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Identifying HSDD in the family medicine setting.

Hypoactive sexual dysfunction disorder (HSDD) occurs among women of all ages but continues to be underdiagnosed and undertreated. (1) A lack of patient-physician communication is a major reason underlying the failure to identify HSDD. Research has revealed that this problem represents a 2-way street: patients are reluctant to discuss sexual difficulties with their physicians, and physicians are reluctant to inquire about such issues. (2,3) Moreover, some physicians are concerned that conversations about sexual function might consume too much time during the office visit. (4) An additional consideration is the fact that many physicians do not believe they have the requisite knowledge and experience to diagnose and manage HSDD. (1) By recognizing the nature of these barriers and implementing strategies to overcome them, family physicians can play an important role in promoting more widespread screening for female sexual dysfunction (FSD), leading to greater use of diagnostic modalities designed to ascertain the exact nature of the dysfunction.

Obstacles to screening for HSDD

Studies have found that the topic of sexual dysfunction may never come to light if the responsibility for initiating a discussion is left to the patient. (5) In 2000, a report from a survey of women receiving routine gynecologic care from family practitioners revealed that 87% struggled with lack of interest in sexual activity. (5) Yet, a 2004 update of a 1999 survey found that only 8% of US women aged 45 to 49 years and 12% of those aged 50 to 59 years had sought treatment from their personal physicians for a sexual problem. (6) Of particular note is the fact that the overall proportion of women who had sought treatment for sexual dysfunction from any health professional remained consistent, at 10%, between the 1999 survey and the 2004 update. (6) This finding suggests that little progress has been made in encouraging patients to discuss such problems with their physicians.

According to other studies, embarrassment is a key obstacle to patients' ability to broach the subject of sexual function with their physicians. (7) Apart from the patients' own embarrassment, a survey found that 68% of patients were actually afraid the physician would be embarrassed if they brought up sexual issues. (3) Of interest in this regard are data from a survey of nearly 2000 health care professionals who cited embarrassment as a major obstacle to their initiating discussions about sexual health. (1) These providers also stated that limited time and training were important barriers to their addressing sexual problems. Approximately 60% of respondents rated their knowledge and comfort level with the subject of FSD as only fair or poor.

Identifying who should be screened

Overcoming obstacles to patient-provider communication

The investigations described above suggest that direct questioning by physicians is often critical to uncovering patients' concerns about sexual function. (1) Even if the patient offers information spontaneously, questions initiated by the physician will convey concern and let the patient know that it is appropriate to discuss these issues. (4)

Studies have demonstrated that training in communication skills is the strongest predictor that a physician will take a sexual history? Physicians should work on improving their communication abilities, both to put themselves at ease and to put the patient at ease. (9) TABLE 1 lists additional physician characteristics that patients find important in order to establish a comfortable discussion of sexual issues. (10) This information was obtained in a survey of women receiving routine gynecologic care, 90% of whom stated that they believed these physician traits made it more comfortable for them to talk about sexual concerns. (10)

Physicians' concerns regarding the amount of time necessary to address sexual disorders during the office visit are not well founded? Indeed, just a few brief questions can allow the family physician to evaluate whether a woman is experiencing sexual problems and should be screened for FSD (TABLE 2). (4,11,12)

Medical factors that should prompt screening

Many health-related conditions may be associated with the development of sexual problems. Therefore, office visits related to these circumstances provide vital opportunities to inquire about changes in sexual function. (11) Examples of such situations include visits prior to surgery for uterine prolapse, hysterectomy, or oophorectomy; antenatal and postnatal visits; consultations regarding infertility; and visits for the management of chronic conditions such as diabetes, renal failure, and coronary artery, cerebrovascular, neurological, or adrenal disease. (11, 13) The use of certain antidepressants (for instance, selective serotonin reuptake inhibitors), as well as depression itself, can lead to a decrease in sexual desire and subjective arousal in women. (13) Other medications (for example, antihypertensives, antipsychotics, antiepileptics, antiandrogens, and narcotics) can also have such effects. (13) Furthermore, in light of the fact that postmenopausal women embody a key population at increased risk of FSD, the subject of sexual dysfunction should always be raised as a patient enters this crucial period. (11, 14) Such a conversation can be initiated during a routine visit or during a visit specifically dedicated to the management of menopause-related symptoms, including the discussions of the pros and cons of hormonal therapy. (4)

