ASSESSING & MANAGING

Female sexual
2.0

CONTACT HOURS

42 The Nurse Practitioner Vol. 34, No. 1

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dysfunction
Clair Kaplan, RN/MSN, APRN (WHNP), MHS, MT (ASCP)

he prevalence of female sexual dysfunction (FSD)

is poorly studied and methodologic inconsistencies between studies make it difficult to describe
prevalence. These include varying definitions of FSD and
discrepancies among populations surveyed, as well as a lack
of validated instruments.1-6 In studies, 43% of female respondents age 18 to 59 suffered from sexual dysfunction,
and the most common complaint was low libido.1,7
However, there is continued debate about the
accuracy of this estimate.3,6
Most studies are limited in that they use
intercourse to define sexual activity. However,

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for some women, including heterosexual women, activities

such as touching and caressing may be more significant to
sexual satisfaction than the act of penile-vaginal intercourse.
In addition to study inconsistencies, the overwhelming majority of study data focus only on partnered heterosexual
women. This lack of attention to lesbian and unpartnered
heterosexual women may also result in inaccuracies. Some
studies are even more restrictive, having only
surveyed married, heterosexual women.
Researchers occasionally addressed the
limitations of the data collected from
only partnered, heterosexual women,

The Nurse Practitioner January 2009 43

Sexual dysfunction

1,6,8,9,14,15,16-18

Classifications of FSD

HSDD
Persistent or recurring deficiency or absence of sexual
fantasies or thoughts, or absence of sexual receptivity
that causes personal distress.
Sexual aversion disorder
Persistent or recurring phobic aversion and avoidance of
sexual contact, often secondary to physical abuse or
trauma that causes personal distress.
Sexual arousal disorder
Persistent or recurring inability to attain or maintain
sexual excitement, causing personal distress. This may
be subjective, with absent or reduced feelings of sexual
arousal despite physical reactions to lubrication and
genital swelling; or it may be genital, characterized by
lack of physical reaction to sexual stimuli despite
subjective arousal. Both can exist in combined form.
Orgasmic disorder
Persistent or recurrent difficulty in attaining orgasm after
sufficient stimulation and arousal, causing personal
distress.
Dyspareunia
One of the sexual pain disorders characterized by
recurrent or persistent pain with sexual intercourse.
Vaginismus
Recurrent or persistent involuntary muscle spasm of
the outer third of the vagina that interferes with desired
vaginal penetration (sexual and otherwise), causing
personal distress.
Vestibulodynia
(formerly referred to as vulvar vestibulitis syndrome)
Severe pain with touch to the vaginal vestibule, and
tenderness with light touch, such as with a cotton swab.

stating that because sexual dysfunction is likely to interfere

with partnered relationships, the data cannot begin to address the scope of the problem among women.4,5,8-10 Data
about lesbian women are almost completely lacking, and
are of interest not only because of the unaddressed needs
of this population, but also because of the nature of relationships between women. Among female-female couples,
sexual dysfunction may manifest as a mutual lack of spontaneous sexual desire. Studies of heterosexual women are
more focused on assessing differences in receptive sexual
acceptance as opposed to spontaneous sexual desire. In
heterosexual couples, a womans wish to meet her partners
needs may facilitate intercourse despite lack of desire.5,9
Physiology
An understanding of FSD must begin with an understanding of the multifaceted female sexual response cycle, which
involves physical, psychological, emotional, and interper44 The Nurse Practitioner Vol. 34, No. 1

