ASSESSING & MANAGING. Female sexual 2.0 CONTACT HOURS The Nurse Practitioner Vol. 34, No. 1

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1 ASSESSING & MANAGING Female sexual 2.0 CONTACT HOURS 42 The Nurse Practitioner Vol. 34, No. 1

2 dysfunction Clair Kaplan, RN/MSN, APRN (WHNP), MHS, MT (ASCP) T he prevalence of female sexual dysfunction (FSD) is poorly studied and methodologic inconsistencies between studies make it difficult to describe prevalence. These include varying definitions of FSD and discrepancies among populations surveyed, as well as a lack of validated instruments. 1-6 In studies, 43% of female respondents age 18 to 59 suffered from sexual dysfunction, and the most common complaint was low libido. 1,7 However, there is continued debate about the accuracy of this estimate. 3,6 Most studies are limited in that they use intercourse to define sexual activity. However, for some women, including heterosexual women, activities such as touching and caressing may be more significant to sexual satisfaction than the act of penile-vaginal intercourse. In addition to study inconsistencies, the overwhelming majority of study data focus only on partnered heterosexual women. This lack of attention to lesbian and unpartnered heterosexual women may also result in inaccuracies. Some studies are even more restrictive, having only surveyed married, heterosexual women. Researchers occasionally addressed the limitations of the data collected from only partnered, heterosexual women, The Nurse Practitioner January

3 Classifications of FSD 1,6,8,9,14,15,16-18 HSDD Persistent or recurring deficiency or absence of sexual fantasies or thoughts, or absence of sexual receptivity that causes personal distress. Sexual aversion disorder Persistent or recurring phobic aversion and avoidance of sexual contact, often secondary to physical abuse or trauma that causes personal distress. Sexual arousal disorder Persistent or recurring inability to attain or maintain sexual excitement, causing personal distress. This may be subjective, with absent or reduced feelings of sexual arousal despite physical reactions to lubrication and genital swelling; or it may be genital, characterized by lack of physical reaction to sexual stimuli despite subjective arousal. Both can exist in combined form. Orgasmic disorder Persistent or recurrent difficulty in attaining orgasm after sufficient stimulation and arousal, causing personal distress. Dyspareunia One of the sexual pain disorders characterized by recurrent or persistent pain with sexual intercourse. Vaginismus Recurrent or persistent involuntary muscle spasm of the outer third of the vagina that interferes with desired vaginal penetration (sexual and otherwise), causing personal distress. Vestibulodynia (formerly referred to as vulvar vestibulitis syndrome) Severe pain with touch to the vaginal vestibule, and tenderness with light touch, such as with a cotton swab. stating that because sexual dysfunction is likely to interfere with partnered relationships, the data cannot begin to address the scope of the problem among women. 4,5,8-10 Data about lesbian women are almost completely lacking, and are of interest not only because of the unaddressed needs of this population, but also because of the nature of relationships between women. Among female-female couples, sexual dysfunction may manifest as a mutual lack of spontaneous sexual desire. Studies of heterosexual women are more focused on assessing differences in receptive sexual acceptance as opposed to spontaneous sexual desire. In heterosexual couples, a woman s wish to meet her partner s needs may facilitate intercourse despite lack of desire. 5,9 44 The Nurse Practitioner Vol. 34, No. 1 Physiology An understanding of FSD must begin with an understanding of the multifaceted female sexual response cycle, which involves physical, psychological, emotional, and interpersonal components. 11 A number of models of the female sexual response were proposed, ranging from work delineating four phases: excitement, plateau, orgasm, and resolution, to research delineating three specific phases: desire, arousal, and orgasm. 1,11 A newer, circular model emphasizes subjective and interpersonal aspects of emotional and relational intimacy, as well as physical satisfaction. 12 This differs from past models derived from male sexual response that focus primarily on physical aspects. 