Houston, we have a female sexual dysfunction problem. Female sexual problems, which can affect women of all ages, are underdiagnosed and undertreated–in part because clinicians are not the best at asking about sex in primary care visits. In the course of this episode, learn about how to have that sex talk you’ve (maybe) been avoiding, what to ask when working up sexual problems in women, and find the words to talk to patients about sex. Today, we’re lucky to have the female sexual health expert of experts, Dr. Stacy Lindau, MD, MA, Professor of Obstetrics and Gynecology and Medicine-Geriatrics at the University of Chicago Medicine, on the show to teach us the best “sex talk” language, the differential for female sexual problems, and explore therapies. Sadly, there’s no sildenafil-like magic bullet, but a multidisciplinary team can make real impact on female sexual problems. Don’t forget to check out http://womanlab.org .
Written and produced by: Nora Taranto MS4
Hosts: Leah Witt MD and Matthew Watto MD
Infographic: Leah Witt MD
Editor: Matthew Watto MD
Guest: Stacy Lindau MD
Female Sexual Dysfunction: The DSM V has very specific criteria for defining female sexual dysfunction. The main categories for dysfunction are female sexual interest and arousal disorders, female orgasmic disorders, and female genital pain/penetration disorders. There are a few others, but the main way to break it down is: problems with arousal, problems with orgasm, and problems with pain/penetration. [APA 2013. DSM-V]
A tip from Dr. Lindau: it may be more useful to think about female sexual problems, not dysfunction as defined by the DSM-V. People may come to clinic with problems that don’t meet criteria for an official disorder, and we don’t have to label someone as having a dysfunction in order to understand and help alleviate the problem.
Dr. Lindau’s work, examining sexuality in a nationally representative sample over adults 57-85 years old: Approximately half of both male and female respondents reported at least one sexual problem that was bothering them, across age groups. The prevalence is pretty stable Among women, most of these problems arose from low desire (43%), problems with vaginal lubrication (39%), or inability to climax (34%). (Among men, erectile difficulty was most prevalent). Only 38% of men and 22% of women reported having discussed sex with a physician since the age of 50 years. [Lindau et al. N Engl J Med 2007]
Time is the enemy of the primary care physician. Especially with complex, chronically ill patients many physicians see in their clinics, the seven minute clinic visit isn’t enough time to manage sexual problems in addition to the Diabetes, Hypertension, and sleep issues (an under-appreciated cause of sexual dysfunction) that are essential to tackle as well.
One framework to consider: First, acknowledge and thank the patient for sharing their concern. Say that difficulties with sexual function are legitimate health problems, which many people experience. Sexual problems are not your age-related destiny. They can be addressed, but it will take time. So ask to schedule a follow-up appointment, where the focus will be the sexual problem specifically. Schedule at least 30 minutes. This will give you the time to take an appropriate biopsychosocial history.
Bio: A patient’s health conditions, and how well they’re managed.
Psycho: What psychological, mental health issues and life stressors (divorce, job, etc.) are present in the patient’s life?
Social: What relationship dynamics are at play? Is there a new partner, are things not going well?
You’ve got to remember to ask about the partner. Most sex occurs between two people. If we focus only on the woman, we may miss the problem that other issues (e.g. erectile dysfunction issues with a male partner or poor sexual communication between partners). Ask about the biopsychosocial aspects, and Age, health conditions of the partner.
You can go through much of the detailed sexual history with the partner in the room.
But It is important, however, to make sure that you have several minutes alone with the patient. You could frame it this way: I request as a matter of routine to have a few minutes alone with the patient without the partner. This needs to be a matter of routine, because it is never wise to ask questions about physical, sexual, or emotional abuse with the partner in the room, and these are essential questions to ask in taking the history. –Dr. Lindau
How to ask about abuse: Reiterate that these are questions that you ask everyone. You can ask them couched by other questions that are routinely asked–about exercise, body weight, body image–and then ask about any history of physical, emotional, sexual abuse/trauma. It is also important to ask the following question: Do you have any history of abuse where you were not the victim directly but where you were the witness to abuse? (Witnessing abuse can be as traumatic as being the person abused directly) [Russell et al. Child Abuse & Neglect, 2010]
When’s the last time you had sex? (A lot of patients will have attempted sex recently so that they can explain what’s going on in the appointment). If there is pain on intercourse, is the pain deep or around the opening of the vagina? (Usually, the pain is superficial. Deep pain is concerning, especially if new onset, and in post-menopausal women. This warrants a thorough gynecologic evaluation and maybe a pelvic ultrasound to rule out an organic problem). Who initiated sex, the last time you had it? Are you still masturbating? (You’ve got to ask. It’s like riding a horse, it gets easier with time). Are you using any soaps or douching? (If so, recommend against).
