Female Sexual Dysfunction

Female sexual dysfunction represents a variety of disorders in any part of the sexual response cycle, including desire disorders, arousal disorders, orgasmic disorders, and pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain disorders. The condition may result from stresses and interpersonal conflicts as well as physical illness or medication/substance use. These disorders cause significant distress to the patient and her partner. Treatment options include psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, physical therapy, and pharmacotherapy.

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Female Sexual Response Cycle

Sexual dysfunction (in males or females) arises from problems involving any stage of the sexual response cycle.

The female sexual response cycle is non-linear and more complex than the male sexual response, with additional factors such as emotional intimacy.

Biopsychosocial model of female sexuality (4 factors)

  1. Biological (physical health, neurobiology, endocrine function)
  2. Psychological (performance anxiety, depression)
  3. Sociocultural (upbringing and cultural norms)
  4. Interpersonal (quality of relationship, life stressors)
Model of female sexuality

A model of female sexuality. A problem that consistently impairs sexual arousal or functioning at any point in this cycle will cause sexual dysfunction.

Image by Lecturio.

Brain structures involved

  • Hippocampus
  • Hypothalamus Hypothalamus The hypothalamus is a collection of various nuclei within the diencephalon in the center of the brain. The hypothalamus plays a vital role in endocrine regulation as the primary regulator of the pituitary gland, and it is the major point of integration between the central nervous and endocrine systems. Hypothalamus
  • Limbic system Limbic system The limbic system is a neuronal network that mediates emotion and motivation, while also playing a role in learning and memory. The extended neural network is vital to numerous basic psychological functions and plays an invaluable role in processing and responding to environmental stimuli. Limbic System
  • Medial preoptic area

Neurotransmitters involved

  • Acetylcholine
  • Dopamine
  • Epinephrine/norepinephrine
  • Nitric oxide
  • Opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics
  • Serotonin
  • Vasoactive intestinal peptide

Neuronal pathways involved

  • Stimulation of clitoris → signals transmitted to the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord via the pudendal nerve 
  • Stimulation of vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor → signals transmitted to the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord via the pelvic nerve as well as the pudendal and hypogastric nerves
  • Primary mediator: spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord reflex system (under the inhibitory control of the brainstem, especially the nucleus paragigantocellularis (within the ventral medulla))
  • Activation of the sympathetic nervous system Nervous system The nervous system is a small and complex system that consists of an intricate network of neural cells (or neurons) and even more glial cells (for support and insulation). It is divided according to its anatomical components as well as its functional characteristics. The brain and spinal cord are referred to as the central nervous system, and the branches of nerves from these structures are referred to as the peripheral nervous system. General Structure of the Nervous System in females facilitates sexual response (unlike in males).

Hormonal effects

  • Under the control of estrogens and androgens Androgens Androgens are naturally occurring steroid hormones responsible for development and maintenance of the male sex characteristics, including penile, scrotal, and clitoral growth, development of sexual hair, deepening of the voice, and musculoskeletal growth. Androgens and Antiandrogens
  • Decreased desire and arousal are related to a decrease in estradiol.
  • Testosterone levels may be related to the level of libido.

Male/female comparison of sexual response stages

Stage of sexual response Changes in females Changes in males Changes in both
Desire
  • Motivation or interest in sexual activity
  • Expressed by sexual fantasies
Excitement/arousal
  • Begins with either fantasy or physical contact
  • Vaginal lubrication
  • Clitoral erection
  • Labial swelling
  • Elevation of the uterus in the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis (tenting)
  • Begins with either fantasy or physical contact
  • Erections and testicular enlargement
  • Flushing
  • Nipple erection
  • Hemodynamic changes (increased respiration, pulse, and blood pressure)
Orgasm Vaginal and uterine contractions
  • Tightening of the scrotal sac
  • Secretion of a few drops of seminal fluid
  • Ejaculation
  • Facial grimacing
  • Release of tension
  • Slight clouding of consciousness
  • Involuntary anal sphincter contractions
  • Acute increase in blood pressure and pulse
Resolution Women experience little or no refractory period. Men have a refractory period lasting minutes to hours, during which they cannot re-experience orgasm.
  • Muscles relax.
  • Cardiovascular state returns to baseline.
  • Sexual organs return to normal baseline.

