Female Sexual Function and Dysfunction

Authors: Drs Tom F Lue and Alan Shindel University of California San Francisco 2008-08-30

Female Sexual Function and Dysfunction: A guide for women and their sexual partners In this article we will discuss female sexual function and some of the sexual problems women may experience at different points in their life. This information has been written for women and their sexual partners.

Introduction 

 

In 1893, the physician and sexual medicine specialist Edward Martin stated, “In the case of a woman, performance of the sexual act, at least insofar as her partner is concerned, requires only the presence of a sufficiently long and patulous (open) mucous canal.”[1]  While this statement may seem shockingly misogynistic (hating or dismissive of women), when it was written it was fairly progressive to openly address women’s sexuality.  Although our understanding of women’s sexual function and dysfunction has not progressed as rapidly as our understanding of men’s sexuality has, we have certainly made progress since Martin’s day.

Female Sexual Function

What are the phases of sexual response in women?

The famed sex researchers William Masters and Virginia Johnson derived a basic scheme for sexual response in men and women consisting of four distinct phases called excitement, plateau, orgasm, and resolution.[2]  In the vast majority of men studied by Masters and Johnson these steps occurred in a fairly predictable pattern.  In contrast, these researchers found much more variation among women with respect to sexual experience.  In some women the sequence of events was similar to what was observed in men (blue line in graphic below).  In other women a discrete orgasm phase did not occur (violet line in graphic below) and in some women there were multiple orgasms during a single sexual encounter (yellow line in graphic below).  Helen Singer Kaplan, another prominent sex researcher, later elaborated on the Masters and Johnson schema by incorporating the concept of desire, defined as an interest in sexual activity that precedes actual sexual arousal.[3]

 

        Adapted from Masters & Johnson(1966) and Kaplan (1974)
The paradigm created by Masters, Johnson, and Kaplan has been accepted for many years as representative of sexual response in both men and women.  Recently, a leading expert in women’s sexual health (Rosemary Basson) has advocated a new model of female sexual function that stresses the interdependence of relationship factors and sexual function in women.  In this new model, sexuality and sexual function in women follow a circular path in which emotional cues and relationship issues play a fundamental role and intrinsic sexual desire plays a much smaller role.[4]

        Adapted from Basson (2004)
  No one model can adequately encompass the sexual experience for all individuals.  In a recent study of 129 women, about 2/3 of respondents endorsed the Masters & Johnson model as most representative of their sexual response, while approximately 1/3 selected the Basson model. Interestingly, women who endorsed the Basson model were more likely to have sexual health concerns, particularly low sexual desire.[5]

What physical changes occur during the sexual response cycle in women?

During sexual arousal in women, numerous changes occur throughout the body.  For the purposes of this review, we will focus on genital changes only.  The attached diagrams demonstrate the anatomy of the female pelvis with a focus on the genital organs.

     

   External view of the female pelvis with labeling of anatomical structures of  the female genitalia and adjacent organs
       



Cross section of the female pelvis showing internal and external organs of the genitalia and neighboring organs

Vaginal lubrication

Prior to the 1960s, it was thought that the vaginal lubrication produced during sexual arousal was derived from glandular tissue.  However, in a series of elegant experiments Masters and Johnson demonstrated that there were no discrete glands within the vagina and therefore vaginal lubrication could not be derived from glands.[2]  It was subsequently discovered that vaginal lubrication is caused by the production of a transudate (a watery fluid with very low protein content) from the blood vessels supplying the vagina.  Normally, the walls of blood vessels do not permit fluid to leak through.   However, during sexual excitement, increased blood flow to the pelvic region causes pressure to build up in the small blood vessels around the vagina.  This process is driven by nerves from the sacral portion of the spinal cord, which is part of the parasympathetic nervous system.   This increased pressure forces fluid out of the blood vessels and into the vaginal canal, thus producing a slippery lubricant fluid.  This fluid is the lubrication that a woman feels when she gets wet from sexual arousal.[6] 

Engorgement of the clitoris

The clitoris is composed of inner-tube like cylinders of spongy tissue called corpora cavernosa.  The internal portion (crura) of the clitoris attaches to the pelvic bones.  During sexual excitement, blood flow to the corpora cavernosa increases, causing them to swell.  Because the veins that drain blood from the clitoris are located to the side of the corpora cavernosa, compression from the swelling corpora will tend to obstruct these veins, causing blood to become trapped inside the clitoris.  The overall process leads to engorgement (enlargement) and increased sensitivity of the clitoris.[7]

What about female ejaculation and the G spot?

