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Female Sexual Dysfunction
Overview
Concepts of female sexual dysfunction are controversial, particularly those based on biological causes. The American Psychological Association (APA) classifies female sexual problems as mental disorders: loss of sexual desire or arousal, discomfort during intercourse, diminished blood flow to the vagina, trauma-related aversion to sex, and the inability to achieve orgasm. Historically, psychiatrists and sex therapists have diagnosed and treated these disorders, perhaps, in many cases, according to limited perspectives maintained by psychiatric literature. Urologists and gynecologists now treat female sexual problems that result from medical conditions causing diminished pelvic and vaginal blood flow and nerve damage.
Currently, urologists, behavioral scientists, and psychologists are looking at medical, cultural, psychological, and relational reasons for women's sexual dysfunction, perhaps more accurately termed sexual dissatisfaction. They are emphasizing education and communication between partners. Surveys of women suggest that therapy should focus on women's physiological needs to experience enjoyable sex instead of medical conditions. Under this view, sexual dissatisfaction is symptomatic of an intimacy problem in which one or both partners fail to communicate their needs.
A useful model for exploring disturbances in female sexual response considers traditional and innovative, psychiatric and medical, and psychological and physiological perspectives. For some women, dysfunction or dissatisfaction is defined by a loss of interest in sex and the inability to become aroused or to achieve orgasm when participating in sex. Many are dissatisfied because their partners are uneducated or inattentive and do not understand female arousal and its anatomical basis. For others, a medical evaluation uncovers a physiological problem that impairs sensitivity. The concept of dysfunction, or dissatisfaction, remains poorly defined.
Incidence and Prevalence
The absence of dependable empirical data combined with varying definitions about sexual dysfunction, and even normal sexual practices, prevents a clear understanding of the prevalence of women's sexual problems. While some studies document a prevalence of dysfunction among non-Caucasian women and women of lower socioeconomic status, opponents of these studies point to a lack of diversity in these test populations.
A survey conducted by the American Medical Association in 1999 indicates that sexual dysfunction affects approximately 43% of women in the United States. Age may not be a significant factor, as women under 20 and over 50 experience problems with arousal, orgasm, and satisfaction. However, there is evidence that the majority of female sexual dysfunction happens after menopause, when hormone production drops and vascular conditions are more common.
Female Sexual Response Cycle
The clinical definition of the female sexual response cycle consists of four stages of arousal, marked by physiological and psychological changes. The first stage is excitement, which can be triggered by psychological or physical stimulation, and is marked by emotional changes, and increased heart rate, respiration, and vaginal swelling and lubrication due to increased blood flow. Sustained excitement is called the plateau, the second stage. Vaginal swelling, heart rate, and muscle tension may increase as long as stimulation continues. The breasts enlarge, the nipples become erect, and the uterus dips. The third stage is orgasm, which involves synchronized vaginal, anal, and abdominal muscle contractions, the loss of involuntary muscle control, and intense pleasure. The final phase, resolution, involves a rush of blood away from the vagina, shrinking breasts and nipples, and a reduction in heart rate, respiration, and blood pressure.
A normal or healthy response cycle may be as poorly defined as a dysfunctional one. How women experience these stages varies; for example, some progress from excitement to orgasm rapidly, and others alternate between plateau and orgasm several times before reaching resolution.
Causes
The causes of female sexual dysfunction are poorly defined. Several factors may impede the sexual response cycle, which requires physical and psychological stimulation:
• Alcohol
• Anxiety
• Depression
• Emotional problems; distraction
• Illness
• Negative body perception
• Stress
Recently, controversy has produced two opposing medical perspectives on the causes (and treatment) for female sexual dysfunction. One concept, known as the vascular theory, is that diminished blood flow to the pelvic region, due to a medical condition, aging, stress, or hypoactive sexual desire, causes reduced sensitivity (particularly of the clitoris) and dryness, and impairs arousal. Decreased blood flow is associated with medical conditions such as diabetes and artherosclerosis. This concept has fueled clinical research and has led to the introduction of topical creams that, when applied to the clitoris, cause vascular dilation, increased blood flow, and vascular congestion associated with the excitement stage. Sensitivity is increased and may lead to arousal.
A second concept, the hormone theory, focuses on decreased levels of sex hormones, such as estrogen and testosterone, caused by aging. For some women, hormone replacement therapy leads to greater sexual desire. Estrogen, a primarily female hormone, is associated with sexual desire. Testosterone, a primarily male sex hormone, plays a role in women's sexual development and function, including sensitivity of the breasts and clitoris. Some women experience diminished sexual desire, absence of sexual fantasies, and impaired sensitivity following menopause or hysterectomy as a result of reduced estrogen.
Other medical causes include the following:
• Bicycle riding (long narrow seats associated with perineal pressure and reduced blood flow)
• Drugs and medications; birth control pill
• Smoking
• Spinal cord injury (can cause nerve damage; paralysis)
• Surgery (of or near reproductive-urinary system or abdomen; may damage nerves)
• Urinary incontinence (can cause embarrassment, avoidance)
• Vaginal atrophy
Antidepressants and benzodiazepines (fluoxetine, Prozac®, alprazolam, Xanax®) used to treat depression and anxiety are the drugs most commonly associated with loss of libido and inability to achieve orgasm. Buproprion (Wellbutrin®, an antidepressant) is sometimes prescribed for those who experience drug-related loss of sexual desire. Some evidence suggests that it restores libido. Chemotherapy drugs used to treat cancer are also associated with a lack of sexual interest. Some evidence suggests that extended use of birth control pills leads to reduced libido. Spinal cord injury, pelvic trauma, and other conditions that affect the peripheral nervous system, such as diabetes, can impair genital sensitivity, as can surgery involving the pelvic floor, bladder, abdomen, and genitals.
