dr. Peter salgo welcome to Second Opinion, where each week we solve a real medical mystery. When we close this file a half an hour from now, youll not only know the outcome of this weeks case, but youll be better able to take charge of your own healthcare and doctors will be able to listen to patients more effectively. Im your host, dr. Peter salgo. Youve already met our special guests, who are joining our primary care physician, dr. Lou papa. Pleasure to have you here. No one on the team has seen this case. And were going to get right to work. Let me tell you a little bit about dora. Dora is 58 years old. She is an attorney, and shes in her Doctors Office for her annual physical exam. Its her first visit with a new primary care physician, who happens to be a gynecologist. And ill tell you that the chart shows that dora was diagnosed with hypertension about 15 years ago. She takes a substantial dose of a betablocker. She is on an arb as well. Shes on some hydrochlorothiazide. Shes 5 foot 6, 142 pounds, and after her mothers death, she started an ssri for depression. Her pelvic exam was unremarkable. But heres something interesting. After asking dora a number of fairly routine questions about her health, doras doctor tells her that many of her patients have questions or concerns related to sexuality, and she wants to know what doras concerns might be. Now, dora is surprised by the question. Should she be . dr. Lou papa yes. peter why . lou because it doesnt happen that often. It doesnt come up in the office, either sex, all that often. peter how often in your combined experiment here on this panel, doctors just come out proactively and ask about sexual history . dr. Pepper schwartz very infrequently. It happens infrequently. I just saw a study where women said, 90 of the women said their doctor never mentioned to it, period. dr. Coral surgeon we ask all our patients on our update sheet, to document what their concerns and questions are. We specifically ask that question about sexuality, and about sexual dysfunction. Are you having any problems with sexual activity, is it uncomfortable. So, theyre very open. peter these sound like very, very good questions. dr. Surgeon specific questions. peter . And important and specific questions. But you all told me that its very uncommon for this to happen. So, if theyre that important, and it doesnt happen, the obvious question is, why not . dr. Schwartz well, one thing i think is that the doctors as well as the patient, and this i think is unfortunate, is that they dont consider it part of wellness. You know, part of, you know, were taking care of your body, were taking care, making sure about your emotions. After all, shes already on an ssri. Her emotions are involved in her wellness, and her sexuality is involved with both her emotions and her body. peter why dont patients bring it up . dr. Lynne shuster theres a very interesting study about that, that showed that actually some, one of the top reasons that patients dont ask their doctor, or talk to their doctors about sexual concerns, is theyre afraid it will make their doctors uncomfortable. And secondly, that they think theres probably going to be no treatment for it. peter dora, i guess, was a bit taken aback. But then she said, sex, and im quoting from the chart here, sex really isnt a priority for me. Ive got a demanding job. I have teenage children at home. My husband and i have sex, but i dont particularly enjoy it. And then she asks, is this normal . Is it normal . dr. Tiefer oh, the normal word, the normal word. But that is how people think about sex. Its not like, i havent enjoyed it, so i want to talk to you about how i can enjoy it. Its like, how do i fit in the big picture of women my age peter what is normal . dr. Surgeon normal is what, what feels good and whats emotionally satisfying. Thats what normal sex is. dr. Tiefer only, if only. peter what do you mean by that . dr. Schwartz well, it may be average for older women to push sexuality away. But is it good . It may be average that we all weigh 50 pounds too much, but is it good . Average is often mistaken for normal, and i think the two need to be teased apart. dr. Tiefer i would broaden the definitions out. We, we have a statistical one, okay, thats average. But then theres cultural and theres clinical normality. And where i think the problem is, is that cultural normality mistakes for clinical normality. And i think thats what happens to the average person, and maybe to dora, as well. When she comes in and says, am i normal, she wants to know clinically is she normal. Is she healthy. dr. Surgeon shes, shes now menopausal, shes 58. So women spend about a third of their life in the menopause, which is, a large part of your lifetime. And so if youre going to spend that much time in the menopause, you should enjoy it. And having a healthy sexual life, should be a part of that. So, is