Tag Archives: sexual health

Focus on sexual health | Bacterial vaginosis: Impact of sexual activity, implications for sexual health

Brooke Professional 2011
Brooke M. Faught

Bacterial vaginosis (BV) is the most prevalent vaginal infection. Although BV is not classified as a sexually transmitted infection, it is considered a sexually associated infection. As such, it may be possible to reduce the chance of developing it or at least reduce the rate of recurrences. Both acute and recurrent BV can have a direct impact on a woman’s perceptions about her body and her sexual health, which can then have an adverse effect on her sexual activities and quality of life. What can healthcare providers do to help?

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Exploring the feasibility of HPV self-collected sampling

According to the American Cancer Society, about 13,170 new cases of invasive cervical cancer are expected to be diagnosed in the United States in 2019, and 4,250 cervical cancer-related deaths are expected to occur.1 More than 99% of cervical cancers develop as a result of persistent infection with high-risk HPV (hrHPV) strains.2 The succession from HPV infection to cancer follows a predictable sequence: transmission, persistence, progression to cell dysplasia and pre-cancer, and invasion.3,4 Cervical cancer virtually never develops without positive hrHPV status, specifically HPV 16, 18, or other high-risk strains.2,4 Most cervical cancers and related deaths occur in women who have not been adequately screened, followed up, or treated for the disease.4

A growing body of evidence supports the feasibility of hrHPV testing as a primary cervical cancer screening (CCS) method for some women.4,5 In 2014, the FDA approved one HPV test for primary CCS.5 In 2015, the Society of Gynecologic Oncology and the American Society of Colposcopy and Cervical Pathology issued an interim guide for healthcare providers (HCPs) who choose to use HPV testing for primary CCS.5 In August 2018, the United States Preventive Services Task Force released new CCS recommendations: The use of hrHPV testing every 5 years for women aged 30-65 was added while retaining the other screening options of cervical cytology alone every 3 years or co-testing (cervical cytology and hrHPV testing) every 5 years.6 Recommendations from the American College of Obstetricians and Gynecologists do not currently include this new option.7

Is self-collected HPV sampling a feasible option for CCS?

Self-collected HPV sampling kits used in clinical studies consist of a Q-tip or brush with an outer shell similar to a tampon that is self-inserted into the vagina. This outer shell prevents sampling from the vulva and lower vagina and limits vaginal contaminants. After the brush is rotated internally, the entire device is withdrawn, and the end of the inner brush is placed in a transport medium to be sent to a laboratory.8 Women have proved to be competent in self-collected sampling.9-15 Studies have shown similar sensitivity in detecting hrHPV when samples are self-collected versus HCP-collected.8,10,11,16

Self-collected HPV testing offers the potential to reach women who lack access to care or who do not seek CCS because of embarrassment, discomfort with the procedure, or past experiences of discrimination in the healthcare setting.12,15,17-19 However, several factors must be considered to determine the feasibility of self-collected HPV sampling as an option for CCS.

Will women utilize self-collected HPV testing?

Overall, studies have indicated that women are satisfied with the experience of self-collected HPV testing. Rates of return of self-collected samples in these studies have varied because of the use of different methods to engage participants and the use of different comparators.

Investigators of a study conducted in rural Canada recruited 818 women from family practice clinics who were overdue for CCS.20 The women were randomized to receive (1) a self-collected HPV kit mailed to their home (n = 335), (2) a mailed reminder to make a Pap test appointment (n = 335), or (3) standard-of-care opportunistic screening (n = 152). Of the 335 women who received a self-collected HPV kit, 70 (21%) self-sampled and returned the kit. In the other two groups, 37 (11%) of the 331 women who received a reminder letter scheduled and underwent a Pap test and 13 (8.5%) of the 152 women in the control group underwent CCS. Among the 70 women in the group who self-sampled and returned the kit, 56 (80%) reported that they would be very likely to choose self-collected sampling in the future.

A study in the Mississippi Delta area focused on women who had not had CCS for at least 3 years.9 Community health workers went door to door offering women the choice of a free Pap test voucher or a self-collected HPV kit. A total of 119 women participated in the study, with 77 (64.7%) choosing self-collection kits and 42 (35.3%) choosing a Pap test voucher. Of the women who chose the kits, 62 (80.5%) returned the samples; of those who chose the Pap test vouchers 17 (40.5%) completed screening.

In a study conducted in Minnesota, researchers investigated the feasibility of recruiting women via advertising on a social networking site to promote the use of HPV self-collection kits, as well as to survey them about their perceptions of self-collection.13 Women were offered the opportunity to participate in self-collection and complete an online survey or to just complete the online survey. A total of 197 women were enrolled, with 67 agreeing to participate in both the self-collection and survey and 130 completing the survey only. Of the 67 women who were sent kits, 62 (92.5%) returned them for testing. Most women who self-collected a sample reported favorable perceptions about self-collection, including ease of sampling (87.1%), absence of pain during sampling (72.6 %), and privacy (85%). Women who returned the sample and completed the survey received a $50 gift card as compensation.

A community outreach approach was used to evaluate the feasibility and acceptability of self-collection HPV testing among Hopi women residing on a reservation in Arizona.15 Flyers and informational brochures about the self-collected HPV test were posted in public places, handed out face to face at community events, and distributed door to door during a health education campaign. The flyer was also circulated by email, published in tribal newsletters, and aired as a public service announcement on the tribal radio station. Among 353 participants, 329 (93.2%) returned a self-collection kit. Satisfaction with self-sampling was high; 96% reported sampling was easy, 87% reported no discomfort, and 62% reported that they preferred self-sampling to receiving a Pap test from an HCP. Reasons for preferring self-sampling were privacy, reduction in embarrassment, and convenience. As with the study conducted in Minnesota,13 women who returned their sample received a gift card.15

Although no CCS was done, a qualitative study used focus groups to ascertain 25 women’s perceptions about self-collected HPV testing; these women all resided in a rural community in Ontario, Canada.21 After attending a brief information session on self-collected HPV testing, the women were asked for their initial perceptions. Perceived advantages of self-collected HPV testing included convenience, privacy, and ease of self-sampling. In addition, the women thought that self-sampling would eliminate the embarrassment and discomfort associated with having an HCP obtain the sample. Perceived disadvantages involved concerns about the reliability of the test and confidence in one’s ability to self-collect properly. The women expressed a need for more information about HPV testing and self-collection before they would feel comfortable and confident in using self-sampling. Barriers that self-sampling could not address included (1) a lack of awareness about the importance of screening in the prevention and early detection of cervical cancer and (2) a fear of cancer.

These studies and several others have demonstrated that women are willing and capable of using self-collected HPV testing. Most women in the studies who completed such testing reported ease of use and satisfaction with the method, and liked aspects such as privacy, decreased embarrassment, and convenience.

Beyond the sampling: Which issues still need to be resolved?

Return rates for self-collected kits in these studies ranged from 21% to 93.2%. Compensation with a gift card likely helped achieve high sample return rates. The intensive multi-component community awareness strategy, along with the gift card, achieved the highest return rate (the one achieved in the Hopi women study). This approach is labor intensive and incurs costs, but it may be needed to ensure participation in this type of screening.

Systems to ensure that women receive their test results and have access to follow-up for abnormal findings is important. Women may have increased access to CCS with self-collected HPV testing, but if they must surmount financial, geographic, or other barriers to deal with abnormal results, then self-testing does not have much benefit. In addition, not all barriers to screening can be resolved with self-collected HPV testing. Women who are not aware of the benefits of CCS for prevention and early detection of cancer are not likely to seek screening via any method.

What are the implications for practice?

Primary HPV testing has growing support as an acceptable CCS option for some women; self-collected HPV tests are an option worth exploring for women who struggle with access to care and other barriers. The opportunity to improve CCS rates among hard-to-reach populations is promising. The future for self-collected HPV testing depends on acceptance of primary HPV testing for CCS, continued awareness campaigns, development of strategies to achieve good self-collected sample kit return rates, and availability of resources for follow-up and treatment when needed.

The June 2018 National Association of Nurse Practitioners in Women’s Health (NPWH) Position Statement: Cervical Cancer ScreeningA provides several recommendations for HCPs who provide care for women aged 21 years or older.22 HCPs should identify those subpopulations in the community they serve who are at risk for not undergoing regular CCS and follow-up and advocate for culturally appropriate outreach. Regardless of CCS method used, HCPs should educate women about the importance of screening, use effective reminder and follow-up systems, and establish resources for referral and treatment. If self-collected HPV testing is utilized in the future, it will provide HCPs with one more tool to reach women and to decrease cervical cancer morbidity and mortality rates.

