Effects of Age and Estrogen Status on Subjective and Physiologic Sexual Responses

Home , Labia, Vasocongestion

Clinical evaluation of female sexual function: effects of age and estrogen status on subjective and physiologic sexual responses

JR Berman1*, LA Berman1, TJ Werbin1, EE Flaherty1, NM Leahy1 and I Goldstein1

1Boston University Medical Center, Boston, MA

Introduction: 30 ± 50% of American women complain of sexual dysfunction. Aging, menopause, and a decline in circulating estrogen levels signi®cantly increase the incidence of sexual complaints. Evaluaton of physiologic components of the female sexual response has, in the past, been technically challenging and dif®cult to standardize. We describe methodology for evaluating physiologic and subjective components of the female sexual response in the clinical setting and determine the effcts of age and estrogen status on them. Methods: 48 women with complaints of sexual dysfunction were evaluated. Physiologic measurements include genital blood peak systolic velocity, vaginal pH, intravaginal pressure ± volume changes (compliance), and genital vibratory perception thresholds. Measurements were recorded at baseline and following sexual stimulation. Baseline subjective sexual function was assessed using a Female Sexual Function Inventory. Age was then correlated with both physiologic and subjective sexual responses. Results: Sexual stimulation resulted in increased mean genital blood peak systolic velocity, vaginal pressure ± volume, and vaginal pH measurements (P < 0.05) in all women. Older women (ages 55 ± 71 y) and menopausal women not on hormone replacement therapy had signi®cantly lower physiologic response sexual complaints. Baseline subjective sexual function complaints included low arousal (67%), low desire (21%), dif®culty achieving orgasm (92%), and pain or discomfort during and=or following intercourse (67%). Conclusions: Clinical evaluation of physiologic and subjective components of the female sexual response are possible using this comprehensive approach. Physiologic measurements were reproducible and easy to perform, and incidence and types of sexual complaints were assessed with the sexual function questionnaire. A comprehensive approach is necessary when evaluating female sexual dysfunction due to the signi®cant emotional and relational factors that can contribute to the problem. This combined subjective=physiologic assessment may also prove useful when evaluating ef®cacy of pharmacotherapy in the future.

Keywords: Female sexual dysfunction; Doppler ultrasound; menopause; vaginal pressure volume; clitoral blood ¯ow

