{"id":1591,"date":"2013-10-11T09:45:48","date_gmt":"2013-10-11T09:45:48","guid":{"rendered":"http:\/\/jacobimed.org\/NS\/?page_id=1591"},"modified":"2013-10-11T09:45:48","modified_gmt":"2013-10-11T09:45:48","slug":"female-sexual-dysfunction-evaluation-and-treatment","status":"publish","type":"page","link":"https:\/\/jacobimed.org\/old\/ambulatory\/mlove\/curriculumwomengeri-2\/female-sexual-dysfunction\/female-sexual-dysfunction-articles\/female-sexual-dysfunction-evaluation-and-treatment\/","title":{"rendered":"Female Sexual Dysfunction: Evaluation and Treatment"},"content":{"rendered":"<p>&nbsp;<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\" bgcolor=\"#ffffff\">\n<tbody>\n<tr>\n<td colspan=\"5\" height=\"96\" bgcolor=\"#ffffff\">\n<table style=\"width: 750px;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\" bgcolor=\"#ffffff\">\n<tbody>\n<tr>\n<td width=\"558\">\n<table border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td width=\"450\" height=\"90\" valign=\"top\" background=\"Female Sexual Dysfunction Evaluation and Treatment - 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July 1, 2000 - American Family Physician_files\/home2_buttonbar_bg.gif\">&nbsp;<\/td>\n<\/tr>\n<tr>\n<td colspan=\"5\" width=\"750\" height=\"20\" bgcolor=\"#ffffff\">\n<div id=\"Gateway-blank\" style=\"position: absolute; top: 129px; visibility: visible;\"><img loading=\"lazy\" decoding=\"async\" src=\"file:\/\/\/C:\/Documents%20and%20Settings\/Matt\/Desktop\/CurriculumWomen&amp;Geri\/Female%20Sexual%20Dysfunction\/Sexual%20Dysfunction%20articles\/Female%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files\/spacer.gif\" border=\"0\" alt=\" \" width=\"750\" height=\"7\" \/><\/div>\n<\/td>\n<td width=\"750\" height=\"20\" bgcolor=\"#ffffff\">&nbsp;<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<blockquote><p>\n  <a href=\"http:\/\/208.34.222.225\/bin\/rdas.dll\/RDAS_SVR=www.aafp.org\/afp\/20000701\/contents.html\"><img loading=\"lazy\" decoding=\"async\" src=\"file:\/\/\/C:\/Documents%20and%20Settings\/Matt\/Desktop\/CurriculumWomen&amp;Geri\/Female%20Sexual%20Dysfunction\/Sexual%20Dysfunction%20articles\/Female%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files\/20000701fl.gif\" border=\"0\" alt=\"AFP - July 1, 2000\" width=\"491\" height=\"73\" \/><\/a><\/p>\n<p>&nbsp;<\/p>\n<h1>Female Sexual Dysfunction: Evaluation and Treatment<\/h1>\n<table style=\"width: 90%;\" border=\"0\">\n<tbody>\n<tr>\n<td>\n<dl>\n<dt>NANCY A. PHILLIPS, M.D.\n          <\/dt>\n<dd>Wellington School of Medicine, University of Otago, Wellington,<br \/>\n          New Zealand <\/dd>\n<\/dl>\n<\/td>\n<td align=\"middle\">\n<table style=\"width: 170px;\" border=\"1\" cellpadding=\"10\">\n<tbody>\n<tr>\n<td><a href=\"http:\/\/208.34.222.225\/bin\/rdas.dll\/RDAS_SVR=www.aafp.org\/afp\/20000701\/141ph.html\"><img loading=\"lazy\" decoding=\"async\" src=\"file:\/\/\/C:\/Documents%20and%20Settings\/Matt\/Desktop\/CurriculumWomen&amp;Geri\/Female%20Sexual%20Dysfunction\/Sexual%20Dysfunction%20articles\/Female%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files\/arrow.gif\" border=\"0\" alt=\"-&gt;\" width=\"15\" height=\"15\" \/><span>A patient information handout on sexual<br \/>\n              dysfunction in women, written by the author of this article, is<br \/>\n              provided on page 141<\/span><\/a><span>.<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<blockquote>\n<p><span style=\"font-family: Arial;\">Sexual dysfunction includes desire, arousal,<br \/>\n    orgasmic and sex pain disorders (dyspareunia and vaginismus). Primary care<br \/>\n    physicians must assume a proactive role in the diagnosis and treatment of<br \/>\n    these disorders. Long-term medical diseases, minor ailments, medications and<br \/>\n    psychosocial difficulties, including prior physical or sexual abuse, are<br \/>\n    etiologic factors. Gynecologic maladies and cancers (including breast<br \/>\n    cancer) are also frequent sources of sexual dysfunction. Patient education<br \/>\n    and reassurance, with early diagnosis and intervention, are essential for<br \/>\n    effective treatment. Patient history and physical examination techniques,<br \/>\n    normal sexual responses and the factors that influence these responses, and<br \/>\n    the application of medical and gynecologic treatments to sexual issues are<br \/>\n    discussed. Basic treatment strategies, which may be successfully provided by<br \/>\n    primary care physicians for most sexual dysfunctions, are outlined. Referral<br \/>\n    can be reserved for patients who do not respond to therapy. (Am Fam<br \/>\n    Physician 2000;62:127-36,141-2.)<\/span><\/p>\n<\/blockquote>\n<p><span style=\"color: #8a5e4f; font-size: small;\">S<\/span>exuality is a complex process,<br \/>\n  coordinated by the neurologic, vascular and endocrine systems.<span><sup>1<\/sup><\/span> Individually, sexuality incorporates family,<br \/>\n  societal and religious beliefs, and is altered with aging, health status and<br \/>\n  personal experience. In addition, sexual activity incorporates interpersonal<br \/>\n  relationships, each partner bringing unique attitudes, needs and responses<br \/>\n  into the coupling. A breakdown in any of these areas may lead to sexual<br \/>\n  dysfunction. <\/p>\n<table border=\"0\" align=\"left\">\n<tbody>\n<tr>\n<td colspan=\"3\" valign=\"top\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" valign=\"top\"><span style=\"font-family: Arial;\"><strong><a href=\"http:\/\/208.34.222.225\/bin\/rdas.dll\/RDAS_SVR=www.aafp.org\/afp\/20000701\/editorials.html\">See<br \/>\n        editorial <br \/>on page 52.<\/a><\/strong><\/span><\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" valign=\"top\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Primary care physicians, skilled in the treatment of medical and<br \/>\n  psychologic disorders, often feel unqualified to treat patients with sexual<br \/>\n  dysfunction. However, with an understanding of sexual functioning and<br \/>\n  application of general medical and gynecologic treatments to sexual issues,<br \/>\n  sexual dysfunction may be effectively approached with the same skills. The<br \/>\n  latter includes obtaining a complete patient history, conducting a physical<br \/>\n  examination, application of basic treatment strategies, providing patient<br \/>\n  education and reassurance, and recommending appropriate referral when<br \/>\n  indicated. <\/p>\n<p><span style=\"font-family: Arial; font-size: xx-small;\"><strong>Diagnosis <\/strong><\/span><\/p>\n<p>Female sexual dysfunction can be subdivided into desire, arousal, orgasmic<br \/>\n  and sexual pain disorders. Sexual pain disorders include dyspareunia and<br \/>\n  vaginismus.<span><sup>2 <\/sup><\/span><\/p>\n<p>Estimates of the number of women who have sexual dysfunction range from 19<br \/>\n  to 50 percent in &#8220;normal&#8221; outpatient populations<span><sup>3-6<\/sup><\/span> and increase to 68 to 75 percent when sexual<br \/>\n  dissatisfaction or problems (not dysfunctional in nature) are included.<span><sup>5,7<\/sup><\/span> Yet, one review of physicians&#8217; chart notes<br \/>\n  revealed a recorded sexual problem in only 2 percent.<span><sup>5<\/sup><\/span> In another review, physician inquiry of patients<br \/>\n  in a gynecologic office setting about sexual problems increased reported<br \/>\n  complaints about sexual dysfunction sixfold.<span><sup>3<\/sup><\/span><br \/>\n  This discrepancy demonstrates a need for physician education in this area.<\/p>\n<table style=\"width: 400px;\" border=\"1\" cellpadding=\"10\" align=\"right\">\n<tbody>\n<tr>\n<td>\n<table style=\"width: 400px;\" border=\"0\" cellspacing=\"10\">\n<tbody>\n<tr>\n<td colspan=\"3\" bgcolor=\"#c6a69b\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" align=\"middle\" valign=\"top\"><img loading=\"lazy\" decoding=\"async\" src=\"file:\/\/\/C:\/Documents%20and%20Settings\/Matt\/Desktop\/CurriculumWomen&amp;Geri\/Female%20Sexual%20Dysfunction\/Sexual%20Dysfunction%20articles\/Female%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files\/127_f1.gif\" border=\"0\" alt=\"figure 1\" width=\"400\" height=\"301\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" align=\"left\" valign=\"top\" bgcolor=\"#c6a69b\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" valign=\"top\"><span style=\"font-family: Arial;\"><strong>FIGURE<br \/>\n              1.