This document discusses female sexual dysfunction. It begins with information about the author, Dr. Santiago Palacios, including his credentials and affiliations. It then provides disclosure statements regarding his relationships with pharmaceutical companies. The bulk of the document consists of slides from a presentation on diagnosing and treating female sexual dysfunction. It discusses causes of female sexual dysfunction, types of sexual disorders, validated questionnaires to assess sexual function and distress, when to treat dysfunction, and potential treatment options including testosterone.

1. DEBATE.
DISFUNCION SEXUAL FEMENINA
Dr. Santiago Palacios
Instituto Palacios, Salud y Medicina de la Mujer
Chairman of CAMS (Council of Affiliated Menopause Societies)
President of SIBOMM (Ibero American Society of Osteology and Mineral
Metabolism)
Antonio Acuña, 9 - 28009 Madrid
Teléfono 91 578 05 17
E-mail: ipalacios@institutopalacios.com
www.institutopalacios.com

2. Santiago Palacios, MD, Ph
• Symposium speaker or advisory board member :
• Bayer Schering, Novo Nordisk, Servier, Eli Lilly,
Daiichi Sankyo, Sanofi, MSD, Gedeon Richter, Exeltis
Procter & Gamble, Teva, Syneron-Candela
• Research grants and/or consulting fees from:
• Pfizer, Servier, Eli Lilly, Daiichi Sankyo, Amgen, Arkochim,
and Bayer Schering, Gedeon Richter , Exeltis

3. Change to either a nonandrogenic or androgenic progestin-containing oral contraceptive preparation is
associated with improved sexual function in women with oral contraceptive-associated sexual dysfunction.
Davis SR, Bitzer J, Giraldi A, Palacios S, Parke S, Serrani M, Mellinger U, Nappi RE.
J Sex Med. 2013 Dec;10(12):3069-79. doi: 10.1111/jsm.12310.
Hypoactive Sexual Desire Disorder and current pharmacotherapeutic options in women.
Palacios S.
Womens Health (Lond). 2011 Jan;7(1):95-107. doi: 10.2217/whe.10.81. Review.
Patient scenario: a 53-year-old woman with hypoactive sexual desire disorder.
Palacios S, Graziottin A.
Maturitas. 2009 Jun 20;63(2):164-8. doi: 10.1016/j.maturitas.2009.05.002. Review.
Hormonal changes during menopause.
Al-Azzawi F, Palacios S.
Maturitas. 2009 Jun 20;63(2):135-7. doi: 10.1016/j.maturitas.2009.03.009. Review.
Breast cancer risk in postmenopausal women using testosterone in combination with hormone replacement
therapy.
Bitzer J, Kenemans P, Mueck AO; FSDeducation Group..
Maturitas. 2008 Mar 20;59(3):209-18. doi: 10.1016/j.maturitas.2008.01.005. Review.
Androgens and female sexual function.
Palacios S.
Maturitas. 2007 May 20;57(1):61-5. Review

4. • A QUIEN TRATAR
• CUANDO TRATAR
• CON QUE TRATAR
• GINECOLOGO VS SEXOLOGO
CONTENIDO
*

5. Es tu competencia como médico
Conecta la información que tienes :
• Salud de la mujer
• Eventos clave a lo largo de la vida
• Temas de pareja
• Temas sexuales
Como diagnosticar la DSF
A.Graziottin, 2009

6. Diagnostico
• Historia medica y sexual
• Conocer la sexualidad ( deseo, excitación ..) pasado y presente
• Contexto psicosocial
• Enfermedades y medicamentos
• Exámen físico
• Vulva
• Clitoris
• Vagina
• Suelo pelvico
• Organos pelvicos
Brandenburg U, Schwenkhagen A (2006) Women’s Sexual Function and Dysfunction; ed. Goldstein, Taylor & Francis
London
Vardi, Y. Basics for women’s sexual dysfunction (ISSWSH Instructional course 2)
• Examenes de laboratorio
• Text diagnosticos especiales
Source: FSDeducation.eu

7. Free Testosterone levels in plasma and
consequences
1.8
1.2
0.6
Agressiveness
Depression
Depression
Osteoporosis
Dispareunia
Libido
Falty Mass
ng/ml
0

