Editorials - July 1, 2000 - American Family Physician

Editorials

Getting the Facts on Restless Legs

CAROLINE E. WELLBERY, M.D.
Georgetown University Medical Center
Washington, D.C.

See article in this issue.

My experience with the Restless Legs Syndrome (RLS) Working Group, which produced the document published in this issue of American Family Physician,¹ reminded me of how much we can learn from our colleagues. Despite the recent focus on evidence-based medicine, we should not overlook the value of clinical experience and dialogue. After countless hours of discussion and revision, the authors of this collaborative review were careful to produce meticulously formulated definitions, as well as practical, solid recommendations. Although many treatments were discussed, they were omitted from the report if the group agreed that the supportive evidence was weak. Because of the lack of scientific support for lifestyle modification and nonpharmacologic therapies, no suggestions relating to these measures were included in this document.² Only established facts found their way into the final draft, whereas any information without solid foundation was eliminated. Given the limitations of our medical knowledge and our fallibility in the real practice of medicine, a consensus among practitioners can be a powerful resource. It suggests that we do not know everything, but given what we know we can agree on a standard of care.

In addition to the valuable summary that the Working Group document provides, this review enhances our awareness of a condition that we may have tended to underdiagnose.³Some illnesses elude diagnosis because they are not common in a given practice or because the symptoms are minor and are not brought to the physician's attention. Although RLS is the fourth leading cause of insomnia, its prevalence ranges from 2 to 15 percent and, therefore, its incidence may vary according to practice. Thus, either of the aforementioned possibilities may come into play.⁴Awareness is important because RLS is diagnosed almost exclusively by history. In this sense, it stands to reason that the Working Group should have devoted a substantial portion of its energies to the definition of RLS, a syndrome that is often called "indescribable."³ In terms of differential diagnosis, however, few conditions resemble it. Nocturnal leg cramps, with their sudden, severe muscle contraction and relatively rapid resolution, are nothing like the almost mental, irritating discomfort of RLS. Remembering its place among sleep disturbances may be all that is required to identify it in susceptible patients.

Another reason that RLS may elude our attention is that none of the medications used in its treatment are primarily indicated for RLS. RLS is essentially a stepchild of other neurologic disorders such as Parkinsonism and anxiety, conditions to which it is unrelated but whose pharmacologic treatments it has inherited. In addition, many common conditions, including pregnancy and iron deficiency anemia, may be associated with RLS. In our routine management of these familiar scenarios, we could easily fail to consider the possibility of RLS.

All of this leads to a final point, which is that RLS can be treated effectively by primary care physicians. First, as previously mentioned, it is diagnosed almost exclusively by history. Second, the differential diagnosis is, for the most part, limited to a few common, easily recognized conditions. Third, the treatment options include medications that family physicians often prescribe for other illnesses, except that lower dosages are used in RLS. Thus, the Working Group has provided an important service to patients suffering from this potentially debilitating condition. It also provides a service to family physicians by adding to the repertoire of ailments we can treat successfully on our own, without subspecialty consultation or unnecessary diagnostic testing.

Caroline E. Wellbery, M.D., is an assistant professor in the Department of Family Medicine at Georgetown University Medical Center, Washington, D.C. She is also assistant deputy editor of American Family Physician. She was a member of the National Heart, Lung, and Blood Institute Working Group on Restless Legs Syndrome in 1999.

Address correspondence to Caroline E. Wellbery, M.D., Department of Family Medicine, 212 Kober-Cogan Building, Georgetown University Medical Center, Washington, DC 20007.

REFERENCES

National Heart, Lung, and Blood Institute Working Group. Restless legs syndrome. Am Fam Physician 2000;62:108-14.

Hening WA, Allen R, Walters AS, Chokroverty S. Motor functions and dysfunctions of sleep. In: Chokroverty S, ed. Sleep disorders medicine: basic science, technical considerations, and clinical aspects. 2d ed. Boston: Butterworth-Heinemann, 1999;441-507.

Evidente VG, Adler CH. How to help patients with restless leg syndrome. Discerning the indescribable and relaxing the restless. Postgrad Med 1999; 105:59-61, 65-6, 73-4.

Feigen A. Restless legs syndrome. JAMA 1995; 274:1191-2.

The Importance of Obtaining a Sexual History

GLORIA BACHMANN, M.D.
UMDNJRobert Wood Johnson Medical School
New Brunswick, New Jersey

See article in this issue.

Regardless of how often practitioners are reminded of the importance of sexual health and the necessity of obtaining a thorough sexual history from all of our patients, this important aspect of the complete medical evaluation is sometimes overlooked.

The article on female sexual dysfunction in this issue of American Family Physician¹re-emphasizes the need to inquire about this important aspect of our patients' health, because sexual dysfunction, although not directly related to morbidity or mortality, distracts from the patient's (and often the couple's) quality of life. The patient and physician share the responsibility for ensuring that a complete sexual evaluation is performed. Physicians should initiate the discussion with some nonjudgmental screening questions. However, even when physicians indicate an openness to discussing sexual health, some patients may be reluctant to talk about it. Clearly, patients themselves often are unsure if they have a sexual difficulty, or they are reluctant to discuss sexual problems.

In addition, sexual concerns and problems may be interwoven with other psychologic or medical issues, making it difficult for patients to know whether they have sexual dysfunction or a medical or emotional problem. Lastly, for women in a committed relationship it is not just a woman's problem, but a couple's problem as well. Because of this, many women feel uncomfortable talking about their sexual problems for fear of betraying their partner. All of these concerns emphasize the need for a periodic review of a patient's sexual function.

