Obstetrics and Gynecology Clinics of North America35 (2008) ppt

Preface
Tristi Muir, MD
Guest Editor
The scope of practice of the gynecologist is broad and challenging. The
gynecologist is blessed with the longitudinal care of women from adoles-
cence through the end stages of life. In fact, many women consider their
gynecologist their primary care physician.
This edition of Obstetrics and Gynecology Clinics of North America
explores many of the daily challenges of office practice. Updates in new
contraceptive options and in management of dysfunctional uterine bleeding
are presented. For the first time in practice of gynecology, we can offer a vac-
cine to reduce the risk or prevent the development of cervical dysplasia and
cancer. The prevention and treatment of human papilloma virus is dis-
cussed, including indications for the vaccine. Urinary tract infections affect
most of the women in our practice. Diagnosis an d current treatment
strategies of primary and recurrent urinary tract infections are delineated.
Ovarian and breast disorders are common and are a concern for many
women. These topics are expanded upon. As women age, osteoporosis
and fecal incontinence limit the quality of life of many of our patients.
Understanding management strategies is a goal of this edition. One of the
most chall enging problems that a gynecologist faces, female sexual dysfunc-
tion, is explored in detail. Procedures that commonly were performed in the
operating room now are moving to the office. Endometrial ablation is
examined, and tips on its performance are presented.
I thank the contributing expert authors for their informative reviews on
these topics. I also thank Carla Holloway for her editing and support.
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Obstet Gynecol Clin N Am
35 (2008) xv–xvi

The breadth of knowledge required to practice gynecology continues to
expand and evolve. Education is truly a lifelong pursuit in medicine.
Although the science of gynecology is multifaceted, the art of medicine is
practiced on a complex, unique individual. The trust and faith that women
place in their gynecologists immeasurably reward all our efforts to expand
our knowledge in the practice of medicine.
Tristi Muir, MD
Section of Female Pelvic Medicine and Reconstructive Pelvic Surgery
Scott & White Temple Clinic
2401 S. 31st Street
Temple, TX 76508, USA
E-mail address:
xvi PREFACE
Foreword
William F. Rayburn, MD, MBA
Consulting Editor
Gynecology is a discipline dedicated to the broad, integrated medical and
surgical care of women’s health throughout their lifespan. Medical practice
in a gynecologist’s office requires an extensive gender-specific understanding
about reproduction, including the physiologic, sexual, cultural, environmen-
tal, and genetic factors that influence disease in women. Preventive counsel-
ing and health education are essential as gynecologists advance the
individual and community-based health of women of all ages.
This issue of the Obstetrics and Gynecology Clinics of North America
pertains to office gynecology, reflecting the expanding outpatient services
available to optimize women’s health and prevent disease. Its content, as de-
veloped by guest editor Tristi Muir, MD, encompasses the detection and
evaluation of common disorders and addresses special concerns among vul-
nerable populations. Common benign breast and gynecologic disorders are
addressed within the context of screening and initial management. Certain

sections cover topics that have a major prevention component, such as os-
teoporosis, new forms of contraception, and human papilloma virus preven-
tion. More procedures previously performed in the operating room are now
moving into the office.
This issue is not intended to be a comprehensive guide to women’s health;
instead, it consolidates useful information on a variety of topics in a single
place. Particular emphasis is given to information not necessarily found in
current textbooks. Treatment guidelines often change, so gynecologists
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doi:10.1016/j.ogc.2008.03.012 obgyn.theclinics.com
Obstet Gynecol Clin N Am
35 (2008) xiii–xiv
should check sources to ensure that they have the most recent recommenda-
tions. The practical information provided by this distinguished panel of con-
tributors will stimulate us further in providing comprehensive health care to
women in our offices.
William F. Rayburn, MD, MBA
Department of Obstetrics and Gynecology
University of New Mexico School of Medicine
MSC10 5580
1 University of New Mexico
Albuquerque, NM 87131-0001, USA
E-mail address:
xiv FOREWORD
Female Sexual Function
and Dysfunction
Dorothy Kammerer-Doak, MD
a,
*
,

Rebecca G. Rogers, MD
b
a
ABQ Health Partners, Women’s Pelvic Specialty Care, University of New Mexico Hospital,
5150 Journal Center Blvd NE, Albuquerque, NM 87109, USA
b
University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM 87131, USA
Sexual health is defined by the World Health Organization as the integra-
tion of somatic, emotional, intellectual, and social aspects in ways that are
positively enriching a nd that will enhance personality, communication, and
love. This article identifies models of sexual function, defines and categorizes
sexual dysfunction, identifies therapeutic mod alities for patients who have
sexual dysfunction, and discusses some of the questionnaires used to evalu-
ate sexual function.
Sexual function
Masters and Johnson [1] were the first to study and report on both
healthy sexual function and sexual dysfunction in the 1960s. In the seminal
‘‘Human Sexual Response,’’ they described four phases of the human sexual
response cycle: excitement, plateau, orgasm, and resolution (Fig. 1). This is
the traditional, linear model of sexual function for both males and females,
and was based on observations of 100, white middle class couples. This lin-
ear model probably more accurately depicts the male than the female sexual
cycle. A more contemporary, intimacy-based model of sexual response and
function has been proposed that is more female-specific [2]. This newer
model of female sexual function describes a circular relationship between
sexuality and satisfaction, and is not linear. In 2002, Basson described
a ‘‘Sexu al Response Circle’’ that incorporates psychological and social as-
pects into female sexual function, such as emotional intimacy and emotional
* Corresponding author.
E-mail address: (D. Kammerer-Doak).

