Female Sexual Dysfunction

Reporters and participants of the 1st Latin American Erectile Dysfunction Consensus Meeting

International Journal of Impotence Research (2003) 15, Suppl 7, S22–S26. doi:10.1038/sj.ijir.3901131

Female sexual dysfunction (FSD) comprises a set of induced by nonintercourse sexual stimulation, frequent disorders that affect one in every three causing personal discomfort. women. Nevertheless, however, knowledge of wo- To that classification are added the following subtypes: men’s sexual response physiology and its alterations remains limited. Primary (life-long persistent) or secondary (acquired). Classification of FSD Generalized or situational (occurs only in given situations). Psychological, organic, mixed or unknown. The current classification of FSD was altered by the Health Council Consensus of the American Founda- tion for Urologic Diseases, of 1998; it is based on the Prevalence of FSD DSM-IV (Mental Disorders Diagnostic and Statistical Manual), which reflects the three-phase model of sexual response described by Helen Kaplan, and it Epidemiological data on the prevalence and inci- identifies four main classes of difficulties:1 dence of female sexual dysfunction are scarce. However, according to data available in the literature, it is an ordinary occurrence that affects about (1) Difficulty related to sexual desire 25–63% of women.1–3 Hypoactive sexual desire: deficiency or ab- In a survey conducted on the general population sence, persistent or recurrent, of sexual fanta- in Argentina, Bechara et al4 studied 384 women sies, and/or desire and/or sexual activity aged on average 40 y (limits: 18–75 y), recording the receptivity, causing personal discomfort. following results: Sexual aversion: phobic aversion, persistent or recurrent, which avoids sexual contact with a 63% claimed difficulties in the desire phase; partner, causing personal discomfort. 30% referred to subjective difficulties in the (2) Difficulty in sexual arousal arousal phase; 31% referred to changes in lubrications; Persistent or recurrent inability to achieve and/ 29% had disorders in the orgasm phase; and or sustain sufficient sexual arousal, and that 13% mentioned dyspareunia. causes personal affliction or distress. It can be expressed as a subjective loss of arousal or loss It was shown furthermore that 24% of the respon- of lubrication, genital congestion or a different dents were little satisfied or even dissatisfied with somatic response. their sexual life. (3) Orgasm-related difficulty Postmenopause women showed a higher dissatis- faction rate as compared to premenopause women: Delay, absence or difficulty, persistent or recur- 33 vs 17%, respectively. It was also pointed out that rent, in achieving orgasm shortly after a phase 92% of those women were willing to seek treatment of normal arousal, causing personal discomfort. in case they were having sexual dysfunction. (4) Sexual pain Similar results were achieved by the same group working on patients in the specific Gynecology area Dyspareunia: genital pain associated with sex- 5 ual intercourse, persistent or recurrent, which in the same hospital. In Brazil, in an assessment of women aged over causes personal discomfort. 6 Vaginismus: involuntary spasm, persistent or 40 y, Lopes and Torres found: recurrent, of the muscles surrounding the vaginal opening, interfering with vaginal pene- predominance of hypoactive sexual desire (58%); tration and causing personal discomfort. orgasm dysfunction (21%); Sexual pain not associated with sexual inter- arousal dysfunction (9%); and course: genital pain, persistent or recurrent, other sexual dysfunctions (12%). Chapter 6 Female sexual dysfunction S23 Causes of FSD responsibility, who should consider the context of the patient’s sexual experiences, her level of self- esteem, corporal image and her ability to relate with According to the literature data, the causes of FSD her partner. Assessment of the psychosexual aspect are multiple, usually associated and they can be is, therefore, imperative, before any treatment option resumed into four different factors (Picture 1): proposal is set forth. psychological, vascular, Scales or self-answering questionnaires neurological, hormonal, urogynecological, and No adequate tool is available for the diagnosis of medications. FSD yet. Several sexual function assessment tools or scales are available for the assessment of the patients’ subjective status and its changes after the

