Insufficient assessment of sexual Dysfunction : a Problem in gynecological Practice

Background and Objective. Sexual health is an important part of a woman’s life and well-being. Female sexual dysfunction is a complicated problem, it is often underestimated in the healthcare process, and its management is complex. Giving women the opportunity to talk about sexual problems is a fundamental part of healthcare and may improve their quality of life. The aim of this study was to find out patients’ experience and attitudes toward the involvement of gynecologists addressing sexual issues, to disclose the main barriers to initiate a conversation, and to assess the prevalence of sexual disorders among patients in a gynecological clinic. Material and Methods. A questionnaire-based approach was used to survey 18to 50-year-old voluntary patients in the gynecological clinic. The study population comprised 300 different gynecological (except oncologic) patients independently of reasons for being in the clinic. The duration of the study was 6 months. Results. Only one-third of the patients had ever been asked about their sexual life by a gynecologist, whilst the majority (80%) of the respondents reported they would like to be asked and discuss sexual issues. The patients mostly did not complain because of psychoemotional barriers, and shame was the main barrier for patients to talk about their problems. Sexual dysfunction was a frequent disorder among gynecological patients, reaching especially high levels in the arousal (46.41%) and lubrication (40.67%) domains. Conclusions. The assessment of sexual health is insufficient in gynecological care, and sexual history-taking and evaluation of sexual functions should be included in routine gynecological health assessments.


Introduction
Sexuality is a fundamental and important part of the human life cycle (1).Female sexual dysfunction is defined as disorders of sexual desire, arousal, orgasm, and pain, which lead to personal distress (2).It is well known that the satisfaction with one's sex life is a major indicator of the quality of life (3).While sexual health has been recognized as an integral part of overall health (4), it is often ignored in routine visits (5).Sexual dysfunction in women is a health issue often overlooked by medical personnel, but it is a topic of great importance to both the patient and her sexual partner (3).Female sexual dysfunction is highly prevalent, occurring in 25%-63% of women (6), and the prevalence tends to increase with age (7).Factors that can contribute to female sexual dysfunction may be psychogenic, physical, mixed or unknown.Psychogenic factors include a lack of knowledge regarding one's body and the sexual response cycle, religious beliefs, social pres-sure, sexual abuse, negative sexual experiences, unrealistic expectations, relationship conflict, or resentment toward a partner.Physical factors include medications and acute or chronic health conditions (1).Sexual problems are often the first symptoms of a disease, and many diseases and drug therapies can increase the prevalence of sexual problems (8,9).Short-duration problems of sexual functions may create frustration and anguish, and if the problems are chronic, they may lead to anxiety and depression and may damage relationships or create problems in other areas of the patient's life (10).The diagnosis and treatment of female sexual dysfunction are currently based on subjective reporting by the woman and physical examination (11).Measuring sexual function is a challenging task, not only because of the sensitive and personal nature of the subject matter but also because measures are subjective.The indicators of sexual function are all selfreported (12).Woman's expression of her sexuality is unique to her and is likely to change over time (13).Most available validated questionnaires for the evaluation of female sexual function and satisfaction ask women to summarize or recall how they felt concerning their sexual experiences over a certain period (12).Specific instruments, such as vaginal probes to measure vaginal blood flow or genitosensory analysis, are used as research tools (14).
Approximately 40%-45% of women are thought to have had at least one sexual dysfunction at some point in time (5).The complexity of sexual dysfunction in women leads to a multidisciplinary approach by the specialists of physical and mental health (15).Healthcare professionals noted embarrassment as a major obstacle to initiate a discussion about sexual health, and the time limit and a lack of training were important barriers to their addressing sexual problems (16).
Sexual functions in women decline with age.The relationship among sexuality, interest, satisfaction, and other factors among older people is complex (17), although numerous studies have demonstrated that many older women retain an interest in their sex life (18).Physicians need a biopsychosocial model rather than the traditional medical illness model in the management of sexual dysfunction (19).Since gynecologists are physicians who have knowledge about the impact of different reproductive endocrine changes on women's well-being, mood, and physiology of the sexual response throughout their life, they are one of the most eligible specialists to find the first signs and symptoms of female sexual dysfunction.
There are no previous studies about the prevalence of sexual dysfunction among gynecological patients in Latvia, as well as there are no data about the level of underreporting of sexual complaints and its reasons.Barriers to talking about these issues can be population and culture specific.The objective of this study was to investigate whether the assessment of sexual dysfunction in the gynecological clinic was sufficient, to disclose women's experience and attitudes toward sexual issues in the gynecological healthcare process, and to find out the prevalence of sexual disorders in the gynecology clinic.The tasks of the study were to survey the patients attending the gynecological clinic by using a questionnairebased approach, to perform statistical analysis of the obtained data, and to draw conclusions.

