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Female Sexual Dysfunction: Evaluation and Treatment

NANCY A. PHILLIPS, M.D. Wellington School of Medicine, University of Otago, Wellington, New Zealand

A patient information handout on sexual dysfunction in women, written by the author of this article, is provided on page 141.

Sexual dysfunction includes desire, arousal,
orgasmic and sex pain disorders (dyspareunia and vaginismus). Primary care
physicians must assume a proactive role in the diagnosis and treatment of
these disorders. Long-term medical diseases, minor ailments, medications and
psychosocial difficulties, including prior physical or sexual abuse, are
etiologic factors. Gynecologic maladies and cancers (including breast
cancer) are also frequent sources of sexual dysfunction. Patient education
and reassurance, with early diagnosis and intervention, are essential for
effective treatment. Patient history and physical examination techniques,
normal sexual responses and the factors that influence these responses, and
the application of medical and gynecologic treatments to sexual issues are
discussed. Basic treatment strategies, which may be successfully provided by
primary care physicians for most sexual dysfunctions, are outlined. Referral
can be reserved for patients who do not respond to therapy. (Am Fam
Physician 2000;62:127-36,141-2.)

Sexuality is a complex process,
coordinated by the neurologic, vascular and endocrine systems.¹ Individually, sexuality incorporates family,
societal and religious beliefs, and is altered with aging, health status and
personal experience. In addition, sexual activity incorporates interpersonal
relationships, each partner bringing unique attitudes, needs and responses
into the coupling. A breakdown in any of these areas may lead to sexual
dysfunction.

See editorial on page 52.

Primary care physicians, skilled in the treatment of medical and
psychologic disorders, often feel unqualified to treat patients with sexual
dysfunction. However, with an understanding of sexual functioning and
application of general medical and gynecologic treatments to sexual issues,
sexual dysfunction may be effectively approached with the same skills. The
latter includes obtaining a complete patient history, conducting a physical
examination, application of basic treatment strategies, providing patient
education and reassurance, and recommending appropriate referral when
indicated.

Diagnosis

Female sexual dysfunction can be subdivided into desire, arousal, orgasmic
and sexual pain disorders. Sexual pain disorders include dyspareunia and
vaginismus.²

Estimates of the number of women who have sexual dysfunction range from 19
to 50 percent in “normal” outpatient populations^3-6 and increase to 68 to 75 percent when sexual
dissatisfaction or problems (not dysfunctional in nature) are included.^5,7 Yet, one review of physicians’ chart notes
revealed a recorded sexual problem in only 2 percent.⁵ In another review, physician inquiry of patients
in a gynecologic office setting about sexual problems increased reported
complaints about sexual dysfunction sixfold.³
This discrepancy demonstrates a need for physician education in this area.

FIGURE 1.Cycle of sexual dysfunction. Example showing how a patient can enter the cycle of sexual dysfunction in one area (i.e., decreased orgasm) and proceed to another area (i.e., decreased desire) so that the presenting complaint may not represent the problem that actually requires evaluation and treatment. Adapted with permission from Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res 1998;10(suppl 2):S117-20.

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 conditions, and elicits psychosocial
information.⁸ Preappointment questionnaires or
appointments at which only the history is taken allow patient-physician
communication to be unhindered by time constraints or patient fears of an
upcoming physical examination.

Establishment of the patient’s sexual orientation is necessary for
appropriate evaluation and management. Nonjudgmental, direct questions best
achieve this goal. Because gender identity conflicts are often a cause of
sexual dysfunction, the mode and type of questions asked by physicians should
create an environment where patients may openly express their concerns.
Specialized counseling is important for these patients.

The sexual dysfunction should be defined in terms of onset and duration and
situational versus global effect. A situational dysfunction occurs with a
specific partner, in a certain setting or in a definable circumstance.

The presence of more than one dysfunction should be ascertained, because
considerable interdependence may exist. For example, a patient complaining
about decreased desire might have a primary orgasmic disorder from
insufficient stimulation, with decreased desire developing secondarily as a
result of unsatisfying sexual encounters (Figure 1).⁸ Thus, treating the orgasmic disorder would
indirectly enhance desire; whereas, treating a desire disorder would be
unsuccessful and perhaps add to patient frustration and perpetuate the cycle
of dysfunction.

