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Female Dysfunction
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Concepts of female sexual dysfunction are controversial,
particularly those based on biological causes. The American
Psychological Association (APA) classifies female sexual
problems as mental disorders: loss of sexual desire or
arousal, discomfort during intercourse, diminished blood flow
to the vagina, trauma-related aversion to sex, and the
inability to achieve orgasm. Historically, psychiatrists and
sex therapists have diagnosed and treated these disorders,
perhaps, in many cases, according to limited perspectives
maintained by psychiatric literature. Urologists and
gynecologists now treat female sexual problems that result
from medical conditions causing diminished pelvic and vaginal
blood flow and nerve damage.
Currently, urologists, behavioral scientists, and
psychologists are looking at medical, cultural, psychological,
and relational reasons for women's sexual dysfunction, perhaps
more accurately termed sexual dissatisfaction. They are
emphasizing education and communication between partners.
Surveys of women suggest that therapy should focus on women's
physiological needs to experience enjoyable sex instead of
medical conditions. Under this view, sexual dissatisfaction is
symptomatic of an intimacy problem in which one or both
partners fail to communicate their needs.
A useful model for exploring disturbances in female sexual
response considers traditional and innovative, psychiatric and
medical, and psychological and physiological perspectives. For
some women, dysfunction or dissatisfaction is defined by a
loss of interest in sex and the inability to become aroused or
to achieve orgasm when participating in sex. Many are
dissatisfied because their partners are uneducated or
inattentive and do not understand female arousal and its
anatomical basis. For others, a medical evaluation uncovers a
physiological problem that impairs sensitivity. The concept of
dysfunction, or dissatisfaction, remains poorly defined.
Incidence and Prevalence
The absence of dependable empirical data combined with varying
definitions about sexual dysfunction, and even normal sexual
practices, prevents a clear understanding of the prevalence of
women's sexual problems. While some studies document a
prevalence of dysfunction among non-Caucasian women and women
of lower socioeconomic status, opponents of these studies
point to a lack of diversity in these test populations.
A survey conducted by the American Medical Association in 1999
indicates that sexual dysfunction affects approximately 43% of
women in the United States. Age may not be a significant
factor, as women under 20 and over 50 experience problems with
arousal, orgasm, and satisfaction. However, there is evidence
that the majority of female sexual dysfunction happens after
menopause, when hormone production drops and vascular
conditions are more common.
Female Sexual Response Cycle
The clinical definition of the female sexual response cycle
consists of four stages of arousal, marked by physiological
and psychological changes. The first stage is excitement,
which can be triggered by psychological or physical
stimulation, and is marked by emotional changes, and increased
heart rate, respiration, and vaginal swelling and lubrication
due to increased blood flow. Sustained excitement is called
the plateau, the second stage. Vaginal swelling, heart rate,
and muscle tension may increase as long as stimulation
continues. The breasts enlarge, the nipples become erect, and
the uterus dips. The third stage is orgasm, which involves
synchronized vaginal, anal, and abdominal muscle contractions,
the loss of involuntary muscle control, and intense pleasure.
The final phase, resolution, involves a rush of blood away
from the vagina, shrinking breasts and nipples, and a
reduction in heart rate, respiration, and blood pressure.
A normal or healthy response cycle may be as poorly defined as
a dysfunctional one. How women experience these stages varies;
for example, some progress from excitement to orgasm rapidly,
and others alternate between plateau and orgasm several times
before reaching resolution.
Causes
The causes of female sexual dysfunction are poorly defined.
Several factors may impede the sexual response cycle, which
requires physical and psychological stimulation:
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Alcohol
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Anxiety
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Depression
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Emotional
problems; distraction
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Illness
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Negative body
perception
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Stress
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Recently, controversy has produced two
opposing medical perspectives on the causes (and treatment)
for female sexual dysfunction. One concept, known as the
vascular theory, is that diminished blood flow to the pelvic
region, due to a medical condition, aging, stress, or
hypoactive sexual desire, causes reduced sensitivity
(particularly of the clitoris) and dryness, and impairs
arousal.
Decreased blood flow is associated with
medical conditions such as diabetes and artherosclerosis. This
concept has fueled clinical research and has led to the
introduction of topical creams that, when applied to the
clitoris, cause vascular dilation, increased blood flow, and
vascular congestion associated with the excitement stage.
Sensitivity is increased and may lead to arousal.
A second concept, the hormone theory,
focuses on decreased levels of sex hormones, such as estrogen
and testosterone, caused by aging. For some women, hormone
replacement therapy leads to greater sexual desire. 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 as a result of
reduced estrogen.
Other medical causes include the following:
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Bicycle
riding (long narrow seats associated with perineal
pressure and reduced blood flow)
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Drugs and
medications; birth control pill
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Smoking
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Spinal cord
injury (can cause nerve damage; paralysis)
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Surgery (of
or near reproductive-urinary system or abdomen; may damage
nerves)
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Urinary
incontinence (can cause embarrassment, avoidance)
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Vaginal
atrophy
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Antidepressants and benzodiazepines (fluoxetine, Prozac®,
alprazolam, Xanax®) used to treat depression and anxiety
are the drugs most commonly associated with loss of libido
and inability to achieve orgasm. Buproprion (Wellbutrin®,
an antidepressant) is sometimes prescribed for those who
experience drug-related loss of sexual desire. Some
evidence suggests that it restores libido.
