Virtually Everything You Need to Know, Want to Know or Have to Know. Knowledge and treatment of female sexual dysfunction is at the same point now where male erectile dysfunction studies and treatment was in 1975, but is rapidly closing the gap. With the advent of Viagra in 1998 treatments for male dysfunction have been utilized for females with certain types of sexual dysfunction
.In the process of developing these PDE-5 inhibitors (the mechanism for Viagra, for example) he physiology of the female sexual anatomy appears to be analogous to males and those diseases that effect males often impact females . Therefore, therapies for male treatment of ED may and should be effective in females as well, we are now finding.
Females are much more complex than males and the relationship between the psychogenic and physical aspects of sexuality are more closely interrelated and represent a more intimacy-based sexual drive cycle than in the males.
Scope of Problem
A 1999 survey at the University of Chicago, Department of Sociology, on 3,000 American men and women aged 18 to 59 revealed that 31 percent of men and 43 percent of women experience some degree of sexual dysfunction. Some 22 percent of those women had low sexual desire, 14 percent had arousal or lubrication difficulties, and 7 percent complained of sexual pain. Sexual difficulties appeared to occur in the less educated, unmarried, and sexually abused women. Sexual dysfunction was associated with negative experiences in relationships, low rate of happiness, and overall well-being. These negative impacts appeared to be much more severe for women than for men due to the closer relationship between the physical and the psychosocial aspects of sexuality.
Normal Female Sexual Response
The normal female sexual response cycle is usually divided in to four stages: desire, arousal (excitement), orgasm, and resolution.
Desire is defined as the development of the energy that allows an individual to initiate sexual activity or respond to sexual stimuli. In both sexes desire originates in the limbic system of the brain primarily in the hippocampus and the preoptic nuclei. These areas are dopamine sensitive excitatory centers and serotonin sensitive inhibitory centers. Testosterone, the male hormone, maintains the responsiveness of these centers in both males and females. Desire is also affected and modulated by connections with other areas of the brain such as those involved in emotional closeness and intimacy. A total of these positive and negative influences generates neurological impulses that pass down the spinal cord to the reflex centers that govern excitement and orgasm.
The second stage, excitement or arousal, is due to spinal cord release of parasympathetic nerve impulses traveling along the pelvic nerves to the uterovaginal plexus. The end result is vascular engorgement of the clitoris, which results in lengthening and thickening of the clitoral organ, vasodilatation of the perivaginal blood supply causing transudation of fluid through the vaginal epithelium which appears to the partners as "wetness" or "lubrication."
Estrogen is required for this transudation and results in lubrication by maintaining the health of the vaginal mucosa. Continued vasocongestion of the vagina causes blood sequester in the upper half of the vagina leading to ballooning of the distal portion and elevation of the uterus. The excitement phase also causes vasodilatation in the breasts leading to increased breast size, nipple erection, and engorgement of the surrounding areola. Pulse, blood pressure, and respiratory rates increase and muscle tension throughout the body also increases. A sexual flush causing redness and erythema of the face, neck, chest, and frequently much of the body occurs in 75 percent of women. Pelvic and extragenital changes culminate in the "Plato phase" of the excitement stage where the clitoris retracts beneath its protective foreskin or hood. Vasocongestion occurs in the outer-third of the vagina with swelling to form the so called "orgasmic platform."
Orgasm is characterized by maximum physical and emotional excitement. This is accompanied by a series of involuntary ( 0.86 second) contractions of the rectal and urethral muscles as well as the uterus. Orgasm is a reflex and requires the woman to relinquish her sense of control and in addition for the orgasmic response to be activated stimulation primarily of the clitoris must be applied and must be of sufficient intensity and duration to reach the threshold for this reflex. Masters and Johnson showed that female orgasm almost always involves clitoral stimulation.
The last stage is resolution in which blood flow and pelvic congestion along with bodily tensions resolves within seconds unless the woman returns to orgasm. Females do not always fall back to the low excitement stage and many women are capable of returning to excitation with stimulation that can rapidly produce a repeat orgasm. Whether the orgasmic experience is multiple or single, resolution of all excitement phase changes may take one hour or longer in contrast to men.
