CHAPTER 13: Psychosocial Issues and Female Sexuality

Thirty years ago, psychiatrist George Engel coined the term “biopsychosocial model” to describe a developing paradigm for patient care (Engel, 1977). As shown in Figure 13-1, the model encourages treatments that consider the mind and body of a patient as two intertwining systems influenced by a third system—society. This was perhaps the first time a distinction was drawn between “disease” and “illness.” Namely, disease is the pathological process, and illness is the patient’s experience of that process. In keeping with this model, psychological factors have two distinct relationships with women’s reproductive health. At times, they are a consequence (infertility has been linked with psychological distress). At other times, they may be an insidious cause of a health problem (increased hysterectomy rates are noted in women with a low tolerance for the physical discomfort of menstruation).

Years before Engel’s work, Erik Erikson (1963) created a model that describes psychological maturation in stages across the life span. Specifically, adolescents are confronted with identity development; reproductive-aged women with intimacy concerns; peri- and early menopausal women with productivity issues; and older women with life review. Combining Erikson’s developmental model with Engel’s psychosocial model provides a dimensional perspective to aid the evaluation, diagnosis, and treatment of any patient.

Not only do women use more health care services in general than men in the United States, but more women approach their physicians with psychiatric complaints, and more women have comorbid illness than men (Andrade, 2003; Kessler, 1994). Because primary care is the setting in which most patients with psychiatric illness are first seen, obstetricians and gynecologists often are the first to evaluate a woman in psychiatric distress. The clinical interview in Table 13-1 provides an example of an assessment that includes all three domains from the biopsychosocial model.

Mood, anxiety, and alcohol or substance use disorders are three families of psychiatric disorders commonly seen and often comorbid with reproductive problems. These three groups are defined by specific criteria described by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2013). Each family of disorders is characterized by predominant features, and each disorder within those families is identified by specific symptoms of that feature.

Of these families, mood disorders are categorized as depressive disorders (major depressive disorder, persistent depressive disorder, premenstrual dysphoric disorder, other specified depressive disorder, and unspecified depressive disorder) or as bipolar and related disorders (bipolar I, bipolar II, cyclothymic disorder, other specified bipolar disorder, and unspecified bipolar disorder). For bipolar disorders, defining behaviors include racing thoughts, inflated grandiosity, psychomotor agitation, loquaciousness, and high-risk behavior, among others. These are severe enough to impair occupational or social relationships.

For depressive disorders, symptoms include those in Table 13-2. The lifetime prevalence in the general U.S. population approximates 20 percent (Kessler, 2005). As such, depression is a major cause of disability, and females are l.6 times more likely than men to suffer from a major depressive episode (Substance Abuse and Mental Health Services Administration, 2013). Women also may experience one or more comorbid psychiatric disorders, most commonly an anxiety disorder and/or substance use disorder.

Self-report questionnaires are generally used to identify individuals who require further psychiatric evaluation (screening measures) and may also assess the frequency and intensity of depressive symptoms (severity measures). The Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) is one such tool easily implemented for clinical use (Tables 13-3 and 13-4) (Rush, 2003). Further information regarding the instrument is available at www.ids-qids.org. By patient report, this questionnaire assesses symptom severity required by DSM-5 criteria to diagnosis major depressive disorder. Ultimately, diagnosing mood disorders requires assessment by a trained clinician.

Anxiety disorders have the highest prevalence rates in the United States. Lifetime rates approximate 30 percent, and similar to depression, women are 1.6 times more likely to be diagnosed than men (Kessler, 2005). Criteria established in the DSM-5 provide guidelines to help distinguish anxiety disorders from normally expected worries (Table 13-5).

In the United States, the lifetime prevalence for alcohol and substance use disorders approximates 15 percent. This diagnosis is twice as likely in males, although rates in women are increasing (Kessler, 2005). Indicators of substance misuse are found in Table 13-6. Often substance abuse disorders coexist with mood and anxiety disorders. A detailed discussion of these issues is beyond this chapter’s scope, but additional information regarding alcohol and other commonly abused substances, including prescription medications, is found at: http://www.drugabuse.gov.

Specific feeding and eating disorders classified by the DSM-5 and relevant to women’s health care are anorexia nervosa, bulimia nervosa, binge-eating disorder, and unspecified feeding or eating disorder (Tables 13-7 and 13-8). The core symptoms of both anorexia and bulimia are preoccupation with weight gain and excessive self-evaluation of weight and body shape, accompanied by either restriction of food intake (anorexia) or the use of compensatory behaviors to prevent weight gain after binge eating (bulimia). Binge-eating disorder is differentiated by consuming larger amounts of food, lacking a sense of control over the eating, but not engaging in subsequent weight-loss behaviors. These disorders are 10 to 20 times more common in females than in males, particularly in those aged 15 to 24 years (Mitchell, 2006). In young females, an estimated 4 percent suffer from anorexia, 1 to 1.5 percent from bulimia, and 1.6 percent from binge-eating disorder. While anorexia usually begins early in adolescence and peaks around age 17, bulimia nervosa typically has a later onset than anorexia and is more prevalent over the life span (Hoek, 2006). Pathological eating is also found in older women, particularly binge-eating disorder and unspecified eating disorder (Mangweth-Matzek, 2014).

The exact etiology of such abnormal consumption is unknown. However, evidence suggests a strong familial aggregation for eating disorders (Stein, 1999). In the restricting type of anorexia, the concordance rate among monozygotic twins approximates 66 percent and 10 percent for dizygotic twins (Treasure, 1989). Various biologic factors have been implicated in eating disorder development. Abnormalities in neuropeptides, neurotransmitters, and hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes are reported (Stoving, 2001). In addition, psychological and psychodynamic factors related to an absence of autonomy are thought to influence obsessive preoccupations. Although eating disorders are believed to be a Western culture phenomenon, rates are also increasing in non-Western cultures (Lai, 2013).

Diagnosis

Anorexia nervosa is divided into two subtypes: (1) a restricting type and (2) a binge-eating/purging type, which is distinguished from bulimia by weighing less than the minimum standard for normal. Symptoms begin as unique eating habits that become more and more restrictive. Advanced symptoms may include extreme food intake restriction and excessive exercise. Up to 50 percent of anorectics also show bulimic behavior, and these types may alternate during the course of anorexic illness. Bulimic-type anorectics have been found to engage in two distinct behavior patterns, those who binge and purge and those who solely purge. The body-mass index percentile, clinical symptoms, degree of disability, and need for supervision determine clinical severity.

Diagnosis of anorexia is initially challenging as patients often defend their eating behaviors upon confrontation and rarely recognize their illness. They increasingly isolate themselves socially as their disorder progresses. Multiple somatic complaints such as gastrointestinal symptoms and cold intolerance are common. In the disorder’s later stages, weight loss becomes more apparent, and medical complications may prompt patients to seek help. Findings often include dental problems, general nutritional deficiency, electrolyte abnormalities (hypokalemia and alkalosis), and decreased thyroid function. Electrocardiogram changes such as QT prolongation (bradycardia) and inversion or flattened T-waves may be noted. Rare complications include gastric dilatation, arrhythmias, seizure, and death.

