Though theoretical, the threat of aerosolized viral particles places health care providers at risk. Certain safety measures can be taken. View the full, peer-reviewed article, and more, in this month's edition of Contemporary OB/GYN.

July 2020 | Vol 65 No 07

Obstetrics and Gynecology has undergone notable change in the last few decades: advancement in subspecialties, greater diversity in practitioners, liability, robotics, and much more. The healthcare industry overall is experiencing an historic transformation that is impacting many facets of medicine. 

Patients’ expectations, communication, access to health information, and desire for transparency and accessibility are just a few of the many aspects that are different today than they were a short time ago.

In the midst of the proliferation of the Internet and related technologies, the Millennial generation emerged in the workforce, and according to the U.S. Bureau of Labor Statistics, Millennials will comprise 75% of employees by 2030. 

Generational awareness and proactive adaptations are paramount to enhance relationships among providers and patients and to maximize the attributes of each respective workplace age group.

Generations are defined as cohorts of people born in a span of roughly 15 to 20 years that are influenced and often characterized by the social, economic, and political events that occur during their formative years. 

These experiences help to shape a common system of beliefs, attitudes, and values held prominently within each group. Generations are often named by pop culture and the media, however, the United States Census Bureau defined one generation, the Baby Boomers.


The current healthcare workforce is composed of members of the Silent Generation (born 1928-1945), Baby Boomers (1946-1964), Generation X (1965-1980), and Millennials (1981-1996). 

Members of Generation Z (1997-2012) are just beginning to enter medical school and careers in healthcare (Figure 1). 

Although each generation has stereotyped descriptors, it is important to acknowledge that individual members may not always demonstrate these characteristics or self-identify with their own generation, depending on unique cultural conditions and life experiences.

Figure 2 summarizes the characteristics, experiences, innovations, and workplace attitudes for each generation. Members of the Silent Generation were children of crisis; their formative years occurred during the Great Depression and World War II, and thus birth rates were the lowest of any generation. 

The Silent Generation came of age in an era of great scarcity and austerity and are known to be hard-working rule-followers who value stability and avoid rocking the boat. 

Early in their careers, members were thought to be happy to have a secure job, even if it was not the most desirable, and loyally kept their noses to the grindstone. For many, this loyalty holds fast today.

Baby Boomers were born during social and political upheaval but were also raised during a period of economic prosperity. They are characterized as competitive and ambitious, and are high-achieving, goal-oriented employees. 

Striving towards and realizing the American Dream was a priority for many. Baby Boomers live to work, and many continue to work beyond the typical retirement age due to the joy they find in their occupations.

Resourceful and self-sufficient, Generation X’ers were dubbed “latchkey kids”; both parents often worked outside the home, so members of this generation looked after themselves and their younger siblings. 

Many saw their mother and father divorce and were raised in single-parent households. Having witnessed the workaholic approaches of their Silent Generation or Baby Boomer predecessors, Generation X’ers have a mantra of “work to live” and value a more flexible work environment.

Millennials are the first generation to have been immersed in digital technology early in life; many had computers in their classrooms and were natural adopters of electronic modes of communication. 

Their parents tended to be protective and very involved; “helicopter” and “snowplow” parents are widely used descriptors. Millennials are the most educated of any generation; nearly 40% of millennials have a bachelor’s degree or higher, compared with 15% of the Silent Generation.

Members of this cohort are marrying later, starting families later, and are the most racially and ethnically diverse generation in the history of the workforce. 

More than any other generation, Millennials are in search of a work-life integration that grants both personal and professional fulfillment.

From house calls to smartphones, communication among members of the healthcare team and with patients has varied widely over the last several decades. While members of the earlier generations may recall a time when house calls were not unheard of, the evolution of clinical productivity standards now demands that physicians from all generations embrace email and increasingly text messaging. 

Even the telephone is quickly becoming obsolete as practitioners seek to both deliver and consume communication asynchronously, sending and receiving when time allows. 

Millennials who came of age during the smart machine revolution, which began around the turn of the 21st century and is ongoing, strongly prefer and are hastening the adoption of more modern communication regimes. 

Millennials often expect this type of communication to be the norm, and it is not uncommon for them, when joining a practice, to start a group text thread among partners that they use freely at all hours of the day and night.

