Anger must also be acknowledged—and these patients are angry. Their anger may be directed at their partner, a former physician, or you. You may elicit a surprising outburst of pent-up anger when you ask what seems to be a neutral question.
The patient always has an internal theory and everything you say is filtered through this theory. If there is a dichotomy, it must be addressed before you can proceed successfully. Usually, you can simply ask, “What do you think is the cause?” Often she will tell you. If she is uncertain, you might say, “I realize you don’t really know. What do you think it might be? What are you afraid it might be?”
You have to ask
Many patients do not express the fact that their chief complaint is sexual dysfunction. (See How to take a sexual history,).
In many cases, sexual dysfunction may be suggested in the investigation of another complaint such as infertility, pelvic pain with no particular pattern, malaise, or depression. With these complaints, it is important to pursue a sexual history. Determine any associated or causal condition and look for associated dysfunction.
How to take a sexual history
The sexual history is like a history for any disease, in that you begin with the present illness. The differential diagnosis begins with a determination of where in the cycle the dysfunction occurs.
- One way to start is to describe the normal human sexual response. I find it best to sketch out the response cycle (FIGURE 1 ) on a piece of paper and ask, “Is this what happens to you?” Most patients understand and can tell where in the cycle the interruption occurs.
- 3 questions in a review of systems disclose nearly all sexual dysfunction:
- “How often do you have intercourse?” The only “right” answer is “as often as I want to.” If the patient is not having intercourse, is it by choice or involuntary?
- “Do you have pain with intercourse?”
- “How often do you have orgasm?” Most answer “hardly ever” or “most of the time.”
- Allegories like these are useful:
- Elements and example questions
Physical examination
Ageneral physical examination with pelvic examination should always be performed. If the patient complains of pain, the site of pain should be determined. A wet prep is useful to exclude vaginitis. A patient may have dyspareunia from vaginitis even if there are no obvious physical signs.
The most common dysfunctions: Desire phase disorders
Female sexual arousal disorder is either low libido or inhibited sexual desire. In both cases the patient is likely to report that she has no desire. But if you ask what happens when her partner wants to have intercourse, a patient with low libido describes low interest behavior, and a patient with inhibited desire describes aversion behavior.
Patients with low libido sometimes report that their orgasms are less intense, or that they do not become excited. Women on estrogen replacement after oophorectomy may have low libido related to decreased androgen.
Depression is by far the most common cause. Other contributors: chronic disease, hypoestrogenic states, hyperprolactinemia, and breastfeeding.
Inhibited sexual desire, which is a result of pain or other dysfunction, is far more common than low libido. Careful history usually reveals aversion behavior. They avoid going to bed at the same time as their partner, or develop other behaviors that preclude intercourse.
Women with inhibited desire have a conditioned negative response. In studies, these patients exhibit normal objective measures of vaginal vasocongestion in response to sexual stimuli, but self-reported subjective measures of arousal do not correlate.
They report that they simply have no desire, but the cause of their avoidance is negative conditioning. Here’s where the therapist supports, but also confronts their belief system, and attempts to help them understand that they have a normal desire for intercourse. The therapist may ask the patient to consider whether she ever has sexual dreams, reads romance novels, or fantasizes, to show that these phenomena demonstrate normal desire.
The role of testosterone in inhibited sexual desire
Measuring serum testosterone isn’t helpful. It is my belief that inhibited desire is most often related to other factors. Counseling should be the first-line therapy. Drug therapy without counseling is less likely to be effective than therapy that includes counseling.
Normal serum testosterone levels are 20 to 80 ng/dL in reproductive-age women, who produce 0.2 to 0.3 mg/day of testosterone. Levels increase 10% to 20% at midcycle. Testosterone falls 40% to 60% at natural menopause and by similar amounts with use of oral contraceptive pills, and by 80% with surgical menopause.