Dr Catherine Stone (2015) outlines treatment methods for improving orgasm in women, and details the use of PRP for effective outcomes in a range of gynaecologic indications.
Introduction
A healthy sex life is thought to have significant benefits to both the mind and body. Sexual dysfunction such as anorgasma, dysparenuria, decreased libido and vaginal dryness, along with urinary stress incontinence (USI), can occur after childbirth or during menopause and may be prevalent in up to 43% of women.1 Sexual dysfunction in both men and women can result in a reduction in sexual intimacy in a relationship, which may then negatively affect family life and self-esteem.2 While there are many treatments available for erectile dysfunction in men, there are currently no Food and Drugs Administration (FDA) approved treatments for sexual dysfunction in women.
Current methods for improving sexual dysfunction
A variety of different substances have been injected into the peri-urethral area to help treat both USI and female sexual dysfunction. Calcium hydroxyapatite crystals are FDA approved for peri-urethral injection to treat USI, however issues such as urinary obstruction, erosion, infection and granuloma formation requiring surgical removal can occur,3,4 and no studies show improvement in sexual function – unsurprisingly, as they are not intended for this use. Hyaluronic acid (HA) fillers have been injected into the Grafenberg Spot (often referred to as the G-spot) on the anterior vaginal wall to enhance a woman’s orgasmic intensity.5 While a pilot study on the treatment found that 87% of women reported enhanced sexual arousal or gratification,5 the American College of Obstetricians and Gynecologists published a paper in 2007 condemning this kind of treatment, which was reaffirmed in 2014.6 The paper argued that there was no valid reason to perform the procedure, and highlighted that it had not been proven to be safe or effective through randomised controlled studies. In addition, they noted that women should be informed of the lack of data supporting the efficacy of the procedures and their potential complications.6
Other off-label treatments for female sexual dysfunction have included hormone treatments with vaginal estrogen creams, and transdermal testosterone patches, prescribed by a clinician specialising in this area. The testosterone dose for women should only be a small fraction of that required for men,7 and side effects can include hirsuitism, acne, virilisation and potentially increased cardiovascular risk.8 With both testosterone and estrogen treatments, there is a concern of an increased risk of breast cancer.9 Cognitive and Behavioural Therapy (CBT) is another tool for managing sexual dysfunction.10 In our clinic, we encourage our patients to see a specialist in hormone balancing and, if necessary, seek advice from a CBT practitioner. We need to keep in mind that female sexual arousal is multifactorial,11 often with psychological and emotional as well as physical factors, so there is no one ‘magic bullet’ treatment.
PRP: Background
A recent pilot study has shown that injections of Platelet-Rich Plasma (PRP) may be a safe and effective treatment for improving sexual function.12 In multiple studies, PRP has been shown to be effective and without any serious side effects in the areas of orthopedics13, sports medicine, wound care14-16, dental surgery, ophthalmology and in many cosmetic procedures.17-24
PRP is isolated from a small sample of blood (about 10-20ml) taken from the patient, and centrifuged in a specialised tube. There are many different preparations available, however at our clinic we use a patented system comprising a tube that contains a gel to separate the red cells from the platelets and plasma. Other means of preparing PRP use non-gel tubes, or an all-in-one machine that separates the PRP for you. We have found the tubes with the separating gel to be the cleanest and easiest way to isolate the appropriate levels of platelets and plasma. The resulting PRP is usually clear and straw-coloured, and can be activated with either calcium chloride or calcium gluconate to create a ‘Platelet-Rich Fibrin Matrix’ – the small amount of added calcium initiates fibrinogen cleavage and fibrin polymerisation. Once the calcium is added, you have about 10-12 minutes to inject the solution before it solidifies into a fibrin clot. This ‘scaffolding’ helps to localise the growth factors, essentially increasing the local concentration in the target tissues to help guide tissue regeneration.25,26 The gel-like consistency of the fibrin clot may also give a more sustained volume effect than with plain PRP. In our practice, we have stopped activating the PRP for cosmetic procedures as, for skin rejuvenation, it can be painful and the gel consistency is not necessary, but we continue to use calcium chloride for our sexual dysfunction procedures.