Are you taking any of the following medications? Medications that could cause or contribute to sexual dysfunction: Systemic antihistamines (every day, can cause vaginal dryness), Antidepressants (SSRIs can cause low libido. But sexual dysfunction and depression are often in tension, you can also have sexual problems if depression isn’t managed appropriately—Dr. Lindau’s expert opinion), Anti-hormonal therapy (patients with cancer, especially on aromatase Inhibitors, which inhibit estrogen synthesis and can cause extreme vaginal atrophy).
Repeat after me (and repeat to the patient): vaginal dryness and painful interourse is not in the patient’s head, it’s physiologically in her vulva and her vagina, or in her bulbocavernosus muscle spasm. Anxiety, stress, a history of abuse and psychiatric illness CAN cause sexual dysfunction, and there’s a definite role for getting these evaluated and treated. [Van Lankvelt et al. Arch Sex Behav 2000]; [Lutfey et al. Fertil Steril. 2008]
BUT the majority of women who experience painful intercourse or decreased libido have NO history of mental illness or abuse. And yet, so many women think that the problem is in their head, because they’ve been told that.
Dr. Lindau’s expert opinion. No estradiol or testosterone level would change her management, except in tracking a cancer’s natural history. Consider checking a thyroid stimulating hormone and STD testing, including HIV. Overall, most female sexual dysfunction isn’t caused by hormone “levels” and can be treated without extensive labs. Even androgen levels, the most commonly cited hormone labs, aren’t particularly useful. [Dennerstein et al. Maturitas. 1997]; [Davis et al. JAMA. 2005]
Dr. Lindau’s overall philosophy: We need to identify what’s working. How do we leverage those assets to help restore function, and to help you get you back to where we want you to be. Let’s look at your partner and optimize there as well. If we need tests or drugs, we’ll use them, but let’s see if we can get you back to where you want to be without those interventions. There may be people who choose not to come back to see me, but most of my patients would prefer not to have more blood drawn, and not to take more medicines if they don’t need to.
Do not presumptively treat with estrogen in an attempt to avoid doing an external and internal pelvic exam. You need to look “down there.” The exam should focus on signs of skin irritation, atrophy, and dryness. You can treat some of these–dryness, atrophy–with estrogen, or lubricants/moisturizers. And then, you’ve got to do an internal speculum exam to look at the vaginal mucosa. Finish the exam with a bimanual to assess for pelvic masses
The treatment approach to female sexual problems is multi-pronged and multidisciplinary. Some patients should also see a psychologist, a sex/couples therapist, and/or pelvic floor physical therapist (PT). Physical therapists can obtain specialized training in pelvic floor PT, which uses biofeedback to treat some forms of urinary incontinence and sexual problems.
A classic case in which pelvic floor PT can be extremely useful: high tone pelvic floor dysfunction is a very common cause of sexual function problems. High muscle tone of the levator ani or bulbocavernosus can lead to a decrease in blood flow and nerve strangulation. This initially can present as difficulty with penetration, and later, difficulty with arousal. If we can retrain the bulbocavernosus muscle, this will improve blood flow and oxygenation. Pelvic floor PT provides manual, biofeedback-based, therapy to treat this condition. Pelvic floor PTs will conduct a history focusing on straddle injuries and injuries to the low back/coccyx, thorough musculoskeletal evaluation, and pelvic exam.
Flibanserin (the flipside): It received FDA approval a few years ago, for libido improvement among premenopausal women. But the medication has to be taken nightly, and it has some side effects that can be problematic. You cannot drink alcohol while taking it. Insurance hasn’t routinely covered it. The FDA has in place a risk evaluation mitigation strategy that requires training by the physician, the pharmacist, and consent by the patient.
Estrogen: Estrogen can provide significant relief to many patients. Most often used in local formulations, either as a cream in the vulva or vagina, or a tablet/ring. The cream can be used more widely though.
There is no evidence to support profiling based on age, relationship status, health status, or anything else, in helping decide who to ask about sexual function. Screen all of your patients, with the genitourinary review of systems questions (validated Single Item Screeners on sexual function that can also be used) [Flynn et al. J Gen Intern Med 2015]
Men relay their concerns about sexual function to their doctors more frequently than women do. This may be because sildenafil can provide men with relief from their sexual problems, which most commonly are related to erectile dysfunction. [Lindau et al. N Engl J Med 2007]
Listeners will define, classify, and diagnose female sexual dysfunction and develop a practical approach nonpharmacologic and pharmacologic management of this condition.
After listening to this episode listeners will…
Dr Lindau reports no relevant financial disclosures. The Curbsiders report not relevant financial disclosures.
Links from the show are included in the text above.
Extra Credit Reading!
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
Got feedback? Suggest a Curbsiders topic. Recommend a guest. Tell us what you think.
We love hearing from you.
Yes, you can now join our exclusive community of core faculty at Kashlak Memorial Hospital along with all the perks:
Close this notice to consent.