Sexual problems in females are very prevalent and commonly associated with physiological concerns and the quality of life
“Based on the National Health & Social Life survey of 1749 women, 43 % experienced sexual dysfunction.”
30 % of men report sexual problems.
The National Health and Social Life Survey conducted in 1992 population between the ages of 18-59 found that: . 43% of females have had significant sexual complaints in the preceding year . 33% reported lack of sexual interest . 24% reported difficulty reaching orgasm . 19% reported lubrication problems . As providers, we should bring up the topic of sexual health because only approximately 18% of women with sexual concerns will spontaneously volunteer information about sexual dysfunction to their doctor
Simple screening questions could include the following: “Sexuality is such an important part of our overall health. I would like to ask you some questions about that now. Is that okay with you?” “Are you currently sexually active?” “With?” “Do you have any concerns about your sexual health? ” Based on her responses, clinicians should further tailor their questioning around areas of concern Abused Gynecological cancer Sexual trauma Genital mutation Childhood sex abuse Radiation
Chemotherapy Peri-menopausal Post menopausal Neurogenic disease Pregnancy Multiple sclerosis Post-partum Lack of sensitivity Post-hysterectomy Spinal cord injury Vascular disease
“The etiologies of female sexual dysfunction affect a variety of populations and may be caused by psychological, emotional, or physiological reasons. Often, the etiology is multifactorial And interrelated.”
(Brassil et. al, 2002) Masters & Johnson (1970) two-tier model: 1. Immediate causes • Performance fears • Adoption of spectator role • Observer vs. participant 2. Distal (historical) causes • Sociocultural • Biological causes • Sexual traumas • Homosexual inclinations
© 2015 John Wiley & Sons, Inc. All rights reserved. © 2015 John Wiley & Sons, Inc. All rights reserved. © 2015 John Wiley & Sons, Inc. All rights reserved. Female sexual dysfunction can be temporary, episodic or continuous Can resolve by itself or need treatment
Reasons are evaluated in 2 headings. I- Psychological and Psychosocial Factors II- organic problem
The different aspects of psychological and psychosocial factors and their etiologies have been entwined as follows;
mental inhibition, education that refused sexuality during growing-up: pleasure regarded as a sin ethically
Past psychosexual trauma. (Rape, Early childhood sexual or Emotional abuse)
Fears: unwanted pregnancy, pain during coitus Problems with the partner: Not desiring intimacy with the partner, relations that are falling apart
Relationship problems (Anger, hostility, poor communication, Underlying anxiety about relationship security)
Psychological disorders(Major depression, anxiety, or panic disorder)
Sexual anhedonia, Stress and exhaustion Self Esteem Low physiological arousal Genital pain, Interpersonal relationship, Age and menopause, Negative cognitions Surgical operations
As with most disorders, female sexual dysfunction can be caused and aggravated by psychological causes.
dyspareunia Vulvitis, kolpitis, atrophy, vaginal stenosis Adhesions (Endometriosis, intra-abdominal adhesions) Gynecologic surgeries, specially radical surgeries hysterectomy, menopause Systemic disease: Malignant tumors, diabetes, stress related exhaustion, depression, multiple sclerosis Drugs: Contraceptives, tricyclic antidepressant, MAO inhibitors, antihypertensive drugs
Personality is considered an important factor which keeps one isolated to avoid possible negative responses.
Inhibitions may be due to any disparity or any prominently visible physical disabilities.
In addition there are some abnormalities which the women never like to share with anybody.
These can be related with the vital stimulating organs such as breasts and/or clitoris. Breasts, accommodates the nipple-areolar complex which is the most sensitive part to stimulate sex. However; when they are very small or feebly developed, they become a matter of inhibition from any exposition Some women have oversize breast (gigantomastia), which present an unpleasant appearance, causing resistance and/or inhibition.
The other stimulating organ is a clitoris (vestigial penis in female).
When the clitoris grows to abnormal proportions, it is called as clitoromegaly.
This anomaly can also be an inhibition from any desire that warrant exposure
Obesity and/or abnormal personality are also a psychological inhibition in women, which promotes avoidance of sex.
It is caused by higher estrogen and insulin levels and a greater concentration of growth factors in adipose tissue, in addition to hypertension, cholesterol metabolism abnormalities and immune malfunction. These inhibitions directly interfere with normal sexual function Sexual anhedonia is one of the marks of anhedonia in depressive state.
It is due to sexual disharmony and is accompanied by a wider spectrum of sexual problems, for example: anorgasmia, dyspareunia, marital disharmony and others. In sexual anhedonia, there is absence of sensation (emotional and physical) during sexual foreplay and intercourse, lack of enjoyment in sexual communication, sometimes to unpleasant and even disgusting feelings during sexual act This can include child abuse, domestic violence, rape These can lead to long term sexual dysfunction with women due to problems such as overall trust issues to desensitization. Between 75% to 94% of women with a sexual dysfunction could be accurately identified on the basis of prior abuse, but many non- dysfunctional women were misclassified.
