Chad P. Hubsher, MD
■ Adam Luchey, MD
■ Stanley Zaslau, MD, MBA, FACS
■ Introduction
■ As previously discussed, female sexual dysfunction is a highly prevalent problem, with approximately 40% of women experiencing sexual complaints.
■ However, few women volunteer a history of sexual dissatisfaction and, therefore, information needs to be actively elicited.
■ Evaluation involves an open discussion with the patient, followed by a thorough physical exam and laboratory testing.
■ Assessment of female sexual dysfunction can be used for both the purpose of diagnosis as well as measuring changes in specific parameters over time.
■ Due to its multifactorial etiology, the ability to accurately and reliably assess sexual complaints in women is a difficult task for any health professional. A significant amount of time should be allocated for patient evaluation.
■ Patient History
■ As female patients are unlikely to volunteer their history of sexual dysfunction to their medical providers, it is necessary to obtain a thorough medical history that includes medical, surgical, obstetric, gynecologic, psychiatric, and sexual information.
■ Medical History
■ All concurrent medical disorders must be delineated.
■ According to Sipski and colleagues, neurological diseases such as diabetes, multiple sclerosis, and spinal cord injuries can affect sexual function by impairing both arousal and orgasm.1
■ Also, cardiovascular disease has been linked to female arousal disorder as a result of atherosclerosis of the vessels supplying the vagina and clitoris, as described by Berman and associates.2
Medications
■ Several medications have been shown to impact libido, arousal, and orgasm. These include contraceptive agents, antihypertensive medications, antidepressive agents, antipsychotics, and anti-epileptic drugs.
■ It is important to obtain a complete list of all medications the patient is taking as a simple switch of medication, for example from a selective serotonin reuptake inhibitor to a norepinephrine and dopamine reuptake inhibitor such as bupropion, may quickly alleviate the sexual complaints.
■ Surgical History
■ Previous surgery that a patient has undergone, and the surgical details, may provide clues to the etiology of sexual dysfunction.
• For example, a history of pelvic injury or trauma, as is seen with motor vehicle collisions, may be an important etiology for diminished sensation, or even pain.
■ As described by Weber and colleagues,3 certain surgical repairs, such as Burch bladder suspension with posterior colporrhaphy, may be associated with increased rates of dyspareunia postoperatively.
■ Additionally, Vassallo and Karram have shown that vaginal stenosis may result from levatorplasty at the time of posterior colporrhaphy or aggressive trimming of the vaginal mucosa at the time of colporrhaphy, and, in turn, result in dyspareunia or apareunia.4
■ Patients are often unaware of the exact procedure performed or details of their surgery, and thus medical records, such as an operative report, should be obtained to gain further insight into the procedure and any complications that may have occurred during the surgery.
■ Obstetric and Gynecologic History
■ Gynecologic conditions such as infections, endometriosis, fibroids, prolapse, and incontinence are common causes of female sexual dysfunction and should be addressed whenever possible.
■ Additionally, it is important to discuss:
• Menopausal status
• Abnormal genital tract bleeding
• Past episodes of urinary or fecal incontinence
• Any incidence of vulvovaginal pruritis
• Dryness, discharge, or pain
• A complete pregnancy history
■ Obstetric history, specifically detailing any previous cesarean or vaginal deliveries, including tears or episiotomy, may outline sites for potential denervation or dyspareunia.
■ Additionally, removal of the ovaries may lead to sexual dysfunction secondary to estrogen or androgen depletion.
■ Psychiatric History
■ It is imperative to discuss and explore any current or past psychiatric diseases, such as depression or anxiety, as these are part of the differential diagnosis of sexual dysfunction.
■ Additionally, addiction disorders, including the use of cigarettes, alcohol, and/or illicit drugs, are important to discuss when discerning a cause of female sexual dysfunction.
■ Finally, the patient should be screened for previous visits to a therapist. Although influential events in a patient’s life, such as sexual assault or trauma, may not warrant a medical diagnosis, they still may serve as a potential contributor to sexual dysfunction.
