sign in sign up
<<
Home , Vaginal lubrication

C Female : O N Definitions, Causes, and Treatment T I N Donna F. Brassil U Mary Keller I N G uman sexuality is now Only recently has there been some focus on female sexual function. more openly discussed Due to increasing knowledge regarding male sexual dysfunction and within our society and increasing focus on women’s health care issues, female sexual dys- E is a quality of life issue. function and its relationship to quality of life is slowly attracting the D HSexuality is an organic, normal, attention of health care professionals and women in general. Health physiologic, and emotional com- U care professionals in urologic, gynecologic, and family practice C ponent of human life. It is com- offices and clinics are in key roles to identify females experiencing plex, encompassing physiologic sexual dysfunction. is shaped throughout our life. It A as well as psychological compo- T nents. The diagnosis and treat- depends on religious and cultural beliefs and is strongly related to ment of female sexual dysfunc- early sexual experiences. I tion today is probably where O male sexual dysfunction was 15 N years ago. Despite anatomic sim- Objectives ilarities between men and This educational activity is designed for nurses and other health women, female sexual dysfunc- care professionals who care for and educate patients regarding female tion is more multifaceted sexual dysfunction. The multiple choice examination that follows is (Berman & Berman, 2001). Com- designed to test your achievement of the following educational objec- plaints by women about changes tives. After studying this offering, you will be able to: in their sexual functioning are 1. Identify the four different female sexual dysfunction disorders and becoming common, although possible causes. they are frequently not the pre- 2. Assist women to select the best treatment plan for their sexual dys- senting symptom when seeing function. their health care provider. Knowledge of the normal female sexual response and sexual dys- To better understand the etiol- Testosterone is also needed. function etiology will assist ogy of female sexual dysfunction During excitement, the parasym- health care professionals in diag- (FSD), it is imperative to under- pathetic nervous system mediates nosing and treating female sexual stand female pelvic and genital vascular engorgement. There is an disorders. The purpose of this anatomy and normal female sexual increase of blood flow to the geni- article is to define female sexual response. Response includes psy- tals accompanied by a feeling of dysfunction, explore the popula- chologic and physiologic norms, pressure in the pelvis. The vaso- tions in which it is seen, empha- including endocrine and neurolog- congestion causes vaginal lubrica- size diagnosis, and review cur- ic influences. Both female and tion, swelling of the lower third of rent treatment options. male sexual response has four dis- the , tenting of the upper tinct but related phases: desire two-thirds of the vagina, clitoral (), excitement (arousal), or- enlargement and elevation, and Donna F. Brassil, MA, RN, CURN, is gasm (climax), and resolution labial engorgement. the Director of Clinical Trials, , (American Psychiatric Association, plays a key role in New York University Medical Center, 1994; Masters & Johnson, 1966). vaginal lubrication. Extragenital New York, NY. During the desire phase, sexual fan- changes during this stage include tasy and thoughts are stimulated an increase in blood pressure, Mary Keller, BS, RN, is a Certified by a dopamine-sensitive excitato- tachycardia, tachypnea, general- Research Coordinator, Urology, New ry center in balance with a sero- ized myotonia, and nipple and Yo rk University Medical Center, New tonin sensitive inhibitory center. Yo r k , N Y. areolar . During the

UROLOGIC NURSING / August 2002 / Volume 22 Number 4 237 C orgasmic phase, which is the al stimulation and arousal, are often the result of a disease O peak of the cycle, the sympathe- which causes personal distress. entity, hormonal changes, or tic nervous system mediates to This may be a primary condition medication. N contribute to pleasurable con- in which the female has never In addition to the type of dis- T tractions of the vagina, uterus, achieved , known as anor- order diagnosed, the following I and sometimes the rectum. gasmia, or secondary to surgery, subtypes assist in more clearly Contractions begin at 0.8-second emotional trauma, or hormonal defining the individual patient’s N intervals and then diminish in changes. diagnosis. U intensity and duration. Clitoral Sexual pain disorder. Sexual 1. Lifelong vs. Acquired I result from direct stimu- pain disorder is defined as the 2. Generalized vs. Situational lation, and pelvic floor orgasms recurrent