Female Sexual Dysfunction

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)

Brain structures involved

• Hippocampus
• Hypothalamus
• Limbic system
• Medial preoptic area

Neurotransmitters involved

• Acetylcholine
• Dopamine
• Epinephrine/norepinephrine
• Nitric oxide
• Opioids
• Serotonin
• Vasoactive intestinal peptide

Neuronal pathways involved

• Stimulation of clitoris → signals transmitted to the spinal cord via the pudendal nerve 
• Stimulation of vagina → signals transmitted to the spinal cord via the pelvic nerve as well as the pudendal and hypogastric nerves
• Primary mediator: 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 in females facilitates sexual response (unlike in males).

Hormonal effects

• Under the control of estrogens and androgens
• 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

Etiology

Physical illness

• Cardiovascular diseases
• Chronic diseases (diabetes mellitus, autoimmune disorders)
• Neurologic impairment
• Malignancies
• Urologic or gynecologic abnormalities
• Estrogen deficiency (leading to vaginal dryness; seen in patients with 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)
• Antihistamine and anticholinergic medications
• Oral contraceptive agents
• Antiandrogens
• Anticonvulsants

Psychological and cultural factors

• Stress and interpersonal conflicts (e.g., infidelity)
• Anxiety
• 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 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.
  • Lipid panel (to rule out hyperlipidemia and vascular 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)
• 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 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.

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:
  • 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 and syncope
• Female orgasmic disorder:
  • Directed masturbation
  • Use of fantasies and vibrators
• Genitopelvic 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: This syndrome occurs in 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. Treatment consists mainly of vaginal lubricants and topical vaginal estrogen.
• Major depressive disorder (MDD): a mood disorder marked by depressed mood, 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.