RFM - Revista Fluminense de Medicina
REVISÃO
FJM - Fluminense Journal of Medicine
REVIEW
Female Sexual Dysfunction: Assessment of Clinical
Characteristics among Women Attended in a Rio de
Janeiro University Medical Center
Disfunção Sexual Feminina: Avaliação das Características Clínicas de Mulheres
Atendidas em um Centro Médico Universitário do Rio de Janeiro
Carlos Romualdo B Gama1, Ricardo Lasmar2, Gustavo F Gama3, Camila S Abreu4, Carlos P Nunes5,
Mauro Geller6, Lisa Oliveira7, Alessandra Santos8, Mauro Romero L Passos9, Daiane Bergamim10
1
PhD in Gynecology – Universidade Estadual Paulista – UNESP. Professor & Chairman of Gynecology – Fundação Educacional Serra dos Órgãos –
UNIFESO. Fellow of the Colégio Brasileiro de Cirurgiões – Rio de Janeiro. Professor & Coordinator of the Post-Graduation Course in Gynecologic
Endoscopy – UNIFESO. 2PhD in Gynecology – Universidade Estadual Paulista – UNESP. Associate Professor of Gynecology – Universidade Federal
Fluminense – UFF. 3Fellow of the Post-Graduate Course in Gynecologic Endoscopy – UNIFESO. Head of the Gynecology & Obstetrics Service – Hospital
das Clínicas – UNIFESO. 4Bachelor’s in Pharmaceutics – Universidade Federal do Rio de Janeiro – UFRJ. 5Associate Professor of Internal Medicine –
UNIFESO. Associate Professor of Clinical Immunology – Instituto de Pós-Graduação Médica Carlos Chagas – IPGMCC. 6Professor and Chairman of
Immunology – UNIFESO. Professor and Chairman of Clinical Immunology – IPGMCC. 7Researcher in Immunology and Microbiology – UNIFESO. 8PostGraduate Student in Clinical Immunology – IPGMCC –UFRJ. Post-Graduate Student in Clinical Genetics – UFRJ. 9Associate Professor and Head of the
Department of Sexually Transmitted – UFF. 10Medical Student – Teresópolis Medical School – UNIFESO.
Abstract
Objective: To review the literature and to assess female sexual dysfunction and the clinical characteristics of patients attended at the
UNIFESO medical school facilities. Methods: Literature published between 2004 and 2014 and indexed in PubMed was reviewed. Data
from a total of 144 patients was included and statistically analyzed. Results: The following information was obtained for each patient:
date of birth; ethnicity; marital status; stature; weight; body mass index; previous use of contraceptives; previous pregnancies; history
of abortion; history of depression; intermenstrual bleeding; history of amenorrhea; history of dysmenorrhea; blood pressure; cardiac
frequency; laboratory evaluation (total/free testosterone, DHEA); and the Female Sexual Function Index scores. Conclusion: Female sexual
dysfunction is a complex disorder influenced by many factors that combine psychosocial as well as physiological entities. The diagnosis is
difficult and a multifaceted approach should be considered. Treatment of this disorder must be individualized to the specific complaints of
each woman. Hormones and other agents are relevant treatment options but need to be further studied.
Keywords: female sexual dysfunction, sexual disorder, epidemiological study
RESUMO
Objetivo: Revisar, atualizar a literatura referente à avaliação da disfunção sexual feminina e as características clínicas dos pacientes
atendidos nas instalações da escola médica UNIFESO. Métodos: Revisão da literatura publicada entre 2004 e 2014 e indexados no PubMed.
Foram incluídos e analisados estatisticamente dados de um total de 144 pacientes. Resultados: A seguinte informação foi obtida para
cada paciente: data de nascimento; etnia; estado civil; estatura; peso; índice de massa corporal; uso prévio de contraceptivos; gestações
anteriores; história do aborto; histórico de depressão; hemorragia intermenstrual; história de amenorreia; história da dismenorreia; pressão
arterial; frequência cardíaca; avaliação laboratorial (testosterona total/livre, DHEA); e as pontuações do Índice de Função Sexual Feminina.
Conclusão: A disfunção sexual feminina é um distúrbio complexo influenciado por muitos fatores que se combinam psicossocialmente,
bem como aspectos fisiológicos. O diagnóstico é difícil e uma abordagem multifacetada deve ser considerada. O tratamento desta condição
clinica deve ser individualizado em função das queixas específicas de cada mulher. Hormônios e outros agentes terapêuticos são opções de
tratamento relevantes, mas precisam ser mais pesquisados.
