The path to overcoming female sexual disorder (FsD) has grown much clearer over the last decade. At Premier Women’s Center for Continence and sexual Health we now have a wide array of diagnostic tools, medications and treatment protocols with which to help our patients. By taking into account the interconnected realms that effect female sexuality, we can often achieve success for women who had all but given up hope.

The Case

A 59-year-old post-menopausal woman presents with complaints of decreased libido and pain with intercourse over the last 10 years. She reports having sexual relations 4-5 times a year with her husband of 24 years, noting that her spouse is always the initiator. Patient reports no longer enjoying sexual relations with her spouse, a situation she fears will only continue to get worse.

The History

Patient reports a history of depression and is able to coincide her decreased libido with the onset of her depression and the initiation of anti-depressant therapy. She has had 3 C-sections with no vaginal births, a total hysterectomy, and spinal surgery. Currently, she is taking Tramadol for back pain and a selective serotonin reuptake inhibitor (SSRI) for depression. Tests for urinary tract infections, bacterial, and yeast infections done by previous providers have been negative. She has not had any sexually transmitted diseases or pelvic trauma caused by rape, infections, or vaginal births. The patient’s partner is able to maintain relations through orgasm. She reports difficulty becoming aroused and notes that pain with intercourse limits the intimate time she spends with her spouse.

The Examination

The physical exam includes a vulvoscopy to assess the vagina and vulva through magnification. The vaginal tissue is noted to be pale pink and dry, with atrophy of the minor labial folds bilaterally and of the vaginal opening. The vestibule is erythematous, with decreased rugae noted within the vagina. Upon examination of the glands within the vestibule, the patient reports pain on a scale of 9/10.

A vaginal culture is obtained in order to rule out any infections as a cause of the patient’s pain and erythema. Blood tests are ordered to assess patient’s hormone levels, adrenal function, sex hormone binding globulins and thyroid function. A complete metabolic panel is obtained to help determine whether she is a candidate for use of certain hormonal treatments.

The Diagnosis

The physical exam reveals that the patient suffers from atrophic vaginitis-postmenopausal—the thinning and decreased lubrication of the tissues—caused by aging and a lack of hormones. Her pain with intercourse (dyspareunia) arises from the irritated glands and atrophied vaginal opening, lending to the diagnosis of vulvar vestibulitis. The patient also suffers from female orgasmic disorder and hypoactive sexual desire disorder, as deduced from her history.

The Treatment

The patient’s blood work shows her to be deficient in several hormones. After discussing treatment options with the patient, it is decided to begin a regimen of topical hormone replacement therapy (HrT), using various creams to provide for a healthy vaginal environment. The patient was advised to follow-up with the doctor who prescribes her SSRI therapy to discuss alternatives to her depression management, such as medications that bind with the excitatory neurochemical, which would help during the orgasmic phase. Using water-based lubricating solutions free from parabens and other irritants was recommended to decrease pain with penetration. The patient was also encouraged to bring her partner in to the next visit to discuss her therapy. Sensate activities were explored and the patient was educated regarding the pleasure receptors, which will help her and her spouse rekindle their bond and strengthen their relationship.

The Outcome

Six weeks after initial evaluation, repeat blood work shows a slight increase in hormone levels. Patient reports being titrated off of her SSRIs with no increase in depression. She is happy with the effects of the topical creams and reports a 50 percent decrease in pain with intercourse. At the three month visit, the patient reports increased libido and that she has begun to initiate sexual relations with her spouse. She reports a 90 percent resolution of pain with intercourse and expresses satisfaction with her sexual relationship.