Lauren M. Tom is a family nurse practitioner with Parkview Gynecologic Oncology and Deborah Baresic is a women’s health nurse practitioner at Purdue University Fort Wayne and Clinical Assistant Professor and Director of the Lafayette Street Family Health Clinic, all in Fort Wayne, Indiana. This article was written as part of a capstone project at Purdue University Fort Wayne. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

Selected references

1. American Cancer Society. Key Statistics for Cervical Cancer. 2019. cancer.org/cancer/cervical-cancer/about/key-statistics.html

2. Bosch FX, Robles C, Díaz M, et al. HPV-FASTER: broadening the scope for prevention of HPV-related cancer. Nat Rev Clin Oncol. 2016;13(2):119-132.

3. Kessler TA. Cervical cancer: prevention and early detection. Sem Oncol Nurs. 2017;33(2):172-183.

4. Melnikow J, Henderson JT, Burda BU, et al. Screening for Cervical Cancer with High-Risk Human Papillomavirus Testing: A Systematic Evidence Review for the US Preventive Services Task Force. Evidence Synthesis No. 158. Rockville, MD: Agency for Healthcare Research and Quality; 2018.

5. Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing for cervical cancer: interim clinical guidance. Gynecol Oncol. 2015;136(2):178-182.

6. U.S. Preventive Services Task Force. Final Recommendation Statement: Cervical Cancer: Screening. August 2018. www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening2

7. American College of Obstetricians and Gynecologists. Practice Bulletin #168: Cervical Cancer Screening and Prevention. Obstet Gynecol. 2016:128(4):e111-e130.

8. Castle PE, Gage JC, Partridge EE, et al. Human papillomavirus genotypes detected in clinician-collected and self-collected specimens from women living in the Mississippi Delta. BMC Infect Dis. 2013:13(5) 1-7.

9. Castle PE, Rausa A, Walls T, et al. Comparative community outreach to increase cervical cancer screening in the Mississippi Delta. Prev Med. 2011;52(6):452-455.

10. Des Marais A, Zhao Y, Hobbs M, et al. Home self-collection by mail to test for human papillomavirus and sexually transmitted infections. Obstet Gynecol. 2018;132(6):1412- 1420.

11. Kobetz E, Seay J, Amofah A, et al. Mailed HPV self-sampling for cervical cancer screening among underserved minority women: study protocol for a randomized controlled trial. Trials. 2017;18(1):19.

12. Madzima TR, Vahabi M, Lofters A. Emerging role of HPV self-sampling in cervical cancer screening for hardto- reach women: focused literature review. Can Fam Physician. 2017;63(8):597-601.

13. Nelson E, Hughes J, Oakes J, et al. Human papillomavirus infection in women who submit self-collected vaginal swabs after internet recruitment. J Community Health. 2015;40(3):379-386.

14. Racey CS, Gesink DC, Burchell AN, et al. Randomized intervention of self-collected sampling for human papillomavirus testing in under-screened rural women: uptake of screening and acceptability. J Womens Health. 2016;25(5):489-497.

15. Winer RL, Gonzales AA, Noonan CJ, et al. Assessing acceptability of self-sampling kits, prevalence, and risk factors for human papillomavirus infection in American Indian women. J Community Health. 2016;41(5):1049-1061.

16. Porras C, Hildesheim A, González P, et al. Performance of self-collected cervical samples in screening for future precancer using human papillomavirus DNA testing. J Natl Cancer Inst. 2014;107(1):400.

17. Garcia C, Lothamer H, Mitchell EM. Provider-identified barriers to cervical cancer screening and perceptions toward self-collection of human papillomavirus in Southwest Virginia. Public Health Nurs. 2016;33(6):539-546.

18. Shoenberg NE, Studts CR, Hatcher-Keller J, et al. Patterns and determinants of breast and cervical cancer non-screening among Appalachian women. Women Health. 2013;53(6):552-571.

19. Waterman L, Voss J. HPV, cervical cancer risks, and barriers to care for lesbian women. Nurse Pract. 2015;40(1):46-54.

20. Racey CS, Gesink DC, Burchell AN, et al. Randomized intervention of self-collected sampling for human papillomavirus testing in under-screened rural women; uptake of screening and acceptability. J Womens Health (Larchmt). 2016;25(5):489-497.

21. Racey CS, Gesink DC. Barriers and facilitators to cervical cancer screening among women in rural Ontario, Canada: the role of self-collected HPV testing. J Rural Health. 2016;32(2):136-145.

22. National Association of Nurse Practitioners in Women’s Health. Position statement: cervical cancer screening. Womens Healthcare. 2018;6(2):13-17.

Making the diagnosis: Vaginal infections

Most women experience at least one vaginal infection characterized by vaginal discharge, itching, and/or odor during their lives. In women who present with these vaginal symptoms, the three most common conditions are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. In some cases, more than one vaginal infection is present. A problem-focused history, physical examination, and laboratory evaluation are necessary for accurate diagnosis. The author describes characteristic findings for these vaginal infections and discusses currently available diagnostic tests.

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Female cosmetic genital surgery: In search of the perfect vulva

The United States leads all other countries in the number of female cosmetic genital surgeries (FCGSs) performed each year despite limited evidence of their relevance, safety, and effi cacy. In February 2018, the Cosmetic Surgery Committee of the International Society for the Study of Vulvovaginal Disease (ISSVD) released a report on this topic. Even more recently, the FDA issued a warning about the use of energy-based treatments for vaginal rejuvenation. This column highlights recommendations from the ISSVD report on FCGS, and offers a clinical perspective from a board-certifi ed plastic surgeon. Continue reading »

Pessary use for pelvic organ prolapse in sexually active women

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

Pelvic organ prolapse (POP), a common condition in women, increases in prevalence with advancing age. Treatment for POP may include pelvic floor exercises, surgery, and/or use of pessaries. Pessaries offer women a nonsurgical, cost-effective, low risk option for treating symptomatic prolapse. This column focuses on what healthcare providers need to know when caring for sexually active women with POP who choose to use a pessary. Continue reading »

Implementation of the HSDD process of care into clinical practice

Distressing low sexual desire is the most common sexual complaint among women in the United States. Despite the prevalence of this condition and others like it, many healthcare providers find the diagnosis and treatment of female sexual disorders elusive. In late 2016, a team of sexual health experts from the International Society for the Study of Women’s Sexual Health met to develop a process of care (POC) to streamline the management of women with hypoactive sexual desire disorder (HSDD). In April 2018, Mayo Clinic Proceedings published the HSDD POC, which is summarized here. Continue reading »

Persistent genital arousal disorder: The uninvited guest (Part 2)

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

Healthcare providers (HCPs) need to understand a patient’s experience of a health condition in order to provide effective care in a holistic manner. This recommendation is especially important in cases of elusive health conditions that may be unfamiliar to most patients and even to some HCPs. In Part 1 of this two-part series, readers learned that persistent genital arousal disorder (PGAD) involves unwanted, unwarranted, persistent symptoms of genital arousal that frequently border on pain. In many cases, these symptoms are debilitating. In part 2 of this series, two women share their personal experiences with PGAD. Two additional accounts of PGAD are available. Continue reading »

Persistent genital arousal disorder: The uninvited guest (Part 1)

Persistent genital arousal disorder (PGAD) is a per- plexing and elusive health condition of unknown prevalence. Until recently, little was known about its etiology or amenability to treatment. However, re- cent advances in sexual medicine research provide a better understanding of PGAD, enhancing health- care providers’ ability to properly diagnose and manage it. In part 1 of this two-part series, diagno- sis and management of PGAD are discussed; in part 2, the focus is on the patient experience of PGAD.

Medical models of sexual response represent arousal as a desirable and pleasurable experience.1-3 In some women, however, genital arousal occurs in the absence of sexual interest or desire. First described in the literature by Leiblum and Nathan,4 persistent genital arousal disorder (PGAD), previously referred to as persistent genital arousal syndrome, is manifested by intrusive and unwanted symptoms such as persistent genital arousal, vulvar congestion, discomfort, and even pain.5 In such cases, orgasm provides little or only short-lived relief. Markos and Dinsmore6 liken the presentation of PGAD to that of vulvodynia. Of note, although cases of male PGAD have been reported as well,7 this article focuses on female PGAD.

