Female Sexual Dysfunction:

 Evaluation and Treatment

Sexual dysfunction includes desire, arousal, orgasmic and sex pain disorders (dyspareunia and vaginismus). Primary care physicians must assume a proactive role in the diagnosis and treatment of these disorders. Long-term medical diseases, minor ailments, medications and psychosocial difficulties, including prior physical or sexual abuse, are etiologic factors. Gynecologic maladies and cancers (including breast cancer) are also frequent sources of sexual dysfunction. Patient education and reassurance, with early diagnosis and intervention, are essential for effective treatment. Patient history and physical examination techniques, normal sexual responses and the factors that influence these responses, and the application of medical and gynecologic treatments to sexual issues are discussed. Basic treatment strategies, which may be successfully provided by primary care physicians for most sexual dysfunctions, are outlined. Referral can be reserved for patients who do not respond to therapy. (Am Fam Physician 2000;62:127-36,141-2.)

Sexuality is a complex process, coordinated by the neurological, vascular and endocrine systems.¹

Individually, sexuality incorporates family, societal and religious beliefs, and is altered with aging, health status and personal experience. In addition, sexual activity incorporates interpersonal relationships, each partner bringing unique attitudes, needs and responses into the coupling. A breakdown in any of these areas may lead to sexual dysfunction.

Primary care physicians, skilled in the treatment of medical and psychological disorders, often feel unqualified to treat patients with sexual dysfunction. However, with an understanding of sexual functioning and application of general medical and gynecologic treatments to sexual issues, sexual dysfunction may be effectively approached with the same skills. The latter includes obtaining a complete patient history, conducting a physical examination, application of basic treatment strategies, providing patient education and reassurance, and recommending appropriate referral when indicated.

Diagnosis

Female sexual dysfunction can be subdivided into desire, arousal, orgasmic and sexual pain disorders. Sexual pain disorders include dyspareunia and vaginismus.²

Estimates of the number of women who have sexual dysfunction range from 19 to 50 percent in "normal" outpatient populations^3-6 and increase to 68 to 75 percent when sexual dissatisfaction or problems (not dysfunctional in nature) are included.^5,7 Yet, one review of physicians' chart notes revealed a recorded sexual problem in only 2 percent.⁵ In another review, physician inquiry of patients in a gynecologic office setting about sexual problems increased reported complaints about sexual dysfunction sixfold.³ This discrepancy demonstrates a need for physician education in this area.

FIGURE 1.Cycle of sexual dysfunction. Example showing how a patient can enter the cycle of sexual dysfunction in one area (i.e., decreased orgasm) and proceed to another area (i.e., decreased desire) so that the presenting complaint may not represent the problem that actually requires evaluation and treatment. Adapted with permission from Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res 1998;10(suppl 2):S117-20.

The diagnosis of female sexual dysfunction requires the physician to obtain a detailed patient history that defines the dysfunction, identifies causative or confounding medical or gynecologic conditions, and elicits psychosocial information.⁸ Preappointment questionnaires or appointments at which only the history is taken allow patient-physician communication to be unhindered by time constraints or patient fears of an upcoming physical examination.

Establishment of the patient's sexual orientation is necessary for appropriate evaluation and management. Nonjudgmental, direct questions best achieve this goal. Because gender identity conflicts are often a cause of sexual dysfunction, the mode and type of questions asked by physicians should create an environment where patients may openly express their concerns. Specialized counseling is important for these patients.

The sexual dysfunction should be defined in terms of onset and duration and situational versus global effect. A situational dysfunction occurs with a specific partner, in a certain setting or in a definable circumstance.

The presence of more than one dysfunction should be ascertained, because considerable interdependence may exist. For example, a patient complaining about decreased desire might have a primary orgasmic disorder from insufficient stimulation, with decreased desire developing secondarily as a result of unsatisfying sexual encounters (Figure 1).⁸ Thus, treating the orgasmic disorder would indirectly enhance desire; whereas, treating a desire disorder would be unsuccessful and perhaps add to patient frustration and perpetuate the cycle of dysfunction.

Questioning the patient about what she thinks is causing the problem may add insight. She may reveal fear of redeveloping an abnormal Papanicolaou smear from penile penetration, or she may admit that she is not attracted to her partner. Obtaining this information early in the evaluation process will expedite diagnosis and initiation of treatment.

Medical conditions are a frequent source of direct or indirect sexual difficulties. Vascular disease associated with diabetes might preclude adequate arousal; cardiovascular disease may inhibit intercourse secondary to dyspnea (Table 1).¹ Arthritis or urinary incontinence may cause discomfort or embarrassment, leading to dysfunction or decreased sexual activity.² Aggressive treatment of long-term disease and minor ailments, with attention to their sexual implications, will help enhance sexuality.