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Obstet Gynecol Clin N Am
35 (2008) 169–183
satisfaction as well as sexual desire and physical satisfaction (Fig. 2) [2]. This
model recognizes that sexual function and response are different in men and
women. Importantly, for women, desire does not always precede sexual
arousal, with many women participating in sexual activity out of love and
affection for their partners. Once engaged in sexual activity, women may
Fig. 1. Sexual response cycle defined by Masters and Johnson. (From Masters WH, Johnson
VE. Human sexual response. Boston: Little Brown & Company; 1966; with permission.)
Fig. 2. The interrelatedness of intimacy, sexual arousal, desire and satisfaction. (From Basson
R. Are the complexities of women’s sexual function reflected in the new consensus definitions of
dysfunction? J Sex Marital Ther 2001;27:105–12; with permission.)
170
KAMMERER-DOAK & ROGERS
then become aroused, and then experience desire. For many women, the sex-
ual response cycle is intimately intertwined with the overall relationship that
they are in, and incorporates the societal and psychological milieu.
Although prevalence and incidence data are scarce for rates of sexual ac-
tivity, what data there are support the conclusion that women are sexually
active throughout the lifespan. Data from the National Survey of Family
Growth indicate that approximately 40% of females 15 to 19 years of age
have had sexual intercourse within the last 3 months [3]. Although frequency
of sexual activity declines with age, population-based studies indicate con-
tinued sexual activity in 47% of married women aged 66 to 71 years, and
in one third of women over the age of 78. Recent population-based surveys
of younger as well as middle aged and older women reported that 50% to
75% are sexually active [4,5]. Lack of interest and lack of partner were
the most common reasons for sexual inactivity. Norms of sexual activity

are not well characterized for women. Most women engage in heterosexual
practices, with only 1.2% reporting sex with other women [3,6]. The average
frequency of sexual activity is six times per month for women compared
with seven for men, with vaginal intercourse the most common sexual prac-
tice, and oral sex a distant second, although not an uncommon practice [6].
Most women report the inability to achieve orgasm with vaginal intercourse
and require direct clitoral stimulation [7,8]. About 20% have coital climaxes,
and 80% of women climax before or after vaginal intercourse when stimu-
lated manually, orally, or with a vibrator or other device. Only 30% women
almost always or always achieve orgasm with sexual activity in contrast to
75% of men [7,8].
Although there are variations among individuals, differences in the sexual
function of men and women start with the sexual response. For men, sexual
function and response centers on the ability to achieve and maintain an erec-
tion. For women, however, sexual response is much more complex, involv-
ing social, psychological, neurologic, vascular, and hormonal processes and
includes complex interaction of sexual stimulation, the central nervous sys-
tem, the peripheral neurovascular system, and hormonal influences, which
are not understood completely [9–11]. Female sexual dysfunction (FSD) is
therefore a complex problem with neurovascular, psychosocial, and endo-
crine etiologies.
Sexual dysfunction
Sexual dysfunction is recognized as a widespread problem, but data are
scarce as to the prevalence, which ranges from 25% to 63% of women de-
pending on the source and definition used. An early study of sexual dysfunc-
tion in the United States analyzed data from the National Health and Social
Life Survey. The survey was based on a probability sample of sexual behav-
ior in a 1992 cohort of 1749 women and 1410 men aged 18 to 59 years and
171FEMALE SEXUAL FUNCTION AND DYSFUNCTION
noted a prevalence of sexual dysfunction in 43% of women and 31% of men

[12]. Low libido was the most common complaint reported in 51% of re-
spondents, followed by problems with arousal in 33%, and pain disorders
in 16%. Se xual dysfunction was more common in women as compared
with men (43% versus 31%), and was associated with younger age (18 to
39 years), less education, and unmarried status. Importantly, in this study,
sexual dysfunction was linked to poor physical and emotional health and
significantly impacted quality of life. These data, however, are limited by
lack of information on individuals greater than 59 years of age, and whether
the sexual dysfunction was problematic or a cause of distress to the affected
individual. Recent studies have addressed sexual practices in a more inclu-
sive population up to age 79 years and have reported on sexual dysfunction
in about 35% of participants [4,5]. In one study [4], 71% of women were sex-
ually active, and 33% of the sexually active women were classified with FSD
by the answer of ‘‘somewhat of a problem’’ or ‘‘ve ry much a problem’’ in at
least one of the four domains studied including lack of interest, lack of en-
joyment, difficulty in arousal, or difficulty in orgasm. When women not sex-
ually active were included in those with sexual dysfunction, then the overall
prevalence of FSD in this study was 45% [4].
The definition of FSD is problematic, and may be defined better by what
it is not, rather than what it is. Media attention and progress in the pharma-
ceutical treatment of male erectile dysfunction have focused attention on fe-
male sexuality. This scrutiny may have created an artificial standard of
expected female sexual function that if not attained is labeled a dysfunction.
A less than perfect sex life becomes FSD when it causes personal distress as
determined by the affected women, and not necessarily her partner [13]. The
diagnosis of FSD requires that the symptom be persistent, pervasive, and
cause personal distress to the woman. Symptoms that bother the woman’s
partner but are not distressful to the woman herself, such as lack of the
woman’s interest in sex, are not classified as her sexual dysfunction.
FSD has been classified into four areas by an international consensus