Etiology

Physical illness

  • Cardiovascular diseases
  • Chronic diseases ( diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, autoimmune disorders)
  • Neurologic impairment
  • Malignancies
  • Urologic or gynecologic abnormalities
  • Estrogen deficiency (leading to vaginal dryness; seen in patients with menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause or premature ovarian failure)
  • Other conditions that directly or indirectly affect sexual function:
    • Amenorrhea
    • Bulimia
    • Postpartum state 

Medication or other forms of therapy

  • Psychiatric medications (antipsychotics, antidepressants, mood stabilizers, etc.)
  • Cardiovascular drugs (beta-blockers, digoxin, calcium channel blockers Calcium Channel Blockers Calcium channel blockers (CCBs) are a class of medications that inhibit voltage-dependent L-type calcium channels of cardiac and vascular smooth muscle cells. The inhibition of these channels produces vasodilation and myocardial depression. There are 2 major classes of CCBs: dihydropyridines and non-dihydropyridines. Class 4 Antiarrhythmic Drugs (Calcium Channel Blockers))
  • Antihistamine and anticholinergic Anticholinergic Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs medications
  • Oral contraceptive agents
  • Antiandrogens Antiandrogens Antiandrogenic drugs decrease the effect of androgens. Classes include androgen receptor blockers, 5-alpha-reductase inhibitors, and androgen synthesis inhibitors. Both men and women may use antiandrogens, which treat advanced prostate cancer, benign prostatic hyperplasia (BPH), alopecia, and hirsutism. Androgens and Antiandrogens
  • Anticonvulsants

Psychological and cultural factors

  • Stress and interpersonal conflicts (e.g., infidelity)
  • Anxiety
  • Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder (MDD)
  • Substance abuse
  • Prior history of abuse (both sexual or physical)

Diagnosis

Ruling out anatomic/physiologic causes

Before turning toward the diagnosis of a psychiatric condition, anatomic or physiologic causes should be ruled out via laboratory or radiologic imaging.

  • Laboratory studies
    • Order complete blood count (CBC) to rule out anemias.
    • Measure various hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview involved directly or indirectly in sexual function (thyroid-stimulating hormone (TSH), prolactin, dehydroepiandrosterone (DHEA), estrogen, progesterone, and testosterone levels) to rule out thyroid disorders, in addition to hormonal deficiencies and hyperprolactinemia Hyperprolactinemia Hyperprolactinemia is defined as a condition of elevated levels of prolactin (PRL) hormone in the blood. The PRL hormone is secreted by the anterior pituitary gland and is responsible for breast development and lactation. The most common cause is PRL-secreting pituitary adenomas (prolactinomas). Hyperprolactinemia.
    • Lipid panel (to rule out hyperlipidemia and vascular diseases)
    • Liver function tests Liver function tests Liver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases. Liver Function Tests (to rule out liver dysfunction)
  • Vaginal examination with cervical and urethral swab and assessment of cervical motion tenderness (to rule out pelvic inflammatory disease Pelvic inflammatory disease Pelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and Gardnerella vaginalis. Pelvic Inflammatory Disease)
  • Transvaginal ultrasonography
    • Biothesiometry: assessment of neurologic pelvic status
    • Perineometry: assessment of pelvic floor musculature
    • Vaginal photoplethysmography: assessment of genital blood flow
    • Vulvoscopy: assessment of vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor and surroundings areas

Diagnostic criteria

The diagnosis of female sexual dysfunction and its types is made by clinical observation based on the type of symptoms presented, their severity, and duration.

  • Symptoms must be present for at least 6 months and cause clinically significant distress for the individual.
  • The following conditions must be excluded:
    • Other psychiatric disorders
    • Relationship distress or other stressors
    • Effects of substance abuse/medication use 
  • It is important to note that the specific disorders of female sexual dysfunction often overlap and coexist.
Table: Diagnostic features of disorders of female sexual dysfunction
Female sexual interest/arousal disorder Female orgasmic disorder Genitopelvic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain/penetration disorder (formerly dyspareunia and vaginismus)
  • Lack of or reduced sexual interest/arousal
  • ↓ interests or thoughts of sexual activity
  • No initiation of sexual activity
  • ↓ response or interest in sexual intimacy with partner
  • ↓ sexual pleasure during intercourse
  • ↓ genital/non-genital sensation during sexual activity
  • Marked delay or absence of orgasm
  • Decreased intensity of orgasm
  • Pain during vaginal penetration
  • Fear or anxiety about experiencing pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain during sex
  • Contraction of the pelvic floor muscles during attempted vaginal penetration