Many healthcare providers (HCPs) are unaware of the existence of PGAD, leaving many women who have this condition without a timely diagnosis or treatment. Even if some HCPs are aware of PGAD, their patients may hesitate to mention their symptoms because the condition is so highly stigmatized. In fact, approximately 25% of women with PGAD wait more than 10 years to report symptoms to their HCP or they never report their symptoms.8

Prevalence and etiology

Little is known about PGAD prevalence. Most research on PGAD is in the form of case studies or surveys of limited populations.9,10 PGAD is likely under-reported because of patient embarrassment and fear of being labeled as hypersexual.11 A survey of a sexual health practice in the United Kingdom identified a PGAD prevalence of approximately 1% with all the diagnostic characteristics of the condition, although 33% of participants reported at least one identifying characteristic of PGAD.12 PGAD appears to affect women of all ages.4 A recent survey of more than 100 women with PGAD indicated an age range of 18-79 years (mean age, 47 years).10

No consensus exists regarding the etiology of PGAD, although it is thought that symptoms may arise as a result of dysregulation at central and peripheral levels.11 In addition, psychological conditions and external factors such as diet and pharmacologic agents may elicit symptoms of persistent arousal.11 Antidepressant use is cited as a trigger in 20% of women with PGAD.13 Vascular anomalies of the pelvis and compression of the pudendal nerve, as with Tarlov cysts, may play a role in some cases.14-16

Diagnosis

Women vary in terms of the presentation and experience of PGAD (Box).9 Because women may hesitate to disclose information about PGAD, HCPs should consider asking those presenting for annual checkups about whether they experience any genital pain, discomfort, persistent arousal, numbness, tingling, or throbbing.13,17 If PGAD is suspected, HCPs should review the patient’s health history, with a focus on potential co-morbidities and past/ current medication use, supplement use, and illicit drug use. Diet and exercise are important factors when assessing for PGAD.17 In addition, women should be asked about past and current sexual practices and partner(s), as well as a possible history of sexual abuse or trauma.

A comprehensive vulvovaginal and pelvic examination, including a neurologic and musculoskeletal assessment, can identify or exclude overt structural defects. In some cases, laboratory testing (e.g., thyroid panel, prolactin level, testosterone panel) and imaging studies (e.g., pelvic ultrasonography, magnetic resonance imaging) may provide useful diagnostic information.15 Women with PGAD should be screened for symptoms of restless leg syndrome (RLS) and overactive bladder (OAB). If symptoms of RLS and/or OAB co-exist with those of PGAD, a diagnosis of restless genital syndrome should be considered.5,18

Treatment

No medications are currently indicated specifically for the treatment of PGAD. All pharmacologic interventions for PGAD discussed in this article are investigational. Of note, HCPs should address potentially reversible causes of PGAD before pursuing further intervention.4 As with many complex and poorly understood health conditions, the treatment for PGAD necessitates an interdisciplinary approach, with consideration of all potential biopsychosocial causes.4 Further supporting the multifactorial causation of PGAD is the fact that clitoridectomy does not appear to benefit patient outcomes.19

Dysregulation of sensory excitation remains the focus of pharmacologic intervention for PGAD.20 Off-label use of medications such as selective serotonin reuptake inhibitors, varenicline, zolpidem, and tramadol appears to reduce PGAD symptoms in some cases, although further research is needed.17,20 Of interest, withdrawal from the aforementioned medications has been implicated in the onset of PGAD.17 Surgical correction of Tarlov cysts may effectively treat PGAD, whereas periclitoral injections of botulinum toxin do not appear to improve symptoms long term.14,16,21 Electroconvulsive therapy may ameliorate PGAD symptoms in patients with co-morbid bipolar disorder.22

Recommendations

Persistent genital arousal disorder is a legitimate health condition that warrants increased HCP awareness.10 Although PGAD is often represented in a comedic light, it is no laughing matter to women who carry the daily burden of the embarrassing and debilitating symptoms that accompany it. Women with PGAD report insensitive comments from their HCPs such as “You should be a porn star” or “Your symptoms are every husband’s dream.”10 Comments from a trusted HCP that embarrass, insult, or ridicule an already vulnerable woman can have devastating consequences. Compared with the general population, patients with PGAD have a two-fold increase in suicidal ideation.13 Care of patients with PGAD begins by providing a safe and nonjudgmental atmosphere in which to facilitate an open and honest discussion. If PGAD is suspected, HCPs can consider referral to a sexual medicine provider or visit the International Society for the Study of Women’s Sexual Health (ISSWSH) website for more resources.

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 an ISSWSH Fellow. The author states that she serves as a speaker and advisory board member for Shionogi and Valeant and an advisory board member for the Female Health Company.

References

  1. Masters WH, Johnson VE. Human Sexual Response. Boston, MA: Little Brown; 1966.
  2. Kaplan HS. The New Sex Therapy. New York, NY: Brunner/Mazel; 1974.
  3. Basson R. Using a different model for female sexual response to address women’s problematic low sexual desire. J Sex Marital Ther. 2001;27(5):395-403.
  4. Leiblum SR, Nathan SG. Persistent sexual arousal syndrome: a newly discovered pattern of female sexuality. J Sex Marital Ther. 2001;27(4):365-380.
  5. Waldinger MD, Schweitzer DH. Persistent genital arousal disorder in 18 Dutch women: part II. A syndrome clustered with restless legs and overactive bladder. J Sex Med. 2009;6(2):482-487.
  6. Markos AR, Dinsmore W. Persistent genital arousal and restless genitalia: sexual dysfunction or subtype of vulvodynia? Int J STD AIDS. 2013;24(11):852-858.
  7. Waldinger MD, Venema PL, van Gils AP, et al. Stronger evidence for small fiber sensory neuropathy in restless genital syndrome: two case reports in males. J Sex Med. 2011;8(1):325-330.
  8. Jackowich R, Pink L, Gordon A, Pukall C. Prevalence of persistent genital arousal disorder criteria in a sample of Canadian undergraduate students. Poster session presented at: Annual Meeting of the International Society for the Study of Women’s Sexual Health; February 23-26, 2017; Atlanta, GA.
  9. Parish S, Goldstein A, Goldstein S, et al. Toward a more evidence-based nosology and nomenclature for female sexual dysfunction-part II. J Sex Med. 2016;13(12):1888-1906.
  10. Jackowich R, Pink L, Gordon A, Pukall C. Health care experiences of women with symptoms of persistent genital arousal. Poster session presented at: Annual Meeting of the International Society for the Study of Women’s Sexual Health; February 23-26, 2017; Atlanta, GA.
  11. Jackowich R, Pink L, Gordon A, Pukall C. Persistent genital arousal disorder: a review of its conceptualizations, potential origins, impact and treatment. Sex Med Rev. 2016;4(4);329-342.
  12. Garvey LJ, West C, Latch N, et al. Report of spontaneous and persistent genital arousal in women attending a sexual health clinic. Int J STD AIDS. 2009;20(8):519-521.
  13. Pukall CF, Jackowich R. Persistent genital arousal disorder: when is pain assessment relevant? Presented at: International Society for the Study of Women’s Sexual Health Annual Meeting. February 23-26, 2017; Atlanta, GA.
  14. Komisaruk BR, Lee HJ. Prevalence of sacral spinal (Tarlov) cysts in persistent genital arousal disorder. J Sex Med. 2012;9(8):2047-2056.
  15. Pink L, Rancourt V, Gordon A. Persistent genital arousal disorder in women with pelvic and genital pain. J Obstet Gynaecol Can. 2014;36(4):324-330.
  16. Feigenbaum F, Boone K. Persistent genital arousal disorder caused by spinal meningeal cysts in the sacrum. Obstet Gynecol. 2015;126(4):839-843.
  17. Facelle TM, Sadeghi-Nejad H, Goldmeier D. Persistent genital arousal disorder: characterization, etiology, and management. J Sex Med. 2013;10(2):439-450.
  18. Aquino CC, Mestre T, Lang AE. Restless genital syndrome in Parkinson disease. JAMA Neurol. 2014;71(12):1559-1561.
  19. Waldinger MD, Venema PL, van Gils AP, et al. Restless genital syndrome before and after clitoridectomy for spontaneous orgasms: a case report. J Sex Med. 2010;7(2 pt 2):1029-1034.
  20. Pfaus JG. Persistent genital arousal disorder-fact or fiction? J Sex Med. 2017;14(3):318-319.
  21. Rubin R, Winter A, Minton J, et al. Peri-clitoral botulinum toxin as a treatment for persistent genital arousal disorder (PGAD). Poster session presented: Annual Meeting of the International Society for the Study of Women’s Sexual Health. February 23-26, 2017; Atlanta, GA.
  22. Yero SA, McKinney T, Petrides G, et al. Successful use of electroconvulsive therapy in 2 cases of persistent sexual arousal syndrome and bipolar disorder. J ECT. 2006;22(4):274-275.

