Gynecologic and Therapeutic Assessment and Management of Female Sexual Function
Laura A.C. Berman
Table Of Contents
Laura A.C. Berman, LCSW, PhD
OVERVIEW OF SEXUAL SYMPTOMS|
PHYSIOLOGIC CHANGES DURING SEXUAL AROUSAL
AFUD CLASSIFICATION AND DEFINITION OF FEMALE SEXUAL DISORDERS
SEXUAL PAIN DISORDERS
GENERAL ETIOLOGIES OF FEMALE SEXUAL DYSFUNCTION
IN-OFFICE SEXUAL COUNSELING
The few studies that have addressed the treatment of sexual symptoms in a medical setting have found that although family physicians are more likely to be consulted for a sexual problem than anyone else,1,2 if patients perceive their family physician as less capable of treating a sexual problem, then they will be less likely to consult that physician about those symptoms.2 One Web-based survey asked 4000 women with sexual dysfunction about their experiences seeking help from their health care professionals.3 Only 40% of the women reported that they did not seek help from a physician for sexual function symptoms, but 54% of the women reported that they would like to seek help but did not for reasons like embarrassment, believing the physician would not be able to help, or the patient was not asked.
Men and women may fear discussing sexual problems with their doctors because of concerns that physicians might find the topic embarrassing. One survey involves patients seen in a general medical practice.4 Of the 228 patients assessed, 91% reported believing that discussing sex was appropriate during their visit to the physician. Patients more frequently considered the sexual history an appropriate part of the interview (98%) if their physicians had actually discussed sexual functioning with them. The internists observed that routine sexual history taking yielded information of medical importance in 26% of the cases. The study concluded that at least one of the three indices of value, improved understanding, information of medical importance, or effect on treatment or follow-up, was reported by the physician in 50% of the encounters.
Typical reactions of a physician unprepared to hear sexual symptoms include embarrassed silences, misinformation, the imposition of one's personal values, a surprised or shocked expression, apparent boredom or preoccupation, personal discounting, and belittling.5 There are many reasons why a medical professional may not willingly deal with a patient's sexual concerns. In an older population of patients, physicians may subscribe to larger social norms that devalue sexuality among the aged, viewing them as asexual or not capable of sustaining a sexual relationship. In more general terms, physicians may experience anxiety when confronting their own unresolved sexual issues or conflicts in the face of the patients' reports. Furthermore, physicians may be particularly sensitive to community standards and to what is acceptable to discuss with patients without offending them or, ultimately, risking the loss of the patient to another doctor.1 Finally, medicine is only just beginning to address female sexual function symptoms and obtain an adequate scientific knowledge base to effectively treat these problems; certainly, this lack of understanding and knowledge may contribute to many doctors' lack of willingness to deal with the sexual issues.
Women, however, expect leadership from physicians in raising the issue of sexual health. They want more frequent and routine physician inquiry about sexual concerns and a more open, clear, comfortable, and empathic discussion of these issues.1 Yet, physicians are not necessarily aware of their patients' needs in this area. A survey of 132 residents and 21 faculty members in eight family practice training programs found that the physicians did not routinely raise the subject of sex with their patients unless there appeared to be a psycho-social problem.1 Many physicians believe that the occurrence of sexual concerns is rare in their practice. It seems likely that this is the result of a self-fulfilling prophecy. The patients identify their sexual problem as a physical problem best dealt with by a physician, but they expect physicians to initiate the discussion as they would regarding other functional systems.6 The lack of inclusion of questions regarding sexual function in a systems review results in a missed opportunity for the patient and physician to connect on this dimension of life.
The prevalence of female sexual dysfunction is a topic that has generated extensive discussions in the medical and lay communities alike. According to the National Health and Social Life Survey, approximately 43% of American women experience sexual dysfunction, with the actual number perhaps being as high as 50 million American women.7 United States population census data reveal that 9.7 million American women aged 50 to 74 self-report symptoms of diminished vaginal lubrication, pain and discomfort with intercourse, decreased arousal, and difficulty achieving orgasm. Female sexual dysfunction is clearly an important women's health issue that affects the quality of life of many female patients.
According to Helen Singer Kaplan's “triphasic concept of sexual response,” desire disorders are identified in approximately 34% of the population, sexual arousal concerns in 11% to 48%, and inhibited orgasm in 5% to 10%.8 Painful intercourse is reported in community-based studies in 8% to 23% of the female population. Vaginismus, defined as involuntary pelvic floor spasm, has only been reported from sex therapy clinical studies, in which 12% to 17% of the patients are identified as having this problem.
With this high prevalence of sexual concerns in the population, women are likely to identify their primary care physician as the professional most frequently consulted about sexual concerns, and they expect their physician to take a leadership role in raising the issue of sexual health. They expect empathy, warmth, confidentiality, and professional competence in discussing their sexual concerns with their physician. This expectation conflicts, however, with a survey of family physicians, 59% of whom would not actively interrogate a patient about a sexual concern either because of lack of time or because of lack of competence.9 Other impediments acknowledged by the physicians who did interact with patients include lack of knowledge and skills (63%) and emotional inhibitions to discussing sex (49%).
|OVERVIEW OF SEXUAL SYMPTOMS|
Sexual symptoms in women, known as female sexual dysfunction (FSD), have historically been considered a problem rooted in psychology. However, whereas there are emotional and relational elements to sexual function, it has become increasingly evident that female sexual dysfunction can occur secondary to medical problems and have organic roots. Ongoing epidemiological studies in women suggest that the same disease processes and risk factors that are associated with male erectile dysfunction, including aging, hypertension, cigarette smoking, and hypercholesterolemia, are also associated with female sexual dysfunction.10
However, to understand the etiologies and treatments, it is important to first understand the physiology of the response cycle. The successive phases of sexual response include arousal (otherwise considered excitement and plateau phases), orgasm, and resolution.11 During sexual arousal, the clitoris and the labia minora become engorged with blood, and vaginal and clitoral length and diameter increase. The labia minora also increase in diameter by two-times to three-times during sexual excitement and consequently become everted, exposing their inner surface. The component of “desire” as preceding and inciting the entire sexual response cycle was first proposed by Helen Singer Kaplan.12
Kaplan's three-phase model of desire, orgasm, and resolution is the basis for the DSM IV definitions of female sexual dysfunction, as well as the recent reclassification system made by the American Foundation of Urologic Disease (AFUD) Consensus Panel in October of 1998.13 Others have recently suggested that sexual function should be considered as a circuit with four main domains: libido, arousal, orgasm, and satisfaction. Each aspect may overlap and/or negatively or positively feed back on the next.14
|PHYSIOLOGIC CHANGES DURING SEXUAL AROUSAL|
The vasculature of female genitalia was elucidated by the work of Shabsigh and colleagues on the microvasculature of the rat vagina.15 The female rat genitalia are supplied by the external and internal iliac arteries. Blood is drained from the vaginal venous plexus, which is a complex network of veins. The plexus gives rise to several veins that merge with other tributaries and ultimately combine into the superior vesical vein, which then enters the common iliac vein. In addition, multiple collaterals connect the major vessels of the vagina, and numerous serpentine vessels were found to maintain adequate blood perfusion to the vagina during vaginal dilation at the time of sexual intercourse.
