Female Sexual Problem - Female Sexual Dysfunction Vaginismus

Sexual Health and

Sexual Problems

Sexual health refers to the ability to enjoy sex. It also includes birth control, abortion, and the avoidance and treatment of sexually transmitted disease.

Sexuality is an important part of health, quality of life, and general wellbeing. As a consequence of the impact of Viagra on male sexual dysfunction, considerable attention is now being paid to sexual dysfunctions in women, which might respond to pharmacological treatment.

In 1918, Marie Stopes published some letters from women who expressed their anxieties about their ‘unnatural’ sexual desire or lack of pleasure in sexual intercourse. Stopes stated that enjoyment of sex could be brought about through information, education and good contraception.

Sexual dysfunction is more prevalent for women (43%) than men (31%). Women of different racial groups demonstrate different patterns of sexual dysfunction. Differences among men are not as marked but generally consistent with women. Experience of sexual dysfunction is more likely among women and men with poor physical and emotional health. Moreover, sexual dysfunction is highly associated with negative experiences in sexual relationships and overall well-being. Sexual dysfunction is an important public health concern, and emotional problems likely contribute to the experience of these problems.⁹⁹⁰¹

Normal sexual response in women

Female sexual arousal is strongly modulated by thoughts and emotions triggered by the state of sexual excitement. An emotional relationship with the partner and emotional wellbeing are the strongest predictors of absence of sexual distress.

Spontaneous sexual desire is common among younger women and those in new relationships. It can be cyclical in younger women and can be disrupted by medical intervention. However, in some women innate desire can endure for decades.

A Model Of Female Sexual Response  - After Taylor & Francis

Stage One - Excitement

This stage can last anywhere from a few minutes to several hours. Sexual activity during this stage is often called foreplay. Extending foreplay can sometimes make the other stages more intense. During this stage:

the blood flow to the genitalia increases

the clitoris swells

the vagina begins to lubricate (becomes wet and slippery)

blood flow to a woman's breasts increases and her nipples may get hard

heart rate and blood pressure increase

breathing may speed up

Stage Two - Plateau

During this stage:

due to increased blood flow, the outer third of the vagina swells and the genitalia appear darker

the clitoris is very sensitive and retracts beneath its hood

heart rate, blood pressure and breathing continue to increase

muscle tension increases and spasms may occur in the feet, face and hands

Stage Three - Orgasm

This stage is also called climax. During this stage:

muscles in the outer third of the vagina contract in a rapid series of pulses

the first contractions are the most intense and the closest together

the muscles in the uterus also contract

heart rate, blood pressure and breathing are at their highest rate

the skin may appear red or flushed (this may begin in earlier stages)

Orgasm is the shortest of the four stages, usually measured in seconds.

Just before or during orgasm, some women release a clear fluid from their urethra. This is now commonly called female ejaculation. Most researchers believe that this is not urine, but instead a clear fluid similar to the fluid containing a man's sperm. Ejaculation is most likely to occur when a woman is being penetrated vaginally and pressure is being applied to the top wall of the vagina. This is where the back of the clitoris meets the wall of the vagina and is sometimes called the G-spot.

Stage Four - Resolution

During this stage:

a woman's clitoris and nipples become softer

the vagina and genitalia return to their normal size and colour

breathing, heart rate and blood pressure decreases

This process typically takes longer for women than men, although some women may be able to return to the plateau stage at this point.

Recommended Books:

 A Woman's Guide to Overcoming Sexual Fear and Pain

Female Sexual Problems

Low sexual desire is more likely to occur in women in relationships for 20-29 years (odds ratio 3.7) and less likely in women reporting greater satisfaction with their partner as a lover or who placed greater importance on sex. Low genital arousal is more likely among women who are perimenopausal (4.4), postmenopausal (5.3,), or depressed (2.5), and is less likely in women taking hormone therapy (0.2), more educated (0.5), in their 30s (0.2) or 40s (0.2), or placed greater importance on sex (0.2). Low orgasmic function is less likely in women who are in their 30s (0.3) or who placed greater importance on sex (0.3). Sexual distress is positively associated with depression (3.1) and is inversely associated with better communication of sexual needs (0.2). Relationship factors are more important to low desire than age or menopause, whereas physiological and psychological factors are more important to low genital arousal and low orgasmic function than relationship factors. Sexual distress is associated with both psychological and relationship factors.⁰⁸⁰¹

Studies indicate that less than half of patients' sexual concerns are known by their physicians, and physicians are unaware of how common these sexual concerns are in their practices. Nussbaum et al⁰⁰⁰¹ mailed their survey in waves. Of 1480 women seeking routine gynecological care 964 responded. The main outcome measures were self-reported sexual concerns and their experiences with discussing these concerns with a physician. A total of 98.8% of the women we surveyed reported one or more sexual concerns. The most frequently reported concerns were

lack of interest (87.2%)

difficulty with orgasm (83.3%)

inadequate lubrication (74.7%)

dyspareunia (71.7%)

body image concerns (68.5%)

unmet sexual needs (67.2%)

need for information about sexual issues (63.4%)

More than half reported concerns about physical or sexual abuse, and more than 40% reported sexual coercion at some point in their lives. It was concluded that sexual health inquiry should be a regular and important part of health care maintenance.

