Chapter 17 - Female Sexual Dysfunction - Module 2

Question 1

Sexuality, broad definition

Answer 1

Sexuality is interwoven with every aspect of human existence, and in its broadest sense, sexuality is defined as a desire for contact, warmth, tenderness, or love. Humans express and live their sexuality in their daily lives. Sexuality is not limited to an act of seduction or intercourse but encompasses every area in our lives: the way we relate to others, our friends, our family, and our work. It is evident in what we believe, how we behave, and the way we look.

Question 2

Clitoris

Answer 2

The clitoris is a wishbone-shaped structure measuring between 9 and 11 centimeters in length.

Question 3

Three phases of sexual response

Answer 3

Desire, arousal, and orgasm

Question 4

Classification of sexual dysfunction identifies problems with …

Answer 4

Problems within the three phases of sexual response and includes the sexual pain disorders dyspareunia and vaginismus.

Question 5

Etiology of sexual dysfunction

Answer 5

Developmental, health-related, partner, and relationship factors as well as sociocultural influences may all contribute to female sexual dysfunction. Physical and psychological etiologies are possible, and an individual woman may have multiple causes of sexual dysfunction.

Question 6

Assessment for sexual dysfunction

Answer 6

• Determine whether the problems are partner specific.

- Evaluate relationship stressors.

Question 7

Comprehensive Health history includes …

Answer 7

• Physical and psychosocial history as well as sexual health

Question 8

Comprehensive Health history, physical concerns …

Answer 8

• Surgeries (can affect vascular or neurological function of the genital tract),
• chronic illnesses (neurologic, endocrine or vascular problems impact sexual function, such as thyroid disease, DM, HTN),
• medications (can cause or exacerbate sexual problems),
• allergies (check for latex allergies because latex products used both for contraception and during pelvic examinations may be a source of sexually related pain)

Question 9

Medications that can cause or exacerbate female sexual dysfunction

Answer 9

Amphetamines
Anticonvulsants
Antidepressants
Antihypertensives
Antipsychotics
Anti-ulcer drugs 
Benzodiazepines
Combined estrogen and progestin contraceptives
Digoxin
Gonadotropin-releasing hormone (GnRH) agonists
Hormone therapy (estrogen &/or progestogens)
Lipid-lowering agents
Narcotics

Question 10

Comprehensive Health history, psychosocial concerns …

Answer 10

• Ask about woman’s partner(s) and relationships.
• Prior or present history of physical, emotional, or sexual abuse, or sexual assault
• Assess for s/sx of major depression and other mental health problems, PTSD and obsessive-compulsive disorder, which potentially affect sexual function.
• Assess for life stressors, coping mechanisms, body image.
• Use of recreational drugs, alcohol, and cigarettes (b/c of their impact on sexual function).
• Assess for STIs which can be a source of sexual pain.
• Assess for contraception b/c combined estrogen and progestin contraceptives (pills, patch, ring) can cause decreased desire in some.
• Assess for cultural and religious beliefs

Question 11

Samples of Open-ended Questions for Sexual Concerns

Answer 11

• Which sexual concerns, problems, or issues are you experiencing?
• How does this concern affect your sexual function, relationship(s), and life?
• What is the most distressing part of this problem?
• Which treatments have you used?
• What kind of conversations have you had with your partner(s) so far, and how have they gone?
• What do you think is the source of your sexual problem?

Question 12

Female Sexual Function Index (FSFI)

Answer 12

The FSFI is a useful assessment tool but does not replace a thorough sexual history. The FSFI assesses six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain.

Question 13

Physical exam

Answer 13

The physical examination should specifically look for potential health problems that could affect sexual functions, such as undiagnosed diabetes or HTN. Height, weight, and vital signs should be recorded. Neurologic and vascular systems should be examined. Genital exam includes inspection and palpation of external and internal genital structures.

Question 14

Diagnostic testing

Answer 14

Only when there is a clinical indication for them. Consider: fasting glucose, lipid profile, thyroid-stimulating hormone, prolactin, follicle-stimulating hormone, estradiol.

Question 15

Women’s sexual Interest/Desire Disorder

Answer 15

“Absent or diminished feelings of sexual interest of desire, absent sexual thoughts or fantasies, and a lack of responsive desire. Motivations for attempting to have sexual arousal are scarce or absent. The lack of interest is considered to be beyond the normative lessening with life cycle and relationship duration.”