Introduction status on both the physiologic and subjective components of the female sexual response will also be addressed. During female sexual arousal, sensory stimulation With aging and menopause, a majority of women leads to central nervous system activation resulting experience some change in sexual function. Common in vaginal and clitoral smooth muscle relaxation and sexual complaints include loss of desire, decreased increased genital blood ¯ow. This culminates in a frequency of sexual activity, painful intercourse, series of vasocongestive and neuromuscular events, diminished sexual responsiveness, dif®culty achiev- which include increased clitoral and vaginal length ing orgasm, and decreased genital sensation. Symp- and diameter, increased vaginal lubrication and toms related to alterations in genital sensation and wall engorgement.1±3 This study describes effective blood ¯ow are, in part, secondary to declining means for assessing physiologic and subjective estrogen levels, and there is a direct correlation components of the female sexual response in the between the presence of sexual complaints and levels clinical setting. The effects of age and estrogen of estradiol below 50 pg=cc. Symptoms markedly decrease with estrogen replacement.2 Similar to the impact of natural menopause, *Correspondence: Jennifer R Berman, MD, 720 Harrison Avenue, Suite 606, Boston, MA 02134, USA; surgical menopause brought on by hysterectomy= e-mail: [email protected] oophorectomy has signi®cant negative impacts on {Financial support: departmental funds. sexual function. Even hysterectomy alone, without Clinical evaluation of female sexual function JR Berman et al S32 the removal of the ovaries, can result in sexual We use duplex Doppler ultrasonography to assess dysfunction.4 Symptoms women commonly experi- changes in female genital hemodynamics during ence post-operatively include decreased desire, sexual arousal. This technique provides continuous, decreased arousal, decreased genital sensation and realtime imaging of anatomic, as well as vasocon- orgasmic dysfunction. The anatomic=physiologic gestive (engorgement) components of the female basis for sexual dysfunction post-hysterectomy is sexual response. In additon, it records blood still unclear. At present, we have limited under- velocity in absolute units; centimeters per second standing of the female neurovascular anatomy vital (cm=s). to normal sexual arousal and function. This is an In addition to documenting genital blood velo- area of focus and research in our laboratory, and in city, we also measure changes in vaginal lubrication, the future, we hope to provide women with nerve- vaginal elasticity or compliance, as well as genital sparing pelvic procedures similar to those now sensation. Information obtained from these physio- routinely performed in men. logic measurements helps to clarify the etiology of Female sexual complaints are often not purely an organically based sexual dysfunction, and may psychologically based. In fact, the same medical lead to improved diganostic and evaluative techni- problems that cause erectile dysfunction in men, ques for female sexual complaints. Furthermore, such as diabetes, high blood pressure, high choles- development of reliable methodology as well as terol levels, etc., may also result in sexual dysfunc- establishment of treatment outcomes will allow us, tion in women. For example, the recently named in the future, to effectively evaluate the effects of vaginal and clitoral erectile insuf®ciency syndromes drug therapies. are, in fact, directly related to diminished genital To assess subjective sexual function, in particular blood ¯ow.3 Diminished pelvic blood ¯ow second- sexual arousal, few instruments have been vali- ary to aorto-iliac or atherosclerotic disease leads to dated. We use the Brief Index of Sexual Function vaginal wall and clitoral smooth muscle ®brosis.5 Inventory (BISF-W), which is a 21-item self-report Histomorphometric evaluaton of clitoral erectile inventory of sexual interest, activity, satisfaction tissue from atherosclerotic animals demonstrates and preference. This instrument has been validated cavernosal artery wall thickening, loss of corporal and found to be highly reliable and to discriminate smooth muscle and an increase in collagen deposi- between depressed and sexually dysfunctional tion. In human clitoral tissue, there is a loss of healthy patients.8,9 Subjective sexual response data corporal smooth muscle, replacement by ®brous re¯ect the personal experience of the patient. This is connective tissue in associaton with atherosclerosis an important variable to evaluate because our of clitoral cavernosal arteries.6 ultimate goal is to enhance the personal sexual Any traumatic injury to the iliohypogastric experience of the woman. The intervention is not pudendal arterial bed from pelvic fractures, blunt considered successful unless the woman is able to trauma, surgical disruption, or chronic perineal subjectively experience sexual arousal, pleasure and pressure from bicycle riding for instance, can result satisfaction. Thus, it is important to determine if in diminished vaginal and clitoral blood ¯ow and physiological changes or improvement in blood complaints of sexual dysfunction. ¯ow, translates into an improved sexual experience. Although other underlying conditons, either For instance, a physiologically documented increase psychological or physiological, may manifest as in blood ¯ow and pH is irrelevant, unless the patient decreased vaginal and clitoral engorgement, arterial actually experiences increased arousal, sensation, insuf®ciency