What’s New in Sexual Medicine?: Expert Interviews With Michael Krychman, MD, and Susan Kellogg-Spadt, PhD, BSN, CRNP

Laurie Barclay, MD

October 22, 2008

October 22, 2008 — Editor's note: Advances and new developments in sexual medicine were presented at the National Association of Nurse Practitioners in Women’s Health (NPWH) annual meeting, held from October 15 to 18 in Seattle, Washington. The nurse practitioner can play a vital role in incorporating sexual medicine into clinical practice by asking about sexual function and relationships, understanding the differential diagnosis of common sexual complaints, carrying out a pertinent history and physical evaluation, and managing therapeutic interventions.

Other topics of interest at the meeting included pharmacologic treatment of female sexual dysfunction, the newly recognized phenomenon of sexsomnia (sleep sex), and evidence related to throat cancer and human papillomavirus (HPV). To learn more about these areas and their relevance to clinical practice, Medscape interviewed presenters Michael L. Krychman, MD, and Susan Kellogg-Spadt, PhD, BSN, CRNP.

Dr. Krychman is medical director of sexual medicine at Hoag Hospital in Newport Beach, California, executive director of the Southern California Center for Sexual Health and Survivorship Medicine, an American Association of Sexuality Educators, Counselors and Therapists (AASECT)-certified sexual counselor, and associate clinical professor at the University of Southern California and at the University of California, Irvine. His Web site is www.thesexualhealthcenter.com.

Dr. Susan Kellogg-Spadt is professor of obstetrics and gynecology at Drexel University College of Medicine, in Philadelphia, and professor of human sexuality at Widener University, in Chester, Pennsylvania. She is cofounder and director of sexual medicine at the Pelvic and Sexual Health Institute of Philadelphia. She is also an OB/GYN practitioner, a maternal-child clinical specialist, a vulvovaginal specialist, a colposcopist, a researcher, and a sexual-dysfunction consultant. In addition, she on the editorial board of the Journal of Sexual Medicine and the Scientific and Education Committees of the International Society for the Study of Women's Sexual Health, and she has published and lectured widely on comprehensive biopsychobehavioral sexual wellness.

Medscape: How can sexual medicine best be incorporated into clinical practice?

Dr. Krychman: The best way to incorporate sexual medicine into clinical practice is to ask. Most healthcare providers are embarrassed and do not take the time to ask about intimacy and sexual expression. There is not 1 disease, not 1 medication, nor is there a patient–doctor interaction that does not affect the relationship dynamic when that patient leaves the doctor's office. The act of giving a medication or a diagnosis will affect that person and their significant relationships. 

Medscape: Are there specific recommendations regarding evaluation and management in sexual medicine?

Dr. Krychman: Sexual medicine is not only about sex, but about connectedness and the human spirit. A comprehensive history and physical examination, as well as appropriate lab testing, is often required. Not everyone will feel comfortable incorporating sexual healthcare concerns into their practice, so clinicians should know the community resources that are available and refer patients if necessary.

It is detailed and complex evaluation and management that incorporates sexual medicine (including knowledge of the involved veins, artery, and nerves), medication management, hormone therapy, second- and third-line treatment, and sexual psychology (assessing the dynamics of the relationship and managing stress and lifestyle issues). Clinicians should treat if they feel comfortable doing so, or refer the patient if they know sexual healthcare providers in the community who are interested in referrals.

Medscape: What role does pharmacotherapy play in sexual medicine?

Dr. Krychman: Sexual pharmacology remains the mainstay of treatment, using female sexual hormones like estrogen and progesterone when needed. Testosterone is implicated with libido; however, it is not approved by the Food and Drug Administration (FDA) in the United States. The testosterone patch Intrinsa [Proctor and Gamble], used in Europe, is widely accepted and used. Lower physiological doses are rarely associated with adverse effects, but there are still some concerns about long-term safety with respect to cardiovascular disease and breast cancer

Medscape: What agents, either newly available or in the pipeline, appear to be most promising?

Dr. Krychman: There are many new drugs on the horizon, although none will be the female version of Viagra. Flibanserin [Boerhinger Ingelheim], currently in stage 3 clincial trials, is definitely in the forefront of everyone's mind concerning the treatment of female sexual-desire issues.

