What is female sexual dysfunction? 

Female Sexual dysfunction is an age-related, progressive and highly prevalent problem affecting nearly 30-50 percent of women globally. 

Sexual activity incorporates interpersonal relationships, each partner bringing unique attitudes, needs and responses into the coupling. A breakdown in any of these areas may lead to sexual dysfunction. 

The American Psychological Association (APA) classifies female sexual problems as - 

a. Mental disorders - loss of sexual desire or arousal,

b. Discomfort during intercourse, 

c. Diminished blood flow to the vagina, 

d. Trauma-related aversion to sex, 

e. Inability to achieve orgasm. 


How do you know if you have a problem? 

If you don't want to have sex or it never feels good, you might have a sexual problem. The best person to decide if you have a sexual problem is you hence awareness of the problem is important. 


What are some of the Types of ‘Female Sexual Dysfunction’ ? 

Hypoactive sexual desire disorder is characterized by an absence of libido or the intrinsic lack of desire to have sexual relationship. Persistent or recurring deficiency (or absence) of sexual fantasies/thoughts and sexual activity may sometimes cause personal distress. 
It may also result from psychological/emotional factors or be secondary to medical problems such as hormone deficiencies, and medical or surgical interventions. Any disruption of the female hormonal system caused by natural menopause, surgically or medically induced menopause, or endocrine disorders can also result in inhibited sexual desire. 

Sexual aversion disorder is characterized by an aversion to or avoidance or dismissal of sexual contact with a sexual partner. It is generally a psychological or emotional problem that can be due to various other underlying long standing emotional problems , (for e.g -physical or sexual abuse or childhood trauma). 

Female sexual arousal disorder When you don't feel a sexual response in your body or you start to respond but can't keep it up. Some disorders of arousal include, lack of or diminished vaginal lubrication, decreased clitoral and labial sensation, decreased clitoral and labial engorgement or lack of vaginal smooth muscle relaxation. These conditions may occur secondary to psychological factors, however often there is a medical/physiologic basis such as diminished vaginal/clitoral blood flow, previous injury or fracture to pelvic bones, pelvic surgery or sometimes due to certain medications.

Female orgasmic disorder is defined as the delay or absence of orgasm after "normal" arousal. 
This may be a primary (never achieved orgasm) or secondary condition, as a result of surgery, trauma, or hormone deficiencies. Primary orgasm can be secondary to emotional trauma or sexual abuse, however medical/physical factors can certainly contribute to the problem. 

Dyspareunia is a medical term that indicates genital pain before, during, or after intercourse. In some women, the muscles in the outer part of the vagina tighten when they start to have sex leading to the discomfort. 

Dyspareunia can also develop secondary to medical problems such as vestibulitis (inflammation of a gland), vaginal atrophy or dryness of vagina or vaginal infection. Dyspareunia can also be either physiologically or psychologically based, or a combination of the two.

Vaginismus is another medical term that indicates recurrent or persistent involuntary spasm of the musculature of the outer third the vagina and this interferes with vaginal penetration. Vaginismus usually develops as a conditioned response to painful penetration, or secondary to psychological/emotional factors. 

What are the causes of sexual dysfunction ? 

The causes of female sexual dysfunction are poorly
defined. The reason for this is perhaps because sexual intercourse or stimulation is an act that involves many systems to function in harmony for it to reach the stage of orgasm. To simplify its understanding it is best divided depending on the system that predominates in the dysfunction. Sometimes there may be multiple factors leading to the dysfunction Below are few of the causes that can case sexual dysfunction. 

The most common are listed first

 Alcohol 
 Anxiety 
 Depression - an unhappy relationship or abuse (now or in the past) can also cause sexual problems. 
Emotional problems; distraction 
 Illness 
 Negative body perception 
Stress- the stresses of everyday life can affect your ability to have sex. Being tired from a busy job or caring for young children may make you feel less desire to have sex. 
You may have less sexual desire during pregnancy, right after childbirth or when you are breast-feeding. After menopause many women feel less sexual desire, have vaginal dryness or have pain during sex.