During sexual climax, some women experience a spurting of fluid from the urethra; this is commonly referred to as female ejaculation.  This is an atypical but not abnormal occurrence and should not be interpreted as a problem.  The G spot (or Grafenberg Spot, for the physician who first described it) is an anatomical area that can be a source of great pleasure during sexual stimulation for some women.  It is most commonly located on the front wall of the vagina near the base of the bladder although the exact location may vary.   The G Spot has been a source of great controversy in the medical community as some investigators contend that there is not enough evidence to prove its existence.[8] Other experts and many women very strongly maintain that the G spot does exist and can play an important role in sexual pleasure.[9]  The existence and importance of the “G spot” for a particular woman’s enjoyment of sex varies from woman to woman, like most aspects of sexuality.    Interestingly, women who ejaculate at climax report sensitivity in the expected location of the G spot more frequently than women who do not ejaculate. [9] The G-spot has often been referred to as a “female prostate,” and recent evidence has supported the notion that the “G-spot” may indeed be a gland that surrounds the urethra and produces the fluid ejaculated at orgasm.  The physical characteristics of female ejaculate have been not been well studied but there is good evidence that it is similar in some respects to semen, which is ejaculated by men at climax.[10]  Further research is needed before definitive statements about the G spot and female ejaculation can be made.  For the time being, G spot sensitivity and ejaculation can be considered normal variants of female sexual response.

Female Sexual Disorders

 

What are female sexual disorders?

Female sexual disorders (FSD) refers not to a single disease, but rather to a recurrent or persistent disruption of one or more facets of a woman’s sexual experience, leading to sexual dissatisfaction and/or personal distress.[11]   

Why are female sexual disorders important?

Sexual problems can be detrimental to a woman’s mood, sense of self-esteem, and quality of life at any age.  Sexual problems may also put strain on a woman’s relationship with her partner, which can lead to relationship stress and further exacerbate depression and anxiety.  Sexual problems in women are poorly understood; there is need for more research and understanding of this important issue. 

There is little dispute that sexuality and satisfying sexual relationships are important factors in young people’s assessment of quality-of-life, but a recent study has highlighted that sexual function remains an important aspect of many people’s lives even into old age. That survey study of older adults in America found that almost 40% of women aged 65-74 and 17% of women aged 75-85 continue to engage in sexual intercourse.[12]  

What kinds of problems may occur in women with a female sexual disorder?

Irrespective of its applicability to any given woman, the model of normal sexual function promulgated by Masters and Johnson remains a useful means by which to develop a classification system for sexual disorders in both men and women.[13] 

• Desire Disorders:

• Hypoactive sexual desire disorder (HSD):  Lack of sexual thoughts and/or receptivity to sexual activity.
• Sexual Aversion Disorder (SAD): Phobic aversion to and avoidance of sexual contact.

• Arousal Disorders:

• Female Sexual Arousal Disorder (FSAD): Inability to attain or maintain sexual excitement.  It is important to note that sexual excitement refers not just to physical signs of arousal, such as clitoral erection and vaginal lubrication, but also to subjective feelings of being “turned on” or “horny.”

                                                              -      Genital FSAD: Impairment of vaginal lubrication and/or clitoral erection with adequate sexual stimulation.

                                                             -      Subjective FSAD: Impairment of subjective sexual excitement with adequate sexual stimulation.

                                                            -      Mixed FSAD: Combination of genital and subjective FSAD.

• Persistent Sexual Arousal Disorder (PSAD): Persistent, intrusive, and unwanted signs of genital arousal with or without sexual thoughts.

• Orgasmic Disorders:

• Anorgasmia:  Loss of orgasmic potential after sufficient sexual stimulation and arousal.  It is important to reiterate that this diagnosis is made only when there is failure to orgasm despite sufficient sexual stimulation.  Many women have difficulty climaxing through coital (vaginal) intercourse alone; a woman who does not climax from coital intercourse but can climax through clitoral stimulation does not technically have anorgasmia.

