Group 3: Webinar on PCOS and Sexual Dysfunction

Obenita, Rivera, San Miguel, Sendin

1st Topic: Polycystic Ovarian Syndrome (PCOS)

I. Introduction - Sendin
What is Polycystic Ovarian Syndrome (PCOS)?
In polycystic ovarian syndrome or PCOS, the prefix “poly” means many or multiple,
and “cystic” refers to cysts; therefore, polycystic ovarian syndrome is a condition where
the ovaries are enlarged due to the multiple cyst formations within the ovaries. It is also
formerly known as Stein-Leventhal syndrome because of the two gynecologists who first
recognized an association between the presence of polycystic ovaries and signs of
hirsutism and amenorrhea, Irving F. Stein, Sr., and Michael Leo Leventhal.
It is a hormonal disorder common among women of reproductive age. Women with
PCOS may have infrequent or prolonged menstrual periods or excess male hormone
(androgen) levels. The ovaries may develop numerous small collections of fluid (follicles)
and fail to regularly release eggs. This can cause more problems with a woman’s
menstrual cycle.
Ovulation occurs when a mature egg is released from an ovary. This happens so
it can be fertilized by a male sperm. If the egg is not fertilized, it is sent out of the body
during your period. In some cases, a woman doesn’t make enough of the hormones
needed to ovulate. Thus, PCOS occurs when follicles don’t ovulate, thus, developing
many small cysts in the ovaries.

Types of Polycystic Ovarian Syndrome (PCOS)

1. Insulin Resistant PCOS
- This is the most common type of PCOS, affecting around 70% of people. Insulin
resistance is often a result of high blood sugar and insulin. In this, high levels of insulin
prevent ovulation and trigger the ovaries to create excessive amount of testosterone
which cause issues like excess hair, male pattern hair loss, and acne.
2. Post-Pill or Pill-Induced PCOS
- This type is the second most common PCOS. PCOS can develop in women who have
been on the birth control pill for several years and then decide to come off. It gets
developed due to the birth control pills which suppress ovulation to prevent a pregnancy.
It does this by shutting down communication between the brain and the ovary. As a result,
the female no longer ovulates or menstruates. Due to a lack of ovulation, the follicle does
not break to release the egg. As a result, the follicles stay in the ovary and the ovaries
appear to contain many cysts.

3. Adrenal PCOS
- This type of PCOS is due to an abnormal stress response and affects around 10% of
those diagnosed. Women with adrenal PCOS are either experiencing high levels of
stress, or their bodies are reacting abnormally to stress. They have high levels of
dehydroepiandrosterone sulfate [DHEA-S] (androgen produced in the adrenal glands),
which is released due to the trigger of the stress hormones to the adrenocorticotropic
hormone that stimulates the adrenal to produce male hormones.
4. Inflammatory PCOS
- Chronic inflammation causes the ovaries to make excess testosterone, resulting in
physical symptoms and issues with ovulation. Ovulation is prevented, hormones get
imbalanced, and androgens are produced.

II. Epidemiology – Rivera

PCOS impacts women of all races and ethnicities who are of reproductive age. It
is a health problem that affects 1 in 10 women of childbearing age. It is a syndrome that
is seen only in women and is most often characterized by an imbalance of the sex
hormones. Studies consistently report that the prevalence estimates using the Rotterdam
criteria are two to three times greater than those obtained using the NIH/NICHD criteria.
Prevalence estimates for PCOS, as defined by the NIH/NICHD criteria, indicate
that PCOS is a common endocrinopathy affecting 4%–8% of women of reproductive
age (12-51 years old) worldwide. PCOS has a very high percentage of individuals who
remain undiagnosed when visiting their doctor, estimated to be as high as 75%. Recently,
several groups have demonstrated that the prevalence of PCOS varies depending on the
diagnostic criteria used. In some European studies, the prevalence of PCOS has been
reported to be 6.5-8%.

Age and Racial Demographics

PCOS affects premenopausal women, and the age of onset is most often
premenarchal (before bone age reaches 16 y). Between 5% and 10% of women between
15 and 44, or during the years they have children, have PCOS. Most women find out they
have PCOS in their 20s and 30s, when they have problems getting pregnant and see
their doctor. But PCOS can happen at any age after puberty. In hirsutism cases, Asian
women have less hirsutism than white women given the same serum androgen values.
In a study that assessed hirsutism in Southern Chinese women, investigators found a
prevalence of 10.5%. In hirsute women, there was a significant increase in the incidence
of acne, menstrual irregularities, and polycystic ovaries.
Risk Factors
PCOS has been most frequently recognized in women of reproductive age, in
whites, and person of Asians background, although it does occur on all races and all age
groups. Family history is also considered as a risk factor for PCOS as there’s a high
prevalence of PCOS among first-degree relatives is suggestive of genetic influences, it is
considered to be a heritable disorder. However, the mode of inheritance remains
unknown. A history of weight gain often precedes the development of the clinical features
of PCOS and following a healthy lifestyle has been shown to reduce body weight,
abdominal fat, reduce testosterone, improve insulin resistance, and decrease hirsutism
in women with PCOS. In an unselected population, prevalence of PCOS did not vary
significantly based on obesity class. PCOS prevalence rates for underweight, normal-
weight, overweight, mildly obese, moderately obese, and severely obese women were
8.2%, 9.8%, 9.9%, 5.2%, 12.4%, and 11.5%, respectively.