8. Hypoactive Sexual Desire Disorder and current
pharmacotherapeutic options in women
Palacios S
Womens Health (Lond Engl) 2011 Jan;7(1):95-107
Abstract
Hypoactive Sexual Disorder (HSDD) is the most common female sexual dysfunction. The
diagnosis of HSDD requires the existence of personal distress or
interpersonal difficulties associated with low sexual desire, that
cannot be explained by any other psyquiatric affection and that is not exclusively due to a
disease or substance. HSDD can have a serious effect on emotional wellbeing and
interpersonal relationships, and it occurs in premenopausal and postmenopausal women. The
Decreased Sexual Desire Screener is a shortened diagnostic method designed to help doctors
who are not specialized in female dysfunction to diagnose acquired HSDD in women.
There is evidence that treatment with androgens or with estrogens is effective in HSDD;
however, important unanswered questions still exist. Presently, new therapeutic strategies to
combat HSDD are being researched, including novel methods of testosterone provision and
drugs that act upon the CNS.

9. Cuestionario validado: Breve perfil de la función sexual en la mujer
Lea atentamente cada frase y rodee con un círculo el número que mejor se corresponda con su experiencia durante los últimos 2-
3 meses. A continuación, sume todos los números para obtener la puntuación total y escriba la puntuación en la casilla que
aparece más abajo.
Nunca Rara vez A veces A
menudo
Muy a
menudo
Siempre
1. He tenido ganas de tener
relaciones sexuales
0 1 2 3 4 5
2. Me he sentido descontenta
por mi poco interés en el
sexo
5 4 3 2 1 0
3. Tardaba muchísimo en
excitarme
5 4 3 2 1 0
4. Me he sentido totalmente
indiferente con respecto al
sexo
5 4 3 2 1 0
5. He sentido poco deseo
sexual
5 4 3 2 1 0
6. Me he sentido
decepcionada por mi poco
interés en el sexo
5 4 3 2 1 0
7. He llegado al orgasmo con
facilidad
0 1 2 3 4 5

10. Nunca Pocas veces
Algunas
veces
Con
frecuencia Siempre
1. Angustiada por su vida sexual 0 1 2 3 4
2. Infeliz con respecto a sus relaciones sexuales 0 1 2 3 4
3. Culpable por sus problemas sexuales 0 1 2 3 4
4. Frustrada por sus problemas sexuales 0 1 2 3 4
5. Estresada por sexuales 0 1 2 3 4
6. Inferior por sus problemas sexuales 0 1 2 3 4
7. Preocupada por el sexo 0 1 2 3 4
8. Sexualmente inadaptada 0 1 2 3 4
9. Con remordimientos por su vida sexual 0 1 2 3 4
10. Avergonzada por sus problemas sexuales 0 1 2 3 4
11. Insatisfecha por su vida sexual 0 1 2 3 4
12. Enfadada por su vida sexual 0 1 2 3 4
Cuestionario validado: Preocupación sexual femenina
Este cuestionario consta de 12 preguntas cuyas respuestas nos permiten analizar el grado de preocupación de la mujer
por su vida sexual en el último mes.
Es necesario un resultado > a 15 puntos para considerar la existencia de un trastorno sexual

11. Ejemplos de preguntas de detección de trastornos
sexuales
• Trastorno de deseo sexual:
“¿Ha notado algún cambio en su deseo de practicar el sexo?”
• Trastorno de excitación sexual:
“¿Ha notado algún cambio en su capacidad para excitarse
sexualmente?”
• Trastorno orgásmico:
“¿Qué hay de sus experiencias en cuanto a los orgasmos?”
• Trastorno de dolor sexual:
“¿Le duele algo al practicar el sexo?”
Todas esta preguntas deben ir seguidas de la pregunta:
“¿Está angustiada/preocupada por ello?”

