key: cord-0035468-woezb9tc
authors: Koehler, Jean D.
title: Sexual Dysfunction
date: 2007
journal: Primary Care in Obstetrics and Gynecology
DOI: 10.1007/978-0-387-32328-2_20
sha: 6ddab202a9238f60e5680afad8242759c2c057f0
doc_id: 35468
cord_uid: woezb9tc

Female sexual dysfunction or dissatisfaction is a common complaint among obstetric-gynecology patients. These complaints may result from medical treatments and procedures, or may secondarily complicate the management and patient compliance of treatment for other medical issues. Therefore, it is important that clinicians treating females obtain basic information regarding human sexual function and dysfunction. This chapter presents an integration of the clinical research as well as the author’s experience regarding sexual function and the management of sexual problems often presented in an obstetricgynecology practice.

Female sexual dysfunction or dissatisfaction is a common complaint among obstetric-gynecology patients. These complaints may result from medical treatments and procedures, or may secondarily complicate the management and patient compliance of treatment for other medical issues. Therefore, it is important that clinicians treating females obtain basic information regarding human sexual function and dysfunction. This chapter presents an integration of the clinical research as well as the author's experience regarding sexual function and the management of sexual problems often presented in an obstetricgynecology practice.

The Sexual Response Cycle Sexual functioning is often described through the sexual response cycle, which includes sexual drive (libido), arousal, orgasm, and resolution. Each phase interacts with and infl uences the presence or absence of the other, and does not necessarily proceed in a linear fashion. Each is affected by psychological, sociological, and relational processes. However, natural sexual function throughout the whole sexual response cycle is physiologically dependent on adequate hormone levels-particularly estrogen and testosterone, enzymes that convert precursor hormones to the above-mentioned hormones, nonhormonal neurotransmitters like dopamine, adequate blood supply, and adequate central and peripheral nerve conduction. The clinician who assesses all of the physiologic and nonphysiologic areas, when presented with a patient with sexual dysfunction, will obtain a better diagnosis and treatment plan.

Sexual drive is the urge to obtain sexual stimulation. It can take the form of an urge to masturbate, watch or hear erotica, experience sexual dreams, or engage in stimulation with another person.

Sexual arousal occurs in two basic forms: mental and physiologic. Mental arousal occurs when a person reports feeling "turned on" or pleasure to erotic stimuli. Physiologic arousal usually includes genital vasocongestion, vaginal lubrication, increased genital erotic sensitivity, and the presence of prostatic-type secretions in the bladder and urethra as well as increases in respiration, pulse, and blood pressure. Mental arousal and physiologic arousal do not always occur together, as is sometimes the case with rape or unwanted stimulation, where vaginal lubrication may occur without any sense of subjective arousal. Physical reactions of sexual arousal in the female are presented in Table 20 .1. Not all of these are observed in every woman.

The orgasmic phase of the sexual response cycle mainly consists of the 0.8-second involuntary contractions of the vaginal canal and uterus, accompanied by a subjective sense of sudden heightened pleasure. Some 1. Swelling of the labia, clitoris, and introitus 2. Lubrication of the vaginal canal-a "sweating phenomenon" through the mucous membranes lining the vaginal walls 3. Minor secretions of the Bartholin glands 4. Erythema of the genitalia 5. Lengthening, ballooning, and involuntary spasms of the vagina 6. Lifting of the uterus into the false pelvis 7. Descending of the uterus with G-spot stimulation 8. Swelling of the breasts 9. Nipple erections 10. Reddening of the neck and chest of some women 11. Increase in heart rate, blood pressure, and respiration 12. Milky, prostatic-like fl uid from the paraurethral gland either emitted out of urethra or present in the bladder or urethra poststimulation women with strong vaginal and uterine muscle strength will ejaculate the milky prostatic-type fl uid that is already present in the arousal phase, from the urethra during orgasm. When not ejaculated externally, this fl uid can be found in the bladder poststimulation. The clitoris is probably the most reliable source of stimulation for female orgasm, although some women report a preference and facility for orgasms mediated primarily by vaginal or cervical stimulation. Even women with complete spinal cord injuries have reported laboratory-documented orgasms. The G-spot (an area felt through the anterior wall of the vagina, halfway between the back of the pubic symphysis and cervix, along the urethra) is a common site of intravaginal orgasmic stimulation. If a patient is unsure as to whether she has ever experienced orgasm, preorgasmic sensations may be described as a wave of pleasure that extends over her pelvic area much like the sensation of going over a roller coaster hill followed by the sensation of vaginal contractions and then a feeling of satisfaction. Intense orgasm can be compared to the sudden pleasure and intensity of a sneeze, usually accompanied by a throbbing sensation in the vagina. The vaginal sensations of less intense orgasms feel more like a ripple than an intense series of contractions. Table 20 .2 lists the typical physiologic reactions during the orgasm phase. Orgasm contractions usually last from 3-5 seconds and will be followed either by a sense of physiologic satisfaction (especially in the case of an intense orgasm) or by an urge to continue the stimulation (possibly resulting in more orgasms). When orgasm occurs in a very positive context, the woman often has subjective feelings of satisfaction and/or emotional bonding toward her partner. However, these positive feelings can also result without experiencing the orgasm phase of sexual response, a phenomenon that is diffi cult for many men to relate to. 1. 0.8 second contractions of the vaginal canal 2. Possible contractions of the uterus, rectum, urethra, perineum, and lower abdomen 3. Milky, prostatic-like fl uid from the paraurethral gland either ejaculated out of urethra or present in the bladder or urethra poststimulation 4. Heart rate increases to 110-180 beats per minute 5. Systolic blood pressure increases 30-80 mm Hg 6. Diastolic blood pressure increases 20-40 mm Hg 7. Respiratory rate increases up to 40 breaths per minute 8. Muscular tension (different from anxious tension) throughout the whole body

After orgasm, all of the physiologic changes return to the unstimulated state in most women. This is called the resolution phase. A few women will retain the vasocongestion, sometimes resulting in an uncomfortable condition called pelvic congestion syndrome or persistent sexual arousal syndrome.

This section lists the defi nitions, etiologies, and treatment of sexual dysfunctions and problems. The information on pharmacologic and medical causes of dysfunctions cannot be considered all-inclusive, because all conditions and medications listed have not been supported by controlled research, especially in women. Many of the conditions and drugs listed have been supported by research, while others are included because of clinical experience that is consistent with mechanisms of action known to infl uence sexual response. However, medication effects vary across individuals, with higher dosage levels and greater length of use increasing the incidence of sexual side effects. The clinician is encouraged to refer to the two sexual pharmacology compendia in the reference section to obtain information on the sexual effects of specifi c drugs as well as preferred alternatives within classes of drugs.