is one etiology that should be con- and satisfaction that re¯ects those physiological sidered. processes. In the clinical setting, female sexual responses have been dif®cult to quantify objectively. The changes that occur with female sexual arousal are Materials and methods not only dif®cult to measure, but are also not always recognized by the patient. Previously described techniques for evaluating physiologic changes dur- Following Institutional Review Board approval, 48 ing female sexual arousal include estimates of women who presented to the Women's Sexual vaginal engorgement, labial and vaginal temperature Health Clinic with complaints of sexual dysfunction changes, and pelvic contractions with orgasm.7 were evaluated. A psychosocial, as well as full Vaginal photoplethysmography is the most used medical exam was performed on each patient. and validated estimate of vaginal blood ¯ow, or Each patient had physiologic measurements more speci®cally, engorgement. This method, how- recorded at baseline and following sexual stimulation ever, is subject to movement artifact and is thus not using a 15-min standardized erotic video (Sinclair suitable for studying the patient during masturba- Institute, Femme Productions, Chapel Hill, NC) and tion=stimulation. In addition, it provides arbitrary vibrator (Ferticare, ITLS, Inc., Evans, CA). Visual rather than absolute units of measurement and no stimulation was maintained throughout the entire anatomic information is provided.7 evaluation using 3-D surround sound glasses (I.O. Clinical evaluation of female sexual function JR Berman et al S33 Display Systems LLC, San Francisco, CA). The time established. Menopausal status (with or without that was required to complete the entire evaluation hormone replacement therapy) was then correlated was approximately 7 ± 10 min. with subjective sexual complaints using a two-tail The physiologic parameters evaluated included Fisher's exact test. genital blood peak systolic velocity, vaginal pH, vaginal pressure=volume (compliance) changes, and genital vibratory perception thresholds. Clitoral, Results labial (vestibular bulb), urethral, and vaginal arterial peak systolic velocity and end diastolic velocity is The physiologic and subjective sexual response data measured using duplex Doppler ultrasonography from 48 women, (mean age 45.7 y Æ 10.8) was (General Electric Logic 400, MA). A 12 mHz probe evaluated. All women had complaints of sexual was used externally to measure right and left clitoral dysfunction including, but not limited to, sexual cavernosal, as well as right and left labial and arousal disorder, hypoactive sexual desire disorder, urethral arterial blood ¯ow. Urethral measurements and orgasmic disorder (Table 1). were recorded on the ventral surface. The largest A total of 45.8% of women (n 22) were branch on either the right or left side was recorded. menopausal (no spontaneous menstruation for Labial measurements were recorded from the poster- greater than six months or FSH levels > 40 ng and ior labial=bulbar artery. The vestibular bulb is estradiol levels < 20 ng). Of these menopausal located directly beneath the skin of the labia minora. women, 59% (n 13) were receiving HRT. Patients A transvaginal probe was used to measure right and were not categorized by type of HRT. left vaginal arterial blood ¯ow. The mean of three consecutive measurements was recorded for each site. Vaginal pH was measured with a digital pH meter (Sandhill, Inc., Highlands Ranch, CO). The probe Physiologic measurements: clitoral, labial, urethral was inserted into the vagina and the mean of and vaginal artery peak systolic (PSV) and end consecutive measurements was recorded. diastolic velocities (EDV): Vaginal pressure=volume (compliance) changes were measured with a commercially available com- Sexual stimulation resulted in signi®cant increases in pliance balloon (Schuster Balloon, Sandhill, Inc.). genital blood velocity in all patients (48=48). Follow- Measurements were recorded at 0 cc and then following sexual stimulation, mean clitoral peak systolic ing 30 cc increments of air instillation. Maximum velocity and end diastolic velocities signi®cantly vaginal pressure=volume (compliance) was de®ned as increased. Mean right and left vestibular bulb (labial) the intravaginal pressure at maximum intravaginal peak systolic and end diastolic velocities also sig- volume. The maximum volume was determined when ni®cantly inceased. Mean urethral and right and left the patient experienced vaginal pressure or fullness vaginal arterial peak systolic velocity and end diasto- that was uncomfortable, but not painful. lic velocity signi®cantly increased (Table 2). Vibratory perception thresholds were recorded In the menopausal group, women receiving HRT from the clitoris (dorsal midline) and right and left had higher pre- and post-stimulation vaginal, clitor- labia minora using a standard biothesiometer. The al, urethral and labial blood velocity than meno- mean of three measurements was recorded for each pausal women not receiving HRT; however, these site. differences were not signi®cant. When analyzed by All 48 patients completed the Brief Index of age, older women (ages 55 ± 67 y) had signi®cantly Sexual Function Inventory (BISF-W) prior to the lower pre-stimulation clitoral, labial, urethral and medial, physiological, orpsychosocial evaluations. vaginal blood velocities than younger women (ages Demographic information including age, menopausal and estrogen status, and past medical and surgical history were also recorded. Table 1 Incidence of speci®c sexual complaints for all 48 women

