Sexual Health and How to Recognize a Problem

Written by on December 31, 2012 in Features - No comments

Interview with Sheryl A. Kingsberg, PhD. by Philip Driver regarding the issue of sexual health and why it is important to clinicians. 

If you don’t think your patients are having sexual problems, you are not asking.  There are high instances of sexual dysfunction in women, especially those going through menopause.  About 43% report having problems and about 11% have a diagnosed condition.  Patients tend to be hesitant to bring these issues up, and they often don’t know where to turn. A good place to start is with  their primary care provider or their GYN, but in reality, patients should discuss their problem with whichever HCP they are comfortable with and discuss their issues at a minimum on a yearly basis.  Patients want you, the provider, to open the door. Make sure your patients know you are willing to talk about their issues and try to put them at ease.  There are many ways to make your patient more comfortable when discussing their sexual problems, such as placing literature in the waiting room and informing your patients through your web site that you treat sexual related problems.  Doctors can have links to informational web sites like menopause.org, which has a whole module on sexuality and menopause, and ARHP.org .

It is importantto assure your patient that their sexual problems are treatable and they are not alone.  Hopefully this will normalize their problem.  If the issue is beyond your expertise, it is still very helpful to simply acknowledge your patient’s right to her sexual health and to normalize her sexual concerns.  From there it is helpful to have a network set up so you can make an informed referral.  Often general practitioners don’t know where to send patients. They can refer to North American Menopause Society (NAMS) and menopause.org or www.ISSWSH.org (Find a Practitioner section) which can help practitioners become more comfortable with diagnosing women’s sexual health.

Doctors should not assume that  younger women in their 30’s and 40’s do not have sexual problems—the prevalence is still over 10% regardless of age However menopause is a time when problems can develop or be exacerbatedEstrogen deficiency has a significant impact on vulvovaginal tissue and many women and many HCPS don’t realize that vulvo-vagina atrophy (VVA) is a common disorder, affecting 25-50% of postmenpausal women, which needs to be addressed.

There are several female sexual disorders including hypoactive sexual desire disorder (HSDD), female orgasmic disorder and arousal disorder. The most prevalent sexual disorder is HSDD but you should also be aware that 25% of women will experience some form of vulvovaginal pain in their lives and this is particularly true in postmenopausal women. As noted before, 25-50% of postmenopausal women have VVA and yet many have never discussed this with their HCPS and only 7% are currently being treated with prescription therapyOver time, postmenopausal women may not have hot flashes anymore, but VVAcan occur years after menopause is over and progresses with time.

The treatment for VVA Typically follows a 3 tiered approach

-  If a woman is experiencing pain during sex (dyspareunia) that is due primarily to dryness, you may advise that she try using a water based lubricant during sex; it won’t reduce atrophy (which causes a change in the tissue that becomes thinner) but it will  help with the dryness induced pain

-  Long acting moisturizers can help with Ph balance and dryness, but often won’t be enough to resolve atrophy

-  Local estrogen in the form a tablet, cream or longacting ring can be applied which improves vaginal cytomorphology and reduces atrophic vaginal symptoms of dyspareunia, vaginal itching and dryness.

Although it is a normal function of menopause that atrophy occurs without estrogen, it is preventable and treatable. While local estrogens are generally safe since they don’t create a systemic absorption, women are often fearful of taking a hormone. Often cancer survivors are candidates for local estrogen therapy, and the HCP and the woman should talk with oncologists with that in mind. It should not automatically be ruled out.

Women often don’t have enough knowledge about the changes that occur during menopause and the vaginal changes that take place. Women may be embarrassed to even bring the topic up with HCPs.  The REVEALsurvey (revealsurvey.com), a market research survey sponsored by Pfizer, asked 1000 postmenopausal women questions about their beliefs about menopause, aging and society’s perceptions and confirmed that they are uncomfortable to talk about vulvovaginal symptoms of menopause or don’t know that they are symptoms so don’t ask.

Essential questions to include in a sexual assessment are:
  • Are there problems in desire, arousal , orgasm or is she experiencing dyspareunia and can the patient determine the primary problem?
  • How does the patient see/describe the problem?
  • How long has the problem been present (also specify if life-long or occurred after a period of normal function)?
  • Was the onset sudden or gradual?
  • Is the problem specific to a situation/partner or is it generalized?
  • Where there likely precipitating events (biologic or situational)?
  • Are there problems in the patient’s primary sexual relationship (or any relationship in which the sexual problem is occurring)?
  • Are there current life stressors that might be contributing to sexual problems and if so how are they perceived and managed?
  • Is there a history of physical, emotional or sexual abuse that may be contributing?
  • Does the partner have any sexual problems?

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