Sexuality in the aging population: Statement of the problem

This column is the first part of a 2-part series.

The aging process can compromise sexual functioning in both women and men. Many older persons deal with this situation by terminating sexual activity—perhaps because they are unaware of various therapeutic approaches that are available. If patients address this problem, they can find themselves enjoying sex as much now as they did in the past. Some patients even report experiencing an improvement in sexual functioning. When caring for older patients, then, healthcare providers should recognize sexuality as an important component of their overall health, diagnose sexual dysfunction if it exists, and either treat the condition or refer patients to specialists as needed.

According to a survey conducted by AARP in 2009, among 1,670 individuals aged 45 years or older, 77.4% of women and 67% of men reported having sexual intercourse infrequently: once or twice a month, less than once a month, or not at all. Table 1 shows this and other similar findings from the AARP survey.1 Although fairly large proportions of female and male respondents in the survey did not engage in sexual activities very often, 58% reported believing that sex is critical to a good relationship. Therefore, many midlife and older adults may not be experiencing the sex lives they want to have, but they have little recourse. Either they do not broach the topic with their healthcare providers (HCPs) or their HCPs are not as well informed as they might be about identifying sexual dissatisfaction or dysfunction in their patients or managing these situations.2

For example, Maes and Louis3 conducted a study to identify the sexual history-taking practices of 500 U.S. nurse practitioners (NPs) with regard to patients aged 50 years or older. Only 2% of the NPs reported always conducting a sexual history and 23.4% reported never or seldom doing so. The biggest barrier to sexual history taking was lack of time. Other barriers included interruptions, limited communication skills, embarrassment, and feeling that taking such a history in older patients was inappropriate. A study of general practitioners in Great Britain revealed that many of them did not discuss sexual health matters with older patients because they thought that these matters were of “legitimate” interest only to younger patients.From the perspective of midlife or older patients, many of them do not discuss sexual problems with their HCP because they do not feel their problems are serious or sufficiently bothersome.5 Many older patients, already assumed to be invisible and post-sexual by society, may be even less likely than their younger counterparts to approach their HCPs with sexual problems and concerns—even though research suggests that these patients often hope that their HCPs will approach them in this regard.6

Sexual dysfunction in older patients

In 1998, sildenafil (Viagra®) hit the market, initiating a sexual revolution. Advertisements for this product— and for two similar prescription products approved in subsequent years—targeted over-50 males, leaving similarly aged women “in the dust.” Desire, arousal, and orgasmic dysfunctions in the older female population remained without an FDA-approved treatment option. Although history was made in August 2015 when the FDA approved the firstever medication for hypoactive sexual desire disorder, this medication is indicated only for premenopausal women. With the exception of two medications used to treat dyspareunia related to menopausal changes, conjugated estrogens cream (Premarin® Vaginal Cream) and ospemifene oral tablets (Osphena®), sexual complaints in older women must be addressed with off-label options.7

Sexual interest/arousal disorders

A telephone survey of 1,491 U.S. adults aged 40-80 years showed that a lack of sexual interest (33.2%) and lubrication difficulties (21.5%) were the most common female sexual problems and early ejaculation (26.2%) and erectile difficulties (22.5%) were the most common male sexual problems.5 Fewer than 25% of these adults with a sexual problem had sought help for their problem from an HCP. A study of 3,005 female and male interviewees aged 57-85 years showed that as women got older, a larger proportion became unable to achieve orgasm.8 Table 2 shows the prevalence of sexual problems in the preceding year among sexually active female participants in this study.8

Genito-pelvic pain/penetration disorder

According to the aforementioned telephone survey, 12.7% of women aged 40-80 years reported pain with sex.5 Causes of dyspareunia in older women can include vulvovaginal atrophy (VVA), disuse atrophy, pelvic floor dysfunction, vaginal anatomic changes related to surgery such as vaginal hysterectomy, and vulvovaginal skin conditions and infections.7 

Menopause is accompanied by a significant drop in circulating estrogen levels, which adversely affects the maturation of vaginal epithelial cells, resulting in VVA.9 Subsequently, a shift in the vaginal ecosystem occurs, allowing overgrowth of pathogenic organisms.10 Nearly half of all postmenopausal women experience VVA symptoms, including burning with urination, dyspareunia, bleeding with intercourse, vaginal discharge, and vulvovaginal soreness, itching, and burning—all of which warrant regular screening in this population.9-13 Genital pain often results in avoidance of sexual encounters and/or involuntary tensing of pelvic floor muscles in response to anticipated pain. As a result, disuse atrophy and high-tone pelvic floor dysfunction are commonly seen in postmenopausal women.7

Sexually transmitted infections

Most sexually active individuals contract a sexually transmitted infection (STI) at some point in their lives.14 Midlife and older individuals who are engaging in sex are not immune. However, HCPs may be less likely to inquire about or test for STIs in older individuals, who may also be hesitant to discuss STI symptoms with their HCP. The most common risky behaviors in persons aged 50 or older include sexual contact with MSM (men who have sex with men), intravenous drug use, and receipt of blood products,although all sexually active individuals are at risk for STIs. Undiagnosed and untreated STIs can have longterm sequelae such as chronic pain, cancer, heart damage, blindness, and, in severe cases, death.

A British study showed that, over a 7-year period, the number of STI cases more than doubled in persons aged 45 years or older.15 Rates of chlamydia, genital herpes, genital warts, gonorrhea, and syphilis all increased. Genital warts and genital herpes were identified as the most common STIs, and persons aged 55-59 years were the most likely to be affected. In the U.S., trichomoniasis is most prevalent in women older than 40 years, whereas chlamydia and gonorrhea have the lowest prevalence in this age category.16

Conclusion

Statistics show that most people of any age are, or want to be, sexually active. HCPs should never assume that a given person, based on her or his age, appearance, or presence of a disability, does not engage in sexual activity or does not wish to do so. Regardless of a person’s age, HCPs should take a sexual history during healthcare encounters, and they should offer counseling, treatment, or referrals in appropriate cases of sexual dysfunction or disease.

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. The author states that she serves as a speaker and advisory board member for Shionogi and Actavis and as an advisory board member for Valeant.

References

1. Fisher LL. Sex, Romance, and Relationships: AARP Survey of Midlife and Older Adults. April 2010.

2. Shindel AW, Parish SJ. Sexuality education in North American medical schools: current status and future directions. J Sex Med. 2013;10(1):3-17.

3. Maes CA, Louis M. Nurse practitioners’ sexual history-taking practices with adults 50 and older. J Nurse Pract. 2011;7(3):216-222.

4. Gott M, Hinchliff S, Galena E. General practitioner attitudes to discussing sexual health issues with older people. Soc Sci Med. 2004;58(11):2093-2103.

5. Laumann EO, Glasser DB, Neves RC, Moreira ED Jr; GSSAB Investigators’ Group. A population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America. Int J Impot Res. 2009;21(3):171-178.

6. Kleinplatz PJ. Sexuality and older people. BMJ. 2008;337:a239.

7. Moore A, Arthur R, Hull A, Faught B, Glass C. Sexual health issues in the aging population. In: Cash JC, Glass CA, eds. Adult-Gerontology Practice Guidelines. New York, NY: Springer Publishing Co.; 2016:516-535.

8. Laumann EO, Waite LJ. Sexual dysfunction among older adults: prevalence and risk factors from a nationally representative U.S. probability sample of men and women 57-85 years of age. J Sex Med. 2008;5(10):2300-2311.

9. Sturdee DW, Panay N; International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13(6):509-522.

10. Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15(1):36-44.

11. Tan O, Bradshaw K, Carr BR. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review. Menopause. 2012;19(1):109-117.

12. The North American Menopause Society. The 2012 hormone therapy position statement of: The North American Menopause Society. Menopause. 2012;19(3):257-271.

13. Kingsberg SA, Krychman ML. Resistance and barriers to local estrogen therapy in women with atrophic vaginitis. J Sex Med. 2013;10(6):1567-1574.

14. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: prevalence estimates, 2008. Sex Transm Dis. 2013;40(3):187-193.

15. Bodley-Tickell, AT, Olowokure B, Bhaduri S, et al. Trends in sexually transmitted infections (other than HIV) in older people: analysis of data from an enhanced surveillance system. Sex Transm Infect. 2008;84(4):312-317.

