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    Female sexual dysfunction: what is known and what can be done?

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    Female sexual dysfunction: what is known and what can be done?

    By Ira I. Kohn, MD, and Steven A. Kaplan, MD

    There are various reasons for sexual dysfunction in women. Read about diagnostic and therapeutic tools that you can use to help your patients overcome these common problems.

    Media reports on male sexual dysfunction and the growing availability of viable treatment alternatives for it have resulted in increasing numbers of men seeking treatment for this previously taboo condition.1-3 Since such problems usually arise within the context of relationships, some investigators have found increased rates of sexual dysfunction among the partners of these men.4 In addition, among women seeking treatment for other complaints, some with underlying chronic conditions have increased rates of concomitant sexual dysfunction.5,6 Gynecologists who have a good rapport with these patients are in a unique position to help with these intimate problems that are often difficult for women to discuss. Therefore, it is important for gynecologists to be knowledgeable about and comfortable with evaluating and possibly treating female sexual dysfunction. In this article we review the physiologic and other causes of sexual dysfunction and strategies for evaluating and treating various categories thereof.

    Prevalence of female sexual dysfunction

    Sexual dysfunction can be defined as "the persistent impairment of a couple's normal or usual pat terns of sexual interest and/or response."7 Pioneering works by Kinsey in the 1950s and Masters and Johnson in the 1960s provided insights into the range of normal sexual functioning and the physiologic processes underlying sexual stimulation.8,9 The media have popularized the results of these and other studies, dispelling many myths and taking human sexual functioning out of the closet, yet at the same time possibly imposing false standards of normalcy through misrepresentation of data. For example, misinterpretation of Masters and Johnson's research on multiple orgasms in women may result in feelings of inadequacy and dysfunction if a woman does not experience multiple orgasms.

    There is a paucity of epidemiological data regarding the incidence and prevalence of female sexual dysfunction. Available epidemiological studies of sexual dysfunction suffer from methodological problems, including small sample size, skewed sample populations, failure to sample nonresponders, and lack of a uniform definition of sexual dysfunction. These shortcomings notwithstanding, Hawton states that women report more sexual problems than men, with a prevalence rate of 35% to 60%, and disorders of desire and arousal are the most common complaints.7

    Table 1 summarizes data from two recent population studies on the prevalence of sexual dysfunction in women.10,11 Of note, age and relationship status were significant predictors of sexual satisfaction, with older women and singles more frequently reporting sexual difficulty.10 In addition, despite their sexual difficulties, 68% of women reported being somewhat to very satisfied with their overall sexual relationship.10 Therefore, relationship satisfaction for women may not be entirely determined by sexual function. Moreover, many women may tolerate a certain level of sexual dysfunction before considering it a source of relationship dissatisfaction.

     

     

    Evaluating sexual problems

    Despite the high prevalence of female sexual dysfunction, many women are too embarrassed or reluctant to discuss their sexual problems. An unassuming two-part question such as "Are you sexually active?" followed by "Do you have any questions or concerns regarding your sexual health?" may be all that is needed to establish confidence and pursue further inquiry if needed. Assessment of female sexual dysfunction begins with a thorough history, physical examination, and appropriate laboratory studies (Table 2). You must determine whether the problem is new or chronic in duration, caused by local or systemic disease, or a by-product of a relationship or deep-rooted emotional conflict.

     

     

    History. First determine if there is a history of childhood sexual abuse, incest, rape, or sexual harassment and arrange appropriate counseling. Sexual expectations of both partners should be assessed for compatibility. In addition, ask about relationship, social, or job stress that may overtly or covertly cause anxiety.

    There are several landmark physiologic events in a woman's life that may affect her current sexual functioning. Sexual interest and activity often decline as pregnancy progresses, although except for the third trimester there are few medical restrictions on coitus during pregnancy. Women who breastfeed may be more likely to report decreased sexual desire or an increase in coital pain. This may be secondary to elevated prolactin levels during lactation that inhibits ovarian function, resulting in lower testosterone (desire) and estrogen (vaginal comfort) levels.12,13 There appears to be a biologically-driven periovulatory peak of female sexual desire associated with increases in serum levels of testosterone and adrostenedione.14 Sherwin and associates reported in a prospective, double-blind, randomized study that testosterone replacement therapy enhances sexual desire in women with surgically-induced menopause.15

    Menopause is reportedly associated with decreased female sexual function. This association, which is controversial, suggests a pos-sible hormonal mechanism, but the exact hormonal basis of normal female sexual functioning remains incompletely understood. Estrogen deficiency impairs vaginal mucosa, blood flow, and lubrication. Although estrogen replacement therapy may restore vaginal epithelial function, increase blood flow, and improve overall sense of well-being in postmenopausal women, it does not guarantee satisfactory sexual functioning.

