Female Sexual Dysfunction
Nancy Pesta Walsh
Definition
A.Any persistent problem with desire, sexual response, or function, which may affect the patient and her relationship and occurs for at least 6 months. It is classified into subtypes:
1.Desire disorder: Lack of interest or desire (most common).
2.Arousal disorder: Inability to become aroused during sexual activity; absent or reduced genital sensations.
3.Orgasm disorder: Delay, absence, or decreased intensity of orgasm:
a.Primary: The patient has never had an orgasm.
b.Secondary: The patient has achieved orgasm in the past, but is unable to achieve orgasm at the time of presentation.
4.Pain disorder: Genitopelvic pain/penetration disorder (formerly dyspareunia and vaginismus). This is described as pelvic or vulvovaginal pain during vaginal penetration, anxiety, and/or fear related to the thought of vaginal penetration, or marked tightening of pelvic floor muscles (PFMs) during vaginal penetration.
Incidence
A.Affects an estimated 22% to 43% of women worldwide, and 14% of women aged 45 to 64 years. Only 12% have diagnosable disorders. This includes women who report issues with sexual desire (64%), arousal difficulty (31%), and pain (26%).
Pathogenesis
A.Multiple models exist to describe the phases of normal sexual function:
1.Masters and Johnson—consists of the stages of excitement, plateau, orgasm, and resolution.
2.Kaplan and Leif—consists of desire, excitement, and orgasm.
3.Basson—consists of emotional intimacy, sexual stimuli, psychological factors, and relationship satisfaction.
B.Sexual dysfunction includes various biological, psychological, and social components:
1.Biological factors include aging; medical conditions such as diabetes and hypertension; and declining testosterone or estrogen.
2.Psychological factors include depression or anxiety, history of sexual abuse, childhood trauma, personality disorders, body image disorders, and perceived stress.
3.Social factors include cultural or religious values, relationship issues, career issues, financial hardship, and household responsibilities.
C.Diagnosis is made based on the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5; 2013) and requires the following: Symptoms must be present for a minimum of 6 months, a woman experiences personal distress, symptoms are not a result of substance or medication use or medical conditions, and symptoms are not related to a nonsexual medical disorder.
D.Orgasm disorders can be caused by neurologic and/or vascular disease such as spinal cord injury, diabetes, or multiple sclerosis.
Predisposing Factors
A.Emotional:
1.Depression.
2.Mood disorders.
3.Poor body image.
4.Low self-esteem.
5.Fatigue.
6.Stress.
B.Poor health status:
1.Spinal cord injury.
2.Diabetes.
3.Premature ovarian failure (POF).
4.Trauma.
C.Partner relationship issues.
D.Medications that are associated with low sexual desire in women:
1.Serotonin-specific reuptake inhibitors (SSRIs).
2.Anxiolytics.
3.Antihistamines.
4.Anticholinergics.
5.Calcium channel blockers.
6.Angiotensin-converting enzyme (ACE) inhibitors.
7.Oral contraceptives.
8.Anticonvulsants.
9.Opiates.
10.Illicit drugs.
E.History of sexual abuse may contribute to low desire.
F.Advancing age: Menopausal women affected more frequently. Low sexual desire may result from decreasing hormone levels, specifically testosterone and estrogen levels. Low estrogen levels are also linked to vulvovaginal atrophy (VVA) and dyspareunia, both of which may decrease sexual desire in women.
Common Complaints
A.Women:
1.Absence of orgasm.
2.Pain during vaginal penetration.
3.Difficulty relaxing PFMs to allow vaginal penetration.
B.Both sexes:
1.Lack of interest or desire (most common).
2.Inability to become aroused.
3.Pain with intercourse.
C.Men: Common complaints for men are specifically discussed in Chapter 15 (Genitourinary Guidelines) in the sections Sexual Dysfunction, Male-Erectile Dysfunction
and Sexual Dysfunction Male, Premature Ejaculation.
Other Signs and Symptoms
A.Vaginal discharge.
B.Vulvar itching.
C.Vulvar pain, described as stinging, burning, irritation, raw sensation.
Subjective Data
A.Include full medical, gynecologic, and sexual history, using open-ended questions:
1.Assess the patient for signs of depression, anxiety, and sexual concerns.
2.Review the medication list with the patient. Specifically ask about the types of medications that may contribute to low sexual desire:
a.SSRIs.
b.Anxiolytics.
c.Antihistamines.
d.Anticholinergics.
e.Calcium channel blockers.
f.ACE inhibitors.
g.Oral contraceptives.
h.Anticonvulsants.
i.Opiates.
j.Illicit drugs.
3.Assess for medical conditions that contribute to sexual dysfunction, which may include the following:
a.Chronic diseases (cardiovascular disease, diabetes, kidney or liver failure).
b.Neurologic disorders.
c.Hormone imbalances.
d.Alcoholism.
e.Illicit drug use.
f.Evaluate for causes of pelvic pain: vaginal dryness, vaginal discharge, or vaginal infectious causes (such as sexually transmitted infections (STIs,) yeast infections, or pelvic inflammatory disease [PID]).