(Sarwe & Durlak, 1996) Genital pain during stimulation or intercourse is due to many factors including dyspareunia, adhesions, vaginismus and vasculogenic pain cause inhibitions due to the fear of pain. Especially, vasculogenic pain is a conditioned response that results from associating sexual activity with pain and fear. It is a severe problem for many women, who may experience not only extreme physical pain on attempted penetration but also severe psychological pain. It consists of a phobia of penetration of the vagina and involuntary spasm of the pubococcygeal and associated muscles surrounding the lower third of the vagina . The nature of interpersonal relationship, marital conflict, relationship imbalances, commitment issues, Intimacy and communication problems, lack of trust, mismatches in sexual desire, and poor sexual technique are some of the common sources of sexual dissatisfaction noted among couples of all ages .
Psychologically, achieving menopause for many women is loss of self-image, self-esteem and a feeling of being less feminine and less attractive to their partners . Many older women report feeling sexually frustrated at the lack of an available sexual partner Lack of interest Lack of lubrication Takes longer to feel aroused More difficult to achieve orgasm Painful sex Not uncommon to have more than one complaint 12 straight months without a period Between age 40 and 58, with average age of 51 Natural menopause is a gradual process that takes years Can occur suddenly through surgery, chemotherapy, radiation, or hormone treatments
Vaginal dryness and/or Sleep problems discomfort Stress, fatigue Pain in the vulva or pelvis Poor self image Incontinence Depression Hot Flashes Anxiety Night sweats Mood swings Decreased libido Irregular cycles
Vaginal walls thin Breast sensitivity may decrease Vaginal pH changes Bladder changes – incontinence, Less vaginal elasticity infections Vaginal lubrication decreases Decreased erotic response Muscle tension decreases Fewer uterine contractions with Decreased blood flow to clitoris orgasm
The surgical interventions of gynecologic and breast cancer or vulvo-vaginal surgery often have a deleterious effect on sexual function in women, who are sensitive about their self-esteem
Negative sexual expectations, or schemas, are believed to be another contributing factor in the etiology of sexual dysfunctions
For example, beliefs such as ‘I will not become sexually aroused’ are theorized to lead to interpretations about the partner or the sexual situation, which, in turn, result in the fulfillment of the initial negative expectations
Not surprisingly, both clinical observations and research findings have consistently noted an association between relationship dissatisfaction and impaired sexual function
A healthy relationship is based on trust, intimacy, and communication.
A study in the last five years found that sexual dysfunction is highly associated with negative experiences in sexual relationships and overall well-being.
Other factors that can affect the sexual health of a relationship are conflicts about cultural, social or religious beliefs. These can invoke feelings of guilt during sexual activity and affect the ability of a women to be aroused, obtain an orgasm, or have any desire to have sex. Today most people are so busy and are often too stressed or too exhausted to have sex. When some women have decreased desire to have sex, it will become more difficult to become aroused and to orgasm High stress factors include workplace stress, social or financial crises To have a healthy response to sex, a woman must have a good body image and self esteem. If a woman does not feel comfortable in her own body, she will not feel comfortable experiencing sex.
Among the Axis I disorders, most attention has focused on depression and anxiety, where associations with sexual functioning have been found across a wide number of studies. The Axis II personality disorders consist of pervasive patterns of personality that are far less responsive to change than are the Axis I disorders.
Major depressive disorder Anxiety disorders Psychotic disorders Bipolar disorder
Major depressive disorder is defined when there has been one or more major depressive episodes – the latter of which is characterized by 2 weeks of depressed mood or loss of interest/pleasure along with four other depressive symptoms
Research and clinical practice have consistently found a strong relationship between depression and sexual dysfunction
This includes dysfunctions of sexual desire, both decreased as well as persistent sexual arousal, sexual pain and, less frequently, orgasmic functioning.
Generally the women with depressive symptoms reported greater desire for a solo sexual activity than the non-depressed women.
Antidepressants such as Prozac or Zoloft often have sexual dysfunction as a side effect in women.
More recently, researchers using functional MRI have found that women with MDD have significantly reduced activation in numerous areas of the brain associated with sexual functioning during the viewing of erotic visual stimuli, compared with healthy women
These side effects can occur either through direct physiological drug effects, such as on neurotransmitter receptors, and/or through indirect effects, such as through weight gain and sedation.
Consequently, differentiating the direct and indirect effects of medications versus the effects of depression itself on sexual function is often very difficult, with important implications for treatment compliance.
Very recently, sildenafil citrate has been found to be effective for reversing the sexual side effects of selective serotonergic reuptake inhibitor antidepressants in a very small, highly selective group of women with anorgasmia .
Anxiety has long been assumed to play a significant role in sexual dysfunctions.
In fact, early psychodynamic theories presumed anxiety to underlie all sexual difficulties, and the influential sex therapy protocols of Masters and Johnson and Kaplan focused on anxiety in both the etiology of the dysfunction and as a target for treatment.