Sexual complaint Incidence % Statistical analysis No sexual desire or interest 21 No sexual arousal during sexual activity 67 Changes in mean pre- to post-stimulation physio- Little or no lubrication during sexual 60 logic measurements were evaluated using a paired t- activity Unable to maintain lubrication during 20 test. Comparisons between groups of women (young sexual activity to old, and menopausal with HRT to menopausal Genital numbness (asleep feeling in the 30 without HRT) were performed using an unpaired t- genital area) during sexual activity test, and P-values 0.05 were considered statisti- Dif®culty or inability achieving orgasm 92 Pain or discomfort with sexual activity 67 cally signi®cant. For subjective sexual function Pain or discomfort following sexual activity 67 complaints, trends, in terms of percentages, were Clinical evaluation of female sexual function JR Berman et al S34 Table 2 Mean pre- and post-stimulation clitoral, labial, urethral and vaginal arterial blood ¯ow measurements

Blood ¯ow

Pre-Stimulation Post-Stimulation

Artery EDV (cm=s) PSV (cm=s) EDV (cm=s) PSV (cm=s)

Clitoral 3.35 Æ 2.24 12.39 Æ 6.22 8.20 Æ 5.68* 22.00 Æ 6.22* Left Labial 4.07 Æ 3.12 16.91 Æ 9.52 12.58 Æ 14.9* 27.18 Æ 18.06* Right Labial 3.21 Æ 2.20 15.20 Æ 7.08 6.94 Æ 4.10* 25.31 Æ 12.32* Urethral 2.74 Æ 2.07 15.10 Æ 7.77* 7.31 Æ 4.50* 29.00 Æ 16.64* Left Vaginal 4.12 Æ 3.30 20.33 Æ 10.99 9.51 Æ 5.97* 39.96 Æ 20.69* Right Vaginal 4.56 Æ 4.60 18.32 Æ 10.31 9.70 Æ 5.60* 31.41 Æ 12.80*

*Statistically signi®cant increase in PSV=EDV from pre- to post-stimulation at the P < 0.05 level. PSV peak systolic velocity; EDV end diastolic velocity. Table 4 Mean pre- and post-stimulation pH values 25±54y)(P 0.048, 0.027, 0.030 and 0.050, respec- tively). Post-stimulation, there were no signi®cant pH values differences in genital blood velocity between young- Pre-Stimulation Post-Stimulation er and older women (Table 3). All 48 women 5.68 Æ 0.96 6.16 Æ 0.99* Vaginal pH `Younger' women 5.58 Æ 0.90 6.16 Æ 1.06 (ages 25 ± 54; n 36) `Older' women 5.93 Æ 1.12 5.59 Æ 1.92 (ages 55 ± 67; n 12) Mean pH measurements signi®cantly increased Menopausal women; on 5.12 Æ 0.56* 5.60 Æ 0.70* following sexual stimulation from a mean baseline HRT (n 13) value of 5.68 to a mean post-stimulaton value of 6.16 Menopausal women; no 6.14 Æ 1.14* 6.79 Æ 1.06 in all 48 women. In the menopausal group (n 22), HRT (n 9) women receiving HRT (n 13) had signi®cantly *Statistically signi®cant increase in pH, pre- to post-stimulation lower baseline vaginal pHs than those who were at the P < 0.05 level. not (n 9) (P < 0.05). Post-stimulation, vaginal pH measurements signi®cantly increased in menopau- receiving HRT (n 13) had higher maximum vaginal sal women receiving HRT. Although there was an pressure ± volume measurements (190cm3) than increase in post-stimulation pH measurements from those who were not (120 cm3 n 9). In addition, menopausal women not receiving HRT, the changes younger women (ages 25 ± 54 y) had higher max- were not signi®cant. There was no signi®cant imum pressure ± volume measurements than older difference between pre- or post-stimulaton vaginal women (ages 55 ± 67 y); however these differences pHs between younger women (ages 25 ± 54 y) and were not statistically signi®cant (Table 5). older women (ages 55 ± 67 y) (Table 4).