DSM-IV classification of female sexual dysfunction: 1999

1. Sexual Desire Disorders

Hypoactive sexual desire disorder

Sexual aversion disorder

Basson et al⁰⁰⁰² evaluated and revised existing definitions and classifications of female sexual dysfunction. An interdisciplinary consensus conference panel consisting of 19 experts in female sexual dysfunction selected from 5 countries was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease. Classifications were expanded to include

psychogenic and organic causes of desire

arousal, orgasm and sexual pain disorders.

An essential element of the new diagnostic system is the "personal distress" criterion. In particular, new definitions of sexual arousal and hypoactive sexual desire disorders were developed, and a new category of noncoital sexual pain disorder was added. In addition, a new subtyping system for clinical diagnosis was devised. Guidelines for clinical end points and outcomes were proposed, and important research goals and priorities were identified.

Risk Factors for Female Sexual Dysfunction in the General Population: Exploring Factors Associated with Low Sexual Function and Sexual Distress.(2008-01)

The high prevalence of sexual concerns among women seeking routine gynecological care.(2000-01)

Report of the international consensus development conference on female sexual dysfunction: definitions and classifications.(2000-02)

Sexual dysfunction in the United States: prevalence and predictors.(1999-01)

Sexual disorders

Sexual problems can be primary or secondary and generalised or situational.

Physical illness and medication should be considered, but psychological factors are often more important. In some cases there is more than one dysfunction; for example, the woman who experiences sex as painful can develop vaginismus and then have problems becoming aroused. Avoidance of sex can follow and this can lead to loss of intimacy and relationship problems.

Sexual desire disorder

Desire disorders become more common as women age. Desire is affected to some extent by hormones; loss of desire can be experienced at the menopause, regardless of age, and is often reported after a surgically-induced menopause. From early to late menopausal transition, the percentage of women with scores indicating sexual dysfunction rose from 42% to 88%. Decreasing scores correlated with decreasing oestradiol but not with androgens. By the postmenopausal phase there was a significant decline in sexual arousal and interest, frequency of sexual activities, and the Total Score. There was a significant increase in vaginal dryness and dyspareunia and women's reports of their partner's problems in sexual performance. Women with low scores of sexual functioning were more likely to be distressed on the Female Sexual Distress Scale. There is a dramatic decline in female sexual functioning with the natural menopausal transition.⁰³⁰⁴

If a woman expects sexual activity to be rewarding she may well embark on it and enjoy it, whatever her hormonal status. There can be negative psychological factors such as distraction, prediction of a negative outcome because of previous experience of pain, guilt, low sexual esteem, shame, embarrassment and awkwardness. These factors can be the result of earlier negative experiences triggered by culture, loss, trauma or past relationships. Women may learn to keep a tight rein on their emotions generally to avoid conflict and, in particular, to suppress anger.

There may be problems in the current relationship or with a partner’s sexual dysfunction or there may be inadequate stimulation. Depression is a common cause of loss of desire and selective serotoninreuptake inhibitors (SSRIs) affect the sexual response and orgasm in men and women. The existing literature confirms sexual dysfunction as a possible adverse event of all antidepressants, but it is not sufficiently robust to support claims for differences in the incidence of drug-induced sexual dysfunctions between existing antidepressant therapies.⁰²⁰¹

It may help women with hypoactive desire disorder to know that many women do not have spontaneous sexual desire. Thus, treatment can be centred away from why a woman does not have such thoughts and focused on how she can access sexual satisfaction.

Certain types of oestrogen (HRT) therapy are associated with increased frequency of sexual activity, enjoyment, desire, arousal, fantasies, satisfaction, vaginal lubrication, and feeling physically attractive, and reduced dyspareunia, vaginal dryness, and sexual problems. Certain types of testosterone therapy (combined with oestrogen) are associated with higher frequency of sexual activity, satisfaction with that frequency of sexual activity, interest, enjoyment, desire, thoughts and fantasies, arousal, responsiveness, and pleasure. Whether specific serum hormone levels are related to sexual functioning and how these group effects apply to individual women are unclear. Other unknowns include long-term safety, optimal types, doses and routes of therapy, which women will be more likely to benefit from (or be put at risk), and the precise interplay between the two sex hormones.⁰⁴⁰¹

In surgically menopausal women (both ovaries have been removed, usually during hysterectomy) with hypoactive sexual desire disorder, a 300 mug/d testosterone patch significantly increases satisfying sexual activity and sexual desire, while decreasing personal distress, and is well tolerated through up to 24 weeks of use. Tibolone is licensed for the treatment of loss of desire among postmenopausal women.

