Gynecologic changes related to a woman's reproductive life (e.g., puberty, pregnancy, the postpartum period and menopause) present unique problems and potential obstacles to sexuality. Puberty may lead to concerns regarding sexual identity. Pregnancy and the postpartum period are often associated with a decrease in sexual activity, desire and satisfaction, which may be prolonged with lactation.¹⁵

For patients with dyspareunia, a "monomanual" examination is appropriate, with the physician inserting one or two fingers into the vagina and the other hand held away from the abdomen so as not to confuse the source of discomfort.

The hypoestrogenic state of menopause may cause significant physical changes^16,17 (Table 4)¹⁷ and alterations in mood or a diminished sense of well-being, which have been found to have a significant, negative impact on sexuality.¹⁸ A decline in desire, arousal and frequency of intercourse and an increase in dyspareunia have been associated with menopause,^19-21 although these findings are not universal.¹⁸

The final goal is to elicit psychosocial information. Previous experiences and current intra- and interpersonal factors should be explored (Table 5).

Physical Examination
Each patient should undergo a thorough examination, with the gynecologic examination individually guided by and tailored to patient comfort. The goal of the examination is detection of disease; however, the examination also provides an opportunity to educate the patient about normal anatomy and sexual function, and to reproduce and localize pain encountered during sexual activity.

TABLE 4 Physiologic Changes of Menopause Skin Decreased activity of sweat and sebaceous glands, decreased tactile stimulation Breasts Decreased fat content, decreased breast swelling and nipple erectile response with sexual arousal Vagina Shortening and loss of elasticity of vaginal barrel, diminished physiologic secretions, rise in vaginal pH from 3.5 to 4.5 to greater than 5, thinning of epithelial layers Internal reproductive organs Ovaries and fallopian tubes diminish in size, ovarian follicles undergo atresia, ovarian stroma becomes fibrotic, uterine body weight decreases 30 to 50 percent, cervix atrophies and decreases mucous production Bladder Urethra and bladder trigone atrophy Reproduced with permission from Phillips NA, Rosen RC. Menopause and sexuality. In: Lobo RA, ed. Treatment of the postmenopausal woman. 2d ed. Phildelphia: Lippincott Williams and Wilkins, 1999:437-43.

TABLE 5 Psychosocial Factors of Female Sexual Dysfunction Intrapersonal conflicts Religious taboos, social restrictions, sexual identity conflicts, guilt (i.e., widow with new partner) Historical factors Past or current abuse (sexual, verbal, physical), rape, sexual inexperience Interpersonal conflicts Relationship conflicts; extra-marital affairs; current physical, verbal or sexual abuse; sexual libido; desire or practices different from partner; poor sexual communication Life stressors Financial, family or job problems, family illness or death, depression

A routine examination seeks signs of general medical conditions. The gynecologic examination is comprehensive (Table 3),⁸ beginning with inspection of the external genitalia, including a cotton swab test if indicated (gently touching the vestibule of the vagina with a cotton swab will elicit moderate to severe pain in patients with vulvar vestibulitis). For patients with dyspareunia, a "mono-manual" examination should follow, with one or two fingers in the vagina (proceeding from posterior to anterior), and the other hand held away from the abdomen so as not to confuse the source of discomfort (Table 3).⁸ Bimanual and rectovaginal examinations are then performed. The timing of the speculum examination is guided by patient symptoms. In patients with deep dyspareunia, the speculum examination should follow the bimanual examination because localization of pain is crucial in these patients. In patients in whom vaginitis, cervical cancer or a sexually transmitted disease is suspected, cultures and vaginal samples should be obtained first.

Laboratory testing should be guided by patient symptoms and examination findings. No specific tests are universally recommended for patients with sexual dysfunction. Attention to routine screening tests must not be overlooked.

General Treatment Guidelines

Following the patient history and physical examination, a suspected etiology may be treated.

