mg/day transdermal Randomized controlled trial in which postmenopausal Medical Outcomes Study Sexual No significant improvement in estradiol group vs.
patch women aged 60–80 years (n = 417) were treated with Problems Index “Orgasm placebo at any time point
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 Anorgasmia decreased significantly in both groups
0.625 mg PO or 0.0625 mg/1 g either oral (0.625 mg of conjugated equine estrogens symptoms using a validated (P < 0.05)
Table 1 Continued
vaginal cream daily per tablet; n = 27) or topical (0.625 mg conjugated questionnaire before and 3
Treatment equine
Study estrogens per 1 g vaginal cream; n = 30)
description months after estrogen therapy
Measures Results
estrogen administered once daily
Estradiol (women with surgical Randomized controlled trial in which healthy FSFI orgasm domain All hormonal treatments reported to improve orgasm
menopause), 0.625 mg/day or postmenopausal women (n = 169) were divided into a domain scores (P reported as “0.000”), with oral
estradiol 1 mg/day + drospirenone control group (n = 58), surgically induced menopausal tibolone achieving the highest improvement
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 Neither estradiol (0.1 mg patch/day) or progesterone
progesterone 200 mg suppository induced hypogonadic females with resultant decreased Functioning (DISF) orgasm (200 mg suppository BID) significantly improved
BID quality of orgasm who were otherwise healthy (n = 20) subscale orgasm subscale scores
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 No significant change in score at any time period
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 Ginkgo biloba extract combined with sex therapy
to placebo, gingko biloba extract, sex therapy, or sex (vaginal photoplethysmography) produced a significant increase in sexual desire
therapy plus gingko biloba extract measures of sexual function and contentment beyond placebo alone. No
difference between placebo and ginkgo biloba
Fazit: z.T. positiver Effekt, z.T. kein Effekt
extract alone. Sex therapy alone enhanced orgasm
function when compared with placebo
Methyltestosterone 2 mg PO daily Randomized controlled trial in which women with Sexual Energy Change Scale, Conjugated estrogens (0.625 mg/
+/- Conjugated estrogens postmenopausal sexual complaints(n = 60) were monthly orgasm frequency diary Ishak
day) et al., J Sex Med
+ medroxyprogesterone acetate2010
(2.5 mg/day)
0.625 mg PO daily and treated with estrogen + progesterone hormone increased orgasm frequency (P < 0.001), but
medroxyprogesterone acetate replacement + placebo (n = 29) or hormone methyltestosterone did not significantly improve
2.5 mg PO daily
P. Stute replacement + methyltestosterone (2 mg/day) (n = 31) orgasm frequency beyond hormone replacement35Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Nijland et al., J Sex Med. 2008
Tibolon und HRT Cayan et al., J Sex Med. 2008
Osmanağaoğlu et al., Climacteric 2006
Sexuelle Funktion in der Postmenopause
n Intervention Dauer Ergebnis
[Mo]
403 • Tibolon (Livial®) 3 HRT = Tibolon
• 50 mcg E2+140 mcg NETA • Zunahme sex. Fukntion
patch (z.B. Estalis®) • Zunahme sex. Kontakte
• Abnahme Leidensdruck
169 • orales E2 (HE+OVX) 6 Sex. Funktion:
• E2+DRSP (Angeliq®) ê * Kontrolle
• Tibolon (Livial®) é * Hormontherapie
• vaginales E2 (Vagifem®) Tibolon: v.a. Orgasmus
• Kontrolle Östrogene: v.a. Lubrikation,
Erregung
158 • Tibolon (Livial®) 6 Sex. Funktion:
• 2 mg E2+2 mg DNG Tibolon > orale HRT
(z.B. Lafamme) Dyspareunie:
• Kontrolle Tibolon = orale HRT
P. Stute 36Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Medikamentöse Therapie der
weiblichen Orgasmusstörung
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 37Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern 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
Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
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 39Table 1Abt.Pharmacological
für Gynäkologischetreatments
Endokrinologie
forund Reproduktionsmedizin,
disorders of orgasm in Frauenklinik
women Inselspital Bern
Treatment Study description Measures Results
Ishak et al., J Sex Med 2010
Medikamentöse Therapie der
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
Frequency of orgasm and score
changes from baseline using
Female Sexual Function Index
Achievement of orgasm increased significantly
(P = 0.026)
weiblichen Orgasmusstörung
used at least six doses (n = 25) (FSFI) and Female Sexual
Distress Scale (FSDS) (secondary
measures)