Bulimia nervosa is identified by periods of uncontrolled eating of high-calorie foods (binges), followed by compensatory behaviors such as self-induced vomiting, fasting, excessive exercise, or misuse of laxatives, diuretics, or emetics. Unlike patients with anorexia, those with bulimia often recognize their maladaptive behaviors. Severity is based on the frequency of the inappropriate behaviors, clinical symptoms, and level of disability. Most bulimics have normal weights, although their weight may fluctuate. Physical changes may be subtle and include dental problems, swollen salivary glands, or knuckle calluses on the dominant hand. Termed Russell sign, calluses form in response to repetitive contact with stomach acid during purging (Strumia, 2005).

Binge-eating disorder is distinct from anorexia and bulimia. It is characterized by ingesting large amounts of food within a short time and is accompanied by feelings that one cannot control the amount of food eaten. Severity is assessed according to the number of gorging episodes per week. Binge-eating is associated with obesity. That said, most obese individuals do not necessarily engage in binge episodes and consume comparatively fewer calories than those with the syndrome. Prevalence in the United States approximates 1.6 percent for females and 0.8 percent for males, and in middle-aged women, binge-eating is more common than anorexia or bulimia (Mangweth-Matzek, 2014).

All these are complex disorders that affect both psychological and physical systems and are often comorbid with depression and anxiety. Rates of mood symptoms approximate 50 percent, and anxiety symptoms, 60 percent (Braun, 1994). Simple phobia and obsessive-compulsive behaviors may also coexist. In many cases, patients with anorexia have rigid, perfectionistic personalities and low sexual interest. Patients with bulimia often display sexual conflicts, problems with intimacy, and impulsive suicidal tendencies.

Treatment

A multidisciplinary approach benefits the treatment of eating disorders. Practice approaches include: (1) nutritional rehabilitation, (2) psychosocial treatment that includes individual and family therapies, and (3) pharmacotherapeutic treatment of concurrent psychiatric symptoms. Online resources for information and support are provided by the National Eating Disorder Association, www.edap.org and Academy for Eating Disorders, www.aedweb.org. However, health care providers should also be aware of eating disorder advocacy websites (Norris, 2006).

Data concerning the long-term physical and psychological prognosis of women with eating disorders are limited. Most may symptomatically improve with aging. However, complete recovery from anorexia nervosa is rare, and many continue to have distorted body perceptions and peculiar eating habits. Overall, the prognosis for bulimia is better than for anorexia.

Frequently, reproductive-aged women experience symptoms during the late luteal phase of their menstrual cycle. Collectively these complaints are termed premenstrual syndrome (PMS) or, when more severe and disabling, premenstrual dysphoric disorder (PMDD). Nearly 300 different symptoms have been reported and typically include both psychiatric and physical complaints. For most women, these are self-limited. However, approximately 15 percent report moderate to severe complaints that cause some impairment or require special consideration (Wittchen, 2002). Current estimates are that 3 to 8 percent of menstruating women meet the strict criteria for PMDD (Halbreich, 2003b).

Pathophysiology

The exact causes of these disorders are unknown, although several different biological factors have been suggested. Of these, estrogen and progesterone, as well as the neurotransmitters gamma-aminobutyric acid (GABA) and serotonin, are frequently studied.

First, estrogen and progesterone are integral to the menstrual cycle. The cyclic complaints of PMS begin following ovulation and resolve with menses. PMS is less common in women with surgical oophorectomy or drug-induced ovarian hypofunction, such as with gonadotropin-releasing hormone (GnRH) agonists (Cronje, 2004; Wyatt, 2004). Moreover, women with anovulatory cycles appear protected. One potential effect stems from estrogen and progesterone’s influence on central nervous system neurotransmitters: serotonin, noradrenaline, and GABA. The predominant action of estrogen is neuronal excitability, whereas progestins are inhibitory (Halbreich, 2003a). Menstruation-related symptoms are believed to be associated with neuroactive progesterone metabolites. Of these, allopregnanolone is a potent modulator of GABA receptors, and its effects mirror those of low-dose benzodiazepines, barbiturates, and alcohol. These effects may include loss of impulse control, negative mood, and aggression or irritability (Bäckström, 2014). Wang and colleagues (1996) noted fluctuations in allopregnanolone across the various menstrual cycle phases. These changes were implicated with PMS symptom severity.

Second, evidence also supports a role for serotonergic system dysregulation in PMS pathophysiology. Decreased serotonergic activity has been noted in the luteal phase. Moreover, trials of serotonergic treatments show PMS symptom reduction (Majoribanks, 2013).

Last, sex steroids also interact with the renin-angiotensin-aldosterone system (RAAS) to alter electrolyte and fluid balance. The antimineralocorticoid properties of progesterone and possible estrogen activation of the RAAS system may explain PMS symptoms of bloating and weight gain.

Diagnosis

PMDD is identified in the DSM-5 by the presence of at least five symptoms accompanied by significant psychosocial or functional impairment (Table 13-9). PMS refers to the presence of numerous symptoms that are not associated with significant impairment. During evaluation, the revised criteria in DSM-5 recommend that clinicians confirm symptoms by prospective patient mood charting for at least two menstrual cycles. In certain instances, complaints may be an exacerbation of an underlying primary psychiatric condition(s). Thus, other common psychiatric conditions such as depression and anxiety disorders are excluded. Additionally, other medical conditions that have a multisystem presentation are considered. These include hypothyroidism, systemic lupus erythematosus, endometriosis, anemia, fibromyalgia, chronic fatigue syndrome, fibrocystic breast disease, irritable bowel syndrome, and migraine.

Treatment

Therapy for PMDD and PMS include psychotropic agents, ovulation suppression, and dietary modification. Generalists may consider treatment of mild to moderate cases. However, if treatment fails or if symptoms are severe, then psychiatric referral may be indicated (Cunningham, 2009).

Selective serotonin-reuptake inhibitors (SSRIs) are considered primary therapy for psychological symptoms of PMDD and PMS, and fluoxetine, sertraline, and paroxetine are Food and Drug Administration (FDA) approved for this indication (Table 13-10). Standard dosages are administered in either continuous dosing or luteal phase (14 days prior to expected menses) dosing regimens. Several well-controlled trials of SSRIs have shown these drugs to be efficacious and well tolerated (Shah, 2008). In addition, short-term use of anxiolytics such as alprazolam or buspirone offers added benefits to some women with prominent anxiety. However, in prescribing benzodiazepines, caution is taken in women with prior history of substance abuse (Nevatte, 2013).