conference: problems with arousal, orgasm, desire, and pain (Box 1) [14].
Women may have symptoms that fall into more than one dysfunction cate-
gory. Sexual arousal disorder (FSAD) is defined as the persistent or recur-
rent inability to attain or maintain sexual excitement, with an emotional
lessening of excitement or sensation. Orgasmic disorder (FOD) is defined
as the difficulty or inability to reach orgasm after sufficient sexual stimula-
tion and arousal. Sexual desire disorders are divided into two categories: hy-
poactive sexual desire disorder (HASDD), which involves the lack of desire
for sexual activity and/or a deficiency or absence of sexual thought and fan-
tasies, and sexual aversion disorder, defined as the fear and avoidance of
sexual thought and situations. Sexual pain disorders are subdivided into
three categories: dyspareunia, vagini smus, and noncoital sexual pain disor-
der. The first type of FSD pain disorder is dyspareunia, or genital pain that
occurs with intercourse. Vaginismus, the second type of sexual pain
172 KAMMERER-DOAK & ROGERS
disorder, involves involuntary muscle spasms of the lower third of the
vagina that interferes with intercourse. The last category is noncoital sexual
pain disorder, defined as genital pain that occurs with any type of noncoital
sexual stimulation. FSD can be characterized further as primary or second-
ary, and persistent , versus situational. The etiology may be physical or psy-
chological, a combination, or the cause may be unknown.
Assessment of female sexual dysfunction
The approach to the treatment of FSD involves identification of women
who have the problem, identification and treatment of causes of pain, iden-
tification of the class of sexual dysfunction, and treatment tailored to the
individual patient as well as her partner. The most common reason health
care providers fail to questi on their patients about possible FSD is because
of a lack of time [15]. Plouffe [16], however, has demonstrated that three
simple questions are as effective as lengthy interviews to screen for sexual
problems. Screening questions for female sexual function include [16]:

 Are you sexually active?
 Are there any problems?
 Do you have pain with intercourse?
An intake questionnaire with these three questions may be helpful for ef-
ficiency and privacy. The nature of the sexua l problem is characteriz ed as
being associated with arousal, desire, problems with orgasm, or symptoms
of pain. In addition, the history should focus on the duration of the problem
(primary or secondary) and the psychosocial factors involved, such as any
recent life changes or stressors. There are several female sexual function
Box 1. Classification of female sexual dysfunction
Sexual arousal disorder
Orgasmic disorder
Sexual desire disorders
 Hypoactive sexual desire disorder
 Sexual aversion disorder
Sexual pain disorders
 Dyspareunia
 Vaginismus
 Noncoital sexual pain disorder
Data from Basson R, Berman J, Burnett A, et al. Report of the international con-
sensus development conference on female sexual dysfunction: definitions and
classifications. J Urol 2000;163:888–93.
173
FEMALE SEXUAL FUNCTION AND DYSFUNCTION
questionnaires that can be useful, such as the Female Sexual Function Index
(FSFI, available at www.fsfi-questionnaire.com), which has been validated
based on Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) diagnoses of HASDD, FSAD, and FSOD [17]. A total
FSFI score of 26 or less is considered at risk for sexual dysfunction.
Medical history is important, as chronic illnesses or medications that af-

fect neurologic, endocrine, vascular, or psychological function can impact
on sexual function [18,19]. Examples of illnesses that may affect sexual func-
tion include spinal cord injur ies, thyroid disease, diabetic neuropathy, surgi-
cal or medical castration with accompanying marked decreased estrogen
and testosterone levels, cardiovascular disease, and depression. Medications
can interfere with sexual functio n by alteration of mood and libido, such as
antidepressants, antipsychotics, and sedatives, by alteration of blood flow to
the genitals decreasing arousal and/or lubrication, such as certain antihyper-
tensives or antiestrogens, or by increasing sex hormone-binding globulins
and therefore decreasing free testosterone levels such as with oral contracep-
tives. Illicit drug use and alcoholism also are associated with FSD. Excessive
tobacco abuse may lead to vascular insufficiency and decreased genital
blood flow. Difficult vaginal delivery or vaginal surgery may cause denerva-
tion or dyspareunia. Surgical castration is another common intervention
that may affect sexual function adversely, pa rticularly in pr emenopausal
women. Bilateral oophorectomy is the most common prophylactic opera-
tion performed with removal of otherwise healthy tissue.
The physical manifestations of the normal female sexual response cycle
are the result of increased blood flow (engorgement) that occurs in the pelvis
and breasts, and increased muscle tension in the body. Vaginal increases in
blood flow result in increased vaginal secretions, which are important for lu-
brication, and are estrogen-dependent. Low estrogen levels are associated
with significant decreases in clitoral, vaginal, and urethral blood flow and
histologic changes of thin mucosal layers. Thus, any medical illness or med-
ication that interferes with this complex process can contribute to sexual
dysfunction.
An evaluation for possible need for psychotherapy is important, based on
the patient’s current life stressors, social situation and relationships, history
of psychiatric illnesses, and history of sexual trauma. Dete rmination of sex-
ual partner involvement in the FSD is crucial. The physical examination fo-

cuses on general health and on the identification of treatable causes of pain.
Additionally, women who have incontinence and prolapse have lower sexual
function scores than women without these problems [20].
Routine laboratory testing is not recommended unless a hormonal abnor-
mality is suspected, and it includes screening for prolactinoma, thyroid
dysfunction, and adrenal disorders. There is some suggestion that free
testosterone levels less than the lowest quartile may be associated with
FSD or androgen insufficiency syndrome [18,21]. Androgen insufficiency
syndrome, with symptoms of decreased sexual interest and well-being,
174 KAMMERER-DOAK & ROGERS
fatigue, persistent postmenopausal vasomotor symptoms despite estrogen
replacement, and lack of motivation recently has been postulated. Normal
range of test osterone levels have not been established in women, however,
and testosterone levels do not correlate with libido, so random values are
worthless in the evaluat ion of FSD [18,19]. If adrenal insufficiency is sus-
pected, measurement of dehydroepiandrosterone sulfate (DHEAS) is useful
because of isolated adrenal production [21]. Although estrogen deficiency
and urogenital atrophy can contribute to FSD, including dyspareunia and
vascular insufficiency, measurement of estrogen level s is also not useful
[10,19]. Progesterone appears to have little impact either alone or with estro-
gen on female sexual function [10].
Treatment of female sexual dysfunction
The advent of new therapies for male sexual erectile dysfunction and the
media attention it has received have led to widespread attention of FSD.
The treatment of sexual dysfunction in the female, however, is more com-
plex than the male. Male sexual dysfunction mainly involves the arousal
stage of the sexual response and problems with erection or premature ejac-
ulation. In the case of erectile disorders, pharmaceutical interventions that
increase penile blood flow have proven efficacy. Female sexual dysfunction
less commonly occurs in the arousal phase of the sexual response, with more