16. Ginocchio CC, Chapin K, Smith JS, et al. Prevalence of Trichomonas vaginalis and coinfection with Chlamydia trachomatis and Neisseria gonorrhoeae in the United States as determined by the Aptima Trichomonas vaginalis Nucleic Acid Amplification Assay. J Clin Microbiol. 2012;50(8):2601-2608.

Dyspareunia for a dozen years in a young woman

A 30-year-old woman named CL presents to the office as a new patient. Her health history is notable for dysmenorrhea; irritable bowel syndrome (IBS), diarrhea dominant; and dyspareunia since the onset of sexual activity at age 18. CL has never been pregnant.

CL tells the nurse practitioner (NP) that her dysmenorrhea has been well managed since age 15 with combination oral contraceptives (COCs) and an occasional NSAID on day 1 of her period. She does not take any medication for her IBS, and she avoids foods that might cause bouts of diarrhea. CL tells the NP she is seeking relief of the pain she experiences during sex, which has worsened over the past 6 months and which she fears might ruin her current relationship. She tearfully tells the NP that three prior relationships ended badly because she was unable to have comfortable, enjoyable sex. Although she said she was able to tolerate sexual touching and intercourse in the past, her symptoms have been gradually getting worse.

She goes on to tell the NP that she has been dating her current partner for 6 months and that they have had sex 3 times, which caused great discomfort. She says she tried various over-the-counter (OTC) lubricants and different positions, to no avail. Although CL says she enjoys cuddling and kissing with her partner, she has been avoiding this type of contact for the past 2 months because of fear that it would lead to intercourse. At the same time, she wants to enjoy intercourse and please her partner.

What else would be helpful to know about CL’s symptoms and health history?

CL tells the NP she feels she is “a mess down there.” She reports experiencing itching and burning in the vulvar area. The symptoms are present on most days and worsen with her period. She ascribes the symptoms to yeast infections (3-4 in the past year), which she treats with OTC antifungal creams. She also reports that, in the past year, she has been treated by another healthcare provider (HCP) for bacterial vaginosis with a vaginal gel. In addition, she has gone to an urgent care center twice for treatment of urinary tract infections— even though she is unsure whether the urine culture findings were positive or negative.

A year ago, at the suggestion of a friend to whom she mentioned the painful sex, CL went to a clinic for sexually transmitted disease testing and a Pap smear with a human papillomavirus (HPV) co-test. She reports that all findings were negative but adds that she hesitates to “go through that again” because the speculum examination was very painful. She says, “I don’t even use tampons because they hurt too much.” She tells the NP that she wears a panty liner every day because she does not take her COC consistently; when she forgets to take a pill or takes it late, she has some spotting. She remarks that she never feels really clean because of the frequent diarrhea, and uses feminine wipes daily.

As she tears up again, CL tells the NP that, over the past few months, she has felt more stressed than usual because of worries about her relationship and because of work pressures with a new boss. She laughs a little as she says, “I don’t drink, use drugs, or smoke, but when I get home from work, all I want to do is take a long hot bath with some scented oils to help me relax and feel clean.”

The NP seeks more details about the dyspareunia, and asks CL to rate the pain she experiences during and after sexual intercourse using a Likert scale, with 0 = no pain and 10 = maximum pain. CL rates the pain she feels in the vestibule area when her partner’s penis enters the vagina as an 8, and describes it as burning or a “razor blade” sensation. During penile thrusting, she experiences vaginal pain rated as a 6. After sexual touching, she has heightened burning pain in the vestibule area rated as a 4; the pain lasts 12-24 hours.

Which differential diagnoses would you consider at this point?

CL describes chronic vulvar itching and burning, significant vestibular pain during and after sex, and vaginal pain with thrusting. These symptoms may have similar or overlapping causes such as:

• Vulvitis;

• Vulvar dermatoses (e.g., lichen sclerosus);

• Vulvar cancer (pruritus is the most common early symptom);

• Vulvovaginal atrophy (associated with the patient’s prolonged COC use);

• Vaginismus; and

• Vulvodynia.

What would you include in your problem-focused physical examination?

The NP begins with inspection of the vulva and vestibule to assess for anatomic changes or variations, pigmentation changes, lesions, and integrity of vulvar tissues. The inspection reveals normal vulvar structures and mildly erythematous, dry labia majora with no other pigmentation changes or lesions. The labia minora are moist and pink. Vulvar hair is absent; CL reports that she has been removing this hair with a razor and shaving cream for years.

In the absence of abnormal visible findings other than mild erythema of the labia majora, the NP performs a cotton-swab test to specifically localize any areas of altered sensation in the vulvar area. The test is done prior to digital palpation and an attempt at insertion of a speculum. A standard cotton tip applicator is used to apply light touch starting on the upper inner thigh and following in a clockwise fashion in a manner that includes the labia majora, the vestibular duct openings for Skene’s and Bartolin glands, the clitoris/hood, and the perineum. The patient is asked to rate her pain on a scale of 0-10 at each location (Figure). CL’s cotton-swab test produces scores of 0 on the inner thighs and labia majora, 2 at the clitoris, and 2 at the perineal body. Pain at the vestibular gland duct openings is rated at 6-7 for the Skene’s glands and 7-8 for the Bartholin glands.

Because CL has high vestibular pain scores, the NP does not perform a speculum exam. The NP uses a cotton swab to obtain a vaginal specimen for pH and microscopic wet mount evaluation.

The pH is 4.0. A whiff test is negative. Mature squamous epithelial cells are present, with no pseudohyphae, clue cells, or motile trichomonads seen on the wet mount. A vaginal specimen is sent for fungal culture to assess for infection caused by atypical Candida species. The culture results are negative.

Pelvic floor muscle (PFM) assessment is done using one finger inserted into the vagina without touching the vestibule. The Oxford Grading System uses a 6-point scale to measure PFM strength: 0 = no contraction; 1 = flicker; 2 = weak; 3 = moderate; 4 = good (with lift); and 5 = strong. CL’s PFM strength is rated a 4. Palpation of the levator ani group and obturator internus muscles reveals hypertonicity and tenderness.

Based on the history and exam findings, what is the diagnosis?

CL has three interconnected diagnoses contributing to the dyspareunia: contact vulvitis, vulvodynia, and vaginismus.

Vulvitis may be caused by chronic or recurrent infection by pathogens such as Candida, herpes simplex virus, or HPV; contact with allergens or irritants; or injury/trauma. CL has reported regular use of vulvar contact irritantsuch as panty liners, feminine wipes, shaving cream, and scented bath oils. Pubic hair shaving may heighten one’s sensitivity to contact irritants. CL’s physical exam and wet mount findings tend to rule out infection as the cause of the vulvitis. The labia majora dryness may be related to prolonged use of COCs.

Vulvodynia is defined as vulvar discomfort (usually described as burning pain) occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder.1 It is a diagnosis of exclusion when all other potential causes have been ruled out and when symptoms persist longer than 3 months.1 The etiology of vulvodynia is unknown but may be related to genetic susceptibility,chronic inflammation,3 a combination of factors (e.g., PFM abnormalities, neuropathic pain, anxiety, primary/secondary sexual dysfunction),4 regionally elevated cytokines produced by vulvar vestibule-specific fibroblasts,hormonal changes,6 or dietary oxalates.7, 8 Chronic inflammation related to the contact irritants, recurrent infections, hormonal changes, or chronic skin conditions acts as a trigger. Normal sensations are perceived as abnormal, resulting in heightened sensitivity.

Estimates of vulvodynia prevalence range from 3% to 18%.9 Onset is most likely to occur between the ages of 18 and 25. Among symptomatic women, 60% see an average of three HCPs before receiving the correct diagnosis and 40% remain undiagnosed.9

Vulvodynia is classified as localized or generalized. Localized vulvodynia is subdivided into primary, in which vestibular pain begins during the first attempt at vaginal penetration, or secondary, in which pain occurs after a period of pain-free sex. Generalized vulvodynia may include all of the vulva or be limited to one side, with pain occurring in the absence of a triggering event. Of note, about 10% of women with generalized vulvodynia have a co-existing pain syndrome such as interstitial cystitis/painful bladder syndrome, IBS, fibromyalgia, or chronic fatigue syndrome.10

Prolonged use of COCs as a risk factor for vulvodynia is controversial. Several studies have supported the theory that use of COCs or progesterone-only contraceptives in females younger than age 18 causes down-regulation of estrogen receptors, leading the vestibular epithelium to become thin and fragile.11, 12 Although some women with vulvodynia have increased perception of pain when taking COCs, stopping COCs does not necessarily lead to resolution of the symptoms.12

Vaginismus is defined as recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration and that causes personal distress or interpersonal difficulties.13

What can the NP offer CL as first-line treatment?

