Sexual disorders in women

Many women initiate or agree to have sexual intercourse, because they want emotional closeness 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 the sexual desire causes excitement and a sense of pleasure (subjective activation), genital tension (physical sexual activation) also appears.

The desire for sexual satisfaction, even in the absence of one or multiple orgasms during sexual intimacy, is physically and emotionally useful for the initial initiation of a woman. The female sexual cycle is directly influenced by the quality of its relationship with the partner. Sexual desire decreases with age, but increases with the appearance of a new partner at any age.

The physiology of female sexual reaction has not been fully studied, but it is associated with hormonal influence and is regulated by the CNS, as well as subjective and physical activation and orgasm. Estrogens and androgens also affect sexual activation. The production of androgens in the postmenopausal period remains relatively constant, but adrenal androgen production begins to decrease in women after 40 years; whether this decrease in hormone production plays a role in reducing sexual desire, interest or sexual activation is unclear. Androgens probably affect both androgen receptors and estrogen receptors (after intracellular conversion of testosterone to estradiol).

Excitation promotes the activation of brain regions responsible for cognition, emotion, motivation and the formation of genital tension. The process involves neurotransmitters acting on specific receptors; dopamine, noradrenaline and serotonin are of great importance in this process, despite the fact that serotonin, prolactin and y-aminobutyric acid are usually sexual inhibitors.

Genital excitement is a reflex autonomic reaction that appears during the first seconds after an erotic stimulus and causes sexual tension and liberation of the lubricant. Smooth muscle cells around the vessels of the vulva, clitoris and vaginal arterioles widen, increasing blood stasis, and the transudation of the interstitial fluid with the vaginal epithelium occurs in the vagina (lubricant is produced). Women do not always know about stagnation in the genital organs, and this can occur without subjective activation. As women age, basal genital blood flow decreases and tension in response to erotic stimuli (for example, erotic video) may be absent.

Orgasm is the peak of excitement, which is characterized by contractions of the pelvic muscles every 0.8 s and a slow decrease in sexual arousal. Thoracolumbal sympathetic outflow can be involved in the process, but an orgasm is possible even after a complete dissection of the spinal cord (for example, when using a vibrator to stimulate the cervix). When orgasm is released prolactin, antidiuretic hormone and oxy-tocin, causing a sense of satisfaction, relaxation or fatigue, which follow after sexual intercourse. However, many women experience a sense of satisfaction and relaxation without experiencing orgasm.

[1], [2], [3], [4], [5], [6], [7], [8]

Causes of Sexual Disorders in Women

The traditional division of psychological and physical causes is artificial; Psychological distress can be the cause of a change in physiology, and physical changes can lead to stress. There are several causes of disorders that lead to dysfunctions, the etiology of which is unknown. Historical and psychological reasons are the causes that violate the psychosexual development of women. For example, cases of negative experience of sexual contacts in the past or other cases that may lead to a decrease in self-esteem, disgrace or guilt. Emotional, physical or sexual abuse in childhood or puberty can teach children to hide their emotions and manage them (a useful defense mechanism), but such inhibition in the expression of their feelings can lead to difficulty in expressing sexual feelings in a later period. Traumatic events - the early loss of a parent or another loved one - can block the intimacy with a sexual partner because of the fear of such a loss. Women with sexual desire (interest) are prone to anxiety, to low self-esteem, they are characterized by mood instability even in the absence of clinical disorders. Women with an orgasm disorder often have behavioral problems in case of non-sexual circumstances. A subgroup of women with dyspareunia and vestibulitis (see below) has a high level of anxiety and fears of negative evaluation by surrounding people.

Contextual psychological causes are specific to the current circumstances of women. They include negative feelings or decreased attractiveness of the sexual partner (for example, due to a change in the behavior of the partner as a result of increased attention to it by women), sexual sources of anxiety or anxiety (for example, because of family problems, at work, financial problems , cultural restrictions), anxiety associated with secret information about unwanted pregnancy, sexually transmitted diseases, lack of orgasm, erectile dysfunction in the partner. Medical causes that lead to disorders are associated with conditions causing fatigue or weakness, hyperprolactinaemia, hypothyroidism, atrophic vaginitis, bilateral ovarianectomy in young women and psychiatric disorders (eg anxiety, depression). It is important to take drugs such as selective inhibitors of serotonin, beta-adrenoblockers and hormones. Oral estrogens and oral contraceptives increase the level of steroid-binding a-globulin (SHBG) and reduce the number of free androgens available for binding to tissue receptors. Antiandrogens (eg, spironolactone and GnRH agonists) can reduce sexual desire and sexual arousal.

