Female Sexual dysfunction is defined as a disturbance in a woman's sexual response. This problem is more difficult to diagnose and treat in women than it is in men because of the intricacy of the female sexual response. In 1998, the Sexual Function Health Council of the American Foundation of Urologic Disease revised the preexisting definitions and classifications of FSD. Medical risk factors, etiologies, and psychological aspects were classified into four categories of FSD: hypoactive sexual desire, arousal, orgasmic disorders, and sexual pain disorders.
Approximately 40 million American women are affected by FSD. The National Health and Social Life Survey, a probability sample study of sexual behavior in a demographically representative cohort of U.S. adults ages 18 to 59, found that sexual dysfunction is more prevalent in women (43%) than in men (31%), and increases as women age. Married women have a lower risk of sexual dysfunction than unmarried women. Hispanic women consistently report lower rates of sexual problems, whereas African American women have higher rates of decreased sexual desire and pleasure than do white women. The survey clearly indicates that sexual dysfunction affects many women.
FSD has both physiologic and psychological components. It is important to first understand the normal female sexual response to understand sexual dysfunction. Physiologically, sexual arousal begins in the medial preoptic, anterior hypothalamic, and limbic-hippocampal structures within the central nervous system. Electrical signals are then transmitted through the parasympathetic and sympathetic nervous systems.
Many changes occur in the female genitalia during sexual arousal. Increased blood flow promotes vasocongestion of the genitalia. Secretions from uterine and Bartholin glands lubricate the vaginal canal. Vaginal smooth muscle relaxation allows for lengthening and dilation of the vagina. As the clitoris is stimulated, its length and diameter increase and engorgement occurs. In addition, the labia minora promote engorgement because of increased blood flow.
FSD is psychologically complex. The female sexual response cycle was first characterized by Masters and Johnson in 1966 and included four phases: excitement, plateau, orgasm, and resolution. In 1974, Kaplan modified this theory and characterized it as a three-phase model that included desire, arousal, and orgasm. Basson proposed a different theory for the female sexual response cycle, suggesting that the sexual response is driven by the desire to enhance intimacy (Figure 1) . The cycle begins with sexual neutrality. As a woman seeks a sexual stimulus and responds to it, she becomes sexually aroused. Arousal leads to desire, thus stimulating a woman's willingness to receive or provide additional stimuli. Emotional and physical satisfaction is gained by an increase in sexual desire and arousal. Emotional intimacy is then ultimately achieved. Various biologic and psychological factors can negatively affect this cycle, thereby leading to FSD.
Sexual dysfunction manifests in a variety of ways. Some women make generalizations about their sexual problems-describing the trouble as a decrease in libido or overall dissatisfaction. Other women may be more specific and recount anorgasmia (climax difficulty), delayed orgasm, and decreased arousal. Postmenopausal women with estrogen deficiency and vaginal atrophy may also describe a decrease in vaginal lubrication.
An accurate diagnosis of FSD requires a thorough medical and sexual history. Issues such as sexual preference, domestic violence, fears of pregnancy, human immunodeficiency virus, and sexually transmitted diseases must be discussed. In addition, specific details of the actual dysfunction, identifying causes, medical or gynecologic conditions, and psychosocial information must be obtained. FSD is often multifactorial, and the presence of more than one dysfunction should be ascertained. Patients may be able to provide insight into the cause or causes of the problem; however, various tools are available to assist with obtaining a good sexual history. The Female Sexual Function Index (FSFI) is one such example. This questionnaire contains 19 questions and categorizes sexual dysfunction in the domains of desire, arousal, lubrication, orgasm, satisfaction, and pain. The FSFI and other similar questionnaires can be filled out before the appointment time to expedite the process.
FSD needs to be categorized according to the onset and duration of symptoms. It is also imperative to determine whether the symptoms are situational or global. Situational symptoms occur with a specific partner or in a particular setting, whereas global symptoms relate to an assortment of partners and circumstances.
A variety of medical problems can contribute to FSD (table 1) Vascular disease, for example, may lead to decreased blood flow to the genitalia, causing decreased arousal and delayed orgasm. Diabetic neuropathy may also contribute to the problem. Arthritis may make intercourse uncomfortable and even painful. It is essential to aggressively treat these diseases and inform patients of how they can affect sexuality.
|Coronary artery disease||Irritable bowel||Multiple sclerosis||Arthritis||Thyroid disease||Intra- or interpersonal conflicts|
|Myocardial infarction||Colostomy||Neuropathies||Autoimmune disorders||Adrenal disorders||Life stressors|
|Peripheral vascular disease||Stroke||Prolactinomas||Anxiety|
Data from Bachman GA, Phillips NA. Sexual dysfunction. In Steege JF, Metzger DA, Levy BS (eds): Chronic Pelvic Pain: An Integrated Approach. Philadelphia, WB Saunders, 1998, pp 77-90.
