Module 2 Study Guide Flashcards
Describe the sexual health assessment for women WITHOUT sexual concerns.
★History
○ Positive tone, rapport, remain dressed, eye level
○ Monitor verbal and nonverbal responses
○ Move from least to most sensitive topics
○ Elicit responses about values, attitudes, and beliefs - How did you learn about sex?
○ Focus on behaviors and practices more than assumption building topics like orientation labels
○ CDC recommends asking about the 5 Ps - Partners, Practices, Protection from STIs, and Prevention of pregnancy
○ Intimate partner violence
○ Examples of open-ended questions p. 202 Box 10-2
★ Physical exam
○ Only needed if indicated by history or chief complaint
○ Sometimes needed for treatment goals or referral
○ Some reasons for further assessment
■ Medical factors
■ Adolescents - puberty related physical changes, sexual activity, proactive teaching
■ Pregnant and postpartum women
■ Midlife women
■ Older women
■ Cultural influences
Describe the sexual health assessment for women WITH sexual concerns.
★ Purpose - identify all possible biological and psychosocial sources of the concern
★ Special notes/make sure to
○ Determine if this concern
■ Primary - lifelong
■ Secondary - emerged after a period of normal sexual function
■ Situational - specific to certain circumstances
■ Generalized - across all circumstances - masturbation, intercourse, manual stimulation, etc
○ Determine relationship stressors - intimate partner violence
★ History
○ Comprehensive health history
○ Surgeries that could affect vascular or neuro function of the genital tract or other erogenous areas
○ Injuries to the pelvis, genital structures, spine or brain
○ Chronic illnesses
○ Medications - list on p383 Box 16-1
○ Allergies - latex
○ Sexual orientation
○ Prior abuse or trauma - physical, emotional, or sexual, assault
■ s/s of depression, PTSD, OCD
○ Lifestyle - diet, exercise, stress, coping mechanisms, body image
○ Illicit drugs, ETOH, and tobacco
○ Risk factor screening - multiple partners, contraception use, STIs,
○ Cultural and religious beliefs - consider about tx
○ Sometimes all that is needed is reassurance that what she is experiencing is normal
○ May need to review anatomy and sexual function
○ Female Sexual Function Index (FSFI) can be helpful
■ http://www.fsfiquestionnaire.com/FSFI%20questionnaire2000.pdf
○ Open-ended question examples p. 384 box 16-2
★ Physical exam
○ Height, weight, vital signs
○ Potential health conditions like underlying DM or hypertension
○ Neuro and vascular systems
○ Pelvic exam - if indicated, always with shared decision making
★ Diagnosis and treatment
○ Clinical indication, not as a standard
○ Tests to consider
■ Fasting glucose
■ Lipid profile
■ TSH
■ Prolactin
○ Women presenting with sexual pain
■ Vaginal pH and microscopy of vag secretions with NS and 10% KOH
○ Controversial - measurement of androgen levels - no FDA approved tx for “low”
★ Differential diagnosis
○ Start by categorizing concern into one of the three DSM-V categories
■ Sexual interest/arousal disorder
■ Orgasmic disorder
■ Genito-pelvic pain/penetration disorder
○ Use Hx, physical exam, and lab tests to decide if the source of dysfunction is psychological, physical or combination
What is normal sexual function? What isn’t?
★ In order for an alteration in sexual function to be a dysfunction, the woman must perceive her symptoms as distressing, otherwise, it is just an alteration
○ In other words, a dx of sexual dysfunction requires that a woman perceive her symptoms as distressing
★ Sexual function is “normal” based on the woman’s individual perceptions and values, it is difficult to “define”. Here are some definitions of sexual health that might help.
○ Sexual health is a state of well-being in relation to sexuality across the lifespan that involves physical, emotional, mental, social, and spiritual dimensions
○ Sexual health is an inextricable element of human health and is based on positive, equitable, and respectful approach to sexuality, relationships, and reproduction that is free of coercion, fear, discrimination, stigma, shame, and violence.
○ Sexual health includes the ability to understand the benefits, risks, and responsibilities of sexual behavior; the prevention of disease and other adverse outcomes; and the possibility of fulfilling sexual relationships.
○ Sexual health is impacted by socioeconomic and cultural contexts (including policies, practices, and services) that support healthy outcomes for individuals and their communities
Identify life stages that can affect sexual response and function.
