Definitions

Sexual dysfunction is defined as a disturbance in, or pain during, the 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. ¹ Medical risk factors, etiologies, and psychological aspects were classified into four categories of FSD: hypoactive sexual desire, arousal, orgasmic disorders, and sexual pain disorders. An explanation of each entity follows:

1. Hypoactive sexual desire is the persistent or recurrent deficiency (or absence) of sexual fantasies or thoughts and/or the lack of receptivity to sexual activity.
2. Sexual arousal disorder is the persistent or recurrent inability to achieve or maintain sufficient sexual excitement, expressed as a lack of excitement or a lack of genital or other somatic re-sponses.
3. Orgasmic disorder is the persistent or recurrent difficulty, delay, or absence of attaining orgasm after sufficient sexual stimulation and arousal.
4. Sexual pain disorder includes dyspareunia (genital pain associated with sexual intercourse); vaginismus (involuntary spasm of the vaginal musculature that causes interference with vaginal penetration), and noncoital sexual pain disorder (genital pain induced by noncoital sexual stimulation).

Each of these definitions has three additional subtypes (1) lifelong versus acquired; (2) generalized versus situational; and (3) of organic, psychogenic, mixed, or unknown causative origin.

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Prevalence

Approximately 40 million American women are affected by FSD. ² 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. ³ 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. Sexual pain, however, is more likely to occur in white women. This survey was limited by its cross-sectional design and age restrictions, because women older than 60 years were excluded. Also, no adjustments were made for the effects of menopausal status or medical risk factors. Despite these limitations, the survey clearly indicates that sexual dysfunction affects many women.

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Pathophysiology

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. ²

Physiologic and biochemical mediators that modulate vaginal and clitoral smooth-muscle tone and relaxation are currently under investigation. Neuropeptide Y, vasoactive intestinal polypeptide, nitric oxide synthase, cyclic guanosine monophosphate, and substance P have been found in vaginal-tissue nerve fibers. Nitric oxide is believed to mediate clitoral and labial engorgement, whereas vasoactive intestinal polypeptide, a nonadrenergic/noncholinergic neurotransmitter, may enhance vaginal blood flow, lubrication, and secretions. ⁴

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. ⁵ In 1974, Kaplan modified this theory and characterized it as a three-phase model that included desire, arousal, and orgasm. ⁶ Basson proposed a different theory for the female sexual response cycle, ⁷ suggesting that the sexual response is driven by the desire to enhance intimacy (Fig. 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.

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Signs and symptoms

Sexual dysfunction manifests in a variety of ways. It is important to elicit specific signs and symptoms because many 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 pain with sexual stimulation or intercourse, anorgasmia, delayed orgasm, and decreased arousal. Postmenopausal women with estrogen deficiency and vaginal atrophy may also describe a decrease in vaginal lubrication.

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Diagnosis

History

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. ⁸ 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. ⁹ 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 ). ¹⁰ 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.

There are many gynecologic causes of FSD, contributing to physical, psychological, and sexual difficulties (Box 1). ⁸ 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. ¹¹

Prescription and over-the-counter medications should be re-viewed to identify any contributing agents (Table 2 ). ^12,13 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.

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.

Physical Examination

A thorough physical examination is required to identify disease. The entire body and genitalia should be examined. The genital examination can be used to reproduce and localize pain that is encountered during sexual activity and vaginal penetration. ¹⁴ External genitalia should be inspected. Skin color, texture, thickness, turgor, and the amount and distribution of pubic hair should be assessed. Internal mucosa and anatomy should then be examined and cultures taken if indicated. Attention should be given to muscle tone, location of episiotomy scars and strictures, tissue atrophy, and the presence of discharge in the vaginal vault. Some women with vaginismus and severe dyspareunia may not endure a normal speculum and bimanual examination—a “monomanual” examination using one to two fingers may be better tolerated. ⁸ The bimanual or monomanual examination can give information about rectal disease, uterine size and position, cervical motion tenderness, internal muscle tone, vaginal depth, prolapse, ovarian and adnexal size and location, and vaginismus.

Laboratory Tests

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. ¹⁵ Hyperprolactinemia may also be associated with decreased libido.

Other Tests

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. ¹⁶ These tests may be helpful in guiding medical therapy.

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Treatment and outcomes

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 ( Table 3 ).

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. ¹⁷

Hypoactive Sexual Desire

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. ¹⁸ 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). ¹⁸ 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. ¹⁴

Before initiating therapy, potential side effects and risks of treatment should be discussed. Androgenic side effects can occur in 5% to 35% of women taking testosterone and they include acne, weight gain, hirsutism, clitorimegaly, deepening of the voice, and lowering of high-density lipoprotein cholesterol. ¹⁹ Baseline levels of lipids, testosterone (free and total), and liver function enzymes should be obtained in addition to a mammogram and Pap smear if indicated.

Postmenopausal women may benefit from 0.25 to 2.5 mg of methyltestosterone (Android, Methitest, Testred, Virilon) or up to 10 mg of micronized oral testosterone. Doses are adjusted according to symptom control and side effects. Methyltestosterone is also available in combination with estrogen (Estratest, Estratest H.S.). Some women may benefit from topical methyltestosterone or testosterone propionate compounded with petroleum jelly in a 1% to 2% formula. This ointment can be applied up to three times per week. ^8,18 It is important to periodically monitor liver function, lipids, testosterone levels, and androgenic side effects during treatment.

