Female Sexual Dysfunction:

 Evaluation and Treatment

NANCY A. PHILLIPS, M.D. Wellington School of Medicine, University of Otago, Wellington, New Zealand

Sexual dysfunction includes desire, arousal, orgasmic and sex pain disorders (dyspareunia and vaginismus). Primary care physicians must assume a proactive role in the diagnosis and treatment of these disorders. Long-term medical diseases, minor ailments, medications and psychosocial difficulties, including prior physical or sexual abuse, are etiologic factors. Gynecologic maladies and cancers (including breast cancer) are also frequent sources of sexual dysfunction. Patient education and reassurance, with early diagnosis and intervention, are essential for effective treatment. Patient history and physical examination techniques, normal sexual responses and the factors that influence these responses, and the application of medical and gynecologic treatments to sexual issues are discussed. Basic treatment strategies, which may be successfully provided by primary care physicians for most sexual dysfunctions, are outlined. Referral can be reserved for patients who do not respond to therapy. (Am Fam Physician 2000;62:127-36,141-2.)

Sexuality is a complex process, coordinated by the neurological, vascular and endocrine systems.¹

Individually, sexuality incorporates family, societal and religious beliefs, and is altered with aging, health status and personal experience. In addition, sexual activity incorporates interpersonal relationships, each partner bringing unique attitudes, needs and responses into the coupling. A breakdown in any of these areas may lead to sexual dysfunction.

Primary care physicians, skilled in the treatment of medical and psychological disorders, often feel unqualified to treat patients with sexual dysfunction. However, with an understanding of sexual functioning and application of general medical and gynecologic treatments to sexual issues, sexual dysfunction may be effectively approached with the same skills. The latter includes obtaining a complete patient history, conducting a physical examination, application of basic treatment strategies, providing patient education and reassurance, and recommending appropriate referral when indicated.

Diagnosis

Female sexual dysfunction can be subdivided into desire, arousal, orgasmic and sexual pain disorders. Sexual pain disorders include dyspareunia and vaginismus.²

Estimates of the number of women who have sexual dysfunction range from 19 to 50 percent in "normal" outpatient populations^3-6 and increase to 68 to 75 percent when sexual dissatisfaction or problems (not dysfunctional in nature) are included.^5,7 Yet, one review of physicians' chart notes revealed a recorded sexual problem in only 2 percent.⁵ In another review, physician inquiry of patients in a gynecologic office setting about sexual problems increased reported complaints about sexual dysfunction sixfold.³ This discrepancy demonstrates a need for physician education in this area.

FIGURE 1.Cycle of sexual dysfunction. Example showing how a patient can enter the cycle of sexual dysfunction in one area (i.e., decreased orgasm) and proceed to another area (i.e., decreased desire) so that the presenting complaint may not represent the problem that actually requires evaluation and treatment. Adapted with permission from Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res 1998;10(suppl 2):S117-20.

The diagnosis of female sexual dysfunction requires the physician to obtain a detailed patient history that defines the dysfunction, identifies causative or confounding medical or gynecologic conditions, and elicits psychosocial information.⁸ Preappointment questionnaires or appointments at which only the history is taken allow patient-physician communication to be unhindered by time constraints or patient fears of an upcoming physical examination.

Establishment of the patient's sexual orientation is necessary for appropriate evaluation and management. Nonjudgmental, direct questions best achieve this goal. Because gender identity conflicts are often a cause of sexual dysfunction, the mode and type of questions asked by physicians should create an environment where patients may openly express their concerns. Specialized counseling is important for these patients.

The sexual dysfunction should be defined in terms of onset and duration and situational versus global effect. A situational dysfunction occurs with a specific partner, in a certain setting or in a definable circumstance.

The presence of more than one dysfunction should be ascertained, because considerable interdependence may exist. For example, a patient complaining about decreased desire might have a primary orgasmic disorder from insufficient stimulation, with decreased desire developing secondarily as a result of unsatisfying sexual encounters (Figure 1).⁸ Thus, treating the orgasmic disorder would indirectly enhance desire; whereas, treating a desire disorder would be unsuccessful and perhaps add to patient frustration and perpetuate the cycle of dysfunction.

Questioning the patient about what she thinks is causing the problem may add insight. She may reveal fear of redeveloping an abnormal Papanicolaou smear from penile penetration, or she may admit that she is not attracted to her partner. Obtaining this information early in the evaluation process will expedite diagnosis and initiation of treatment.