Questioning the patient about what she thinks is causing the problem may
add insight. She may reveal fear of redeveloping an abnormal Papanicolaou
smear from penile penetration, or she may admit that she is not attracted to
her partner. Obtaining this information early in the evaluation process will
expedite diagnosis and initiation of treatment.

TABLE 1 Medical Causes of Female Sexual Dysfunction The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

Medical conditions are a frequent source of direct or indirect sexual
difficulties. Vascular disease associated with diabetes might preclude
adequate arousal; cardiovascular disease may inhibit intercourse secondary to
dyspnea (Table 1).¹ Arthritis or
urinary incontinence may cause discomfort or embarrassment, leading to
dysfunction or decreased sexual activity.²
Aggressive treatment of long-term disease and minor ailments, with attention
to their sexual implications, will help enhance sexuality.

Prescription and over-the-counter medications, illicit drugs and alcohol
abuse contribute to sexual dysfunction^9,10
(Table 2).¹⁰ Medication
changes, drug discontinuation, or dosage or schedule alterations may provide
relief. Cigarette smoking, known to cause erectile dysfunction in men, may
have a similar negative effect on arousal in women.

Gynecologic conditions contribute physically to sexual difficulties
(Table 3),⁸ and treatment must address
both of these issues. For example, treatment of a patient with recurrent
cystitis as a cause of dyspareunia should include the use of lubricants and
distraction techniques at first intercourse to assure adequate lubrication and
relaxation, respectively. These steps help resolve any secondary difficulties
that may have developed (e.g., an arousal disorder or mild vaginismus). For
patients with a female partner, details concerning sexual habits and objects
of penetration, if any, are necessary. In these instances, hygienic use of
vibrators may result in fewer episodes of cystitis.

Hysterectomy, gynecologic malignancies and breast cancer present medical
and mortality concerns, and alter or remove physical and psychologic symbols
of femininity that may result in feelings of decreased sexuality. In one
study,¹¹ 74 percent of patients who underwent
surgery for gynecologic malignancy reported decreased desire, and 40 percent
reported dyspareunia. In another study¹² of
patients who had undergone hysterectomy for benign disease, a decrease in
sexual responsiveness of up to 30 percent was noted. Breast cancer survivors
report a 21 to 39 percent incidence of sexual dysfunction,¹³ although a recent study¹⁴ suggests that this may be related to chemotherapy
or hypoestrogenism secondary to ovarian failure. Preoperative counseling,
including explanations of postoperative anatomy and potential effects on
sexuality, is essential in these patient populations. Continued postoperative
counseling and early recognition and treatment of sexual difficulties may also
help these patients maintain satisfying sexual relationships.

TABLE 2 Medications and Female Sexual Dysfunction Medications that cause disorders of desire Psychoactive medications Antipsychotics Barbiturates Benzodiazepines Selective serotonin reuptake inhibitors Lithium Tricyclic antidepressants Cardiovascular and antihypertensive medications Antilipid medications Beta blockers Clonidine (Catapres) Digoxin Spironolactone (Aldactone) Hormonal preparations Danazol (Danocrine) GnRh agonists (e.g., Lupron, Synarel) Oral contraceptives Other Histamine H2-receptor blockers and promotility agents Indomethacin (Indocin) Ketoconazole (Nizoral) Phenytoin sodium (Dilantin) Medications that cause disorders of arousal Anticholinergics Antihistamines Antihypertensives Psychoactive medications Benzodiazepines Selective serotonin reuptake inhibitors Monoamine oxidase inhibitors Tricyclic antidepressants Medications that cause orgasmic dysfunction Methyldopa (Aldomet) Amphetamines and related anorexic drugs Antipsychotics Benzodiazepines Selective serotonin reuptake inhibitors Narcotics Trazadone (Desyrel) Tricyclic antidepressants* *–Also associated with painful orgasm Adapted with permission from Drugs that cause sexual dysfunction: an update. Med Lett Drugs Ther 1992;34:73-8.

