Evaluation and Management of Female Patients often fail to bring it up, and clinicians may be reluctant to discuss it, but ignoring sexual dysfunction can disrupt a woman’s most intimate relationships.

Melissa L. Dawson, DO, MS, Nima M. Shah, MD, Rebecca C. Rinko, DO, Clinton Veselis, MD, Kristene E. Whitmore, MD

Female sexual dysfunction (FSD) has Melissa L. PRACTICE RECOMMENDATIONS complex physiologic and psychologic com- Dawson, Nima • Obtain a detailed history and evaluate M. Shah, Rebecca ponents that require a detailed screening, C. Rinko, Clinton obstetric, gynecologic, sexually history, and physical examination. Our goal transmitted disease, sexual abuse, urinary Veselis, and in this review is to provide primary care pro- Kristene E. and bowel complaint, and surgical history Whitmore are in in women of all ages. B viders with insights and practical advice to help screen, diagnose, and treat FSD, which the Department of • Consider a variety of lifestyle and OB/GYN at Drexel pharmacologic approaches, as well as can have a profound impact on patients’ University College in combination with pelvic most intimate relationships. of Medicine in floor physical therapy, to address your Philadelphia. female patient’s sexual dysfunction. B UNDERSTANDING STRENGTH OF THE TYPES OF FSD RECOMMENDATION (SOR) Most women consider sexual health an im- 2 A Good-quality patient-oriented evidence portant part of their overall health. Factors that can disrupt normal sexual function B Inconsistent or limited-quality patient- oriented evidence include aging, socioeconomics, and other medical comorbidities. FSD is common in C Consensus, usual practice, opinion, disease-oriented evidence, case series women throughout their lives and refers to various sexual dysfunctions including diminished arousal, problems achieving care of women with sexual disorders orgasm, , and low desire. Its has made great strides since Mas- prevalence is reported to be as high as 20% C ters and Johnson began their study to 43%.3,4 in 1957. In 2000, the Sexual Function Health The World Health Organization and the Council of the American Foundation for US Surgeon General have released state- Urologic Disease devised the classification ments encouraging health care providers to IN THIS system for female sexual dysfunction, which address sexual health during a patient’s an- ARTICLE was officially defined in the Diagnostic and nual visits.5 Unfortunately, despite this call • Causes of Statistical Manual of Mental Disorders-IV- to action, many patients and providers are pain, page 28 1 6 TR. There are now definitions for sexual de- initially hesitant to discuss these problems. • Screening, sire disorders, sexual arousal disorders, or- The Diagnostic and Statistical Manual page 28 gasmic disorder, and sexual pain disorders. of Mental Disorders, Fifth Edition (DSM- • Multimodal Dr. Whitmore discloses that she receives grants/research support from Allergan (makers of Botox), as well as from treatment, Astellas Pharma US and Coloplast Corp. Drs. Dawson, Shah, Rinko, and Veselis report no potential conflict of page 30 interest relevant to this article, which originally appeared in The Journal of Family Practice (2017;66[12]:722-728).

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TABLE month requirement. The diagnosis of sexual What’s Causing Your Patient’s Sexual Pain? dysfunction due to a general medical con- dition and sexual aversion disorder are ab- Superficial Deep sent from the DSM-5.7 A common symptom. Female sexual Atrophy Adenomyosis disorders can be caused by several com- Condylomas Endometriosis plex physiologic and psychologic factors. A Infectious lesions High-tone dysfunction common symptom among many women is Trauma dyspareunia. It is seen more often in post- Irritable bowel syndrome menopausal women, and its prevalence Vulvovaginitis Pelvic adhesive disease ranges from 8% to 22%.8 Pain on vaginal en- Pelvic congestion syndrome try usually indicates vaginal atrophy, vagi- Pelvic inflammatory disease nal dermatitis, or provoked vestibulodynia. Sexual abuse history Pain on deep penetration could be caused Uterine leiomyomas by endometriosis, interstitial cystitis, or 9 Uterine retroversion uterine leiomyomas. The physical examination will repro- Other generalized pain disorders duce the pain when the vulva or vagina is Sources: ACOG. Obstet Gynecol. 20119; Clayton and Hamilton. Psychiatr Clin touched with a cotton swab or when you in- North Am. 201710; Morrissey et al. Female Pelvic Med Reconstr Surg. 2015.11 sert a finger into the vagina. The differential diagnosis is listed in the Table.9-11

