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S pecial f ocus:
S e x u a l D y s f u n c t i o n
Since 1948, when sex researcher Alfred C. Kinsey, PhD, PREVENTION AND SCREENING
All women should be screened for sexual dysfunction during began publishing his seminal works on human sexual a routine health maintenance exam. In addition to having the The robust promotion of erectile dysfunction medications has behavior, scientists have followed Dr. Kinsey’s lead into same risk factors as men, women also may be at high risk perhaps made it easier for patients to broach the subject of because of genital pain caused by endometriosis, vaginis- people’s bedrooms, hoping to learn what prevents sexual dysfunction. But experts say that, for most patients, mus, vulvodynia or interstitial cystitis, or by infections, such them from thoroughly enjoying sexual encounters.
it’s up to physicians to “break the ice” and actively screen for as candidiasis, bacterial vaginosis or chlamydia. sexual dysfunction. (See also “Sex talks dos and don’ts,” It might, however, be easier to eliminate the factors that do not influence sexual satisfaction, rather than A few questions can help guide your initial discussion. Ask DIAGNOSIS
encompass all the ones that do. Besides the physical patients, for instance, if they are happy with their sexual per- For both men and women, use a comprehensive history and issues, sexual response (or the lack thereof) is closely formance and response. If patients are in a committed rela- physical exam to look for common causes of sexual dysfunc- tied to emotional and relational factors, as well as to tionship—regardless of whether it’s heterosexual or homo- tion, which include cardiovascular, endocrine, neurological sexual—ask if any aspects of their sexual life have changed.
and urogenital disorders, and medication use.
Various diseases, including diabetes, heart disease, Talk about displays of affection and whether any health prob- Identifying the cause of sexual dysfunction will directly affect multiple sclerosis and alcoholism, affect sexual per- lems, the patients’ or their partners’, have interfered with sexual expression. Studies have shown, for instance, that the formance in both men and women. And medical majority of men who suffer myocardial infarction are afraid treatments can have a pronounced impact on the that sex will bring on another heart attack. quality of a patient’s sex life: As many as 80% of men You can make an erectile dysfunction diagnosis when treated for prostate cancer, for instance, experience Ask patients who are single what their needs are for an inti- patients have a consistent inability over the course of three erectile dysfunction—a condition that also has mate relationship, how they achieve sexual satisfaction, and months to attain and maintain an erection sufficient for sexu- been linked to the use of more than 300 prescription what changes, if any, they have experienced in sexual desire.
al intercourse. The International Index of Erectile Function-5questionnaire may help you determine the severity (mild, medications, including antidepressants and antihy- Encourage all patients who have modifiable risk factors for moderate or severe) of that dysfunction. sexual dysfunction to try and change that risk. Both men andwomen should be urged to quit smoking, moderate alcohol You also need to categorize the dysfunction’s cause as psy- Men, at least, have a clear-cut definition of sexual use, discontinue recreational drug use, and achieve blood chogenic (psychological or interpersonal factors); organic, dysfunction, as well as new drug therapy options. For pressure control for hypertension and hyperglycemic control resulting from endocrinological, neurological or vascular dis- women, “[t]he word ‘dysfunction’ … suggests that orders; or a combination of both. You can tailor laboratorytesting to a patient’s clinical situation, keeping in mind that there is an acknowledged norm of female sexual Make sure patients with chronic conditions—including extensive testing—including specialized endocrinological function,” according to a May 2004 article in the rheumatoid arthritis, irritable bowel syndrome, low back pain assessment—shouldn’t be performed routinely.
“Harvard Health Publications” series. “That norm has or migraines—have adequate pain control, because chronic never been established. Unlike penile erection, which pain can interfere with sexual function. But remember that For patients with a history of cardiac disease, assign them to is a quantifiable physical event, a woman’s sexual these patients also present a dilemma: While they need pain a low, intermediate or high risk category, and manage that response is qualitative.” (www.health.harvard.edu/ control, their medications can often lead to further sexual risk before recommending sexual dysfunction treatment or dysfunction. You may need to advise sex therapy for these Those with low risk have, among other issues, confirmed What is clear is that sexual dysfunction can impair And see that patients receive appropriate treatment for psy- hypertension, mild stable angina and fewer than three cardio- patients’ mental and physical health, as well as their chosocial issues such as depression, anxiety and any history vascular risk factors. Those in the second tier have, among quality of life. “Sexual dysfunction,” wrote Abraham other factors, moderate angina, left ventricular dysfunction Morgentaler, MD, in the June 23/30, 2004, Journal of and/or class II congestive heart failure, and have experienced Screen for sexual dysfunction in men with identifiable risk the American Medical Association (JAMA), “can lead a heart attack within the last six weeks. The high-risk catego- factors. These include chronic illnesses such as diabetes, to depression and a profoundly altered sense of self- ry includes patients with unstable or refractory angina, con- heart disease, hypertension and decreased HDL cholesterol gestive heart failure (class III or IV), obstructive cardiomy- esteem that negatively affects many relationships” levels; medications for those conditions; pelvic trauma or sur- opathies and moderate to severe valvular disease.
