UPDATE: SEXUAL DYSFUNCTION
How to ask about, and manage, the undertreated problem of sexual dysfunction
IN THIS ARTICLE
One last caveat: When you are evaluating a patient’s sexual function, don’t assume that she has a male partner—or any partner at all.
Don’t overlook psychosocial variables when assessing desire disorders
Prevalence of low sexual desire ranges from 26.7% among premenopausal women to 52.4% among naturally menopausal women—no small problem.5
The Female Sexual Function Index (FSFI), a multidimensional self-reporting tool used widely in research, describes sexual desire as “a feeling that includes wanting to have a sexual experience, feeling receptive to a partner’s sexual initiation, and thinking or fantasizing about having sex.”6 The FSFI attempts to discern whether a desire disorder is present by asking about the patient’s feelings over the preceding 4 weeks.
Among the questions it poses are:
- How often have you felt sexual desire?
- How would you rate your level of sexual desire or interest?
These questions may be useful as a starting point when a patient complains of low desire.
Low desire may have multiple causes
Desire disorders may be associated with depression, but they also may arise from experiences and attitudes that occurred during childhood. For example, women who had a strict religious upbringing or were exposed to negative parental attitudes toward sex may suffer lifelong psychological effects. Other deep-seated sources of impaired desire include childhood physical, sexual, and emotional abuse.
These influences may not be readily apparent if the woman is in a new relationship, when powerful hormonal determinants of attraction—driven by phenylethylamine—hold sway. Once the relationship matures, however, and the “lust” begins to recede and a more comfortable, stable relationship emerges—these psychological barriers to physical enjoyment may come to the fore.
Referral is indicated for SAD
Sexual aversion disorder (SAD) is characterized by “persistent or recurrent extreme aversion to and avoidance of all (or almost all) genital sexual contact with a sexual partner,” according to DSM-IV.2 Unlike HSDD, which reflects a lack of interest in sex, SAD may involve physiologic aversion responses such as nausea, revulsion, and shortness of breath.3
SAD is a psychiatric illness that requires management by a qualified mental health professional, preferably a sex therapist. (For information on how to find a qualified therapist, consult the American Association of Sexuality Educators, Counselors, and Therapists at www.aasect.org.)
No FDA-approved drug for HSDD
HSDD is characterized by “a deficiency or absence of sexual fantasies and desire for sexual activity,” according to DSM-IV.4 It may be treated by an experienced psychotherapist without additional training in sexual therapy.
Regrettably, attempts to treat HSDD with pharmacologic agents have been modestly successful at best, and we lack FDA-approved medications. Some trials demonstrated a slight improvement in desire among surgically menopausal women on estrogen therapy when a supraphysiologic dose of testosterone was given. Off-label use of a compounded testosterone or a lower dose of a male testosterone product may be useful.
Avoid laboratory assays for testosterone—serum or salivary—in the diagnosis of HSDD. However, if a commercial testosterone product is given, testing may be useful to prevent excessive levels of testosterone and associated (and sometimes irreversible) physiologic changes, such as male-pattern hair loss and deepening of the voice.
Failure to lubricate is the hallmark of female sexual arousal disorder
The DSM-IV defines female sexual arousal disorder as persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate physiologic response (lubrication, swelling) of sexual excitement.4 It is analogous to erectile dysfunction in men. In women, however, it may be difficult to distinguish this condition from primary desire disorder, particularly in cases in which a pattern of poor arousal, dryness, and dyspareunia has developed. The hallmark of female sexual arousal disorder is a failure to lubricate.
A few simple questions
Among the questions you might ask the patient:
- Do you feel interested in sexual activity?
- Do you have a problem lubricating well?
- Do you use a lubricant for sexual activity? If so, does it work to make sexual intercourse comfortable?
Other variables to consider
Arousal occurs secondary to genital vasodilation and tissue engorgement. It may be disturbed by any physiologic condition that reduces blood flow, such as smoking, hypertension, diabetes, and hypoestrogenism.
Decreased sensation sometimes may contribute to arousal disorder. For example, when the vagina and external genitalia experience decreased sensation, the cause may be physiologic, neurologic, or supratentorial.
Unlike men, women experience very little direct feedback regarding arousal. A disconnect between the sensory afferent input and higher-level awareness is not unusual. A thorough physical and neurologic exam may be necessary to assess the sensory nerves, integrity of the skin (signs of any inflammation), and blood flow to the genitalia.