During sexual arousal, genital vasocongestion occurs as a result of increased blood flow. The vaginal canal is lubricated by secretions from uterine glands and from a transudate that originates from the subepithelial vascular bed, passively transported through the intraepithelial spaces, sometimes referred to as intercellular channels. Engorgement of the vaginal wall raises pressure inside the capillaries and creates an increase in transudation of plasma through the vaginal epithelium.15 This vaginal lubricative plasma flows through the epithelium onto the surface of the vagina, initially forming sweatlike droplets that coalesce to form a lubricative film that covers the vaginal wall. Additional moistening during intercourse comes from secretions of the paired greater vestibular or Bartholin's glands, although some believe that these glands also have a more primal function of emitting an odiferous fluid to attract the male. In addition to lubricating, the vagina lengthens and dilates during sexual arousal as a result of relaxation of the vaginal wall smooth muscle. In human and animal models, sexual stimulation results in increased vaginal blood flow and decreased vaginal luminal pressure.15,16
Clitoris and Vestibular Bulbs
With sexual stimulation, increased blood flow to the clitoral cavernosal and labial arteries result in increased clitoral intracavernous pressure, tumescence, and protrusion of the glans clitoris, and eversion and engorgement of the labia minora. Studies show that, unlike the penis, the clitoris and vestibular bulbs lack a subalbugineal layer between the erectile tissue and the tunica albuginea layer. In the male, this layer possesses a rich venous plexus that, during sexual excitement, expands against the tunica albuginea, reducing venous outflow and making the penis rigid. The absence of this venous plexus in the clitoris and vestibular bulbs suggests that this organ achieves tumescence, but not rigidity, during sexual arousal.
A recent study by Min and colleagues showed that pelvic nerve stimulation (PNS) caused a frequency-dependent increase in genital blood flow in New Zealand white rabbits17 and confirmed that genital tissue engorgement is regulated by PNS. It was suggested that the arterial blood flow might be the primary determinant of the state of engorgement, because there does not appear to be a venoocclusive mechanism in female genital tissues.
Further, sildenafil (a phosphodiesterase type-5 inhibitor) was shown to cause a significant increase in the amplitude and duration of the nerve-mediated genital arousal response and also enhanced PNS changes in vaginal lubrication. Based on these findings and other data, the study indicates that the NO-cGMP pathway is involved in the physiological mechanism of female genital arousal and that in an in vivo animal model, sildenafil facilitates this response.17
|AFUD CLASSIFICATION AND DEFINITION OF FEMALE SEXUAL DISORDERS|
In October 1998, AFUD put together a consensus panel consisting of an interdisciplinary team including 19 experts in female sexual dysfunction selected from five countries. The specialists were from the fields of endocrinology, family medicine, gynecology, nursing, pharmacology, physiology, psychiatry, psychology, rehabilitation medicine, and urology. The objective of the panel was to evaluate and revise existing definitions and classifications of female sexual dysfunction so that they could cross disciplines.
Specifically, medical risk factors and etiologies for female sexual dysfunction were incorporated with the preexisting psychologically based definitions. The following classifications are subtyped as lifelong versus acquired, generalized versus situational, and organic versus psychogenic or mixed. Most importantly, for a woman to have FSD diagnosed, she must be experiencing significant personal distress. The etiology of any of these disorders may be multifactorial and often times the disorders overlap.13
Hypoactive Sexual Desire Disorder
Hypoactive sexual desire disorder (HSDD) is defined as the persistent or recurring deficiency (or absence) of sexual fantasies, thoughts, and/or receptivity to sexual activity, which causes personal distress. Sometimes the lack of receptivity takes on a phobic quality, which is known as sexual aversion disorder. Hypoactive sexual desire disorder may have physiologic roots, such as hormone deficiencies, and medical or surgical interventions. Any disruption of the female hormonal milieu caused by natural menopause, surgically or medically induced menopause, or endocrine disorders can result in inhibited sexual desire. Furthermore, the lack of desire may actually be secondary to poor arousal, response, or pain.
HSDD is sometimes a psychologically or emotionally based problem that can result from a variety of reasons beyond history of abuse or trauma. For instance, depression and the treatment of depression are common intrapsychic problems in patients with low sexual desire.18 The depression can be caused by general life events, or it can be secondary to sexual conflicts in the relationship. Substance abuse, particularly drug and alcohol abuse, can result in problems of dependency, depression, and lack of self-esteem. Lack of desire and sexual dysfunction may occur because of the substance abuse, or it may present as a significant problem once the abuser has made a commitment to stop the abuse.
From the standpoint of the impact of HSDD on the woman's life, when there is uneven desire in a relationship, conflicts often arise. If one partner contains feelings of anger, resentment, fear, hostility, or disappointment, the results can be a withdrawal from the intimate relationship. A chronically conflicted relationship with a struggle for control may result in a further voluntary blocking of sexual appetite perpetuated by the partner who feels less valued or less powerful.
Female Sexual Arousal Disorder
Female sexual arousal disorder (FSAD) is the persistent or recurring inability to attain or maintain adequate sexual excitement, causing personal distress. It may be experienced as a lack of subjective excitement or a lack of genital (lubrication/swelling) or other somatic responses. Disorders of arousal include, but are not limited to, lack of or diminished vaginal lubrication, decreased clitoral and labial sensation, decreased clitoral and labial engorgement, or lack of vaginal smooth muscle relaxation. There is a medical/physiologic basis such as diminished vaginal/clitoral blood flow, previous pelvic trauma, pelvic surgery, or medications.
These conditions may occur secondary to psychological factors, also. If the woman is struggling with body image issues that create self-consciousness in certain sexual situations, her response will be inhibited. Furthermore, if she has low self-esteem, lack of confidence, depression, stress, or anxiety, her general emotional state may preclude her from relaxing into the arousal process. Many evolutionary psychologists believe that lack of arousal and response in women is often connected to their evolutionary history as multitaskers, found in the form of their gathering role in the hunter–gatherer societies.