    Some researchers have documented a decrease in sexual desire due to testosterone deficiency in premenopausal women who have undergone oophorectomy.16 However, postmenopausal women demonstrate more variability in hormone-sensitive sexual desire than testosterone-deficient men.16 Simple estrogen or testosterone replacement therapy does not necessarily restore sexual functioning for the postmenopausal woman and replacement doses for an individual probably depend on nonphysiologic as well as physiologic factors. In addition to hormonal changes, there are many psychosocial factors concomitant with the onset of menopause, including issues of aging and body image, that may affect sexual functioning.

    A number of medical conditions have been associated with a predilection towards female sexual dysfunction. Spinal cord injury may impinge on sexual function; women with spinal cord lesions at TI and below are probably anorgasmic, but this observation is controversial.17 In addition, women with neurologic diseases such as Parkinson's disease or multiple sclerosis may have sexual problems.18 Chronic diseases affecting multiple systems, such as thyroid disease or diabetes, may also have an impact on female sexual function.19

    Patients with traumatic head injury sometimes experience decreased sexual desire, and many temporal-lobe epileptics have been shown to have decreased sex drive.20 Women with acromegaly (giantism secondary to increased pituitary excretion of growth hormone) experience a decrease in libido as the disease progresses. Depression is also a major risk factor for sexual dysfunction and any chronic disease may result in depression, making delineation of the etiology of sexual dysfunction somewhat problematic. Therefore, a measure for depression, such as the Beck Inventory, may be useful when evaluating patients for sexual dysfunction. Of course, the condition may have multiple causes.

    Ask the patient if she has any history of abdominal/pelvic trauma, sexually transmitted diseases, or pelvic inflammatory disease. Prior surgical procedures, including abdominal­perineal resection, pelvic exenteration, retroperitoneal lymphadenopathy, sympathectomy, or aortoiliac surgery, may have either a mechanical or neurological effect on sexual function. Hysterectomy may foreshorten the vaginal vault or result in internal scarring that prevents full ballooning of the vagina. In addition, loss of the uterus results in diminished total vasocongestion and loss of uterine contractions with stimulation. Whether supracervical hysterectomy preserves greater sexual function remains a matter of debate.21 In addition, take note if the woman has undergone pelvic radiation therapy.

    Current knowledge regarding the sexual side effects of certain medications is not as well defined for women as it is for men. However, the adverse sexual effects of several psychotropic medications have been documented in women.22 Caution in evaluating this data is in order, because research indicates that many patients with underlying psychiatric disorders may have a low level of sexual functioning to begin with and the sedative effects of these medications may further limit sexual functioning.

    Major tranquilizers such as diazepam are believed to inhibit sexual functioning secondary to antidopaminergic action. Antipsychotic medications such as thioridazine and fluphenazine have been reported to cause orgasmic dysfunction.22 Antidepressants such as imipramine cause deleterious sexual side effects in up to 75% of patients treated.23 Selective serotonin reuptake inhibitors (SSRIs) seem to more frequently cause decreased sexual desire and inhibited orgasm than monoamine oxidase inhibitors or tricyclic antidepressants. Interestingly, treatment with fluoxetine has been reported to result in a spontaneous sensation of orgasm.22 Alcohol and drug abuse can alter sexual response; refer addicted patients to appropriate rehabilitation centers. Occupational or environmental exposure to toxins such as lead, mercury, pesticides, and vinyl chloride, among others, may also affect sexual function.

    Physical exam. Do a comprehensive physical examination, including a pelvic exam. Examine the introitus for signs of mucosal atrophy, discharge, or erythema suggestive of vaginitis. Note Fourchette irritation and any increased tone suggestive of vaginismus. Bartholin's glands should be palpated for tenderness and the urethra and bladder palpated for tenderness or mass. Note any degree of prolapse. Assess vaginal vault depth for radiation-induced fibrosis or strictures. Tender episiotomy scars or constricting bands within the vaginal vault and cervical motion tenderness need to be evaluated.

    Findings upon bimanual examination may suggest endometriosis, varices of the broad ligament, ovarian adhesions or tenderness, adnexal masses, or PID. Evaluate rectal tone, masses, and any tenderness or fluid in the posterior cul-de-sac and assess posterolateral rectal support for levator ani myalgia.