<\/strong>Cycle of sexual dysfunction. Example showing how a patient<br \/>\n              can enter the cycle of sexual dysfunction in one area (i.e.,<br \/>\n              decreased orgasm) and proceed to another area (i.e., decreased<br \/>\n              desire) so that the presenting complaint may not represent the<br \/>\n              problem that actually requires evaluation and treatment.<\/span><\/p>\n<p><span>Adapted with permission from Phillips NA. The<br \/>\n              clinical evaluation of dyspareunia. Int J Impot Res 1998;10(suppl<br \/>\n              2):S117-20.<\/span><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>The diagnosis of female sexual dysfunction requires the physician to obtain<br \/>\n  a detailed patient history that defines the dysfunction, identifies causative<br \/>\n  or confounding medical or gynecologic conditions, and elicits psychosocial<br \/>\n  information.<span><sup>8<\/sup><\/span> Preappointment questionnaires or<br \/>\n  appointments at which only the history is taken allow patient-physician<br \/>\n  communication to be unhindered by time constraints or patient fears of an<br \/>\n  upcoming physical examination.<\/p>\n<p>Establishment of the patient&#8217;s sexual orientation is necessary for<br \/>\n  appropriate evaluation and management. Nonjudgmental, direct questions best<br \/>\n  achieve this goal. Because gender identity conflicts are often a cause of<br \/>\n  sexual dysfunction, the mode and type of questions asked by physicians should<br \/>\n  create an environment where patients may openly express their concerns.<br \/>\n  Specialized counseling is important for these patients.<\/p>\n<p>The sexual dysfunction should be defined in terms of onset and duration and<br \/>\n  situational versus global effect. A situational dysfunction occurs with a<br \/>\n  specific partner, in a certain setting or in a definable circumstance. <\/p>\n<p>The presence of more than one dysfunction should be ascertained, because<br \/>\n  considerable interdependence may exist. For example, a patient complaining<br \/>\n  about decreased desire might have a primary orgasmic disorder from<br \/>\n  insufficient stimulation, with decreased desire developing secondarily as a<br \/>\n  result of unsatisfying sexual encounters <em>(Figure 1)<\/em>.<span><sup>8<\/sup><\/span> Thus, treating the orgasmic disorder would<br \/>\n  indirectly enhance desire; whereas, treating a desire disorder would be<br \/>\n  unsuccessful and perhaps add to patient frustration and perpetuate the cycle<br \/>\n  of dysfunction.<\/p>\n<p>Questioning the patient about what she thinks is causing the problem may<br \/>\n  add insight. She may reveal fear of redeveloping an abnormal Papanicolaou<br \/>\n  smear from penile penetration, or she may admit that she is not attracted to<br \/>\n  her partner. Obtaining this information early in the evaluation process will<br \/>\n  expedite diagnosis and initiation of treatment.<\/p>\n<table style=\"width: 45%;\" border=\"1\" cellpadding=\"10\" align=\"right\">\n<tbody>\n<tr>\n<td>\n<table border=\"0\" cellspacing=\"10\">\n<tbody>\n<tr>\n<td colspan=\"2\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"><span style=\"font-family: Arial; font-size: xx-small;\"><strong>TABLE 1<\/strong><br \/>Medical<br \/>\n              Causes of Female Sexual Dysfunction<\/span> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" align=\"left\" valign=\"top\">\n<table style=\"width: 90%;\" border=\"1\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td><em>The rightsholder did not grant rights to reproduce<br \/>\n                    this item in electronic media. For the missing item, see the<br \/>\n                    original print version of this<br \/>\n              publication.<\/em><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Medical conditions are a frequent source of direct or indirect sexual<br \/>\n  difficulties. Vascular disease associated with diabetes might preclude<br \/>\n  adequate arousal; cardiovascular disease may inhibit intercourse secondary to<br \/>\n  dyspnea <em>(Table 1)<\/em>.<span><sup>1<\/sup><\/span> Arthritis or<br \/>\n  urinary incontinence may cause discomfort or embarrassment, leading to<br \/>\n  dysfunction or decreased sexual activity.<span><sup>2<\/sup><\/span><br \/>\n  Aggressive treatment of long-term disease and minor ailments, with attention<br \/>\n  to their sexual implications, will help enhance sexuality. <\/p>\n<p>Prescription and over-the-counter medications, illicit drugs and alcohol<br \/>\n  abuse contribute to sexual dysfunction<span><sup>9,10<br \/>\n  <\/sup><\/span><em>(Table 2)<\/em>.<span><sup>10<\/sup><\/span> Medication<br \/>\n  changes, drug discontinuation, or dosage or schedule alterations may provide<br \/>\n  relief. Cigarette smoking, known to cause erectile dysfunction in men, may<br \/>\n  have a similar negative effect on arousal in women.<\/p>\n<p>Gynecologic conditions contribute physically to sexual difficulties<br \/>\n  <em>(Table 3)<\/em>,<span><sup>8<\/sup><\/span> and treatment must address<br \/>\n  both of these issues. For example, treatment of a patient with recurrent<br \/>\n  cystitis as a cause of dyspareunia should include the use of lubricants and<br \/>\n  distraction techniques at first intercourse to assure adequate lubrication and<br \/>\n  relaxation, respectively. These steps help resolve any secondary difficulties<br \/>\n  that may have developed (e.g., an arousal disorder or mild vaginismus). For<br \/>\n  patients with a female partner, details concerning sexual habits and objects<br \/>\n  of penetration, if any, are necessary. In these instances, hygienic use of<br \/>\n  vibrators may result in fewer episodes of cystitis.<\/p>\n<p>Hysterectomy, gynecologic malignancies and breast cancer present medical<br \/>\n  and mortality concerns, and alter or remove physical and psychologic symbols<br \/>\n  of femininity that may result in feelings of decreased sexuality. In one<br \/>\n  study,<span><sup>11<\/sup><\/span> 74 percent of patients who underwent<br \/>\n  surgery for gynecologic malignancy reported decreased desire, and 40 percent<br \/>\n  reported dyspareunia. In another study<span><sup>12<\/sup><\/span> of<br \/>\n  patients who had undergone hysterectomy for benign disease, a decrease in<br \/>\n  sexual responsiveness of up to 30 percent was noted. Breast cancer survivors<br \/>\n  report a 21 to 39 percent incidence of sexual dysfunction,<span><sup>13<\/sup><\/span> although a recent study<span><sup>14<\/sup><\/span> suggests that this may be related to chemotherapy<br \/>\n  or hypoestrogenism secondary to ovarian failure. Preoperative counseling,<br \/>\n  including explanations of postoperative anatomy and potential effects on<br \/>\n  sexuality, is essential in these patient populations. Continued postoperative<br \/>\n  counseling and early recognition and treatment of sexual difficulties may also<br \/>\n  help these patients maintain satisfying sexual relationships. <\/p>\n<table style=\"width: 90%;\" border=\"1\" cellpadding=\"10\" align=\"center\">\n<tbody>\n<tr>\n<td align=\"middle\" valign=\"top\">\n<table border=\"0\" cellspacing=\"10\">\n<tbody>\n<tr>\n<td colspan=\"2\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"><span style=\"font-family: Arial; font-size: xx-small;\"><strong>TABLE<br \/>\n              2<\/strong><br \/>Medications and Female Sexual Dysfunction<\/span> <\/p>\n<hr \/>\n<\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\">\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Medications that cause disorders<br \/>\n                of desire<\/strong><\/span>\n                <\/dt>\n<dd>\n<dl>\n<dt><span style=\"font-family: Arial;\">Psychoactive medications<\/span>\n                  <\/dt>\n<dd><span style=\"font-family: Arial;\">Antipsychotics<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Barbiturates<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Benzodiazepines<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Selective serotonin reuptake<br \/>\n                  inhibitors<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Lithium<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Tricyclic antidepressants<\/span>\n                  <\/dd>\n<\/dl>\n<\/dd>\n<dd>\n<dl>\n<dt><span style=\"font-family: Arial;\">Cardiovascular and<br \/>\n                  antihypertensive medications<\/span>\n                  <\/dt>\n<dd><span style=\"font-family: Arial;\">Antilipid