or persistent genital 3. Etiologic origin (organic, psy- N are derived from stimulation of pain associated with sexual chogenic, mixed, unknown). G the or anterior vaginal intercourse known as dyspareu- In the past, the origin was fre- wall. Blood flow is expelled from nia. Possible causes include quently listed as “mixed” E the pelvis to systemic circula- vestibulitis or vaginal atrophy, when often it was unknown. tion. After orgasm, the physiolog- hormonal deficiency (decrease in Therefore, the subtype un- D ic changes that took place during estrogen), physiological inflam- known should now be used U arousal are reversed and the body mation, poor surgical outcomes, when indicated. C returns to a nonaroused state infections, or psychological rea- referred to as resolution (Reading sons. The disorder also includes Prevalence A & Bragonier, 1998). vaginismus, which is the recur- Epidemiologic data related T rent or persistent involuntary to female sexual dysfunction are I Four Classifications of spasm of the musculature of the scarce. Female sexual dysfunc- Sexual Dysfunction outer third of the vagina that tion is age related, progressive, O Hypoactive dis- interferes with vaginal penetra- and affects 30% to 50% of N order. Hypoactive sexual desire tion and noncoital activity. women (Read, King, & Watson, disorder (HSDD) is defined as the Vaginismus usually develops 1997; Rosen, Taylor, Leiblum, & persistent or recurrent deficiency due to psychological or emotion- Backmann, 1993). In a National (or absence) of sexual fantasies al stressors. Health and Social Life Survey of and/or desire for, or receptivity Each of these definitions 1,749 women and 1,410 men, to, sexual activity which causes includes marked distress or aged 18 to 59 years of age, sexu- personal distress. This includes interpersonal difficulty. If the al dysfunction was more com- sexual aversion, which is the per- female is not troubled by any of mon in women (43%) than in sistent or recurrent phobic aver- these, she will never be diag- men (31%). Among females, sion to and avoidance of sexual nosed with having the problem. 22% reported a decrease in sex- contact with a sexual partner. Many women will be diagnosed ual desire, 14% reported diffi- Sexual aversion is often the with more than one sexual disor- culty with arousal, and 7% result of a psychological or emo- der. For example, a woman expe- experienced pain during coitus. tional root. riencing arousal disorder may The report indicated that sexual Female disor- also have hypoactive desire dis- dysfunction is more common der. Female sexual arousal disor- order. There has been an attempt among females with poor physi- der (FSAD) is defined as the per- to create parallels between male cal and emotional health and is sistent or recurrent inability to and female sexual dysfunctions; influenced by negative experi- attain or maintain sufficient sexu- however, it is much more diffi- ences in sexual relationships al excitement, causing personal cult to diagnose female sexual and well-being. is distress. It may be expressed as a arousal disorder compared to reported by 18% to 20% of lack of subjective excitement or a male erectile disorder. Sexual premenopausal women, and lack of genital lubrication/ dysfunction may be primary in 30% to 40% of adult women swelling or other somatic which sexual experiences have perceive their sexual desire as response. This may occur due to never met the definitions; sec- abnormally low (Laumann, physiologic conditions, medica- ondary, in which all phases func- Park, & Rosen, 1999). tions, hormonal changes, or psy- tioned in the past but one or In a comparison study of chological reasons. more phases are not now; or situ- female diabetic clients and non- Orgasmic disorder. Orgasmic ational, in which the response diabetic clients, sexual dysfunc- disorder is defined as the persis- cycle functions sometimes but tion was more prevalent in the tent or recurrent difficulty, delay not always. Primary sexual disor- diabetic group. The major dys- in, or absence of, attaining ders are usually psychogenic function was identified as orgasm following sufficient sexu- while secondary sexual disorders decreased vaginal lubrication

