Sexual Dysfunction

Describe what happens during the four phases of sexual response described by stimuli Masters and Johnson

1.    Excitement: internal or external

activation of the central nervous system (CNS) deep breathing, increase in heart rate,blood pressure, and sexualtension; generalized vasocongestion skin flush, breast engorgement, nipple

        erection, engorgement of labia and clitoris, vaginal transudation, and uterine tenting

2.    Plateau: marked degree of vasocongestion throughout the body _ further engorgement of the labia,  lower third of vagina, breast, and areolae. Secretion from the Bartholin glands, retraction of the clitoris, vagina lengthens with dilation of the upper two-thirds, muscle tension begins to build up

3.    Orgasm: release of sexual tension, generalized myotonic contractions, perivaginal muscles and   

Anal sphincter contract at precise intervals, vaginal and uterine contractions

4.    Resolution: a gradual diminution of sexual tension and response

What is the biopsychosocial model of female sexual response?

The biopsychosocial nature of female sexual response is influenced by the dynamic interaction of four components: biologic, psychologic,sociocultural influences, and interpersonal relationships. All of these components must be addressed in order to achieve sexual satisfaction

What are the possible etiologies of sexual dysfunction?

1. Change in vascularity (atherosclerosis, pudendal artery insufficiency affecting vaginal

vasocongestion)

2. Neurogenic causes (spinal cord dysfunction or injuries)

3. Depression or anxiety disorders

4. Medications (selective serotonin reuptake inhibitor [SSRI], tricyclic antidepressants, H2 blocker, and some antihypertensive medication)

5. Psychosocial factors (prior history of sexual abuse, religious or cultural expectation, fear of rejection or intimacy, and distorted body image)

6. Hormonal changes (premature ovarian failure and menopause)

What is the prevalence of sexual dysfunction?

Studies show a range of 10–60%; the average is 43%

What are the types of female sexual dysfunction and what is the main symptom of each?

1. Sexual desire disorders:decreased sexual fantasy and/or desire, sexual aversion

2. Sexual arousal disorders: decreased genital vasocongestion and lubrication

3. Orgasmic disorders: anorgasmia

4. Sexual pain disorders: vaginismus, dyspareunia, noncoital sexual pain

How should the question of sexual dysfunction be addressed?

The evaluation should involve an interview of the couple and each partner separately. A complete assessment should include past medical, psychological, sexual history and physical examination including gynecologic examination. Each patient should be asked if she has any

questions or concerns about her sexual activity. The most important aspect of taking a sexual history is to make the patient feel comfortable

What hormones influence vaginal blood flow?

Estrogen and testosterone increase vaginal blood flow; Progesterone diminishes vaginal blood flow

What types of therapies are available for the treatment of sexual dysfunction?

1. Nonpharmacologic therapy: Patient education, lifestyle and behavioral changes—should be tried first

2. Pharmacologic therapy: Hormones: estrogen—increases genital blood flow and enhanced lubrication Testosterone—may improve libido, data nonconclusive Herbal therapy: (e.g., St. John’s wort, ginseng, yohimbine) generally ineffective L-Arginine: increases nitric oxide

(NO) leading to genital vasocongestion; needs further study Tibolone: used for osteoporosis; has

androgenic activity that may improve sexual function Sildenafil: a vasodilator; datainconclusive on its benefit for women, not FDA approved

Describe what changes occur with aging that affect sexual function

1. Decreased libido

2. Hormonal changes—estrogen levels gradually drop leading to vaginal atrophy and dryness.

Testosterone levels decrease leading to a decrease in arousal andintensity and frequency of orgasm

3. Medical issues—increase in medical problems and use of medications that may affect sexual

function

4. Past experiences—for example, recurrent dyspareunia can lead to introital spasm, which can further impede sexual function

5. Relationship issues

6. Self-esteem changes

What types of medication or substances can lead to sexual dysfunction?

Alcohol; antihypertensives; illicit drugs; SSRIs Psychotropic Antihistaminic

What are the adverse effects of SSRI use on sexual function?

SSRIs have been reported to reduce libido in women and men, to cause anorgasmia in women, and to

increase ejaculation latency in men

What types of changes occur under the following circumstances that may affect female sexual function?

            During pregnancy: breast tenderness, mild cervical bleeding during intercourse, and uterine

contractions with orgasm

Postpartum: fatigue, vaginal dryness, bleeding, vaginal discomfort

What is hypoactive sexual desire disorder (HSDD)?

Recurrent and persistent lack of sexual fantasies or desires or receptivity to sexual activity that

causes personal distress

How should HSDD be evaluated?

Take a careful history including medications, medical illness, depression, substance abuse, and

stress. Thyroid test and prolactin levels may be indicated if there is any suggestion of hyperprolactinemia. Androgen levels are not useful in the majority of cases

How should HSDD be treated?

Physiologic causes should be assessed and managed. Further treatment may require individual therapy or relationship therapy

What is sexual aversion disorder?

It is characterized by a phobia with avoidance of sexual contact and severe anxiety associated with contemplation of sexual activity

What are sexual arousal disorders and how are they treated?

When women experience desire and orgasm, but lack signs of sexual stimulation, such as lubrication and genital vasocongestion. Treatment includes masturbation, vaginal lubricants, vibrator to increase stimulation, foreplay, distraction technique to alleviate anxiety, and/or

estrogen replacement therapy for postmenopausal women

What is orgasmic dysfunction and how is it treated?

A persistent delay in or absence of orgasm after sufficient stimulation and arousal resulting in distress or interpersonal difficulty. Treatment involves orgasm goal directed sexual

Counselling

What types of orgasmic dysfunction exists?

Primary anorgasmia is found in 5–10% of women and is lifelong

Secondary anorgasmia is often related to relationship problems, medications, medical illness,

depression, substance abuse, and self-monitoring/anxiety during arousal

What types of sexual pain disorders exist and what are they?

Vaginismus (recurrent involuntary contraction of the vaginal musculature during vaginal penetration)

Dyspareunia (general pain that occurs before, during, or after intercourse)

What organic disorders must be ruled out when vaginismus is diagnosed?

Endometriosis; PID; partial imperforate hymen; vaginal stenosis

How is vaginismus treated?

Education; relaxation techniques; kegel exercises; progressive vaginal dilatation

What organic disorders must be ruled out when dyspareunia is diagnosed?

Bartholin cysts; vulvitis; vestibulitis;vaginitis; clitoral irritation/ hypersensitivity; rigid hymenal ring/introital scar tissue; vaginal atrophy and dryness; pelvic adhesion; fibroid; endometriosis

How is dyspareunia treated?

The treatment depends on the etiology