medications<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Beta blockers<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Clonidine (Catapres)<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Digoxin<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Spironolactone (Aldactone)<\/span>\n                  <\/dd>\n<\/dl>\n<\/dd>\n<dd>\n<dl>\n<dt><span style=\"font-family: Arial;\">Hormonal preparations<\/span>\n                  <\/dt>\n<dd><span style=\"font-family: Arial;\">Danazol (Danocrine)<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">GnRh agonists (e.g., Lupron,<br \/>\n                  Synarel)<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Oral contraceptives<\/span>\n                <\/dd>\n<\/dl>\n<\/dd>\n<dd>\n<dl>\n<dt><span style=\"font-family: Arial;\">Other<\/span>\n                  <\/dt>\n<dd><span style=\"font-family: Arial;\">Histamine H<sub>2<\/sub>-receptor<br \/>\n                  blockers and promotility agents<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Indomethacin (Indocin)<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Ketoconazole (Nizoral)<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Phenytoin sodium<br \/>\n                  (Dilantin)<\/span> <\/dd>\n<\/dl>\n<\/dd>\n<\/dl>\n<\/td>\n<td align=\"left\" valign=\"top\">\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Medications that cause disorders<br \/>\n                of arousal<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Anticholinergics<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Antihistamines<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Antihypertensives<\/span>\n                <\/dd>\n<dd>\n<dl>\n<dt><span style=\"font-family: Arial;\">Psychoactive medications<\/span>\n                  <\/dt>\n<dd><span style=\"font-family: Arial;\">Benzodiazepines<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Selective serotonin reuptake<br \/>\n                  inhibitors<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Monoamine oxidase<br \/>\n                  inhibitors<\/span>\n                  <\/dd>\n<dd><span style=\"font-family: Arial;\">Tricyclic antidepressants<\/span>\n                  <\/dd>\n<\/dl>\n<\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Medications that cause orgasmic<br \/>\n                dysfunction<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Methyldopa (Aldomet)<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Amphetamines and related anorexic<br \/>\n                drugs<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Antipsychotics<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Benzodiazepines<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Selective serotonin reuptake<br \/>\n                inhibitors<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Narcotics<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Trazadone (Desyrel)<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Tricyclic antidepressants*<\/span>\n                <\/dd>\n<\/dl>\n<\/td>\n<\/tr>\n<tr valign=\"top\">\n<td colspan=\"2\" align=\"left\" valign=\"top\">\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\"><span>*&#8211;Also associated with<br \/>\n              painful orgasm<\/span><\/p>\n<p><span>Adapted with permission from Drugs that cause<br \/>\n              sexual dysfunction: an update. Med Lett Drugs Ther<br \/>\n              1992;34:73-8.<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<tr>\n<td align=\"middle\" valign=\"top\">\n<table border=\"0\" cellspacing=\"10\">\n<tbody>\n<tr>\n<td bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td><span style=\"font-family: Arial; font-size: xx-small;\"><strong>TABLE 3<\/strong><br \/>Gynecologic Causes<br \/>\n              of Female Sexual Dysfunction and Method of Gynecologic<br \/>\n              Examination<\/span> <\/p>\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"bottom\">\n<table style=\"width: 100%;\" border=\"0\" cellpadding=\"5\">\n<tbody>\n<tr valign=\"bottom\">\n<td align=\"left\" valign=\"bottom\"><strong><span style=\"font-family: Arial;\">Examination<\/span><\/strong><\/p>\n<hr \/>\n<\/td>\n<td align=\"left\" valign=\"bottom\"><strong><span style=\"font-family: Arial;\">Condition<\/span><\/strong><\/p>\n<hr \/>\n<\/td>\n<\/tr>\n<tr valign=\"top\">\n<td colspan=\"2\" align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\"><em>External genitalia<\/em><\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Assess<br \/>\n                    muscle tone<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Vaginismus<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Assess<br \/>\n                    skin color and texture<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Vulvar<br \/>\n                    dystrophy, dermatitis<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Assess<br \/>\n                    skin turgor and thickness<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Atrophy<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Assess<br \/>\n                    pubic hair amount and distribution<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Atrophy<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Expose<br \/>\n                    clitoris<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Clitoral<br \/>\n                    adhesions<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Assess<br \/>\n                    for ulcers<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Herpes<br \/>\n                    simplex virus<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Perform<br \/>\n                    cotton swab test of vestibule<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Vulvar<br \/>\n                    vestibulitis<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Palpate<br \/>\n                    Bartholin glands<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Bartholinitis<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Assess<br \/>\n                    posterior forchette and hymenal ring<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Episiotomy scars, strictures<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td colspan=\"2\" align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\"><em>Monomanual<\/em> <\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Palpate<br \/>\n                    rectovaginal surface<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Rectal<br \/>\n                    disease<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Palpate<br \/>\n                    levator ani<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Levator<br \/>\n                    ani myalgia, vaginismus<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Palpate<br \/>\n                    bladder\/urethra<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Urethritis, interstitial cystitis, urinary tract<br \/>\n                    infection<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Assess<br \/>\n                    for cervical motion tenderness<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Infection, peritonitis<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Assess<br \/>\n                    vaginal depth<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Postoperative changes, postradiation changes,<br \/>\n                    stricture<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td colspan=\"2\" align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\"><em>Bimanual<\/em><\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Palpate<br \/>\n                    uterus<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Retrogression, fibroids, endometritis<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Palpate<br \/>\n                    adnexa<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Masses,<br \/>\n                    cysts, endometriosis, tenderness<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Perform<br \/>\n                    rectovaginal examination<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Rule out<br \/>\n                    endometriosis<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Obtain<br \/>\n                    guaiac test<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Bowel<br \/>\n                    disease<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td colspan=\"2\" align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\"><em>Speculum<\/em><\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Evaluate<br \/>\n                    discharge, pH<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Vaginitis, atrophy<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Evaluate<br \/>\n                    vaginal mucosa<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Atrophy<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Perform<br \/>\n                    Papanicolaou smear<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Human<br \/>\n                    papillomavirus infection, cancer<\/span><\/td>\n<\/tr>\n<tr valign=\"top\">\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Assess<br \/>\n                    for prolapse<\/span><\/td>\n<td align=\"left\" valign=\"top\"><span style=\"font-family: Arial;\">Cystocele, rectocele, uterine<br \/>\n                prolapse<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\"><span>Adapted with permission from Phillips<br \/>\n              NA. The clinical evaluation of dyspareunia. Int J Impot Res<br \/>\n              1998;(suppl 2):S117-20.