Sexual dysfunction in women

Many women initiate or agree to sexual contact because they desire emotional intimacy or want to improve their health, confirm their attractiveness, or satisfy their partner.

In established relationships, a woman often lacks sexual desire, but as soon as sexual desire causes excitement and a feeling of pleasure (subjective activation), genital tension also appears (physical sexual activation).

The desire for sexual satisfaction, even in the absence of one or multiple orgasms during sexual intercourse, is physically and emotionally beneficial to a woman's initial arousal. A woman's sexual cycle is directly influenced by the quality of her relationship with her partner. Sexual desire declines with age, but increases with the appearance of a new partner at any age.

The physiology of female sexual response is not fully understood, but is related to hormonal influences and is regulated by the central nervous system, as well as subjective and physical arousal and orgasm. Estrogens and androgens also influence sexual arousal. Ovarian androgen production remains relatively constant during the postmenopausal period, but adrenal androgen production begins to decline in women after age 40; whether this decline in hormonal production plays a role in the decline in sexual desire, interest, or sexual arousal is unclear. Androgens probably act on both androgen receptors and estrogen receptors (after intracellular conversion of testosterone to estradiol).

Arousal activates areas of the brain involved in cognition, emotion, arousal, and genital tension. Neurotransmitters acting on specific receptors are involved; dopamine, norepinephrine, and serotonin are important in this process, although serotonin, prolactin, and γ-aminobutyric acid are usually sexual inhibitors.

Genital arousal is a reflex autonomic reaction that occurs within the first seconds of an erotic stimulus and causes sexual tension and lubrication. Smooth muscle cells around the vessels of the vulva, clitoris, and vaginal arterioles expand, increasing blood stagnation, and transudation of interstitial fluid by the vaginal epithelium occurs in the vagina (lubrication is produced). Women are not always aware of stagnation in the genital organs, and it can occur without subjective activation. With age, basal genital blood flow decreases in women and tension in response to erotic stimuli (e.g., erotic video) may be absent.

Orgasm is a peak of arousal characterized by contractions of the pelvic muscles every 0.8 s and a slow decline in sexual arousal. The thoracolumbar sympathetic outflow tract may be involved, but orgasm is possible even after complete transection of the spinal cord (for example, when using a vibrator to stimulate the cervix). Orgasm releases prolactin, antidiuretic hormone, and oxytocin, causing feelings of satisfaction, relaxation, or fatigue that follow sexual intercourse. However, many women experience feelings of satisfaction and relaxation without having an orgasm.

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Causes of sexual disorders in women

The traditional distinction between psychological and physical causes is artificial; psychological distress may cause physiological changes, and physical changes may cause stress. There are several causes of disorders that lead to dysfunctions whose etiology is unknown. Historical and psychological causes are those that interfere with a woman's psychosexual development. For example, past negative sexual experiences or other events that may lead to decreased self-esteem, shame, or guilt. Emotional, physical, or sexual abuse in childhood or adolescence may teach children to hide and manage their emotions (a useful defense mechanism), but such inhibition in expressing their feelings may lead to difficulty expressing sexual feelings later in life. Traumatic events - the early loss of a parent or other loved one - may block intimacy with a sexual partner due to fear of similar loss. Women with disorders of sexual desire (interest) are prone to anxiety, low self-esteem, and mood instability even in the absence of clinical disorders. Women with orgasmic disorders often have problems with behavior in non-sexual situations. The subgroup of women with dyspareunia and vestibulitis (see below) has a high level of anxiety and fear of negative evaluation by others.

Contextual psychological causes are specific to the woman’s current circumstances. They include negative feelings or decreased attractiveness of the sexual partner (e.g., due to changes in the partner’s behavior as a result of increased attention from women), non-sexual sources of worry or anxiety (e.g., due to family problems, work problems, financial problems, cultural restrictions), worries related to confidential information about unwanted pregnancy, sexually transmitted diseases, lack of orgasm, erectile dysfunction in the partner. Medical causes that lead to problems are related to conditions causing fatigue or weakness, hyperprolactinemia, hypothyroidism, atrophic vaginitis, bilateral oophorectomy in young women, and psychiatric disorders (e.g., anxiety, depression). The use of drugs such as selective serotonin inhibitors, beta-blockers, and hormones is important. Oral estrogens and oral contraceptives increase levels of steroid-binding globulin (SHBG) and decrease the amount of free androgens available for binding to tissue receptors. Antiandrogens (eg, spironolactone and GnRH agonists) may decrease sexual desire and sexual arousal.