4.Evaluate for history of previous pelvic disorders or surgery (fibroids, endometriosis, malignancy, uterine/bladder prolapse, or episiotomy).
5.Evaluate for the degree of distress that this may cause the patient.
B.The use of self-report screening tools is recommended to identify women with low sexual desire. These tools may include the following:
1.Decreased Sexual Desire Screener: Found at www.obgynalliance.com/files/fsd/DSDS_Pocketcard.pdf
2.Brief Sexual Symptom Checklist for Women: May be downloaded from www.researchgate.net/figure/The-modified-Brief-Sexual-Symptom-Checklist-for-Women-BSSC-W_fig1_277610474
3.Female Sexual Function Index: Found at www.fsfiquestionnaire.com
Physical Examination
A.Vital signs: Check blood pressure (BP), pulse, and respirations.
B.Inspect:
1.Thyroid for presence of nodules.
2.Breasts for presence of nipple discharge if history warrants.
3.Skin for hirsutism, acne, alopecia, and truncal obesity may indicate hyperandrogenism.
C.Palpate:
1.Thyroid for presence of nodules.
2.Breasts for presence of nipple discharge if history warrants.
Pelvic Examination
A.Inspect:
1.Examine external genitalia for erythema, lesions, atrophy, or unusual discharge.
2.Inspect for vulvar dermatoses, such as lichen sclerosus or lichen planus. Lichen sclerosus may look like white skin discolorations or wrinkled patches of skin. Severe cases may have bleeding or ulcerated lesions. Lichen planus may look like purple-colored lesions or bumps with flat tops. Thin white lines or blisters may appear over the lesions.
3.Inspect for pelvic floor prolapse and PFM contraction.
B.Palpate external genitalia for presence of pain.
C.Speculum examination: Assess for atrophy (common in postmenopausal women, PFM, strength, masses, prolapse, and deep pelvic pain.
D.Bimanual examination:
1.Check for cervical motion tenderness (CMT), uterine size, and position.
2.Check adnexa for masses or tenderness.
Diagnostic Tests
A.Laboratory tests should be performed as indicated by the history and physical examination for any medical conditions that may contribute to low desire.
B.Pap smear, STI testing, wet prep.
C.Serum testing may include thyroid function tests and prolactin levels.
D.Androgen levels and testosterone levels alone are unreliable, unless you suspect a hyperandrogenic condition, as evidenced by hirsutism, acne, alopecia, and truncal obesity.
E.Transvaginal ultrasound may be warranted if pelvic pain upon examination.
Differential Diagnoses
A.Arousal disorder.
B.Desire disorder.
C.Orgasm disorder.
D.Pain disorder.
E.Vulvar dermatoses, such as lichen planus or lichen sclerosis.
F.Vaginal atrophy.
G.Infectious issues, such as STIs, candidiasis, or bacterial vaginosis (BV).
H.Depression or anxiety.
I.Cardiovascular disease.
J.Diabetes.
K.Thyroid disorder.
L.Neurologic disorder.
M.Hormonal imbalance.
Plan
A.General interventions:
1.Set realistic goals for treatment.
2.Empower women to take an active role in treatment plan. Encourage discussion about anatomy and sexual function, allowing the women to ask questions as they are comfortable.
3.Office-based therapy may be useful for providers who wish to include this in their practice. The Permission, Limited Information, Specific Suggestion, Intensive Therapy (PLISSIT) model is one office-based counseling model detailed as follows:
a.Permission: Women are given permission for full discussion of the topic.
b.Limited information: The provider gives educational information on sexual function and sexual dysfunction in the form of handouts or videos.
c.Specific suggestion: The provider gives very specific advice tailored to each patient and her presenting issues.
d.Intensive therapy: The provider makes a referral for individual or couples therapy.
B.Patient teaching:
1.Educate about normal anatomical and sexual functions.
2.Encourage healthy lifestyle behaviors of diet, exercise, avoiding tobacco, and minimizing stress.
3.Educate patients about the use of vaginal lubricants to assist with vaginal dryness or dyspareunia. KY Jelly or Astroglide: Dose as needed with intercourse.
C.Pharmaceutical therapy is considered when nonpharmacological interventions are not successful:
1.Vaginal estrogen for the treatment of vaginal atrophy:
a.Vagifem: 10 mcg, one tablet in vagina nightly for 2 weeks, then twice a week for maintenance.
b.Estring: One ring, placed intravaginally every 3 months.
c.Premarin: 0.625 mg/g: Insert 0.5 g/d for 21 days on, 7 days off. May adjust dose based upon patient response.
d.Estrace: 100 mcg/g: Insert 2 to 4 g in vagina nightly for 2 weeks, then gradually taper to half the initial dose for 1 to 2 weeks, then a maintenance dose of 1 g one to three times a week for maintenance. Taper or discontinue at 3- to 6-month intervals.
2.Ospemifene: