Chapter 049. Sexual Dysfunction (Part 8)

Female Sexual Dysfunction: TreatmentGeneral An open discussion with the patient is important as couples may need to be educated about normal anatomy and physiologic responses, including role of orgasm in sexual encounters. Physiologic changes associated with aging and/or disease should be explained. Couples may need to be reminded that clitoral stimulation rather than coital intromission may be more beneficial.Behavioral modification and nonpharmacologic therapies should be a first step. Patient and partner counseling may improve communication and relationship strains. Lifestyle changes involving known risk factors can be an important part of the treatment process. Emphasis on maximizing physical health and...
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Chapter 049. Sexual Dysfunction (Part 8) Chapter 049. Sexual Dysfunction (Part 8) Female Sexual Dysfunction: Treatment General An open discussion with the patient is important as couples may need to beeducated about normal anatomy and physiologic responses, including role oforgasm in sexual encounters. Physiologic changes associated with aging and/ordisease should be explained. Couples may need to be reminded that clitoralstimulation rather than coital intromission may be more beneficial. Behavioral modification and nonpharmacologic therapies should be a firststep. Patient and partner counseling may improve communication and relationshipstrains. Lifestyle changes involving known risk factors can be an important part ofthe treatment process. Emphasis on maximizing physical health and avoidinglifestyles (e.g., smoking, alcohol abuse) and medications likely to produce FSD isimportant (Table 49-2). The use of topical lubricants may address complaints ofdyspareunia and dryness. Contributing medications, such as antidepressants, mayneed to be altered, including the use of medications with less impact on sexualfunction, dose reduction, medication switching, or drug holidays. Hormonal Therapy In postmenopausal women, estrogen replacement therapy may be helpful intreating vaginal atrophy, decreasing coital pain, and improving clitoral sensitivity(Chap. 342). Estrogen replacement in the form of local cream is the preferredmethod, as it avoids systemic side effects. Androgen levels in women declinesubstantially before menopause. However, low levels of testosterone or DHEA arenot effective predictors of a positive therapeutic outcome with androgen therapy.The widespread use of exogenous androgens is not supported by the literatureexcept in select circumstances (premature ovarian failure or menopausal states)and in secondary arousal disorders. Oral Agents The efficacy of PDE-5 inhibitors in FDS has been a marked disappointmentgiven the proposed role of nitric oxide-dependent physiology in the normal femalesexual response. The use of PDE-5 inhibitors for FSD should be discouragedpending proof that it is effective. Clitoral Vacuum Device In patients with arousal and orgasmic difficulties, the option of using aclitoral vacuum device may be explored. This handheld battery-operated devicehas a small soft plastic cup that applies a vacuum over the stimulated clitoris. Thiscauses increased cavernosal blood flow, engorgement, and vaginal lubrication. Further Readings Araujo AB et al: Changes in sexual function in middle-aged and older men:Longitudinal data from the Massachusetts male aging study. J Am Geriatr Soc52:1502, 2004 [PMID: 15341552] Basson R: Recent advances in womens sexual function and dysfunction.Menopause 11:714, 2004 [PMID: 15543024] Bhasin S et al: Sexual dysfunction in men and women with endocrinedisorders. Lancet 369(9561):597, 2007 [PMID: 17307107] Burnett AL: Erectile dysfunction. J Urol 175:S25, 2006 Davis SR et al: Endocrine aspects of female sexual dysfunction. J Sex Med1:82, 2004 [PMID: 16422987] Doggrell SA: Comparison of clinical trials with sildenafil, vardenafil, andtadalafil in erectile dysfunction. Expert Opin Pharmacother 6:75, 2005 [PMID:15709885] Pauls RN et al: Female sexual dysfunction: principles of diagnosis andtherapy. Obstet Gynecol Surv 60:196, 2005 [PMID: 16570398] Rees PM et al: Sexual function in men and women with neurologicaldisorders. Lancet 369(9560):512, 2007 [PMID: 17292771]