FEMALE SEXUAL DYSFUNCTION

*Angelo E. Gousse, MD, 2011.

Summary:

Female sexual dysfunction (FSD) is a common disorder with a reported prevalence of 38%. Female sexual dysfunction is more prevalent and is very different from male sexual dysfunction.  Decreased sexual desire, subjective feeling of poor genital arousal (lubrification) and pain during intercourse are all classified under female sexual dysfunction. Biological causes for female sexual dysfunction play a major   role. Vaginal   and   vulvar   vasocongestion   is   very   important   to   maintain   lubrication and sexual arousal. Both vascular and endocrine factors play crucial roles in this process. Hormonal changes  affect  libido.  Hypertension,  coronary  artery  disease,  diabetes,  dyslipidemia,  cigarette smoking, hypothalamus and pituitary dysfunction can all lead to female sexual dysfunction. Other causes include antidepressants, oral contraceptive pills, depression, stressors, and interpersonal conflicts.

Female sexual function encompasses physiologic, psychological and emotional factors. All of which must be taken into consideration prior to initiating therapy. Non-pharmacological therapy should be employed as the first line option. Hormonal therapy has shown increasing promise and should be cautiously used. Pharmacological agents may benefit specific patient population and should be used in the correct clinical setting. To date, phosphodiesterase inhibitors are not approved for use in women. Future research in FSD pharmacotherapy is clearly necessary.

Résumé:
La dysfonction sexuelle féminine (DSF) est un trouble fréquent avec une prévalence de 38%. Cette DSF est plus répandue et est très différente de celle  masculine. La diminution du désir sexuel, le sentiment subjectif d’une pauvre excitation génitale (lubrification) et les douleurs pendant les rapports sont tous classés dans la DSF. Des causes biologiques  jouent un rôle majeur. La vasocongestion vaginale et vulvaire  est  très  importante  pour  maintenir  la  lubrification  et  l’excitation  sexuelle.  A  la  fois  des facteurs vasculaires et endocriniens jouent un rôle crucial dans ce processus. Des changements hormonaux affectent la libido. L’hypertension artérielle, la maladie coronarienne, le diabète, la dyslipidémie, le tabagisme, la dysfonction hypothalamique et hypophysaire peuvent tous mener à la DSF. D’autres causes incluent les antidépresseurs, les  pilules contraceptives, la dépression, le stress et des conflits interpersonnels.

La fonction sexuelle féminine englobe des facteurs physiologiques, psychologiques et émotionnels. Tout cela doit être pris en considération avant l’instauration du traitement. Le traitement non pharmacologique doit être employé comme  l’option première ligne. La thérapie hormonale a montré des résultats prometteurs croissants mais devrait être utilisée avec prudence. Une population de patients spécifiques peut bénéficier d’agents pharmacologiques à  utiliser dans des cas clinique précis.
À ce jour, les inhibiteurs de phosphodiestérase ne sont pas approuvés pour leur utilisation chez les femmes. La recherche en pharmacothérapie contre le DSF est clairement nécessaire.

Introduction
Female sexual dysfunction (FSD) is a common disorder and the prevalence has been reported to be approximately 38% [1]. FSD is defined as a disturbance in sexual functioning involving one or multiple phases of the sexual response cycle.  Decreased sexual desire, subjective feeling of poor genital arousal and pain during intercourse are all classified under female sexual dysfunction [1]. Women’s sexuality is different from males. Amongst women sexual desire is an infrequent motive for having sex. Female sexual function is not solely dependent on the physiological function of the genital organs. Partnership, psychological and biological factors influence women’s arousability.

Factors involved in female sexual response
The four phases of the female sexual response cycle are excitement, plateau, orgasm and resolution. Sexual  interest  or  desire  is  dependent  on  the  levels  of  dehydroepiandrosterone  (DHEA)  and testosterone. Declining levels contribute to decline in sexual desire, arousal and orgasm [2]. Deficiency of estrogens results in genital atrophy and insufficient lubrication [3]. Sexual arousal is influenced and maintained by a combination of chemical mediators: vasoactive intestinal polypeptide (VIP), nitric oxide (NO), prostaglandin E, phosphodiesterase type 5, DHEA and testosterone. Alteration in the hypothalamic pituitary  gonadal  axis  adversely  affects  the  onset  and  maintenance  of  sexual  arousal.  Sudden contractions of the pelvic muscles due to a surge of oxytocin results in orgasm [4]. Table -1 illustrates the classification of female sexual dysfunction [5].

Hypoactive sexual disorder (HSD)
HSD is defined as persistent or recurrent absence of sexual fantasies, thoughts, and sexual desire. Several cross sectional studies have reported the prevalence of HSD to be 32-39% [6]. Despite increased awareness about sexual problems among women, many patients remain reserved about discussing such problems with physicians.  The lack of clarity on the current definitions of female sexual disorders remains an obstacle for clinicians to effectively discuss the problems with their patients.  Additionally, physicians are frustrated by the lack of effective treatment options for female hypoactive sexual disorders, which contributes to reluctance in discussing sexual health disorders with patients. The most meaningful treatment outcome reported by patients was an “improvement in level of desire” rather than an increase in satisfying sexual events. Patients who noticed an improvement in their sexual desire were more likely to return for medical assessments [7]. Women in long-term relationships tend to have sexual thoughts infrequently. However, they rate their sexual lives to be satisfying. The motive to be sexual in this population is not necessarily sexual desire at all times.