Brief screening tools for FSD and HSDD

Once a woman has been identified as a candidate for FSD screening, she should be evaluated using formal screening instruments. Several brief screening tools for FSD and HSDD are readily available for use in clinical practice (see examples listed in TABLE 3). (15-21) These validated instruments assess major categories of FSD, explore quantitative and qualitative aspects of the woman's sexual experience, and evaluate past and current levels of sexual desire. The screeners can often be self-administered by the patient, are simple to understand, and take little time to complete. For example, the Decreased Sexual Desire Screener (DSDS) was designed for use by clinicians with limited experience diagnosing HSDD. (17) The DSDS, which is comprised of a series of questions answered by the patient and a multi-point question to assist the clinician with a diagnosis of HSDD, was recently validated for use in pre-, peri-, and postmenopausal women (TABLE 4). (17)

Establishing a diagnosis

If screening tools suggest the presence of FSD, a diagnosis can be established by evaluating the patient's past medical history, undertaking a comprehensive sexual assessment, performing a physical examination, and conducting selected laboratory tests. (9,22) The medical history should include reproductive history and current status; presence of any endocrine, neurologic, cardiovascular, or psychiatric disorders; and current use of prescription and over-the-counter medications? The comprehensive sexual assessment should encompass inquiries aimed at identifying the components of the complaint. Essential questions to include in the sexual assessment are listed in TABLE 5. (23) The physical examination should include inspection of the external genitalia as well as mono- and bimanual examinations to check for conditions that may impair sexual function (such as vaginismus, vulvar vestibulitis, rectal disease, urinary tract infection, fibroids, endometriosis, and cysts, among others). (22,24) Appropriate laboratory tests should be ordered to check the patient's thyroid function, liver function, lipid profile, and fasting glucose level. (25) If a hormonal problem is suspected, assessment of prolactin, total and free testosterone, sex hormone-binding globulin, dihydroepiandrosterone, and estrogens may be warranted. (26) Androgen levels in premenopausal women should be measured at the time they peak (on days 8 through 10 of the menstrual cycle).


Lack of physician-patient communication is a major contributor to the underdiagnosis of sexual dysfunction in women. Without proper recognition of these problems, women affected by FSD remain untreated and experience adverse consequences that undermine their relationships and quality of life. As primary care providers, family physicians have numerous opportunities to screen women for various types of FSD, including HSDD, and to implement appropriate strategies for establishing a diagnosis. Candidates for FSD screening can be identified by overcoming obstacles to discussing sexual issues and by maintaining an awareness of medical factors that can contribute to sexual dysfunction. Simple screening tools can determine which women should be further evaluated with medical and sexual histories, physical examination, and laboratory tests to establish a diagnosis. Greater involvement of family physicians in the detection of sexual dysfunctions such as HSDD will undoubtedly improve the lives of the many women who continue to experience these problems.


(1.) Bachmann G. Female sexuality and sexual dysfunction: are we stuck on the learning curve? l Sex Med. 2006;3:639-645.

(2.) Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281:537-544.

(3.) Marwick C. Survey says patients expect little physician help on sex. JAMA. 1999;291:2173-2174.

(4.) Kingsberg S. Just ask! Talking to patients about sexual function. Sexuality Reprod Menopause. 2004;2:199-203.

(5.) Nusbaum MR, Gamble G, Skinner B, et al. The high prevalence of sexual concerns among women seeking routine gynecological care. J Fam Pract. 2000;49:229-232.

(6.) American Association of Retired Persons. Sexuality at Midlife and Beyond. 2004 Update of Attitudes and Behaviors. Washington, DC: American Association of Retired Persons; 2005. pdf. Accessed March 26. 2009.