238 UROLOGIC NURSING / August 2002 / Volume 22 Number 4 Table 1. Table 2. C Populations Who May Physiologic and Psychologic Factors That O Experience Female Sexual May Contribute to FSD Dysfunction N Physiological/Psychological Medications T Abused Estrogen Antipsychotics Perimenopausal Testosterone Barbiturates I Female circumcision DESIRE Tricyclic antidepressants N Multiple sclerosis Genitourinary condition SSRIs U Childhood sex abuse Radiation therapy Antihypertensives Chemotherapy Lymphedema Oral contraceptives I Genital mutation Anticonvulsants N Postmenopausal Emotional abuse H2 receptor blockers Gynecological cancer Depression G Radiation Self-esteem Battered Relationship issues Neurogenic disease Chemotherapy E Sexual trauma D Spinal cord injury Smoking Vascular disease Hypertension U Post-hysterectomy Low self-esteem C Lack of sensitivity Coronary artery disease A Postpartum High cholesterol Anticholinergics Medications Vascular deficiencies Antihistamines T Perineal trauma AROUSAL MAO inhibitors I Pelvic surgery SSRIs Genitourinary condition Tricyclic antidepressants O (70% vs. 40%). Inability to Lymphedema Antihypertensives N achieve orgasm, dyspareunia, Sexual abuse and decrease in libido were also Emotional abuse more common in diabetic Depression females than in the control group Self-esteem Relationship issues (Meeking et al., 1998). Rhodes (1999) conducted a 2- Neurogenic deficiencies year prospective study on the Perineal trauma effects of hysterectomy on sexual Female circumcision functioning. The percentage of Genitourinary condition Antipsychotics women who engaged in sexual Radiation therapy Narcotics activity increased significantly Chemotherapy ORGASM Tricyclic antidepressants from 70.5% before hysterectomy Sexual abuse SSRIs to 77.6% and 76.7% at 12 and 24 Emotional abuse Benzodiazepines months postoperatively. The rate Depression Low self-esteem of dyspareunia dropped signifi- Relationship issues cantly from 18.6% preoperatively to 4.3% and 3.6% at 12 and 24 Genitourinary condition months post-surgery. The rates of Gynecologic surgeries PAIN lack of orgasm decreased signifi- Sexual abuse cantly from 7.6% pre-operatively Emotional abuse to 5.2% and 4.9% at 12 and 24 months post-surgery. Low libido decreased from 10.4% before surgery to 6.3% and 6.2% at 12 by psychological, emotional, or drogens, have a direct effect on and 24 months postoperatively. physiological reasons (see Tables sexual functioning. Both estro- The investigator concluded that 1 & 2). Often, the etiology is mul- gen and testosterone are needed frequency of sexual activity tifactorial and interrelated. to regulate female sexual func- increased and sexual dysfunction tion. There are certain times decreased after hysterectomy. Physiological Causes when these hormonal levels are The etiologies of female sex- Hormonal issues. The sex altered. During , ual dysfunction affect a variety of steroid hormones, including estrogen and testosterone levels populations and may be caused estrogen, progesterone, and an- decrease. The loss of estrogen

UROLOGIC NURSING / August 2002 / Volume 22 Number 4 239 C Table 3. Medications. Some medica- toris, vagina, and uterus are dam- O Medications That Can tions can contribute to a decrease aged can lead to a decrease in Diminish Sexual Function in arousal, libido, or orgasm. sexual arousal. Hysterectomy, for N in Females Some that contribute to a disorder example, may lessen blood flow T of desire include antipsychotics, resulting in decreased vaginal I Antipsychotics barbiturates, tricyclic antidepres- lubrication. Antidepressants sants, selective serotonin reuptake Genitourinary conditions. N Antihypertensives inhibitors (SSRIs), antihyperten- Genitourinary conditions such as U Anticholinergics sives, oral contraceptives, and endometriosis, fibroids, vulvody- Diuretics I Antianxiety agents anticonvulsants. Those causing nia, cystitis, lower urinary tract disorders of arousal include anti- symptoms, and pelvic floor dys- N cholinergics, antihistamines, anti- function may contribute to disor- G hypertensives, monoamine oxi- ders of desire, arousal or orgasm, dase (MAO) inhibitors, SSRIs, and or sexual pain disorder. leads to hot flashes, vaginal E tricyclic antidepressants. Medica- Cancers. Cancers, especially mucosal dryness and atrophy, tions causing orgasmic dysfunc- gynecologic and breast cancers, D urinary incontinence, decrease tion include antipsychotics, nar- may be a cause of sexual dys- U in skin elasticity, depression, and cotics, tricyclic antidepressants, function. The breast is a social C a loss of libido. The loss of testos- SSRIs, and benzodiazepines (see sign of femininity. Breast surgery terone contributes to the loss of Tables 2 & 3). will affect sensuality and recep- A appetite, energy, memory, libido, Vascular deficiencies. Vas- tiveness through physical body T orgasm, and genital sensation. cular deficiencies result in image changes. Gynecologic I Perimenopausal and post- decreased blood flow to the surgery may lead to vaginal dry- menopausal women, and those pelvis, vagina, and , which ness and dyspareunia. Lymph- O with premature ovarian failure, contributes to atherosclerosis of edema may alter body image, fos- N commonly complain of decreased the pelvic arteries and decreased tering a decrease in desire and desire, decrease in vaginal lubri- sensation and lubrication. This arousal. Pelvic radiation