Vaginal pressure ± volume changes (compliance) Vibratory perception thresholds Sexual stimulation resulted in signi®cant increases In all women, sexual stimulaton resulted in de- in maximum vaginal compliance (P 0.003) in all creased clitoral and labial vibratory perception patients. In the menopausal group (n 22), women thresholds; however, these changes were not statis-

Table 3 Mean pre- and post-stimulaton clitoral, labial, urethral and vaginal blood velocity measurements in `younger' versus `older' women

Blood velocity

Younger women (ages 25 ± 54 y, n 36) Older women (ages 55 ± 67 y, n 12)

Pre-Stim Post-Stim Pre-Stim Post-Stim

Artery PSV EDV PSV EDV PSV EDV PSV EDV

Clitoral 12.8 3.6 21.6 7.8 11.2 2.7 23.2 9.2 Right Labial* 16.5 3.6 25.4 7.4 11.2 2.1 25.1 5.7 Left Labial* 17.6 4.6 28.9 7.5 14.0 2.4 21.2 7.9 Urethral* 15.9 3.1 30.4 7.3 11.7 1.6 24.8 7.3 Right Vaginal* 21.6 5.5 33.5 11.0 12.5 2.8 26.2 6.4 Left Vaginal* 24.1 4.13 44.1 11.3 12.8 4.1 29.8 5.1 Clinical evaluation of female sexual function JR Berman et al S35 tically signi®cant. There ws no difference between increasing age. In the future, this methodology can pre- or post-stimulation vibratory perception thresh- be used to determine baseline female sexual func- olds between menopausal women receiving HRT tion following speci®c treatments. and those who were not. In addition, when analyzed Despite subjective complaints of decreased sexual by age, there was no difference in clitoral or labial arousal, sexual stimulaton resulted in signi®cant vibratory perception thresholds between younger physiologic responses in these women. The explan- and older women (Table 6). ation for this phenomenon is two-fold. First, women are often not cognizant of their level of arousal (i.e. the amount of lubrication or genital swelling) or the Discussion

The female sexual response has been dif®cult to quantify and evaluate clinically. In the past, instruments to measure female sexual responses have been technically limited, and were often not reproducible or reliable. The techniques described in this study, which utilize current medical tech- nologies, are being validated and compared to previously described techniques. New female sexual function questionnaires, speci®c for arousal disorder, are also being developed and validated. We describe a comprehensive subjective and physiologic approach to evaluate the female sexual response in the clinical setting. Using this combined approach, we documented changes in physiologic parameters of the female sexual response, determined trends for female sexual complaints, and correlated them with risk factors, in particular

Table 5 Mean pre- and post-stimulation values of maximum pressure ± volume measurements in cm3

Maximal pressure ± volume measurements (cm3)

Pre-Stimulaton Post-Stimulation

All 48 women 150.7 174.8* `Younger' women 159.0 184.0 (ages 25 ± 54; n 36) `Older' women 127.5 147.0 (ages 55 ± 67; n 12) Menopausal women; on 140.8 167.5* HRT (n 13) Menopausal women; no 100.0 102.9 Figure 1 Left clitoral cavernosal arterial blood ¯ow changes pre- HRT (n 9) and post-sexual stimulaton. Vmax increased from 12.3 cm=sto 26.2cm=s and Vmin increased from 3.69 cm=s to 9.84 cm=s. *Statistically signi®cant increase in pressure ± volume V peak systolic velocity; V end diastolic velocity; measurements, pre- to post-stimulation at the P < 0.05 level. max min

Table 6 Mean pre- and post-stimulation vibratory perception measurements for the clitoris and right and left labia

Vibratory measurements

Pre-Stimulation Post-Stimulation

Clitoris Right Labia Left Labia Clitoris Right Labia Left Labia

All 48 women 6.6 7.2 6.7 5.7 7.3 6.5 `Younger' women (ages 25 ± 54; n 36) 6.7 7.2 6.9 5.2 6.9 5.2 `Older' women (ages 55 ± 67; n 12) 6.6 7.5 6.3 7.5 8.3 7.9 Menopausal women; on HRT (n 13) 6.0 8.6 7.3 5.7 8.2 6.9 Menopausal women; no HRT (n 9) 5.9 5.6 5.1 8.9 8.6 7.1 Clinical evaluation of female sexual function JR Berman et al S36 It is also possible that sexual responses that occurred in these women, although signi®cant, were not suf®cient enough for the patient to subjectively notice a difference. Normative data is being gathered for comparison to determine what the normal physiologic responses are for women in different age groups.

