Guidelines for Diagnosis and Treatment of Sexual Dysfunction

continued from

The Committee on Sexual Dysfunctions in Women emphasized that assessment of psychosocial and psychosexual history is strongly recommended for all sexual dysfunctions (Basson et al., 2004a). The psychosocial history needs to establish the woman's current mood and mental health; identify the nature and duration of her current relationships, as well as societal values and beliefs impacting sexual problems; clarify the woman's developmental history as it relates to caregivers, siblings, traumas and losses; clarify circumstances, including relationship at the time of the onset of sexual problems; clarify the woman's personality factors; and clarify her partner's mood and mental health.

For women who disclose a history of past sexual abuse, further assessment was recommended (Basson et al., 2004a):

This includes assessment of the woman's recovery from the abuse (with or without past therapy), whether she has a history of recurrent depression, substance abuse, self-harm or promiscuity, if she is unable to trust people, especially those of the same gender as the perpetrator, or if she has an exaggerated need for control or need to please (and an inability to say no). The details of the abuse may be needed, especially if they were previously unaddressed. Assessment of the sexual dysfunctions per se may be deferred temporarily.

Sexual dysfunctions are often comorbid (e.g., sexual interest/desire disorder and subjective or combined sexual arousal disorder) (Bason et al., 2004a):

Occasionally women with emotionally traumatic pasts reveal that their sexual interest occurs only when emotional closeness with a partner is absent. In such cases, there is inability to sustain that interest when and if emotional intimacy with the partner develops. This is a fear of intimacy and is not strictly a sexual dysfunction.

With regard to sexual functioning, Clayton told PT the Clinical Evaluation and Management Strategies Committee looked at various instruments to assess the current level of sexual functioning. Several were found to be comprehensive and useful, including the Changes in Sexual Functioning Questionnaire (CSFQ) developed at the University of Virginia, the Derogatis Interview for sexual functioning (DISF-SR), the Female Sexual Function Index (FSFI), the Golombok-Rust Inventory of Sexual Satisfaction (GRISS), the International Index of Erectile Function (IIEF) and the Sexual Function Questionnaire (SFQ). The sexual function instruments can be used not only at the beginning stages of assessment but to follow patients through the course of treatment.

Treatment Considerations

After patients receive a comprehensive evaluation, patients (and their partners where possible) should be given a detailed description of available medical and nonmedical treatment options (Hatzichristou et al., 2004).

Rosen noted that treatment is the most advanced in the area of ED. "We have three approved drugs: sildenafil [Viagra], vardenafil [Levitra] and tadalafil [Cialis] as first-line treatment agents, along with couple's or individual therapy for treatment of ED," he said. "Effective and safe treatments are lacking for most sexual dysfunctions in women."

For psychological management of low sexual interest and comorbid arousal disorders in women, cognitive-behavioral techniques (CBT), traditional sex therapy and psychodynamic treatments are used (Basson et al., 2004a). There is limited evidence of the benefits of CBT in terms of controlled trials and some empirical support for traditional sex therapy with sensate focus. Psychodynamic treatment is currently recommended, but there are no randomized studies to support its use. For vaginismus, conventional psychotherapy has included psychoeducation and CBT. Cognitive-behavioral therapy is also used for treating anorgasmia, according to the Disorders of Orgasm in Women Committee (Meston et al., 2004):

Cognitive-behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually-relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. Behavioral exercises traditionally prescribed to induce these changes include directed masturbation, sensate focus, and systematic desensitization. Sex education, communication skills training, and Kegel exercises are also often included.

For patients with ED, oral therapies, such as selective phosphodiesterase type 5 (PDE5) inhibitors (e.g., sildenafil, vardenafil and tadalafil); apomorphine SL (sublingual), a centrally acting nonselective dopamine agonist registered in several countries since 2002; and yohimbine, a peripherally and centrally acting α-blocker, "may be considered first-line therapies for the majority of patients with ED because of potential benefits and lack of invasiveness" (Lue et al., 2004b). It should be noted, however, that PDE5 inhibitors are contraindicated in patients receiving organic nitrates and nitrate donors.

For treatment of premature ejaculation, there are three drug treatment strategies: daily treatment with serotonergic antidepressants; as-needed treatment with antidepressants; and the use of topical local anesthetics, such as lignocaine or prilocaine (McMahon et al., 2004). A meta-analysis of daily treatment with paroxetine (Paxil), clomipramine (Anafranil), sertraline (Zoloft) and fluoxetine (Prozac) found that paroxetine exerts the strongest ejaculation delay (Kara et al., 1996, as cited in McMahon et al., 2004). (See related article on premature ejaculation on p16 of the printed version of this issue--Ed.)

Administration of an antidepressant as needed four to six hours prior to intercourse is efficacious and well tolerated and associated with less ejaculatory delay. It is "unlikely that phosphodiesterase inhibitors have a significant role in the treatment of PE with the exception of men with acquired PE secondary to comorbid ED" (McMahon et al., 2004).

