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34 Cards in this Set

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Describe the sexual health assessment for women without sexual concerns.
1. Begin with less threatening material such as obstetrical history
2. Begin with questions about sex ed history ie. How did you learn about sex?
3. Proceed with personal attitudes about sexuality.
4. Finally assess actual sex behaviors.
1. Are you sexually active?
2. Do you have any sexual difficulties or problems at this time?
3. Do you have pain with intercourse?
4. Has (illness, problem, pregnancy) interfered with your sex life? Has it changed the way you feel about yourself as a woman? Has it altered your ability to respond sexually?
5. Is sex pleasurable for you? Any problems with lubrication? Are you able to have an orgasm?
6. Are you satisfied with your sex life?
7. Do you have any sexual problems or questions?
8. Do you limit contact with your partner because you’re afraid it will lead to sex?
9. Do you get annoyed when your partner initiates sex?
10. Do you feel that having sex is an imposition?
Describe the sexual health assessment for women with sexual concerns.
1. Reviewing normal sexual response in women may be all that is needed to make the woman realize she is normal.
2. A diagram may be helpful
3. Many people do not realize that the majority of women can not achieve orgasm without direct clitoral stimulation.
4. Required a comprehensive medical history including surgeries, chronic illness, medications and allergies (latex).
5. Social history including present or past abuse, recreational drugs, alcohol and cigarettes, multiple sex partners and contraception.
6. Cultural and religious beliefs
7. psychological history such as stress, body image, coping mechanisms
Identify medical conditions that can affect sexual response and function.
1. those that involve neurologic, endocrine or vascular problems ie.
2. thyroid disease
3. diabetes
4. hypertension
Identify medications that can affect sexual response and function.
1. anorectics
2. anticholinergics
3. anticonvulsants
4. antidepressants
5. antiestrogens
6. antihistamines
7. antihypertensives
8. antipsychotics
9. antiulcer drugs
10. barbiturates
11. benzodiazepines
12. GnRH agonists
13. narcotics
14. oral contraceptives
Define Hypoactive sexual desire disorder
The persistant or recurrent deficiency of sexual fantasies/thoughts, and/or desire for or receptivity to sexual activity, which causes personal distress.
Assessment of Hypoactive sexual desire disorder
1. Duration – has the pt always felt this way or has something changed?
2. Frequency of sex – the problem may be related to differing expectations of frequency of sex between partners after the normal slowing down of sex.
3. Has the change in desire resulted in a decrease in frequency? If the woman has continued to have sex despite her decreased desire she may first need to deal with issues of power in her relationship.
4. Investigate the timing of sex and what occurs afterwards. Many women are not relaxed as men are after sex and may worry about the lost sleep associated with sex.
5. Do the negatives that result from sex outweigh the benefits? If her needs for intimacy are not being met she may lose her motivation for sex.
6. Do her associated symptoms lead to a physiological cause such as hypothyroid?
Management of Hypoactive sexual desire disorder
1. Treat underlying physiological problems
2. Educate about normal fluctuations in desire that result from life stress such as pregnancy, parenting, and menopause.
3. If it is a side effect of SSRI adding wellbutrin or buspar may help.
4. If she is perimenopausal estrogen and/or testosterone may help. Side effects incude hirtuism, deeping of the voice, hair loss and enlargement of clitoris.
Define Sexual aversion disorder
The persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner that causes psychological distress
Assessment of Sexual aversion disorder
1. Ask about prior history of abuse
2. Screen for depression, anxiety and drug abuse as these are frequent in survivors of child or adult sexual abuse or assault.
3. Screen for anorexia and bulimia, and chronic pelvic pain.
4. Though usually result of trauma also could be fear of harming the patient’s sexual partner or fear of performance anxiety.
Management of Sexual aversion disorder
1. Attempt to determine the underlying cause
2. Therapy should be directed at resolving issues of abuse or trauma.
3. Behavior modification with desensitization to teach a woman to be more comfortable first with her own body then with a partners.