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Gynecologic changes related to a woman&#8217;s reproductive life (e.g., puberty,<br \/>\n  pregnancy, the postpartum period and menopause) present unique problems and<br \/>\n  potential obstacles to sexuality. Puberty may lead to concerns regarding<br \/>\n  sexual identity. Pregnancy and the postpartum period are often associated with<br \/>\n  a decrease in sexual activity, desire and satisfaction, which may be prolonged<br \/>\n  with lactation.<span><sup>15<\/sup><\/span><\/p>\n<table style=\"width: 40%;\" border=\"1\" align=\"right\">\n<tbody>\n<tr>\n<td align=\"middle\" valign=\"center\">\n<table border=\"0\" cellspacing=\"6\">\n<tbody>\n<tr>\n<td colspan=\"3\" valign=\"top\" bgcolor=\"#c6a69b\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" valign=\"top\"><span style=\"font-family: Arial;\">For patients with<br \/>\n              dyspareunia, a &#8220;monomanual&#8221; examination is appropriate, with the<br \/>\n              physician inserting one or two fingers into the vagina and the<br \/>\n              other hand held away from the abdomen so as not to confuse the<br \/>\n              source of discomfort.<\/span> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" valign=\"top\" bgcolor=\"#c6a69b\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>The hypoestrogenic state of menopause may cause significant physical<br \/>\n  changes<span><sup>16,17 <\/sup><\/span><em>(Table 4)<\/em><span><sup>17<\/sup><\/span> and alterations in mood or a diminished sense of<br \/>\n  well-being, which have been found to have a significant, negative impact on<br \/>\n  sexuality.<span><sup>18<\/sup><\/span> A decline in desire, arousal and<br \/>\n  frequency of intercourse and an increase in dyspareunia have been associated<br \/>\n  with menopause,<span><sup>19-21<\/sup><\/span> although these findings<br \/>\n  are not universal.<span><sup>18<\/sup><\/span><\/p>\n<p>The final goal is to elicit psychosocial information. Previous experiences<br \/>\n  and current intra- and interpersonal factors should be explored <em>(Table<br \/>\n  5)<\/em>.<\/p>\n<p><strong>Physical Examination<\/strong> <br \/>Each patient should undergo a thorough<br \/>\n  examination, with the gynecologic examination individually guided by and<br \/>\n  tailored to patient comfort. The goal of the examination is detection of<br \/>\n  disease; however, the examination also provides an opportunity to educate the<br \/>\n  patient about normal anatomy and sexual function, and to reproduce and<br \/>\n  localize pain encountered during sexual activity.<\/p>\n<table style=\"width: 90%;\" border=\"1\" cellpadding=\"10\">\n<tbody>\n<tr>\n<td width=\"50%\" align=\"middle\" valign=\"top\">\n<table border=\"0\" cellspacing=\"10\">\n<tbody>\n<tr>\n<td bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td><span style=\"font-family: Arial; font-size: xx-small;\"><strong>TABLE 4<\/strong> <br \/>Physiologic<br \/>\n              Changes of Menopause<\/span> <\/p>\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"bottom\">\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Skin<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Decreased activity of sweat and<br \/>\n                sebaceous glands, decreased tactile stimulation<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Breasts<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Decreased fat content, decreased<br \/>\n                breast swelling and nipple erectile response with sexual<br \/>\n                arousal<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Vagina<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Shortening and loss of elasticity<br \/>\n                of vaginal barrel, diminished physiologic secretions, rise in<br \/>\n                vaginal pH from 3.5 to 4.5 to greater than 5, thinning of<br \/>\n                epithelial layers<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Internal reproductive<br \/>\n                organs<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Ovaries and fallopian tubes<br \/>\n                diminish in size, ovarian follicles undergo atresia, ovarian<br \/>\n                stroma becomes fibrotic, uterine body weight decreases 30 to 50<br \/>\n                percent, cervix atrophies and decreases mucous production<\/span>\n                <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Bladder<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Urethra and bladder trigone<br \/>\n                atrophy<\/span> <\/dd>\n<\/dl>\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\"><span>Reproduced with permission from<br \/>\n              Phillips NA, Rosen RC. Menopause and sexuality. In: Lobo RA, ed.<br \/>\n              Treatment of the postmenopausal woman. 2d ed. Phildelphia:<br \/>\n              Lippincott Williams and Wilkins, 1999:437-43.<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<td width=\"50%\" align=\"middle\" valign=\"top\">\n<table border=\"0\" cellspacing=\"10\">\n<tbody>\n<tr>\n<td bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td><span style=\"font-family: Arial; font-size: xx-small;\"><strong>TABLE 5<\/strong> <br \/>Psychosocial<br \/>\n              Factors of Female Sexual Dysfunction <\/span><\/p>\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"bottom\">\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Intrapersonal<br \/>\n                conflicts<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Religious taboos, social<br \/>\n                restrictions, sexual identity conflicts, guilt (i.e., widow with<br \/>\n                new partner)<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Historical factors<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Past or current abuse (sexual,<br \/>\n                verbal, physical), rape, sexual inexperience<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Interpersonal<br \/>\n                conflicts<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Relationship conflicts;<br \/>\n                extra-marital affairs; current physical, verbal or sexual abuse;<br \/>\n                sexual libido; desire or practices different from partner; poor<br \/>\n                sexual communication<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Life stressors<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Financial, family or job problems,<br \/>\n                family illness or death, depression<\/span> <\/dd>\n<\/dl>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\">&nbsp;<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>A routine examination seeks signs of general medical conditions. The<br \/>\n  gynecologic examination is comprehensive <em>(Table 3)<\/em>,<span><sup>8<\/sup><\/span> beginning with inspection of the external<br \/>\n  genitalia, including a cotton swab test if indicated (gently touching the<br \/>\n  vestibule of the vagina with a cotton swab will elicit moderate to severe pain<br \/>\n  in patients with vulvar vestibulitis). For patients with dyspareunia, a<br \/>\n  &#8220;mono-manual&#8221; examination should follow, with one or two fingers in the vagina<br \/>\n  (proceeding from posterior to anterior), and the other hand held away from the<br \/>\n  abdomen so as not to confuse the source of discomfort <em>(Table 3)<\/em>.