5) provides the definition and diagnostic EVALUATING THE PATIENT guidelines for the different components of Initially, many patients and providers may FSD. Its classification of sexual disorders hesitate to discuss sexual dysfunction, but was simplified and published in May 2013.7 the annual exam is a good opportunity to There are now only three female dysfunc- broach the topic of sexual health. tions (as opposed to five in DSM-IV): • Female hypoactive desire dysfunction Screening and history and female arousal dysfunction were Clinicians can screen all patients, regardless merged into a single syndrome labeled of age, with the help of a validated sex ques- female sexual interest/arousal disorder. tionnaire or during a routine review of sys- • The formerly separate dyspareunia tems. There are many validated screening (painful intercourse) and vaginismus tools available. A simple, integrated screen- are now called genitopelvic pain/pen- ing tool to use is the Brief Sexual Symptom etration disorder. Checklist for Women (BSSC-W), created by • Female orgasmic disorder remains as a the International Consultation on Sexual category and is unchanged. Medicine.12 Although recommended by To qualify as a dysfunction, the problem the American Congress of Obstetricians must be present more than 75% of the time, and Gynecologists, the BSSC-W is not vali- for more than six months, causing significant dated.9 The four items in the questionnaire distress, and must not be explained by a non- ascertain personal information regarding sexual mental disorder, relationship distress, an individual’s overall sexual function sat- substance abuse, or a medical condition. isfaction, the problem causing dysfunction, Substance- or medication-induced how bothersome the symptoms are, and sexual dysfunction falls under “Other Dys- whether the patient is interested in discuss- functions” and is defined as a clinically ing it with her provider.12 significant disturbance in sexual function It’s important to obtain a detailed obstet- that is predominant in the clinical picture. ric and gynecologic history that includes The criteria for substance- and medication- any sexually transmitted diseases, sexual induced sexual dysfunction are unchanged abuse, urinary and bowel complaints, or and include neither the 75% nor the six- . In addition, you’ll want to differ-

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entiate between various types of dysfunc- vaginal fornix possibly indicating endome- tions. A thorough physical examination, triosis, and adnexal fullness and/or masses including an external and internal pelvic should be identified and evaluated. exam, can help to rule out other causes of Neurologic exam of the pelvis will in- sexual dysfunction. volve evaluation of sensory and motor func- tion of both lower extremities and include General exam: What to look for a screening lumbosacral neurologic exami- The external pelvic examination begins with nation. Lumbosacral examination includes visual inspection of the vulva, labia majora, assessment of PFM strength, anal sphincter and labia minora. Often, this is best ac- resting tone, voluntary anal contraction, complished gently with a gloved hand and and perineal sensation. If abnormalities are a cotton swab. This inspection may reveal noted in the screening assessment, a com- changes in pubic hair distribution, vulvar plete comprehensive neurologic examina- skin disorders, lesions, masses, cracks, or tion should be performed. fissures. Inspection may also reveal redness and pain typical of vestibulitis, a flattening It’s important to assess and pallor of the labia that suggests estro- pelvic floor muscle strength gen deficiency, or . Sexual function is associated with normal The internal pelvic examination begins PFM function.13,14 The PFMs, particularly the with a manual evaluation of the muscles pubococcygeus and iliococcygeus, are re- of the pelvic floor, uterus, bladder, urethra, sponsible for involuntary contractions dur- anus, and adnexa. Make careful note of any ing orgasm.13 Orgasm has been considered a unusual tenderness or pelvic masses. Pelvic reflex, which is preceded by increased blood floor muscles (PFMs) should voluntarily flow to the genital organs, tumescence of the contract and relax and are not normally vulva and vagina, increased secretions dur- tender to palpation. Pelvic organ prolapse ing sexual arousal, and increased tension and/or hypermobility of the bladder may and contractions of the PFMs.15 indicate a weakening of the endopelvic Lowenstein et al found that women fascia and may cause sexual pain. The size with strong or moderate PFM contractions and flexion of the uterus, tenderness in the scored significantly higher on both orgasm