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Classification of sexual disorders in women

There are the following main categories of sexual dysfunction in women: desire/interest disorder, sexual arousal disorder, and orgasm disorder. Disorders are diagnosed when symptoms of the disorder cause distress. Many women are not bothered by decreased or absent sexual desire, interest, arousal, or orgasm. Almost all women with sexual dysfunction have more than one disorder. For example, chronic dyspareunia often results in desire/interest and arousal disorders; decreased genital arousal makes sex less enjoyable and even painful, reducing the likelihood of orgasm and decreasing libido. However, dyspareunia due to decreased vaginal lubrication may occur as an isolated symptom in women with high levels of desire/interest and subjective arousal.

Sexual dysfunction in women may be congenital or acquired; situation-specific or general; moderate or severe, based on the degree of suffering and distress experienced by the patient. These disorders are likely to be found in women in heterosexual and homosexual relationships. Less is known about homosexual relationships, but for some women these disorders may be a manifestation of the transition to another sexual orientation.

Disturbance of sexual desire/interest - absence or decrease of sexual interest, desire, decrease of sexual thoughts, fantasies and absence of sensitive desire. Motivations of initial sexual arousal are insufficient or absent. Disturbance of sexual desire is related to the woman's age, life circumstances and duration of the relationship.

Sexual arousal disorders may be categorized as subjective, combined, or genital. All definitions are clinically based on a woman's different understanding of her sexual response to arousal. In sexual arousal disorders, there is subjective arousal in response to any type of sexual arousal (eg, kissing, dancing, watching erotic videos, genital stimulation). There is no response or a decreased response in response to this, but the woman is aware of normal sexual arousal. In combined sexual arousal disorders, subjective arousal in response to any type of stimulation is absent or decreased, and women do not report this because they are not aware of it. In genital arousal disorders, subjective arousal in response to extragenital stimulation (eg, erotic videos) is normal; but subjective arousal, awareness of sexual tension, and sexual sensations in response to genital stimulation (including intercourse) are absent or decreased. Disturbances in genital arousal are common in postmenopausal women and are often described as sexual monotony. Laboratory studies confirm decreased genital arousal in response to sexual stimulation in some women; in other women, decreased sexual sensitivity of the engorged tissues.

Orgasmic dysfunction is characterized by the absence of orgasm, a decrease in its intensity, or orgasm being noticeably delayed in response to arousal, despite high levels of subjective arousal.

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Diagnosis of sexual disorders in women

The diagnosis of sexual dysfunction and the identification of its causes are based on the collection of the medical history of the disease and a general examination. It is ideal to study the medical history of both partners (separately or jointly); the woman is first interviewed to clarify her problems. Problematic issues (e.g., past negative sexual experiences, negative sexual image) identified at the first visit can be more fully identified at subsequent visits. The general examination is important for determining the causes of dyspareunia; the technique of examination may differ slightly from the tactics usually used in gynecological practice. Explaining to the patient how the examination will be carried out helps her to relax. Explaining to her that she must sit in a chair and that her genitals will be examined in mirrors during the examination reassures the patient and gives her a sense of control over the situation.

Examination of vaginal discharge smears, their Gram staining, sowing on media or determination of DNA by the probe method are carried out to diagnose gonorrhea and chlamydia. Taking into account the examination data, a diagnosis can be made: vulvitis, vaginitis or pelvic inflammatory process.

Sex hormone levels are rarely measured, although decreased estrogen and testosterone levels may be important in the development of sexual dysfunction. An exception is the measurement of testosterone using well-established methods for monitoring testosterone therapy.

Components of sexual history for the assessment of sexual dysfunction in women

Sphere	Specific elements
Medical history (life history and history of current disease)	General health (including physical health and mood), drug use, history of pregnancies, outcome of pregnancies; sexually transmitted diseases, contraception, safe sex
Relationships between partners	Emotional closeness, trust, respect, attractiveness, sociability, loyalty; anger, hostility, resentment; sexual orientation
Current sexual context	Sexual dysfunction in partner, what happens in the hours before attempts at sexual activity, whether the sexual activity is inadequate to sexual arousal; unsatisfactory sexual relationship, disagreement with partner about methods of sexual contact, limited privacy
Effective triggers for sexual desire and arousal	Books, videos, dating, holding partners while dancing, music; physical or non-physical, genital or non-sexual stimulation
Mechanisms of inhibition of sexual arousal	Neuropsychic arousal; negative past sexual experience; low sexual self-esteem; concerns about the consequences of contact, including loss of control over the situation, unwanted pregnancy or infertility; tension; fatigue; depression
Orgasm	Presence or absence; concern about lack of orgasm or not; differences in sexual response with partner, occurrence of orgasm during masturbation
Result of sexual contact	Emotional and physical satisfaction or dissatisfaction
Localization of dyspareunia	Superficial (introital) or deep (vaginal)
Moments of occurrence of dyspareunia	During partial or complete, deep penetration of the penis, during friction, during ejaculation or subsequent urination after intercourse
Image (self-esteem)	Confidence in yourself, your body, your genitals, your sexual competence and desirability
History of the disease development	Relationships with admirers and siblings; trauma; loss of a loved one; emotional, physical, or sexual abuse; impaired emotional expression as a result of childhood trauma; cultural or religious restrictions
Past sexual experience	Sex that is desired, forced, abusive or a combination; enjoyable and positive sexual practice, self-stimulation
Personal factors	Ability to trust, self-control; suppression of anger, which causes a decrease in sexual emotions; sense of control, unreasonably inflated desires, goals