Female sexual arousal disorder (FSAD)
FSAD is defined as persistent or recurrent inability to maintain desire and arousal until completion of sexual activity. Often patients report inadequate lubrication and poor swelling response. The prevalence has been estimated to be 21% amongst women aged 18-59 years [6].

Orgasmic disorders
Lack and markedly diminished intensity of orgasmic sensations or marked delay of orgasm despite self report of sexual arousal is termed orgasmic dysfunction. The prevalence reported to be 21-26% in women aged 18-59 years [6]

Sexual pain disorders
Dyspareunia is defined as persistent or recurrent pain with attempted or complete vaginal entry and/or with penile vaginal intercourse. Dyspareunia is classified based on the origin of the pain: superficial/introital dyspareunia, vaginal dyspareunia, or deep dyspareunia [5].
Veganism’s is persistent or recurrent difficulty to allow vaginal entry of a penis, finger, or object, despite a women’s expressed wish to do so [5].
Sexual pain can also result in the absence of the sexual act. This can be a result of vaginal infections, vestibulitis, infected or enlarged Skene’s or Bartholin gland cyst.

Urinary incontinence and female sexual dysfunction
The prevalence of urinary incontinence (UI) is constantly increasing, partly due to increased awareness amongst patients and increasing number of female patients seeking medical attention. Studies have shown that regardless of the type, urinary incontinence has a negative impact on female sexual function and quality of life [8]. Urge urinary incontinence (UUI) and mixed incontinence have shown to affect sexual function more adversely than stress incontinence (SUI) [9, 10]. Women with urinary incontinence report to be concerned about coital incontinence which may be related to either stress or urge incontinence. This decreases ones desire to be sexually active and leads to sexual aversion.

Biological causes for female sexual dysfunction
Vaginal and vulvar vasocongestion is very important to maintain lubrication and arousal. Both vascular and endocrine factors play crucial roles in this process. Hypertension, coronary artery disease, diabetes, dyslipidemia, cigarette smoking, hypothalamus and pituitary dysfunction can all lead to female sexual dysfunction. Other causes include antidepressants, oral contraceptive pills, depression, stressors, and interpersonal conflicts.

Management of Female Sexual Dysfunction
Female sexual dysfunction is multifactorial. Patients should be evaluated for all sexual issues and associated physical or psychological factors before starting treatment. Significant overlap of sexual disorders is common amongst women.  Women with complaints of decreased libido, often report to have issues with arousal or pain during sexual activity. After careful assessment of the presenting complaint, the physician should enquire patient’s goal prior to commencing therapy. This allows the physician to set realistic patient expectations.
Detailed history and physical examination aid in assessing general medical condition. Gynecologic examination should include bimanual, rectovaginal and speculum exams. Monomanual examination should be performed for patients with dyspareunia. Validated questionnaires such as female sexual function index (FSFI- Table 2) [11] should be employed on all patients. This allows to subjectively confirm the domain resulting in highest bother.

Non-Pharmacological treatment
Women with sexual dysfunction  often benefit from counseling with a sex therapist. This helps to alleviate the psychological and relationship issues which often tend to exacerbate sexual dysfunction between partners. Sex therapy also includes informal discussion about sexual dysfunction, employs exercises to increase mutual sexual pleasure and decrease pain. Given the efficacy sex therapy is recommended prior to patients commencing medical therapies. Lifestyle modifications

Table2:   Female   Sexual   Function   Index

Hormonal therapy
Testosterone therapy is primarily employed to improve sexual desire and responsiveness in women. Studies have shown that it also improves arousal and orgasmic responses [12]. Concomitant use of estrogens or progestins is recommended. Cosmetic androgenic side effects such as acne and hirsutism are common with androgen therapy. Rare cases of permanent voice deepening and clitoromegaly have also been reported. Testosterone therapy has been positively associated with breast cancer.
Estrogen therapy is beneficial in post-menopausal women with vaginal atrophy and dryness. Re- vascularization of the vaginal epithelium decreases dyspareunia and has shown to have positive impact on sexual health.

Phosphodiesterase inhibitors
In general the use of PDE-5 inhibitors have not shown great promise in the treatment of female sexual dysfunction. However, studies have shown that sexual arousal and orgasm improved for patients on selective serotonin reuptake inhibitors treated with Sildenafil R. Further studies are warranted to determine its use in diabetics, and neurological patients [13].

Other agents
ApomorphineR, BupropionR and BuspironeR have been used to treat female sexual dysfunction with questionable results.

Conclusion
Female sexual function encompasses physiologic, psychological and emotional factors. All of which must be  taken  into  consideration  prior  to  initiating  therapy.  Non-pharmacological  therapy  should  be employed as the first line option. Hormonal therapy has shown increasing promise and should be cautiously used. Pharmacological agents may benefit specific patient population and should be used in the correct clinical setting.

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