指南速递 | 2019 ACOG实践简报：女性性功能障碍（No.213）（上）

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译者：谭晓伟 烟台毓璜顶医院

审校：徐晖 山东大学第二医院

女性性功能障碍

女性性功能障碍的情况是多方面的，主要是对以下一种或多种方面感到痛苦：性欲望、性冲动、性高潮或性交疼痛(1)。尽管女性性功能障碍的问题相对比较普遍，但是女性不太可能与他们的卫生保健提供者主动讨论这个问题,除非被刻意问到(2)，许多卫生保健提供者因为种种原因也不愿意问这个问题，比如其对性功能障碍患者的诊断与管理缺乏足够的知识和培训，处理问题的临床时间不充足 ，低估了性功能障碍的普遍性。本文的目的是对女性性功能障碍进行综述，概述最新的诊断标准，并根据现有的有效证据讨论目前推荐的管理策略。

背景

大约有43%的美国妇女曾报告自己在性方面存在问题，有12%的人因性功能障碍导致的个人痛苦而感到很烦恼 (3)。女性性功能障碍的发病率从中年阶段开始增加，在18至44岁年龄段的女性当中大约有10%存在性困扰， 45至64岁年龄段的女性存在性困扰问题的比例达到15% 的峰值，然后在老年阶段又下降，在65至85岁年龄段的老年女性中，性功能障碍的发病率下降到9%左右(3)。表框1列出了一些更常见的性功能障碍的病因和危险因素。

正常性反应

对于女性正常性反应的最初研究倾向于线性模型(4-6)。而更现代女性性反应模型是非线性的，包括女性性反应原始四个阶段以及其他阶段的各种序列 (图1)(7)。今天，我们把中枢神经内分泌系统通过调整性兴奋和性抑制因素之间平衡来调节女性性反应的过程描述为动态的过程  (8)。

雌激素在女性性生理(包括维持生殖器官组织的敏感性、弹性、分泌物、pH值和微生物菌群)、排尿节律、盆底肌张力和关节活动方面起着关键作用(8,12)。外周血雌激素随着女性的衰老自然减少，也会因手术或药物所致雌激素减少导致更年期的到来，雌激素的这些变化会对女性性功能产生多种多样的影响(7,12)。

女性的雄激素水平在20多岁时达到顶峰，在育龄期早期(直到30多岁)急剧下降，在60岁左右趋于稳定，自60岁以后不再进一步的下降(13-15)。睾酮在调节女性性欲和性功能方面的作用尚不清楚。虽然有证据表明短期应用经皮吸收睾酮药物对性欲低下的绝经后妇女有益，但是并没有特定的雄激素或雄激素前体血清水平或下限值可作为女性性功能减退的诊断标准(16-18)。

性功能障碍的类型

美国精神病学协会的《精神障碍诊断与统计学手册(第五版)》(DSM-5)确定了四种特定类型的女性性功能障碍(1)(表框1)。此外，DSM-5还将性功能障碍分为“其他特定性功能障碍”和“非特定性功能障碍”。

女性性欲和觉醒障碍

女性性欲觉醒障碍是一种新的分类，它取代了DSM-IV术语中的性欲减退和女性性觉醒障碍。(在本文件中，性欲减退仅用于描述使用DSM-IV-TR标准考量的一种条件或结果的研究。)性欲和性唤起的波动可能会伴随女性一生，这些波动由一些个人的 或性伴侣因素引起，但是常常会被忽略。这些因素包括睡眠模式的改变或长期睡眠质量下降，压力，身体外貌、身材或体重的变化，妊娠，哺乳，久坐不动的生活方式，酗酒或其他药物滥用，人际关系因素等(19-26)。许多女性说她们缺乏性欲望或性冲动，意味着她们已经失去了对性的生理渴望。她们描述了性的问题，但是他们考虑的是如何避免性行为，或者是如何通过性行为来维持一段感情或者是通过性来满足其伴侣的需求 (27)。女性还描述了一种痛苦，就是她们虽然对性没有兴趣，但是当其性伴侣开始有性活动时，她们也能被唤醒 (27)。

虽然女性的性兴趣和性唤起障碍问题可以在没有诊断出的并发病的情况下发生，但新的并发病可能是未被诊断或亚临床条件下的一个指标，甚至在年轻女性群体中也是如此(28)。药物治疗，特别是选择性血清素再摄取抑制剂(SSRIs)，通常与性唤起相关(框1)(29)。

