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Guideline Summary
Guideline Title
Female sexual dysfunction.
Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Female sexual dysfunction. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2011 Apr. 12 p. (ACOG practice bulletin; no. 119).  [100 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Female sexual dysfunction, including sexual desire disorders, sexual arousal disorder, orgasmic disorder, and sexual pain disorders

Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Obstetrics and Gynecology
Intended Users
Physicians
Guideline Objective(s)
  • To describe the basics of female sexual dysfunction, including the physiology of the normal female sexual response
  • To outline the criteria for diagnosis as listed in the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, fourth edition, text revision (DSM-IV-TR)
  • To highlight current management strategies based on available evidence
  • To target areas that require more study
Target Population

Women with sexual dysfunction

Interventions and Practices Considered
  1. Sexual history, including patient's medical, surgical, social, and psychiatric history
  2. Treatment, including
    • Patient education
    • Cognitive and behavioral psychotherapy (systematic desensitization)
    • Androgen replacement therapy (e.g., transdermal testosterone)
    • Vaginal estrogen
  3. Referral to specialist
Major Outcomes Considered
  • Sexual response (desire, arousal, ability to achieve orgasm)
  • Adverse effects of treatments

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985–July 2010. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles. When reliable research was not available, expert opinions from obstetrician–gynecologists were used.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I Evidence obtained from at least one properly designed randomized controlled trial.

II-1 Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician-gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Level C recommendations.

Rating Scheme for the Strength of the Recommendations

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

Recommendations

Major Recommendations

The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of the "Major Recommendations" field.

The following conclusion is based on good and consistent scientific evidence (Level A):

  • Transdermal testosterone has been shown to be effective for the short-term treatment of hypoactive sexual desire disorder, with little evidence to support long-term use (longer than 6 months).

The following conclusions are based on limited or inconsistent scientific evidence (Level B):

  • Prospective studies constructed to address the effect of hysterectomy on postoperative sexual function have failed to show a difference in total versus subtotal hysterectomy.
  • Vaginal estrogen for the treatment of postmenopausal atrophy results in improved dyspareunia, less vaginal dryness, improved vaginal mucosal maturation indices, and reduced vaginal pH.
  • The main risks associated with androgen replacement therapy in women are hirsutism, acne, virilization, and cardiovascular (CV) complications. In addition, a possible association with breast cancer has been reported.

The following conclusions are based primarily on consensus and expert opinion (Level C):

  • Female sexual dysfunction conditions can be categorized as sexual desire disorders, sexual arousal disorder, orgasmic disorder, and sexual pain disorders. Hypoactive sexual desire disorder is the most prevalent female sexual dysfunction.
  • Obtaining a thorough sexual history includes recording the patient's medical, surgical, social, and psychiatric history.
  • The most common medications linked to sexual dysfunction are the selective serotonin reuptake inhibitors (SSRIs). The most frequently reported problems are orgasmic dysfunction, decreased sexual desire, and decreased arousal.
  • There is no proven clinical utility to monitoring androgen levels before or during the treatment for hypoactive sexual desire disorder.
  • After initial evaluation, treatment can be initiated or, depending on the comfort level and training of the physician, a referral can be made to a trained specialist, such as a marriage counselor or sex therapist.

Definitions:

Grades of Evidence

I Evidence obtained from at least one properly designed randomized controlled trial.

II-1 Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis and management of female sexual dysfunction

Potential Harms
  • Androgen replacement (transdermal testosterone): The main risks associated with androgen replacement therapy in women are hirsutism, acne, virilization, and cardiovascular (CV) complications. In addition, a possible association with breast cancer has been reported.
  • Vaginal estrogen: Systemic absorption of vaginal estrogen is limited, but still a concern because serum levels of estrogen in a treated patient are higher than in the nontreated patient. The lowest effective dose should be used for the least amount of time to alleviate symptoms.

Qualifying Statements

Qualifying Statements

The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Foreign Language Translations
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Female sexual dysfunction. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2011 Apr. 12 p. (ACOG practice bulletin; no. 119).  [100 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2011 Apr
Guideline Developer(s)
American College of Obstetricians and Gynecologists - Medical Specialty Society
Source(s) of Funding

American College of Obstetricians and Gynecologists (ACOG)

Guideline Committee

Committee on Practice Bulletins - Gynecology

Composition of Group That Authored the Guideline

American College of Obstetricians and Gynecologists (ACOG) committees are created or abolished and their overall function defined by the Executive Board. Appointments are made for one year, with the understanding that such appointment may be continued for a total of three years. The majority of committee members are Fellows, but Junior Fellows also are eligible for appointment. Some committees may have representatives from other organizations when this is particularly appropriate to committee activities. The president elect appoints committee members annually.

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: None available

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site External Web Site Policy.

Availability of Companion Documents

A brief sexual symptom checklist for women is included in the original guideline document.

Patient Resources

The following are available:

  • When sex is painful. American College of Obstetricians and Gynecologists (ACOG); 2010. Electronic copies: Available from the ACOG Web site External Web Site Policy. Copies are also available in Spanish External Web Site Policy.
  • Your sexual health. American College of Obstetricians and Gynecologists (ACOG); 2010. Electronic copies: Available from the ACOG Web site External Web Site Policy. Copies are also available in Spanish External Web Site Policy.

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 4500, Kearneysville, WV 25430-4500; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on June 14, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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