Female Sexual Dysfunction

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.¹ Female sexual dysfunction (FSD) is a serious problem in the United States, and unfortunately 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.

DEFINING SEXUAL DYSFUNCTION

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 preexisting definitions and classifications of FSD.² Medical risk factors, etiologies, and psychological aspects were classified into four categories of FSD: desire, arousal, orgasmic disorders, and sexual pain disorders:

• 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.
• 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 responses.
• Orgasmic disorder is the persistent or recurrent difficulty, delay, or absence of attaining orgasm after sufficient sexual stimulation and arousal.
• 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: lifelong versus acquired; generalized versus situational; and of organic, psychogenic, mixed, and unknown etiologic origin.

PREVALENCE

Approximately 40 million American women are affected by FSD.3 The National Health and Social Life Survey, a probability sample study of sexual behavior in a demographically representative cohort of US adults ages 18 to 59, found that sexual dysfunction is more prevalent in women (43%) than in men (31%), and decreases as women age.⁴ 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 Caucasian women. Sexual pain, however, is more likely to occur in Caucasians. This survey was limited by its cross-sectional design and age restrictions, since women more than 60 years old 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.

PATHOPHYSIOLOGY

FSD has both physiologic and psychological components. It is important to first understand the normal female sexual response in order 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.³

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 thought to mediate clitoral and labial engorgement, while vasoactive intestinal polypeptide, a nonadrenergic/noncholinergic neurotransmitter, may enhance vaginal blood flow, lubrication, and secretions.⁵

Many changes occur in the female genitalia during sexual arousal. Increased blood flow promotes vasocongestion of the genitalia. Secretions from uterine and Bartholin's glands lubricate the vaginal canal. Vaginal smooth muscle relaxation allows for lengthening and dilatation of the vagina. As the clitoris is stimulated, its length and diameter increase and engorgement occurs. In addition, the labia minora promote engorgement due to 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.⁶ In 1974, Kaplan modified this theory and characterized it as a three-phase model that included desire, arousal, and orgasm.⁷ Basson proposed a different theory for the female sexual response cycle,⁸ 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 are gained by an increase in sexual desire and arousal. Emotional intimacy is then ultimately achieved. Various biological and psychological factors can negatively affect this cycle, thus leading to FSD.

SIGNS AND SYMPTOMS

Sexual dysfunction presents in a variety of ways. It is important to elicit specific signs and symptoms since 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.

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.⁽⁹⁾ 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.⁽¹⁰⁾ 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 in order 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).⁽¹¹⁾ 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 (table2).⁽⁹⁾ Women who have undergone gynecologic surgeries, ie, 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.⁽¹²⁾

Prescription and over-the-counter medications should be reviewed in order to identify any contributing agents (table 3).^(13,14) 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.

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Last reviewed 10/05.

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