Some medical causes could be

Drugs and medications; birth control pill 
Smoking 
Spinal cord injury (can cause nerve damage; paralysis) 
Rarely - Bicycle riding (long narrow seats associated with perineal pressure and reduced blood flow) 
Surgery (of or near reproductive-urinary system or abdomen; may damage nerves) 
Urinary incontinence (can cause embarrassment, avoidance) 
Vaginal atrophy 
Vascular causes ;
       High blood pressure 
       High cholesterol levels 
       Diabetes 
       Smoking 
       Heart disease 

Any traumatic injury to the to the genitals or pelvic region, such as pelvic fractures, blunt trauma, surgical disruption, extensive bike riding, for instance, can result in diminished vaginal and clitoral blood flow and complaints of sexual dysfunction. 

Neurological causes :

Spinal cord injury or disease of the central or peripheral nervous system. Women with spinal cord injury have significantly more difficulty achieving orgasm than able-bodied women. 
Hormonal/Endocrine causes:

Dysfunction of the hypothalamic/pituitary axis

Surgical or medical castration 

Natural menopause

Premature ovarian failure

Chronic birth control pills 

Hormonally based female sexual dysfunction can lead to decreased desire and libido, vaginal dryness, and lack of sexual arousal. Estrogen, a primarily female hormone, is associated with sexual desire. Testosterone, a primarily male sex hormone, plays a role in women's sexual development and function, including sensitivity of the breasts and clitoris. Some women experience diminished sexual desire, absence of sexual fantasies, and impaired sensitivity following menopause or hysterectomy or due to aging as a result of reduced estrogen. 

Dissatisfaction theory

In some instances it is neither psychological nor medical. A great deal of women's sexual dysfunction is not caused by hormone deficiency or diminished pelvic blood flow; it results from inadequate genital stimulation.

Poor communication by both partners may result in men not knowing how to stimulate a woman so that she becomes aroused. This leads to unsatisfactory sex and can cause arousal problems, lack of sexual interest, depression, and aversion to sex.

Psychogenic

Emotional and relational issues are also found to significantly effect sexual arousal. 

Self-esteem

Body image

Relationship with partner

Ability to communicate ones sexual needs with ones partner

Psychological disorders such as depression, obsessive compulsive disorder, anxiety disorder, etc., are associated with female sexual dysfunction. 

Medications - Antidepressants and benzodiazepines used to treat depression and anxiety are the drugs most commonly associated with loss of libido and inability to achieve orgasm. 

What are the diagnostic Tests that might be done? 

These are not undertaken commonly. However more recently a few investigations are available. 

1) Vagnial pH testing

It is commonly performed by gynecologists and urologists to detect bacteria-causing vaginitis.

A probe is inserted into the vagina which takes the reading.

Decreasing hormone levels and diminished vaginal secretion associated with menopause cause a rise in pH (over 5), which is easily detected with the test.

2) Vaginal photoplethysmography

It is used to measure Vaginal blood flow and engorgement (pooling and swelling of vaginal tissue)

For the procedure an acrylic tampon-shaped instrument inserted in the vagina and it uses reflected light to sense flow and temperature.

3) Biothesiometer

A small cylindrical instrument, may be used to assess the sensitivity of the clitoris and labia to pressure and temperature.

What are the treatment options available?

There are three primary types of treatment for female sexual dysfunction: 

When blood flow, hormone levels, and sexual anatomy are normal - Education on female anatomy, arousal and response can help; 

When there is hormonal dysfunction ( especially in post menopausal women) - Hormone replacement therapy can be considered and is found to be helpful.

When there is a vascular or Blood flow problem - Vascular treatment may be required.


1. Education:

Educating both women and men on how to talk about and respond to a woman's psychological and physical stimulatory needs can only happen if both partners recognize that there is a problem. 

