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Many women initiate or agree to sexual activity because they seek emotional intimacy or wish to increase their sense of well-being, confirm their desirability, please or placate a partner, or a combination. Especially in established relationships, women often have little or no initial sense of sexual desire but access sexual desire (responsive desire) once sexual stimulation triggers excitement and pleasure (subjective arousal) and genital congestion (physical genital arousal). Desire for sexual satisfaction, which may or may not include one or multiple orgasms, builds as sexual activity and intimacy continue, and a physically and emotionally rewarding experience fulfills and reinforces the woman's original motivations. A woman's sexual response cycle is strongly influenced by the quality of the relationship with her partner. Initial desire typically lessens with age but increases with a new partner at any age.
Physiology of the female sexual response is incompletely understood but involves hormonal and CNS regulation of subjective and physical arousal and of orgasm. Estrogens and androgens both appear to influence arousal. Postmenopausal ovarian androgen production stays relatively constant, but adrenal androgen production begins to decrease during a woman's 40s; whether this decrease plays any role in diminishing sexual desire, interest, or arousal is unclear. Androgens probably act via both androgen receptors and estrogen receptors (after intracellular conversion of testosterone to estradiol ).
Arousal involves activation of brain areas involved in cognition, emotion, motivation, and organization of genital congestion. Neurotransmitters acting on specific receptors are involved; dopamine , norepinephrine , and serotonin play a role, even though serotonin is usually sexually inhibitory, as are prolactin and γ-aminobutyric acid (GABA).
Genital congestion is a reflexive autonomic response occurring within seconds of an erotic stimulus and causing genital engorgement and lubrication. Smooth muscle cells around blood spaces in the vulva, clitoris, and vaginal arterioles dilate, increasing blood flow (engorgement) and, in the vagina, transudation of interstitial fluid across the vaginal epithelium (lubrication). Women are not always aware of congestion, and it may occur without subjective arousal. As women age, basal genital blood flow decreases, but genital congestion in response to erotic stimuli (eg, erotic videos) may not.
Orgasm is an experience of peak excitement and release characterized by contractions of pelvic muscles every 0.8 sec and slow release of genital congestion. Thoracolumbar sympathetic outflow tracts appear to be involved, but orgasm is possible even after complete spinal cord transection (eg, when a vibrator is used to stimulate the cervix). Prolactin, ADH, and oxytocin are released at orgasm and may contribute to the sense of well-being, relaxation, or fatigue that follows. However, many women experience a sense of well-being and relaxation without experiencing orgasm.
Classification
There are 5 major categories of female sexual dysfunction: sexual desire/interest disorder, sexual arousal disorders, orgasmic disorder, vaginismus, and dyspareunia. Disorder is diagnosed when symptoms cause distress. Some women may not be distressed or bothered by decreased or absent sexual desire, interest, arousal, or orgasm. Overlap is often marked, and almost all women with sexual dysfunction have features of more than one disorder. For example, chronic dyspareunia of vestibulitis often leads to sexual desire/interest and arousal disorders; impaired arousal may make sex less enjoyable or even painful, decreasing the likelihood of orgasm and subsequent spontaneous desire. However, dyspareunia due to impaired lubrication may occur as an isolated symptom in women with a high level of sexual desire, interest, and subjective arousal.
Female sexual disorders may be secondarily categorized as lifelong or acquired; situation-specific or generalized; and mild, moderate, or severe based on the degree of distress it causes the woman. These disorders probably apply equally to women in heterosexual and same-sex relationships. Little is known about the latter, but for some women, these disorders may be a manifestation of transitioning sexual identity or orientation.
Sexual
desire/interest disorder is absence of or a decrease in sexual interest, desire, sexual thoughts, and fantasies and an absence of responsive desire. Motivations to become sexually aroused are scarce or absent. The decrease is greater than what might be expected based on a woman's age, life circumstances, and relationship duration.
