By: Dr. Lisa Valle
What if the cure for adding more luster to your life is a fulfilling, sex life? But what happens when a woman feels distress about her sex life? Or she experiences sexual pain? Is there anything that she can do about it?
The answer is an emphatic yes!
There is an array of sexual conditions that can affect a woman’s sexual function. Female sexual dysfunction is defined as a perceived persistent problem with sexual response that causes her distress. This can include sexual pain, inability to achieve orgasm, arousal problems, and lack of sexual desire. This can be lifelong or acquired.
Unfortunately, many women are uncomfortable bringing this up with their physician. In addition, some physicians are uncomfortable addressing this issue as well. Finding a provider that is comfortable and skilled at evaluating and addressing these conditions is key to a successful treatment.
What is involved in an evaluation and treatment of female sexual dysfunction?
An in-depth medical history is first taken. We use this to seek out psychological, medical, and medication related causes of sexual dysfunction. This should also address relationship factors and satisfaction level, as well as socio-cultural attitudes. I feel that the most important part of the history is a focus on a detailed sexual history. This should include a focus on sexual activity, function, sexual/gender identity and orientation. An identification of the specific concern is made and a detailed assessment of how this affects her life and her level of distress is determined. In my practice, we use standardized questionnaires to help with the latter. This also gives us a baseline status to compare later on in her treatment.
In essence, an integrative, 360-degree approach to an evaluation is performed. A sexual problem is like a prism- each aspect of it needs to be addressed and treated. Examples of some topics that are often addressed might include: a history of trauma, attitudes and familial upbringing about sex, menopausal status, childbirth history, prior surgeries, medication and over the counter supplement usage. Throughout a woman’s life cycle, her feelings and needs about sexuality may change as may her relationships. Also, every woman’s sexual interest, response, and needs differ. The purpose of the history is to assess what specifically distresses her and how it is impacting her life and her relationships.
I believe that the most important factor to treatment of female sexual dysfunction is finding the correct diagnosis to address. In my practice, I take an integrative approach and explain to our patients that a team approach of utilizing other health professionals to help address her condition is key to a successful outcome. I first assess the patient’s goals and we address her expectations.
Firstly, any medical or psychological conditions that were discovered during her intake are addressed and the appropriate referrals are made. For example, if someone with sexual pain also has gastrointestinal complaints suggestive of irritable bowel syndrome or inflammatory bowel disease, I refer her to a gastroenterologist while we are treating her sexual condition.
Utilization of a network of sex therapists, marriage and family therapists, pelvic floor physical therapists, neurologists specializing in treating pain, acupuncturists, nutritionists, gynecological dermatopathologists and others are vital to the management of her condition.
Lifestyle changes, nutrition and patient education regarding sexuality are also topics which are frequently discussed. Involving her partner with her treatment is also important.
Medications such as hormones, psychotropic agents, or herbal supplements are often used depending on the condition. If the sexual dysfunction is possibly related to the side effects of her medications, a discussion with the prescribing physician can be made to address this.
It is generally recommended that the patient be seen for regular follow up visits until her condition has improved.
What are risk factors of female sexual dysfunction?
As I mentioned previously, female sexual dysfunction has various facets to consider. The etiology can be from multiple issues such as: psychological (anxiety or depression), relationship issues, history of abuse, medication side effects (such as oral contraceptives), medical conditions (such as diabetes), fatigue, stress, and gynecological issues such as pelvic floor problems, endometriosis or a history of a traumatic delivery. Of note, this is not an all-inclusive list.
What are types of female sexual dysfunction?
There are various phases in the sexual response cycle and each condition can frequently overlap. Female sexual dysfunction can be organized into the following general categories:
-Sexual pain disorders
Each category has specific conditions which cause distress for the patient. The listing and description of each diagnosis is beyond the scope of this particular blog post. To give an example, there are an array of sexual pain disorders such as: vulvodynia, vestibulodynia, pain related to endometriosis, overactive pelvic floor muscle dysfunction and pudendal neuralgia.
What does the physical exam involve?
Depending on the type of sexual concern, a targeted comprehensive gynecological exam is performed. A visual exam is performed making various observations of anatomy and structure. We look at any skin abnormalities. If pain is involved over the vestibule. which is the entryway of the vagina, a cotton swab or Q tip test is performed as well. The Q tip test involves very light touch along specific areas which are used to characterize the areas of tenderness using a numeric scale. Vulvoscopy is often used to exam skin changes that usually cannot be seen without magnification. Vulvoscopy involves a magnification lens and light which is used with diluted vinegar to look for precancerous skin changes or other dermatologic conditions. The abnormal areas often appear white. If this occurs, a small biopsy is recommended with a local anesthetic.
Testing for infections such as yeast, bacterial infections, sexual transmitted infections, and vaginal cultures can be obtained from a vaginal examination depending on the condition. An examination of the vaginal walls as well as the opening of the bladder should also be performed.
A muscular digital examination of the pelvic floor muscles as well as the nerve supply to the pelvic floor is utilized to assess for any areas of pain, tight muscles or tenderness.
What types of additional tests might be ordered?
As a gynecologist, we frequently order pelvic ultrasounds. I feel this is a great adjunct tool to the physical exam. A bimanual examination can frequently miss abnormalities. A CT scan or an MRI can sometimes be indicated as well. Hormonal testing via a blood test is routinely performed.
Overall, I feel that the time has come for women to embrace their sexuality and optimize their sexual health. It is an important facet to our humanity. Fortunately, more providers are learning how to evaluate and manage these conditions. It is my hope that female sexual dysfunction will no longer be a taboo topic but discussed openly and addressed appropriately.
About the guest author:
Lisa M. Valle, D.O., FACOG, ABIHM is a board certified Obstetrician/Gynecologist and has been in practice for over 12 years. Her integrative practice solely focuses on caring for women with female sexual concerns in Santa Monica, California. Her emphasis has been on concerns such as: pelvic & vulvovaginal pain disorders, loss/decreased libido, inability/difficulty achieving orgasm, arousal disorders, and various vulvovaginal disorders. She is a member of the International Society for the Study of Women’s Sexual Health (ISSWSH), the International Society for Sexual Medicine (ISSM), the Academy of Integrative Health & Medicine and a Fellow of the American College of Obstetricians & Gynecologists. Dr. Valle has been featured as a medical expert on TLC, the Discovery Health channel, radio, and print media. You can find her at her website at www.OWSFC.com or on Twitter, Facebook and Instagram at @Oasiswomensfc.