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Feminine issues
women problems

May 15, 2020

Female Sexual Dysfunction:

Evaluation and Treatment

Part-2return to page-1 of sexual disorders

Wellington School of Medicine, University of Otago, Wellington, New Zealand

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 changes16,17 (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.

Physiologic Changes of Menopause
Decreased activity of sweat and sebaceous glands, decreased tactile stimulation
Decreased fat content, decreased breast swelling and nipple erectile response with sexual arousal
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.
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
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