Painful Uterine retroversion intercourse Adenomyosis Vulvodynia Endometriosis

Atrophy CONDYLOMA Muscle Penetration TRAUMA Orgasm PAIN Pelvic Arousal floordysfunction mdedge.com/clinicianreviews APRIL 2018 • Clinician Reviews 29 SEXUALDYSFUNCTION

and arousal domains of the Female Sexual vator ani, piriformis, and internal obtura- Function Index (FSFI), compared with tor muscles bilaterally and rated by the pa- women with weak PFM contractions.16 Or- tient’s reactions. Pelvic muscle tenderness, gasm and arousal functions may be associ- which can be highly prevalent in women ated with PFM strength, with a positive as- with chronic pelvic pain, is associated with sociation between pelvic floor strength and higher degrees of dyspareunia.21 Digital sexual activity and function.17,18 evaluation of the pelvic floor musculature The function and dysfunction of the varies in scale, number of fingers used, and PFMs have been characterized as normal, parameters evaluated. overactive (high tone), underactive (low Lukban et al have described a 0 to 4 tone), and nonfunctioning. numbered scale that evaluates tenderness in the pelvic floor.22 The scale denotes Female sexual dysfunction (FSD) has “1” as comfortable pressure associated † with the exam, “2” as uncomfortable complex physiologic and psychologic pressure associated with the exam, “3” as moderate pain associated with the components that require a detailed exam that intensifies with contraction, screening, history, and physical examination. and “4” indicating severe pain with the exam and inability to perform the con- traction maneuver due to pain. Normal PFMs are those that can volun- tarily and involuntarily contract and relax.19,20 EFFECTIVE TREATMENT INCLUDES Overactive (high-tone) muscles are MULTIPLE OPTIONS those that do not relax and possibly con- Lifestyle modifications can help tract during times of relaxation for micturi- Lifestyle changes may help improve sex- tion or defecation. This type of dysfunction ual function. These modifications include can lead to voiding dysfunction, defecatory physical activity, healthy diet, nutrition dysfunction, and dyspareunia.19 counseling, and adequate sleep.23,24 Underactive, or low-tone, PFMs cannot Identifying medical conditions such as contract voluntarily. This can be associated depression and anxiety will help delineate with urinary and anal incontinence and differential diagnoses of sexual dysfunc- pelvic organ prolapse. tion. Cardiovascular diseases may contrib- Nonfunctioning muscles are completely ute to arousal disorder as a result of athero- inactive.19 sclerosis of the vessels supplying the vagina How to assess. There are several ways to and clitoris. Neurologic diseases such as assess PFM tone and strength.20 The first is multiple sclerosis and diabetes can affect intravaginal or intrarectal digital palpation, sexual dysfunction by impairing arousal which can be performed when the patient is and orgasm. in a supine or standing position. This exam- Identification of concurrent comorbidi- ination evaluates PFM tone, squeeze pres- ties and implementation of lifestyle chang- sure during contraction, symmetry, and es will help improve overall health and may relaxation. However, there is no validated improve sexual function.25 scale to quantify PFM strength. Contrac- In addition, Herati et al found food sen- tions can be further divided into voluntary sitivities to grapefruit juice, spicy foods, al- and involuntary.19 cohol, and caffeine were more prevalent in During the exam, ask the patient to con- patients with interstitial cystitis and chronic tract as much as she can to evaluate the pelvic pain.26 Avoiding irritants such as maximum strength and sustained contrac- soap and other detergents in the perineal tion for endurance. This measurement can region may help decrease dysfunction.27 Fi- be done with digital palpation or with pres- nally, foods high in oxalate and other acidic sure manometry or dynamometry. items may cause bladder pain and worsen- Examination can be focused on the le- ing symptoms of vulvodynia.28 continued on page 35 >>