There are many gynecologic causes of FSD, contributing to physical, psychological, and sexual difficulties. Women who have undergone gynecologic surgeries (i.e., hysterectomies and excisions of vulvar malignancies) may experience feelings of decreased sexuality because of alterations in or loss of psychological symbols of femininity. Women with vaginismus may find vaginal penetration painful and virtually impossible. Alterations in hormones during pregnancy or the postpartum period may lead to a decrease in sexual activity, desire, and satisfaction, which may be prolonged by lactation.
|Box 1 Gynecologic Etiologies of Female Sexual Dysfunction|
|· Bartholin gland cysts|
|· Clitoral adhesions|
|· Cystocele or rectocele|
|· Episiotomy scars|
|· Lichen sclerosis|
|· Pelvic inflammatory disease|
|· Uterine fibroids|
|· Uterine prolapse|
|· Vaginal tissue atrophy|
|· Vulvar dystrophy|
Prescription and over-the-counter medications should be reviewed to identify any contributing agents Consideration should be given to dosage adjustments, medication alterations, and even drug discontinuation, if possible. In addition, use of recreational drugs, alcohol, and alternative therapies should be discussed.
|Antihypertensives||Antidepressants||Anxiolytics||Illicit and Abused Drugs||Miscellaneous|
|Benazepril (Lotensin)||Amoxapine (Asendin)||Alprazolam (Xanax)||Alcohol||Acetazolamide (Diamox)|
|Clonidine (Catapres)||Bupropion (Wellbutrin, Zyban, Wellbutrin SR)||Barbiturates||Amphetamines||Amiodarone (Cordarone, Pacerone)|
|Lisinopril (Prinivil, Zestril)||Buspirone (BuSpar)||Clomipramine (Anafranil)||Amyl nitrate||Bromocriptine (Parlodel)|
|Methyldopa (Aldomet)||Fluoxetine (Prozac, Seraphim)||Clonazepam (Klonopin)||Barbiturates||Cimetidine (Tagamet)|
|Metoprolol (Lopressor, Toprol XL)||Imipramine (Tofranil)||Diazepam (Valium, Diastat)||Cocaine||Danazol (Danocrine)|
|Propranolol (Inderal, Inderal LA)||Paroxetine (Paxil)||Lithium (Eskalith, Eskalith CR, Lithobid, Lithonate)||Diazepam (Valium, Diastat)||Digoxin (Lanoxin, Digitek, Lanoxicaps)|
|Reserpine (Serpasil)||Phenelzine (Nardil)||Lorazepam (Ativan)||Marijuana||Diphenhydramine (Benadryl)|
|Spironolactone (Aldactone)||Sertraline (Zoloft)||Perphenazine (Trilafon)||MDMA (ecstasy, methyl-methylene dexamphetamine)||Ethinyl estradiol (Estinyl, FEMHRT, various oral contraceptives)|
|Timolol (Blocadren)||Trazodone (Desyrel)Venlafaxine (Effexor)||Prochlorperazine (Compazine)||MorphineTobacco||Gemfibrozil (Lopid)Medroxyprogesterone (Amen, Cycrin, Depo-Provera, Provera)Metronidazole (Flagyl)Niacin (Niacor, Niaspan)Phenytoin (Dilantin)Ranitidine (Zantac)|
Data from Drugs that cause sexual dysfunction: an update. Med Lett Drugs Ther 1992;34:73-78; Finger WW, Lund M, Slagle MA: Medications that may contribute to sexual disorders. A guide to assessment and treatment in family practice. J Fam Pract 1997;44:33-43.
Psychosocial and psychological factors should also be identified. For example, a woman with a strict religious upbringing may have feelings of guilt that decrease sexual pleasure. A history of rape or sexual abuse may contribute to vaginismus. Financial struggles may preclude a woman's desire for intimacy.
Although no specific laboratory tests are universally recommended for the diagnosis of FSD, routine Pap smears and stool guaiac tests should not be overlooked. Baseline hormone levels may be helpful when indicated, including thyroid-stimulating hormone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), total and free testosterone levels, sex hormone-binding globulin (SHBG), estradiol, and prolactin.