she having pain . Is that why shes not enjoying her sex life . peter well, she doesnt mention pain. dr. Schwartz let me make a distinction. One between arousal and the other between desire. One is, if they have no desire, honestly, ive heard, ive heard women say, if i never did it again in my life, it would be okay. Thats not having any desire. The other one is, i, i want my partner, i want to be sexual, i dont feel anything when i am. Thats different. So those two things have to be distinguished. dr. Shuster one of the things thats really useful in, in my care of women at midlife with sexual function changes is, teasing out drive and desire. So very commonly postmenopausally, theres not the same hormonal drive perhaps for sex, but often there is the desire for intimacy, the deep desire for intimacy. So for this woman, though, i would try to find out for dora, is this, is this distressing to her or not. Because if its not, if im sure, if its not painful and its not distressing, and shes happy with her relationship, and shes, you know, emotionally healthy. Then i try not to assume that she needs to be having sex. dr. Tiefer i would go right to the distress question. Is this a problem for you . But a lot of women are interested. I think thats a good word to use. A lot of women get turned on. Thats a good word to use. A lot of women arent interested, and a lot of women dont get turned on. dr. Shuster but a lot of women will also say that theyre, theyre not concerned about it themselves, but when you ask them question further, or give them more time to talk about it, they say, you know, it is different between my husband and i. He, we dont show affection to each other as much anymore. We dont have the same closeness anymore. And for that reason, i miss the sex. And so sometimes theyll say theyre not, that theyre not distressed by it, but that it does matter to them. peter ill tell you the buzzword that i keep hearing. Its female sexual dysfunction as a disease state. You name it, they like to name things in medicine. Now you can treat it as a disease. dr. Tiefer specifically with female sexual dysfunction is that it implies that there is a normal female sexual function from which this case is deviating. So i dont like the term, female sexual dysfunction. I think its a marketing term that the pharmaceutical industry is pushing. dr. Shuster but in order to care for women with sexual concerns in the medical realm, we, we have to actually have a diagnosis to attach for it, for the visit. And so i think it is an artificial construct, and then because its been so generalized, i think that is a problem. But within the medical realm, i, i think we just use it for, for the purpose that it serves, in order to bill. peter well, let me put you on the spot, since you, you at least would use the term, female sexual dysfunction. dr. Shuster i wouldnt yet for her. None, none of the information so far would lead me to diagnose this as female sexual dysfunction. peter yeah. If youre going to use the term clinically, you need a definition. How would you define it . dr. Shuster female sexual dysfunction in general . peter yes, dr. Shuster it is a, well, its broken down into four main categories, by the conventional wisdom. And so female sexual dysfunction may be classified as a dysfunction of desire, a function of arousal, a function or a problem with orgasm, or a problem with pain with intercourse. And for defining that as a dysfunction, it has to be a problem in one of those areas, associated with personal distress. peter all right, well, what causes it . dr. Shuster sexual dysfunction is multifactorial. It can be caused by medications, menopause, social issues, like childcare issues in younger women, Birth Control pills. dr. Schwartz a bad marriage. dr. Surgeon a bad, yeah, relationship issues, poor communication. dr. Schwartz religion, education. dr. Surgeon religion, cultural issues, postsurgical issues. peter youre the one who brought up age and menopause. Is that part of it . And is that physical, with decreasing hormone levels with, with menopause . dr. Surgeon absolutely. Theres a, theres a distinct drop in testosterone when a woman becomes menopausal. dr. Tiefer and theres no correlation between testosterone level and sexual dysfunction symptoms. dr. Surgeon well, testosterone does decline as a woman ages. And, and. dr. Shuster im sorry, go ahead. dr. Surgeon and all the studies have shown that it has something to do with your libido. dr. Tiefer im afraid i cant agree with that. dr. Surgeon well. peter why dont you agree. Dr. Tiefer well, i dont think thats what the literature shows. I think we can talk about a lot of other medical possibilities that havent been looked into as well as this one, but this is one that has been looked into so well, because the prescription of testosterone, unfortunately, is something thats really happening, even off