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>> continued from page 30 Topical therapies worth considering visualizing the activity to achieve conscious Lubricants and moisturizers may help control over contraction of the pelvic floor women with dyspareunia or symptoms of and ceasing the cycle of spasm.35 Ger et al vaginal atrophy. For instance investigated patients with levator spasm and Zestra, which contains a patented blend found biofeedback decreased pain; relief of botanical oils and extracts and is applied was rated as good or excellent at 15-month to the vulva prior to sexual activity, has been follow-up in six of 14 patients (43%).36 proven more effective than placebo for im- Home devices such as Eros Therapy, an proving desire and arousal.29 FDA-approved, nonpharmacologic battery- Neogyn, a nonhormonal cream contain- operated device, provide vacuum suction ing cutaneous lysate, has been shown to to the clitoris with vibratory sensation. Eros improve vulvar pain in women with vulvo- Therapy has been shown to increase blood dynia. A double-blind placebo-controlled flow to the clitoris, vagina, and pelvic floor randomized crossover trial followed 30 pa- and increase sensation, orgasm, lubrica- tients for three months and found a signifi- tion, and satisfaction.37 cant reduction in pain during sexual activity Vaginal dilators allow increasing and a significant reduction in erythema.30 lengths and girths designed to treat vagi- Alprostadil, a prostaglandin E1 ana- nal and pelvic floor pain.38 In our practice, logue that increases genital vasodilation we encourage pelvic muscle strengthening when applied topically, is currently under- tools in the form of Kegel trainers and other going investigational trials.31,32 insertion devices that may improve PFM Patients can also choose from many OTC coordination and strength. lubricants that contain water-based, oil- based, or silicone-based ingredients. Pharmacotherapy has its place The treatment of FSD may require a multi- Don’t overlook physical therapy modal systematic approach targeting genito- Manual therapies, including the transvagi- pelvic pain. But before the best options can nal technique, are used for FSD that results be found, it is important to first establish the from a variety of causes, including high- cause of the pain. Several tone pelvic floor dysfunction. The transvag- drug formulations have inal technique can identify myofascial pain; been effectively used, in- treatment involves internal release of the cluding hormonal and PFMs and external trigger-point identifica- nonhormonal options. % tion and alleviation. Conjugated estrogens 5 One pilot study examined use of trans- are FDA approved for the vaginal Thiele massage twice a week for five treatment of dyspareunia, weeks in 21 symptomatic women with in- which can contribute to of PAs have terstitial cystitis and high-tone pelvic floor decreased desire. System- a Doctorate dysfunction. The researchers found it de- ic estrogen in oral form, creased hypertonicity of the pelvic floor and transdermal preparations, generated statistically significant improve- and topical formulations 32% of them are ment in the Symptom and Problem Indexes may increase sexual desire ≥ 46 years old of the O’Leary-Sant Questionnaire, Likert and arousal and decrease Visual Analogue Scales for urgency and dyspareunia.39 Even syn- pain, and the Physical and Mental Compo- thetic steroid compounds such as tibolone nent Summary from the SF-12 Quality-of- may improve sexual function, although it is Life Scale.33 Transvaginal physical therapy not FDA approved for that purpose.40 is also an effective treatment for myofascial Ospemifene is a selective estrogen recep- pelvic pain.34 tor modulator that acts as an estrogen ago- Biofeedback, which can be used in com- nist in select tissues, including vaginal epi- bination with pelvic floor physical therapy, thelium. It is FDA approved for dyspareunia teaches the patient to control the PFMs by in postmenopausal women.41,42 A daily dose