■ Sexual History
■ In addition to discussing basic gynecologic health, safe sex practices, and contraception, all women should be asked open-ended questions describing any sexual concerns they may have.
■ If the patient indicates sexual concerns, then a comprehensive history should be obtained.
■ At this time, the practitioner can ease patient anxiety by explaining that sexual history is part of a normal history and physical examination for all patients.
■ It is important that assessment of sexual function take place in a private setting in which confidentiality is assured. It is imperative that the physician not make any assumptions, such as gender of sexual partner or that the patient’s sexual behavior is limited to the identified partner or spouse.
■ Patients rarely volunteer information concerning sexual dysfunction and, thus, it is key to identify the essential components of a sexual complaint.
• Table 9.1 lists questions devised by Basson that help to:
■ Elicit the patient’s perception of the problem
■ Determine the problem’s time line
■ Discern current health problems that might be affecting sexual function
■ Identify which components of the sexual response cycle may be compromised5
■ Furthermore, sexuality questionnaires may delineate the source of the problem by asking questions that address libido, arousal, orgasm, pain, and relationship factors.
Sexuality Questionnaires
■ Female sexual dysfunction diagnosis currently relies on a nonstandardized expert interview, as sexual function involves behaviors and psychological factors that are not amenable to direct observation.
■ Two basic modes exist for the initial assessment of sexual function, clinician interviews and self-report through the use of questionnaires or diaries.
■ Sexuality questionnaires play an integral role in the diagnosis and treatment of sexual dysfunction in today’s office setting.
Table 9.1 Essential Questions to Include in a Sexual Assessment
- How does the patient describe the problem?
- How long has the problem been present?
- Was the onset sudden or gradual?
- Is the problem specific to a situation/partner or is it generalized?
- Were there likely precipitating events (biologic or situational)?
- Are there problems in the woman'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?
- Is there guilt, depression, or anger that is not being directly acknowledged?
- Are there physical problems such as pain?
- Are there problems in desire, arousal, or orgasm?
- Is there a history of physical, emotional, or sexual abuse?
- Does the partner have any sexual problems?
Source: Adapted from Basson R. Taking the sexual history: part 1: eliciting the sexual concerns of your patient in primary care. Med Aspects Hum Sex. 2000;11:91-93.
■ According to Althof and Symonds, they may be used to:
• Identify/diagnose individuals with a particular dysfunction
• Assess the severity of the dysfunction
• Measure improvement of satisfaction with treatment
• Examine the impact of the dysfunction on the individual’s quality of life (e.g., relationship satisfaction, mood, sexual confidence)
• Study the impact of the dysfunction on the partner and his or her quality of life6
■ Since 1980, several brief assessment questionnaires that are specific to or inclusive of female sexual dysfunction have been introduced and are suitable for office-based use, including:
I. The Golombok Rust Inventory of Sexual Satisfaction (GRISS; 1987), created by Rust and Golombok, is a 28-item questionnaire that pertains to five domains specific to women, including vaginismus, anorgas- mia, female avoidance, female nonsensuality, and female dissatisfaction.7
II. The Brief Index of Sexual Functioning for Women (BISF-W; 1994), created by Taylor, Rosen, and Leiblum, is a 22-item questionnaire that assesses female arousal, thoughts and desires, frequency of sexual activity, receptivity/initiation, pleasure/orgasm, relationship satisfaction, and problems that affect sexual function.8 The index was subsequently revised by Mazer and colleagues to include a new scoring algorithm that provides composite scores and domain scores.9
III. The Sexual Desire Inventory (SDI; 1996) is a 14- item questionnaire that was developed by Spector, Carey, and Steinberg.10 Its intent is to measure dyadic sexual desire and solitary sexual desire.
IV. The Derogatis Interview for Sexual Functioning (DISF/DISF-SRl; 1997) is a 25-item gender-keyed questionnaire that is suitable for both men and women.11 It includes a total score as well as assesses five domains: cognition, arousal, behavior, orgasm, and drive or relationship.
