Female sexual disorders: assessment, diagnosis, and treatment.

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AND QUALITY OF LIFE 3EXUAL PROBLEMS HAVE BEEN ASSOCIATED WITH RELATIONSHIP PROBLEMS AND MAY INTERFERE WITH OVERALL HEALTH AND THEY MAY ALSO BE A MARKER FOR OTHER UNDIAGNOSED COMORBID MEDICAL CONDITIONS )N ORDER FOR HEALTHCARE PRO FESSIONALS TO MANAGE THE SEXUAL HEALTH CON CERNS OF THEIR PATIENTS IT IS IMPORTANT FOR THEM TO UNDERSTAND WHAT CONSTITUTES GOOD SEXUAL HEALTH 4O THAT END IT IS NECESSARY TO HAVE A WORKING KNOWLEDGE OF THE EVOLVING THEORETICAL MODELS OFFERED TO DESCRIBE A HEALTHY SEXUAL

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CONSTRAINTS AND EMBARRASSMENT 4REATMENT FOR FEMALE SEXUAL PROBLEMS IS USUALLY INDIVIDUALIZED AND MAY INCLUDE A COMBINATION OF OFFICE BASED EDUCATION AND BASIC COUNSELING COGNITIVE BEHAV IORAL PSYCHOTHERAPY PHARMACOTHERAPY AND TREAT MENT OF CONCOMITANT MEDICAL CONDITIONS

/," 1 /" Ê 3EXUAL HEALTH HAS LONG BEEN KNOWN TO BE A FUNDAMENTAL COMPONENT TO QUALITY OF LIFE 9ET IN WHILE THE CONCEPT OF HEALTHY SEXUALITY IS THEORETICALLY AN ACCEPTED PREROGATIVE WOMEN ARE STILL STRUGGLING AGAINST CULTURAL TABOOS AND INADEQUATE CONSIDERATION FROM HEALTHCARE PROFES SIONALS (#0S IN THEIR QUEST TO CLAIM THEIR RIGHT TO A SATISFYING SEXUAL LIFE !CCORDING TO THE 7ORLD (EALTH /RGANIZATION MAINTAINING SEXUAL HEALTH FALLS UNDER THE RESPONSIBILITY OF PHYSICIANS 3EXUAL DYSFUNCTION HAS BEEN SHOWN TO BE ASSO CIATED WITH STATISTICALLY SIGNIFICANT DECREASES IN MENTAL HEALTH VITALITY SOCIAL FUNCTION AND BODILY PAIN )N CONTRAST THERE IS GROWING EVIDENCE OF THE BENEFIT OF SEXUAL SATISFACTION ON HEALTH AND WELL BEING $ESPITE THIS EDICT SEXUAL PROBLEMS ARE UNDERDIAGNOSED AND UNDERTREATED !LTHOUGH THERE IS RISING AWARENESS WITHIN THE MEDICAL PRO FESSION THAT SEXUAL PROBLEMS AMONG WOMEN ARE COMMON PARTICULARLY THE PROBLEM OF HYPOACTIVE SEXUAL DESIRE DISORDER THERE ARE A NUMBER OF BARRIERS TO (#0S ADDRESSING THEM

-1 /Ê Ê 1 /" É /, !LTHOUGH (#0S ARE EXPECTED TO ASSESS AND MANAGE THE SEXUAL CONCERNS OF THEIR PATIENTS UNDERGRADUATE RESIDENT AND POSTGRADUATE MEDI CAL EDUCATION OF HUMAN SEXUALITY IS INCOMPLETE 3EXUAL HEALTH HAS SELDOM BEEN A PRIORITY IN MED ICAL EDUCATION AND EVEN LESS SO IN GIVEN THE INTENSE COMPETITION FOR CONTENT IN AN EVER DIMIN ISHING AMOUNT OF CLASSROOM TIME -OREOVER MEDICAL SCHOOL FACULTIES OFTEN LACK TRAINED SEXUAL ITY EDUCATORS REGARDLESS OF SUBSPECIALTY ! SURVEY OF .ORTH !MERICAN MEDICAL SCHOOLS FOUND THAT MOST DEVOTE n HOURS TO SEXUAL HEALTH EDUCATION OVER THE ENTIRE YEAR UNDERGRADUATE CURRICULUM )N A SURVEY OF MEDICAL STUDENTS AT THE 5NIVERSITY OF 6ERMONT 3CHOOL OF -EDICINE 7ITTENBERG AND 'ERBER FOUND THAT OF STU


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DENTS FELT THAT TAKING A SEXUAL HISTORY WOULD BE AN IMPORTANT COMPONENT OF THEIR FUTURE CAREERS AND BELIEVED THAT TREATING SEXUAL CONCERNS WOULD AN IMPORTANT COMPONENT OF THEIR FUTURE CAREERS 9ET ONLY FELT ADEQUATELY TRAINED TO TAKE A SEXUAL HISTORY AND ONLY FELT ADE QUATELY TRAINED TO TREAT A SEXUAL PROBLEM 3INCE SEXUAL HEALTH IS NOT GIVEN A HIGH PRIORITY IN MEDI CAL EDUCATION THIS MAY RESULT IN AN UNDERESTIMA TION OF THE IMPORTANCE OF SEXUAL HEALTH HAS ON OVERALL HEALTH AND QUALITY OF LIFE

*/ / *Ê "1 /" Ê* ! LACK OF PATIENT (#0 COMMUNICATION IS A MAJOR REASON UNDERLYING THE FAILURE TO IDENTIFY FEMALE SEXUAL DISORDERS &3$S PARTICULARLY THE MOST PREV ALENT HYPOACTIVE SEXUAL DESIRE DISORDER (3$$ (ESITANCY TO DISCUSS SEXUAL PROBLEMS EXISTS FOR BOTH THE PATIENT AND THE PHYSICIAN 0ATIENTS REA SONS FOR RELUCTANCE INCLUDE CONCERNS ABOUT EMBAR RASSING THEIR PHYSICIAN BELIEF THAT THEIR PHYSICIAN WAS UNINTERESTED AND LACK OF AVAILABLE TREATMENTS (#0SDISINCLINATION MAY STEM FROM A VARIETY OF SOURCES 'IVEN THEIR LACK OF SEXUAL MEDICINE EDUCA TION IN MEDICAL SCHOOL AND RESIDENCY THEY OFTEN FEEL INADEQUATELY TRAINED TO ADDRESS SEXUAL PROBLEMS &URTHERMORE MEDICAL SCHOOL EDUCATION DOES NOT TYPICALLY INCLUDE KNOWLEDGE OF CULTURAL DIFFERENCES IN SEXUALITY NOR DOES IT ADEQUATELY TRAIN MEDI CAL STUDENTS IN COMMUNICATION SKILLS PARTICULARLY REGARDING SENSITIVE TOPICS SUCH AS SEXUALITY MUCH LESS TOPICS SUCH AS SEXUAL ORIENTATION OR MONOG AMY (#0S ARE ALSO CONCERNED ABOUT TIME CON STRAINTS AND WORRY THAT THEY MAY EMBARRASS THEIR PATIENTS BY DISCUSSING SEXUAL CONCERNS !N (#0S MISPERCEPTION THAT SEXUAL HEALTH IS NOT IMPORTANT TO OVERALL HEALTH MAY ALSO BE A BARRIER TO DISCUS SION 4HEY MAY NOT REALIZE THAT SEXUAL DISORDERS MAY BE A MARKER FOR OTHER UNDIAGNOSED COMORBID MEDICAL PROBLEMS AND MAY CAUSE COMORBID CON DITIONS SUCH AS DEPRESSION OR MAY BE THE CONSE QUENCE OF A SEXUAL TRAUMA WHICH IS ALSO UNDER THEIR PURVIEW TO ADDRESS $ESPITE THE REALITY OF THESE BARRIERS RECOG NIZING THE NATURE OF THESE BARRIERS AND IMPLE MENTING STRATEGIES TO OVERCOME THEM WILL ALLOW PHYSICIANS TO ADDRESS THE SEXUAL HEALTH NEEDS OF THEIR FEMALE PATIENTS #REATING AN ENVIRONMENT IN WHICH WOMEN ARE COMFORTABLE TALKING ABOUT SEXUAL PROBLEMS CAN BENEFIT BOTH PATIENT AND PHYSICIAN 7ITH APPROPRIATE EVALUATION AND MAN AGEMENT PHYSICIANS CAN ADDRESS MANY OF THEIR PATIENTS SEXUAL CONCERNS iLÀÕ>À ÞÊ Óä££

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" -Ê",Ê/ Ê Ê- 81Ê , -*" - )N ORDER FOR CLINICIANS TO ADDRESS SEXUAL DYS FUNCTION IT IS IMPORTANT FOR THEM TO UNDERSTAND WHAT CONSTITUTES FUNCTIONAL OR HEALTHY SEXUAL ITY )T IS HELPFUL TO CONSIDER THE EVOLVING THEORETI CAL MODELS OFFERED TO DESCRIBE A HEALTHY SEXUAL RESPONSE 4HESE VARYING MODELS ARE LINKED TO KEY CONCEPTUALIZATIONS OF DESIRE AND (3$$ 4HE TRADITIONAL LINEAR MODELS OF -ASTERS AND *OHNSON AND +APLAN AND ,EIF PROPOSE THAT SEXUAL RESPONSE IS LINEAR SUCH THAT DESIRE ALWAYS PRECEDES AROUSAL FOLLOWED BY ORGASM AND RESOLU TION AND THE ORDER OF THESE STAGES OF RESPONSE DO NOT VARY &IGURE "ASSON RECENTLY DEVELOPED A NON LINEAR MODEL OF FEMALE SEXUAL RESPONSE THAT INTEGRATES EMOTIONAL INTIMACY SEXUAL STIMULI AND RELATIONSHIP SATISFACTION &IGURE "ASSON SUGGESTS THAT THE LINEAR MODEL HAS A NUMBER OF LIMITATIONS INCLUDING WOMEN OFTEN CHOOSE TO BE SEXUAL FOR REASONS OTHER THAN SEXUAL DESIRE EG THE DESIRE TO EXPRESS LOVE TO RECEIVE AND SHARE PHYSICAL PLEASURE TO FEEL PHYSICAL PLEASURE TO FEEL EMOTIONALLY CLOSER TO PLEASE A PARTNER AND TO INCREASE A WOMANS OWN FEELINGS OF WELL BEING DESIRE AND AROUSAL ARE DIFFICULT TO DISENTANGLE AS DISTINCT ENTITIES PSYCHOLOGICAL MOTIVATION OFTEN OVERRIDES GENITAL SENSATION AND WOMENS SEXUAL RESPONSES ARE VARIABLE FROM ONE OCCASION TO ANOTHER NOTED THAT FOR MANY WOMEN