Sexual
arousal disorders can be categorized as subjective, combined, or genital. All definitions are clinically based, distinguished in part by the woman's awareness of her genital response to stimulation. In subjective sexual arousal disorder, subjective arousal in response to any type of sexual stimulation (eg, kissing, dancing, watching an erotic video, genital stimulation) is absent or low, but the woman is aware of normal genital arousal (genital congestion). In combined sexual arousal disorder, subjective arousal in response to any type of sexual stimulation is absent or low, and women report absent or impaired physical genital arousal (ie, they are unaware of it). In genital arousal disorder, subjective arousal in response to nongenital stimulation (eg, erotic video) is normal, but subjective arousal, awareness of genital congestion, and sexual sensations in response to genital stimulation (including intercourse) are absent or low. Genital arousal disorder typically affects postmenopausal women and is often described as “genital deadness”. Laboratory studies confirm reduced genital congestion in response to sexual stimulation in some women; in others, the sexual sensitivity of the normally engorged tissues seems reduced.
Orgasmic
disorder is orgasm that is absent, markedly diminished in intensity, or markedly delayed in response to stimulation, despite high levels of subjective arousal.
Vaginismus is reflexive tightening around the vagina when vaginal entry is attempted (eg, using a penis, finger, dildo, or any object), despite the woman's expressed desire for penetration, in the absence of structural or other physical abnormalities. The disorder is often associated with anticipation, fear, or experience of pain and phobic avoidance of attempted penetration.
Dyspareunia is pain during attempted or completed vaginal penetration or intercourse; the pain may occur at the moment of penetration (superficial/introital), with deeper entry, with penile movement, or postcoitally.
Etiology
The traditional separation of psychologic and physical etiologies is artificial; psychologic distress causes changes in physiology, and physical changes may generate major distress. There are often several causes of symptoms within and between categories of dysfunction, and the cause is often unclear.
Historical psychologic causes are experiences that affect a woman's psychosexual development. For example, past negative sexual or other experiences may lead to low self-esteem, shame, or guilt. Emotional, physical, or sexual abuse during childhood or adolescence can teach children to control and hide emotions—a useful defense mechanism—but such inhibition can make expressing sexual feelings difficult later. Early traumatic loss of a parent or another loved one may inhibit intimacy with a sex partner for fear of similar loss. Women with desire/interest disorders tend to be anxious, to have a low self-image, and to have mood instability even in the absence of a clinical mood disorder. Women with orgasmic disorder often have difficulty relinquishing control in nonsexual circumstances. A subgroup of women with dyspareunia and vulvar vestibulitis (see Sexual Dysfunction in Women: Etiology) have high expectations of self and fear of negative evaluation by others.
Contextual psychologic causes are specific to a woman's current circumstances. They include negative feelings or reduced attraction toward a sex partner (eg, due to the partner's behaviors or to a growing awareness of attraction to women), nonsexual sources of anxiety or distraction (eg, family, work, finances, cultural restrictions), concerns about privacy, and concerns about unwanted outcomes (eg, unwanted pregnancy, sexually transmitted diseases, inability to have an orgasm, erectile dysfunction in a partner).
Medical conditions that may lead to dysfunction include conditions causing fatigue or debility, hyperprolactinemia, hypothyroidism, atrophic vaginitis, bilateral oophorectomy in younger women, and psychiatric disorders (eg, anxiety disorder, depression). Drugs, most notably SSRIs, β-blockers, and hormones, may play a role. Oral estrogen and oral contraceptives increase sex hormone–binding globulin (SHBG), decreasing the amount of free androgen available for tissue receptor binding. Antiandrogens (eg, spironolactone , gonadotropin-releasing hormone agonists) may also reduce sexual desire and arousal.
