www.NPWOMENSHEALTHCARE.com November 2013 Women’s Healthcare 23

Approximately 43% of womenreport symptoms of sexual dysfunction.1 Fewother health conditions have such a high preva-lence. Although FDA-approved treatment isavailable for women experiencing dys-pareunia related to vulvovaginal at-rophy (VVA), no medication hasbeen approved by the FDA totreat female sexual dysfunction(FSD)—that is, problems relat-ed to libido, arousal, and or-gasm in women. Nevertheless,these complaints are relevantto nurse practitioners provid-ing healthcare to women andare important to address.

OverviewMasters and Johnson2 are hailed asthe pioneers of sexual research datingback to 1957. Their four-stagemodel of human sexual responsecomprised excitement,plateau, orgasm, andresolution; according toMasters and Johnson,these four stages pro-ceed in a linear fash-ion. In 1997, Whippleand Brash-McGreer3 intro-duced the circular model offemale sexual response,which comprised fourstages: seduction (en-compassing desire), sen-sations (excitement andplateau), surrender (orgasm), and re-flection (resolution). The circular model showedhow pleasure and satisfaction during one sexualexperience could lead to the seduction phase of

the next sexual experience. In 2001, Basson4

published a revised sexual response model spe-cific to women that incorporated the importanceof emotional intimacy, sexual stimuli, and rela-tionship satisfaction. Unlike Masters and Johnson,whose linear model of sexual response applied to both genders, Basson introduced anonlinear model, which acknowledged that fe-male sexual functioning proceeds in a more com-plex and circuitous manner than male sexualfunctioning. These models are summarized in anAssociation of Reproductive Health Professionals

clinical fact sheet on female sexualresponse.

In 1998, amidst allthe research abouthuman sexual func-tion, sildenafil (Viagra) was in-troduced as apharmacologicintervention forerectile dys-function, revo-lutionizing theconcept of ahuman sexualproblem as being

amenable to phar-macotherapy. At that

point, research in therealm of female sexuality

was limited; most sexual healthstudies enrolled only males, with resultsextrapolated to the female population.

In the 15 years that have elapsedsince the approval of sildenafil andmedications like it, no treatment hasbeen approved by the FDA for FSDother than Eros Therapy, a clitoralsuction device that was discontinueddue to the cost and the minimal con-sumer response. The circular and non-

linear models for female sexual response demon-strate why not: Because of the circular pathwayand the inclusion of emotional components, it isnearly impossible to create a “magic pill” that ad-dresses all the potential causes of FSD. In order toappropriately identify, diagnose, and manage pa-tients with FSD, a holistic approach must be uti-

Assessment & management

Assessment and managementof female sexual dysfunction By Brooke M. Faught, MSN, WHNP-BC, IF

A

lized and adapted to each individual woman.

AssessmentOne of the main reasons for healthcare practition-er (HCP) failure to address women’s FSD com-plaints is the lack of time. One way to expeditesuch a discussion is to utilize screening tools thatpatients can fill out prior to their scheduled ap-pointment. The Female Sexual Function Index iscomposed of 6 categories of questions related todesire, arousal, lubrication, orgasm, satisfactionand pain.5 This index identifies the exact com-plaint(s) and quantifies the severity of the symp-tom(s). The Female Sexual Distress Scale – Revised(FSDS-R) determines whether the problem is dis-tressing to the patient through a series of 13 spe-cific questions.6 To diagnose a patient with FSD,she must have symptoms that cause interpersonaldistress. The FSDS-R not only identifies distressbut also supports a potential diagnosis.Another limitation to HCP management of FSD

is a lack of sexual health training. According toHaboubi and Lincoln,7 90% of HCPs agree that ad-dressing sexual concerns should be included in aholistic care plan, although 86% were found to beunprepared to deal with these problems and 94%were unlikely to initiate a relevant discussion withpatients. Many professional organizations can help

prepare HCPs, including NPs, to better addressand treat FSD (Online resources). After review of screening questionnaires and

the initial consultation, NPs should perform aphysical examination. In some cases, only a gen-eral visual scan is needed. In most cases in whicha patient reports a sexual complaint, however, apelvic exam is warranted. NPs will need to do afull vulvar inspection, especially when women re-port diminished sensation, difficulty with arous-al/orgasm, and pain. Laboratory tests, includingwet prep, vaginal pH, vaginal cultures, and serumblood testing, further enhance FSD evaluation.NPs need to inform patients how they will receivethese results—for example, in an office follow-upvisit or by phone call, email, or mail. Patientsshould receive a written plan detailing the diagno-sis, any referral(s) with contact information, thetreatment regimen, and a follow-up appointment.Because of the sensitive nature of FSD, this lastrecommendation is vital. Many patients are nerv-ous or anxious when discussing such intimatematters and do not remember everything said dur-ing the initial visit.

