Sexual dysfunction is a common problem that diminishes the quality of life for many women. International surveys have found that 39% of sexually active women have complaints associated with sexuality.1 Most healthcare providers do not routinely discuss sexuality with their patients, and many women are hesitant to broach the subject.2 But the identification of sexual problems should be a routine aspect of healthcare.
Shifren et al explored the occurrence of low sexual desire in American women ages 18 to 102.3 They found that 38.7% of the 31,581 women surveyed reported low or no desire for sexual activity.3 Physiologic and psychologic elements play roles in sexuality. Physiologic etiologies of sexual dysfunction in women may arise from hormonal/endocrine, musculogenic, neurogenic, psychogenic or vasculogenic disorders. Psychologic etiologies may arise from relationship problems, sexual partner characteristics, poor body image or low self-esteem. Each of these etiologies is manifested in its own ways.4 Women diagnosed with sexual dysfunction may have overlapping etiologies, posing an evaluation and treatment challenge.5
Hormonal & Endocrine Etiologies
Hormones, especially estrogen and testosterone, play an important role in a woman's sexual desire. Estrogen assists in maintaining vaginal mucosal integrity, vaginal sensation, vasoconstriction, genital blood flow and vaginal secretions. These events lead to enhanced arousal. Testosterone, a precursor to estrogen, is the strongest endogenous androgen in both men and women. Androgens are responsible for male traits and reproductive activity in men. One of the main purposes of androgens in a woman's body is conversion into estrogen. A decrease in androgen level leads to decline in sexual arousal, decreased genital sensation, diminished libido, reduced sense of well-being and energy, and decreased bone mass.6
Examples of hormonal or endocrine etiologies of sexual dysfunction in women are hypothalamic-pituitary axis dysfunction, natural or premature menopause and prolonged use of oral contraceptives. These etiologies most often occur as a result of decreased estrogen and/or testosterone levels. They may manifest in decreased libido, vaginal dryness and lack of arousal.4
Pelvic floor muscles play an important role in sexual function and response in women. Hypertonicity and hypotonicity of pelvic floor muscles, especially the levator ani and the perineal membrane, are two types of musculogenic etiologies that lead to sexual dysfunction in women. Sexual arousal and orgasm are intensified by voluntary and involuntary contraction of the perineal membrane. The levator ani muscles are responsible for motor responses during orgasm as well as vaginal receptivity.
Hypertonic musculogenic etiologies may manifest in sexual pain disorders such as vaginismus or dyspareunia. Vaginismus is an involuntary or persistent spasm of the vagina that causes discomfort, burning, pain and penetration problems. Dyspareunia is vaginal pain experienced with attempted or actual vaginal penetration. Hypotonic musculogenic etiologies may manifest in vaginal hypoanesthesia, coital anorgasmy and urinary incontinence with intercourse or orgasm.7
The medial preoptic area/anterior hypothalamus and related limbic-hippocampal structures within the central nervous system are responsible for sexual arousal. When activated, electrical signals are transmitted by these centers through the parasympathetic and sympathetic nervous systems.7 Interaction among multiple neurotransmitters and hormones is necessary for sexual response. These pathways are both centrally and peripherally located in the body.
Neurogenic etiologies of sexual dysfunction are spinal cord injury and central or peripheral nervous system disorders such as diabetes, multiple sclerosis or upper motor neuron injury. Anorgasmy is usually the result of a neurogenic etiology that may be present at birth or acquired. Women with incomplete spinal cord injuries may retain the capacity for sexual arousal and vaginal lubrication, but they may have difficulty achieving orgasm.6
The most common psychogenic etiologies of sexual dysfunction are relationship problems, poor body image, decreased self-esteem, mood disorders and adverse effects of psychotropic medications. Psychogenic etiologies may manifest as decreased libido or desire, decreased arousal, hypoesthesia or anorgasmy.