Because studies on the cause and treatment of vulvodynia are limited, the American College [now Congress] of Obstetricians and Gynecologists recommends that therapy be based on evidence from descriptive studies, expert reports, and clinical experience— with the understanding that the condition is difficult to treat and that no single approach is successful for all women.14

Individualized treatment usually involves multiple therapies over time.Treatment is considered in a step-wise progression, starting with self-management and moving upward on the scale of complexity. Total symptom resolution can be unrealistic. Primary goals are symptom reduction, return of satisfactory sexual function, and improved quality of life. Patient education concerning the manageability yet chronicity of this neuropathic condition is essential in setting realistic goals and in instituting a treatment plan that leads to improvement and satisfaction.

Mental health counseling is an important component. Approximately 50% of women with vulvodynia have a concordant diagnosis of anxiety.15 An increased occurrence of childhood physical/sexual abuse in women with vulvodynia has been reported.16 Referral to a mental health specialist with expertise in women’s sexual health and chronic pain conditions can be helpful.

Self-management is essential in CL’s case. She is educated to avoid use of feminine hygiene wipes/washes, panty liners (at times other than menses), and repetitive use of OTC antifungals.She is encouraged to stop removing her vulvar hair, which provides a protective barrier for sensitized vestibular tissues. She is advised to avoid exposure to very hot water in bathtubs and hot tubs, which can exacerbate vestibular discomfort. Application of unscented, hypoallergenic emollients to the vulvar skin and sitz baths in lukewarm water can be soothing, however.

CL and her partner should explore alternatives to penetrative sex (e.g., light physical contact with her genitalia). As pain diminishes with treatment over time, CL can consider restarting penetrative sex. The NP advises her to implement strategies for PFM relaxation, to adopt positions during intercourse that minimize pressure on sensitive areas, and to use liberal amounts of water-soluble lubrication.

A low-oxalate diet has been suggested to reduce high levels of oxalate in urine. However, little evidence supports the efficacy of this dietary modification in reducing vulvar pain.7, 8

What types of pharmacologic agents are appropriate?

Topical medications can be used on a short-term basis.17 Options include lidocaine 5% ointment, doxepin 5% cream in water-soluble base, gabapentin 2%-6% in watersoluble base, and amitriptyline 2% with baclofen 2% in water-soluble base. When topicals are used, those with an ointment base, rather than a cream base, are preferred.17 Cream bases contain more preservatives and stabilizers, which can act as contact irritants and cause burning upon application.

The next line of treatment is the use of oral neuropathic pain modulators, either antidepressants (e.g., amitriptyline, desipramine, venlafaxine) or anticonvulsants (e.g., gabapentin, pregabalin, lamotrigine, topiramate).17 Side-effect profiles and patient tolerance drive dosing regimens. Pruritus can be managed with an antihistamine such as hydroxyzine or cetirizine. In addition, nerve blocks, topical nitroglycerin, topical capsaicin, interferon injection, and trigger point injections have shown some efficacy in treating vulvodynia.17 Vaginal valium, injectable botulinum toxin, and topical baclofen have been used in the treatment of vaginismus.

What role does physical therapy play in CL’s treatment?

Pelvic floor physical therapy (PT) is an essential component of treatment for CL once she can withstand cotton-swab touch with lowered vestibular pain scores. A person with expertise in pelvic floor PT may use a combination of interventions to decrease CL’s dyspareunia and to improve her sexual function.17, 18 Interventions include (1) bio-feedback, which can help CL learn to relax her PFMs; (2) external soft tissue mobilization and myofascial release techniques; (3) trigger point pressure; and (4) transcutaneous electrical stimulation applied to the sacral nerve. The physical therapist or NP may teach CL how to use vaginal dilators to gradually overcome the tension in the PFMs. When CL is ready to resume sexual activity, she can use the dilator to prepare herself for and facilitate penetration.

When is surgery an option?

For women who continue to experience intractable symptoms after all other treatments have been tried, vestibulectomy—excision of the vestibule with vaginal advancement— is an option. Patient selection is critical for success; women can consider this option only if symptoms are confined to the vestibule. Success rates range from 60% to 85%.19, 20 Referral to a pelvic and reconstructive surgeon is advised in these cases.

Reflection for practice

Vulvodynia is a complex chronic pain condition. The interrelated physical, psychological, and psychosexual components make management challenging for both clinician and patient. CL has sought an NP’s help in seeking relief of her dyspareunia. The treatment plan focuses on symptom reduction to allow for sexual functioning that provides intimacy and satisfaction. Total relief of pain may not be achievable. A multidisciplinary approach to treatment may produce the best results. In fact, when available, referral to vulvovaginal disease specialists can facilitate an individualized, coordinated, comprehensive approach to treatment.

Susan Hoffstetter is a Fellow in the International Society of the Study of Vulvovaginal Diseases and an Associate Professor at Saint Louis University School of Medicine in St. Louis, Missouri. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Haefner HK. Report of the International Society for the Study of Vulvovaginal Disease terminology and classification of vulvodynia. J Low Genit Tract Dis. 2007;11(1):48-49.

2. Goldstein AT, Kim N, Burrows LJ, Goldstein I. Genetic differences may reflect differences in susceptibility to vulvodynia in general or in spontaneous remission propensity: a response. J Sex Med. 2015;12(2):578-579.

3. Akopians AL, Rapkin AJ. Vulvodynia: the role of inflammation in the etiology of localized provoked pain of the vulvar vestibule (vestibulodynia). Semin Reprod Med. 2015;33(4):239-245.

4. Edwards L. Vulvodynia. Clin Obstet Gynecol. 2015;58(1):143-152.

5. Foster DC, Piekarz KH, Murant TI, et al. Enhanced synthesis of proinflammatory cytokines by vulvar vestibular fibroblasts: implications for vulvar vestibulitis. Am J Obstet Gynecol. 2007;196(4):346e1-8.

6. Eva LJ, MacLean AB, Reid WM, et al. Estrogen receptor expression. Am J Obstet Gynecol. 2003;189(2):458-461.

7. Greenstein A, Militscher I, Chen J, et al. Hyperoxaluria in women with vulvar vestibulitis syndrome. J Reprod Med. 2006;51(6):500-502.

8. Harlow BL, Abenhaim HA, Vitonis AF, Harnack L. Influence of dietary oxalates on the risk of adult onset vulvodynia. J Reprod Med. 2008; 53(3):171-178.

9. Harlow BL, Stewart EG. A population based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. 2003;58(2):82-88.

10. Reed BD, Harlow SD, Sen A, et al. Relationship between vulvodynia and chronic comorbid pain conditions. Obstet Gynecol. 2012;120(1):145-151.

11. Bohm-Starke N, Johannesson U, Hilliges M, et al. Decreased mechanical pain threshold in the vestibular mucosa of women using oral contraceptives: a contributing factor in vulvar vestibulitis? J Reprod Med. 2004;49(11):888-892.

12. Goldstein AT, Krapf J, Belken Z. Do oral contraceptive pills cause vulvodynia? Time to finally end the controversy. International Pelvic Pain Society Blog. October 2015.

13. Curtis M, Linares S, Antoniewicz L. Glass’ Office Gynecology. 7th ed. Philadelphia, PA: Wolters Kluwer Health; 2014.

14. American College of Obstetricians and Gynecologists. 2006. Committee Opinion Number 345. Vulvodynia. Washington, DC: American College of Obstetricians and Gynecologists; 2006.

15. Tribo MJ, Andio O, Ros S et al. Clinical characteristics and psycho-pathological profile of patients with vulvodynia: an observational and descriptive study. Dermatology. 2008; 216(1):24-30.

16. Harlow BJ, Stewart EG. Adult onset vulvodynia in relation to childhood violence victimization. Am J Epidemiol. 2005;161(9):871-880.

17. Haefner HK, Collins ME, Davis GD, et al. The vulvodynia guideline. J Low Genit Tract Dis. 2005;9(1):40-51.

18. DeBevoise TM, Dobinsky AF, McCurdy Robinson CB, et al. Pelvic floor physical therapy: more than Kegels. Womens Healthcare. 2015;3(2):34-41.

19. McCormack WM, Spence MR. Evaluation of surgical treatment of vulvar vestibulitis. Eur J Obstet Gynecol Reprod Biol. 1999;86(2):135-138.

20. Haefner HK. Critique of new gynecologic surgical procedures: surgery for vulvar vestibulitis. Clin Obstet Gynecol. 2000;43(3):689-700.