Just as the lines of communication are being redrawn, perhaps more uncomfortable for some, the traditional clinical chains of command are being blurred by eager and confident members of later generations. 

Years ago, it would have been improper for a medical student to address an attending by their first name, but some new attendings actually prefer and invite trainees to dismiss formalities. This type of disregard for hierarchy sends ripple effects throughout academic departments and practices that are tolerated differently based on organizational philosophy and cultural acceptance of change. 

A side effect of the gradual dissolution of hierarchy may be an exaggeration of ambiguity in how trainees and colleagues of different generations perceive workplace mistreatment by both peers and superiors.

Team-based approaches to learning and problem solving have been hardwired into newer generations. While most can easily conjure images from childhood of a favorite teacher at the chalkboard espousing wisdom to the masses, Millennials experienced the beginning phases of an ongoing reformation of classroom teaching that more heavily emphasizes problem-based learning in peer groups. 

Recognizing that collaboration in the healthcare workplace is natural and necessary, many medical schools have trended in this direction, as well. 

This evolution of teaching and learning has broad implications for how generations of physicians relate and work together. Millennials, for example, may have learned to frequently seek out the opinions of various care-team members while earlier generations might have been trained to make decisions based more on their own understanding and experience.

What is work and what is life? There are thousands of articles on work-life “balance,” “fit,” “blend,” and “integration.” 

The ratios of time and energy spent on personal and professional endeavors may vary not only by generation but also depending on stage of life. The values of any one member of a generation may change as the milestone events of life unfold. 

What remains constant, however, are the positive professional and personal benefits of sustained maintenance of self-care. 

Many are familiar with pre-flight instructions that advise passengers to don their own oxygen masks before assisting others; if providers aren’t mentally and physically healthy themselves, how can anyone expect them to care for their patients effectively?

Just as generation and stage of life are important determinants of values, gender cannot be overlooked. Today, more than half of ob/gyns are women, and over 80% of medical students who match into the specialty are female.

Compare these numbers to 1970 when 93% of ob/gyns were men. And in 1970, many male physicians were not also responsible for caregiving and domestic duties. Women in medicine are almost twice as likely as men to have partners who are employed full-time (86% of females versus 45% of males). 

Females in medicine with partners and children reported spending an average of 8.5 hours more on parenting and domestic tasks than their male counterparts each week.

Physicians feel they are being asked to do more with less. There never seem to be enough hours in the day to complete work responsibilities, let alone adequate time for family and pleasure. 

And while it may be easy for some to dismiss these sentiments as an insufficient work ethic in younger generations, one must carefully consider the disruptive transformation of modern healthcare delivery that is significantly influencing the dynamics of work-life integration. 

Volumes could be devoted to an exploration of how this topic impacts other vital industries just as acutely as medicine, but take for example the mass exodus of teachers from the K-12 education arena. Only in recent history have regulations led to a demand for student recordkeeping so burdensome that the careers of many educators are extinguished prematurely. 

The original meaning many teachers sought from a profession once regarded as a cornerstone of our society is being increasingly eroded, and this is a refrain that sounds all too familiar to many physicians today.

Whether symptoms of burnout have actually increased dramatically, or there is now more attention called to exhaustion, or both, job flexibility that allows for some work-life integration is highly valued, especially by younger generations. This begs the question: Is it possible to achieve work-life balance as a physician? 

Understandably, there will be less of a balance and more of a blend as an ob/gyn, but creative solutions are imperative to ensure the feasibility of fulfilling both home and work responsibilities, within reason. 

Further, these adaptations play a critical role in preventing exacerbation of the upcoming physician shortage by doctors who don’t maximize their career potential and instead retire early, decrease to part-time or less, or even change careers.

One would assume that shifting careers from a physician to a different profession was previously unlikely, but Millennials and likely future generations perceive their careers to be less defining of their identities. As mentioned, professional 

 personal fulfillment are highly regarded by Millennials. 

As such, opportunities to develop hobbies, devote time to family and friends, and volunteer in the local community and beyond will need to be recognized and supported by employers to ensure satisfaction and stability in the workforce.

A generational divide may seem inevitable; however, gaps can be narrowed with effort.

Employers and organizations that provide support in the way of formalized mentoring programs will facilitate the dissemination of wisdom to newer generations and encourage goal setting. Clinical skills, productivity pearls, and expertise amassed through decades of practice are invaluable resources for junior partners. 