12. TRATAREMOS A TODA MUJER CON
DISFUNCION SEXUAL QUE CAUSA
PREOCUPACION

13. • A QUIEN TRATAR
• CUANDO TRATAR
• CON QUE TRATAR
• GINECOLOGO VS SEXOLOGO
CONTENIDO
*

14. Cuando tratar
1. Cuando lo diagnosticas
2. Ser proactivo
3. Momentos de más prevalencia
Basson R. Maturitas 2007

15. El desafio de hablar de sexo
– Entendemos que no es tan sencillo como hablar de la tension
arterial
– No existe una conversación ideal
– Es muy prevalente
– Afecta a la claidad de vida y a la imagen
• Es responsabilidad del medico hablar de ello
Brandenburg U, Schwenkhagen A (2006) Women’s Sexual Function and Dysfunction; ed.
Goldstein, Taylor & Francis London
Source: FSDeducation.eu

16. Momentos de más prevalencia
1. Toma de anticonceptivos
2. Postpartum
3. Perimenopausia
4. Postmenopausia
Basson R. Maturitas 2007

17. • A QUIEN TRATAR
• CUANDO TRATAR
• CON QUE TRATAR
• GINECOLOGO VS SEXOLOGO
CONTENIDO
*

18. Causas de los trastornos sexuales femeninos
Diagnóstico
Orgánico
Trastornos médicos
Fármacos
Cambios
urogenitales
Hormonas
Trastorno
psiquiátrico
Psicológico
Cambios de humor
Antecedentes de
trauma o abuso
Autoestima
Conflictoos
intrapersonales
De relación y
social
Conflictoos
interpersonales
Disfunción sexual
de la pareja
Mala comunicación
Problemas
familiares y
financieros

19. Trastorno del deseo sexual
Trastorno de deseo sexual hipoactivo
Deficiencia (o ausencia) persistente o
recurrente de fantasías/pensamientos
sexuales, y/o deseo de o receptividad a la
actividad sexual, que causa angustia
personal
Trastorno de aversión sexual
Aversión fóbica persistente o recurrente al
contacto sexual y evitar el contacto sexual
con un compañero sexual, que causa
angustia
Clasificación de los trastornos sexuales
Trastornos del
deseo sexual
Trastorno de
excitación sexual
Trastorno
orgásmico
Vaginismo
Dispareunia
Basson, R et al.(2000) Report on the International Consensus Development Conference on Female
Sexual Dysfunction:
Definitions and Classification. The Journal of Urology, 163, 888:893

20. Source: FSDeducation.eu
Sexual Desire Disorders and Sexual arausal disrders
DESORDEN DEL INTERES SEXUAL FEMENINO
Orgasmic Disorder
Vaginismus
Dyspareunia
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, 5th edition, text revision.
Washington, DC: American Psychiatric Press; 2013.

21. QUÉ TENEMOS
• DESEO.
-Testosterona en parches, en gel y en comprimidos.
-Tibolona
-Flibanserina..historia que …seguirá
-Bremelanotide
-DESEO Y EXCITACION
- Libicare

22. Androgen Production
Ovaries &
Adrenal Glands
Precursors
Peripheral
Action
Tissue-
specific
conversion to
hormones
Hormones
Peripheral TissuesCirculation
Production
Endocrinology
Tissue-
specific
production of
hormones
Intra-
crinology
Adapted from Arlt W (2006) Eur J Endocrinol 154: 1–11
• Androgens are also produced in specific tissues themselves, either from
circulating “precursors” (e.g. DHEA, DHEAS, Androstenedione, T, DHT) or de-
novo (just in certain tissues)
• The tissue-specific hormone production is called “Intracrinology”

23. • Androgens are produced in the following peripheral tissues:
– Adipose Tissue
– Mammary Gland
– Endometrial Tissue
– Skin
– Bone
– Cardiovascular System
– Brain
• Secretion of these androgens into the blood system can be neglected
• Serum levels of testosterone may not reflect the availability of
testosterone and other androgen metabolites at a local levels
Intracrinology of Androgens

24. Lobo, RA (2001) Obstet Gynecol Surv 56: 361-76
 Androgens are present at higher circulating levels than oestradiol
 Androgen levels fall more dramatically after surgical menopause
 Post menopause, androgen levels decline by 50% compared with
pre-menopausal levels
1260 ±
360
100 ± 20
1970 ±
430
200 ± 20
Below assay
detection limit
(
70%)
(
53%)
4200 ± 210DHEA (pg/ml)
(
75%)
(
50%)
400 ± 30
Testosterone
(pg/ml)
Below assay
detection limit
40 ± 3Oestradiol (pg/ml)
Surgical Menopause
(Oophorectomy)
Natural Menopause
Reproductive
Age
Mean Plasma Hormone Levels:
Pre- and Post-Menopausal

