The classification of sexual dysfunction follows the pattern of sexual response and a simplified version is given in Table Common sexual dysfunctions. It is of paramount importance to note that for a disorder to be diagnosed the mere presence of a condition is not enough; it must also cause personal distress. For example, we cannot diagnose hypoactive sexual desire in a woman who reports no sexual fantasies but is not troubled by it. Each of the diagnoses in Table Common sexual dysfunctions is subclassified as (1) life-long versus acquired; (2) generalized versus situational; and (3) etiologic/organic, psychogenic, mixed or unknown.

Table Common sexual dysfunctions

Sexual desire disorders
hypoactive sexual desire
sexual aversion/avoidance
Sexual arousal disorders
Orgasmic disorders
Sexual pain disorders
dyspareunia
vaginismus

Problems of sexual response

Any part of the female sexual response can be affected. It is useful to have some working definitions when attempting to evaluate and help women.

Sexual desire disorders

Low sexual desire If a woman can generate sexual fantasies and daydreams or if she masturbates, then by definition her sexual desire is intact. If, however, there is a lack of thoughts about sex or masturbation, or a lack of responsiveness to her partner’s initiation, then sexual desire is said to be impaired. An estimated 17-30% (depending on the population studied) of women have a hypoactive sexual desire disorder. Often, women presenting with low sexual desire disclose that their partner’s desire is higher than their own. The presenting problem then is discrepant sexual desire. However, sexual activity may still be present even if sexual desire is low. For example, many women are sexually active — but only to please their partner or to preserve the relationship. It has been reported that for 6% of women sex is an obligation rather than an enjoyable activity. Such women are defined as having a low proactivity (not seeking sexual behavior) but an intact receptivity (ability to respond to sexual advances). The presence of desire depends on several factors: biological drive, good sexual experiences, the availability of a partner and a good relationship in non-sexual areas. Damage to any of these factors may result in decreased desire. Other factors that can suppress sexual desire are depressants of the central nervous system, abstinence from sex for a prolonged period of time, major illness or an affected body image (mastectomy, ileostomy, colostomy, hysterectomy orvulvectomy).

Inhibition of desire may be a defensive way of protecting against unconscious fear of sex or pregnancy. Loss of desire may also be an expression of hostility or the sign of a deteriorating relationship. It is important to establish a baseline of sexual interest before the disorder began because sexual activity varies among people (one study found that 8% of couples have intercourse less than once a month). The diagnosis should not be made unless the lack of desire is a source of distress to the patient.

Sexual aversion disorders Sexual aversion disorders are defined as a persistent or recurrent extreme aversion to, and avoidance of, all or almost all genital sexual contact with a sexual partner. This condition goes beyond the simple avoidance of sexual activity to include sexual panic states, sexual aversion and sexual phobias. Some of these patients may have a normal sex drive and sexual fantasies, and be able to enjoy autoerotic activity, but when confronted with a sexual partner in a sexual situation, they may experience aversion to the partner’s touch or to contact with the partner’s genitalia or semen.

Impaired sexual excitement (arousal)

Problems with sexual excitement present as either an inadequate physiologic response to sexual stimulation (lubrication, swelling, etc.) or a lack of sense of pleasurable feeling during sexual stimulation. It is thought to present in about 20% of patients. Women who have impaired sexual arousal often have orgasm problems as well. Sexual arousal naturally fluctuates, with some women reporting greatest sexual excitement immediately after a period and others at the time of ovulation. Impairment with physiologic excitement can be recognized by the lack of genital changes in response to effective sexual stimulation. It should be noted that some women do not register that genital changes have occured when in fact they have. Changes in testosterone, estrogen, prolactin and thyroxin levels have been implicated in arousal disorders. The progestogenic effect of the progestogen-only pill, antihistamine and anti-cholinergic medications can cause a decrease in vaginal lubrication. An insufficient genital response may simply be due to inadequate sexual stimulation. The lack of pleasurable feeling during sexual stimulation is more likely to be psychologic, and numerous psychologic factors are associated with sexual inhibition (Table Summary of psychologic causes of sexual dysfunction). These conflicts may be expressed through inhibition of excitement or orgasm and are discussed in the section on Orgasmic disorders, below. However, decrease in sensitivity in erogenous areas may occur with hormonal deficiencies (Table Summary of organic and iatrogenic causes of female sexual response disorders).