Because gonadal hormonal dysregulation is implicated in the genesis of PMS symptoms, ovulation suppression is another option. There is some data to support combination oral contraceptive (COC) pills in general for premenstrual mood symptoms. Moreover, in randomized trials, Yasmin, a COC containing the spironolactone-like progestin drospirenone, showed therapeutic benefits. It carries an FDA indication for PMDD treatment in women who desire contraception (Pearlstein, 2005; Yonkers, 2005). Alternatively, GnRH agonists are another means of ovulation suppression. These agents are infrequently selected due to their hypoestrogenic side effects and risks. If elected for PMDD and used longer than 6 months, add-back therapy, as discussed in Chapter 10, can potentially blunt these side effects. Rarely, symptoms warrant bilateral oophorectomy, and a trial of GnRH agonists prior to surgery may be prudent to determine the potential efficacy of castration. Last, the synthetic androgen danocrine (Danazol) also suppresses ovulation, but androgen-related acne and hair growth are usually poorly tolerated.

Of other possible agents, prostaglandin inhibitors such as ibuprofen and naproxen offer benefits through their antiinflammatory effects and alleviate cramping and headaches associated with PMS (Table 10-1). Diuretics such as combined hydrochlorothiazide and triamterene (Dyazide) and spironolactone (Aldactone) may be prescribed to alleviate fluid retention and leg edema. Monitoring for potential side effects such as orthostatic hypotension and hypokalemia is critical since these can be severe.

Diet—namely, foods and beverages high in sugar and caffeine—can aggravate premenstrual symptoms in some women. Calcium, 600 mg orally twice daily, has shown benefits, theoretically by correcting deficiency-related symptoms such as muscle cramps (Thys-Jacobs, 2000). Vitamins such as pyridoxine (vitamin B₆) and vitamin E may offer some relief. Pyridoxine is a cofactor to tryptophan hydroxylase, which is the key enzyme in the serotonin synthesis (Wyatt, 1999). The recommended dose of pyridoxine is 50 to 100 mg/day, but doses exceeding 100 mg/day are avoided to prevent pyridoxine toxicity. Magnesium in combination with vitamin B₆ appears to reduce anxiety-related premenstrual symptoms (De Souza, 2000). Of nonpharmacologic alternatives to treatment, there is growing evidence assessing efficacies of acupuncture, bright-light therapy, exercise, and omega fatty acids (Brandon, 2014).

In general, psychiatric disorders during pregnancy have a course and presentation similar to that in nonpregnant women. For this reason, there are no distinct diagnostic criteria for psychiatric disorders experienced in the context of pregnancy and the puerperium.

Perinatal Depression

In the revised DSM-5, a major depressive episode, with its onset during pregnancy or within 4 weeks following childbirth, is categorized by a specifier term that notes “with peripartum onset.” Some women experience the first onset of depression during this time, whereas others are vulnerable for relapse (Cohen, 2006a). Etiologic studies have been inconclusive, but both hormonal changes and psychosocial stressors are implicated (Bloch, 2006; Boyce, 2005). Treatment is critical, as suicide is a leading cause of maternal death in developed countries (Centre for Maternal and Child Enquiries, 2011). Accordingly, health professionals are encouraged to thoroughly assess psychiatric and psychosocial history to enable early identification, prevention, and treatment of perinatal depression (Moses-Kolko, 2004). The American College of Obstetricians and Gynecologists (2012) currently notes insufficient evidence for universal peripartum depression screening but recommends that evaluation be considered for women with current depression or prior major depression. Other risks include life stress, poor social support (particularly from the partner), and maternal anxiety (Lancaster, 2010).

To screen for and assess severity of peripartum depressive symptoms, the Edinburgh Postnatal Depression Scale (EPDS) is one tool specifically developed for pregnancy (Cox, 1987). Unlike screening measures that score symptoms characteristic of pregnancy itself (appetite, weight change, sleep disturbance, and fatigue), the EPDS inquires about neurovegetative symptoms that are more specific to depression. Available in numerous languages, the EPDS is an efficient way for a clinician to identify patients at risk for perinatal depression. It is available through the American Academy of Pediatrics at: http://www2.aap.org/sections/scan/practicingsafety/toolkit_resources/module2/epds.pdf.

Antepartum

The prevalence of depression during pregnancy has been estimated to be highest (11 percent) in the first trimester, falling to 8.5 percent in the second and third trimesters. For treatment, the American Psychiatric Association and American College of Obstetricians and Gynecologists have issued pregnancy guidelines for depression management that recommend careful risk and benefit analysis of existing treatment (especially medications) (Yonkers, 2009). For major depression, psychotropic medication and psychotherapy have the largest evidence-based support (Stuart, 2014). However, data also note efficacy for several complementary interventions (Deligiannidis, 2013). The FDA (2006, 2011b) recommends careful and transparent risk assessment during pregnancy before prescribing psychotropic medications. On the other hand, women who discontinue antidepressant medication during pregnancy relapse into depression significantly more frequently than women who maintain their pharmacologic treatment (Cohen, 2006a). And as noted, suicide accounts for a significant proportion of pregnancy-associated death. Thus, a clinician must assess the risk of relapse in severely depressed women against potential risk to the newborn of antidepressant medication exposure. Additional guidance is found in Williams Obstetrics, 24th edition (Cunningham, 2014). Patients may benefit the most from a combination of treatment options, guided by the information available and the woman’s attitudes and preferences regarding potential treatments. Nonpharmacologic and complementary approaches are also potential options for depressive symptoms during pregnancy. These include acupuncture, bright light therapy, exercise, omega fatty acid supplementation, and yoga and massage therapies (Field, 2012; Manber, 2010; Shivakumar, 2011; Su, 2008; Wirz-Justice, 2011).

Postpartum

Depression after childbirth is largely divided into three categories: “postpartum blues,” postpartum depression, and postpartum psychosis. The strongest predictors of postpartum depression include prior history of depression or anxiety, family history of psychiatric illness, poor marital relationship, poor social support, and stressful life events in the previous 12 months (Boyce, 2005; Sayil, 2007).

Postpartum blues describes a transient state of heightened emotional reactivity that can develop in up to 50 percent of women. The onset is 2 to 14 days after childbirth, and its duration is less than 2 weeks (Gaynes, 2005). Blues generally require no intervention. Rest and social support contribute significantly to remission. However, postpartum blues do constitute a significant risk factor for subsequent depression during the puerperium.

Postpartum depression, as noted, includes onset during pregnancy and within 4 weeks following delivery. However, in research and most clinical settings, any depression developing within 12 months following childbirth is considered to have postpartum onset (Sharma, 2014). With this definition, the prevalence of postpartum depression approximates 15 percent of delivered women (Gaynes, 2005). Postpartum depression warrants careful assessment by a mental health professional, and treatment is initiated immediately to minimize impaired caregiving. Infants of depressed mothers exhibit cognitive, temperamental, and developmental differences compared with infants of unaffected mothers (Kaplan, 2009; Newport, 2002). SSRIs are usually first-line agents, although fluoxetine use is discouraged due to relatively high concentrations in breast milk (Sie, 2012). Several psychosocial interventions have also demonstrated efficacy in treating postpartum depression. Of these, the most significant effects have been achieved with interpersonal therapy and cognitive-behavioral therapy (Stuart, 2014). Additionally, Postpartum Support International is an excellent resource of information for both clinicians and patients. Information can be obtained at www.postpartum.net and MedEd PPD websites (http://mededppd.org/default2.asp).