<span><sup>8<\/sup><\/span> Bimanual and rectovaginal examinations are then<br \/>\n  performed. The timing of the speculum examination is guided by patient<br \/>\n  symptoms. In patients with deep dyspareunia, the speculum examination should<br \/>\n  follow the bimanual examination because localization of pain is crucial in<br \/>\n  these patients. In patients in whom vaginitis, cervical cancer or a sexually<br \/>\n  transmitted disease is suspected, cultures and vaginal samples should be<br \/>\n  obtained first.<\/p>\n<p>Laboratory testing should be guided by patient symptoms and examination<br \/>\n  findings. No specific tests are universally recommended for patients with<br \/>\n  sexual dysfunction. Attention to routine screening tests must not be<br \/>\n  overlooked.<\/p>\n<p><span style=\"font-family: Arial; font-size: xx-small;\"><strong>General Treatment Guidelines <\/strong><\/span><\/p>\n<p>Following the patient history and physical examination, a suspected<br \/>\n  etiology may be treated.<\/p>\n<p>If no etiology is discovered, basic treatment strategies are applied<br \/>\n  <em>(Table 6)<\/em>. The patient&#8217;s (and partner&#8217;s) personal tastes and comfort<br \/>\n  must be considered. Physicians should respect a patient&#8217;s choice to decline<br \/>\n  treatment, because studies show that sexual activity is not correlated with<br \/>\n  overall sexual satisfaction or intimacy in all persons.<span><sup>18,22 <\/sup><\/span>In general, treatments are similar despite<br \/>\n  sexual orientations.<\/p>\n<table style=\"width: 90%;\" border=\"1\" cellpadding=\"10\">\n<tbody>\n<tr>\n<td>\n<table border=\"0\" cellspacing=\"10\">\n<tbody>\n<tr>\n<td bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td><span style=\"font-family: Arial; font-size: xx-small;\"><strong>TABLE 6<\/strong> <br \/>Basic Treatment<br \/>\n              Strategies for Female Sexual Dysfunction<\/span> <\/p>\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"bottom\">\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Provide education<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Provide information and education<br \/>\n                (e.g., about normal anatomy, sexual function, normal changes of<br \/>\n                aging, pregnancy, menopause). Provide booklets, encourage<br \/>\n                reading; discuss sexual issues when a medical condition is<br \/>\n                diagnosed, a new medication is started, and during pre- and<br \/>\n                postoperative periods; give permission for sexual<br \/>\n                experimentation.<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Enhance stimulation and<br \/>\n                eliminate routine<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Encourage use of erotic materials<br \/>\n                (videos, books); suggest masturbation to maximize familiarity<br \/>\n                with pleasurable sensations; encourage communication during<br \/>\n                sexual activity; recommend use of vibrators*; discuss varying<br \/>\n                positions, times of day or places; suggest making a &#8220;date&#8221; for<br \/>\n                sexual activity.<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Provide distraction<br \/>\n                techniques**<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Encourage erotic or nonerotic<br \/>\n                fantasy; recommend pelvic muscle contraction and relaxation<br \/>\n                (similar to Kegel exercise) exercises with intercourse;<br \/>\n                recommend use of background music, videos or television.<\/span>\n                <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Encourage noncoital<br \/>\n                behaviors***<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Recommend sensual massage,<br \/>\n                sensate-focus exercises (sensual massage with no involvement of<br \/>\n                sexual areas, where one partner provides the massage and the<br \/>\n                receiving partner provides feedback as to what feels good; aimed<br \/>\n                to promote comfort and communication between partners); oral or<br \/>\n                noncoital stimulation, with or without orgasm.<\/span>\n              <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Minimize dyspareunia<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Superficial: female astride for<br \/>\n                control of penetration, topical lidocaine, warm baths before<br \/>\n                intercourse, biofeedback.<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Vaginal: same as for superficial<br \/>\n                dyspareunia but with the addition of lubricants.<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Deep: position changes so that<br \/>\n                force is away from pain and deep thrusts are minimized,<br \/>\n                nonsteroidal anti-inflammatory drugs before intercourse.<\/span>\n                <\/dd>\n<\/dl>\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\"><span>NOTE: For a review, see Striar S,<br \/>\n              Bartlik B. Stimulation of the libido: the use of erotica in sex<br \/>\n              therapy. Psych Annals 1999;29:60-2.<\/span><\/p>\n<p><span>*&#8211;Provide information for obtaining one<br \/>\n              discreetly.<\/span><\/p>\n<p><span>**&#8211;Helpful in eliminating anxiety, increasing<br \/>\n              relaxation and diminishing spectatoring.<\/span><\/p>\n<p><span>***&#8211;Also helpful if partner has erectile<br \/>\n              dysfunction.<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><strong>Disorders of Desire<\/strong> <br \/>Women with disorders of desire are difficult<br \/>\n  to treat. Occasionally, decreased desire in patients is secondary to boredom<br \/>\n  with sexual routines. Suggesting changes in positions or venues, or the<br \/>\n  addition of erotic materials is helpful. <\/p>\n<p>Disorders of desire in premenopausal patients may be secondary to lifestyle<br \/>\n  factors (e.g., careers, children), medications or another sexual dysfunction<br \/>\n  (e.g., pain or orgasmic disorder). No medical treatment is available specific<br \/>\n  to patients with disorders of desire. If no underlying medical or hormonal<br \/>\n  etiology is discovered, individual or couple counseling may be helpful.<\/p>\n<table style=\"width: 40%;\" border=\"1\" align=\"right\">\n<tbody>\n<tr>\n<td align=\"middle\" valign=\"center\">\n<table border=\"0\" cellspacing=\"6\">\n<tbody>\n<tr>\n<td colspan=\"3\" valign=\"top\" bgcolor=\"#c6a69b\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" valign=\"top\"><span style=\"font-family: Arial;\">Estrogen replacement<br \/>\n              therapy has been shown to correlate positively with sexual<br \/>\n              activity, enjoyment and desire, although the findings are not<br \/>\n              universal.<\/span> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" valign=\"top\" bgcolor=\"#c6a69b\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>In peri- and postmenopausal women, the relationship between hormones and<br \/>\n  sexuality is unclear.<span><sup>18-21<\/sup><\/span> Nonetheless,<br \/>\n  estrogen replacement therapy has been shown to correlate positively with<br \/>\n  sexual activity, enjoyment and fantasies&#8211;the latter thought to represent<br \/>\n  desire.<span><sup>23,24<\/sup><\/span> The mechanism of estrogen&#8217;s<br \/>\n  effect on desire is indirect and occurs through improvement in urogenital<br \/>\n  atrophy, vasomotor symptoms and menopausal mood disorders (i.e., depression).<br \/>\n  This relationship helps predict which patients are likely to respond to<br \/>\n  estrogen replacement therapy (i.e., those with symptoms of hypoestrogenism)<br \/>\n  and may explain why some studies do not show estrogen-mediated improvement in<br \/>\n  sexual functioning.<span><sup>25 <\/sup><\/span><\/p>\n<p>The role of progesterone therapy, which is necessary in estrogen-treated<br \/>\n  patients with an intact uterus, has not been widely studied in terms of<br \/>\n  sexuality, but one study<span><sup>24<\/sup><\/span> suggests that it<br \/>\n  exhibits a negative impact by dampening mood and decreasing available<br \/>\n  androgens. The addition of estrogen for several weeks before progesterone<br \/>\n  therapy is initiated, or taking into account monthly symptom calendars, will<br \/>\n  help determine each hormone&#8217;s influence and guide dosage and schedule<br \/>\n  adjustments.