Female Sexual Dysfunction: Evaluation and Treatment - Brief Article

American Family Physician,  July 1, 2000  by Nancy A. Phillips

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Table 5

Psychosocial Factors
of Female Sexual Dysfunction
Intrapersonal conflicts
Religious taboos, social restrictions,
 sexual identity conflicts, guilt (i.e., widow with new partner)
Historical factors
Past or current abuse (sexual, verbal, physical),
 rape, sexual inexperience
Interpersonal conflicts
Relationship conflicts; extra-marital affairs;
 current physical, verbal or sexual abuse; sexual libido; desire or
 practices different from partner; poor sexual communication
Life stressors
Financial, family or job problems, family illness or death, depression
Table 6

Basic Treatment Strategies for Female Sexual Dysfunction

Provide education
Provide information and education (e.g., about normal anatomy, sexual
 function, normal changes of aging, pregnancy, menopause).
 Provide booklets, encourage reading; discuss sexual issues
 when a medical condition is diagnosed, a new medication is started,
 and during pre- and postoperative periods; give permission for sexual
 experimentation.
Enhance stimulation and eliminate routine
Encourage use of erotic materials (videos, books); suggest
 masturbation to maximize familiarity with pleasurable
 sensations; encourage communication during sexual activity;
 recommend use of vibrators[*]; discuss varying positions,
 times of day or places; suggest making a "date" for sexual activity.
Provide distraction techniques[]
Encourage erotic or nonerotic fantasy; recommend pelvic
 muscle contraction and relaxation (similar to Kegel exercise)
 exercises with intercourse; recommend use of background music,
 videos or television.
Encourage noncoital behaviors[]
Recommend sensual massage, sensate-focus exercises (sensual
 massage with no involvement of sexual areas, where one
 partner provides the massage and the receiving partner
 provides feedback as to what feels good; aimed to promote
 comfort and communication between partners); oral or noncoital
 stimulation, with or without orgasm.
Minimize dyspareunia
Superficial: female astride for control of penetration,
 topical lidocaine, warm baths before intercourse, biofeedback.
Vaginal: same as for superficial dyspareunia but with the
 addition of lubricants.
Deep: position changes so that force is away from pain and deep
 thrusts are minimized, nonsteroidal anti-inflammatory
 drugs before intercourse.

NOTE: For a review, see Striar S, Bartlik B. Stimulation of the
libido: the use of erotica in sex therapy. Psych Annals
1999;29:60-2.

[*]--Provide information for obtaining one discreetly.

[]--Helpful in eliminating anxiety, increasing relaxation
and diminishing spectatoring.

[]--Also helpful if partner has erectile dysfunction.
TABLE 7
Testosterone Therapy for Treatment of Disorders of Desire[*]

Screening
Baseline testosterone levels[] (free and total),
 baseline lipid profile, baseline liver enzyme levels,
 mammography, Papanicolaou smear
Initiate therapy[]
Combination product (Estratest or Estratest hs)
Methyltestosterone (Android), 1.25 to 2.5 mg daily
Micronized oral testosterone, 5 mg twice daily
Testosterone proprionate 2 percent in petroleum applied
 daily to every other day
Testosterone injectables/pellets
Reevaluation at three to four months
Repeat testosterone levels, lipid profile, liver enzyme levels
Monitor symptoms, side effects
Continued therapy
Taper to lowest effective dosage
Monitor lipid levels, liver enzyme levels once or twice yearly
Routine Papanicolaou smear and mammography schedules

[*]--These are recommendations; no evidence-based protocols are
available on testosterone therapy for the treatment of
women with desire disorders.

[]--Many authors recommend that total levels remain in
"normal" range for premenopausal women.

[]--None of these medications are labeled by the U.S. Food and Drug
Administration for treatment of desire disorders.

[para]--Alternate daily combined with estrogen-only pill,
take testosterone pill every other day, 5 days a week, etc. (not
shown in studies to be safer or have fewer side effects).
TABLE 8
Kegel Exercises

Potential uses
Increased pubococcygeal tone
Improved orgasmic intensity
Correction of orgasmic urine leakage
Distraction technique during intercourse
Improved patient awareness of sexual response
Teaching Kegel exercises
Instructional examination with examiner's finger
 in vagina
Initial patient home exercise with patient's finger
 in vagina
Slow count to 10, with movement directed "in
 and up"
Hold for count of 3
Slow release to count of 10
Repeat 10 to 15 times daily
Consider vaginal weights, biofeedback clinics
Maintaining Kegel exercises
Advise repetitions during routine activities
 (standing in line, at stop lights, etc.)
Schedule follow-up appointments to discuss progress
TABLE 9

Female Sexual Dysfunction: When to Refer

Longstanding dysfunction
Multiple dysfunctions
Current or past abuse
Psychologic disorder or acute psychologic event
Unknown etiology
No response to therapy