III. Etiology - Rivera

The exact cause of PCOS is not known. Factors that might play a role include:
Heredity.
PCOS often runs in families. Up to 70 percent of daughters of women with PCOS also
develop it, but genetic variation doesn’t fully explain the high incidence within families.
According to Dunaif, if a woman is diagnosed with PCOS, her sister has about a 40%
chance of having it as well. In monozygous/identical twins, if one twin has PCOS, the
other twin is highly likely to also have PCOS.

High levels of androgens.

Androgens are sometimes called "male hormones," although all women make small
amounts of androgens. Androgens control the development of male traits, such as male-
pattern baldness. Women with PCOS have more androgens than normal. Higher than
normal androgen levels in women can prevent the ovaries from releasing an egg
(ovulation) during each menstrual cycle, and can cause extra hair growth and acne, two
signs of PCOS.

High levels of insulin.

Insulin is a hormone that controls how the food you eat is changed into energy. Insulin
resistance is when the body's cells do not respond normally to insulin. As a result, your
insulin blood levels become higher than normal. Many women with PCOS have insulin
resistance, especially those who are overweight or obesity, have unhealthy eating habits,
do not get enough physical activity, and have a family history of diabetes (usually type 2
diabetes). Over time, insulin resistance can lead to type 2 diabetes. Excess insulin might
also increase androgen production, causing difficulty in ovulation.

Low-grade inflammation.
This term is used to describe white blood cells' production of substances to fight infection.
Research has shown that women with PCOS have a type of low-grade inflammation that
stimulates polycystic ovaries to produce androgens, which can lead to heart and blood
vessel problems.

IV. Pathophysiology - Sendin

Physiology of Menstruation in relation to PCOS
The normal menstrual cycle can be divided into two phases: the follicular phase
(before ovulation; Day 1-13) and the luteal phase (after ovulation; Day 15-28). During the
follicular phase, the hypothalamus secretes gonadotropin-releasing hormones (GnRH) in
pulses. GnRH makes the anterior pituitary gland to secrete two other hormones called
gonadotropins in equal amounts. One of these gonadotropins is the luteinizing hormone
(LH), and the other is the follicle-stimulating hormone (FSH) that travels to the follicles in
the ovaries.
The follicles are small clusters of theca cells and granulosa cells to protect the
developing oocyte (egg). The theca cells develop LH receptors which allow them to bind
LH, and in response they secrete a hormone called androstenedione. Granulosa cells
develop FSH receptors, which allow them to bind to FSH and produce an enzyme called
aromatase, which converts the androstenedione into 17𝛽-estradiol (member of the
estrogen family).
As follicles grow, the level of 17𝛽-estradiol in the blood increases, and it acts as a
negative feedback signal, it tells the pituitary to secrete less FSH. Less FSH in the blood
means there’s only enough to stimulate one follicle. The follicle that has the most FSH
receptors grows the quickest, and becomes the dominant follicle. About midway through
the follicular phase, the granulosa cells also begin to develop LH receptors. As that
happens, the dominant follicle keeps secreting estrogen, and the rising estrogen levels
make the pituitary more sensitive to the pulsatile action of GnRH from the hypothalamus.
Blood estrogen levels start to climb, and now the estrogen from the dominant
follicle becomes a positive feedback signal – it makes the pituitary secrete a whole lot of
FSH and LH in response to GnRH. This happens a day or two before ovulation, and the
massive surge of FSH and LH binds to the granulosa and theca cells which help facilitate
rupture of the ovarian follicle and release of the oocyte. While the rest theca and
granulosa cells degenerate and die off, a now fully-matured oocyte breaks away from the
dominant follicle, and pops out of the ovary. The egg begins its journey down the fallopian
tube to the uterus. The luteal phase has begun.
PCOS
While polycystic ovary syndrome affects the whole menstrual cycle, it really starts
with a breakdown in the follicular phase.
In polycystic ovarian syndrome, the anterior pituitary makes too much LH, at least
double the amount as FSH. Excessive LH causes the theca cells to produce excess
amounts of androstenedione, way too much for the granulosa cells to convert. The excess
androstenedione flows into the blood and some of it gets converted into estrone by
aromatase in fat or adipose tissue. Estrone, like estradiol, is a member of the estrogen
family, and it acts as a negative feedback signal, stopping the anterior pituitary from
releasing FSH.
Because LH levels are really high, there’s no LH surge to trigger the dominant
follicle to break away from the ovary, so it may remain there, appearing as a cyst, or it
might degenerate with the other follicles. The bottom line is that ovulation doesn’t occur.