The sexual dysfunctions of female patients are (1) hypoactive sexual desire disorder; (2) arousal disorders; (3) orgasmic disorders; (4) dyspareunia and noncoital sexual pain disorders; (5) vaginismus; and (6) sexual aversion. Other sexual problems that might be encountered include (1) sexual drive discrepancy between the patient and her partner, (2) concern over types of sexual activities, and (3) sexually compulsive behavior in the patient or her partner. In addition, heterosexual patients may seek advice about sexual dysfunction in their male partners, including (1) hypoactive sexual desire disorder, (2) erectile dysfunction, (3) premature ejaculation, and (4) delayed or absent ejaculation.

This disorder is characterized by a persistent absence or near absence of sexual drive and receptivity that cause personal and/or interpersonal distress. In the general population, about one-third of women reported low sexual drive in the immediate past year of their lives. The range of normality is affected by the patient's age, length and quality of sexual and emotional relationship with her current partner, and her health status. In population-based studies, most women aged 18-29 years engage in partnered sex between two times a week and a few times a month. In contrast, almost a third of women aged 50-59 years claim to be sexually inactive with partners, while 57% engage in partnered sex a few times a month to a few times a year. Of those who are sexually active with partners, the average frequency of sex ranges from seven times a month for young women to four times a month for women in their fi fties.

Potential physical causes of low sex drive are listed in Table 20 .3. Androgen insuffi ciency has become increasingly recognized as an important cause of this disorder, and is present in women following oophorectomy or ovarian shutdown from medications or radiation, the binding of free testosterone from oral estrogen medications, hypothyroidism, hypopituitarism, and adrenal insuffi ciency. Table 20.4 lists psychotropic drugs, Table 20 .5 outlines antihypertensives, and Table 20 .6 provides information on miscellaneous drugs that have been shown to lower sex drive in some patients.

One type of sexual arousal disorder is the persistent or recurrent inability to attain or maintain suffi cient sexual excitement as noted by a lack of genital vasocongestion, erotic genital sensitivity, and vaginal lubrication. Another type involves a failure to mentally perceive sexual stimulation as arousing or pleasurable despite adequate physiologic indications. In a study of the general population, around 20% of women complained either of unpleasurable sex or diffi culty with lubrication. Vaginal lubrication and elasticity are highly dependent on estrogen. Likewise, lubrication is dependent indirectly on cholinergic transmitter activity. External genital vasocongestion is also dependent on nonadrenergic/ noncholinergic neurotransmitters like nitric oxide synthetase and polypeptides, such as vasoactive intestinal peptide. Therefore estrogen levels and a review of medications that might interfere with transmitter action are warranted. Also, the conditions or medications that affect sexual desire or orgasmic capacity can affect arousal through a negative feedback loop. In other words, if a woman does not desire to be sexually active because of a testosterone defi ciency, she may comply with her partner's initiations but fail to lubricate because of disinterest. There are drugs and conditions believed to inhibit arousal directly and they are listed in Tables 20.7 and 20.8, respectively.

A third type of arousal disorder is persistent sexual arousal syndrome or "PSAS." Prevalence statistics are not available for this disorder. In PSAS, the physiologic responses characteristic of sexual arousal mentioned above may persist for hours or days, and are not necessarily triggered by sexual stimulation or resolved by orgasm. Most, but not all women complaining of this disorder fi nd the symptoms intrusive, worrisome, and sometimes depressing. The research into this syndrome is so new that much is not known about the cause or treatment. All treatments reported to date have failed, but occasionally a patient's symptoms will remit spontaneously.

Orgasm dysfunction occurs when a woman fails to reach that peak level of pleasurable release accompanied by vaginal contractions after suffi cient genital stimulation. She is considered dysfunctional only if the condition is persistent and causes her distress. Over 20% of women in the general population claimed a. Any disruption to the nervous or vascular supply to the genitalia can indirectly lead to low sex drive because of the loss of pleasurable feedback to the brain (i.e., colon and rectal surgery for cancer) b. Any surgery that disrupts the sex centers of the brain 6. Injury-any injury that disrupts the nervous and vascular supply to the pelvis or sex centers of the brain diffi culty with orgasm in the prior year, whereas only 4% claimed to have never orgasmed. A woman is considered dysfunctional if she fails to achieve orgasm under any circumstance, if her orgasms come so infrequently that sex is disappointing to her, or if orgasm requires such prolonged stimulation that sex becomes a chore. Although many women can learn to reach orgasm with sexual intercourse, failure to reach orgasm regularly with penetration is common and 

Dyspareunia (coital pain), which occurs in about 15% of women in the general population, and noncoital sexual pain can be the result of a variety of physical sources. Types of pain range from itching, burning, or friction of the mucosa, pinpoint sharp pain upon light touch, tightness, and pain upon deep penetration. Even psychological sources can eventually lead to a physiologic cause. For example, failure to arouse mentally can prevent vaginal lubrication causing friction, and fear of pain may cause the vaginal muscles to tighten, making the canal too small to accommodate the penis comfortably. 

Vaginismus is an involuntary contraction of the perivaginal musculature making vaginal penetration impossible, or nearly impossible without signifi cant discomfort or pain. Its prevalence is unclear due to the lack of sampling in populationbased studies. However, clinical experience suggests that this problem is being presented at increasing rates to health care providers due to the impact of vulvodynia. Vaginismus is often caused by a prior history of dyspareunia for reasons listed in Table 20 .11, by fear of painful intercourse learned from folklore, or by a history of sexual abuse. This condition can be worsened by the gynecologist who is too eager to complete a pelvic examination, despite the patient's warnings of prior painful penetrations or painful protestations during the pelvic examination. Women with vaginismus sometimes retain normal sex drive and the ability to achieve orgasm by noncoital methods.

Sexual aversion is the negative or phobic reaction to sexual activity or to the anticipation of sexual activity. Sometimes aversion to a particular sexual activity, like fellatio, or to a sexual part, like the penis, makes the woman avoid all sexual activity. When aversion is of phobic proportions, physical reactions are those of panic disorder: overwhelming anxiety, sweating, nausea, vomiting, diarrhea, or palpitations. Once sexual activity begins, some women proceed through the sexual response cycle. A previous history of dyspareunia and low testosterone could be physical precursors to this condition, though most causes are believed to be psychological. 

Sexual drive differences between partners constitute one of the most common sexual concerns presented to sex therapists. It is not necessarily accompanied by sexual dysfunction in either partner. When drive differences cause signifi cant problems, it is often because one partner believes that his or her drive is the norm and the other partner's drive is abnormal. Physicians can educate their patients about the wide range of normal sexual frequencies and discuss options for compromise.