label, and without any fda approval, and thats a problem. dr. Surgeon clearly theres decline in ovarian function when you become menopausal. Now, not all testosterone is produced just only by the ovary. You get adrenal production, and peripheral conversion from. dr. Tiefer true. dr. Surgeon . Other hormones. But there is a decline when you become menopausal. dr. Tiefer theres no question about that. But i think that the correlation with the presence of sexual symptoms, is, i just think, you know, the data are not supportive of that at the moment. dr. Surgeon i know, but thats why i said its multifactorial. Clearly there are some women who go through life and because their relationship is great, their marriage is great, theyre comfortable with communicating with their partners, and theyre comfortable with themselves. They continue to have very normal desire, they still get aroused, they have no problems with having comfortable sex. But there are some women who, they may have lower sex drive all through their lives, and when they become menopausal, its totally gone. They have no desire, no arousal, and its, its uncomfortable for them. Those are be treated. dr. Shuster hormones are very important to sexual function, but they are not probably the most important cause of sexual function changes at midlife and beyond. Testosterone and estrogen are two very different issues with regard to sexual function. If you look just purely at testosterone blood levels in women, it is absolutely true that there is not a level of testosterone thats correlated with good sexual function or good health, in general. With estrogen, there are some interesting studies that show that the level of estrogen matters. When the estrogen level gets to a certain amount, interest or desire might change. And when it gets to the lowest level of all, theres often pain with intercourse. dr. Schwartz you know, i, when i go back to the clinical case that is presented, you know, you sort of wonder, if its not important, when did it stop being important, and when did, when did sex stop. Because i really think that sometimes a lot of these hormones are produced by your behavior, by your activity. Its a reflexive kind of system. So, you know, the longer youve been away from it, the more likely you are to have pain, the more likely you are to, to have trouble, you know, being embarrassed to reenter that, that area. peter does sex have to be important to dora . She certainly didnt bring it up. lou how do you get out of that box, and that, thats part of what i, some of the difficulty having that conversation. How much do you push it, how much is an issue for the patient, because theres so much societal, you know. dr. Tiefer pressure. lou . Pressure, where it was from one extreme to where it was, like, you dont talk about it, to where if youre not doing it three times a day, theres something wrong with you. dr. Shuster this is part of the medicalization to assume that, that it needs to matter, or some, that theres a problem that needs to be fixed here. So this, this really is the, the issue, if were assuming that she has sexual dysfunction at this point, that is a problem with the medicalization of, of sex. peter well, let me point something out that i, that i didnt hear. Maybe the drugs shes on, are why. covertalkn dr. Shuster absolutely. dr. Tiefer ssri. peter shes on an ssri, shes on. dr. Tiefer oh yeah, thats right. peter . Shes on hydrochlorothiazide, and maybe the reason that she has this issue. dr. Shuster there is not any doubt at all, that those would impact on it, especially the ssri medicine. dr. Schwartz right. dr. Shuster so ss. peter thats an antidepressant, yeah. dr. Shuster thats an antidepressant. dr. Schwartz yes. dr. Shuster so those have profound effects on sexual function. dr. Tiefer i just want to point out her mother died a year ago, so maybe shes grieving. Life experiences affect peoples interest in sex, as well. peter all right, lets pause just for a minute here, and sum up what weve been talking about. Weve covered a lot of ground here. Sexual response is influenced by a number of factors. Some of them are biological, there are social, psychological, cultural. All of them come into play in understanding your own sexual health, not the least of which is medication that you may be taking. Dora says to her doctor, and again its a quote, sex is not a priority for me. I dont enjoy it. What do you think doras doctor should ask now . dr. Schwartz i would like to know this question, did you used to enjoy . But also, well what about it dont you enjoy . Why, you know, have, have you always not liked it, and if you have, if you used to, what, whats changed for you . Id like to know specifically. lou im not sure id get into that with the first visit, because very often from my point of perspective, it would be very different being a sex expert that you can get into that