Today's modern woman can multitask in her work and home life, enabling her to juggle many things at the same time, but it can be an impediment sexually, because if she is not feeling good enough about herself, her body, and the person she is with, or if she is distracted by something relating to work or home life, it is difficult for her to focus on the sexual scenario and to reach arousal.19 This is actually quite different from male sexual response. In the research performed with sildenafil in men, it was found that only approximately 10% of male erectile dysfunction is psychogenic. Surprisingly even psychogenic erectile dysfunction is resolved more than 80% of the time with Viagra. In other words, with the added advantage of increased blood flow, men could focus on the sexual scenario and move past the psychogenic factors. The same has not been found to be true with women.19,20 Also, much like with erectile dysfunction, the lack of arousal is connected to performance anxiety. The first time a woman is unable to respond may be situational circumstantial, but if she worries that it will happen again, then her response is inhibited. As she becomes anxious, her blood vessels constrict, and as that constriction occurs, she experiences dryness and lack of arousal.
Female Orgasmic Disorder
Female orgasmic disorder (FOD) is the persistent or recurrent difficulty, delay in, or absence of attaining orgasm after sufficient sexual stimulation and arousal that causes personal distress. FOD may be a primary (never achieved orgasm) or a secondary condition (was able to achieve orgasm at one point in time but now no longer able). FOD can even be situational, referring to the woman who can experience orgasm in some circumstances (e.g. masturbation) but cannot in other situations. Secondary FOD is often a result of surgery, trauma, or hormone deficiencies. Primary FOD is typically secondary to emotional trauma or sexual abuse, and situational FOD, although often also associated with a history of trauma, is also commonly related to emotional stressors and relationship conflicts. However, in both of these cases, medical/physical factors and medications (i.e., selective serotonin reuptake inhibitors) can contribute to or exacerbate the problem.
Another kind of anorgasmia commonly experienced by women is coital FOD, or the inability to achieve orgasm from coital thrusting without added sexual stimulation. Only 30% of women experience orgasm regularly from sexual intercourse, 30% never reach orgasm during intercourse, and 40% have difficulty achieving orgasm from coital thrusting alone.21 In the primary care setting, many women describing themselves as anorgasmic are in fact experiencing coital anorgasmia. Most heterosexual women and their partners believe that they should be able to obtain orgasm through sexual intercourse. When this belief, held by either the man or the woman, is incompatible with the woman's actual stimulation needs, failure to achieve this goal can result in sexual dissatisfaction, relationship conflict, and a lack of sexual confidence.
The effect of anorgasmia on women is unpredictable. Some women can “accommodate”' intercourse with minimal levels of arousal, no discomfort, and no apparent psychological effect. Women who achieve high levels of sexual arousal but are unable to complete their sexual response into resolution phase often experience emotional frustration and may experience pelvic pain indicative of chronic pelvic congestion.
As with the etiology of other sexual symptoms, the etiology of anorgasmia can be categorized into physical factors, intrapsychic factors, and interpersonal factors. The factors alone or together can play a role in the evolution of this problem.
Women who fake orgasm initially in the relationship to please their partner may feel locked into continuing to fake orgasm for fear of their partner's reaction. They fear the partner will discover not only the anorgasmia but also the deception, which will impact negatively on the relationship. Many women's sex role perception requires them to be coitally orgasmic to be viewed as a loving sexual partner. Education and office counseling can be reassuring to the woman who needs to establish some clear communication with her partner about her sexual needs. If a woman is embarrassed, or if she is afraid of her partner's sadness or anger on learning that she has been faking orgasm, the physician can be helpful in making appropriate therapy referrals. The physician who is familiar with both members of the couple can help work through the disappointment and anger by encouraging the couple to focus on their desire to have an intimate sexual relationship that includes female orgasm.
|SEXUAL PAIN DISORDERS|
In 1985, the International Society for the Study of Vulvar Disease (ISSVD) recommended the term vulvodynia to describe any vulvar pain, regardless of the etiology. Vulvodynia is often accompanied by physical and psychological disabilities. The prevalence of vulvodynia is estimated to be as high as 15% in the general population.22 The precise etiology for vulvodynia is unclear. At present there is no definitive evidence favoring autoimmune, infectious, inflammatory, or structural etiology.23
Several subsets of vulvodynia have been identified. For instance, one is cyclic vulvovaginitis (CVV), in which the pain is cyclic, usually worsening just before or during menses. The etiology of CVV is thought to be multifactorial including hypersensitivity to Candida antigen, cyclic changes in pH, and selective IgA (immunoglobulin class A) deficiency. Another category is vulvar vestibulitis syndrome (VVS), involving inflammation of the Bartholin's glands and/or the minor vestibular glands at the base of the hymen. Symptoms include vulvar stinging, burning, irritation, and excoriation.
Etiology for this syndrome is also multifactorial including recurrent yeast vaginitis, use of chemicals or other irritants, previous treatment with carbon dioxide laser or cryotherapy, and allergic drug reactions. Vulvar burning has also been associated with higher levels of urinary calcium oxalate and can coexist with other pain disorders, such as interstitial cystitis and fibromyalgia. Dysesthetic vulvodynia is known as essential or idiopathic vulvodynia and refers to altered cutaneous perception or nerve sensory damage. Patients are typically older women who are perimenopausal or postmenopausal.
However, symptoms may occur in younger women who frequently identify a specific event, such as childbirth, with the onset of symptoms. Pudendal neuralgia and reflex sympathetic dystrophy have been implicated in causing vulvar dysesthesia. Vulvar dermatosis can produce a noncyclic, acute, or chronic vulvar pruritus or burning pain and patients are typically perimenopausal or postmenopausal. Inflammatory dermatosis is often seen in patients with topical steroid overuse or intolerance. Contact dermatosis should be considered in patients who use feminine hygiene products, such as deodorant sprays, scented douches and soaps, or lubricants.23,24
Other etiologic explanations in these cases include previous obstetric or gynecologic trauma to the vagina, menopausal or radiation atrophy, inflammation of the urinary tract, rectum, or vagina, or fixation of pelvic tissues. Patients with an organic problem are often unaware of chronic constipation as the primary source of their discomfort. Symptoms are often not only physiologically based but also psychologically based or some combination of the two.25,26
Intrapsychic issues are the main contributing factor in 43% of patients presenting with dyspareunia. Elements of fear, anxiety, and intimacy problems are often identified. Interpersonal conflict is the primary contributing factor in 27% of cases of dyspareunia. These relationships are characterized by poor communication, with special difficulty in talking about sex and emotions. Psychologic pressure to “perform” sexually can be present, especially when sexual intercourse is the primary or sole source of sexual pleasure and coital orgasm is a measure of intimacy for one or both partners.25,26
Most women who are coitally active will experience some genital pain at some time in their lives,25,26 and the pain often interferes with sexual satisfaction and may result in repeated disappointment and frustration. Comfortable sexual intercourse is important in most heterosexual relationships in providing pleasure and sustaining intimacy.