Beyond these attributes, mentors may guide mentees by facilitating network connections and providing advice on promotion and career pathway optimization. Mentors serve as sounding boards during professionally challenging times or when difficult situations arise.

Reverse mentoring can occur in the same partnership; in this scenario the junior physician mentors the senior physician in unique skillsets they possess, especially adaptation to technology, which is second nature to Generation X and certainly to Millennials. 

Reverse mentorship can offer mentees advice on electronic health record efficiency, template sharing, app utilization, website and social media presence, and more.

Formal mentorships are excellent resources for physicians in every career stage. These relationships can be created in departments and practices, or through utilization of the American College of Obstetricians and Gynecologists Mentor Program, especially when local connections are more limited. 

As mentors and mentees begin to exchange viewpoints and develop relationships, generational understanding is naturally achieved, reinforced, and enriched.

Opportunities forflexibility in scheduling can be employee-friendly and also patient-friendly. Consider offering evening or weekend office hours a few times per month, which are highly desirable to Millennial patients. 

Members of younger generations may gladly exchange morning hours for evening hours on occasion, as this may afford the opportunity to be involved in school activities for their children or errand-running that is otherwise not possible with a traditional physician schedule.

Similarly, setting up a practice to offer and receive reimbursement for e-visits or video visits is another convenient way to efficiently deliver healthcare. This can allow for occasional windows of time to work outside of the traditional office setting or even from home. 

Though Obstetrics and Gynecology may be more limited than specialties such as Psychiatry in the visit types that can be offered electronically, opportunities do exist and will become more commonplace as generational demand increases.

Laborist and gynecologic hospitalist models have increased patient safetyand can provide unique appeals of acute, inpatient medicine and defined shifts.

Though these models lack the benefit of patient continuity, both junior and senior physicians, as well as many practices, find this to be an attractive alternative to relinquishing obstetric services earlier in a career than desired and can also increase productivity in the office.

Encourage input from all generations when crafting new policies and procedures and in solving problems. Harnessing the creativity of the group is likely to yield different perspectives and invoke innovation. When meeting together, all generations will appreciate a clear agenda with defined and respected start and end times. 

Consider whether an email or text thread would be just as effective and more efficient than face-to-face contact. Leaders should strive to acknowledge the attributes and perspectives of each generation to achieve harmony and optimize productivity.

As we strive to enhance our relationships with our colleagues and patients, it would benefit us all to consider the values, characteristics, and experiences of every generation. 

With some effort, generational gaps can be narrowed and ob/gyns of all ages will thrive at home and at work and continue to deliver high-quality care to our patients.

Bialik K, Fry R. Millennial life: How young adulthood today compares with prior generations. https://www.pewsocialtrends.org/essay/millennial-life-how-young-adulthood-today-compares-with-prior-generations/. Pew Research Center. February 14, 2019.

Rayburn W. The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implication. Washington, DC: ACOG; 2017.

Jolly S, Griffith K, DeCastro R, Stewart A, Ubel P, Jagsi R. Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers. 

Association of American Medical Colleges.New findings confirm predictions on physician shortage. https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage. August 23, 2019.

ACOG Committee Opinion 459. The Obstetric and Gynecologic Hospitalist. Committee Opinion No. 459. American College of Obstetricians and Gynecologists. 

Articles

Bridging the generational gap in the physician workforce.

Introducing Dr. Millennial

The scientific approach to categorizing mesh complications, as well as optimal methods to address them, have been complicated by the rapid proliferation and evolution of materials and techniques that have been used over the past 20 years in surgical treatment of pelvic floor disorders. 

In addition, terminology used to diagnose and categorize mesh complications, as well as the descriptions of surgical procedures to manage them, have been adopted inconsistently, further hampering development of a collective experience with a standardized lexicon. 

Finally, much of the high-quality data on management of mesh complications is based on materials that are rarely used or not commercially available today.

Women experiencing mesh complications need to be heard, and should have access to resources and providers who are most able to help. Many women require multiple procedures to address their mesh complications, and for some of these patients, relief is incomplete. 

We should strive to optimize the treatment at the initial diagnosis of a mesh-related complication.

: Using the best and most relevant evidence available, provide guidance for the FPMRS subspecialist caring for patients who may be experiencing mesh complications.

: Provide an algorithm outlining treatment choices for patients with mesh-related complications that can be used as a platform for shared decision-making in the treatment of these complications.

: Identify and prioritize gaps in evidence concerning specific mesh complications and their treatments.

: Identify provider and health facility characteristics that may optimize the outcomes of treatments for these complications

The treatment algorithm requires consistent and accurate terminology for treatment procedures, as follows:

: either no mesh is removed (e.g., dissecting and primarily closing vaginal epithelium), or a small edge of mesh is removed such that the structural integrity of the implant is left intact.

: a segment/component of the mesh is removed or transected, such that the structural integrity of the implant is altered.

 removal of segments or components of mesh beyond, or not in contact with, the vagina

the surgical goal is the removal of 100% of the implant; extirpation.

The treatment algorithm is presented, along with the level of evidence supporting each decision node. Recognizing that some patients will require more than one procedure, the recommendation is made that treatments are not repeated; if a given treatment is unsuccessful, consideration should be given to advancing to the next item on the algorithm.

Full text of “Management of Mesh-Related Complications for the FPMRS Specialist” can be found 

This was created in partnership with the American Urogynecologic Society (AUGS). AUGS was established in 1979 and represents more than 1,900 members, including practicing physicians, nurse practitioners, physical therapists, nurses and health care professionals, and researchers from many disciplines.

The American Urogynecologic Society (AUGS) released new information on managing mesh problems, which includes guidance, treatment algorithms and ways to optimize treatment outcomes for these complications.

AUGS Consensus Statement: Managing mesh problems

The data below is a reflection of data collected weekly by the 

Centers for Disease Control and Prevention

 (CDC). The cases reported are only confirmed cases with laboratory evidence of SARS-CoV-2 infection.

Here’s the latest data, updated on July 2:

Pregnant women with COVID-19, United States

Stay tuned for the next data update on July 7, 2020. 

Data is updated weekly based on data collected by the Centers for Disease Control and Prevention (CDC). The cases reported are only confirmed cases with laboratory evidence of SARS-CoV-2 infection. CDC’s case numbers are validated through a confirmation process with each jurisdiction.

Currently, there are 56 U.S.-affiliated jurisdictions reporting cases of COVID-19, including 50 states, District of Columbia, Guam, New York City, the Northern Marina Islands, Puerto Rico, and the U.S. Virgin Islands.

Data on COVID-19 during pregnancy, as reported by the CDC, in collaboration with state, local, and territorial health departments and external partners.

COVID-19 Pregnancy Data in the United States: July 2 Update

Recent studies have found that neonatal intensive care unit (NICU) admissions, initial hospitalized days, short stays, and additional NICU utilization trends vary significantly in the United States health care system.

 However, NICU utilization trends have yet to be thoroughly investigated.

set out to explore NICU utilization trends using the Kaiser Permanente Southern California health care system. Participants included every woman who gave birth in a Kaiser Permanente Southern California hospital, and her newborn, from January 2010 to December 2018.

Trends studied included NICU admission, NICU patient-days, readmission rates and mortality rates. 

In those 8 years, 320,340 births occurred, and researchers found that NICU utilization had decreased. However, researchers noted that it did not lead to an increase in readmissions or mortality.

For more information about this study and its additional findings, visit 

NICU utilization trends have yet to be thoroughly investigated. 

New study analyzes NICU utilization trends

Forty-three percent of American women aged 18 to 85 report experiencing some form of sexual complaint; however, the actual incidence of self-reported significant distress from these issues is closer to 12%.

Defined as distress due to lack of desire, impaired arousal, inability to achieve orgasm, pain with sex, or a combination of the above, sexual dysfunction is a commonly ignored topic given the societal stigma surrounding open discussion of female sexuality.

Unfortunately, this bias toward under reportingextends to health care providers, who also report being less comfortable bringing up female sexuality.

While in part, this is due to the perception that there is inadequate time in clinic to address sexuality issues, some providers do not feel proficient in sexual dysfunction knowledge or management.

Although over the last 10 years there has been a cultural shift toward acknowledging the spectrum of sexual relationships and conditions, several recent studies on training received in sexual medicine have not found increased attention on education in this area.

Discomfort among practitioners who are managing sexual dysfunction remains high.

 In addition, while the Internet has made it easier for patients to find information about their symptoms, they remain less likely to bring up intimate issues with their healthcare providers unless directly asked.

Despite this hesitancy from patients and practitioners to delve into sexual health, many studies support the idea that regular sexual expression is associated with improved psychological well-being and reduction in physical problems.

Intimacy has been found to be vital to overall well-being.

The aim of this article is to briefly review how to incorporate sexual dysfunction evaluation and simple treatments into current practice.

As health care practitioners, we effectively diagnose and treat disorders within our specialty. The challenge of sexual dysfunction is that the etiology may be complex, which can make starting the conversation about sexual function daunting. 

However, the American College of Obstetricians and Gynecologists (ACOG) recommends that all obstetrician and gynecologists should be initiating “clinical discussion of sexual function during routine care visits to identify issues that may require further exploration and to helpdestigmatize discussion.”

Although medical education regarding sexual medicine remains lacking, an advanced understanding is not needed to help patients feel comfortable. 

Start by normalizing the topic, ensuring patients that sexual problems are common and that the first step in improvement is being willing to talk about it. It can be effective to start the conversation with a simple open-ended question, for example: “Many women have concerns about sex. I wanted to check in and see how you’re doing.”

Allowing the patient to speak freely, followed by empathetic listening and asking pointed, detailed clarifying questions gives the patient space to express herself.

If short appointment times are the primary barrier to discussing sexual health, there are validated sexual function checklists, such as the Patient-Reported Outcomes Measurement System or Female Sexual Function Index (FSFI), that can be incorporated into the intake process; however, the onus is then on the provider to acknowledge aberrant answers and schedule follow-up appointments.

If a patient raises specific issues, begin by validating her concerns. If you are under time constraints, it’s acceptable toschedule a future focused sexual health follow-up appointment.

During that visit, take a detailed sexual history that includes: the patient’s sexual/gender identities, nature/duration/chronology and onset of symptoms, severity of distress caused by symptoms, patients’ personal attempts to alleviate symptoms, relationship quality, past/current abuse history (sexual, verbal, emotional or physical), and Internet/social media usage.

Assess hygiene, sleep quality, and body changes/image concerns.

 In addition, as part of obtaining a history, discussing the female sexual response cycle can be helpful to evaluate where in the cycle the breakdown is occurring: desire, arousal, orgasm, or resolution. 

It is useful to review that in women, the sexual response is not always linear and that a satisfying sexual encounter (SSE) does not always require moving through all phases, nor is an orgasm always necessary for a SSE.

A discussion focused on one area of concern of the cycle may shed light on underlying causes related to another problem. 

For example, a patient with pain with sex may think that her decreased ability to become aroused is due to other factors (relationship issues, age, lack of foreplay, etc.), when in actuality it is underlying vulvar vestibulitis and vulvar pathology that needs to be addressed. 

As part of this appointment, screen all patients for intimate partner violence because sexual dysfunction may be the primary and only manifestation. It is important to acknowledge that even after an initial intake appointment, the patient may not reveal the extent of her sexuality concern and that multiple appointments may be necessary for full disclosure.

Finally, assumptions in sexual medicine can be detrimental. Do not assume that all patients are heterosexual and engaging in monogamous relationships. Multiple relationship paradigms exist, and clinicians should be familiar with these sexual variations. 

Most importantly, try to create a welcoming, non-judgmental environment. Ensure that medical intake forms use inclusive language and pay attention to the descriptors a patient uses during her visit (for example, partner versus husband). You may never get a second chance to make a first impression. 

Comprehensive diagnosis, patience, and empathetic listening are the cornerstones for building a therapeutic alliance with your patient and facilitating a joint partnership in development of a treatment paradigm.

Although the etiology of female sexual dysfunction is often multifactorial, do not forget that the problem may actually be due to an underlying preexisting medical condition.

For example, changes in levels of thyroid hormone lead to alterations in circulating sex hormones. This can lead to autonomic dysregulation, causing sexual dysfunction.

In women, both hypothyroidism and hyperthyroidism have been associated with altered desire, arousal, orgasm, and satisfaction with intercourse.

 If the patient has a male partner, thyroid disease can be associated with erectile and ejaculatory disfunction.

Other chronic conditions may also impact sexual functioning. The role of diabetes in male sexual dysfunction is well established because erectile function can be severely diminished due to vascular complications of diabetes.