[9], [10], [11], [12], [13], [14], [15], [16]

Classification of sexual disorders in women

There are the following main categories of sexual disorders in women: violation of sexual desire / interest, disorders of sexual arousal, violation of orgasm. Infringements are diagnosed when the symptoms of the disease lead to stress. Many women are not concerned about the decline or absence of sexual desire, interest, arousal or orgasm. Almost all women with sexual dysfunction have more than one disorder. For example, chronic dyspareunia often leads to violations of sexual desire / interest and arousal; a decrease in genital arousal makes sex less pleasant and even painful, reducing the likelihood of developing orgasm and reducing libido. However, dyspareunia due to decreased production of lubricant in the vagina can occur as an isolated symptom in women with a high level of sexual desire / interest and subjective activation.

Sexual disorders in women can be congenital and acquired; defined for a specific situation and general; moderate or severe, based on the degree of suffering and distress in the patient. These violations are likely to be determined in women with heterosexual and homosexual relationships. There is less knowledge of homosexual relationships, but for some women these disorders can be a manifestation of a transition to another sexual orientation.

Violation of sexual desire / interest - the lack or reduction of sexual interest, desire, reduction of sexual thoughts, fantasies and lack of a sensitive desire. Motivation for initial sexual arousal is insufficient or absent. Violation of sexual desire is associated with the age of the woman, the circumstances of life and the duration of the relationship.

Sexual arousal disorders can be categorized as subjective, combined, or genital. All definitions are clinically based on the woman's different understanding of her sexual reaction to stimulation. Violations of sexual arousal are subjective activation in response to any type of sexual arousal (for example, kissing, dancing, watching erotic videos, stimulating the sex organs). In response, there is a lack of response or reaction is reduced, but the woman is aware of normal sexual arousal. With combined disorders of sexual arousal, subjective activation of excitation in response to any type of stimulation is absent or decreased and women do not talk about it, because they do not realize this. In disorders of genital excitation, subjective excitation in response to extragenital stimulation (for example, erotic video) is normal; but subjective excitement, understanding of sexual tension and sexual feelings in response to genital stimulation (including sexual contact) are absent or reduced. Violations of genital arousal are typical for postmenopausal women and are often described as sexual monotony. Laboratory studies confirm a decrease in genital arousal in response to sexual stimulation in some women; in other women, the sexual sensitivity of blood-filled tissues decreases.

Violation of an orgasm is characterized by a lack of orgasm, a decrease in its intensity, or an orgasm is noticeably late in response to excitation, despite high levels of subjective excitation.

[17], [18], [19], [20], [21], [22], [23], [24]

Diagnosis of sexual disorders in women

The diagnosis of sexual disorders and the identification of their causes are made on the basis of a history of the disease and general examination. It is ideal to study the anamnesis of both partners (separately or together); First they interview a woman and find out her problems. Distressed moments (for example, past negative sexual experience, negative sexual image), revealed at the first visit, can be more fully determined at subsequent visits. General examination is important for determining the causes of dyspareunia; The technique of inspection may differ slightly from the tactics usually used in gynecological practice. The explanation to the patient of how the examination will be conducted helps her to relax. Explaining to her that she should sit in a chair and that her genitals will be examined in the mirrors during the examination, calms the patient and causes her to feel the control of the situation.

Investigation of vaginal discharge smears, Gram staining, culture on media or DNA detection using the probe are performed for the diagnosis of gonorrhea and chlamydia. Given the survey data, you can diagnose: vulvitis, vaginitis or inflammatory process of the pelvic organs.

Levels of sex hormones are rarely determined, although a decrease in levels of estrogens and testosterone may be important in the development of sexual disorders. An exception is the measurement of testosterone using well-established techniques for control during testosterone therapy.