In an otherwise healthy woman, pain may be caused by a change in the physiologic sexual response (arousal phase) that promotes comfortable intercourse. The three elements necessary for comfortable intercourse include vaginal lubrication, vaginal expansion, and relaxation of the pelvic floor muscles. In patients with pain caused by these factors, basic education, over-the-counter lubricants and pelvic floor relaxation may help; however, in many cases, further evaluation and treatment is needed.
Vaginismus involves the recurrent or persistent involuntary spasms of the musculature of the outer third of the vagina that interferes with vaginal penetration and that causes personal distress. Vaginismus usually develops as a conditioned response to painful penetration or secondary to psychological/emotional factors. Vaginismus can be diagnosed by careful history and digital examination.
Vaginismus is a common finding during a pelvic examination. We can learn much by carefully observing our patients during this examination. Ignoring the signs of discomfort on the patient's face or in her body language will result in a missed opportunity to assess and treat vaginismus.27,28 Vaginismus is the primary problem in more than 55% of patients presenting with a symptom of dyspareunia. Some women exhibit involuntary muscle spasm at the first attempt to insert anything in the vagina (primary vaginismus). This problem persists with each attempt at inserting something in the vagina.27,28 Secondary vaginismus occurs when other causes of dyspareunia go untreated. The patient anticipates that the insertion of anything into the vagina will be uncomfortable, and this anticipation induces the involuntary muscle spasm of the pelvic floor.
Although there is much to be learned from observing the patient's comments and reactions on the examining table, digital palpation of the edge of the levator muscle in spasm is diagnostic of the problem. In some cases, the patient will exhibit perineal spasm, elevation of the buttocks, and adduction of the thighs despite the physician's reassurance. In this extreme situation, it is fruitless to proceed with the examination because it will only reinforce her fear through another painful experience. If the patient will allow a digital examination or an educational pelvic examination, gentle pressure on the side of the levator will reproduce her discomfort; however, if it is combined with a Kegel exercise, the physician can demonstrate a contraction–relaxation technique necessary to establish voluntary control over the muscles.
Primary vaginismus is often related to some past psychosexual or physical trauma. Psychosexual trauma based on misinformation, sexual interference, or religious proscription can result in phobic reactions to inserting anything in the vagina. On occasion, this problem can be produced iatrogenically by an unskilled or insensitive physician.
In the past, the problem of vaginismus has been badly managed by physicians. Patients are still treated surgically for this problem with hymenotomy, or Fenton's procedure. Because this is primarily a problem of muscle contraction or spasm, enlarging the introitus is not helpful. Some well-meaning physicians attempt to teach the patient “stretching exercises,” which again are not helpful. This approach conceptually encourages the patient to force the dilator into the vagina with the hope of enlarging the space. This suggestion reinforces the spasm and increases the pain. For vaginismus, a combination of brief office psychotherapy and gynecologic physical therapy can be useful in promoting understanding and muscle relaxation.
Other Sexual Pain Disorders
Other pain disorders involve recurrent and persistent genital pain induced by noncoital sexual stimulation. This includes anatomic and inflammatory conditions, including infections (i.e., HSV), vestibulitis, previous genital mutilation or trauma, and endometriosis.
|GENERAL ETIOLOGIES OF FEMALE SEXUAL DYSFUNCTION|
Many of the psychogenic etiologies for the different sexual disorders have been discussed; however, it is important to remember that in women, despite the presence or absence of organic disease, emotional and relational issues significantly affect sexual arousal. In every woman with a sexual function symptom, there are relationship, emotional, and medical factors happening simultaneously and interacting with one another in a nonlinear fashion. From the relationship standpoint (Fig. 1), partner sexual dysfunction, lack of communication, relationship conflict, and lack of information about sexual stimulation can all impact on a woman's sexual response. Furthermore, when a woman is struggling with a sexual function symptom, it may create conflict in the relationship, which then cycles back to negatively affect her function. The same is true for the emotional part of the equation (Fig. 2). For the woman herself, issues such as self-esteem and body image can affect her ability to respond sexually. In fact, a recent study highlighted that even the way a woman feels about the appearance and function of her genitals may impact on her desire and other elements of her sexual function.29
Other mood disorders and psychological stressors like depression, anxiety, chronic stress, and fatigue are all associated with female sexual function symptoms. In addition, the medications commonly used to treat depression can significantly affect the female sexual response. The most frequently used medications for uncomplicated depression are the selective serotonin reuptake inhibitors (SSRI). Women receiving these medications often report decreased desire, decreased arousal, decreased genital sensation, and difficulty achieving orgasm. Several studies have recently been published documenting the efficacy of sildenafil for improving SSRI-induced sexual dysfunction in women.30
High blood pressure, high cholesterol levels, smoking, and heart disease are associated with sexual dysfunction in women and impotence in men. The recently named clitoral and vaginal vascular insufficiency syndromes are, in fact, directly related to diminished genital blood flow, secondary to atherosclerosis of the iliohypogastric/pudendal arterial bed.31 Although other underlying conditions, either psychological or physiological/organic, may also manifest as decreased vaginal and clitoral engorgement, arterial insufficiency is one etiology that should be considered. Diminished pelvic blood flow secondary to aortoiliac or atherosclerotic disease leads to vaginal wall and clitoral smooth muscle fibrosis. This ultimately results in symptoms of vaginal dryness and dyspareunia. Histomorphometric evaluation of clitoral erectile tissue from atherosclerotic animals demonstrates clitoral cavernosal artery wall thickening, loss of corporal smooth muscle, and an increase in collagen deposition.32 In human clitoral tissue, there is a similar loss of corporal smooth muscle with replacement by fibrous connective tissue in association with atherosclerosis of clitoral cavernosal.33 While the precise mechanism is unknown, it is possible that the atherosclerotic changes that occur in clitoral vascular and trabecular smooth muscle interfere with normal relaxation and dilation responses to sexual simulation.
Aside from atherosclerotic disease, alterations in circulating estrogen levels associated with menopause contribute to the age-associated changes in clitoral and vaginal smooth muscle. In addition, any traumatic injury to the iliohypogastric/pudendal arterial bed from pelvic fractures, blunt trauma, surgical disruption, or chronic perineal pressure from bicycle riding, for instance, can result in diminished vaginal and clitoral blood flow and symptoms of sexual dysfunction.
