Sexuality is an important component of physical, intellectual, psychologic and social well-being. This central role of sexuality in a person’s life is affected by health or illness and by many psychologic factors. Physicians have the opportunity to assess the sexual function in the course of routine history taking; however, this is rarely done. Additionally, many doctors are uncomfortable with the patient’s questions about sexuality and feel uneasy about broaching the subject themselves. In some cases, they feel that such questions are an intrusion on the patient’s privacy, even though they realize that bowel and drug habits, cigarette and alcohol use and reproductive status are also private matters. In other cases, they believe that the patient’s sexual concerns are not of medical significance or that their own ability to treat such concerns is limited. In this way, they ignore or dismiss the patient’s concerns.
Patients may expect their physician to be an authority on sexual matters but frequently are unable to express their concerns for fear of being criticized or misunderstood. Surveys of clinical practices show that only 10% of patients will initiate a discussion of sexual problems if the physician does not, but over 50% will describe a sexual concern if the doctor provides an opportunity for discussion. Thus, the onus of breaking the vicious circle of avoiding talking about sexual matters seems to fall on the physician. Such enquiry may lead to a diagnostic clue in an otherwise elusive diagnosis.
Concerns about sexual matters and sexual dysfunctions affect all ages. It is important to remember that the demographics of the Western societies are changing. There is an increase in longevity, which leads to two separate phenomena. On the one hand, there is a large population of middle and retirement age people who are spared the ravages of harsh physical labor, and who age in good general health with a secure income. On the other hand, many patients with previously untreatable chronic diseases, such as cancer, hypertension, angina, diabetes, depression, rheumatoid arthritis and osteoarthritis, live much longer with an improved prognosis. In both groups, the presence of a sexual dysfunction may completely spoil the enjoyment of better health. Therefore, it is necessary that health professionals nowadays should have a basic understanding of human sexuality and sexual dysfunctions.
Pregnancy And The Puerperium
There are two special situations which warrant further discussion: pregnancy and puerperium and the menopause. Sexual activity during pregnancy decreases from 85% in the first trimester to 23% in the 36th week. Common reasons are physical discomfort, loss of interest and fear of injuring the fetus. After delivery, sexual activity resumes in three months for most couples. However, 50% of mothers and 15% of fathers report lower sexual desire and 60% of couples have less sexual activity at one year after delivery of the baby. The main reasons for this decline in sexual activity are summarized in Table Causes for decline in sexual activity in the puerperium.
Table Causes for decline in sexual activity in the puerperium
|raised prolactin and low estrogen|
|milk release on arousal|
|Change of role to mother|
|Weight gain and poor body image|
|Fear of pregnancy|
|Disturbed sleep pattern|
All these factors need to be addressed in a simple and practical manner before extensive investigations are undertaken and before the couple is labeled as suffering from sexual dysfunction.
Specific features of sexuality in the perimenopause and the menopause are given in Table Factors contributing to sexual dysfunction in the menopause.
Table Factors contributing to sexual dysfunction in the menopause
|Aging and its effects: dry skin, brittle hair, dry mucosae, painful joints, muscles Pendulous breasts with increased fat content|
|Redistribution of body fat, especially to the buttock and abdomen (middle-aged spread)|
|Sex hormone deficiency affecting|
|Reaction to changed body image|
|Attitude to menopause|
|Support network and coping with midlife crises|
|Society emphasis on youth and slimness|
The psychologic and sociocultural dimensions need to be addressed in their own right. Adequate explanation about the process of aging and its effects on sexual dysfunction goes a long way. Most middle-aged and older people would not expect themselves to be as fit or to look as well as when they were young; however, some retain these expectations with regard to sexuality.
Practical steps such as prolonging foreplay, using gels for lubrication and topical estrogens may be of help when the problem resides in sexual response. Systemic estrogen and testosterone have been shown to be effective. Estrogen and testosterone act locally to increase the genital sensitivity, congestion and lubrication and centrally to increase sexual fantasies and sexual desire. Although there is anxiety about testosterone supplements in many women and some medical practitioners, our own extensive experience with testosterone implants shows that after adequate explanation most women with a sexual response disorder will try an implantation at least once. The main points in counseling are summarized in Table Counseling women regarding testosterone implantation. Recently, testosterone patches have been developed. In controlled studies a 300 ug patch was shown to be safe and effective treatment for sexual dysfunction in women over 48 years of age who had undergone a hysterectomy or oophorectomy. Additional benefits of testosterone are increases in lean body mass and bone density.
Table Counseling women regarding testosterone implantation
|50 mg implant over 6 months equals approximately 0.27 mg/day, which is similar to the natural production rate of testosterone|
|Adverse side-effects include|
|altered lipid profile|
Adverse side-effects are uncommon, but oily skin and acne are reported with frequency. The incidence of hirsutism is less than 1% in our clinic. Alopecia, voice change and clitoromegaly are rare, so it is not possible to give an accurate estimate. Altered lipid profile does not represent a real problem. In our opinion, testosterone supplementation is an under-utilized treatment option.