sonal components.11 A number of models of the female sexual response were proposed, ranging from work delineating
four phases: excitement, plateau, orgasm, and resolution, to
research delineating three specific phases: desire, arousal,
and orgasm.1,11 A newer, circular model emphasizes subjective and interpersonal aspects of emotional and relational
intimacy, as well as physical satisfaction.12 This differs from
past models derived from male sexual response that focus
primarily on physical aspects.11 The circular model provides
a more holistic way of addressing the multifactorial nature
of womens sexual responses and expands on the reasons
why women engage in sexual activity.
For some women, sexual activity is desired for its intimacy and relationship satisfaction component, not because
of spontaneous physical desire. However, once sexual activity is initiated, arousal and orgasm can occur.10 There are
cultural, ethnic, and religious beliefs that influence what a
woman would regard as normal or desired female sexuality.
There are also a significant minority of women who do not
rate sexual activity as necessary for their well-being, and so
definitions of forms of FSD take into account a qualifier
that the condition must cause personal distress.11
Physiologic mechanisms of the cycle of female response
involve vasocongestion and neuromuscular events, central
and peripheral nervous system, and a variety of neurotransmitters and hormones.13,14 As in males, sexual arousal in
females involves vasocongestion with physical changes to
the genital organs. Lubrication increases, and the clitoris,
vulva, and vaginal canal increase in size.14 Rhythmic, involuntary contraction of muscles in the vagina, the pelvic floor
(primarily the levator ani), and of the perineal membrane
occurs, resulting in female orgasm.1,9,14,15
Classification and assessment
There are several different categories of FSD (see Classifications of FSD). The Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV) describes sexual dysfunction
as disorders of hypoactive sexual desire, disorders of sexual excitement (female sexual arousal disorder), and the
orgasmic disorder of anorgasmia, but it neglects complex
psychosocial components.1,6,9,11,14
Primary care NPs can incorporate screening questions
into medical history forms, followed (for positive responders) by self-assessment questionnaires.8 Validated instruments that may be useful for clinical care as well as research
have been reviewed and referenced.15,19 Some women may
prefer to be asked open-ended questions such as, I find
that prevalence of sexual problems among women is
almost 50%, so I ask all my patients if they have any
questions or issues with their sexual life that they would
like to talk about.9
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Sexual dysfunction