<\/p>\n<table style=\"width: 50%;\" border=\"1\" cellpadding=\"10\" align=\"left\">\n<tbody>\n<tr>\n<td>\n<table border=\"0\" cellspacing=\"10\">\n<tbody>\n<tr>\n<td bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td><span style=\"font-family: Arial; font-size: xx-small;\"><strong>TABLE 7<\/strong> <br \/>Testosterone<br \/>\n              Therapy for Treatment of Disorders of Desire*<\/span> <\/p>\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"bottom\">\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Screening<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Baseline testosterone levels**<br \/>\n                (free and total), baseline lipid profile, baseline liver enzyme<br \/>\n                levels, mammography, Papanicolaou smear<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Initiate therapy***<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Combination product (Estratest or<br \/>\n                Estratest hs)<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Methyltestosterone (Android), 1.25<br \/>\n                to 2.5 mg daily<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Micronized oral testosterone, 5 mg<br \/>\n                twice daily<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Testosterone proprionate 2 percent<br \/>\n                in petroleum applied daily to every other day<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Testosterone<br \/>\n                injectables\/pellets<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Reevaluation at three to four<br \/>\n                months<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Repeat testosterone levels, lipid<br \/>\n                profile, liver enzyme levels<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Monitor symptoms, side<br \/>\n                effects<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Continued therapy<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Taper to lowest effective<br \/>\n                dosage&para;<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Monitor lipid levels, liver enzyme<br \/>\n                levels once or twice yearly<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Routine Papanicolaou smear and<br \/>\n                mammography schedules<\/span> <\/dd>\n<\/dl>\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\">\n<p><span>*&#8211;These are recommendations; no evidence-based<br \/>\n              protocols are available on testosterone therapy for the treatment<br \/>\n              of women with desire disorders.<\/span><\/p>\n<p><span>**&#8211;Many authors recommend that total levels<br \/>\n              remain in &#8220;normal&#8221; range for premenopausal women.<\/span><\/p>\n<p><span>***&#8211;None of these medications are labeled by the<br \/>\n              U.S. Food and Drug Administration for treatment of desire<br \/>\n              disorders. <\/span><\/p>\n<p><span>&para;&#8211;Alternate daily combined with estrogen-only<br \/>\n              pill, take testosterone pill every other day, 5 days a week, etc.<br \/>\n              (not shown in studies to be safer or have fewer side<br \/>\n              effects).<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Testosterone appears to have a direct role in sexual desire.<span><sup>20<\/sup><\/span> However, because studies evaluate mostly<br \/>\n  testosterone-deficient, oophorectomized women or women who develop<br \/>\n  supraphysiologic levels secondary to testosterone treatment, clinical<br \/>\n  applications are limited. No guidelines for testosterone replacement therapy<br \/>\n  for women with disorders of desire and no consensus of &#8220;normal&#8221; or<br \/>\n  &#8220;therapeutic&#8221; levels of testosterone therapy exist. Many physicians are<br \/>\n  concerned about the lack of safety data on the role of testosterone in breast<br \/>\n  cancer and on hepatic side effects; however, hepatocellular damage or<br \/>\n  carcinoma is rare at prescribed dosages,<span><sup>26 <\/sup><\/span>and<br \/>\n  the development of breast cancer has not been reported clinically.<span><sup>27<\/sup><\/span><\/p>\n<p>The side effects of testosterone, which occur in 5 to 35 percent of<br \/>\n  patients, include lower levels of high-density lipoprotein, acne, hirsutism,<br \/>\n  clitorimegaly and voice deepening.<span><sup>27<\/sup><\/span> However,<br \/>\n  these side effects on lipoprotein levels are rarely significant if estrogen<br \/>\n  and testosterone are coadministered; moreover, most other side effects are<br \/>\n  reversible with discontinuation of testosterone or a dosage adjustment.<span><sup>26<\/sup><\/span><\/p>\n<p>A role for testosterone treatment exists in selected patients <em>(Table<br \/>\n  7)<\/em>. Coadministration with estrogen therapy should be provided to prevent<br \/>\n  deleterious effects on lipoprotein levels. Before initiating testosterone<br \/>\n  treatment, physicians should discuss the potential and theoretic risks, and<br \/>\n  individual risk and benefit assessments with the patient. In general, patients<br \/>\n  with current or previous breast cancer, uncontrolled hyperlipidemia, liver<br \/>\n  disease, acne or hirsutism should not receive testosterone therapy. <\/p>\n<p><strong>Arousal Disorders<\/strong> <br \/>Current treatment of patients with arousal<br \/>\n  disorders is limited to the use of commercial lubricants, although vitamin E<br \/>\n  and mineral oils are also options. Arousal disorders may be secondary to<br \/>\n  inadequate stimulation, especially in older women who require more stimulation<br \/>\n  to reach a level of arousal that was more easily attained at a younger age.<br \/>\n  Encouraging adequate foreplay or the use of vibrators to increase stimulation<br \/>\n  may be helpful. Taking a warm bath before intercourse may also increase<br \/>\n  arousal. Anxiety may inhibit arousal, and strategies to alleviate anxiety by<br \/>\n  employing distraction techniques are helpful.<\/p>\n<p>Urogenital atrophy is the most common cause of arousal disorders in<br \/>\n  postmenopausal women, and estrogen replacement, when appropriate, is usually<br \/>\n  effective therapy. However, women taking systemic estrogens occasionally<br \/>\n  require supplementation with local therapy. Long-term use of<br \/>\n  estrogen-containing vaginal creams is considered an unopposed-estrogen<br \/>\n  treatment in women with an intact uterus, requiring progesterone opposition.<br \/>\n  An oral progesterone such as medroxyprogesterone 5 mg daily for 10 days every<br \/>\n  one to three months (or equivalent) may be used initially, with frequency or<br \/>\n  dosage increased if withdrawal bleeding occurs. Estring (an<br \/>\n  estradiol-containing vaginal ring) has little systemic absorption and does not<br \/>\n  require the addition of progesterone. Patients who are uncomfortable wearing<br \/>\n  the ring during the day often achieve relief with night use only.<\/p>\n<p>Premenopausal women with arousal disorders, women who do not respond to<br \/>\n  estrogen therapy and women who are unable or unwilling to take estrogen<br \/>\n  represent difficult patient groups because few treatment options are<br \/>\n  available.<\/p>\n<table style=\"width: 45%;\" border=\"1\" cellpadding=\"10\" align=\"right\">\n<tbody>\n<tr>\n<td>\n<table border=\"0\" cellspacing=\"10\">\n<tbody>\n<tr>\n<td bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td><span style=\"font-family: Arial; font-size: xx-small;\"><strong>TABLE 8<\/strong><br \/>Kegel<br \/>\n              Exercises<\/span> <\/p>\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"bottom\">\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Potential uses<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Increased pubococcygeal tone<\/span> <\/p>\n<\/dd>\n<dd><span style=\"font-family: Arial;\">Improved orgasmic intensity<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Correction of orgasmic urine<br \/>\n                leakage<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Distraction technique during<br \/>\n                intercourse<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Improved patient awareness of<br \/>\n                sexual response<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Teaching Kegel<br \/>\n                exercises<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Instructional examination with<br \/>\n                examiner&#8217;s finger in vagina<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Initial patient home exercise with<br \/>\n                patient&#8217;s finger in vagina<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Slow count to 10, with movement<br \/>\n                directed &#8220;in and up&#8221;<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Hold for count of 3<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Slow release to count of 10<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Repeat 10 to 15 times daily<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Consider vaginal weights,<br \/>\n                biofeedback clinics<\/span> <\/dd>\n<\/dl>\n<dl>\n<dt><span style=\"font-family: Arial;\"><strong>Maintaining Kegel<br \/>\n                exercises<\/strong><\/span>\n                <\/dt>\n<dd><span style=\"font-family: Arial;\">Advise repetitions during routine<br \/>\n                activities (standing in line, at stop lights, etc.)