Some pelvic muscle hypertonicity, manifest as voluntary guarding and high muscle tension, is a common finding in all types of chronic dyspareunia. The most common type of superficial/introital dyspareunia is vulvar vestibulitis. Vulvar vestibulitis (localized vulvar dysesthesia) is probably a form of chronic pain syndrome (see Pain: Chronic Pain) of the vulva, in which the nervous system, from peripheral receptors to the cerebral cortex, is sensitized and remodeled for unknown reasons. With sensitization, discomfort due to a stimulus that might otherwise be perceived as mild or trivial (eg, touch) is instead perceived as significant pain (allodynia). Some women have accompanying GU disorders (eg, vulvovaginal candidiasis, hyperoxaluria), but the etiologic role of these disorders is unproven. Some women also have other pain disorders (eg, irritable bowel syndrome—see Irritable Bowel Syndrome (IBS), interstitial cystitis—see Voiding Disorders: Interstitial Cystitis). Pain due to vestibulitis typically occurs immediately with introital pressure, with penile movement, and with the man's ejaculation. Vestibulitis may also cause postcoital vulvar burning and dysuria. Vaginismus causes similar pain with introital pressure and penile containment and movement, but pain due to vestibulitis typically stops when penile movement stops and resumes when it starts again; pain due to vaginismus continues when penile movement stops but may progressively fade during intercourse despite continued penile movement.
Other causes of superficial/introital dyspareunia include atrophic vaginitis, vulvar lesions or disorders (eg, lichen sclerosus, vulvar dystrophies), congenital malformations, radiation fibrosis, postsurgical introital narrowing, and recurrent tearing of the posterior fourchette.
Causes of deep dyspareunia include pelvic muscle hypertonicity and uterine or ovarian disorders (eg, fibroids, endometriosis). Penile size and depth of penetration influence presence and severity of symptoms.
Damage to genital sensory or autonomic nerves and, much more commonly, use of SSRIs may lead to acquired orgasmic disorder.
Diagnosis
Diagnosis of sexual dysfunction and its causes is by history and physical examination. Ideally, history is taken from both partners, interviewed separately as well as together; it begins by asking the woman to describe the problem in her own words. Important elements of the history are listed in Table 1: Sexual Dysfunction in Women: Components of the Sexual History When Assessing Female Sexual Dysfunction . Problematic areas (eg, past negative sexual experiences, negative sexual self-image) identified at the 1st visit can be investigated more fully at a follow-up visit.
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Table 1
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Components of the Sexual
History When Assessing Female Sexual Dysfunction
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Area
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Specific Elements
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Medical history (past and current)
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General health (including physical energy level and mood), drugs, pregnancies, pregnancy terminations, STDs, contraception, safer practices
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Relationship with partner
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Emotional intimacy, trust, respect, attraction, communication, fidelity, anger, hostility, resentment, sexual orientation
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Current sexual context
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Sexual dysfunction in partner, what occurs in the hours before attempts at sexual activity, is there inadequate sexual stimulation, unsatisfactory sexual communication, disagreement with partner about sexual practices, lack of privacy
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Effective triggers of desire and arousal
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Books, videos, dates, showering together, dancing, music; physical or nonphysical, genital or nongenital stimulation
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Inhibitors of arousal
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Distractions; negative past sexual experiences; poor sexual self-image; fears about outcome, including loss of control, unwanted pregnancy, or confirmed infertility; stress; fatigue; depression
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Orgasms
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Presence or absence; whether distressed by absence or not; differences in responses with partner and with masturbation
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Outcome
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Emotional and physical satisfaction or dissatisfaction
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Location of dyspareunia
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Superficial/introital or deep vaginal tissues
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Timing of dyspareunia
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During partial or full entry, deep thrusting, penile movement, the man's ejaculation, or subsequent urination after intercourse
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Self-image
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Self-confidence, feelings about desirability, body, genitals, sexual competence
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Developmental history
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Relationship with caregivers and siblings; traumas; loss of loved one; emotional, physical, or sexual abuse; consequences of expressing emotions as a child; cultural or religious restrictions
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Past sexual experiences
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Desired, coercive, abusive, or a combination; pleasing and successful sexual practices, self-stimulation
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Personality factors
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Ability to trust, comfort with vulnerability, suppressed anger causing suppression of sexual emotions, need to feel in control, unreasonable expectations of self
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STDs = sexually transmitted diseases.
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Physical examination is most important for determining causes of dyspareunia; the technique may differ slightly from that used in a routine gynecologic examination. An explanation of what will occur during the examination helps the woman relax and should be repeated as the examination is done. Asking her to sit up and view her genitals in a mirror during the examination imparts a sense of control.