Classification of Female Sexual Dysfunction
Classification of female sexual dysfunction was first developed by an international consensus conference in 1998 and formalized and published in 2000. FSD is divided into four categories: sexual desire disorder, sexual arousal disorder, orgasmic disorder, and sexual pain disorder. A significant addition was "causing personal distress." This has implication for women who are happy with their frequency and response to sexual activity; however, their partners may not be. This incompatibility among couples may require counseling; however, the women will no longer be labeled with the diagnosis of FSD.
Disorders of Sexual Desire
Hypoactive sexual desire disorder (HSDD) is the persistent or recurrent absence of sexual fantasy, thought, or desire for sexual activity which causes personal distress. Lowen reported an incidence of 22 percent, others as high as 55 percent, and appears to represent the most common form of FSD. All aspects of sexuality can cause HSDD. Psychosocial aspects of the relationship between partners appears to be a major cause. The couch potato, football watching, beer drinking husband is not uncommon. Demanding careers, raising children, motherhood, stressful life milestones, job loss, and the death of a loved one can all play a role. On the other hand, physical factors such as general health conditions, drug and alcohol abuse, aging, and many of the antidepressants may have a potential affect as well.
Diminution of sexual desire is a side effect of many medications, many of which are listed in our table one. SSRIs increase serotonin activity, inhibit the limbic system, and decrease sexual desire. Bupropion (Wellbutrin) has been demonstrated to increase sexual desire both alone as primary treatment or in combination with SSRIs and may have a beneficial effect both for depression and the associated sexual dysfunction. Patients who are on SSRIs can take "drug holidays" in which they discontinue their antidepressants during romantic getaways. Included in SSRIs would be St. John's Wort, a common herbal medication for depression. Yohimbe has been shown as promising treatment to reduce SSRI, and St. John's Wort induced sexual dysfunction in women.
Medications that suppress ovarian function will also suppress testosterone, which is primarily produced by the ovary. Without testosterone the central nervous system limbic systems cannot respond adequately to stimulation. GnRH agonists for endometriosis, Depo-Provera, and to a lesser extent oral contraceptives decrease ovarian production of testosterone and may also decrease libido.
Testosterone replacement has been documented to increase sexual interest and activity particularly after the ovaries have been removed, and testosterone has been proposed as a medical treatment for HSDD. It may also be helpful for women who are receiving hormone replacement therapy since estrogens increase serum-binging globulins, decreasing the non-bound free testosterone and the active form of the hormone testosterone. There also appears to be a female androgen deficiency syndrome (FADS) described by the Australian research, Dr. Susan Davis, in which women have low libido, poor motivation, fatigue, and lack of well being in the presence of normal estrogen and free testosterones in the lower third of the normal laboratory range. Dr. Davis recommends treating women with oral or transdermal testosterone under these circumstances.
Sexual Aversion Disorder
Sexual aversion disorder (SAD) is an exaggerated form of HSDD and represents the persistent or recurrent phobic aversion to genital contact with a sexual partner. Women with SAD have a history of sexual or physical abuse or serious problems in their relationship that usually requires extensive psychotherapy for these women who are apathetic towards sex and who have negative sexual experiences. Female sexual arousal disorder (FSAD) is the persistent or inability to attain or maintain sexual excitement, i.e. lubrication/swelling which causes personal distress. Arousal disorders may have a psychological aspect either primarily or secondary and are frequently tied to issues of HSDD. Sex therapy of arousal disorders usually involves teaching women how to appreciate their bodily responses and focusing on ways to enhance these responses with sexual thoughts of stimulation. On the other hand, arousal disorders can be physiologic in origin. SSRIs and other medications can interfere with arousal as well as desire. Hormonal preparations that decrease testosterone such as contraceptives decrease arousal and conversely testosterone may aide arousal. Blood flow in the hemodynamic basis of sexual arousal can be affected by antihypertensives, anticholinergics, and antihistamines. The hemodynamic aspects of arousal may, in fact, be a major area in which pharmacological therapy of FSD will be demonstrated.