V. The Female Sexual Function Index (FSFI; 2000) is a 19-item questionnaire specific to women that was devised by Rosen and colleagues and is frequently used to evaluate female sexual dysfunction.12 It comprises six domains: desire, subjective arousal, lubrication, orgasm, satisfaction, and pain.
VI. The Menopausal Sexual Interest Questionnaire (MSIQ; 2004), developed by Rosen and associates, is a 10-item questionnaire that is specifically designed for use in menopausal women and contains three domains of sexual function: desire, responsiveness, and satisfaction.13
■ In addition to providing information about the source of the sexual dysfunction, the results of sexuality questionnaires provide baseline scores that can be compared to later scores following intervention.
■ Of the above-mentioned questionnaires, the Female Sexual Function Index (FSFI) (Appendix 1) is the most frequently used in office settings to evaluate female sexual dysfunction. The 19-item questionnaire is designed to measure sexual function over the past four weeks in each of the six aforementioned areas.
• Since its development in 2000, the FSFI has undergone further psychometric tests that have confirmed its reliability and validity. One such test, performed by Meston, validated the FSFI in terms of the DSM-IV diagnoses of orgasmic disorder and hypoactive desire disorder.14
• The FSFI is frequently used in clinical trials and is becoming the gold standard for the evaluation of women with sexual problems due to the fact that it is easy to use, relatively short, and considered reliable and valid.
• A recent study by Wiegel and colleagues suggested that subjects scoring 26 or lower on the total FSFI score should be considered at risk for sexual dysfunction and should be further evaluated.15
■ Physical Examination
■ Attention during the physical exam should be initially directed at the external genitalia, including the clitoris, labia, and vestibular glands.
• Upon inspection, signs of atrophy or infection may be noted, in addition to episiotomy scars or previous surgical incision sites, which should be examined as they may be areas of tenderness on account of vaginal narrowing, scarring, or nerve entrapment.
■ The pelvic floor should also be examined. The strength of the pelvic muscles can be graded based on degree of contraction during the pelvic examination.
• Any evidence of prolapse (cystocele and/or rectocele) or disorders of the pelvic floor needs further evaluation.
■ Additionally, neurological screening should be performed to assess sensation in the female genitalia.
■ If the patient mentions or complains of pain, it is important to try to reproduce this complaint.
• As described by Pauls, pain mapping may be achieved using a cotton swab on the vestibule.16
• While the labia are held apart, the vestibule, vulva, hymen, and minor vestibular glands are touched gently with the swab.
• Any elicited tenderness or erythema may suggest vulvar vestibulitis, which may require treatment.
■ A digital internal examination should be performed to assess the levator muscles for spasms and pelvic organs for any masses or tenderness. Upon digital examination, the presence of vaginismus may also be noted as an involuntary contraction of the outer third of the vagina.
■ Laboratory Tests
■ If hormonal deficiency is suspected, laboratory studies may be performed.
■ Estradiol, follicle-stimulating hormone, and luteniz- ing hormone may be obtained if menopausal state is uncertain.
■ Dehydroepiandrosterone, together with its sulfate ester (DHEA-S), may be measured to reflect adrenal androgen secretion, and can indicate an adrenal insufficiency.
■ Thyroid-stimulating hormone may identify a thyroid dysfunction.
■ Androgen production may be assessed by obtaining levels of total and free testosterone, total testosterone and sex hormone-binding globulin, or free testosterone and sex hormone-binding globulin.
• As described by Guay, androgen measurements are highest in the morning and in the middle third of the menstrual cycle, approximately days 8 through 18, and, if possible, should be measured at this time.17
■ In addition to the above-mentioned laboratory tests, a complete blood count, liver function tests, and lipid profile may be helpful in managing the patients, especially if it is anticipated that medication may be used to treat the sexual dysfunction.
■ Special Tests
■ Although useful for study purposes, specialized diagnostic testing such as duplex Doppler ultrasonography, vaginal pH measurements, and vaginal/clitoral sensory perception thresholds are not essential to evaluate and diagnose female patients with sexual dysfunction. Furthermore, these special tests are not widely available and often require expensive equipment.
