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Handbook On Female Sexual Health And Wellness


Sexual Dysfunction And Common Ob/Gyn Issues

 

PELVIC SURGERY

  • Few studies have addressed the role of pelvic surgery and female sexual dysfunction
  • Common gynecologic conditions such as fibroids, prolapse and adnexal pathology may cause female sexual dysfunction
    • Pelvic surgery to correct these conditions may improve, have no effect on, or even worsen sexual function
    • Approximately 13% to 37% of women undergoing hysterectomy experience a decline in sexual function with complaints ranging from decreased desire to painful intercourse, diminished sensation or difficulty achieving orgasm
    • Vaginal surgery resulting in significant vaginal narrowing is rare even in women undergoing posterior colporrhaphy (without levator plication) and may improve function
    • Risks of the newer interpositional vaginal mesh delivery systems, however, include vaginal mesh exposure, decreased
      vaginal caliber with contraction, dyspareunia and pelvic pain necessitating additional surgery for mesh removal
  • The possible etiology of sexual dysfunction following pelvic surgery warrants further investigation and patients need to be aware of potential benefits and risks

GYNECOLOGIC CANCERS

  • Research suggests that up to 83% of women report sexual problems after gynecologic cancer (vulvar, cervical endometrial), and 90% of women report sexual problems after breast cancer
  • The most prevalent sexual problems following treatments for gynecologic cancers include decreased desire, impaired lubrication, change in intensity of orgasm, reduced vaginal sensitivity, and superficial dyspareunia related to loss of elasticity and vaginal shortening/narrowing (fatigue is also a common factor in impaired sexual function)
  • In addition to the physical changes related to cancer, psychological and interpersonal difficulties may contribute to sexual problems including anxiety, altered body image, and difficulty communicating with partner(s) about altered sexual response
  • Healthcare professionals should recognize and normalize cancer patients’ and partner experiences with altered sexuality in order to provide comprehensive survivorship care
  • Counseling should included suggestions to improve sexual intimacy such as changing from intercourse to other forms of touching

INCONTINENCE

  • Research suggests that >40% of women with urinary incontinence and other lower urinary tract symptoms have concomitant female sexual dysfunction
  • A significant relationship exists between urodynamically proven stress urinary incontinence and desire disorders, urge type urinary incontinence and orgasm disorders, and recurrent urinary tract infections and dyspareunia
  • Women should be asked specifically about coital incontinence (10% to 27% of women) which is underreported and can be associated with shame and sexual abstinence

PELVIC PAIN

  • An estimated 16% to 25% of women experience dyspareunia, often leading to sexual avoidance as a result of chronic pelvic pain
  • Careful physical examination should be performed to identify and treat specific pain generators such as vulvodynia, endometriosis, interstitial cystitis, provoked vestibulodynia, pelvic floor muscle hypertonus
  • Multi-disciplinary care and referrals for concomitant sexual therapy and physical therapy are integral to regaining sexual function for women with chronic pelvic pain

PREGNANCY

  • Sexuality changes throughout pregnancy and can be attributed to changes in anatomy, increased size of the gravid uterus, and psychological concerns
  • Most couples can continue having sexual intercourse throughout pregnancy provided there is no obstetric contraindication
  • The psychologic and logistical challenges of parenthood also commonly influence sexuality and sexual expression
  • Sexual activity does not stimulate labor, and most studies do not link sexual activity to changes in Apgar scores or preterm delivery
  • The majority of women recover prepregnancy sexual functioning. However, there are some women who report significantly impaired sexual function after pregnancy, including complaints of dyspareunia or HSDD, that are not the consequence of the challenges of caring for an infant
    • Sexual function should be assessed at the post-partum visit

SEXUALLY TRANSMITTED INFECTIONS

  • Research suggests that diagnosis and treatment of a sexually transmitted infection (STI) can result in sexual problems in up to 55% of women (and 35% of men)
  • Psychosexual vulnerability particularly manifested as depression, anger, guilt, shame and anxiety may accompany the STI diagnosis and decrease sexual satisfaction for months to years thereafter
  • It is important for clinicians to emphasize that most STIs are manageable conditions, and should not be viewed as a punishment or judgment — Involvement in support groups can be very helpful for individuals who struggle with their diagnosis

HORMONAL CONTRACEPTIVES

  • Many women enjoy sexual activity more freely without the fear of pregnancy
  • 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
  • Other studies, 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
  • Caution should be exercised if one is attributing poor sexual health directly to OCs alone; a comprehensive and individualized assessment is warranted

BODY IMAGE

  • Body image may have a profound impact on a woman’s ability to enjoy a satisfying and positive sexual life
  • Negative thoughts about one’s body (e.g., feeling overweight or unattractive) or self-consciousness about aspects of one’s body (e.g., breast size, facial features) will diminish a woman’s enjoyment of sexual encounters
  • Heterosexual women are more likely to experience body dissatisfaction than heterosexual men, and lesbian-identified women have as much body dissatisfaction as heterosexual women

MENOPAUSE

  • The menopausal transition is marked with lowered sex steroid levels and atrophic vulvar vaginal changes, which may contribute to lowered sexual enjoyment and increased reports of pain during sexual activity
    • A comprehensive assessment and physical examination is often required for diagnosis
    • Minimally absorbed, local vaginal estrogen products (rings, creams, and tablets) can reverse changes in the vaginal mucosa
  • Changes in sexual desire are also seen
  • The menopausal period can include many lifestyle changes (e.g., diagnosis of chronic illnesses, retirement, empty-nest syndrome, divorce, the impact of psychosocial stresses) that should be considered when assessing sexual function