○ Adolescence
○ Pregnancy and lactation
○ Midlife 40-60 yo
○ Postmenopause
○ Older women 65+
Identify medical conditions that can affect sexual response and function.
○ Surgeries - especially those that could affect the vascular or neurologic function of the genital tract and other erogenous areas (breasts)
○ Past injuries to the pelvis, genital structures, spine, and brain
○ Chronic illnesses
■ Thyroid disease
■ Diabetes
■ Hypertension
■ Certain Cancers
■ Chronic pain
■ Hyperprolactinemia
■ Cognitive disorders
■ Heart disease
○ Pregnancy, birth, lactation history
Identify medications that can affect sexual response and function.
○ Latex allergies
○ Amphetamines
○ Anticonvulsants
○ Antidepressants
○ Antihypertensives and other cardiovascular agents, digoxin, lipid-lowering agents
○ Antiulcer drugs
○ Benzos
○ Combined estrogen and progestin contraceptives
○ GnRH agonists
○ Histamine receptor blockers
○ Hormone therapy - both estrogen and progesterone
○ NSAIDs
○ Opioid pain meds
○ Psychotropics
○ Substances: ETOH, amphetamines, cocaine, heroin, marijuana
Describe the assessment for the following condition: Female sexual interest/arousal disorder (Hypoactive sexual desire disorder)
★ Assessment
○ Duration of symptoms and factors surrounding them - have you always felt this way or is it a change in level of desire?
○ Look for negative factors - sexual assault, conflicts in relationships, pain with intercourse, financial stress, small kids need care at night, opposing work schedules
○ Frequency of sexual activity - there may be different expectations among partners
○ Has the change in desire → change in frequency?
■ Does she have sex even when she doesn’t want to?
■ Belief she has no choice - may need to address issues of power and control before it can be determined if he sexual concern has a physical basis
○ If she does not initiate, does she still enjoy sex when partner initiates? NORMAL
○ Explore any changes that may alter satisfaction with relationship - does she orgasm? If not, this may decrease motivation for future sexual encounters
○ Negatives outweigh positives? May → low motivation
○ Hormonal changes with menopause - overall aren’t a major contributor for most women
■ Other factors like hot flashes, night sweats, fatigue, weight gain, vag dryness, painful intercourse
○ Inability to get pregnant - stress of ART tx
○ Associated symptoms indicate a physical problem?
■ Fatigue - thyroid or sleep disorders
■ Chronic med condition that makes sex painful - arthritis, back pain
○ Sexual interest disorder is related to thyroid, epilepsy, and renal disease
○ Medications or symptoms that affect hormone levels - combined oral contraceptives, GnRH agonists, antiestrogens, hysterectomy, and oophorectomy
○ Androgen insufficiency - no clear consensus on testing and replacement - insufficiency can be diagnosed by history alone and therapy initiated without lab testing
Describe the Characteristics/Diagnosis for the following condition: Female sexual interest/arousal disorder (Hypoactive sexual desire disorder)
★ Characteristics/Diagnosis
○ Complete lack of or significant reduction in sexual interest or arousal associated with three or more of the following symptoms
■ Absence or reduction of interest in sex
■ Absence or reduction in fantasies or erotic thoughts
■ Absence or decreased desire to initiate sexual encounters with partner and usually not receptive when the partner attempts to initiate encounters
■ Absent or reduced sense of excitement/pleasure during sex
■ Absent or reduced response to sexual cues - verbal, visual
■ Absent or reduced sensation in genitals or elsewhere during sex
○ Symptoms must persist for a minimum of 6 months
○ May be lifelong, acquired, situational, or general
○ Severity falls on a continuum
○ Must be no other mental health, physical, or substance-induced cause
Describe the Management plan for the following condition: Female sexual interest/arousal disorder (Hypoactive sexual desire disorder)
★ Management plan
○ Depends on etiology
○ Relational or life problem - avoid suggesting medical tx and refer to counseling for the individual and/or couple
○ Some couples strategies include planning time, listing stress causes, placing it outside the door, honest communication, sex therapy
○ Treat underlying diagnosis, medical or mental health problems
○ Consider changing meds known to be associated with affecting sexual desire
○ If related to pain - identify and treat source of pain
○ Educate on normal lifespan alterations - pregnancy, lactation, menopause
○ Flibanserin - only approved medication
○ If it is a side effect from SSRIs consider Wellbutrin /bupropion SR 150mg BID or sildenafil 50-100mg prior to sexual activity
■ Also consider switching to antidepressant with fewer sexual side effects - mirtazapine/Remeron, nefazodone/Serzone or bupropion
■ Off label use of bupropion SR 150mg daily can improve desire and decrease distress
○ Transdermal estrogen therapy after menopause
○ If symptoms persist, other causes r/o - testosterone therapy can be considered off label
Describe the assessment for the following condition: Sexual arousal disorder
