Female Sexual Response and Sexual Dysfunction
Nina Resetkova
Linda Rogers
EPIDEMIOLOGY
In the 1999 National Health and Social Life Survey, 1,410 men and 1,749 women aged 18 to 59 years were surveyed and 43% of these women reported sexual concerns. A British national survey found that 54% of women reported at least one sexual problem lasting at least 1 month but only 21% sought help.
The most common female sexual problem in both studies was a lack of interest. Difficulty with orgasm was reported by 24%, difficulty with arousal by 19%, and pain
with sex by 14%. Accurate assessments of female sexual dysfunction are hampered by the fact that many patients have more than one type of dysfunction. Additionally, many patients complaining of lack of interest actually have a problem with another phase of the sexual response cycle, in part because they lack familiarity with the terms.
Multiple studies have found that female sexual dysfunction is associated with a decreased sense of physical and emotional satisfaction and a decreased sense of overall well-being.
DIAGNOSIS OF SEXUAL DISORDERS
Screening
Many physicians infrequently discuss sexual dysfunction due to limited time and training, embarrassment, or the perceived notion that there is an absence of effective treatment options. A few simple questions can initiate the discussion:
Are you currently involved in a sexual relationship?
Do you have sex with men, women, or both?
Do you have any concerns about or pain with sex?
Do you have any concerns you would like to discuss?
Once a dialogue has been initiated, a complete history can be obtained. This should include the nature and frequency of the problem, the degree of distress, whether the problem is lifelong versus newly acquired, situational, or generalized. Additionally, the partner’s sexual problems or concerns, partner reaction, and history of prior treatment or intervention should be discussed.
It is important to elicit the patient’s thoughts concerning the cause of the problems and their expectations from treatment. The physician must also get a medical history, a psychological/psychiatric history (e.g., mood disorders, body image disorders), sexual history including sexual abuse or violence, and a psychosocial history (e.g., relationship difficulties, cultural and religious beliefs that may affect function, work/finance/children, and other life stressors). It is also important to inquire about the use of medications that may cause sexual side effects and about the use of personal hygiene products such as soaps, laundry products, douches, or other possible skin irritants.
Physical Exam
A thorough physical exam can help identify causes, address concerns, and educate the patient about her anatomy.
During visual inspection of the external female genitalia and perineum, it is important to note any atrophy, lack of estrogenization, loss of architecture, scarring, hypopigmentation or hyperpigmentation, or possible infection. The exam should include the urethral meatus and anus. Wet prep and pH should be performed to evaluate signs of infection. Fungal cultures or polymerase chain reaction (PCR) testing should be sent if there is any doubt about the presence of yeast, as wet prep has a sensitivity of only 50%. Suspicious skin changes on the vulva warrant biopsy.
A moistened cotton swab is used to systematically examine the vulva and map any areas of pain. If present, tenderness is most commonly found adjacent to the hymenal ring, but it is important to check the rest of the vulva for more generalized tenderness.
A speculum exam and gentle digital exam are then performed. Attention should be paid to tenderness, adnexal masses or nodularity, pelvic floor muscle tone, prolapse, and the anal reflex.
Laboratory tests are rarely useful, as they are poorly predictive of function and perception of function.
PHYSIOLOGY OF FEMALE SEXUAL FUNCTION
Female sexual function is a complex interplay of the central nervous system (CNS), peripheral nervous system, and end organs.
The medial preoptic, anterior hypothalamic, and limbohippocampal areas are involved in sexual arousal.
Estrogens, androgens, oxytocin, and dopamine are believed to promote female sexual response. In contrast, progesterone, prolactin, and serotonin are inhibitory.
The vasculature and musculature changes involved in arousal are mediated by dopaminergic stimulation of the peripheral nervous system. Autonomic nerves release nitric oxide and vasointestinal polypeptide that modulate vasodilatation.
Increased blood flow causes labial engorgement, increased vaginal lubrication, vaginal lengthening and dilation, and increased clitoral size.
The pelvic floor muscles and the smooth muscle of the vagina spasm during orgasm. Contraction of the pelvic floor muscles involves adrenergic and cholinergic mechanisms from the efferent pudendal nerve.
Estrogen primarily maintains the integrity of the tissues. Androgen levels are associated with libido and arousal.
The arousal response in women involves increased heart rate, muscle tension, changes in breast sensations, and a subjective state of arousal.
THEORIES OF SEXUAL FUNCTION
For many years, female sexual function was described with a model more characteristic of men than of women. In 1966, Masters and Johnson defined the human sexual response as a sequential model including excitement (desire and arousal), plateau, orgasm, and resolution (Table 42-1). Recent research has found that the female sexual response is much more complex and is usually not linear.
The Study of Women’s Health Across the Nation (SWAN) surveyed 2,400 women of various ethnicities (Hispanic, White non-Hispanic, African American, Chinese, and Japanese) in six US cities. The study found that 40% of these women never or infrequently felt desire, although the majority reported being capable of arousal. Only 13% expressed discontent.
In 2011, Rosemary Basson developed a model of sexual arousal that incorporated psychological and social aspects of women’s lives. In her model, desire does not always precede sexual arousal. Instead, women often begin at a state of “sexual neutrality” and respond to or seek sexual stimuli based on many possible psychological motivations. The response to this stimulus is usually arousal, which leads to desire and improved arousal. This model can be explained to patients concerned about lack of desire and can normalize what women commonly experience (a lack of spontaneous desire but the presence of reactive desire) (Figure 42-1).
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), recently published in 2013, made some significant changes compared to the prior edition. Importantly, the diagnosis of sexual dysfunction requires a minimum duration of 6 months. The new edition combines female sexual desire disorder and female sexual arousal disorder into female sexual interest/arousal disorder, reflecting the research showing that most women experience both of these disorders and have difficulty distinguishing between them. A new diagnosis, genitopelvic pain/penetration disorder, merged vaginismus and dyspareunia, reflecting the difficulty women have in distinguishing the cause of penetration pain and the inadequacy of vaginal muscle spasm.
TABLE 42-1 Physiologic Female Sexual Response | ||||||||||||||||||
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