The impact of diabetes on female sexual functioning is less clear; however, some studies confirm that it can diminish genital sensation.

Similarly, neurologic diseases, such as Parkinson’s, multiple sclerosis, or sequalae of a cerebrovascular accident, can impact sexual function as mobility and sensation is often compromised.

Transient changes in health status should not be ignored. With all the focus on the arrival of a new baby, it can be easy for providers to forget to address sexual functioning with pregnant and postpartum women. 

Research has shown that hypoactive sexual desire disorder and painful intercourse/dyspareunia are common in postpartum women due to the interplay of low estrogen levels, mood changes, and fatigue.

Remember to ask about sexual function at postpartum appointments, even if it is not a patient’s chief concern.

Medication use may also be the cause of sexual problems. It is not uncommon for changes in sexual functioning to be associated with the start of a new medication. For example, some psychiatric medications have a reputation for causing sexual dysfunction; however, the true incidence is difficult to assess as sexual dysfunction can also be independently associated with psychiatric disorders such as depression, anxiety, and psychosis.

Most commonly, selective serotonin receptor inhibitors (SSRIs),

 benzodiazepines, and first-generation antipsychotics impact the sexual response cycle.

Maintaining a patient’s mental health is the main priority and if she feels that her medication is to blame for a decreased libido, consider recommending that she discuss a medication switch with her psychiatrist. 

Aside from psychiatric medications, antiepileptics may be associated with sexual dysfunction,

 as have hormonal contraceptives, although the data are conflicting and many confounding factors may be present.

Above all, optimization of general medical health conditions and well-being will allow you to provide the best care, treating the whole person rather than just her sexual considerations. Treatment of female sexual complaints should start by stabilizing any preexisting medical conditions and monitoring polypharmacy/ excessive medication use. 

Medications can directly and indirectly impact sexual function and care should be taken to assess and evaluate the impact of prescriptions, herbs, supplements, and over-the-counter (OTC) formulations on sexual responsivity.

Sexual dysfunction rarely exists in a vacuum. Ensure that you take a thorough medical history prior to assuming intercourse is the real problem.

Aside from addressing underlying medical issues, providing patients with simple behavioral modifications or interventions has been shown to improve or enhance sexual well-being. When men and women are satisfied with their sex lives, their overall health improves.

Therefore, talking with patients about prioritizing time for intimacy and sex, as well as planning intimate activities with their partners, such as regular date nights, can help reset relationships. 

In a world where distractions and technology overload are commonplace, effort needs to be made to shift the focus back toward enhancing connections and fortifying bonds.

Aside from encouraging couples time, you may also want to suggest novel sexual adventures. Many patients may never have explored sex toys/aids, accessories, or the use of supplemental lubricating products. Patient education and support can be therapeutic as well. Patients may not be aware that multiple medical conditions and medications can impact arousal and sexual lubrication. 

For example, during menopause, vaginal tissue becomes pale, frail, and inelastic due to a hypoestrogenic state.

 As a result, the vagina produces less physiologic lubrication. Given that genitourinary syndrome of menopause (GSM) and vaginal dryness is a common etiology of painful intercourse, having frank conversations about vaginal moisturizers and lubricants is a solution that is easy to implement.

Water-based lubricants are commonly used in most situations (sensitive skin, condoms, sex toys); however, they are stickier and shorter-lasting than the alternative silicone- or oil-based lubricants. 

Silicone-based lubricants will feel slicker and last longer than water-based lubricants. In addition, silicone-based lubricants are safe for use during water-based sexual activity (pools, hot tubs, showers, lakes) and also can be used with sex toys. Caution is advised if using with other silicone-based toys as it can impact the integrity of rubber products.

It’salso very important to instruct your patients to read labels and understand ingredients as some additives can be caustic to the sensitive vaginal mucosal lining.

Educate patients that some of the OTC options, whether lubricants or herbal concoctions, are not based in science and can be damaging. For example, vaginal tighteninggelsare not approved by the US Food and Drug Administration and many may negatively impact the healthy vaginal biome.

Many OTC supplements promise results but often fail on performance and scientific support.30 Nevertheless, in general, lubrication and sex aids are easy recommendations that any provider can safely make.

Understand the context of the relationship

Aside from treating the patient in your office, counsel her that the health of a relationship (or relationships) can significantly impact sexual functioning. 