25. Transdermal Testosterone Plus Oestrogen
Phase III testosterone patch studies in surgically
menopausal women
• Two Separate Phase III Clinical Trials:
• Surgical menopause 1 (INTIMATE SM 1), n=562 women
• Surgical menopause 2 (INTIMATE SM 2), n=532 women
• Objective:
• Assess efficacy / safety of transdermal testosterone in surgically menopausal women with
Hypoactive Sexual Desire Disorder
• Design:
• 24-week randomised, double-blind, placebo-controlled, multinational trial
• Placebo or transdermal testosterone patch 300 g/day
• All patients on oral or transdermal oestrogen
• Inclusion / Exclusion criteria similar
• Female testosterone patch:
• Alcohol-free, translucent, matrix patch
• Twice-a-week application to abdomen
• Contains 8.4 mg testosterone
• Delivers 300 g/day testosterone
Simon JA, et al. (2005) J Clin Endocrinol Metab 90: 5226–5233
Buster JE et al. (2005) Obstet Gynecol 105: 944–952
Source: FSDeducation.eu

26. • Generally well-tolerated with frequency of adverse events overall comparable to placebo
• No clinically meaningful effect on lipids, lipoprotein profile, renal and liver function
• No appreciable change in serum levels of oestradiol, oestrone and SHBG
• Most common AE: application site reactions
• 91–96% of androgenic AEs were mild
• The safety of the female testosterone patch has been demonstrated in studies of up to 1
year and in open-label extension up to 3 years; there is little information on long-term
safety
SM 1 SM 2
Androgenic AE‘s Placebo
(n=279)
%
Testosterone Patch
(n=283)
%
Placebo
(n=266)
%
Testosterone Patch
(n=266)
%
Acne 6.1 6.0 4.1 7.5
Alopecia 3.2 3.2 2.6 5.3
Hirsutism 6.5 5.7 5.3 9.0
Voice deepening 2.9 2.5 1.5 3.0
Clitoromegaly 0.0 0.0 0.0 0.4
Simon JA, et al. (2005) J Clin Endocrinol Metab 90: 5226–5233
Buster JE et al. (2005) Obstet Gynecol 105: 944–952
Nachtigall L et al., European Society for Sexual Medicine Abstract #P-01-009, December 2006
Testosterone Patch – Safety Adverse Event (AE) Profile at 24 Weeks
Source: FSDeducation.eu
SHORT TERM ?

27. Testosterone-LONG-TERM-Risks?
System/ Organ Effect
Skin Mild hirsutism (4-6%) & acne (3–8%),
dose response with higher doses
Cardiovascular
Blood pressure NS
Lipids HDL ↓ with oral route; NS with transdermal route
Vascular reactivity Enhanced vasodilatation
Viscosity NS
Coagulation NS
Hemoglobin No polycythemia
Insulin Resistance NS
Endometrium In vitro inhibitory effect, no Ca
Breast Prospective / retrospective epidemiological studies with mixed reuslts.
Experimental studies suggesting decrease in estrogen-induced breast epithelial
proliferation with low dose testosterone.
Liver NS
CNS
Sleep/Behavior No sleep apnea / Possible ↑ aggressiveness
Braunstein GD. Management of female sexual dysfunction in postmenopausal women by
testosterone administration: Safety issues and controversies J Sex Med 2007;4:859–866.
Shufelt CL & Braunstein GD. Safety of testosterone therapy in women. Maturitas 2009. epub
ahead of print.

28. TIBOLONE improves sexual function in postmenopausal women
Palacios et al 1995
-0.4
0
0.4
0.8
1.2
1.6
Tibolone (n=14)
Placebo (n=14)
Tibolone significantly different
for all values at p <0.01 at 12 m

29. March 5, 2018
Balance between excitatory activity
driven by DA (desire) and NE (arousal)
and inhibitory activity driven by 5-HT
(satiety) is believed to be necessary for a
healthy sexual response
This balance may be disrupted in sexual
dysfunction
By selectively modulating these
neurotransmitters in a regionally specific way,
flibanserin may act to re-balance these
systems in women with HSDD
What is Desire in the brain?