• Sexual Pain Disorders:

• Dyspareunia: Genital pain associated with sexual intercourse.

                                                               -      Superficial Dyspareunia: Pain localized to the skin of the vulva or the introitus (entrance) of the vagina.

                                                             -      Deep Dyspareunia: Pain localized deep in the pelvis.

• Vaginismus: Involuntary contraction and cramping of the vaginal musculature associated with attempted penetration of the vagina by a penis, finger, or other object despite the woman’s express desire to be penetrated.
• Non-coital genital pain disorder: Pain felt in the genitals that is not associated with sexual intercourse, but is associated with sexual activities.

  It is important to emphasize that to qualify as a true disorder, personal distress related to the problem should be present.  For example, a woman with low sexual desire who is not bothered by it does not, by definition, have hypoactive sexual desire disorder.

How common are female sexual disorders?

It is difficult to accurately measure sexual disorders in a population.  Many people are uncomfortable talking about sex and refuse to participate in surveys on sexual problems.  Those that choose to participate in sexuality surveys may not be representative of the overall population.  Additionally, an issue which may be a serious impediment to one woman’s enjoyment of sex might not cause any problems for another woman, so it is difficult to accurately assess the true rate of sexual disorders. Despite the problems associated with assessing sexual problems, a number of researchers have investigated the epidemiology of female sexual dysfunction using a combination of surveys, interviews, and questionnaires distributed to women from around the world.  

Decreased Sexual Desire

Decreased desire for sex has been reported to occur in 13-17% of women aged 18-59 in one study from the U.S.[14]  Globally, the rate of decreased desire for sex is about 33% in women aged 40-80.[15]  This suggests that sexual desire tends to decline with increasing age.  However, there is no age at which someone is “too old” for sex. It is unclear how common sexual aversion disorder is in the general female population, but it is known that women who have been the victims of abuse are at increased risk of this problem.[16]  

Decreased Sexual Arousal

Trouble with adequate vaginal lubrication was reported by 18-27% of U.S. women aged 18-59, and by 27% of women aged 40-80 globally.  This trend in age is to be expected given that vaginal atrophy and decreased lubrication are both known to be associated with increasing age.  Similarly, 17-27% of U.S. women aged 18-59 and 22% of women 40-80 from around the world reported that they did not find sex pleasurable.[14,15]

Persistent Sexual Arousal

This is a rare and poorly documented condition characterized by involuntary genital and clitoral arousal unrelated to feelings of sexual desire.  This condition persists despite one or more orgasms and feels intrusive and unwanted for the woman.  In some cases, this condition has been linked to sudden discontinuation of antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs).[17,18].

Anorgasmia

Difficulty attaining orgasm has been reported by 22-28% of U.S. women aged18-59 and 14.5% in women aged 40-80 globally.[14,15] It must again be emphasized that many women do not climax from vaginal penetration alone; for this reason, a woman who can reach orgasm through clitoral stimulation but not through vaginal penetration should not be diagnosed as anorgasmic.[19]  One study has found that anorgasmia is more common in women who are unmarried, have pelvic floor disorders, and/or have lower levels of education.[14,20]
Sexual Pain
Pain with sex has been reported to occur in 8-21% of U.S. women aged 18-59 and 14% of women aged 40-80 from around the world.[14,15] It appears to be more common in younger women, those with less education, and/or women suffering from ill health or emotional problems.[14]  

What causes sexual problems in women?

A variety of physical and medical causes for sexual problems in women have been discovered.  While a physical/medical cause should always be sought when evaluating a sexual problem, it is important to keep in mind that a woman’s emotional state, her relationship with her partner, and her sexual beliefs and mores play major roles in her sexuality.  Psychological and social factors should always be considered as co-contributing factors to all sexual difficulties.  

