Sexual dysfunction in women: Can we talk about it?
ABSTRACT
Sexual dysfunction in women is common and often goes unreported and untreated. Its management is part of patient-centered primary care. Primary care providers are uniquely positioned to identify and assess sexual health concerns of their patients, provide reassurance regarding normal sexual function, and treat sexual dysfunction or refer as appropriate.
KEY POINTS
- Sexual dysfunction in women is complex and often multifactorial and has a significant impact on quality of life.
- Primary care providers can assess the problem, provide education on sexual health and normal sexual functioning, and manage biological factors affecting sexual function, including genitourinary syndrome of menopause in postmenopausal women and antidepressant-induced sexual dysfunction.
- Treatment may require a multidisciplinary team, including a psychologist or sex therapist to manage the psychological, sociocultural, and relational factors affecting a woman’s sexual health, and a physical therapist to manage pelvic floor disorders.
PHYSICAL EXAMINATION
Perform a focused physical examination to evaluate for potential causes of pain (eg, infectious causes, vulvar dermatoses, pelvic floor muscle dysfunction). The examination is also an opportunity to teach the patient about anatomy and normal sexual function.
No standard laboratory tests or imaging studies are required for the assessment of sexual dysfunction.28
IT’S NOT JUST PHYSICAL
Evaluation and treatment of female sexual dysfunction is guided by the biopsychosocial model, with potential influences from the biological, psychological, sociocultural, and interpersonal realms (Table 3).29,30
Biological factors include pelvic surgery, cancer and its treatment, neurologic diseases, and vascular diseases. Medications, including antidepressants, narcotics, anticholinergics, antihistamines, antihypertensives, oral contraceptives, and antiestrogens may also adversely affect sexual response.26
Psychological factors include a history of sexual abuse or trauma, body image concerns, distraction, stress, anxiety, depression, and personality disorders.22
Sociocultural factors include lack of sex education, unrealistic expectations, cultural norms, and religious influences.
Relationship factors include conflict with one’s partner, lack of emotional intimacy, absence of a partner, and partner sexual dysfunction. While there appears to be a close link between sexual satisfaction and a woman’s relationship with her partner in correlational studies and in clinical experience, there has been little research about relationship factors and their contribution to desire and arousal concerns.31 Sexual dysfunction in one’s partner (eg, erectile dysfunction) has been shown to negatively affect the female partner’s sexual desire.32
GENERAL APPROACH TO TREATMENT
In treating sexual health problems in women, we address contributing factors identified during the initial assessment.
A multidisciplinary approach
As sexual dysfunction in women is often multifactorial, management of the problem is well suited to a multidisciplinary approach. The team of providers may include:
- A medical provider (primary care provider, gynecologist, or sexual health specialist) to coordinate care and manage biological factors contributing to sexual dysfunction
- A physical therapist with expertise in treating pelvic floor disorders
- A psychologist to address psychological, relational, and sociocultural contributors to sexual dysfunction
- A sex therapist (womenshealthapta.org, aasect.org) to facilitate treatment of tight, tender pelvic floor muscles through education and guidance about kinesthetic awareness, muscle relaxation, and dilator therapy.33
Even in the initial visit, the primary care provider can educate, reassure regarding normal sexual function, and treat conditions such as genitourinary syndrome of menopause and antidepressant-associated sexual dysfunction. The PLISSIT model (Permission, Limited Information, Specific Suggestions, and Intensive Therapy) is a useful tool for initiating counseling about sexual health (Table 4).34
AGING VS MENOPAUSE
Aging can affect sexual function in both men and women. About 40% of women experience changes in sexual function around the menopausal transition, with common complaints being loss of sexual responsiveness and desire, sexual pain, decreased sexual activity, and partner sexual dysfunction.35 However, studies seem to show that while menopause results in hormonal changes that affect sexual function, other factors may have a greater impact.
The Study of Women’s Health Across the Nation36 found vaginal and pelvic pain and decreased sexual desire were associated with the menopausal transition, but other sexual health outcomes (frequency of sexual activities, arousal, importance of sex, emotional satisfaction, or physical pleasure) were not. Physical and psychological health, marital status, and a change in relationship were all associated with differences in sexual health.
The Massachusetts Women’s Health Study II37 found a greater association between physical and mental health, relationship status, and smoking and women’s sexual functioning than menopausal status.
The Penn Ovarian Aging Study38 found that sexual function declined across the menopausal transition. Risk factors for sexual dysfunction included postmenopausal status, anxiety, and absence of a sexual partner.
The Melbourne Women’s Midlife Health Project39 also found that sexual function declined across the menopausal transition. Sexual dysfunction with distress was associated with relationship factors and depression.37
Genitourinary syndrome of menopause and its treatment
As the ovaries shut down during menopause, estradiol levels decrease. Nearly 50% of women experience symptoms related to genitourinary syndrome of menopause (formerly called atrophic vaginitis or vulvovaginal atrophy).40,41 These symptoms include vaginal dryness and discomfort or pain with sexual activity, but menopausal hormone loss can also result in reduced genital blood flow, decreased sensory perception, and decreased sexual responsiveness.22
Estrogen is the most effective treatment for genitourinary syndrome of menopause, with low-dose vaginal preparations preferred over systemic ones for isolated vulvar and vaginal symptoms.40 While estrogen is effective for vaginal dryness and sexual pain associated with estrogen loss, replacing estrogen systemically has not been associated with improvements in sexual desire.42
