Mary Beth Nierengarten is a freelance medical writer with over 25 years of experience. Her work appears regularly in a number of print and online publications.

Mary Beth Nierengarten, MA

	An integral part of a treatment plan for managing sexual dysfunction in women is the use of hormonal and pharmaceutical agents. For women who opt to incorporate these agents in their treatment plan, a variety of agents are available.

 Hormonal agents used to treat sexual dysfunction in women include estrogen and androgens (testosterone).

 Because these hormone levels decline as a woman ages, particularly in postmenopausal women, it is thought that replacing these hormones in the body may improve sexual functioning in women.

	However, data on use of hormones to improve sexual functioning in women is mixed. The Women’s Health Initiative found that estrogen when used systemically (taken orally) with progestin therapy did not improve sexual satisfaction in women.

Data do show, however, that estrogen therapy can be effective in improving symptoms of menopause that can interfere with a women’s otherwise healthy sex life. As such, reasonable approaches are available to using estrogen therapy for women with sexual dysfunction (Table 1).

	Less data are available on the effectiveness of testosterone to treat sexual dysfunction in women. There is some evidence suggesting that testosterone may have a positive impact on desire, arousal, and orgasmic response in postmenopausal women, but results are mixed and little long-term follow-up data are available.

 Currently, testosterone is not approved by the Food and Drug Administration (FDA) in the United States to treat female sexual dysfunction. However, testosterone is sometimes used “off-label” by clinicians to treat sexual problems in women, and current data suggest that specific testosterone preparations are most likely to achieve therapeutic levels in women (Table 2). However, it is important to inform patients of the potential side effects of testosterone therapy, particularly given that many of the testosterone formulations are too high for women and increase the likelihood that side effects will develop.

 Along with hormonal agents, other pharmacological agents that have been considered to treat sexual dysfunction in women include the phosphodiesterase (PDE-5) inhibitors commonly used for men with erectile problems (i.e., sildenafil, tadalafil, vardenafil). However, none of these agents are usually recommended based on the lack of data showing their ability to improve sexual function in women.

 The one exception is that sildenafil may have a positive effect on sexual arousal and orgasm in premenopausal women taking antidepressant medications that adversely affect their sexual functioning.

	To date, there is only one FDA approved drug to treat sexual problems in select women. Approved in 2015, flibanserin is approved for treating low desire for sex in premenopausal women in whom such a lack of desire causes distress.

However, clinicians need to let patients know that this medication can cause side effects, including low blood pressure or fainting. Other side effects may include nausea, dizziness, and headache.

	Finally, an inexpensive and effective treatment for women with vaginismus and vulvodynia is an injection of botulin into the bulbospongiosus muscles.

	1.    Finding Solutions for Female Sexual Dysfunction. American College of Obstetricians and Gynecologists. July, 2010. 

http://mail.ny.acog.org/website/FSDResourceGuide.pdf

	2.    Shifren JL. Patient Education: Sexual Problems in Women (Beyond the Basics). UpToDate. 2017. 

http://www.uptodate.com/contents/sexual-problems-in-women-beyond-the-basics?view=print

	3.    Female sexual dysfunction. Practice Bulletin No. 119. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:996-1007. 

http://journals.lww.com/greenjournal/Citation/2011/04000/Practice_Bulletin_No__119__Female_Sexual.38.aspx

Articles

An integral part of a treatment plan for managing sexual dysfunction in women is the use of hormonal and pharmaceutical agents, a variety of which are available.

Hormonal and Pharmaceutical Treatment Approaches

	Given the different types of sexual dysfunction in women caused by a host of varying physiological, psychological, and interpersonal components, treatment is anything but straightforward. It requires addressing the specific needs and wants of each patient as well as consideration of both nonpharmaceutical and pharmaceutical options.  

	To help clinicians navigate the complexity of treating female sexual dysfunction, Jan L. Shifren, MD, Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, provided a stepwise approach that ensures that all the potential issues and needs affecting a women’s sexual dysfunction are addressed prior to initiating management strategies.

 Table 1 provides a step-by-step description of this approach.

	A number of non-pharmacological options are available to women depending on their needs and preferences. Counseling patients to make lifestyle changes can help them manage stress and address relationship issues, as both stress and conflicts in relationships can significantly adversely affect sexual desire and response in women.

 Specific lifestyle changes that may help improve sexual function include healthy diet, regular exercise (including pelvic exercises like Kegels), quitting smokin, avoiding excessive consumption of alcohol, and making time for sex. To increase libido and sexual response, women should be encouraged to add novelty to their relationships through such things as sensual massage, trying different sexual positions or activities, sharing a bath, having sex at different times of the day.

 Some women may need lubricants to avoid painful or uncomfortable intercourse due to vaginal dryness.

	For some women, referral to a specialist as discussed above may be the best approach for managing specific issues (Table 2).

	Along with these nonpharmaceutical approaches, some women may benefit from various devices or procedures that can improve sexual functioning (Table 3).

A stepwise approach ensures that all the potential issues and needs affecting a women’s sexual dysfunction are addressed prior to initiating management strategies. 