The diagnosis of primary and secondary hypogonadism can be assessed with FSH and LH. An elevation of FSH and LH may suggest primary gonadal failure, whereas lower levels suggest impairment of the hypothalamic-pituitary axis. Decreased estrogen levels can lead to decreased libido, vaginal dryness, and dyspareunia. Testosterone deficiencies can also cause FSD, including decreased libido, arousal, and sensation. SHBG levels increase with age but decrease with the use of exogenous estrogens. Hyperprolactinemia may also be associated with decreased libido.
Some medical centers have the capacity to perform additional testing, although many of these tests are still investigational. The genital blood flow test uses duplex Doppler ultrasonography to determine peak systolic and diastolic velocities of blood flow to the clitoris, labia, urethra, and vagina. Vaginal pH can serve as an indirect measurement of lubrication. Pressure-volume changes can identify dysfunction of vaginal tissue compliance and elasticity. Vibratory perception thresholds and temperature perception thresholds may offer information regarding genital sensation.2 Clitoral electromyography may also be beneficial in evaluating the autonomic innervation of the corpus clitoris. These tests may be helpful in guiding medical therapy.
Once a diagnosis is made, suspected causes should be addressed. For example, diseases such as diabetes or hypothyroidism must be aggressively treated. Consideration should also be given to changes in medications or dosages.
Patients should be educated about sexual function and dysfunction. Information about basic anatomy and the physiologic changes associated with hormonal fluctuations may help a woman better understand the problem. There are many good books, videos, websites, and organizations available that can be recommended to patients
If no exact cause can be identified, basic treatment strategies should be applied. Patients should be encouraged to enhance stimulation and avoid a mundane routine. Specifically, the use of videos, books, and masturbation can help maximize pleasure. Patients should also be encouraged to make time for sexual activity and communicate with their partners about sexual needs. Pelvic muscle contraction during intercourse, background music, and the use of fantasy may help eliminate anxiety and increase relaxation. Noncoital behaviors, such as massage and oral or noncoital stimulation, should also be recommended, especially if the partner has erectile dysfunction. Vaginal lubricants and moisturizers, positional changes, and nonsteroidal anti-inflammatory drugs may reduce dyspareunia.
Desire disorders are often multifactorial and may be difficult to treat effectively. For many women, lifestyle issues such as finances, careers, and family commitments may greatly contribute to the problem. In addition, medications or another type of sexual dysfunction (i.e., pain) may contribute to the dysfunction. Individual or couple counseling may be of benefit because there is no medical treatment geared toward this specific disorder.
Hormone replacement therapy can affect sexual desire. Estrogen may benefit menopausal or perimenopausal women. It can enhance clitoral sensitivity, increase libido, improve vaginal atrophy, and decrease dyspareunia. In addition, estrogen can improve vasomotor symptoms, mood disorders, and symptoms of urinary frequency and urgency. Progesterone is necessary for women with intact uteri using estrogen; however, it may negatively affect mood and contribute to decreased sexual desire.
Testosterone appears to directly influence sexual desire, but data are controversial regarding its replacement in androgen-deficient premenopausal women. Indications for testosterone replacement include premature ovarian failure, symptomatic premenopausal testosterone deficiency, and symptomatic postmenopausal testosterone deficiency (includes natural, surgical, or chemotherapy-induced deficiency). Currently, however, there is no national guideline for testosterone replacement in women with sexual dysfunction. In addition, there is no consensus regarding what are considered normal or therapeutic levels of testosterone therapy for women.
Inadequate stimulation, anxiety, and urogenital atrophy may contribute to arousal disorder. A pilot study of 48 women with arousal disorder showed that sildenafil (Viagra) significantly improved subjective and physiologic parameters of the female sexual response. Other treatment options for arousal disorder include lubricants, vitamin E and mineral oils, increased foreplay, relaxation, and distraction techniques. Estrogen replacement may benefit postmenopausal women, because urogenital atrophy is one of the most common causes of arousal disorder in this age group.
Women with orgasmic disorders often respond well to therapy. Sex therapists encourage women to enhance stimulation and minimize inhibition. Pelvic muscle exercises can improve muscle control and sexual tension, whereas the use of masturbation and vibrators can increase stimulation. The use of distraction (i.e., background music, fantasy, and so forth, can also help minimize inhibition).8
The complexity of sexual dysfunction in women makes the diagnosis and treatment difficult. Disorders of desire, for example, are difficult to treat, whereas disorders such as vaginismus and orgasmic dysfunction easily respond to therapy. Numerous women suffer from FSD; however, it is unknown how many women are successfully treated.
Until recently, there has been limited clinical or scientific research in the field of FSD. Although some progress has been made, additional research is needed to assess treatment efficacy and establish national treatment guidelines.