DIAGNOSIS OF FEMALE SEXUAL DYSFUNCTION & ERECTILE DYSFUNCTION

A modified process of care approach is used for the management of women with sexual health problems in our sexual health clinic.

We start with "identification" of the sexual problem through history (sexual, medical, gynecologic, psychosocial), physical examination, laboratory blood tests, psychologic interview and specialized genital sensory, pelvic floor and blood flow testing.

We follow with "education", specifically about the role of androgens and estrogens in sexual function.

We subsequently discuss "modification" and the role of hormonal replacement especially if blood tests are low.

During "identification" of the sexual problem genital function testing has revealed that abnormal genital sensation was found in more than half of the women. In addition, approximately 75% of these patients also showed abnormal genital blood flow (abnormal duplex Doppler ultrasound) before and after sexual stimulation. Most significantly, when we evaluated hormone levels, we found that approximately two thirds of these women had low levels of dehydroepiandrosterone (DHEA), DHEA sulfate, androstenedione, dihydrotestosterone, free testosterone and total testosterone. We concluded that sexual dysfunction in these otherwise young and healthy patients had a significant organic component. How could this be explained?

Basic research shows that following sexual stimulation, the most effective genital smooth muscle relaxation and arousal response occurs in the presence of adequate androgen levels. In the absence of androgens, poor genital smooth muscle relaxation and poor arousal follows sexual stimulation. In addition to their effects on smooth muscle relaxation, androgens also appear to maintain the integrity of sensory receptors in the labia, clitoris, and vagina. We have always known that androgens affect desire. Therefore, it can now be further researched that androgen deficiency adversely impacts all three components of the female sexual response, that is, desire arousal, and orgasm.

Thus, we now have good evidence that there are substantial physiologic issues underlying female sexual dysfunction. The basis, in part, for many women with female sexual dysfunction is not vascular disease—as it appears in the majority of men with ED––but an underlying hormonal abnormality affecting the zona reticularis of the adrenal gland. Much research is underway to better understand the nature of the suspected hormonal insufficiency.

The condensed definition of erectile dysfunction is the persistent or repeated inability for 3 months duration or more to attain and/or maintain an erection sufficient for satisfactory sexual performance.

The first step in the process is the taking of a comprehensive sexual, medical and psychosocial history.

In obtaining a sexual history, special attention should be paid to personal or cultural sensitivities.

History taking should be aimed at characterizing the severity, onset and duration of the problem, and evaluating the need for specialized testing.

A physical examination and selected laboratory testing should be performed on all patients with complaints of erectile dysfunction.

Although not different from a routine physical examination, special emphasis is placed on review of genito-urinary, endocrine, vascular and neurologic systems.

The physical examination may corroborate aspects of the medical history (e.g. poor peripheral circulation), and may occasionally reveal unsuspected physical findings (e.g. Peyronie's plaques, small testes, prostate cancer).

The physical examination also provides an opportunity for patient education and reassurance regarding normal genital anatomy.

Selective laboratory testing should be performed in all cases. This includes investigation of the hypothalamic-pituitary-gonadal axis via assessment of androgenic status, particularly if sexual desire is reduced. There is disagreement about the relative value of the various testosterone assays, including total, free and bioavailable testosterone. However, strong consensus exists that at least one of these assays should be performed. A serum prolactin determination may be obtained in selected cases. Standard serum chemistries, CBC and lipid profiles may be of value and should be obtained, if not performed in the past year. Serum TSH determination may also be of value, as both hyper- and hypothyroidism are associated with erectile difficulties. Finally, a serum PSA may be indicated based upon the patient's age and relative risk status.

Specialized diagnostic procedures, such as nocturnal penile tumescence and rigidity (NPTR) testing or other specialized vascular or neurologic procedures, should only be performed in special cases. For example, these procedures may be of value in evaluating young patients with pelvic or penile trauma who may be candidates for reconstructive vascular surgery. Patients with complicated diabetes or other endocrinopathies may benefit from referral for specialized endocrinologic evaluation. Similarly, patients with complicated psychological or relationship problems may benefit from referral to an appropriate mental health specialist. Finally, patients with a history of cardiac disease or significant cardiovascular risk factors should be evaluated for potential cardiac risk associated with sexual activity. Consensus guidelines have recently been established for evaluating cardiac risks associated with sexual.

Results of the initial evaluation and specialized testing should be carefully reviewed with the patient and patient’s partner, if possible, prior to initiating therapy.

Potentially modifiable risk factors, such as cigarette smoking or alcohol abuse, should be addressed.

Prescription drugs such as antihypertensives or antidepressants may be implicated in the patient’s erectile difficulties, and should be altered when medically indicated.

Patients with specific endocrine deficiencies such as hypogonadism should be placed on hormone replacement therapy prior to initiation of direct therapies for erectile dysfunction.

Additionally, sexual problems in the partner such as a lack of lubrication, hypoactive sexual desire or dyspareunia (painful intercourse) should be addressed.

Patients and partners should be fully informed about the range of treatment options available, and the risks and benefits associated with each should be addressed.
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