Compared with healthy controls, significantly higher rates of anxiety have been found in patients with sexual dysfunctions and significantly higher rates of sexual dysfunctions have been found in patients with anxiety disorders
These anxiety disorders include panic disorder , social phobia , obsessive–compulsive disorder , post-traumatic stress disorder and generalized anxiety disorder , although differences in rates of sexual difficulties across these disorders have been found Bipolar disorder, defined by the presence of one or more manic or mixed episodes that results in functional impairments, is also associated with shifts in sexual function.
During a manic episode, defined as at least a 1-week period of abnormally persistent elevated, expansive or irritable mood , individuals may show hyper sexuality , while during depressive episodes, impairments in sexual functioning congruent with those discussed previously in MDD are frequently present Thus, when considering treatment for the individual with sexual symptoms in the context of bipolar disorder, one must take into account whether the person is in a manic, depressive or asymptomatic phase of their illness Specifically, older women seeking treatment for mixed sexual dysfunctions had higher neuroticism scores ,whereas in younger women, the trait of extraversion was more prominent . Cluster A includes paranoid, schizoid and schizotypal personality disorders. Almost no empirical data exist on the relationship between Cluster A personality disorders/traits and women’s sexuality
Compared with Cluster A, much more research has explored the association between Cluster B personality disorders and traits and sexual functioning in women
This cluster includes antisocial ,borderline, histrionic and narcissistic personality disorders, and those in this group are often characterized as dramatic, emotional and/or erratic
The Cluster C personality disorders include avoidant, dependent and obsessive– compulsive personality disorders and are characterized by anxiety and fear.
Compared with the available research on obsessive–compulsive disorder and women’s sexuality that shows significantly lower rates of desire, arousal and satisfying orgasms compared with sexually healthy controls
DSM-5 Criteria for Sexual Interest/Arousal Disorder in Women:
• Diminished, absent, or reduced frequency of at least three of the following for 6 months or more:
Interest in sexual activity Sexual/erotic thoughts or fantasies Initiation of sexual activity and responsiveness to partner’s attempts to initiate
Sexual excitement/pleasure during 75% sexual encounters Sexual interest/arousal elicited by any internal or external erotic cues
Genital or nongenital sensations during 75% sexual encounters
• Causes marked distress or interpersonal problems • Not due to a medical illness, another psychological disorder (except another sexual dysfunction), or the effects of a drug Identify the warning signs! Touching takes place only in the bedroom. Sex does not give you feelings of connection and sharing. One of you is always the initiator and the other feels pressured. You no longer look forward to sex. Sex is mechanical and routine. You almost never have sexual thoughts or fantasies about your spouse. You have sex once or twice a month at most.
A 34-year-old female, Mrs Jones, presents to your clinic for several issues.
She is 6 months post-partum and she reports fatigue, difficulty with losing the weight she gained with pregnancy, and notes that her husband thinks they are not having sex very often. She has a history of depression and insomnia.
Her medications include citalopram 20 mg daily, and diphenhydramine 25 mg at bedtime as needed for insomnia. Additional patient history:
Mrs Jones feels that she is not currently interested in sex, she attributes this to feeling tired and unattractive, but the lack of interest bothers her
she previously had a good sexual relationship with her husband and she would like to again. Relationship issues and religious or cultural beliefs can certainly influence libido.
Sleep deprivation, stress, depression, or treatments with antidepressants or antipsychotics are common contributors.
Pregnancy, breast-feeding, or a postmenopausal state can be associated with decreased libido.
Any number of chronic medical conditions, including hypothyroidism, may contribute as well. The data on this are conflicting.
Most of the available data are on combined oral contraceptives (COCs), and most often they are libido neutral.
A comprehensive review article on the subject was published in 2012. 13 In some cases, libido may be decreased from COCs due to antiandrogenic effects and a decrease in lubrication. In other studies, libido may increase due to decreased fear of pregnancy and improvement in certain gynecologic conditions, such as dysmenorrhea, menorrhagia, or endometriosis.
Unfortunately, the media has given us an unrealistic view of typical sexual practices.
Helping your patients understand that there are a wide variety of practices and frequency of sexual activity may help alleviate concern.
Based on the results of a survey performed in the United States in 2009, you can provide the patient with information regarding the average frequency of sexual activity in women: for women older than 25 years, the most common frequency of vaginal intercourse reported was “a few times per month to weekly”; overall, in women in their 40s, 30.5% reported intercourse a few times a month to weekly, 17.5% reported intercourse 2 to 3 times a week, and 3.5% reported intercourse 4 or more times a week.
Overall, the frequency of intercourse decreased with age Mrs Jones feels better knowing that it is not uncommon for her to feel diminished libido considering the multiple issues affecting her on a daily basis.
However, she still asks about testosterone therapy.
She heard about it from a friend of hers Many women will ask their providers about whether testosterone therapy is an option.
