What are the recommendations for the provider technique in treating female sexual dysfunction?

The PROVIDER Technique for Female Sexual Dysfunction

The PROVIDER technique is not a recognized clinical framework in the management of female sexual dysfunction; however, healthcare providers should initiate discussions about sexual health at diagnosis and reassess periodically throughout follow-up, using structured approaches like PLISSIT or ALLOW to facilitate conversations and guide treatment. 1, 2

Structured Communication Approaches

PLISSIT Model

The PLISSIT framework provides a tiered approach to addressing sexual concerns 2:

• Permission: Legitimize the topic by asking directly about sexual function, making it clear this is an appropriate medical concern 2
• Limited Information: Provide basic education about normal sexual response and how cancer/treatments affect sexual function 2
• Specific Suggestions: Offer targeted interventions based on the patient's specific symptoms (lubricants for dryness, exercises for arousal) 2
• Intensive Therapy: Refer to specialized sex therapists or counselors when basic interventions are insufficient 2

ALLOW Method

An alternative structured approach includes 2:

• Ask: Directly inquire about sexual concerns at each clinical encounter 2
• Legitimize: Normalize the discussion and validate the patient's concerns 2
• Limitations: Acknowledge your own scope of practice and when referral is needed 2
• Open up: Create space for the patient to discuss concerns without judgment 2
• Work together: Collaborate on a treatment plan that addresses the patient's priorities 2

Essential Assessment Components

Initial Screening Questions

Healthcare providers should assess specific domains 1, 3:

• Sexual desire: "Have you noticed changes in your interest in sexual activity?" 3
• Arousal: "Do you experience adequate lubrication and physical response during sexual activity?" 3
• Orgasm: "Have you had difficulty achieving orgasm or changes in orgasmic intensity?" 3
• Pain: "Do you experience pain, burning, or discomfort during sexual activity?" 1, 3
• Distress level: "How much does this concern you or affect your quality of life?" 3

Partner Involvement

Discussions should initially be held with the patient alone, with the option of later partner inclusion only if desired by the patient. 1 This protects patient autonomy while allowing for couples-based interventions when appropriate 1.

Cultural and Individual Considerations

Conversations must be congruent with 1:

• The patient's literacy level 1
• Cultural and religious beliefs 1
• Sexual orientation 1
• Relationship status (partnered vs. single) 1

Treatment Algorithm by Symptom Category

For Vaginal Dryness and Dyspareunia

First-line treatment consists of hormone-free water-based lubricants for sexual activity and daily vaginal moisturizers for maintenance. 4, 1

• Start with water-based lubricants during intercourse 4
• Add daily vaginal moisturizers for ongoing symptom management 4
• Consider silicone-based products if water-based options provide insufficient duration of relief 4
• If inadequate response after 2-4 weeks, add pelvic floor physical therapy 4
• Low-dose vaginal estrogen may be considered for postmenopausal women without hormone-sensitive cancers 1, 4

For Decreased Desire and Arousal

Psychosexual counseling (cognitive behavioral therapy or sex therapy) should be offered as first-line treatment, with consideration of flibanserin for premenopausal women with hypoactive sexual desire disorder. 1, 5, 3

• Initiate cognitive behavioral therapy focused on sexual desire 5, 3
• Screen for reversible factors: medications (especially SSRIs), depression, relationship issues, fatigue 5
• For premenopausal women with persistent hypoactive sexual desire disorder, flibanserin can result in approximately one additional satisfying sexual event every two months 5
• Important caveat: Flibanserin has not been evaluated in women with cancer history or those on endocrine therapy, and the risk/benefit ratio remains uncertain 1

For Orgasmic Disorders

Treatment focuses on education and therapy 3:

• Provide education about normal female sexual response and orgasmic variation 3
• Refer for sex therapy with focus on sensate exercises and self-exploration 3
• Encourage any form of regular sexual stimulation, including masturbation 1

For Body Image and Relationship Issues

Psychosocial counseling should be offered, with couples-based interventions when the patient is partnered and desires partner involvement. 1

• Assess for body image concerns early and throughout the cancer care continuum 1
• Offer individual counseling for body image distress 1
• When partnered and patient agrees, couples-based interventions are more effective than individual therapy alone 1
• Screen for preexisting depression, as these patients are at higher risk 1

Critical Pitfalls to Avoid

Common Provider Errors

• Failing to initiate the conversation: Sexual dysfunction will not be addressed if providers wait for patients to bring it up 1
• Prescribing hormonal therapies without considering cancer history: Estrogen-containing therapies are contraindicated in hormone-sensitive cancers 5
• Ignoring psychological and relationship factors: These are often primary contributors and must be addressed for effective treatment 5
• Using paroxetine or fluoxetine in breast cancer patients on tamoxifen: These SSRIs interfere with tamoxifen metabolism 1

Timing Considerations

Sexual health discussions should occur at multiple time points, not just once 1:

• At initial cancer diagnosis 1
• Before starting treatment 1
• During active treatment 1
• At transition to survivorship 1
• At routine follow-up visits 1

Referral Indications

Refer to specialized providers when 1, 4:

• Basic interventions fail after 2-4 weeks 4
• Significant relationship distress is present 1
• Complex psychological factors require intensive therapy 1
• Pelvic floor dysfunction requires physical therapy 4
• Hormonal management is needed in patients with cancer history 4