A SEXUAL ENCOUNTER MAY BEGIN WITHOUT ANY DESIRE INITIALLY PRESENT "ASSONS MODEL RECOGNIZES THAT FEMALE SEXUAL FUNCTIONING IS MORE COMPLEX AND IS NOT AS LINEAR AS MALE SEXUAL FUNCTIONING AND MANY WOMEN INITIALLY BEGIN A SEXUAL ENCOUNTER FROM A POINT OF SEXUAL NEUTRALITY 4HE DECISION TO BE SEXUAL MAY COME FROM A CONSCIOUS WISH FOR EMOTIONAL CLOSENESS OR AS A RESULT OF SEDUCTION OR SUGGESTION FROM A PARTNER 7OMEN HAVE MANY REASONS FOR ENGAGING IN SEXUAL ACTIVITY OTHER THAN SIMPLY SEXUAL DRIVE IE SEXUAL IMPULSES THAT TRIG GER SEXUAL BEHAVIOR 3EXUAL NEUTRALITY OR BEING RECEPTIVE TO RATHER THAN INITIATING SEXUAL ACTIVITY IS CONSIDERED A NOR MAL VARIATION OF FEMALE SEXUAL FUNCTIONING )N ADDI TION WOMENS AROUSAL WILL OFTEN PRECEDE DESIRE 4HESE THEORETICAL MODELS OF THE SEXUAL RESPONSE MAY REFLECT THE VARIATION THAT WOMEN EXPERIENCE IN SEXUALITY 3ANDS AND &ISHER DEM ONSTRATED THIS BY ASKING A SAMPLE OF NURSES VIA MAIL IN SURVEY TO ENDORSE THE MODEL THAT BEST FIT THEM !PPROXIMATELY ENDORSED THE -ASTERS AND *OHNSON MODEL ENDORSED +APLANS MODEL AND ENDORSED "ASSONS $ESIRE MODEL /F %XCITEMENTWITH SEXUAL $IVIDEDCONCERNS WERE MORE NOTE WOMEN !ROUSAL LIKELY TO ENDORSE THE "ASSON MODEL 0LATEAU

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DYNAMIC PROCESS THAT INVOLVES A BALANCE BETWEEN EXCITATORY AND INHIBITORY FACTORS 0ERLEMAN HAS LABELED THIS THE hSEXUAL TIPPING POINTv ! NUMBER OF SEX STEROIDS NEUROTRANSMIT TERS AND HORMONES HAVE IMPORTANT EXCITATORY OR INHIBITORY EFFECTS ON THE FEMALE SEXUAL RESPONSE 4HE EXCITATORY FACTORS INCLUDE ESTROGEN AND TES TOSTERONE AND THE NEUROTRANSMITTERS DOPA MINE AND NOREPINEPHRINE -ELANOCORTIN MORE SPECIFICALLY THE MELANOCORTIN RECEPTOR AND OXYTOCIN HAVE ALSO BEEN IMPLICATED AS EXCITATORY FACTORS )N CONTRAST SEROTONIN PROLACTIN AND ENDOGENOUS OPIOIDS ARE CONSIDERED TO HAVE INHIBITORY EFFECTS $ESIRE HAS BEEN HYPOTHESIZED TO BE TRIGGERED BY AREAS IN THE HYPOTHALAMUS AND ACTIVATION OF DOPAMINE SYSTEM 2ESEARCH SUGGESTS THAT THE DOPAMINE SYSTEM IS ACTIVATED EARLY IN THE SEXUAL RESPONSE AND MAY PLAY A ROLE IN ACTIVAT ING OTHER AREAS OF THE BRAIN INCLUDING THE LIMBIC SYSTEM $OPAMINE ALONG WITH NOREPINEPH RINE INCREASES SEXUAL EXCITATION AND THE DESIRE TO CONTINUE SEXUAL ACTIVITY 4HE NORADRENERGIC SYSTEM HAS BEEN HYPOTHESIZED TO BE INVOLVED IN SEXUAL AROUSAL BY INCREASING SENSE OF EXCITEMENT AS DEMONSTRATED BY INCREASED HEART RATE AND INCREASED SYSTOLIC AND DIASTOLIC BLOOD PRESSURE ASSOCIATED WITH SEXUAL EXCITEMENT 4HE NEUROBIOLOGY OF ORGASM REMAINS UNKNOWN #URRENT THEORIES HAVE IMPLICATED ACTIVATION OF THE MESOLIMBIC DOPAMINE PATHWAY DURING ORGASM AND THE PUDENDAL PELVIC AND HYPOGASTRIC NERVES /RGASM IS ASSOCIATED WITH THE RELEASE OF A NUMBER OF SUBSTANCES IN THE BRAIN INCLUDING ENDOGENOUS OPIOIDS SEROTONIN PROLACTIN AND OXYTOCIN )N ANIMAL MODELS RESOLUTION HAS BEEN SHOWN TO BE ASSOCIATED WITH AN INCREASE IN BRAIN SEROTONERGIC ACTIVITY AND A DECREASE IN DOPAMINE LEVELS

THE LEVATOR PLATE 4HE CLITORIS LENGTHENS AND WID ENS "LOOD FLOW TO THE VULVA RESULTS FROM ACTIVE NEUROGENIC DILATION OF SINUSOIDAL BLOOD SPACES IN THE CORPORAL TISSUE OF THE CLITORIS VESTIIBULAR BULBS AND SPONGIOSAL TISSUE SURROUNDING THE URE THRA !S WITH THE PENIS THE CORPORA CAVERNOSA OF THE CLITORIS CONSIST OF BUNDLES OF TRABECULAR SMOOTH MUSCLE AND A FIBROELASTIC NETWORK 0ELVIC NERVE STIMULATIONS RESULT IN CLITORAL SMOOTH MUS CLE RELAXATION AND ARTERIAL SMOOTH MUSCLE DILA TION !S A WOMAN BECOMES SEXUALLY AROUSED THE INCREASE IN CLITORAL ARTERY INFLOW RESULTING IN CLITORAL INTRACAVERNOSAL PRESSURE WHICH CAUSES TUMESCENCE AND PROTRUSION OF THE CLITORIS (OWEVER "ASSON PROVIDES A SLIGHTLY DIFFER ENT PERSPECTIVE NOTING THAT VULVAR STRUCTURES BECOME ENGORGED BUT THEY DO NOT BECOME ERECT BECAUSE THE THINNER TUNICA IN WOMEN DOES NOT TRAP VENOUS BLOOD AND THEREFORE IT POOLS WITH PERSISTENT INFLOW AND OUTFLOW 6AGINAL LUBRICATION RESULTS FROM ENGORGEMENT OF A NETWORK OF GENITAL VASCULATURE INCREASING THE PRESSURE INSIDE THE VAGINAL CAPILLARIES .ITRIC OXIDE IS THOUGHT TO BE AN IMPORTANT NEU ROTRANSMITTER IN SEXUAL RESPONSE POTENTIALLY RELATED TO CLITORAL VASOCONGESTION AND TUMESCENCE 3EXUAL STIMULATION TRIGGERS THE RELEASE OF NITRIC OXIDE WHICH STIMULATES THE RELEASE OF GUANYLATE CYCLASE 4HIS THEN CONVERTS GUANOSINE TRIPHOSPHATE INTO CYCLIC GUANOSINE MONOPHOSPHATE C'-0 3INCE THIS STIMULATES SMOOTH MUSCLE RELAXATION IN THE PENILE ARTERIES AND CORPORA CAVERNOSUM CAUSING BLOOD FLOW TO THE PENIS THE SAME MECHANISM MAY BE TRUE FOR CLITORAL VASOCONGESTION 6ASOACTIVE INTESTINGAL POLYPEPTITDE 6)0 PEPTIDE HISTIDINE METHIONINE HELSPECTIN NEUROPEPTIDE 9 SUBSTANCE 0 AND CALCITONIN GENE RELATED PEPTIDE HAVE ALSO BEEN IMPLICATED IN FEMALE GENITAL AROUSAL 1UESTIONS STILL OFTEN ARISE EVEN AMONG EXPERTS IN SEXUAL MEDICINE AS TO THE DIFFERENCE IF ANY BETWEEN A CLITORAL AND A VAGINAL ORGASM 4HE SHORT ANSWER IS THAT AN ORGASM IS THE SAME REGARDLESS OF WHERE STIMULATION OCCURS TO TRIG GER IT )N GENERAL THE CLITORIS IS MORE SENSITIVE TO STIMULATION THAN IS THE VAGINA AND THEREFORE MORE RELIABLY ABLE TO TRIGGER ORGASM WHEN STIMULATED (OWEVER IN SOME WOMEN VAGINAL STIMULATION MAY TRIGGER ORGASM OR IT MAY CREATE A SECONDARY STIMULATION OF THE CLITORIS !LSO SOME WOMEN ARE AWARE OF UTERINE CONTRACTIONS DURING ORGASM !N ADDITIONAL CONTROVERSY THAT SHOULD BE MEN TIONED HAS TO DO WITH THE h' 3POTv 3OME WOMEN DESCRIBE EXPERIENCING INTENSE SEXUAL PLEASURE

Ê- 81Ê /"9Ê Ê *9-""9 4HE FEMALE SEXUAL ANATOMY INCLUDES THE MONS PUBIS THE VULVA INCLUDING THE LABIA MAJORA LABIA MINORA INTERLABIAL SPACE CLITORIS AND THE VES TIBULAR BULB AND THE INNER GENITALIA INCLUDING THE VAGINA PERIURETHRAL GLAND UTERUS FALLOPIAN TUBES AND OVARIES 3EXUAL AROUSAL IN WOMEN RESULTS IN AN INCREASE IN BLOOD FLOW TO THE GENITALS RESULT ING IN SWELLING OF THE LABIA AND VAGINAL WALL AND LUBRICATING SECRETIONS FROM THE UTERINE GLANDS AND TRANSUDATE FROM THE SUBEPITHELIAL VASCULA TURE 4HE VAGINA LENGTHENS AND DILATES TO ACCOM MODATE PENETRATION WHILE THE UTERUS RISES OVER


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AND ORGASM FROM STIMULATION OF A SENSITIVE SPOT OR AREA FELT THROUGH THE ANTERIOR WALL OF THE VAGINA APPROXIMATELY HALFWAY BETWEEN THE BACK OF THE PUBIC BONE AND THE CERVIX ALONG THE COURSE OF THE URETHRA 4HIS AREA WAS FIRST DESCRIBED BY 'RAFENBERG AND WAS NAMED THE ' 3POT IN HIS HONOR BY ,ADAS AND COLLEAGUES (OWEVER THE SCIENTIFIC EVIDENCE SUPPORTING THE EXISTENCE OF SUCH AN ANATOMICAL AREA REMAINS EQUIVOCAL AND IS STILL A HOTLY DEBATED TOPIC