If no etiology is discovered, basic treatment strategies are applied (Table 6). The patient's (and partner's) personal tastes and comfort must be considered. Physicians should respect a patient's choice to decline treatment, because studies show that sexual activity is not correlated with overall sexual satisfaction or intimacy in all persons.^18,22 In general, treatments are similar despite sexual orientations.

TABLE 6 Basic Treatment Strategies for Female Sexual Dysfunction Provide education Provide information and education (e.g., about normal anatomy, sexual function, normal changes of aging, pregnancy, menopause). Provide booklets, encourage reading; discuss sexual issues when a medical condition is diagnosed, a new medication is started, and during pre- and postoperative periods; give permission for sexual experimentation. Enhance stimulation and eliminate routine Encourage use of erotic materials (videos, books); suggest masturbation to maximize familiarity with pleasurable sensations; encourage communication during sexual activity; recommend use of vibrators*; discuss varying positions, times of day or places; suggest making a "date" for sexual activity. Provide distraction techniques** Encourage erotic or nonerotic fantasy; recommend pelvic muscle contraction and relaxation (similar to Kegel exercise) exercises with intercourse; recommend use of background music, videos or television. Encourage noncoital behaviors*** Recommend sensual massage, sensate-focus exercises (sensual massage with no involvement of sexual areas, where one partner provides the massage and the receiving partner provides feedback as to what feels good; aimed to promote comfort and communication between partners); oral or noncoital stimulation, with or without orgasm. Minimize dyspareunia Superficial: female astride for control of penetration, topical lidocaine, warm baths before intercourse, biofeedback. Vaginal: same as for superficial dyspareunia but with the addition of lubricants. Deep: position changes so that force is away from pain and deep thrusts are minimized, nonsteroidal anti-inflammatory drugs before intercourse. NOTE: For a review, see Striar S, Bartlik B. Stimulation of the libido: the use of erotica in sex therapy. Psych Annals 1999;29:60-2. *--Provide information for obtaining one discreetly. **--Helpful in eliminating anxiety, increasing relaxation and diminishing spectatoring. ***--Also helpful if partner has erectile dysfunction.

Disorders of Desire
Women with disorders of desire are difficult to treat. Occasionally, decreased desire in patients is secondary to boredom with sexual routines. Suggesting changes in positions or venues, or the addition of erotic materials is helpful.

Disorders of desire in premenopausal patients may be secondary to lifestyle factors (e.g., careers, children), medications or another sexual dysfunction (e.g., pain or orgasmic disorder). No medical treatment is available specific to patients with disorders of desire. If no underlying medical or hormonal etiology is discovered, individual or couple counseling may be helpful.

Estrogen replacement therapy has been shown to correlate positively with sexual activity, enjoyment and desire, although the findings are not universal.

In peri- and postmenopausal women, the relationship between hormones and sexuality is unclear.^18-21 Nonetheless, estrogen replacement therapy has been shown to correlate positively with sexual activity, enjoyment and fantasies--the latter thought to represent desire.^23,24 The mechanism of estrogen's effect on desire is indirect and occurs through improvement in urogenital atrophy, vasomotor symptoms and menopausal mood disorders (i.e., depression). This relationship helps predict which patients are likely to respond to estrogen replacement therapy (i.e., those with symptoms of hypoestrogenism) and may explain why some studies do not show estrogen-mediated improvement in sexual functioning.²⁵

The role of progesterone therapy, which is necessary in estrogen-treated patients with an intact uterus, has not been widely studied in terms of sexuality, but one study²⁴ suggests that it exhibits a negative impact by dampening mood and decreasing available androgens. The addition of estrogen for several weeks before progesterone therapy is initiated, or taking into account monthly symptom calendars, will help determine each hormone's influence and guide dosage and schedule adjustments.