Another sexual problem commonly encountered is the discrepancy between a woman and her partner over the type of sexual activity they enjoy. The inclusion of oral sex is a common source of disagreement between partners. These discrepancies, if left unresolved, can lead to sexual dysfunction. The physician can assess whether the patient needs accurate information about the normality of a given activity, how to engage in sexual practices effectively, or how to prevent injury or disease. Oral sex participants should know that many sexually transmitted diseases can be transmitted orally and condoms or dental dams should be used when there is a risk of disease. Additionally, there is a statistically signifi cant, positive association between oral sex and repeated vulvovaginal candidiasis.

Likewise, anal sex recipients should be encouraged to lubricate and gradually dilate their anal openings before penetration with a penis or dildo to prevent tears of the mucosa. Frequent anal eroticism is associated with anorectal pain, ulcers or fi ssures, rectal prolapse or leakage, and hemorrhoids. Condoms should be used to prevent transmission of sexually transmitted diseases (STDs). There should be no penetration of the vagina with anything that has just been in the rectum because normal bacterial fl ora in the rectum will cause infection.

The physician may encounter sexually compulsive behavior in the patient or her partner. This problem is defi ned as a pathologic need for sexual activity that gradually replaces the desire to have healthy relationships and activities. And while compulsive sexual activity can be secondary to other compulsive, addictive, mood, or posttraumatic stress disorders, it may also be a primary comorbid condition. Clues to sexual compulsivity that may present in the gynecologist's offi ce include genital injury from compulsive masturbation, repeated STDs or unplanned pregnancies, a history of multiple sexual partners in a short period of time, or a demanding attitude about frequency or activity. This patient may also be seductive with her physician.

More often, the patient is the victim of her partner's sexual compulsions. In this situation she may present with genital injury, STDs, a loss of sex drive due to the excessive demands of her partner, or a complaint of infrequent sex due to the partner acting compulsively outside of the relationship. Use of Internet pornography has become an increasing complaint of sex therapy patients, with research showing some participants spending over 20 hours a week in such activities-neglecting family, job, or the need for adequate sleep. Patients with simply high sex drives, or practices that are not part of the cultural norm, can be misdiagnosed as compulsive by conservative partners or clinicians. Such diagnoses should be left to sexual specialists. Furthermore, true sexual compulsion is a very complex problem to treat and almost always warrants a referral to a sex therapist.

Sexual dysfunction in the heterosexual patient's partner may lead to her own sexual dysfunctions. A patient may also seek guidance for the partner's dysfunction. It is important for the gynecologist to know how to diagnose and refer these patients. (Lesbian partner's dysfunctions can have similar effects on your patient and likewise need to be addressed.) Male sexual dysfunctions are listed in Table 20 .12.

Hypoactive sexual desire disorder in a male is essentially the same phenomenon as in women in defi nition and causes (see related tables). One main difference is in the role of estrogen, which, when excessive in the male, lowers his drive. Some diseases, such as alcoholism, result in a relative increase of estrogen in a man's body because of the pathologic state of the liver. In other cases, medications may raise his estrogen levels to sexually dysfunctional proportions. A man with a global decline in sex drive should be evaluated by his primary care physician. However, the man whose sex drive has remained intact in general but is turned off only by his current partner can be referred for couples therapy or to a sex therapist.

Erectile dysfunction is a failure to attain an erection during genital stimulation, or failure to maintain an erection until ejaculation or the man's desire to stop. This label also applies to erections lacking adequate rigidity for penetration. The ability to maintain an erection to ejaculation with manual stimulation, or with an alternate partner's stimulation, is a good indicator that there is no Referral to a urologist who specializes in sexual dysfunction is the safest way to ensure diagnostic accuracy. As psychogenic erectile dysfunction is more adequately treated if it is addressed sooner, prompt referral to an appropriate specialist is important.

Premature ejaculation occurs when a man lacks the ability to exert some control over his ejaculatory latency. Usually this diagnosis is more appropriate when the man ejaculates sooner than several minutes after penetration. The human male would naturally ejaculate within 2 minutes of vaginal thrusting if he were not purposefully delaying this refl ex. A patient might complain of the partner's premature ejaculation because she has not reached orgasm with vaginal penetration, even after as much as 10 minutes of thrusting. This patient merely needs to be educated about the relative differences in vaginal and penile sensitivity and the importance of clitoral stimulation and increased foreplay before penetration. Premature ejaculation is rarely a result of medical conditions, and unless the man is complaining of other symptoms indicative of urinary tract infection or prostatitis, referral to a sex therapist is appropriate.

Delayed ejaculation occurs when a man or his partner complains of his inability to ejaculate after suffi cient stimulation to the penis. The inability to ejaculate within 5-10 minutes (when a man is not intentionally suppressing this refl ex to please his partner) can be considered dysfunctional. As with female orgasmic dysfunction this defi nition is subjectively defi ned by the couple, and especially the man's subjective sense of a failure to progress to orgasm. When the man has no diffi culty ejaculating with noncoital stimulation, the problem is assumed to be psychogenic and referral to a sex therapist is appropriate. However, diseases such as diabetes and medications such as selective serotonin reuptake inhibitors (antidepressants) are often associated with this symptom and referral to an internist or urologist is recommended. 

Immediate causes of sexual dysfunction are those that occur during the lovemaking process and include the following.

This phenomenon occurs when a person mentally stands outside herself and watches during sexual activity. As she watches, she will often internally criticize herself whether or not that evaluation has any basis in reality. These mental processes lower her mental pleasure and send inhibitory messages to the pelvic nerves, thus damping her sexual refl exes.

This occurs when a woman has certain expectations of the "right" way to respond sexually and does not live up to her own expectations.

A woman may have trouble responding if she is focused so much on her partner's pleasure that she does not attend to the type of stimulations or conditions she needs to be aroused.

Sometimes a woman focuses on certain negative characteristics of her lover during or just before the sexual experience-body type, manner of dress, etc. Although perhaps justifi able, this may also stem from being a perfectionist and thus unable to focus on the total love-making experience.

Although commonalities exist, each woman is unique in her preferences. Furthermore, the same stimulation may produce opposite reactions in the same woman at different times. Thus, it is very important that the woman be free to communicate her sexual preferences to her partner. The clinician should urge the patient to be a good communicator.