The benefit of testosterone therapy in postmenopausal women with HSDD is supported by several randomized controlled trials. Review of the literature is of benefit for several reasons. There is a good evidence base regarding a benefit of testosterone therapy in the treatment of HSDD, but the magnitude of this benefit is small. It is thought that an increase of1 satisfying sexual episodes per 4 weeks is meaningful to patients, but when weighed against potential risks, this needs to be carefully considered. It also should be noted that long-term safety data are nonexistent Finally, availability of the studied testosterone replacement preparations is limited.
Mrs Jones is on an antidepressant. Is there anything to help with HSDD in this population? Selective serotonin reuptake inhibitors (SSRIs) can negatively affect any component of the sexual response cycle, including desire, arousal, and/or orgasm, with estimates of 30% to 70% of patients on SSRIs reporting some degree of sexual dysfunction.
Delay of orgasm and lack of orgasm are the most commonly reported side effects.
Sexual dysfunction is a potential side effect for all drugs within the SSRI class of antidepressants. In addition, sexual side effects are frequently reported with venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI).
Evidence regarding the severity of sexual side effects with mirtazapine is mixed, in some studies comparable to SNRIs, in others much less severe
Notably, bupropion, an antidepressant that is thought to primarily act on the dopamine and noradrenergic receptors, is not commonly associated with high rates of sexual side effects Continue SSRI, add bupropion sustained release 150 mg twice a day Continue SSRI, prescribe sildenafil 50–100 mg as needed before sexual activity Reduce dose of SSRI if possible Switch antidepressant classes from SSRI to bupropion Or a “drug holiday” could be considered. There is one small observational study regarding this in which 30 patients were instructed to hold their SSRI antidepressant, fluoxetine, sertraline, or paroxetine, on Friday and Saturday for a month
First, it is important to investigate the onset of a patient’s sexual dysfunction. Depression itself may lead to sexual dysfunction, and treatment with an SSRI may actually be helpful, although this may take weeks of therapy.
It is also possible that the symptom will resolve spontaneously; similar to other common SSRI side effects, such as nausea, it has been estimated that10% of the time sexual side effects will resolve as the body adapts to the medication Several studies have found a reduction in SSRI-related sexual side effects with the addition of bupropion
Mrs Jones returns to your clinic a month later. She is concerned that when she and her husband have been sexually active over the past several weeks it has been uncomfortable, noting that she has poor vaginal lubrication. AROUSAL DISORDERS Arousal disorder is defined as the recurrent inability to attain or maintain sufficient sexual arousal despite adequate stimulation. Once again, numerous psychosocial Educating patients on the importance of adequate stimulation and the use of lubricants and vaginal moisturizers can be helpful. There are a variety of lubricant products on the market available without a prescription. Broad categories include water-based, silicon-based, and oil-based lubricants. Many women will report using oil-based lubricants, such as baby oil, which can irritate the vaginal tissues and should not be used with latex condoms as they can reduce the effectiveness of the contraception and the prevention of sexually transmitted illnesses. Natural oils, including olive oil or avocado oil, are less irritating, although still should be avoided if the patient is using condoms with her partner.
Teaching patients about self-stimulation with vibrators or medical devices such as the Eros Clitoral Therapy device can be effective. The Eros Clitoral Therapy device is an FDA-approved hand- held vacuum used to increase blood flow to the clitoris and surrounding vaginal tissues.
The method of using pornography can be doing even larger damage to the sexual aspect of the couple’s relationship.
Pornography links to poor body image feelings in women when they watch it with their male partners.
The last thing a woman needs to feel or experience before sex is a negative view of her appearance; this will simply link yet another negative thing to sex.
DSM-5 Criteria for Female Orgasmic Disorder:
On at least 75 percent of sexual occasions:
• Marked delay, infrequency, or absence of orgasm
• Markedly reduced intensity of orgasmic sensation
• Causes marked distress or interpersonal problems
• Not due to a medical illness, another psychological disorder (except another sexual dysfunction), or the effects of a drug
© 2015 John Wiley & Sons, Inc. All rights reserved.
Mrs Jones returns to clinic again, several months later. Several issues have improved; she feels that her interest in sexual activity has returned to a level she is happy with, and with adequate stimulation she has normal vaginal lubrication.
Today she is concerned about a decrease in the frequency of orgasms; she feels that she more frequently had orgasms before her pregnancy. Female orgasmic disorder can be primary or secondary. A patient who has never had an orgasm would be described as having primary orgasmic disorder. There may be a history of sexual abuse, and if so, psychotherapy may be useful in treatment. But in some cases it is idiopathic, in which case there are no recommended treatments. Patients with secondary orgasmic disorder have achieved orgasm in the past but have a distressing change in their ability to achieve orgasm at the time of presentation.