■ Conclusions
■ Medical professionals must actively question women who report sexual dysfunction, as this is a topic that is not often voluntarily discussed by the patient.
■ Evaluation involves:
• A discussion using open-ended questions to determine the patient’s perception of the sexual problem
• A detailed patient history, including medical, surgical, psychiatric, and obstetric and gynecologic histories
• Administration of sexuality questionnaires to help delineate the source of the problem
• A thorough physical exam and laboratory tests to assess the genitalia and measure the levels of various hormones in the blood, respectively.
■ Upon completion of the evaluation, the patient should return for discussion to the physician’s office without her partner.
■ Using the American Foundation of Urologic Disease classification system, as described by Basson and colleagues at the international consensus development conference on female sexual dysfunction, the patient should be classified as falling into one or more categories, i.e., desire, arousal, orgasm, or pain disorders.18
• It is important to ascertain the most distressing symptom, as patient complaints often overlap.
■ Once the sexual complaints are classified and evaluated by the physician, therapeutic options can begin to be addressed.
■ References
1. Sipski ML, Alexander CJ, Rosen RC. Sexual response in women with spinal cord injuries: implications for our understanding of the able-bodied. J Sex Marital Ther. 1999;25:11-22.
2. Berman JB, Berman L, Goldstein I. Female sexual dysfunction: incidence, pathophysiology, evaluation and treatment options. Urology. 1999;54:385-391.
3. Weber AM, Walters MD, Piedmonte MR. Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol. 2000;182:1610-1615.
4. Vassallo BJ, Karram MM. Management of iatrogenic vaginal constriction. Obstet Gynecol. 2003;101:512-520.
5. Basson R. Taking the sexual history: part 1: eliciting the sexual concerns of your patient in primary care. Med Aspects Hum Sex. 2000;11:91-95.
6. Althof SE, Symonds T. Patient reported outcomes used in the assessment of premature ejaculation. Urol Clin North Am. 2007;34:581-589.
7. Rust J, Golombok S. The GRISS: a psychometric instrument for the assessment of sexual dysfunction. Arch Sex Behav. 1986;15:157-165.
8. Taylor JF, Rosen RC, Leiblum SR. Self-report assessment of female sexual function: psychometric evaluation of the Brief Index for Sexual Functioning for Women. Arch Sex Behav. 1994;23:627-643.
9. Mazer NA, Leiblum SR, Rosen RC. The brief index of sexual functioning for women (BISF-W): a new scoring algorithm and comparison of normative and surgically menopausal populations. Menopause. 2000;7:350-363.
10. Spector IP, Carey MP, Steinberg L. The sexual desire inventory: development, factor structure, and evidence of reliability. J Sex Marital Ther. 1996;22:175-190.
11. Derogatis LR. The Derogatis Interview for Sexual Functioning (DISF/DISF-SR): an introductory report. J Sex Marital Ther. 1997;23:291-304.
12. Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26:191-208.
13. Rosen RC, Lobo RA, Block BA, Yang H-M, Zipfel LM. Menopausal Sexual Interest Questionnaire (MSIQ): a unidimensional scale for the assessment of sexual interest in postmenopausal women. J Sex Marital Ther. 2004;30(1):235-250.
14. Meston CM. Validation of the Female Sexual Function Index (FSFI) in women with female orgasmic disorder and in women with hypoactive sexual desire disorder. J Sex Marital Ther. 2003;29:39-46.
15. Wiegel M, Meston C, Rosen R. The Female Sexual Function Index (FSFI): cross-validation and development of clinical cutoff scores. J Sex Marital Ther. 2005;31:1-20.
16. Pauls RN, Kleeman SD, Karram MM. Female sexual dysfunction: principles of diagnosis and therapy. Obstet Gynecol Surv. 2005;60:196-205.
17. Guay AT. Screening for androgen deficiency in women: methodological and interpretative issues. Fertil Steril. 2002;77:S83-88.
18. Basson R, Berman J, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol. 2000;163:888-893.