Research demonstrates that women are less likely to require sexual attraction when selecting their committed partners versus their dates. After the newness of a relationship wears off, a woman may fi nd sex with her partner of decreasing appeal. An often overlooked factor in women's arousal is the bodily scent of 1. Immediate-spectatoring, performance anxiety, need to please, negative focus, ineffective stimulation, lack of attraction, distracting fantasies/ thoughts 2. Relational-anger, power struggle, infi delity, mistrust, lack of emotional intimacy, fear of pregnancy, divergent preferences, sexual addiction/compulsion 3. Psychiatric-depression, anxiety, posttraumatic stress disorder, some personality disorders 4. Historical-religious repression, sexual trauma, negative parental input 5. Societal-myths, media, double standard her partner. Therefore, a woman turned off by her partner's scent will be negatively affected by a common precursor to women's sexual receptivity-the physically affectionate touching that precedes sexual interaction. Such partners should pay strict attention to their hygiene to minimize this impact.

Sometimes disruptive fantasies and thoughts occur during sex. They may include images of prior sexual abuse causing anxiety and disgust, images of other desirable sexual partners or taboo, but arousing sexual activities inducing guilt, or simply images or thoughts of which chores need to get done.

Relational causes of sexual dysfunction, which occur with one's sexual partner, are characterized by the following.

Displaced Anger. Unresolved anger often affects the ability and desire to respond to one's partner sexually.

Power Struggle. Some individuals withhold sex to punish or engage in sex to manipulate their partner, in response to a lack of power or agreement in other aspects of the relationship.

Infi delity. If the patient has had an affair, her drive toward her committed partner may decrease out of guilt, a sense of loyalty to her other lover, or fear of infecting her committed partner with an STD. Likewise, if her partner has been unfaithful, her drive may decrease as a result of a feeling of betrayal, depression, anger, or fear of contracting a disease.

Mistrust. In addition to the mistrust that results from an affair, women's drives may be decreased by their inability to trust their partners with the intimate physical and verbal reactions that come from uninhibited sex. Similarly, they may refuse sex because they are not certain that the relationship will last.

Lack of Emotional Intimacy. Women tend to respond best when they feel emotionally close to their partners. Poor communication patterns and lack of personal differentiation can prevent emotional intimacy from developing in a couple.

For a woman to respond best during sex, she must be uninhibited and free of fears. The woman who is not ready to risk a pregnancy may keep herself "in check" so that she will not have intercourse or forget to use contraception.

Some women avoid sex because of the fear of being pressured into unappealing sexual activity (such as anal sex). Others may not respond well because their partners do not want to touch them the way they most prefer. Remind the patient that a healthy partner appreciates not having to guess, is aroused by his or her partner's forthrightness, and is willing to fi nd sexual activities that appeal to both.

Compulsive tendencies may cause a decrease in responsiveness as a result of oversatiation. Likewise, sexual activity may not be particularly pleasurable because the goal may be to numb negative emotions rather than to express sexual urges. The woman with a sexually compulsive partner may become less responsive because of the pressure to be sexual regardless of her feelings or needs. Conversely, some compulsive partners engage in sex elsewhere, leaving the woman to complain of infrequent sex.

Psychiatric disorders can produce sexual problems. The most frequent associations are with depression, anxiety disorders, posttraumatic stress syndrome, and alcoholism or drug addiction. Other common psychiatric disorders, such as personality disorders, can be related to sexual dysfunction, but not necessarily.

Historical inputs to sexual dysfunction, including events in the individual's upbringing that have negatively affected current sexual attitudes, may occur through the following ways.

The Judeo-Christian ethic has traditionally been sexually repressive, assigning negative attitudes to sexual pleasure. While this message has changed in some religions, the current trend of sexual conservatism has resulted in mixed messages, leaving young newlyweds with sexual anxiety and guilt, aging couples with the belief that sex solely for pleasure is inappropriate, and homosexual individuals struggling to function within heterosexual marriages.

An estimated one-third of women have experienced sexual abuse in their past. This is most often associated with subsequent sexual dysfunction, but compulsive and irresponsible sexual activity can also result. Adolescent girls who have been abused are more likely to attempt to or to become pregnant and to initiate sex at a younger age than their nonabused peers.

Parents convey sexual attitudes to their children whether they refer to sex directly or not. By not educating children positively about the sexual aspects of their bodies and feelings, or by conveying only the consequences of sex, parents inadvertently convey a negative or shameful attitude about sex and sexual body parts.

Societal causes, which are those generalized beliefs and behaviors within a culture that affect women's sexual self-image and self-esteem, are conveyed through the following.

Myths. Our society has a history of withholding sexual information, and myths develop out of this ignorance. A very common myth is that women should fi nd sexual intercourse as physically stimulating as men. Another is that what stimulates one person will automatically stimulate that person's partner.

Media. Use of beautiful, slender models in media advertising has resulted in a negative body image in some women. These women tend to focus on their perceived bodily imperfections during sex rather than on their pleasure.

Double Standard. The double standard still exists, causing women confusion about claiming their sexuality. Sexually assertive men may be revered, whereas the same behavior in women may be seen as "loose." This double standard extends to some medical sexual studies when it ignores the research on the complexity of female sexual function and satisfaction, and how often the sexual responses of females are attained differently from those of males.

Taking a thorough sexual history of a patient is the key to accurate diagnosis and treatment. Three types of histories, listed in Table 20 .14, are appropriate in an obstetric-gynecology practice: one occurs within a routine review of systems during an annual examination or request for a physical; the second occurs when the physician is consulted about physical symptoms that may be related to sexual activity; and the third occurs when a patient specifi cally discloses a sexual dysfunction and asks for help. A sex history can be covered in several minutes.

Although a high percentage of patients (85-91%) believe it is appropriate for physicians to take sexual histories, studies show that physicians are generally reluctant to initiate questions concerning sex with their patients for fear of seeming inappropriate, because they feel unskilled, or because they believe they do not have time to cover this area. Other physicians are reluctant Table 20 .14. Types of sexual histories.

1. Routine review of systems 2. Secondary to pelvic symptomatology 3. Sexual dysfunction to bring up sex because of their own embarrassment or lack of skill in discussing sex or because they do not want to make their patients uncomfortable. Because research shows that more than half of women admit to sexual problems when specifi cally asked, and because STDs can have far-reaching health consequences for women, it is imperative that clinicians initiate these discussions.

Effective sexual history taking requires more sensitivity than other reviews. A patient is more likely to be honest if she believes that her physician is interested, nonjudgmental, and comfortable with the topic. Physicians who are uncomfortable are encouraged to seek guidance from an experienced sex therapist and/or attend a "Sexual Attitude Reassessment" seminar (for a list of SARs call The American Association of Sex Educators, Counselors, and Therapists-804-752-0026). Questions should be worded in a way that makes no assumptions about sexual orientation or monogamy.