AS SEXUAL PROBLEMS TEND TO OVERLAP IE IT IS NOT UNCOMMON FOR LACK OF DESIRE TO RESULT IN DIFFICUL TIES IN AROUSAL AND ORGASM !LTHOUGH THIS OVER LAP MAY APPEAR CONFUSING THE BEST APPROACH IS TO IDENTIFY THE PRIMARY OR MOST SIGNIFICANT PROB LEM AND FOCUS INITIAL TREATMENT IN THAT DIRECTION

- (3$$ IS DEFINED IN THE $3- )6 42 AS PERSISTENT OR RECURRENT DEFICIENT OR ABSENT SEXUAL FANTASIES THOUGHTS ANDOR DESIRE FOR SEXUAL ACTIVITY 4HE JUDG MENT OF DEFICIENCY IS SUBJECTIVE AND MADE WHEN THE LACK OF DESIRE IS CONSIDERED TO BE BEYOND THE NORMAL REDUCTION EXPECTED WITH RELATIONSHIP DURA TION AND AGE AND FACTORS IN HEALTH AND PERSONAL LIFE CIRCUMSTANCES 0REVALENCE ESTIMATES VARY DEPEND ING ON THE POPULATION SURVEY CONDUCTED 3EGRAVES AND 7OODARD SUGGEST THE PREVA LENCE OF (3$$ VARIES BETWEEN AND 7EST AND COLLEAGUES REPORTED AN PREVA LENCE OF (3$$ BASED ON A NATIONALLY REPRESENTA TIVE SAMPLE OF ^ 5NITED 3TATES WOMEN 4HE 0REVALENCE OF &EMALE 3EXUAL 0ROBLEMS !SSOCIATED WITH $ISTRESS AND $ETERMINANTS OF 4REATMENT 3EEKING 02%3)$% SURVEY OF WOMEN YEARS OF AGE INCLUDED A VERY LARGE REPRESENTA TIVE 53 SAMPLE THAT WAS ANALYZED BY AGE GROUP AND INCLUDED A VALIDATED DISTRESS SCALE THE FEMALE SEXUAL DISTRESS SCALE REVISED ;&3$3 2= 3INCE DISTRESS IS A CRITICAL CRITERIA FOR A DIAGNOSIS OF A SEXUAL DISORDER 02%3)$% NOT ONLY PROVIDES PREVALENCE OF WOMEN WHO REPORT HAVING A PROB LEM BUT ALSO WOMEN WHO REPORT ASSOCIATED DIS TRESS WHICH COULD BE A SURROGATE FOR ESTIMATING THOSE WHO HAVE A DISORDER 7HILE OF WOMEN REPORTED HAVING HAD A SEXUAL PROBLEM WHEN DIS TRESS WAS ALSO INCLUDED AND ANALYZED BY AGE THE RESULTS INDICATE OF WOMEN n YEAR OF AGE HAD LOW DESIRE AND DISTRESS OF WOMEN n YEARS OF AGE AND OF WOMEN YEARS OF AGE4HE 7OMENS )NTERNATIONAL 3TUDY OF (EALTH AND 3EXUALITY 7)3(E3 INCLUDED WOMEN n YEARS OF AGE FROM THE 53 AND %UROPE 7)3(E3 INDICATED A PREVALENCE OF (3$$ DEFINED AS LOW SEXUAL DESIRE AND PERSONAL DISTRESS AND BASED ON OBJECTIVE MEASURES AS RANGING FROM TO IN 53 WOMEN 4HE PREVALENCE OF (3$$ WAS IN PREMENOPAUSAL WOMEN IN NATURALLY MENO PAUSAL WOMEN IN SURGICALLY MENOPAUSAL WOMEN n YEARS OF AGE AND IN SURGICALLY POSTMENOPAUSAL WOMEN n YEARS OF AGE 7OMEN OFTEN PRESENT WITH THE COMPLAINT OF LOSS OF DESIRE BUT HAVE LIMITED INSIGHT INTO HOW

/ Ê Ê- 81Ê -", ,-\Ê Ê"6 ,6 7Ê"Ê -- /" ]Ê *, 6

Ê Ê/, / / !CCORDING TO THE $IAGNOSTIC AND 3TATISTICAL -ANUAL OF -ENTAL $ISORDERS &OURTH %DITION 2EVISED THERE ARE SIX SEXUAL DISORDERS WHICH ENCOMPASS DYSFUNCTIONS ACROSS THE SEXUAL RESPONSE CYCLE 4ABLE &OUR OF THE DISORDERS ENCOMPASS THE SEXUAL RESPONSE TWO DYSPAREU NIA AND VAGINISMUS DO NOT 4HE $3- )6 42 FUR THER SPECIFIES THAT IN ORDER TO MAKE THE DIAGNOSIS OF A SEXUAL DISORDER THE SYMPTOMS MUST CAUSE PERSONAL DISTRESS OR INTERPERSONAL DIFFICULTIES %ACH DISORDER IS FURTHER SUBTYPED INTO LIFELONG VERSUS ACQUIRED AND GENERALIZED VERSUS SITUA TIONAL !LTHOUGH EACH DISORDER IS DISTINCT IN CLINI CAL PRACTICE THERE IS A GREAT DEAL OF COMORBIDITY / Ê£°

-6/,Ê >ÃÃvV>ÌÃÊ vÊ i>iÊ -iÝÕ>Ê ÞÃvÕVÌÃÎ 3EXUAL $ESIRE $ISORDERS (YPOACTIVE 3EXUAL $ESIRE $ISORDER !BSENCE OR DEFICIENCY OF SEXUAL FANTASIES ANDOR DESIRE 3EXUAL !VERSION $ISORDER !VERSION TO AND AVOIDANCE OF GENITAL SEXUAL CONTACT WITH A PARTNER 3EXUAL !ROUSAL $ISORDER &EMALE 3EXUAL !ROUSAL $ISORDER )NABILITY TO ATTAIN OR MAINTAIN ADEQUATE LUBRICATIONSWELLING RESPONSE OF SEXUAL EXCITEMENT /RGASMIC $ISORDER &EMALE /RGASMIC $ISORDER $ELAY IN OR ABSENCE OF ORGASM AFTER A NORMAL SEXUAL EXCITEMENT PHASE 0AIN $ISORDERS $YSPAREUNIA 'ENITAL PAIN ASSOCIATED WITH SEXUAL PENETRATION INTERCOURSE 6AGINISMUS )NVOLUNTARY CONTRACTION OF THE PERINEAL MUSCLES PREVENTING VAGINAL PENETRATION +INGSBERG 3! +NUDSON ' #.3 3PECTR 6OL .O


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WHEN OR WHY THE PROBLEM OCCURRED 4HIS LEAVES PATIENTS AND CLINICIANS FRUSTRATED AND CONFUSED $ESIRE IS A SURPRISINGLY COMPLEX CONCEPT THAT REQUIRES DELINEATING THE COMPONENTS THAT COM PRISE DESIRE IN ORDER TO RECOGNIZE THE ETIOLOGY OF THE PROBLEM AND TO DEVELOP A TREATMENT PLAN 4HE BIOPSYCHOSOCIAL MODEL OF DESIRE SUGGESTED BY ,EVINE INDICATES THAT DESIRE IS COMPRISED OF THREE DISCRETE BUT INTERRELATED COMPONENTS 4HE FIRST COMPONENT IS A BIOLOGICAL COMPONENT LABELED DRIVE $RIVE IS DETERMINED BY NEUROENDO CRINE MECHANISMS AND EVIDENCED AS SPONTANEOUS SEXUAL INTEREST 5NPROMPTED SEXUAL THOUGHTS FANTASIES DREAMS OR SENSATIONS SUCH AS GENI TAL TINGLING ARE SIGNS OF DRIVE $RIVE IS VARIABLE BETWEEN INDIVIDUALS AND ALSO MAY VARY OVER TIME SUCH THAT IT NORMALLY DECLINES WITH AGE IN BOTH MEN AND WOMEN 4HE SECOND COMPONENT REFLECTS A PERSONS EXPECTATIONS BELIEFS AND VALUES ABOUT SEX AND IS LABELED hEXPECTATIONSBELIEFSVALUESv 4HE THIRD COMPONENT IS THE EMOTIONAL OR INTERPER SONAL COMPONENT AND CHARACTERIZED BY THE WILL INGNESS OF A PERSON TO ENGAGE IN SEXUAL ACTIVITY AND IS LABELED MOTIVATION -OTIVATION IS IMPACTED BY THE QUALITY OF A RELATIONSHIP PSYCHOLOGICAL FUNCTIONING AND CONCERNS ABOUT HEALTH CHILDREN AND OTHER PSYCHOSOCIAL FACTORS / ÊÓ°

i`V>ÌÃÊ Ì>ÌÊ }ÌÊ >ÕÃiÊ -iÝÕ>Ê -ìÊ vviVÌÃ{Çx£ÊÊ

-iÝÕ>ÊÛiÀÃÊ ÃÀìÀ 4HE $3- )6 42 DEFINES SEXUAL AVERSION DIS ORDER AS THE PERSISTENT OR RECURRENT AVERSIVE RESPONSE TO ANY GENITAL CONTACT WITH A SEXUAL PARTNER AND EMPHASIZES THE ROLE OF AVOIDANCE !LTHOUGH THIS DISORDER IS PROBABLY BEST CONCEPTU ALIZED AS A PHOBIA SEXUAL AVERSION ALSO INCLUDES ELEMENTS OF REVULSION AND DISGUST THAT ARE NOT AS COMMON IN SIMPLE PHOBIAS )NFORMATION REGARD ING ETIOLOGY AND PREVALENCE IS VERY LIMITED OTHER THAN THE KNOWLEDGE THAT IT IS A LIFELONG OR ACQUIRED CONDITIONED RESPONSE IS OFTEN ASSOCIATED WITH A HISTORY OF SEXUAL TRAUMA OR ABUSE AND IT AFFECTS MORE WOMEN THAN MEN )NTERVENTIONS ARE INVARIABLY PSYCHOLOGICAL TYPI CALLY COGNITIVE BEHAVIORAL PSYCHOTHERAPY AND OFTEN FACILITATED BY PSYCHOTROPIC MEDICATIONS EG ANTIDE PRESSANTS #OGNITIVE BEHAVIORAL STRATEGIES INCLUDE A GRADUATED EXPOSURE PARADIGM IN WHICH PATIENTS PAIR RELAXATION EXERCISES WITH A GRADED AND PATIENT CONTROLLED REINTRODUCTION OF SEXUAL BEHAVIOR

!NTIDEPRESSANTS AND -OOD 3TABILIZERS 332)S 3.2)S 4#!S AND -!/)S !NTIPSYCHOTICS !NTIEPILEPTICS AND BENZODIAZEPINES !NTIHYPERTENSIVES ` BLOCKERS _ BLOCKERS AND DIURETICS #ARDIOVASCULAR AGENTS ,IPID LOWERING AGENTS AND DIGOXIN ( RECEPTOR BLOCKERS (ORMONES /RAL CONTRACEPTIVES ESTROGENS PROGESTINS ANTIANDROGENS AND 'N2( AGONISTS .ARCOTICS !MPHETAMINES !NTICONVULSANTS 3TEROIDS +INGSBERG 3! +NUDSON ' #.3 3PECTR 6OL .O