Last, postpartum psychosis develops in less than 2 percent of new mothers, and its onset is generally within 2 weeks of childbirth (Gaynes, 2005). The risk for this severe form of depression is increased for women who have had prior mood disorders. Particularly, prior postpartum psychosis increases by 30 to 50 percent a woman’s risk with subsequent deliveries (American Psychiatric Association, 2013). Evaluation and antipsychotic pharmacologic treatment is essential for these patients. Hospitalization is often indicated until the safety of mother and infant is assured.

Other Psychiatric Disorders

Clinicians most often focus on mood disorders during the perinatal period. However, other psychiatric illnesses such as anxiety disorders, bipolar disorder, and schizophrenia may also be present. Of these, bipolar disorders and schizophrenia are serious, recurrent psychiatric illnesses that require pharmacologic treatment. Treatment planning is critical with such patients, and decisions are made in collaboration with a psychiatric professional. The FDA (2011a) issued a safety communication alerting health care providers concerning some antipsychotic medications that are associated with neonatal extrapyramidal and withdrawal symptoms similar to the neonatal behavioral syndrome seen in those exposed to SSRIs. Thus, a careful balance must be struck between minimizing medication risk to the fetus and maternal risk from untreated or undertreated disease.

Perinatal Loss

With perinatal loss, many studies have focused on identifying factors that modify grieving styles, and a few have studied interventions for families after such loss. Health care providers are most helpful if they speak directly, use understandable language, and share information that would provide parents a sense of control over their situation and that would address their fears. Additional time with health professionals and a perception of being a priority are also important (DiMarco, 2001; Flenady, 2014). Since grief is individual, no generalizations can be made concerning clinical treatment in these situations. Thus, a clinician must ask a patient what she needs and wants. Couples therapy may be helpful if mother and father find it difficult to grieve congruently. Family therapy may be indicated if other children need support to process the loss and their parents’ grief. Many hospitals provide support groups, and the Hygeia Foundation (http://hygeiafoundation.org) offers both useful information and online support.

The menopausal transition has long been investigated as a vulnerable period for emergence of mood symptoms. Anxiety, irritable mood, and sleep problems are more likely to develop in perimenopausal women than in premenopausal counterparts (Brandon, 2008; Freeman, 2006). Moreover, data suggest that rates of new-onset depression during menopausal transition are nearly twice those for premenopausal women (Cohen, 2006b). This risk persists even after adjusting for sleep disturbances and vasomotor symptoms.

Other possible risks for depression and anxiety are a prior history of depression, severe premenstrual distress, hot flushes, and disrupted sleep. Demographic predictors of increased risk during the perimenopause are lower educational status, African-American ethnicity, unemployment, and major life stressors (Bromberger, 2001; Freeman, 2006; Maartens, 2002). Moreover, psychosocial issues include a woman’s recognition that her reproductive years are ending and that her children will leave to establish their own lives. Developmentally, many women are transitioning from being family focused to finding new avenues in which to invest time and energy.

Mood vulnerability during menopausal transition is believed to follow erratic physiologic fluctuations in reproductive hormones. Detailed discussion of these hormones as they relate to mood changes during this transition is found in Chapter 21.

Evaluation and Treatment

Perimenopausal women with psychological symptoms warrant a comprehensive psychosocial inventory and risk factor assessment. Since medical conditions may concurrently develop during this transition, evaluation excludes these before symptoms are considered psychosomatic. In particular, thyroid function is evaluated.

The approach to treating mood symptoms involves both pharmacotherapy and psychotherapy (Brandon, 2008). Recommended psychotropic medications are SSRIs and selective noradrenergic-reuptake inhibitors (SNRIs) such as venlafaxine (Effexor). These agents are good options for women who decline hormone therapy. Additional benefits include alleviation of vasomotor symptoms and sleep disturbance.

Studies suggest that short-term administration of estrogen is an option for perimenopausal women with depressive symptoms (Soares, 2001). However, the psychotropic role of estrogen-progesterone preparations in postmenopausal women remains unclear. Moreover, benefits are weighed against safety concerns raised by the Women’s Health Initiative (WHI) Study regarding estrogen use (Chap. 22). Of nonpharmacologic alternatives investigated to date for mood disturbance during menopause, yoga and moderate-intensity exercise have demonstrated benefit (Brandon, 2014). However, these studies are small.

According to estimates by the Census Bureau, the number of older people in the United States will significantly increase over the next decade as the “Baby Boomer” generation ages. By 2030, nearly 20 percent of the population will be older than 65 (He, 2005). Psychosocial issues addressed are significantly different for these women. Stressors may include diminished mental and physical function and loss of partner, family, or friends. Erikson identified the task of this final developmental stage of life as one of consolidation and integration. In this model, women retrospectively examine their life. They may manage their last years with integrity and with satisfaction in a life well lived, or may suffer despair, feeling that all was in vain.

According to the 2000 U.S. Census, functionally impairing mental disorders affected 11 percent of adults aged 65 to 74 and 10 percent of those older than 74 (He, 2005). Of these disorders, depression, anxiety, late-onset psychotic and paranoid disorders, and alcoholism are those most likely to be observed in clinical practice. As in the general population, anxiety is the most common psychiatric disorder in the elderly. However, the prevalence of depression is generally thought to be lower in postmenopausal women compared with reproductive-aged women. Moreover, most studies suggest that the gender gap between rates of depression closes in late life (Zarit, 1998).

Evaluation and Treatment

If a psychiatric disorder is suspected, careful evaluation is required to exclude underlying medical causes for these changes. For example, depression may be a comorbid disorder with or an early symptom of Alzheimer and Parkinson disease (Polidori, 2001). Alternatively, depression, anxiety, and psychosis may also result from a single medication or medication combinations.

Specific screening questionnaires for depression have been developed for the elderly, such as the Geriatric Depression Scale (Brink, 1982). This screening tool is available in various languages at: http://www.stanford.edu/∼yesavage/GDS.html. In addition, neuropsychologic evaluation is helpful to discriminate between the source and nature of mood symptoms and cognitive impairment. Dementia screening is discussed in Chapter 1.

Recognizing the natural decline in serotonin levels with aging, many gerontologists prescribe SSRIs for their patients. However, communication among all treating physicians to coordinate medications and minimize interactions is particularly important for elderly patients.

Psychosocial treatments are often helpful for the patient and, where applicable, her caregivers. Cognitive-behavioral therapy and interpersonal therapy have both been found efficacious with the elderly. Moreover, family therapy can be of great value to those struggling with end-of-life issues, functional impairments, multiple losses, and caregiver burden. Social workers are also of tremendous value if a patient and family need to locate additional care resources.

For depression in older adults, one metaanalysis of 89 studies found that pharmacotherapy or psychotherapy achieved comparable results. In contrast, for anxiety, another analysis of 32 studies found pharmacotherapy slightly more effective than psychotherapy (Pinquart, 2006, 2007). Thus, treatment planning is individualized and assesses patient preference, contraindications, and treatment access.

