Our expert is Anita H. Clayton, MD, David C. Wilson Professor and Chair, Department of Psychiatry and Neurobehavioral Sciences, Professor of Clinical Obstetrics & Gynecology University of Virginia.
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SEXUAL DYSFUNCTION IS COMMON
Forty-four percent of women have a sexual complaint, with 32% experiencing a lack of desire, 27% not experiencing orgasm, and 21% having pain during sex. Although 44% have a sexual complaint, not all of these women feel distressed about their sexual problem or problems. In the cases where dysfunction isn’t causing distress, it doesn’t meet the criteria for a sexual disorder and generally doesn’t need an intervention. However, when sexual dysfunction is a problem and isn’t treated, it’s associated with decreased quality of life, depression, and interpersonal conflicts.
IT’S CRITICAL FOR THE PROVIDER TO INDICATE THAT IT’S OK TO TALK ABOUT SEXUAL DYSFUNCTION
Primary care providers can help, but only if they know there’s a problem. An obstacle to good communication is that a woman may assume that she’s the only one struggling with a sexual problem. When she has no idea how common her problem is, or how treatable it can be, she may be reluctant to bring it up. Her provider can and should bring up the topic the same way we ask a woman about other lifestyle areas such as smoking, drinking, and diet.
CONSIDER THE MANY POSSIBLE CAUSES OF SEXUAL DYSFUNCTION
With a sexual complaint, the provider should take a comprehensive history, looking for medical, psychological, and emotional factors that may be causing the sexual dysfunction. In addition, consider interpersonal relationship issues and sociocultural factors. A detailed sexual history is key to evaluating a woman’s sexual issues. In addition, a thorough physical exam may include an assessment for vulvovaginal conditions and the condition of the pelvic floor.
THE PRIMARY CARE PROVIDER CAN PROVIDE PRACTICAL INFORMATION
Sometimes simple, practical information can be a solution. For example, a woman is uneasy about having sex because the kids might come into her bedroom at the wrong moment. The answer? “Get a lock on your bedroom door.” Or maybe she’s one of the many women who are unaware that lubricants are easily available and may relieve her vaginal dryness during sexual activity. She may need to hear that that many women use lubricants, and that in effect, she “has permission” to use them.
HORMONAL BIRTH CONTROL CAN INFLUENCE SEXUAL FUNCTION
A common and easily treatable etiology of low desire is hormonal birth control. A woman using hormonal contraceptives may experience a loss of desire if her birth control method significantly decreases her bioavailable testosterone. In the setting of diminished sexual desire, measurement of sex hormone binding globulin (SHBG) and total testosterone, to generate the free testosterone level is appropriate and may suggest the need to change to another kind of contraception to improve her sexual interest.
SHE MAY BENEFIT FROM A MULTIDISCIPLINARY APPROACH
She may benefit from a specialist or a combination of specialists. These may include a medical provider with expertise in sexual health, a sex therapist, or a physical therapist with expertise in pelvic floor disorders. It’s also important to involve her partner.
PHARMACOLOGICAL TREATMENTS ARE AVAILABLE TO THOSE WHO DO NOT RESPOND TO NON-PHARMACOLOGICAL APPROACHES.
Vaginal dryness can be treated with commercially available lubricants. Low dose vaginal estrogen therapy can improve symptoms of vaginal atrophy and dryness, dyspareunia, and urinary frequency and urgency. Flibanserin can also prove helpful for hypoactive sexual desire disorder; fifty percent of women who use it have a significant clinical response including increased sexual desire, decreased associated distress and an increased number of satisfying sexual events. Without flibanserin, women might average 5 sexual events a month, while enjoying only one-half of them (2.5/month). In premenopausal women responding to flibanserin, the average number of sexual events increases, with mean satisfying sexual events increasing to 7.5 times a month.
The most common side effects of flibanserin are nausea, dizziness, and sedation, which are well-tolerated and managed by dosing at bedtime. One concern with flibanserin is the danger of hypotension or syncope when excessive amounts of alcohol are consumed. For this reason, the FDA has required that women who are using flibanserin be instructed not to drink during the time they are on the drug. My own belief is that this restriction is unnecessarily broad. In the 6-month flibanserin registration trials, 60% of the women were social or moderate alcohol users, yet only 0.5% of women on flibanserin had episodes of hypotension or syncope. Women on placebo experienced these symptoms at almost the identical rate of 0.3%. This is far lower than the rate of hypotension/syncope in the general population. Additional studies on alcohol use have been required by the FDA, and may better articulate appropriate use of alcohol in women taking flibanserin.