S16 From whence comes HSDD? - The Journal of Family Practice

Identifying HSDD in the family medicine settingTable 3Medical and psychosocial effects of diseaseon female sexual functionModality/Screening tool administration time DomainsFemale Sexual Self-report; Desire, arousal, lubrication, orgasm,Function Index 19 10-15 minutes satisfaction, painBrief Index of Self-report; Thoughts/desires, arousal, frequency of sexualSexual Functioning 15-20 minutes activity, receptivity, pleasure/orgasm, relationshipfor Women 21satisfaction, problems affecting sexualityBrief Profile of Female Self-report DesireSexual Function 20Decreased Sexual Self-report/ interview; DesireDesire Screener 17 15 minutesBrief HSDD Screener 18Self-report; 3-8 minutes DesireFemale Sexual Distress Self-report; DistressScale/Female Sexual 10-15 minutesDistress Scale–Revised 15,16Table 4Decreased Sexual Desire Screener 17Dear Patient,Please answer each of the following questions:1. In the past was your level of sexual desire or interest good and satisfying to you? Yes/No2. Has there been a decrease in your level of sexual desire or interest? Yes/No3. Are you bothered by your decreased level of sexual desire or interest? Yes/No4. Would you like your level of sexual desire or interest to increase? Yes/No5. Please check all the factors that you feel may be contributing to your current decrease in sexualdesire or interest:A. An operation, depression, injuries, or other medical condition qB. Medication, drugs, or alcohol you are currently taking qC. Pregnancy, recent childbirth, menopausal symptoms qD. Other sexual issues you may be having (pain, decreased arousal or orgasm) qE. Your partner’s sexual problems qF. Dissatisfaction with your relationship or partner qG. Stress or fatigue qClinicianVerify with the patient each of the answers she has given.The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, characterizesHypoactive Sexual Desire Disorder (HSDD) as a deficiency or absence of sexual fantasies and desirefor sexual activity, which causes marked distress or interpersonal difficulty, and which is not betteraccounted for by a medical, substance-related, psychiatric, or other sexual condition. HSDD canbe either generalized (not limited to certain stimulation, situations, or partners) or situational, andcan be either acquired (develops only after a period of normal functioning) or lifelong.If the patient answers “NO” to any of the questions 1 through 4, then she does not qualify for thediagnosis of generalized acquired HSDD.If the patient answers “YES” to all of the questions 1 through 4, and your review confirms “NO” answersto all of the factors in question 5, then she does qualify for the diagnosis of generalized acquired HSDD.If the patient answers “YES” to all of the questions 1 through 4 and “YES” to any of the factorsin question 5, then decide if the answers to question 5 indicate a primary diagnosis other thangeneralized acquired HSDD. Co-morbid conditions such as arousal or orgasmic disorder do notrule out a concurrent diagnosis of HSDD.Based on the above, does the patient have generalized acquired HSDD?Yes/NoClayton AH, Goldfischer ER, Goldstein I, et al. Validation of the Decreased Sexual Desire Screener (DSDS): a brief diagnostic instrumentfor generalized acquired female hypoactive sexual desire disorder (HSDD). J Sex Med. 2009;6:730-738. Copyright © 2009 BlackwellPublishing Ltd. Reproduced with permission of Blackwell Publishing Ltd.Establishing a diagnosisIf screening tools suggest the presenceof FSD, a diagnosis can be establishedby evaluating the patient’spast medical history, undertaking acomprehensive sexual assessment,performing a physical examination,and conducting selected laboratorytests. 9,22 The medical history shouldinclude reproductive history andcurrent status; presence of any endocrine,neurologic, cardiovascular,or psychiatric disorders; and currentuse of prescription and over-thecountermedications. 9 The comprehensivesexual assessment shouldencompass inquiries aimed at identifyingthe components of the complaint.Essential questions to includein the sexual assessment are listed inTable 5. 23 The physical examinationshould include inspection of the externalgenitalia as well as mono- andbimanual examinations to check forconditions that may impair sexualfunction (such as vaginismus, vulvarvestibulitis, rectal disease, urinarytract infection, fibroids, endometriosis,and cysts, among others). 22,24Appropriate laboratory tests shouldbe ordered to check the patient’sthyroid function, liver function, lipidprofile, and fasting glucose level. 25 Ifa hormonal problem is suspected, assessmentof prolactin, total and freetestosterone, sex hormone–bindingglobulin, dihydroepiandrosterone,and estrogens may be warranted. 26Androgen levels in premenopausalwomen should be measured at thetime they peak (on days 8 through 10of the menstrual cycle).ConclusionLack of physician-patient communicationis a major contributor tothe underdiagnosis of sexual dysfunctionin women. Without properrecognition of these problems, women affectedby FSD remain untreated and experience adverseconsequences that undermine their relationshipsand quality of life. As primary careproviders, family physicians have numerous opportunitiesto screen women for various typesof FSD, including HSDD, and to implement appropriatestrategies for establishing a diagnosis.Candidates for FSD screening can be identifiedby overcoming obstacles to discussing sexual issuesand by maintaining an awareness of medicalfactors that can contribute to sexual dysfunction.Simple screening tools can determinewhich women should be further evaluated withmedical and sexual histories, physical examination,and laboratory tests to establish a diagnosis.Greater involvement of family physiciansin the detection of sexual dysfunctions such asHSDD will undoubtedly improve the lives of themany women who continue to experience theseproblems. nDisclosureDr. Kingsberg receives research grants from BioSante Pharmaceuticals,Boehringer Ingelheim Pharmaceuticals, Inc., and Procter& Gamble Pharmaceuticals; is a consultant for Boehringer IngelheimPharmaceuticals, Inc., and Wyeth; and is a speaker for EliLilly and Company and Johnson & Johnson.References1. Bachmann G. Female sexuality and sexual dysfunction:are we stuck on the learning curve? J SexMed. 