Clinical Review


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How to ask about, and manage, the undertreated problem of sexual dysfunction




New study: ObGyns aren’t fully addressing their patients’ sexual function
(Web News, April 2012)

How to prepare your patient for the many nuances of postpartum sexuality
Roya Rezaee, MD; Sheryl Kingsberg, PhD (January 2012)

Update on sexual dysfunction
Barbara S. Levy, MD (September 2011)

Sexual dysfunction is common among women, with an overall incidence of about 40%—even higher in some populations.1,2 All the more surprising, then, that only a minority of women raise the topic with their physician. In one well-regarded study, for example, only 22% of older women reported having discussed sex with their physician after the age of 50.3

One reason for the lack of communication may be a sense of discomfort around sexuality, among physicians as well as patients. Other reasons may include limited time on the part of physicians, and a lack of clarity about how to evaluate sexual function in women.

How, then, to assess a woman’s sexual function? In this Update, I address this question, and offer numerous others you can discuss with your patients without adding a significant time burden to your day. “A sidebar on page 27 focuses on a few strategies for tackling sexual function in an efficient and timely manner.”

How to find time to address sexual function

In an ObGyn practice already pressed for time, adding a new domain of concern to the mix can be a challenge. (This is assuming you do not already ask patients routinely about sexual function.) It may not be as challenging as you think, however. One way to start is to add a few basic questions about sexual function to the intake form. This approach serves two purposes:

  • It validates sexual function as an important part of health
  • It allows the patient to identify any problems without having to raise the subject herself.

The second purpose is especially important because many patients are reluctant to broach the topic of sex.

After reviewing the intake form, you can take a more detailed history, addressing the concerns gently and matter of factly, to determine the scope of the problem, its duration, and any steps the patient has already taken to remedy it. The physical exam then can be more appropriately focused.

Straightforward areas of dysfunction, such as perimenopausal vaginal dryness, usually can be addressed in the same visit. More extensive problems may merit a separate office visit.

Linear model of female sexual function is not clinically useful

The classical linear model that proposes that women progress from sexual excitement to plateau, orgasm, and resolution is not that helpful when we are trying to determine the cause of our patient’s sexual problem and choose a course of treatment. More revealing is the biopsychosocial model, which considers physical, psychological, relational, and situational variables in exploring sexual function. If a physician focuses the history on these four aspects of sexual function, she generally can discover the source of any problem.

According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), female sexual dysfunction typically falls into one or more categories:

  • desire disorders – hypoactive sexual desire disorder (HSDD) and sexual aversion disorder
  • problems with arousal – female sexual arousal disorder
  • pain disorders – dyspareunia and vaginismus
  • orgasmic disorders – female orgasmic disorder.4

If we superimpose this framework over the biopsychosocial model, diagnosis and management can be elucidated further. For example, we might see a 57-year-old patient who complains during her annual exam about decreased libido. We ask about menopausal symptoms and general health and screen for depression and intimate partner violence. On questioning, we discover that her partner was diagnosed with prostate cancer 2 years earlier and is able to achieve an erection on occasion with the use of medication, but there is fear, for both of them, that the erection will not last. This development has changed their sexual behaviors in ways that are not satisfying for either of them.

Clearly, addressing this fairly common scenario as “female sexual dysfunction” will overlook the main issues. This couple needs help communicating their love and support for each other and some direction to help them learn new ways to express themselves sexually that can be satisfying for both. It is important to remain sensitive to the patient’s (and partner’s) social and medical history, age, and physiological status.

Keep in mind, however, that it is common to see overlapping disorders in a patient with sexual dysfunction. For example, a lack of desire can lead to diminished arousal and anorgasmia. For this reason, when one disorder is diagnosed, ask the patient to describe any other problems she may have. Also inquire about the chronology of multiple sexual disorders in order to determine which problem came first.


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