therapy cation, lack of arousal, and diffi- can affect arousal. Coronary artery and/or chemotherapy often affects culty achieving orgasm. Lack of disease, hypertension, hypercho- ovarian function, resulting in a desire is also common during pre- lesterolemia, and smoking may decrease in sexual desire and menstrual tension. Postnatally, also lead to this. orgasm. Tamoxifen blocks the women who experience postpar- Diabetes. Women with dia- estrogen receptor in breast cancer tum depression will also experi- betes who have neurogenic tumor cells, which can lead to ence a decrease in testosterone and/or vascular complications complaints of vaginal dryness and contributing to a decrease in sexu- may exhibit arousal and/or orgas- have a negative effect on sexual al desire. Breastfeeding suppress- mic dysfunction. Reduced vagi- arousal. es and estrogen produc- nal lubrication, which is the tion, therefore leading to a most common disorder of diabet- Psychological Causes decrease in lubrication. Women ics, may result from vaginal tis- Sexual or emotional abuse with disorders of the thyroid, sue fibrosis. may lead to sexual dysfunction. pituitary, and adrenal glands also Blunt perineal trauma. Blunt Sexual trauma is a broad term complain of sexual dysfunction. perineal trauma experienced that refers to a continuum of Neurogenic issues. The neu- during gymnastics or extensive behaviors from child abuse, rologic system contributes to nor- bicycle riding can contribute to domestic violence and to mal sexual response. Women arousal and orgasmic disorders sexual exploitation. The abuse who have central or peripheral from neurovascular bundle dam- involves a person of greater nervous system disease may age. Trauma caused by childbirth power who exploits the victim complain of loss of sensation of with or without an episiotomy for sexual gratification. Child- the clitoris preventing them from may lead to neurogenic or vascu- hood sexual abuse is highly cor- achieving orgasm. Sex steroids lar changes in the perineum related with sexual dysfunction regulate the secretion and uptake resulting in decreased perineal in adulthood. Any type of abuse of some neurotransmitters as sensation and/or blood flow. In whether it is sexual, verbal, well as their receptors on neu- certain cultures, female circum- physical, or emotional may have rons that regulate sexual behav- cision remains a ritual. These a long-term residual on a female’s ior. Women with spinal cord women display desire and orgas- sexual functioning. It is not injuries have greater difficulty mic dysfunction. unusual for these women to achieving orgasm than other Pelvic surgery. Pelvic surgery experience any or all of the sexu- women (Tarcan et al., 1999) in which the nerves to the cli- al disorder classifications.

240 UROLOGIC NURSING / August 2002 / Volume 22 Number 4 Depression, with or without Table 4. C an accompanied anxiety compo- Diagnosis O nent, may lead to a decrease in desire, arousal, or orgasm. When • Collaboration between primary care provder and psychologist N grieving, most females experi- •Inclusion of partner in process inclusive of diagnosis, treatment, and T ence a loss of sexual desire. evaluation I Relationship issues can lead • Complete medical and surgical history to sexual dysfunction. A healthy • Comprehensive physical examination (including genitourinary exam) N • Hormonal evaluation (estrogen and testosterone) sexual relationship is based on • Laboratory evaluation (to evaluate for underlying disease) U trust, intimacy, and good commu- • Psychological evaluation I nication. If there is a conflict in •Diagnostic testing the relationship, the female’s sex- N ual response will be altered. For G example, a woman will not re- spond in a healthy manner if she E thinks her partner is unfaithful. If since the four disorders are so on intake forms in an office set- the male partner is experiencing closely related in the normal sex- ting, there should be questions D or premature ual response cycle and women about sexual function. Women in U , the female will fre- will often have a combination of gynecologic and urologic offices C quently experience desire, arousal, two or more of the disorders. It is should be provided with a sexual or orgasmic dysfunction. important to establish a primary function questionnaire to com- A In a committed relationship, diagnosis as treatment may also plete during the initial appoint- T sexual dysfunction is a couple’s improve the symptoms of sec- ment. Patients always have the I problem. If a couple experiences ondary disorders. Because diag- option of not completing them. If differences in sexual desire, it nosis is crucial and because there the patient does not feel comfort- O may lead to a major conflict in are so many contributing physio- able discussing it today, she