topic. This patient is coming to me for medical care. One of the things im going to be concerned about is that getting too deep into that topic, its not, you know, its not dr. Tiefer you, you raised it in the first place. I mean, youre either going to talk about it, or youre not going to talk about. lou no, no i disagree. Because im a primary care physician. Now im not going to see this patient never again. Theres a good chance ill never see her again if she goes home to her husband and says, this guy kept asking me about my sex life and i just met him. I have opportunities, multiple opportunities down the road to tackle that. covertalkn dr. Tiefer so you would raise it . You would. dr. Shuster . For another year, remember, she just came in for her. lou possibly. dr. Shuster . Yearly. lou but shes hypertensive, shes depressed, im going to see her again. dr. Tiefer wait a minute. You would, you said, you would raise it. lou absolutely. But i also raise other issues as well with the patient. dr. Tiefer and you dont follow up on those either . lou of course i do. dr. Tiefer sure you do. lou of course i do. But this is a relationship. I just met this lady. And theres lots of issues patients may not be able to talk about or want to talk about on the first visit. dr. Tiefer so she says, you say do you have any concerns. She says, well, im not interested anymore. You say, all right, well talk about that next time. lou no, no. No thats not the case at all. What i would say is, well, if it is a concern, or it becomes a concern to you, there are options for treatment, if there is dissatisfaction in your sex life. I would something to the, the issue that where im not slamming the door, which youre implying im doing. Im leaving that door wide open. You can walk through it when you want. Im not pulling you through. peter all right, let me tell you a little bit more about what dora tells her physician. Dora says she has no interest in sex. She denies pain with sex. Her only real discomfort is dryness and even if she gets aroused shes dry. She has to use a lubricant. She doesnt orgasm. She says she used to enjoy sex, but in her mid 40s she began to lose interest, between her job, and her kids, shes tired, shes stressed, just wants to be left alone. She doesnt really miss sex, but she does feel sorry for her husband, and sometimes she worries that he might lose interest in her. Okay. With all this information, ill go back to you, does she have fsd, female sexual dysfunction . Does this make the diagnosis . dr. Shuster i, i still, i personally wouldnt call it a dysfunction, but i think that the semantics of that dont matter. The question is, are we going to address this further, and, and so if shes saying that it affects her relationship, then i would find out more about. peter shes worried about it. dr. Shuster . About their relationship. And then we absolutely should explore it further. peter how do you help dora. dr. Schwartz well, what i would say, if some patient came to someone here, and said, you know, ive given up tennis because my elbow hurts. Wed say, boy, its important that you enjoy tennis. Well fix your elbow, even though your elbow can get you through a normal day, you cant play tennis anymore. And i would hear this and think, this is a woman who hasnt had an orgasm. dr. Tiefer ever, ever . dr. Schwartz its not clear from that. Either. peter its not clear from this note. She says shes certainly not having orgasms now. dr. Schwartz . If shes ever had it or she doesnt have it. dr. Tiefer this is important because its one of the incentives, and sometimes over, overemphasized, but for her to actually say that, i think is to disclose an important thing. lou its very different when the patient makes an appointment. dr. Tiefer yes. lou comes in and says, my elbow hurts, i need it fixed. Versus, theyre coming in to have their Blood Pressure checked and on the review of systems, said, yeah, my tennis elbow is bothering me a little bit. I used to play tennis, but, you know, its okay. peter well, ill tell you. lou im not going to jump in and say, well do surgery. peter but lou, shes already said thats shes worried. lou right. peter . About her partner. dr. Shuster about her marriage. peter shes worried about her husband. lou right. peter so, i, let us for the sake of argument, take this as an admission that shes concerned and would like somebody to intervene. What do you do . dr. Shuster my opinion is that, if she wants to pursue this further, and she is indicating that its a concern, i think referral to someone that can help address the whole of this issue, is very important. Because if we just look at the medicine aspects of it, or just the Blood Pressure aspects, or just the gynecologic or hormonal aspects, and not get at the, at the whole picture, then, then were not going to get anywhere. So i think this is the perfect example that brings up the