TABLE 3 Gynecologic Causes of Female Sexual Dysfunction and Method of Gynecologic Examination Examination Condition External genitalia Assess muscle tone Vaginismus Assess skin color and texture Vulvar dystrophy, dermatitis Assess skin turgor and thickness Atrophy Assess pubic hair amount and distribution Atrophy Expose clitoris Clitoral adhesions Assess for ulcers Herpes simplex virus Perform cotton swab test of vestibule Vulvar vestibulitis Palpate Bartholin glands Bartholinitis Assess posterior forchette and hymenal ring Episiotomy scars, strictures Monomanual Palpate rectovaginal surface Rectal disease Palpate levator ani Levator ani myalgia, vaginismus Palpate bladder/urethra Urethritis, interstitial cystitis, urinary tract infection Assess for cervical motion tenderness Infection, peritonitis Assess vaginal depth Postoperative changes, postradiation changes, stricture Bimanual Palpate uterus Retrogression, fibroids, endometritis Palpate adnexa Masses, cysts, endometriosis, tenderness Perform rectovaginal examination Rule out endometriosis Obtain guaiac test Bowel disease Speculum Evaluate discharge, pH Vaginitis, atrophy Evaluate vaginal mucosa Atrophy Perform Papanicolaou smear Human papillomavirus infection, cancer Assess for prolapse Cystocele, rectocele, uterine prolapse Adapted with permission from Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res 1998;(suppl 2):S117-20.

Gynecologic changes related to a woman’s reproductive life (e.g., puberty,
pregnancy, the postpartum period and menopause) present unique problems and
potential obstacles to sexuality. Puberty may lead to concerns regarding
sexual identity. Pregnancy and the postpartum period are often associated with
a decrease in sexual activity, desire and satisfaction, which may be prolonged
with lactation.¹⁵

For patients with dyspareunia, a “monomanual” examination is appropriate, with the physician inserting one or two fingers into the vagina and the other hand held away from the abdomen so as not to confuse the source of discomfort.

The hypoestrogenic state of menopause may cause significant physical
changes^16,17 (Table 4)¹⁷ and alterations in mood or a diminished sense of
well-being, which have been found to have a significant, negative impact on
sexuality.¹⁸ A decline in desire, arousal and
frequency of intercourse and an increase in dyspareunia have been associated
with menopause,^19-21 although these findings
are not universal.¹⁸

The final goal is to elicit psychosocial information. Previous experiences
and current intra- and interpersonal factors should be explored (Table
5).

Physical Examination
Each patient should undergo a thorough
examination, with the gynecologic examination individually guided by and
tailored to patient comfort. The goal of the examination is detection of
disease; however, the examination also provides an opportunity to educate the
patient about normal anatomy and sexual function, and to reproduce and
localize pain encountered during sexual activity.

TABLE 4 Physiologic Changes of Menopause Skin Decreased activity of sweat and sebaceous glands, decreased tactile stimulation Breasts Decreased fat content, decreased breast swelling and nipple erectile response with sexual arousal Vagina Shortening and loss of elasticity of vaginal barrel, diminished physiologic secretions, rise in vaginal pH from 3.5 to 4.5 to greater than 5, thinning of epithelial layers Internal reproductive organs Ovaries and fallopian tubes diminish in size, ovarian follicles undergo atresia, ovarian stroma becomes fibrotic, uterine body weight decreases 30 to 50 percent, cervix atrophies and decreases mucous production Bladder Urethra and bladder trigone atrophy Reproduced with permission from Phillips NA, Rosen RC. Menopause and sexuality. In: Lobo RA, ed. Treatment of the postmenopausal woman. 2d ed. Phildelphia: Lippincott Williams and Wilkins, 1999:437-43.

TABLE 5 Psychosocial Factors of Female Sexual Dysfunction Intrapersonal conflicts Religious taboos, social restrictions, sexual identity conflicts, guilt (i.e., widow with new partner) Historical factors Past or current abuse (sexual, verbal, physical), rape, sexual inexperience Interpersonal conflicts Relationship conflicts; extra-marital affairs; current physical, verbal or sexual abuse; sexual libido; desire or practices different from partner; poor sexual communication Life stressors Financial, family or job problems, family illness or death, depression

A routine examination seeks signs of general medical conditions. The
gynecologic examination is comprehensive (Table 3),⁸ beginning with inspection of the external
genitalia, including a cotton swab test if indicated (gently touching the
vestibule of the vagina with a cotton swab will elicit moderate to severe pain
in patients with vulvar vestibulitis). For patients with dyspareunia, a
“mono-manual” examination should follow, with one or two fingers in the vagina
(proceeding from posterior to anterior), and the other hand held away from the
abdomen so as not to confuse the source of discomfort (Table 3).⁸ Bimanual and rectovaginal examinations are then
performed. The timing of the speculum examination is guided by patient
symptoms. In patients with deep dyspareunia, the speculum examination should
follow the bimanual examination because localization of pain is crucial in
these patients. In patients in whom vaginitis, cervical cancer or a sexually
transmitted disease is suspected, cultures and vaginal samples should be
obtained first.