In addition to the helpful information about sexual evaluation and treatment presented in this article,¹ we as practitioners can use the following additional factors to help in assessing and treating patients with a sexual concern:

A detailed sexual history is often impractical for the practitioner to obtain when patients have other issues they wish to discuss. I have found that a two-sentence sexual inquiry of the patient is highly effective in identifying the majority of patient concerns and problems: (1) "Are you sexually active?" and (2) "Are you having any sexual difficulties, such as pain with intercourse or lack of sexual desire?"²

In her article,¹ Dr. Phillips outlines an extremely helpful way to perform the pelvic examination. I have found that women who have vaginismus experience difficulties in undergoing any type of pelvic examination in the dorsalis lithotomy position and, therefore, should be examined in an alternative position. Patients feel in a compromised position at this time, especially because they cannot see the examination of the perineal area. I have my patients stand while I perform a bimanual examination and try to feel for Bartholin's gland enlargement, prolapse, cystocele, rectocele and tightening of the vaginal muscles on digital insertion. In this way, the patient is standing and feels that she is in more control. Patients can also squat during the initial part of the pelvic evaluation. Once they are comfortable with these positions, they can be examined in the dorsalis lithotomy position.

If a patient is nervous and the use of a speculum is necessary, it is important to use the smallest one (e.g., a Pediatric Peterson). It may not allow total visualization of the vaginal vault and cervix, but it will again reinforce to the patient that you will not be harming her during the pelvic examination. The size of the speculum can gradually be increased as the patient becomes more comfortable with the pelvic examination.

Often, patients do not feel comfortable discussing sexual problems the first time the physician attempts to obtain a sexual history. However, I have found that many patients remember that their practitioner is open to discussing their problem. Thus, at subsequent visits, patients may say, "By the way, when you discussed the issue of sexual problems, I forgot to mention that I have been noticing that I do have difficulty in achieving orgasm." Therefore, do not hesitate to obtain a brief sexual history even if few patients respond positively at first.

Some literature supports the cause and effect of androgens and sex drive motivational activities.^3,4 Much of the work of Sherwin and Gelfand^5,6 has clearly shown that androgen replacement improves sexual desire, fantasy and arousal. Phillips¹ suggests that in order to prescribe an estrogen/androgen formulation (e.g., Estratest HS) labeled by the U.S. Food and Drug Administration, an androgen level should be obtained. I disagree. Patients who are beginning estrogen replacement therapy do not need a serum estrogen level and follicle-stimulating hormone level initially drawn, because it is expensive and it is not helpful in the management of the patient. Additionally, more ambulatory practice time is added because the medical office has to follow up on and report laboratory test results to the patient.
The same is true with estrogen/androgen replacement therapy. For patients who are menopausal and estrogen/androgen therapy is indicated, the practitioner can prescribe this combination therapy without the expense of drawing androgen levels. I recommend that further evaluation with hormone blood levels be obtained only in patients who do not adequately respond to estrogen replacement therapy or estrogen/androgen replacement therapy.

Although we often equate the increasing prevalence of sexual dysfunction in menopausal and postmenopausal women with the loss of gonadal hormones, we must not ignore the fact that a large number of younger women may also experience a decline in sexual interest. Therefore, an age limit should not be placed on obtaining a sexual history. Rather, a sexual history should also be obtained from those patients seeking contraception and who are sexually active.

Lastly, although we accept that menopausal and postmenopausal patients have an increased prevalence of sexual problems, we also accept sexual abstinence as a norm in our geriatric population. Sexual appetite does not decrease with an increase in the age of the patient. Any patient who complains of a sexual dysfunction should be evaluated and treated. Appropriate referral, counseling and therapy should never be withheld because of age.

Because some patients are more comfortable writing down their concerns about sex, physicians should ensure that questions about sexual health are included on any new patient intake forms. Hopefully, as computerized medical records or standardized chart forms become more common, prompts will remind physicians to routinely ask questions about sexual health, which will improve compliance with taking a sexual history.

Dr. Bachmann is professor and chief of the Division of General Obstetrics and Gynecology and professor of medicine at UMDNjRobert Wood Johnson Medical School, and chief of the Obstetrics and Gynecology Service at Robert Wood Johnson University Hospital, New Brunswick, N.J.

Address correspondence to Gloria Bachmann, M.D., UMDNJRobert Wood Johnson Medical School, 125 Paterson St., New Brunswick, NJ 08901.

REFERENCES

Phillips NA. Female sexual dysfunction: evaluation and treatment. Am Fam Physician 2000;62:127-36,141-2.

Bachmann GA, Leiblum S, Grill J. Brief sexual inquiry into gynecologic practice. Obstet Gynecol 1989;73:425-7.

Persky H, Lief HI, Strauss D, Miller WR, O'Brien CP. Plasma testosterone level and sexual behavior of couples. Arch Sex Behav 1978;7:157-73.

Brincat M, Magos A, Studd JW, Cardozo LD, O'Dowd T, Wardle PJ, et al. Subcutaneous hormone implants for the control of climacteric symptoms. A prospective study. Lancet 1984;1(8367): 16-8.

Sherwin BB, Gelfand MM, Brender W. Androgen enhances sexual motivation in females: a prospective crossover study of sex steroid administration in the surgical menopause. Psychosom Med 1985; 47:339-51.

Sherwin BB, Gelfand MM. The role of androgen in the maintenance of sexual functioning in oophorectomized women. Psychosom Med 1987;49:397-409.

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