women reporting difficulties with libido and orgasm [12]. Because the female
sexual response is more complex involving neurovascular, endocrine and
psychosocial factors, simply increasing clitoral and vaginal blood flow
with pharmaceutical agents usually does not result in improved desire,
arousal, or orgasm.
Education of women who have sexual problems about average sexual
behaviors and frequencies as well as determination of whether their own
personal sexual practices are distressing to them can be very helpful. Specifi-
cally, media portrayals do not accurately represent the average American
experience in terms of sexual activity and quality of sexual experience. In
addition, it is important that women know that there is no medically ex-
pected level of sexual activity or function, and that lack of libido or ability
to climax does not represent a sexu al dysfunction as long as the woman ex-
periences no personal distress. Other information that is useful is that about
only 20% of women experience orgasm with vaginal intercourse and that
most require clitoral stimulation to climax. Not all women experience
orgasm with every sexual encounter; only 30% of women climax with
almost every sexual activity [7,8]. An anatomy lesson regarding clitoral
location and techniques for stimulation such as the vibrator may be helpful
in givi ng the woman with psychosocial barriers medical permission to treat
her sexual problems in this way [22].
Exploration for any recent significant physical or social changes such as
childbirth, menopause, work status, or a death should be made as these life
175FEMALE SEXUAL FUNCTION AND DYSFUNCTION
events can affect sexual function negatively. Optimal female sexual health
incorporates physical, mental, and emotional aspects, and these are the con-
text in which a woman experiences desire, arousal, and orgasm. No medical
treatment will improve a bad situation or relationship. Psychosocial inter-
vention may be necessary based on the woman’s relationship, current life
stressors, and sexual problems. Women who have sexual aversion disorder,

primary FOD, and noncoital pain disorder and those who have history of
sexual abuse usually require psychotherapy.
Alteration of contributors to FSD, such as smoking, excess alcohol or il-
licit drug use, obesity, and optimal treatment of medical diseases that can
affect FSD such as hypertension and diabetes are also part of management.
Simple things, including exercise, a healthy diet, and adequate rest, improve
physical and mental, and therefore sexual health. The woman and her part-
ner need to improve communication and reduce relationship strains when
present, as a strong impetus for female sexuality is intimacy [21]. Sensate
focus is a technique that can be used by couples to resolve sexual problems
and improve intimacy through communication regarding what is pleasur-
able [22]. This technique aims to make both partners aware of what each
finds enjoyable and to reduce anxiety about performance. Initially, inter-
course is banned, and the focus is on the sensation of nongenital touching,
with mutual pleasure the goal. Gradually, the level of intimacy is advanced
when both partners are comfortable, to mutual touching to include the gen-
itals, and finally to intercourse with the same focus of pleasure and enjoy-
ment that was learned in the first levels.
Sexual activity is often begun by women to improve emotional closenes s
with their partners, and this can impact libido. Scheduling date nights and
time for sexual relations can be effective even when desire is not apparent.
Remind patients that for women, desire does not always precede arousal,
and making protected time for intimacy can improve sexual function [21].
Medications
The effects of systemic hormone therapy (HT) on female sexual function
are inconsistent in randomized controlled trials (RCTs), including placebo-
controlled trials [10,18,21]. Estrogen improves vaginal and clitoral blood
flow, improving lubrication. Dyspareunia caused by atrophy is treated
best by vaginal estrogen, either delivered as a cre
`

me, tablet, or ring. Proges-
terone can ameliorate these changes and cause persistent dryness and dys-
pareunia depending on type of progesterone used [18]. The ability of
systemic HT to enhance sexual arousal, desire, and ability to achieve orgasm
is not definitive. Studies from the 1970s did not find any changes in satisfac-
tion, orgasm, or frequency of sexual intercourse or masturbation [18]. More
recent RCTs have reported beneficial effects of estrogen therapy (ET) on
sexual desire, enjoyment, orgasmic frequency, and vaginal lubrication, but
176 KAMMERER-DOAK & ROGERS
no difference in coital frequency [18]. Another study evaluating transdermal
estrogen noted improvement in satisfaction, increase in sexual activity and
vaginal lubrication, decreased dyspareunia, but no change in arousal or or-
gasm frequency [18]. Many experts do initiate systemic HT in the absence of
contraindications in postmenopausal women who have FSD [21].
The role of androgens in the treatment of FSD is controversial. Testos-
terone has been linked to sexual desire [10,18,19 ,21]. Androg en levels grad-
ually decrease with age starting at about 30 years, but there is no abrupt
drop at the time of menopause. Ovarian and adrenal production of andro-
gens continue into the menopause, with levels about half of peak levels [21].
The data on testosterone use for the treatment of FSD are limited, however,
with few RCTs and no information on long-term use. The best studies come
from the treatment of postmenopausal and surgically castrated women eval-
uated in RCT [23–26] . The addition of testosterone, either oral or transder-
mal to ET resulted in significant improvement in sexual function, including
desire, arousal, and orgasm, compared with ET alone. Some patients with-
drew secondary to adverse effects [23], howeve r, and supraphysiologic
testosterone levels were reported [26]. The use of androgens in premeno-
pausal women who have FSD has been poorly studied. One small RCT re-
ported improvement in arousal with use of testosterone gel administered
4 to 8 hours before planned sexual activity compared with placebo [27]. Pre-