    Laboratory studies. Laboratory evaluation must be tailored to findings from history and physical examination. A complete blood count may reveal anemia or possibly suggest occult malignancy that may be the underlying malaise. A fasting biochemical profile should prove useful to help evaluate renal, adrenal, hepatic, pancreatic, thyroid, and parathyroid function. Urinalysis may reveal infection or occult diabetes. Optional but sometimes useful laboratory tests include thyroid stimulating hormone, hepatitis panel, testosterone, progesterone, LH, FSH, prolactin. hemoglobin A1C, erythrocyte sedimentation rate, HIV, and serum levels for toxins such as lead or mercury. Pap smear, cervical, and vaginal cultures may suggest causes for a sexual problem. Clinical suspicion should guide the use of imaging modalities such as ultrasound and computed tomography.

    What is normal sexual function?

    Originally, Masters and Johnson outlined a progressive three-phase sexual response cycle consisting of arousal, orgasm, and resolution.9 Subsequently, sexologists attempting to treat patients who chronically fail to initiate or respond to sexual stimuli added an initial phase, desire, to the sexual response cycle.24,25 The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) categorizes the sexual response cycle into four related but neurophysiologically discrete phases: (1) appetitive, desire, or libido; (2) arousal or excitement; (3) orgasm or climax; and (4) refractory or resolution (Table 3).26 Currently, researchers are considering whether a fifth phase, namely satisfaction, would help further subclassify certain patients with sexual dysfunction.25

     

     

    Desire. Sexual desire appears to be controlled by a dopamine-sensitive excitatory center, balanced by a serotonin-sensitive inhibitory center. In both males and females, testosterone is responsible for programming these centers in prenatal life and for maintaining their threshold of response. Stimulation and ablation experiments in cats and other mammalian species have located these centers within the limbic system, with significant nuclei in the hypothalamic and preoptic areas. Desire is modulated by connections between these centers and other parts of the brain. The net effect of these positive and negative influences modulates genital sexual response via impulses passing down the spinal cord to the spinal reflex centers that govern excitement and orgasm.

    Excitement. During the excitement phase, vascular engorgement occurs, mediated primarily by the parasympathetic nervous system. Genital changes include enlargement in the diameter and length of the clitoris; dilation of perivaginal arterioles with seeping of vascular transudate across the vaginal epithelium, resulting in lubrication, and expansion and "tenting" of the upper half of the vagina. Estrogen, the hormone responsible for maintaining the vaginal mucosa, allows transudation and lubrication to occur. Hypoestrogenism is by far the most common cause of excitement phase dysfunction in women.

    Extragenital changes during the excitement phase include increase in heart rate and blood pressure; enhanced muscle tension throughout the body; increase in breast size, nipple erection, and engorgement of the surrounding areola. The sex flush, an erythematous rash over the chest, neck, and face, occurs to a noticeable degree in 75% of women. Afferent stimuli travel via the dorsal nerve of the clitoris to the pudendal nerve to sacral centers. Efferent stimuli occur via the pelvic nerve to the uterovaginal plexus.

    Orgasm. During the orgasmic phase, a series of reflex clonic contractions of the levator sling and related genital musculature occur, mediated primarily via the sympathetic nervous system. Extragenital reactions during orgasm include contraction of muscle groups throughout the body, maximal intensity of the sex flush, and maximal elevations of heart rate, blood pressure, and respiratory rate.

    Excitement and orgasm are reflexes. For the orgasmic reflex to be activated, the stimulus must be applied where the sensory nerve endings are located (primarily in the area of the clitoris) and stimulation must be of sufficient intensity and duration to reach the threshold for the reflex.

    Categories of sexual dysfunction and their treatment

    True sexual dysfunction is manifested by a failure of one or more sexual response cycle phases (desire, excitement, and orgasm). According to DSM-IV, sexual dysfunction should be categorized with reference to the earliest phase of the sexual response cycle during which disruption occurs (Table 4).26 Disruption frequently begins with orgasmic problems, but loss of excitement and finally loss of desire may follow if the problem is neglected.

     

     

    Sexual dysfunction may be further described as primary, secondary, or situational. When the dysfunction is primary, realistic sexual expectations have never been met under any circumstances; when it is secondary, all phases have functioned in the past, but one or more no longer do so; and when it is situational, the response cycle functions under some circumstances but not others.

    Following is a discussion of major types of sexual dysfunction in women and appropriate therapeutic strategies.