30. March 5, 2018
Flibanserin MOA – Key messages
• Two main pharmacological targets in the brain:
• post-synaptic 5-HT1A receptors (agonism)
• 5–HT2A receptors (antagonism)
• Flibanserin administration leads to region-specific
• increases in dopamine (DA) and norepinephrine (NE)
• decrease in serotonin (5-HT)
 Our hypothesis:
By modulating these neurotransmitters in selective brain areas
flibanserin helps to restore balance between inhibitory and
excitatory factors leading to a healthy sexual response

31. Tratamientos para la excitación
• Terapia hormonal
• Vasodilatadores vascutlares
• Estimuladores del clitoris
• Fisioterapia del suelo pelvico
• Cambios de estilo de vida
• Terapia psicosexual

32. Clin Ther. 2017 Mar;39(3):514-526.e14. doi: 10.1016/j.clinthera.2017.01.018. Epub 2017 Feb 9.
Phase I Randomized Placebo-controlled, Double-blind Study of the Safety and Tolerability of Bremelanotide
Coadministered With Ethanol in Healthy Male and Female Participants.
Clayton AH1, Lucas J2, DeRogatis LR3, Jordan R2.
IMPLICATIONS:
Female sexual dysfunction is a multifactorial condition with anatomic,
physiologic, medical, psychological, and social components. BMT is a synthetic
peptide analogue of the naturally occurring hormone α-melanocyte-stimulating
hormone and a melanocortin receptor agonist that is being developed for the
treatment of hypoactive sexual desire disorder. Its mechanism of action involves
activation of endogenous melanocortin hormone pathways involved in the sexual
no reports of drug-related serious adverse events. Phase III trials of subcutaneous
BMT for the treatment of hypoactive sexual desire disorder in premenopausal
women are in progress. ClinicalTrials.gov identifiers NCT02338960 and
NCT02333071.

38. "EFECTO DE LA TRIGONELLA FOENUM
GRAECUM- SUPLEMENTO ALIMENTICIO
SOBRE LA FUNCIÓN SEXUAL EN MUJERES
CON DESEO SEXUAL BAJO . ESTUDIO
PILOTO"
Palacios S, Ramírez M, Soler EM and Lilue M
Instituto Palacios de Salud y Medicina de la Mujer (Madrid)

39. Introducion y metodos
• Libicare® es un suplemento alimenticio conteniendo Trigonella foenum
graecum, Turnera diffusa, Tribulus terrestris y extracto seco de Ginkgo biloba.
• Objectivo: Evaluar la eficacia deLibicare® para mejorar la función sexual en
mujeres peri y postmenopausicas.
• Metodos : Prospectivo, no-controlado y estudio observacional
• Pacientes: Mujeres de 45 -65 años con bajo deseo sexual fueron incluidas
durante una visita de rutina y tratadas con 2 tabletas de Libicare® diarias por 2
meses.
• Objetivos:
• Primario : cambio vs linea basal del Indice de deseo sexual femenino
(FSFI) .
• Secondario: 1) cambios de niveles de testosterona y SHBG 2)
tolerabilidad

40. • Un total de 29 pacientes (edad media 53.9 yaños )
Resultados

41. • No related adverse events were reported.
Testosterona y SHBG
Baseline Month 2 Absolute change
(post-pre)
Relative change
([post-pre]/pre x100%)
p
Testosterona (pg/ml)
Mean (SD) 0,41 (0,26) 0,50 (0,34) 0,09 (0,17) 79,27 (205,31) 0,03861
SHBG (nmol/l)
Mean (SD)
85,05 (32,94) 73,0 (26,82) -12,05 (11,48) -13,17 (11,78) 0,00012
1 Wilcoxon 2T-test
Resultados

42. • En este estudio piloto, una mejoria significativa en la
función sexual y niveles hormonales relacionados
fueron pbservados con el uso de Libicare®.
• Otros estudios deben de reañizarse para confirmar
estos resultados.
Conclusion

43. • A QUIEN TRATAR
• CUANDO TRATAR
• CON QUE TRATAR
• GINECOLOGO VS SEXOLOGO
CONTENIDO
*

44. DEBATE
1. Primero la ve el ginecologo y luego si es
necesario la manda al sexologo
2. Si creo que es una causa hormonal u organica la
trato primero, veo resultados y decido
Basson R. Maturitas 2007