Medical conditions are a frequent source of direct or indirect sexual difficulties. Vascular disease associated with diabetes might preclude adequate arousal; cardiovascular disease may inhibit intercourse secondary to dyspnea (Table 1).¹ Arthritis or urinary incontinence may cause discomfort or embarrassment, leading to dysfunction or decreased sexual activity.² Aggressive treatment of long-term disease and minor ailments, with attention to their sexual implications, will help enhance sexuality.

Prescription and over-the-counter medications, illicit drugs and alcohol abuse contribute to sexual dysfunction^9,10 (Table 2).¹⁰ Medication changes, drug discontinuation, or dosage or schedule alterations may provide relief. Cigarette smoking, known to cause erectile dysfunction in men, may have a similar negative effect on arousal in women.

Gynecologic conditions contribute physically to sexual difficulties (Table 3),⁸ and treatment must address both of these issues. For example, treatment of a patient with recurrent cystitis as a cause of dyspareunia should include the use of lubricants and distraction techniques at first intercourse to assure adequate lubrication and relaxation, respectively. These steps help resolve any secondary difficulties that may have developed (e.g., an arousal disorder or mild vaginismus). For patients with a female partner, details concerning sexual habits and objects of penetration, if any, are necessary. In these instances, hygienic use of vibrators may result in fewer episodes of cystitis.

Hysterectomy, gynecologic malignancies and breast cancer present medical and mortality concerns, and alter or remove physical and psychologic symbols of femininity that may result in feelings of decreased sexuality. In one study,¹¹ 74 percent of patients who underwent surgery for gynecologic malignancy reported decreased desire, and 40 percent reported dyspareunia. In another study¹² of patients who had undergone hysterectomy for benign disease, a decrease in sexual responsiveness of up to 30 percent was noted. Breast cancer survivors report a 21 to 39 percent incidence of sexual dysfunction,¹³ although a recent study¹⁴ suggests that this may be related to chemotherapy or hypoestrogenism secondary to ovarian failure. Preoperative counseling, including explanations of postoperative anatomy and potential effects on sexuality, is essential in these patient populations. Continued postoperative counseling and early recognition and treatment of sexual difficulties may also help these patients maintain satisfying sexual relationships.

TABLE 2 Medications and Female Sexual Dysfunction Medications that cause disorders of desire Psychoactive medications Antipsychotics Barbiturates Benzodiazepines Selective serotonin reuptake inhibitors Lithium Tricyclic antidepressants Cardiovascular and antihypertensive medications Antilipid medications Beta blockers Clonidine (Catapres) Digoxin Spironolactone (Aldactone) Hormonal preparations Danazol (Danocrine) GnRh agonists (e.g., Lupron, Synarel) Oral contraceptives Other Histamine H2-receptor blockers and promotility agents Indomethacin (Indocin) Ketoconazole (Nizoral) Phenytoin sodium (Dilantin) Medications that cause disorders of arousal Anticholinergics Antihistamines Antihypertensives Psychoactive medications Benzodiazepines Selective serotonin reuptake inhibitors Monoamine oxidase inhibitors Tricyclic antidepressants Medications that cause orgasmic dysfunction Methyldopa (Aldomet) Amphetamines and related anorexic drugs Antipsychotics Benzodiazepines Selective serotonin reuptake inhibitors Narcotics Trazadone (Desyrel) Tricyclic antidepressants* *--Also associated with painful orgasm Adapted with permission from Drugs that cause sexual dysfunction: an update. Med Lett Drugs Ther 1992;34:73-8.

TABLE 3 Gynecologic Causes of Female Sexual Dysfunction and Method of Gynecologic Examination Examination Condition External genitalia Assess muscle tone Vaginismus Assess skin color and texture Vulvar dystrophy, dermatitis Assess skin turgor and thickness Atrophy Assess pubic hair amount and distribution Atrophy Expose clitoris Clitoral adhesions Assess for ulcers Herpes simplex virus Perform cotton swab test of vestibule Vulvar vestibulitis Palpate Bartholin glands Bartholinitis Assess posterior forchette and hymenal ring Episiotomy scars, strictures Monomanual Palpate rectovaginal surface Rectal disease Palpate levator ani Levator ani myalgia, vaginismus Palpate bladder/urethra Urethritis, interstitial cystitis, urinary tract infection Assess for cervical motion tenderness Infection, peritonitis Assess vaginal depth Postoperative changes, postradiation changes, stricture Bimanual Palpate uterus Retrogression, fibroids, endometritis Palpate adnexa Masses, cysts, endometriosis, tenderness Perform rectovaginal examination Rule out endometriosis Obtain guaiac test Bowel disease Speculum Evaluate discharge, pH Vaginitis, atrophy Evaluate vaginal mucosa Atrophy Perform Papanicolaou smear Human papillomavirus infection, cancer Assess for prolapse Cystocele, rectocele, uterine prolapse Adapted with permission from Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res 1998;(suppl 2):S117-20.

