Virtually Everything You Need to Know, Want to Know or Have to Know. Knowledge and treatment of female sexual dysfunction is at the same point now where male erectile dysfunction studies and treatment was in 1975, but is rapidly closing the gap. With the advent of Viagra in 1998 treatments for male dysfunction have been utilized for females with certain types of sexual dysfunction.
In the process of developing these PDE-5 inhibitors (the mechanism for Viagra, for example) he physiology of the female sexual anatomy appears to be analogous to males and those diseases that effect males often impact females. Therefore, therapies for male treatment of ED may and should be effective in females as well, we are now finding.
Females are much more complex than males and the relationship between the psychogenic and physical aspects of sexuality are more closely interrelated and represent a more intimacy-based sexual drive cycle than in the males.
Scope of Problem
A 1999 survey at the University of Chicago, Department of Sociology, on 3,000 American men and women aged 18 to 59 revealed that 31 percent of men and 43 percent of women experience some degree of sexual dysfunction. Some 22 percent of those women had low sexual desire, 14 percent had arousal or lubrication difficulties, and 7 percent complained of sexual pain. Sexual difficulties appeared to occur in the less educated, unmarried, and sexually abused women. Sexual dysfunction was associated with negative experiences in relationships, low rate of happiness, and overall well-being. These negative impacts appeared to be much more severe for women than for men due to the closer relationship between the physical and the psychosocial aspects of sexuality.
Normal Female Sexual Response
The normal female sexual response cycle is usually divided in to four stages: desire, arousal (excitement), orgasm, and resolution.
Desire is defined as the development of the energy that allows an individual to initiate sexual activity or respond to sexual stimuli. In both sexes desire originates in the limbic system of the brain primarily in the hippocampus and the preoptic nuclei. These areas are dopamine sensitive excitatory centers and serotonin sensitive inhibitory centers. Testosterone, the male hormone, maintains the responsiveness of these centers in both males and females. Desire is also affected and modulated by connections with other areas of the brain such as those involved in emotional closeness and intimacy. A total of these positive and negative influences generates neurological impulses that pass down the spinal cord to the reflex centers that govern excitement and orgasm.
The second stage, excitement or arousal, is due to spinal cord release of parasympathetic nerve impulses traveling along the pelvic nerves to the uterovaginal plexus. The end result is vascular engorgement of the clitoris, which results in lengthening and thickening of the clitoral organ, vasodilatation of the perivaginal blood supply causing transudation of fluid through the vaginal epithelium which appears to the partners as "wetness" or "lubrication."
Estrogen is required for this transudation and results in lubrication by maintaining the health of the vaginal mucosa. Continued vasocongestion of the vagina causes blood sequester in the upper half of the vagina leading to ballooning of the distal portion and elevation of the uterus. The excitement phase also causes vasodilatation in the breasts leading to increased breast size, nipple erection, and engorgement of the surrounding areola. Pulse, blood pressure, and respiratory rates increase and muscle tension throughout the body also increases. A sexual flush causing redness and erythema of the face, neck, chest, and frequently much of the body occurs in 75 percent of women. Pelvic and extragenital changes culminate in the "Plato phase" of the excitement stage where the clitoris retracts beneath its protective foreskin or hood. Vasocongestion occurs in the outer-third of the vagina with swelling to form the so called "orgasmic platform."
Orgasm is characterized by maximum physical and emotional excitement. This is accompanied by a series of involuntary ( 0.86 second) contractions of the rectal and urethral muscles as well as the uterus. Orgasm is a reflex and requires the woman to relinquish her sense of control and in addition for the orgasmic response to be activated stimulation primarily of the clitoris must be applied and must be of sufficient intensity and duration to reach the threshold for this reflex. Masters and Johnson showed that female orgasm almost always involves clitoral stimulation.
The last stage is resolution in which blood flow and pelvic congestion along with bodily tensions resolves within seconds unless the woman returns to orgasm. Females do not always fall back to the low excitement stage and many women are capable of returning to excitation with stimulation that can rapidly produce a repeat orgasm. Whether the orgasmic experience is multiple or single, resolution of all excitement phase changes may take one hour or longer in contrast to men.
