A.

Ideal setting to discuss issues with your patient:

sexual

Patients may have difficulty talking to health care providers about sexuality and sexual health for many reasons, even when they clearly are sexually active. Most people are not raised to discuss sexual matters openly, and when sexuality is taught, it is often done in negative terms. As patients move through the stages of life, the dialogue with providers on this topic will evolve; a conversation with a sexually active adolescent should differ significantly from a discussion with a married perimenopausal woman. Research suggests that communication between health care providers and patients can improve sexual health. Effective patient/provider communication has been correlated with increased use of condoms, whereas lack of communication about sex is a risk factor for HIV and STIs (sexually transmitted infections).1 Many providers say they dont broach sexuality issues because they lack the training and skills to deal with these concerns, are uncomfortable with the subject, fear offending the patient, have no treatments to offer, or feel constrained by time.2,3 At the same time, 68 percent of patients surveyed cited fear of embarrassing a provider as a reason for not broaching sexuality issues.4 Clearly, discussing sexuality is difficult for many providers and their patients. Best Practices: Counseling Guidelines

To facilitate effective communication with patients on sexuality and sexual health, providers should5:

Promote sexual health in clinical practice environments. Provide patients with current information regarding sexual health. Acknowledge their patients feelings, attitudes, and norms that may be obstacles to individual sexual health and use this information to help patients establish realistic goals. Assist patients with development of skills they may need to achieve personal goals for sexual health (e.g., communication, negotiation, and planning strategies). Participate in continuing education activities focused on sexual health. Be aware and respectful of their patients sexual values and lifestyles. Understand how values of the health care provider or the clinical setting may influence practices and take care to provide unbiased and comprehensive care. Some providers may feel that their patients sexual lives are too personal to ask about, and patients may assume that their providers will tell them what they need to know. Communication about sexual health is a complex matter influenced by many factors. It is important for providers to:5

Understand their own feelings about sexual matters Be willing to speak truthfully at the risk of increasing their own vulnerability

Be able to listen and interpret patients sexual values, experiences, and concerns Be willing to reply honestly and clearly to patients sexual concerns Encourage enough trust from the patient to permit open communication about sex Breaking the Ice: Taking a Sexual History Taking a patients sexual history can facilitate a discussion on sexuality and sexual health and neednt take an inordinate amount of time.3 The following questions convey your willingness to discuss sexual issues:

Are you currently involved in a sexual relationship? Do you have sex with men, women, or both? Are you or your partner having any sexual difficulties at this time? Additional questions can include:

Are you satisfied with your current sexual relations? Do you have any sexual concerns you would like to discuss? If a patients answers suggest that she wants to discuss sexual issues, the following questions might be productive:

Tell me about your sexual history first sexual experiences, masturbation, how many partners youve had, any sexually transmitted infections or sexual problems youve had, and any past sexual abuse or trauma.

How often do you engage in sexual activity? What kinds of sexual activities do you engage in? o Depending on the sexual orientation of the patient, ask about the specific forms of sex, including penis in mouth, vagina, or rectum; mouth on vulva. o If the patient is a lesbian, ask if she has ever had penetrative sex with a man, to assess risk of cervical cancer and sexually transmitted infections. Do you have difficulty with desire, arousal, or orgasm? (If the woman is perior postmenopausal, begin by noting that many women experience vaginal dryness and changes in sexual desire around the time of menopause.)

A sexual history should include standard questions about menstrual and obstetric history: age at onset of menses, dates of last menstrual period, characteristics of menstrual periods, problems associated with menses in the past, pregnancyrelated problems, and symptoms of 3 perimenopause or menopause. Although talking about sex can be difficult for patients and providers, practicing and using the skills that promote candid communication will help to ensure the best possible care -----------------------------------------------------------------------------

B. Overview about sexual dysfunction in women

Sexual dysfunction refers to a problem during any phase of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from the sexual activity. The sexual response cycle includes excitement, plateau, orgasm and resolution. While research suggests that sexual dysfunction is common (43 percent of women and 31 percent of men report some degree of difficulty), it is a topic that many people are hesitant to discuss. Fortunately, most cases of sexual dysfunction are treatable, so it is important to share your concerns with your partner and health care provider. What are the types of sexual dysfunction? Sexual dysfunction generally is classified into four categories:

Desire disorders The lack of sexual desire or interest in sex Arousal disorders The inability to become physically aroused during sexual activity Orgasm disorders The delay or absence of orgasm (climax) Pain disorders Pain during intercourse (This condition mostly affects women.)