Management

Treatment modalities used for all female sexual dysfunction disorders

  • Sex therapy: 
    • Utilizes the concept of the marital unit, rather than the individual
    • Couples meet with a therapist to identify and discuss their sexual problems. 
    • The therapist recommends sexual exercises for the couple to attempt at home.
    • Most useful when no other psychopathology is involved
  • Cognitive behavioral therapy (CBT): 
    • Approaches sexual dysfunction as a learned maladaptive behavior
    • Provokes patients’ anxiety and helps them to reach a better response
  • Hypnosis:
    • Most often used adjunctively with other therapies
    • More useful if anxiety is present
  • Psychodynamic psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy:
    • Individual long-term therapy
    • Focuses on feelings, past relationships (including familial), fears, fantasies, dreams, and interpersonal problems that may be contributing to sexual disorder

Disorder-specific treatments

  • Female sexual interest/arousal disorder:
    • Low doses of testosterone may improve libido in women, especially in postmenopause.
    • Low-dose vaginal estrogen replacement may improve vaginal dryness and atrophy in postmenopausal women.
    • New medications: 
      • Bremelanotide:
        • Melanocortin receptor agonist
        • Administered subcutaneously before anticipated sexual activity
      • Flibanserin: 
        • 5-HT 1A receptor agonist and 5-HT 2A receptor antagonist 
        • Boosts sexual drive
        • May cause severe hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension and syncope Syncope Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope
  • Female orgasmic disorder:
    • Directed masturbation
    • Use of fantasies and vibrators
  • Genitopelvic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain/penetration disorder:
    • Gradual desensitization to achieve intercourse:
      • Start with muscle relaxation techniques
      • Progressing to erotic massage
      • Finally achieving sexual intercourse
    • Hegar dilator

Differential Diagnosis

The following conditions are differential diagnoses of female sexual dysfunction:

  • Genitourinary syndrome of menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause: This syndrome occurs in menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause due to estrogen deficiency, and is marked by vulvar or vaginal dryness, itching, and painful intercourse. The syndrome is associated with urinary changes (frequency, urgency, incontinence). Physical exam findings include a narrow vaginal inlet, decreased elasticity, and pallor of the vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor. Treatment consists mainly of vaginal lubricants and topical vaginal estrogen.
  • Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder (MDD): a mood disorder marked by depressed mood, sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disturbance, anhedonia, feelings of guilt or worthlessness, loss of energy, low concentration, weight or appetite changes, psychomotor retardation or agitation, and suicidal ideation. These symptoms last for ≥ 2 weeks. A decrease in libido and sexual dysfunction may be a sign of underlying depression.

References

  1. Ganti, L. et al. (2016). Sexual dysfunctions and paraphilic disorders Paraphilic disorders Paraphilic disorders are characterized by intense sexual interests that are manifested as unusual behaviors or fantasies other than normal genital stimulation used to reach sexual arousal. They are directed toward persons, animals, or objects and cause significant clinical distress or functional impairment for the patient. Paraphilic Disorders. First Aid for the Psychiatry Clerkship, 4th edition, chapter 16, p. 173-176. http://med-mu.com/wp-content/uploads/2018/08/first-aid-psychiatry.pdf
  2. Shifren, Jan L., MD (2020). Overview of sexual dysfunction in women: Epidemiology, risk factors, and evaluation. UpToDate. Retrieved September 2, 2020, from https://www.uptodate.com/contents/overview-of-sexual-dysfunction-in-women-epidemiology-risk-factors-and-evaluation?search=female%20sexual%20dysfunction&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
  3. Shifren, Jan L., MD (2020). Overview of sexual dysfunction in women: Management. UpToDate. Retrieved September 4, 2020, from https://www.uptodate.com/contents/overview-of-sexual-dysfunction-in-women-management?search=female%20sexual%20dysfunction&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

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