A differential diagnosis for causes of FSD should begin

woman to share her sexual needs with her partner(s),
with an assessment of the contributions of low libido,
including the need for clitoral stimulation and discussion of
anorgasmic response, and pain with sexual activity. A thorforms of nonpenetrative sex that may be more satisfying
ough medical, surgical, obstetric, and social history should
than intercourse.
include comorbid medical and psychiatric conditions,
A physical exam should include a total assessment for
medications, herbal or alternative products, and over-thesystemic conditions and a comprehensive genital exam.
counter supplements. A sensitive social and sexual history
Assessment should be done for signs and symptoms of
should be obtained.9 Inquire about all past mental health
sexually transmitted infection with appropriate lab testing.
issues and social information, including relationship hisExamine for inflammatory vulvar presentation and dermatory and current status. Assess for any history of intimate
tologic lesions, and for pelvic and vulvar pain with bimanpartner violence, family violence or abuse, sexual or physual exam suggestive of fibroids, tumors, endometriosis,
ical assault, or major life stressors. The use of cigarettes,
polyps, and pelvic inflammatory disease. Assess for any
alcohol, and drugs should be elicited.2,8,14
prolapse or weakness of pelvic floor muscles, tenderness,
The incidence of woman-to-woman variation exists
or erythema. Evidence of vaginismus may present during
depending on how comfortable patients are in talking about
a gynecologic exam and, in fact, may preclude speculum
sexuality. Interviews must be individually tailored for painsertion.2
tient comfort. In a best case situation, a NP should be able
Lab tests for specific contributing conditions and gento inquire about:
eral medical screening may include:
satisfaction with ones current relationship and assessment
vaginal wet prep
for violence or abuse
gonorrhea and chlamydia testing
sexual satisfaction or lack of satisfaction, and other issues
thyroid-stimulating hormone (TSH) to assess thyroid
in past relationships
function
whether masturbation is practiced and how
luteinizing hormone (LH), possibly follicle-stimulating
the type of preferred sexual activity, and any associated
hormone (FSH) and prolactin levels
pain with sexual activity.
complete blood cell (CBC) count, chemistry panel, lipid
Psychosocial history should include any past history of
profiles, and fasting glucose
victimization or abuse. Keep in mind that a woman who
total and free testosterone levels, sex hormone binding
has a complaint of FSD may not have a current partner, and
globulin (SHBG), and estrogen levels.14
her relationship status may be related to FSD. Did a relaDecreased libido or hypoactive sexual desire disorder
tionship end because of sexual difficulties? Is the woman
(HSDD) may be a result of relationship factors, endocrine
reluctant to pursue intimate relationships because of sexual dysfunction?
A physical exam should include a total
Is her partner experiencing sexual
difficulties of his or her own that are
assessment for systemic conditions and a
contributory to FSD in your patient?
comprehensive genital exam.
Never begin a sexual history with the
assumption that a woman is heterosexual; partners may be female, male,
or both, and a variety of sexual activities may be preferred.
disorders, menopause, aging, depression, or medications.
Determine if the FSD is primary or secondary. For
Sexual arousal disorder is seen most often in women folexample, in assessing anorgasmia, a primary response means
lowing pelvic surgeries, and as a result of psychological
not only that the woman has never had an orgasm during
and relationship factors. Orgasmic disorder can be seen as
sexual activity but that she is unable to achieve orgasm
a consequence of some medications, sexual abuse, or as a
through masturbation. If secondary, determine the circumresult of surgery or hormonal deficiency. Postpartum sexstances under which the woman has (or currently can) reach
ual dysfunction may be related to life stresses and role
orgasm, and the situations where she cannot. Some women
changes, but may also be caused by perineal trauma from
may report ability to reach orgasm through masturbation,
childbirth.8,9,15
but not with a partner. Relationship issues concerning lack
of intimacy and trust may be involved, and referrals for coun Pain syndromes
seling should be readily available. Within the limitations of
If pain is associated with your patients FSD, try to get her
a primary care visit, an NP can be helpful in encouraging a
to describe the pain including duration, onset, quality,
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The Nurse Practitioner January 2009 45

Sexual dysfunction

severity, aggravating factors, relieving factors, if pain is

present during all sexual activity or only during some
encounters, and if it is present in nonsexual situations.
Pain may be present with attempted vaginal entry or only
with deep penetration.2,8,16 Sexual pain disorders include
vaginismus and dyspareunia. Vaginismus, which can be
painful, is defined as an involuntary spasm that occurs
with any type of sexual or nonsexual vaginal penetration.
Dyspareunia is genital pain associated with sexual intercourse.15 There may also be pelvic, vaginal, or vulvar pain
that is not associated with sexual stimulation. Examples
include pain that occurs with the insertion of tampons,
rubbing of clothing, or pain that is exacerbated by activities like bicycling or horseback riding. Vestibulodynia is
severe pain with vestibular touch or attempted vaginal
penetration, and tenderness of the vaginal vestibule with
light pressure.16,17
Dyspareunia may be seen as a consequence of poor
lubrication, damage to pelvic nerves following surgery, or
sexual practices that inadequately emphasize foreplay.
Many of these issues can be successfully addressed, and
lubrication can be provided via hypoallergenic water-based
gels that are available over-the-counter. When indicated

signs of allergic vulvar dermatoses. Use of so-called feminine hygiene productsdouches, scented sanitary pads,
and even bubble-bathcan cause vulvar irritation with
edema, pruritus, burning, and inflammatory discharge, and
should be discouraged.9
Menopause
Levels of testosterone and estrogen decline with menopause,
and women commonly experience decreased genital blood
flow, loss of sexual desire, decreased sexual responsiveness,
low sexual arousal, and lack of lubrication and atrophy of
genital tissues.14,15