(http://jama.ama-assn.org/cgi/content/extract/ gery; neurological disease or injury; and depression. 291/24/2994). And sexual dysfunction frequently isbrought on or aggravated by advanced age, a keyconcern for internists who treat older patients.
Despite the fact that physicians now routinely takepatients’ sexual history in attempts to diagnose sexu- Kathleen Walsh, DO, a clinical assistant professor at the to treat it. But they don’t always have to treat it—just ally transmitted diseases, doctors often fail to ask University of Wisconsin Medical School in Madison, spe- acknowledging the problem can make a huge difference.” patients about sexual function. A study published in cializes in treating sexual dysfunction in women. the Aug. 23, 2003, British Medical Journal, for instance, On choosing between estrogen and testosterone treat- On primary care physicians’ ability to diagnose and found that 40% of female patients and 22% of male ments: “I lean toward prescribing testosterone for treat- treat FSD: “They are very competent if they read arti- ing the libido and estrogen for perimenopausal dryness.
patients in 13 British general practices had a sexual cles, know how to ask the important questions and But you have to be careful treating perimenopausal dysfunction diagnosis—but only 4% had that diagno- determine the baseline evaluation. But very few do.
women with estrogen because of their fluctuating hor- “At the same time, we assume that patients are sexually mone levels. I start off prescribing low dosages until I knowledgeable and competent, but many aren’t.
Some patients diagnosed with sexual dysfunction will Physicians have to ask questions in such a nonjudgmen- need to be referred to a subspecialist, but many “Most physicians working in the area of sexual dysfunc- tal way and setting—with the patient fully clothed, and won’t. According to the JAMA article, primary physi- tion believe a certain level of estrogen is necessary in face to face—and that helps a patient feel comfortable cians can treat most men with erectile dysfunction.
the body for testosterone to be effective.” enough to discuss their sexual concerns. If they don’tapproach the patient the right way the first time, their On classifying sexual dysfunction among women: “In And they can treat their female patients as well.
patient will unlikely bring it up again.” my practice, a conservative estimate among pre- “Acknowledgement of sexual concerns is very impor- menopausal women is 20%-30%, which includes low tant for women,” said Kathleen Walsh, DO, a, clinical On whether female sexual dysfunction is now more libido, anorgasmia, diminished arousal and genital pain.
widely treated: “Over the last six years, I’ve seen a very assistant professor at the University of Wisconsin Among perimenopausal women, it increases to 50%, pri- significant rise in physicians’ interest about sexual dys- Medical School in Madison. “Physicians should marily because of hormonal fluctuations. It could also function and how to treat it. It takes only one or two address the physical and psychological issues that be that, after they’ve had sexual problems for years, patients to bring up the topic of sexual dysfunction, and may affect sexual dysfunction, such as hypertension, women finally admit to them and seek help. In the post- the physician usually tries to locate the literature or peripheral vascular disease, depression and anxiety.
menopausal group, it drops down to 30%. Why? They another clinician in the community to help. Many physi- don’t have to worry about getting pregnant, and they If it is a gynecological issue, such as vaginal dryness, cians are frightened to talk about sexual dysfunction have figured out what type of sexual stimulation works with their female patients, because they don’t know how For women:
As part of your clinical history, assess patients’ sexual history
for issues affecting desire, arousal, orgasm and pain. Using adiagnostic questionnaire—such as the Female Sexual Arthur L. Burnett, MD, professor of urology and director “The medications require some lead time. We know Function Index (www.fsfi-questionnaire.com/) or the Brief of the Male Consultation Clinic at Baltimore’s Johns they typically have efficacy within one half hour or one Index of Sexual Functioning for Women—can help qualify Hopkins Medical Institutions, spoke with ACP Observer hour, and the less food, the better. However, food does patient information about dysfunction. You also should about treating erectile dysfunction. He primarily treats not affect the maximal serum concentration of tadalafil explore the content of patients’ key emotional relationships.
patients who have undergone radical prostatectomies.
after it is taken because of the two-hour duration to As with male patients, consider lab testing as part of a sys- On differentiating among erectile dysfunction drugs: tematic evaluation, and refer patients who need a specialized “They are mostly interchangeable, they all work by the On the impact of direct-to-consumer advertising: same mechanism and action. Tadalafil has a longer half “All the media events and societal changes have life of degradation and is being billed as the “weekend helped. At the same time, only a minority of men are TREATMENT
drug”—take it once and you’re good all weekend.
getting treated. We know that only 10%-25% of men Sildenafil and vardenafil have four hours before they with ED get treatment. Treatment barriers include the are degraded by 50%; tadalafil has 17.” absence of sexual activity for many years, fears of start- Use non-drug therapies for all male patients, including: ing relationships and other interpersonal issues. The On drug dosing: “Physicians should use a midrange interpersonal relationship looms over everything, and ■ Changing or discontinuing medications that adversely dose. Sildenafil, 50 mg; tadalafil and vardenafil, 10 mg.