(7.) Goldstein I, Lines C, Pyke R, et al. National differences in patient-clinician communication regarding hypoactive sexual desire disorder. J Sex Med. 2009;6:1349-1357.

(8.) Tsimtsiou Z, Hatzimouratidis K, Nakopoulou E, et al. Predictors of physicians' involvement in addressing sexual health issues, l Sex Med. 2006;3:583-588.

(9.) Kingsberg SA. Taking a sexual history. Obstet Gynecol Clin N Am. 2006;33:535-547.

(10.) Risen CB. A guide to taking a sexual history. Psychiatr Clin N Am. 1995; 18:39-53.

(11.) Basson R. Sexuality and sexual disorders. Clin Updates Women's Health Care. 2003; 11:1-94.

(12.) Nusbaum MR, Hamilton CD. The proactive sexual health history. Am Fam Physician. 2002;66:1705-1712.

(13.) Basson R, Shultz WW. Sexual sequelae of general medical disorders. Lancet. 2007;369:409-424.

(14.) Dennerstein L, Randolph J, Taffe J, et al. Hormones, mood, sexuality, and the menopausal transition. Fertil Steril. 2002;77(suppl 4):S42-S48.

(15.) Derogatis LR, Rosen R, Leblum S, et al. The Female Sexual Distress Scale (FSDS): initial validation of a standardized scale for assessment of sexually related personal distress in women. I Sex Martial Ther. 2002;28:317-320.

(16.) Derogatis LR, Clayton A, Lewis-D'Agostino D, et al. Validation of the Female Sexual Distress Scale-Revised for assessing distress in women with hypoactive sexual desire disorder. J Sex Med. 2008;5:327-364.

(17.) Clayton AH, Goldfischer ER, Goldstein I, et al. Validation of the Decreased Sexual Desire Screener (DSDS): a brief diagnostic instrument for generalized acquired female hypoactive sexual desire disorder (HSDD). J Sex Med. 2009;6:730-738.

(18.) Leiblum S, Symonds I, Moore J, et al. A methodology study to develop and validate a screener for hypoactive sexual desire disorder in postmenopausal women, l Sex Med. 2006;3:455-454.

(19.) Rosen R, Brown C, Heiman l, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. I Sex Marital Ther. 2000;26:191-208.

(20.) Rust J, Derogatis L, Rodenberg C, et al. Development and validation of a new screening tool for hypoactive sexual desire disorder: the Brief Profile of Female Sexual Function (B-PFSF). Gynecol Endocrinol. 2007;23:638-644.

(21.) Taylor JF, Rosen RC, Leiblum SR. Self-report assessment of female sexual function: psychometric evaluation of the Brief Index of Sexual Functioning for Women. Arch Sex Behav. 1994;23:627-643.

(22.) Kingsberg SA, Janata JW. Female sexual disorders: assessment, diagnosis, and treatment. Urol Clin N Am. 2007;34:497-506.

(23.) Basson R. Eliciting the sexual concerns of your patient 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 strategy for sexual dysfunction in men and women, J Sex Med. 2004;1:49-57.

(26.) Meston CM, Bradford A. Sexual dysfunctions in women. Annu Rev Clin Psychol. 2007;3:233-256.

Sheryl A. Kingsberg, PhD

Associate Professor

Departments of Reproductive

Biology and Psychiatry

Case Western Reserve

University School of Medicine

Chief, Division of Behavioral Medicine

Department of Obstetrics and Gynecology

University Hospitals Case Medical Center

MacDonald Women's Hospital

Cleveland, Ohio

Physician characteristics that make it easier
for patients to discuss sexual concerns

* Physician has seen the patient before

* Physician knows the patient

* Physician seems concerned about sexual wellness

* Physician has professional demeanor

* Physician appears comfortable

* Physician seems kind and understanding


Questions to prompt patients to discuss
sexual concerns (4,11,12)

* Are you currently involved in a sexual relationship?
With men, women, or both?

* How often do you engage in sexual activity?