Question 16

Motivators for sexual activity by women

Answer 16

Emotional closeness, increased commitment, bonding, and tolerance of imperfections in the relationship.

Question 17

Assessment of Sexual Interest/Desire disorder

Answer 17

Start with determining the duration of the problem.
Look for factors, psychological or physical, that affect desire. Relationship conflict? Painful intercourse? Financial stress, small children, work schedules?
Evaluate frequency of sexual relations
Impact of change in desire on frequency of sex
Investigate the timing of sexual relations.
Explore what happens after intercourse.
Is lack of desire d/t underlying illness?

Question 18

Reported sexual frequency among married women, 25 - 69 years of age.

Answer 18

Frequency of sexual relations Married women, 25 – 69 YO
Not at all in the past year 3.5 – 37.9%
A few times per year to monthly 11.6 – 23.7%
A few times per month to weekly 35.9 – 50.2%
Two to three times per week 6.2 – 35.2%
Four or more times per week 0 – 5.1%

Question 19

Management of Sexual Interest/Desire Disorder

Answer 19

Dependent upon the type of problem(s) identified.
Diagnose and treat underlying physical or mental health problems.
Consider medication changes.
If intercourse is painful, remedy that.
Education: decreased desire r/t aging process, relationship length, life changes such as pregnancy, lactation, and menopause.
Stress induced: individual and/or couples counseling.
Suggestions: open communication about needs and differences, vary time of day or location for sexual activities, set aside planned time for intimacy.
Therapy: cognitive behavioral therapy and sex therapy.
Medications: transdermal estrogen therapy for post-menopausal women

Question 20

Major depressive disorder, SSRIs, and decreased sexual interest/desire disorder

Answer 20

Selective serotonin reuptake inhibitors (SSRIs) have a 36 - 43% rate of sexual dysfunction associated with their use. Consider:
- Bupropiron SR (Wellbutrin) 150 mg BID
- Sildenafin 50 - 100 mg before sex (not in the presence of cardiovascular disease)
- Buspirone (BuSpar) 10 - 30 mg BID
Or, switch to antidepressants with fewer sexual SE:
- Mirtazapine (Remeron)
- Nefazodone (Serzone)
- Bupropion

Question 21

Sexual Arousal Disorders, four types

Answer 21

Four types of sexual arousal disorders are:

• Genital sexual arousal disorder
• Subjective sexual arousal disorder
• Combined genital and subjective arousal disorder
• Persistent sexual arousal disorder

Question 22

Genital sexual arousal disorder

Answer 22

Absent or impaired genital sexual arousal. Self-report may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. Subjective sexual excitement still occurs from nongenital stimuli.

Question 23

Subjective sexual arousal disorder

Answer 23

Absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation. Vaginal lubrication or other signs of physical response still occur.

Question 24

Combined genital and subjective arousal disorder

Answer 24

Absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation as well as complaints of absent or impaired genital sexual arousal (vulval swelling, lubrication).

Question 25

Persistent sexual arousal disorder

Answer 25

Spontaneous intrusive and unwanted genital arousal (e.g. tingling, throbbing, pulsating) in the absence of sexual interest and desire. Any awareness of subjective arousal is typically but not invariably unpleasant. The arousal is unrelieved by one or more orgasms and the feelings or arousal persist for hours or days. Uncommon. Refer to an experienced sex therapist.

Question 26

Assessment of sexual arousal disorders.

Answer 26

• Ask whether the client experiences vaginal lubrication of feelings of genital engorgement.
• Is there adequate stimulation to achieve arousal prior to intercourse?
• Assess for physiologic problems r/t vascular or neurologic changes to the body, i.e. DM, HTN, CAD.
• Ask about bicycle riding or gymnastics which can result in nerve trauma.
• Atrophic vaginitis and certain medications can result in nerve trauma.
• Medications impacting arousal: anticholinergics, antihistamines, monoamine oxidase inhibitors, tricyclic antidepressants, antihypertensives.
• Smoking and alcohol can impact sexual arousal.