TABLE 7 Testosterone Therapy for Treatment of Disorders of Desire* Screening Baseline testosterone levels** (free and total), baseline lipid profile, baseline liver enzyme levels, mammography, Papanicolaou smear Initiate therapy*** Combination product (Estratest or Estratest hs) Methyltestosterone (Android), 1.25 to 2.5 mg daily Micronized oral testosterone, 5 mg twice daily Testosterone proprionate 2 percent in petroleum applied daily to every other day Testosterone injectables/pellets Reevaluation at three to four months Repeat testosterone levels, lipid profile, liver enzyme levels Monitor symptoms, side effects Continued therapy Taper to lowest effective dosage¶ Monitor lipid levels, liver enzyme levels once or twice yearly Routine Papanicolaou smear and mammography schedules *--These are recommendations; no evidence-based protocols are available on testosterone therapy for the treatment of women with desire disorders. **--Many authors recommend that total levels remain in "normal" range for premenopausal women. ***--None of these medications are labeled by the U.S. Food and Drug Administration for treatment of desire disorders. ¶--Alternate daily combined with estrogen-only pill, take testosterone pill every other day, 5 days a week, etc. (not shown in studies to be safer or have fewer side effects).

Testosterone appears to have a direct role in sexual desire.²⁰ However, because studies evaluate mostly testosterone-deficient, oophorectomized women or women who develop supraphysiologic levels secondary to testosterone treatment, clinical applications are limited. No guidelines for testosterone replacement therapy for women with disorders of desire and no consensus of "normal" or "therapeutic" levels of testosterone therapy exist. Many physicians are concerned about the lack of safety data on the role of testosterone in breast cancer and on hepatic side effects; however, hepatocellular damage or carcinoma is rare at prescribed dosages,²⁶ and the development of breast cancer has not been reported clinically.²⁷

The side effects of testosterone, which occur in 5 to 35 percent of patients, include lower levels of high-density lipoprotein, acne, hirsutism, clitorimegaly and voice deepening.²⁷ However, these side effects on lipoprotein levels are rarely significant if estrogen and testosterone are coadministered; moreover, most other side effects are reversible with discontinuation of testosterone or a dosage adjustment.²⁶

A role for testosterone treatment exists in selected patients (Table 7). Coadministration with estrogen therapy should be provided to prevent deleterious effects on lipoprotein levels. Before initiating testosterone treatment, physicians should discuss the potential and theoretic risks, and individual risk and benefit assessments with the patient. In general, patients with current or previous breast cancer, uncontrolled hyperlipidemia, liver disease, acne or hirsutism should not receive testosterone therapy.

Arousal Disorders
Current treatment of patients with arousal disorders is limited to the use of commercial lubricants, although vitamin E and mineral oils are also options. Arousal disorders may be secondary to inadequate stimulation, especially in older women who require more stimulation to reach a level of arousal that was more easily attained at a younger age. Encouraging adequate foreplay or the use of vibrators to increase stimulation may be helpful. Taking a warm bath before intercourse may also increase arousal. Anxiety may inhibit arousal, and strategies to alleviate anxiety by employing distraction techniques are helpful.

Urogenital atrophy is the most common cause of arousal disorders in postmenopausal women, and estrogen replacement, when appropriate, is usually effective therapy. However, women taking systemic estrogens occasionally require supplementation with local therapy. Long-term use of estrogen-containing vaginal creams is considered an unopposed-estrogen treatment in women with an intact uterus, requiring progesterone opposition. An oral progesterone such as medroxyprogesterone 5 mg daily for 10 days every one to three months (or equivalent) may be used initially, with frequency or dosage increased if withdrawal bleeding occurs. Estring (an estradiol-containing vaginal ring) has little systemic absorption and does not require the addition of progesterone. Patients who are uncomfortable wearing the ring during the day often achieve relief with night use only.

Premenopausal women with arousal disorders, women who do not respond to estrogen therapy and women who are unable or unwilling to take estrogen represent difficult patient groups because few treatment options are available.