Stepwise Approach to Treat Sexual Dysfunction in Women

	Female sexual dysfunction is not rare. In the United States, 44% of women are reported to experience some form of sexual dysfunction and 12% of these women report distress associated with dysfunction.

	Despite this high prevalence, many women never talk to their providers about their sexual difficulties or concerns and many providers fail to broach the topic with their patients. Unease with the topic, time restraints on the provider, and lack of training on how to discuss the subject with sensitivity and expertise, all conspire to keep women silent about sexual difficulties that can interfere, sometimes significantly, with their quality of life.

	“We know that women want their providers to bring up the topic but won’t typically ask, even if they have questions or concerns,” said Stephanie S Faubion, MD, Director, Office of Women’s Health, Mayo Clinic, Rochester, Minnesota. “Women are even concerned that they might embarrass their providers!”  For providers, Dr Faubion underscored their concern over lack of training and skills in dealing with issues of sexual dysfunction as well as the ever-present lack of time. What can providers do to improve communication with their patients about sexual difficulties they may be experiencing?

Tips for talking to women about sexual dysfunction

	“The most important thing clinicians can do is simply to ask,” emphasized Dr Faubion. “Just opening the door with a question and genuine interest gives the patient permission to discuss their concerns.”  In a recent review, Faubion and Parish provide specific tips on how to introduce the topic during office visits and the questions to ask women to screen for sexual dysfunction (Table 1).

	These questions highlight that female sexual dysfunction may involve a complex interaction of biological, psychological, sociocultural, and relationship factors, all of which need to be addressed to understand a particular woman’s difficulties (Table 2). 

	Overall, Dr Faubion emphasizes the importance of introducing sexual health as a normal issue to discuss during a routine clinical assessment and suggests introducing the topic by a statement such as “

many women in your situation (fill in the blank) experience concerns about their sexual health. What about you?”

	To strike the right tone for women to feel comfortable talking about their sexuality, she emphasizes the need for providers to approach the discussion without judgements and assumptions about sexuality and sexual actions. She also emphasized the need to assure patients of confidentiality.

	1.    Faubion SS, Parish SJ. Sexual dysfunction in women: Can we talk about it: Cleveland Clinic Journal of Medicine. 2017;84(5):367-376. 

Female sexual dysfunction is not rare. In the United States, 44% of women are reported to experience some form of sexual dysfunction and 12% of these women report distress associated with dysfunction. Despite this high prevalence, many women never talk to their providers about their sexual difficulties or concerns and many providers fail to broach the topic with their patients.

Talking to women about sexual dysfunction: Just do it!

	Despite the prevalence of female sexual dysfunction, many women never talk to their providers about it and providers often don’t take the lead in asking patients about their sexual health during a routine clinical visit. Learning strategies to better elicit such information from women is important to first understand the types of sexual dysfunction and associated distress a woman may be experiencing and then to help guide women about options to manage the particular dysfunction.

	As discussed in a separate article, simply asking patients about their sexual health and any difficulties they may be experiencing is the most important thing a provider can do to initiate effective communication on sexual dysfunction. Asking specific questions about a woman’s sexual history, experience, and emotions associated with sexual encounters in a nonjudgmental and open way provides a safe way for women to talk about an issue that can be fraught with unease.

	For particular groups of women, reluctance to talk about sexual difficulties may be enhanced by perceived societal judgements and misconceptions. Older women, for example, may feel that sexual dysfunction is a normal part of aging and so refrain from discussing it with their providers. Providers, too, may hold unrecognized misconceptions about specific populations of women and therefore not recognize the need to address potential sexual dysfunction in these women (Table).

	For all women, including these specific populations, effective communication about sexual dysfunction is essential to ensure that any sexual difficulties creating distress in women are addressed. “We are all sexual beings, and women remain sexual throughout their lives, irrespective of age, sexual orientation, gender identity, race or ethnicity,” said Stephanie S Faubion, MD, Director, Office of Women’s Health, Mayo Clinic, Rochester, Minnesota, who recently wrote an article focusing on talking about women about sexual dysfunction.

	She emphasized the need to remain nonjudgmental when asking women about their sexual health to assure patients feel comfortable sharing their concerns.

	When initiating a conversation with older women, for example, providers can place the issue of sexual health in the context of getting older by saying something like “Some studies show that as women get older, they may have less desire for sex or decreased lubrication, which makes intercourse uncomfortable. Have you noticed any changes?” 

	When talking to a non-heterosexual woman, providers should ask about sexual encounters that include penetration either by male partners or fingers/vibrators/dildos.

	Overall, Dr. Faubion emphasized that “just opening the door with a question and genuine interest gives the patient permission to discuss their concerns.”

	1.    Female sexual dysfunction. Practice Bulletin No. 119. American College of Obstetricians and Gynecologists. 

	2.    Faubion SS, Parish SJ. Sexual dysfunction in women: Can we talk about it: Cleveland Clinic Journal of Medicine. 2017;84(5):367-376. 