The form of sexual history taking shown in Table 20 .15 is used as a screening device for sexual activities that may affect a woman's health or sexual satisfaction. In addition, it can provide a baseline of functioning that can be used for comparison in later years to more effectively assess the impact of gynecologic surgeries, medication, menopause, or pregnancy on the patient's sexuality.

This sexual data gathering seems to fl ow best at the end of a menstrual history. Using the same matter of fact tone of voice and pacing, proceed with the questions in Table 20 .15. If you are fearful of being misunderstood, begin with something like this: "Ms. Jones, I'd like to ask you some questions about your sexual functioning if you don't mind. Sexual activity can affect your health and your health can affect your sexual activity. I want to make sure I don't miss anything important. I am not here to judge you, so please feel free to be candid with me." Some of the questions in Table 20 .15 are best asked the fi rst time a patient is seen. For ongoing patients, use judgment to modify questions based on what is already known about the patient. For example, a long-term patient whose previous history shows she is monogamous and heterosexual might be insulted by questions that suggest she is not. It is best to review the sexual functioning questions in terms of whether the patient has developed any new symptoms or concerns since the last visit. Try to assess the patient's level of sophistication with vocabulary and modify questions using the terms with which she seems comfortable. It may be necessary to defi ne some terms, especially if the patient seems confused. Likewise, begin questions with "how often do you" or "when you." Phrases such as "have you ever" suggest that such a practice is unusual and is likely to elicit a false-negative reply.

If the patient seems unusually uncomfortable with sexual history taking, stop and note her discomfort and ask her if she would like to talk about it. She may reveal that she experienced sexual abuse as a child and has kept this a secret. Be sure to stop the history taking and show appropriate concern. The patient may feel she is taking a major risk in revealing this information. Another patient may be uncertain of the physician's motives in asking sexually explicit questions. If the prologue mentioned above was not used, now is the time to briefl y explain that sexual symptoms and dissatisfaction can affect a woman's health and how well she takes care of herself. After explaining this to the uncomfortable patient, always ask her permission to continue with the sexual history. If she will not allow it, nonjudgmentally suggest that if she ever wants to discuss her concerns in the future, you are willing to do so. Likewise, offer a referral to a therapist if she reveals a history of abuse or dysfunction. It may take multiple visits for a patient to build enough trust to reveal her sexual concerns. By opening the door each time with sexual questions, it allows her to address these issues when she is ready, without having to openly admit that she withheld information in the past.

Most physicians' concerns about sexual history taking can be alleviated by showing their patients they care about their health and are sensitive to the embarrassment that many have in discussing sex.

Parts of the same sexual history used for routine examinations noted in Table  20 .15 can be used for the patient with pelvic symptomatology. Just preface these questions differently, such as, "Ms. Johnson, sometimes the symptoms you are having are related to a woman's sexual practices. I'd like to ask you some questions that could help me treat your symptoms more successfully. Please feel free to be honest. I just want to help you get over these symptoms." Table 20 .16 lists general questions to ask when a patient presents with a sexual dysfunction or when you have uncovered a problem in a routine screening. Note that a patient with no personal or interpersonal distress about her sexual responses needs no treatment unless she specifi cally wants to improve her functioning. Obtain information on the entire sexual response cycle of the patient and her partner, as one dysfunction may be at the root of another. For example, a patient who presents with low sex drive may have dyspareunia as the causative factor. Assess desire, lubrication/erection, orgasm/ejaculation, presence of sexual pain, and satisfaction regardless of which dysfunction is initially presented. If the patient shows distress in discussing these problems, be sure to make empathic statements such as "this has really bothered you, hasn't it?"

If the patient's complaints include decreased sexual desire, she should always be screened for depression. Table 20 .17 lists the appropriate questions. A positive reply in several areas indicates a need for further evaluation by an internist and possibly a referral to a psychiatrist or experienced nonmedical therapist. Reassure the patient that she will get a thorough assessment and appropriate treatment.

It should be noted that diagnostic tools for identifying organic causes of female sexual dysfunction are greatly underresearched and lag far behind those for male sexual dysfunction. Vaginal photoplethysmography is of some benefi t and other measures of clitoral and labial temperature and blood fl ow are being developed. Well-researched neurologic tools for genital sensitivity are needed as well as greater understanding of hormonal and other neurochemical mediators. Furthermore, current testosterone assays for normal female levels are unreliable at the lower ranges and laboratory ranges are not correlated with good sexual functioning. Therefore the recommendations given below may change greatly over the next few years. 

If the history and physical examination suggest it, laboratory studies should be done to screen out physical causes of low sex drive, especially hypothyroidism and hypopituitarism. Androgen defi ciency is emerging as a likely medical cause of this disorder, especially if the patient is well estrogenized. A woman with insuffi cient androgens will give a history of persistent absent or almost absent sexual drive for partnered sex, masturbation, and erotica, and few if any sexual dreams. Additionally, she may complain of a persistent unexplained fatigue, lowered mood, and decreased sexual receptivity, orgasm, and pleasure. Recommended laboratory screening for low sex drive is presented in 1. Do you feel depressed? (A negative reply does not necessarily rule out depression) 2. Is your sleep disrupted in any way, such as diffi culty getting to sleep within 10-15 minutes, waking during the night with diffi culty getting back to sleep easily, awakening 1-2 hours earlier than you need or want to? 3. Has your appetite greatly increased or decreased? 4. Has your weight fl uctuated more than 10 pounds without effort on your part (not due to smoking cessation)? 5. Do you experience constipation? Diarrhea? 6. Has your drive for sex been lowered under all circumstances? 7. Has your energy decreased a lot? 8. Has your concentration decreased a lot? 9. Are you feeling excessively guilty about something? 10. Do you feel inadequate or like a failure? 11. Do you have persistent thoughts of death or suicide? (A positive reply to this question warrants immediate referral to a psychiatrist.)

should be obtained in the morning, but there is lack of consensus as to whether they should be drawn in the follicular phase, when androgens are lowest, or in the midcycle, when testosterone peaks at ovulation. Treatment for most physical causes of low sex drive listed in the tables is well documented. However, treatment recommendations for androgen insuffi ciency are just emerging and thus it will be discussed in detail here. It has been suggested that because testosterone assays are not sensitive at lower levels of female normal ranges, a free testosterone level in the lower quartile of the normal range accompanied by symptoms of testosterone defi ciency warrants a trial of replacement therapy. Ironically, because oral contraceptives lower free testosterone, replacing them with nonhormonal methods may be all that is needed in some women. Likewise, women on oral forms of estrogen (replacement) therapy should switch to a transdermal approach, which does not bind free testosterone except at high doses. If sexual symptoms persist 6-12 weeks after these medication changes, laboratory tests should be repeated to rule out continued androgen defi ciency. Options for androgen replacement therapy are presented in Table 20 .22.