Classification of Female Sexual Dysfunction
Classification of female sexual dysfunction was first developed by an international consensus conference in 1998 and formalized and published in 2000. FSD is divided into four categories: sexual desire disorder, sexual arousal disorder, orgasmic disorder, and sexual pain disorder. A significant addition was "causing personal distress." This has implication for women who are happy with their frequency and response to sexual activity; however, their partners may not be. This incompatibility among couples may require counseling; however, the women will no longer be labeled with the diagnosis of FSD.
Disorders of Sexual Desire
Hypoactive sexual desire disorder (HSDD) is the persistent or recurrent absence of sexual fantasy, thought, or desire for sexual activity which causes personal distress. Lowen reported an incidence of 22 percent, others as high as 55 percent, and appears to represent the most common form of FSD. All aspects of sexuality can cause HSDD. Psychosocial aspects of the relationship between partners appears to be a major cause. The couch potato, football watching, beer drinking husband is not uncommon. Demanding careers, raising children, motherhood, stressful life milestones, job loss, and the death of a loved one can all play a role. On the other hand, physical factors such as general health conditions, drug and alcohol abuse, aging, and many of the antidepressants may have a potential affect as well.
Diminution of sexual desire is a side effect of many medications, many of which are listed in our table one. SSRIs increase serotonin activity, inhibit the limbic system, and decrease sexual desire. Bupropion (Wellbutrin) has been demonstrated to increase sexual desire both alone as primary treatment or in combination with SSRIs and may have a beneficial effect both for depression and the associated sexual dysfunction. Patients who are on SSRIs can take "drug holidays" in which they discontinue their antidepressants during romantic getaways. Included in SSRIs would be St. John's Wort, a common herbal medication for depression. Yohimbe has been shown as promising treatment to reduce SSRI, and St. John's Wort induced sexual dysfunction in women.
Medications that suppress ovarian function will also suppress testosterone, which is primarily produced by the ovary. Without testosterone the central nervous system limbic systems cannot respond adequately to stimulation. GnRH agonists for endometriosis, Depo-Provera, and to a lesser extent oral contraceptives decrease ovarian production of testosterone and may also decrease libido.
Testosterone replacement has been documented to increase sexual interest and activity particularly after the ovaries have been removed, and testosterone has been proposed as a medical treatment for HSDD. It may also be helpful for women who are receiving hormone replacement therapy since estrogens increase serum-binging globulins, decreasing the non-bound free testosterone and the active form of the hormone testosterone. There also appears to be a female androgen deficiency syndrome (FADS) described by the Australian research, Dr. Susan Davis, in which women have low libido, poor motivation, fatigue, and lack of well being in the presence of normal estrogen and free testosterones in the lower third of the normal laboratory range. Dr. Davis recommends treating women with oral or transdermal testosterone under these circumstances.
Sexual Aversion Disorder
Sexual aversion disorder (SAD) is an exaggerated form of HSDD and represents the persistent or recurrent phobic aversion to genital contact with a sexual partner. Women with SAD have a history of sexual or physical abuse or serious problems in their relationship that usually requires extensive psychotherapy for these women who are apathetic towards sex and who have negative sexual experiences. Female sexual arousal disorder (FSAD) is the persistent or inability to attain or maintain sexual excitement, i.e. lubrication/swelling which causes personal distress. Arousal disorders may have a psychological aspect either primarily or secondary and are frequently tied to issues of HSDD. Sex therapy of arousal disorders usually involves teaching women how to appreciate their bodily responses and focusing on ways to enhance these responses with sexual thoughts of stimulation. On the other hand, arousal disorders can be physiologic in origin. SSRIs and other medications can interfere with arousal as well as desire. Hormonal preparations that decrease testosterone such as contraceptives decrease arousal and conversely testosterone may aide arousal. Blood flow in the hemodynamic basis of sexual arousal can be affected by antihypertensives, anticholinergics, and antihistamines. The hemodynamic aspects of arousal may, in fact, be a major area in which pharmacological therapy of FSD will be demonstrated.