There are many possible etiologies, including psychosocial causes such as relationship conflict, religion or cultural beliefs, and body image issues. Neurologic and vascular disease can lead to orgasm disorders; examples include spinal cord injury, diabetes, and multiple sclerosis
A class of medications frequently associated with anorgasmia and delayed orgasm is SSRIs. Management of secondary female orgasm disorder involves normalizing the patient’s experience, educating the patient on possible ways to achieve orgasm, consideration of counseling, and possible change of antidepressant if the patient is taking an SSRI, as described previously. A model of assessment and treatment that could be used by the primary care provider is the PLISSIT model. PLISSIT stands for Permission, Limited Information, Specific Suggestions, Intensive Therapy.
Permission stands for the discussion with the patient around normalization of sexual behaviors.
Limited Information could include information about behaviors that may increase arousal, including foreplay and a discussion of medical conditions or medications that could be contributing to the problem.
Specific Suggestions could include use of lubricants, vaginal estrogen, and position changes.
Intensive Therapy would be referral to a specialist, such as a sex therapist or couples counselor, if appropriate.
“Sex therapy” is psychotherapy aimed at treating sexual dysfunction.
The focus of sex therapy can be variable based on the patient’s needs.
It frequently focuses on reducing anxiety in sexual situations, based on the assumption that anticipation and performance anxiety often contribute to sexual dysfunction, in addition to discussion of sexual skills.
Sexual exercises are frequently assigned; these may include sensate focus, in which the focus of intimate physical interactions is on sensations and not orgasm.
This therapy has not been well studied, and there is great heterogeneity in both specific treatments and results.
Persistent or recurrent difficulties with at least one of the following:
Inability to have vaginal intercourse/penetration
Marked vulvar, vaginal, or pelvic pain during vaginal penetration or intercourse attempts
Marked fear or anxiety about pain or penetration
Marked tensing of the pelvic floor muscles during attempted vaginal penetration
Causes clinically significant distress or interpersonal problems
Not due to another psychological disorder, a medical condition, or the effects of a drug
© 2015 John Wiley & Sons, Inc. All rights reserved. DSM-5: Genitopelvic pain/penetration disorder . Persistent or recurrent pain during intercourse . Diagnosable in both men and women ▪ Rare in men . R/O medical cause (e.g., infection), lack of vaginal lubrication, or menopausal problems . Most women experience sexual arousal and orgasms from manual or oral stimulation that does not involve penetration . 10-30% prevalence rates . DSM-IV-TR: Vaginismus and Dyspareunia
© 2015 John Wiley & Sons, Inc. All rights reserved. Mrs Jones returns to clinic 2 years later.
She had her second child 4 months ago.
Despite reviewing all the recommendations you made to her previously she is again having pain with intercourse.
Even with adequate stimulation she feels that she doesn’t have adequate vaginal lubrication and is having significant pain with insertion. She is currently breast-feeding and is back on the “mini pill.” In the DSM-5 criteria, the categories of dyspareunia and vaginismus were merged under a new category called genito-pelvic pain/penetration disorder (GPPD). The primary reason for this change was because these 2 disorders could not be reliably differentiated. The presence of “vaginal muscle spasm,” which is part of the diagnostic criteria for vaginismus, has not been supported by empirical evidence and the fear of pain or the fear of penetration is common in the clinical descriptions of vaginismus.
Because there is tremendous overlap between dyspareunia and vaginismus, the term “genito-pelvic pain/penetration disorder” is all encompassing
For the diagnosis of GPPD, one of the following should occur persistently or recurrently: difficulty in vaginal penetration, marked vulvovaginal or pelvic pain during penetration or attempt at penetration, fear or anxiety about pain in anticipation of, during, or after penetration, and tightening of pelvic floor muscles during attempted penetration Sexual pain may be localized to the vulva, vestibule, vagina, pelvis, or at multiple sites simultaneously.
To diagnose GPPD, other causes of pelvic pain must be ruled out. Etiologies for genito-pelvic pain are numerous.
From the perspective of a health care provider, it may be easier to think of broader categories such as “irritative,” “anatomic,” and “infectious” causes; see Regarding infectious causes, evaluate for sexually transmitted illnesses, candidiasis, and pelvic inflammatory disease when appropriate.
Under the category of “anatomic,” one might elicit a history or physical examination finding of previous pelvic surgery, episiotomy, fibroids, uterine or bladder prolapse, gynecologic malignancy, or endometriosis, to name a few.
In this article, we focus on “irritative” causes, which include diminished lubrication, atrophic vaginitis, vulvar dermatoses, and vulvodynia
Atrophic vaginitis is most common in menopausal women.
Hypoestrogenic states also can occur in the postpartum period, during lactation, and in premenopausal women with the administration of antiestrogenic drugs, such as tamoxifen, aromatase inhibitors, and medroxyprogesterone that may cause vaginal atrophy.
Placing a piece of pH paper on the vaginal wall until it is moistened can test vaginal pH.
