A 53-year-old woman comes to the office for a routine follow-up visit. She has seen the physician for menopausal symptoms for the past 2 years and started medication for worsening hot flashes 6 months ago. She says, "I'm doing pretty well; that medication you gave me seems to have helped my hot flashes somewhat. My sleep isn't great, but it's not that different from usual. At least I'm not waking up 3 times a night anymore." Her medical problems include hypertension and chronic insomnia. Medications include enalapril and venlafaxine that was started at her last visit to target vasomotor symptoms. The patient drinks a glass of wine each day and does not use tobacco. She works as a librarian and is married to her second husband. She exercises regularly and enjoys socializing with her friends when she has the opportunity. When the physician inquires about her home life, she says her marriage is "fine" although she wishes that she and her husband had more time for each other and were more intimate. She says, "Actually, I am a little upset with my husband. He comes home from work exhausted and just wants to watch television. He doesn't understand the changes I'm going through. He doesn't seem interested in anything, including me!"
Which of the following questions would be most helpful to address the patient's concerns?

Question

A 53-year-old woman comes to the office for a routine follow-up visit.  She has seen the physician for menopausal symptoms for the past 2 years and started medication for worsening hot flashes 6 months ago.  She says, "I'm doing pretty well; that medication you gave me seems to have helped my hot flashes somewhat.  My sleep isn't great, but it's not that different from usual.  At least I'm not waking up 3 times a night anymore."  Her medical problems include hypertension and chronic insomnia.  Medications include enalapril and venlafaxine that was started at her last visit to target vasomotor symptoms.  The patient drinks a glass of wine each day and does not use tobacco.  She works as a librarian and is married to her second husband.  She exercises regularly and enjoys socializing with her friends when she has the opportunity.  When the physician inquires about her home life, she says her marriage is "fine" although she wishes that she and her husband had more time for each other and were more intimate.  She says, "Actually, I am a little upset with my husband.  He comes home from work exhausted and just wants to watch television.  He doesn't understand the changes I'm going through.  He doesn't seem interested in anything, including me!" 
Which of the following questions would be most helpful to address the patient's concerns?

Quizplus · Accepted Answer

Explanation: This postmenopausal patient reports that her physical symptoms have improved (venlafaxine appears to have improved her vasomotor symptoms and sleep to some extent) but describes intimacy problems with her husband. Taking a sexual history should be considered part of a routine medical examination, and physicians should seek to normalize sexual health concerns. Patients have varying degrees of comfort discussing sexual issues and may be reluctant to bring up these topics. The physician should facilitate the discussion with a sensitive, nonjudgmental, and open-ended approach. An open-ended question such as "Can you tell me more about your sex life?" is effective in initiating the discussion. (Choice A) Although the patient's comments raise concern about her husband's mental health, focusing on her own concerns should take priority. (Choice C) This patient has a history of chronic insomnia that was likely exacerbated by nighttime awakenings due to menopausal hot flashes. However, treating her vasomotor symptoms with venlafaxine has improved her sleep, which is now close to her baseline. Obtaining further history about lack of intimacy with her husband, which is the main cause of her current distress, is the priority. (Choice D) Although assessing a patient's mood is useful, this patient is not currently experiencing depression and appears to be functioning well (eg, working, exercising, socializing). Exploring her concerns about her relationship is more important. (Choice E) Although this couple may benefit from therapy, the physician should first obtain additional information about the patient's concerns regarding intimacy. If a sexual problem is identified, it may need to be addressed medically. Educational objective: Sexual history should be obtained routinely in health visits. Physicians should normalize sexual health concerns and provide patients with the opportunity to openly discuss these issues. References: General practitioners' procedures for sexual history taking and treating sexual dysfunction in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/24261826) Standard operating procedures for taking a sexual history. (http://www.ncbi.nlm.nih.gov/pubmed/22970717)

A 53-Year-Old Woman Comes to the Office for a Routine