Gynecologic changes related to a woman's reproductive life (e.g., puberty, pregnancy, the postpartum period and menopause) present unique problems and potential obstacles to sexuality. Puberty may lead to concerns regarding sexual identity. Pregnancy and the postpartum period are often associated with a decrease in sexual activity, desire and satisfaction, which may be prolonged with lactation.¹⁵

For patients with dyspareunia, a "monomanual" examination is appropriate, with the physician inserting one or two fingers into the vagina and the other hand held away from the abdomen so as not to confuse the source of discomfort.

The hypoestrogenic state of menopause may cause significant physical changes^16,17 (Table 4)¹⁷ and alterations in mood or a diminished sense of well-being, which have been found to have a significant, negative impact on sexuality.¹⁸ A decline in desire, arousal and frequency of intercourse and an increase in dyspareunia have been associated with menopause,^19-21 although these findings are not universal.¹⁸

The final goal is to elicit psychosocial information. Previous experiences and current intra- and interpersonal factors should be explored (Table 5).

Physical Examination
Each patient should undergo a thorough examination, with the gynecologic examination individually guided by and tailored to patient comfort. The goal of the examination is detection of disease; however, the examination also provides an opportunity to educate the patient about normal anatomy and sexual function, and to reproduce and localize pain encountered during sexual activity.

TABLE 4 Physiologic Changes of Menopause Skin Decreased activity of sweat and sebaceous glands, decreased tactile stimulation Breasts Decreased fat content, decreased breast swelling and nipple erectile response with sexual arousal Vagina Shortening and loss of elasticity of vaginal barrel, diminished physiologic secretions, rise in vaginal pH from 3.5 to 4.5 to greater than 5, thinning of epithelial layers Internal reproductive organs Ovaries and fallopian tubes diminish in size, ovarian follicles undergo atresia, ovarian stroma becomes fibrotic, uterine body weight decreases 30 to 50 percent, cervix atrophies and decreases mucous production Bladder Urethra and bladder trigone atrophy Reproduced with permission from Phillips NA, Rosen RC. Menopause and sexuality. In: Lobo RA, ed. Treatment of the postmenopausal woman. 2d ed. Phildelphia: Lippincott Williams and Wilkins, 1999:437-43.

TABLE 5 Psychosocial Factors of Female Sexual Dysfunction Intrapersonal conflicts Religious taboos, social restrictions, sexual identity conflicts, guilt (i.e., widow with new partner) Historical factors Past or current abuse (sexual, verbal, physical), rape, sexual inexperience Interpersonal conflicts Relationship conflicts; extra-marital affairs; current physical, verbal or sexual abuse; sexual libido; desire or practices different from partner; poor sexual communication Life stressors Financial, family or job problems, family illness or death, depression

A routine examination seeks signs of general medical conditions. The gynecologic examination is comprehensive (Table 3),⁸ beginning with inspection of the external genitalia, including a cotton swab test if indicated (gently touching the vestibule of the vagina with a cotton swab will elicit moderate to severe pain in patients with vulvar vestibulitis). For patients with dyspareunia, a "mono-manual" examination should follow, with one or two fingers in the vagina (proceeding from posterior to anterior), and the other hand held away from the abdomen so as not to confuse the source of discomfort (Table 3).⁸ Bimanual and rectovaginal examinations are then performed. The timing of the speculum examination is guided by patient symptoms. In patients with deep dyspareunia, the speculum examination should follow the bimanual examination because localization of pain is crucial in these patients. In patients in whom vaginitis, cervical cancer or a sexually transmitted disease is suspected, cultures and vaginal samples should be obtained first.

Laboratory testing should be guided by patient symptoms and examination findings. No specific tests are universally recommended for patients with sexual dysfunction. Attention to routine screening tests must not be overlooked.

General Treatment Guidelines

Following the patient history and physical examination, a suspected etiology may be treated.

If no etiology is discovered, basic treatment strategies are applied (Table 6). The patient's (and partner's) personal tastes and comfort must be considered. Physicians should respect a patient's choice to decline treatment, because studies show that sexual activity is not correlated with overall sexual satisfaction or intimacy in all persons.^18,22 In general, treatments are similar despite sexual orientations.