Evaluation of superficial/introital dyspareunia focuses on inspection of all of the vulvar skin, including the creases between the labia minora and majora (for fissures typical of chronic candidiasis), and the clitoral hood, urethral meatus, hymen, and openings of major vestibular gland ducts (for atrophy, signs of inflammation, and skin lesions typical of lichen sclerosus). Vulvar vestibulitis can be diagnosed using a cotton swab to elicit allodynia; nonpainful external areas are touched before moving to more typically painful areas (ie, outer edge of the hymenal ring, clefts adjacent to the urethral meatus). Pelvic muscle hypertonicity may be suspected if pain similar to that which occurs during intercourse can be elicited by palpating the deep levator ani muscles, particularly around the ischial spines. Palpating the urethra and bladder may identify abnormal tenderness.
Evaluation of deep dyspareunia requires a careful bimanual examination to elicit pain with cervical motion or with uterine or adnexal palpation and to check for nodules in the cul-de-sac or vaginal fornices. A rectal examination may also be indicated to check the rectovaginal septum and posterior surface of the uterus and adnexa.
Diagnosis of vaginismus requires exclusion of physical causes by physical examination after treatment makes examination possible. While sitting up, using a mirror, and in control, the woman may spread her labia and insert her or the examiner's gloved finger past the hymen as she bears down. This simple digital examination can simultaneously confirm a normal vagina and the presumed diagnosis of vaginismus.
Wet-preparation examination of vaginal discharge and Gram stain with culture or DNA probe for Neisseria gonorrhoeae and chlamydiae are indicated when history or examination suggests vulvitis, vaginitis, or pelvic inflammatory disease. Although low estrogen and testosterone levels may contribute to sexual dysfunction, measuring levels is rarely indicated. An exception may be measuring testosterone using well-validated assays to monitor investigational testosterone therapy.
Treatment
Treatment varies by disorder and cause; often, more than one treatment is required because disorders overlap. Sympathetic understanding of the patient and careful evaluation may themselves be therapeutic. Because SSRIs may contribute to several categories of sexual dysfunction, substitution with antidepressants that have fewer negative sexual adverse effects (eg, bupropion , meclobomide, mirtazapine , venlafaxine ) may be considered. Phosphodiesterase inhibitors (eg, sildenafil , tadalafil , vardenafil ) may be recommended for empiric use in some cases defined below, but efficacy is unproven.
Sexual
desire/interest and subjective and combined sexual arousal disorders:
If factors that limit trust, respect, attraction, and emotional intimacy between partners are the cause, the couple should be counseled that emotional intimacy is a normal requirement for female sexual response and needs to be developed with or without professional help. Education about sufficient and appropriate stimuli may help; women may need to remind their partner of their need for nonphysical, physical nongenital, and nonintercourse genital stimulation. Recommendations for more intensely erotic stimuli and fantasies may help eliminate distractions; practical suggestions to improve privacy and a sense of security can help when fear of discovery, pregnancy, or sexually transmitted diseases inhibits arousability. For patient-specific psychologic factors, psychotherapy may be required, although simple awareness of the importance of these factors may be sufficient for women to change patterns of thinking and behavior.
Hormonal abnormalities require targeted treatment: eg, topical estrogen for atrophic vulvovaginitis and bromocriptine for hyperprolactinemia. Benefits and risks of testosterone supplementation are under study. In the absence of interpersonal, contextual, and intrapersonal factors, investigational supplementation (eg, with oral methyltestosterone 1.5 mg once/day or transdermal testosterone 300 μg daily) is considered by some clinicians experienced in both women's sexual disorders and endocrinology for the following: postmenopausal women who are taking estrogen therapy and who develop sexual dysfunction in their 40s and 50s when adrenal androgens are declining, women who develop sexual dysfunction after surgical or chemotherapy-induced menopause, and women with adrenal or pituitary disorders. Careful follow-up is essential. Tibolone, a synthetic steroid used extensively in Europe, has tissue-specific estrogenic, progestogenic, and androgenic activity and appears to increase sexual desire, arousability, and vaginal congestion. In low doses, it does not stimulate endometrium, increases bone density, and does not have estrogenic effects on lipids and lipoproteins. However, its effect on risk of breast cancer is unclear, and it is currently unavailable in the US.