The same neurogenic etiologies that cause erectile dysfunction in men can also cause sexual dysfunction in women. These include spinal cord injury or disease of the central or peripheral nervous system, including diabetes, and complete upper motor neuron injuries affecting sacral spinal segments. Women with incomplete injuries may retain that capacity for psychogenic arousal and vaginal lubrication.34 With regard to orgasm, women with spinal cord injury have significantly more difficulty achieving orgasm than do normal controls.35 The effects of specific spinal cord injuries on female sexual response and the role of vasoactive pharmacotherapy in this population are being investigated.
Dysfunction of the hypothalamic/pituitary axis, hypopituitarism, Addison disease, corticosteroid therapy, ovarian failure or oophorectomy, menopause, oral estrogen replacement therapy or oral contraceptive use, and surgical or medical castration are the most common causes of hormonally based female sexual dysfunction. The most common symptoms associated with decreased estrogen and/or testosterone levels are decreased libido, vaginal dryness, and lack of sexual arousal. While testosterone replacement is not FDA-approved for use in women, more research is being performed every day to determine the causes of androgen deficiency in women and the most effective ways to replace it. Protocols for replacing testosterone will be addressed in the treatment section.
Although estrogen replacement therapy comes with its own host of risks, we know that estrogen improves the integrity of vaginal mucosal tissue and has beneficial effects on vaginal sensation, vasocongestion, and secretions, which all lead to enhanced arousal. Estrogen deprivation causes a significant decrease in clitoral intracavernosal blood flow and vaginal and urethral blood flow. Histologically, it causes diffuse clitoral fibrosis, thinned vaginal epithelial layers, and decreased vaginal submucosal vasculature. Thus, a decrease in circulating estrogen levels can produce significant adverse effects on structure and function of the vagina and clitoris, ultimately affecting sexual function.
The pelvic floor muscles, in particular the levator ani and the perineal membrane, participate in female sexual function and responsiveness. The perineal membrane, consisting of the bulbocavernosus and ischiocavernosus muscles, when voluntarily contracted, contributes to and intensifies sexual arousal and orgasm. In addition, they are responsible for the involuntary rhythmic contractions during orgasm. The levator ani muscles also modulate motor responses during orgasm and vaginal receptivity. When hypertonic, vaginismus can develop, leading to or causing dyspareunia and other sexual pain disorders.
Every woman is at risk for sexual dysfunction, and the more open the physician is to hearing about these symptoms the more likely the patient will bring them up. It is crucial that clinicians provide appropriate cues that they are open to discussion of sexual concerns, and this can be achieved in many ways. Doctors may give patients a sexual function questionnaire along with their paperwork or just include a question like, “Do you have any questions or concerns about your sexual response or interest?” in the history. It is also helpful to place flyers or booklets about sexual function in the waiting and examination rooms to let patients know that the doctor is receptive to hearing their concerns.
One interesting study compared the effectiveness of three simple questions applied routinely to patients admitted to a gynecologic service with a more detailed interview conducted by an experienced sex therapist.36 Patients reported sexual problems to a receptive physician who displayed a willingness to discuss the subject. Ease with the subject matter was proven less important than had been estimated previously. Three simple questions applied by an inexperienced interviewer yielded the same results as a more detailed interview conducted by an experienced interviewer. This should be encouraging to inexperienced primary care physicians, who may feel relatively lacking in their comfort and skill regarding patients' sexual concerns.
These issues can be assessed effectively by two or three nonintrusive questions related to desire, discomfort, and satisfaction. These simple questions benefit the relationship between the physician and patient, even if the patient does not respond to the questions. There are two main benefits to these questions: (1) the patients are informed that they can discuss these issues with the physician when they are ready and (2) the mere fact that the questions are asked can help to create an expectation of continued clinical interest in the patient's sexual function.
In assessing a specific sexual concern raised by the patient, a more detailed history is appropriate (Table 1). Elements conducive to eliciting a sexual problem in detail include sufficient time to explore the concern, a setting that ensures privacy, listening while the patient explains her concern in detail, a comfortable attitude on the part of the physician, and the use of language that is common to and understood by both the physician and the client.
A problem-solving approach to the patient's sexual report is recommended and will enlist relevant questions to clarify whether the report relates to desire, arousal, orgasm, or discomfort. Specific questions can assess the presence of a dysphoric disorder and a history of medication ingestion. Intrapsychic factors of particular importance include stress, fatigue, depression, and substance abuse. Questions about the patient's early sex life may reveal a life-long inhibited sexual desire, sexual avoidance, or revulsion suggestive of childhood sexual trauma or abuse. If trauma or abuse history is discovered, it is crucial to send the patient for further support and evaluation by a trained therapist.
Relationship factors should be assessed for their relevant impact on the presenting report. Issues of grief, power, intimacy, and communication each require assessment to clarify whether the sexual concern is recent or a product of more serious long-standing conflicts. The importance of listening skills cannot be overemphasized. If the patient is allowed to talk, she will likely narrow the list of possible explanations of the problem to one or two in a very short discussion. The physician's comfort in exploring these issues is most important. A relaxed physician in a comfortable atmosphere will encourage full disclosure by the patient. Staccato questions that run through a list of issues will likely yield little information and much frustration. If time is a factor, the assessment can be performed over several visits. These symptoms are rarely an emergency and may be better dealt with over more than one visit, as long as the second visit is not long after the first.
Educational Pelvic Examination
Once a sexual problem has been presented, the goal is to identify all the potential contributing variables and to design a treatment plan that addresses all of them. A first step is the educational pelvic examination. This examination is a useful enhancement of the standard medical examination of the pelvis and genitals and affords an opportunity for educating the patient about her body. The educational nature of the examination provides opportunities for evaluating for sexual function symptoms that may not have become clear during the medical and surgical history. It is an easily learned skill, equipment costs are minimal, and there are many good indications for its use.37A successful pelvic examination involves elements of rapport, relaxation, and power sharing.38,39,40,41,42 A rapport between the physician and patient is created by physician behaviors that acknowledge her discomfort and respect her privacy. Relaxation is the result of information flow between a skilled and knowledgeable physician and an anxious patient who needs to know what is going to happen and why. Power sharing can occur only if the physician acknowledges the anxiety and vulnerability of the patient and involves her in decision-making. If the physician is unaware, insensitive, or unwilling to acknowledge these dynamics during the pelvic examination and the patient's vulnerability is exploited, the chances for high-quality reproductive health care and health promotion are lost.