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Chemotherapy drugs used to treat
cancer are also associated with a lack of sexual interest.
Some evidence suggests that extended use of birth control
pills leads to reduced libido. Spinal cord injury, pelvic
trauma, and other conditions that affect the peripheral
nervous system, such as diabetes, can impair genital
sensitivity, as can surgery involving the pelvic floor,
bladder, abdomen, and genitals.
A third perspective, what could be called
the dissatisfaction theory, 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. The fact that
young, healthy women experience sexual dysfunction gives
credence to this view. 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. Interestingly, the APA lists the
"adequacy of [female] sexual stimulation" as a factor only in
its discussion of female orgasmic disorder. This implies that
it is not a fundamental aspect of female sexual function and
so not affected by medical or psychological conditions.
Diagnosis
Psychological
The APA classifies sexual disorders in the Diagnostic and
Statistical Manual of Mental Disorders (DSM IV) because they
tend to disrupt interpersonal relationships and cause
psychological distress. All disorders listed in the DSM in
some way disturb the process of arousal and the sexual
response cycle. Although controversial, it is the standard
approach used by many psychiatrists and clinicians in the
United States and other countries to female sexual problems.
Hypoactive sexual desire disorder is characterized by an
absence of libido. There is no interest in initiating sex and
little desire to seek stimulation. Sexual aversion disorder is
characterized by an aversion to or avoidance or dismissal of
sexual prompts or sexual contact. It may be acquired following
sexual or physical abuse or trauma and may be life-long. The
main feature of female sexual arousal disorder is an inability
to achieve and progress through the stages of "normal" female
arousal. Female orgasmic disorder is defined as the delay or
absence of orgasm after "normal" arousal. Dyspareunia is
marked by genital pain before, during, or after intercourse.
Vaginismus is the involuntary contraction of the perineal
muscles around the vagina as a response to attempted
penetration. Contraction makes vaginal penetration difficult
or impossible.
These disorders must cause personal distress and must not be
accounted for by a medical condition. A distinction is made
between disorders that are life-long and those that are
acquired, as well as those that are situational and
generalized.
Medical
In cases where a medical condition is suspected as the
underlying cause, whether it causes inadequate blood flow,
nerve-related loss of sensitivity, or reduced hormone levels,
a specialist conducts an appropriate diagnosis. Sexual
problems may be symptomatic of diseases that require
treatment, like diabetes, endocrine disorders of the
hypothalamic-pituitary-gonadal axis, and neurological
disorders.
The American Foundation of Urologic Disease (AFUD) classifies
the APA's criteria into these four types of disorder:
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Hypoactive
sexual desire disorder; includes sexual aversion disorder
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Sexual
arousal disorder
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Orgasmic
disorder
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Sexual pain
disorders; includes vaginismus, dyspareunia
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Contrary to APA stipulation, dyspareunia
(pain during intercourse) may be diagnosed as a result of
inadequate vaginal lubrication, which may be considered an
arousal disorder and treated as such. Pain is associated with
recurrent medical conditions, including cystitis.
Physiological Diagnostic Tests
Vaginal blood flow and engorgement (pooling and swelling of
vaginal tissue) can be measured with vaginal
photoplethysmography, in which an acrylic tampon-shaped
instrument inserted in the vagina uses reflected light to
sense flow and temperature. It cannot be used to assess
advanced levels of arousal, say, during orgasm, because
movement skews its reading. Also, limited knowledge of
normative vaginal engorgement levels makes for only
speculative results. Vaginal pH testing, commonly performed by
gynecologists and urologists to detect bacteria-causing
vaginitis, may be useful. A probe inserted into the vagina
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. A
biothesiometer, a small cylindrical instrument, may be used to
assess the sensitivity of the clitoris and labia to pressure
and temperature. Readings are taken before and after the
subject watches erotic video and masturbates with a vibrator
for approximately 15 minutes.
Treatment
There are three primary types of experimental treatment for
female sexual dysfunction:
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Education on
female anatomy, arousal, and response; where blood flow,
hormone levels, and sexual anatomy are normal
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Hormone
replacement therapy (including treatment of the underlying
disorder)
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Vascular
treatment (including treatment of the underlying disorder)
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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.
Hormone replacement therapy (HRT) is
aimed at restoring hormone levels affected by age, surgery, or
hormone dysfunction to normal, thus restoring sexual function.
Estrogen and testosterone levels are measured and treated by
endocrinologists.
Sildenafil (Viagra®), used in men with erectile
dysfunction, is currently being tested in women. Some evidence
suggests that it may restore libido lost to antidepressant
use.
A medical condition that causes diminished blood flow to the
vagina must be addressed in light of sexual dysfunction.
However, some women who are not diagnosed with underlying
medical conditions have found that nonprescription topical
solutions, such as Sensua!™ (formerly called Viacreme®) or
Viagel®, increase sensitivity and assist in achieving orgasm.
Sensua!™ is an amino-acid based (L-arginine) solution
that contains menthol. L-Arginine is involved in nitric oxide
synthesis, which is responsible for vascular and nonvascular
smooth muscle relaxation. When applied to the clitoris, Sensua!™
may increase blood flow by dilating clitoral blood vessels.
More research being done to assess the possible effects and
complications of topical creams.
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.
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