Complications of PCOS:
• Endometrial Cancer
- When ovulation does not occur, which is typical in PCOS, the lining is not shed
and is exposed to much higher amounts of estrogen causing the endometrium to
grow much thicker than normal. This is what increases the chance of cancer cells
beginning to grow.
• Heart Disease
- Having PCOS increases a woman’s chances of getting high blood pressure and
cardiovascular disease.
• Diabetes
- Women with PCOS frequently have insulin resistance that results to consistently
high levels of glucose in the blood that can lead to diabetes.
• Metabolic Syndrome
- The most common metabolic changes associated with this syndrome include the
following: increased abdominal weight, high levels of triglycerides, low levels of
good cholesterol or HDL (high-density lipoprotein), high blood pressure, and high
fasting blood sugar.
• Infertility
 - To get pregnant, you have to ovulate. Women who don’t ovulate regularly don’t
release as many eggs to be fertilized.

V. Signs and Symptoms – San Miguel

Signs and symptoms of PCOS often develop around the time of the first menstrual period
during puberty. Sometimes PCOS develops later, for example, in response to substantial
weight gain.
The following are some signs and symptoms of PCOS:
▪ Irregular periods. Infrequent, irregular, or prolonged menstrual cycles are the most
common sign of PCOS. For example, you might have fewer than nine periods a year,
more than 35 days between periods and abnormally heavy periods.
▪ Polycystic ovaries. Your ovaries might be enlarged and contain follicles that
surround the eggs. As a result, the ovaries might fail to function regularly.
▪ Hirsutism. Unwanted hair growth on the face, chin, breasts, stomach, or thumbs and
toes.
▪ Hair loss. Women with PCOS might see thinning hair on their head, which could
worsen in middle age.
▪ Acne or oily skin. Hormone changes due to PCOS can cause oily skin and pimples.
▪ Darkening of skin. This condition is called acanthosis nigricans. You may see thick,
dark, velvety patches of skin under your arms or breasts, on the back of your neck,
and in your groin area.
▪ Problems sleeping or feeling tired all the time. You could have trouble falling
asleep. Or you might have a disorder known as sleep apnea. This means that even
when you do sleep, you do not feel well-rested after you wake up.
▪ Weight gain. About half of women with PCOS struggle with weight gain or have a
hard time losing pounds. PCOS can make you gain a lot of weight. And being
overweight can make PCOS symptoms more serious.
▪ Headaches. The surging hormones that cause PCOS can give you headaches, too.

VI. Diagnostic Procedures – San Miguel

There's no test to definitively diagnose PCOS. Your doctor is likely to start with a
discussion of your medical history, including your menstrual periods and weight changes.
A physical exam will include checking for signs of excess hair growth, insulin resistance
and acne. A diagnosis of PCOS is made when you experience at least two of these signs:
irregular periods, excess androgen, and polycystic ovaries.

Your doctor might then recommend:

 • A pelvic exam. The doctor visually and manually inspects your reproductive organs
for masses, growths, or other abnormalities.

• Blood tests. These look for high levels of androgens and other hormones. Your
health care provider may also check your blood glucose levels. And you may have
your cholesterol and triglyceride levels checked.

• Human chorionic gonadotropin (hCG). This is a hormone test that can check to
see if you’re pregnant.

• Anti-Mullerian hormone (AMH). This test can check how well your ovaries are
working and to help estimate how far off menopause may be. The levels would be
higher with PCOS.

• Pelvic ultrasound (sonogram). This test uses sound waves and a computer to
create images of blood vessels, tissues, and organs. This test is used to look at the
size of the ovaries and see if they have cysts. The test can also look at the thickness
of the lining of the uterus (endometrium).

VII. Medical Management - Obenita

Medical management is completed through medications or surgical removal of the
ovarian cysts/hysterectomy. Medications can be used to shrink ovarian cysts through
control of the menstrual cycle and subsiding release of excess luteinizing hormone thus
preventing the overproduction of testosterone.

To regulate your menstrual cycle, your doctor might recommend:

Combination birth control pills - Pills that contain estrogen and progestin decrease
androgen production and regulate estrogen. Regulating your hormones can lower your
risk of endometrial cancer and correct abnormal bleeding, excess hair growth and acne.
Instead of pills, you might use a skin patch or vaginal ring that contains a combination of
estrogen and progestin.
Progestin therapy - Taking progestin for 10 to 14 days every one to two months can
regulate your periods and protect against endometrial cancer. Progestin therapy doesn't
improve androgen levels and won't prevent pregnancy. The progestin-only minipill or
progestin-containing intrauterine device is a better choice if you also wish to avoid
pregnancy.

To help you ovulate and treatment for infertility, your doctor might recommend:
Clomiphene -This oral anti-estrogen medication is taken during the first part of your
menstrual cycle. It acts directly by producing a surge of LH and could cause ovulation
within days.
Letrozole (Femara) - This breast cancer treatment can work to stimulate the ovaries.
Metformin - This oral medication for type 2 diabetes improves insulin resistance and
lowers insulin levels. If you don't become pregnant using clomiphene, your doctor might
recommend adding metformin. If you have prediabetes, metformin can also slow the
progression to type 2 diabetes and help with weight loss. It also increases spontaneous
ovulation for women with insulin resistance/increased insulin production.
Gonadotropins - These hormone medications are given by injection.