    Hypoactive sexual desire disorder. Thirty to fifty percent of patients in sex therapy clinics present with complaints of hypoactive sexual desire disorder, defined as persistent or recurrent absence or deficit of sexual fantasies and desire for sexual activity.24,25 There are two major concerns with this diagnosis: (1) there are no norms for sexual desire stratified by age; and (2) this complaint develops and persists for diverse reasons, suggesting a heterogeneous etiology.

    Important physical factors affecting sexual desire include general health status, depression, hormonal status, and use of both prescription and recreational drugs. Tricyclic antidepressants, monoamine oxidase inhibitors, SSRIs, lithium, and certain antipsychotics are among medications reported to reduce sexual interest.22

    Psychological and interpersonal issues are often involved. Factors that contribute to impaired sexual desire include sudden events such as job loss or family member death; cumulative factors such as a woman's response to aging and menopause; life milestones such as a child leaving home; and ongoing relationship stress.

    Appropriate treatment depends on the underlying etiology. Generalized and lifelong low sexual desire suggests the need for screening for endocrine disorders, chronic illness, or long-term medication use. The use of testosterone has been shown to increase desire, but its long-term use is limited by potential side effects, including cardiovascular and liver dysfunction.27 Antidepressants may help depression-related low desire, although many of these medications decrease sexual desire, at least initially.

    When no causative medical disorder is found, individual or couples therapy is often recommended. However, hypoactive sexual desire is one of the more difficult disorders to treat, with one study suggesting success rates of less than 50%.28 The more long-standing the disorder, the more resilient it is to treatment.

    Sexual aversion disorder. Persistent or recurrent aversion to and avoidance of genital contact with a sex partner, known as aversion disorder, is less common than other sexual disorders. It is usually accompanied by low sexual desire and occasionally by vaginismus or dyspareunia. Women with this disorder may have a history of sexual or physical abuse. They may also have extensive negative, unexpressed feelings about their relationships.

    Individual counseling, employing psychological techniques of intervention such as cognitive-behavioral techniques, desensitization, and working through past issues of abuse, is often useful. Couples therapy may focus on resolving conflict areas, emotional differences, and issues of control. Specific aversions that are phobic in nature, such as aversion to semen, are difficult to overcome.

    Sexual arousal disorder. Partial or total lack of physical signs of arousal, such as lubrication, during sexual stimulation in women without concomitant menopausal, dyspareunia, or anorgasmic symptoms, is rare. Physical and subjective sexual arousal are not necessarily correlated in women. However, a continual lack of lubrication may lead to discomfort during sex, thus impairing a woman's subjective arousal, and can be interpreted by her sexual partner as a lack of interest, which may damage the relationship.

    A thorough review of possible physical causes for this complaint comprises the initial evaluation. Recommendations to use topical lubricants or estrogenic compounds depends on a woman's physical condition, age, and risk factors for estrogen therapy.

    Orgasmic disorders. Persistent delay or absence of orgasm is a common sexual complaint. Approximately 10% of women report lifelong lack of orgasm and at least 50% report situational or intermittent orgasmic problems.29

    Physical causes of orgasmic dysfunction may possibly include pelvic or spinal surgery/trauma or use of certain medications such as antidepressants or antipsychotics. However, primary lifelong orgasmic disorder rarely has a physical cause. Psychological and interpersonal factors, such as a woman's values regarding sex or unpleasant earlier sexual experiences, may contribute to lack of orgasm. Typically her partner feels responsible for the woman's lack of orgasm, further compounding relationship tension.

    Effective treatments for orgasmic disorder include masturbation and traditional sex therapy techniques. Individual, couples, and group therapy have been shown to be effective.29 Self-help guides, which may be used alone or with a partner and are designed to teach positive body image, relaxation techniques, acceptance of sexual feelings, and sensual touching, are available in many bookstores. Lack of progress using any of the techniques described in such books should merit consultation with a sex therapist. Success rates in the 90% range for becoming orgasmic during masturbation and in the 75% range for attaining orgasm with a partner have been reported following therapy.29

    Dyspareunia. Recurrent genital pain before, during, or after intercourse is known as dyspareunia. Before starting treatment, do a careful physical examination to identify anatomic sites and abnormalities that may cause pain. Anatomic factors associated with dyspareunia such as scar tissue, PID, vaginal stenosis, or endometriosis often improve following medical or surgical treatment. However, not all organic factors are amenable to or resolve following treatment.

    Pain of a diffuse, long-term nature is more difficult to treat. In such instances, referral for psychotherapy may prove beneficial. Treatment strategies may include reliance on noncoital sexual expression, counseling regarding less painful coital positions, use of antidepressants to treat chronic pain syndromes, and anxiety reduction-behavior modification.