Managing female sexual dysfunction

 

By Casey B. Giebink, MSN, NP-C, WHNP-BC and Ivy M. Alexander, PhD, APRN, ANP-BC, FAAN

Although about one-third of women report concerns with sexual functioning, many healthcare providers (HCPs) do not feel comfortable screening for, diagnosing, or managing female sexual dysfunction (FSD). The authors offer guidance to HCPs for screening and diagnosing a variety of FSD disorders. In addition, the authors discuss pharmacotherapeutic options for managing these conditions, as well as these agents’ benefits, risks, and monitoring parameters.

Key words: female sexual dysfunction, estrogen, testosterone, bupropion, ospemifene, flibanserin

Female sexual dysfunction (FSD) is highly prevalent among women in the United States, yet patients rarely discuss sexual concerns with their healthcare provider (HCP). Investigators of the Women’s International Study of Health and Sexuality sent questionnaires to 2,050 U.S. women regarding health status, sexual desire, and distress caused by low desire.1 The study showed that 24%-36% of women aged 20-70 years could be classified as having low sexual desire. This prevalence highlights the need for HCPs to know how to communicate with, identify, and manage patients’ sexual concerns. To this end, the authors provide evidence-based recommendations drawn from the current literature regarding assessment and diagnosis of FSD, with an emphasis on pharmacologic options available to treat FSD. Most of the pharmacologic options for desire, arousal, and orgasm problems are prescribed off label.

Common barriers to identifying and managing FSD

Despite the high prevalence of FSD, many women do not broach the topic with their HCP, and many HCPs do not screen their patients for sexual disorders.2 In fact, fewer than 20% of HCPs ask about their patients’ sexual activity, including difficulties, enjoyment, and frequency.3

Urologists, gynecologists, and psychiatrists are the HCPs most likely to inquire about sexual functioning.4 However, one study showed that among 187 urologists, only 10% asked every patient about sexual function on a regular basis, as opposed to 87% who asked about sexual activity when the chief complaint was related to abdominal pain, urgency/frequency, incontinence, or a urinary tract infection.5 A survey of the attitudes of nurse practitioners (NPs) and physician assistants (PAs) toward management of sexual dysfunction revealed that only one-half felt comfortable discussing the topic and only 21% of NPs and 11% of PAs felt confident in managing FSD.6 Nevertheless, most NPs and PAs had a positive attitude toward the possibility of evaluating and managing their female patients’ sexual concerns.6

Various factors may hinder HCP–patient communication regarding sexual concerns. Potential barriers for HCPs include lack of time, lack of knowledge about FSD management options, and lack of training in how to communicate about FSD; barriers for patients include embarrassment and a belief that their HCP cannot help them.7 Some HCPs fear embarrassing or offending patients if they raise the topic,3 although most patients will discuss their sex practices if the HCP initiates the conversation.8

Even if a patient does discuss her sexual problems with her HCP, her concerns may not be properly addressed. One survey showed that among 3,807 women who considered seeking help for sexual dysfunction, fewer than half reported feeling hope, relief, validation, or satisfaction after discuss­ing their concerns with a provider.9 In addition, patients were disappointed by their HCPs’ inability or unwillingness to evaluate, treat, and follow up on their complaints.9

Overcoming the barriers

Healthcare providers can increase the likelihood that FSD will be identified and addressed by initiating the conversation with patients, which will strengthen the HCP–patient relationship and help normalize patients’ concerns.9 Once both parties are comfortable, the HCP can take a sexual history, perform a thorough physical examination, and order appropriate laboratory tests.

History
To transition smoothly into taking a sexual history, HCPs can incorporate questions into the genitourinary/gynecologic/obstetric review of systems.10 Some patients may feel uneasy answering these questions, so HCPs can explain why such questions are being posed. For example, one can say, “I will be asking you some questions about your sexual activity to get a better idea of you as a whole and to ensure we are providing the most comprehensive care possible.” Informing women that FSD is common can facilitate a frank conversation.10

Screening for FSD with just a few questions can be informative. A literature review by Giraldi et al11 indicated that although multiple FSD screening tools are available, few standardized and culturally acceptable questionnaires are validated in general populations and can be used to assess for FSD in women with or without a partner and independent of the partner’s gender. As a result, HCPs can develop their own unbiased FSD screening questions based on their unique patient population. A patient’s sexual orientation should not be assumed; instead, HCPs need to ask about any and all sexual partners. Brief questions regarding sexual satisfaction and pain and the ability to reach an orgasm can determine if further screening is warranted.12 Three targeted questions include the following13:

• Do you have any questions or concerns about your sexual activity?
• Have you experienced any changes in sexual response, lubrication, or pain with sexual activity?
• Are you aware of any changes in your level of interest or desire for sexual activities?

If a woman—premenopausal or postmenopausal—answers “yes” to any of these questions, then further investigation is needed.

For a specific problem, HCPs need to explore the nature of the problem, its severity and duration, the degree of distress it causes, and any history of similar problems.13 The patient is asked to use her own words to describe any sexual difficulties she may be having.14 Because sexual functioning is multifaceted, HCPs need to consider a woman’s physical, surgical, medication, and social histories to uncover all possible factors causing or contributing to the sexual dysfunction (Table 1).14-16Physical examination
A physical exam is conducted to identify or exclude conditions that might cause or exacerbate FSD. This exam includes a general systemic survey with a focused cardiovascular exam, which can uncover systemic perfusion abnormalities that might contribute to FSD.15 A neurologic assessment of the effects of light touch and pressure on the external genitalia may reveal locations with hypersensitivity. A genitourinary exam is done to evaluate for structural abnormalities such as an imperforate hymen or vaginal septum and to look for signs of estrogen depletion (e.g., loss of vaginal rugae, pale mucosa, thin lining).15 An evaluation of pelvic muscle tone is important; both high tone and low tone can be associated with FSD. This evaluation is best done using a perineometer, a device placed within the vagina that provides feedback on the tone of the levator ani complex and obturator internus muscles.17 In the absence of this device, HCPs can evaluate tone during an internal exam by asking the woman to squeeze and relax the vaginal muscles.17 Of note, many women with FSD have normal physical exam findings.

Laboratory testing
Evaluating certain lab values can aid in identifying health conditions that may be contributing to sexual dysfunction. These lab tests include a complete blood count, fasting prolactin, a lipid profile, blood glucose, and thyroid hormone levels.18 Abnormal test results may reveal an underlying condition (e.g., anemia, thyroid disease, dyslipidemia, metabolic disorders, hormonal imbalances) causing or exacerbating the FSD.19 Evaluating the calculated free androgen index can also help in classifying sexual complaints; age-based normative values have been established.20 When a patient’s primary complaint is dyspareunia, vaginal, cervical, and/or vulvar cultures can be obtained to rule out infectious causes.14

DSM-5 changes to FSD diagnoses

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which was published by the American Psychiatric Association in 2013, includes revisions to previous editions based on new research.21 Specific to the category of sexual dysfunction, the DSM-5 now requires that symptoms be present for at least 6 months. In addition, the DSM-5 includes gender-specific diagnoses, combines disorders that were previously separate, and removes the subtype of FSD due to psychological factors versus combined factors. Research suggests that sexual response cannot be categorized into specific stages and is not always linear. As a result, the DSM-5 combines sexual arousal disorder and sexual desire disorder into female sexual interest/arousal disorder. Another combined disorder in the DSM-5 is genito-pelvic pain/penetration disorder, which was developed because of the difficulty distinguishing between vaginismus and dyspareunia.

Treatment approaches

Initial management of FSD requires treating any contributing underlying physical conditions. If treatment of these conditions does not result in restoration of sexual function, other interventions for FSD are considered. Although this article focuses on pharmacotherapeutic options, patients can try nonpharmacologic interventions such as cognitive behavioral therapy (CBT), sex therapy, self-stimulation, and lubricating gels (Table 2).22,23 If nonpharmacologic therapies do not offer relief, pharmacologic options are considered.