To reduce excessive hair growth, your doctor might recommend:

Spironolactone (Aldactone) - This medication blocks the effects of androgen on the
skin. Spironolactone can cause birth defects, so effective contraception is required while
taking this medication. It isn't recommended if you're pregnant or planning to become
pregnant.
Finasteride - It works by blocking androgens to reduce PCOS-related hair loss and
hirsutism.
Eflornithine (Vaniqa) - This cream can slow facial hair growth in women.
Electrolysis - A tiny needle is inserted into each hair follicle. The needle emits a pulse of
electric current to damage and eventually destroy the follicle. You might need multiple
treatments.
Depilatories - These are creams, gels, and lotions that break down the protein structure
of hair, so it falls out of the skin.

Oral Contraceptives (for women who don’t want to get pregnant):

Medroxyprogesterone (Depo-Provera) injections - to decrease endometrial
hyperplasia/cancer and can induce withdrawal bleeding.
Ethinyl Estradiol - Ethinyl estradiol reduces the secretion of LH and FSH from the
pituitary by decreasing the amount of GnRH. Use ethinyl estradiol 30-35 mg combined
with any form of progesterone. Restoration of the regular menstrual cycles prevents
endometrial hyperplasia associated with anovulation.
Oral combination contraceptive containing estrogen and progestin – increase sex-
hormone binding globulin (SHBG) levels and thereby reduce the free testosterone level.
LH and FSH are also suppressed. This restores cyclic exposure of the endometrium to
estrogen-progestin, with the resumption of menstrual periods and decreased hirsutism
and acne.

To improve fertility:
Surgery - A procedure called ovarian drilling might make your ovaries work better when
ovulation medications don't, but it's being done less often than it used to. The doctor
makes a small cut in your belly and uses a tool called a laparoscope with a needle to
poke your ovary and wreck a small part of it. The procedure changes your hormone levels
and may make it easier for you to ovulate.
In vitro fertilization, or IVF - With this procedure your egg is fertilized outside of your
body and then placed back inside your uterus. This may be the best way to get pregnant
when you have PCOS, but it can be expensive.

Lifestyle Changes
For women who are overweight or obese, it is recommended to get them on a diet or
exercise to reduce their BMI, reduce their weight, and normalize their insulin, insulin
tolerance, and glucose tolerance. Losing weight may also increase the effectiveness of
medications your doctor recommends for PCOS and can help with infertility. Another
lifestyle change is to quit smoking as women who smoke have higher levels of androgens.

VIII. PT Management - Obenita

Exercise training has shown great improvement in 50% of the women diagnosed
with Polycystic Ovarian Syndrome PCOS, by targeting menstrual irregularities and
promoting ovulation. Weight reduction is an important component of the physical therapy
program since weight reduction improves glucose intolerance which in turn could resolve
the reproductive and metabolic derangements often associated with PCOS. Weight loss
may also reduce the pulse amplitude of luteinizing hormone thus reducing androgen
production.

Considered exercises for PCOS include the following:

Yoga – It is the most beneficial form of exercise to perform for PCOS. It specifically helps
with hormonal imbalance and is very effective in controlling mood swings.
High-Intensity Interval Training (HIIT) – It involves balancing intense exercise bursts
with rest intervals. Parker (2017) found that 24 minutes of HIIT was beneficial to blood
sugar control. It encompasses a broad spectrum of activities such as indoor and outdoor
walking and running, bodyweight circuits, spin classes, and other cardio machine
workouts. A study published in the journal PLOS ONE found that women with obesity
reported greater enjoyment of HIIT exercises compared to those who engaged in
continuous moderate to vigorous exercise.
Mind-body exercises - Studies show that women with PCOS have an enhanced bodily
response to stress and distress, according to an article in the journal Physical Exercise
for Human Health. Mind-body exercises like yoga, Pilates, and tai chi can help not only
burn calories, but also reduce stress levels that worsen your PCOS symptoms.
Strength training – It involves the use of resistance bands and weights. This training
type can help you build healthy muscles and bones. Increasing the muscle mass could
help burn more calories at rest, helping you maintain a healthy weight.
Pool workouts - such as swimming and aqua aerobics or Zumba are great activities for
women with PCOS to do. These exercises use resistance to work the entire body and are
easy on the joints.

Exercise and, ideally, weight loss of at least 5 percent of a woman’s body weight, can
help women restore ovulation cycles and improve the regularity of their cycles. Combining
diet and exercise efforts is more effective than diet alone in managing PCOS and
infertility.
 2nd Topic: Sexual Dysfunction

I. Introduction – Sendin
What is Sexual Dysfunction?
According to Mandal (2019), sexual dysfunction is a term that covers any problem
affecting any of the phases of sexual response, and which inhibits one or both partners
from attaining sexual satisfaction. The various phases of the sexual cycle include
excitement, plateau, orgasm, and resolution. It can be caused by physical problems,
medical conditions, and psychological problems. Satisfying sex involves your body, mind,
health, beliefs, and your feelings toward your partner, among other factors.