Decreased sexual desire

Life stressors, emotional distress, and decline in household income have been associated with decreased desire for sex in women.[14] Additionally, disorders of hormones (such as testosterone and estrogen) and use of certain prescription drugs (such as SSRIs  taken for depression, oral contraceptives, and chemotherapy drugs for cancer) have been shown to be risk factors for decreased sexual desire in women.[21,22]

Decreased sexual arousal

Similar to what is observed in desire disorders, women who have a history of abuse, are under emotional stress, and/or have intercourse infrequently have a higher rate of difficulty being subjectively “turned-on” compared to other women.[14]  The most common risk factor for decreased physical arousal is vaginal atrophy, the condition in which the vaginal tissues shrivel and do not become as engorged with blood, which in turn leads to decreased lubrication.  This condition is most commonly associated with menopause and the associated decline of estrogen levels.  It must be emphasized that the physical indicators of female sexual arousal (vaginal lubrication, clitoral erection, etc.) are poor predictors of how subjectively “turned-on” a woman may feel.  In other words, some women may feel very sexually aroused but not have vaginal lubrication, and others may have copious lubrication and not be aroused at all.

            MRI study of the female genitalia, during orgasm, and after orgasm from Schultz WW et al. BMJ.                                                                                 1999;319(7225):1596-600.

Difficulty attaining orgasm

Perhaps the most common cause of orgasm difficulty in women is misunderstanding of genital anatomy and normal sexual response in women; this is not uncommon among both women and their sexual partners.  While some women can climax from vaginal penetration alone, many require clitoral stimulation to reach orgasm.  Unrealistic expectations, poor technique, and lack of clear communication between partners may contribute to this problem.
In cases where adequate stimulation is present and a woman is still unable to climax, causes such as emotional stress and side effects of some drugs (such as SSRIs used to treat depression) are the most common causes of orgasmic dysfunction.  

Sexual pain  Superficial dyspareunia is most often due to a condition called vulvar vestibulitis, a poorly understood inflammatory condition of the external genitalia.[23]  Other superficial anatomical abnormalities of the genitalia may also lead to pain with sex.  Deep dyspareunia has been associated with conditions such as endometriosis (a condition in which tissue similar to the lining of the uterus is found in other parts of the body), urethral diverticula (an abnormal pouch on the urethra, the channel which drains urine from the bladder), and a history of pelvic or vaginal surgery.[24]  Unfortunately, in some cases of both superficial and deep dyspareunia, no distinct cause can be found.  The contribution of relationship problems, a history of trauma or abuse, and emotional stress to sexual pain syndromes should not be neglected.  These factors may contribute to sexual pain and may be the root cause of such pain in some cases.  In the case of vaginismus, psychological problems and/or discomfort with sexuality and/or penetration can often be the principal cause of the disorder.  Non-coital genital pain disorder is a relatively new diagnosis 

which is also most commonly associated with psychological problems and/or discomfort with sexuality or the sexual partner.

 Treatment of sexual disorders in women

How are sexual problems in women evaluated?

The first step in evaluating a sexual problem is consulting with a health care provider.  A primary care provider can provide an initial assessment and  possibly  treatment for some sexual problems.  However, given that sexual problems in women are relatively poorly understood, few primary care providers have extensive expertise in female sexual health.  Oftentimes a referral to a sexual medicine specialist, gynecologist, or urologist is recommended for a more thorough evaluation of sexual problems.  Referral to a psychologist or psychiatrist may also be an important intervention in the treatment of sexual problems.[25]

Before the actual appointment, many sexual medicine specialists will ask patients to complete a short survey of their sexual function.  A variety of brief questionnaires for women’s sexual health exist, such as the Female Sexual Function Index (FSFI), the Brief Index of Sexual Function for Women (BISF), and the Female Sexual Distress Scale (FSDS).[26] Questionnaires of this type may help to screen for certain disorders and may serve as an “ice-breaker” to facilitate open and honest communication between patient and provider.

The most important component of the evaluation by a sexual medicine specialist is a thorough history and focused physical examination.  Important points of the history include the nature of the sexual problem, how long it has been present, and any factors that are associated with the onset of the problem.  A general medical history may provide clues to other conditions (such as medication use, endometriosis, menstrual irregularities or menopause) that may contribute to sexual problems.  The provider may ask for details of the patient’s most recent sexual encounter; this often provides valuable information that will help the provider make an accurate diagnosis.