<\/span>\n                <\/dd>\n<dd><span style=\"font-family: Arial;\">Schedule follow-up appointments to<br \/>\n                discuss progress<\/span> <\/dd>\n<\/dl>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\">&nbsp;<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Investigators recognize that small-vessel atherosclerotic disease of the<br \/>\n  vagina and clitoris may contribute to arousal disorders and are exploring<br \/>\n  vasoactive medications as treatment.<span><sup>28<\/sup><\/span> Small<br \/>\n  studies<span><sup>29,30<\/sup><\/span> have been conducted with<br \/>\n  favorable results, but larger studies are needed. Currently, treatment of<br \/>\n  arousal disorder in women who are taking these medications, including<br \/>\n  sildenafil (Viagra), is not recommended, although anecdotal success has been<br \/>\n  reported.<span><sup>30<\/sup><\/span><\/p>\n<p><strong>Orgasmic Disorders<\/strong> <br \/>Anorgasmia is quite responsive to therapy.<br \/>\n  This condition is caused by sexual inexperience or the lack of sufficient<br \/>\n  stimulation and is common in women who have never experienced orgasm. Orgasmic<br \/>\n  disorders may also be psychologic (&#8220;involuntary inhibition&#8221; of the orgasmic<br \/>\n  reflex) or caused by medications or chronic disease. <\/p>\n<p>Treatment relies on maximizing stimulation and minimizing inhibition.<span><sup>31<\/sup><\/span> Stimulation may include masturbation with<br \/>\n  prolonged stimulation (initially up to one hour) and\/or the use of a vibrator<br \/>\n  as needed, and muscular control of sexual tension (alternating contraction and<br \/>\n  relaxation of the pelvic muscles during high sexual arousal). The latter is<br \/>\n  similar to Kegel exercises<em> (Table 8).<\/em> Methods to minimize inhibition<br \/>\n  include distraction by &#8220;spectatoring&#8221; (observing oneself from a third-party<br \/>\n  perspective), fantasizing or listening to music. Women who do not respond to<br \/>\n  therapy should be referred to an appropriate therapist.<\/p>\n<p><strong>Sex Pain Disorders<\/strong> <br \/>Dyspareunia can be divided into three types<br \/>\n  of pain: superficial, vaginal and deep <em>(Table 6). <\/em>Superficial<br \/>\n  dyspareunia occurs with attempted penetration, usually secondary to anatomic<br \/>\n  or irritative conditions, or vaginismus. Vaginal dyspareunia is pain related<br \/>\n  to friction (i.e., lubrication problems), including arousal disorders. Deep<br \/>\n  dyspareunia is pain related to thrusting, often associated with pelvic disease<br \/>\n  or relaxation.<span><sup>7<\/sup><\/span><\/p>\n<table style=\"width: 40%;\" border=\"1\" align=\"left\">\n<tbody>\n<tr>\n<td align=\"middle\" valign=\"center\">\n<table border=\"0\" cellspacing=\"6\">\n<tbody>\n<tr>\n<td colspan=\"3\" valign=\"top\" bgcolor=\"#c6a69b\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" valign=\"top\"><span style=\"font-family: Arial;\">Treatment of orgasmic<br \/>\n              disorders relies on maximizing stimulation and minimizing<br \/>\n              inhibition.<\/span> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" valign=\"top\" bgcolor=\"#c6a69b\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Diagnosis of an underlying etiology should be aggressively sought, even if<br \/>\n  surgical investigation (laparoscopy) is required. The physical examination<br \/>\n  must include meticulous detail, with the physician&#8217;s focus on recreating the<br \/>\n  pain. Treatment of the underlying etiology is fundamental, but as in long-term<br \/>\n  pain disorders, counseling and pain control strategies are essential. General<br \/>\n  recommendations for improved sexual function are discussed in <em>Table 6<\/em><br \/>\n  and are similar despite sexual orientation. <\/p>\n<table style=\"width: 45%;\" border=\"1\" cellpadding=\"10\" align=\"right\">\n<tbody>\n<tr>\n<td>\n<table border=\"0\" cellspacing=\"10\">\n<tbody>\n<tr>\n<td bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<tr>\n<td><span style=\"font-family: Arial; font-size: xx-small;\"><strong>TABLE 9<\/strong><br \/>Female Sexual<br \/>\n              Dysfunction: When to Refer<\/span> <\/p>\n<hr \/>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"bottom\">\n<p><span style=\"font-family: Arial;\">Longstanding<br \/>\n              dysfunction<\/span><\/p>\n<p><span style=\"font-family: Arial;\">Multiple dysfunctions<\/span><\/p>\n<p><span style=\"font-family: Arial;\">Current or past abuse<\/span><\/p>\n<p><span style=\"font-family: Arial;\">Psychologic disorder or acute<br \/>\n              psychologic event<\/span><\/p>\n<p><span style=\"font-family: Arial;\">Unknown etiology<\/span><\/p>\n<p><span style=\"font-family: Arial;\">No response to<br \/>\ntherapy<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#8a5e4f\"><img loading=\"lazy\" decoding=\"async\" src=\"\/admin\/page\/edit\/u:%5CGeriatrics%20&amp;%20Women%27s%5CFemale%20Sexual%20Dysfunction%20Evaluation%20and%20Treatment%20-%20July%201,%202000%20-%20American%20Family%20Physician_files%5Cspacer%281%29.gif\" border=\"0\" alt=\"{short description of image}\" width=\"4\" height=\"4\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Vaginismus, the involuntary contraction of the muscles of the outer one<br \/>\n  third of the vagina, is often related to sexual phobias or past abuse or<br \/>\n  trauma.<span><sup>10,32<\/sup><\/span> Vaginismus may be complete or<br \/>\n  situational, so that a pelvic examination might be possible while intercourse<br \/>\n  is not. Therapy for and counseling of women with vaginismus can be initiated<br \/>\n  and often successfully completed by primary care physicians.<\/p>\n<p>Treatment of women with vaginismus consists of progressive muscle<br \/>\n  relaxation and vaginal dilatation (actually a misnomer because the vagina is<br \/>\n  not physically stretched). Progressive muscle relaxation can be taught during<br \/>\n  an instructional examination by having the patient alternate contracting and<br \/>\n  relaxing the pelvic muscles around the examiner&#8217;s finger. Women with<br \/>\n  vaginismus can achieve vaginal dilatation with the use of commercial dilators<br \/>\n  or tampons of increasing diameter, placed into the vagina for 15 minutes twice<br \/>\n  daily. Once the patient can easily accept an equivalent-sized dilator into the<br \/>\n  vagina, penile penetration by the partner can occur. Success rates approach 90<br \/>\n  percent.<span><sup>31,32<\/sup><\/span> Patients who do not respond to<br \/>\n  this therapy should be referred to a sex therapist who specializes in the<br \/>\n  treatment of women with this disorder <em>(Table 9)<\/em>.<\/p>\n<hr \/>\n<p><strong><span style=\"font-family: Arial; font-size: xx-small;\">The Author<\/span><\/strong><\/p>\n<p>NANCY A. PHILLIPS, M.D., <br \/>is a senior lecturer and consultant in the<br \/>\n  Department of Obstetrics and Gynecology at the Wellington School of Medicine,<br \/>\n  University of Otago, Wellington, New Zealand. Dr. Phillips earned her medical<br \/>\n  degree from the University of Medicine and Dentistry of New Jersey, Robert<br \/>\n  Wood Johnson Medical School, Piscataway and completed her obstetrics and<br \/>\n  gynecology residency at George Washington University Hospital, Washington,<br \/>\n  D.C.