Recurrent, multiple, often unexplained physical symptoms are hallmark features of somatic symptom disorders. These disorders are common, and their estimated prevalence in general clinical practice is 16 percent (de Waal, 2004). Their prevalence may be even higher in specialty clinics such as pain management clinics. Somatic symptom disorders are complex and poorly understood. However, symptoms cause significant distress and/or impairment in various domains of an affected individual’s life. Moreover, one in four somatic symptom patients suffer from comorbid anxiety and depressive symptoms. Thus, a multidisciplinary approach is often required to effectively manage these women’s symptoms.

Sexual assault is a broad term that includes rape, unwanted genital touching, and even forced viewing of or involvement in pornography. Rape is a legal term and in the United States refers to penetration of a body orifice without consent (mouth, vagina, or anus) and with force or the threat of force or incapacity (young or old age, cognitive or physical disability, or drug or alcohol intoxication). The definition of rape includes spousal rape (Linden, 2011). Rape is often motivated by aggression and rage, with the assailant using sexual contact as a weapon for power and control.

For sexual assault, large population-based surveys indicate a lifetime prevalence of 13 to 39 percent among women and 3 percent among men (Tjaden, 2000). Certain populations are at increased risk and include the physically or mentally disabled; homeless persons; persons who are gay, lesbian, bisexual, or transgendered; alcohol and drug users; college students; and persons younger than 24 (Lawyer, 2010).

Well-known sequelae of rape include isolation, depression, anxiety, somatic symptoms, suicide attempts, and posttraumatic stress disorder (PTSD). The experience has a strong effect on the victim’s subsequent health and thus is a major public health issue. Importantly, in caring for sexual assault victims, clinicians should be familiar with the complex array of reactions (emotional and physical), common injuries, and elements of proper evaluation and treatment of these patients.

Physical Findings

Initial evaluation of a sexual assault victim concentrates on identifying serious injuries. Although 70 percent of rape victims sustain no obvious physical injuries, 24 percent sustain minor injuries, and up to 5 percent sustain major nongenital injuries. Common nongenital injuries include bruises, cuts, scratches, and swelling (81 percent); internal injuries and unconsciousness (11 percent); and knife or gunshot wounds (2 percent) (Sommers, 2001). In the genital area, the posterior fourchette is the area most often injured. Although death is rare, the fear of death during an assault is one of the most intense reactions (Deming, 1983; Marchbanks, 1990).

Once life-threatening injuries are excluded, a patient is ideally moved to a quiet, private setting for further evaluation. A systematic, thorough, but compassionate approach to obtaining a history and collecting evidence is essential for appropriate treatment of the victim and for future prosecution of her assailant (American College of Obstetricians and Gynecologists, 2014).

Examination and Documentation

Although valid evidence may be collected up to 5 days after sexual assault, immediate examination increases the opportunity to obtain valuable physical evidence (Table 13-11). Consent is obtained prior to physical and genital examination and evidence collection. This step helps to reestablish a victim’s sense of control and is essential for entry of evidence in a court of law (Plaut, 2004). Providers emphasize that vital information may be lost if evidence is not collected early. Moreover, evidence collection does not commit a victim to pressing criminal charges (Linden, 1999). A patient is also counseled that she may terminate an examination if it is too emotionally or physically painful.

Most states have standardized kits for evidence collection and storage in which kits may be locked to ensure that legal evidence procedures are maintained. Documentation of all physical injuries is essential, and objective evidence of trauma (even minor) is associated with increased chances of successful prosecution. Clothing is collected as a patient undresses on a white sheet and placed in properly labeled bags (Ingemann-Hansen, 2013). Any debris, such as hair, fibers, mud, or leaves, is also collected.

Evidence gathering includes a sample of the patient’s saliva and swabs of all involved orifices. A thorough pelvic examination with evidence collection is essential, even if there are no complaints of genital pain. Up to one third of victims can have traumatic genital injuries without symptoms. Common patterns of genital injury include tears of the posterior fourchette and fossa, labial abrasions, and hymenal bruising. Significant genital injuries are more common in postmenopausal or prepubertal victims. Colposcopy is used if available because this technique increases detection of more subtle injuries of the cervix and vagina. Lenahan (1998) reported that the use of colposcopy increased genital trauma recognition from 6 percent to 53 percent. In addition, a Wood’s lamp may aid identification of semen on the skin, which then is collected with moistened cotton swabs. A blood sample is collected for typing, to differentiate the blood type of the victim from that of the assailant. After evidence is collected, it is signed, sealed, and locked in a secure place (Mollen, 2012; Rambow, 1992).

Treatment

Pregnancy Prevention

Medication prophylaxis to prevent pregnancy and common sexually transmitted diseases is provided to women following sexual assault. The risk of rape-related pregnancy approximates 5 percent per rape among reproductive-aged victims (Holmes, 1996). Most of these pregnancies, unfortunately, occur in adolescents, often the victims of incest, who never report the incident or receive medical attention. Because of variation in a woman’s menstrual cycle, pregnancy prophylaxis, also termed emergency contraception, is offered to all victims with reproductive organs. Prophylaxis can be administered for up to 72 hours after rape but is most effective in the first 24 hours (Table 13-12). Some studies indicate that prophylaxis may be effective for up to 5 days following rape.

A negative pregnancy test to exclude a preexisting pregnancy is confirmed before administering emergency contraception. This is especially true for ulipristal (Ella), a progesterone antagonist, because of fetal loss risks if used in the first trimester. With estrogen/progestin combinations, side effects include nausea and vomiting, breast tenderness, and heavier menstrual period. In comparison, with levonorgestrel (Plan B), the risk of nausea and vomiting is less (Arowojolu, 2002). An antiemetic can be prescribed 30 minutes prior to hormone administration to decrease nausea (Table 42-7).

Patients are informed that their next menses may be delayed following this prophylaxis. Although current regimens are 74 to 89 percent effective, women are counseled to return if their next menses is more than 1 to 2 weeks late (Task Force on Postovulatory Methods of Fertility Regulation, 1998; Trussell, 1996; Yuzpe, 1982).

Sexually Transmitted Disease Prevention

The risk of acquiring sexually transmitted disease (STD) after rape has been estimated. The risk for trichomoniasis approximates 12 percent; bacterial vaginosis, 12 percent; gonorrhea, 4 percent to 12 percent; chlamydial infection, 2 to 14 percent; syphilis, 5 percent; and human immunodeficiency virus (HIV) infection, 0.1 percent (Jenny, 1990; Katz, 1997; Schwarcz, 1990). However, these risks are difficult to predict and vary by geographic location, type of assault, assailant, and presence of preexisting infections. General recommendations describe prophylaxis for hepatitis, gonorrhea, and chlamydia (see Table 13-12).

