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Handbook On Female Sexual Health And Wellness


Elements of a Complete Sexual History


Sexual functioning is multifactorial. Factors associated with female sexual dysfunction include medications, psychologic disorders, comorbidities, relationship/partnership issues, and hormone use and non-use.

A thorough sexual history should assess medical, reproductive(obstetric/gynecologic), surgical, psychiatric, social, and sexual information.

  • DSM-IV-TR: sexual dysfunction that is not better accounted for by a general medical or psychiatric condition, nor due exclusively to the direct physiologic effects of a substance or medication.

A patient’s history may not be sufficient to assess her sexual function, and a physical examination or laboratory testing may be needed to determine if anatomic or physiologic factors are involved in a sexual complaint (The American College of Obstetricians and Gynecologists note that local practices and expectations can differ regarding the use of chaperones, and recommend that the request by either a patientor physician to have a chaperone present during a physical examination should be accommodated, regardless of the physician’s sex.
— ACOG Guidelines for Women’s Health Care, 3rd edition 2007).

ELEMENTS OF A THOROUGH SEXUAL HISTORY

Because a variety of general health and psychosocial factors can impact sexual function, a thorough sexual history must cover a lot of ground:

Psychosocial Issues

  • Relationship status
  • History of abuse (verbal, emotional, physical, or sexual)
  • Alcohol, tobacco, illicit drug use

Medical Issues

  • Current health status
  • Past medical history
  • Medications
  • Reproductive history and current status
    • Age of menarche
    • Menstrual history
    • Obstetric history (pregnancies, losses, duration of labor, and consequences of delivery, delivery type, birthweights)
    • Infertility
    • Contraception
    • Sexually transmitted infections
    • Gynecologic problems (pain, pelvic floor disorders, postpartum)
    • Surgeries
    • Urologic problems (incontinence episodes)
  • Surgical history
  • Endocrine system
    • Diabetes
    • Thyroid disorders
    • Hyperprolactinemia
  • Androgen deficiency
  • Neurologic disorders
  • Hypertension
  • Psychiatric illnesses
    • Mood disorders (major depression, bipolar illness)
    • Anxiety disorders
  • Psychotic illness
  • Other chronic illnesses
    • Breast cancer
    • Rheumatoid arthritis
    • Psoriasis

GYNECOLOGIC EXAMINATION:

If the history indicates that a physical examination is necessary, it should include the elements outlined in the table below.

ELEMENTS OF THE GYNECOLOGIC EXAMINATION

Inspection Of External Genitalia
Muscle tone, skin color/texture, skin turgor and thickness, pubic hair amount, vaginal pH
Cotton swab test of vulva, vestibule, hymenal ring, Bartholins and Skenes gland ostium (pain mapping)
Retract clitoral prepuce, expose clitoral glans
Examine posterior fourchette and hymenal ring

Monomanual Examination
Palpate rectovaginal surface, assess contraction/relaxation capability and tenderness
with palpation of levator muscles, bladder, urethra
Evaluate vaginal depth

Bimanual Examination
Palpate uterus and adnexa and perform rectovaginal examination

Speculum Examination
Examine the vaginal lining and mucosa, assess Portia and vaginal vault for estrogenization, etc.
Perform genital cultures if infection is suspected
Test vaginal pH if vaginal atrophy is a concern

Adapted from Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res. 1998;(suppl 2):S117-S120.

COMMON MEDICATIONS THAT MAY IMPACT FEMALE SEXUAL FUNCTION
  • Antidepressants and mood stabilizers
    • Tricyclic antidepressants
    • MAOIs (monoamine oxidase inhibitors)
    • SSRIs (selective serotonin-uptake inhibitors)
    • SNRIs (serotonin-norepinephrine reuptake inhibitors)
    • Typical antipsychotics (phenothiazines, thioxanthenes, butyrophenones)
    • Atypical antipsychotics
    • Mood stabilizers (e.g., carbamazepine, lithium)
  • Other CNS drugs
    • Anticonvulsants (e.g., phenobarbital, phenytoin)
    • Anticholinergics (e.g., diphenhydramine, benztropine)
    • Opioids
    • Amphetamines
  • Hormones and hormone antagonists
    • Hormonal contraception*, estrogens, progestins, antiandrogens, GnRH agonists
  • Antihypertensive agents
    • Beta blockers
    • Alpha blockers
    • Diuretics
  • Cardiovascular agents
    • Triglyceride lowering agents
    • Digoxin
  • Weight loss agents
  • Histamine receptor (H2) blockers
  • Chemotherapeutic agents (e.g., busulfan, chlorambucil, cyclophosphamide)
  • Aromatase inhibitors
  • Immunosuppressants
  • Steroids

*Although there are some reports of sexual side effects in women using a range of hormonal contraception, there is no consistent pattern of effect. Some published data has indicated that premenopausal women who take oral contraceptive pills may have a lower average frequency of sexual thoughts, interest, and days of sexual activity/month (it is hypothesized that oral contraceptive pills increase sex hormone-binding globulin and lower free testosterone). Other studies, however, show that sexual interest scores do not change significantly for women on oral contraceptive pills. Further research is required to clarify the effect of oral contraceptive pills on sexual function.