Taking a Sexual History

Given that women now live approximately one-third of their lives after menopause and continue to be sexually active beyond the cessation of reproductive functioning, the sexual history should now be a routine component of the annual clinical visit of the woman in midlife and beyond. ⁽¹⁾ Kingsberg suggests that pre- and postsurgical visits (for uterine prolapse, hysterectomy, oophorectomy, mastectomy, etc.), as well as those related to menopause, chronic illnesses, and depression, also lend themselves to the inclusion of assessment for sexual disorders. ⁽²⁾

Contraception and Risk of Unintended Pregnancy and STIs in Perimenopausal and Menopausal Women

Women over the age of 40 have the second highest proportion of unintended pregnancies, so the need for effective contraception continues into midlife until menopause.³ No contraceptive method is contraindicated by age, and certain methods, such as oral contraceptives (OCs) and other hormonal methods, may stabilize hormone levels and ease the transition through menopause.^3,4 The decision about which method to use should be guided by patient preference, lifestyle, behaviors (e.g., cigarette smoking), and medical history.^3,4 Safe-sex practices should be discussed with all patients regardless of their age or sexual orientation.

Starter Questions

Kingsberg suggests that a general sexual assessment needn't take an inordinate amount of time.⁽²⁾ Begin the assessment by asking the patient the following questions to 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 or concerns at this time, or do you have any questions or concerns about sex?

More extensive questioning can include the following:

• Are you satisfied with your current sexual relations?
• Do you have any sexual concerns you would like to discuss?

If a patient responds with answers suggesting she has concerns and wants to discuss them, you might then proceed as follows:

• "Tell me about your sexual history-your first sexual experiences, masturbation, how many partners you've had, any sexually transmitted infections or past sexual problems you've 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?
  • 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.
  • If the woman is a lesbian, ask if she has ever had penetrative sex with a man, to assess her risk of cervical cancer and sexually transmitted infections.
• "Do you have difficulty with desire, arousal, or orgasm?"
  • If the woman is peri- or postmenopausal, preface these questions with information that many women often experience vaginal dryness and changes in sexual desire around the time of menopause.

Along with sexual activity questions, a standard menstrual and obstetric history should be obtained, inquiring about the age of onset of menses, last menstrual period, characteristics of menstrual periods, problems associated with menses in the past, pregnancy-related problems, and perimenopausal/menopausal symptoms. ⁽²⁾

Physical Examination

A comprehensive physical examination should be conducted to detect potential contributors to or causes of sexual problems. This examination, which should be conducted with close monitoring and input from the patient to isolate potentially painful areas, should also be used to educate the patient about her reproductive anatomy and sexual functioning.⁽⁵⁾

Click here to see table 9

Diagnosis

Basson has developed an algorithm (click here to see Figure 4) to help providers establish a diagnosis of sexual problems in women. This algorithm incorporates both physical and psychosocial elements of sexual functioning (such as whether a woman is distressed about a change in her sexual functioning).^(2,6)

References:

1. Kingsberg SA. The impact of aging on sexual function in women and their partners. Arch Sex Behav 2002;31(5):431-437.
2. Kingsberg S. Just ask! Talking to patients about sexual function. Sexuality, Reproduction & Menopause 2004;2(4):199-203.
3. Stewart F. Menopause. In: Hatcher RA, Trussell J, Stewart F, et al., eds. Contraceptive Technology. 17th ed. New York: Ardent Media; 1988, pp 78-79.
4. Williams JK. Contraceptive needs of the perimenopausal woman. Obstet Gynecol Clin North Am 2002;29:575-588.
5. Phillips NA. Female sexual dysfunction: evaluation and treatment. Am Fam Physician 2000;62:127-136, 141-142.
6. Basson R. Sexuality and sexual disorders. Clinical Updates in Women's Healthcare 2003:1:1-84.