    Vaginismus. Recurrent, involuntary spasm of the outer third of the vagina, a condition referred to as vaginismus, interferes with intercourse. In many patients with this complaint, stresses such as relationship problems or desire for pregnancy are prominent causative factors. Psychological factors typically include strong sexual inhibition, sexual trauma (such as rape or incest), unexpressed negative feelings toward a sex partner, and a pain-tension cycle that maintains itself independently of conscious thoughts or emotions.

    The cornerstone of treatment is for the patient to use a series of graduated dilators while practicing relaxation techniques. Gradual involvement of the partner includes his introduction of the dilators, then fingers, and finally gradual insertion of the penis under the woman's guidance and control. For severely phobic women, additional techniques and systematic desensitization may be necessary.

    New frontiers in treatment

    Neurogenic causes of female sexual dysfunction are currently being investigated. The Boston University group has developed an animal model to study female sexual dysfunction.30 Stimulation of the pelvic nerve leads to increased vaginal blood flow, resulting in engorgement and lubrication. In addition, pelvic nerve stimulation results in increased clitoral blood flow, tumescence, and vaginal lengthening. Moreover, these effects were diminished in the presence of vascular abnormalities. As in the penis, vascular abnormalities such as atherosclerotic or ischemic changes resulted in decreased muscle and increased collagen deposition. Whether these histologic changes translate or correlate with sexual dysfunction remains to be determined.

    What is the role of medications approved for erectile dysfunction in treating sexual problems in women? There have been anecdotal reports of the potential lubrication-enhancing effects of phentolamine and sildenafil. We recently conducted an open-label trial utilizing sildenafil in 33 consecutive postmenopausal women with sexual dysfunction.31 All patients received 50 mg of sildenafil. Efficacy was assessed at 4, 8, and 12 weeks, utilizing a newly-developed, self- administered Index of Female Sexual Function (IFSF) (Figure 1). This index quantifies desire, quality of sexual intercourse, and overall satisfaction using measures of sexual function, orgasm, lubrication and clitoral sensation.

     

    Thirty participants (91%) completed the study and were available for follow-up at 3 months. Mean baseline score prior to therapy was 24.8 ± 9.8 and mproved to 31.4 ± 10.4 at 12 weeks (P=0.25). Mean scores for questions No. 2 (lubrication), No. 8 (orgasm) and No. 9 (clitoral sensation) improved by 23.2%, 7.4%, and 31.3%, respectively, at 12 weeks. Overall, only six (18.1%) of 33 patients had a significant therapeutic response, defined as a 60% or more improvement in IFSF score.

    Clitoral discomfort and "hypersensitivity" occurred in seven (21%) of these women, three of whom withdrew from the study. Other side effects, which did not result in withdrawal from the study, included dizziness in two patients and dyspepsia in one.

    The results suggest that sildenafil is safe but of limited efficacy in treating postmenopausal women with self-described sexual dysfunction. Overall sexual function did not improve significantly, although there were changes in vaginal lubrication and clitoral sensitivity. It should be emphasized that this study did not contain a placebo arm, was limited to postmenopausal women, and used only one dose. Whether these results can be duplicated in larger and more varied populations remains to be determined. Nevertheless, the role of various agents in treating this heretofore underaddressed problem is an exciting avenue of future research.

    Conclusion

    In general, the more longstanding the sexual dysfunction, the more difficult it becomes to treat. In addition, the earlier the sexual response cycle is interrupted, the more resilient to treatment it potentially becomes. Therefore, desire phase disorders are generally harder to treat than arousal phase disorders, which in turn are more difficult to treat than orgasmic dysfunction. Finally, multiple interrelationship sexual dysfunctions, such as female anorgasmia coupled with male premature ejaculation, tend to have a synergistic effect and are often more difficult to treat than either problem alone. As we continue to learn more about the specifics of the sexual response cycle, new and exciting treatments will emerge. Gynecologists who are familiar with the basics of diagnosis and therapy can counsel and either treat or appropriately refer these patients.

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    Dr. Kohn is a practicing urologist at Delta Medix, Scranton, Pa., and Clinical Assistant, Department of Urology, College of Physicians and Surgeons, Columbia University, New York, N.Y., where Dr. Kaplan is Professor and Vice Chairman.

     

    Ira J. Kohn, MD
    Dr. Kohn is a practicing urologist at Delta Medix, Scranton, Pa., and Clinical Assistant, Department of Urology, College of Physicians ...

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