menopausal women who have serum-free testosterone levels below the low-
est quartile of normal range and who have sympt oms of androgen
insufficiency including FSD may be offered testosterone but need to be
counseled on the absence of efficacy data and safety. Blood levels should
be monitored to achieve physiologic levels in the mid–upper level of normal
range [10,18,21]. Transdermal testosterone may minimize the adverse ef-
fects. Because testosterone can affect lipid profile negatively and cause liver
damage, it may be prudent to evaluate liver function and lipids at regular
intervals. Long-term adverse effects of testosterone therapy that are irre-
versible include clitoral enlargement, voice changes, and male pattern bald-
ness, but these complications are rare with physiologic levels [21]. Other
androgens such as DHEAS and dehydroepiandrosterone (DHEA) have
been used to treat FSD but with very lim ited evidence for effectiveness.
One small uncontrolled study reported an improvement in desire, arousal,
satisfaction, and orgasm in pre- and postmenopausal women with decreased
androgen levels and libido treated with DHEA [28]. DHEA is available as
a nutritional supplement, and although not regulated by the FDA, it can be
used to treat premenopausal women with androgen insufficiency at a dose
of 50 mg/d after counseling regarding the experimental nature of this use
[21].
Tibolone is a synthetic steroid with estrogenic, progesterogenic, and an-
drogenic properties, with possible positive effect on sexual function used in
Europe for more than 20 years [10,21]. In a recent RCT, tibolone was shown
to increase clitoral circulation and sexual function scores significantly as
177FEMALE SEXUAL FUNCTION AND DYSFUNCTION
compared with conventional HT in postmenopausal women who had FSD
[29].
Medications used to treat male erectile dysfunction such as sildenafil also
have been studied in women who have FSD. These medications increase
genital blood flow by inhibition of phosphodiesterase, thereby facilitating

nitric oxide-mediated relaxation of clitoral and vaginal smooth muscle. In
women, increased vaginal and clitoral blood flow and increased lubrication
and engorgement caused by sildenafil did not translate into consistently im-
proved sexual function in several large trials of women with FSD [19,21].
There does not appear to be any clear benefit to the use of sildenafil in
women FSD. In women with isolated FSAD who have low vaginal engorge-
ment as measured by vaginal pulse amplitude with photoplethysmography,
however, a few RCTs have reported significantly increased subjective
arousal and perception of genital arousal [21,30,31]. Women who benefit
from this class of drugs may be those who have deficient genital engorge-
ment, especially those who have a specific underlying cause of FSAD,
such as type 1 diabetes, and not those who have deficient subjective arou sal
[21,32].
Other medications used to treat HASDD, FSAD, and FOD include top-
ical and oral medications. Arginmax is an oral nutritional supplement con-
taining L-arginine, a precursor for nitric oxide, which facilitates genital
smooth muscle relaxation, damiana, ginseng, ginkgo, multivitamins and
minerals [21,33]. Two small, placebo-controlled RCTs both conducted by
the same authors noted significantly improved desire, orgasm, sexual fre-
quency, and clitoral sensation, including increased sexual function scores us-
ing the FSFI in women randomized to Arginmax [33,34].
Zestra is a botanical massage oil composed of PA-free borage seed oil,
evening primrose oil, angelica extract, coleus extract, vitamin C, vitamin
E, and natural fragrances to applied to the vulva before sexual activity.
One small RCT in 20 women, 10 who had FSAD, reported significant
improvement in arousal, desire, orgasm, and sexual pleasure as compared
with placebo [35].
Avlimil is a tablet advertised on the Internet and magazines as a ‘‘daily
supplement shown to promote better blood flow and increased muscular
relaxation for an improved libid o and a healthier, more energetic sexual

response.’’ Although the company reports significant improvement in sexual
function in a RCT, there are no studies published in peer-reviewed journals
using this product, which contains multiple herbs. The US Federal Trade
Commission has charged the marketers of Avlimil in making false and
unsubstantiated claims. Avlimil’s ingredients are substantially different
from the formula used in the clinical trial cited in advertisements.
Alprostadil, a prostaglandin topically applied to the genitals, is under in-
vestigation to treat FSD. Alprostadil increases genital vasocongestion, lubri-
cation, and some indices of sexual arousal, but results are inconsistent, with
not all trials demonst rating significant benefit compared with control [36].
178 KAMMERER-DOAK & ROGERS
There are ongoing clinical trials that will help to determine if alprostadil is
beneficial for FSD, however.
In summary, women who have sexual dysfunction may have problems
that overlap the different stages of sexual function, arousal, desire, orgasm,
or pain. Management involves assessment of the level of dysfunction, edu-
cation of average sexual practices, ways to improve intimacy, treatment of
pain, evaluation for psychotherapy depending on current and past relation-
ships and life stressors including history of sexual abuse, and medical
management when indica ted. Hormone replacement therapy, including
testosterone, may be used in postmenopausal wom an, but the role of andro-
gens in premenopausal women who have sexual dysfunction remains under
investigation. Primary orgasmic disorder, sexual aversion disorder, and non-
coital sexual pain disorder are difficult to treat and generally require psychi-
atric referral and long-term counseling.
Sexual function in women with pelvic floor disorders
Pelvic floor disorders, including urinary and anal incontinence and pelvic
organ prolapse, are common and have a negative impact on the sexual func-
tion of women [20]. In a large national survey of sexual functi on, urinary
tract symptoms were associated with increased rates of arousal and sexual

