Clinical Review
2016 Update on fertility
Too many women and men around the world are affected by infertility. Unfortunately, access to assisted reproduction therapies (ART) when necessary...
In general, patients are comfortable speaking about sexual function and health. Having this talk can help identify a pattern, which can be discussed further during another visit. Such a follow-up would not take long—a level 3 visit should suffice.
Differential diagnosis. Consider the effects of current medications.8,9 The psychiatric illnesses and general health factors that may affect sexual function should be considered as well (FIGURE 2).10–22
When is it important to refer?
There are many reasons to refer a patient to another physician, including:
- a recommended treatment is not working
- abuse is suspected
- the patient shows symptoms of depression, anxiety, or another psychiatric condition
- a chronic, generalized (vs situational) disorder may be involved
- physical pain issues must be addressed
- you simply do not feel comfortable with a particular problem or patient.
Given the range of potential issues associated with sexual function, it is important to be able to provide the patient with expert assistance from a multidisciplinary team of specialists. This team can include psychologists, psychiatrists, counselors, sex educators, and, for pain issues, pelvic floor specialists and pelvic floor physical therapists. These colleagues are thoroughly familiar with the kinds of issues that can arise, and can offer alternative and adjunctive therapies.
Referrals also can be made for the latest nonpharmacologic and FDA-approved pharmacologic treatment options. Specialists tend to be familiar with these options, some of which are available only recently.
It is important to ask patients about sexual function and, if necessary, give them access to the best treatment options.
CASE Resolved
During the sexual status examination, your patient describes her most recent sexual encounter with her husband. She is frustrated with her lack of sexual response and describes a dry, tearing sensation during intercourse. You recommend first-line treatment with vaginal lubricants, preferably iso-osmolar aqueous− or silicone/dimethicone−based lubricants during intercourse. You also can discuss topical estrogen therapy via estradiol cream, conjugated equine estrogen cream, estradiol tablets in the vagina, or the estrogen ring. She is reassured that topical estrogen use will not pose significant risk for cancer, stroke, heart disease, or blood clot and that progesterone treatment is not necessary.
For patients who are particularly concerned about vaginal estrogen use, 2 or 3 times weekly use of a vaginal moisturizer could be an alternative for genitourinary symptoms and dyspareunia.
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