TABLE 8 Kegel Exercises Potential uses Increased pubococcygeal tone Improved orgasmic intensity Correction of orgasmic urine leakage Distraction technique during intercourse Improved patient awareness of sexual response Teaching Kegel exercises Instructional examination with examiner's finger in vagina Initial patient home exercise with patient's finger in vagina Slow count to 10, with movement directed "in and up" Hold for count of 3 Slow release to count of 10 Repeat 10 to 15 times daily Consider vaginal weights, biofeedback clinics Maintaining Kegel exercises Advise repetitions during routine activities (standing in line, at stop lights, etc.) Schedule follow-up appointments to discuss progress

Investigators recognize that small-vessel atherosclerotic disease of the vagina and clitoris may contribute to arousal disorders and are exploring vasoactive medications as treatment.²⁸ Small studies^29,30 have been conducted with favorable results, but larger studies are needed. Currently, treatment of arousal disorder in women who are taking these medications, including sildenafil (Viagra), is not recommended, although anecdotal success has been reported.³⁰

Orgasmic Disorders
Anorgasmia is quite responsive to therapy. This condition is caused by sexual inexperience or the lack of sufficient stimulation and is common in women who have never experienced orgasm. Orgasmic disorders may also be psychologic ("involuntary inhibition" of the orgasmic reflex) or caused by medications or chronic disease.

Treatment relies on maximizing stimulation and minimizing inhibition.³¹ Stimulation may include masturbation with prolonged stimulation (initially up to one hour) and/or the use of a vibrator as needed, and muscular control of sexual tension (alternating contraction and relaxation of the pelvic muscles during high sexual arousal). The latter is similar to Kegel exercises (Table 8). Methods to minimize inhibition include distraction by "spectatoring" (observing oneself from a third-party perspective), fantasizing or listening to music. Women who do not respond to therapy should be referred to an appropriate therapist.

Sex Pain Disorders
Dyspareunia can be divided into three types of pain: superficial, vaginal and deep (Table 6). Superficial dyspareunia occurs with attempted penetration, usually secondary to anatomic or irritative conditions, or vaginismus. Vaginal dyspareunia is pain related to friction (i.e., lubrication problems), including arousal disorders. Deep dyspareunia is pain related to thrusting, often associated with pelvic disease or relaxation.⁷

Treatment of orgasmic disorders relies on maximizing stimulation and minimizing inhibition.

Diagnosis of an underlying etiology should be aggressively sought, even if surgical investigation (laparoscopy) is required. The physical examination must include meticulous detail, with the physician's focus on recreating the pain. Treatment of the underlying etiology is fundamental, but as in long-term pain disorders, counseling and pain control strategies are essential. General recommendations for improved sexual function are discussed in Table 6 and are similar despite sexual orientation.

TABLE 9 Female Sexual Dysfunction: When to Refer Longstanding dysfunction Multiple dysfunctions Current or past abuse Psychologic disorder or acute psychologic event Unknown etiology No response to therapy

Vaginismus, the involuntary contraction of the muscles of the outer one third of the vagina, is often related to sexual phobias or past abuse or trauma.^10,32 Vaginismus may be complete or situational, so that a pelvic examination might be possible while intercourse is not. Therapy for and counseling of women with vaginismus can be initiated and often successfully completed by primary care physicians.

Treatment of women with vaginismus consists of progressive muscle relaxation and vaginal dilatation (actually a misnomer because the vagina is not physically stretched). Progressive muscle relaxation can be taught during an instructional examination by having the patient alternate contracting and relaxing the pelvic muscles around the examiner's finger. Women with vaginismus can achieve vaginal dilatation with the use of commercial dilators or tampons of increasing diameter, placed into the vagina for 15 minutes twice daily. Once the patient can easily accept an equivalent-sized dilator into the vagina, penile penetration by the partner can occur. Success rates approach 90 percent.^31,32 Patients who do not respond to this therapy should be referred to a sex therapist who specializes in the treatment of women with this disorder (Table 9).

The Author

NANCY A. PHILLIPS, M.D.,