Although the woman may intellectually consent to undergoing a pelvic examination, emotional consent is rare. It is common for a woman to feel that this experience is an involuntary intrusion into her life and into her body. Despite her inhibition and society's rules about hiding the genitals, at her first examination a woman has to reveal this hidden part of her body to a relative stranger. It is no wonder that many women openly state their dislike of the speculum and bimanual examination necessary to complete this important part of assessing sexual reports. It is not uncommon for an adult (physician or patient) to be embarrassed about a woman's body and phobic about her genitals. This discomfort may cause a physician to ignore that sexual and reproductive questions need to be included in the system's review and that a complete physical examination should be performed, including the patient's disrobing and undergoing a pelvic or rectal examination.
The typical scenario of a pelvic examination is as follows: the woman lies on her back in the lithotomy position, draped with a sheet, staring at the ceiling in anxious expectation. There may be no eye contact between the patient and physician; in fact, the drape across the knees may be a physical barrier to any visual or verbal communication. The patient experiences a dehumanizing environment, which causes her to feel that this experience is an involuntary intrusion into her body.
The educational pelvic examination is quite different in that it allows a patient to participate in the examination and learn from it. This requires the physician to educate the patient actively about the procedure to obtain informed consent and to continue a dialogue with the patient during the examination that provides reassurance and information about what is happening and why. Before the examination begins, the patient is reminded that she may stop the examination at any point.
The patient is positioned on the table with her head elevated and her heels in padded stirrups. She is encouraged to use a hand mirror so she can watch all the various parts of the examination, including visualization of her vaginal mucosa and cervix. She is reminded that she may put the mirror down at any time if she wishes. A good light source that is small enough that it does not block her line of vision is useful in illuminating the internal organs. The use of diagrams and models is helpful to enable the patient to develop a three-dimensional view of her pelvis. Allowing the patient to handle the speculum and explaining how and why it is used may provide some reassurance about her anxiety with respect to possible discomfort of the speculum examination.
Once the examination begins, the patient watches as the physician identifies various aspects of the external anatomy of the genitals. The clinical approach to this part of the examination helps to alleviate anxiety and embarrassment and generates interest on the part of the patient in learning about her body. Comments about the position of the clitoris, the size and shape of the labia minora, and the general health of the epithelium continue the pattern of reassurance and education. When possible, the hymen, vestibular glands, and urethra are identified.
Before moving on to the speculum examination, it is helpful to remind the patient of the purpose of this part of the examination, to make sure she is properly positioned on the table, and to emphasize the importance of her relaxing the pelvic floor and perineal muscles. Warming the speculum and checking it on her thigh before insertion ensure further comfort of the examination. Verbal cues, emphasizing each step of the speculum examination and pointing out the possible pressure sensation associated with passing the blade of the speculum over the levator muscle, can be given before each step of the examination. If there appears to be any tightness of the introitus, it may be helpful to remove the speculum and to start with some Kegel exercises, which she can view in the mirror. These will help her realize how much her relaxation can facilitate the opening of the introitus. The next move that may be necessary is inserting a lubricated finger to the level of the levator muscle and having the patient perform several Kegel exercises, emphasizing the relaxation half of the exercise while applying consistent pressure posteriorly toward the bed. This will help her visualize the relaxation of the muscle as she lets go after a Kegel contraction.
The educational pelvic examination can be quite useful in the overall treatment of vaginismus. In some cases, a patient can be taught Kegel exercises and reverse Kegel exercises during the examination and will benefit from the desensitization component of this examination to facilitate therapy and hasten a satisfactory outcome. In most cases, gynecologic physical therapy is needed in follow-up of the examination. In the case of vaginismus, it is especially important for the patient to feel that she is in control of the examination.
Once the speculum is fully inserted and opened, the patient can view her cervix and the cervical os, which can be identified with a sterile cotton-tipped applicator. The nature of the vaginal mucosa and its color and consistency can be identified. After the speculum is removed, the bimanual examination is performed. The patient may wish to palpate the fundus of her uterus during the bimanual examination by the physician elevating the uterus with the vaginal finger. The examination is completed with a rectovaginal examination. Finally, the patient is placed in a sitting position, covered with the sheet, and asked if she has any questions about her gynecologic health or her examination.
There are a number of situations in which an educational pelvic examination proves to be a useful clinical tool (Table 2).37,41,42 Patients previously traumatized by a pelvic examination may be the most reluctant and anxious patients seen in any physician's office. It is important to ask patients if they have ever had a negative experience or traumatic examination in the past. If so, acknowledging the trauma and encouraging the patient's participation in the decision-making about her care will help establish her confidence in your competence. The adult survivor of childhood sexual abuse and the woman who has been raped may require special attention in the form of absolute control of the pace of the examination. Continued dialogue about relaxation and a description of each step in the examination will prevent the patient from dissociating during the examination and losing control.
A young woman's first pelvic examination is a key opportunity for health education and reproductive counseling. This approach will allow her to gain important information about her body and to understand that the gynecologic examination can be performed without discomfort. A few extra minutes devoted to discussing her first pelvic examination will ensure her relaxation for future examinations and will convince her that these examinations need not be uncomfortable. At some point during the visit, the need for and recommended frequency of future pelvic examinations should be discussed.
A final point about these examinations is their usefulness in the assessment and treatment of sexual problems. In particular, women who have dyspareunia, vaginismus, an unconsummated relationship, or a sexual dysfunction resulting from sexual misinformation will benefit from this examination. The focus of this examination is to correct information deficits and to sensitize the women to her anatomy and its functions.
The educational pelvic examination allows the physician to assess problems, inform the patient, and recommend specific medical, surgical, or therapeutic treatments indicated by the examination.
Other Medical Tests
Beyond the educational pelvic examination, a medical and surgical history should be performed, and a hormonal profile is crucial in assessing the role of hormones in a woman's sexual function. This does not only apply to older, menopausal women. Birth control pills, chronic stress, depression, and childbirth can all contribute to response and desire problems in women. A complete hormonal profile should include follicle-stimulating hormone, luteinizing hormone, testosterone (free and total), and estradiol levels. Medications or medical conditions that adversely affect libido or sexual function should be noted.Table 3 provides a complete list of medications that may affect sexual function.
Estrogen therapy has many advantages. Recently, however, The National Institute of Health halted a longitudinal hormone replacement study on the basis that there was increased risk for heart disease, breast cancer, and ovarian cancer.43,44,45,46 As a result, patients are now closely involved in the decision-making process, and it is the responsibility of the physician to thoroughly discuss the options and risks with patients and help them make informed decisions.