Picture 1 therapeutic intervention, among which, the ‘Brief PREDISPOSING FACTORS Index of Sexual Functions Inventory (BISF–W)’ and the ‘Female Sexual Function Index (FSFI)’, which HORMONE FACTORS PSYCHOLOGICAL FACTORS are some of the resources mostly used in the FSD • Post-partum hormone deficiency • Sexual abuse therapeutic and diagnostic approach.3,7 • Diabetes • Marital conflicts • Endocrionopathies • Depression • Menopause • Drug addiction • Stress Psychosexual assessment • Self-esteem and identity problems DRUG FACTORS • Corporal image problems • Antihypertensives Assessment of psychoemotional factors is a crucial • Antiulcers UROGYNECOLOGICAL FACTORS aspect and it should remain under the responsibility • Contraceptives • Cystitis of a mental health professional. • Anticonvulsives • Endometriosis Self-esteem, corporal image and the quality of • Antidepressants • Uterine myoma • Pelvic prolapse interpersonal relationship with her partner are • Neuroleptics and sedatives • Vulvovaginitis factors that strongly affect women’s sexual function. • Chemotherapics • Vulvodynia In the cases in which organic factors responsible for the dysfunction are detected, the emotional compo- NEUROGENIC FACTORS VASCULAR FACTORS nent may be present, adding difficulties to the • Cyclism • Alcoholism sexual response. • Diabetes • Coronary diseases There are a series of factors that, although not • Hysterectomy • Diabetes • Hypercholesterolemia • Spinal cord lesion fully accounting for the psychological origin of the • Hypertension • Pelvic trauma problem, they justify the sexual therapist’s required • Smoking intervention:

Picture 1 Predisposing factors. primary symptoms, situational symptoms, nonresolved previous history of sexual abuse FSD—diagnostic assessment or trauma, previous psychiatric events, history of depression condition, anxiety or stress, Owing to the complex series of factors that affect conflicts in the relationship with her partner (loss women’s sexual response, it is important to establish of intimacy, hostile atmosphere, poor communi- a multidisciplinary focus through which the differ- cation, etc.), and ent specialists (urologists, gynecologists, psychia- partner’s sexual dysfunction. trists, psychologists, sexual therapists and There are, in turn, medical conditions with a high endocrinologists) are able to fully assess the woman psychosexual component that favor sexual dysfunc- with sexual dysfunction. tion, which should be adequately considered, such as: It should be emphasized that the diagnostic approach and the initial guidance are provided menopause, considering the patient’s history and they are pregnancy, complemented by the physical examination, parti- hysterectomy, cularly of the genital area for local factors that could breast cancer, affect sexual response. chronic diseases, Assessment of emotional and entailing factors is age, and pivotal, and it is usually under the sexual therapist’s infertility.