The fear of contracting HIV after sexual assault is common in survivors and is often the primary concern following rape (Baker, 1990). However, postexposure prophylaxis (PEP) against HIV remains controversial, given the low risk of transmission after a single sexual assault (Gostin, 1994). With regard to sexual exposures, the per-contact risk of HIV transmission associated with receptive penile-anal exposures is estimated to be 0.5 to 3.2 percent and with receptive penile-vaginal exposures, 0.05 to 0.15 percent (Wieczorek, 2010). Although rare, HIV transmission associated with receptive oral intercourse has been reported. Experts recommend offering PEP to candidates who are at a higher risk of being exposed to HIV and who are willing to complete the full course of medications and comply with surveillance testing (Table 13-13). The risks and side effects of these medications and need for close monitoring is discussed with patients. Nausea is a common side effect with PEP. Thus, a prescription for an antiemetic such as phenergan, to be used as needed, is commonly provided. PEP should begin within 72 hours, if indicated. For sexual assault patients presenting outside of this time frame, information is provided regarding follow-up HIV antibody testing and referral options.

Because of the emotional intensity of the experience, a woman may not recall all the information provided, and thus written instructions are helpful. Survivors are referred to local rape crisis centers and encouraged to visit within 1 to 2 days. Sexual assault victims receive subsequent medical evaluation at 1 to 2 weeks, and 2 to 4 months following their rape. During these visits, examination for STDs and blood testing for HIV and syphilis is performed. Remaining hepatitis vaccinations are administered, if needed.

Psychological Response to Sexual Assault

Survivors of sexual assault may display an array of reactions that frequently include anxiety, agitation, crying, or a quiet, calm, and removed affect. In 1974, Burgess and Holmstrom first characterized the “rape trauma syndrome.” They described two response phases to the trauma of sexual assault: (1) the acute disorganization phase, lasting several weeks, and (2) the reorganization phase, lasting from several weeks to years. During the acute phase, shock and disbelief, fear, shame, self-blame, humiliation, anger, isolation, grief, somatic manifestations, and loss of control are common. During the reorganization phase, feelings of vulnerability, despair, guilt, and shame may continue. Symptoms can include nonspecific anxiety, somatic complaints, or depression. Longitudinal data indicate that sexual assault survivors are at increased lifetime risk for PTSD, major depression, and suicide contemplation or attempt (Linden, 2011). Health care providers ideally enlist the input of social workers or rape crisis counselors to help evaluate the patient’s immediate and future emotional and safety needs.

Sexual abuse is defined as a child engaged in sexual activities that he or she cannot comprehend, for which he or she is developmentally unprepared and cannot give consent, and/or that violate societal laws or social taboos (Kellogg, 2005). Sexual activities can include vaginal/anal intercourse, oral-genital contact, genital-genital contact, fondling, and exposure to pornography or to adults engaging in sexual activity. In the United States, the overall prevalence of child sexual abuse ranges from 11 to 32 percent for females and 4 to 14 percent for males (Sapp, 2005). Thus, indicators that prompt evaluation include: (1) statements by the child or family of abuse, (2) genital or anal injury without concordant history of unintentional trauma, (3) semen or pregnancy identified, or (4) STD diagnosed beyond the incubation period of vertical (natal mother-to-child) transmission (Bechtel, 2010).

Determining whether genital findings in children are normal variants or indicative of assault can be difficult, and these have been categorized according to their likelihood of associated sexual abuse. An exhaustive list of normal and indeterminate signs has been compiled by Adams and colleagues (2007, 2008), and those considered diagnostic are listed in Table 13-14. A provider completing the examination should have formal training in the evaluation of suspected child sexual abuse. A list of local specialist providers can be found on the American Academy of Pediatrics Section on Child Abuse and Neglect website at http://www.aap.org/sections/childabuseneglect/. Importantly, acute injuries associated with child sexual abuse heal and resolve rapidly. Thus, examination is completed as soon as sexual assault is suspected (McCann, 2007). As signs may be subtle, a careful history and full examination are carried out with the aid of photodocumentation, preferably using a colposcope (Price, 2013).

The prevalence of STDs in child victims of sexual abuse is low (Girardet, 2009a). Thus, the decision to obtain specimens from a child is individualized. Situations that typically prompt testing include: (1) signs or complaints of genital penetration or of an STD, (2) suspected assailant with a high risk for STDs, (3) another household member with an STD, (4) abuse by a stranger, or (5) community with a high STD rate (Centers for Disease Control and Prevention, 2015).

If indicated, recommended testing includes: cultures for Neisseria gonorrhoeae from the pharynx, anus, and vagina; cultures for Chlamydia trachomatis from the anus and vagina; and culture and wet mount evaluation of a vaginal swab specimen for Trichomonas vaginalis infection and bacterial vaginosis. Culture rather than nucleic acid amplification tests (NAATs) are preferred. Swab specimens from vagina, rather than endocervix, are recommended for prepubertal girls (Centers for Disease Control and Prevention, 2015). Decisions regarding serologic testing for Treponema pallidum, HIV, and hepatitis B virus are individualized.

The general concept that sexually transmissible infections found beyond the neonatal period are evidence of sexual abuse has exceptions. For example, perinatally acquired C trachomatis infection has, in some cases, persisted up to age 3 years in girls. Genital warts have been diagnosed in children who have no other evidence of sexual abuse. Finally, most hepatitis B virus infections in children result from household exposure to those chronically infected with the virus (Centers for Disease Control and Prevention, 2015).

Routine STD prophylaxis for children who have been sexually abused is generally not recommended due to lower rates of associated infection and a greater guarantee of scheduled follow-up. However, if the clinical setting dictates or if test results are positive for infection, antibiotics are provided. Rates of HIV transmission following sexual abuse are also very low in children (Girardet, 2009b). However, antiretroviral treatment is well tolerated by children, and PEP can be offered based on the clinical setting (Cybulska, 2012). When considered, antiretroviral PEP is initiated, similar to other prophylaxis, within the first 72 hours. The CDC (2015) recommends consulting professionals who specialize in care of HIV-infected children.

The terms domestic violence (DV), gender-based violence, and violence against women encompass a multitude of abuses directed at women and girls. The United Nations Declaration on the Elimination of Violence against Women (1993) defines violence as acts that cause or have the potential to cause harm. Introduction of the term “gender-based” emphasizes that the act is rooted in inequality between women and men (Krantz, 2005). Intimate-partner violence (IPV) refers to harm inflicted by one intimate partner on the other, with the intention of causing pain or controlling the other’s behavior. Honor-based violence (HBV) is most prevalent in south Asian and Middle Eastern countries, where acts are committed to maintain family honor in the community. The prevalence of HBV in the United States is increasing with increasing immigration from these areas (Dickson, 2014).

Violence against women varies and includes wife battering, sexual assault, incest, and elder abuse (Burge, 1997; Straka, 2006). Most victims know their assailant and have been assaulted more than once. The average length of victimization is 4 years for repeatedly raped women and for physically assaulted women (Tjaden, 2000).

Risks

In the United States, nearly one in four women has experienced IPV at some point in her life. Aside from youth and ethnicity, few traits characterize women who are assaulted by violent men. Peters and colleagues (2002) analyzed data from 5298 IPV reports. They found that women aged 16 to 24 years are at greatest risk for IPV, a risk that was more than twice as great as the risk for women aged 25 to 34 years. Rates of IPV decreased throughout the reproductive years and reached a nadir in women aged 65 or older. Hotaling and Sugarman (1986) in their review found only one consistent risk marker of being an abused wife. Witnessing violence as a child was a significant risk factor in 11 of 15 studies.

