Introduction
Pathophysiology
Normal Female Sexual Physiology
Sexual Dysfunction in Women with Diabetes Mellitus
Clinical Presentation/Diagnosis
Initiating the Conversation
Permission
Tips to facilitate dialogue |
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Posture and language |
Ask open-ended questions with silences that encourage the patient to speak |
Use words and body language that put the patient at ease |
Maintain an open, non-defensive body posture |
Sit and maintain eye contact |
Avoid nervous gestures |
Choose language appropriate to the age, ethnicity, and culture of the patient |
Questions |
Do you have any sexual concerns you would like to discuss? |
Are you satisfied with your current sexual relations? |
Please describe your sexual problem |
What distresses you the most about this sexual problem? |
“Tell me about [it]” are probably the four most powerful words in medicine |
Limited Information
Specific Suggestions
Intensive Therapy
Diagnosis and Screening Tools for HSDD
Step 1: Initiate the conversation using the PLISSIT model |
Step 2: Utilize the screening tool: decreased sexual desire screener An answer of “yes” to the first four questions is consistent with HSDD Question 5 can identify reasons for the decrease in sexual desire |
Step 3: Take a thorough sexual history considering psychosocial issues a. Relationship status b. History of abuse (verbal, emotional, physical, or sexual) c. Alcohol, tobacco, or illicit drug abuse |
Step 4: Take a thorough sexual history considering medical/medication issues a. Current health status b. Past medical history c. Reproductive history and current status (age of menarche, menstrual history, obstetric history, infertility, contraception, sexually transmitted diseases, gynecologic problems, surgeries, urologic problems) d. Endocrine system (diabetes, thyroid disorders, hyperprolactinemia, androgen deficiency) e. Neurologic disorders f. Hypertension g. Psychiatric Illness (mood disorders, anxiety disorders, psychotic illness) h. Surgical history i. Medications (antidepressants, mood stabilizers, anticonvulsants, anticholinergics, opioids, amphetamines, hormones (estrogens, progestins), anti-androgens, GnRH agonists, antihypertensive agents (beta blockers, alpha blockers, diuretics), cardiovascular agents (triglyceride-lowering agents, digoxin), weight loss agents, histamine receptor blockers, chemotherapy agents, aromatase inhibitors, immunosuppressant therapies, steroids) j. Other chronic conditions (breast cancer, rheumatoid arthritis, psoriasis) |
Step 5: Additional evaluation if needed a. Physical exam b. Gynecological examination c. Glycemic control d. Thyroid hormones e. Prolactin levels f. Testosterone and sex hormone binding globulin levels |
Step 6. Refer to specialists if needed a. Certified sexual therapists b. Certified sexual counselors c. Psychiatrists or psychologists |
Management
Pharmacotherapy
Treatment | Indications |
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Flibanserin (Addyi®) | FDA-approved for generalized acquired HSDD in premenopausal women |
Testosterone (oral, injectable, and transdermal) | Off-label, but increases sexual desire and satisfaction in pre- and postmenopausal women with HSDD |
Bupropion (Buspar®) | Off-label, but can improve sexual function |
Sildenafil (Viagra®) | Not effective for HSDD. Some improvement in FAD |
Alternative therapies: DHEA, ginkgo biloba, l-arginine | Limited data regarding effectiveness |