Laboratory testing should be guided by patient symptoms and examination
findings. No specific tests are universally recommended for patients with
sexual dysfunction. Attention to routine screening tests must not be
overlooked.

General Treatment Guidelines

Following the patient history and physical examination, a suspected
etiology may be treated.

If no etiology is discovered, basic treatment strategies are applied
(Table 6). The patient’s (and partner’s) personal tastes and comfort
must be considered. Physicians should respect a patient’s choice to decline
treatment, because studies show that sexual activity is not correlated with
overall sexual satisfaction or intimacy in all persons.^18,22 In general, treatments are similar despite
sexual orientations.

TABLE 6 Basic Treatment Strategies for Female Sexual Dysfunction Provide education Provide information and education (e.g., about normal anatomy, sexual function, normal changes of aging, pregnancy, menopause). Provide booklets, encourage reading; discuss sexual issues when a medical condition is diagnosed, a new medication is started, and during pre- and postoperative periods; give permission for sexual experimentation. Enhance stimulation and eliminate routine Encourage use of erotic materials (videos, books); suggest masturbation to maximize familiarity with pleasurable sensations; encourage communication during sexual activity; recommend use of vibrators*; discuss varying positions, times of day or places; suggest making a “date” for sexual activity. Provide distraction techniques** Encourage erotic or nonerotic fantasy; recommend pelvic muscle contraction and relaxation (similar to Kegel exercise) exercises with intercourse; recommend use of background music, videos or television. Encourage noncoital behaviors*** Recommend sensual massage, sensate-focus exercises (sensual massage with no involvement of sexual areas, where one partner provides the massage and the receiving partner provides feedback as to what feels good; aimed to promote comfort and communication between partners); oral or noncoital stimulation, with or without orgasm. Minimize dyspareunia Superficial: female astride for control of penetration, topical lidocaine, warm baths before intercourse, biofeedback. Vaginal: same as for superficial dyspareunia but with the addition of lubricants. Deep: position changes so that force is away from pain and deep thrusts are minimized, nonsteroidal anti-inflammatory drugs before intercourse. NOTE: For a review, see Striar S, Bartlik B. Stimulation of the libido: the use of erotica in sex therapy. Psych Annals 1999;29:60-2. *–Provide information for obtaining one discreetly. **–Helpful in eliminating anxiety, increasing relaxation and diminishing spectatoring. ***–Also helpful if partner has erectile dysfunction.

Disorders of Desire
Women with disorders of desire are difficult
to treat. Occasionally, decreased desire in patients is secondary to boredom
with sexual routines. Suggesting changes in positions or venues, or the
addition of erotic materials is helpful.

Disorders of desire in premenopausal patients may be secondary to lifestyle
factors (e.g., careers, children), medications or another sexual dysfunction
(e.g., pain or orgasmic disorder). No medical treatment is available specific
to patients with disorders of desire. If no underlying medical or hormonal
etiology is discovered, individual or couple counseling may be helpful.

Estrogen replacement therapy has been shown to correlate positively with sexual activity, enjoyment and desire, although the findings are not universal.

In peri- and postmenopausal women, the relationship between hormones and
sexuality is unclear.^18-21 Nonetheless,
estrogen replacement therapy has been shown to correlate positively with
sexual activity, enjoyment and fantasies–the latter thought to represent
desire.^23,24 The mechanism of estrogen’s
effect on desire is indirect and occurs through improvement in urogenital
atrophy, vasomotor symptoms and menopausal mood disorders (i.e., depression).
This relationship helps predict which patients are likely to respond to
estrogen replacement therapy (i.e., those with symptoms of hypoestrogenism)
and may explain why some studies do not show estrogen-mediated improvement in
sexual functioning.²⁵

The role of progesterone therapy, which is necessary in estrogen-treated
patients with an intact uterus, has not been widely studied in terms of
sexuality, but one study²⁴ suggests that it
exhibits a negative impact by dampening mood and decreasing available
androgens. The addition of estrogen for several weeks before progesterone
therapy is initiated, or taking into account monthly symptom calendars, will
help determine each hormone’s influence and guide dosage and schedule
adjustments.

