Female Sexual Dysfunction: Clinical approach What nurses want to know

Alessandra Graziottin is currently Director of the Centre of Gynaecology and Medical Sexuology at the H. San Raffaele Resnati in Milan (IT). She is Consultant
Professor at the Universities of Florence and Parma (IT). She received her medical degree at the University of Padua (IT) in 1978, where she specialised in
Obstetrics and Gynaecology in 1982 and in Oncology in 1985. She is also a certified Psychotherapist in Sexual Medicine.

Below you will find a summary of the workshop ‘Female sexual dysfunction: clinical approach’ she gave during the 8th International Meeting of the EAUN
in Berlin, Germany.

Introduction
Nurses have an increasingly important role to play in the health care system worldwide. They should be given the opportunity to become primary confidents of the many issues and questions diseases raise in the domain of quality of life and sexuality. Training of nurses in sexual medicine may significantly improve their competence in addressing critical sexual concerns and increase the quality of support the health system offers. It may also increase their professional
satisfaction thanks to a more comprehensive and patient-centred approach.

Characteristics of women’s sexuality
Women’s sexuality is multifactorial and multisystemic, involving all biological systems that contribute to an appropriate physical and emotional response.
More than in men, co-morbidity - the contemporary presence of more than one sexual disorder - is the cause of most complaints. Furthermore female sexuality is discontinuous throughout women’s life. These potent psychosexual variables have biased past researches, with missed diagnoses and disappointing treatments as a result.

Diagnosis of FSD
From the clinical point of view, an integrated diagnostic approach is necessary to tailor treatment according to the individual and couple’s needs. The most recent classification of FSD is summarised in Fig. 1.

It is especially important for nurses to help the patient
understand whether the disorder is associated with or
caused by the medical condition they are being treated
for. Accurate examination of the woman, and particularly
of the external genitalia, the vagina and the pelvic floor
may be very informative for nurses. This is mandatory
when genital arousal disorders, sexual pain disorders and orgasmic disorders are involved.
Co-morbidity with other FSD should indeed be accurately recorded with attention to which sexual disorder came first, together with the meaning of the
symptom for the woman. Co-morbidity with medical conditions should be investigated, as well as the high association between sexual pain disorders and urogenital dysfunction. The worsening genital arousal disorders many women complain of may cause vaginal dryness, dyspareunia and post-coital cystitis, usually appearing 24-72 hours after intercourse.

Treatment of FSD
Key points in the medical treatment of:

a) Desire and central arousal disorders
Desire and central arousal consistently overlap from the neurobiological and
psychosexual point of view. The two conditions are therefore usually treated in parallel and indeed respond to the same treatment(s).

Hormone treatment is indicated when desire disorders and associated FSD are acquired after menopause and have a prominent hormonal aetiology.
Recent studies have shown the efficacy of testosterone patches in improving sexual desire and satisfaction. Testosterone patches (300 mcg twice/week) have been approved in Europe in 2006, with the specific indication HSDD in surgically menopausal women. Women and partners should be informed about the “lag time” (up to two, three months) between onset of treatment with testosterone patches and sexual improvement.

b) Genital Arousal disorders

According to the diagnosis, acquired genital arousaldisorders may be treated with:
• Systemic or topical sexual hormones, estrogens or testosterone or both
* Systemic estrogenic hormonal therapy (ET) is the choice for central and genital arousal disorders and when vaginal dryness is the leading complaint. In women with uterus, progesterone or progestins must be added to protect the uterus;

* Topical (i.e. vaginal) treatment with estradiol is effective when genital arousal disorder causes or is associated with dyspareunia, post-coital cystitis
and orgasmic difficulties and when systemic treatment is not indicated or not desired;

* Recurrent vaginitis and cystitis from colonic germs may as well be improved by topical vaginal estrogens;

* Topical testosterone applied daily may improve the clitoral and bulb-avernosal arousal response, easing vulvar congestion and the orgasmic response.
• Pelvic floor rehabilitation and/or biofeedback, that may improve perivaginal muscle tone and competence.

c) Orgasmic disorders
Acquired orgasmic disorder my benefit from:
• Hormone therapy, topical and/or systemic, with or without androgens, if the leading etiology is hormonal;

• Pelvic floor rehabilitation, if there is this comorbidity with hypotonic pelvic floor conditions;

• Appropriate pharmacologic and/or rehabilitative treatment when the woman is afraid to leak urine during an orgasm, in association with urgency and/ or when urge incontinence with an overactive bladder is diagnosed;
• EROS-clitoral device, indicated when there is an arousal co-morbidity;
When FSD comorbidity is diagnosed, i.e when sexual response is entirely impaired, accurate treatment of predisposing, precipitating and maintaining factors, biological, psychosexual and/or contextual, should be proposed;

d) Sexual pain disorders: dyspareunia and vaginismus
Dyspareunia and vaginismus may interfere with all dimensions of the sexual response (Fig.1). Specific issues involve the diagnosis and treatment of coital pain.

Lifelong sexual pain disorders should be approached with a deep understanding of the pathophysiology of pain, in its nociceptive and neuropathic component. Lifelong dyspareunia is reported in on average one
third of our patients.

Accurate recording of the “pain map” is mandatory in both lifelong and acquired dyspareunia, as location of pain and its onset are the strongest predictors and
should be diagnosed and addressed.

Acquired co-morbidity in libido and arousal disorders is a complaint in another third to half of women suffering from dyspareunia and should be treated
accordingly.

Anxiety, fear of pain and sexual avoidant behaviour should be addressed. The shift from pain to pleasure is then key from the sexual point of view. Sensitive and committed psychosexual support to the woman/couple is therefore mandatory.

Acquired vaginismus is usually overlapping with dyspareunia.

e) Sexual Satisfaction disorders
They are a new controversial entity, not yet accepted in the international nosography. However, they should be considered in their biological and psychosexual meaning, per se and for the potential co-morbidity
with other FSD.

Key points in the psychosexual treatment of FSD:

Individual psychosexual therapy
Lifelong desire and central arousal disorders (often in co-morbidity) may benefit from individual psychosexual or behavioural therapy if sexual inhibitions, poor erotic skills, poor body image, low self confidence, but also previous abuse, are in play. Lifelong “isolated” orgasmic disorders may benefit from a behavioural educational treatment, encouraging self–knowledge and eroticism. More often, however, the orgasmic disorder is associated with poor arousal, with or without performance anxiety. These conditions should therefore be treated together.

Lifelong vaginismus should be addressed with a behavioural therapy, progressive rehabilitation of the pelvic floor and pharmacologic treatment aimed at modulating the intense systemic arousal in the subset of intensely phobic patients.

Couple therapy
Couple issues should be addressed when the couple shares the same inhibitions or communication difficulties, when symbiotic dynamics with poor
differentiation are critical, or when conflicts and aggressiveness contribute to loss of desire.

Male disorders

Male Sexual Disorders (MSD) should also be diagnosedand treated. This issue is of special importance for nurses working with male urological patients.

Conclusion
The complexity of FSD requires a dedicated diagnostic and therapeutic team, sharing a common pathophysiologic and psychodynamic cultural scenario, and aiming to offer the most integrated understanding of the consequences of the symptom and the most effective comprehensive treatment.

In this quality scenario, trained nurses can be a critical part of the FSD team, addressing the first consultation with the patient and/or the couple.

For the English-language website and the full abstract, please go to  www.alessandragraziottin.it - English.