In many instances, a safer and more effective medication could be prescribed in lieu of HRT, such as raloxifene or a bisphosphonate for bone demineralization, statins for lipid disorders, and aspirin for coronary heart disease and stroke prevention. It is important to educate patients about the level of increased risks. A 26% increase in the risk of breast cancer means that if 10,000 women were using HRT for 1 year, eight more will have breast cancer.47
The bottom line is that the doctor must help each woman weigh the risks and benefits of HRT. Estrogen may relieve hot flashes, improve clitoral sensitivity, increase libido, and decrease pain and burning during intercourse. Local or topical estrogen application relieves symptoms of vaginal dryness, burning, and urinary frequency/urgency. In perimenopausal, menopausal, or oophorectomized women, reports of vaginal irritation, pain, or dryness may be relieved locally with low-dose topical estrogen cream, vaginal estradiol rings, or vaginal estradiol pellets, which may help to minimize the risks of estrogen.
The only FDA-approved testosterone replacement available to women is methyltestosterone, indicated for menopausal women, used in combination with estrogen (Estratest), for symptoms of inhibited desire, dyspareunia, or lack of vaginal lubrication, as well as for its vasoprotective effects. A testosterone patch is presently being tested, and early trials indicate that the patch may improve sexual activity and help create overall sense of well being.48 According to the Princeton Consensus Panel on Female Androgen Insufficiency, if a woman exhibits symptoms of low testosterone (e.g., low libido and decreased energy and well-being), it is important to first determine an alternative explanation for these symptoms. This means ruling out major depression, chronic fatigue symptoms, and the range of other emotional and relationship conflicts that may impact on a patient's desire and happiness. The next step is to determine if the patient is in an adequate estrogen state and, if not, to consider the pros and cons of replacement.49
The physician should measure the patient's testosterone levels, which should include at least two to three measures of total and free testosterone. Normal value range for total testosterone is 49 to120 ng/dL, and for free testosterone it is 3.0 to 8.5 pg/mL for premenopausal women. Normal value range for total testosterone for postmenopausal women is 3.0 to 6.7 pg/mL. If the patient has a treatable cause for the androgen deficiency (e.g., oral estrogens or contraceptive use), treat the specific causes by changing medications. If not, consider a trial of androgen replacement therapy.
There are conflicting reports regarding the best way to use testosterone, in particular, in premenopausal women. Any premenopausal woman treated with testosterone must be on some form of reliable birth control and understand the risks. Topical vaginal testosterone is often used in premenopausal women as a first step because it is delivered locally and is also used for treatment of vaginal lichen planus. Topical testosterone (methyltestosterone or testosterone propionate) preparations can be compounded in 1% to 2% formulations and should be applied up to three times per week. The suggested dose of oral testosterone (pill or sublingual spray or lozenge) for premenopausal and postmenopausal women range from .25 to 1.25 mg/day. The dose should be adjusted according to symptoms, free testosterone levels, cholesterol levels, triglyceride levels, HDL levels, and LFT. The potential side effects of testosterone include weight gain, clitoral enlargement, increased facial hair, and hypercholesterolemia. Testosterone can also be converted into estrogen, so physicians should take this risk into account when counseling their patients. Increased clitoral sensitivity, decreased vaginal dryness, and increased libido have been reported with the use of a 2% testosterone cream. Preliminary studies on the effectiveness of dehydroepiandrosterone (DHEA) as a form of testosterone replacement are promising as well.50
Aside from hormone replacement therapy, all medications listed here, although used in the treatment of male erectile dysfunction, are still in the experimental phases for use in women. Currently, we have limited information regarding the exact neurotransmitters that modulate vaginal and clitoral smooth muscle tone. Recently, nitric oxide (NO) and phosphodiesterase type 5 (PDE5), the enzyme responsible for both the degradation of cGMP and NO production, have been identified in clitoral and vaginal smooth muscle.2 In addition, organ bath studies of rabbit clitoral cavernosal muscle strips demonstrate enhanced relaxation in response to the nitric oxide donors, sodium nitroprusside, L-arginine, and sildenafil.
Functioning as a selective type 5 (cGMP specific) phosphodiesterase inhibitor, sildenafil decreases the catabolism of cGMP, which is the second messenger in nitric oxide-mediated relaxation of clitoral and vaginal smooth muscle. Sildenafil may prove useful alone or possibly in combination with other vasoactive substances for treatment of female sexual arousal disorder. Phase two clinical studies assessing safety and efficacy of this medication for use in women are currently in progress. A recent study demonstrated that sildenafil is successful in treating female sexual arousal disorder in hormonally replete women without psychosexual causal factors in a placebo-controlled study.51,52 Other studies have found that sildenafil helps to alleviate arousal problems associated with aging and menopause and secondary to SSRI use.30,32
This amino acid functions as a precursor to the formation of nitric oxide, which mediates the relaxation of vascular and nonvascular smooth muscle. L-arginine has not been used in clinical trials in women. However, preliminary studies in men appear promising. A combination of L-arginine and yohimbine (an alpha-2 blocker) is currently undergoing investigation in women.
Yohimbine is an alkaloid agent that blocks presynaptic alpha-2 adrenoreceptors. This medication affects the peripheral autonomic nervous system, resulting in a relative decrease in adrenergic activity and an increase in parasympathetic tone. There have been mixed reports of its efficacy for inducing penile erections in men, and no formal clinical studies have been performed in women to date, nor have potential side effects been effectively determined.
PROSTAGLANDIN E1 (MUSE)
An intraurethral application, absorbed via mucosa (MUSE), is now available for male patients. A similar application of prostaglandin E1 delivered intravaginally is currently undergoing investigation for use in women. Clinical studies are necessary to determine the efficacy of this medication in the treatment of female sexual dysfunction.
Currently available in an oral preparation, this drug functions as a nonspecific alpha-adrenergic blocker and causes vascular smooth muscle relaxation. This drug has been studied in male patients for the treatment of erectile dysfunction. A pilot study in menopausal women with sexual dysfunction demonstrated enhanced vaginal blood flow and subjective arousal with the medication.53
Apomorphine is a short-acting dopamine agonist that facilitates erectile responses in normal males and males with psychogenic erectile dysfunction or organic impotence. Data suggest that dopamine is involved in the mediation of sexual desire and arousal. The physiologic effects of this drug are currently being tested in women with sexual dysfunction.
Nitroglycerin (glyceryl trinitrate) has been used for more than a century to relieve anginal symptoms associated with coronary artery disease. It has been administered to humans via oral, sublingual, intravenous, and transdermal routes. Nitroglycerin has been found to relax most smooth muscle, including bronchial, gastrointestinal tract, urethral, and uterine muscle. It also produces dilation of both arterial and venous vascular beds. Metabolism of nitroglycerin leads to the formation of the reactive free radical nitric oxide. Recent evidence suggest that application of nitroglycerin to painful areas, including the genitals, may provide analgesia to the affected areas.23,54 More work needs to be performed in this area, but many experts are finding this to be an effective treatment for helping women manage vulvar pain, especially when in combination with topical estrogen and testosterone creams and vaginal physical therapy.