There are new data forthcoming from greater numbers of women concerning Zestra [Zestra Laboratories Inc], a feminine arousal fluid that is topically applied. Alista cream [Vivus Inc], another topical agent, is also being studied. LibiGel [BioSante Pharmaceuticals], a topically applied testosterone product, is in clinical trials, and [researchers] are studying concerns regarding cardiovascular and breast diseases.

Even existing companies such as Wyeth, which does a lot of development concerning women's health and hormonal therapy, are reassessing their products and looking at sexual function. Results should be forthcoming shortly. It's an exciting time, with a lot of energy and focus on women's sexual healthcare concerns.

Medscape: What data presented at NPWH most captured your attention regarding recent advances in sexual medicine, and how are these findings likely to affect management? 

Dr. Krychman: Various data were presented concerning the issues I've mentioned. Other topics for discussion included HPV and the link to oral cancer, and obsessive love and sexual addiction, which are both on the rise!

Medscape: How has the epidemiology of oropharyngeal cancer changed with respect to HPV infection?

Dr. Kellogg-Spadt: Overall, rates of non-HPV-related head and neck cancer, which is historically most prevalent in men older than 60 years, have been declining over the past 20 years because of lifestyle changes, decreased smoking, and alcohol consumption.

According to recent articles in the New England Journal of Medicine (2007;356:1944-1956) and Cancer (2007;110:1429-1435), rates of HPV-positive (most often HPV16) oropharyngeal cancers have risen dramatically, from an estimated 23% of head and neck cancer in 1970 to approximately 72% in 2005. Changes in sexual practices, including an increase in unprotected oral–genital pleasuring among teens and young adults, is thought to be associated with this rise. Currently, men 30 to 40 years old are most likely to be diagnosed — 3 times more likely than women — with head and neck cancer.

Medscape: What role should the nurse practitioner play in screening for and managing HPV?

Dr. Kellogg-Spadt: Currently, there is no standard screening for oral HPV, other than visual inspection, which is done at most dental visits and some general practice visits, and there is no FDA-approved treatment for the eradication of HPV of the oropharyngeal tract if no cancer is identified. There are 12,000 to 15,000 new cases of HPV-related head and neck cancer each year, accounting for approximately 3000 deaths. This is very similar to HPV-related cervical cancer, with 11,000 new cases each year and 4000 deaths.

Being HPV16-positive also carries risks for penile and anal cancer in men.Gardasil [Merck & Co.] vaccine is only approved for women 9 to 26 years. The take-home messages are that oral sex is not risk-free behavior, and that healthcare practitioners should educate patients and their partners about safer sex practices and should examine patients at routine visits for oropharyngeal lesions. We should also encourage pharmaceutical studies that will produce the necessary data to glean FDA approval to extend HPV vaccination to boys and men.

Medscape: Describe the phenomenon of sexsomnia. How is it diagnosed, what are the risk factors and associated morbidities, and how is it managed?

Dr. Kellogg-Spadt: The first comprehensive literature review of sleep-related disorders, including those associated with sexual behavior, was published in the June 1, 2007, issue of Sleep (2007;30:683-702). Sexsomnia is a unique form of sleep-related behavior in which a person engages in sexual behavior while sleeping, usually with no recollection upon wakening. Of 31 published case reports of sleep sex, 48% included sleeptalking and moaning; 19.4% included groping, fondling, and attempts at intercourse with a partner; and 29% involved no behaviors other than pelvic movements by the sleeper.

The reaction of the sleeper with sexsomnia is often bewilderment, embarrassment, shame, and denial. The response of the partner is often shock, alarm, annoyance, and emotional distancing. These relationship conflicts are often best handled with skilled marriage and family therapy. Patients are not likely to report this to a medical provider, owing to embarrassment and bewilderment, but will often answer truthfully when asked about it.

The condition is highly responsive to treatment with clonazepam at bedtime. Patients with a history of other sleep disorders, such as sleepwalking and sleeptalking, should be screened. There are 8 documented cases where sexsomnia has been used as a legal defense in cases of sexual misconduct involving adults: 2 involving an adult with another adult have been acquitted; and the remaining 6, involving behaviors between an adult and a minor, are pending.

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