Sex – SOGC 2013

1 In patients, specifically pregnant women, adolescents, and perimenopausal women:

a) Inquire about sexuality (e.g., normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction).

b) Counsel the patient on sexuality (e.g., normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction).

Sexual history:
  • age of first intercourse,
  • perceived gender of self, gender of partners
  • current relationship status, current sexual activity
  • pain or bleeding with intercourse
  • type of sexual activity
  • satisfaction (desire, arousal, orgasm)
  • assault/abuse, contraception methods and use thereof, review safer sex practices

Recommendations:
Adolescnet
  • Encourage adolescents to use condoms consistently, and to take other steps to promote sexual health and prevent sexually transmitted infections (e.g., human papillomavirus vaccination), even while they are in a relationship.
  • Balance concern about adverse sexual consequences for girls with positive messages about adolescent girls’ expression of their sexuality.
  • Consider the effect of the relationship when assessing a woman’s sexual well-being.
  • Discuss sexuality at the early prenatal visit, before discharge from the hospital postpartum, and at the postnatal check-up.
    • communicate that they are open to discussing sexual concerns;
    • educate patients about normal fluctuations in sexual interest and frequency;
    • discuss the range of non-coital sexual activities if intercourse is difficult, painful, or prohibited for medical reasons; and emphasize the importance of the quality of lovemaking rather than coital frequency to sexual satisfaction.
  •  discuss safer sex, particularly with newly single women.
Pregnancy
  • provide advice to support sexual adjustment and deal with challenges to sexual function during pregnancy and childbirth (e.g., suggest adapting coital position to accommodate changing body shape, suggest topical lubricant to reduce dyspareunia postpartum).
  • help women deal with their concerns related to breastfeeding and sexual activity. This should include providing reassurance about the hormonal causes of erotic feelings during breastfeeding and informing women that if they are distressed by milk ejection during orgasm, this can be reduced by emptying the breast before sexual activity.
Menopause
  • enquire about both the woman’s functioning and her partner’s functioning in assessing changes to sexual activity with menopause and aging.
  • Changes in sexual functioning should be treated only if the woman expresses distress about these changes.
  • recommend the use of a lubricant or estrogen (local or systemic) for problems arising from vaginal dryness.
  •  understand that all women are sexual and acknowledge that women have sexual needs.
  •  respect for diverse individual patterns of sexual behaviour and orientation across the lifespan.
  •  Couples should be encouraged to include sexual pleasuring without penetration in their activities if penetration is impossible.
  • recognize the need for sensitivity to a woman’s life stage, to her individual situation, and to her sexual orientation when they assess sexual health concerns.

2 Screen high-risk patients (e.g., post-myocardial infarction patients, diabetic patients, patients with chronic disease) for sexual dysfunction, and screen other patients when appropriate (e.g., during the periodic health examination).

High risk populations:

Medications Antihypertensives (thiazide, ACEI, CCB, spironolactone),   anticonvulsants, opioids, benzos, H2 receptor blockers (ranitidine), antineoplastics, antipsychotics, antidepressants, anticholinergics, anti-emetics (haldol, maxeran, prochlorperazine, dimenhydrinate), chemotherapy, ketoconazole
Cancer Surgical disfigurement, alopecia, weight changes, hormonal changes, fatigues, depression/anxiety, fungating wounds, fistulas, alteration in physical perceptions, brain metastases, RT, effect of sx medications
Neuro MS, CVA, spinal cord injury
Endocrine Hypo/hyperthyroidism, diabetes, menopause, andropause, hypogonadism, hyperprolactinemia
Vascular HTN, CAD, PVD
Urology/Gyne Anatomic abnormality, menopause, vestibulitis, STI
Psychiatric Depression, anxiety, PTSD, psychosis, sexual orientation issues, developmental issues
Psychosocial ETOH, smoking, mood altering drugs, marijuana, LSD, cocaineRelationship changes, new couple, infertility, miscarriage, post-partum, parenthood, teen, empty nest, loss of spouse, affairs, different sexual expectationsSocial stressors (job, money, work, etc..)