TABLE 6 Basic Treatment Strategies for Female Sexual Dysfunction Provide education Provide information and education (e.g., about normal anatomy, sexual function, normal changes of aging, pregnancy, menopause). Provide booklets, encourage reading; discuss sexual issues when a medical condition is diagnosed, a new medication is started, and during pre- and postoperative periods; give permission for sexual experimentation. Enhance stimulation and eliminate routine Encourage use of erotic materials (videos, books); suggest masturbation to maximize familiarity with pleasurable sensations; encourage communication during sexual activity; recommend use of vibrators*; discuss varying positions, times of day or places; suggest making a "date" for sexual activity. Provide distraction techniques** Encourage erotic or nonerotic fantasy; recommend pelvic muscle contraction and relaxation (similar to Kegel exercise) exercises with intercourse; recommend use of background music, videos or television. Encourage noncoital behaviors*** Recommend sensual massage, sensate-focus exercises (sensual massage with no involvement of sexual areas, where one partner provides the massage and the receiving partner provides feedback as to what feels good; aimed to promote comfort and communication between partners); oral or noncoital stimulation, with or without orgasm. Minimize dyspareunia Superficial: female astride for control of penetration, topical lidocaine, warm baths before intercourse, biofeedback. Vaginal: same as for superficial dyspareunia but with the addition of lubricants. Deep: position changes so that force is away from pain and deep thrusts are minimized, nonsteroidal anti-inflammatory drugs before intercourse. NOTE: For a review, see Striar S, Bartlik B. Stimulation of the libido: the use of erotica in sex therapy. Psych Annals 1999;29:60-2. *--Provide information for obtaining one discreetly. **--Helpful in eliminating anxiety, increasing relaxation and diminishing spectatoring. ***--Also helpful if partner has erectile dysfunction.

Disorders of Desire
Women with disorders of desire are difficult to treat. Occasionally, decreased desire in patients is secondary to boredom with sexual routines. Suggesting changes in positions or venues, or the addition of erotic materials is helpful.

Disorders of desire in premenopausal patients may be secondary to lifestyle factors (e.g., careers, children), medications or another sexual dysfunction (e.g., pain or orgasmic disorder). No medical treatment is available specific to patients with disorders of desire. If no underlying medical or hormonal etiology is discovered, individual or couple counseling may be helpful.

Estrogen replacement therapy has been shown to correlate positively with sexual activity, enjoyment and desire, although the findings are not universal.

In peri- and postmenopausal women, the relationship between hormones and sexuality is unclear.^18-21 Nonetheless, estrogen replacement therapy has been shown to correlate positively with sexual activity, enjoyment and fantasies--the latter thought to represent desire.^23,24 The mechanism of estrogen's effect on desire is indirect and occurs through improvement in urogenital atrophy, vasomotor symptoms and menopausal mood disorders (i.e., depression). This relationship helps predict which patients are likely to respond to estrogen replacement therapy (i.e., those with symptoms of hypoestrogenism) and may explain why some studies do not show estrogen-mediated improvement in sexual functioning.²⁵

The role of progesterone therapy, which is necessary in estrogen-treated patients with an intact uterus, has not been widely studied in terms of sexuality, but one study²⁴ suggests that it exhibits a negative impact by dampening mood and decreasing available androgens. The addition of estrogen for several weeks before progesterone therapy is initiated, or taking into account monthly symptom calendars, will help determine each hormone's influence and guide dosage and schedule adjustments.

TABLE 7 Testosterone Therapy for Treatment of Disorders of Desire* Screening Baseline testosterone levels** (free and total), baseline lipid profile, baseline liver enzyme levels, mammography, Papanicolaou smear Initiate therapy*** Combination product (Estratest or Estratest hs) Methyltestosterone (Android), 1.25 to 2.5 mg daily Micronized oral testosterone, 5 mg twice daily Testosterone proprionate 2 percent in petroleum applied daily to every other day Testosterone injectables/pellets Reevaluation at three to four months Repeat testosterone levels, lipid profile, liver enzyme levels Monitor symptoms, side effects Continued therapy Taper to lowest effective dosage¶ Monitor lipid levels, liver enzyme levels once or twice yearly Routine Papanicolaou smear and mammography schedules *--These are recommendations; no evidence-based protocols are available on testosterone therapy for the treatment of women with desire disorders. **--Many authors recommend that total levels remain in "normal" range for premenopausal women. ***--None of these medications are labeled by the U.S. Food and Drug Administration for treatment of desire disorders. ¶--Alternate daily combined with estrogen-only pill, take testosterone pill every other day, 5 days a week, etc. (not shown in studies to be safer or have fewer side effects).