Chronic disease and aging

FSD may be the first indication of a previously undiagnosed chronic illness, such as coronary disease or diabetes.10
Diabetes, hypertension, coronary artery disease, and hyperlipidemia are all associated with atherosclerosis, which
can decrease blood flow to the vagina and clitoris. Multiple sclerosis is a chronic disease noted to have an inhibitory
effect on genital sensation, ability to reach orgasm, and sexual desire.9,14,15 Chronic cardiac disease and diabetes are
implicated in contributing to FSD.8 Spinal cord injury does
not always limit a womans sexual
function nor her ability to become
pregnant and parent, but it may comFSD may be the first indication of a
promise female sexual function in a
previously undiagnosed chronic illness,
variety of ways, with both psychologsuch as coronary disease or diabetes.
ical and physical effects. The level of
injury may affect lubrication and ability to reach orgasm, as well as sexual
by urogential atrophy, most commonly associated with
desire. This is also likely to be influenced by psychosocial
menopause or increased age, estrogen-containing creams
and relationship dynamics.8,10,15,20,21
can be provided. Chronic pelvic pain may be associated
Pelvic surgery, including hysterectomy, bladder surgery,
with a great number of conditions, including fibroids and
and surgery for pelvic organ prolapse, can damage nerves
endometriosis. Assess any cyclic nature of chronic pelvic
that are essential to female sexual response. However,
pain, preferably with the help of a detailed menstrual diary,
data are confounded by inconsistencies in subject selecand consider whether ultrasound or laparoscopy would
tion.6,15 Newer surgical techniques are being developed and
10,16
be indicated for diagnosis.
utilized to avoid complications and adverse reactions,
including FSD. As mentioned, removal of the ovaries is
Various conditions
associated with a precipitous drop in hormones and may
Infections and dermatologic conditions
result in sudden onset of FSD. In addition to surgery itself,
There is controversy about the role of sexually transmitted
radiotherapy used for oncological management, as well as
infections and nonsexually transmitted vaginitis, but
the psychosocial stress associated with cancer, can play a
16
screening is easily accomplished for most of these. A
role in FSD.15
careful sexual and medical history, in addition to the physAging is associated with increased incidence of FSD.
ical exam, should provide for diagnosis of a missed infecCauses may include relational issues, chronic illness and
tion that may be involved in genital pain disorders.However,
overall lack of physical well-being, lifestyle stressors, changes
an atypical herpes outbreak without visible lesions that
in body image, physical and emotional effects of decreased
causes genital pain may be difficult to determine. Dermahormone levels, lack of a partner or lack of a partner with
tologic conditions may present with atypical lesions or with
interest and ability to engage in sexual activity.8

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Sexual dysfunction

Medications
A variety of medications are associated with FSD, including some categories of antihypertensives, drugs used for
chemotherapy, anticonvulsants, psychiatric medications
(especially those used to treat depression), anticholinergics,
hormonal birth control, and antiandrogens.15

used for some types of FSD. Testosterone also decreases

with age, and while there are no FDA-approved regimens
for testosterone therapy for FSD, there are promising study
data and recommendations for use in certain categories.5
Additional medical treatments may include phosphodiesterase type-5 (PDE-5) inhibitors (nitric oxide donors),
dopaminergic agonists, and prostaglandins.15 Still, there
is controversy in the literature about pharmaceutical
treatment for FSD.