Eros-CTD is the first FDA-approved treatment on the market for arousal and orgasmic disorders in women. It is a small, hand-held medical device that works by applying a genital vacuum to the clitoris, increasing blood flow to the clitoris and surrounding tissue. Initial clinical trials showed improvement in premenopausal and postmenopausal women with female sexual arousal disorder or female orgasmic disorder.55,56
InterStim therapy was designed to treat urinary incontinence. The therapy involves placing a lead in the S-2 to S-4 region. The lead is passed to a neurostimulator, which sends mild electrical pulses to the sacral nerve. Many women who have undergone this procedure have anecdotally reported that their sexual arousal and ability to achieve orgasm increased. More retrospective and prospective research testing this device for orgasmic improvement is currently underway.
GYNECOLOGIC PHYSICAL THERAPY
Pelvic pain, vaginismus, and vaginal atrophy can often be treated with physical therapy. When muscle tension or spasm appears to be a factor, a physical therapist, through gentle massage, biofeedback, or other techniques, can help restore normal muscle balance. Physical therapy can also be helpful for women who have vaginal, rectal, or uterine prolapse, and can be helpful to those women with incontinence and weak Kegel muscles.
More often than not, there are psychological and relationship factors contributing to a sexual problem. Even if the primary etiologic domain is physical, there are emotional and relationship outgrowths to the problem that cannot be ignored. Similarly, not all women are candidates for medical intervention and are better suited for other psychological or couples therapies.19,56,57 Usually the best treatment is a combination of medical and talk therapy. It should be noted here that beginning talk therapy without evaluating the potential medical causes for female sexual dysfunction is not recommended. Extensive talk therapy with a woman with undiagnosed medical issues can be a frustrating experience for the patient and caregiver.
The ideal way to determine candidates for medical intervention in a clinical setting is to collaborate with a trained sex therapist. If the medical practitioner has access to a therapist on site, evaluation and diagnosis are optimized. Unfortunately, not all physicians have access to or facilities for incorporating a sex therapist into their practice. In this case, it is crucial for the physician to perform an extensive assessment of the sexual symptoms and the context in which they are experienced. This process not only entails a good global history but also includes clarification of the sexual concern in a way that allows psychosexual “red flags” to be identified so that an appropriate therapy referral can be made (Table 4).
*None of these factors guarantee the problem is psychosexually based but simply point to a need for further clarification by a trained sex therapist.
The key to making a therapy referral is helping the patient understand how talk therapy fits into the treatment equation. It may need to be clarified that although you do not think her problems are “all in her head,” she would benefit from talk therapy as well as medical treatment. Often if the physician supports the role of talk therapy and helps the patient understand how it will be incorporated into her treatment plan, rather than feeling “pawned off” to someone else, she will feel validated and encouraged. Even if the physician refers the patient to a sex therapist, if it is discussed as part of the treatment plan, the patient will usually respond positively.
|IN-OFFICE SEXUAL COUNSELING|
The physician can play an effective role in managing women's sexual function symptoms when there are no significant intrapsychic or relationship issues at play, the relationship is not in crisis, and the problems have not been long-standing or involving multiple dysfunctions. The best model to support the value of brief office treatment is described by Annon.58 With the P-LI-SS-IT model, many sexual symptoms can be managed by a comfortable, informed physician through education and office counseling. The P-LI-SS-IT model outlines the various stages of education, counseling, or therapy as follows: P = permission. This relates to the patient whose question centers on, “am I normal?” LI = limited information. This involves educating the patient regarding facts of physiology, endocrinology, contraception, or normal sexual response. SS = specific suggestion. This refers to suggestions for changes in attitude, behavior, or technique that will enhance communication, sensuality, or sexual pleasure for the patient and her partner. IT = intensive therapy. At this stage, a referral to a trained sex therapist is typically necessary. Intensive therapy is reserved for patients for whom the physician has identified psychosexual red flags or for those who clearly need more time and psychological care than the physician feels equipped to provide.
The ideal approach to female sexual health is a collaborative effort between physicians and therapists and should include a complete medical and psychosocial evaluation. Although there are significant anatomic and embryological parallels between men and women, the multifaceted nature of female sexual dysfunction is clearly distinct from that of the male. Thus, we cannot approach female patients or their sexual function problems in a similar fashion as male patients. Frequently, the emotional and relationship well-being a woman experiences contributes more to her sexual enjoyment than does her physiological response. These issues need to be addressed in conjunction with medical therapy for treatment to be effective. The presence of organic disease is often accompanied by psychosocial, emotional, and/or relational factors that contribute to female sexual dysfunction. For this reason, a comprehensive approach, addressing psychological and physiologic factors, is instrumental to the evaluation of female patients with sexual symptoms.
17. Andry C, Goldstein I, Park K et al: Vasculogenic female sexual dysfunction: the hemodynamic basis for vaginal engorgement insufficiency and clitoral erectile insufficiency. Int J Impotence Res 9:27–37, 1997
29. Berman L, Berman J, Miles M et al: Genital Self-Image as a Component of Sexual Health: Relationship between Genital Self-Image, Female Sexual Function, and Quality of Life Measures. J Sex Marital Ther 29:S: 11–21, 2003
33. Goldstein I, Moreland RB, Park K et al: Characterization of phosphodiesterase activity in human clitoral corpus cavernosum smooth muscle cells in culture. Biochem Biophys Res. Com 249:612–617, 1998
43. Writing Group for the Women's Health Initiative Investigators: Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principle results from the Women's Health Initiative randomized controlled trial. JAMA 28:321–333, 2002
44. Grady D, Herrington D, Blumenthal R et al: Cardiovascular disease outcomes during 6.8 years of hormone therapy. Heart and Estrogen/Progestin Replacement Study Follow-up (HERS II). JAMA 288:49–57, 2002
45. Hulley S, Furberg C, Barrett-Connor E et al: Noncardiovascular disease outcomes during 6.8 years of hormone therapy. Heart and Estrogen/Progestin Replacement Study Follow-up (HERS II). JAMA 288:58–66, 2002
52. Berman JR, Berman LA, Lin H et al: Effect of sildenafil on subjective and physiologic parameters of the female sexual response in women with sexual arousal disorder. J Sex Marital Ther 27:411–420, 2001
55. Berman LA, Berman JR, Werbin T et al: The use of the female intervention efficacy index (FIEI) as an immediate outcome measure of medical intervention to treat female sexual dysfunction. J Sex Marital Ther 27:427–433, 2001