Question 27

Management

Answer 27

• Lubricants, additional clitoral stimulation
• Treat medical conditions to increase blood flow to genital tissues.
• Warm bath to increase blood flow/vasodilation.
• Atrophic vaginitis: localized estrogen therapy

Question 28

Women’s Orgasmic Disorder

Answer 28

Orgasmic disorder is present when “despite the self-report of high sexual arousal/excitement, there is either lack or orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm from any kind of stimulation.”

Question 29

Assessment of orgasmic disorder

Answer 29

• Determine duration and extent of problem.
• Has the woman ever achieved an orgasm? If so, through self-stimulation or with a partner? What sexual activities lead to orgasm in the past?
• Causes include: trauma and abuse, particularly for women who have never had an orgasm; chronic illness, such as multiple sclerosis, chronic kidney disease, fibromyalgia, pelvic disorders or surgeries, medications, relationship issues, inadequate partner communication, cultural, religious, or familial beliefs or inhibitions.

Question 30

Medications impacting orgasm

Answer 30

SSRIs, other antidepressants, anti-psychotics, and mood stabilizers; alcohol and illicit drug use

Question 31

Management of orgasmic disorder

Answer 31

• Address any underlying causes.
• Education, most women can achieve orgasm only through direct or indirect stimulation of the clitoris.
• Kegel exercises to control muscular tnesion
• Use of a vibrator to obtain required stimulation
• Cognitive-behavioral therapy or sexual therapy

Question 32

Dyspareunia

Answer 32

Dyspareunia is “persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse.”

Question 33

Vaginismus

Answer 33

Vaginismus is the “persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger, and/or any object, despite the woman’s expressed interest to do so. There is often (phobic) avoidance and anticipation/fear/experience of pain, along with variable involuntary pelvic muscle contraction. Structural or other physical abnormalities must be ruled out/addressed.”

Question 34

Dyspareunia assessment

Answer 34

• Determine the exact location of the pain.
• Ask about onset, duration, quality, severity, factors that cause the pain to improve or worse.
• Ask about the timing of the pain WRT the menstrual cycle, especially if endometriosis is suspected.

Question 35

Dyspareunia assessment, external causes

Answer 35

External causes of painful intercourse include:

• vaginal infections
• dermatologic disorders (such as lichen sclerosus)
• atrophic vaginitis
• allergy (including latex)
• vulvar vestibulitis

Question 36

Perimenopausal, postmenopausal, or lactating women with dyspareunia should be evaluated for …

Answer 36

Atrophic vaginitis.

Question 37

Vulvar vestibulitis

Answer 37

Vulvar vestibulits may be the cause of persistent pain at the vaginal introitus or inability to achieve penetration secondary to pain. Can also result in pain in tampon insertion.

Question 38

Evaluation of vulvar vestibulitis

Answer 38

Gently palpate the vestibule with a cotton swab. Pain is most often elicited at the region of six o’clock in the vulvar vestibule. Pain is often described as sharp or burning sensation.

Criteria for diagnosis: pain with touch or vaginal entry, localizaiton of pain within the vestibule, and vestibular erythema.

Etiology is unknown.

Question 39

Evaluation of the woman with vaginal pain following intercourse

Answer 39

Evaluate for chronic vaginitis, atrophic vaginitis, and allergy. If recent delivery, consider episiotomy as the pain source.

Question 40

Management of dyspareunia

Answer 40

Depends upon the etiology.
Treat vaginal infections
Atrophic vaginitis - consider vaginal estrogen preparations if perimenopausal or postmenopausal.
Vulvar vestibulitis - avoid irritants, wear cotton underwear, use only water to cleanse the vulva.

Question 41

Vaginismus assessment

Answer 41

Often not able to complete a pelvic exam d/t involuntary contractions of the vaginal muscles.
Often a history of sexual abuse or pain or trauma resulting from medical procedures such as catheterization.

Question 42

Management of vaginismus

Answer 42

Treatment includes: vaginal dilation, progressive desensitization, and muscle relaxation. Kegel exercises to teach a woman to control her vaginal muscles. Biofeedback training.

Question 43

Referral triggers

Answer 43

Long-standing dysfunction, multiple dysfunctions, current or past abuse, psychological disorder or acute psychological event, dysfunction with an unknown etiology, and dysfunction unresponsive to therapy.

Question 44

Chapter 17 is

Answer 44

done.