By Brooke M. Faught, MSN, WHNP-BC, IF

When appropriate, many providers utilize creative methods to manage certain health problems experienced by their patients. Practitioners in the field of sexual healthcare are no exception. In this column, I offer clinical pearls for addressing a variety of challenging sexual concerns in women.

1. Recommend a vibrating penis band for partnered heterosexual women struggling with decreased arousal and orgasm during intercourse. The clitoris is typically not externally stimulated during penetrative play. As a result, many women complain about difficulty achieving orgasm during intercourse. Vibrators can be cumbersome, and they limit the use of hands during sexual activity. An elastic band with a small vibrator that sits at the base of the penis provides handsfree, external clitoral stimulation during intercourse. These penis rings—often referred to as venous constriction bands in the medical literature—have another purpose as well; they are frequently used to maintain blood flow in men with erectile dysfunction.¹
2. Prescribe a diluted hydrogen peroxide (H₂0₂) solution douche after intercourse for women with recurrent bacterial vaginosis. Although I normally advise against douching, H₂0₂ is produced by lactobacilli in the normal female ecosystem and it maintains the normal vaginal pH (3.8-4.2).²  Instruct patients to mix equal parts of distilled water and H₂0₂ to create a 50- to 100-mL solution, and administer it with traditional douche supplies or even a simple irrigation syringe.
3. In women who cannot or will not use traditional treatments for genitourinary syndrome of menopause (GSM), coconut oil and vegetable shortening are great alternatives. Keep in mind that moisturizers and lubricants provide only temporary relief of symptoms and do not target the pathophysiology of GSM.
4. Consider prescribing PDE-5 inhibitors such as sildenafil (Viagra) for women with diminished arousal and orgasm. This suggestion is especially relevant for women with sexual dysfunction related to antidepressant use.³ Although PDE-5 inhibitors do not directly increase libido in men or women, your patient may experience improved sexual receptivity, with improved arousal and/or orgasmic response.
5. Encourage scheduled sex for busy couples. Although it may not sound romantic or spontaneous, scheduling sex is, at the very least, practical, and, at the very most, a means of heightening partners’ anticipation of intimacy.
6. Destigmatize the use of sexual aids and toys. Refer to them as physical therapy for the vulva and vagina. Many women in my practice say that they have never purchased a vibrator because they associate sexual toys with promiscuity. A simple explanation of the benefits that sexual aids and toys provide can easily change this erroneous perception. I normalize sexual aids and toys by explaining that sexual arousal of any type is therapeutic for vulvovaginal tissue and pelvic floor muscles (PFMs).
7. Recommend books such as Petals and Femalia when patients inquire about “normal” female anatomy. Keep a mirror handy so that women can visualize their own anatomy during a pelvic exam (if they consent).
8. Recommend home use of G-spot vibrators for women unable to attend physical therapy (PT) sessions for PFM dysfunction. G-spot vibrators have curved tips that access tight PFMs within the vaginal canal. Many of my patients use the G-spot vibrator as a “pretreatment” for intercourse or as a PT tool on a regular basis at home. Patients should be counseled that this approach is not a replacement for PT but, rather, a secondary option when PT is unavailable because of logistic or financial limitations.
9. Encourage patients with PFM dysfunction or sexual pain to achieve orgasm before penetration. Orgasm results in the release of endorphins, adrenaline, and oxytocin, all of which promote relaxation and pain relief.⁴ Some women who have PFM dysfunction or who experience dyspareunia find relief in orgasm before attempted vaginal penetration.⁴
10. Recommend books such as Enabling Sex and even the Kama Sutra to assist women and couples with physical disabilities. Modified positions and the use of assistive devices such as supportive pillows and suspension harnesses can reduce discomfort and improve pleasure. The Sinclair Institute^® offers videos (BetterSex Video Series.) featuring real couples that cover topics such as Sex Over 40, Sex & Pregnancy, and the Kama Sutra.
11. Be careful when prescribing “arousal creams.” Many over-the-counter arousal enhancing creams contain harsh ingredients that irritate sensitive vulvovaginal tissue. I recommend compounded formulations in benign cream bases consisting of various strengths of aminophylline, arginine, sildenafil, phentolamine, and/or nitroglycerin. Remind patients to avoid oral sex after application of arousal creams.
12. Consider the female condom for women with dyspareunia. The female condom sits inside the vaginal canal throughout intercourse, which reduces friction to the vaginal walls and introitus. Also, the female condom is made of nitrile, which transmits body heat (latex does not). The transfer of body heat improves sensation and sexual pleasure.⁵
13. When fitting a woman for a pessary, consider her sexual status. Many pessaries are not conducive for self-removal on a regular basis and may not be optimal for women who engage in frequent vaginal penetrative sex play. In sexually active women, ring and Shaatz pessaries are ideal options. However, not all women are candidates for these basic shapes. On occasion, patients with more complicated pessaries come to my office for pessary removal prior to romantic vacations. They return a few days or weeks later to have the pessary replaced.
14. Suggest that patients write down their troublesome thoughts and worries on a piece of paper and place the paper outside the bedroom to help them focus on upcoming sex play. Many women tell me that they have difficulty setting aside troublesome thoughts and worries, albeit temporarily, so that they can relax and enjoy sexual encounters. One way to help them refocus on their body and on sex is to write down a to-do list and place it outside the bedroom door. Women come to realize that everything on their list can be dealt with after their intimate encounter.
15. Establish a sexual healthcare team. Identify local professionals who can collaborate with you in caring for women facing sexual health challenges. In the absence of colleagues’ personal recommendations, I suggest looking for pelvic floor physical therapists through the American Physical Therapy Association and sex therapists through the Society for Sex Therapy & Research or the American Association of Sexuality Educators, Counselors and Therapists. It’s important to get to know and trust the members of your team.

Brooke M. Faught is a nurse practitioner and the Clinical Director of the Women’s Institute for Sexual Health (WISH), A Division of Urology Associates, in Nashville, Tennessee. She is a Fellow of the International Society for the Study of Women’s Sexual Health (ISSWSH). The author states that she serves as a speaker and an advisory board member for Duchesnay, Valeant, and AMAG and as an advisory board member for Symbiomix.

References

• Albaugh JA. Addressing and managing erectile dysfunction after prostatectomy for prostate cancer. Urol Nurs. 2010;30(3):167-177.
• Borges S, Silva J, Teixeira P. The role of lactobacilli and probiotics in maintaining vaginal health. Arch Gynecol Obstet. 2014;289(3):479-489.
• Nurnberg HG, Hensley PL, Heiman JR, et al. Sildenafil treatment of women with antidepressant-associated sexual dysfunction: a randomized controlled trial. JAMA. 2008;300(4):395-404.
• Mayberry L, Daniel J. ‘Birthgasm’: a literary review of orgasm as an alternative mode of pain relief in childbirth. J Holist Nurs. 2016;34(4):331-342.
• Faught B, Goldstein I, Martens M, et al. Female condom provides a non-hormonal dual protection option for female contraception. J Womens Health. 2016;25(4):A29-A30.