11 The circular model provides a more holistic way of addressing the multifactorial nature of women s sexual responses and expands on the reasons why women engage in sexual activity. For some women, sexual activity is desired for its intimacy and relationship satisfaction component, not because of spontaneous physical desire. However, once sexual activity is initiated, arousal and orgasm can occur. 10 There are cultural, ethnic, and religious beliefs that influence what a woman would regard as normal or desired female sexuality. There are also a significant minority of women who do not rate sexual activity as necessary for their well-being, and so definitions of forms of FSD take into account a qualifier that the condition must cause personal distress. 11 Physiologic mechanisms of the cycle of female response involve vasocongestion and neuromuscular events, central and peripheral nervous system, and a variety of neurotransmitters and hormones. 13,14 As in males, sexual arousal in females involves vasocongestion with physical changes to the genital organs. Lubrication increases, and the clitoris, vulva, and vaginal canal increase in size. 14 Rhythmic, involuntary contraction of muscles in the vagina, the pelvic floor (primarily the levator ani), and of the perineal membrane occurs, resulting in female orgasm. 1,9,14,15 Classification and assessment There are several different categories of FSD (see Classifications of FSD). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) describes sexual dysfunction as disorders of hypoactive sexual desire, disorders of sexual excitement (female sexual arousal disorder), and the orgasmic disorder of anorgasmia, but it neglects complex psychosocial components. 1,6,9,11,14 Primary care NPs can incorporate screening questions into medical history forms, followed (for positive responders) by self-assessment questionnaires. 8 Validated instruments that may be useful for clinical care as well as research have been reviewed and referenced. 15,19 Some women may prefer to be asked open-ended questions such as, I find that prevalence of sexual problems among women is almost 50%, so I ask all my patients if they have any questions or issues with their sexual life that they would like to talk about. 9

4 A differential diagnosis for causes of FSD should begin with an assessment of the contributions of low libido, anorgasmic response, and pain with sexual activity. A thorough medical, surgical, obstetric, and social history should include comorbid medical and psychiatric conditions, medications, herbal or alternative products, and over-thecounter supplements. A sensitive social and sexual history should be obtained. 9 Inquire about all past mental health issues and social information, including relationship history and current status. Assess for any history of intimate partner violence, family violence or abuse, sexual or physical assault, or major life stressors. The use of cigarettes, alcohol, and drugs should be elicited. 2,8,14 The incidence of woman-to-woman variation exists depending on how comfortable patients are in talking about sexuality. Interviews must be individually tailored for patient comfort. In a best case situation, a NP should be able to inquire about: satisfaction with one s current relationship and assessment for violence or abuse sexual satisfaction or lack of satisfaction, and other issues in past relationships whether masturbation is practiced and how the type of preferred sexual activity, and any associated pain with sexual activity. Psychosocial history should include any past history of victimization or abuse. Keep in mind that a woman who has a complaint of FSD may not have a current partner, and her relationship status may be related to FSD. Did a relationship end because of sexual difficulties? Is the woman reluctant to pursue intimate relationships because of sexual dysfunction? Is her partner experiencing sexual difficulties of his or her own that are contributory to FSD in your patient? Never begin a sexual history with the assumption that a woman is heterosexual; partners may be female, male, or both, and a variety of sexual activities may be preferred. Determine if the FSD is primary or secondary. For example, in assessing anorgasmia, a primary response means not only that the woman has never had an orgasm during sexual activity but that she is unable to achieve orgasm through masturbation. If secondary, determine the circumstances under which the woman has (or currently can) reach orgasm, and the situations where she cannot. Some women may report ability to reach orgasm