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Try out PMC Labs and tell us what you think. Learn More. Methods: Experts in sexual health compiled research and experience on the impediments to women receiving adequate assessment and treatment for their sexual health. Specific solutions and a roadmap for overcoming such barriers and improving patient—clinician communication are presented.

Moreover, midlife women are typically unaware or have misconceptions about conditions that may adversely impact their sexual life, such as genitourinary syndrome of menopause and hypoactive sexual desire disorder. Without understanding there may be underlying medical conditions, there is also a lack of awareness that safe and effective treatments are available. Lack of training, tools, time, and limited treatment options impede HCPs from providing women with necessary sexual health support.

More specifically, HCPs can be trained to initiate and maintain a sexual health conversation in a manner that is comfortable for women to convey sexual health needs and concerns, and for HCPs to correctly identify, diagnose, and treat the sexual problems of their female patients. Conclusions: Solutions exist to address the barriers currently impeding patient—clinician interactions around sexual health. The concept of sexual health has evolved ificantly since the definition offered by the World Health Organization in Although adult women of all ages can experience distressing sexual health-related conditions or concerns, women through the menopausal transition and beyond tend to experience these conditions with greater frequency.

These symptoms are often chronic, persisting through menopause, 10—12 and have the potential to interfere with a woman's sexual activity, intimate relationships, lifestyle, and self-esteem. Female sexual dysfunction FSDwhich refers to a of sexual dysfunctions e. A hallmark criteria for all FSDs is personal distress, 17 resulting in a reduced quality of life for affected women. For example, women with hypoactive sexual desire disorder HSDDthe most common FSD, report low scores on medically recognized instruments that measure quality of life including the SF and SF Health Surveys and the EQ-5D 1819 that are comparable in magnitude to people suffering from back pain or diabetes.

Gaps in care for these types of sexual health concerns occur for multiple reasons. Collectively, these issues often lead to inadequate sexual health outcomes for women. The purpose of this article was to explore key obstacles to better outcomes in women's sexual health and suggest a roadmap for developing solutions to these barriers. Figure 2 outlines major barriers and the possible solutions that will be discussed in this article. Patient-related and health care provider-related barriers aligned with potential solutions.

Based on cultural norms and biases, conversations about sex are sometimes thought of as taboo in American society and in many other cultures worldwide. This is especially true for women, and particularly when sex is for pleasure rather than reproductive purposes. Failure to have informative discussions about sex often le to misperceptions about sex and sexuality, including a sense that pain or lack of interest in sexual activity is inevitable and nonmodifiable, which can also lead to women not seeking the care they need.

In addition, women sometimes assume that older people do not, or should not, engage in sexual activity. For many older individuals, sexuality is still important despite age-related difficulties such as erectile dysfunction ED or limited mobility, and for such couples, sexual activity may include other forms of intimacy or masturbation.

Several U. negative experiences discussing sexual health with a clinician or concerns about how an HCP may react to the conversation often deter women from raising sexual health topics. Many fear that their concerns will be dismissed or considered unimportant. Women in internationally conducted focus groups reported that when they broached the subject of sexual health symptoms, their HCPs tended to display a lack of sensitivity to these symptoms affecting their quality of life.

Women may also wrongfully fear they are alone in experiencing these kinds of symptoms or that their HCPs will view them and their sexual health concerns as unimportant. Women may also be concerned that there is not enough time during their appointment to address such a sensitive and multifaceted topic. Although some women would like to discuss their sexual health with their HCP, they may not know how to bring up the subject or may be unsure of which clinician they should discuss it with. Women want hot sex Level Plains may also be unsure of how to articulate their symptoms and may downplay the extent of their symptoms if they are uncomfortable discussing them.

Numerous surveys highlight that women tend to expect their HCPs to initiate dialog around sexual health. Some HCPs do not initiate the conversation on sexual health because of a lack of confidence, personal discomfort, or a sense of discomfort on the part of the patient.

HCPs have self-reported on the frequency with which they discuss sexual health with patients. Women often do not think of their sexual health concerns as a medical condition, which may be a reason why they do not raise the subject with their HCPs. In particular, many women do not recognize GSM as a common consequence of menopause, especially because symptoms, including vaginal dryness and dyspareunia, often do not present until several years after they stopped experiencing menstrual cycles.

