older female patient via shutterstock
It is not uncommon for a physician to examine a female patient in her mid 60 s and think Have I made the necessary recommendations for appropriate screening? without giving much thought to a very common, yet seldom talked about issue: sexual dysfunction.
With the popularity and long track record (going on 20 years now) of medications for erectile dysfunction, like Viagra, it is generally expected for men to approach their physicians with sex-related concerns. But it seems that almost the opposite is true for women.
Sexual dysfunction affects about 40 percent of American women, with only 12 percent reporting distressing sexual problems. Dyspareunia, which means bad or painful mating, is a pain disorder that can result from an intricate interaction of anatomical, physiological, and psychological factors that contribute to painful intercourse. Although it can affect women of all ages, it is most commonly seen in post-menopausal females, 8 22 percent who are afflicted.
Dyspareunia and vaginismus (painful spasmodic contracting of the vagina that is recurrent or persistent, induced by physical contact during intercourse) are now defined together in the DSM V as part of the genito-pelvic pain/penetration disorder (GPPPD). For menopausal females, the pain related to atrophy of the vagina/vulva is classified under genitourinary syndrome of menopause (GSM).
Renee Horowitz, MD, an OB/Gyn at Farmington Hills Obstetrics and Gynecology, a part of Beaumont Health System, in Farmington Hills, MI, says, I think the first thing is always to figure out when they re having the dyspareunia to distinguish when it is occurring and after that, you tailor your treatments.
She also adds, I do a lot of sexual medicine and I have women come in that are menopausal, and have had pain for a long time for what they think is atrophy, and they are prescribed estrogen and it doesn t help, but the reason it doesn t help is they probably have vestibulodynia [chronic, unexplained pain in the area around the opening of the vagina].
A deficiency in estrogen causes changes in the vagina and a lack of adequate vaginal lubrication with sexual arousal, both of which result in dyspareunia. Estrogen deficiency predominates in the older woman, but is possible in any age group.
In a younger woman, inadequate lubrication is associated with inhibited arousal resulting from inadequate foreplay technique, relationship issues and interpersonal conflict and some medications used to treat high blood pressure or depression. It would also be a good idea to look at the side effect profile of any medications to see if it might be associated with vaginal dryness or sexual dysfunction.
Treatment
Management of the underlying condition (physical or psychiatric), avoiding causative medications when possible and use of topical moisturizers and lubricants can be helpful. Hormonal treatments with testosterone or dihydroepiandrostenedione (DHEA) are treatment options, but they are not without undesirable side effects.
There are also pills like the recently-approved female Viagra (flibanserin) but it has limited efficacy, if any at all. Medications to treat erectile dysfunction in men have not been shown to have any benefits in women. With regards to herbal therapies, there are never any guarantees that they work any better than a placebo, or that they are free of any potentially dangerous additives.
Surgery is also rarely, if ever, a treatment option unless there has been traumatic injury to the vaginal area or any anatomic abnormalities.
A public health educational outreach campaign would be beneficial to inform women that they should not shy from approaching their doctors with concerns regarding sexual dysfunction. Doctors also have to be more cognizant of their post-menopausal patients concerns, and that if they are not equipped to treat their patient then they need to find to make a physician referral.