Psychiatric medications
Sexual adverse reactions are very common from psychiatric
medications, in particular the selective serotonin reuptake
inhibitor antidepressants and conventional antipsychotic
Estrogen
medications.2,10,14,22 In women, problems may involve lack
Estrogen plays a major role in female sexual function. It is
involved in synthesis of nitric oxide, which mediates relaxof desire, problems with dyspareunia and lubrication, and
ation of clitoral and vaginal smooth muscle. Estrogen levels
anorgasmia.23 A careful history can help to delineate if
depression or other psychiatric illness
was initially concomitant with FSD,
or if the problem began with the onSexual adverse reactions are common in
set of medication. Strategies for manselective serotonin reuptake inhibitors
agement may include changing to
and antipsychotic medications.
medications with better profiles for
adverse sexual effects and drug holidays. The risk of exacerbation of psysignificantly decline in menopause.8 Estrogen is the most
chiatric symptoms must be carefully monitored and balanced
against the harm caused by medication-associated FSD.2,8
commonly used pharmaceutical intervention for FSD, especially for syndromes of FSD that are related to menopause.
Hormonal contraception
Nonetheless, caution is advised because estrogen therapy
Oral contraceptives reduce testosterone levels by increasdecreases levels of SHBG, thereby depleting levels of
ing levels of SHBG and may be associated with hypoactive
bioavailable testosterone with a potential corresponding
sexual desire, although studies are inconclusive.5,8 As with
decrease in libido.2,5,8 This effect may be reduced through
any nuisance adverse reaction from oral contraceptives,
the use of transdermal preparations.8 Used in postmenprudent management is to change to a different pill formuopausal women, estrogen improves lubrication and conveys
lation and continue to monitor symptoms of FSD while
protective effects on thinned and atrophied genital tissue.14
encouraging women to use an alternative contraceptive
Estrogen has demonstrated beneficial effects on mood and
method, if necessary.
sexual desire, clitoral and vaginal sensitivity, and on the ability to reach orgasm. It can be supplied in a variety of forms,
Medical treatment
including topical creams, gels, intravaginal rings, oral pills,
Pharmacologic attention to FSD has largely focused on
and transdermal patches. Topical treatment avoids potential
the involvement and provision of hormonal mediators
risks with systemically delivered estrogen and is preferred
and neurotransmitters to treat arousal and orgasmic disas a first-line therapy.15 Treatment regimens with estrogen
orders. Depending on the type of FSD, medication may
are numerous and beyond the scope of this article. In
be part of a treatment plan. However, as female sexual rewomen with an intact uterus, concomitant progestin must
sponse is multifaceted, there is no single efficacious treatbe considered to counteract endometrial hyperplasia
ment.24,25 Hormonal treatment is one of the mainstays of
from unopposed estrogen.
treatment for some types of FSD, primarily with estrogen
Testosterone
and testosterone. The primary hormones studied involved
Testosterone is the major androgen in women, synthesized
in the female sexual response are estrogen and testosfrom androstenedione and derived from the ovaries and
terone. Estrogen is important in maintenance of adequate
adrenal glands. Levels drop precipitously with surgical relubrication and prevention of atrophy of vaginal and vulmoval of the ovaries and decrease with aging. Testosterone
var tissues, with many complaints of dyspareunia in
may be deficient in younger women, especially as a consemenopause correlated to the decrease in estrogen levels.
quence of surgical menopause. Clinically, meaningful levels
Estrogen therapy, often applied topically, is commonly
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The Nurse Practitioner January 2009 47

Sexual dysfunction

of decreased testosterone are difficult to measure in the lab.5

There are no established normal levels for testosterone or
free testosterone in women, and few assays can provide the
necessary sensitivity and specificity to recommend widespread use of lab measurements.26,27 Low levels of testosterone are associated with a number of adverse reactions,
including overall diminished sense of well-being, decreased
sexual arousal and desire, decreased genital sensation, thinning of vaginal mucosa, and difficulty reaching orgasm.2,14
Androgen therapy is off-label use and not FDA approved.
Testosterone can be supplied in oral form, in topical or sublingual preparations, and may be used alone or in combination with estrogen.2,15 Randomized clinical trial data are
unavailable comparing the efficacy of testosterone-only
regimens versus regimens that include concomitant estrogen. Demonstrated effects include increased clitoral sensitivity and sexual arousal. Known adverse reactions from
provision of endogenous testosterone can include hirsutism,
acne, unfavorable lipid profiles, and virilization of a female
fetus if taken in pregnancy.2,15 Because testosterone is con-

synthetic steroid that is approved in other countries for

treatment of hypoactive sexual desire, but not in the
United States.8,15 A small study of a nutritional and herbal
supplement, ArginMax, has recently reported increased
sexual desire in some postmenopausal women.25
A prescriptive mechanical device for clitoral stimulation is approved by the FDA to use for sexual arousal disorder.15 However, it is expensive and may not be covered
by insurance. It is different from a vibrator in that it works
by creating a vacuum that increases clitoral blood flow.
Women who are uninsured or whose insurance will not
cover the device may want to first try simple vibrators that
are available over-the-counter in most drugstores.