Instead, many women view GSM symptoms as an inevitable part of the aging process, rather than a medical condition amenable to treatment. Many women remain unaware that GSM symptoms, including dyspareunia, may be because of menopause, 814242634 and the associated decreased levels of estrogens Women want hot sex Level Plains other sex steroids.

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Similarly, surveys of participants in an HSDD registry found the most frequent reason women suffering from HSDD did not seek medical help was because they believed the symptoms were just a Women want hot sex Level Plains part of aging or being in a long-term relationship. Lack of women's awareness of the availability of effective treatments for sexual health conditions also creates barriers. Despite the decades-long availability of effective vaginal estrogen therapies to treat GSM, the Women's EMPOWER survey found approximately two-thirds of participants were only somewhat familiar to unaware of effective treatments for their symptoms.

As with patients, many HCPs also remain unaware of available and approved treatment options; and some HCPs may even believe that certain sexual health conditions are not real medical conditions, are not within their purview, or are exaggerated by pharmaceutical companies. When women are aware of the availability of vaginal hormone therapy, including estrogens and prasterone a synthetic form of dehydroepiandrosterone or DHEAfor treatment of GSM, they frequently have concerns about safety.

The North American Menopause Society NAMS and others have advocated for modification of labeling for low-dose vaginal estrogens based upon the minimal systemic exposure with blood levels remaining within the normal postmenopausal range and without increased risk of heart disease, stroke, blood clots, or probable dementia. As a result, HCPs may find it challenging to overcome this negative perception when counseling their patients on low-dose vaginal treatment options.

Women may also receive inaccurate information about the efficacy of treatments marketed to address sexual health conditions. Unfortunately, the popularization of claims about unproven treatments is prevalent, as are negative perceptions about effective treatments. Most HCPs, including physicians, physician assistants, nurse practitioners, and nurses, receive limited formal sexual health training.

Although sexual medicine has grown substantially in the past 20 years, aspects of training continue to lag behind scientific and clinical knowledge in the field. Despite the fact that medical society guidelines and associated tools exist for screening common sexual health conditions like HSDD, HCPs may be unfamiliar with them or may fail to use them for patient diagnosis.

Office-visit time constraints may contribute to HCP hesitating to raise sexual health concerns, especially if they have not received training and tools to help conduct these conversations in an efficient manner. In addition, clinicians may feel they have limited therapeutic options to use to treat certain sexual health conditions. Kingsberg et al. Although the indicated population for flibanserin in HSDD is currently limited to premenopausal women only, data showed that flibanserin improved sexual function in postmenopausal women with HSDD.

Considerable public debate has ensued over a perceived gender disparity in sexual health drug development, as there have been approved treatments for men with ED for 20 years. This may be because of differences in the underlying etiologies of these conditions, the additional regulatory burden of evaluating separately pre- and postmenopausal women, or some combination thereof.

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Regardless, the advent of safe, effective treatment options for men suffering from ED, coupled with frequent direct-to-consumer advertising, has largely moved a ly stigmatized condition into open and acceptable dialog, with men now comfortable vocalizing their sexual health needs to their HCPs and HCPs feeling equipped with therapeutic options to address the concern.

Cost is a consideration for any treatment, particularly if managed care organizations and other gatekeepers of health care dollars deprioritize the relative importance of a therapeutic area, as is often the case with female sexual health.

Clinicians may be reluctant to prescribe effective treatments if they suspect the cost to the patient at the pharmacy may be higher than she is willing or able to pay. Moreover, given their patients' numerous and varied insurance benefits, HCPs may find it difficult to know offhand which treatments are covered by which insurance plans. Cost may also be a barrier for referrals to other clinicians for counseling and cognitive-behavior therapy for treating sexual dysfunction. Relatedly, reimbursement of treatments for women's sexual health-related conditions is often lacking.

The necessity of a boxed warning for safety, currently required as part of the label for low-dose, vaginal estrogen-containing therapies to treat GSM, is a further obstacle that has been called into question by gynecologic HCPs in recent years. However, boxed warnings remain for all vaginal estrogen therapies.