The physical exam includes a general assessment of the cardiovascular and neurological systems, as well as of general health.  Particular attention will be directed towards the genitalia, looking for any abnormalities of the vulva, vagina, or internal organs of the pelvis, which may predispose a woman to sexual problems.

This image from1822 shows how gynecologists of that era examined female patients. Contemporary  physical examination for potential causes of female sexual problems is more precise.

When evaluating a sexual problem, serious consideration should be given to involving or at least communicating with the sexual partner.  Some women are hesitant to speak with their partner about these issues, but open and honest communication is essential to maintaining healthy sexual relationships.  Problems with desire, arousal, and sexual pain have been associated with unhappiness in relationships and low emotional and physical satisfaction.[14]  Additionally, sexual problems are prevalent in both men    and women and failure to diagnose and treat a sexual problem in a woman’s partner will hinder the efficacy of treatment given for the woman’s sexual problem.[27]                                     

 

What additional tests are useful to detect sexual problems?

Cardiovascular disease (such as high blood pressure, high cholesterol, and atherosclerosis) and diabetes are known to be risk factors for sexual problems in men, but the relationship of these risk factors to sexual problems in women is poorly understood. Nevertheless, there is evidence to suggest that they may be contributing factors to sexual problems in women as they are in men.[28]  If a woman has not had a recent evaluation for potential vascular risk factors, several simple blood tests may be taken.  Blood tests may also be ordered to check a woman’s hormonal status as hormones play very important roles in sexual health.  Hormones of interest include dehydroepiandrosterone (DHEA), testosterone, estrogen, progesterone, sex hormone binding globulin, luteinizing hormone, follicle stimulating hormone, thyroid stimulating hormone, and prolactin.[29]

Nerve conduction studies may be ordered for cases when genital numbness is part of the problem.  These studies assess nerve health and may reveal important information for women who have arousal or orgasmic problems.[30]
In research settings, assessment of the response of vaginal tissues to sexual arousal may be conducted using plethysmography.  In this procedure, a temperature and pressure sensitive probe is inserted in the vagina; increasing vaginal blood flow during sexual arousal is recorded with this device.  Measurement of clitoral size and blood flow using ultrasound or magnetic resonance imaging (MRI) has also been used to study women’s sexual response.  Studies have even been conducted of couples having sex during MRI examination.[31] 
While plethysmography, ultrasound, and MRI have provided interesting information on sexual function in women, the utility of these procedures in evaluating a given woman with a sexual problem is unclear. For this reason, these tests are used almost exclusively in a research rather than a clinical setting.

How are sexual problems in women treated?

Sexual Education

Many people (both women and men) have a poor understanding of normal sexual function.  In some cases, education about normal sexual function and encouragement to experiment with different means of sexual expression (such as changes in foreplay and/or different sexual positions) may lead to significant improvements. 

Treatment of medical conditions that may impact women’s sexual function

Some medical problems may lead to sexual difficulties in women.  Examples include: urinary problems; breast or gynecological cancers; neurological disorders such as multiple sclerosis or spinal cord injury metabolic diseases such as diabetes; polycystic ovarian syndrome; thyroid hormone abnormalities, and; psychological problems such as depression or anxiety. [32,33]  Medical and/or surgical therapies for these problems may be beneficial in improving a woman’s ability to enjoy sex.
Treatment of some conditions may improve sexual function in women.  On the other hand some medications, such as antidepressants and some oral contraceptives (OCP), have been associated with diminished sexual desire and difficulty with arousal in some women.  For women with depression who are concerned about sexual functioning, antidepressant medications that have lesser effects on sexual function may be prescribed.  Bupropion is one such medication and may be a good selection as an initial treatment or as a change of therapy in a woman who has significant sexual side effects from her antidepressant medication.[34]  If an OCP is thought to be contributive to a sexual desire problem in a woman, an alternative OCP or means of birth control can be contemplated.   What if sex education and treatment of other medical problems doesn’t work?

