The evaluation and management of female sexual dysfunction
Patients often fail to bring it up, and physicians may be reluctant to discuss it, but ignoring sexual dysfunction can disrupt a woman’s most intimate relationships.
PRACTICE RECOMMENDATIONS
› Obtain a detailed history and evaluate obstetric, gynecologic, sexually transmitted disease, sexual abuse, urinary and bowel complaint, and surgical history in women of all ages. B
› Consider a variety of lifestyle and pharmacologic approaches, as well as biofeedback in combination with pelvic floor physical therapy, to address your female patient’s sexual dysfunction. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Trigger point and Botox injections
Although drug therapy has its place in the management of sexual dysfunction, other modalities that involve trigger point injections or botulinum toxin injections to the PFMs may prove helpful for patients with high-tone pelvic floor dysfunction.
A prospective study investigated the role of trigger point injections in 18 women with levator ani muscle spasm with a mixture of 0.25% bupivacaine in 10 mL, 2% lidocaine in 10 mL, and 40 mg of triamcinolone in 1 mL combined and used for injection of 5 mL per trigger point.46 Three months after injections, 13 of the 18 women improved, resulting in a success rate of 72%. Trigger point injections can be applied externally or transvaginally.
OnabotulinumtoxinA (Botox) has also been tested for relief of levator ani muscle spasm. Botox is FDA approved for upper and lower limb spasticity but is not approved for pelvic floor spasticity or tension. It may reduce pressure in the PFMs and may be useful in women with high-tone pelvic floor dysfunction.47
In a prospective 6-month pilot study, 28 patients with pelvic pain who failed conservative treatment received up to 300 U Botox into the pelvic floor.11 The study, which used needle electromyography guidance and a transperineal approach, found that the dyspareunia visual analog scale improved significantly at Weeks 12 and 24. Keep in mind, however, that onabotulinumtoxinA should be reserved for patients who fail conventional treatments.47,48
Addressing psychological issues
Sex therapy is a traditional approach that aims to improve individual or couples’ sexual experiences and help reduce anxiety related to sex.42 Cognitive behavioral sex therapy includes traditional sex therapy components but puts greater emphasis on modifying thought patterns that interfere with intimacy and sex.42
Mindfulness-based cognitive-behavioral treatments have shown promise for sexual desire problems. It is an ancient eastern practice with Buddhist roots. This therapy is a nonjudgmental, present-moment awareness comprised of self-regulation of attention and accepting orientation to the present.49 Although there is little evidence from prospective studies, it may benefit women with sexual dysfunction after intervention with sex therapy and cognitive behavioral therapy.
Female sexual dysfunction is common and affects women of all ages. It can negatively impact a women’s quality of life and overall well-being. The etiology of FSD is complex, and treatments are based on the causes of the dysfunction. Difficult cases warrant referral to a specialist in sexual health and female pelvic medicine. Future prospective trials, randomized controlled trials, the use of validated questionnaires, and meta-analyses will continue to move us forward as we find better ways to understand, identify, and treat female sexual dysfunction.
CORRESPONDENCE
Melissa L. Dawson, DO, MS, Department of OB/GYN, Drexel University College of Medicine, 207 N Broad St. 4th Floor, Philadelphia, PA 19107; Melissa.Dawson.DO@gmail.com.
