How can we improve the detection, assessment, and treatment of female sexual dysfunction?
Charlotte Methorst, MD, a urologist from Paris, and Carol Burté, MD, a sexologist and andrologist from Nice, dealt with these themes during a session at the French Urology Association’s 2023 conference, emphasizing the need for doctors to be involved in female sexual health.
“There’s currently a real disconnect; doctors talk very little about sexual health, yet it’s a topic that patients would really like to talk about. And this is even truer for women,” said Methorst.
“We need to spot sexual dysfunction because the topic is rarely broached spontaneously by female patients (19%) and even less so by healthcare workers (9%). Nowadays, it’s a very common problem (40%). Sexual dysfunction affects quality of life and a couple’s relationship. It also can reveal other conditions,” added Burté.
Spot and Assess
In terms of detecting the condition, the reference tool is the self-assessed Female Sexual Function Index, which comprises 19 questions covering six areas of sexual dysfunction: Desire, subjective arousal, lubrication, orgasm, satisfaction, and pain or discomfort.
But it is also possible to use the Sexual Complaints Screener for Women that evaluates sexual health over the past 6 months, explains Burté. For example, the patient is asked if she has had a lack of or low interest in sex or sexual desire in the past 6 months and if this has been a problem. She is also asked if she has experienced any pain during or after sexual activity.
To understand the root cause of sexual dysfunction, clinicians need to investigate the patient’s sexual health and perform a medical assessment. It’s also essential to ask the patient about her previous sexual, medical, and psychological history and to evaluate the couple and contributory factors, such as stress, fatigue, etc. This approach is known as the biopsychosocial model.
Once the contributory factors have been determined, relevant information can be given to the patient about her specific sexual problem, and the most suitable therapeutic approaches can be discussed with her.
Which Treatment Pathway?
Some problems may be improved with simple advice and lifestyle changes, but sex therapy and medication are options in other cases, explained the two doctors. “Since the causes of sexual dysfunction in women are mostly multifactorial, an integrative approach is needed,” said Burté.
The two main types of therapy that might be proposed for sexual dysfunction are sex therapies with cognitive behavioral therapy (CBT) and certain medicines being used as first-line treatment.
Using CBT in sexology requires patients and therapists to look past prejudices, preconceived ideas, and dysfunctional patterns and learn new behavioral, cognitive, and attentional strategies in terms of sexual health, regardless of whether an individual or couple is being treated.
Which Medicines?
Vasoactive drugs such as phosphodiesterase 5 inhibitors and prostaglandin have produced disappointing results. Drugs that act on the central nervous system to stimulate sexual desire, such as bremelanotide and flibanserin, don’t have marketing authorization in France due to their “insufficient” risk-benefit ratio.
However, topical hormone treatments (such as estrogen and dehydroepiandrosterone) are often used, particularly for cases of recurrent cystitis, in postmenopausal women and to treat urinary incontinence. “These topical treatments are very effective and can really change the life of a woman who no longer has a sex life because she is in discomfort and simply has dryness of the vulva and vagina,” said Burté, who recommends prescribing creams, which are better tolerated than pessaries.
General hormone treatments, hormone replacement therapy (HRT), and tibolone are prescribed to postmenopausal women.
Another option not yet authorized in France is testosterone because sexual desire depends on this hormone. An international consensus (2019, 10 learned societies) and recommendations made by the International Society for the Study of Women’s Sexual Health advise treatment with testosterone in the postmenopausal period, with or without HRT. The dose prescribed is a 10th of the male dose administered subcutaneously (300 µ/d) once a woman’s blood testosterone level has been determined to make sure there is an actual deficiency and to restore her testosterone to near premenopausal levels.
Both doctors indicated that having the chance to work with other doctors as part of a network is essential, especially with a sexual health specialist, if necessary.
Burté reported no conflicts of interest regarding the content of this article. Methorst reported relationships with several pharmaceutical laboratories.
This article was translated from the Medscape French edition.
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