Research results indicate that injectable forms of testosterone produce reliably positive sexual drive effects in oophorectomized women and have not been shown to adversely affect high-density lipoprotein (HDL) and liver toxicity like oral forms. While clinical experience attests to the effi cacy of injectable routes of testosterone administration in premenopausal, testosterone-defi cient women, there are no published data to support this approach while keeping testosterone levels within physiologic ranges. Once replacement begins, laboratory tests need to be repeated every few months to make sure the patient stays within normal ranges. Though not well supported by controlled research results, methyltestosterone (oral form) dosed at 1.25-2.50 mg/day is effective for some women and is available for hormone therapy (HT) either as Estratest or can be individually compounded. Surgically menopausal women have not demonstrated any hepatotoxicity at dosages of 2.5 mg of methyltestosterone daily, but have demonstrated adverse trends in lipoproteins. Furthermore, research on higher replacement dosages of methyltestosterone (often in men) reports signifi cantly lower HDL cholesterol, liver toxicity, and polycythemia. Therefore, pretreatment laboratory measures of hepatic function, lipid profi le, triglycerides, and hematocrit, as listed in Table 20 .23, are indicated with repeat studies in intervals of several months to 1 year once replacement begins.

In controlled studies, dehydroepiandrosterone (DHEA) tablets have been shown to be effective in raising sex drive and responsiveness for pre-and postmenopausal women with documented adrenal insuffi ciency and for premenopausal women with hypopituitarism. The overall effi cacy of DHEA for premenopausal women with androgen insuffi ciency remains to be clarifi ed. Effective dosages ranged from 30-50 mg/day. However, fi nding a brand of DHEA with guaranteed potency is diffi cult since it is unregulated by the Food and Drug Administration (FDA). Both oral forms of androgen replacement-DHEA and methyltestosterone-appear to be safe in the short run in the dosages mentioned. Controlled research on testosterone gels in this population so far shows positive sexual effects only when free testosterone was elevated to supraphysiologic ranges.

Anecdotally, a 2% testosterone cream has also been used with mixed feedback as to its effectiveness for libido problems, possibly because some patients tend to use insuffi cient doses to bring testosterone into normal ranges. The lack of controlled studies on this route of administration leaves the clinician with only experiential guidelines and repeated laboratory assays Table 20 .23. Laboratory tests prior to and during androgen replacement.

1. Lipid profi le-total, high-density lipoprotein, low-density lipoprotein 2. Hepatic function 3. Triglycerides 4. Hematocrit to determine if dosages are producing improved levels of circulating androgens. The same is true for testosterone gels, modifi ed from male dosages that are currently available. However, controlled research does support the effi cacy of a testosterone patch in raising several sexual function parameters in oophorectomized women, but this approach currently lacks FDA approval until longer term safety studies can be conducted. This product has excellent shortterm safety results. No matter which route of hormone administration is used, patients will likely need several months-possibly 4-6-of consistent treatment, with regulation of dosages often based on repeated laboratory assays and symptom relief, before positive effects can be seen or androgen replacement therapy can be considered ineffective.

The most common side effects of any form of testosterone replacement therapy include weight gain, increased facial hair, and acne. However, when levels are kept within normal ranges, these side effects are not common and do not require discontinuation of treatment. Lipid profi les may worsen, especially with oral routes, and therefore need to be monitored before administration and at intervals of several months during usage. Dosages can be lowered to obtain a balance between sexually enhancing effects and unwanted side effects.

If desire stays low despite several months of documented normal androgen values, the couple should be referred for sex therapy. Replacement therapy can be continued during the course of psychotherapy to see if the combination produces effective results. However, couples with long-term desire diffi culties and androgen insuffi ciency often benefi t from combining sex therapy and androgen replacement therapy at the beginning of treatment, to counteract negative attitudes and ineffective coping strategies.

Reproductive aged women who choose androgen replacement therapy should be informed of the potential masculinizing risks to a fetus and be encouraged to use highly reliable birth control methods. Until long-term studies can document the safety of androgen replacement therapy, women with an already adverse lipoprotein profi le, documented atherosclerotic cardiovascular disease, or a marked family history of cardiovascular disease, diabetes, or breast cancer should be informed of the potential for exacerbation of these diseases or their side effects with androgen replacement therapy.

Patients with no discernible medical cause for low sex drive should be referred with their partners to a sex therapist. Sometimes the patient presents with a complaint of low sex drive based only on the discrepancy of drives between partners. When no sexual dysfunction is present, couples should be encouraged to use the following paradigm. If the patient is approached for sex but would resent participation, her partner can be encouraged to masturbate, if that is within the partner's value system. If the patient is neutral, she might propose a sexual encounter where no expectations about outcome would be the ground rule. That way, if she does not become aroused, her partner need not take it personally, but can nonetheless benefi t from the stimulation received. Similarly, the sexually neutral patient can offer to stimulate her partner without receiving any stimulation in return. Of course, if any of these solutions become the norm, or if both people are not willing to be fl exible, a referral for sex therapy is warranted.

For all the sexual dysfunctions, the obstretic-gynecologic clinician can provide immediate help in the form of accurate information, permission to be sexual, or encouragement to communicate the patient's sexual needs to her partner. However, because low drive tends to be a multifactorial problem, treatment often requires a trained sex therapist who may recommend a combination of psychotherapy, couples therapy, bibliotherapy, and at-home sexual exercises. If there is sexual abuse in the patient's history, direct referral to a psychotherapist is indicated.

Standard applications of vaginally inserted estrogen cream or tablets in those with laboratory documented serum defi ciencies of estrogen or who otherwise show signs of vaginal atrophy should be prescribed for those lacking genital vasocongestion and lubrication. If coincident with androgen insuffi ciency, lack of genital sensitivity can be treated with a topical testosterone cream applied to the vulva, though its effectiveness is yet to be documented with controlled research. Other androgen replacement options mentioned above could be considered as well. In selected cases, oral vasodilators such as Sildenafi l have increased genital vasocongestion with sexual stimulation. Clinical trials are under way to determine the effectiveness of Sildenafi l and other vasodilators such as L-arginine, yohimbine, apomorphine, and phentolamine. Topical prostaglandin E 1 and vasoactive intestinal peptide are also under investigation for arousal disorder.

If physical causes of this disorder have been ruled out, and the patient's sexual attraction for her partner is intact, her problem may be caused simply by a lack of proper stimulation. The patient should be encouraged to communicate the type of touch she wants to her partner. If not already known from prior experience, this can be learned through masturbation or by reading books designed to help women to orgasm. Often she will need emotional connection or a different type of initiation to become receptive, but she has failed to communicate to her partner how that can be established. Women who are unable to follow through with communication or whose arousal disorder is not amenable to simple education and permission giving by their physician will need psychotherapy to address the more complex causes such as relationship problems or sexual trauma.