This REMS requires prescribers to become certified to prescribe and pharmacists to dispensewhich has limited access for women. In addition, the recent approval of flibanserin in Canada does not have an alcohol intake restriction as it does in the United States.

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The FDA should maintain warnings and restrictions on such medications that are based on objective criteria and not hold medications for sexual dysfunction to a different standard. As outlined ly, barriers to optimal sexual health outcomes for women are numerous, complex, and often interrelated.

We recognize some problems are more solvable than others. Although we support efforts to address all obstacles, a necessary and achievable first step is to foster more open and informed dialog about sexual health between women and their HCPs. This simple but critical measure will improve women's health outcomes 4849 and can be accomplished in the near future.

Therefore, the specific recommendations of this article address strategies to enable better HCP—patient communication with a focus on skills training for professionals and patient education and empowerment programs Fig. We believe that several barriers need to be addressed with such training and education. All HCPs physicians, nurse practitioners, physician assistants, mental health professionals, nurses, etc. More specifically, HCP training should focus on integrating knowledge about sexual health with skills for counseling patients and shared decision-making based on individual needs and goals.

Despite the ever-growing competition for time with exponential growth in knowledge to be learned, advocacy efforts must be expanded to protect sexual health content and communication skills in core curricula. Further training or in some cases, even initial training can occur in residency or other postgraduate training. HCPs already in clinical practice who need basic training or are interested in enhanced training in female sexual medicine can seek out CME programs on sexual health education. Such best practices can be accomplished in almost any office visit setting.

HCPs can first legitimize the importance of assessing sexual function and normalize the discussion by including it as part of the routine medical history. One suggestion to put patients at ease may be to mention at the outset that many patients have sexual health concerns or symptoms, providing an opening for them to ask if the patient has similar concerns.

In addition, open-ended inquiries give patients permission to talk about their sexual concerns. Routine discussion of sexual health allows HCPs to reassure women that some feelings and symptoms are common and legitimate.

Any problems related to sexual response, including desire, arousal, orgasm, and pain can be explored, along with potential treatment options. This is an efficient model for HCPs to simultaneously educate women about normal sexual response and assess for problems with desire, arousal, orgasm, or pain.

Essential clinical competencies for communication about sexual health concerns include the ability to initiate a direct and concise conversation about sexual health in a space that ensures privacy and comfort. For example, the HCP and patient should both be seated face-to-face Women want hot sex Level Plains the patient clothed.

The HCP should complete a brief sexual health history, discuss any concerns, and close the conversation with shared decision-making and a suggestion for a follow-up appointment to further assess and treat. Alternatively, the HCP can provide a referral to a sexual medicine expert or sex therapist who can address more complex concerns. The International Urogynecological Association IUGA and International Continence Society ICS stress that sexual concerns should be addressed routinely and in a recent report suggested an educational process similar to the above to be used in women with pelvic floor dysfunction, given that most pelvic floor dysfunctions are believed to negatively affect sexual health.

Appropriate sexual health referrals could apply to HCPs in any specialty area. For example, a neurologist treating a patient with multiple sclerosis could discuss sexual health with her patients, and if lacking in expertise, be able to provide them with some appropriate HCP Women want hot sex Level Plains.

Professional associations could help HCPs direct women to sexual health specialists by having a mechanism for HCPs to identify appropriate professionals by location and areas of expertise. Increasing HCPs' familiarity with appropriate International Classification of Diseases ICD codes for FSDs Table 3 will help address the barrier to care caused by HCPs avoidance of assessing sexual concerns because of lack of awareness that there are corresponding billing codes they can easily use for ensuring insurance coverage and payment of visits and treatments for patients with sexual health-related concerns.

HCPs in the clinical setting should consider correlating symptom codes, which may be more appropriate when patients present with symptoms of FSD, before an actual diagnosis is made. Various other codes may also be considered to support the diagnostic workup of FSD and referral to pelvic floor physical therapy.

The known causal condition of any symptom should be coded first, followed by any associated symptoms of the condition. For example, low libido because of pain with intercourse would be coded first by pain with intercourse and then for low libido Table 3.

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