期待欲望、生理唤醒、主观唤醒、性唤醒及欲望响应、回报（身体或心理满足）、性动机、主观自愿、性刺激及环境、大脑处理信息。

框1所示。女性的性反应。循环的性反应周期呈现出重叠的变阶式阶段。性动机有很多，性欲可能在一开始就存在，也可能不存在，但在大脑将性信号处理为性唤醒(与性欲合并)之后便产生了性动机。后者进一步增强性冲动，允许接受逐渐强烈的性刺激。

(Basson R. Sexuality and sexual disorders. Clin Update Womens Health Care 2014;XIII(2);1–108. Available at:https://www.clinicalupdates.org/viewissue.cfm?
issue5cuwhc-v13n2. Retrieved February 22,2019.)

*当女性存在性功能障碍时，只要排除无性的精神疾病、性伴侣痛苦关系（比如性伴侣暴力）、化学物质、药物及其他医学治疗引起的性功能障碍就可诊断为性功能障碍疾病。

性功能障碍无法用一种独立的性功能障碍疾病来诠释。有证据表明，非化学物质/药物引起的性功能障碍，应包括有独立的性功能障碍病史，在应用化学物质或药物治疗前就存在症状，在急性戒断或严重中毒终止后症状至少持续一个月。

Data from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington (VA): APA;2013.

女性性高潮障碍

女性性高潮障碍的定义为明显的性高潮时间延迟、性高潮稀发、无性高潮或明显的高潮快感强度降低(1)。原发性性高潮障碍的女性通常有正常的性欲水平(27)。大多数性高潮障碍患者是获得性的，与新开始的医学治疗、解剖学异常、伴侣关系不和谐、个人行为改变、以及心理状况相关 (表框1)，通常表现为性欲及性觉醒障碍、生殖器盆腔痛及阴道插入障碍症状并存 (1)。在个别罕见案例当中，获得性高潮障碍可能是由潜在神经系统疾病、生殖器或盆底手术相关损伤、放疗或药物治疗引起 (1 7)。尽管研究资料非常有限,但是接受过生殖器官切除手术的女性可能有终生性高潮障碍或获得性性高潮障碍，且她们患性功能障碍的风险更高(30)。

生殖器盆腔痛和阴道插入障碍

阴道痉挛和性交困难现在已并入生殖器-盆腔疼痛和阴道插入障碍。这种障碍可能是终生的，也可能是后天获得性的。生殖器-盆腔疼痛和阴道插入障碍包括以下一种或多种症状：阴道肌肉紧缩，接受插入的能力降低或根本无法接受阴茎插入；性伴侣尝试插入阴道时女性会感到紧张、疼痛或灼烧感；性交的欲望减少或没有性交欲望；逃避性行为；对疼痛的强烈恐惧与害怕 (1)。生殖器-盆腔疼痛和阴道插入障碍的症状常常同时出现，多是由重叠的医学、环境和心理社会原因一起导致的，解除这些病因后，疼痛或阴道插入障碍症状便可得到缓解 (31,32)。需要注意的是，即便患者的性行为不包括性交，只要她们存在性功能相关疼痛，那么她们仍然可能患有这种疾病。

化学物质或药物因素所致性功能障碍

化学物质或药物引起的性功能障碍是临床上一种重要的性功能障碍，多发生于服用某种药物时，或服药后不久，或停服某种药物时。这些化学物质或药物很容易被认为有引起性功能障碍的作用 (1)。与其他类型的女性性功能障碍相比,这种性功能障碍的诊断要求病人有相关的痛苦经历。抗胆碱能药物、激素药物、心血管病药物和精神病药物可能与女性性功能障碍有关(24)。酒精、大麻和麻醉剂也可能导致女性性功能障碍。

其他特定或非特定性功能障碍

病人表现出性功能障碍的痛苦症状，但是又不符合已经定义的性功能障碍的分类标准，这种性功能障碍可以诊断为其他特定或非特定性功能障碍 (1)。其他特定性功能障碍和其他非特定性功能障碍之间主要区别是临床医生确定引起患者所描述症状的病因不符合其他性功能障碍分类标准。