Orgasmic dysfunction may be medical in etiology. Certainly physicians should assess for symptoms indicative of medical causes listed in the tables, for example, unregulated diabetes or diabetic neuropathy, androgen defi ciency, and selective serotonin reuptake inhibitor (SSRI) antidepressants. Sexual dysfunction in diabetics may subside once blood sugar levels are brought under control.

Androgen insuffi ciency should be treated using the guidelines in the low sex drive section. Preliminary controlled trials show that the testosterone/estrogen patch can signifi cantly improve orgasm and pleasure beyond estrogen replacement alone in surgically menopausal women; however, not all women low in testosterone have diffi culties with orgasm. Likewise, Tibolone, a drug with androgenic, estrogenic, and progestogenic activity (not available in the United States) is showing signifi cantly positive sexual effects on orgasm and responsivity in surgically menopausal women compared to estrogen replacement therapy alone. However, its adverse impact on lipid profi les is a concern.

A 2% testosterone cream can be applied to the vulva prior to sexual activity in those who complain of decreased genital sensitivity and delayed orgasm, though its effectiveness remains anecdotal. Since many patients are on antidepressants, management of SSRI-induced orgasmic delay will often be warranted. Options include waiting for tolerance to develop, reducing the dosage, switching to a different antidepressant like the dopamine-agonist bupropion, or taking drug holidays on the weekends. Augmenting SSRIs with 5-HT 2 , 5-HT 3 , α 2 -adrenergic receptor antagonists, PDE5 inhibitors, and dopamine receptor agonists has been proposed. Such drugs include buspirone, Sildenafi l, and yohimbine and may show potential once large-scale studies are undertaken. However, their safety in combination with SSRIs is currently in question. Because genital sexual arousal and orgasm depend on adequate nerve conduction involving the pudendal, pelvic, hypogastric, and sensory vagus nerves, gynecologic surgeons should be careful to spare those nerve pathways.

Patients with primarily nonmedical causes of orgasm disorder should be educated about the importance of clitoral and G-spot stimulation and the relative insensitivity of the back two-thirds of the vagina for the average woman. Women tend to learn how to achieve orgasm most easily through their own masturbation, followed by teaching these techniques to their partners. Furthermore, patients should be taught Kegel exercises as vaginal muscle strength is correlated with orgasmic potential. The stronger her vaginal muscles, the more likely the woman is to be orgasmic with intercourse. The patient should be informed that most women do not easily reach orgasm with intercourse and that only with effective stimulation and communication will she fi nd out whether she will be coitally orgasmic. Books written for anorgasmic women can be recommended. Preorgasmic women need to be encouraged to engage in prolonged stimulation, perhaps 30-60 minutes, to break through the emotional barriers to responding. Vibrators work for most preorgasmic women, but learning to achieve orgasm by less intense methods is preferable. Women unable to benefi t from these suggestions should be referred to therapy-with their partners if possible.

When a patient presents with vaginismus, physicians should proceed with the pelvic examination very slowly, if at all, ideally using a pediatric speculum.

Sometimes the patient is so phobic that an internal examination to rule out physical causes is inadvisable until the patient has benefi ted from psychotherapy. If the patient has other symptoms indicative of a pelvic fl oor disorder, such as painful defecation, then referral to a pelvic fl oor physical therapist is also indicated. Vaginismus is sometimes accompanied by pelvic pain disorders such as vulvodynia. The physician should be thorough in ruling out and/or treating these medical precursors to vaginismus, although sometimes a combined approach has been shown to be effective.

Physicians should educate the patient with nonmedical vaginismus symptoms by explaining the spasm of paravaginal muscles and stressing that she can learn to relax them. Physician-assigned relaxation exercises and Kegel exercises followed by the insertion of lubricated dilators of graduated circumference may be all that is needed in milder cases. Dilator insertion may be done by the physician in multiple offi ce visits or at home by the patient and her partner. However, vaginismus is often associated with such a phobic element that a psychotherapy background is needed to treat it successfully. A combination of sex therapy and pelvic fl oor physical therapy has been shown to be highly effective. Assuring the patient that pain is not involved will help her take that fi rst step.

This condition should be treated by a psychotherapist because of the complexity involved. If the patient is amenable, rule out both physical causes of dyspareunia via a pelvic examination as well as medical causes of low sex drive. Psychotherapy, often involving treatment for sexual abuse, and couples therapy may be warranted.

Because sexual disorders may require diagnosis and management beyond the usual training and focus of the obstetric-gynecologic clinician, it is important to develop referral sources in internal medicine, endocrinology, urogynecology, psychiatry/psychotherapy, and pelvic fl oor physical therapy. For a listing of pelvic fl oor physical therapists in your area, call The American Physical Therapy Association at 800-999-2782 and ask for the "women's health division." For nonmedical causes of sexual dysfunction, the most effective referral is to a psychotherapist who has been extensively trained to do sex therapy and couples therapy. Since Florida is the only state that currently licenses sex therapists, the most reliable credential of a good sex therapist is certifi cation by a national organization. Currently, the American Association of Sexuality Educators, Counselors, and Therapists (AASECT) is the oldest, largest, and most nationally recognized certifying organization for sex therapists. Referrals can be reached online at www.aasect.org or by calling the national offi ce at 804-752-0026. Likewise, clinical members of the American Association for Marriage and Family Therapy (go to www.aamft.org for a list of clinical members) will have training in couples therapy, although not necessarily in sex therapy.

Therapists from all disciplines-psychiatry, social work, psychology, marriage and family therapy, and psychiatric nursing-can be credentialed in these areas with the appropriate training.

The referral will be more effective if the clinician (1) can assure the patient that this therapist has been effective with other patients; (2) reassures the patient that no sexual touching is done or demonstrated by the therapist;

(3) knows that this therapist is comfortable with the subject and will not judge the patient; (4) stresses that the patient's partner (if she has a steady, committed one) often needs to be involved in the therapy for therapy to be most effective; and (5) assures the patient that the therapist will make every effort to work within the patient's value system.