The pH of an estrogenized vagina ranges from 3.5 to 5.0. A vaginal pH of 4.5 or greater in the absence of infection or recent semen in the vaginal vault can be an indicator of vaginal atrophy due to estrogen deficiency
Categories Examples
Irritative Vaginal dryness Atrophic vaginitis Vulvar dermatoses Vulvodynia/vestibulitis
Anatomic Endometriosis Fibroids Uterine or bladder prolapse Scarring related to previous pelvic surgery, episiotomy Gynecologic malignancy
Infectious Sexually transmitted infections (gonorrhea, chlamydia) Vulvovaginal candidiasis Pelvic inflammatory disease
The DSM-5 includes separate diagnoses for sexual dysfunctions that are caused by medical illnesses . Somewhat controversial because many sexual dysfunctions have a biological contribution Diseases of vascular system Diseases of the nervous system Low levels of testosterone or estrogen Heavy alcohol consumption before sex History of chronic alcoholism Heavy cigarette smoking Medications . Antihypertensives . SSRIs
© 2015 John Wiley & Sons, Inc. All rights reserved.
When there is evidence that use of alcohol or other drugs directly causes Sexual Dysfunction in excess of what would normally be expected from intoxication, and involving desire, arousal, orgasm or pain, diagnosis of the Substance Related Disorder may be appropriate.
Diagnostic criteria for Substance-Induced Sexual Dysfunction cautionary statement)
A. Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty predominates in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the sexual dysfunction is fully explained by substance use as manifested by either (1) or (2): (1) the symptoms in Criterion A developed during, or within a month of, Substance intoxication (2) medication use is etiologically related to the disturbance
Evaluations may differ from person to person . The way of diagnosing is through physiological response which could result in problems with not considering psychological evaluations.
Population surveys indicate a high concordance of FSD and marital discord and symptoms of anxiety and depression.
Studies of sexual function in psychiatric patients suggests that sexual disorders are more common in patients diagnosed with depression, schizophrenia, anorexia, and anxiety disorders.
. On the other hand sexual activity and libido are reported to increase in manic episodes.
Anxiety reduction
Directed masturbation
Procedures to change thoughts and attitudes . Sensory awareness procedures . Rational-emotive therapy
Sexual skills and communication training
Couples therapy
Medications and physical treatments . Squeeze technique for early ejaculation . PDE-5 inhibitors for erectile dysfunction ▪ Phosphodiesterase type 5 inhibitors: sildenafil (Viagra), tadafil (Cialis) and vardenafil (Levitra)
Failure and disengagement thoughts: the domain that is constituted by thoughts of incapacity for sexual performance, and lack of motivation to engage in sexual activity.
‘‘I’m not satisfying my partner’
‘‘I’m not getting turned on’’, ‘‘when will this be over?’’ the dimension represented by thoughts of female sexual passivity and control, reflecting the idea that women must wait for the men’s first step in order to match cultural values (not being seen as frivolous) and also in order to prevent eventual emotional harm. the factor characterized by thoughts of not being comfortable with one’s body image. Anxiety(worry, fear) :neutral or even facilitative Depressive affect (sadness, lack of pleasure and satisfaction, guilt):sadness, guilt, Anger :desire and arousal Thought
Emotion sexual response To grow the size of breasts, a number of creams and drugs are commercially available.
Many women with gigantomastia get reconstructive surgery
The only treatment for clitoromegaly is surgical excision of a part of clitoris, without losing the sensitive areas . To control obesity in women the strategies to be adopted are diet control and exercise.
The natural products used against obesity are Ginkgo biloba, java tea, herbal slim,.
orlistat and sibutramine to be very effectual synthetic drugs used against obesity. In loss of sexual desire, a psychogenic aspect is taken up when the medical aspects are thoroughly worked out.
Most of the psychogenic treatment is based on cognitive behavioral and psychodynamic approaches based on discussions.
The discussions on loss of desire generally involve the feelings of the partners and could detect how she felt as well as, how it should have been felt and hence the differences in sexuality and sexual needs can be explored. It is felt and expected that the other partner also to feel the same way as she feels and to know when she feels the need. With counseling, the aim is to encourage acceptance of difference Thus, psychotherapy by counseling and discussions is the only solution to psychological and psycho-social problems of FSD
Dyspareunia, a very frustrating FSD problem, is a recurrent genital pain associated with sexual activity. The term is used to describe a pain that starts on genital stimulation and aggravates on penetration Repeated sexual pain can set up a cycle, in which fear of pain leads to avoidance of sexual activity that produces it, in turn leads to loss of sexual desire, lack of arousal and failure to achieve orgasm.
This can progress to total avoidance of any desire for sexual activity and cause relationship complications
The dyspareunia of three types (i) superficial vulvar pain (ii) vaginal pain (iii) deep dyspareunia. The pain in vulva can be relapsing and remitting.
Experiences of burning, itching, and stinging, inflamed sensation may be felt not only on sexual stimulation but can be present all the time and triggered by non-sexual activities such as walking.
The main causes are vulvities, vulvovaginities, vulvovestibulities, genital herpes, urethritis and atrophic vulvitis, as well as inadequate lubrication and use of topical irritants such as spermicides or latex.
