Female sexual dysfunction: dysfunction of sexual desire, arousal, and orgasm

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Chapter 36 FEMALE SEXUAL DYSFUNCTION: DYSFUNCTION OF SEXUAL DESIRE, AROUSAL, AND ORGASM

Problems with sexual desire, arousal, and orgasm in women are very common and cause significant personal distress. The American Foundation for Urologic Disease classifies these problems as four disorders: hypoactive sexual desire disorder, sexual aversion disorder, sexual arousal disorder, and female orgasmic disorder. A discussion of each of these disorders is beyond the scope of this text. Dyspareunia is discussed in Chapter 11.

A wide variety of factors contribute to sexual dysfunction, including age, smoking, chronic diseases, relationship difficulties, prior trauma, surgery, low socioeconomic status, and education. Individually, sexuality incorporates family, societal, and religious beliefs and is altered with aging, health status, and personal experience. Sexual activity also incorporates interpersonal relationships; each partner brings unique attitudes, needs, responses, and health matters into the sexual experience.

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 problems, and contains pertinent psychosocial information. Establishment of the patient’s sexual orientation is necessary and is best achieved through nonjudgmental, direct questions. Questioning the patient about what she thinks is causing the problem may elicit insight.

Key Historical Features

✓ Symptoms of systemic disease

• Shortness of breath

• Musculoskeletal pain or stiffness

• Claudication

✓ Medical history

• Especially a history of diabetes, breast cancer, gynecologic cancers, cardiovascular disease, neurologic diseases, musculoskeletal diseases, endocrinologic diseases, use of urinary catheters, or colostomies

✓ Psychiatric history

• Symptoms of or a prior diagnosis of depression or anxiety, which can cause sexual dysfunction (psychiatric illness can also be exacerbated by sexual dysfunction)

✓ Medications

✓ History of recreational drug use

• Alcohol, tobacco, or illicit drug use, which can be risk factors for sexual dysfunction

✓ Obstetric/gynecologic history

• Obstetric history, especially prior surgical deliveries and trauma during deliveries

• History of surgery, endometriosis, prolapse, urinary incontinence, and pelvic trauma (including motor vehicle accidents)

✓ Sexual history (consider using a validated index, such as the Female Sexual Function questionnaire)

• Prior sexual experience

• Sexual orientation

• Nature of the problem

• Onset and duration of the problem

• Partner’s response to problem

• Response to masturbation

• History of sexual abuse

Key Physical Findings

✓ Vital signs

✓ General appearance

✓ Neck examination to evaluate for thyroid nodules or a goiter

✓ Cardiovascular examination to evaluate for murmurs, abnormal heart sounds, and peripheral pulses

✓ Pulmonary examination to evaluate for crackles or wheezes

✓ Musculoskeletal examination to evaluate for disabilities that could interfere with sexual function

✓ Neurologic examination to evaluate evidence of weakness, numbness, or abnormal reflexes

✓ Gynecologic examination

• Examination of the external genitalia for any lesions, atrophy, tenderness, or potentially embarrassing abnormalities (such as labial asymmetry); also, evaluation of amount of pubic hair, a decrease of which may indicate androgen deficiency

• Single-finger vaginal examination to palpate the walls of the vagina, as well as the bladder and urethra; evaluation of the tone of the pelvic floor muscles and voluntary muscle control; and assessment for cystocele, rectocele, or uterine prolapse, which may result in incontinence and in avoidance of sexual relations

• Speculum examination with a narrow speculum that is lubricated, to examine the vaginal mucosa and cervix

• Bimanual examination to evaluate for cervical motion tenderness, adnexal or uterine tenderness, or any masses or nodules

Suggested Work-Up

Measurement of follicle-stimulating hormone (FSH) and luteinizing hormone (LH)	To evaluate for hormonal imbalance and menopausal status
Measurement of thyroid-stimulating hormone (TSH)	To evaluate for thyroid disease
Measurement of prolactin level	To evaluate for hyperprolactinemia
Measurement of serum estradiol	To evaluate for estrogen deficiency
Measurements of total and free testosterone	To evaluate for testosterone deficiency
Measurement of fasting blood glucose	To evaluate for diabetes

Additional Work-Up

Measurement of dehydroepiandrosterone sulfate (DHEAS)	To evaluate for adrenal hyperplasia
Complete blood cell count	To evaluate for anemia
Liver function tests	If liver disease or liver failure is suspected
Measurement of blood urea nitrogen (BUN) and creatinine	If renal failure is suspected

FURTHER READING

Basson R. Sexual desire and arousal disorders in women. N Engl J Med. 2006;354:1497-1506.

Carey JC. Pharmacological effects on sexual function. Obstet Gynecol Clin North Am. 2006;22:599-620.

Drugs that cause sexual dysfunction: an update. Med Lett Drugs Ther. 1992;34(876):73-78.

Lightner DJ. Female sexual dysfunction. Mayo Clin Proc. 2002;77:698-702.

Pauls RN, Kleeman SD, Karram MM. Female sexual dysfunction: principles of diagnosis and therapy. Obstet Gynecol Surv. 2005;60(3):196-205.

Phillips NA. Female sexual dysfunction: evaluation and treatment. Am Fam Physician. 2000;62:127-136.

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