TABLE 7 Testosterone Therapy for Treatment of Disorders of Desire* Screening Baseline testosterone levels** (free and total), baseline lipid profile, baseline liver enzyme levels, mammography, Papanicolaou smear Initiate therapy*** Combination product (Estratest or Estratest hs) Methyltestosterone (Android), 1.25 to 2.5 mg daily Micronized oral testosterone, 5 mg twice daily Testosterone proprionate 2 percent in petroleum applied daily to every other day Testosterone injectables/pellets Reevaluation at three to four months Repeat testosterone levels, lipid profile, liver enzyme levels Monitor symptoms, side effects Continued therapy Taper to lowest effective dosage¶ Monitor lipid levels, liver enzyme levels once or twice yearly Routine Papanicolaou smear and mammography schedules *–These are recommendations; no evidence-based protocols are available on testosterone therapy for the treatment of women with desire disorders. **–Many authors recommend that total levels remain in “normal” range for premenopausal women. ***–None of these medications are labeled by the U.S. Food and Drug Administration for treatment of desire disorders. ¶–Alternate daily combined with estrogen-only pill, take testosterone pill every other day, 5 days a week, etc. (not shown in studies to be safer or have fewer side effects).

Testosterone appears to have a direct role in sexual desire.²⁰ However, because studies evaluate mostly
testosterone-deficient, oophorectomized women or women who develop
supraphysiologic levels secondary to testosterone treatment, clinical
applications are limited. No guidelines for testosterone replacement therapy
for women with disorders of desire and no consensus of “normal” or
“therapeutic” levels of testosterone therapy exist. Many physicians are
concerned about the lack of safety data on the role of testosterone in breast
cancer and on hepatic side effects; however, hepatocellular damage or
carcinoma is rare at prescribed dosages,²⁶ and
the development of breast cancer has not been reported clinically.²⁷

The side effects of testosterone, which occur in 5 to 35 percent of
patients, include lower levels of high-density lipoprotein, acne, hirsutism,
clitorimegaly and voice deepening.²⁷ However,
these side effects on lipoprotein levels are rarely significant if estrogen
and testosterone are coadministered; moreover, most other side effects are
reversible with discontinuation of testosterone or a dosage adjustment.²⁶

A role for testosterone treatment exists in selected patients (Table
7). Coadministration with estrogen therapy should be provided to prevent
deleterious effects on lipoprotein levels. Before initiating testosterone
treatment, physicians should discuss the potential and theoretic risks, and
individual risk and benefit assessments with the patient. In general, patients
with current or previous breast cancer, uncontrolled hyperlipidemia, liver
disease, acne or hirsutism should not receive testosterone therapy.

Arousal Disorders
Current treatment of patients with arousal
disorders is limited to the use of commercial lubricants, although vitamin E
and mineral oils are also options. Arousal disorders may be secondary to
inadequate stimulation, especially in older women who require more stimulation
to reach a level of arousal that was more easily attained at a younger age.
Encouraging adequate foreplay or the use of vibrators to increase stimulation
may be helpful. Taking a warm bath before intercourse may also increase
arousal. Anxiety may inhibit arousal, and strategies to alleviate anxiety by
employing distraction techniques are helpful.

Urogenital atrophy is the most common cause of arousal disorders in
postmenopausal women, and estrogen replacement, when appropriate, is usually
effective therapy. However, women taking systemic estrogens occasionally
require supplementation with local therapy. Long-term use of
estrogen-containing vaginal creams is considered an unopposed-estrogen
treatment in women with an intact uterus, requiring progesterone opposition.
An oral progesterone such as medroxyprogesterone 5 mg daily for 10 days every
one to three months (or equivalent) may be used initially, with frequency or
dosage increased if withdrawal bleeding occurs. Estring (an
estradiol-containing vaginal ring) has little systemic absorption and does not
require the addition of progesterone. Patients who are uncomfortable wearing
the ring during the day often achieve relief with night use only.

Premenopausal women with arousal disorders, women who do not respond to
estrogen therapy and women who are unable or unwilling to take estrogen
represent difficult patient groups because few treatment options are
available.

