1. Gevirtz, Clifford MD, MPH

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MANY PATIENTS WITH chronic pain consider their pain symptoms to be the major obstacle to enjoying sex with their partner. Because of this-and because of endocrine changes that occur over time secondary to medication-taking a sexual history is important when you assess a patient with chronic pain. Here's what you need to know.


Taking a sexual history

Establish rapport with your patient before taking a sexual history to encourage an accurate and detailed account. A good sexual history should include information about:


* the problem as described by the patient


* the patient's marital status


* the number of previous sexual partners


* the identity of the current partner or partners and duration of the relationship


* the number of children, and whether any live with the patient


* any stress the family is under, including financial stress.



Also assess her pain in relation to sexual activity. For example, does she have dyspareunia (painful intercourse), and if so, does the pain start before, during, or after intercourse? Does the situation or position prompt the pain, or does it occur randomly? Where is it located and what is its quality? Is it accompanied by other sexual dysfunction, such as insufficient lubrication?


Also explore the patient's medical history-for example, a woman's obstetric history. Document the patient's history of abdominal surgery, radiation therapy, sexually transmitted disease, or dermatologic disorders such as eczema.


The link between pain medications and sexual dysfunction can remain unrecognized unless health care providers specifically review sexual issues with patients. Many commonly prescribed pain medications produce adverse reactions that interfere with sexual functioning. For example, antidepressants, nonsteroidal anti-inflammatory drugs (NSAIDs), antispasmodics, opioids, benzodiazepines, and chlorpromazine can cause erectile dysfunction and orgasmic dysfunction. Antidepressants, opioids, benzodiazepines, and chlorpromazine also can decrease the sex drive. Chlorpromazine can cause priapism (painful erection lasting more than 4 hours).


Several medications for pain, when taken chronically, may affect various endocrine systems. Chronic opioid use, for example, can lead to hypogonadism, leading to decreased sexual functioning, changes in thyroid function (which may lead to weight changes), and changes in hormonal responses to stress.


How to intervene

Therapeutic interventions for patients with chronic pain and sexual dysfunction include sex therapy, medications, topical preparations, and alternate positions that reduce or eliminate pain.


* Positions. Some sexual positions can exacerbate lower back pain, for example, from spinal stenosis. Advise the patient to try other positions or the relatively weightless environment of a pool or hot tub.


* Lubrication. A patient with significant autonomic or hormonal dysfunction may benefit from using a personal topical lubricant. Estrogen supplementation is controversial because of the increased risk of cardiovascular events and a possible link to increased breast cancer risk.


* Erectile dysfunction drugs. A male patient taking pain medications that interfere with erection may find a trial of PDE-5 inhibitors (such as sildenafil, vardenafil, or tadalafil) helpful, unless contraindicated. If his health care provider isn't familiar with prescribing these drugs, he may suggest a consultation with a specialist.


* Sex therapy. If you don't feel comfortable discussing sexual issues with your patient, or he needs additional help, seek a formal sex therapy consult. A listing of credentialed sex therapists is available at the American Association of Sexuality Educators, Counselors, and Therapists' Web site at Depending on the patient's condition, a consult with a urologist or gynecologist may be indicated.



Many patients are uncomfortable broaching sexual topics, so health care professionals should take the initiative to assess for problems. Be aware that sexual dysfunction is linked to many chronic conditions and pain medications, and encourage your patient to seek help as indicated. The days of suffering in silence need to be retired.




Daniell HW. Hypogonadism in men consuming sustained-action oral opioids. Journal of Pain. 3(5):377-384, October 2002.


George S, et al. Review of neuroendocrine correlates of chronic opiate misuse: Dysfunctions and pathophysiological mechanisms. Addictive Disorders and Their Treatment. 4(3):99-109, September 2005.


Gevirtz C. The impact of chronic pain on sexuality. Topics in Pain Management. 23(1):1-5, August 2007.