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Female Sexual Dysfunction: O N Definitions, Causes, and Treatment T I N Donna F

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Female Sexual Dysfunction: O N Definitions, Causes, and Treatment T I N Donna F C Female Sexual Dysfunction: 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. Sexual identity 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 vagina, tenting of the upper tinct but related phases: desire two-thirds of the vagina, clitoral (libido), 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, Urology, (American Psychiatric Association, Estrogen 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 erection. 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 orgasm, 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 orgasms 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 cervix 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 sexual desire 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 sexual arousal 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. Dyspareunia 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 Pregnancy Female circumcision DESIRE Tricyclic antidepressants N Multiple sclerosis Genitourinary condition SSRIs
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