International Journal of Impotence Research Chapter 6 Female sexual dysfunction S24 Psychosexual assessment also enables analysis Management of FSD of the patient’s and her partner’s need for sexual instruction, since many times unawareness Sexual therapy of anatomy and sexual response are the factors that actually render sexual activity difficult. Sexual therapy has been shown to be effective in cases of FSD in relation to sexual desire and Hormone assessment anorgasmy, as well as to vaginismus. Inclusion of the partner in the treatment scheme is important and it increases the chances for therapeu- The female hormones mainly associated with sexual tic success. function are the sexual steroids: In certain occasions, guidance for a change in attitudes during the sexual activity resolves many androgenic and situations that arise from unawareness, prejudice or estrogen. ignorance. In other circumstances, there may be The role played by estrogen has been associated more clinically relevant factors that require a deeper with the arousal phase, particularly with and more detailed approach, perhaps even the use of vaginal lubrication, since it favors maintenance of drugs. the vaginal mucosa integrity, vaginal blood flow and the regulation of nitric-oxide (NO) synthetase en- 1 zyme synthesis. Hormone Replacement Therapy (HRT) Androgenic hormones would be associated with the sexual desire phase, arousal and, most likely, with orgasm. HRT, especially indicated in menopause (sponta- The ovaries and the adrenal glands are the neous or surgical), can improve sexual function, sources of androgenic hormones. Among the and it can be carried out by administering estrogen former are testosterone and androstenedione, to women who underwent panhysterectomy, whereas, among the latter, are andr- or in combination with progesterone, on a contin- ostenedione, dehydroepiandrosterone (DHEA) and uous or sequential basis, to reduce the risk its sulfate form. of endometrial hyperplasia. Precautions in the Hormone assessment in FSD should include the use of HRT and its contraindications should be following laboratory controls: considered. Estrogen replacement can reduce pain during plasma estradiol (days 1–5 of the menstrual cycle sexual intercourse, upon improving genital troph- in premenopause women), ism. free testosterone (of preference) or bioavailable It should be emphasized that estrogens increase (between days 8 and 15 of the menstrual cycle), the concentration of the sexual steroids carrying DHEAs, protein (SHBG), reducing free androgens and be- FSH, coming a factor to be considered, since it can LH, generate sexual dysfunction. That is why a further prolactin, and aspect to be considered is the triple hormone TSH. replacement (estrogen, androgen and progestagen), In clinical practice, measurement of free testoster- in an attempt to reduce the incidence of that adverse one, prolactin and TSH, as a rule should suffice in event. For example: tibolone or combined estrogens relation to hypoactive sexual desire. The presence of þ progestagens þ androgens. vaginal atrophy at physical examination shows an On the other hand, the entity defined as androgen estrogen deficiency, and the usual estradiol mea- deficiency syndrome should be suspected in cases surement is not necessary. of loss of libido, fatigue and/or lack of motivation associated with low androgen levels. The major adverse effects of androgen therapy are: Vascular and neurological assessment acne, hirsutism, The diagnostic methods to assess vascular clitorimegaly, and neurological responses are in an investiga- fluid retention, and tion phase,8–10 and they can be indicated lipid alteration to an atherogenic profile. for patients reporting vaginal sequels, pain Although those risks are small in the minimal during sexual intercourse or orgasm difficulties doses recommended (25 mg testosterone enantate, attributable to their clinical–surgical or drug prior every 3 weeks or 50 mg DHEA/day), should not be history. underestimated. The literature is controversial in