Prescription and over-the-counter medications, illicit drugs and alcohol abuse contribute to sexual dysfunction^9,10 (Table 2).¹⁰ Medication changes, drug discontinuation, or dosage or schedule alterations may provide relief. Cigarette smoking, known to cause erectile dysfunction in men, may have a similar negative effect on arousal in women.

Gynecologic conditions contribute physically to sexual difficulties (Table 3),⁸ and treatment must address both of these issues. For example, treatment of a patient with recurrent cystitis as a cause of dyspareunia should include the use of lubricants and distraction techniques at first intercourse to assure adequate lubrication and relaxation, respectively. These steps help resolve any secondary difficulties that may have developed (e.g., an arousal disorder or mild vaginismus). For patients with a female partner, details concerning sexual habits and objects of penetration, if any, are necessary. In these instances, hygienic use of vibrators may result in fewer episodes of cystitis.

Hysterectomy, gynecologic malignancies and breast cancer present medical and mortality concerns, and alter or remove physical and psychologic symbols of femininity that may result in feelings of decreased sexuality. In one study,¹¹ 74 percent of patients who underwent surgery for gynecologic malignancy reported decreased desire, and 40 percent reported dyspareunia. In another study¹² of patients who had undergone hysterectomy for benign disease, a decrease in sexual responsiveness of up to 30 percent was noted. Breast cancer survivors report a 21 to 39 percent incidence of sexual dysfunction,¹³ although a recent study¹⁴ suggests that this may be related to chemotherapy or hypoestrogenism secondary to ovarian failure. Preoperative counseling, including explanations of postoperative anatomy and potential effects on sexuality, is essential in these patient populations. Continued postoperative counseling and early recognition and treatment of sexual difficulties may also help these patients maintain satisfying sexual relationships.

TABLE 2 Medications and Female Sexual Dysfunction Medications that cause disorders of desire Psychoactive medications Antipsychotics Barbiturates Benzodiazepines Selective serotonin reuptake inhibitors Lithium Tricyclic antidepressants Cardiovascular and antihypertensive medications Antilipid medications Beta blockers Clonidine (Catapres) Digoxin Spironolactone (Aldactone) Hormonal preparations Danazol (Danocrine) GnRh agonists (e.g., Lupron, Synarel) Oral contraceptives Other Histamine H2-receptor blockers and promotility agents Indomethacin (Indocin) Ketoconazole (Nizoral) Phenytoin sodium (Dilantin) Medications that cause disorders of arousal Anticholinergics Antihistamines Antihypertensives Psychoactive medications Benzodiazepines Selective serotonin reuptake inhibitors Monoamine oxidase inhibitors Tricyclic antidepressants Medications that cause orgasmic dysfunction Methyldopa (Aldomet) Amphetamines and related anorexic drugs Antipsychotics Benzodiazepines Selective serotonin reuptake inhibitors Narcotics Trazadone (Desyrel) Tricyclic antidepressants* *--Also associated with painful orgasm Adapted with permission from Drugs that cause sexual dysfunction: an update. Med Lett Drugs Ther 1992;34:73-8.

TABLE 3 Gynecologic Causes of Female Sexual Dysfunction and Method of Gynecologic Examination Examination Condition External genitalia Assess muscle tone Vaginismus Assess skin color and texture Vulvar dystrophy, dermatitis Assess skin turgor and thickness Atrophy Assess pubic hair amount and distribution Atrophy Expose clitoris Clitoral adhesions Assess for ulcers Herpes simplex virus Perform cotton swab test of vestibule Vulvar vestibulitis Palpate Bartholin glands Bartholinitis Assess posterior forchette and hymenal ring Episiotomy scars, strictures Monomanual Palpate rectovaginal surface Rectal disease Palpate levator ani Levator ani myalgia, vaginismus Palpate bladder/urethra Urethritis, interstitial cystitis, urinary tract infection Assess for cervical motion tenderness Infection, peritonitis Assess vaginal depth Postoperative changes, postradiation changes, stricture Bimanual Palpate uterus Retrogression, fibroids, endometritis Palpate adnexa Masses, cysts, endometriosis, tenderness Perform rectovaginal examination Rule out endometriosis Obtain guaiac test Bowel disease Speculum Evaluate discharge, pH Vaginitis, atrophy Evaluate vaginal mucosa Atrophy Perform Papanicolaou smear Human papillomavirus infection, cancer Assess for prolapse Cystocele, rectocele, uterine prolapse Adapted with permission from Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res 1998;(suppl 2):S117-20.

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