Amantadine, buspirone Randomized controlled trial in which women with Diary rating orgasm frequency and Neither amantadine nor buspirone improved orgasm
Table 1 Pharmacological treatments fluoxetine-induced
for disorders sexualofdysfunction
orgasmwere treated with
in women quality, Interview Rating of Sexual measures compared to placebo
Psychopharmaka
amantadine (n = 18), buspirone (n = 19), or placebo Function
Treatment (n = description
Study 20) for 8 weeks Measures Results
ArginMax (proprietary nutritional Randomized controlled trial in which 77 women with Self-report 73.5% of ArginMax group reported improved
supplement
Alprostadil, 400containing
mg vaginalginseng,
cream interest in improving
Randomized controlled sexual
trial in function
which 51were treated
women withfor 4 Frequency of orgasm and score satisfaction in
Achievement of overall
orgasmsex life compared
increased with 37.2%
significantly
ginkgo, damiana, L-arginine, weeks were
with ArginMax
treated foror6placebo = 0.026)group (P < 0.01). Other noted
of(Pplacebo
Buspiron (Angststörung): Agonist an 5-HT1A-Rezeptoren, Antagonist an D2-Rezeptoren.
prior to intercourse
multivitamins, and minerals)
FSAD weeks with placebo or
alprostadil. Results were analyzed for women who
changes from baseline using
Female Sexual Function Index improvements were in sexual desire, reduction of
used at least six doses (n = 25) (FSFI) and Female Sexual vaginal dryness, frequency of sexual intercourse,
Amantadin (Influenza-A-Grippe, Parkinson Syndrom): u.a. Dopamin Agonist Distress Scale (FSDS) (secondary orgasm, and clitoral sensation. No significant side
measures) effects noted
Bremelanotide,
Amantadine, 20 mg intranasal
buspirone 80 married, menstruating
Randomized controlled trialwomen (mean
in which women age with
31 years) FSFI,
Diary total
ratingnumber
orgasmoffrequency
sexual events,
and Pretreatment orgasm nor
Neither amantadine scores: treatment
buspirone group orgasm
improved 4.3,
spray 45–60 minutes prior to with female sexual sexual
fluoxetine-induced arousaldysfunction
disorder were weretreated
treatedwith
with total number
quality, of orgasms,
Interview personal
Rating of Sexual control
measures group 4.2. Post-treatment
compared to placebo scores: treatment
attempted intercourse placebo or intranasal bremelanotide 45–60
amantadine (n = 18), buspirone (n = 19), or placebo minutes distress,
Functionand adverse drug effects group 5.3 (P = 0.01), control group 4.4 (P = 0.1).
prior
(n to attempted
= 20) for 8 weeks intercourse Treatment group reported greater intercourse
ArginMax (proprietary nutritional Randomized controlled trial in which 77 women with Self-report satisfaction
73.5% (P = 0.001)
of ArginMax groupand more drug-related
reported improved
Bupropion (Depression): Dopamin-, Noradrenalin-, Serotonin-Reuptake-Hemmer
supplement containing ginseng,
ginkgo, damiana, L-arginine,
interest in improving sexual function were treated for 4
weeks with ArginMax or placebo
adverse effects;
satisfaction
therapy
5% (2 sex
in overall subjects) had to discontinue
life compared
of placebo group (P < 0.01). Other noted
with 37.2%
Bupropion SR, 150
multivitamins, andmg PO BID
minerals) Randomized controlled trial in which women with major Changes in Sexual Functioning No improvements
significant improvement with bupropion
were in sexual SR
desire, reduction of
depressive disorder who experienced SSRI-associated Questionnaire (CSFQ), orgasm 150 mg BID
vaginal vs. placebo
dryness, at week
frequency 2 or week
of sexual 4
intercourse,
sexual dysfunction (n = 42) were treated with completion scale orgasm, and clitoral sensation. No significant side
bupropion SR or placebo for 4 weeks
effects noted
Bupropion, 150 mg PO daily or Single-blind sequential treatment of 20 and 10 Satisfaction with intensity of orgasm Significant improvement in satisfaction with intensity
Bremelanotide, 20 mg intranasal 80 married, menstruating women (mean age 31 years) FSFI, total number of sexual events, Pretreatment orgasm scores: treatment group 4.3,
300 mg PO daily non-depressed women and men, respectively, with of orgasm in females at 150 mg/day (P < 0.05) but
spray 45–60 minutes prior to with female sexual arousal disorder were treated with total number of orgasms, personal control group 4.2. Post-treatment scores: treatment
orgasmic delay or inhibition with placebo, bupropion not 300 mg/day (P = 0.10)
attempted intercourse placebo or intranasal bremelanotide 45–60 minutes distress, and adverse drug effects group 5.3 (P = 0.01), control group 4.4 (P = 0.1).