If sex education and treatment of contributing medical problems does not restore the ability for satisfying sexual interactions, a number of therapies are available to treat sexual problems in women.  A number of these are established and accepted treatments; others show great promise in improving sexual function in women but are still somewhat experimental. Psychotherapy and counseling for sexual problems

In cases where psychological or emotional stresses may be the primary cause of sexual problems, sexual therapy or counseling is the mainstay of treatment.  Even in cases where a physical cause for a sexual problem is identified, counseling may be a valuable adjunctive treatment to address issues that arise with sexual problems.  Sexual therapy is tailored to the unique situation of each woman/couple but often focuses on identifying misconceptions about sexuality and sexual response, improving communication between partners, and addressing underlying psychological issues that may prevent a woman from fully  enjoying sexual activity.[35]

Medical therapies for sexual desire disorders in women

Treatment with "male" hormones (androgens)

Testosterone is a hormone that has numerous functions in the body in both men and women, including a role in producing sexual desire.  Both men and women naturally produce this hormone although levels of testosterone are much higher in men.  Based on studies that have shown a significant increase in sexual desire and satisfaction in women treated with testosterone versus those treated with placebo.  
A skin patch that delivers testosterone into the body has been approved in Europe for the treatment of low sexual desire in women.  This patch has not received approval from the U.S. Food and Drug Administration (FDA) as a result of concerns about the long term safety of testosterone supplementation in women.[36]  Another hormone called dehydroepiandrosterone (DHEA) has also been investigated as a potential treatment for sexual problems in women.  To date there is little evidence to support its use for HSD as it has not been shown to be consistently superior to placebo in treating sexual problems in women.[37,38]  Tibolone is a unique steroid hormone that has effects similar to estrogen, progesterone, and testosterone.  This compound has been shown to be effective in the treatment of sexual problems in menopausal women[39] but further research is needed to ascertain its’ proper role in the management of female sexual problems.
The issue of testosterone supplementation in women is very controversial.  Many experts argue that that: 1) there is insufficient evidence at this time to accurately diagnose women with testosterone deficiency; 2) the connection between sexual desire and testosterone in women is unclear, and 3) there is a lack of data on the long term safety of testosterone supplementation in women, and this treatment may theoretically increase the risk of cardiovascular disease and/or some kinds of cancer.[40]  Other experts have cited evidence showing that the risk of these complications is very slight and that testosterone may have substantial benefits with respect to sexual function and satisfaction and possibly also with respect to mood and sense of well being.[41,42]

Regardless of their stance on testosterone therapy in women at this time, all experts agree that there is a need for further research to clarify this issue.  At this time, testosterone therapy for women in the U.S. is available as an “off-label” prescription, but patients and health care providers need to have a frank and thorough discussion of risks and benefits.  Known risks of testosterone therapy in women include an increase in acne and body hair. Skin patch preparations have been associated with skin irritation.  The additional theoretical risks with respect to cancer risk and cardiovascular problems must be considered.  Testosterone has not been investigated in women who are not also taking estrogen supplements, or naturally making estrogen (i.e. premenopausal); consequently, until further research data becomes available testosterone most definitely should not be taken by post-menopausal women who are not taking estrogen supplements.

Bremelanotide

Bremelanotide (aka PT-141) is a synthetic replica of a naturally occurring hormone (melanocortin) that is active in the brain and modulates sexual responses in addition to other functions.  In a small study of 18 premenopausal women, bremelanotide was shown to enhance sexual desire during exposure to erotic stimuli and to improve subjective assessment of adequacy of sexual arousal during intercourse.[43  However, the FDA has raised concerns about potentially hazardous elevations in blood pressure after bremelanotide treatment and further studies are required to assess the safety of this drug before it can be utilized outside of a research setting.

Medical therapies for sexual arousal disorders in women

Devices

In the United States, only one treatment for sexual problems in women has received approval from the FDA. This treatment is the Eros® (NuGyn, Minnesota, USA), a small battery operated device designed to create suction over the clitoris.  The intent of this treatment is to increase clitoral blood flow and improve feelings of arousal and clitoral sensation.  This device is placed over the clitoris three times a day for 20 minute periods for a period of several weeks. A number of small studies (the largest to date consisted of 32 patients, 20 of whom had diagnosed sexual dysfunction) have indicated that this device improves lubrication, arousal, orgasmic function, and overall sexual satisfaction, particularly in women who had FSAD at baseline.  It is thought that these findings are based on improvements in clitoral blood flow and enlargement.[44]  The device is generally safe if used properly and evidence supports its efficacy in the treatment of some kinds of female sexual problems.