Types of Sexual Dysfunction

1. Sexual Desire Disorders
- These are problems that involve a lack or absence of sexual drive, also referred to as a
low libido. The lack of desire may apply in general or towards the current partner. Low
levels of the female hormone estrogen and the male hormone testosterone can lead to a
decrease in sexual desire. Testosterone maintains sexual drive in addition to sperm
production.
2. Sexual Arousal Disorders
- These disorders make it difficult or impossible to become physically aroused during
sexual activity, can occur in both men and women. These individuals may have an
aversion to or tendency to avoid sexual contact with a partner. Males may find they can
only maintain a partial erection, or they may be unable to obtain one at all. Affected males
may also find they gain no pleasure or excitement from sexual activity. Among affected
females, the vagina may fail to become lubricated prior to intercourse.
3. Orgasm Disorders
- These involve the absence of orgasm or delayed orgasm, are a common problem with
women, but they can also occur in men. Pain during sexual activity, stress, fatigue,
hormonal changes, and reduced libido can all lead to delayed or absent orgasm.
4. Sexual Pain Disorders
- These involve pain during intercourse, can affect both men and women. In women, pain
is caused by inadequate lubrication of the vagina during sex. This may be caused by a
lack of stimulation or excitement about the sexual activity or by hormonal changes that
occur as a result of pregnancy, breastfeeding or menopause. Sexual pain may also be
caused by a condition called vaginismus, where the muscles of the vaginal wall spasm
involuntarily during intercourse. One sexual pain disorder that occurs in males is referred
to as priapism, which is a painful erection that may persist for several hours, even in the
absence of sexual stimulation. This is caused by blood entrapment within the penis, failing
to drain adequately. Other source of sexual pain in males include Peyronie’s disease
which is the physical damage to the penis where scar tissue causes the penis to curve or
lose length.

Sexual Dysfunction in Women

Sexual dysfunction is a common problem among women. Many women
experience problems with sexual function at some point, and some have difficulties
throughout their lives. Female sexual dysfunction can occur at any stage of life. It can
occur only in certain sexual situations or in all sexual situations
Types of Sexual Dysfunction in Women:
• Anorgasmia – orgasmic disorder, or inability to have an orgasm.
• Dyspareunia – pain during sex
• Hypoactive sexual desire disorder – low libido or lack of sexual drive
• Sexual arousal disorder – difficulty becoming aroused
• Hormone deficiency – reduced estrogen can affect sexual desire

Sexual Dysfunction in Men

Sexual dysfunction can affect men of all ages but is especially common in older
men. Your health, stress, relationship concerns, and other issues can lead to these
problems.
Types of Sexual Dysfunction in Men:
• Erectile Dysfunction (ED) – AKA impotence. It is the most common sexual
dysfunction among men. It is the inability to get and keep an erection firm enough
for sex.
• Ejaculation Disorders – classified into: premature ejaculation is ejaculation that
happens before or immediately after penetration, inhibited or delayed ejaculation
is ejaculation that takes a very long time or not at all following penetration, and
retrograde ejaculation is ejaculation into the bladder rather than through the penile
orifice.
• Hormone deficiency – reduced testosterone levels can affect the ability to have
a satisfying sex due to lack of sex drive (libido) and erectile dysfunction.
II. Epidemiology - Rivera
Experiencing sexual dysfunction is more likely among women and men with poor
physical and emotional health. Moreover, sexual dysfunction is highly associated with
negative experiences in sexual relationships and overall well-being. In the 1999 data
gathered by Laumann et. al. (1999), sexual dysfunction is more prevalent for females
(43%) than males (31%) and is associated with various demographic characteristics,
including age and educational attainment.
In the 2018 data gathered by Asefa et.al. (2019), the prevalence of global sexual
dysfunction among study participants was 53.3%. Gender-wise, sexual dysfunction is
more prevalent for females (56.6%) than males (52%). Women of different racial groups
demonstrate different patterns of sexual dysfunction. Differences among men are not as
marked but generally consistent with women.
According to the study conducted by Laumann et.al. (1999) that was based on the
few available community studies, it appears that sexual dysfunctions are highly prevalent
in both sexes, ranging from 10% to 52% of men and 25% to 63% of women. Research
data from the Massachusetts Male Aging Study (MMAS) showed that 34.8% of men aged
40 to 70 years had moderate to complete erectile dysfunction, which was strongly related
to age, health status, and emotional function. Men in the oldest age group (50 to 59) were
more than 3 times as likely to experience erection problems and to report low sexual
desire compared with men 18 to 29.
According to the results of the study conducted by McCool et.al. (2016), it showed
that female sexual dysfunction is a significant public health problem that affects 41% of
premenopausal women around the globe.
Risk Factors:
Many more studies investigated risk factors for sexual dysfunction in men than in women.
For women and men, diabetes, heart disease, urinary tract disorders, and chronic illness
were significant risk factors for sexual dysfunction. Depression and anxiety and the
medications used to treat these disorders also were risk factors for sexual dysfunction in
women and men. Furthermore, substance abuse was associated with sexual dysfunction.