SR 150 mg/day, and bupropion SR 300 mg/day
prior to attempted intercourse Treatment group reported greater intercourse
Bupropion, 150 mg, 300 mg or Randomized placebo-controlled trial of premenopausal CSFQ, orgasm completion scale Significant improvement in orgasm completion
satisfaction (P = 0.001) and more drug-related
400 mg PO daily women with hypoactive sexual desire disorder treated (P = 0.0057) at days 28, 56, 84, and 112 as
adverse effects; 5% (2 subjects) had to discontinue
with escalating doses of bupropion (150, 300, or compared to placebo
therapy
400 mg/day) (n = 31) vs. placebo (n = 35)
Bupropion SR, 150 mg PO BID Randomized controlled trial in which women with major Changes in Sexual Functioning No significant improvement with bupropion SR
Bupropion SR, 150 mg PO daily 30 adults (both men and women) who had received Arizona sexual experience (sexual There were no significant differences between the
depressive disorder who experienced SSRI-associated Questionnaire (CSFQ), orgasm 150 mg BID vs. placebo at week 2 or week 4
SSRIs for at least 6 weeks were currently euthymic, dysfunction determined by score bupropion SR and placebo groups
sexual dysfunction (n = 42) were treated with completion scale
and who had sexual dysfunction were randomly greater than 19/30)
bupropion SR or placebo for 4 weeks
assigned to receive 150 mg/day of bupropion SR or
Bupropion, 150 mg PO daily or Single-blind
placebo for sequential
3 weeks treatment of 20 and 10 Satisfaction with intensity of orgasm Significant improvement in satisfaction with intensity
300 mg PO daily non-depressed women andin men,
whichrespectively, with No of orgasm in females at 150 (P < 0.05)
mg/daygroup vs. but
Fazit: positiver Effekt, wenn keine SSRI parallel
Estradiol,
patch
0.014 mg/day transdermal Randomized
orgasmic
controlled
delay or
trial
inhibition with
postmenopausal
placebo,
women aged 60–80 years (n = 417) were treated with
SR 150 mg/day,
placebo (n = 209)andor abupropion
0.014 mg/daySR 300
bupropion
mg/day
transdermal
Medical Outcomes Study Sexual
Problems Index “Orgasm
frequency and quality” measure
significant
not 300
improvement
mg/day (P =
in estradiol
0.10)
placebo at any time point
kein Effekt, wenn SSRI parallel
Bupropion, 150 mg, 300 mg or Randomized placebo-controlled trial
estradiol patch (n = 208) for 24 months of premenopausal CSFQ, orgasm completion scale Significant improvement in orgasm completion
400 mg POequine
Conjugated daily estrogens, 57women with hypoactive
hysterectomized women sexual
were desire
randomizeddisorder treated
to receive Personal interviews for sexual (P = 0.0057)
Anorgasmia at days significantly
decreased 28, 56, 84, and 112groups
in both as
0.625 mg PO or 0.0625 mg/1 g with escalating doses of bupropion (150,
either oral (0.625 mg of conjugated equine estrogens 300, or symptoms using a validated compared
(P < 0.05) to placebo
vaginalP.cream
Stutedaily 400 mg/day)
per tablet; = 31)
n =(n27) vs. placebo
or topical (0.625(nmg = 35)
conjugated questionnaire before and 3 40
Bupropion SR, 150 mg PO daily 30 adults (both men and women) who had received Arizona sexual experience (sexual There were no significant differences between theAbt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Medikamentöse Therapie der
Table 1 Pharmacological treatments for disorders of orgasm in women
Treatment Study description Measures Results
weiblichen Orgasmusstörung
Alprostadil, 400 mg vaginal cream Randomized controlled trial in which 51 women with Frequency of orgasm and score Achievement of orgasm increased significantly
prior to intercourse FSAD were treated for 6 weeks with placebo or changes from baseline using (P = 0.026)
alprostadil. Results were analyzed for women who Female Sexual Function Index
used at least six doses (n = 25) (FSFI) and Female Sexual
Distress Scale (FSDS) (secondary
Bremelanotid
measures)
Amantadine, buspirone Randomized controlled trial in which women with Diary rating orgasm frequency and Neither amantadine nor buspirone improved orgasm
fluoxetine-induced sexual dysfunction were treated with quality, Interview Rating of Sexual measures compared to placebo