Female orgasmic disorder (FOD) is defined as persistent or recurrent difficulty, delay in, or absence of obtaining orgasm following sufficient sexual stimulation and arousal which causes personal distress. FOD is a common problem with 10 percent of women never experiencing orgasm and 50 percent reporting intermittent or situational difficulties achieving orgasm. There are psychological aspects to FOD, however, physical aspects including neurological conditions such as multiple sclerosis and spinal cord injuries, diabetic neuropathy, and medications including SSRIs, tricyclic antidepressants, appetite suppressants, and psychotic agents may also play a role. Obviously any aspect of sexual dysfunction could affect orgasm and therefore a careful history must be obtained of the entire sexual situation with an individual and her partner. The history should include whether or not the individual has ever had an orgasm or whether or not it is situational and related to certain circumstances. Such problems may be amenable to education, counseling, or therapy. Not uncommonly sex-related articles in women's magazines raise unrealistic expectations and education may be extremely helpful. For example, the amount and type of stimulation required to trigger orgasms varies from woman to woman. Only approximately 42 percent of women experience multiple orgasms, and there is great doubt as to the existence of the G-spot. In another study 4 percent of women could not masturbate to orgasm, but 70 percent were unable to achieve orgasm with intercourse implying that most women are physically capable of experiencing orgasm. Lastly, some women fear the loss of self control that is required to reach orgasm or worry about how they might look to their partners if sexually aroused. Addressing these issues may successfully treat FOD.
In those patients who have never experienced an orgasm sex therapy and support groups to educate women about their bodies and learning to appreciate their bodily responses may be helpful.
Sexual Pain Disorders
Sexual pain disorders, medically known as dyspareunia, is recurrent or persistent genital pain associated with sexual intercourse. Its true incidence is unknown, however, 60 percent of women report some pain sometime in their live, but one-third report continuous problems.. The physical and psychological aspects of dyspareunia are often interrelated. Women may be the victim of sexual trauma and perceive intercourse as painful even in the absence of pelvic pathology. Guilt and shame can lead to an unsatisfactory relationship particularly if the partner does not provide foreplay to arouse them.
On the other hand, a physical cause is not uncommon and an evaluation by a gynecologist or sexual specialist should be performed first ascertaining whether the pain is during penetration or deep thrusting is necessary. Penetration pain is likely related to vulva, vagina, or bladder conditions. Hymenal tags or episiotomy scars may also cause such.
Pain on deep penetration indicates significant pelvic disease and may be the hallmark of endometriosis, pelvic inflammatory disease, pelvic adhesions, previous pelvic surgery, uterine fibroids, retroverted uterus, or ovarian pathology. A pelvic exam can determine the correct cause although in some cases it is extremely difficult.
Vaginismus is a subcategory of sexual pain disorder and is defined as the recurrent or persistent involuntary spasm of the musculature of the outer-third vagina which interferes with vaginal penetration and causes personal distress. The incidence is not well known, is relatively rare, and is believed to be the leading cause of unconsummated marriage. Vaginismus usually dates from the first attempt at intercourse and is due to psychological factors such as sexual inhibition, rape or incest, negative feelings towards the sexual partner, or intense fear of pregnancy. Spasm of the musculature appears to be independent of these thoughts and emotions which frequently remain subconscious. Treatment of vaginismus consists of muscle awareness and relaxation exercises, vaginodilatation, counseling, and sex therapy.
Treatment of Female Sexual Dysfunction
Treatment for sexual dysfunction depends on the cause. If physical, medical treatment may be aimed at correcting the problem or relieving the problem, and if psychological counseling in combination with medical therapies may be necessary.
Subsection of Medical Treatment
Lubricating creams, gels, or suppositories. Vaginal dryness and a lack of arousal, i.e. lubrication caused by medications, chronic medical problems, or declining estrogen levels such as occurs during menopause may be helped by using water-based over-the-counter vaginal lubricants such as Replens, Astroglide, or KY-Jelly. All water-based products should not be used with a condom since this may cause breakage of the condom.
Topical estrogens. For menopausal women with vaginal thinning, dryness, and insensitivity estrogen creams such as Estrace and Premarin or vaginal inserts such as Estring may be helpful. A vaginal tablet (Vagifem) containing estradiol, a type of estrogen, is also available and may not have the messiness of the creams. The creams are usually used at night where as Vagifem can be inserted any time of the day.
