Chapter 049. Sexual Dysfunction (Part 8) docx

Chapter 049. Sexual Dysfunction (Part 8) Female Sexual Dysfunction: Treatment General 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 avoiding lifestyles (e.g., smoking, alcohol abuse) and medications likely to produce FSD is important (Table 49-2). The use of topical lubricants may address complaints of dyspareunia and dryness. Contributing medications, such as antidepressants, may need to be altered, including the use of medications with less impact on sexual function, dose reduction, medication switching, or drug holidays. Hormonal Therapy In postmenopausal women, estrogen replacement therapy may be helpful in treating vaginal atrophy, decreasing coital pain, and improving clitoral sensitivity (Chap. 342). Estrogen replacement in the form of local cream is the preferred method, as it avoids systemic side effects. Androgen levels in women decline substantially before menopause. However, low levels of testosterone or DHEA are not effective predictors of a positive therapeutic outcome with androgen therapy. The widespread use of exogenous androgens is not supported by the literature except 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 disappointment given the proposed role of nitric oxide-dependent physiology in the normal female sexual response. The use of PDE-5 inhibitors for FSD should be discouraged pending proof that it is effective. Clitoral Vacuum Device In patients with arousal and orgasmic difficulties, the option of using a clitoral vacuum device may be explored. This handheld battery-operated device has a small soft plastic cup that applies a vacuum over the stimulated clitoris. This causes increased cavernosal blood flow, engorgement, and vaginal lubrication. Further Readings Araujo AB et al: Changes in sexual function in middle- aged and older men: Longitudi nal data from the Massachusetts male aging study. J Am Geriatr Soc 52:1502, 2004 [PMID: 15341552] Basson R: Recent advances in women's sexual function and dysfunction. Menopause 11:714, 2004 [PMID: 15543024] Bhasin S et al: Sexual dysfunction in men an d women with endocrine disorders. 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 Med 1:82, 2004 [PMID: 16422987] Doggrell SA: Co mparison of clinical trials with sildenafil, vardenafil, and tadalafil in erectile dysfunction. Expert Opin Pharmacother 6:75, 2005 [PMID: 15709885] Pauls RN et al: Female sexual dysfunction: principles of diagnosis and therapy. Obstet Gynecol Surv 60:196, 2005 [PMID: 16570398] Rees PM et al: Sexual function in men and women with neurological disorders. Lancet 369(9560):512, 2007 [PMID: 17292771] . Chapter 049. Sexual Dysfunction (Part 8) Female Sexual Dysfunction: Treatment General An open discussion with the patient. 15341552] Basson R: Recent advances in women's sexual function and dysfunction. Menopause 11:714, 2004 [PMID: 15543024] Bhasin S et al: Sexual dysfunction in men an d women with endocrine disorders 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 Med 1:82, 2004 [PMID: 16422987] Doggrell