Material and Methods
A 2-part questionnaire was used to survey patients in the gynecological clinic.The first part was an 8-item questionnaire developed by the authors in order to find out patients' experience regarding sexual disorders, level of reporting symptoms to a gynecologist, barriers for talking to a physician, information sources about sexuality, involvement of a gynecologist by questioning, attitudes to the role of a gynecologist in addressing sexual issues, and relationship status.All patients completed the first part of the questionnaire.The second part was the standardized and validated Female Sexual Function Questionnaire 28 (6,20) with 28 questions to assess the function of female sexuality in the main domains (desire, arousal sensations, lubrication, cognitive excitement, orgasm, pain, satisfaction, and partner) and to evaluate the level of the sexual function of sexually active patients.The second part was applied only to those women who had had sexual activities during the last 4 weeks.The validity of the Female Sexual Function Questionnaire 28 at both the item and domain levels supports the use of individual domains as primary endpoints.The Female Sexual Function Questionnaire 28 can identify both the presence of sexual dysfunction and the specific components of the sexual function affected.Both the physical and cognitive aspects of sexual response are evaluated within the items, and cutoff scores for the function of each domain are generated.In compliance with the Female Sexual Function Questionnaire 28, the patient's sexual function was classified into 3 categories for all domains (desire, arousal sensations, lubrication, cognitive excitement, orgasm, pain, satisfaction, and partner): normal sexual function, borderline function, and sexual dysfunction.The borderline function is defined as the tendency to and probability of sexual dysfunction, but additional information is required before making a diagnosis.According to the questionnaire interpretation, there is no section of sexual dysfunction in the partner domain.There is only a normal versus borderline function, which indicates a possible sexual problem because of a partner/relationship.The study population was directed to analyze different patients independently of reasons for being in the gynecological clinic in order to see problems and attitudes of an average gynecological patient and to apply conclusions to ordinary gynecological care visits.A central, wide-spectrum gynecological clinic, representing patients from all over the country, was chosen for this study.The study population comprised 18-to 50-year-old patients from the Department of Gynecology, Riga East Clinical University Hospital, who voluntarily agreed to participate in the study.The age restriction of 18 years was related to the study interest in adult sexuality, but the age restriction of 50 years was related to a highly possible impact of menopause on sexuality.The duration of the study was 6 months; the response rate was 89.82%.In total, 300 correctly completed questionnaires were collected and used for data analysis.The researcher who had a direct contact with the patients for the study purposes was not directly involved in patients' clinical care to minimize any influence on answers.Comfortable conditions and privacy were provided as well as time being enough to complete the questionnaire accurately.Each questionnaire got a code, and no private data were used.gynecological patients in this study in general corresponds to the prevalence in the general population (3,15,23), nonetheless showing a higher prevalence of arousal dysfunction in all 3 domains describing arousal (arousal sensation, lubrication, and cognitive excitement).
Only a small part of the patients with sexual complaints asked for help, and this is in line with the data reported in the literature (3,(24)(25)(26).The most common causes for not asking were also similar, but showing the more frequent tendency of being shy and waiting when the doctor will ask first, despite the fact that the categories for the barriers mentioned may also overlap.The explanation for this could be the mentality and character features of the study population.Disbelief that a physician will be able to help or will not pay attention to the problem predominates in other studies (3).If nearly two-thirds of patients with sexual complaints do not talk to a physician and it is mostly because of the shame, it is a serious reason to revise the current approach to the structure of taking a case history during gynecological healthcare visits, because most of patients admit they would like to discuss sexual issues with their gynecologist.Even though education systems vary across countries, a lack of sexual education as part of medical education is observed in many countries (1,27).If professionals are not accordingly educated, they are not able to deal with such problems appropriately.The results of our study also show a considerable lack of information about sexuality in the general education systemonly few patients had got knowledge about sexuality from education.If society is not educated properly, the use of unreliable sources of information leads to growing myths, illusions, false perceptions, and more frequent sexual difficulties.
Wide interpretation of the study results and generalization to the whole population of gynecological patients are restricted by a relatively small sample size, but it gives an opportunity to see and analyze tendencies and demonstrate the problem.An intrinsic disadvantage of a questionnaire-based approach is a subjective conception of questions, recall failures, and impossible verification of answers.However, considering the objective of the study and an emotional and intimate nature of this topic, the questionnaire-based approach was chosen as most suitable for this study.
In general, a proof of the existing problem of the insufficient assessment of sexual health in gynecological practice and the insight into associated problems were achieved by this study.Gynecologists in daily practice cannot manage all forms of sexual dysfunctions and it would not be possible also because of lack of knowledge, skills, time, and different therapeutic approaches required in sexology; however, our practical recommendation from this study is that the gynecologist should screen all patients for sexual disorders, provide basic information and recommendations, and refer to a specialist if it is necessary.

Conclusions
The assessment of sexual dysfunction in the gynecological clinic is insufficient as gynecologists do not ask women about sexual complaints routinely and most of the patients do not complain of their sexual problems, which is mostly because of psychoemotional barriers.The main source of information about sexuality is the Internet, but the vast majority of patients would want to talk to their gynecologists about sexuality.Female sexual dysfunction is a frequent disorder among gynecological patients, and arousal dysfunction is the most common form.

statement of Conflict of Interest
The authors state no conflict of interest.