Female orgasmic disorder (FOD) is defined as persistent or recurrent difficulty, delay in, or absence of obtaining orgasm following sufficient sexual stimulation and arousal which causes personal distress. FOD is a common problem with 10 percent of women never experiencing orgasm and 50 percent reporting intermittent or situational difficulties achieving orgasm. There are psychological aspects to FOD, however, physical aspects including neurological conditions such as multiple sclerosis and spinal cord injuries, diabetic neuropathy, and medications including SSRIs, tricyclic antidepressants, appetite suppressants, and psychotic agents may also play a role. Obviously any aspect of sexual dysfunction could affect orgasm and therefore a careful history must be obtained of the entire sexual situation with an individual and her partner. The history should include whether or not the individual has ever had an orgasm or whether or not it is situational and related to certain circumstances. Such problems may be amenable to education, counseling, or therapy. Not uncommonly sex-related articles in women's magazines raise unrealistic expectations and education may be extremely helpful. For example, the amount and type of stimulation required to trigger orgasms varies from woman to woman. Only approximately 42 percent of women experience multiple orgasms, and there is great doubt as to the existence of the G-spot. In another study 4 percent of women could not masturbate to orgasm, but 70 percent were unable to achieve orgasm with intercourse implying that most women are physically capable of experiencing orgasm. Lastly, some women fear the loss of self control that is required to reach orgasm or worry about how they might look to their partners if sexually aroused. Addressing these issues may successfully treat FOD.In those patients who have never experienced an orgasm sex therapy and support groups to educate women about their bodies and learning to appreciate their bodily responses may be helpful.
1 Comment
In the process of developing these PDE-5 inhibitors (the mechanism for Viagra, for example) he physiology of the female sexual anatomy appears to be analogous to males and those diseases that effect males often impact females . Therefore, therapies for male treatment of ED may and should be effective in females as well, we are now finding.
Females are much more complex than males and the relationship between the psychogenic and physical aspects of sexuality are more closely interrelated and represent a more intimacy-based sexual drive cycle than in the males.
Scope of Problem
A 1999 survey at the University of Chicago, Department of Sociology, on 3,000 American men and women aged 18 to 59 revealed that 31 percent of men and 43 percent of women experience some degree of sexual dysfunction. Some 22 percent of those women had low sexual desire, 14 percent had arousal or lubrication difficulties, and 7 percent complained of sexual pain. Sexual difficulties appeared to occur in the less educated, unmarried, and sexually abused women. Sexual dysfunction was associated with negative experiences in relationships, low rate of happiness, and overall well-being. These negative impacts appeared to be much more severe for women than for men due to the closer relationship between the physical and the psychosocial aspects of sexuality.
Normal Female Sexual Response
The normal female sexual response cycle is usually divided in to four stages: desire, arousal (excitement), orgasm, and resolution.
Desire is defined as the development of the energy that allows an individual to initiate sexual activity or respond to sexual stimuli. In both sexes desire originates in the limbic system of the brain primarily in the hippocampus and the preoptic nuclei. These areas are dopamine sensitive excitatory centers and serotonin sensitive inhibitory centers. Testosterone, the male hormone, maintains the responsiveness of these centers in both males and females. Desire is also affected and modulated by connections with other areas of the brain such as those involved in emotional closeness and intimacy. A total of these positive and negative influences generates neurological impulses that pass down the spinal cord to the reflex centers that govern excitement and orgasm.
The second stage, excitement or arousal, is due to spinal cord release of parasympathetic nerve impulses traveling along the pelvic nerves to the uterovaginal plexus. The end result is vascular engorgement of the clitoris, which results in lengthening and thickening of the clitoral organ, vasodilatation of the perivaginal blood supply causing transudation of fluid through the vaginal epithelium which appears to the partners as "wetness" or "lubrication."
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Orgasm is characterized by maximum physical and emotional excitement. This is accompanied by a series of involuntary ( 0.86 second) contractions of the rectal and urethral muscles as well as the uterus. Orgasm is a reflex and requires the woman to relinquish her sense of control and in addition for the orgasmic response to be activated stimulation primarily of the clitoris must be applied and must be of sufficient intensity and duration to reach the threshold for this reflex. Masters and Johnson showed that female orgasm almost always involves clitoral stimulation.