Changes in vaginal pH

With sexual stimulation, a transudate develops from vaginal mucosal epithelial cells, and secretions are released from the cervix. The transudate occurs as a result of increased blood ¯ow to the vagina and increased hydrostatic pressure within the capillaries of the vaginal wall. Vaginal pH subsequently increases, approaching values of 6.5 ± 7.8. This increase in vaginal pH, with sexual arousal, is believed to promote sperm capacitance and survival, which ordinarily cannot survive in the acidic pH of the unaroused vagina. Attempts to measure vaginal pH, as an indirect measurement of vaginal lubrication, have in the past been technically dif®cult, intrusive and with con¯icting reports. One study showed that sexual arousal can induce changes in the surface pH of one part of the vagina while not affecting the other.11 In addition, the estrogen status of the woman, as well as local bacterial ¯ora can effect vaginal pH. We established a highly sensitive means for measuring changes in vaginal pH using a soft, Figure 2 Left labia pre- and post-sexual stimulaton. V max 1 cm probe. In this study, vaginal pH signi®cantly increased from 15.7 cm=s to 35.7 cm=s and V increased from min increased with sexual stimulation. Menopausal 3.81 cm=s to 5.74 cm=s. Vmax peak systolic velocity; Vmin end diastolic velocity; R1 resistive index. women receiving HRT had signi®cantly lower baseline vaginal pH levels than those who were not (5.12 vs 6.14; P < 0.05). This technique may prove useful in the evaluaion of changes in vaginal pH following physiologic changes that are occurring, but rather vasoactive drug treatment. In addition, baseline know more subjectively how they `feel'.10 Secondly, information prior to implementing HRT or other it is also possible that emotional=psychological treatment can be obtained. issues interfere with the patient's subjective sexual experience. This suggests that in the future, subjective questionnaires should be included in the Changes in genital blood velocity evaluation of female sexual function. Furthermore, the emotional aspects and the context in which a woman experiences her sexuality are equal, if not Sexual arousal and stimulaton results in increased more important than the physiologic outcome. For blood ¯ow to the hypogastric=pudendal arterial bed. this reason, we suggest that all women with This leads to increased perfusion to the sexual complaints of sexual dysfunction undergo a psy- organs, speci®cally the vagina, clitoris, labia and chosocial evaluation to determine the emotio- urethra. Using duplex Doppler ultrasound, we nal=relational components that may be documented signi®cant increases in blood velocity contributing to the problem. If there are signi®cant to these structures. With sexual stimulation and interpersonal or relational issues in women, phar- arousal, in addition to increased genital blood macotherapy is not the sole solution to the problem. velocity, there is also concomitant smooth muscle This differs in some ways from the treatment of relaxation of clitoral and vestibular bulb erectile psychogenic male erectile dysfunction for which tisue.3 This results in an increase in length and pharmacotherapy is 85 ± 90% effective. diameter of the clitoris, as well as engorgement of the clitoris and labia. Following sexual stimulation, Clinical evaluation of female sexual function JR Berman et al S37 this phenomenon was demonstrated anatomically maximum compliance measurements (c 127.5 cm3) on ultrasound, by increased engorgement and than younger women (159 cm3). venous pooling in the clitoris and labia and Aging and menopause and the concomitant physiologically by increased peak systolic and end decrease in circulating estrogen levels leads to diastolic velocities in these structures. This is the atrophy of vaginal wall smooth muscle with second- ®rst study to utilize duplex Doppler ultrasound to ary vaginal wall ®brosis and collagen deposition. evaluate female genital hemodynamics during sex- This results in diminished vaginal engorgement and ual arousal. This technique is currently being smooth muscle relaxation in response to sexual validated and compared to photoplethysmography stimulation. Vaginal pressure ± volume measure- and other existing methods to assess genital blood ments appear to provide information about the ¯ow. ability of the vagina to relax and dilate with sexual Older women (ages 55 ± 67 y; n 12) had signi®- stimulation. In addition, baseline information can be cantly lower baseline vaginal, clitoral, urethral, and obtained prior to implementing HRT in postmeno- labial blood velocities (PSV and EDV) than younger pausal women with dyspareunia secondary to women (ages 25 ± 54 y; n 36). These ®ndings cor- vaginal muscle atrophy and vaginal wall ®brosis. respond to those in aging men that demonstrated