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Biologic Negative reproductive events (unwanted pregnancies, abortion, traumatic delivery with damage of the pelvic oor, child problems, infertility) Postpartum depression Vulvovaginitis/sexually transmitted diseases Sexual pain disorders Age at menopause Premature ovarian failure (POF) menopause before age 40 Premature menopause menopause between age 40 and 45 Biologic vs surgical menopause (especially for premature menopause) Surgical menopause Androgen (besides estrogen) loss Associated disorder/disease Extent and severity of menopausal symptoms and impact on well-being Current disorders Current pharmacologic treatment Substance abuse (mainly alcohol and opiates) Psychosexual Loss of loving feelings toward partner Unpleasant/humiliating sexual encounters or experiences Affective and anxiety disorders Relationship of fertility loss to ful llment of life goals Contextual Relationship discord Life-stage stressors (eg child s diseases, divorce, separation, partner in delity) Loss or death of close friends or family members Lack of access to medical/psychosocial treatment and facilities Economic dif culties Modi ed from Graziottin (2005) [75]

Corporation (limited company)

532 533 537

Sexual distress should be distinguished from nonsexual distress and from depression The degree of reported distress may have implications for the woman s motivation for therapy and for prognosis

538 539 542

potential medical factors, endocrinologic, vascular, dysmetabolic, neurologic, neuroimmunologic or iatrogenic factors, as well as the neglected role of pelvic oor disorders in contributing to and maintaining FSD, is essential to avoid both a systematic medical omission and a gender bias [1 7,12,17,72 76] What to look for while examining the patient and the key potential ndings and associated co-morbidities

A corporation is a business that operates as a legal entity separate from its owner or owners Corporations are registered in a provincial or federal registry and must file annual reports, submit tax returns, and pay taxes The shareholders who own the company aren t personally liable for the company s debts unless they have signed a personal guarantee Corporations may have one or more shareholders, who typically enter a shareholders agreement setting forth the conditions of their involvement They also elect directors who manage the corporation on a day-to-day basis

550 550 551

Biologic Diagnostic omissions: unaddressed predisposing/precipitating biologic etiologies Untreated or inadequately treated co-morbidities: Physical: pelvic oor disorders Urologic: incontinence, lower urinary tract symptoms, urogenital prolapse Proctologic: constipation, rhagades Metabolic: diabetes Psychiatric: depression, anxiety, phobias Pharmacologic treatments Substance abuse Multisystemic changes associated with chronic disease or secondary to menopause Hormonal Vascular Muscular Neurologic Immunologic Contraindications to hormone therapy (HT) Inadequacy of HT in ameliorating menopause-associated biologic symptoms Psychosexual Low or loss of sexual self-con dence Performance anxiety Distress (personal, emotional, occupational, sexual) Diminished affection for, or attraction to, partner Unaddressed affective disorders (depression and/or anxiety) Negative perception of menopause-associated changes Body image concerns and increased body changes (wrinkles, body shape/weight, muscle tone) Contextual Omission of FSD investigation from provider s diagnostic and therapeutic approach Lack of access to adequate care Partner s general health or sexual problems or concerns Ongoing interpersonal con ict (with partner or others) Environmental constraints (lack of privacy, lack of time) Modi ed from Graziottin (2005) [75]

552 552 553

will be detailed in each subchapter related to women s sexual problems In addition, there is information concerning addressing FSD in both s 26 and 27

555 561

.

An interdisciplinary team is a valuable resource for a patient-centered approach, both for diagnostic accuracy and tailored treatment Disciplines that may take part in such a team of professional gures, or be available for referral, include medical sexologist, gynecologist, urologist, psychiatrist, endocrinologist, psychologist, anethesiologist, neurologist, proctologist, dermatologist, psychotherapist (individual and couple), sex therapist, and physical therapist This latter professional is emerging as a key resource in addressing pelvic oor disorders Clearly not all are needed in any team or for a particular consultation