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Female sexual dysfunction

Female sexual dysfunction

Sexual dysfunction includes pain during intercourse, involuntary painful contraction (spasm) of the muscles around the vagina, and lack of interest in (desire for) sex and problems with arousal or orgasm. Female sexual dysfunction is a common problem. Depending on the questions asked, surveys have shown that from 35% to 98% of women report sexual concerns.

Questions related to sexual functioning should be asked as part of the routine medical history. Three helpful questions to broach the topic are “Are you currently involved in a sexual relationship?” “With men, women, or both?” and “Do you have any sexual concerns or any pain with sex?” If the woman is not involved in a sexual relationship, she should be asked if there are any concerns that are contributing to a lack of sexual behavior.

If a history of sexual dysfunction is elicited, a complete history of factors that may affect sexual function should be taken. These factors include her reproductive history (including pregnancies and mode of delivery) as well as history of infertility, sexually transmitted diseases, rape or sexual violence, gynecologic or uro­logic disorders, endocrine abnormalities (such as diabetes mellitus or thyroid disease), neurologic problems, cardiovascular disease, psychiatric disease, and current prescription and over-the-counter medication use.

A detailed history of the specific sexual dysfunction should be elicited, and a gynecologic examination should focus on findings that may contribute to sexual complaints.

Causes

A. Disorders of Sexual Desire

Sexual desire in women is a complex and poorly understood phenomenon. Emotion is a key factor in sexual desire. Anger toward a partner, fear or anxiety related to previous sexual encounters, or history of sexual abuse violence may contribute. Physical factors such as chronic illness, fatigue, depression, and specific medical disorders (such as diabetes mellitus, thyroid disease, or adrenal insufficiency) may contribute to a lack of desire. Menopause and attitudes toward aging may play a role. In addition, sexual desire may be influenced by other sexual dysfunction, such as arousal disorders, dyspareunia, or anorgasmia.

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B. Sexual Arousal Disorders

Sexual arousal disorders may be both subjective and objec­tive. Sexual stimulation normally leads to genital vasocon­gestion and lubrication. Some women may have a physiologic response to sexual stimuli, but may not subjec­tively feel aroused because of factors such as distractions; negative expectations; anxiety; fatigue; depression; or med­ications, such as selective serotonin reuptake inhibitors (SSRIs) or oral contraceptives. Other women may lack both a subjective and physiologic response to sexual stimuli related to vaginal atrophy.

C. Orgasmic Disorders

In spite of subjective and physiologic arousal, women may experience a marked delay in orgasm, diminished sensa­tion of an orgasm, or anorgasmia. The etiology is complex and typically multifactorial, but the disorder is usually amenable to treatment.

D. Sexual Pain Disorders

Dyspareunia and vaginismus are two subcategories of sex­ual pain disorders.

Dyspareunia is defined as recurrent or persistent genital pain associated with sexual intercourse that is not caused exclusively by lack of lubrication or by vaginismus and causes marked distress or interpersonal difficulty.

Vulvo­dynia is the most frequent cause of dyspareunia in premeno­pausal women. It is characterized by a sensation of burning along with other symptoms, including pain, itching, sting­ing, irritation, and rawness. The discomfort may be constant or intermittent, focal or diffuse, and experienced as either deep or superficial. There are generally no physical findings except minimal erythema that may be associated in a subset of patients with vulvodynia, those with vulvar vestibulitis.

Vulvar vestibulitis is normally asymptomatic but pain is associated with touching or pressure on the vestibule, such as with vaginal entry or insertion of a tampon. Pain occur­ring with deep thrusting during coitus is usually due to acute or chronic infection of the cervix, uterus, or adnexa; endo­metriosis; adnexal tumors; or adhesions resulting from prior pelvic disease or operation.

Vaginismus is defined as recurrent or persistent invol­untary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse, resulting from fear, pain, sexual violence, or a negative attitude toward sex, often learned in childhood, and causing marked distress or interpersonal difficulty. Other medical causes of sexual pain may include vulvovaginitis; vulvar disease, including lichen planus, lichen sclerosus, and lichen simplex chronicus; pelvic disease, such as endome­triosis or chronic PID; or vaginal atrophy.

Treatment

A. Disorders of Sexual Desire

In the absence of specific medical disorders, arousal or orgasmic disorders or dyspareunia, the focus of therapy is psychological. Cognitive behavioral therapy, sexual therapy, and couples therapy may all play a role. Success with pharmacologic therapy, particularly the use of dopa­mine agonists or testosterone with estrogen, has been reported, but data from large long-term clinical trials are lacking.

B. Sexual Arousal Disorders

As with disorders of sexual desire, arousal disorders may respond to psychological therapy. The phosphodiesterase inhibitors used in men do not appear to benefit the major­ity of women with sexual arousal disorders. However, there is some evidence to suggest a role for sildenafil in women with sexual dysfunction due to multiple sclerosis, type 1 diabetes mellitus, spinal cord injury, and antidepressant medications if other established approaches fail.

Flibanse­rin (Addyi), an antidepressant, was approved by the FDA in August 2015 as an effective treatment of hypoactive sexual desire disorder in premenopausal women; however, it must be used long term to be effective and has significant risks that require specific certifications of providers and pharmacies for dispensation to patients in the United States. While this medication remains available, it is not commonly prescribed.

C. Orgasmic Disorders

For many women, counseling or sex therapy may be ade­quate treatment. There is an FDA-approved vacuum device that increases clitoral blood flow and may improve the likelihood of orgasm.

D. Sexual Pain Disorders

Specific medical disorders, such as endometriosis, vulvo­vaginitis, or vaginal atrophy, should be treated as outlined in other sections of this chapter. Lichen scle­rosus, a thinning and whitening of the vulvar epithelium, is treated with clobetasol propionate 0.05% ointment, applied twice daily for 2–3 months.

Vaginismus may be treated initially with sexual coun­seling and education on anatomy and sexual functioning. The patient can be instructed in self-dilation, using a lubri­cated finger or dilators of graduated sizes. Before coitus (with adequate lubrication) is attempted, the patient—and then her partner—should be able to easily and painlessly introduce two fingers into the vagina. Penetration should never be forced, and the woman should always be the one to control the depth of insertion during dilation or inter­course. Injection of botulinum toxin has been used suc­cessfully in refractory cases.

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Since the cause of vulvodynia is unknown, management is difficult. Few treatment approaches have been subjected to methodologically rigorous trials. A variety of topical agents have been tried, although only topical anesthetics (eg, estrogen cream and a compounded mixture of topical amitriptyline 2% and baclofen 2% in a water washable base) have been useful in relieving vulvodynia.

Useful oral medications include tricyclic antidepressants, such as ami­triptyline in gradually increasing doses from 10 mg/day to 75–100 mg/day; various SSRIs; and anticonvulsants, such as gabapentin, starting at 300 mg three times daily and increasing to 1200 mg three times daily. Biofeedback and physical therapy, with a physical therapist experienced with the treatment of vulvar pain, have been shown to be help­ful. Surgery—usually consisting of vestibulectomy—has been useful for women with introital dyspareunia

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