through masturbation, but not with a partner. Relationship issues concerning lack of intimacy and trust may be involved, and referrals for counseling should be readily available. Within the limitations of a primary care visit, an NP can be helpful in encouraging a woman to share her sexual needs with her partner(s), including the need for clitoral stimulation and discussion of forms of nonpenetrative sex that may be more satisfying than intercourse. A physical exam should include a total assessment for systemic conditions and a comprehensive genital exam. Assessment should be done for signs and symptoms of sexually transmitted infection with appropriate lab testing. Examine for inflammatory vulvar presentation and dermatologic lesions, and for pelvic and vulvar pain with bimanual exam suggestive of fibroids, tumors, endometriosis, polyps, and pelvic inflammatory disease. Assess for any prolapse or weakness of pelvic floor muscles, tenderness, or erythema. Evidence of vaginismus may present during a gynecologic exam and, in fact, may preclude speculum insertion. 2 Lab tests for specific contributing conditions and general medical screening may include: vaginal wet prep gonorrhea and chlamydia testing thyroid-stimulating hormone (TSH) to assess thyroid function luteinizing hormone (LH), possibly follicle-stimulating hormone (FSH) and prolactin levels complete blood cell (CBC) count, chemistry panel, lipid profiles, and fasting glucose total and free testosterone levels, sex hormone binding globulin (SHBG), and estrogen levels. 14 Decreased libido or hypoactive sexual desire disorder (HSDD) may be a result of relationship factors, endocrine A physical exam should include a total assessment for systemic conditions and a comprehensive genital exam. disorders, menopause, aging, depression, or medications. Sexual arousal disorder is seen most often in women following pelvic surgeries, and as a result of psychological and relationship factors. Orgasmic disorder can be seen as a consequence of some medications, sexual abuse, or as a result of surgery or hormonal deficiency. Postpartum sexual dysfunction may be related to life stresses and role changes, but may also be caused by perineal trauma from childbirth. 8,9,15 Pain syndromes If pain is associated with your patient s FSD, try to get her to describe the pain including duration, onset, quality, The Nurse Practitioner January

5 severity, aggravating factors, relieving factors, if pain is present during all sexual activity or only during some encounters, and if it is present in nonsexual situations. Pain may be present with attempted vaginal entry or only with deep penetration. 2,8,16 Sexual pain disorders include vaginismus and dyspareunia. Vaginismus, which can be painful, is defined as an involuntary spasm that occurs with any type of sexual or nonsexual vaginal penetration. Dyspareunia is genital pain associated with sexual intercourse. 15 There may also be pelvic, vaginal, or vulvar pain that is not associated with sexual stimulation. Examples include pain that occurs with the insertion of tampons, rubbing of clothing, or pain that is exacerbated by activities like bicycling or horseback riding. Vestibulodynia is severe pain with vestibular touch or attempted vaginal penetration, and tenderness of the vaginal vestibule with light pressure. 16,17 Dyspareunia may be seen as a consequence of poor lubrication, damage to pelvic nerves following surgery, or sexual practices that inadequately emphasize foreplay. Many of these issues can be successfully addressed, and lubrication can be provided via hypoallergenic water-based gels that are available over-the-counter. When indicated FSD may be the first indication of a previously undiagnosed chronic illness, such as coronary disease or diabetes. by urogential atrophy, most commonly associated with menopause or increased age, estrogen-containing creams can be provided. Chronic pelvic pain may be associated with a great number of conditions, including fibroids and endometriosis. Assess any cyclic nature of chronic pelvic pain, preferably with the help of a detailed menstrual diary, and consider whether ultrasound or laparoscopy would be indicated for diagnosis. 10,16 Various conditions Infections and dermatologic conditions There is controversy about the role of sexually transmitted infections and nonsexually transmitted vaginitis, but screening is easily accomplished for most of these. 