A third perspective, what could be called the dissatisfaction theory, is neither psychological nor medical. A great deal of women's sexual dysfunction is not caused by hormone deficiency or diminished pelvic blood flow; it results from inadequate genital stimulation. The fact that young, healthy women experience sexual dysfunction gives credence to this view. Poor communication by both partners may result in men not knowing how to stimulate a woman so that she becomes aroused. This leads to unsatisfactory sex and can cause arousal problems, lack of sexual interest, depression, and aversion to sex. Interestingly, the APA lists the "adequacy of [female] sexual stimulation" as a factor only in its discussion of female orgasmic disorder. This implies that it is not a fundamental aspect of female sexual function and so not affected by medical or psychological conditions.
Diagnosis
Psychological
The APA classifies sexual disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) because they tend to disrupt interpersonal relationships and cause psychological distress. All disorders listed in the DSM in some way disturb the process of arousal and the sexual response cycle. Although controversial, it is the standard approach used by many psychiatrists and clinicians in the United States and other countries to female sexual problems.
Hypoactive sexual desire disorder is characterized by an absence of libido. There is no interest in initiating sex and little desire to seek stimulation. Sexual aversion disorder is characterized by an aversion to or avoidance or dismissal of sexual prompts or sexual contact. It may be acquired following sexual or physical abuse or trauma and may be life-long. The main feature of female sexual arousal disorder is an inability to achieve and progress through the stages of "normal" female arousal. Female orgasmic disorder is defined as the delay or absence of orgasm after "normal" arousal. Dyspareunia is marked by genital pain before, during, or after intercourse. Vaginismus is the involuntary contraction of the perineal muscles around the vagina as a response to attempted penetration. Contraction makes vaginal penetration difficult or impossible.
These disorders must cause personal distress and must not be accounted for by a medical condition. A distinction is made between disorders that are life-long and those that are acquired, as well as those that are situational and generalized.
Medical
In cases where a medical condition is suspected as the underlying cause, whether it causes inadequate blood flow, nerve-related loss of sensitivity, or reduced hormone levels, a specialist conducts an appropriate diagnosis. Sexual problems may be symptomatic of diseases that require treatment, like diabetes, endocrine disorders of the hypothalamic-pituitary-gonadal axis, and neurological disorders.
The American Foundation of Urologic Disease (AFUD) classifies the APA's criteria into these four types of disorder:
• Hypoactive sexual desire disorder; includes sexual aversion disorder
• Sexual arousal disorder
• Orgasmic disorder
• Sexual pain disorders; includes vaginismus, dyspareunia
Contrary to APA stipulation, dyspareunia (pain during intercourse) may be diagnosed as a result of inadequate vaginal lubrication, which may be considered an arousal disorder and treated as such. Pain is associated with recurrent medical conditions, including cystitis.
Physiological Diagnostic Tests
Vaginal blood flow and engorgement (pooling and swelling of vaginal tissue) can be measured with vaginal photoplethysmography, in which an acrylic tampon-shaped instrument inserted in the vagina uses reflected light to sense flow and temperature. It cannot be used to assess advanced levels of arousal, say, during orgasm, because movement skews its reading. Also, limited knowledge of normative vaginal engorgement levels makes for only speculative results. Vagnial pH testing, commonly performed by gynecologists and urologists to detect bacteria-causing vaginitis, may be useful. A probe inserted into the vagina takes the reading. Decreasing hormone levels and diminished vaginal secretion associated with menopause cause a rise in pH (over 5), which is easily detected with the test. A biothesiometer, a small cylindrical instrument, may be used to assess the sensitivity of the clitoris and labia to pressure and temperature. Readings are taken before and after the subject watches erotic video and masturbates with a vibrator for approximately 15 minutes.
Treatment
There are three primary types of experimental treatment for female sexual dysfunction:
• Education on female anatomy, arousal, and response; where blood flow, hormone levels, and sexual anatomy are normal
• Hormone replacement therapy (including treatment of the underlying disorder)
• Vascular treatment (including treatment of the underlying disorder)
Educating both women and men on how to talk about and respond to a woman's psychological and physical stimulatory needs can only happen if both partners recognize that there is a problem. Behavioral and sex therapists note the need for partners to examine the actual act of having sex, including foreplay, intercourse, and talking about sex. Sex therapists and psychologists may assist in improving communication between partners.
Hormone replacement therapy (HRT) is aimed at restoring hormone levels affected by age, surgery, or hormone dysfunction to normal, thus restoring sexual function. Estrogen and testosterone levels are measured and treated by endocrinologists.
Sildenafil (Viagra®), used in men with erectile dysfunction, is currently being tested in women. Some evidence suggests that it may restore libido lost to antidepressant use.
A medical condition that causes diminished blood flow to the vagina must be addressed in light of sexual dysfunction. However, some women who are not diagnosed with underlying medical conditions have found that nonprescription topical solutions, like Viacreme® or Viagel®, increase sensitivity and assist in achieving orgasm. Viacreme® is an amino-acid based (L-arginine) solution that contains menthol. L-Arginine is involved in nitric oxide synthesis, which is responsible for vascular and nonvascular smooth muscle relaxation. When applied to the clitoris, Viacreme® may increase blood flow by dilating clitoral blood vessels.
More research is needed to assess the possible effects and complications of topical creams. At this time, the United States Food and Drug Administration (FDA) has not approved them.
Eros Therapy™
The Eros Therapy™ is an FDA-approved device for the treatment of female sexual dysfunction. This small handheld device is used 3 to 4 times per week to increase blood flow to the clitoris and external genitalia, which improves clitoral and genital sensitivity, lubrication, and the ability to experience orgasm. It may take several weeks of conditioning before experiencing the benefits of this therapy.
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