妊娠相关性功能障碍

任何类型的孕期性功能障碍都是产后性功能障碍的一个关键风险因素。剖宫产、器械助产、会阴切开术和会阴撕裂引起的创伤也会增加发生产后生殖器-盆腔痛和阴道插入障碍疾病的风险，并与性欲和性觉醒功能障碍存在相关性 (33-36)。母乳喂养还会导致阴道干燥，从而出现生殖器-盆腔疼痛/阴道插入障碍的症状。女性产后面临许多问题，比如长期睡眠紊乱，母亲角色改变，家庭关系问题，新生儿健康问题，亲子关系社会心理调整(对女性和她的伴侣)，产后身体改变。这些女性产后问题与产科分娩相关因素相比，产科因素似乎是产后女性性功能障碍更重要的驱动因素 (35)。产后抑郁症除了与性欲减退和性生活频率降低有关外(37)，还可能有潜在的严重健康风险，需要早发现并及时干预 (38)。家庭暴力在怀孕期间可能升级，对妇女及其新生儿的整体健康和幸福构成严重威胁，并与产后性功能障碍有关(39)。产后女性性功能障碍的评估和管理类似于非产后女性性功能障碍的评估、管理和治疗，只是进行了一些修改，以避免应用哺乳期禁用的医学治疗。

更年期相关性功能障碍

2014年，根据美国女性性健康与北美更年期协会的研究，国际学会提出绝经后泌尿生殖系统综合征的术语，这一术语不但描绘了阴道萎缩，同时还包含了全部生殖系统改变、性功能障碍症状及泌尿系统症状，这些症状均与更年期发生的外周血雌激素及其他类固醇激素水平下降有关 (12)。典型症状包括令人烦恼的阴道干涩、灼烧和刺激感；性交时阴道润滑性降低及性交疼痛；尿急、排尿困难和复发性尿路感染 (12)。据估计，高达50%的更年期妇女受到更年期泌尿生殖系统综合征相关症状的影响(40,41)，在育龄期，更年期泌尿生殖系统综合征也可能发生，比如低雌激素状态(如产后)或使用芳香化酶抑制剂等抗激素药物期间(42,43)。

临床思考与建议

如何进行女性性功能障碍筛查？

妇产科医生应在日常对病人进行诊疗与随访期间就开始对性功能进行临床讨论，以确定可能需要进一步探讨的问题，并帮助消除患者对讨论性功能问题的偏见(44-46)。在患者入院时让其填写简短的性功能自查表，例如使用患者报告的结果测量信息系统研究框架（47）开发的经过验证的单项选择题，可能有助于促进对性功能的临床讨论。在日常卫生保健访谈中介绍性功能的另一种方法是使用一种宽泛的陈述模式，目的是使问题正常化，然后是一个封闭式问题和一个开放式问题(48)。例如，“许多女性都经历过对性的担忧，你在性方面有什么问题吗(是/否)? 你在担心什么?”提出这个话题的另一种方式是在日常的聚会中提出宽泛的、开放式的问题。如果发现了性方面的问题，建议进行后续评估。

对于可能存在性功能障碍的妇女，我们应该如何初步处理？

对女性性功能障碍患者的初步评估可能需要较长时间的随访，并应包括综合病史采集(45、46、49、51)和体格检查，以评估可能的妇科病因。在最初评估女性性功能障碍时，通常不需要实验室检测，除非怀疑有未诊断的医学病因。

全面的病史采集

详细的性生活史应包括病人的性生活和性别认同问题；性功能障碍症状的性质、持续时间和发病时间；个人对症状有怎样的苦恼；自我保健情况、自我用药情况或其他接受过哪些减轻症状的治疗；性伴侣因素，包括目前的性伴侣数量以及他们的性生活情况、身体健康问题和性功能问题；与性伴侣的关系是否融洽，包括病人的性问题；既往和现在所遭受的虐待或暴力(44,52)；可能影响生殖器-盆腔部位的个人体力劳动、损伤(如跨骑伤或尾骨伤)和生活习惯(如个人卫生和久坐)；睡眠质量；个人身体变化或形象问题(如乳房切除术、造瘘术后或妊娠)(49,51)。同样，糟糕的伴侣关系和伴侣性功能障碍也应该得到认知和解决。由于一种性功能障碍可能引发另一种性问题 (例如，疼痛可能导致性欲丧失)，应评估现症情况以及症状未来的发展情况。了解处方药和非处方药物和化学物质的使用情况。在科研领域，我们已经有了各种有效的自我报告问卷来评估有性功能障碍症状女性的性功能，这些问卷也可能用来帮助进行临床访谈和性生活史采集 (53)。例如女性性功能指数(54)和女性性困扰量表(55)。