Components of a sexual anamnesis for assessing sexual disorders in women

Sphere	Specific elements
History of the disease (history of life and the history of the present disease)	General health (including physical health and mood), use of drugs (drugs), the presence of pregnancies in the anamnesis, than the pregnancies ended; Sexually Transmitted Diseases, Contraception, Safe Sex
Mutual relations of partners	Emotional intimacy, trust, respect, attractiveness, sociability, loyalty; anger, hostility, resentment; sexual orientation
Current sexual context	Sexual dysfunction in the partner that occurs in the hours before sexual activity attempts, whether this sexual activity is inadequate to sexual arousal; unsatisfactory sexual relations, disagreement with the partner about the methods of sexual contacts, restriction of confidentiality
Effective trigger mechanisms of sexual desire and arousal	Books, video films, meetings, pressing partners during the dance, music; physical or non-physical, genital or non-sexual stimulation
Mechanisms of inhibition of sexual arousal	Neuropsychiatric agitation; negative past sexual experience; low sexual self-esteem; fears about the consequences of contact, including loss of control over the situation, unwanted pregnancy or infertility; voltage; fatigue; depression
Orgasm	Presence or absence; concern about the lack of orgasm or not; differences in sexual reaction with a partner, the appearance of orgasm with masturbation
The result of sexual contact	Emotional and physical satisfaction or dissatisfaction
Localization of dyspareunia	Superficial (introroital) or deep (vaginal)
Moments of dyspareunia	During partial or complete, deep introduction of the penis, with frictions, with ejaculation or subsequent urination after intercourse
Image (self-assessment)	Self-confidence, your body, sexual organs, sexual competence and desire
History of the disease	Relations with fans and siblings; injuries; loss of a loved one; emotional, physical or sexual abuse; violation of the expression of emotions as a result of psychological trauma in childhood; cultural or religious restrictions
Past Sexual Experience	Desirable sex, forced, abusive or combination; pleasant and positive sexual practice, self-excitation
Personal factors	Ability to trust, self-control; suppression of anger, causing a decrease in sexual emotions; sense of control, unreasonably inflated desires, goals

[25], [26], [27], [28], [29], [30], [31]

Treatment of sexual disorders in women

Treatment is carried out in accordance with the type of disorders and their causes. With 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 appointment of selective serotonin inhibitors can lead to the development of some forms of sexual disorders, they can be replaced with antidepressants that have less adverse effects on sexual function. You can recommend the following drugs: bupropion, moclobemide, mirtazapine, venlafaxine. For empirical use, phosphodiesterase inhibitors can be recommended: sildenafil, tadalafil, vardenafil, but the efficacy of these drugs has not been proven.

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

If there are factors in the relations between partners that limit trust, respect, attractiveness and violate emotional intimacy, then such a pair recommends a survey of specialists. Emotional proximity is the main condition for the emergence of sexual reaction in women, and therefore it must be developed with professional help or without it. Patients can be helped by information on sufficient and adequate incentives; women should remind their partners about the need for emotional, physical, sexual and genital stimulation. Recommendations for the use of stronger erotic stimuli and fantasies can help to eliminate attention disturbance; practical recommendations for the preservation of secrecy and a sense of security can help with fear of unwanted pregnancy or sexually transmitted diseases, i.e. Of what are inhibitors of sexual arousal. If patients have psychological factors of sexual abuse, psychotherapy may be required, although a simple understanding of the importance of these factors may be sufficient for women to change their attitudes and behavior. Hormonal disorders require treatment. For example, active estrogens are used to treat atrophic vulvovaginitis and bromocriptine for the treatment of hyperprolactinaemia. The benefits and risk of additional treatment with testosterone are in the research stage. In the absence of interpersonal, contextual and deeply personal factors, additional examinations (for example, with oral methyltestosterone 1.5 mg once daily or transdermal testosterone 300 μg daily) by some clinical physicians of a group of patients with both sexual disorders and endocrine pathology . Patients with the following endocrine pathology leading to sexual disorders are subject to examination: women in the postmenopausal period who undergo estrogen replacement therapy; women 40-50 years old, who have a decrease in the level of androgens in the adrenal glands; women in whom sexual dysfunction is associated with surgical or medicamentally induced menopause; patients with impaired adrenal and pituitary functions. Careful continuation of the examination is of great importance. In Europe, the synthetic steroid tibolone is widely used. It has a specific effect on the receptors of estrogens, progestogen, shows androgenic activity and increases sexual excitability and vaginal secretion. In low doses, it does not stimulate the endometrium, increase the mass of bone tissue and does not have an estrogenic effect on lipids and lipoproteins. The risk of developing breast cancer when taking tibolone in the US is being studied.

It may be recommended to replace the drug (eg, transdermal estrogen for oral or oral contraceptives or oral contraceptives for barrier methods).

Sexual arousal disorders

With 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). In the absence of effect in the treatment with estrogens, phosphodiesterase inhibitors are used, but this only helps patients with reduced vaginal secretion. Another method of treatment is the appointment of clitoral applications with a 2% ointment of testosterone (0.2 ml of solution on vaseline, prepared in a pharmacy).

Violation of orgasm

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