2006;3:639-645.2. Laumann EO, Paik A, Rosen RC. Sexual dysfunctionin the United States: prevalence and predictors.JAMA. 1999;281:537-544.3. Marwick C. Survey says patients expect little physicianhelp on sex. JAMA. 1999;291:2173-2174.4. Kingsberg S. Just ask! Talking to patients aboutsexual function. Sexuality Reprod Menopause.2004;2:199-203.5. Nusbaum MR, Gamble G, Skinner B, et al. Thehigh prevalence of sexual concerns amongwomen seeking routine gynecological care. J FamPract. 2000;49:229-232.6. American Association of Retired Persons. Sexualityat Midlife and Beyond. 2004 Update of Attitudesand Behaviors. Washington, DC: AmericanAssociation of Retired Persons; 2005. http://assets.aarp/org/rgcenter/general/2004-sexuality.pdf. Accessed March 26. 2009.7. Goldstein I, Lines C, Pyke R, et al. National differencesin patient-clinician communication regardinghypoactive sexual desire disorder. J SexMed. 2009;6:1349-1357.8. Tsimtsiou Z, Hatzimouratidis K, NakopoulouE, et al. Predictors of physicians’ involvementin addressing sexual health issues. J Sex Med.2006;3:583-588.9. Kingsberg SA. Taking a sexual history. Obstet GynecolClin N Am. 2006;33:535-547.Table 5Essential questions to include in a sexual assessment 23• How does the patient understand or describe the problem?• How long has the problem been present?• Is the problem lifelong or acquired after a period of normal function?• Was the onset sudden or gradual?• Is the problem specific to a situation or partner or is it generalized?• Were there likely precipitating events (biological or situational)?• Are there problems in the patient’s primary sexual relationship(or any relationship in which the sexual problem is occurring)?• Are there current life stressors that might be contributing to sexual problems;and, if so, how is stress perceived and managed?• Is there some underlying guilt, depression, or anger that is notbeing directly acknowledged?• Are there physical problems, such as pain?• Are there problems with desire, arousal, or orgasm, and can the patient determinethe primary problem?• Is there a history of physical, emotional, or sexual abuse that maybe contributing?• Does the partner have any sexual problems?10. Risen CB. A guide to taking a sexual history. PsychiatrClin N Am. 1995;18:39-53.11. Basson R. Sexuality and sexual disorders. ClinUpdates Women’s Health Care. 2003;11:1-94.12. Nusbaum MR, Hamilton CD. The proactivesexual health history. Am Fam Physician.2002;66:1705-1712.13. Basson R, Shultz WW. Sexual sequelae of generalmedical disorders. Lancet. 2007;369:409-424.14. Dennerstein L, Randolph J, Taffe J, et al. Hormones,mood, sexuality, and the menopausaltransition. Fertil Steril. 2002;77(suppl 4):S42-S48.15. Derogatis LR, Rosen R, Leblum S, et al. The FemaleSexual Distress Scale (FSDS): initial validationof a standardized scale for assessment ofsexually related personal distress in women. JSex Martial Ther. 2002;28:317-320.16. Derogatis LR, Clayton A, Lewis-D’Agostino D,et al. Validation of the Female Sexual DistressScale–Revised for assessing distress in womenwith hypoactive sexual desire disorder. J SexMed. 2008;5:327-364.17. Clayton AH, Goldfischer ER, Goldstein I, etal. Validation of the Decreased Sexual DesireScreener (DSDS): a brief diagnostic instrumentfor generalized acquired female hypoactivesexual desire disorder (HSDD). J Sex Med.2009;6:730-738.18. Leiblum S, Symonds T, Moore J, et al. A methodologystudy to develop and validate a screenerfor hypoactive sexual desire disorder in postmenopausalwomen. J Sex Med. 2006;3:455-454.19. Rosen R, Brown C, Heiman J, et al. The FemaleSexual Function Index (FSFI): a multidimensionalself-report instrument for the assessmentof female sexual function. J Sex Marital Ther.2000;26:191-208.20. Rust J, Derogatis L, Rodenberg C, et al. Developmentand validation of a new screening tool forhypoactive sexual desire disorder: the Brief Profileof Female Sexual Function (B-PFSF). GynecolEndocrinol. 2007;23:638-644.21. Taylor JF, Rosen RC, Leiblum SR. Self-reportassessment of female sexual function: psychometricevaluation of the Brief Index of SexualFunctioning for Women. Arch Sex Behav.1994;23:627-643.22. Kingsberg SA, Janata JW. Female sexual disorders:assessment, diagnosis, and treatment. UrolClin N Am. 2007;34:497-506.23. Basson R. Eliciting the sexual concerns of yourpatient in primary care. Med Asp Human Sex.2000;1:11-18.24. Phillips NA. The clinical evaluation of dyspareunia.Int J Impot Res. 1998;10(suppl 2):S117-S120.25. Hatzichristou D, Rosen RC, Broderick G, et al.Clinical evaluation and management strategyfor sexual dysfunction in men and women. J SexMed. 2004;1:49-57.26. Meston CM, Bradford A. Sexual dysfunctions inwomen. Annu Rev Clin Psychol. 2007;3:233-256.S24 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S25