III. Etiology - Rivera

Physical causes of sexual dysfunction in males may include:
• Cardiovascular disease (atherosclerosis, hypertension and peripheral vascular
disease) – These diseases damage small blood vessels that supply blood to the areas of
the body away from the heart. The changes in these blood vessels reduce the blood flow
to these areas, which include the genitals. Poor blood flow to the penis affects a person's
ability to become aroused and have sexual intercourse. Some studies suggest that 30 to
50% of cases of erectile dysfunction are the result of blood vessel disease.
• Diabetes - Diabetes also can affect the blood vessels, leading to ED. In addition, a
condition called diabetic neuropathy—which involves damage to the nerves—may cause
orgasm without ejaculation. In men, diabetes can lead to a hardening and narrowing of
the blood vessels that supply the erectile tissue of the penis. This can cause problems in
getting an erection, and the penis may be less firm while erect.

• Low testosterone levels - Low testosterone can make it difficult to get or maintain
erections. Testosterone stimulates the penile tissues to produce nitric oxide, which starts
several reactions that result in an erection. If levels of the hormone are too low, a man
may not be able to get an erection.

• Prescription drugs (antidepressants, high blood pressure medicine) – ED is a common

side effect of a number of prescription drugs. While these medications may treat a disease
or condition, in doing so they can affect a man's hormones, nerves or blood circulation.
The result may be ED or an increase in the risk of ED.

• Stroke or nerve damage from diabetes or surgery

• Smoking - An erection is only possible when blood vessels in the penis enlarge and fill
with blood. Smoking disrupts blood vessels in that area of the body, meaning the erection
can’t always happen. In fact, smoking can cause erectile dysfunction in men as young as
20.

• Alcoholism and drug abuse – Alcohol reduces the production of testosterone. It also
interferes with the messengers in the brain that tell the penis to fill with blood. Drug abuse
can lead to the damage of blood vessels and can restrict blood flow to the penis.

Psychological causes of sexual dysfunction in males may include:

The brain plays a key role in triggering the series of physical events that cause an
erection, starting with feelings of sexual excitement. A number of things can interfere with
sexual feelings and cause or worsen erectile dysfunction. These include:
• Concern about sexual performance
• Marital or relationship problems
• Depression, feelings of guilt
• Effects of past sexual trauma
• Work-related stress and anxiety

Physical causes of sexual dysfunction in females may include:

• Physical (Medical Conditions) - Such as cancer, kidney failure, multiple sclerosis,

heart disease and bladder problems.

• Blood flow disorders - Some research points to vascular (blood vessel) disorders.
These disorders may prevent blood flow to parts of the female reproductive system.
The vagina, clitoris and labia need increased blood flow for sexual arousal.

• Certain medications and treatment - Some medications affect sexual function.

Antidepressants may reduce your sex drive or your ability to have an orgasm.
Selective serotonin uptake inhibitors (SSRIs) are especially likely to cause sexual side
effects. Chemotherapy and other cancer treatments can also affect hormone levels
and cause problems.

• Gynecologic conditions - Endometriosis, ovarian cysts, uterine fibroids and vaginitis

can all cause pain during sex. Vaginismus, a condition that causes vaginal muscle
spasms, can also make intercourse uncomfortable.

• Hormonal Changes - Low level of estrogen after menopause. A decrease in estrogen

leads to decreased blood flow to the pelvic region, which can result in less genital
sensation, as well as needing more time to build arousal and reach orgasm. Hormone
imbalances may cause vaginal dryness or vaginal atrophy, making sex painful.

• Particular health conditions - A number of health conditions can affect your ability
to enjoy sex. These include diabetes, arthritis, multiple sclerosis and heart disease.
Drug addiction or alcohol abuse may also prevent a healthy sexual experience.
Psychological causes of sexual dysfunction in females may include:

• Depression - Depression may cause a lack of interest in activities you enjoyed before,
including sex. Low self-esteem and feelings of hopelessness can also contribute to
sexual dysfunction.

• Stress - Stress at home or work can make it hard to focus on enjoying sex. Some
studies show that stress can increase levels of the hormone cortisol. This increase
may lower sex drive.

• Past physical or sexual abuse - Trauma or abuse may cause anxiety and a fear of
intimacy. These feelings can make it difficult to have sex

• Relationship issues - Some women may be unhappy with their partner or feel bored
during sex. Other strains on the relationship may lead to sexual dysfunction.

IV. Pathophysiology – Sendin

The pathophysiology/complication of sexual dysfunction includes the following:
• An unsatisfactory sex life
- Having low testosterone levels prevent males to have an unsatisfactory sex life
with their partner due to low libido and inability to get an erection (erectile
dysfunction). In females, problems with blood flow to the vagina and clitoris may
affect lubrication and arousal that also results to unsatisfied sex.

• Embarrassment or low self-esteem

- Men with ED end up avoiding sex because it becomes so shaming for them.
Erections are important to men as they often use it as a measure of manhood. In
females, vaginal dryness can make them feel embarrassed towards their partner
because it will seem like they can’t get aroused easily.

• Relationship problems
- Sexual dysfunction is also tough on partners, making them feel unattractive,
undesirable, or like they’re doing something wrong. It can cause a gap on the
relationship between partners if they can’t communicate well with each other.