will N their relationship (Gregoire, logic and psychosocial factors, it know that these issues may be 1999). Intrapersonal conflicts, is imperative that the diagnosis discussed when she is ready. including cultural, social, or reli- be made collaboratively between Because of the great number gious beliefs, may invoke feelings a physician and trained sexual of physiologic causes of FSD, the of guilt during sexual activity. psychologist (see Table 4). health care professional must Stress can lead to sexual dys- To be truly effective in treat- obtain a thorough, detailed med- function. In today’s busy lives, ing FSD, the health care profes- ical history as well as a list of people are often stressed, and sional must demonstrate self- current medications (including often too exhausted to participate confidence in his/her own sexu- over-the-counter medications, in sexual activity. Some women ality in order to convey a sense of vitamins, and herbal supple- may experience a decrease in trust and understanding to the ments). This should be followed desire and it will become more patient. Providers must convey a by a thorough physical examina- difficult to become aroused and level of comfort in discussing the tion, including a genitourinary orgasm. Couples who are infer- subject. The chance of a female evaluation, which should assess tile and who are participating in expressing sexual concerns is for trauma, physiologic etiolo- invitro fertilization (IVF) will influenced by her perception of gies, and pain. Serum estrogen, often experience a decrease in the health care professional’s level free testosterone, total testos- desire associated with the stress of comfort in discussing the sub- terone, and DHEA (dihy- of having to perform. ject. When that level of comfort droepiandosterone) levels will Self-esteem is necessary for a and trust is perceived, the female aid in the diagnosis. If the healthy female sexual response. patient will provide more details woman is complaining of dys- Modern day female identity is of her dysfunction allowing for a pareunia, a pediatric speculum associated with motherhood, more definitive diagnosis. and lubrication may be used to beauty/enticement, eroticism, and Some patients may not feel ease her discomfort during the professional status. Without a comfortable with the topic. There gynecologic examination. A thor- good body image and self-esteem, are two effective opening ques- ough psychological interview sexual response will not be tions that may let the patient should be conducted by a psy- attained. know that her sexuality is a safe chologist to determine if there topic for discussion. They are has been any history of abuse and Diagnosis “Are you sexually active?” and if emotional or partner issues that Diagnosing a specific sexual so, “Are you experiencing any may be affecting the female’s sex- disorder is often very difficult sexual difficulties?” Additionally, ual response.

UROLOGIC NURSING / August 2002 / Volume 22 Number 4 241 C There are a variety of sexual available to help in the physio- The introduction of erotism may O function questionnaires that are logic diagnosis of FSD. These entice more sexual thoughts and available for female patients to include clitoral Doppler ultra- fantasy. In menopausal women, N complete prior to the formal sex- sonography to determine clitoral hormone replacement therapy T ual questioning (see Table 5). cavernosal artery and vaginal (HRT) including estrogen, testos- I These questionnaires will not blood flow, vaginal plethysmog- terone, and DHEA may improve only help in the diagnosis but raphy and thermal and vibratory symptoms. DHEA is available N may also enlighten her to more stimulation probes to assess cold, over the counter as an androgen U symptomatology. A thorough warm, and vibratory sensation steroid and is currently being I sexual history includes past sex- thresholds at both the vagina and studied in clinical trials for a ual activity and the current clitoris. FSD indication. In relation to N description of sexual dysfunc- desire, systemic estrogen is pre- G tion including the onset and Treatment ferred while intravaginal estro- duration. For psychological etiologies, gen may improve lubrication. E Questions may include: How the patient should be referred to Women should be reminded that would you describe the problem? a psychologist who specializes in changes from hormonal therapy D Have things ever been better? sexuality for psychological sexu- take place slowly and over a long U Was the onset gradual or sudden? al therapy. When possible, her period of time. C Has it been consistent or inter- partner should be included in Sexual arousal disorder. mittent? Is it partner related? Is it this therapy. Changes from the normal expect- A situational? Is it related to a spe- For