ManagementWith the paucity of FDA-approved treatment op-tions for manifestations of FSD, NPs must utilize aholistic approach tailored to patients’ individualneeds. Collaboration with outside providers suchas physical therapists, sex therapists, reputablecompounding pharmacists, OB/GYNs, and en-docrinologists can be helpful. In fact, NPs are ad-vised to establish a network of local collaboratingprofessionals who are familiar with FSD and wel-come receiving such referrals. As stated previous-ly, the NP and the patient should agree on a fol-low-up plan before the patient leaves the office;this plan is documented in the health record,which establishes a degree of accountability forthe patient and reinforces the NP’s willingness tomanage her concerns.The only FDA-approved treatments for VVA-re-

lated dyspareunia are conjugated estrogens vaginalcream (Premarin Vaginal Cream) and ospemifene(Osphena), a non-estrogen-containing oral tablet.Although treatment options for the remaining FSDdiagnoses are limited, off-label therapies such ascompounded testosterone replacement, oxytocintroches/spray, and arousal creams containing suchingredients as sildenafil, aminophylline, and l-argi-

24 November 2013 Women’s Healthcare www.NPWOMENSHEALTHCARE.com

Online resources• American Association of Sexuality Educators,Counselors and Therapists

• American Society for Reproductive Medicine

• Association of Reproductive HealthProfessionals

• International Society for the Study ofVulvovaginal Disease

• International Society for the Study of Women’sSexual Health

• National Association of Nurse Practitioners inWomen’s Health

• National Vulvodynia Association

• Society for Sex Therapy and Research

nine, can be considered in appropriate circum-stances. Given the lack of regulation with off-labeltreatment options, close management and follow-up are mandatory. Over the past decade, pharma-ceutical company interest in FSD has intensified.NPs can expect to have better treatment optionsavailable in the near future for problems related tofemale libido, arousal, and orgasm.

ConclusionWith the Internet at their fingertips, many womenwith symptoms of FSD are researching their symp-toms, learning that help is available, and seekingout an HCP to help them deal with their problem.For now at least, treatment of FSD is complicatedand multifaceted, requiring thoughtful holistic in-tervention. As with any other health complaint,patients deserve acknowledgment and validity oftheir FSD, as well as treatment and/or referral asappropriate. =

Brooke Faught is a nurse practitioner and Clini-cal Director of the Women’s Institute for SexualHealth, *A Division of Urology Associates,* inNashville, Tennessee.

References1. Laumann EO, Paik A, Rosen RC. Sexual dysfunction inthe United States: prevalence and predictors. JAMA. 1999;281(6):537-544.

2. Masters WH, Johnson VE. Human Sexual Response.Boston, MA: Little, Brown & Co.; 1966.

3. Whipple B, Brash-McGreer K. Management of femalesexual dysfunction. In: Sipski ML, Alexander CJ, eds. Sexu-al Function in People with Disability and Chronic Illness. AHealth Professional’s Guide. Gaithersburg, MD: Aspen Pub-lishers, Inc.; 1997:509-534.

4. Basson R. Female sexual response: the role of drugs inthe management of sexual dysfunction. Obstet Gynecol.2001;98(2):350-353.

5. Quirk F, Haughie S, Symonds T. The use of the sexualfunction questionnaire as a screening tool for women withsexual dysfunction. J Sex Med. 2005;2(4):469-477.

6. Derogatis LR, Clayton A, Lewis-D’Agostino D, Wun-derlich G, Fu Y. Validation of the female sexual distressscale-revised for assessing distress in women with hypo -active sexual desire disorder. J Sex Med. 2008;5(2):357-364.

7. Haboubi NHJ, Lincoln N. Views of health professionalson discussing sexual issues with patients. Disabil Rehabil.2003;25(6):291-296.

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