Psychosocial components
Individual or couple psychotherapy often plays a role in
treating FSD, whether to address underlying issues that are
contributory or personal, or relational distress that arises as
a consequence of the condition.9 Successful management of
FSD often involves collaboration between medical and psychiatric professionals.14 Any woman
with FSD that presents with a history
Phentolamine is a vasodilator that has
of sexual abuse, trauma, or intimate
partner or family violence should be
been demonstrated to improve lubrication
medically managed in partnership
and sexual arousal.
with mental health professionals.8,14
If your practice includes initial assessment and management of women
verted into estrogen, it should not be used in women with a
with FSD, it is important to maintain current knowledge of
history of breast cancer or with a breast mass that has not
referrals for social and psychiatric professionals in your
14
been evaluated.
community, as well as investigation of coding and insurance
reimbursement issues.9 You can further serve your patients
Phosphodiesterase type-5 inhibitors
by making initial inquiries before referring as to whether
PDE-5 inhibitors such as sildenafil (Viagra) are widely used
both single women and same-sex couples are served.
for male erectile dysfunction. Much attention has focused
on whether similar medications could be useful for FSD.13 A
Provide good guidance
number of studies have not demonstrated efficacy. Sexual
NPs can be important first-line, healthcare providers for
response in women is influenced by psychosocial and conwomen with FSD. Open communication about sexuality is
textual factors. One of the reasons for limited success in
critical to making an accurate assessment. NPs can use their
women taking PDE-5 inhibitors is that the physiologic
awareness of the complex nature of womens sexual responses
mechanism of action, involving increasing vasocongestion,
to assess and counsel. Some treatment options can be protargets only one aspect of physiologic functioning.14 Therevided by NPs, but successful management of FSD often
fore, it does not address far more complicated nonphysioinvolves having a referral network for employing multidislogic reasons for lack of arousal.5,8,10,11,15 At this time, no oral
ciplinary collaboration. Knowledge of the scope of FSD can
help provide patients with the best guidance when referring
PDE-5 inhibitors have received FDA approval for the treatthem to specialty providers.
ment of FSD, and clinical research on sildenafil for FSD
has been halted.28
REFERENCES

Additional medications and treatments

Phentolamine is a vasodilator that has been demonstrated
to improve lubrication and sexual arousal. Tibolone is a
48 The Nurse Practitioner Vol. 34, No. 1

1. Amato P. Categories of female sexual dysfunction. Obstet Gynecol Clin North

Am. 2006;33:527-534.
2. Pauls RN, Kleeman SD, Karram MM. Female sexual dysfunction: principles
of diagnosis and therapy. Obstet Gynecol Surv. 2005;60:196-205.

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3. Moynihan R. The marketing of a disease: female sexual dysfunction. BMJ.