* Do you have difficulty with desire, genital or subjective
or orgasm?

* Are you satisfied with your current sexual relations?

* Do you have any sexual concerns you would like to discuss?

Medical and psychosocial effects of disease
on female sexual function

Screening tool             tration time        Domains

Female Sexual              Self-report;        Desire, arousal,
Function Index (19)        10-15 minutes       lubrication, orgasm,
                                               satisfaction, pain

Brief Index of             Self-report         Thoughts/desires,
Sexual Functioning         15-20 minutes       arousal, frequency of
for Women (21)                                 sexual activity,
                                               satisfaction, problems
                                               affecting sexuality

Brief Profile of Female    Self-report         Desire
Sexual Function (20)

Decreased Sexual           Self-report/        Desire
Desire Screener (17)       interview;
                           15 minutes

Brief HSDD Screener (18)   Self-report;        Desire
                           3-8 minutes

Female Sexual Distress     Self-report;        Distress
Scale/Female               10-15 minutes
Sexual Distress
Scale-Revised (15,16)

Decreased Sexual Desire Screener (17)

Dear Patient,
Please answer each of the following questions:

1. In the past was your level of sexual desire or interest       Yes/No
   good and satisfying to you?

2. Has there been a decrease in your level of sexual desire      Yes/No
   or interest?

3. Are you bothered by your decreased level of sexual desire     Yes/No
   or interest?

4. Would you like your level of sexual desire or interest to     Yes/No

5. Please check all the factors that you feel may be
   contributing to your current decrease in sexual desire or

   A. An operation, depression, injuries, or other medical         []
   B. Medication, drugs, or alcohol you are currently taking       []
   C. Pregnancy, recent childbirth, menopausal symptoms            []
   D. Other sexual issues you may be having (pain, decreased       []
      arousal or orgasm)
   E. Your partner's sexual problems                               []
   F. Dissatisfaction with your relationship or partner            []
   G. Stress or fatigue                                            []

Verify with the patient each of the answers she has given.

The Diagnostic and Statistical Manual of Mental Disorders, 4th
edition, Text Revision, characterizes Hypoactive Sexual Desire
Disorder (HSDD) as a deficiency or absence of sexual fantasies and
desire for sexual activity, which causes marked distress or
interpersonal difficulty, and which is not better accounted for by a
medical, substance-related, psychiatric, or other sexual condition.
HSDD can be either generalized (not limited to certain stimulation,
situations, or partners) or situational, and can 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 the diagnosis of generalized acquired HSDD.

If the patient answers "YES" to all of the questions 1 through 4 and
your review confirms "NO" answers to 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 factors in question 5, then decide if the answers
to question 5 indicate a primary diagnosis other than generalized
acquired HSDD. Co-morbid conditions such as arousal or orgasmic
disorder do not rule out a concurrent diagnosis of HSDD.

Based on the above, does the patient have generalized            Yes/No
acquired HSDD?

Clayton AH, Goldfischer ER, Goldstein I, et al. Validation of the
Decreased Sexual Desire Screener (DSDS): a brief diagnostic instrument
for generalized acquired female hypoactive sexual desire disorder
(HSDD). J Sex Med. 2009;6:730-738. Copyright (c) 2009 Blackwell
Publishing Ltd. Reproduced with permission of Blackwell Publishing


Essential 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

* Was the onset sudden or gradual?

* Is the problem specific to a situation or partner or is it

* Were there likely precipitating events (biological or

* 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 not
being directly acknowledged?

* Are there physical problems, such as pain?

* Are there problems with desire, arousal, or orgasm, and can the
patient determine
the primary problem?

* Is there a history of physical, emotional, or sexual abuse that
be contributing?

* Does the partner have any sexual problems?
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Title Annotation:hypoactive sexual dysfunction disorder
Author:Kingsberg, Sheryl A.
Publication:Journal of Family Practice
Geographic Code:1USA
Date:Jul 1, 2009
Previous Article:From whence comes HSDD?
Next Article:Opportunities for intervention in HSDD.

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