Testosterone appears to have a direct role in sexual desire.²⁰ However, because studies evaluate mostly testosterone-deficient, oophorectomized women or women who develop supraphysiologic levels secondary to testosterone treatment, clinical applications are limited. No guidelines for testosterone replacement therapy for women with disorders of desire and no consensus of "normal" or "therapeutic" levels of testosterone therapy exist. Many physicians are concerned about the lack of safety data on the role of testosterone in breast cancer and on hepatic side effects; however, hepatocellular damage or carcinoma is rare at prescribed dosages,²⁶ and the development of breast cancer has not been reported clinically.²⁷

The side effects of testosterone, which occur in 5 to 35 percent of patients, include lower levels of high-density lipoprotein, acne, hirsutism, clitorimegaly and voice deepening.²⁷ However, these side effects on lipoprotein levels are rarely significant if estrogen and testosterone are coadministered; moreover, most other side effects are reversible with discontinuation of testosterone or a dosage adjustment.²⁶

A role for testosterone treatment exists in selected patients (Table 7). Coadministration with estrogen therapy should be provided to prevent deleterious effects on lipoprotein levels. Before initiating testosterone treatment, physicians should discuss the potential and theoretic risks, and individual risk and benefit assessments with the patient. In general, patients with current or previous breast cancer, uncontrolled hyperlipidemia, liver disease, acne or hirsutism should not receive testosterone therapy.

Arousal Disorders
Current treatment of patients with arousal disorders is limited to the use of commercial lubricants, although vitamin E and mineral oils are also options. Arousal disorders may be secondary to inadequate stimulation, especially in older women who require more stimulation to reach a level of arousal that was more easily attained at a younger age. Encouraging adequate foreplay or the use of vibrators to increase stimulation may be helpful. Taking a warm bath before intercourse may also increase arousal. Anxiety may inhibit arousal, and strategies to alleviate anxiety by employing distraction techniques are helpful.

Urogenital atrophy is the most common cause of arousal disorders in postmenopausal women, and estrogen replacement, when appropriate, is usually effective therapy. However, women taking systemic estrogens occasionally require supplementation with local therapy. Long-term use of estrogen-containing vaginal creams is considered an unopposed-estrogen treatment in women with an intact uterus, requiring progesterone opposition. An oral progesterone such as medroxyprogesterone 5 mg daily for 10 days every one to three months (or equivalent) may be used initially, with frequency or dosage increased if withdrawal bleeding occurs. Estring (an estradiol-containing vaginal ring) has little systemic absorption and does not require the addition of progesterone. Patients who are uncomfortable wearing the ring during the day often achieve relief with night use only.

Premenopausal women with arousal disorders, women who do not respond to estrogen therapy and women who are unable or unwilling to take estrogen represent difficult patient groups because few treatment options are available.

TABLE 8 Kegel Exercises Potential uses Increased pubococcygeal tone Improved orgasmic intensity Correction of orgasmic urine leakage Distraction technique during intercourse Improved patient awareness of sexual response Teaching Kegel exercises Instructional examination with examiner's finger in vagina Initial patient home exercise with patient's finger in vagina Slow count to 10, with movement directed "in and up" Hold for count of 3 Slow release to count of 10 Repeat 10 to 15 times daily Consider vaginal weights, biofeedback clinics Maintaining Kegel exercises Advise repetitions during routine activities (standing in line, at stop lights, etc.) Schedule follow-up appointments to discuss progress

Investigators recognize that small-vessel atherosclerotic disease of the vagina and clitoris may contribute to arousal disorders and are exploring vasoactive medications as treatment.²⁸ Small studies^29,30 have been conducted with favorable results, but larger studies are needed. Currently, treatment of arousal disorder in women who are taking these medications, including sildenafil (Viagra), is not recommended, although anecdotal success has been reported.³⁰

Orgasmic Disorders
Anorgasmia is quite responsive to therapy. This condition is caused by sexual inexperience or the lack of sufficient stimulation and is common in women who have never experienced orgasm. Orgasmic disorders may also be psychologic ("involuntary inhibition" of the orgasmic reflex) or caused by medications or chronic disease.

Treatment relies on maximizing stimulation and minimizing inhibition.³¹ Stimulation may include masturbation with prolonged stimulation (initially up to one hour) and/or the use of a vibrator as needed, and muscular control of sexual tension (alternating contraction and relaxation of the pelvic muscles during high sexual arousal). The latter is similar to Kegel exercises (Table 8). Methods to minimize inhibition include distraction by "spectatoring" (observing oneself from a third-party perspective), fantasizing or listening to music. Women who do not respond to therapy sh