The effects of postmenopausal hormone therapies on female sexual functioning: a review of double-blind, randomized controlled trials.(2004-01)

The menopause and sexual functioning: a review of the population-based studies.(2003-04)

Antidepressant medications: a review of the evidence for drug-induced sexual dysfunction.(2002-01)

 

Sexual arousal disorder

A woman with sexual arousal disorder cannot access excitement when she wishes to be sexual. Studies show that she may experience the swelling and lubrication of physical arousal but have little subjective experience of pleasure. In women, peripheral feedback from consciously detected genital arousal seems to be a relatively unimportant determinant of subjective sexual arousal.⁹⁵⁰¹

A woman may prevent herself from accessing pleasure for a variety of reasons or she may be mentally disengaged and unaware of any sensations of arousal. There is a small group of women who report subjective feelings of arousal but who do not become physically aroused. Peripheral neuropathy secondary to diabetes, spinal cord injury and surgery may be implicated.

Pharmacological and physical treatments include the use of estrogen, lubricants and vibrators. There may be a place for drugs that increase vasocongestion and vasodilation. One study examined the effect of a single oral dose of sildenafil citrate (Viagra, Pfizer, Inc., New York, NY) on vaginal vasocongestion and subjective sexual arousal in healthy premenopausal women. Twelve women without sexual dysfunction were randomly assigned to receive either a single oral 50 mg dose of sildenafil or matching placebo in a first session and the alternate medication in a second session. Subjective measures of sexual arousal were assessed after participants had been exposed to erotic stimulus conditions. Vaginal vasocongestion was recorded continuously during baseline, neutral, and erotic stimulus conditions. At the end of each session, subjects were also asked to specify which treatment they suspected they had received. Significant increases in vaginal vasocongestion were found with sildenafil treatment compared with placebo. There were no differences between treatments on subjective sexual arousal experience. Analyses by suspected treatment received found that significantly stronger sexual arousal and vaginal wetness were reported for the treatment that was believed to be sildenafil vs. the treatment that was believed to be placebo. The suspected treatment sequence was incorrect for half of the women. Sildenafil was well tolerated, with no evidence of significant adverse events. Sildenafil was found to be effective in enhancing vaginal engorgement during erotic stimulus conditions in healthy women without sexual dysfunction but was not associated with an effect on subjective sexual arousal.

However, the evidence does not show sildenafil to be an effective treatment for women with sexual dysfunction. In a review the pathophysiology of female sexual dysfunction (FSD) and the literature regarding the use of sildenafil in its treatment, search terms included female sexual dysfunction; sexual dysfunction, psychological; phosphodiesterase inhibitors; and sildenafil. The lack of a clear understanding of FSD contributes to the limited treatment options available. Studies regarding the safety and efficacy of the phosphodiesterase 5 inhibitor sildenafil in the management of FSD were evaluated. Many trials have been of poor quality, making clinical application of their results difficult. The current literature does not show sildenafil to be an effective treatment option for FSD.⁰⁶⁰²

Use of sildenafil for female sexual dysfunction.(2006-02)

Determinants of subjective experience of sexual arousal in women: feedback from genital arousal and erotic stimulus content.(1995-01)

Persistent sexual arousal

Persistent sexual arousal is an uncommon condition that was first reported in 2000. The disorder is characterised by sensations of spontaneous and persistent genital arousal that occur without any conscious awareness of sexual desire; orgasm offers only temporary relief. Women are very distressed by this condition, the causes of which are as yet unknown; no definitive treatment can be recommended.

Orgasmic disorder

An orgasm in the human female is a variable, transient peak sensation of intense pleasure, creating an altered state of consciousness, usually with an initiation accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions, and myotonia (muscle relaxation) that resolves the sexually induced vasocongestion and myotonia, generally with an induction of well-being and contentment.

Anorgasmia (inability to experience orgasm) is more common among younger women, demonstrating that sexual response is a learned response. The problem of anorgasmia may be constant, or may occur only with a partner or with penetration.

Women's orgasms can be induced by erotic stimulation of a variety of genital and nongenital sites. As of yet, no definitive explanations for what triggers orgasm have emerged. Studies of brain imaging indicate increased activation at orgasm, compared to pre-orgasm, in the paraventricular nucleus of the hypothalamus, periaqueductal gray of the midbrain, hippocampus, and the cerebellum. Psychosocial factors commonly discussed in relation to female orgasmic ability include age, education, social class, religion, personality, and relationship issues. Findings from surveys and clinical reports suggest that orgasm problems are the second most frequently reported sexual problems in women. Cognitive-behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. To date there are no pharmacological agents proven to be beneficial beyond placebo in enhancing orgasmic function in women.

Sex education, communication skills training and Kegel exercises are often included in cognitive behavioural treatment programmes for anorgasmia. To date there are no trials showing that any pharmacological agent is more efficacious than placebo in enhancing orgasmic function among these women.

Sexual pain disorders

Historically, these conditions are categorised as dyspareunia or vaginismus, but they often overlap. Each case should be considered as a pain syndrome and managed as such.

Approximately 15% of women have chronic dyspareunia that is poorly understood, infrequently cured, often highly problematic, and distressing. Chronic dyspareunia is an urgent health issue.⁰⁵⁰²