pain disorders [12]. In another epidemiologic study that evaluated women
undergoing hysterectomy, urinary incontinence was associated with low
libido, vaginal dryness, and dyspareunia, but pelvic organ prolapse was
not associated with any sexual complaints measured [37]. Coital inconti-
nence, or loss of urine with sexual intercourse, can be particularly trouble-
some to patients and occurs either with vaginal penetration in women
who have stress incontinence or with orgasm in women who have overactive
bladder symptoms [38]. The effects of pelvic organ prolapse and urinary
incontinence as well as vaginal anatomy on sexual function have been eval-
uated in two studies by the same authors [39,40]. Although increasing grade
of prolapse predicted interference with sexual activity, prolapse itself did not
affect frequency of intercourse or subjective satisfaction. Sexual activity was
not correlated with vaginal length or introital caliber, and no association
was noted between anatomy and complaints of dyspareunia. More ad-
vanced stages of prolapse have been associated with reports of impairment
in sexual lif e and increased rates of abstinence [41]. Multiple studies have
shown that surgical treatment of the underlying pelvic floor disorder, either
prolapse or stress urinary incontinence, improves sexual function as mea-
sured by a condition-specific validated questionnaire [42–44]. Not all studies
report an improvement, however, A recent publication reported no differ-
ence in sexual function following vaginal surgery for prolapse and stress uri-
nary incontinence, but these authors used a validated questionnaire, which
was not specific for pelvic floor disorders [45].
179FEMALE SEXUAL FUNCTION AND DYSFUNCTION
Sexual function after hysterectomy
Hysterectomy is the most common major gynecologic surgery, and there
is popular belief of adverse effect on sexual function. Older studies that re-
ported the effects of hysterectomy on sexual function did not use validated
questionnaires or prospective design. Multiple prospective studies have
demonstrated a positive effect of total and subtotal abdominal and vaginal

hysterectomy on sexual function [46–49]. RCTs have shown no benefit for
sexual function by cervical preservation with subtotal (supracervical) hyster-
ectomy [49].
Pregnancy and childbirth
Sexual dysfunction is common after childbirth, but generally is addressed
poorly by providers. Up to 86% of women report sexual problems in the
first 3 months after childbirth [50,51]. At 6 months postpartum, 18% to
30% of women still experience sexual problems, mostly related to dyspareu-
nia [52]. Fortunately, most women resume prepregnancy orgasmic function
and sexual intercourse without severe pain by 6 months postpartum [53].
Risk factors for postpartum sexual dysfunction include continued breast
feeding and severity of genital tract trauma sustained at childbirth [53,54].
At 6 months postpartum, women who have severe perineal lacerations
into the anal sphincter are 270% more likely to report pain with intercourse
than women who delivered without laceration [54]. Compared with sponta-
neous vaginal delivery, assisted vaginal delivery is associated with pos tpar-
tum sexual dysfunction, but the effect of cesarean delivery on sexual
function is not consistent [51,53]. Prevention of severe laceration at child-
birth and increa sed communication postpartum with women, especially
those who are breast feeding, would improve the detection and subsequent
treatment of FSD in this young population.
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183
FEMALE SEXUAL FUNCTION AND DYSFUNCTION
New Forms of Contraception
Kristen A. Plastino, MD
a,
*
,1
, Patricia J. Sulak, MD
b,2
a
Department of Obstetrics & Gynecology, University of Texas Health Science Center
at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
b
Department of Obstetrics & Gynecology, Texas A&M University System Health Science
Center College of Medicine, Scott & White Hospital, 2401 S. 31st St., SLAB,
Rm. 109, Temple, TX 76508, USA
The United States unfortunately has one of the highest unintended preg-
nancy and abortion rates in developed countri es [1], even though highly
effective reversible methods are available, some approaching or equaling
the efficacy of sterilization. In addition to decreasing a woman’s risk of preg-
nancy, many of the hormonal methods reduce monthly menstrual symp-
toms, regulate cycles, improve complexion, and decrease cancer risks.
Women can expect more from their contraception besides birth control
and have many more options today than in the past.
New formulations of combined estrogen and progestin regimens have de-
viated from the standard regimen of 21 active pills and 7 days of placebos to
decrease monthly hormone-withdrawal symptoms and withdrawal bleeding.

Also, women are using hormonal contraceptives for noncontraceptive ben-
efits such as reducing the risk of ovarian and endometrial cancer. A variety
of delivery systems, including oral, intramuscular, transdermal, transvagi-
nal, intrauterine, and subdermal methods, also are available to assist with
compliance and side effects. Permanent contraception is av ailable as an
in-office procedure in which tubal occlusion devices are placed hysteroscopi-
cally with minimal postoperative pain.
Oral contraceptives
The most common reversible method of contraception is the oral contra-
ceptive pill (OCP), first introduced in 1954 to Dr. John Rock’s 50 patients
1
Kristen Plastino, MD, has financial relationships with Bayer and Wyeth.
2
Patricia J. Sulak, MD, has served as a consultant to Duramed, Wyeth, Bayer, and
Warner Chilcott and has received research grants from Organon, Duramed, and Warner
Chilcott.
* Corresponding author.
E-mail address: (K.A. Plastino).
0889-8545/08/$ - see front matter. Published by Elsevier Inc.
doi:10.1016/j.ogc.2008.03.009 obgyn.theclinics.com
Obstet Gynecol Clin N Am
35 (2008) 185–197
for 20 days each month [2]. All the patients failed to ovulate during treat-
ment [2]. Rock and his colleagues had discovered a reversible method to
control fertility. Following this discovery, pharmaceutical companies devel-
oped various combinations of OCPs. In the late 1970s the relationship be-
tween steroid dose and adverse cardiovascular events was noted, resulting
in dramatic lowering of estrogen and progest in doses and eventual removal
of high-dose formulations from the market. The approach remains, after
40 years, to use the lowest doses of steroids to provide the most effective