Behavioral and sex therapists note the need for partners to examine the actual act of having sex, including foreplay, intercourse, and talking about sex. 

Sex therapists and psychologists may assist in improving communication between partners. 

2)Hormone Replacement Therapy:

With aging and menopause, and the decreasing estrogen levels, a majority of women experience some degree of change in sexual function. Common sexual complaints include loss of desire, decreased frequency of sexual activity, painful intercourse, diminished sexual responsiveness, difficulty achieving orgasm, and decreased genital sensation. 

Hormones play a significant role in regulating female sexual function. In animal models, estrogen administration results in expanded touch receptor zones, suggesting that estrogen effects sensation. In post-menopausal women, estrogen replacement restores clitoral and vaginal vibration and sensation to levels close to those of pre-menopausal women. Estrogens also have protective effects which result in increased blood flow to the vagina and clitoris. This helps to maintain female sexual response over time.

Low testosterone levels are also associated with a decline in sexual arousal, genital sensation, libido, and orgasm. However clinical studies are underway assessing the potential benefits of testosterone for the treatment of female sexual dysfunction. 

Thus Hormone replacement therapy is aimed at restoring hormone levels affected by age, surgery, or hormone dysfunction to normal, thus restoring sexual function.

3) Medical Management :

  1.Sildenafil (Viagra®)

It serves to increase relaxation of clitoral and vaginal smooth muscle and blood flow to the genital area.

Used in men with erectile dysfunction, is currently being tested in women. Some evidence suggests that it may restore libido lost to antidepressant use. 

  2.L-arginine

This amino acid functions as a precursor to the formation of nitric oxide, which mediates relaxation of vascular and non-vascular smooth muscle. 

When applied to the clitoris, may increase blood flow by dilating clitoral blood vessels. 

L-arginine has not been used in clinical trials in women; however preliminary studies in men appear promising. 
 
  3.Phentolamine (Vasomax)

Currently available in an oral preparation, this drug causes vascular smooth muscle relaxation and increases blood flow to the genital area. 

This drug has been studied in male patients for the treatment of erectile dysfunction. A pilot study in menopausal women with sexual dysfunction demonstrated enhanced vaginal blood flow and improved subjective arousal with the medication.

  4.Eros Therapy

The Eros Therapy is an FDA-approved device for the treatment of female sexual dysfunction. This small handheld device is used 3 to 4 times per week to increase blood flow to the clitoris and external genitalia, which improves clitoral and genital sensitivity, lubrication, and the ability to experience orgasm. It may take several weeks of conditioning before experiencing the benefits of this therapy. 

Diagnostic procedures for ED may include the following:
 
1. Patient medical/sexual history - may reveal conditions or diseases that lead to impotence and helps distinguish among problems with erection, ejaculation, orgasm, or sexual desire. 

2. Physical examination - to look for evidence of systemic problems, such as the following: 
A problem in the nervous system may be involved if the penis does not respond as expected to certain touching. 
Secondary sex characteristics, such as hair pattern, can point to hormonal problems, which involves the endocrine system. 

Circulatory problems could be indicated by an aneurysm. 
Unusual characteristics of the penis itself could suggest the basis of the impotence. 

3. Laboratory tests - to help diagnose impotence include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. When low sexual desire is a symptom, measurement of testosterone in the blood can yield information about problems with the endocrine system. 

4. Psychosocial examination - to help reveal psychological factors. The sexual partner also may be interviewed to determine expectations and perceptions encountered during sexual intercourse. 

Which doctor should I consult for Female Sexual Dysfunction? 

Talk to your doctor about your sexual health. However many general practitioner may not fully understand the problem hence it may be better to see a Urologist or a Gynecologist to discuss the problem. Explain your problems openly and honestly. Your doctor can also give you ideas about treating your sexual problems or can refer you to a sex therapist or counselor if it is needed. 

Glossary 

Corpora cavernosa - part of the penis. 


testosterone - sex hormone in males