★Assessment
○ Vaginal lubrication or feeling of genital engorgement with sex play
○ Adequate stimulation to achieve arousal
○ Physiologic conditions that might cause vascular or neurologic changes
■ Diabetes, hypertension, CAD
■ Physical activities that may compress the nerves and blood vessels leading to the genitals - Bicycle or horseback riding
○ Medications - SSRIs, MAOIs, TCAs, antihypertensives
○ Substances - smoking, alcohol, drugs
Describe the Management plan for the following condition: Sexual arousal disorder
★ Management
○ Artificial lubricants
○ Clitoral stimulation vaginal moisturizers
○ Change medications if possible/indicated
○ Localized estrogen therapy
○ Sexual aids/toys
○ Complementary and alternative treatments
○ Compounds - usually topicals
Describe the assessment for the following condition: Orgasmic disorder
★ Marked delay in and/or marked infrequency of or absence of orgasm or reduced intensity of orgasm sensations
★ Assessment
○ Duration and extent of the problem
○ Knowledge of achieving orgasm
○ Trauma, abuse, chronic illness, medications, and substance abuse along with cultural/religious beliefs
○ Communication between partners
Describe the diagnosis criteria for the following condition: Orgasmic disorder
★ Diagnostic criteria
○ Lasting more than 6 months
○ Cannot be related to physical or mental health conditions or relationship problems
○ Can be lifelong or recent
○ Can be generalized to all types of sexual encounters
Describe the Management plan for the following condition: Orgasmic disorder
★ Management
○ Address underlying causes such as chronic disease, medications, and mental health
○ Education - anatomy, vibrator, toys
○ CBT and sex therapy
Describe the assessment for the following condition: Dyspareunia/pain with intercourse
★ Assessment
○ Location and experience
○ OLDCARTS
○ Timing of pain with menstrual cycle
○ Penetrative sex activity only or with all internal and external stimulation
○ Direct contact or if arousal/orgasm → pain
○ Life changes - perimenopausal/postmenopausal
○ Medications - tamoxifen, danazol, medroxyprogesterone acetate, GnRH agonist
○ Allergies - semen (rare), latex
★ Physical exam may see
○ Pale and dry vaginal walls
○ Decreased rugae
○ Vulvar fissures
○ Petechiae
○ Loss of vulvar architecture
○ pH>5.0
Describe the diagnosis for the following condition: Dyspareunia/pain with intercourse
★ Difficulty with vaginal penetration during intercourse or attempted penetration
★ Vulvovaginal or pelvic pain during intercourse or attempted penetration
★ Fear or anxiety about pain before, during, or after vaginal penetration
★ Pelvic floor muscles tensing or tightening when vaginal penetration is attempted
★ Diagnostic criteria
○ Symptoms must be present for a minimum of 6 months
○ Must cause significant distress
○ Not explained by other physical or mental conditions
★ Possible contributors
○ Vaginal infections
○ Dermatologic disorders
○ Atrophic vaginitis - can be related to low estrogen levels d/t lactation
○ Trauma
○ Allergies
○ Vulvodynia - pain without an identifiable cause
○ Vaginismus
○ Vulvar vestibulitis
○ Endometriosis
○ Chronic vaginitis
Describe the Management plan for the following condition: Dyspareunia/pain with intercourse
○ Treat vaginal infections and dermatologic disorders
○ Treat perimenopausal/menopausal or postpartum
○ Ospemifene - nonhormonal selective estrogen receptor modulator (SERM) for atrophic vaginitis
○ Monalisa touch - vaginal laser to stimulate healthy collagen production
○ Vulvodynia/vestibulodynia - cotton underwear and avoid common irritants
○ Avoid self-treatment for vaginal infections
○ Pelvic floor therapy
○ Cognitive-behavior therapy
○ Pharmacology - topical lidocaine, oral antidepressants, and oral anticonvulsants
○ Surgery to remove vestibule
Describe the assessment, characteristics, diagnosis, and management plan for the following condition: Vulvodynia
★ Vaginal pain without an identifiable cause, often one spot is painful during sex
★ Cotton underwear and avoid common irritants
★ Multidisciplinary care
Describe the assessment, characteristics, diagnosis, and management plan for the following condition: Vaginismus
★ Recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with penis, finger, tampon or speculum is attempted
★ Treatment
○ Combination of cognitive approaches to anxiety reduction, ensuring the woman feels she is in control of sex encounters, and physical therapy
○ Pelvic floor desensitization and relaxation
○ Graduated use of dilators to help with muscular control
○ Voluntary relaxation and stretching
Describe the assessment, characteristics, diagnosis, and management plan for the following condition: Vulvar vestibulitis/vestibulodynia
★ Persistent pain at the vaginal introitus or inability to achieve penetration
★ Diagnosis
○ Gently palpate the vestibule with moist cotton swab
○ Pain will usually be about the 6 o’clock region - described as a sharp or burning sensation with light touch
○ Erythema may or may not be present
Identify barriers to optimal health encountered by sexual or gender minority patients.
