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 Physician1 reemphasizes 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 Gelfand5,6 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.