,ÃÊ>VÌÀÃÊi`ÊÌÊ- Ê (EALTH STATUS AND MEDICAL HISTORY OFTEN CONTRIB UTE TO SEXUAL FUNCTION ! NUMBER OF DISEASES AND PHYSICAL CONDITIONS HAVE BEEN LINKED TO SEXUAL PROBLEMS PARTICULARLY (3$$ INCLUDING MANY CAN CERS NOTABLY BREAST AND GYNECOLOGICAL CANCERS AND THEIR TREATMENTS PREGNANCY DEPRESSION DIA BETES URINARY INCONTINENCE MULTIPLE SCLEROSIS AND AUTOIMMUNE DISORDERS -EDICATION SIDE EFFECTS HAVE BEEN KNOWN TO LOWER DESIRE AND NEG ATIVELY IMPACT ORGASMIC ATTAINMENT 4ABLE -ENOPAUSE HAS LONG BEEN ASSUMED TO RESULT IN (3$$ AS A RESULT OF BIOLOGICAL FACTORS AGING LEAD ING TO DECLINING SEX STEROIDS (OWEVER RECENT LONGITUDINAL STUDIES SUGGEST THAT RELATIONSHIP FACTORS AND OTHER NONBIOLOGICAL CHANGES HAVE A STRONGER IMPACT ON SEXUAL DESIRE THAN DOES AGE OR MENOPAUSE ALONE .EVERTHELESS MENOPAUSE PARTICULARLY SURGICAL MENOPAUSE MAY NEGATIVELY IMPACT SOME WOMENS SEXUAL DESIRE PRIMARILY DUE TO THE SIGNIFICANT AND OFTEN SUDDEN WITH SUR GICAL OR CHEMICAL MENOPAUSE DECLINE IN TESTOS TERONE LEVELS 4ESTOSTERONE IS OFTEN NECESSARY FOR A NORMAL SEX DRIVE IN BOTH MEN AND WOMEN AND PLAYS A ROLE IN MOTIVATION DESIRE AND SEXUAL SENSATION 7OMEN ACHIEVE THEIR PEAK ANDROGEN PRODUCTION IN THEIR MID TWENTIES "Y THEIR S WOMEN ARE ALREADY GRADUALLY LOSING TESTOSTER ONE !T YEARS OF AGE WOMEN WILL NOW HAVE ABOUT HALF THE TESTOSTERONE THEN THEY HAD WHEN THEY WERE IN THEIR S

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i>iÊ-iÝÕ>ÊÀÕÃ>Ê ÃÀìÀ &EMALE SEXUAL AROUSAL DISORDER &3!$ IS DEFINED AS THE INABILITY TO ATTAIN OR MAINTAIN AN ADEQUATE LUBRICATION SWELLING RESPONSE OF SEXUAL EXCITEMENT !BSENT OR IMPAIRED GENITAL RESPON SIVENESS TO SEXUAL STIMULATION IS THE CENTRAL $3- )6 42 DIAGNOSTIC CRITERION 4HE .ATIONAL (EALTH AND 3OCIAL ,IFE 3URVEY FOUND THAT OF WOMEN REPORTED A LACK OF VAGINAL LUBRICATION DURING SEX UAL STIMULATION !CCORDING TO THE 02%3)$% SUR VEY AROUSAL PROBLEMS ASSOCIATED WITH DISTRESS WERE FOUND IN OF WOMEN n YEARS OF AGE IN WOMEN n YEAR OF AGE AND IN WOMEN YEARS OF AGE !CCORDING TO THE !MERICAN &OUNDATION FOR 5ROLOGIC $ISEASE !&5$ CONSENSUS PANEL &3!$ MAY BE BETTER UNDERSTOOD BY USING THE FOLLOW ING SUBTYPES SUBJECTIVE SEXUAL AROUSAL DISORDER GENITAL SEXUAL AROUSAL DISORDER COMBINED GENITAL AND SUBJECTIVE AROUSAL DISORDER -ÕLiVÌÛiÊ-iÝÕ>ÊÀÕÃ>Ê ÃÀìÀÊ 3UBJECTIVE SEXUAL AROUSAL DISORDER IS DEFINED AS THE hABSENCE OR MARKEDLY DIMINISHED FEEL INGS OF SEXUAL AROUSAL SEXUAL EXCITEMENT AND SEXUAL PLEASURE FROM ANY TYPE OF SEXUAL STIMULA TION 6AGINAL LUBRICATION OR OTHER SIGNS OF PHYSICAL RESPONSE STILL OCCURv iÌ>Ê-iÝÕ>ÊÀÕÃ>Ê ÃÀìÀÊ 'ENITAL SEXUAL AROUSAL DISORDER IS DEPICTED AS h!BSENT OR IMPAIRED GENITAL SEXUAL AROUSALv 3ELF REPORT MAY INCLUDE MINIMAL VULVAR SWELLING OR VAGINAL LUBRICATION FROM ANY TYPE OF SEXUAL STIMULATION AND REDUCED SEXUAL SENSATIONS FROM CARESSING GENITALS 3UBJECTIVE SEXUAL EXCITEMENT STILL OCCURS FROM NONGENITAL STIMULI 4HIS SUBTYPE WOULD MORE TYPICALLY BE FOUND IN WOMEN WITH AUTONOMIC NERVE DAMAGE AND ESTROGEN DEFI CIENCY WHO DO NOT DEMONSTRATE VASOCONGESTION 4HESE WOMEN WILL REPORT SUBJECTIVE AROUSAL BUT HAVE A MARKED LOSS OF INTENSITY OF ANY GENITAL RESPONSE INCLUDING ORGASM

Li`ÊiÌ>Ê>`Ê-ÕLiVÌÛiÊÀÕÃ>Ê ÃÀìÀÊ #OMBINED GENITAL AND SUBJECTIVE AROUSAL DISOR DER IS THE MOST COMMON CLINICAL PRESENTATION FOR AN AROUSAL DISORDER AND IS DEFINED AS h!BSENCE 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 VUL VAR SWELLING LUBRICATION v


i>iÊ"À}>ÃVÊ ÃÀìÀ &EMALE ORGASMIC DISORDER AS DEFINED IN THE $3- )6 42 IS THE PERSISTENT OR RECURRENT DELAY IN OR ABSENCE OF ORGASM FOLLOWING SUFFICIENT SEXUAL STIMULATION AND AROUSAL !CCORDING TO THE 02%3)$% RESULTS THE PREVALENCE OF ORGASMIC DIS ORDER IS IN WOMEN n YEARS OF AGE IN WOMEN n YEARS OF AGE AND IN WOMEN YEARS OF AGE /RGASM IS BEST UNDERSTOOD AS A TRANSIENT PEAK SENSATION OF INTENSE PLEASURE ACCOMPANIED BY RHYTHMIC CONTRACTIONS OF THE PERINEAL BULBOCAVERNOSUS AND PUBOCOCCYGEUS MUSCLES 4HE ORGASMIC REFLEX CENTER IS SUBJECT TO MULTIPLE INHIBITORY AND FACILITORY INFLUENCES FROM DIRECT SENSORY INPUT AND HIGHER NEURAL CENTERS )T IS CONSIDERED A NORMAL VARIATION IN FEMALE SEX UAL FUNCTION FOR WOMEN TO BE SITUATIONALLY ORGAS MIC 4HAT IS MANY WOMEN CAN ACHIEVE ORGASM READILY AND RELIABLY WITH SOME PARTICULAR FORMS OF STIMULATION BUT NOT OTHERS &OR EXAMPLE A WOMAN MAY BE RELIABLY ORGASMIC WITH MANUAL STIMULATION OR CUNNILINGUS BUT NOT WITH INTERCOURSE 4HE CAUSE OF ORGASMIC DIFFICULTIES IS LIKELY MULTI FACTORIAL AND DIFFERS FOR EACH WOMAN 4HE ETIOLOGY OF LIFE LONG ORGASMIC DISORDER MAY BE DISTINCT FROM THE ETIOLOGY OF SECONDARY ORGAS MIC DISORDER -ANY WOMEN DEVELOP PERFORMANCE ANXIETY AROUND HAVING AN ORGASM WITH A PART NER 3IMILARLY SOME WOMEN ARE RELIABLY ORGASMIC WITH MASTURBATION BUT ARE SELF CONSCIOUS WITH A PARTNER AND THIS INTERFERES WITH ORGASMIC ATTAIN MENT 0SYCHOSOCIAL FACTORS INCLUDING AGE SOCIAL CLASS PERSONALITY AND RELATIONSHIP STATUS HAVE ALSO BEEN RELATED TO ORGASMIC ABILITY -ANY MEN AND WOMEN DO NOT ACTUALLY KNOW WHERE THE CLITO RIS OR OTHER EROGENOUS ZONES ARE LOCATED AND THIS LACK OF KNOWLEDGE OF BASIC GENITAL ANATOMY MAY CONTRIBUTE TO ORGASMIC DIFFICULTIES ÞÃ«>ÀiÕ> 4HE $3- )6 42 DEFINES DYSPAREUNIA AS PERSIS TENT RECURRENT UROGENITAL PAIN OCCURRING BEFORE DURING OR AFTER SEXUAL INTERCOURSE THAT IS NOT CAUSED EXCLUSIVELY BY LACK OF LUBRICATION OR BY VAGINISMUS (OWEVER THERE IS CONSIDERABLE CON TROVERSY OVER THIS DEFINITION AND THE CONCEPT OF UROGENITAL PAIN BEING A SEXUAL DISORDER #URRENT PERSPECTIVES TEND TO CHARACTERIZE DYSPAREUNIA AS A PAIN DISORDER THAT INTERFERES WITH SEXUALITY RATHER THAN AS A SEXUAL DISORDER CHARACTERIZED BY PAIN &URTHERMORE DYSPAREUNIA AS A PAIN DISOR DER HAS MULTIPLE POTENTIAL ETIOLOGIES WITH INTERDE PENDENT PSYCHOLOGICAL AND BIOLOGICAL CONTRIBUTING 55