Serotonin reuptake inhibitors (SSRIs) represent the most commonly prescribed class of medications used to treat depression. Common side effects of SSRIs are decreased desire, decreased arousal, decreased genital sensation and difficulty achieving orgasm.4
Blood flow to the clitoral and labial arteries increases during sexual arousal. Without this increase in blood flow, women may be unable to attain or maintain adequate sexual excitement for intercourse to occur. Vasculogenic etiologies of female sexual dysfunction are trauma, hormonal influences and diminished blood flow to genitals. Decreased pelvic blood flow may be a result of atherosclerosis. It leads to vaginal wall and clitoral smooth muscle fibrosis, which results in vaginal dryness and dyspareunia. Pelvic fractures, blunt trauma, surgical disruption or chronic perineal pressure may be a result of traumatic injury to the iliohypogastric/pudendal arterial bed. Lipid abnormalities, hypertension and smoking are three modifiable risk factors related to vasculogenic causes of sexual dysfunction.7
Obtaining a comprehensive sexual history is an important part of primary care. Nusbaum et al found that only 14% to 17% of women surveyed (n = 2,073) reported that a provider had inquired about their sexual functioning.8 Most women had never spoken to their provider about sex. In the same study, 98% reported one or more sexual concerns. Most women avoided discussing sexual concerns with their provider out of embarrassment or fear that he or she would not be interested.8
Open-ended questions are the most successful way to initiate a discussion about sexuality. A focused sexual history should be obtained when a sexual concern is reported. Areas of a sexual history to include are menstrual, obstetric, reproductive, current relationships and sexual activity, family and personal sexuality beliefs, and sexual trauma or abuse history. It is also important to include personal medical and surgical history; family medical history; prescription and over-the-counter medication use; alcohol, tobacco and drug use; and birth control method.4
Two models used to initiate discussions about sexual functioning are the PLISSIT model9 and the ALLOW model.10 The PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) model can be used to initiate discussions about sexual dysfunction and its management. First, the provider obtains permission to discuss sexuality. Next, he or she offers limited information about normal sexual functioning. The provider then offers specific suggestions to address the woman's particular complaint. Intense therapy with a sexual health specialist is considered.9
The ALLOW (Ask, Legitimize, Limitations, Open up, Work Together) model can be used to help obtain sexual history, to initiate treatment and to further evaluate a sexual problem. The provider first asks the woman about her sexual activity and functioning. If problems are identified, the provider explains that sexual dysfunction as a clinical issue. He or she evaluates limitations, opens up the discussion to allow for potential referral, and works with the patient to construct goals and formulate a management plan.10, 11
A complete physical examination is the first step in identifying sexual dysfunction. A focused pelvic examination is important to identify pathology and to educate the woman about her anatomy. The physical and pelvic examinations also may direct the provider toward an etiology of sexual dysfunction by assisting in the identification of possible hormonal or endocrine disorders and musculogenic, neurogenic, psychogenic and vasculogenic components.
Possible abnormal physical examination findings related to sexual dysfunction in women include: cystocele; rectocele; uterine prolapse; retroverted uterus; vulvar vestibule or uterosacral ligament tenderness; vaginal discharge; hypertonic pelvic muscles; sparse pubic hair; abnormal blood pressure or peripheral pulses; neuropathy; pallor; galactorrhea; thyroid enlargement; and/or musculoskeletal abnormalities. Abnormal findings are more likely to be identified in women who have not received regular medical care, women who have a chronic disease, and women with a history of gynecologic problems.
It is important to note that physical examination findings in women with sexual dysfunction may be normal. Normal findings do not rule out sexual dysfunction.4
Laboratory evaluation is warranted if a medical condition is suspected based on the history or examination findings. Relevant laboratory tests include a hormonal profile, fasting glucose, thyroid function, liver function, and cholesterol and lipid levels.2 Some experts recommend androgen testing when levels are at their highest (days 8 to 10 of menstrual cycle); others argue that there is no reliable correlation between hormone levels and sexual function.4
Many factors complicate the treatment of sexual dysfunction in women. Evidence-based therapies are fairly new in sexual medicine.10 Past research has primarily focused on sexual problems in men, but research about women is increasing.2 Factors to consider in treatment include lack of a single cause, limited treatment options, lack of proven treatment, limited knowledge, and lack of provider experience.