Table Summary of psychologic causes of sexual dysfunction

Deteriorating relationship — anger/boredom/habituation
Depression
Lack of
trust between partners
communication with the partner about sex
sex for a prolonged period of time
knowledge about sex organs and their function
Aging
Fears of
pregnancy
intimacy/dependency/rej ection
partner’s genitals/semen
loss of control
performance failure
painful sex
Physiologic changes: transition to motherhood
Loss of fertility (i.e., early menopause)
Inhibitory factors
guilt after pleasurable experience/masturbation
religious upbringing/cultural expectations/societal restriction
trauma: forceful sex/rape/incest
belief in sexual myths, e.g., nice girls don’t initiate sex Bereavement/grief

Table Summary of organic and iatrogenic causes of female sexual response disorders

a) Organic causes Endocrine Estrogen deficiency Testosterone deficiency Diabetes
Hyperprolactinemia
Hypothyroidism
Hypopituitarism
Addison’s disease
Cushing’s disease
Neurologic
Spinal cord conditions (i.e., multiple sclerosis, trauma)
Epilepsy
Stroke
Lumbar canal stenosis
Head injury
Tumor
Substance abuse
Alcohol
Drugs
b) Iatrogenic
Surgical
Mastectomy and other disfiguring surgery, e.g., colostomy
Sympathectomy
Retroperitoneal lymphadenopathy/lymphadenectomy
Pelvic/vaginal surgery
Induced premature menopause
Surgery
Radiotherapy
Chemotherapy
Medications
Dopamine antagonists
Sedatives
Hypnotics
Antidepressants (fluoxetine, monoamine oxidase inhibitors, tricyclic antidepressants)
Anxiolytics
a-Adrenoreceptor antagonists
Combined oral contraceptives
Antiandrogens

Orgasmic disorders (anorgasmia)

Anorgasmia is an inability to achieve orgasm by masturbation or coitus and this accounts for approximately 5% of sexual disorders. A futher 15-20% report dissatisfaction with the quality of their orgasms. It can be an isolated problem with sexual desire and arousal being intact. Often, however, excitement and orgasmic disorders coexist and share the same etiology. Anorgasmia may be situational, i.e., more commonly present with the partner and not with masturbation (i.e., many women are orgasmic with manual stimulation but not during coitus). Orgasm during coitus may be achieved by the combination of manual clitoral stimulation and penile vaginal stimulation.

Primary orgasmic dysfunction exists when the woman has never experienced orgasm with any sort of stimulation. Secondary orgasmic dysfunction exists if the woman has experienced at least one orgasm regardless of circumstances or means of stimulation. According to Kinsey, the first orgasm occurs during adolescence in about 50% of women, and this proportion increases as women get older. Kinsey found that the proportion of married women over 35 years old who had never achieved orgasm by any means was only 5%. Increased orgasmic potential in women over 35 has been explained on the basis of less psychologic inhibition or greater sexual experience, or both. Orgasmic dysfunction is a common complaint. A number of psychologic, organic and iatrogenic factors areassociated with inhibited female orgasms (Tables Summary of psychologic causes of sexual dysfunction and Summary of organic and iatrogenic causes of female sexual response disorders).

Sexual pain disorders

Vaginismus is an involuntary contraction of the pelvic floor muscles and outer third of the vagina, making penetration impossible or very painful. It is usually a psychologic problem, being a phobia of vaginal penetration. For example, a phobic response may be triggered by painful sex (especially forceful sex), fear of pregnancy, or a strict religious upbringing.

Dyspareunia means genital pain during or after intercourse. The pain may be superficial, involving the vulva, the introitus and the lower third of the vagina, or deep, when it is felt near the cervix or the lower abdominal area. Vaginismus and dyspareunia are closely linked as vaginismus may be a cause of superficial pain and dyspareunia may result in protective vaginismus reflex. Common pathologic causes of painful intercourse are listed in Table Common causes of painful intercourse.

Table Common causes of painful intercourse

Superficial pain
Vulvovaginal atrophy
Episiotomy
Tight skin bridge or fissure at the fourchette
Infections
herpes
genital warts
candidiasis
trichomoniasis
bartholinitis
Dermatologic conditions
allergy/irritations
eczema
lichen sclerosus
psoriasis
Vulvovaginal surgery
Cystocele
Vestibulitis
Lack of lubrication
Deep pain
Constipation
Endometriosis
Postoperative adhesions
Pelvic inflammatory disease
Fibroids
Inflammatory bowel disease
Ovarian cysts
Cystitis
Superficial and deep pain estrogen deficiency

Vulvar vestibulitis is inflammation of the vestibular glands, which are mucous-secreting glands. These glands are arranged concentrically around the introitus between the labia minora and the hymen. Should they become inflamed, they lead to dyspareunia with penetration, pruritus and erythema. On inspection there may be erythema at the area and the vestibular glands may be raised, giving a rough (uneven) appearance. Probing with a cottonwool swab reveals an exquisite tenderness (point tenderness).

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