Clayton noted that the biggest sexual problem that women in the general population tend to have is low desire, adding that studies are underway to look for potential pharmacologic treatments.

There are no approved non-hormonal pharmacologic therapies for women with low sexual interest and arousal disorders (Basson et al., 2004a). These authors noted that the use of tibolone for postmenopausal women is promising, but the women in those two randomized clinical trials did not have sexual dysfunction. Tibolone is a steroid compound marketed in the United Kingdom; it combines oestrogenic, progestogenic and androgenic properties that mimic the action of the sex hormones. The use of bupropion (Wellbutrin) is of interest but needs further study (Basson et al., 2004a). The use of phosphodiesterase inhibitors is not recommended for low interest and comorbid arousal disorders in women. (Recently, Pfizer, Inc. reported that several large-scale, placebo-controlled studies including some 3,000 women with female sexual arousal disorder showed inconclusive results in the efficacy of sildenafil--Ed.)

While estrogen therapy may improve low interest and/or arousal disorders, low doses and the use of progesterogen to oppose estrogen's adverse effects are recommended in all women with an intact uterus (Basson et al., 2004a). More research is needed on the use of testosterone therapy.

In women with genital arousal disorder, the use of local estrogen therapy for sexual symptoms resulting from vulvovaginal atrophy is recommended. These include not only genital arousal disorder with its lack of pleasure from direct genital stimulation, vaginal dryness and dyspareunia, but also frequent urinary tract infections lowering sexual interest and arousability. However, long-term systemic estrogen therapy is not recommended because of the lack of safety versus benefit data. For genital arousal disorder unresponsive to estrogen therapy, the investigational use of phosphodiesterase inhibitors is "cautiously recommended" (Basson et al., 2004a).

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For women suffering from vulvar vestibulitis syndrome, the use of tricyclic antidepressants, venlafaxine (Effexor, Effexor SR) or anticonvulsants, such as gabapentin (Neurontin), carbamazepine (Tegretol, Carbatrol) or topiramate (Topamax), was also "cautiously recommended" (Basson et al., 2004a).

In women suffering from female orgasmic disorder, data on pharmacological approaches were noted to be scarce (Meston et al., 2004):

Placebo-controlled research is needed to examine the effectiveness of agents with demonstrated success in case series or open-label trials (i.e., bupropion, granisetron [Kytril], and sildenafil) on orgasmic function in women.

Regardless of the treatment options chosen for specific sexual dysfunctions, "follow-up is essential to ensure the best treatment outcome" (Hatzichristou et al., 2004). Important aspects of follow-up include "monitoring of adverse events, assessing satisfaction or outcome associated with a given treatment, determining whether the partner may also suffer from a sexual dysfunction, and assessing overall health and psychosocial function."

Next: Sex Therapy: Dealing with the Psychological Issues of Sex Problems

SOURCES:

Basson R, Althof S, Davis S et al. (2004a), Summary of the recommendations on sexual dysfunctions in women. Journal of Sexual Medicine 1(1):24-34.

Basson R, Leiblum S, Brotto L et al. (2003), Definitions of women's sexual dysfunction reconsidered: advocating expansion and revision. J Psychosom Obstet Gynecol 24(4):221-229.

Basson R, Leiblum S, Brotto L et al. (2004b), Revised definitions of women's sexual dysfunction. Journal of Sexual Medicine 1(1):40-48.

Hatzichristou D, Rosen RC, Broderick G et al. (2004), Clinical evaluation and management strategy for sexual dysfunction in men and women. Journal of Sexual Medicine 1(1):49-57.

Laumann EO, Paik A, Rosen RC (1999), Sexual dysfunction in the United States: prevalence and predictors. [Published erratum JAMA 281(13):1174.] JAMA 281(6):537-544 [see comment].

Lewis RW, Fugl-Meyer KS, Bosch R et al. (2004), Epidemiology/risk factors of sexual dysfunction. Journal of Sexual Medicine 1(1):35-39.

Lue TF, Basson R, Rosen R et al., eds. (2004a), Second International Consultation on Sexual Medicine: Sexual Dysfunctions in Men and Women. Paris: Health Publications.

Lue TF, Giuliano F, Montorsi F et al. (2004b), Summary of the recommendations on sexual dysfunctions in men. Journal of Sexual Medicine 1(1):6-23.

McMahon CG, Abdo C, Incrocci L et al. (2004), Disorders of orgasm and ejaculation in men. Journal of Sexual Medicine 1(1):58-65.

Meston CM, Hull E, Levin RJ, Sipski M (2004), Disorders of orgasm in women. Journal of Sexual Medicine 1(1):66-68.

Last updated: 10/04.  Last reviewed: 11/05.

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