TABLE 8 Kegel Exercises Potential uses Increased pubococcygeal tone Improved orgasmic intensity Correction of orgasmic urine leakage Distraction technique during intercourse Improved patient awareness of sexual response Teaching Kegel exercises Instructional examination with examiner’s finger in vagina Initial patient home exercise with patient’s finger in vagina Slow count to 10, with movement directed “in and up” Hold for count of 3 Slow release to count of 10 Repeat 10 to 15 times daily Consider vaginal weights, biofeedback clinics Maintaining Kegel exercises Advise repetitions during routine activities (standing in line, at stop lights, etc.) Schedule follow-up appointments to discuss progress

Investigators recognize that small-vessel atherosclerotic disease of the
vagina and clitoris may contribute to arousal disorders and are exploring
vasoactive medications as treatment.²⁸ Small
studies^29,30 have been conducted with
favorable results, but larger studies are needed. Currently, treatment of
arousal disorder in women who are taking these medications, including
sildenafil (Viagra), is not recommended, although anecdotal success has been
reported.³⁰

Orgasmic Disorders
Anorgasmia is quite responsive to therapy.
This condition is caused by sexual inexperience or the lack of sufficient
stimulation and is common in women who have never experienced orgasm. Orgasmic
disorders may also be psychologic (“involuntary inhibition” of the orgasmic
reflex) or caused by medications or chronic disease.

Treatment relies on maximizing stimulation and minimizing inhibition.³¹ Stimulation may include masturbation with
prolonged stimulation (initially up to one hour) and/or the use of a vibrator
as needed, and muscular control of sexual tension (alternating contraction and
relaxation of the pelvic muscles during high sexual arousal). The latter is
similar to Kegel exercises (Table 8). Methods to minimize inhibition
include distraction by “spectatoring” (observing oneself from a third-party
perspective), fantasizing or listening to music. Women who do not respond to
therapy should be referred to an appropriate therapist.

Sex Pain Disorders
Dyspareunia can be divided into three types
of pain: superficial, vaginal and deep (Table 6). Superficial
dyspareunia occurs with attempted penetration, usually secondary to anatomic
or irritative conditions, or vaginismus. Vaginal dyspareunia is pain related
to friction (i.e., lubrication problems), including arousal disorders. Deep
dyspareunia is pain related to thrusting, often associated with pelvic disease
or relaxation.⁷

Treatment of orgasmic disorders relies on maximizing stimulation and minimizing inhibition.

Diagnosis of an underlying etiology should be aggressively sought, even if
surgical investigation (laparoscopy) is required. The physical examination
must include meticulous detail, with the physician’s focus on recreating the
pain. Treatment of the underlying etiology is fundamental, but as in long-term
pain disorders, counseling and pain control strategies are essential. General
recommendations for improved sexual function are discussed in Table 6
and are similar despite sexual orientation.

TABLE 9 Female Sexual Dysfunction: When to Refer Longstanding dysfunction Multiple dysfunctions Current or past abuse Psychologic disorder or acute psychologic event Unknown etiology No response to therapy

Vaginismus, the involuntary contraction of the muscles of the outer one
third of the vagina, is often related to sexual phobias or past abuse or
trauma.^10,32 Vaginismus may be complete or
situational, so that a pelvic examination might be possible while intercourse
is not. Therapy for and counseling of women with vaginismus can be initiated
and often successfully completed by primary care physicians.

Treatment of women with vaginismus consists of progressive muscle
relaxation and vaginal dilatation (actually a misnomer because the vagina is
not physically stretched). Progressive muscle relaxation can be taught during
an instructional examination by having the patient alternate contracting and
relaxing the pelvic muscles around the examiner’s finger. Women with
vaginismus can achieve vaginal dilatation with the use of commercial dilators
or tampons of increasing diameter, placed into the vagina for 15 minutes twice
daily. Once the patient can easily accept an equivalent-sized dilator into the
vagina, penile penetration by the partner can occur. Success rates approach 90
percent.^31,32 Patients who do not respond to
this therapy should be referred to a sex therapist who specializes in the
treatment of women with this disorder (Table 9).

---

The Author

NANCY A. PHILLIPS, M.D.,
is a senior lecturer and consultant in the
Department of Obstetrics and Gynecology at the Wellington School of Medicine,
University of Otago, Wellington, New Zealand. Dr. Phillips earned her medical
degree from the University of Medicine and Dentistry of New Jersey, Robert
Wood Johnson Medical School, Piscataway and completed her obstetrics and
gynecology residency at George Washington University Hospital, Washington,
D.C.

Address correspondence to Nancy Phillips, M.D.,
119 Mitchell St., Brooklyn, Wellington, New Zealand. Reprints are not
available from the author.

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