Drug substitutions (eg, transdermal for oral estrogen or oral contraceptives, or barrier methods for oral contraceptives) may also be indicated.
Genital
arousal disorder:
Initial treatment is local estrogen (or systemic estrogen if indicated for other perimenopausal symptoms) when estrogen deficiency is present. Use of a phosphodiesterase inhibitor may be tried empirically for symptoms refractory to estrogen therapy; it will benefit only those with reduced genital congestion. Other investigational therapy includes a trial of 0.2 mL topical 2% testosterone in petrolatum prepared by a pharmacist and applied to the clitoris.
Orgasmic
disorder:
Data support encouraging self-stimulation. A vibrator placed on the mons close to the clitoris may help, as may increasing the number and intensity of stimuli (mental, visual, tactile, auditory, written), simultaneously if necessary. Psychotherapy may help women identify and manage fear of relinquishing control, fear of vulnerability, or issues of trust with a partner. Phosphodiesterase inhibitors may be used empirically for acquired orgasmic disorder with autonomic nerve damage, although no scientific evidence supports their use.
Vaginismus:
Treatment is behavioral and incremental, involving experiences of neutral self-touch remote from the introitus and moving slowly toward it, to reduce fear of subsequent pain. The woman should be encouraged to touch herself daily as close to the introitus as possible, separating the labia with her fingers. Once her fear and anxiety from introital self-touch has diminished, she can insert her finger past her hymen, pushing or bearing down as she inserts her finger to ease entry. If finger insertion causes no discomfort, vaginal cones graded in size can be prescribed for progressive insertion; they allow perivaginal muscles to become accustomed to gently increasing pressure without reflex contraction. The woman first inserts the cones into her vagina; when comfortable with them, she can allow her partner to help her insert one during a sexual encounter to confirm that it can go in comfortably when she is sexually excited. If this insertion is comfortable, the couple should be encouraged to include penile vulvar stimulation during sexual play so that the woman becomes accustomed to feeling the penis on her vulva. Ultimately, the woman can insert her partner's penis partially or fully, holding it like an insert. She may feel more confident in the woman superior position. Some men experience situational erectile dysfunction in this process and may benefit from a phosphodiesterase inhibitor.
Dyspareunia:
Treatment is aimed at specific causes (eg, endometriosis, lichen sclerosus, vulvar dystrophies, vaginal infections, congenital malformations, radiation fibrosis—see elsewhere in The Manual). Optimal treatment of vulvar vestibulitis is unclear; many approaches are currently used, and there are probably as yet undefined subtypes of the disorder that require different treatment. Commonly used but unproven approaches involve avoiding topical irritants and using systemic drugs (eg, tricyclic antidepressants, anticonvulsants) or topical drugs (eg, 2% cromoglycate or 2 or 5% lidocaine in glaxal base) to interrupt chronic pain circuits. Cromoglycate stabilizes WBC membranes, including those of mast cells, interrupting the neurogenic inflammation thought to underlie vestibulitis. Cromoglycate or lidocaine must be placed precisely on the area of allodynia using a 1-mL syringe without a needle. Physician supervision and use of a mirror (at least initially) are helpful. Psychotherapy and sex therapy may also help some women with vestibulitis.
Topical estrogen is helpful for atrophic vulvovaginitis (see Menopause: Hormone therapy) and recurrent posterior fourchette tearing.
Women with pelvic muscle hypertonicity may benefit from pelvic physical therapy using pelvic floor muscle training, possibly with biofeedback to teach pelvic muscle relaxation.
While specific causes are being managed, couples should be encouraged to develop satisfying forms of nonpenetrative sex and treated for coexisting disorders of desire/interest and arousal.
Last full review/revision November 2005
Content last modified November 2005
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