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Treatment of sexual disorders in women

Treatment is carried out in accordance with the type of disorders and their causes. In case of a combination of symptoms, complex therapy is prescribed. Empathy and understanding of the patient's problems, patient attitude and careful examination can become an independent therapeutic effect. Since the prescription of selective serotonin inhibitors can lead to the development of some forms of sexual disorders, they can be replaced by antidepressants that have a less adverse effect on sexual function. The following drugs can be recommended: bupropion, moclobemide, mirtazapine, venlafaxine. Phosphodiesterase inhibitors can be recommended for empirical use: sildenafil, tadalafil, vardenafil, but the effectiveness of these drugs has not been proven.

Sexual desire (interest) and subjective general disorders of sexual arousal

If there are factors in the relationship between partners that limit trust, respect, attractiveness and disrupt emotional intimacy, then such a couple is recommended to be examined by specialists. Emotional intimacy is a basic condition for the emergence of sexual response in women and therefore it should be developed with or without professional help. Patients can be helped by information about sufficient and adequate stimuli; women should remind their partners of the need for emotional, physical non-sexual and genital stimulation. Recommendations for the use of stronger erotic stimuli and fantasies can help to eliminate the disturbance of attention; practical recommendations for maintaining secrecy and a sense of security can help with fears about unwanted pregnancy or sexually transmitted diseases, i.e., what are inhibitors of sexual arousal. If patients have psychological factors of sexual disorders, psychotherapy may be required, although simple understanding of the importance of these factors may be enough for women to change their views and behavior. Hormonal disorders require treatment. Examples of treatments used include active estrogens for atrophic vulvovaginitis and bromocriptine for hyperprolactinemia. The benefits and risks of additional testosterone treatment are being studied. In the absence of interpersonal, contextual, and deeply personal factors, some clinicians may additionally examine female patients with both sexual dysfunction and endocrine disorder (e.g., using oral methyltestosterone 1.5 mg once daily or transdermal testosterone 300 mcg daily). Patients with the following endocrine disorders causing sexual dysfunction are eligible for examination: postmenopausal women receiving estrogen replacement therapy; women aged 40–50 with decreased adrenal androgen levels; women with sexual dysfunction associated with surgically or medically induced menopause; patients with dysfunction of the adrenal glands and pituitary gland. Careful follow-up examination is of great importance. In Europe, the synthetic steroid tibolone is widely used. It has a specific effect on estrogen receptors, progestogen, exhibits androgenic activity and increases sexual arousal and vaginal secretion. In low doses, it does not stimulate the endometrium, does not increase bone mass and does not have an estrogenic effect on lipids and lipoproteins. The risk of developing breast cancer when taking tibolone is being studied in the United States.

A change in medication may be recommended (eg, transdermal estrogen to oral estrogen or oral contraceptives or oral contraceptives to barrier methods).

Sexual arousal disorders

In case of estrogen deficiency, local estrogens are prescribed at the beginning of treatment (or systemic estrogens are prescribed if there are other symptoms of the perimenopausal period). If there is no effect during treatment with estrogens, phosphodiesterase inhibitors are used, but this only helps patients with reduced vaginal secretion. Another method of treatment is the prescription of clitoral applications of 2% testosterone ointment (0.2 ml of a solution in petroleum jelly, prepared in a pharmacy).

Orgasm disorder

Self-stimulation techniques are recommended. A vibrator placed in the clitoral area is used; if necessary, a combination of stimuli (mental, visual, tactile, auditory, written) can be used simultaneously. Psychotherapy can help patients recognize and cope with the situation in cases of decreased control over the situation, low self-esteem, and decreased trust in the partner. Phosphodiesterase inhibitors can be used empirically in acquired orgasm disorders with damage to the bundles of autonomic nerve fibers.