体格检查

一般来说，妇科检查的重点是在病史采集时已经确定的重点部位，可以帮助我们评估可能导致或促成性功能障碍的原发性妇科疾病 (56)。正在接受女性性功能障碍检查的妇女可能会受益于有机会在镜子的帮助下查看和参与检查。对其进行简短的生殖器官教育,包括观看生殖器官插图，识别阴蒂，阴唇，尿道，阴道口，阴道前厅。可以帮助病人更好的告诉医生疼痛的位置以及其他性功能障碍症状的情况。也可以帮助卫生保健提供者更好的跟病人沟通体格检查结果并提出治疗建议。有一种描绘疼痛症状的方法是使用棉签系统地轻触前庭来定位不适区域(57)，尽管这项测试的特异性受到了人们的质疑(58)。

诊断

性功能障碍症状持续至少6个月(除外化学物质/药物引起的性功能障碍)，并且给病人造成明显的个人痛苦，诊断为DSM-5女性性功能障碍(表1)。此外，诊断需排除非性心理健康障碍、医疗状况、严重的人际关系困扰或其他重大的生活压力，以及化学物质或药物影响 (除外化学物质/药物引起的性功能障碍)。我们必须要记住，女性经常经历不止一种类型的性功能障碍。即使女性的性功能症状不符合DSM-5标准，她仍然可以从性功能评估和治疗中获益。

心理干预在女性性功能障碍治疗中的作用是什么？

作为女性性功能障碍治疗的一部分，我们建议进行心理干预，包括性技巧训练、行为认知治疗(包括药物治疗或非药物治疗)、基于心智觉知的治疗和夫妻治疗。应综合考虑妇产科医生的专业水平和患者的个人治疗意愿，向具有治疗女性性功能障碍方面的专业知识并接受过培训的精神卫生专家(如性治疗师、心理学家、精神病学家和婚姻/情感关系顾问)咨询或推介。

性技能训练，如手淫指导，长期以来一直是治疗性高潮障碍的主要方法(59)。一些有高潮障碍的患者确实通过手淫或其他性刺激体验到了性高潮，但他们并不认为这些体验就是高潮。在其他案例当中，女性缺乏关于阴蒂刺激的知识或经验，以及认为阴蒂刺激是不被允许的或者对手淫感到内疚和羞愧，都是引发性功能障碍的原因 (60)。通过加强与性伴侣进行性需求和性偏好的沟通,进行感觉集中练习，和系统脱敏疗法(61)以及加强教育和行为技术训练，改变女性消极态度和减轻焦虑情绪，来增加女性身体舒适度和性欲望(60)。遭受过性侵犯的女性性高潮障碍患者可能会受益于创伤心理治疗 (62)。基于小组的或基于夫妻的认知行为疗法专注于识别和改变功能失调信念，可能有助于改善性欲低下 (61，63-65)。心智觉知疗法，是只专注于体验当下，不加判断地接受自己的想法和感受，已被证明有助于改善几种不同类型的女性性功能障碍，包括性欲/觉醒障碍和获得性高潮缺乏症(61,66)。

专家简介

徐晖

徐晖，男，1973年3月出生。1997年6月毕业于山东医科大学临床医学系，获得学士学位，2010年6月毕业于山东大学医学院，获得妇产科硕士学位。自1997年7月至今在在山东大学第二医院妇产科从事临床医疗工作。2013年9月聘为副主任医师。主要擅长妇科肿瘤、微创领域。承担山东省科技厅及卫计委基金项目各一项，迄今在国内外杂志发表论文7篇，SCI收录2篇, 主编专著2部，参编专著7部。

主要社会兼职

1.山东中西医结合学会生殖内分泌专业委员会常务委员

2.山东省微量元素科学研究会妇产科专业委员会第一届委员

3.山东省抗癌协会妇科肿瘤分会首届青年委员会委员

4.山东省医师协会妇科微创医师分会第一届委员会委员

5. 山东省医师协会妇产科医师分会子宫内膜异位症和慢性盆腔痛委员会第一届委员

6. 济南市健康服务促进会常务理事

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