<\/p>\n<blockquote>\n<p><span style=\"font-family: Arial;\">Address correspondence to Nancy Phillips, M.D.,<br \/>\n    119 Mitchell St., Brooklyn, Wellington, New Zealand. Reprints are not<br \/>\n    available from the author.<\/span><\/p>\n<\/blockquote>\n<p>REFERENCES<\/p>\n<ol>\n<li><span>Bachmann GA, Phillips NA. Sexual dysfunction. In: Steege<br \/>\n    JF, Metzger DA, Levy BS, eds. Chronic pelvic pain: an integrated approach.<br \/>\n    Philadelphia: Saunders, 1998:77-90.<\/span>\n    <\/li>\n<li><span>ACOG technical bulletin. Sexual dysfunction. No. 211.<br \/>\n    Washington, D.C.: American College of Obstetricians and Gynecologists,<br \/>\n    September 1995.<\/span>\n    <\/li>\n<li><span>Bachmann GA, Leiblum S, Grill J. Brief sexual inquiry in<br \/>\n    gynecologic practice. Obstet Gynecol 1989;73(3 pt 1):425-7.<\/span>\n    <\/li>\n<li><span>Angst J. Sexual problems in healthy and depressed persons.<br \/>\n    Int Clin Psychopharmacol 1998;13(suppl 6): S1-4.<\/span>\n    <\/li>\n<li><span>Read S, King M, Watson J. Sexual dysfunction in primary<br \/>\n    medical care: prevalence, characteristics and detection by the general<br \/>\n    practitioner. J Public Health Med 1997;19:387-91.<\/span>\n    <\/li>\n<li><span>Michael RT. Sex in America: a definitive survey. Boston:<br \/>\n    Little, Brown, 1994:111-31.<\/span>\n    <\/li>\n<li><span>Schein M, Zyzanski SJ, Levine S, Medalie JH, Dickman RL,<br \/>\n    Alemagno SA. The frequency of sexual problems among family practice<br \/>\n    patients. Fam Pract Res J 1988;7:122-34.<\/span>\n    <\/li>\n<li><span>Phillips NA. The clinical evaluation of dyspareunia. Int J<br \/>\n    Impot Res 1998;10(suppl 2):S117-20.<\/span>\n    <\/li>\n<li><span>Weiner DN, Rosen RC. Medications and their impact. In:<br \/>\n    Sipski ML, Alexander CJ, eds. Sexual function in people with disability and<br \/>\n    chronic illness: a health professional&#8217;s guide. Gaithersburg, Md.: Aspen,<br \/>\n    1997.<\/span>\n    <\/li>\n<li><span>Drugs that cause sexual dysfunction: an update. Med Lett<br \/>\n    Drugs Ther 1992;34:73-8.<\/span>\n    <\/li>\n<li><span>Thranov I, Klee M. Sexuality among gynecologic cancer<br \/>\n    patients&#8211;a cross-sectional study. Gynecol Oncol 1994;52:14-19.<\/span>\n    <\/li>\n<li><span>Virtanen H, Makinen J, Tenho T, Kiilholma P, Pitkanen Y,<br \/>\n    Hirvonen T. Effects of hysterectomy on urinary and sexual symptoms. Br J<br \/>\n    Urol 1993;72:868-72.<\/span>\n    <\/li>\n<li><span>Goldstein MK, Teng NN. Gynecologic factors in sexual<br \/>\n    dysfunction of the older woman. Clin Geriatr Med 1991;7:41-61.<\/span>\n    <\/li>\n<li><span>Ganz PA, Rowland JH, Desmond K, Meyerowitz BE, Wyatt GE.<br \/>\n    Life after breast cancer: understanding women&#8217;s health-related quality of<br \/>\n    life and sexual functioning. J Clin Oncol 1998;16:501-14.<\/span>\n    <\/li>\n<li><span>Byrd JE, Hyde JS, DeLamater JD, Plant EA. Sexuality during<br \/>\n    pregnancy and the year postpartum. J Fam Pract 1998;47:305-8.<\/span>\n    <\/li>\n<li><span>Bachmann GA. Influence of menopause on sexuality. Int J<br \/>\n    Fertil Menopausal Stud 1995;40(suppl 1): 16-22.<\/span>\n    <\/li>\n<li><span>Phillips NA, Rosen RC. Menopause and sexuality: basic and<br \/>\n    clinical aspects. In: Lobo RA, ed. Treatment of the postmenopausal woman. 2d<br \/>\n    ed. Philadelphia: Lippincott Williams and Wilkins, 1999:437-43.<\/span>\n    <\/li>\n<li><span>Cawood EH, Bancroft J. Steroid hormones, the menopause,<br \/>\n    sexuality and well-being of women. Psychol Med 1996;26:925-36.<\/span>\n    <\/li>\n<li><span>Laan E, van Lunsen RH. Hormones and sexuality in<br \/>\n    postmenopausal women: a psychophysiological study. J Psychosom Obstet<br \/>\n    Gynecol 1997;18:126-33.<\/span>\n    <\/li>\n<li><span>Davis SR, Burger HG. Clinical review 82: androgens and the<br \/>\n    postmenopausal woman. J Clin Endocrinol Metab 1996;81:2759-63.<\/span>\n    <\/li>\n<li><span>Bachmann GA, Leiblum SR. Sexuality in sexagenarian women.<br \/>\n    Maturitas 1991;13:43-50.<\/span>\n    <\/li>\n<li><span>Rosen RC, Taylor JF, Leiblum SR, Bachmann GA. Prevalence<br \/>\n    of sexual dysfunction in women: results of a survey study of 329 women in an<br \/>\n    outpatient gynecological clinic. J Sex Marital Ther 1993;19: 171-88.<\/span>\n    <\/li>\n<li><span>Nathorst-Boos J, Wiklund I, Mattsson LA, Sandin K, von<br \/>\n    Schoultz B. Is sexual life influenced by transdermal estrogen therapy? A<br \/>\n    double blind placebo controlled study in postmenopausal women. Acta Obstet<br \/>\n    Gynecol Scand 1993;72:656-60.<\/span>\n    <\/li>\n<li><span>Sherwin BB. The impact of different doses of estrogen and<br \/>\n    progestin on mood and sexual behavior in postmenopausal women. J Clin<br \/>\n    Endocrinol Metab 1991;72:336-43.<\/span>\n    <\/li>\n<li><span>Myers LS, Dixen J, Morrissette D, Carmichael M, Davidson<br \/>\n    JM. Effects of estrogen, androgen and progestin on sexual psychophysiology<br \/>\n    and behavior in postmenopausal women. J Clin Endocrinol Metab<br \/>\n    1990;70:1124-31.<\/span>\n    <\/li>\n<li><span>Gelfand MM, Wiita B. Androgen and estrogen&shy; androgen<br \/>\n    hormone replacement therapy: a review of the safety literature, 1941 to<br \/>\n    1996. Clin Ther 1997;19:383-404;367-8. <\/span>\n    <\/li>\n<li><span>Slayden SM. Risks of menopausal androgen supplementation.<br \/>\n    Semin Reprod Endocrinol 1998; 16:145-52. <\/span>\n    <\/li>\n<li><span>Park K, Goldstein I, Andry C, Siroky MB, Krane RJ. Azadzoi<br \/>\n    KM. Vasculogenic female sexual dysfunction: the hemodynamic basis for<br \/>\n    vaginal engorgement insufficiency and clitoral erectile dysfunction. Int J<br \/>\n    Impot Res 1997;9:27-37. <\/span>\n    <\/li>\n<li><span>Rosen RC, Phillips NA, Gendrano NC 3d, Ferguson DM. Oral<br \/>\n    phentolamine and female sexual arousal disorders: a pilot study. J Sex<br \/>\n    Marital Ther 1999; 25:137-44.<\/span>\n    <\/li>\n<li><span>Fava M, Rankin MA, Alpert JE, Nierenberg AA, Worthington<br \/>\n    JJ. An open trial of oral sildenafil in antidepressant-induced sexual<br \/>\n    dysfunction. Psychther Psychosom 1998;67:328-31.<\/span>\n    <\/li>\n<li><span>Kaplan HS. The illustrated manual of sex therapy. 2d ed.<br \/>\n    New York: Brunner\/Mazel 1987:72-98.<\/span>\n    <\/li>\n<li><span>Rosen RC, Leiblum SR. Treatment of sexual disorders in the<br \/>\n    1990s: an integrated approach. J Consult Clin Psychol 1995;63:877-90.<\/span>\n    <\/li>\n<\/ol>\n<blockquote>\n<p><span>Copyright &copy; 2000 by the American Academy of Family<br \/>\n    Physicians. <br \/>This content is owned by the AAFP. A person viewing it<br \/>\n    online may make one printout of the material and may use that printout only<br \/>\n    for his or her personal, non-commercial reference. This material may not<br \/>\n    otherwise be downloaded, copied, printed, stored, transmitted or reproduced<br \/>\n    in any medium, whether now known or later invented, except as authorized in<br \/>\n    writing by the AAFP. Contact <a href=\"mailto:afpserv@aafp.org\">afpserv@aafp.org<\/a> for copyright questions<br \/>\n    and\/or permission requests.<\/span><\/p>\n<\/blockquote>\n<hr \/>\n<p><a href=\"http:\/\/208.34.222.225\/bin\/rdas.dll\/RDAS_SVR=www.aafp.org\/afp\/20000701\/contents.html\">July<br \/>\n  1, 2000 Contents<\/a> | <a href=\"http:\/\/208.34.222.225\/bin\/rdas.dll\/RDAS_SVR=www.aafp.org\/afp\"><em>AFP<\/em><br \/>\n  Home Page<\/a> | <a href=\"http:\/\/208.34.222.225\/bin\/rdas.dll\/RDAS_SVR=www.aafp.org\/\">AAFP<br \/>\n  Home<\/a> | <a href=\"http:\/\/208.34.222.225\/bin\/rdas.dll\/RDAS_SVR=www.aafp.org\/search.html\">Search<\/a> <\/p>\n<hr \/>\n<\/blockquote>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; Advanced Search &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 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&#8230;.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1587,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-1591","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1591","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=1591"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1591\/revisions"}],"predecessor-version":[{"id":1593,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1591\/revisions\/1593"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1587"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=1591"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}