organic causes, treat the ed include the use of T cific position or a specific activi- underlying medical disorder. If toys and vibrators that aid in cir- I ty? Are there any precipitating medication induced, prescribe culation. A warm bath and a events? Is there evidence of more different medications to treat the massage from the sexual partner O than one dysfunctional classifi- disease which do not alter sexual will promote circulation and N cation? For example, has the dif- functioning. Education for all of relaxation. ficulty achieving orgasm lead to a these women should include If lubrication is a problem there decrease in desire? Direct ques- normal female anatomy and are several products that can substi- tions related to abuse and sexual physiology, normal female sexual tute for natural lubrication, most of experience as a child or adoles- response, sexually transmitted which are available over the counter. cent may provide insight into the diseases, safe-sex practices, and Examples include Replens® (a vagi- roots of the dysfunction. Is the contraception. This is a good nal moisturizer) Crème de la problem physiologic or psycho- opportunity to teach women Femme®, Sylk®, K-Y® jelly, vitamin logic? about hormonal changes and E oil or suppositories, sesame, canola Open-ended questions about menopause, including hormone or other high-quality oil, and saliva the patient’s relationship with replacement, diet, osteoporosis, (Northrup, 1998). her partner will enlighten the and exercise. Estrogen therapy restores relationship issues. This should Currently many treatment glycogen deposition in the vagina also include questions about the options for female sexual dys- and returns the vaginal pH to nor- partner’s sexual functioning. function are being explored in mal. Blood flow to the vagina can What does your partner think of clinical trials. These include (but be increased by up to 50% with the situation? Does arousal and are not limited to) testosterone HRT. Estrogen vaginal creams, orgasm change with masturba- and some medications currently tablets (VagiFem®), or rings tion? Has anything made it better used to treat male sexual dys- (Estring®) will aid in lubrication or worse? Have you been previ- function. To date, the FDA (Food and sensation. Testosterone and ously treated for it? How often do and Drug Administration) has DHEA can also increase sensation. you partake in sexual activity? approved two types of therapy, Currently there are clinical Do you initiate sexual activity? estrogen replacement and EROS, trials taking place to study the How has this affected your quali- which will be described. Other effects of PDE5 inhibitors on ty of life? Is there any indication nonmedical treatment modalities female arousal. Many of these that there are psychological will also be described (see Table 6). medications have already been implications for the FSD? If so, Hypoactive sexual desire dis- approved for treating male erec- the patient should be referred to order. Loss of desire is the most tile dysfunction. It is hypothe- a psychologist who specializes in common female sexual disorder. sized that these drugs will sexuality to complete a detailed Often, changes in the environ- enhance female genital arousal psychological interview and ment, timing, lovemaking tech- and sensation and increase circu- make the diagnosis. There are nique, or changes in foreplay and lation similar to their activity in currently some diagnostic tests will induce desire. men.

242 UROLOGIC NURSING / August 2002 / Volume 22 Number 4 C Patient Education Information O Female Sexual Dysfunction N Today women are becoming more aware of their own sexual needs and choices. Although women often have prob- T lems they find difficult to discuss with a partner, close friend, or physician, is becoming more openly discussed within our society and is a quality-of-life issue. Women can have a positive and healthy response I to sex throughout their lifetime. N What is a normal sexual response? What can cause female sexual dysfunction? U A woman’s body and mind experience a series of regular Some physical or psychological conditions can cause prob- I changes during a sexual response. Female sexual response lems with a woman’s sex life. Certain medicines, diseases has four distinct phases: (such as breast cancer, diabetes, high cholesterol, or high N blood pressure), smoking, alcohol use, or changes in hor- G 1. Desire phase – Sexual fantasy and thoughts are stimu- mone levels during pregnancy or menopause can cause sex- lated, causing the woman to start sexual activity. ual problems. Depression, problems in a relationship, or any experience with abuse can also cause sexual problems. Poor 2. Excitement phase – Physical changes take place in surgical results and infections are other possible causes of E response to sexual thoughts or being touched. A feeling sexual dysfunction. D of pressure in the pelvis begins. The vagina gets moist. There is enhanced muscle tension throughout the body The stresses of everyday life can affect a woman’s desire or U and the nipples become erect. ability to have sex. When stressed, women are often too C exhausted to participate in sexual activity. 