In addition to the Eros® device, some women with arousal difficulty may benefit from the use of commercially available vibrators or other devices to enhance their enjoyment of sexuality with or without a partner.  While these devices are not FDA approved for the treatment of any sexual disorder, their utility in enhancing the sexual experience for some women cannot be denied.[45]  

Hormonal Treatments

In women who have genital FSAD and trouble lubricating, estrogen supplementation may be of benefit in reducing vaginal atrophy and improving the ability of the vagina to produce adequate lubrication.[46]  Estrogen may be administered systemically as a pill or locally as a vaginal cream or gel.

Phosphodiesterase Type 5 Inhibitors (PDE5I)

PDE5I are the class of oral medications first introduced in 1998 for the treatment of erectile dysfunction in men.  These drugs enhance blood flow to the penis and, by extension, penile erection.  Because enhanced blood flow is also important in the physical process of genital arousal in women, there has been a great deal of interest in PDE5I as a treatment for arousal disorders in women.  Studies of PDE5I versus placebo for sexual problems in women have produced conflicting results.  One study of 202 post-menopausal women with FSAD and hormone profiles (estrogen and testosterone) within normal ranges showed significant improvements in genital sensation and intercourse satisfaction after treatment with PDE5I vs. placebo, assuming that concomitant sexual desire disorder was not present.[47]  Additional studies from Europe have also suggested a potentially beneficial role for PDE5I treatment of female sexual problems.[48]  However, another study enrolling 781 women with FSAD did not show any difference in sexual satisfaction between PDE5I or placebo treatment.  Interestingly, less than half of these women actually presented to their physician with FSAD as their primary concern.[49]  Given that FSAD was not the focus of the clinic visit in over half of these women, the level of distress that FSAD was causing these women is somewhat unclear.

  "Couple, " 13th century India                                                                                                                                                                 (www.metmuseum.org)

 

At this time, the role of PDE5I in the treatment of FSAD is uncertain.  Currently these medications are not FDA approved for the treatment of sexual dysfunctions in women although they are available for "off label" use by women. It is entirely possible that a subset of women with sexual problems may experience enhancement of their sexual experience with the use of these drugs; the decision to trial PDE5I in a particular woman should be based on a frank and honest discussion between patient and provider about benefits, risks, and unknowns regarding this type of treatment.

Topical Ointments/Lubricants

Alprostadil is a prostaglandin, a type of protein produced naturally within the body that has numerous effects, including vasodilation (opening of blood vessels).  Drugs of this type have been used for over 20 years to treat erectile problems in men.  Several recent studies have investigated whether genital application of an ointment containing these compounds might enhance sexual arousal in women.  Three of four trials of alprostadil vs. placebo in women with FSAD have shown improvements in sexual arousal and overall satisfaction with sexual intercourse.[50] Side effects from this treatment have been generally mild and have consisted mostly of brief genital burning or itching that resolves within several minutes.  Research on alprostadil as a treatment for FSAD is continuing and the drug may be submitted for FDA approval in the near future.

 A variety of commercially available lubricants may also be of use in the management of sexual problems in women.  A diverse array of lubricants are available, many of which have particular properties that may (in some cases and with some people) enhance the sexual experience for one or both partners.  Lubricants may be broadly classified into three categories; water-based, silicone-based, or oil-based.  Each type of lubricant has advantages and disadvantages.  It should be kept in mind that oil based lubricants may cause latex condoms or other contraceptive devices to fail and that many lubricants are spermatotoxic (meaning they may kill sperm and impair fertility)

Herbal Therapies

Numerous herbal supplements are available online and in certain stores for the treatment of FSAD.[51]  While some of these medicines have been demonstrated to be of some benefit in women with FSAD,[52] by and large, there is little scientific data to support their use outside of a research setting at this time.  Additionally, due to the lack of federal regulation of drugs sold as herbal “supplements,” many of these “natural” remedies could be contaminated with other drugs and/or may not even contain the advertised supplements.[53]
 