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FACTORS )DENTIFYING THE INITIATING AND MAINTAINING FACTORS IS NOT ONLY HELPFUL TO THE DIAGNOSIS BUT ALSO TO DETERMINING TREATMENT OPTIONS $ESIRE#OMMON UNDERLYING CONDITIONS$IVIDED INCLUDE VAGINISMUS VUL %XCITEMENT !ROUSAL VOVAGINAL ATROPHY INADEQUATE LUBRICATION AND 0LATEAU VULVODYNIA 5RETHRAL DISORDERS CYSTITIS AND INTER STITIAL /RGASM CYSTITIS MAY ALSO RESULT IN PAIN WITH SEXUAL PENETRATION ,ESS COMMON BUT POSSIBLE CONTRIB 2ESOLUTION INCLUDE INFECTIONS ENDOMETRIOSIS UTING PROBLEMS AND PELVIC CONGESTION ,INEAR PROGRESSION 7HEN CONSIDERING ETIOLOGY IT IS IMPORTANT TO RECOGNIZE THAT EVEN IF THE DYSPAREUNIA IS FOUND TO HAVE A PRIMARILY ORGANIC ETIOLOGY THERE ARE TYPI CALLY CONCURRENT PSYCHOLOGICAL OR BEHAVIORAL CON TRIBUTIONS SUCH AS ANXIETY OR DISTRESS RELATED TO A HISTORY OF ABUSE !LSO MANY PSYCHOLOGICAL FAC TORS HELP TO MAINTAIN THE SYMPTOM OF PAIN SUCH AS ANTICIPATORY ANXIETY RESULTING IN AVOIDANCE OF INTERCOURSE OR NEGATIVE SEXUAL EXPECTATIONS THAT HELP TO MAINTAIN THE PAIN 4HIS CYCLE OF PAIN OFTEN /UT RESULTS IN CONCURRENT %MOTIONAL LOSS OF DESIRE AND3EEKING AROUSAL AND "EING PROBLEMS THAT THEN PERPETUATE THE PROBLEM )NTIMACY 2ECEPTIVE BY TO %MOTIONAL AND WORSENING OF PAIN OVER TIME

ON %RECTILE AND 3EXUAL $YSFUNCTION h4HE PER SISTENT OR RECURRENT DIFFICULTIES OF THE WOMAN TO ALLOW VAGINAL ENTRY OF A PENIS A FINGER AND OR ANY OBJECT DESPITE THE WOMANS EXPRESSED WISH TO DO SO 4HERE IS OFTEN PHOBIC AVOIDANCE AND ANTICIPATIONFEAR OF PAIN 3TRUCTURAL OR PHYSICAL ABNORMALITIES MUST BE RULED OUTADDRESSEDv 4HIS COMMITTEE ALSO REPORTED PREVALENCE RATES TO RANGE BETWEEN TO !LTHOUGH CATEGORIZED UNDER PAIN DISORDERS MANY WOMEN WITH VAGINISMUS MAY NOT FEEL PAIN PARTICULARLY IF THERE HAS NEVER BEEN ANY PENETRA TION (OWEVER IT IS THE CASE THAT VAGINISMUS IS TYPICALLY THE RESULT OF THE ANTICIPATION OF PAIN !LTHOUGH VAGINISMUS REFLECTS ANTICIPATORY ANXIETY FOR WANTED SEXUAL PENETRATION MANY WOMEN ALSO HAVE ASSOCIATED MUSCLE TIGHTENING AND FEAR DUR ING PELVIC EXAMS AS WELL

/ /" Ê Ê-- --- /Ê "Ê- 81Ê*," .UMEROUS BARRIERS EXIST THAT INTERFERE WITH PATIENT PHYSICIAN COMMUNICATION REGARDING SEX UAL FUNCTION 3TUDIES HAVE SHOWN THAT PATIENTS ARE RELUCTANT TO INITIATE SUCH DISCUSSIONS CITING EMBARRASSMENT AND FEAR OF EMBARRASSING THEIR PHYSICIAN BUT VERY MUCH WANT THEIR (#0 TO OPEN THE DIALOGUE $IRECT QUESTIONING IS CRITICAL TO UNCOVERING PATIENTS SEXUAL CONCERNS AND IT HAS BEEN DEMONSTRATED THAT TRAINING IN COMMU NICATION SKILLS IS THE BEST PREDICTOR THAT A PHYSI CIAN WILL TAKE A SEXUAL HISTORY %STABLISHING A RAPPORT AND SIGNALING THAT YOU ARE COMFORTABLE DISCUSSING SEXUAL HEALTH CONCERNS SETS UP AN APPROPRIATE ENVIRONMENT FOR SUCH A DISCUSSION "ELIEFS THAT ADDRESSING SEXUAL CONCERNS DUR ING AN OFFICE VISIT REQUIRES AN EXCESSIVE AMOUNT OF TIME ARE NOT WELL FOUNDED )NQUIRING ABOUT SEXUAL FUNCTION CAN BE INCORPORATED ALMOST ANY WHERE IN AN OFFICE VISIT 4AKING A SEXUAL HISTORY DURING A NEW PATIENT VISIT PROVIDES IMPORTANT INFORMATION FOR THE CLINICIAN AS WELL AS INDICAT ING TO A PATIENT THAT DISCUSSING SEXUAL CONCERNS IS APPROPRIATE AND AN IMPORTANT PART OF THEIR HEALTH 2OUTINE OFFICE VISITS AS WELL AS VISITS FOR HEALTH RELATED CONDITIONS ARE ALSO APPROPRIATE AND ASSESSMENT CAN BE INCLUDED IN THE REVIEW OF SYSTEMS $EVELOPMENTAL MILESTONES OR MAJOR LIFE EVENTS EG MENARCHE MARRIAGE POSTPARTUM MENOPAUSE MAY CARRY SOME RISK FOR THE DEVEL OPMENT OF SEXUAL PROBLEMS !CKNOWLEDGING THIS OPENS THE DOOR TO A DISCUSSION OF SEXUAL CON CERNS !NY OFFICE VISIT CAN INCLUDE A BRIEF ASSESS

0HYSICAL 3ATISFACTION

3EXUAL 3PONTANEOUS 6>}ÃÕÃ 3TIMULI 3EXUAL $RIVE 4HE $3- )6 42 DEFINES VAGINISMUS AS INVOLUN !ROUSAL AND TARY 3EXUAL RECURRENT AND PERSISTENT SPASM OF THE OUTER $RIVE THIRD OF THE VAGINAL MUSCULATURE THAT INTERFERES "IOLOGIC 3EXUAL !ROUSAL WITH VAGINAL PENETRATION (OWEVER THE DEFINI 0SYCHOLOGICAL TION HAS BEEN CRITICIZED AS BEING INACCURATE PAR TICULARLY AS TO WHETHER THE MUSCULATURE ACTUALLY SPASM !LTERNATE DEFINITIONS HAVE BEEN PROPOSED INCLUDING THE FOLLOWING FROM AN EXPERT COMMITTEE CONVENED AT THE ND )NTERNATIONAL #ONSULTATION

1, ÊÎ°

ÀivÊÃVÀii}ÊvÀÊ- s ,EGITIMIZE THE IMPORTANCE OF ASSESSING SEXUAL FUNCTION s .ORMALIZE AS PART OF THE USUAL HISTORY AND PHYSICAL

s 7HAT CONCERNS OR QUESTIONS DO YOU HAVE ABOUT YOUR SEXUAL FUNCTIONING .ONE s !RE YOU CURRENTLY IN A SEXUAL RELATIONSHIP s $O YOU HAVE DIFFICULTY WITH DESIRE AROUSAL OR ORGASM s )F YOU ARE NOT CURRENTLY SEXUAL ARE THERE ANY PARTICULAR PROBLEMS THAT ARE CONTRIBUTING TO YOUR LACK OF SEXUAL BEHAVIOR

s 0LEASE FEEL FREE TO ASK IN THE FUTURE

+INGSBERG 3! *ANATA *7 5ROL #LIN .ORTH AM !DAPTED WITH PERMISSION +INGSBERG 3! +NUDSON ' #.3 3PECTR 6OL .O


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MENT OF SEXUAL FUNCTION 4HE QUESTIONS LISTED IN &IGURE 88 ARE SUFFICIENT FOR AN INITIAL SCREEN FOR SEXUAL PROBLEMS )F SCREENING SUGGESTS THE PRESENCE OF A SEXUAL PROBLEM OR DISORDER A DIAGNOSIS CAN BE ESTAB LISHED BY INCLUDING A MORE THOROUGH EVALUATION OF THE PATIENTS PAST MEDICAL HISTORY A COM PREHENSIVE SEXUAL ASSESSMENT PERFORMING A PHYSICAL EXAMINATION AND IF A MEDICAL PROBLEM APPEARS TO BE A POTENTIAL ETIOLOGIC FACTOR CON DUCTING SELECTED LABORATORY TESTS 4HE MEDICAL HISTORY SHOULD INCLUDE A PATIENTS CURRENT HEALTH STATUS HER REPRODUCTIVE HISTORY THE PRESENCE OF ANY ENDOCRINE NEUROLOGIC CARDIOVASCULAR OR PSYCHIATRIC DISORDERS AND CURRENT USE OF PRESCRIP TION AND OVER THE COUNTER MEDICATIONS 4ABLE LISTS MEDICATIONS KNOWN TO CAUSE SEXUAL SIDE EFFECTS )T IS ALSO IMPORTANT THAT THE (#0 ASK ABOUT THE GENDER OF PARTNERS AND NOT MAKE ASSUMPTIONS OR MAKE IT UNCOMFORTABLE FOR WOMEN WHO HAVE SEX WITH WOMEN TO DISCLOSE THIS .OT ALL PATIENTS ARE HETEROSEXUAL OR BEHAVE HETEROSEXUALLY EVEN IF THEY LABEL THEMSELVES AS SUCH ! COMPREHENSIVE SEXUAL HISTORY AND ASSESS MENT SHOULD FOCUS ON SPECIFYING THE COMPONENTS

OF THE SEXUAL RESPONSE THAT ARE COMPROMISED +EY INFORMATION TO COLLECT IN THE SEXUAL ASSESSMENT IS LISTED IN 4ABLE !NSWERS TO THESE QUESTIONS HELP DETERMINE WHICH COMPONENTS OF THE SEXUAL RESPONSE ARE COMPROMISED ETIOLOGY AND CAN OFTEN SERVE AS THE BASIS FOR TREATMENT CONSIDERATIONS ! PATIENTS HISTORY MAY NOT BE SUFFICIENT TO ASSESS HER SEXUAL FUNCTION AND A PHYSICAL EXAMI NATION ANDOR LABORATORY TESTING MAY HELP IN DETERMINING THE PHYSIOLOGIC FACTORS INVOLVED IN A SEXUAL COMPLAINT 4HERE ARE A NUMBER OF VALIDATED SCALES FOR USE IN OFFICE BASED PRACTICES THAT ARE HELPFUL IN SCREEN ING ANDOR DIAGNOSING SEXUAL DISORDERS 4ABLE 4HE &EMALE 3EXUAL &UNCTION )NDEX &3&) IS A BRIEF MULTIDIMENSIONAL SELF REPORT INSTRUMENT FOR ASSESSING KEY DIMENSIONS OF SEXUAL FUNCTION IN WOMEN 4HE &3&) CONSISTS OF ITEMS THAT MEA SURE SEXUAL FUNCTION OVER THE PAST FOUR WEEKS AND PROVIDES DOMAIN SCORES IN SIX AREAS SEXUAL DESIRE AROUSAL LUBRICATION ORGASM SATISFACTION AND PAIN 4HE &3&) IS FREQUENTLY USED IN CLINICAL TRIALS AND IS BECOMING THE GOLD STANDARD FOR THE EVALUATION OF WOMEN WITH SEXUAL PROBLEMS 4HE 0ROFILE OF &EMALE 3EXUAL &UNCTION 0&3& IS A SELF ADMINISTERED QUESTIONNAIRE MEASURING LOSS OF SEXUAL DESIRE AND RELATED ASPECTS OF SEXUAL FUNCTION IN POSTMENOPAUSAL WOMEN WITH (3$$ 4HE 0&3& MEASURES SEVEN DOMAINS INCLUDING DESIRE AROUSAL ORGASM PLEASURE SEXUAL CON CERNS RESPONSIVENESS AND SEXUAL SELF IMAGE 4HE $ECREASED 3EXUAL $ESIRE 3CREENER WAS SPECIFICALLY DEVELOPED FOR USE BY CLINICIANS NOT NECESSARILY TRAINED IN SEXUAL MEDICINE TO HELP THEM IDENTIFY GENERALIZED ACQUIRED (3$$ IN PRE PERI AND POSTMENOPAUSAL WOMEN IN A TIME EFFI CIENT MANNER

