Break the silence: Discussing sexual dysfunction

In a recent U.S. survey, 43% of female respondents reported being dissatisfied with their sexual functioning, a significantly higher percentage than among male respondents.¹ Even more disturbing were separate findings: 71% of adults 25 and older believed their physician would dismiss any sexual concerns they might bring up, while 68% avoided discussing sexual dysfunction with their doctors for fear of embarrassing them.²

A lack of desire for sex is the most common sexual complaint.

These statistics highlight clinicians’ inability to elicit information about and treat sexual disorders in women. Many Ob/Gyns feel they lack the necessary background in fundamental science and psychology to competently evaluate and treat sexual complaints. It is difficult to approach these problems without a complete understanding of the physiology and psychology of female sexual response.

But times are changing. The availability of sildenafil to treat male erectile dysfunction has dramatically increased our patients’ awareness of sexual disorders, as has the open discussion of sexual dissatisfaction on the talkshow circuit. Patients are increasingly likely to expect their health-care providers to evaluate and treat sexual complaints. The following pearls offer a framework for assessing sexual dysfunction, as well as guidelines for therapeutic intervention.

Raising the subject. Although women are gradually opening up about sexual dysfunction, I try not to assume that they will raise the subject themselves. A case in point: Among 308 patients taking selective serotonin reuptake inhibitors (SSRIs), 55% reported sexual dysfunction when the physician asked them about it directly compared with only 14% who reported it spontaneously.³ Many women may not realize sexual complaints are an acceptable subject of discussion for their gynecologic visit, while others may feel uncomfortable talking about sex in general.

I usually begin by asking whether the patient is sexually active and, if she is, whether sex is satisfying to her and her partner. I also ask, “Do you have any concerns about your sexual functioning?” Since this question is sufficiently broad to encompass just about any complaint, it sometimes is helpful in triggering a discussion. If the woman has significant concerns, I follow up with a thorough sexual history.

Assessing your attitudes. As an American College of Obstetricians and Gynecologists (ACOG) technical bulletin points out, the physician should be conscious of any biases he or she holds about certain sexual practices or preferences and should “learn to listen to and discuss ideas and behaviors that conflict with these biases without displaying discomfort.”⁴ When a patient first begins to talk about her sexual functioning, few things are more troubling than a harried or distracted physician. If you feel that the patient’s concerns require more attention than you are able to provide during that visit, schedule a future appointment to tackle the subject. I usually tell patients that it is too important a subject to try to address in the short time allocated to their current visit.

Exploring the history. A thorough history can make all the difference in pinpointing the underlying cause of a patient’s dysfunction.

Decreased interest in sexual activity is rarely caused by a hormonal imbalance.

I usually have my nurse take a general medical history, including medications. I then meet with the patient in my office (with her clothes on!) and focus on areas such as prior surgeries, endometriosis, prior pelvic surgery or trauma, vaginal or vulvar pain complaints, and depression. Although our intake form asks about domestic violence or a history of physical or sexual abuse, I always make it a point to ask again. Patients are often embarrassed to discuss these issues and will not divulge such sensitive information initially.

The physical exam. I perform a comprehensive physical, including a pelvic exam. This involves checking the introitus for signs of atrophy or vaginitis and palpating the Bartholin’s glands, urethra, and bladder for tenderness. Also, examine episiotomy scars for hypersensitivity and assess the patient for cervical-motion tenderness.

Then evaluate vaginal tone, looking specifically for spasm or difficulty with relaxation of the levator musculature. I want to distinguish between abdominal wall and pelvic-floor muscle tension as potential sources of pain. (The vaginal portion of the examination should be performed with a single digit and only one hand.) Finally, check for masses, and examine the posterior cul-de-sac. Depending on the findings of the examination, I may order laboratory studies or imaging.