Hormonal therapy. For menopausal women hormonal replacement therapy can improve clitoral sensitivity, ease discomfort caused by vaginal thinning and dryness, and improve blood flow to the pelvis area. In addition, hormone replacement therapy (HRT) can relieve bothersome menopausal symptoms including hot flashes, prevent osteoporosis, and possibly prevent other cardiovascular problems although this is quite controversial at this time. Recent studies have indicated that HRT has a higher incidence of cardiovascular problems including phlebothrombosis, pulmonary emboli, and myocardial infarction (heart attack). Two types of HRT are available. HRT usually refers to the combination of estrogen and the synthetic form of the hormone progesterone (progestins) where as ERT refers to estrogen replacement therapy in which estrogen is used alone mostly in women who do not have a uterus. Several large studies have shown that estrogens without progestins have a greater risk of developing endometrial cancer than women who do not use ERT. The risk is ten fold higher, but scientific evidence showed that combining progestins to estrogens reduces the risk to normal levels. Although HRT can increase sensitivity and decrease discomfort or pain associated with sexual activity in menopausal or postmenopausal women improved sexual desire for some women does not occur. Some professionals recommend adding androgens for desire problems. Androgen is the sex hormone produced by the ovaries and the adrenal glands which contributes to the rapid growth spurt at puberty and regulates a variety of bodily functions.
Androgen is testosterone. It can be prescribed in small amounts to reduce sexual desire in women who have had their ovaries moved often as part of a hysterectomy or in women who are postmenopausal with ovarian failure. Androgen supplementation carries some potential risks if the patients are not monitored appropriately and if the doses are not low enough. Masculinization with facial hair and enlargement of the clitoris, lipid abnormalities, acne, polycythemia, agitation, and aggressiveness may occur.
Some women who have sexual desire problems caused by androgen deficiency may benefit from the treatment with dehydroepiandrosterone (DHEA). DHEA is both a precursor to testosterone and estradiol and when given orally at a twice a day dose tends to increase both the estrogen and the testosterone by natural means. At the 2001 American Urologic Association meeting DHEA appeared to return female levels of testosterone to normal in 80 percent of cases. Most of the women reported a significant increase in spontaneity and decreased time to arousal along with an improved interest in sexual activity. DHEA is a health food supplement, however, it should be administered with medical guidance since the side effects of androgen can be induced if not properly monitored and there is an increased risk of breast and endometrial cancer.
Available hormonal therapy that includes androgen are the Androgel 2.5 gram packages applied to the skin daily after showering over a one-week period, i.e. one seventh of the package is used over one week, Depo-Testosterone injections at dosages of 20 mg every three to four weeks where as males use 200 mg every two weeks, and Estratest tablets which include a combination of estrogen and mentholated testosterone in such low doses that liver toxicity and liver cancer is not as significant as one is concerned with in males who need higher dosages that cause higher incidences of chemical hepatitis and cancer of the liver.
Gels in pump bottles are not available for men at this time, but can be used in 2.5 gram doses for females and testosterone subcutaneous pellets and testosterone buccal lozenges may become available for females in the future.
Clitoral therapy devices. The EROS clitoral therapy device is specifically designed to treat female sexual arousal disorders and has been approved by the FDA. It consists of a small soft suction cup attached to a palm-sized battery operated vacuum pump. The cup is placed over the clitoris before having sex and activation of the pump draws blood in to the clitoris expanding and holding the blood within the clitoris and therefore aiding sexual arousal. The device is available by prescription. No adverse effects were noted.
Viagra (sildenafil). Viagra, as you are aware, is used to treat erectile dysfunction in men by increasing blood flow to the genital organs. Unfortunately all the diseases that cause decreased blood flow in men also affect women, and although the drug has not yet been FDA approved for female sexual dysfunction many are using it for increasing pelvic blood flow, i.e. arousal disorders. At this time there is a pivotal international study going on to determine the effectiveness of Viagra in women with arousal disorders. The side effects of Viagra in women is the same as men, i.e. headaches, flushing, rhinitis, GI upset and abnormal vision, and there are several studies indicating improvement in sexual spots and arousal in women using antidepressants, postmenopausal women, and others with sexual arousal disorders. Viagra should not be used in women taking any form of nitrates since this can be lethal with decrease in blood pressure and major cardiovascular collapse. Women who are unable to tolerate sexual activity or have retinitis pigmentosa should also not use the drug. Lastly, if women are on alpha blockers for hypertension the drug should not be used with the alpha blocker within four hours.
In the near future newer more potent and specific PDE-5 inhibitors similar to Viagra will be introduced and may be useful in female sexual arousal disorders. Levitra (vardenafil) and Cialis (tadalafil) are drugs about to be FDA approved for men. Recently research on drugs that specifically affect the subtype-2 dopaminergic centers in the brain (periventricular nuclei) may be helpful for women in the future not only for arousal disorders, but possibly for desire problems as well. Melanocyte agonists may also play a similar role on the central nervous system. (2004)