The last stage is resolution in which blood flow and pelvic congestion along with bodily tensions resolves within seconds unless the woman returns to orgasm. Females do not always fall back to the low excitement stage and many women are capable of returning to excitation with stimulation that can rapidly produce a repeat orgasm. Whether the orgasmic experience is multiple or single, resolution of all excitement phase changes may take one hour or longer in contrast to men.
Classification of Female Sexual Dysfunction
Classification of female sexual dysfunction was first developed by an international consensus conference in 1998 and formalized and published in 2000. FSD is divided into four categories: sexual desire disorder, sexual arousal disorder, orgasmic disorder, and sexual pain disorder. A significant addition was "causing personal distress." This has implication for women who are happy with their frequency and response to sexual activity; however, their partners may not be. This incompatibility among couples may require counseling; however, the women will no longer be labeled with the diagnosis of FSD.
Disorders of Sexual Desire
Hypoactive sexual desire disorder (HSDD) is the persistent or recurrent absence of sexual fantasy, thought, or desire for sexual activity which causes personal distress. Lowen reported an incidence of 22 percent, others as high as 55 percent, and appears to represent the most common form of FSD. All aspects of sexuality can cause HSDD. Psychosocial aspects of the relationship between partners appears to be a major cause. The couch potato, football watching, beer drinking husband is not uncommon. Demanding careers, raising children, motherhood, stressful life milestones, job loss, and the death of a loved one can all play a role. On the other hand, physical factors such as general health conditions, drug and alcohol abuse, aging, and many of the antidepressants may have a potential affect as well.
Diminution of sexual desire is a side effect of many medications, many of which are listed in our table one. SSRIs increase serotonin activity, inhibit the limbic system, and decrease sexual desire. Bupropion (Wellbutrin) has been demonstrated to increase sexual desire both alone as primary treatment or in combination with SSRIs and may have a beneficial effect both for depression and the associated sexual dysfunction. Patients who are on SSRIs can take "drug holidays" in which they discontinue their antidepressants during romantic getaways. Included in SSRIs would be St. John's Wort, a common herbal medication for depression. Yohimbe has been shown as promising treatment to reduce SSRI, and St. John's Wort induced sexual dysfunction in women.
Medications that suppress ovarian function will also suppress testosterone, which is primarily produced by the ovary. Without testosterone the central nervous system limbic systems cannot respond adequately to stimulation. GnRH agonists for endometriosis, Depo-Provera, and to a lesser extent oral contraceptives decrease ovarian production of testosterone and may also decrease libido.
Testosterone replacement has been documented to increase sexual interest and activity particularly after the ovaries have been removed, and testosterone has been proposed as a medical treatment for HSDD. It may also be helpful for women who are receiving hormone replacement therapy since estrogens increase serum-binging globulins, decreasing the non-bound free testosterone and the active form of the hormone testosterone. There also appears to be a female androgen deficiency syndrome (FADS) described by the Australian research, Dr. Susan Davis, in which women have low libido, poor motivation, fatigue, and lack of well being in the presence of normal estrogen and free testosterones in the lower third of the normal laboratory range. Dr. Davis recommends treating women with oral or transdermal testosterone under these circumstances.
Sexual Aversion Disorder
Sexual aversion disorder (SAD) is an exaggerated form of HSDD and represents the persistent or recurrent phobic aversion to genital contact with a sexual partner. Women with SAD have a history of sexual or physical abuse or serious problems in their relationship that usually requires extensive psychotherapy for these women who are apathetic towards sex and who have negative sexual experiences. Female sexual arousal disorder (FSAD) is the persistent or inability to attain or maintain sexual excitement, i.e. lubrication/swelling which causes personal distress. Arousal disorders may have a psychological aspect either primarily or secondary and are frequently tied to issues of HSDD. Sex therapy of arousal disorders usually involves teaching women how to appreciate their bodily responses and focusing on ways to enhance these responses with sexual thoughts of stimulation. On the other hand, arousal disorders can be physiologic in origin. SSRIs and other medications can interfere with arousal as well as desire. Hormonal preparations that decrease testosterone such as contraceptives decrease arousal and conversely testosterone may aide arousal. Blood flow in the hemodynamic basis of sexual arousal can be affected by antihypertensives, anticholinergics, and antihistamines. The hemodynamic aspects of arousal may, in fact, be a major area in which pharmacological therapy of FSD will be demonstrated.
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