Painful sexual intercourse and inadequate and/or absence of orgasms are the most common complaints of women suffering from sexual dysfunction.
Another cause is positional impact with initial or deep penetration or deep thrusting by woman’s partner hitting the ovary .
The other etiologies include adrenal pathology; cystitis, inadequate lubrication, pelvic adhesions, congestion or infections; urethral disorders; vaginismus; and vulvodynia Inadequate lubrication, vaginal atrophy, vaginismus and vulvodynia are associated with painful entry.
Validating experience of pain Education , Goal Setting Education, anatomy ,Genital self-exploration, Hand-guiding, Anatomy / sensitive parts , Sexual cycle stages Role of foreplay Difference between men and women Communicating Preferences and Feedback Corrective feedback Deemphasizing intercourse Emphasizing affection and sensuality
Use Extra Lubricant
Vaginal Dilators
Education: Kegel Exercises
Coordinating with Physical Therapy
Anxiety Reduction
Adhesions are deposits of fibrous tissue that form as a natural response to the injury of the tissue after infection, inflammation, surgery or trauma.
These adhesions are the bands of scar tissue with the potential to bind organs to other structures, which leads to multiple symptoms including organ dysfunction and/or pain as “pulling” or “stabbing” Vaginismus is another serious problem which cause extreme physical and psychological pain upon penetration .
The severity of the symptom of vaginismus can lead to a general sexual inhibition with avoidance of any sexual touching, and in most severe cases to avoidance of any affectionate touching.
However, some women are sexually responsive and have good quality sexual experiences, with imaginative “foreplay” continuing to orgasm but avoiding penetration.
Attempted penetration leads to pain, fear, humiliation and frustration, often resulting in feelings of inadequacy and abandonment .
Biologically, clitoris is described as the vestigial penis. By structure, it is very insignificant but controls the essence of all the sexual functions. It is main organ of stimulation and is responsible for the trigger of all the phases, including arousal, lubrication, plateau, orgasm and resolution. Beneath the clitoris, in the anterior wall of vagina is presentan arousable area called as the Grafenberg zone (GZ). Excitation of GZ is known to give the highest pleasure to women. In addition the stimulation of this body has been described to discharge a viscous fluid (a phenomenon which is referred to as female ejaculation) from the urethra . The role of orgasm for women is not well defined. Actually there are 2 types of orgasms, these are (i) clitoral orgasm and (ii) vaginal orgasm. The clitoral orgasm, is common and occur within a short period of sexual intercourse. Most of the orgasms, experienced are clitoral. The vaginal orgasm takes longer time and sometimes never happens to many women in their life time, if the GZ is not properly stimulated For some women, the orgasm is extremely important and sought at every sexual encounter.
However, for others it seems less important and sometimes of little relevance; many women can be quite satisfied without it. An important issue is the understanding of the male partner, who often feels that, like him, his partner cannot fully enjoy sexual activity without orgasm. Hence, there is an enormous pressure on the woman to achieve orgasm.
There is another problem, where in the woman may have a strong sexual desire with good arousal and enjoy the sensation of the penis in the vagina, but have a strong fear of losing control over feelings and behavior and wish to achieve orgasm by masturbation but not in coupled sexual activity .
The fear can be conscious or unconscious, but resolution of the conflict is an important aim of treatment. An example of a situational anorgasmia is a woman who can achieve orgasm by masturbation but not in coupled sexual activity
CBT Sex education Communication Skill Kegel Exercises Directed Masturbation
Deficiency of testosterone has been described as one of the factors for loss of sex desire.