Who is affected by sexual dysfunction? Sexual dysfunction is more common in the early adult years, with the majority of people seeking help during their late 20s and early 30s. Sexual dysfunction also is common in the geriatric population, which may be related to a decline in health associated with aging. What are the symptoms of sexual dysfunction? In women:

Inability to relax the vaginal muscles enough to allow intercourse Inadequate vaginal lubrication before and during intercourse Inability to achieve orgasm

In men and women:

Lack of interest in or desire for sex Inability to become aroused Pain with intercourse

What causes sexual dysfunction? Causes of sexual dysfunction include: Physical causes Many physical and/or medical conditions can cause problems with sexual function. These conditions include diabetes, heart and vascular (blood vessel) disease, neurological disorders, hormonal imbalances, chronic diseases such as kidney or liver failure, and alcoholism and drug abuse. In addition, the side effects of some medications, including some antidepressants drugs, can affect sexual function. Psychological causes These include work-related stress and anxiety, concern about sexual performance, marital or relationship problems, depression, feelings of guilt, and the effects of a past sexual trauma. How is sexual dysfunction diagnosed? The doctor likely will begin with a complete physical and history of symptoms. He or she may order diagnostic tests to rule out any medical problems that may be contributing to the dysfunction. An evaluation of the persons attitudes regarding sex, as well as other possible contributing factors (fear, anxiety, past sexual trauma/abuse, relationship problems, alcohol or drug abuse, etc.) will

help the doctor understand the underlying cause of the problem and make recommendations for appropriate treatment. How is sexual dysfunction treated? Most types of sexual dysfunction can be corrected by treated the underlying physical or psychological problems. Other treatment strategies include: Medication Men and women with hormone deficiencies may benefit from hormone shots, pills or creams. For men, drugs including sildenafil (Viagra) may help improve sexual function by increasing blood flow to the penis. Mechanical aids Aids such as vacuum devices and penile implants may help men with erectile dysfunction (the inability to achieve or maintain an erection). Behavioral treatments These involve various techniques, such as self-stimulation, to treat problems with arousal and/or orgasm. Psychotherapy Therapy with a trained counselor can help a person address feelings of anxiety, fear or guiltas well as poor body imagethat may have an impact on sexual function. Education and communication Education about sex, and sexual behaviors and responses may help an individual overcome his or her anxieties about sexual function. Open dialogue with your partner about your needs and concerns also helps to overcome many barriers to a healthy sex life. Can sexual dysfunction be cured? The success of treatment for sexual dysfunction depends on the underlying cause of the problem. The outlook is good for dysfunction that is related to a treatable or

reversible physical condition. Mild dysfunction that is related to stress, fear or anxiety often can be successfully treated with counseling, education and improved communication between partners. ------------------------------------------------------------------------------

C.

Yes it is important to ask questions about women's sexual partner.

D. Screening for sexual dysfunction

Must do CBC, Thyroid test, Renal test, Liver test, Serum cholesterol, Hormone levels test ( testosterone, follicle stimulating hormone, Luteinizing hormone, estrogen, progesterone)

F. Treatment of female sexual dysfunction

is complicated by the lack of a single causative factor, limited proven treatment options,physician unfamiliarity with available treatments,overlap of different types of dysfunction,limited availability of treatment, and limited expertise in the treatment of female sexual dysfunction. Although patient education and therapy are the foundation of treatment, limited research has demonstrated the benefit of pharmacotherapy. PATIENT EDUCATION Many women consider normal sexual function to be the traditional desire-arousal orgasm process. Physicians can alleviate sexual concerns by educating patients about what is normal. For example, women who expect to feel desire for sexual stimulation may be reassured that desire can encompass a need for emotional intimacy through sexual activity rather than a need for sexual activity itself.

1. Education about normal anatomy is another important component in addressing sexual concerns. Use of a handheld mirror during a gynecologic examination can demonstrate to the patient normal and abnormal physical findings and facilitate a discussion about the physiologic basis of sexual functioning. Women may be reassured that normal sexual functioning is widely variable. ALLOW Ask the patient about sexual function and activity Legitimize problems, and acknowledge that dysfunction is a clinical issue. Identify limitations to the evaluation of sexual dysfunction Open up the discussion, including potential referral Work with the patient to develop goals and a management plan PLISSIT Obtain permission from the patient to discuss sexuality (e.g., I ask all my patients about their sexuality, is that okay to do with you now?) Give limited information (e.g., inform the patient about normal sexual functioning) Give specific suggestions about the patients particular complaint (e.g., advise the patient to practice selfmassage to discover what feels good to her) Consider intensive therapy with a sexual health subspecialist 2. Another treatment option is the Eros Clitoral Therapy Device, made by UroMetric. The device is FDA-approved and is designed to improve arousal by increasing blood flow to the clitoris with gentle suction. Two small, short-term studies have shown that the device benefits women with sexual arousal disorder. Lubrication may decrease dyspareunia associated with diminished

desire. Phosphodiesterase inhibitors have been shown to have limited benefit in subgroups of women with sexual arousal disorder, however, most women do not appear to benefit from the treatment. MADE BY DR HANAN ABO ELMKAREM

Module 6
-----------------------------------------------------------------------------

Case2; G. Which of the following can influence the contraception

choice in a 6 week postpartum patient? Ans: A,b,c,d,h

H. Which of the following statements regarding the

utilization of breastfeeding as a contraceptive option is TRUE? Ans: c. intervals between breastfeeding should not exceed 4 hours during the day

I. Discuss different contraceptive options that can be used

in a postpartum patient like mona? Ans: 1- breast feeding; 2- with drawl; 3-safe period; 4- condom; 5- mini pills

Hanan Abu Elmkaren