16 A careful sexual and medical history, in addition to the physical exam, should provide for diagnosis of a missed infection that may be involved in genital pain disorders. However, an atypical herpes outbreak without visible lesions that causes genital pain may be difficult to determine. Dermatologic conditions may present with atypical lesions or with signs of allergic vulvar dermatoses. Use of so-called feminine hygiene products douches, scented sanitary pads, and even bubble-bath can cause vulvar irritation with edema, pruritus, burning, and inflammatory discharge, and should be discouraged. 9 Menopause Levels of testosterone and estrogen decline with menopause, and women commonly experience decreased genital blood flow, loss of sexual desire, decreased sexual responsiveness, low sexual arousal, and lack of lubrication and atrophy of genital tissues. 14,15 Chronic disease and aging FSD may be the first indication of a previously undiagnosed chronic illness, such as coronary disease or diabetes. 10 Diabetes, hypertension, coronary artery disease, and hyperlipidemia are all associated with atherosclerosis, which can decrease blood flow to the vagina and clitoris. Multiple sclerosis is a chronic disease noted to have an inhibitory effect on genital sensation, ability to reach orgasm, and sexual desire. 9,14,15 Chronic cardiac disease and diabetes are implicated in contributing to FSD. 8 Spinal cord injury does not always limit a woman s sexual function nor her ability to become pregnant and parent, but it may compromise female sexual function in a variety of ways, with both psychological and physical effects. The level of injury may affect lubrication and ability to reach orgasm, as well as sexual desire. This is also likely to be influenced by psychosocial and relationship dynamics. 8,10,15,20,21 Pelvic surgery, including hysterectomy, bladder surgery, and surgery for pelvic organ prolapse, can damage nerves that are essential to female sexual response. However, data are confounded by inconsistencies in subject selection. 6,15 Newer surgical techniques are being developed and utilized to avoid complications and adverse reactions, including FSD. As mentioned, removal of the ovaries is associated with a precipitous drop in hormones and may result in sudden onset of FSD. In addition to surgery itself, radiotherapy used for oncological management, as well as the psychosocial stress associated with cancer, can play a role in FSD. 15 Aging is associated with increased incidence of FSD. Causes may include relational issues, chronic illness and overall lack of physical well-being, lifestyle stressors, changes in body image, physical and emotional effects of decreased hormone levels, lack of a partner or lack of a partner with interest and ability to engage in sexual activity The Nurse Practitioner Vol. 34, No. 1

6 Medications A variety of medications are associated with FSD, including some categories of antihypertensives, drugs used for chemotherapy, anticonvulsants, psychiatric medications (especially those used to treat depression), anticholinergics, hormonal birth control, and antiandrogens. 15 Psychiatric medications Sexual adverse reactions are very common from psychiatric medications, in particular the selective serotonin reuptake inhibitor antidepressants and conventional antipsychotic medications. 2,10,14,22 In women, problems may involve lack of desire, problems with dyspareunia and lubrication, and anorgasmia. 23 A careful history can help to delineate if depression or other psychiatric illness was initially concomitant with FSD, or if the problem began with the onset of medication. Strategies for management may include changing to medications with better profiles for adverse sexual effects and drug holidays. The risk of exacerbation of psychiatric symptoms must be carefully monitored and balanced against the harm caused by medication-associated FSD. 2,8 Hormonal contraception Oral contraceptives reduce testosterone levels by increasing levels of SHBG and may be associated with hypoactive sexual desire, although studies are inconclusive. 5,8 As with any nuisance adverse reaction from oral contraceptives, prudent management is to change to a different pill formulation and continue to monitor symptoms of FSD while encouraging women to use an alternative contraceptive method, if necessary. Medical treatment Pharmacologic attention to FSD has largely focused on the involvement and provision of hormonal mediators and neurotransmitters to treat arousal and orgasmic disorders. Depending on the type of FSD, medication may be part of a treatment plan. However, as female sexual response is multifaceted, there is no single efficacious treatment. 