The PRP is a non-viscous fluid, which flows easily into the tissues and can be administered with a small-bore needle, increasing the comfort of the procedure. Once in the tissues, the PRP releases active growth factors which attract and activate pluripotent stem cells in the area of injection, stimulating neoangiogenesis, fibroblast growth, glandular proliferation and new neuronal growth, resulting in rejuvenation and even enhancement of damaged or undamaged tissue.27 PRP is completely autologous, so as yet there are no known contraindications to the treatment. There have been no reports of granuloma, infection, or any other serious side effects with PRP in the medical literature documenting its use – at least when FDA-approved preparation kits are used – although it is imperative that PRP is prepared in properly-sterilised tubes.
Using PRP for gynaecologic concerns
Anecdotal evidence from patients suggest this procedure can be helpful for:28
USI
Reduced sensation
Decreased arousal
Anorgasmia
Vaginal dryness
Reduced sexual desire
Dyspareunia
Lichen sclerosis
Fissures post episiotomy
Before starting a PRP gynaecologic procedure, a strong topical anaesthetic cream is applied to the anterior vaginal wall and the clitoris after retracting the clitoral hood. Almost complete anaesthesia can be achieved if you leave the cream on for 20 minutes while arranging and preparing the PRP, and we aim for an almost painless treatment. PRP is then injected into two very specific sites: one on the anterior vaginal wall and the second in the clitoris. (See Figure 1 for external vaginal anatomy). With the gel-separating PRP kit that we use, generally around 5-6ml of PRP can be isolated from a 10ml blood collection. The first injection is peri-urethral and I have found that this can have an immediate impact on USI due to the volume effect of the PRP – injecting the fluid between the vaginal wall and the urethra changes the vesico-urethral angle in the same way a surgical sling does. By increasing blood flow and cellular regeneration in this area, it is also designed to improve the function of the Skene’s glands, which are the female tissue equivalent of the prostate in men, and play a significant role in female ejaculation. This first injection is usually completely painless. The second injection goes into the proximal corpus cavernosum of the clitoris, with the PRP spreading distally into the hidden part of the clitoris – the glans of the clitoris, or the visible part, is only the tip of the iceberg. (Figure 2) The clitoris is usually about 10cm long, with about 8,000 nerve endings and two corpus cavernosa which surround the urethra and extend into the pelvic area, including the vaginal walls. This may explain the ‘tightening’ of the vagina that many women experience.
Results of PRP treatment
Following the treatment, there is no downtime. The patient can resume sexual activity almost immediately after the procedure, although I recommend waiting until the effects of the local anaesthetic cream have dissipated. From my experience, there is often an immediate improvement in USI and arousal, due to the volume effect of the PRP. This may dissipate over a few days and then slowly improve again over the next three to five weeks, with full effect often achieved at around three to five months. Potential side effects may include, as with any injection, spot bleeding (we provide a sanitary pad for any spotting or discharge, and to prevent local anaesthetic cream from staining their underwear), bruising, tenderness, a warm or burning sensation in the area (this usually settles within minutes/hours), temporary localised numbness due to the local anaesthetic effects, and hypersexuality or increased arousal, especially in younger women with previously normal or close to normal sexual function. We ask all of our patients to complete two surveys – the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale – Revised (FSDS-R) before treatment, at six weeks, three months, six months and 12 months, which over time will help to build a clearer picture of the effects of PRP. The pilot study for this procedure shows a 65% success rate with one treatment, which increases to 85-90% satisfaction after two treatments.12
Conclusion
While this procedure is still in its infancy, results look very promising; we have been achieving excellent results in clinic so far. Because the PRP is autologous – using the body’s own healing system with almost no serious side effects – it seems inherently safer than other options for treating sexual dysfunction. I always tell my patients that it is just one tool that can be used, and other treatment modalities may also be required or more suitable. I would suggest, though, that this procedure needs more definitive research, which is currently underway with Dr Charles Runels, the founder of these specific procedures. With so few options available to women with sexual dysfunction, it’s good to know we can o er something simple, safe, quick and almost painless that can help them in what is usually a private and personal struggle, which impacts on both family life and relationships.