4. Refer to mental health professional.
Define Sexual arousal disorder
The persistent or recurrent ability to attain or maintain sufficient sexual excitement, causing personal distress, which may be expressed as a lack of subjective excitement, or genital lubrication/swelling, or other somatic responses.
Assessment of Sexual arousal disorder
1. Assess for physiological problems causing vascular or neurologic changes to the body.
2. Also question about physical activities such as gymnastics or bike riding that can cause nerve trauma.
3. Medications associated with this are anticholinergics, antihistamines, Mao inhibitors, SSRIs, tricyclic antidepressants, and antihypertensives.
4. Smoking and alcohol can also affect this.
Management of Sexual arousal disorder
1. Teach how to lubricate or stimulate the clitoris
2. treatments usually focus on restoring blood flow to genitals
3. Lubricants or warm baths may help
4. for menopausal women a localized estrogen therapy ma be helpful
5. Eros-CTD (clitoral therapy device) that fits over the clitoris and increases blood flow to the area by creating gentle suction.
6. Herbal therapies include yohimbe or ginko biloba.
7. Viagra, though not labeled for women, has shown some promise in clinical trials. Do not use in hypertensives.
8. Topical testosterone, another off label use, has been used with some success also. Pregnancy category X.
Define orgasmic disorder
The recurrent difficulty, delay, or absence of attaining orgasm following sufficient sexual stimulation and arousal, which results in personal distress.
Assessment of orgasmic disorder
Determine the duration and extent of the problem
Management of orgasmic disorder
1. If never experienced orgasm, start with a diagram to demonstrate genital anatomy.
2. Explain that most women can only reach orgasm through stimulation of the clitoris.
3. Instruct to try self stimulation to explore what elicits the best response.
4. Practicing kegel exercises allows women to learn to control their muscular tension which may decrease inhibition of her sexual response.
5. For some women the use of a vibrator may help.
Define dysparenia
The recurrent or persistent genital pain associated with sexual intercourse.
Name four causes of dyspareunia
1. vulvar vestibulitis
2. vaginal infections or latex allergy
3. semen hypersensitivity
4. atrophic vaginitis
Assessment of vulvar vestibulitis
persistent pain at vaginal introitus or inability to achieve penetration due to pain may be vulvar vestibulitis. May report pain attempting to use tampons prior to first intercourse. To evaluate for this gently palpate the area anterior to the hymen with a cotton swab. The patient will often describe a sharp or burning sensation when touched with the swab. Frequently at 6 o’clock in the vestibule or fossa navicularis.
* rule out infections or dermatological disorder before using this diagnosis.
Management of vulvar vestibulitis
1. initially treated conservatively with discontinuation of vaginal irritants such as excessive bathing, tight clothing or sanitary pads.
2. Topical lidocaine can be applied 20 minutes prior to intercourse
3. Physical therapy may use biofeedback to teach control of muscles
4. Amitryptyline or neurontin
5. surgical removal or laser treatment of vestibule
Assessment and management of vaginal infection or latex allergy
Burning or pain after intercourse should be evaluated for vaginal infections or latex allergy.

tx with antibiotic or antifungal
describe semen hypersensitivity
rare – localized symptoms of edema and burning after sex. May include systemic signs like urticaria, cough and dyspnea. Advise to use latex condoms and see if symptoms abate.
Assessment of atrophic vaginitis
– perimenopausal or lactating – or some meds like tamoxifen, evista, lupron. Causes excessive dryness and burning after intercourse. Altered pH from normal 4.7 to 6 or 7, mucosal color change, and decreased vaginal discharge.
Define Vaginismus
The recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration and causes personal distress.
Assessment of Vaginismus
1. Often unable to complete a pelvic exam as involuntary spasms preclude inserting a speculum.
2. Partner may find sex painful due to spasms
3. may have history of sexual abuse or pain from trauma from repeated medical procedures such as catheterization
Management of Vaginismus
1. progressive muscle relaxation
2. kegels can teach a woman to control the muscles of her vagina
3. physical therapy may use biofeedback to learn to control the muscles
4. once pt can control muscles a series of dilators are used inside vagina until the woman can accommodate a penis
Compare traditional and alternative models of sexual response cycles (EngenderHealth, 2005c and Fogel, 2006, pp. 152-155 from the Required Readings, also covered in Association of Reproductive Health Professionals, 2005a in the Internet Additional Resources). How would the model being used impact the management of sexual concerns?