24,25 Hormonal treatment is one of the mainstays of treatment for some types of FSD, primarily with estrogen and testosterone. The primary hormones studied involved in the female sexual response are estrogen and testosterone. Estrogen is important in maintenance of adequate lubrication and prevention of atrophy of vaginal and vulvar tissues, with many complaints of dyspareunia in menopause correlated to the decrease in estrogen levels. Estrogen therapy, often applied topically, is commonly used for some types of FSD. Testosterone also decreases with age, and while there are no FDA-approved regimens for testosterone therapy for FSD, there are promising study data and recommendations for use in certain categories. 5 Additional medical treatments may include phosphodiesterase type-5 (PDE-5) inhibitors (nitric oxide donors), dopaminergic agonists, and prostaglandins. 15 Still, there is controversy in the literature about pharmaceutical treatment for FSD. Estrogen Estrogen plays a major role in female sexual function. It is involved in synthesis of nitric oxide, which mediates relaxation of clitoral and vaginal smooth muscle. Estrogen levels Sexual adverse reactions are common in selective serotonin reuptake inhibitors and antipsychotic medications. significantly decline in menopause. 8 Estrogen is the most commonly used pharmaceutical intervention for FSD, especially for syndromes of FSD that are related to menopause. Nonetheless, caution is advised because estrogen therapy decreases levels of SHBG, thereby depleting levels of bioavailable testosterone with a potential corresponding decrease in libido. 2,5,8 This effect may be reduced through the use of transdermal preparations. 8 Used in postmenopausal women, estrogen improves lubrication and conveys protective effects on thinned and atrophied genital tissue. 14 Estrogen has demonstrated beneficial effects on mood and sexual desire, clitoral and vaginal sensitivity, and on the ability to reach orgasm. It can be supplied in a variety of forms, including topical creams, gels, intravaginal rings, oral pills, and transdermal patches. Topical treatment avoids potential risks with systemically delivered estrogen and is preferred as a first-line therapy. 15 Treatment regimens with estrogen are numerous and beyond the scope of this article. In women with an intact uterus, concomitant progestin must be considered to counteract endometrial hyperplasia from unopposed estrogen. Testosterone Testosterone is the major androgen in women, synthesized from androstenedione and derived from the ovaries and adrenal glands. Levels drop precipitously with surgical removal of the ovaries and decrease with aging. Testosterone may be deficient in younger women, especially as a consequence of surgical menopause. Clinically, meaningful levels The Nurse Practitioner January

7 Phentolamine is a vasodilator that has been demonstrated to improve lubrication and sexual arousal. of decreased testosterone are difficult to measure in the lab. 5 There are no established normal levels for testosterone or free testosterone in women, and few assays can provide the necessary sensitivity and specificity to recommend widespread use of lab measurements. 26,27 Low levels of testosterone are associated with a number of adverse reactions, including overall diminished sense of well-being, decreased sexual arousal and desire, decreased genital sensation, thinning of vaginal mucosa, and difficulty reaching orgasm. 2,14 Androgen therapy is off-label use and not FDA approved. Testosterone can be supplied in oral form, in topical or sublingual preparations, and may be used alone or in combination with estrogen. 2,15 Randomized clinical trial data are unavailable comparing the efficacy of testosterone-only regimens versus regimens that include concomitant estrogen. Demonstrated effects include increased clitoral sensitivity and sexual arousal. Known adverse reactions from provision of endogenous testosterone can include hirsutism, acne, unfavorable lipid profiles, and virilization of a female fetus if taken in pregnancy. 2,15 Because testosterone is converted into estrogen, it should not be used in women with a history of breast cancer or with a breast mass that has not been evaluated. 