Assessing the dysfunction in the context of a partnership can help shed light on the etiology of the issue. An understanding of relationship dynamics, communication styles, and emotional interactions is important when formulating a comprehensive treatment plan.If the patient is willing, an open discussion with her partner can be beneficial and therapeutic. 

During this appointment, address factors in the relationship that directly relate to sexual dysfunction (unrealistic expectations, different fetishes, etc.), but also lifestyle challenges (shift work, work travel, body changes, etc.).

There is evidence that exercises aimed at improving and enhancing partner communication about sexual wants, needs, and preferences can help alleviate a portion of sexual discomfort.

Furthermore, group-based or couples-based cognitive-behavioral therapy can be useful for improving low sexual interest.

As women’s health care professionals, we are often the only providers who may discuss sexual health concerns. Few residencies offer in-depth, formalized training about normal and abnormal sexual functioning. 

While we may want to tackle all issues related to women’s health, appropriate referral to specialists specifically trained in sexual medicine should not be seen as a clinical failure, but rather as a cornerstone of improving a patient’s sexual health.

ACOG recommends connecting patients with health professionals with expertisein sexual dysfunction, such as sex therapists and marriage/relationship counselors, as well as mental health specialists, such as psychiatrists and psychologists.

Couples counseling is often a good fit for patients looking to spend time addressing broad relationship issues. A sex therapist may offer help but mainly focuses on sexual concerns, such as negotiating discordant sexual desires and assigning exercises to help overcome dysfunction. 

There is emergingscientific data on the efficacy of sex therapy, and the general consensus of sexual medicine experts is that therapy and counseling can significantly improve sexual functioning, relationships, and quality of life.

Genital pelvic floor physical therapists may also play a critical role in the treatment of pelvic pain syndromes.

American Association of Sex Educators Counselors and Therapist (AASECT)

The International Society for the Study of Women’s Sexual Health (ISSWSH)

American College of Obstetricians and Gynecologists (ACOG) 

With the emergence of telehealth and Internet connectivity, even for practices in remote areas, telemedicine can help connect providers to patients. 

There is less information regarding distance counseling as it pertains to sexual health; however, it is effective for gynecologic care.

 For male health, tele-sexual health has been used to address concerns such as erectile dysfunction treatment and testosterone replacement, but its role for women and hormonal therapy is currently still being explored.

Out-of-pocket cost, fee-for-service models and reimbursement for telemedicine vary, by insurance company and geographic distribution.

Patients should be encouraged to investigate their coverage.

Just as the etiology of many sexual dysfunctions is complex, the treatment also requires a multi-faceted, team-based approach. Seeking help from experts is not a clinical failure on the provider’s part. 

Instead, it should be viewed as an opportunity for medical collaboration that can maximize a patient’s chance to recover and thrive.

Sexual dysfunction is an underdiscussed, though prevalent, issue. The aim of this article is to illustrate that there are many ways to help patients struggling with sexual dysfunction. 

Given the paucity of formal training on sexual health that many ob/gyns receive in residency, understanding the basic options that are available and creating safe, open spaces in which patients feel secure enough about to express their concerns is paramount to starting the process of healing.

Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in united states women: Prevalence and correlates. 

Kingsberg S. Just ask! Talking to patients about sexual function. 

Parish SJ, Clayton AH. Sexual medicine education: Review and commentary. 

. 2007. doi:10.1111/j.1743-6109.2007.00430.x

Schloegl I, Köhn FM, Dinkel A, et al. Education in sexual medicine – a nationwide study among German urologists/andrologists and urology residents. 

Burgess EO. sexuality in midlife and later life couples.pdf. In: 

The Handbook of Sexuality in Close Relationships

Brody S. The relative health benefits of different sexual activities. 

. 2010. doi:10.1111/j.1743-6109.2009.01677.x

Patients and practitioners may be hesitant to delve into sexual health, but talking about it is one way to normalize it.

July 2020 | Vol 65 No 07

Introducing Dr. Millennial

AUGS Consensus Statement: Managing mesh problems

COVID-19 Pregnancy Data in the United States: July 2 Update

New study analyzes NICU utilization trends

Discussing patients' sexual concerns

Smoke evacuation in the age of COVID-19

Additional risk factors for COVID-19

A Collision of Crises

Chairman's Letter: Website overhaul, podcast & more

Telehealth codes: What you should know