(285) A CASE REPORT OF MULTIMODAL APPROACH TO PGAD IN A 47 YEAR OLD WOMAN WITH ANXIETY, OBESITY AND PERIMENOPAUSE
Authors: Rahman S , Zusman GL 
Published: December 2024

Abstract

Introduction
Persistent Genital Arousal Disorder (PGAD) is characterized by spontaneous, persistent genital arousal without any sexual desire or stimulation, leading to significant distress and disruption in daily life. A process of care strategy has been developed to diagnose and treat PGAD effectively. This strategy guides clinicians to localize symptoms to one of five regions: End Organ, Pelvis/Perineum, Cauda Equina, Spinal Cord, and Brain. Clinicians can target treatments more effectively by identifying the specific region where symptoms originate. Many times, a multimodal approach is utilized, including treating underlying medical conditions such as Anxiety, Perimenopause, and Obesity and treating more than one region at a time.

Objective
This case report delves into the presentation of a 47-year-old female patient with a particularly challenging PGAD case linked to region 5 (Brain region).

Methods
A 47-year-old female with a long-standing history of Anxiety and Depression (since 2005) presented with symptoms of PGAD and Pelvic Floor Dysfunction, which seemed to correlate with a change in her anti-depressants, change in her therapist, as well as changes in her menstrual cycle with very mild vasomotor symptoms in February 2023. Since June 2023, she has developed PGAD symptoms, worsening anxiety and catastrophisation, aggravating her symptoms. Before being seen in our office, she was hospitalized for Anxiety, treated with TMS, changed her antidepressants, placed on antiseizure medications, muscle relaxers, and neuropathic medications, was treated with a bilateral pudendal nerve block (which made her symptoms worse), and pelvic floor therapy without any success. Upon our evaluation, she underwent a lumbosacral MRI, which revealed a Tarlov cyst measuring 2.3 cm in her S1-S2. She had symptoms consistent with perimenopause, including weight gain, vasomotor symptoms, musculoskeletal symptoms, and GSM-related symptoms, including provoked vestibulodynia, urinary urgency, as well as pelvic floor hypertonicity. She had a BMI of 29 and hypercholesterolemia.

Results
Based on all of her findings, region four was addressed with a transforaminal epidural nerve block (TFESI) performed. Unfortunately, this caused her to have persistent and worsening PGAD symptoms. At the same time, we had addressed her perimenopausal symptoms, which likely contributed to her worsening anxiety and cognitive distress, with an estradiol patch and oral micronized progesterone. She was started on vaginal DHEA and estradiol/testosterone gel, and pelvic floor physiotherapy with vaginal botox to address region 1, end-organ, and region 2, pelvis. She was started on semaglutide for her overweight status plus one other co-morbidity to improve her overall health. She was seen by a new psychiatrist and therapist and had her medications tweaked and discontinued, and pregabalin was started. Over time, with the above regimen, her symptoms improved. The observed improvement in PGAD symptoms following the introduction of hormonal therapy suggests a modulation of neuroendocrine pathways implicated in sexual arousal and reproductive function. Additionally, adding semaglutide may indirectly impact the neurobiological mechanisms associated with PGAD, given the interconnectedness between metabolic health and neurological functioning. These interventions likely influenced brain regions involved in hormonal regulation and metabolic function, ultimately alleviating symptoms.

Conclusions
This case underscores the treatment challenge of PGAD, particularly related to Region 5, and highlights the improvement of these symptoms with a multimodal approach, including correcting for Anxiety and perimenopausal symptoms. Additionally, the unique use of GLP-1 agonists and their possible interference with dopamine and reward pathways lead to improvement in this complex form of sexual dysfunction.

Disclosure
No.