Seven to 20 percent of pregnant women may be victims, and homicide is reported as the leading cause of death during pregnancy. Most cases result from partner abuse (Gazmararian, 1996; Shadigian, 2005). Therefore, screening for IPV is an important component of prenatal care.

The social and medical problem of elder abuse is escalating with an aging population. Currently, each year, approximately 1 in 10 older adults are mistreated, and 84 percent of cases are unreported (Hoover, 2014; Jayawardena, 2006). Elder abuse is divided into seven categories by The National Center on Elder Abuse: physical, emotional, and sexual abuse, financial exploitation, neglect, self-neglect, and abandonment. Of these categories, neglect is the most prevalent. It occurs most often in the home and is perpetrated most frequently by family members. Identified risk factors are caregiver stress, patient cognitive impairment, need for assistance with daily life activities, conflicted family relationships, and poor social support (Hoover, 2014).

Diagnosis

Women who have been assaulted are far more likely to seek help from their medical provider than from legal personnel, mental health professionals, or victim advocates. For years after the assault, victims have an unusually high rate of medical use and may present with psychiatric and somatic complaints (Koss, 1992). Moreover, IPV can adversely affect health, and affected women are more likely to have cardiac disease, asthma, and drink excessively compared with women without prior IPV (Bair-Merritt, 2014).

Although some clinicians may feel awkward asking patients, researchers agree that the single most important thing a physician can do for a battered woman is to ask about violence (Linden, 1999). Additionally, health care providers should ask about violence if they identify symptoms or behaviors that may be associated with victimization (Burge, 1997). These can include bruising, unexplained injuries, depression or anxiety, alcohol or drug abuse, unexplained chronic pain, isolation, inability to cope, limited access to care, noncompliance, husbands with extremely controlling behaviors or intense jealousy, or husbands with substance abuse.

Management

If a patient discloses IPV, a clinician should validate and normalize a patient’s perspective. Patients are counseled that many women have assault experiences, that most are afraid to confide these, that memories of the experience can be painful, and that a fear of future assaults is a reasonable fear. Following a patient’s disclosure, a clinician expresses concern for the woman’s health and safety and conveys a willingness to discuss relationship issues at any time. Moreover, information describing community resources is offered. The National Domestic Violence Hotline (1–800–799-SAFE (7233)) is a nonprofit telephone referral service with access to more than 5000 women’s shelters nationally.

Battery is a crime, yet few states specifically require reporting of IPV. A small number of states require mandatory arrest of batterers, and a few jurisdictions aggressively pursue cases of IPV. Accordingly, each clinician should know their state laws to properly and adequately inform their patients. In addition, providers should thoroughly document physical findings of violence. Such data may be required if criminal charges are pursued.

Sexuality is one of the most complex and yet basic components of human behavior. Expressions of sexuality and intimacy remain important throughout life. Although basic sexual drive is biologic, its expression is determined by various psychological, social, environmental, spiritual, and learned factors. Thus, satisfaction is often less dependent on the physical components of sexuality than on the quality of the relationship and the context in which sexual behavior is undertaken.

In describing the sexual response cycle, several models have been proposed to describe normal sexual response (Kingsberg, 2013). Masters and Johnson, in 1966, were the first to offer a theoretical “human sexual response cycle” that was based on their direct observations of the anatomic and physiologic changes experienced by men and women in a laboratory setting. This was a four-stage linear cycle that they labeled as “excitement,” “plateau,” “orgasm,” and “resolution.” The cycle was independently modified by Kaplan (1979) and Leif (1977) to a triphasic model that emphasized desire—in contrast to physiologic genital arousal—as the first stage of sexual response. In 2001, Basson first published her intimacy-based circular model to help explain the multifactorial character of female sexual response (Fig. 13-2). This model includes the interplay of emotional intimacy, sexual stimuli, psychological factors, and relationship satisfaction. This model also introduces the concept of receptive/responsive desire, which is the idea that arousal often precedes desire and that women often begin a sexual encounter from a position of sexual neutrality. It encompasses the impact of biologic and nonbiologic factors on a woman’s sexual response, including motivation, interpersonal issues, cultural and religious beliefs, partner’s health status, relationship quality, past sexual abuse, and distractions. Basson’s model (2001, 2006) emphasizes that desire and arousal are difficult to separate, and this serves as the basis for DSM-5 classification changes. Namely, the diagnoses of hypoactive sexual desire disorder and female sexual arousal disorder are now combined and considered as female sexual interest/arousal disorder (American Psychiatric Association, 2013; Kingsberg, 2013).

Drive/Desire

The basis of desire and perceived arousal in women is poorly understood, but it appears to involve interactions among multiple neurotransmitters, sex hormones, and environmental factors. The biopsychosocial model of desire as outlined by Levine (1984) suggests that desire is composed of three individual but interrelated components: sexual drive, sexual beliefs, and sexual motivation. The biologic component, drive, is spontaneous and includes cravings for sexual activity, sexual dreams, unprompted sexual thoughts, and genital sensations. It is influenced by neuroendocrine mechanisms. The second component reflects a woman’s beliefs and values about sex. The third component, motivation, reflects the emotional willingness to engage in sexual activity with a given partner (or alone). Motivation often carries the most weight among these components and is altered by psychological function, relationship quality, and concerns about health, occupation, or family. The interplay and input of these realms yield one’s sexual interest. Thus, a clinician’s differential diagnosis and assessment must be broad, and treatment incorporates a biopsychosocial/integrative approach.

Arousal

A woman’s sexual arousal is complex and correlates positively with the sexual stimulus and its emotional context. This subconscious reflex is organized by the autonomic nervous system and processed in the limbic system in response to mental or physical stimuli that are recognized as sexual. Subjective findings of sexual arousal include vaginal and vulvar congestion, increases in vaginal lubrication, and other somatic changes such as blood pressure level, heart rate, muscle tone, respiratory rate, and temperature. However, in sexually healthy women, measurements of genital congestion and subjective arousal vary widely (Everaerd, 2000; Laan, 1995). There are also affective responses to sexual arousal. Feelings of joy and affirmation or feelings of fear, guilt, and awkwardness serve to modulate arousal.

In the basal state, clitoral corporal and vaginal smooth muscles are tonically contracted. After sexual stimulation, neurogenic and endothelial release of nitric oxide (NO) leads to clitoral cavernosal artery relaxation. The resulting arterial inflow increases intracavernosal pressure and clitoral engorgement (Cellek, 1998). The glans clitoris extrudes and sensitivity is enhanced.

In the basal state, the vaginal epithelium reabsorbs sodium from the submucosal capillary plasma transudate. However, after sexual stimulation, several neurotransmitters, including NO and vasoactive intestinal peptide, are released. These modulate vaginal vascular and nonvascular smooth muscle relaxation (Palle, 1990). Submucosal capillary flow dramatically increases and overwhelms sodium reabsorption. Three to 5 mL of vaginal transudate is produced, and this enhanced lubrication aids pleasurable coitus. Smooth-muscle relaxation of the vagina increases vaginal length and luminal diameter, especially in the distal two thirds of the vagina.