3 In patients presenting with sexual dysfunction, identify features that suggest organic and non-organic causes.

SD Common in both men and women

Types of sexual dysfunction:

  • Desire phase: hypo/hyperactive sexual desire, sexual aversion disorder
  • Arousal phase: female sexual arousal disorder, vaginismus, dyspareunia, decreased lubrication, ED
  • Orgasm phase: female orgasmic disorder, premature ejaculation, delayed ejaculation

APA criteria for diagnosing the major female sexual disorders

  • Hypoactive sexual desire disorder — deficient (or absent) sexual fantasies and desire for sexual activity
  • Female sexual arousal disorder — inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement
  • Female orgasmic disorder — delay in, or absence of, orgasm following a normal sexual excitement phase
  • Dyspareunia — genital pain that is associated with sexual intercourse
  • Vaginismus — involuntary contraction of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with penis, finger, tampon, or speculum is attempted

Approach to organic, versus non-organic sexual dysfunction:
  • Sexual history, INCLUDING PARTNER HISTORY
  • Discontinue/switch possibly offending medications
  • Physical exam (emphasis on endocrine, vascular, and uro/gyne)
  • Psychiatric disorder screen (e.g. MDD, anxiety, PTSD, psychotic D/O)
  • Nocturnal penile tumescence testing
  • Duplex Doppler imaging
  • Blood work: free testosterone, total testosterone, prolactin, TSH, CBC
  • Transvaginal ultrasound, cervical swabs for chlamydia and gonorrhea.

(Routine measurement of serum testosterone to detect hypogonadism in ED continues to be debated, however UpToDate suggests measuring testosterone levels in men to detect hypogonadism). Testosterone, FSH,LH level measurements not recommended in women with sexual dysfunction.

Features that suggest a non-organic cause:

  • Abrupt onset
  • No history of trauma
  • No new meds
  • Ongoing nocturnal erections

4 In patients who have sexual dysfunction with an identified probable cause, manage the dysfunction appropriately.

Cause Treatment
Post-menopause Estrogen creams equivalent to Replens for vaginal drynessSee below for details
Surgically-induced menopause Testosterone
Vaginismus Vaginal dilators, counseling, PT, awareness,
Female Anorgasmia Primary: books, counselingSecondary: change meds, sildenafil, vibrators if increase stimulation needsLow libido: if from relationship, treat reason
Female Dyspareunia(treat the cause) Vulvar: skin conditions, vulvitis, vulvar vestibulitis, poorly repaired episiotomyVaginal: lubrication, imperforate hymen, infections, vaginismusPelvic: endometriosis, pelvic varicosities, ovary in cul-de-sac, tumor, adhesions, UTI, interstitial cystitis, constipation, proctitis
Male decrease libido History, possibly counseling
Erectile dysfunction Sildenafil (NO NITRATES), yohimibine or trazodone for psychological to increase libido, intraurethral alprostadil (MUSE), intracavernosal injections (Caverject), vacuum assisted erection device, penile prosthesis
Ejaculatory disorder Couple sex therapy, SSRI

Constructive psychological and lifestyle change
  • balanced healthy diet,
  • increasing physical exercise,
  • decreasing alcohol and tobacco use
    • positively impact sexual health by enhancing well-being, self-worth, and body image and increasing overall stamina.
  • For postmenopausal women with hypoactive sexual desire disorder in whom non-pharmacologic therapy has been unsuccessful, we suggest a trial of testosterone (Grade 2B).
  • For premenopausal women with sexual dysfunction, recommendation is against androgen therapy (Grade 1B).

5 In patients with identified sexual dysfunction, inquire about partner relationship issues.


References:

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Posted in 82 Sex, 99 Priority Topics, FM 99 priority topics, Gyne

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