Estrogen
Declining estrogen levels after menopause can lead to vulvovaginal atrophy (VVA), which can result in vaginal dryness, itching, and pressure and can lead to pain during sexual activity.24 Painful intercourse (dyspareunia) can diminish sexual pleasure and desire for sex. Exogenous estrogen therapies, both systemic and topical, are used to increase vaginal lubrication and promote a more pleasurable sexual experience.25

Compared with systemic estrogen products, vaginal estrogen products have been found to heighten genital vasculature (despite resulting in lower systemic levels of estrogen); systemic estrogen is more useful for relieving vasomotor symptoms (VMS) accompanying menopause.25 Conjugated estrogens vaginal cream (Prem­arin® Vaginal Cream) has an FDA indication for treatment of moderate to severe dyspareunia, a symptom of VVA due to meno­pause.26 Although estrogen therapies alone have not been found to directly increase sexual desire, they diminish dyspareunia, which may indirectly increase a woman’s interest in sexual activity.25

Many formulations of systemic and vaginal estrogen are available. If a woman’s FSD complaint is related to VVA, a vaginal formulation is preferred.27 Three vaginal estrogen formulations are available: creams, a ring, and a tablet (Table 3).27 For the tablet and creams, a higher dose and/or dosing frequency is typically used for 1-2 weeks until relief is achieved; a tapered dose can then be used for maintenance.27 Whereas most women find relief after 3 weeks of treatment, some may require up to 4-6 weeks.28 Low-dose vaginal estrogen therapy can be used indefinitely because of the low adverse effect profile; however, given limited data on use beyond 1 year, women should be evaluated annually to determine the need for continued treatment.29

The most common side effects of topical estrogen cream are headache, breast pain, pelvic pain, vasodilation, leukorrhea, metrorrhagia, vaginitis, and vulvovaginal disorder.26 Most side effects subside with ongoing use. Although systemic estrogen use has been linked to an increased risk for endometrial hyperplasia, venous thromboembolism, and breast cancer, little evidence suggests an increased risk with topical estrogen use.27 The North American Menopause Society (NAMS) released new guidelines for prescribing hormone therapy.30 According to these 2012 guidelines, topical estrogen is less likely than standard-dose oral estrogen to cause blood clots or stroke; however, more research is needed to reach definitive conclusions. A Cochrane review showed no increase in endometrial proliferation with vaginal estrogen versus placebo.27 Nevertheless, local estrogens can be absorbed into the bloodstream and increase the amount of systemic estrogen. Given the limited research, HCPs need to use clinical judgment when prescribing estrogen and monitor women closely for vaginal spotting/bleeding and other worrisome complaints.

Testosterone
If estrogen alone does not ease FSD symptoms, off-label addition of testosterone to estrogen therapy (ET) may increase libido and enhance sexual response.31 Use of testosterone in women is off label; this agent is prescribed with caution after patients are educated about the risks. A 2005 Cochrane review of 23 trials concluded that addition of testosterone therapy (TT) to ET improved sexual desire in postmenopausal women.32 The likely mechanism of action of combined therapy was related to the fact that use of exogenous testosterone increases circulating free testosterone and decreases sex hormone-binding globulin (SHBG). The subsequent increase in bioavailable testosterone may correlate with increased sexual desire.

Limited data on the long-term effects of TT led the FDA to reject a proposed testosterone patch for women with FSD. However, a 1% testosterone gel, FDA-approved for use in men only, is often prescribed off label to postmeno­pausal women with sexual dysfunction.33 One study showed that a dosage of 10 mg/day, applied in a thin layer to 15 cm2 of the inner thigh, led to mean testosterone levels of 3.0 nmol/L, which is in the high-normal range for premenopausal women (?2.5-3.0 nmol/L).33 The advantage of the transcutaneous route of administration over other routes (e.g., subcutaneous implant, intramuscular injection) is that it avoids the high hormone levels in the hepatic portal vein, which helps minimize assault to the liver.33

The most common short-term side effects of TT in women are hirsutism, acne, and a deepened voice, all of which are mild and reversible.34 Long-term side effects of concern are cardiovascular disease (CVD) and breast cancer. Preliminary studies have shown that TT reduces high-density lipoprotein cholesterol levels and increases low-density lipoprotein cholesterol levels; however, no study has looked at the correlation between TT in women and CVD.32 Studies examining the effects of TT on breast cancer risk are incon­clu­sive.32 Absolute contraindications to TT include a history of breast cancer, endometrial cancer, veno­thrombotic events, or CVD.14

When prescribing TT, HCPs should ask women to undergo baseline and annual breast exams and mammography, along with a pelvic exam—with special consideration paid to abnormal bleeding.14 In addition, women must be regularly evaluated for acne, hirsutism, and androgenic alopecia.14 Laboratory parameters monitored at baseline, after 3-6 months of use, and then periodically thereafter include SHBG, total testosterone, fasting lipid panel, and liver function tests.14

In 2005, NAMS published a position statement regarding the role of TT in postmenopausal women. The society concluded that TT is a valuable pharmacologic option for postmenopausal women who pre­sent with symptoms of decreased sexual desire.35 Nevertheless, NAMS cautions that insufficient data are available regarding the safety and efficacy of TT in women for longer than 6 months.35 Given these data, testosterone is prescribed with caution, with extensive patient education.

Bupropion
Bupropion is a norepinephrine and dopamine reuptake inhibitor antidepressant without serotonergic effects.36 Although bupropion is most commonly used as an antidepressant, this agent is used off label to treat sexual dysfunction in non-depressed women.37 The exact mechanism of bupropion’s efficacy for this indication is unknown but may be related to increased uptake of dopamine and norepinephrine, both of which are correlated with increased sexual responsiveness.36

The prescribed dosage of bu­pro­pion should not exceed 400 mg/day for the sustained-release formulation or 450 mg/day for the immediate- or extended release formulations; higher dos­ages can increase the incidence of side effects such as headache, agitation, insomnia, nausea, and possibly seizures.38 Bupropion is not prescribed to patients with a history of anorexia, bulimia, or seiz­ure disorders. Bupropion users must be monitored for neuro­psychiatric changes such as hostility, agitation, depression, and suicidality.39 Patients are counseled that treatment efficacy may not occur for 4-6 weeks.

Bupropion is a promising non-hormonal treatment option for FSD. Preliminary studies have shown encouraging results; however, more extensive research is needed before FSD can be listed as an indication for bupropion use.40Ospemifene
In 2013, the FDA approved ospemifene (OsphenaTM) for treatment of moderate to severe dyspareunia caused by VVA in menopausal women.41 Ospemi­fene, an oral selective estrogen receptor modulator, is the only non-estrogen compound approved in the U.S. to treat moderate to severe dyspareunia.42 This medication can be offered to women who are not candidates for ET but who have FSD related to dyspareunia. In two 12-week phase III clinical trials, ospemifene significantly improved vaginal dryness and dyspareunia, vaginal maturation index, and vaginal pH.43 The most effective dosage is 60 mg/day.43

The most common adverse effect of ospemifene is VMS.43 This agent is contraindicated in women with genital bleeding of unknown cause, estrogen-dependent neoplasia, personal history of deep vein thrombosis, pulmonary embolism, stroke, or myocardial infarction. Ospemifene should not be prescribed to women with a history of breast cancer or who are at high risk for breast cancer. Pre-clinical and clinical trials show a promising effect of ospemifene on bone density and breast tissue, but long-term data on the safety of this medication are limited.42Flibanserin
Flibanserin, an oral agent proposed for treatment of premeno­pausal hypoactive sexual desire disorder, has been shown to significantly increase sexual desire and the number of sexually satisfying events among women taking 100 mg at bedtime.44 The FDA initially rejected this medication in 2010.44 When Sprout Pharmaceuticals reapplied for approval in 2013, flibanserin was once again rejected; this time, the FDA indicated that additional studies in healthy subjects were needed to evaluate drug interactions and the drug’s possible adverse effect on driving.45 Sprout is expecting to resubmit the proposal by the end of the first quarter of 2015.45 No more information on the proposal was available as this article went to press.

Conclusion

Given the prevalence of FSD, HCPs must know how to screen for and diagnose FSD, and then manage it or know when to refer. HCPs need to take a short sexual history in all women, and ask them whether they have concerns about their sexual activity or about changes in their sexual desire or response. If the history uncovers a possibility of FSD, a thorough physical exam and lab testing are done. For women in whom FSD is diagnosed, nonpharmacologic interventions include CBT, sex therapy, self-stimulation, and lubricants. Two medications—conjugated estrogens vaginal cream and ospemifene —have a specific indication for dyspareunia. Although no pharmacologic agent has been approved by the FDA to treat desire, arousal, or orgasmic dysfunction in women, interest in such agents is growing. In each case, HCPs weigh the risks and benefits of specific treatments, offer extensive patient counseling, and provide close follow-up.

Casey B. Giebink is an adult and women’s health nurse practitioner at Medstar Georgetown University Hospital, Department of Ob&Gyn in Washington, DC. Ivy M. Alexander is an adult nurse practitioner specializing in midlife women’s health at the University of Connecticut Health Center in Storrs and Clinical Professor at the University of Connecticut School of Nursing. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

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