The production of testosterone in female is evenly between ovaries and the adrenal glands. Women, who have undergone hysterectomy or bilateral sapingo- oophorectomy often, suffer androgen deficiency. The use of anti cancer drugs is also known to cause deficiency of testosterone Prolactin is reported to represent a peripheral regulatory factor for reproductive function in both men and women. This is like a feedback mechanism that signals CNS centers controlling sexual arousal and behavior. Chronic elevations of in sexual activity, and significant reduction of libido and gonadal function in both men and women . Any health problem that might affect sexual anatomy, vascular and neurological systems, obstetric and gynecology, urology and the endocrine systems may cause loss of sexual desire and interfere with any phase of FSD Additionally, surgical treatment of gynecologic and breast cancer, vulvovaginal surgery often has a deleterious effect on sexual function in women and interfere with normal sexual response . The duration of diabetes, age, among women with diabetes and there is no evidence that peripheral or autonomic neuropathies directly affect the female sexual response Urinary incontinence occurs in up to 25% of older women during intercourse . This disorder commonly leads to dissatisfaction with the sexual relationship or withdrawal from sexual contact due to embarrassment. Renal failure has been reported to cause anorgasmia, decreased libido and impaired vaginal lubrication in women on dialysis Antipsychotic, neuroleptic and antidepressant medicines are known to impair sexual function in women. Side effects associated with antidepressant medications include decreased sexual desire, impaired arousal and lubrication, vaginal atrophy, vaginal anesthesia, delayed orgasm and anorgasmia Antihypertensive drug, clonidine has been shown to impair physiologic sexual response in women by decreasing vaginal blood volume and pulse pressure responses Use of drugs, such as, hypotensives, hypertensives, and nicotine has been reported to cause decreased sexual desire, vaginal atrophy and dryness, impaired arousal and lubrication, vaginal anesthesia, delayed orgasm and analgesia leading to pain during sexual intercourse Coitus, although pleasurable, may be risky. The urological complications of coitus have been reported to be mostly due to peno-vaginal disproportion, excessive force at coitus, or deviations from the normal route, such as urethral coitus and anal intercourse The complications, experienced by women include urethral injuries, vesicovaginal fistulae, bladder and cavernosal ruptures and urinary tract infections . Hysterectomy is the most commonly performed operation in case of pathological changes in the uterus. The surgery has been shown to interfere with the intensity of orgasms, due to loss of uterine contractions . However, it improves the sexual function due to relief from the trauma of pain, abnormal bleeding or cramping Menopause occurs in most women at about age 50. It is associated with substantial reductions in estrogen, progesterone and androgen levels, which cause decreased vaginal lubrication or a thinning of the vaginal lining, both of which may lead to pain during vaginal intercourse . Following menopause, estrogen is almost exclusively derived from the peripheral conversion of adrenal androgens. The decreased estrogen levels have a multitude of effects on sexual function, including (i) decreased support of female pelvis, (ii) loss of ability to adequately lubricate the urinogenital tissue, (iii) urinogenital atrophy, (iv) thinning of the vaginal lining and (v) changes in body configuration, which affects skin, breasts, muscles and skeleton. All these factors contribute, directly or indirectly to FSD . Hormone replacement therapy is given to ameliorate the local anatomic and physiologic changes in postmenopausal and aged women.
Estrogen replacement therapy, when given systemically at high doses, has a beneficial effect on urinogenitalt issue , but this is associated with an increased risk of breast and endometrial cancer. Treatment with testosterone can improve loss of desire. However, its use should be strictly under medical supervision and control. Since the use of androgen is known to affect cholesterol and liver protein levels, at high doses, it may also cause masculinizing effects, such as facial hair or lowered vocal pich . To increase vaginal and clitoral blood flow in patients with FSD, there are a number of oral and topical pharmacologic strategies available. These are (i) phosphodiesterase inhibitors cause genital vaso-congestion in women with minimal clinical efficacy (ii) androgens increase libido (iii) bupropion targets the central nervous system to help women achieve orgasm (iv) several natural products improve FSD . Vasoactive Drugs . Sildenafil increases the genital vasocongestion and lubrication but there is no evidence that these agents have therapeutic benefits for FSD. ▪ This may not be effective because females with FSD often show objective arousal but do not report subjective arousal. Other treatments in progress . Androgen and estrogen treatments have been fairly extensively researched and suggests that a relationship exists between libido and androgen levels in females. . Testosterone treatments are also being researched though chronic dosages would result in masculinization and other side effects. ▪ However it has been shown that testosterone within normal limits influence libido. Flibanserin: One medication that has obtained approval by the FDA to assist with female libido disorders is flibanserin. Other drugs have proved helpful with the disorder as well, including SSRI, or depression, medication.
Viagra: Both a female Viagra and a female Cialis pill are now also on the market. The effectiveness of these pills remains in question, but hope exists that the pills will have a similar successful effect for women, much like three pills succeeded with men. Estrogen therapy: Your doctor will conduct this therapy through the insertion of a vaginal ring, cream, or tablet. The therapy assists female sexual dysfunction because it helps with lubrication and creates more elasticity in the vagina. Androgen Therapy: Androgens typically include testosterone, which plays a big part in sex for both men and women. Women do have lower amounts of testosterone than men, and androgen therapy is still questionable at best. Tibolone: Tibolone is a synthetic steroid that typically treats postmenopausal osteoporosis. However, its side effects are increased risk of breast cancer and increased risk of stroke. Therefore, the FDA has not approved of it. Phosphodiesterase Inhibitors: Another possible treatment is phosphodiesterase inhibitors, which has helped men who suffer from erectile dysfunction.
Stay away from excessive alcohol as it can curb sexual desire.
Take up an exercise program. Physical exercise works to boost mood as well as create a deeper feeling of happiness with oneself, opening the door up for sex.
Eat more green and colored vegetables and fruits.
Counseling can help, especially if you see somebody that focuses on sex and relationship issues.
A therapist can help educate you more about how you can increase the benefits of the sexual experience within your relationships. Therapists often provide extra reading to help with education about sexual intimacy.
A lubricant can help you if you experience vaginal dryness. It can make sex much more enjoyable.
A device can help with foreplay and help with reaching the clitoris during intercourse