■ Treating any underlying medical condition.
■ Treatment efficacy estimates range from 50%-70% with silde- levels before prescribing hormone supplements but monitor Recommending lifestyle changes. One study found that nafil; 98% for vacuum constriction devices; 30% for intrau- more than 30% of obese men who lost weight and began rethral therapy; 90% for intracavernous therapy; and 99% for exercising regained their ability to have an erection, com- There are also two dozen different investigational medica- pared to only 5% in the control group.
tions and devices being tested for female sexual dysfunction that include nasal sprays, creams, patches and devices.
Consider corrective surgery for pelvic or perineal trauma.
For women:
Before prescribing non-hormonal or investigational treat- Other treatment strategies for erectile dysfunction follow a Advise female patients to correct reversible causes of sexual ments, thoroughly discuss potential benefits and side effects dysfunction by making any necessary lifestyle or medication First-line therapy consists of oral erectogenic agents, vacuum
Follow-up
constriction devices and psychosexual therapy. Drug thera- Adjunctive non-drug therapies—including stimulation py—with sildenafil, vardenafil or tadalafil—is an important devices, biofeedback and psychotherapy—can help treat ■ Reevaluate the patient’s medical and psychosocial situa- element in a comprehensive approach to erectile dysfunction.
identifiable disorders. For pain disorders, you can recom- One randomized controlled trial of oral sildenafil in antide- mend that patients vary sexual positions, use lubricants and ■ Assess any possible adverse drug reactions or interaction pressant-associated sexual dysfunction found that 54% of pursue pelvic floor physical therapy.
participants reported sexual function, compared to only 4.4% While researchers have not found a “little blue pill” that can ■ Consider titrating the dosage or substituting another address female sexual dysfunction, drug therapy can play a All three drugs are contraindicated in patients taking nitrates.
significant role in treating women’s low desire, decreased Experts point out that sildenafil does not have any contraindi- ■ Talk to patients about their treatment or any factors that cation with alpha blockers, while tadalafil is contraindicated contributed to the sexual dysfunction.
Consider estrogen therapy, including an estrogen ring, estra- in patients taking terazosin-like drugs (except tamsulosin diol tablets, transdermal patches or topical creams, for hydrochloride), and vardenafil is contraindicated in patients women who complain of vaginal dryness, burning, and uri- taking all forms of alpha blockers. All three drugs have essen- W h e n t o r e f e r
tially the same side effects, which include headaches andflushing. Testosterone therapy remains controversial, but should be For tips on when to refer patients with sexual dysfunc- considered alone or in combination with estrogen in peri- and tion to urologists, gynecologists, sex therapists or other Second- and third-line therapies are reserved for patients
postmenopausal women with decreased desire, dyspareunia specialists, see the online version of Special Focus: who don’t respond to one or more first-line treatments, or for or lack of vaginal lubrication. (When prescribing testosterone, Sexual Dysfunction at www.acponline.org/journals/ whom first-line therapies are contraindicated. Second-line periodically obtain liver function tests and lipid panels to news/march05/sexualdysfunction.htm?hp.
therapy consists of intraurethral suppositories (alprostadil) monitor for side effects.) Choosing between estrogen and and intracavernous injections (alprostadil). Third-line therapy testosterone treatment is primarily based on symptoms, like low libido. Many physicians don’t obtain specific hormone You can access PIER’s Erectile Dysfunction (http://pier.
acponline.org/physicians/diseases/d242/d242.html) and Sexual Dysfunction in Women (http://pier.acponline.org/physicians/diseases/d664/d664.html) modules online.
The module author for Erectile Dysfunction is Arthur L.
Burnett, MD. Module authors for Sexual Dysfunction in Women areKathleen E. Walsh, DO; Jennifer R. Berman, MD; and Laura A. ■ Raise the issue of sexual function, instead of waiting for ■ Assume that a patient of a different race or gen- der is comfortable discussing sex with you, just ■ Be aware of your own attitudes and beliefs about sexuality.
The information included herein should never be used as a ■ Ask only yes/no questions. Frame questions so substitute for clinical judgment and does not represent an ■ Stay conscious of your own body language and of what it patients will be invited to share their experiences.
Keep information about sexuality available in the waiting Assume that just because patients are older, Normalize patients’ problems and let them know they are Make light of or joke about patients’ sexual Use the same terminology as the patient.
Assume that all patients are heterosexual.
Refer patients to a sex therapist if they need specialized Share your own personal sexual attitudes or

Source: http://www.acpinternist.org/archives/2005/03/special_focus.pdf