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of 60 mg is effective and safe, with minimal Cyclobenzaprine, at a starting dose of adverse effects.42 Studies suggest that tes- 10 mg, can be taken up to three times a day tosterone, although not FDA approved in for pelvic floor tension. Tizanidine is a cen- the United States for this purpose, improves trally active alpha 2 agonist that’s superior sexual desire, pleasure, orgasm, and arousal to placebo in treating high-tone pelvic floor satisfaction.39 The hormone has not gained dysfunction.44 FDA approval because of concerns about Other medications include benzodiaz- long-term safety and efficacy.42 epines, such as oral clonazepam and intra- Nonhormonal drugs including flibanse- vaginal diazepam, although they are not rin, a well-tolerated serotonin receptor 1A FDA approved for high-tone pelvic floor dys- agonist, 2A antagonist shown to improve function. Rogalski et al evaluated data for 26 sexual desire, increase the patients who received vaginal diazepam for number of satisfying sex- bladder pain, sexual pain, and levator hy- ual events and reduce dis- pertonus.45 They found subjective and sexual tress associated with low pain improvement assessed on FSFI and the % sexual desire when com- visual analog pain scale. PFM tone signifi- 68 pared with placebo.43 The cantly improved during resting, squeezing, FDA has approved fliban- and relaxation phases. Multimodal therapy serin as the first treatment can be used for muscle spasticity and high- of PAs have targeted for women with tone pelvic floor dysfunction. a Master’s hypoactive sexual desire disorder (HSDD). It can, Trigger point and Botox injections 97% of them are however, cause severe hy- Although drug therapy has its place in the potension and syncope, is management of sexual dysfunction, other 25-35 years old not well tolerated with al- modalities that involve trigger-point injec- Source: Job Satisfaction. Clinician cohol, and is contraindi- tions or botulinum toxin injections to the Reviews. 2017;27(12):25-30. cated in patients who take PFMs may prove helpful for patients with strong CYP3A4 inhibitors, high-tone pelvic floor dysfunction. such as fluconazole, verapamil, and eryth- A prospective study investigated the romycin, or who have liver impairment. role of trigger-point injections in 18 wom- Bupropion, a mild dopamine and nor- en with muscle spasm using a epinephrine reuptake inhibitor and ace- mixture of 0.25% bupivacaine in 10 mL, tylcholine receptor antagonist, has been 2% lidocaine in 10 mL, and 40 mg of tri- shown to improve desire in women with amcinolone in 1 mL combined and used and without depression. Although it is FDA for injection of 5 mL per trigger point.46 approved for major depressive disorder, it is Three months after injections, 13 of the 18 not approved for female sexual dysfunction women showed improvement, resulting in and is still under investigation. a success rate of 72%. Trigger point injec- Tricyclic antidepressants, such as nor- tions can be applied externally or trans- triptyline and amitriptyline, may be effec- vaginally. tive in treating neuropathic pain. Starting OnabotulinumtoxinA (Botox) has also doses of both amitriptyline and nortripty- been tested for relief of levator ani muscle line are 10 mg/d and can be increased to a spasm. Botox is FDA approved for upper maximum of 100 mg/d.44 Tricyclic antide- and lower limb spasticity but is not ap- pressants are still under investigation for proved for pelvic floor spasticity or tension. the treatment of FSD. It may reduce pressure in the PFMs and Muscle relaxants in oral and topical may be useful in women with high-tone compounded form are used to treat in- pelvic floor dysfunction.47 creased pelvic floor tension and spasticity. In a prospective six-month pilot study, 28 Cyclobenzaprine and tizanidine are FDA- patients with pelvic pain for whom conser- approved muscle relaxants indicated for vative treatment did not work received up to muscle spasticity. 300 U Botox into the pelvic floor.11 The study,

