While a number of medical conditions are known to have an effect on sexual health and menopause, taboo topics in women’s health can potentially delay them from receiving necessary care. “It's nice sitting down with the patient, eye to eye and talking to her and getting a history,” Lauren Streicher, MD said. “It's all about asking the right question and then depending on not only the answer but the body language. The look on her face is just as important as the words that are coming out of her mouth.” Clinicians from all specialties should know how to ask their patients about sexual medicine-related symptoms and concerns so that the appropriate referrals for further treatment can be made and quality of life improved.
Dr. Streicher is a clinical professor of ob/gyn at Northwestern University Feinberg School of Medicine and the founder of the Center for Sexual Medicine and Menopause. She has seen firsthand how asking patients about their sexual health and providing referrals to treat often overlooked or invalidated symptoms can transform their clinical care. She found her way to postmenopause and sexual medicine work after noticing a paucity of information available to patients experiencing symptoms.
Dr. Streicher realized that she could have a bigger impact helping the desperate women who came seeking help for dyspareunia, dryness, hot flashes, lack of sensation, and inability to orgasm, as well as raising clinician’s awareness of sexual medicine.
“I was doing so many hysterectomies on women who became menopausal as a result of surgery or having their ovaries removed,” Dr. Streicher shared. “I really felt that they weren't getting the information they needed in terms of how to manage menopause.” She decided that there were plenty of physicians who were capable of performing hysterectomies, and she wanted to pursue a greater impact. Dr. Streicher has since gone on to publish a number of books and research studies, as well as produce a podcast, surrounding women’s health topics.
At the Center of Sexual Medicine, which she founded, clinicians saw a diverse background of medical conditions. “We saw cancer patients, women with diabetes, women with heart disease,” Dr. Streicher said. “We were getting a lot of referrals, particularly from oncology. Every specialty should know how to ask about sexual health because there are many medical conditions that impact sexual medicine and are impacted by menopause.”
In order to fully treat patients and get them the sexual medicine referrals they need, clinicians must know the right questions to ask. The standard question a clinician asks while taking a brief sexual history is usually, “Are you sexually active?” Dr. Streicher argued that clinicians should not ask their patients this question at all.
“You should never ask a patient if they're sexually active because they don’t understand why you're asking,” she said. “If a patient doesn’t understand why they’re being asked a question they may not know how to best answer it or what information is relevant.” The patient may even have a different interpretation of “sexually active” than the one the clinician is using. Per Dr. Streicher, patients may ask themselves: “‘Does that mean anal sex? Does it mean oral sex? Does it mean, was I sexually active today? What about the fact that I broke up with my partner a week ago? What if my partner is [also] a woman?’”
In addition, Dr. Streicher believes that the question, “How many sexual partners do you have?” can be problematic. “When you ask someone about STI screening you don't ask them how many partners they've had,” she said. “It’s irrelevant. [What matters is] whether she has a concern that she might have been exposed to an STI. Asking how many partners she has doesn't decide whether she's at risk or not.” This standard sexual inquiry leaves too much room for misinterpretation; instead, she suggested asking patients specific questions that are inclusive and having clear motives for why they are being asked.
There are three questions every clinician should ask their patients in order to assess the need for a referral for further care in sexual medicine, according to Dr. Streicher: First, “Do you have a need for contraception?” Second, “Would you like me to do an STI screening? And if so, of your mouth, your vagina and/or your anus?” Third, “Do you have any sexual concerns including sexual activity, an inability to have an orgasm, or low libido?”
Once clinicians ask those questions, Dr. Streicher advised providing questionnaires to patients followed by one-on-one meetings to go over their history. “We have a very long questionnaire that women would get prior to their visit and then our amazing NPs would sit down and go through the whole questionnaire and write a summary of what was going on,” she said. According to a recent study published in “Menopause,” “Health care clinicians should broach the topic of dyspareunia with their patients using oral or written questionnaires. In addition to a thorough medical history and physical examination, various tools can be used as further assessments, including vaginal pH, vaginal dilators, imaging, vulvar biopsy, vulvoscopy and photography, the cotton swab test, sexually transmitted infection screening, and vaginitis testing.”
An integral part of the questionnaire is giving the patient the opportunity to correct or further clarify the clinician’s interpretation of their health experience. After the questionnaire the NPs would schedule video meetings to go over their summary with the patient. This gives the patient an opportunity to review the summary meeting with the physician, who would be briefed beforehand. Dr. Schreider recalled that many women were emotional after these meetings with the NPs, making it clear that many of the women coming in for help had not felt like they had been listened to or had their symptoms taken seriously in the past.
While asking these questions gives clinicians an opportunity to learn more about their patient’s health experience, Dr. Streicher emphasized the importance of remembering that the environment and presence of others can affect patients’ desire or ability to disclose helpful information. Clinicians should consider the implicit bias that may affect which patients are assumed to be sexually active. Despite the two-fold increase in STI rates among the elderly, clinicians often overlook the sexual aspect of their health, according to Dr. Streicher. “Clinicians ask married, heterosexual, young women,” she said. “They are not asking 60 year olds or 70 year olds who are single. They only ask ‘healthy’ people because we may assume people who have arthritis, heart disease, or cancer are not interested in sex.”
The clinical encounter can be heavily impacted by the presence of other people in the room while a sexual history is being taken. Many physicians have scribes, medical students, or residents who accompany them to patient visits, which may impact how a woman answers questions, what her comfort level is, and her body language. “Look at body language, if you ask a question and she's kind of looking around, consider who else is in the room that she's not comfortable talking in front of,” Dr. Streicher said. Patients may also come in with someone who makes the environment unsuitable for retaining an accurate sexual history. “We see this with the young cancer patients as well,” she continued. “Their mothers are like velcro to their sides, and you’re like, ‘How do we get mom to leave the room so I can ask you about your sex life?’ Then there’s [the] population of women who are very often accompanied by someone and they don't feel safe.”
Dr. Streicher emphasized that every specialty should be asking their patients about their sexual health because most medical conditions impact sexual health and/or are impacted by menopause. “Many older women experience diabetes,” she said. “With diabetics, most endocrinologists know foot neuropathy. But what about clitoral neuropathy? The rate of inability to have an orgasm in diabetic women is high because the same little nerves that cause foot neuropathy are also in the clitoris, and they're the first to go in diabetics. A diabetic patient that used to be able to use a vibrator before, suddenly has nothing working for them and they don't know what to do because their endocrinologist has not asked them about their ability to have an orgasm.”
As Dr. Streicher sees it, sexual medicine isn’t just about asking the right questions, but how clinicians ask the questions and whether they take the time to make sure the patient feels comfortable and safe enough to share information that could impact diagnosis and treatment. “There's not one single specialty that doesn't need to know this information,” she said. “I was seeing my ophthalmologist and she said, ’Well, at least we don't have to worry about this.’ I asked, ‘Do you see diabetics?’ She replied yes. I told her they have retinopathy, and the same ones that have retinopathy are usually the same ones that can't have an orgasm. When you diagnose retinopathy you should be asking, ‘Can you have an orgasm?’ They looked at me like I was a crazy person. But the point is, it touches every single specialty.”