2005;330:192-194.
4. Hayes RD, Bennett CM, Fairley CK, Dennerstein L. What can prevalence studies tell us about female sexual difficulty and dysfunction? J Sex Med.
2006;3:589-595.
5. Nijland E, Davis S, Laan E, Schultz WW. Female sexual satisfaction and pharmaceutical intervention: a critical review of the drug intervention studies in
female sexual dysfunction. J Sex Med. 2006;3:763-777.
6. Dalpiaz O, Kerschbaumer A, Mitterberger M, et al. Female sexual dysfunction: a new urogynaecological research field. BJU Int. 2008;101:717-721.
7. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States:
prevalence and predictors. JAMA. 1999;281:537-544.
8. Aslan E, Fynes M. Female sexual dysfunction. Int Urogynecol J Pelvic Floor
Dysfunct. 2008;19:293-305.
9. Ohl LE. Essentials of female sexual dysfunction from a sex therapy perspective. Urol Nurs. 2007;27:57-63.
10. Basson R, Schultz WW. Sexual sequelae of general medical disorders. Lancet.
2007;369:409-424.
11. Rosen RC, Barsky JL. Normal sexual response in women. Obstet Gynecol Clin
North Am. 2006;33:515-526.
12. Basson R. Womens sexual dysfunction: revised and expanded definitions.
CMAJ. 2005;172:1327-1333.
13. Mayer M, Stief CG, Truss MC, Uckert S. Phosphodiesterase inhibitors in
female sexual dysfunction. World J Urol. 2005;23:393-397.
14. Berman JR. Physiology of female sexual function and dysfunction. Int J Impot Res. 2005;17:S44-S51.
15. Raina R, Pahlajani G, Khan S, Gupta S, Agarwal A, Zippe CD. Female sexual
dysfunction: classification, pathophysiology, and management. Fertil Steril.
2007;88:1273-1284.

20. Komisaruk BR, Whipple B, Crawford A, Liu WC, Kalnin A, Mosier K. Brain
activation during vaginocervical self-stimulation and orgasm in women with
complete spinal cord injury: FMRI evidence of mediation by the vagus nerves.
Brain Res. 2004;1024:77-88.
21. Tepper MS, Whipple B, Richards E, Komisaruk BR. Women with complete
spinal cord injury: a phenomenological study of sexual experiences. J Sex
Marital Ther. 2001;27:615-623.
22. Aichhorn W, Whitworth AB, Weiss EM, Marksteiner J. Second-generation
antipsychotics: is there evidence for sex differences in pharmacokinetic and
adverse effect profiles? Drug Saf. 2006;29:587-598.
23. Taylor MJ, Rudkin L, Hawton K. Strategies for managing antidepressantinduced sexual dysfunction: systematic review of randomised controlled
trials. J Affect Disord. 2005;88:241-254.
24. Uckert S, Mayer ME, Jonas U, Stief CG. Potential future options in the pharmacotherapy of female sexual dysfunction. World J Urol. 2006;24:630-638.
25. Ito TY, Polan ML, Whipple B, Trant AS. The enhancement of female sexual
function with ArginMax, a nutritional supplement, among women differing
in menopausal status. J Sex Marital Ther. 2006;32:369-378.
26. Wierman M, Basson R, Davis S, et al. Are the endocrine societys clinical practice guidelines on androgen therapy in women misguided? A commentaryresponse. J Sex Med. 2007;4:1782-1783.
27. Wierman ME, Basson R, Davis SR, et al. Androgen therapy in women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab.
2006;91:3697-3710.
28. Althof SE, Dean J, Derogatis LR, Rosen RC, Sisson M. Current perspectives
on the clinical assessment and diagnosis of female sexual dysfunction and
clinical studies of potential therapies: a statement of concern. J Sex Med.
2005;2:146-153.

16. MacNeill C. Dyspareunia. Obstet Gynecol Clin North Am. 2006;33:565-577.

AUTHOR DISCLOSURE

17. Goldstein AT, Burrows L. Vulvodynia. J Sex Med. 2008;5:5-14.

The author has disclosed that she has no significant relationship or financial interest in any commercial companies that pertain to this educational activity.

18. Basson R, Leiblum S, Brotto L, et al. Revised definitions of womens sexual

dysfunction. J Sex Med. 2004;1:40-48.
19. Meston CM, Derogatis LR. Validated instruments for assessing female sexual
function. J Sex Marital Ther. 2002;28:155-164.

Clair Kaplan is an assistant professor of nursing, Yale University School of Nursing, New Haven, Conn.

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