★ Financial - Lack of insurance
○ Employers may deny insurance benefits for same-sex partners who are not legally married
○ Medicaid may exclude women in same-sex partnerships
○ Inability to afford healthcare services
★ History of trauma
○ LGBQ/TGNC persons carry weight of their personal experiences of mistreatment within the healthcare system
○ Also, the cumulative pain and mistreatment experienced by their predecessors
○ Minority stress
★ Lack of clinician knowledge
★ Restrictive healthcare system, infrastructure, and policies
What health issues may occur with greater prevalence in these populations?
★ Asthma
★ Hepatitis
★ UTIs
★ Mental distress
★ Suicide and mental health concerns
★ Increased tendency toward substance use/abuse, tobacco illness, ETOH
★ CAD
★ Increased STI rates
How can clinicians provide support to overcome barriers and improve health outcomes for sexual and gender minority individuals?
★ Welcoming environment
★ Reading materials they could relate to
★ Nongender bathrooms
★ Intake forms that allow/have blanks for gender identity, pronouns, preferred name
★ Check for preferred name/pronoun before interacting
★ Clinicians and staff fully trained in LGBTQ care and appropriate attitude/communication
★ Be willing to research relevant care information
★ Good communication skills with a nonjudgmental approach
★ Encourage them to have support persons
★ Involve partner in care conversations
★ Know your community resources
Identify the history, diagnostic testing, and counseling to include at a preconception visit.
HISTORY
★ Reproductive, family and personal medical symptom history - attention to pelvic symptoms and complex medical conditions
★ Smoking, drugs, and ETOH use
★ Nutrition habits identifying excesses and inadequacies
★ Medications - does anything need to be changed?
★ Risks for STIs with either partner
★ Risk for preterm birth
★ Environmental hazards
★ Physical conditions of workplaces
★ Readiness for parenthood
★ Psych background
★ Financial issues
★ Support system
DIGNOSTIC TESTING
★ Offer STI screening
★ Vaginal wet mount if discharge present
★ Neoplasms - breast, cervical dysplasia, warts, etc
★ Immunity - rubella, tetanus, varicella, HBV, HPV
REFRAMED
★ R - reproductive awareness -birth control and physiology of conception
★ E - environmental toxins and teratogens - occupational and home
★ F - folic acid and nutrition - screen for eating disorders, need for supplements, over/underweight
★ R - reviewed genetic history - including history of pregnancy problems
★ A - alcohol, tobacco, other substances - screen for second-hand exposure
★ M - medical conditions/meds
★ E - educate IZ and infectious diseases - STIs
★ D - domestic violence and psychosocial issues - childhood trauma, access to basic necessities, financial worries, knowledge of resources, social support
COUNSELING
★ Substance abuse treatment referral if indicated
★ Provide genetic counseling for all women - refer if age 35+, significant history, poor pregnancy outcome history, partner of advanced age, high-risk ethnic background, seizure disorders, diabetes
★ Balanced diet
★ Minimizing risk for STIs
★ Weight loss that is gradual until conception
★ Moderate exercise
★ Avoid cat poop
★ Encourage breastfeeding
★ Early prenatal care when pregnancy occurs