contraception.
The standard regimen of hormonal contraception has been 21 days of es-
trogen and progestin components followed by 7 hormone-free days (the 21/7
regimen). This regimen mimicked the average cycle length of 28 days, en-
sured a nonpregnant state, and allowed a brief drug holiday. As hormone
doses continued to decrease over 40 years, however, decreased pituitary-
ovarian suppression and increased monthly hormone-withdrawal symptoms
were noted during the 7-day hormone-free interval (HFI). In 1997 a study
was published suggesting extending the duration of active oral contraceptive
pills to manage hormone-withdrawal symptoms [3] such as menstrual
migraines. These symptoms were described in more detail in 2000 when
more than 250 women, receiving combined OCPs containing 35 mg or less
of ethinyl estradiol (EE), recorded symptoms in daily diaries while taking
the 21 active pills and during the 7-day HFI. Pelvic pain, headaches, breast
tenderness, bloating, and the use of pain medic ations were all significantly
higher during the 7-day HFI than during the 21 active-pill days ( Table 1) [4].
In addition to increased hormone-withdrawal symptoms during the HFI,
greater pituitary-ovarian activity was noted with low-dose 21/7 regimens.
Sullivan and colle agues [5] in 1999 randomly assigned 58 women to standard
21/7 regimen or to a 24/4 regimen with 24 active pills and only a 4-day HFI.
Six of the cycles in the 21/7 group had luteinized unruptured follicles, and
one ovulation occurred; neither of these occurred with the 24/4 regimen.
Serum hormone measurement s also confirmed incomplete pituitary-ovarian
suppression with increases in follicle-stimulating hormone and estradiol
noted during the 7-day HFI, a finding that was reduced dramatically with
the 4-day HFI regimen.
Table 1
Hormone-withdrawal symptoms in oral contraceptive users
Symptom 21 Active pills (%) 7 Hormone-free pills (%) P-value
Pelvic pain 21 70 !.001

Headaches 53 70 !.001
Breast tenderness 19 58 !.001
Bloating/swelling 16 38 !.001
Use of pain medications 43 69 !.001
Data from Sulak PJ, Scow RD, Preece C, et al. Hormone withdrawal symptoms in oral con-
traceptive users. Obstet Gynecol 2000;95:261.
186
PLASTINO & SULAK
Since the 1970s, it has been common practice to use OCPs to suppress the
formation of ovarian cysts. Early studies, with higher-dose formulations of
50 mg of EE or greater, demonstrated a 40% to 70% reduction in the forma-
tion of these cysts [6]. Because estrogen and progestin dosing in OCPs has
decreased, this suppression has been limited. Holt and colleagues [7] per-
formed a case-control study of 18- to 39-year-old women taking 35-mgEE
monophasic OCPs or less-than-35-mg EE monophasic and multiphasic
OCPs over 6 months. She co ncluded that low-dose monophasic and multi-
phasic OCP use with a 7-day HFI had little or no effect on the development
of functional ovarian cysts [7]. Therefore, as OCP dosing has decreased,
many reasons have surfaced to modify the 21/7 contraception regimen, in-
cluding common hormone-withdrawal symptoms, development of func-
tional ovarian cysts, and possible ovulation with unintended pregnancy.
Of importance, the monthly withdrawal bleeding is artificial, unnecessary,
has no health benefits, and can be associated with other symptoms. Several
modifications of the 21/7 regimen have been approved by the Food and
Drug Administration (FDA) that provide greater pituitary-ovarian suppres-
sion. Some of these newer formulations can alter the frequency of
menstruation.
Around the world, most women want to menstruate monthly or at least
to menstruate a few times per year [8–10]. Patient desires regarding men-
strual frequency must be elicited to decide which type of OCP will fit their

needs. The ideal regimen for patients who prefer the reassurance of monthly
bleeding is to shorten the HFI and increase the number of active-pill days.
Multiple studies have been documented decreased endogenous ovarian hor-
mone levels if the HFI is 3 or 4 days instead of 7 days [11–13]. Willis and
colleagues [11] administered a standard 21/7 regimen and then randomly as-
signed the same patients to either a 21/3 or 21/4 regimen. Blood samples
were obtained daily surrounding the HFI to measure follicle-stimul ating
hormone, luteinizing hormone, estradiol, and inhibin-B. Greater pituitary
and ovarian suppression were seen with the shortened HFI. Hormone levels
did not differ between the 3- and 4-day HFI groups. Schlaff and colleagues
[12] compared three groups of patients taking (1) a standar d 21/7 regimen of
EE, 20 mg, and levonorgestrel, 100 mg; or (2) a continuous regimen of
28 days of EE, 20 mg, plus desogestrel, 150 mg, with no HFI; or (3)
21 days of EE, 20 mg, plus desogestrel, 150 mg, with 2 placebo days and
5 days of EE, 10 mg. Subjects using the oral contraceptive with a 7-day
HFI experienced the least suppression. The FDA has approved two oral
contraceptives that shorten the HFI to 4 days and increase the active com-
ponent to 24 days. One co ntains 20 mg of EE and 3 mg of drospirenone. The
other contains 20 mg of EE and 1 mg of norethindrone.
Knowing that some women may want fewer scheduled withdrawal bleeds
in a year and that the HFI and withdrawal bleeding during this time is
unnecessary, many practitioners used extended regimens in an off-label fash-
ion. In 2003 the FDA approved the first extended regimen, levonorgestrel,
187NEW FORMS OF CONTRACEPTION
0.15 mg, and EE, 0.03 mg, consisting of 84 combined active pills and a 7-day
HFI. Thi s 91-day cycle induced four withdrawal bleeds per year but was as-
sociated with breakthrough bleeding a nd spo tting. Earlier studies reported
the use of a 21/2/5 regimen in which there were 21 days of EE (20 mg)
plus desogestrel (150 mg), 2 placebo days, and 5 days of low-dose EE
(10 mg). Greater ovarian suppression was noted with the 21/2/5 regimen