/ ÊÎ°

iÞÊ +ÕiÃÌÃÊ ÌÊ VÕìÊ Ê >Ê -iÝÕ>Ê ÃÃiÃÃiÌÊ Èx]ÈÈÊÊ (OW DOES THE PATIENT DESCRIBE THE PROBLEM (OW LONG HAS THE PROBLEM BEEN PRESENT 7AS THE ONSET SUDDEN OR GRADUAL )S THE PROBLEM SPECIFIC TO A SITUATIONPARTNER OR IS IT GENERALIZED 7ERE THERE LIKELY PRECIPITATING EVENTS BIOLOGIC OR SITUATIONAL

/, / /Ê"Ê Ê- 81Ê -", ,-

!RE THERE PROBLEMS IN THE WOMANS PRIMARY SEXUAL RELATIONSHIP OR ANY RELATIONSHIP IN WHICH THE SEXUAL PROBLEM IS OCCURRING

4HE GENERALIST CAN EFFECTIVELY DIAGNOSE AND TREAT AN ARRAY OF SEXUAL PROBLEMS 4HE PRIMARY CAREGYNECOLOGY SETTING IS OFTEN THE ONLY PLACE

!RE THERE CURRENT LIFE STRESSORS THAT MIGHT BE CONTRIBUTING TO SEXUAL PROBLEMS )S THERE GUILT DEPRESSION OR ANGER THAT IS NOT BEING DIRECTLY ACKNOWLEDGED

/ Ê{°

ÞÊ1Ãi`Ê-V>iÃÊÊÊ

!RE THERE PHYSICAL PROBLEMS SUCH AS PAIN !RE THERE PROBLEMS IN DESIRE AROUSAL OR ORGASM

&EMALE 3EXUAL &UNCTION )NDEX &3&)

)S THERE A HISTORY OF PHYSICAL EMOTIONAL OR SEXUAL ABUSE

0ROFILE OF &EMALE 3EXUAL &UNCTION 0&3&

$OES THE PARTNER HAVE ANY SEXUAL PROBLEMS

$ECREASED 3EXUAL $ESIRE 3CALE $3$3




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WHERE PATIENTS HAVE EASE OF ACCESS TO TREATMENT 4REATMENT FOR FEMALE SEXUAL PROBLEMS TYPICALLY REQUIRES AN INDIVIDUALIZED APPROACH AND MAY INCLUDE A COMBINATION OF OFFICE BASED EDUCATION AND BASIC COUNSELING COGNITIVE BEHAVIORAL PSY CHOTHERAPY PHARMACOTHERAPY AND TREATMENT OF CONCOMITANT MEDICAL CONDITIONS %VEN SEXUAL HISTORY TAKING AND DELINEATION OF PROBLEMS CAN BE THERAPEUTIC 0HYSICIANS CAN OFFER SIMPLE EDUCATION ABOUT SEXUAL FUNCTION OR ADVICE REGARDING COMMUNICATION OR BASIC LIFE STYLE CHANGES OR COMMUNICATION COACHING 4HE 0 ,) 33 )4 MODEL IS A WIDELY RECOGNIZED STEPWISE APPROACH FOR PHYSICIANS TO FOLLOW THAT PROVIDES THEM WITH A STRUCTURE FOR UNDERSTANDING THEIR OWN CHOICES AND LIMITS TO TREAT SEXUAL PROBLEMS 0 0ERMISSION 0ATIENTS ARE GIVEN PERMISSION TO DISCUSS SEXUAL PROBLEMS AND TO EXPLORE POS SIBLE SOLUTIONS ,) ,IMITED )NFORMATION 4HE CLINICIAN EDUCATES THE PATIENT ABOUT SEXUAL PHYSIOLOGY OR PROVIDES EDUCATIONAL RESOURCES SUCH AS LITERATURE OR VIDEOS 33 3PECIFIC 3UGGESTIONS4HESE MIGHT INCLUDE MORE TAILORED APPROACHES DESIGNED TO IMPROVE SEXUAL AND EMOTIONAL COMMUNICATION SUCH AS MASTURBATION +EGEL EXERCISES TECHNICAL ADVICE REGARDING SEXUAL POSITIONS AND THE USE OF LUBRI CANTS OR DILATORS )4 )NTENSIVE 4HERAPY 4HIS MAY INVOLVE REFER RAL FOR INDIVIDUAL THERAPY TO DEAL WITH INTRA PSYCHIC ISSUES OR COUPLES THERAPY TO IMPROVE COMMUNICA TION OR ADDRESS CONFLICT 4HE DECISION TO REFER WILL DEPEND ON THE PHYSI CIANS COMFORT LEVEL OF EXPERTISE AND COMPLEXITY OF THE PROBLEM 3OME SEXUAL PROBLEMS ARE BEST TREATED BY SPECIALISTS ALONE OR IN THE CONTEXT OF A MULTIDISCIPLINARY APPROACH 0ATIENTS ARE MORE LIKELY TO ACCEPT A SUGGESTION OF A REFERRAL WHEN THE PHY SICIAN NORMALIZES BOTH THE NATURE OF THE PATIENTS PROBLEM AND THE PROCESS OF REFERRAL TO A SPECIALIST

WHEN THE PRIMARY ETIOLOGY IS PHYSIOLOGICAL INDI VIDUALS OR COUPLES MAY ALSO NEED CONCOMITANT PSYCHOTHERAPYSEX THERAPY TO HELP ALTER NON SEX UAL OR AVOIDANT BEHAVIOR PATTERNS OR RESENTMENT RELATIONSHIP CONFLICTS THAT HAVE DEVELOPED AS A RESULT OF THE (3$$

*>À>V}VÊ/Ài>ÌiÌÃ /iÃÌÃÌiÀiÊ/iÀ>«Þ 4HERE IS ABUNDANT DATA SUPPORTING THE USE OF EXOGENOUS TESTOSTERONE FOR THE TREATMENT OF (3$$ #URRENTLY THERE ARE NO TESTOSTERONE PRODUCTS APPROVED BY THE 53 &OOD AND $RUG !DMINISTRATION FOR THE TREATMENT OF (3$$ IN WOMEN (OWEVER A NUMBER OF PRACTITIONERS ARE PRESCRIBING TESTOSTERONE OFF LABEL AND MONITOR ING SIDE EFFECTS !CCORDING TO THE )NTERCONTINENTAL -ARKETING 3ERVICES THAT TRACKS PRESCRIPTIONS WRIT TEN BY 53 PHYSICIANS MILLION PRESCRIPTIONS FOR TESTOSTERONE WERE WRITTEN FOR WOMEN IN n /VER THE LAST DECADE NUMEROUS WELL POW ERED WELL DESIGNED CLINICAL TRIALS HAVE SHOWN THAT TRANSDERMAL TESTOSTERONE IN PHYSIOLOGIC TO SLIGHTLY SUPRAPHYSIOLOGICAL DOSES IS EFFECTIVE IN THE TREATMENT OF POSTMENOPAUSAL WOMEN WITH (3$$ WITH FEW SIDE EFFECTS /iÃÌÃÌiÀiÊ*>ÌViÃÊvÀÊ7iÊ ÌÊÛ>>LiÊ ÊÌiÊ1-® 3EVEN DOUBLE BLIND RANDOMIZED TRIALS ON ^ POSTMENOPAUSAL WOMEN WITH (3$$ HAVE DEMONSTRATED SIGNIFICANT INCREASED IN SEXUAL DESIRE COMPARED WITH PLACEBO 4HE MICROGRAMDAY TESTOSTERONE MATRIX PATCH WAS APPROVED BY THE %UROPEAN -EDICINES !GENCY OF THE %UROPEAN 5NION AND HAS BEEN AVAILABLE IN %UROPE SINCE ,ONG TERM SAFETY CONCERNS HAVE STALLED &$! APPROVAL OF TOPICAL TESTOSTERONE THERAPY FOR POSTMENOPAUSAL WOMEN WITH (3$$ IN THE 53 (OWEVER RECENT REVIEWS SUGGEST A GOOD SAFETY PROFILE HAS BEEN DEMONSTRATED AND THERE IS NOW A REPORT ON YEARS OF CLINICAL USE IN %UROPEAN WOMEN WHO HAVE BEEN USING THE )NTRINSA TESTOSTERONE PATCH /À>ÃìÀ>Ê/iÃÌÃÌiÀiÊiÃÊvÀÊiÊÊ "vv>Li® !NDRO'EL AND4ESTIM ARE TESTOSTERONE TRANS DERMAL GELS THAT ARE &$! APPROVED IN THE 53 FOR USE IN MEN 4HEY ARE SOMETIMES USED OFF LABEL FOR WOMEN BY REDUCING THE AMOUNT APPLIED TO ESTIMATE WHAT HAS BEEN SHOWN TO BE THE EFFECTIVE DOSE IN WOMEN MCGDAY 0ATIENTS SHOULD BE MONITORED CLINICALLY AND WITH TESTOSTERONE LEV ELS TO DOCUMENT THERAPEUTIC DELIVERY AND TO AVOID

/, / Ê9*" /6 Ê- 81Ê -, Ê -", , 4REATMENT OPTIONS FOR (3$$ WILL VARY DEPEND ING ON WHICH COMPONENTS OF DESIRE ARE COMPRO MISED EG BIOLOGIC MEDIATORS OF DRIVE VESSUS RELATIONSHIP CONFLICT OR BOTH 3EX THERAPYPSY CHOTHERAPY WOULD TYPICALLY BE THE TREATMENT OF CHOICE EITHER INDIVIDUAL OR COUPLES IF THE PRIMARY SOURCE OF THE (3$$ IS PSYCHOLOGICAL OR INTERPER SONAL WHEREAS A PHARMACOLOGIC OPTION MIGHT BE THE FIRST LINE TREATMENT FOR WOMEN WHOSE PRIMARY SOURCE OF (3$$ IS PHYSIOLOGICAL (OWEVER EVEN