Behavioral, cognitive and sexual therapies provide the foundation for treating sexual dysfunction in women. Limited research is available about the benefit of pharmacologic interventions.5
Researchers have studied estrogen, testosterone, sildenafil (Viagra), bupropion (Wellbutrin) and herbal blends in the treatment of sexual dysfunction in women. Hormone replacement therapy is often used to manage vasomotor symptoms of menopause, along with associated sexual dysfunction. Estrogen alone may be used in menopausal women who have had a hysterectomy. A combination of estrogen and progesterone is the first-line therapy for treating sexual dysfunction in symptomatic menopausal women with an intact uterus.12 Testosterone supplementation may improve sexual desire in women.12
The use of any hormone preparations in this population is controversial because a small percentage of women may have an increased risk for cardiovascular disease, cerebrovascular disease, blood clots, breast cancer and ovarian cancer. An estrogen patch called Intrinsa is available in Europe to treat sexual dysfunction in women; it has not been approved for use in the United States. Testosterone can be converted to estrogen, so testosterone preparations are not recommended for use by women with a history of breast cancer.7 Lubricants may help with vaginal dryness and dyspareunia without causing any long-term effects.13
At this time, the Food and Drug Administration has not approved any specific medication for the treatment of female sexual dysfunction in the United States, but several phase III clinical trials are under way or recently concluded.14 In September 2012, BioSante Pharmaceuticals completed phase III trials for LibiGel, a transdermal testosterone gel developed to treat sexual dysfunction in women. As of press time in February 2014, the FDA has not acted on the application for marketing approval.
Behavioral interventions are an option for treating musculogenic causes of sexual dysfunction. A behavioral intervention that focuses on pelvic muscle tension is biofeedback electromyography (EMG) with visual feedback. In a clinic setting, women are trained to use a vaginal EMG sensor with a biofeedback device. They are taught how to perform pelvic floor contraction exercises and instructed to do so at home twice per day for about 12 weeks. The EMG sensor with biofeedback ensures that the exercises are performed correctly. In some women, this intervention is thought to produce pelvic muscle strengthening and sexual function improvement comparable to surgery.15
Psychologic factors influence sexual response. Sexual dysfunction may be related to depression or a traumatic event. General principles of psychologically-based treatments include improving verbal and physical communication between partners, encouraging sexual experimentation, changing the goal of sex from orgasm to achieving closeness and feeling good, and relieving the pressure of the moment by suggesting another time for sexual activity. These goals may be achieved through individual, partner or group sexual therapy.16 Unfortunately, outcome data for behavioral, cognitive and sexual therapies are limited due to differences in duration, follow-up and evaluation of outcomes.5
Vasculogenic and Neurogenic Issues
Vasculogenic etiologies of sexual dysfunction may improve with smoking cessation and appropriate treatment of hypertension and hyperlipidemia. In a woman who is already taking antihypertensive or hyperlipidemia medications, it may be a matter of adding lifestyle modifications, adjusting doses or prescribing alternative medications. For a woman who has untreated hypertension or hyperlipidemia, lifestyle modifications and medications may help improve sexual functioning.17 Treatment of neurogenic etiologies of sexual dysfunction is thought to require manipulation of the neurogenic mechanisms that are responsible for vaginal and clitoral smooth muscle tone. This approach is under investigation.7
The referral of a patient with sexual dysfunction is based on the comfort level of the healthcare provider and the patient's wishes. Three determinations need to be made when a sexual problem is identified: Is it possible to address the concern at the current appointment? Is a follow-up appointment needed to allow more time to address the concern? Is the concern beyond the provider's scope of practice? Some sexual problems require the expertise of someone who specializes in sexual health. Women may be more apt to accept a referral when the nature of the problem is normalized. Possible referral choices are sex therapists, marital therapists, urologists and urogynecologists.2
Making It Routine
Despite the complexity of treating sexual dysfunction in women, several strategies are available and appropriately provided by NPs and PAs. Discussions about sexuality should become a part of routine care for women. They may be incorporated during yearly examinations and wellness visits. Such discussions will help improve quality of life for women of all ages. Collaboration among the patient, her sexual partner, her primary care provider and sexual health experts constitutes the best approach to sexual dysfunction in women.
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Allison Lesmann is a family nurse practitioner at Trinity Health in Minot, N.D. Billie Madler is a family nurse practitioner who is the director of graduate nursing programs at the University of Mary in Bismarck, N.D. The authors have completed disclosure statements and report no relationships related to this article.