than with the typical 21/7 dosing, and improved bleeding profiles also
were observed [14]. This experience led to the development of an FDA-
approved continuous OCP regimen in 2006. This regimen contained 150
mg of levonorgestrel and 30 mg of EE for 84 days followed by 7 days of
low-dose EE (10 mg), again allowing four withdrawal bleeds per year but
improving the bleeding profile. A prospective, randomized study of 21/7,
84/7, and 84/7 EE regimens confirmed greater pituitary-ovarian suppression
with low-dose EE added to the 7-day interval [15].
As women age, they tend to desire less monthly bleeding [8–10]. Regi-
mens have been designed to eliminate monthly menses entirely. Practitioners
have been prescribing continuous regimens off-label for years. Small studies
with continuous OCPs have reported 49%, 68%, and 88% of women with
no bleeding dur ing 2-month, 6-month, and 12-month cycles, respectively
[16]. Other studies have shown a similar reduction in sanitary protection
use and significantly less bloating and menstrual pain [17]. Currently there
is only one FDA-approved product (90 mg of levonorgestrel and 20 mgof
EE daily) for patients who do not want scheduled monthly bleeding).
Vaginal ring
The vaginal contraceptive ring has been studied for 30 years [2]. The only
one currently available in the United States comes in one size, 54 mm in di-
ameter and 4 mm in thickness. It releases 15 mg of EE and 120 mg of etono-
gestrel per day. It is approved for use in the vagina for 21 days and then
should be removed for 7 days, in a typical 21/7 regimen. There is enough
steroid hormone in the ring to inhibit ovulation for more than 21 days, how-
ever [18]. Barreiros and colleagues [19] prospectively evaluated 75 volunteers
using a 15-mg EE/120-mg etonogestrel ring for 84 days followed by a 7-day
HFI. Eighty-five percent of patients had adequate menstrual patterns.
Miller and colleagues [20] also compared bleeding patterns and the tolerabil-
ity of continuous use of the same contraceptive ring. Bleeding days were
reduced, but breakthrough spotting (BTS) was increased, as in continuous

OCP dosing.
Breakthrough bleeding
The most common side effect of these extended contraceptive regimens, in-
cluding the 91-day and 365-day cycles, is breakthrough bleeding (BTB). The
188 PLASTINO & SULAK
occurrence of BTB or BTS is not predictable and, if not managed correctly,
can lead to discontinuation. Instituting an abbreviated HFI has been shown
to be effective in managing BTB. In a retrospective study, patients instructed
to take a 3- to 4-day HFI for BTB rarely discontinued oral contraceptives
because of bleeding [21]. This managem ent also was studied prospectively.
If more than 7 days of BTB/BTS occurred while using extended oral contra-
ceptive regimens, patients were assigned randomly a 3-day HFI or to continu-
ing the extended regimen. Patients must have taken a minimum of 21
consecutive active pills before a 3-day HFI could be instituted to ensure con-
traceptive efficacy. Randomization to a 3-day HFI was more effective (P !
.001) than continuing the extended regimen in resolving the BTB/BTS [22].
Noncontraceptive uses of combined contraceptives
Overall, many patients accept OC Ps as their method of contraception, and
women use OCPs for other indications. The most common noncontraceptive
use of estrogen and progestin contrac eptives is to control menstrual cycle
bleeding. Menorrhagia [23], dysfunctional uterine bleeding [24], treatment
of anemia caused by menses, and a reduction in menstrual frequency for dis-
orders such as von Willebrand’s syndrome [25] are all off-label uses of OCPs.
Management of pelvic pain caused by dysmenorrhea, of ovulatory pain, and
of endometriosis, as well as skin conditions such as acne and hirsutism [26],
also are common indications for oral contraceptive use. As women are delay
child bearing, the risks of ovarian and endometrial cancer increase. Estrogen
and progestin contraceptives have been shown consistently to help prevent
ovarian and endometrial cancer in epidemiologic findings [27]. There is
some evidence that colon cancer may be reduced in OCP users as well [28].

Newer continuous estrogen and progestin regimens also have shown multiple
benefits, including reductions in bleeding [16,17,22], pelvic pain [17], menstru-
ation-associated headaches [29], and premenstrual symptoms [30].
Several studies have noted that 21/7 OCP regimens often show little or no
improvement in premenstrual symptoms and actually may induce symptoms
[31–33]. Modifying the 21/7 regimen to a 24/4 or continuous regimen does de-
crease premenstrual-type symptoms [30]. Today, data support the use of OCPs
for signs and symptoms of premenstrual syndrome and premenstrual dys-
phoric disorder (PMDD) [34,35]. Therefore, patients requesting contracep-
tion and having a history of PMDD should be offered OCPs because they
will reduce the risk of pregnancy and now have been shown to decrease the
signs and symptoms of premenstrual syndrome and PMDD significantly. At
this time, the FDA has approved only one OCP for the indication of PMDD.
Adverse effects
In most patients, the benefits of combination contraceptive regimens
outweigh the rare risks, but patients must be screened carefully for
189NEW FORMS OF CONTRACEPTION