Female sexual dysfunction represents a variety of disorders in any part of the sexual response cycle. This includes desire disorders, arousal disorders, orgasmic disorders, and pain disorders. It might 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, physical therapy, and pharmacotherapy.

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Introduction

Female sexual response cycle is a non-linear response. It is more complex with additional factors such as emotional intimacy.

  • Biopsychosocial model of female sexuality consists of four factors:
    • Biology (physical health, neurobiology, endocrine function)
    • Psychological (performance anxiety, depression)
    • Sociocultural (upbringing and cultural norms)
    • Interpersonal (quality of relationship, life stressors)
  • Brain structures involved:
    • Hippocampus
    • Hypothalamus
    • Limbic system
    • Medial preoptic area
  • Neurotransmitters involved, e.g.:
    • 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 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 men).
  • Hormonal effects: 
    • Under the control of estrogens and androgens
    • Decreased desire and arousal are related to a decrease in estradiol.
    • Testosterone might be related to the level of libido.
  • Sexual dysfunctions (in males or females) arise from problems involving any stage of the sexual response cycle
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 (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

Ejaucaltion 

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 reexperience orgasm Muscles relax 

Cardiovascular state returns to baseline

Sexual organs return to normal baseline

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Female Sexual Dysfunction by Lynae Brayboy, MD

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 Medications 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 factors

Diagnosis

Before turning towards a psychiatric condition, one must rule out anatomic or physiologic causes via laboratory or radiologic imaging. It is important to note that these disorders often overlap and coexist.

Laboratory studies

  • Order CBC to rule out anemias
  • Measure various hormones involved directly or indirectly in sexual function to rule out thyroid disorders in addition to hormonal deficiencies and hyperprolactinemia.
    • TSH,
    • Prolactin
    • DHEA
    • Estrogens
    • Progesterones
    • Testosterone levels
  • Lipid panel (rule out hyperlipidemia and vascular diseases)
  • Liver function tests (rule out liver dysfunction)

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

DSM-V diagnostic criteria for female sexual dysfunction:

  • Disorder causes clinically significant distress.
  • Present for at least 6-month duration
  • Exclude other disorders:
    • Mental disorder
    • Relationship distress
    • Other stressors
    • Substance/medication 
    • Other medical condition

DSM-V diagnostic criteria for specific female sexual disorder:

  • Female sexual interest/arousal disorder
    • Lack of or reduced, sexual interest/arousal
    • Include at least 3 features from the following:
      • Decreased interests or thoughts of sexual activity
      • No initiation of sexual activity
      • Decreased response or interest to sexual intimacy from partner
      • Decreased sexual pleasure during intercourse 
      • Decreased genital/non-genital sensation during sexual intercourse or activity
  • Female orgasmic disorder
    • Presence of either of the following:
      • Marked delay or absence of orgasm
      • Decreased intensity of orgasm
  • Genitopelvic pain/ penetration disorder (formerly dyspareunia and vaginismus)
    • Persistent difficulties with one (or more) of the following:
      • Pain during penetration.
      • Fear or anxiety about sex or pain during sex
    • Contraction of the pelvic floor muscles during attempted vaginal penetration.
  • Other specific sexual dysfunction
    • Includes disorders with similar symptoms and clinically significant distress but does not meet the full criteria for any of the other disorders
      (e.g., “sexual aversion”).

Treatment

There are general 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. 
    • Therapist recommends sexual exercises for the couple to attempt at home.
    • Most useful when no other psychopathology is involved
  • 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
  • Female sexual interest/arousal disorder treatment
    • 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 treatment
    • Directed masturbation
    • Use of fantasies and vibrators
  • Genitopelvic pain/penetration disorder treatment
    • Gradual desensitization to achieve intercourse:
      • Start with muscle relaxation techniques
      • Progressing to erotic massage
      • Finally achieving sexual intercourse
  • Hegar dilator

Differential Diagnoses

Genitourinary syndrome of menopause
Syndrome occurs in menopause due to estrogen deficiency, it is marked by vulvar or vaginal dryness, itching, and painful intercourse. Associated with urinary changes (frequency, urgency, incontinence). Physical exam findings include narrow vaginal inlet, decreased elasticity, and pallor of the vulva. It is mainly treated by vaginal lubricants and topical vaginal estrogen.

Major depressive disorder (MDD)
MDD is 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 might be a sign of underlying depression.

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