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SUPRAPHYSIOLOGIC DOSING

«Õì`ÊiÃÊ>`Ê Ài>ÃÊvÀÊ7iÊ ÕÃÌÊÀÕ>Ì® 4ESTOSTERONE IN 0,/ GEL COMPOUNDED BY PHARMACIES CAN BE OBTAINED LOCALLY BY PRESCRIP TION OR OVER THE )NTERNET 0,/ GEL TESTOSTERONE IS NORMALLY FORMULATED INTO CC SYRINGES 0ATIENTS SHOULD BE MONITORED CLINICALLY AND WITH TESTOSTER ONE LEVELS TO DOCUMENT THERAPEUTIC DELIVERY AND TO AVOID SUPRAPHYSIOLOGIC DOSING /iÃÌÃÌiÀiÊ«>ÌÃÊ ÕÃÌÊÀÕ>Ì® #USTOM COMPOUNDED TESTOSTERONE PELLETS OF n MG ARE AVAILABLE IN THE 53 FROM COM POUNDING PHARMACIES 4HEY ARE INSERTED WITH A TROCHAR THOUGH A SMALL SURGICAL INCISION USING LOCAL ANESTHESIA 4HEY ARE NORMALLY IMPLANTED EVERY n MONTHS 7HILE THE DOSING IS PHARMA COLOGIC IN THE EARLY PHASES THERE IS INSUFFICIENT DELIVERY IN THE LATTER PHASES OF EACH IMPLANT "À>Ê`À}iÃÊ"vv>Li® -ETHYLTESTOSTERONE IS AVAILABLE IN DOES OF OR MGDAY AND IS USUALLY PRESCRIBED IN COMBI NATION WITH CONJUGATED ESTROGENS MGDAY OR MGDAY AS %STRATEST 4HIS IS THE ONLY TES TOSTERONE PRODUCT APPROVED FOR USE IN WOMEN IN THE 53 BUT NOT FOR THE INDICATION OF (3$$ AND THE MANUFACTURER DISCONTINUED SUPPLYING THE PRODUCT TO THE 53 MARKET IN -ARCH )T IS ALSO ASSOCI ATED WITH SIGNIFICANT DECREASES IN HIGH DENSITY LIPOPROTEIN ($, CHOLESTEROL INCREASED TOTAL CHOLESTEROL($, RATIO BUT A SIGNIFICANT DECREASE IN TRIGLYCERIDES 4HERE IS LIMITED PROSPECTIVE RAN DOMIZED CLINICAL TRIAL DATA ON THIS TREATMENT VÀâi`Ê/iÃÌÃÌiÀi #OMPOUNDED SUBLINGUAL AND BUCCAL FORMU LATIONS ARE AVAILABLE BY PRESCRIPTION FROM COM POUNDING PHARMACIES (OWEVER MICRONIZED TESTOSTERONE IS NOT GENERALLY ABSORBED WELL ORALLY $EHYHDROEPIANDROSTERONE $(%! IS A PRO HORMONE CONVERTED TO TESTOSTERONE AND OTHER ANDROGENTS AVAILABLE AS AN OVER THE COUNTER SUP PLEMENT IN TABLETS OF OR MG #LINICAL TRIALS ARE NOW BEING CONDUCTED A TRANSDERMAL DELIVERY FOR TREATMENT OF (3$$ VAGINAL ATROPHY AND PRE VENTION OF OSTEOPOROSIS Õ«À«À "UPROPRION IS AN ANTIDEPRESSANT AND DOES NOT HAVE AN APPROVED INDICATION FOR THE TREATMENT OF (3$$ (OWEVER IT HAS BEEN SHOWN IN ONE TRIAL TO HAVE A MILD TO MODERATE PROSEXUAL EFFECT AND IS SOMETIMES PRESCRIBED TO TREAT THE SEXUAL SIDE EFFECTS OF SELECTIVE SEROTONIN REUPTAKE INHIBITORS )T IS A COMPOUND WITH BOTH DOPAMINE AND NOREPI


NEPHRINE REUPTAKE INHIBITION

/, / Ê- 81Ê6 ,-" Ê -", , 4REATMENT OF SEXUAL AVERSION IS BEST MANAGED BY EDUCATING THE PATIENT ABOUT THE DISORDER PAR TICULARLY DIFFERENTIATING IT FROM (3$$ AND REFERRAL TO A MENTAL HEALTH PROFESSIONAL TRAINED IN TREATING SEXUAL AVERSION

/, / Ê- 81Ê,"1-Ê -", ,3OME OF THE SAME THERAPEUTIC APPROACHES MAY BE RECOMMENDED FOR DISORDERS OF DESIRE AND AROUSAL !DDRESSING PSYCHOSOCIAL AND RELA TIONSHIP ISSUES IS OFTEN AS RELEVANT TO SUCCESS FUL TREATMENT IN AROUSAL DISORDERS AS IN (3$$ &OR EXAMPLE PATIENTS SHOULD BE EDUCATED THAT AS THEY AGE BOTH MEN AND WOMEN REQUIRE MORE FOCUSED DIRECT AND LENGTHY STIMULATION TO BECOME SUFFICIENTLY AROUSED 0ARTNER ANXIETY AND INHIBITIONS THAT CAN AFFECT AROUSAL ALSO MAY NEED TO BE ADDRESSED

6>}>ÊÕLÀV>ÌÃÊ>`ÊÃÌÕÀâiÀÃ .UMEROUS BRANDS OF LUBRICANTS AND MOISTURIZERS ARE AVAILABLE OVER THE COUNTER ,ONG ACTING MOIS TURIZERS HELP REDUCE GENERAL DISCOMFORT RESULTING FROM DRYNESS ASSOCIATED WITH VULVOVAGINAL ATRO PHY AND ARE APPLIED EVERY FEW DAYS ,UBRICANTS ARE SHORT ACTING AND ARE DESIGNED TO PROVIDE ADDI TIONAL LUBRICATION TO REDUCE VAGINAL IRRITATION DUR ING SEXUAL STIMULATION AND PENETRATION -ÞÃÌiVÊ>`Ê6>}>ÞÊ`ÃÌiÀi`Ê

ÃÌÀ}iÊ 3YSTEMIC AND VAGINALLY ADMINISTERED ESTROGEN THERAPY IS OFTEN OF SIGNIFICANT HELP TO POSTMENO PAUSAL WOMEN WITH &3!$ RESULTING FROM A LACK OF TISSUE SENSITIVITY LUBRICATION AND GENITAL VASO CONGESTION -ANY POSTMENOPAUSAL WOMEN SUFFER FROM VULVOVAGINAL SYMPTOMS AS A RESULT OF LOW ERED ESTROGEN 5NLIKE HOT FLASHES THAT WILL LIKELY SUBSIDE OVER TIME REGARDLESS OF WHETHER ESTRO GEN TREATMENT IS USED VULVOVAGINAL SYMPTOMS ARE CHARACTERISTICALLY PROGRESSIVE AND UNLIKELY TO RESOLVE WITHOUT TREATMENT )T IS ESTIMATED THAT TO OF POSTMENOPAUSAL WOMEN EXPERI ENCE DISCOMFORT DUE TO VULVOVAGINAL ATROPHY THAT REQUIRES TREATMENT 'IVEN THE SAFETY AND HEALTH CONCERNS OF LONGER TERM SYSTEMIC THERAPY FOR VUL VOVAGINAL ATROPHY MANY PATIENTS AND PRACTITIO 59


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/, / /Ê",Ê ",-Ê

NERS PREFER THE USE OF LOCAL MINIMALLY ABSORBED ESTROGEN WHICH HAS SHOWN TO BE EFFECTIVE FOR TREATING DYSPAREUNIA ! NUMBER OF FORMS OF VAGI NAL ESTROGEN AND MANNER OF DELIVERY ARE CURRENTLY AVAILABLE INCLUDING TABLETS CREAMS AND A RING ALL WITH MINIMAL SYSTEMIC ABSORPTION #URRENTLY 0REMARIN 6AGINAL #REAM IS APPROVED IN THE 53 FOR THE TREATMENT OF MODERATE TO SEVERE DYSPA REUNIA

4HE MOST EFFECTIVE TREATMENT FOR ANORGASMIA IS #"4 IN WHICH WOMEN LEARN TO BE COMFORTABLE WITH THEIR OWN GENITALS AND SEXUALITY BY ALTERING NEGATIVE ATTITUDES AND DECREASING ANXIETY 4HESE #"4S INCLUDE DIRECTED MASTURBATION SENSATE FOCUS EXERCISES AND SYSTEMATIC DESENSITIZATION $ISCREDITING THE MYTH THAT MASTURBATION IS DIRTY OR hBADv IS A SIMPLE BUT IMPORTANT COUNSELING TOOL THAT PHYSICIANS CAN EASILY EMPLOY 0ERMISSION GIVEN BY THE PHYSICIAN TO THE PATIENT TO EXPLORE HER BODY AND FIND OUT HOW IT WORKS IS EXTREMELY HELP FUL -ASTURBATION IS OFTEN THE MOST EFFECTIVE WAY FOR WOMEN WHO HAVE NEVER ACHIEVED ORGASM OR WHO HAVE GREAT DIFFICULTY REACHING ORGASM TO LEARN WHAT STIMULATION IS EFFECTIVE TO TRIGGER ORGASM

*Ã«ìÃÌiÀ>ÃiÊLÌÀÃÊ 3ILDENAFIL HAS BEEN INVESTIGATED FOR THE TREAT MENT OF FEMALE SEXUAL AROUSAL DISORDERS WITH INCONCLUSIVE RESULTS $ESPITE EVIDENCE THAT SILDE NAFIL INCREASES THE VASOCONGESTIVE RESPONSE TO SEXUAL STIMULATION STUDIES HAVE PRODUCED INCON SISTENT RESULTS IN TERMS OF SUBJECTIVE AROUSAL POINTING TO THE IMPORTANCE OF DIFFERENTIATING SUB JECTIVE AND GENITAL AROUSAL SUBTYPES OF &3!$ (OWEVER THE 0$%S HAVE MORE RECENTLY BEEN USED OFF LABEL AS A TREATMENT FOR SOME OF THE SEX UAL SIDE EFFECTS OF THE SELECTIVE SEROTONIN REUP TAKE INHIBITORS

