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LEARNING OBJECTIVES

  1. Differentiate between the female and male sexual response.

  2. Describe criteria for the diagnosis of female sexual interest/arousal disorder, female orgasmic disorder, and genito-pelvic pain/penetration disorder.

  3. Describe how medical conditions, medications, and psychological factors contribute to female sexual dysfunction.

  4. Use guideline recommendations for diagnosis and treatment of female sexual disorders.

  5. Devise a treatment plan including nonpharmacologic and pharmacologic treatment options for female sexual dysfunction, and then educate the women about her medications.

INTRODUCTION

Normal Sexual Response—Gender Differences

The traditional human sexual response cycle of Masters and Johnson1 and Kaplan2 depicts a linear sequence of discrete events, including desire, arousal, plateau of arousal, peak of orgasm, possible repeated orgasms, and then resolution. This model was based on the physical observations that occur during the female sexual response, such as clitoral engorgement and clitoral length and diameter changes, and focuses only on the genitalia response during sexual stimulation. An alternative sexual response model for women has been suggested which incorporates biological, psychological, and social aspects of sexuality.3 This model acknowledges that compared with male sexual functioning, female sexual response is more circuitous and is strongly modulated by emotions, recognizing that women can engage in sexual activities out of affection for their partners. Women can enter the cycle at multiple points, and phases of this response can overlap and vary in sequence.

Female Sexual Dysfunction

Female sexual dysfunction describes a heterogeneous group of conditions that women of all ages can experience. Sexual problems and dysfunction impact up to 43% of women 18 years and older.4 In premenopausal women, the prevalence of female sexual dysfunction is reported to be 40.9% (95% CI 37.1-44.7), with an individual prevalence of 20.6% for lubrication difficulties and 28.2% for hypoactive sexual desire disorder.5 Additionally, marriage status and educational level can influence sexual problems, with unmarried women experiencing more climacteric problems and sexual anxiety as compared to married women. College graduates have a lower likelihood of low sexual desire, orgasmic difficulties, dyspareunia, and sexual anxiety than women who do not graduate from high school.

Patient Case (Part 1)

A.L. is a 49-year-old woman in the obstetrics and gynecology clinic.

Subjective Information

Chief Concern: “I do not care if I ever have sex again.”

History of Present Illness: The patient complains of consistently low libido, which began 1 year earlier. She goes to bed after her spouse is asleep to avoid sexual activity. She does not think about sexual activity and denies self-stimulation. She is distressed because she misses her desire and feels guilty because she feels she is disappointing her spouse. A.L. has reduced genital sensations and orgasmic intensity; however, she can achieve an orgasm. She has adequate lubrication and denies pain with intercourse. Normal sexual desire occurred prior to hysterectomy. She complains of hot flushes and night sweats as well as fatigue and decreased ...

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