decreased cavernosal arterial in¯ow on duplex ultrasound, as well as increased incidence of Changes in vibratory perception thresholds erectile dysfunction. Within the menopausal group (n 22), women receiving HRT (n 13) had signi®- Vibratory thresholds provide information about the cantly higher baseline blood velocities than those level of sensation in the genital tissue. Somatic who were not (n 9). There were no signi®cant sensory pathways originate from clitoral skin. There differences in post-stimulation blood velocity mea- is a dense collection of Paccinian corpuscles surements in the menopausal group. These ®ndings innervated by rapidly adapting myelinated affer- 10 correspond with those of Lann and Everaerd who ents, as well as Meissner's corpuscles, Merckel demonstrated with photoplethysmography, that tactile discs, and free nerve endings. These sensory baseline vaginal blood ¯ow in menopausal and afferents pass from the dorsal slitoral nerve to the postmenopausal women was lower in premenopau- pudendal nerve. The primary receptors for vibratory sal women, but that with sexual stimulation, no sensation are the Paccinian and Meissner's corpus- signi®cant differences occurred between premeno- cles. pausal women and untreated menopausal women or In this study, there was a modest decrease in postmenopausal women. clitoral and labial vibratory thresholds following Enhanced pelvic blood ¯ow with estrogen has sexual stimulation, however the change was not been correlated with increased vaginal secretions, found to be statistically signi®cant. Despite the well- decrease in dyspareunia, increased clitoral sensa- known effect of estrogen on enhancing genital 12 tion, orgasmic response and libido. In this study, sensation, there was no difference in pre- or post- post-stimulation blood velocity in women not stimulation vibratory perception thresholds bet- receiving hormone replacement therapy was similar ween women receiving HRT and those who were to those who were receiving HRT. This may be not, or between younger women and older women. secondary to a compensatory or `reserve' mechan- This is contrary to the literature in men, which has ism. Nonetheless, the women without HRT have demonstrated increasing penile vibratory thresholds persistent baseline vaginal mucosal atrophy and with age.13 Nonetheless, this is a population of dryness, despite adequate blood velocity responses women with sexual dysfunction, therefore norma- to sexual stimulation. Further research in this area is tive data is needed for comparison. needed to determine the role of hormones on the The usefulness of this information obtained post- female sexual response. stimulation is questionable, especially once a vibrator had been used for a prolonged period of time, Vaginal pressure ± volume (compliance) changes resulting in desensitization of the sensory receptors. More involved techniques such as somatosensory evoked potentials and pudendal nerve latencies are With sexual stimulaton, relaxation of vaginal smooth useful to obtain baseline information, and may be muscle occurs, resulting in increased length and required for complicated cases. They are, however, 1 luminal diameter of the vagina. This was documen- dif®cult to use as part of the routine sexual response ted using vaginal pressure ± volume measurements. evaluation. Sexual stimulation resulted in signi®cant increases in vaginal pressure ± volume. In the postmenopausal group (n 22), women not receiving HRT (n 9) had Conclusions lower pre- and post-stimulaton maximum vaginal compliance measurements than those who were on Using this approach, documentation of signi®cant HRT (n 13). In addition, older women had lower increases in physiologic parameters of the female Clinical evaluation of female sexual function JR Berman et al S38 sexual response were possible. These evaluations emotional=relational issues need to be addressed are non-invasive, easy to perform, and the presence prior to beginning medical therapies or attempting of an examiner in the room does not appear to to determine treatment ef®cacies. At present, in- interfere with the evaluation or the results. creasing numbers of women are utilizing `off-label' Evaluating the female sexual response in the vasoactive medications, approved for the treatment clinical setting helps to validate the patient's of male erectile dysfunction. The growing use of problem and potentially diagnose organic disease these agents by women supports the need for more processes such as vascular insuf®ciency or neuro- basic science and physiologic research in this area. logic injury. For biofeedback purposes, the patient can also visualize and hear changes in her genital blood ¯ow and receive information regarding the References physiologic basis of her problem. 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