There are various over-the-counter herbal products that advertise improvement in female sexual dysfunction and restoration of hormone levels. Although evidence is conflicting, many of these products lack sufficient scientific studies required to support the manufacturer's claims of efficacy and safety. ^20,21 Patients should be cautioned about the potential for side effects and drug-to-drug interactions with these products.

Tibolone is a synthetic steroid with tissue-specific estrogenic, progestogenic and androgenic properties. It has been used in Europe for the past 20 years in the prevention of postmenopausal osteoporosis and in the treatment of menopausal symptoms, including sexual dysfunction. It is not yet available in the United States, but is actively being studied. ²²

Sexual Arousal Disorder

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. ²³ 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.

Orgasmic Disorder

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

Sexual Pain Disorder

Sexual pain can be classified as superficial, vaginal, or deep. Superficial pain is often caused by vaginismus, anatomic abnormalities, or irritative conditions of the vaginal mucosa. Vaginal pain can be caused by friction as a result of inadequate lubrication. Deep pain can be muscular in nature or associated with pelvic disease. ¹⁴ The type(s) of pain a woman experiences can dictate therapy, thereby making an aggressive approach to an accurate diagnosis imperative. The use of lubricants, vaginal estrogens, topical lidocaine, moist heat to the genital area, NSAIDs, physical therapy, and positional changes may help to minimize discomfort during intercourse. Sex therapy may benefit women with vaginismus because it is often triggered by a history of sexual abuse or trauma.

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Conclusion

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.

Summary

• Physicians must encourage patients to discuss Female Sexual Dysfunction (FSD).
• The Sexual Function Health Council of the American Foundation of Urologic Disease has classified FSD into four categories: desire, arousal, orgasmic, and sexual pain disorders.
• An accurate diagnosis of FSD requires a thorough medical and sexual history including issues of sexual preference, domestic violence and fears of pregnancy, human immunodeficiency virus and sexually transmitted disease.
• Even if no exact cause can be identified, basic treatment strategies such as enhancing stimulation, avoiding mundane routines, making time for sexual activities, communicating with their partners about sexual needs, and using noncoital behaviors can be applied.
• Patients want to talk about sexual problems with physicians, but often fail to do so, thinking their physicians are too busy, the topic is too embarrassing, or there is no treatment available. ²⁴ Female sexual dysfunction (FSD) is a serious problem in the United States and unfortunately it often goes untreated. It is a difficult and complex problem to address in the medical setting, but it must not be neglected. Physicians must encourage patients to discuss FSD, and then aggressively treat the underlying disease or condition.

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Suggested Readings

• Avlimil taken for female sexual dysfunction. A J Nurs. 104: 2004; 27-29.
• Sexual dysfunction. Steege JF, Metzger DA , Levy BS. Chronic Pelvic Pain: An Integrated Approach. 1998; ;Philadelphia. 77-90.
• Human sex-response cycles. J Sex Marital Ther. 27: 2001; 33-43.
• Report of the international consensus development conference on female sexual dysfunction: Definitions and classifications. J Urol. 163: 2000; 888-893.
• Female sexual dysfunction: Incidence, pathophysiology, evaluation, and treatment options. Urology. 54: 1999; 385-391.
• Effect of sildenafil on subjective and physiologic parameters of the female sexual response in women with sexual arousal disorder. J Sex Marital Ther. 27: 2001; 411-420.
• Female sexual dysfunction. Urol Clin North Am. 28: 2001; 405-416.
• Sexuality during pregnancy and the year postpartum. J Fam Pract. 47: 1998; 305-308.
• An update. Med Lett Drugs Ther. 34: 1992; 73-78.
• Medications that may contribute to sexual disorders. A guide to assessment and treatment in family practice. J Fam Pract. 44: 1997; 33-43.
• A placebo-controlled, double-blind trial of Ginkgo biloba for antidepressant-induced sexual dysfunction. Human Psychopharmacology.. 17: 2002; 279-284.
• The New Sex Therapy: Active Treatment of Sexual Disorders. 1974; ;London.
• Sexual dysfunction in the United States: Prevalence and predictors. JAMA. 281: 1999; 537-544.
• Survey says patients expect little physician help on sex. JAMA. 281: 1999; 2173-2174.
• Human Sexual Response. 1966; ;Boston.
• Prevention for the older woman. A practical guide to hormone replacement therapy and urogynecologic health. Geriatrics. 56: 2001; 32-34.
• Female sexual dysfunction in postmenopausal women: Systematic review of placebo-controlled trials. Am J Obstet Gynecol. 188: 2003; 286-293.
• Sildenafil inhibits phosphodiesterase type 5 in human clitoral corpus cavernosum smooth muscle. Biochem Biophys Res Commun. 249: 1998; 612-617.
• Female sexual dysfunction: Evaluation and treatment. Am Fam Physician. 62: 2000; 127-136.
• The clinical evaluation of dyspareunia. Int J Impot Res. 10: 1998; S117-S120.
• The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 26: 2000; 191-208.
• Risks of menopausal androgen supplementation. Semin Reprod Endocrinol. 16: 1998; 145-152.
• Stimulation of the libido: The use of erotica in sex therapy. Psychiatr Ann. 29: 1999; 60-62.
• Clitoral electromyography. J Urol. 167: 2002; 616-620.