14 Phosphodiesterase type-5 inhibitors PDE-5 inhibitors such as sildenafil (Viagra) are widely used for male erectile dysfunction. Much attention has focused on whether similar medications could be useful for FSD. 13 A number of studies have not demonstrated efficacy. Sexual response in women is influenced by psychosocial and contextual factors. One of the reasons for limited success in women taking PDE-5 inhibitors is that the physiologic mechanism of action, involving increasing vasocongestion, targets only one aspect of physiologic functioning. 14 Therefore, it does not address far more complicated nonphysiologic reasons for lack of arousal. 5,8,10,11,15 At this time, no oral PDE-5 inhibitors have received FDA approval for the treatment of FSD, and clinical research on sildenafil for FSD has been halted. 28 Additional medications and treatments Phentolamine is a vasodilator that has been demonstrated to improve lubrication and sexual arousal. Tibolone is a synthetic steroid that is approved in other countries for treatment of hypoactive sexual desire, but not in the United States. 8,15 A small study of a nutritional and herbal supplement, ArginMax, has recently reported increased sexual desire in some postmenopausal women. 25 A prescriptive mechanical device for clitoral stimulation is approved by the FDA to use for sexual arousal disorder. 15 However, it is expensive and may not be covered by insurance. It is different from a vibrator in that it works by creating a vacuum that increases clitoral blood flow. Women who are uninsured or whose insurance will not cover the device may want to first try simple vibrators that are available over-the-counter in most drugstores. Psychosocial components Individual or couple psychotherapy often plays a role in treating FSD, whether to address underlying issues that are contributory or personal, or relational distress that arises as a consequence of the condition. 9 Successful management of FSD often involves collaboration between medical and psychiatric professionals. 14 Any woman with FSD that presents with a history of sexual abuse, trauma, or intimate partner or family violence should be medically managed in partnership with mental health professionals. 8,14 If your practice includes initial assessment and management of women with FSD, it is important to maintain current knowledge of referrals for social and psychiatric professionals in your community, as well as investigation of coding and insurance reimbursement issues. 9 You can further serve your patients by making initial inquiries before referring as to whether both single women and same-sex couples are served. Provide good guidance NPs can be important first-line, healthcare providers for women with FSD. Open communication about sexuality is critical to making an accurate assessment. NPs can use their awareness of the complex nature of women s sexual responses to assess and counsel. Some treatment options can be provided by NPs, but successful management of FSD often involves having a referral network for employing multidisciplinary collaboration. Knowledge of the scope of FSD can help provide patients with the best guidance when referring them to specialty providers. REFERENCES 1. Amato P. Categories of female sexual dysfunction. Obstet Gynecol Clin North Am. 2006;33: Pauls RN, Kleeman SD, Karram MM. Female sexual dysfunction: principles of diagnosis and therapy. Obstet Gynecol Surv. 2005;60: The Nurse Practitioner Vol. 34, No. 1

8 3. Moynihan R. The marketing of a disease: female sexual dysfunction. BMJ. 2005;330: Hayes RD, Bennett CM, Fairley CK, Dennerstein L. What can prevalence studies tell us about female sexual difficulty and dysfunction? J Sex Med. 2006;3: Nijland E, Davis S, Laan E, Schultz WW. Female sexual satisfaction and pharmaceutical intervention: a critical review of the drug intervention studies in female sexual dysfunction. J Sex Med. 2006;3: Dalpiaz O, Kerschbaumer A, Mitterberger M, et al. Female sexual dysfunction: a new urogynaecological research field. BJU Int. 2008;101: Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281: Aslan E, Fynes M. Female sexual dysfunction. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19: Ohl LE. Essentials of female sexual dysfunction from a sex therapy perspective. Urol Nurs. 2007;27: Basson R, Schultz WW. Sexual sequelae of general medical disorders. Lancet. 