Palavras-chave: disfunção sexual feminina, desordem sexual, estudo epidemiológico
INTRODUCTION
Female sexual dysfunction is a complex and multifaceted condition, comprising anatomical, physiological, and social-interpersonal components1-3. It is characterized by the
persistent or recurrent impairment of an individual’s sexual
Address to correspondence:
CARLOS ROMUALDO BARBOSA GAMA
Av. Alberto Torres, 111 – Alto Teresópolis – RJ – Brasil
CEP: 25964-004
E-mail: [email protected]
Recebido em: 6 de setembro de 2013
Aprovado em: 20 de novembro de 2013
DOI: 10.5533/RFM-FJM-2238-9423-201478-79203
response and/or interest4. The various types of sexual dysfunction have recently undergone a re-classification in the
DSM-V, and are now characterized as: a) sexual interest/
arousal disorder; b) orgasmic disorder; and c) genitopelvic
pain/penetration disorder5. It is important to explain to the
patient that transient sexual problems are common; however if the problem persists over months or causes affliction
to the patient or their partner, the cause of the dysfunction
should be investigated6-11.
Sexual dysfunction can occur at any age and affects 4045% of the female worldwide population at some point in
life3,4. The etiology of sexual dysfunction in women is multifactorial and combines psychological, interpersonal, biological and contextual factors12. These include the patient’s
well-being, quality of the relationship, severe medical con-
RFM - Rev Flu Med 2014;78-79(2):11-14 - ISSN: 2238-9423
12
GAMA et al.
ditions (neurological, urogenital, endocrine disorders, pelvic
floor disorders, obesity, etc.), as well as pharmacological and
other therapies (antineoplasmic agents, antipsychotic and antidepressant agents, antihypertensive agents, major surgical
operations, radiation therapies, etc.)1,2,4,9,11-15.
METHODS
The aim of this epidemiological study was to assess sexual
dysfunction in women at the UNIFESO – medical school facilities. To participate in the study, the women had to be older
than eighteen years of age, presenting with some kind of sexual dysfunction, neither pregnant nor breastfeeding. A total
of 144 women were chosen for the study.
The following information was obtained for each patient:
date of birth; ethnicity; marital status; stature; weight; body
mass index; previous use of contraceptives; previous pregnancies; history of abortion; history of depression; intermenstrual bleeding; history of amenorrhea; history of dysmenorrhea; blood pressure; cardiac frequency; laboratory
evaluation (total/free testosterone, DHEA); and the Female
Figure 1 – Marital status of the patients.
Sexual Function Index scores.
The Female Sexual Function Index (FSFI), a validated self-report measure of female sexual function. This is a 19-item
questionnaire that is subdivided into six domains: desire,
arousal, lubrication, orgasm, satisfaction, and pain. The scoring system followed the instructions given by the authors
who developed and validated the questionnaire. The maximum possible score is 36 points and the minimum possible
score is 2 points16.
These descriptive statistics were used to analyze the data:
average median, standard deviation, minimum and maximum
and number of observations for quantitative variables, and
frequency distributions (frequencies and percentages) for categorical variables.
RESULTS
while 70 patients (48.61%) had never been pregnant. Twenty
six patients (18.06%) had history of induced or spontaneous abortion. Of all patients, 42 (29.17%) had a medical history depression. Of all patients, 25 (17.36%) reported the
occurrence of intermenstrual bleeding. Nine patients (6.25%)
reported the occurrence of amenorrhea. Of all patients, 81
(56.25%) reported incidence of dysmenorrhea.
The average weight of the patients was 64.51 kg (± 9.808).
The maximum recorded weight was 94 kg with a minimum of
49 kg, and a median of 63 kg. The average BMI of the patients
was 24.91 (± 3.575), with a median of 24, maximum of 36
and minimum of 18.
Mean systolic blood pressure was 120.7 mmHg (± 7.343),
with a maximum recorded value of 140 mmHg, the minimum
of 102 mmHg and 120 mmHg median. The average diastolic
Data of 144 patients were included in the analysis. The
blood pressure of the patients was 78.2 mmHg (± 9.203),
mean age of the population studied was 41.01 years (±
with a median of 80 mmHg. The maximum recorded was 94
7,066). The minimum age recorded was 24 years and the ma-
mmHg and the minimum was 59 mmHg. The average heart
ximum was 62 years, with a median of 41 years. The average
rate of the patients was 66.56 bpm (± 5,966), with a median
height of all patients was 161.0 cm (± 5.965), with the grea-
of 67 bpm, maximum of 78 bpm and minimum of 54 bpm.
test height recorded between all patients of 171.0 cm and the
Mean DHEA of the patients was 57.83 ng/mL (± 30.11)
minimum height of 150.0 cm, with a median of 160.0 cm. The
(laboratory reference range: 15-170 ng/mL). The minimum
ethnic distribution of the patients was: five patients (3.47%)
registered DHEA during this evaluation was 10 ng/mL and 130
of Asian ethnicity, 60 (41.67%) caucasian, 26 (18.06%) black
ng/mL was the maximum, with a median of 55 ng/mL, as
and 53 (36.81%) of mixed ethnicity.
demonstrated by the Figure 2.