/, / /Ê",Ê6 -13INCE VAGINISMUS IS ESSENTIALLY AN ANXIETY DIS ORDER THE MOST EFFECTIVE TREATMENTS ARE COMBINED COGNITIVE AND BEHAVIORAL STRATEGIES THAT HELP TO DESENSITIZE A WOMAN TO HER ANXIETYFEAR ABOUT PEN ETRATION AND TO HELP HER ACHIEVE A SENSE OF CONTROL OVER A SEXUAL ENCOUNTER OR A PELVIC EXAM 3HE IS TAUGHT PROGRESSIVE MUSCLE RELAXATION TECHNIQUES AND CONTROL OVER HER VAGINAL MUSCLE CONTRACTIONS SO THEY WILL NO LONGER REFLEXIVELY CONTRACT DUE TO ANTICIPATORY ANXIETY 4HE MOST COMMONLY USED TREATMENT TECHNIQUE IS SYSTEMATIC DESENSITIZATION )N THIS CASE WOMEN ARE FIRST TAUGHT DEEP MUSCLE RELAXATION AND THEN TAUGHT TO VERY GRADUALLY INSERT OBJECTS USUALLY DILATORS OF INCREASING DIAMETER INTO THE VAGINA )N ADDITION CONCOMITANT PELVIC FLOOR PHYSICAL THERAPY CAN BE EXTREMELY HELPFUL AND CAN SPEED THE PROCESS TREMENDOUSLY PARTICU LARLY IF THERE IS ALSO MYOFACIAL PAIN OR GUARDING OF PELVIC FLOOR MUSCLES

)NTRAVAGINAL $(%! IS CURRENTLY BEING INVESTIGATED AS A TREATMENT FOR &3!$ AND (3$$ )NTRAVAGINAL $(%! IS CONVERTED TO ESTROGENS WITH THE EPITHELIAL CELLS WITH MINIMAL SYSTEMIC ABSORPTION iV>V>Ê iÛViÃÊ 4HE %2/34- #LITORAL 4HERAPY DEVICE IS THE ONLY &$! APPROVED DEVICE CURRENTLY AVAILABLE TO TREAT ANY &3$ 4HE PRESCRIPTION ONLY DEVICE PRODUCES CLITORAL VASCULAR ENGORGEMENT USING A VACUUM SYSTEM AND IS DESIGNED TO HELP WITH SEXUAL AROUSAL PROBLEMS -ANY WOMEN WILL USE VIBRA TORS OR HAND HELD MASSAGERS TO ADD MORE INTEN SIVE STIMULATION TO ASSIST IN ORGASMIC ATTAINMENT

/, / /-Ê",Ê 9-*, 1 )N VIEW OF THE FACT THAT DYSPAREUNIA IS BEST UNDERSTOOD AS A SYMPTOM AND NOT NECESSARILY A DYSFUNCTION THE BEST hTREATMENTv IS TO TREAT THE UNDERLYING PHYSIOLOGICAL OR PSYCHOLOGICAL SOURCES OF PAIN &OR EXAMPLE TREATING VULVOVAGI NAL ATROPHY OR ENDOMETRIOSIS OR AN ANXIETY DIS ORDERWHATEVER MAY BE THE PRIMARY SOURCE OF PAIN WITH SEXUAL ACTIVITY

"* /,9Ê Ê/ , /6 Ê /, / /4HERE ARE A VARIETY OF COMPLIMENTARY AND ALTER NATIVE MEDICINES THAT PURPORT TO TREAT FEMALE SEX UAL AROUSAL PROBLEMS BUT MANY LACK RANDOMIZED CONTROLLED TRIALS (ERBAL THERAPIES INCLUDE GINKGO BILOBA , ARGENINE AND 'INSENG !LSO A CLINICAL TRIAL WITH WOMEN WITH A VARIETY OF &3$S LEND SUP PORT THAT :ESTRA AN OVER THE COUNTER BOTANICAL MASSAGE OIL THAT IS APPLIED TO THE CLITORIS MAY INCREASE AROUSAL GENITAL SENSATION PLEASURE AND ORGASMIC ABILITY


" 1-" 0RIMARY CARE PROVIDERS HAVE THE BEST OPPORTU NITIES TO ASSESS AND TREAT WOMEN WHO SUFFER FROM A VARIETY OF SEXUAL PROBLEMS OR DISORDERS 9ET 60


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DISCUSSING SEXUAL HEALTH IS STILL TOO OFTEN AVOIDED OR DISMISSED (AVING A BASIC UNDERSTANDING OF THE SEXUAL DISORDERS AND THEIR TREATMENTS AND THE KNOWLEDGE OF HOW TO TAKE A BRIEF AND COM PREHENSIVE SEXUAL ASSESSMENT MAY HELP OVER COME MANY OF THE BARRIERS PREVENTING PHYSICIANS FROM TREATING SUCH AN IMPORTANT COMPONENT TO A WOMANS HEALTH AND QUALITY OF LIFE #.3

, ,

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7ORLD (EALTH /RGANIZATION %DUCATION AND TREATMENT IN HUMAN SEXUALITY THE TRAIN ING OF HEALTH PROFESSIONALS 2EPORT OF A 7(/ MEETING 1 #ORPORATION 3HERIDAN !VENUE !LBANY .9 "IDDLE !+ 7EST 3, $!LOISIO !! ET SL (YPOACTIVE SEXUAL DESIRE DISORDER IN POST MENOPAUSAL WOMEN QUALITY OF LIFE AND HEALTH BURDEN 6ALUE (EALTH *AN ;%PUB AHEAD OF PRINT= ,INDAU 34 3CHUMM -! ,AUMANN %/ ET AL ! STUDY OF SEXUALITY AND HEALTH AMONG OLDER ADULTS IN THE 5NITED 3TATES . %NG * -ED "ACHMANN ' &EMALE SEXUALITY AND SEXUAL DYSFUNCTION !RE WE STUCK ON THE LEARNING CURVE * 3EX -ED 'OLDSTEIN ) ,INES # 0YKE 2 3CHELD *3 .ATIONAL DIFFERENCES IN PATIENT CLINICIAN COM MUNICATION REGARDING HYPOACTIVE SEXUAL DESIRE DISORDER * 3EX -ED 3OLURSH $3 %RNST *, ,EWIS 27 ET AL 4HE HUMAN SEXUALITY EDUCATION OF PHYSICIANS IN .ORTH !MERICAN MEDICAL SCHOOLS )NT * )MPOT 2ES SUPPL 3 3 7ITTENBERG ! 'ERBER * 2ECOMMENDATIONS FOR IMPROVING SEXUAL HEALTH CURRICULA IN MEDICAL SCHOOLS RESULTS FROM A TWO ARM STUDY COLLECTING DATA FROM PATIENTS AND MEDI CAL STUDENTS * 3EX -ED ,AUMANN %/ 0AIK ! 2OSEN 2# 3EXUAL DYSFUNCTION IN THE 5NITED 3TATES PREVALENCE AND PREDICTORS *!-! -ARWICK # 3URVEY SAYS PATIENTS EXPECT LITTLE PHYSICIAN HELP ON SEX *!-! 3HIFREN *, *OHANNES #" -ONZ "5 ET AL (ELP SEEKING BEHAVIOR OF WOMEN WITH SELF REPORTED DISTRESSING SEXUAL PROBLEMS * 7OMENS (EALTH ,ARCHMT "ERMAN , "ERMAN * &ELDER 3 ET AL 3EEKING HELP FOR SEXUAL FUNCTION COMPLAINTS WHAT GYNECOLOGISTS NEED TO KNOW ABOUT THE FEMALE PATIENTS EXPERIENCE &ERTIL 3TERIL +INGSBERG 3! 4AKING A SEXUAL HISTORY /BSTET 'YNECOL #LIN . !M -ASTERS 7 *OHNSON 6 (UMAN 3EXUAL 2ESPONSE "OSTON -! ,ITTLE "ROWN +APLAN ( $ISORDERS OF 3EXUAL $ESIRE AND /THER .EW #ONCEPTS AND 4ECHNIQUES IN 3EX 4HERAPY .EW 9ORK .9 "RUNNER -AZEL ,EIF ( )NHIBITED SEXUAL DESIRE -EDICAL !SPECTS OF (UMAN 3EXUALITY "ASSON 2 (UMAN SEX RESPONSE CYCLES * 3EX -ARITAL 4HER 3ANDS - &ISHER -! 7OMENS ENDORSEMENT OF MODELS OF FEMALE SEXUAL RESPONSE 4HE NURSES SEXUALITY STUDY * 3EX -ED #LAYTON !( %PIDEMIOLOGY AND NEUROBIOLOGY OF FEMALE SEXUAL DYSFUNCTION * 3EX -ED SUPPL 0ERLEMAN -! 4HE SEXUAL TIPPING POINT ! MINDMODEL FOR SEXUAL MEDICINE * 3EX -ED !RCHER *3 ,OVE 'EFFEN 4% (ERBST $AMM +, 3WINNEY $! #HANG *2 %FFECT OF ESTRA DIOL VERSUS ESTRADIOL AND TESTOSTERONE ON BRAIN ACTIVATION PATTERNS IN POSTMENOPAUSAL WOMEN -ENOPAUSE 4UITEN ! 6AN (ONK * +OPPESCHAAR ( ET AL 4IME COURSE OF EFFECTS OF TESTOSTERONE ADMINISTRATION ON SEXUAL AROUSAL IN WOMEN !RCH 'EN 0SYCHIATRY -ESTON #- -C#ALL +- $OPAMINE AND NOREPINEPHRINE RESPONSES TO FILM INDUCED SEXUAL AROUSAL IN SEXUALLY FUNCTIONAL AND SEXUALLY DYSFUNCTIONAL WOMEN * 3EX -ARITAL 4HER %XTON .' 4RUONG 4# %XTON -3 ET AL .EUROENDOCRINE RESPONSE TO FILM INDUCED SEXUAL AROUSAL IN MEN AND WOMEN 0SYCHONEUROENDOCRINOLOGY 3EGRAVES 24 #ROFT ( +AVOUSSI 2 ET AL "UPROPION SUSTAINED RELEASE 32 FOR THE TREATMENT OF HYPOACTIVE SEXUAL DESIRE DISORDER (3$$ IN NONDEPRESSED WOMEN * 3EX -ARITAL 4HER %XTON -3 "INDERT ! +RUGER 4 ET AL #ARDIOVASCULAR AND ENDOCRINE ALTERATIONS AFTER MASTURBATION INDUCED ORGASM IN WOMEN 0SYCHOSOM -ED +OPPELMAN -# 0ARRY ", (AMILTON *! ET AL %FFECT OF BROMOCRIPTINE ON AFFECT AND LIBIDO IN HYPERPROLACTINEMIA !M * 0SYCHIATRY -ARSON , -C+ENNA +% ! ROLE FOR HYDROXYTRYPTAMINE IN DESCENDING INHIBITION OF SPINAL SEXUAL REFLEXES %XP "RAIN 2ES !COSTA -ARTINEZ - %TGEN !- !CTIVATION OF MU OPIOID RECEPTORS INHIBITS LORDOSIS BEHAV IOR IN ESTROGEN AND PROGESTERONE PRIMED FEMALE RATS (ORM "EHAV -ESTON #- &ROHLICH 0% 4HE NEUROBIOLOGY OF SEXUAL FUNCTION !RCH 'EN 0SYCHIATRY


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