Medical therapies for orgasm problems in women

Sexual education and open communication between partners about sexual wants, likes, and dislikes are key factors in the management of anorgasmia in women.  If orgasmic problems persist despite education and communication, a variety of psychological approaches including cognitive-behavioral therapy (a process designed to correct misconceptions and self-defeating thoughts) and treatment of underlying anxieties and/or relationship stressors may be of benefit.[54]

 

 

In addition to psychological assessment, sensate focus (a leisurely exploration of the body with the sexual partner without the express goal of sexual intercourse and orgasm) and/or self-exploration by directed masturbation with or without a vibrator or similar device may be of benefit.[19]  As of this time, no medical therapies have been demonstrated as superior to placebo in the treatment of anorgasmia from SSRI,[55] nor have any medications been shown to be effective for non-SSRI induced anorgasmia.

Medical therapies for sexual pain syndromes in women

 

If a medical condition such as endometriosis or an anatomical abnormality of the female genital system is the root cause of a pain syndrome, treatment should be directed towards the underlying cause.  Additional therapies that have been of benefit in some women with sexual pain include psychotherapy, biofeedback, antidepressant medications, and anti-convulsants. 

A surgical therapy called vulvar vestibulectomy (VV) is available for women with vulvar vestibulitis.  In this procedure, the inflamed tissue external to the vagina which is thought to be the source of pain is excised.  In a randomized study of 78 women treated with VV versus biofeedback versus psychotherapy, all therapies were found to be effective at improving pain, but VV was more effective than either of the other two treatments.[56]   

Sexual pain is a highly personal concern and a woman’s feelings about the issue are of principal concern when selecting a therapy.  It is important that therapy be individualized to the individual woman’s particular concerns and desires.  Regardless of the therapy a woman selects, a multi-disciplinary approach involving some combination of physicians, sex counselors, psychologists, physical therapists, and/or other health care professionals is most often effective. 

 

 

What is the role of the partner in treating sexual problems?

 

Ideally, the partner should be involved in the management of sexual problems in women.  Sexual dysfunction affects not only an individual but rather the couple, and for optimal results both partners must be committed to treatment.  Interestingly, many studies have indicated that treatment of a man’s own sexual problems may help to enhance sexual function in his female partner.[57-59] This intriguing finding underscores the importance of evaluating both members of the couple.

Conclusions

It is undeniable that sexual disorders affect many women at some point in their lives, and that for some of these women difficulty with attaining satisfying sexual interactions will lead to distress and diminished quality of life. It is important to respect diversity in sexuality and acknowledge that levels of sexual functioning that would be a problem for one woman might be perfectly adequate for another. Sexaulity is however a very important quality of life factor for many women.  Women who experience distress related to their sexual functioning have the right to be evaluated by a sexual medicine specialist and receive appropriate treatment.

Effective treatments for female sexual disorders are currently available, although few of these have been officially approved by medical regulatory bodies.  For this reason, a frank discussion between patient and physician is essential prior to starting any kind of treatment for sexual problems.  New research will continue to improve our understanding of sexuality and improve treatment for women struggling with sexual problems in the future.  

Additional internet resources:

1. International Society for the Study of Women’s Sexual Health (http://www.isswsh.org/)
2. Sex Health Matters: (http://www.sexhealthmatters.org/v2/)
3. UrologyHealth.org: (http://www.urologyhealth.org/adult/index.cfm?cat=11) 
4. San Diego Sexual Medicine: (http://www.sandiegosexualmedicine.com) 
5. American Association of Sexuality Educators,  Counselors, and Therapists: (http://aasect.org/)
6. Society of the Scientific Study of Sexuality: (http://www.sexscience.org/)

 

Books on sexual function in women:

1. When Sex Isn’t Good: Stories and Solutions of Women With Sexual Dysfunction by Lillian Arleque and Sue W. Goldstein  (http://www.whensexisntgood.com)
2. Female Sexual Dysfunction - A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References by ICON Health Publications
3. Women's Sexual Function and Dysfunction, Irwin Goldstein, Abdulmaged Traish, Susan Davis, and Cindy Meston, eds.

   

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