For particular groups of women, reluctance to talk about sexual difficulties may be enhanced by perceived societal judgements and misconceptions.

Talking about female sexual dysfunction in specific patient populations

	Despite its prevalence and adverse effect on women’s quality of life, female sexual dysfunction (FSD) is often not addressed for a myriad of reasons. Among these include reluctance on the part of women to initiate conversation about a topic that may make them uncomfortable and anxious. However, clinicians also may not be comfortable broaching the issue with patients because of insufficient training and confidence in talking about the issue, underestimating its prevalence, or for the more practical reason of not having enough time to obtain a sexual history.

	In 2011, the American College of Obstetricians and Gynecologists (ACOG) issued clinical management guidelines for gynecologists to help provide information on (FSD).

 Developed by the Committee on Practice Bulletins – Gynecology, the guidelines offer clinicians a basic understanding of normal female sexual response, criteria for diagnosing female sexual dysfunction, and current management strategies.

This article focuses on criteria for diagnosing FSD by listing and describing the types of dysfunction. As outlined in the ACOG guidelines, there are four main categories of FSD: sexual desire disorder, sexual arousal disorder, orgasmic disorder, and sexual pain disorders. Sexual dysfunction is diagnosed when symptoms of these types of sexual dysfunction cause marked distress in women or create interpersonal difficulties.

	A description of each category, along with estimated prevalence, is listed in Table 1.

	As indicated in Table 1, psychosocial (trauma, sexual abuse) and medical conditions as well as use of specific medications often accompany and are associated with female sexual dysfunction making a thorough assessment critical to understanding what underlies the symptoms of sexual dysfunction. In addition, women may have more than one type of sexual dysfunction.

	As such, the authors of the guidelines emphasize the importance of identifying the primary type of dysfunction. They state, “Because more than one female sexual dysfunction may exist in the same patient, it is important that the clinician determine which is the primary female sexual dysfunction and how comorbid female sexual dysfunctions evolved over time.”

	1. Female sexual dysfunction. Practice Bulletin No. 119. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:996-1007.

	2. Boardman LA, Stockdale CK. Sexual pain. Clin Obstet Gynecol 2009;52:682-90.

Despite its prevalence and adverse effect on women’s quality of life, female sexual dysfunction is often not addressed for a myriad of reasons. 

Types of Female Sexual Dysfunction

ACOG conference attendees who want a glimpse of current and trending issues in the specialty will want to attend the session “Cutting Edge Topics in Ob-Gyn” on Monday, May 8 at 1 pm in the Convention Center Ballroom 6C.

As in past years, the session offers overviews by various academic societies in different subspecialties that highlight evolving and emerging evidence of interest to practicing clinicians. Chesney Thompson, MD, professor of obstetrics and gynecology at the University of Colorado School of Medicine, will moderate presentations by:

·      Alfred Abuhamad, MD, President

Society for Maternal-Fetal Medicine (SMFM)

·      Lee A Learman, MD, PhD, President

Society for Academic Specialists in General Obstetrics and Gynecology (SASGOG)

The Kathryn M and Thomas F Purdon, MD, Generalist Session

·      Ricard J Paulson, MD, President

American Society for Reproductive Medicine (ASRM)

Reproductive Endocrinology & Infertility Session

·      Halina Zyczynski, MD, President

Research and emerging evidence related to counselling patients about ovarian reserve testing and about uterine transplantation, and the advantages and disadvantages of pre-implantation genetic screening of embryos will be the focus of the ASRM segment. Among the emerging evidence Dr Paulson will describe are data published in 2014 showing that letrozole is more effective than clomid as treatment for infertility in women with polycystic ovary syndrome (POS) and data on preimplantation genetic testing that provides evidence on when it is potentially useful, when it is unnecessary, and in whom it is not worthwhile. Worldwide and US experience with uterus transplantation and the challenges and risks to the donor also will be discussed.


Representing the perspective of academic specialists, Dr Learman will talk about 10 research findings in 4 main areas of research: contraception, evaluation of abnormal uterine bleeding, the impact of several treatments on sexual functioning, and surgical alternatives, including a discussion of comparative outcomes of different contraception methods. During the SASGOG segment, emerging data on Bartholin’s management and vasopressin concentration for myomectomy, and comparative long-term outcomes of uterine artery embolization (UEA) versus hysterectomy, and laparoscopic hysterectomy (LH) plus morcellation versus abdominal hysterectomy AH) will be discussed.

, Dr Learman emphasized that the session’s goal is to provide the presidents of the organizations with the opportunity to highlight evolving and cutting-edge information most pertinent to the specialty and specialists in ob/gyn.

“The task of each organization is to convey what is most timely and important, what research is in progress, what research is on the horizon, and what new findings and issues have emerged in the past year to inform practice,” he said.

ACOG conference attendees who want a glimpse of current and trending issues in the specialty will want to attend the session “Cutting Edge Topics in Ob-Gyn." The session offers overviews by various academic societies in different subspecialties that highlight evolving and emerging evidence of interest to practicing clinicians.