3. Orgasmic phase – This is the peak of the cycle. The A woman experiences pleasurable contractions of the How do you know if you have a problem? T vagina, uterus, and sometimes the rectum. Nearly every woman has a problem with sex at some time in her life. Some problems can be worked out with patience I 4. Resolution – After the orgasm the body returns to a non- and a caring partner. Others may take more effort and a O aroused state. different approach with a skilled practitioner. Ask yourself some of the following questions: N What is female sexual dysfunction? ■ Do you feel less sexual desire than before? Sexual function is a cycle of both physical and emotional ■ Does it hurt during sexual relations? events. When there is a problem with one of these events or ■ Do you experience vaginal burning during intercourse? phases there is dysfunction. Female sexual dysfunction is ■ defined in four categories: Recently, is it more difficult to achieve an orgasm? ■ Are you frustrated with your partner’s problem with 1. Decreased sexual desire – A decrease or absence of sex- ? ual thoughts and/or desire for sexual activity, which ■ Have you had an abusive experience in your life that causes personal distress. Some women may also avoid you feel is affecting your sex life? sexual contact with a partner. ■ Do you have decreased vaginal lubrication during ? 2. Decreased arousal – The inability to maintain sufficient ■ Do you have a physical problem that interferes with sexual excitement. It may be expressed as a lack of your sexual functioning? excitement or a lack of genital lubrication or swelling.

3. Decreased ability to orgasm – The inability, difficulty, or If you answered yes to any of these questions, you may have delay in having an orgasm following sufficient sexual a sexual problem. stimulation. Some women have never experienced an orgasm. How can you help yourself? If you think you have a problem in your sex life, you are not 4. Sexual pain – Is recurring or lasting genital pain with alone. Learn about your body and how it works. Talk with known as dyspareunia. This pain your partner about what you are feeling and what you are may happen during entry into the vagina, pain during experiencing. Most types of sexual dysfunction can be cor- intercourse, or pain afterwards. The vagina can spasm rected by treating the underlying physical or psychological or “cramp up” preventing entry into the vagina and problem. Your health care provider can begin to explore the causing pain. causes of sexual dysfunction, discuss treatment options, and start you with counseling, if needed.

The various treatments and therapies for female sexual dys- function are individual and each woman should discuss them with her partner and health care provider. The pros and cons to treating sexual dysfunction depend on the woman’s own physical condition and life’s experiences. Health care providers can support and help each woman with her deci- sion in treating sexual dysfunction.

This patient education page may be photocopied for educational use.

UROLOGIC NURSING / August 2002 / Volume 22 Number 4 243 C In 2000, the FDA approved Table 5. O the use of EROS-CVD (clitoral Questionnaires to Aid in the Diagnosis of vacuum device) for the treatment Female Sexuality Disorders N of arousal disorder. It is a small T battery-powered hand-held de- • International Index of Female Sexual Arousal I vice designed to increase blood • Female Sexual Activity and Life flow by placing a suction cup over •BISF-W Brief Index of Sexual Functioning for Women N the clitoris, thus engorging it. •FIEI Female Intervention Efficacy Index U Clitoral engorgement results in • Female Sexual Function I increased clitoral sensation, en- hanced arousal, and improved N vaginal lubrication. G Orgasmic disorder. In cases Table 6. of anorgasmia, a lack of sexual Sexual Disorder Classifications and Some Available Modalities E experience may require more stimulation. With all orgasmic D disorders , Kegel Hypoactive Sexual Desire Change in the environment exercises, and the use of vibra- Disorder Change in time of day U Change in love making technique C tors may enhance stimulation. Foreplay, fantasy, erotism Sexual pain disorder. Ef- A Hormone therapy, including testos- fective treatment modalities exist terone T for sexual pain disorder after all Videos, different music I genitourinary diseases have been ruled out. If the pain is caused by