amantadine (n = 18), buspirone (n = 19), or placebo Function
Agonist an Melanocortinrezeptor-1 (Hautbräunung) und
ArginMax (proprietary nutritional
(n = 20) for 8 weeks
Randomized controlled trial in which 77 women with Self-report 73.5% of ArginMax group reported improved
supplement containing ginseng, interest in improving sexual function were treated for 4 satisfaction in overall sex life compared with 37.2%
Melanocortinrezeptor-4 (u.a. Libido)
ginkgo, damiana, L-arginine,
multivitamins, and minerals)
weeks with ArginMax or placebo of placebo 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
Bremelanotide, 20 mg intranasal 80 married, menstruating women (mean age 31 years) FSFI, total number of sexual events, Pretreatment orgasm scores: treatment group 4.3,
spray 45–60 minutes prior to with female sexual arousal disorder were treated with total number of orgasms, personal control group 4.2. Post-treatment scores: treatment
attempted intercourse placebo or intranasal bremelanotide 45–60 minutes distress, and adverse drug effects group 5.3 (P = 0.01), control group 4.4 (P = 0.1).
prior to attempted intercourse Treatment group reported greater intercourse
satisfaction (P = 0.001) and more drug-related
adverse effects; 5% (2 subjects) had to discontinue
therapy
Bupropion SR, 150 mg PO BID Randomized controlled trial in which women with major Changes in Sexual Functioning No significant improvement with bupropion SR
depressive disorder who experienced SSRI-associated Questionnaire (CSFQ), orgasm 150 mg BID vs. placebo at week 2 or week 4
sexual dysfunction (n = 42) were treated with completion scale
Fazit: positiver Effekt, aber zu viele Nebenwirkungen,
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 Significant improvement in satisfaction with intensity
300 mg PO daily non-depressed women and men, respectively, with of orgasm in females at 150 mg/day (P < 0.05) but
Daher (noch) keine Weiterentwicklung.
Bupropion, 150 mg, 300 mg or
orgasmic delay or inhibition with placebo, bupropion
SR 150 mg/day, and bupropion SR 300 mg/day
Randomized placebo-controlled trial of premenopausal CSFQ, orgasm completion scale
not 300 mg/day (P = 0.10)
Significant improvement in orgasm completion
400 mg PO daily women with hypoactive sexual desire disorder treated (P = 0.0057) at days 28, 56, 84, and 112 as
with escalating doses of bupropion (150, 300, or compared to placebo
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 There were no significant differences between the
SSRIs for at least 6 weeks were currently euthymic, dysfunction determined by score bupropion SR and placebo groups
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 Ishak improvement
No significant et al., J Sex Med group
in estradiol 2010
vs.
patch women aged 60–80 years (n = 417) were treated with Problems Index “Orgasm placebo at any time point
placebo (n = 209) or a 0.014 mg/day transdermal frequency and quality” measure
P. Stute estradiol patch (n = 208) for 24 months 41
Conjugated equine estrogens, 57 hysterectomized women were randomized to receive Personal interviews for sexual Anorgasmia decreased significantly in both groupsAbt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Medikamentöse Therapie der
Ishak et al., J Sex Med 2010
weiblichen Orgasmusstörung
• 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 42Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
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 DSM-
Kriterien ist selten (5%).
P. Stute 43Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
Fazit - II
• Die FOD Therapie ist multidisziplinär.
• Es sind keine Medikamente zur Behandlung der FOD
zugelassen.
• Positive Effekte wurden beschrieben für
– 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
P. Stute 44Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
DANKE!
P. Stute 45Abt. für Gynäkologische Endokrinologie und Reproduktionsmedizin, Frauenklinik Inselspital Bern
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
King R & Belsky J, Arch Sex Behav 2012
P. Stute 46Sie können auch lesen