2007;369: Rosen RC, Barsky JL. Normal sexual response in women. Obstet Gynecol Clin North Am. 2006;33: Basson R. Women s sexual dysfunction: revised and expanded definitions. CMAJ. 2005;172: Mayer M, Stief CG, Truss MC, Uckert S. Phosphodiesterase inhibitors in female sexual dysfunction. World J Urol. 2005;23: Berman JR. Physiology of female sexual function and dysfunction. Int J Impot Res. 2005;17:S44-S Raina R, Pahlajani G, Khan S, Gupta S, Agarwal A, Zippe CD. Female sexual dysfunction: classification, pathophysiology, and management. Fertil Steril. 2007;88: MacNeill C. Dyspareunia. Obstet Gynecol Clin North Am. 2006;33: Goldstein AT, Burrows L. Vulvodynia. J Sex Med. 2008;5: Basson R, Leiblum S, Brotto L, et al. Revised definitions of women s sexual dysfunction. J Sex Med. 2004;1: Meston CM, Derogatis LR. Validated instruments for assessing female sexual function. J Sex Marital Ther. 2002;28: Komisaruk BR, Whipple B, Crawford A, Liu WC, Kalnin A, Mosier K. Brain activation during vaginocervical self-stimulation and orgasm in women with complete spinal cord injury: FMRI evidence of mediation by the vagus nerves. Brain Res. 2004;1024: Tepper MS, Whipple B, Richards E, Komisaruk BR. Women with complete spinal cord injury: a phenomenological study of sexual experiences. J Sex Marital Ther. 2001;27: Aichhorn W, Whitworth AB, Weiss EM, Marksteiner J. Second-generation antipsychotics: is there evidence for sex differences in pharmacokinetic and adverse effect profiles? Drug Saf. 2006;29: Taylor MJ, Rudkin L, Hawton K. Strategies for managing antidepressantinduced sexual dysfunction: systematic review of randomised controlled trials. J Affect Disord. 2005;88: Uckert S, Mayer ME, Jonas U, Stief CG. Potential future options in the pharmacotherapy of female sexual dysfunction. World J Urol. 2006;24: Ito TY, Polan ML, Whipple B, Trant AS. The enhancement of female sexual function with ArginMax, a nutritional supplement, among women differing in menopausal status. J Sex Marital Ther. 2006;32: Wierman M, Basson R, Davis S, et al. Are the endocrine society s clinical practice guidelines on androgen therapy in women misguided? A commentaryresponse. J Sex Med. 2007;4: Wierman ME, Basson R, Davis SR, et al. Androgen therapy in women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2006;91: Althof SE, Dean J, Derogatis LR, Rosen RC, Sisson M. Current perspectives on the clinical assessment and diagnosis of female sexual dysfunction and clinical studies of potential therapies: a statement of concern. J Sex Med. 2005;2: AUTHOR DISCLOSURE The author has disclosed that she has no significant relationship or financial interest in any commercial companies that pertain to this educational activity. Clair Kaplan is an assistant professor of nursing, Yale University School of Nursing, New Haven, Conn. For more than 81 additional continuing education articles related to Advanced Practice Nursing, go to Nursingcenter.com\CE. Earn CE credit online: Go to and receive a certificate within minutes. INSTRUCTIONS Assessing and managing female sexual dysfunction TEST INSTRUCTIONS To take the test online, go to our secure Web site at On the print form, record your answers in the test answer section of the CE enrollment form on page 36. Each question has only one correct answer. You may make copies of these forms. Complete the registration information and course evaluation. Mail the completed form and registration fee of $21.95 to: Lippincott Williams & Wilkins, CE Group, 2710 Yorktowne Blvd., Brick, NJ We will mail your certificate in 4 to 6 weeks. For faster service, include a fax number and we will fax your certificate within 2 business days of receiving your enrollment form. You will receive your CE certificate of earned contact hours and an answer key to review your results.there is no minimum passing grade. Registration deadline is January 31, DISCOUNTS and CUSTOMER SERVICE Send two or more tests in any nursing journal published by Lippincott Williams & Wilkins together and deduct $0.95 from the price of each test. We also offer CE accounts for hospitals and other healthcare facilities on nursingcenter.com. Call for details. PROVIDER ACCREDITATION Lippincott Williams & Wilkins, publisher of The Nurse Practitioner journal, will award 2.0 contact hours for this continuing nursing education activity. Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP for 2.0 contact hours. Lippincott Williams & Wilkins is also an approved provider of continuing nursing education by the District of Columbia and Florida #FBN2454. LWW home study activities are classified for Texas nursing continuing education requirements as Type I. Your certificate is valid in all states. The Nurse Practitioner January