Female Sexual Arousal Vaginal lubricants O friction, lubricants should be Disorder Hormone therapy N advised. If pain occurs with deep Vibrating aids, toys, masturbation penetration, relaxation tech- Warm bath, massage niques may help. Avoiding deep EROS-CVD penetrative sex may help with Orgasmic Disorder Vibrating aids, masturbation relaxation. Changes in position- Kegel exercises ing may help any pain disorder. Vaginismus, the involuntary con- Sexual Pain Disorder Vaginal lubricants traction of the outer third of the Decrease of penetrative sex vagina, is treated with relaxation Different positions; less thrusting and vaginal dilation. In vaginal Any change from norm may be a dilation a finger, vibrator, or tam- distraction pon of increasing diameter is Biofeedback placed in the vagina several Lidocaine jelly Vaginal dilatation times a day. Dyspareunia may Vestibulectomy improve with biofeedback or lidocaine jelly. Vulvar vestibulitis is an inflammatory condition of the vulvar vestibule, characterized mone therapy is used as a treat- sexual arousal, vaginal lubrica- by pain on vestibular contact or ment, it is important to monitor tion, and orgasm. These event vaginal entry. It has been treated serum levels over time to note logs often provide insight into with amitriptyline, acyclovir, correlation between improve- the current dysfunction and are a interferon, biofeedback, and ment of symptoms and higher means of noting improvement vestibulectomy. hormone levels. when comparing event logs Subjective data, which are before treatment. Treatment Followup vital, may be obtained from Currently, there is no “gold- patients through the use of ques- Conclusion standard” measure for assessing tionnaires and event logs. Event Women with female sexual efficacy in clinical trials of logs, which should be completed dysfunction are well served female sexual dysfunction. soon after each sexual activity, when health care providers edu- Physiologic indicators may be should detail the specific sexual cate and inform them about the vaginal plethysmography and activity including sexual stimu- different disorders, causes, and clitoral Doppler imaging. If hor- lation, physical and emotional possible treatments available to

244 UROLOGIC NURSING / August 2002 / Volume 22 Number 4 them (see Patient Education manual of mental disorders (4th ed.). Read, S., King, M., & Watson, J. (1997). Information on page 243). Washington, DC: American Psychiatric Sexual dysfunction in primary medical Association. care: Prevalent characteristics and Balancing the various therapies Berman, J.R., & Berman, L.A. (2001). For detection by the general practitioner. for female sexual dysfunction is women only: A revolutionary guide to Journal of Public Health Medicine, highly individualized. A collabo- overcoming sexual dysfunction and 19(4), 387-391. rative approach by the primary reclaiming your sex life. New York: Reading, A., & Bragonier, R (1998). Human health care provider, psycholo- Henry Holt and Company. sexuality and . In N. Gregoire, A. (1999) ABC of sexual health: Hacker, & J. Moore (Eds.), Essentials of gist, and the patient can result in Assessing and managing male sexual obstetrics and gynecology (3rd ed.) (pp. a positive outcome to diagnosing, problems. British Medical Journal, 318, 532-542). Philadelphia: W.B. Saunders. treating, and following up on 315-317. Rhodes, J.C. (1999). Hysterectomy and sexu- female sexual dysfunction. Laumann E.O., Park, A., & Rosen, R.C. al functioning. JAMA, 282(20), 1934- (1999). Sexual function in the United 1941. Health care professionals should States prevalence and predictors. Rosen, R.C., Taylor, J.F., Leiblum, S.R., & explore and research female sex- JAMA, 281, 537-544 Bachmann, G.A. (1993). Prevalence of ual dysfunction through more Masters, W.H., & Johnson, V.E. (1966). sexual dysfunction in women: Results research and clinical trials. As Human sexual response. Boston: Little of a survey study of 329 women in an knowledgeable providers, we can Brown. outpatient gynecological clinic. Journal Meeking, D.R. et al. (1998). Sexual dysfunc- of Sex and Marital Therapy, 19(3), 171- offer support to each woman tion and sexual health concerns in 188. with her struggles, decisions, and women with diabetes. Sexual Tarcan, T., Park, K., Goldstein, I., Maio, G., accomplishments. • Dysfunction, I, 83-87. Fassina, A., Krane, R.J., & Azadzoi, Northrup, C. (1998). Menopause. In C. K.M. (1999). Histomorphometric analy- References Northrup (Ed), Women’s bodies, sis of age-related structural changes in women’s wisdom (2nd ed.) (pp. 548- human clitoral cavernosal tissue. American Psychiatric Association. (1994). 550). New York: Bantam Press. Journal of Urology, 161(3), 940-944. DSM-IV: Diagnostic and statistical

284 UROLOGIC NURSING / August 2002 / Volume 22 Number 4