Topical therapies worth considering
Lubricants and moisturizers may help women with dyspareunia or symptoms of vaginal atrophy.
Zestra, for instance, which is applied to the vulva prior to sexual activity, has been proven more effective than placebo for improving desire and arousal.29
Neogyn is a non-hormonal cream containing cutaneous lysate and has been shown to improve vulvar pain in women with vulvodynia. A double-blind placebo-controlled randomized crossover trial followed 30 patients over 3 months and found a significant reduction in pain during sexual activity and a significant reduction in erythema.30
Alprostadil is a prostaglandin E1 analogue that increases genital vasodilation when applied topically and is currently undergoing investigational trials.31,32 Patients can also choose from many over-the-counter lubricants that contain water-based, oil-based, or silicone-based ingredients.
Don’t overlook physical therapy
Manual therapies, including the transvaginal technique, are used for female sexual dysfunction that results from a variety of causes, including high-tone pelvic floor dysfunction. The transvaginal technique can identify myofascial pain; treatment involves internal release of the PFMs and external trigger point identification and alleviation.
One pilot study, which involved transvaginal Thiele massage twice a week for 5 weeks on 21 symptomatic women with IC and high-tone pelvic floor dysfunction found it decreased hyptertonicity of the pelvic floor and generated statistically significant improvement in the Symptom and Problem Indexes of the O’Leary-Sant Questionnaire, Likert Visual Analogue Scales for urgency and pain, and the Physical and Mental Component Summary from the SF-12 Quality-of-Life Scale.33 Transvaginal physical therapy is also an effective treatment for myofascial pelvic pain.34
Biofeedback, which can be used in combination with pelvic floor physical therapy, teaches the patient to control the PFMs by visualizing the activity to achieve conscious control over contraction of the pelvic floor and ceasing the cycle of spasm.35 Ger et al36 investigated patients with levator spasm and found biofeedback decreased pain; relief was rated as good or excellent at 15-month follow-up in 6 out of 14 patients (43%).
Home devices such as Eros Therapy, an FDA-approved, nonpharmacologic battery-operated device, provide vacuum suction to the clitoris with vibratory sensation. Eros Therapy has been shown to increase blood flow to the clitoris, vagina, and pelvic floor and increase sensation, orgasm, lubrication, and satisfaction.37
Vaginal dilators allow increasing lengths and girths designed to treat vaginal and pelvic floor pain.38 In our practice, we encourage pelvic muscle strengthening tools in the form of kegal trainers and other insertion devices that may improve PFM coordination and strength.
Pharmacotherapy has its place
The treatment of FSD may require a multimodal systematic approach targeting genito-pelvic pain. But before the best options can be found, it is important to first establish the cause of the pain. Several drug formulations have been effectively used including hormonal and non-hormonal options.
Conjugated estrogens are FDA approved for the treatment of dyspareunia, which can contribute to decreased desire. Systemic estrogen in oral form, transdermal preparations, and topical formulations may increase sexual desire and arousal and decrease dyspareunia.39 Even synthetic steroid compounds such as tibolone may improve sexual function, although it is not FDA approved for that purpose.40
Ospemifene (Osphena) is a selective estrogen receptor modulator that acts as an estrogen agonist in select tissues, including vaginal epithelium. It is FDA approved for dyspareunia in postmenopausal women.41,42 A daily dose of 60 mg is effective and safe with minimal adverse effects.42 Studies suggest that testosterone, although not FDA approved in the United States for this purpose, improves sexual desire, pleasure, orgasm, and arousal satisfaction.39 The hormone has not gained FDA approval because of concerns about long-term safety and efficacy.42
Non-hormonal drugs including flibanserin (Addyi), a well-tolerated serotonin receptor 1A agonist, 2A antagonist shown to improve sexual desire, increase the number of satisfying sexual events, and reduce distress associated with low sexual desire when compared with placebo.43 The FDA has approved flibanserin as the first treatment targeted for women with hypoactive sexual desire disorder (HSDD). It can, however, cause severe hypotension and syncope, is not well tolerated with alcohol, and is contraindicated in patients who take strong CYP3A4 inhibitors, such as fluconazole, verapamil, and erythromycin, or who have liver impairment.
Buproprion, a mild dopamine and norepinephrine reuptake inhibitor and acetylcholine receptor antagonist, has been shown to improve desire in women with and without depression. Although it is FDA approved for major depressive disorder, it is not approved for female sexual dysfunction and is still under investigation.
Tricyclic antidepressants such as nortriptyline and amitriptyline may be effective in treating neuropathic pain. Starting doses of both amitriptyline and nortriptyline are 10 mg/d and can be increased to a maximum of 100 mg/d.44 Tricyclic antidepressants are still under investigation for the treatment of FSD.
Muscle relaxants in oral and topical compounded form are used to treat increased pelvic floor tension and spasticity. Cyclobenzaprine and tizanidine are FDA-approved muscle relaxants indicated for muscle spasticity.
Cyclobenzaprine, at a starting dose of 10 mg, can be taken up to 3 times a day for pelvic floor tension. Tizanidine is a centrally active alpha 2 agonist that’s superior to placebo in treating high-tone pelvic floor dysfunction.44
Other medications include benzodiazepines such as oral clonazepam and intra-vaginal diazepam, although they are not FDA approved for high-tone pelvic floor dysfunction. Rogalski et al reviewed 26 patients who received vaginal diazepam for bladder pain, sexual pain, and levator hypertonus.45 They found subjective and sexual pain improvement assessed on FSFI and the visual analog pain scale. PFM tone significantly improved during resting, squeezing, and relaxation phases. Multimodal therapy can be used for muscle spasticity and high-tone pelvic floor dysfunction.