Tara, a 31-year-old working mother of two toddlers, was married for 5 years. She was referred to sex therapy for a total loss of sex drive with onset after her fi rst delivery 3 years earlier. In addition to her loss of sex drive, she was usually anorgasmic, though she was able to achieve orgasm with coital stimulation within 5 minutes of penetration and within 1 minute of vibrator stimulation about two times a month. In addition, she reported that she resented her husband's initiations. She was taking low-dose desogesterel containing oral contraceptives for ovarian cysts, Zyrtec, and methyltestosterone for her low drive. She complained of excessive fatigue, which she attributed to raising small children. The only benefi t she obtained from methyltestosterone was the eradication of her dyspareunia and restoration of vaginal lubrication. Her initial laboratory results revealed a very low total and free testosterone. (No other laboratory results were reported but there were no additional symptoms of other endocrine malfunctions.) Tara's husband was involved in the initial evaluation but was unable to attend therapy due to work confl icts. However, the couple seemed to have a warm, cooperative marriage and she appeared to have no substantial psychopathology. Tara's history included some features that clinicians often correlate with sexual repression in adulthood. As a child she had been forced to watch her babysitter sexually stimulate her little brother and felt guilty for not protecting him. She also reported that her father was unusually negative about anything to do with sex throughout her rearing.

Despite having been informed of the probable effect of her oral contraceptives on her free testosterone, Tara chose to remain on them because of signifi cant consequences from prior ovarian cysts. Her methyltestosterone was discontinued and she was started on a regimen of testosterone injections every 3 weeks coinciding with weekly psychotherapy. After stabilizing her dosage in the physician's offi ce, she continued with at-home injections. Tara began to notice a positive change after the second injection, and by the fourth month her drive had substantially risen. She began to initiate sex and was receptive to her husband's initiations most of the month. She began to achieve orgasm in 100% of her sexual encounters, and felt comfortable with proposing a variety of sexual acts. In psychotherapy Tara worked through her traumatic feelings from the sexual abuse incident and confronted her father on the negative impact of his sexual attitudes. She learned a variety of sexual techniques and was reassured of their normalcy.

However, by the fourth month, her total testosterone (T) was rising above physiologic range though her free T remained in midrange. She lowered her dosage at her endocrinologist's request, reducing her total testosterone to normal range and her free T to just below normal range. After 2 months on the lower dosage, she had maintained her level of sexual desire and responsivity, felt emotionally satisfi ed with her sexual relations, and satisfactorily terminated psychotherapy. At no time did she complain of any unwanted side effects.

Tara's case illustrates how the combination of androgen insuffi ciency and sexual trauma and repression can cause sexual dysfunction at all stagesdrive, arousal, orgasm, and satisfaction. The combination of testosterone replacement and psychotherapy restored her to consistently satisfactory sexual functioning.

Sexual dysfunctions can be caused by organic, psychogenic, or mixed etiologies. Obstetric-gynecologic clinicians are often the frontline in diagnosing and treating organic causes of female sexual disorders and are crucial in referring patients whose disorders involve psychogenic and mixed etiologies. Too often, clinicians use their own experiences and value systems to guide the treatment of sexual issues, an approach that may delay effective treatment. Scientifi cally based knowledge is essential in effective management and collaboration with related specialists is often warranted. Women's sexual medicine suffers from a lack of adequate diagnostic techniques, laboratory tests, and treatment norms. Some treatment regimens, especially androgen replacement therapy, are still considered experimental and lack well-done studies with long-term safety data to back up clinical experience. However, research in this area is rapidly increasing and clinicians are encouraged to obtain further training by attending meetings hosted by the American Association of Sexuality Educators, Counselors, and Therapists-AASECT (www.aasect.org), The International Society for the Study of Women's Sexual Health-ISSWSH (www.isswsh.org), The Society for Sex Therapy and Research-SSTAR (www.sstarnet.org), and The Society for the Scientifi c Study of Sexuality-SSSS (www.sexualscience.org). Furthermore, by joining these organizations, the clinician will also have access to publications and Web-based case discussion groups. Those with a special interest in treating female sexual dysfunction are encouraged to obtain certifi cation from The American Association of Sexuality Educators, Counselors, and Therapists. When done with up-to-date, scientifi cally based information, obstetricgynecologic clinicians can play an educational and therapeutic role in the lives

New York: Norton; 1966. of their patients with sexual problems. Those who do will fi nd it a rewarding area of medicine. Reading for the Female Patient Barbach L. For Yourself

Women's Sexualities. 2000 (for general understanding)

Sex Matters For Women-A Complete Guide for Taking Care of Your Sexual Self

Reclaiming Desire: 4 Keys to Finding Your Lost Libido

Becoming Orgasmic. 1988 (book and video)

Private Pain

The G Spot: And Other Discoveries About Human Sexuality

The Sexual Healing Journey. 1991 (for sexual abuse survivors)

Rekindling Desire: A Step by Step Program to Help Low-Sex and No-Sex Marriages

The New Male Sexuality-Revised Edition. 1999 (for the male partner)

DHEA treatment: myth or reality?

Androgen Insensitivity in Women. The Princeton Conference

Dehydroepiandrosterone replacement in women with adrenal insuffi ciency

Effi cacy and safety of estrogen/androgen therapy-menopausal symptoms, bone, and cardiovascular parameters

A two-year, double-blind comparison of estrogenandrogen and conjugated estrogens in surgically menopausal womeneffects on bone mineral density, symptoms, and lipid profi les

The complexities of female sexual arousal disorder

Report of the International Consensus Development Conference on Female Sexual Dysfunction: Defi nitions and Classifi cations

Summary of the Recommendations on Sexual Dysfunctions in Women

Physiology and pathophysiology of female sexual function and dysfunction

Comparative effects of estrogens plus androgens and tibolone on bone, lipid pattern and sexuality in postmenopausal women

Sexual Pharmacology: Drugs That Affect Sexual Function

Endocrine aspects of female sexual dysfunction

Risk factors for vulvovaginal candidiasis: a case-control study among university students

Androgen values in premenopausal women without sexual dysfunction

Clinical evaluation and management strategy for sexual dysfunction in men and women

Sexual behavior of women with repeated episodes of vulvovaginal candidiasis

Low dose dehydroepiandrosterone affects behavior in hypopituitary androgen-defi cient women: a placebo-controlled trial

Persistent sexual arousal syndrome: a newly dis covered pattern of female sexuality

Psychotherapeutic interventions for treating female sexual dysfunction

Los Angeles: UCLA Center for Health Promotion and Disease Prevention

Sexual Medicine in Primary Care

Sex in America

Androgen replacement therapy with dehydroepiandrosterone for androgen insuffi ciency and female sexual dysfunction: androgen and questionnaire results

Sexual Pharmacology: Fast Facts

Safety of estrogen/androgen regimens

Sexual Function in People with Disability and Chronic Illness

Beyond the G spot: new research on human female sexual anatomy and physiology

Sexual response to self-stimulation in women with complete spinal cord injury

The Human Female Prostate