Release and Resolution

Masters and Johnson (1966) proposed that orgasmic release is a reflex-like response that follows once a plateau of excitement has been reached or exceeded. The actual neurobiology of orgasm is unknown, although it seems to include the mesolimbic dopamine pathways and the pudendal, pelvic, and hypogastric nerves. Orgasm occurs with the release of contraction-producing agents such as serotonin and oxytocin, which lead to rhythmic contraction of the levator plate, uterus, and vagina. The physiologic and behavioral indices of orgasm involve the whole body—facial grimaces, generalized muscle myotonia, carpopedal spasms, and contractions of the gluteal and abdominal muscles. The subjective experience of orgasm includes feeling of intense pleasure with a peaking and rapid, exhilarating release. These sensations are reported to be singular, regardless of the manner in which orgasm is achieved (Newcomb, 1983). Women are unique in their ability to be multiorgasmic, that is, capable of a series of distinguishable orgasmic responses without a lowering of excitement between them.

After orgasm, the anatomic and physiologic changes of excitement reverse. In women, genital vasocongestion diminishes, and the vagina shortens and narrows. A filmy sheet of perspiration covers the body, and elevated heart and respiration rates gradually return to normal. If orgasm has occurred, there is concomitant psychologic and physical relaxation. If orgasm does not occur, a similar physiologic processes occurs, but at a slower rate.

Normal Variations in the Physiologic Response

Sexual function and variations in the physiologic response may be affected by many biologic and psychologic aspects of reproduction and the life cycle. First, during pregnancy, sexual function may change, and a reduction in sexual desire and coital frequency is typical (Hyde, 1996). These changes may stem from fears of causing fetal harm during intercourse or orgasm. In addition, fatigue, physical discomfort, or feeling less physically attractive are other reasons.

Women who suffer recurrent miscarriage or infertility or undergo therapeutic abortion, and even those during a normal puerperium, may have an altered physiologic and psychologic sexual response. In the puerperium, fatigue, hormonal changes, and a healing episiotomy scar may contribute to diminished frequency and enjoyment of intercourse (Srivastava, 2008). Hyde (1996) found that women who are breast feeding report less sexual activity and less satisfaction that those who were not breast feeding. The study failed to demonstrate any marked differences according to the method of delivery, although women who had cesarean delivery were more likely to resume intercourse 4 weeks postpartum than women who delivered vaginally.

For older women, baseline data from the Study of Women’s Health Across the Nation (SWAN) addressed sexual behavior in 3262 women aged 42 to 52 years who were either premenopausal or in early menopausal transition. In early menopausal transition, investigators found few changes in sexual practices or function (Cain, 2003). In a group aged 40 to 69 years, Addis and associates (2006) found that 71 percent were sexually active and 65 percent reported satisfaction. Sexual dysfunction was noted in 45 percent and was associated with having a higher education level, poor health, a significant relationship, and a low mental health score.

Late in menopausal transition and with natural menopause, hormonal changes, as a consequence of the hypoestrogenic state, can interfere with physiologic response (Avis, 2000; Tan, 2012). The prevalence of sexual dysfunction is higher and ranges from 68 to 86 percent (Sarrel, 1990). Masters and Johnson (1966) described a delay in reaction time of the clitoris, delayed or absent vaginal lubrication, decreased vaginal congestion, and reduced duration of contractions with orgasm. Loss of estrogen diminishes genital blood flow, vaginal lubrication, and vaginal tissue structural integrity (Freedman, 2002; Pauls, 2005). That said, estrogen replacement in postmenopausal women improves libido and orgasm (Sarrel, 1990). Others have shown improved vaginal lubrication, blood flow, and vaginal compliance in menopausal women using systemic estrogen replacement, but these were not correlated with subjective improvements in sexual function (Berman, 1999; Semmens, 1982).

With aging, sexuality still plays an important role in physical and mental health. Klausmann (2002) and Dennerstein (2001) both suggest that even many years after menopause, an increase in desire and interest is consistently reported with a new relationship. The opportunity for sexual activity in the form of intercourse, however, is often dependent on partner issues. Both partner availability and partner health begin to shape the frequency with which this form of sexual activity occurs. In general, sexual activity declines with increasing age. Activity is reported in 30 to 78 percent of 60-year-old women, in 11 to 74 percent of those older than 70, and in 8 to 43 percent of 80-year-old women (Morley, 2003). Few data describe sexual function in those older than 80, but as the “Baby Boomer” cohort of a more sexually open group continues to age, the future holds promise for the desire to maintain this quality of life (Morley, 1992).

Psychiatric sexual dysfunctions are characterized by painful intercourse or disturbances in desire, arousal, orgasm, or resolution that cause marked distress and relationship difficulty (Table 13-15). Sexual dysfunction stemming from dyspareunia may also originate from gynecologic disease and is discussed more fully in Chapters 4 and 11.

Although many studies have investigated female sexual dysfunction, prevalence rates are difficult to establish due to differing criteria and measures of sexual functioning. However, Hayes and colleagues (2006) estimated that 64 percent of women experience low or no sexual desire, 35 percent have difficulty achieving orgasm, and 26 percent experience sexual pain. Most difficulties last less than 6 months, but one third may persist longer.

Diagnosis and Treatment

Patient history is a primary diagnostic tool. Psychosocial risk factors for sexual dysfunction include comorbid psychological disorders, negative emotions, maladaptive cognitions (such as inaccurate expectations), cultural factors, lack of education regarding sexual functioning, couple distress, and absent physical attraction. Of these, psychiatric disorders such as depression and anxiety are frequently comorbid with sexual disorders. Thus, for most patients who suffer from sexual dysfunction, evaluation does not stop with an organic explanation (Bach, 2001). In accordance with the biopsychosocial approach, diagnosis of sexual disorders begins by judging if dysfunction is caused exclusively by a general medical condition, drug abuse, medication, or toxin exposure. Subsequently, evaluation for a primary psychiatric disorder follows. Assessment typically inventories a woman’s ethnic, cultural, religious, and social backgrounds and includes a frank discussion about her current sexual partner(s) and sexual expectations. Clinical judgment takes into account the patient’s age and sexual experience, symptom frequency and chronicity, and her perception of symptoms. Importantly, a woman is asked if the sexual difficulty is chronic or new-onset and if it persists across all situations or appears only in certain circumstances. Finally, referral to a psychiatrist or psychologist may be indicated for a thorough psychiatric interview.

Multidisciplinary treatment is ideal for patients with sexual dysfunction. A team would typically include the referring physician, gynecologist, psychologist, and a nurse-specialist. In organic disorders, it may be necessary to include specialists in urology, gastroenterology, and anesthesiology. Psychological approaches usually include some combination of sexual education, communication enhancement, identification of emotional and cultural factors, cognitive-behavioral therapy, and couples therapy.