• Inability to get your partner pregnant (for males)

 - Since men with ED can’t get or maintain an erection, this affects fertility by
preventing the sperm’s access into the woman’s uterus.

V. Signs and Symptoms – San Miguel

In females:
• Inability to achieve orgasm
• Inadequate vaginal lubrication before and during intercourse
• Inability to relax the vaginal muscle enough to allow intercourse
In males:
• Inability to achieve or maintain an erection suitable for intercourse (erectile
dysfunction)
• Absent or delayed ejaculation despite enough sexual stimulation (retarded
ejaculation)
• Inability to control the timing of ejaculation (early or premature ejaculation)
In males and females:
• Lack of interest in or desire for sex
• Inability to become aroused
• Pain with intercourse

VI. Diagnostic Procedures – San Miguel

To diagnose female sexual dysfunction, your doctor may:
Discuss your sexual and medical history. You might be uneasy talking with your doctor
about such personal matters, but your sexuality is a key part of your well-being. The more
upfront you can be about your sexual history and current problems, the better your
chances of finding an effective way to treat them.
Perform a pelvic exam. During the exam, your doctor checks for physical changes that
affect your sexual enjoyment, such as thinning of your genital tissues, decreased skin
elasticity, scarring or pain.
Order blood tests. Your doctor may recommend blood tests to check for underlying
health conditions that might contribute to sexual dysfunction.

To diagnose male sexual dysfunction/erectile dysfunction, your doctor may:

Before ordering any tests, your doctor will review your medical history and perform a
thorough physical examination. The doctor will also interview you about your personal
and sexual history.
Physical exam. This might include careful examination of your penis and testicles and
checking your nerves for sensation.
Blood tests. A sample of your blood might be sent to a lab to check for signs of heart
disease, diabetes, low testosterone levels and other health conditions.
Lipid profile. This blood test measures the level of lipids (fats), like cholesterol. High
levels may indicate atherosclerosis which can affect blood circulation in the penis.
Urine tests (urinalysis). Like blood tests, urine tests are used to look for signs of
diabetes and other underlying health conditions.
Duplex ultrasound. This test is usually performed by a specialist in an office. It involves
using a wandlike device (transducer) held over the blood vessels that supply the penis. It
creates a video image to let your doctor see if you have blood flow problems. It is also
used to check for signs of a venous leak, atherosclerosis, or tissue scarring. This test is
sometimes done in combination with an injection of medications into the penis to stimulate
blood flow and produce an erection.
Bulbocavernosus reflex. This test evaluates nerve sensation in the penis. During the
test, your doctor will squeeze the head of your penis, which should immediately cause
your anus to contract. If nerve function is abnormal, there will be a delay in response time.
Nocturnal penile tumescence (NPT). This test measures a man's erectile function while
he is sleeping. Normally, a man will have five or six erections while asleep. A lack of these
erections may indicate there is a problem with nerve function or circulation to the penis.
Penile biothesiometry. This test involves the use of electromagnetic vibration to
determine sensitivity and nerve function. A decreased sensitivity to these vibrations may
indicate nerve damage.
Psychological exam. Your doctor might ask questions to screen for depression and
other possible psychological causes of erectile dysfunction.

VII. Medical Management - Obenita

Nonmedical treatment for female sexual dysfunction
To treat sexual dysfunction, your doctor might recommend that you start with these
strategies:
Talk and listen. Open communication with your partner makes a world of difference in
your sexual satisfaction. Even if you're not used to talking about your likes and dislikes,
learning to do so and providing feedback in a nonthreatening way sets the stage for
greater intimacy.
Practice healthy lifestyle habits. Limit alcohol — drinking too much can blunt your
sexual responsiveness. Be physically active — regular physical activity can increase your
stamina and elevate your mood, enhancing romantic feelings. Learn ways to decrease
stress so you can focus on and enjoy sexual experiences.
Seek counseling. Talk with a counselor or therapist who specializes in sexual and
relationship problems. Therapy often includes education about how to optimize your
body's sexual response, ways to enhance intimacy with your partner, and
recommendations for reading materials or couples exercises.

Medical treatment for female sexual dysfunction:

Effective treatment for sexual dysfunction often requires addressing an underlying
medical condition or hormonal change. Your doctor may suggest changing a medication
you're taking or prescribing a new one.
Possible treatments for female sexual dysfunction might include:
Estrogen therapy - Localized estrogen therapy comes in the form of a vaginal ring,
cream or tablet. This therapy benefits sexual function by improving vaginal tone and
elasticity, increasing vaginal blood flow and enhancing lubrication. The risks of hormone
therapy may vary depending on your age, your risk of other health issues such as heart
and blood vessel disease and cancer, the dose and type of hormone and whether
estrogen is given alone or with a progestin. Talk with your doctor about benefits and risks.
In some cases, hormonal therapy might require close monitoring by your doctor.
Mechanical aids - A vacuum device (EROS-CTD) is also approved for use in women but
can be expensive. Dilators may help women who experience narrowing of the vagina.
Devices like vibrators can be helpful to help improve sexual enjoyment and climax.
Ospemifene (Osphena) - This medication is a selective estrogen receptor modulator. It
helps reduce pain during sex for women with vulvovaginal atrophy.
Androgen therapy - Androgens include testosterone. Testosterone plays a role in
healthy sexual function in women as well as men, although women have much lower
levels of testosterone. Androgen therapy for sexual dysfunction is controversial. Some
studies show a benefit for women who have low testosterone levels and develop sexual
dysfunction; other studies show little or no benefit.
Flibanserin (Addyi) - Originally developed as an antidepressant, flibanserin is approved
by the Food and Drug Administration (FDA) as a treatment for low sexual desire in
premenopausal women. A daily pill, Addyi may boost sex drive in women who experience
low sexual desire and find it distressing. Potentially serious side effects include low blood
pressure, sleepiness, nausea, fatigue, dizziness and fainting, particularly if the drug is
mixed with alcohol. Experts recommend that you stop taking the drug if you don't notice
an improvement in your sex drive after eight weeks.
Bremelanotide (Vyleesi) - Bremelanotide is another FDA-approved treatment for low
sexual desire in premenopausal women. This medication is an injection you give yourself
just under the skin in the belly or thigh before anticipated sexual activity. Some women
experience nausea, which is more common after the first injection but tends to improve
with the second injection. Other side effects include vomiting, flushing, headache and a
skin reaction at the site of the injection.

Medical treatment for male sexual dysfunction:

Oral medications are a successful erectile dysfunction treatment for many men. They
include:
- Sildenafil citrate (Viagra)
- Vardenafil (Levitra, Staxyn)
- Tadalafil (Cialis, Adcirca)
- Avanafil (Stendra)
All four medications enhance the effects of nitric oxide — a natural chemical your body
produces that relaxes muscles in the penis. This increases blood flow and allows you to
get an erection in response to sexual stimulation.
Intracavernous injection therapy – It is a treatment option for ED where you inject drugs
into the spongy tissue in the penis to open the blood vessels.
Mechanical devices - A penis pump (vacuum erection device) is a hollow tube with a
hand-powered or battery-powered pump. The tube is placed over your penis, and then
the pump is used to suck out the air inside the tube. This creates a vacuum that pulls
blood into your penis. Once you get an erection, you slip a tension ring around the base
of your penis to hold in the blood and keep it firm.
Surgery – Penile implant is the main surgical treatment of ED. This treatment involves
surgically placing devices into both sides of the penis. These implants consist of either
inflatable or malleable (bendable) rods. Inflatable devices allow you to control when and
how long you have an erection. The malleable rods keep your penis firm but bendable.
They make a stiff penis that lets you have normal sex.

Most types of sexual dysfunction can be addressed by treating the underlying physical or
psychological problems. Other treatment strategies include:
Sex therapy: Sex therapists can people experiencing sexual problems that can’t be
addressed by their primary clinician. Therapists are often good marital counselors, as
well. For the couple who wants to begin enjoying their sexual relationship, it’s well worth
the time and effort to work with a trained professional.
Behavioral treatments: These involve various techniques, including insights into harmful
behaviors in the relationship, or techniques such as self-stimulation for treatment of
problems with arousal and/or orgasm.
Psychotherapy: Therapy with a trained counselor can help you address sexual trauma
from the past, feelings of anxiety, fear, guilt and poor body image. All of these factors may
affect sexual function.
Education and communication: Education about sex and sexual behaviors and
responses may help you overcome anxieties about sexual function. Open dialogue with
your partner about your needs and concerns also helps overcome many barriers to a
healthy sex life.

VIII. PT Management – Obenita

Healthy sexual function requires physical, mental, and emotional well-being. Physical
presentations that may limit sexual activity include decreased mobility, alterations in
sensation, decreased genital circulation, and pain. Physical therapists play an important
role in facilitating optimal sexual function by providing treatment to restore function,
improve mobility, and relieve pain.
• Kegel Exercises – It is also known as pelvic exercises. It is proven to be effective in
addressing erectile dysfunction and female sexual dysfunction, as it strengthens the
pelvic floor muscles. In females, Kegel exercises can help in improving their sexual
health and pleasure by: relaxing the vaginal muscles, which lets the vagina be more
open, improving blood circulation to the vagina and pelvic floor, making it easier to
reach orgasm, and increasing vaginal lubrication (wetness). In males, a fit pelvic floor
helps to make erections more rigid. A man can maintain an erection longer as well
because a fit pelvic floor can press on an essential blood vessel to keep blood in the
penis during sexual activity. A pelvic floor physiotherapist is specially trained to help
strengthen or rehabilitate pelvic floor muscles.

• Soundwave Treatment - GAINSWave therapy uses painless high-frequency

shockwaves to improve sexual health and performance. The sound waves help
release growth factors in the penis to encourage the tissue to form new blood vessels.
Increased blood flow can prevent or treat ED and give a man stronger, longer-lasting
erection.

• Pelvic Floor Electrical Stimulation - This movement strengthens the pelvic floor
muscles, which can improve urinary frequency, urgency and incontinence, and
increase the strength of the pelvic floor and vaginal muscles.
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