With regard to marital status of the patients, 60 (41.67%)
The mean serum testosterone of all patients was 24.21 ng/
were married, 55 (38.19%) were divorced, 22 (15.28%) were
dL (± 13.17), with a median of 24 ng/dL (laboratory reference
single and seven (4.86%) widows, as seen in Figure 1.
range: 3-63 ng/dL). The maximum level recorded among the
In the evaluation of medical history, 126 patients (87.5%)
reported previous use of contraceptives, while 18 patients
patients was 70 ng/dL and the minimum was 3 ng/dL, as
shown by the Figure 3.
(12.5%) indicated no prior use contraceptives. Of all pa-
The mean free testosterone of all patients was 7.83 pmol/L
tients, 74 (51.39%) reported the occurrence of pregnancy,
(± 4.668) with a maximum value of 27 pmol/L, minimum value
RFM - Rev Flu Med 2014;78-79(2):11-14
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Female Sexual Dysfunction: Assessment of Clinical Characteristics among Women Attended in a Rio de Janeiro University Medical Center
Figure 2 – DHEA of all patients.
of 2 pmol/L, and a median of 7 pmol/L (laboratory reference
range: 2-45 pmol/mL). Displayed in the Figure 4.
The mean free testosterone of all patients was 7.83
pmol/L (± 4.668) with a maximum value of 27 pmol/L, minimum value of 2 pmol/L, and a median of 7 pmol/L (laboratory reference range: 2-45 pmol/mL). Displayed in the
Figure 4.
The results of the sexual function index questionnaire
(FSFI) taken by the patients, are presented in the Table 1.
Figure 4 – Free testosterone of all patients.
Table 1 – Results of the FSFI
Domain
Minimum score
Maximum score
Desire
1.2
6.0
2.51 (± 0.929)
Arousal
0
6.0
2.43 (± 0.866)
Lubrication
0
6.0
3.16 (± 0.952)
Orgasm
0
6.0
2.75 (± 0.914)
0.8
6.0
2.90 (± 1.138)
Pain
0
6.0
2.82 (± 1.631)
Total
2.0
36.0
16.57 (± 4.493)
Satisfaction
Score obtained
DISCUSSION
Figure 3 – Serum testosterone of all patients.
Given that sexual dysfunction in women is a multifaceted disorder, the diagnosis is made primarily through careful clinical history enquiring about past psychosexual development, current life context, comorbid illness, medications
and previous surgery10,14. Physical examination should include
complete pelvic exam; mental status; blood pressure; and
musculoskeletal, thyroid, breast and neurologic abnormalities1. Laboratory evaluations are seldom helpful in guiding the
diagnosis1. Indeed, the patients’ testosterone and DHEA tests
were within laboratory reference ranges.
There are several alternative therapies that can be used in
the treatment of the female sexual dysfunction; however, the
identification of a possible physical or emotional component
is important before starting therapy. Therapeutic approaches
RFM - Rev Flu Med 2014;78-79(2):11-14
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GAMA et al.
include addressing stress and relationship issues, treatment
of vaginal dryness and dyspareunia, and investigation of drug
side effects. The use of testosterone in the form of gels, creams, ointments or tablets is not recommended for premenopausal women and there is a risk of adverse events in addition
to containing very high doses of testosterone17,18. Dehydroepiandrosterone (DHEA) supplementation is effective in the
improvement of sexual interest and sexual satisfaction among
women with adrenal insufficiency; however, the benefit of supplementation in women with normal adrenal function has not
yet been confirmed9,17,18.
CONCLUSION
Female sexual dysfunction is a very complex disorder, and
is influenced by many factors that combine psychosocial as
well as physiologic entities. The diagnosis is difficult and a
multifaceted approach should be considered. Treatment of
this disorder must be individualized to the specific complaints
of each woman. Hormones and other agents are relevant treatment options, but because of the increased risk of adverse
events and little data on the subject, these therapies need to
be further studied.
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