International Journal of Impotence Research Chapter 6 Female sexual dysfunction S25 regard to the use of DHEA in the management of research on new therapeutic modalities sexual dysfunction, particularly of desire in patients oriented to the treatment of alterations in with low DHEA and/or testosterone serum levels, the different phases of female sexual response. requiring better-controlled studies. Within the research area, criteria ought to be unified for the development of clinical trials classified as phases II, III and IV. FSD nonhormone Finally, the importance of disclosing that condition to the general population and the medical class, particularly through sexual Currently, most nonhormone treatments, whether educational campaigns, should be emphasized. oral of topic, remain in the investigation phase. Although there are scientific grounds for their clinical use, their efficacy and indication have not References been sufficiently clarified yet. These drugs are mainly oriented to the treatment of disorders in the arousal phase. 1 Berman JR, Adhikari SP, Goldstein I. Anatomıá y fisiologıáde There are clinical experiences with sildenafil,11 la funcioń sexual femenina y su disfuncioń. Eur Urol 2001; 7: 225–234. phentolamine,12–14 apomorphine,11–15 alprostadil,2 1 2 Islam A et al. Topical alprostadil in the treatment of female yohimbine alone or in combination with L-arginine, sexual arousal disorder: a pilot study. J Sex Marital Ther 2001; of controversial results. Bupropion has been used in 27: 531–540. the dysfunction of sexual desire.16–18 3 Goldstein I. Female sexual arousal disorders: new insights. Int J Impot Res 2000; 12 (Suppl 4): S152–S157. 4 Bechara A et al. Female sexual prevalence in Argentina. In: Abstracts from New Perspectives in The Management of Vacuum devices Female Sexual Dysfunction. Boston, 2000, Site: http:// www.isswsh.org. 5 Bechara A et al. Disfuncioń sexual femenina: prevalencia en la consulta ginecolo´gica. Female sexual dysfunc- ERODS-CTD (‘Clitoris Therapy Device’) is a vacuum tion: prevalence in the clinical practice gynecologist. device recently approved by the ‘FDA–Food Congreso Argentino de Urologıá, XXX Congreso de la and Drug Administration’, of the United States, Confederacioń Argentina de Urologıá. Buenos Aires, 2001, for the treatment of female sexual dysfunction (abstract). 6 Lopes GP, Torres LO. Evaluation of sexual complaints among caused by inadequate blood flow to the sexual women in their forties and over in a sexology office. Acta Port organs, to improve clitoris sensitivity, lubrication, Sexol 1998; 42 (Suppl. 2). orgasm and satisfaction—is in the investigation 7 Rosen R et al. The female sexual function index (FSFI): phase.19 a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26: 191–208. 8 Becher E, Bechara A, Casabe´ A. Clitoral hemodynamic Final considerations changes after topical application of alprostadil. J Sex Marital Ther 2001; 27: 405–410. 9 Bechara A et al. Duplex doppler ultrasound assessment of Diagnostic and therapeutic approaches to clitoral hemodynamics after topical administration of alpros- FSD remain in the research phase and tadil in women with arousal and orgasmic disorders. J Sex require a complex and sustained multidisciplin- Marital Ther 2002, (en prensa). ary work. 10 Yilmaz U et al. Clitoral electromyography. J Urol 2002; 167: 616–620. Despite important embryological, anatomic and 11 Bechara A et al. Assay on the efficacy and safety of sildenafil physiological parallelisms between man and in female sexual dysfunction. ISSWSH Annual Meeting, woman, a similar diagnostic and therapeutic Vancouver 2002, Site: http://www.isswsh.org. approach should not be made. 12 Rosen RC et al. Oral phentolamine and female sexual arousal disorder: a pilot study. J Sex Marital Ther 1999; 25: Emotional aspects, as well as each woman’s 137–144. perception of her own sexuality should be 13 Rubio E et al. Alpha blockade and vaginal blood flow response assessed and possibly treated before pharmacolo- in postmenopausal women with female sexual arousal gical medical procedures are introduced. disorder. Abstracts New Perspectives in the Management of It is important to determine normality standards Female Sexual Dysfunction. Boston, 2000, Site: http:// www.isswsh.org. for female sexual response: 14 Rubio E et al. Combination therapy for female arousal disorder: a clinical trial to evaluate the efficacy of a the role of testosterone, particularly in sexual combination of phentolamine mesylate and apomorphine in desire disorders, and the role of neurotransmis- the subjective response to video sexual stimulation. Abstracts sion in the female arousal response, from Female Sexual Function Forum, Boston 2001, Site: the search for hormone, vascular and neurolo- http://www.isswsh.org. gical diagnostic means; their standardization, 15 Tarcan T et al. Systemic administration of apomorphine improves the hemodynamic mechanism of clitoral and with determination of normal levels, by age vaginal engorgement in the rabbit. Int J Impot Res 2000; group, and 12: 235.

International Journal of Impotence Research Chapter 6 Female sexual dysfunction S26 16 Seagraves RT et al. Bupropion sustained release (SR) for 18 Gitlin M et al. Bupropion-sustained release as a treatment for the treatment of hypoactive sexual desire disorder (HSDD) SSR-Iinduced sexual side effects. J Sex Marital Ther 2002; 28: in nondepressed women. J Sex Marital Ther 2001; 27: 303– 131–138. 316. 19 Pauls R, Berman L, Berman J. A non-pharmacological method 17 Modell JG, May RS, Katholi R. Effect of Burpopion-sf on to enhance vaginal blood flow in patients with sexual arousal orgasmic dysfuction in nondepressed subjects: a pilot study. J disorder. Female Sexual Function Forum 2001, Site: http:// Sex Marital Ther 2000; 26: 231–240. www.isswsh.org.

International Journal of Impotence Research