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which used needle electromyography guid- 4. Laumann E, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. ance and a transperineal approach, found 1999;281:537-544. that the dyspareunia visual analog scale 5. Office of the Surgeon General. The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual improved significantly at weeks 12 and 24. Behavior. Rockville, MD; 2001. Keep in mind, however, that onabotulinum- 6. Pauls RN, Kleeman SD, Segal JL, et al. Practice patterns of physician members of the American Urogynecologic Society toxinA should be reserved for patients for regarding female sexual dysfunction: results of a national whom conventional treatments fail.47,48 survey. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16:460- 467. 7. American Psychiatric Association. Sexual dysfunction. In: Addressing psychologic issues Diagnostic and Statistical Manual of Mental Disorders (5th ed). Washington, DC; 2013. Sex therapy is a traditional approach that 8. Steege JF, Zolnoun DA. Evaluation and treatment of dyspa- aims to improve individual or couples’ reunia. Obstet Gynecol. 2009;113:1124-1136. 9. American College of Obstetricians and Gynecologists. ACOG sexual experiences and help reduce anxi- Practice Bulletin No. 119: Female sexual dysfunction. Obstet ety related to sex.42 Cognitive behavioral Gynecol. 2011;117:996-1007. 10. Clayton AH, Hamilton DV. Female sexual dysfunction. Psy- sex therapy includes traditional sex therapy chiatr Clin North Am. 2017;40:267-284. components but puts greater emphasis on 11. Morrissey D, El-Khawand D, Ginzburg N, et al. Botulinum Toxin A injections into pelvic floor muscles under electromyo- modifying thought patterns that interfere graphic guidance for women with refractory high-tone pelvic with intimacy and sex.42 floor dysfunction: a 6-month prospective pilot study. Female Mindfulness-based cognitive behavioral treatments have shown promise for sexual FSD is common in women throughout desire problems. It is an ancient eastern † practice with Buddhist roots. This therapy is their lives and refers to various sexual a nonjudgmental, present-moment aware- dysfunctions including diminished ness comprised of self-regulation of atten- tion and accepting orientation to the pres- arousal, problems achieving orgasm, ent.49 Although there is little evidence from prospective studies, it may benefit women dyspareunia, and low desire. with sexual dysfunction after intervention Pelvic Med Reconstr Surg. 2015;21:277-282. with sex therapy and cognitive behavioral 12. Hatzichristou D, Rosen RC, Derogatis LR, et al. Recommen- therapy. dations for the clinical evaluation of men and women with sexual dysfunction. J Sex Med. 2010;7(1 pt 2):337-348. 13. Kegel A. Sexual functions of the pubococcygeus muscle. CONCLUSION West J Surg Obstet Gynecol. 1952;60:521-524. 14. Shafik A. The role of the levator ani muscle in evacuation, Female sexual dysfunction is common sexual performance and pelvic floor disorders. Int Urogyne- and affects women of all ages. It can nega- col J. 2000;11:361-376. 15. Kinsey A, Pomeroy WB, Martin CE, et al. Sexual Behavior in tively impact a woman’s quality of life and the Human Female. Philadelphia, PA: WB Saunders; 1998. overall well-being. The etiology of FSD is 16. Lowenstein L, Gruenwald I, Gartman I, et al. Can stronger pelvic muscle floor improve sexual function? Int Urogynecol complex, and treatments are based on the J. 2010;21:553-556. causes of the dysfunction. Difficult cases 17. Kanter G, Rogers RG, Pauls RN, et al. A strong pelvic floor is associated with higher rates of sexual activity in women with warrant referral to a specialist in sexual pelvic floor disorders. Int Urogynecol J. 2015;26:991-996. health and female pelvic medicine. Future 18. Wehbe SA, Kellogg-Spadt S, Whitmore K. Urogenital com- plaints and female sexual dysfunction. Part 2. J Sex Med. prospective trials, randomized controlled 2010;7:2304-2317. trials, the use of validated questionnaires, 19. Messelink B, Benson T, Berghmans B, et al. Standardization of terminology of pelvic floor muscle function and dysfunc- and meta-analyses will continue to move tion: report from the Pelvic Floor Clinical Assessment Group us forward as we find better ways to un- of the International Continence Society. Neurourol Urodyn. 2005;24:374-380. derstand, identify, and treat female sexual 20. Haylen BT, de Ridder D, Freeman RM, et al. An International dysfunction. CR Urogynecological Association (IUGA)/International Conti- nence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29:4-20. REFERENCES 21. Montenegro ML, Mateus-Vasconcelos EC, Rosa e Silva JC, 1. American Psychiatric Association. Diagnostic and Statistical et al. Importance of pelvic muscle tenderness evaluation in Manual of Mental Disorders (4th ed, text revision). Washing- women with chronic pelvic pain. Pain Med. 2010;11:224-228. ton, DC; 1994. 22. Lukban JC, Whitmore KE. Pelvic floor muscle re-education 2. Shifren JL, Monz BU, Russo PA, et al. Sexual problems and treatment of the overactive bladder and painful bladder syn- distress in United States women: prevalence and correlates. drome. Clin Obstet Gynecol. 2002;45:273-285. Obstet Gynecol. 2008;112:970-978. 23. Kalmbach DA, Arnedt JT, Pillai V, et al. The impact of sleep 3. Lewis RW, Fugl-Meyer KS, Bosch R, et al. Epidemiology/risk on female sexual response and behavior: a pilot study. J Sex factors of sexual dysfunction. J Sex Med. 2004;1:35-39. Med. 2015;12:1221-1232. continued on next page >> mdedge.com/clinicianreviews APRIL 2018 • Clinician Reviews 37 SEXUALDYSFUNCTION

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