1. The traditional model of sexual response focused on genital response and customary indicators of desire such as sexual fantasy and the need for self stimulation. Four sequential phases including desire, excitement, orgasm, resolution.
2. Alternatively Basson suggests that a woman’s sexual response cycle more commonly arises from a need for intimacy rather than a desire for sexual arousal, and that a woman’s sense of sexual arousal arises only minimally from an awareness of genital congestion and other physiological changes. In this model sexual desire is a response to a need rather than a spontaneous event. Sexually neutral state, seeking sexual stimuli, sexual arousal, awareness now of desire to continue for sexual arousal reasons also, more arousal +/- orgasm, physical well being, as well as emotional closeness, bonding, commitment, love, affection, acceptance, tolerance, closeness.
3. What are the barriers to lesbian women getting optimal health care and how are these influenced by social and institutional factors?
1. Internal barriers
1. reluctance to disclose their lesbian identity
2. distrust of the system
2. External barriers
1. the assumption by HCPs that all their patients are heterosexual
2. financial due to lack of health insurance or partner coverage
Identify the history needed for a woman presenting with infertility.
1. General medical, family, social, emotional, occupational, recreational and lifestyle history.
2. Duration of infertility and previous evaluations and treatments
3. Detailed gyne history focusing on menstrual and pregnancy history any pgs with this woman and this partner), as well as previous surgery or procedures.
4. Frequency of coitus, hx of STIs, sexual difficulty
5. Nipple discharge, hirtuism, pelvic pain
6. thyroid disorders
Identify the physical examination needed for a woman presenting with infertility.
1. complete physical and pelvic exam (including abnormal anatomy, STI, infection)
2. weight, BMI
3. hirtuism, acne, alopecia
4. thyroid abnormalities, nipple discharge
Identify the diagnostic testing needed for a woman presenting with infertility.
1. ovulation detection
2. semen analysis
3. Possibly laboratory testing, postcoital testing, HSG, endometrial biopsy, laparoscopy, sperm penetration assay
Briefly describe the management options for infertility.
1. Patient education may be effective especially if pt is unaware of timing of ovulation or with irregular cycles. Women can also be counseled to lose weight, stop smoking, and to reduce alcohol and caffeine intake.
2. Ovulation Induction can be done if there is evidence of anovulation or infrequent ovulation. The first choice is clomid (climiphene citrate) which works by binding estrogen receptor in the pituitary gland thereby blocking those receptors from detecting circulating estrogen. As a result the hypothalamus increases its production of GnRH, which stimulated the pituitary to produce FHS and LH, which stimulate and initiate an ovulatory cycle. There is also injectable FHS and LH and hCG can be used to stimulate ovulation once there is a mature follicle.
3. Treatment of short luteal phase is done with prolactin if there is a known deficiency, or with clomid if suspected it is caused by ovulatory disfunction. Is can also be treated with exogenous progesterone.
What are some of the psychosocial and ethical issues related to infertility?
1. Psychosocial issues
1. Many psychological issues are related to infertility and there is much debate about whether they are a cause or effect.
2. depression or anxiety may contribute
3. many issues surrounding stopping treatment too as new opportunities open up people want to feel like they have done everything possible to conceive.
2. Ethical issues
1. Access to treatment
2. what happens to frozen embryos if a couple divorces
3. when a surrogate mother refuses to relinquish and nfant
4. how the “real parent” is defined
5. multiple pregnancies
6. preimplantation genetic testing
The mnemonic REFRAMED
Reproductive awareness
Environmental toxins and teratogens
Folic aid and nutrition
Review genetic history
Alcohol, tobacco, and other substance use
Medical conditions and medications
Evaluate immunizations and infectious diseases
Domestic violence and psychosocial issues