Definitions

Arousal

Definitions of sexual arousal have in the past focused solely on the physiologic aspect of genital arousal, i. e. genital vasocongestion, lubrication, tingling, as well as erection of the nipples and flushing of the skin, as introduced by the largely phenomenologic and objective descriptions by Dickinson, Kinsey, and Masters and Johnson.

However, in the clinical setting, some women very often relate arousal to the subjective feeling of being “turned on” more than the physiologic response, including vaginal lubrication, genital tingling, and warmth. As such, there is a discrepancy between what has been defined as sexual arousal in many studies and what women may perceive as sexual arousal. In the clinical setting women with decreased lubrication will typically complain of vaginal dryness or discomfort with intercourse and, when referring to a lack of arousal, the complaints will more likely be about the lack of subjective excitement in her mind. This discrepancy was emphasized in the Second International Consultation on Sexual Medicine (2003), which suggested a theoretic model including the genital response as well as the subjective response. Studies are being conducted to provide more empirical evidence for the definitions proposed.

Arousal disorder

Definitions of female sexual arousal disorder (FSAD) have undergone significant changes. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) female sexual arousal disorder was defined as: “Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response to sexual excitement. The disturbance causes marked distress or interpersonal difficulty. The sexual dysfunction is not better accounted for by another AXIS I disorder (except another sexual dysfunction) and is not due to the direct physiological effects of substance abuse or a general medical condition”.

The consensus conference 2000 defined female sexual arousal disorder as “the persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress, which may be expressed as lack of subjective excitement, or genital (lubrication I swelling) or other somatic responses”.

The Second International Consultation on Sexual Medicine (2003) made considerable changes in the definition of female sexual arousal disorder based on the observation that subjective arousal does not always correlate strongly with genital congestion. This resulted in a subdivision of female sexual arousal disorder into three categories: subjective, genital, and combined.

Subjective arousal disorder

“Absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation. Vaginal lubrication or other signs of physical response still occur”.

Genital sexual arousal disorder

“Complaints of absent or impaired genital sexual arousal. Self-report may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. Subjective sexual excitement still occurs from non-genital sexual stimuli”.

Combined genital and subjective arousal disorder “Absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation as well as complaints of absent or impaired genital sexual arousal (vulval swelling, lubrication)”.

Persistent sexual arousal disorder

With the 2003 consensus a new category of female arousal disorder was described and recommended for inclusion in the diagnostic system, namely persistent sexual arousal disorder (PSAD). It is defined as: “Spontaneous, intrusive and unwanted genital arousal (e.g. tingling, throbbing, pulsating) in the absence of sexual interest and desire. Any awareness of subjective arousal is typically but not invariably unpleasant. The arousal is unrelieved by one ore more orgasms, and the feelings of arousal persist for hours or days”, (PSAD will be discussed at the end of this site.)

For all definitions, female sexual arousal disorder can be divided into primary arousal problems, meaning that the woman has never experienced sufficient arousal despite sufficient desire and sexual stimulation, and secondary arousal disorder, in which the woman experiences decreased arousal but has previously been able to become aroused. The secondary arousal disorder can be generalized (it appears in all sexual situations) or situational (it only appears in some situations).

It is considered to be a disorder only if the woman is distressed by the problem, and assessment of relative distress is recommended as a part of the diagnosis. Furthermore, the degree of subjective distress may have implications for treatment motivation and, in the end, treatment outcome.

At the present time, the DSM-IV or the first consensus report are the most widely accepted classifications. The revised definitions remain recommendations as they have not been included into the DSM or World Health Organization’s International Classification of Disease (ICD-10). There is an ongoing evolvement of definitions of sexual disorders based on research and clinical data. The revised definitions provide greater specificity and refinement of the variety of sexual arousal disorders. These more specific and detailed diagnoses may be included in future diagnostic systems. Clinical studies are being conducted to obtain more empirical evidence for the definitions proposed. In the meantime, it is hoped that the new definitions will be helpful in the clinical diagnosis and treatment of arousal disorders.

Prevalence

The prevalence of female sexual arousal disorder is based on the conventional definitions of arousal, namely genital measures — mostly lubrication. As such, most epidemiologic research has focused on the genital arousal disorder. Furthermore, many epidemiologic investigations have not included the distress factor in their investigations, making it difficult to give accurate estimates on how large the problem really is. The epidemiologic investigations of the prevalence of arousal problems show considerable differences between the different investigations, ranging overall from 6% up to 49% of the women who were asked, with a majority of prevalence ranging between 13% and 24%. Two studies have demonstrated that the prevalence of female sexual arousal disorder is increased with increasing age, peaking after the age of 50 years, In a Swedish study it was found that, in women aged 50 or more, approximately 25% complained of lubrication problems, while 6-11% of women aged 18 — 49 experienced lubrication problems.

Pathophysiology

Biologic factors

As described in site, lubrication and genital congestion rely on intact nerve mediation and vascular function, as well as the hormonal milieu, which is crucial for a moistened vagina. Therefore, disruptions to any of these parameters may result in impaired genital arousal response.

An estrogenized milieu is strongly correlated with the ability to lubricate, and genital arousal disorders are therefore correlated to the menopausal transition. Furthermore, genital arousal disorder may be associated with medical diseases (for example, neurologic conditions affecting the autonomic nervous system, diabetes mellitus with neuropathy and vascular complications) and medical therapies (for example, surgical procedures or radiation damaging tissue structures and autonomic nerves and vessels). Recurrent urinary tract infections also affect the arousal response as well as recurrent vaginal infections, which create irritation, pain, and decreased lubrication.

Psychosocial and context-dependent factors

Many factors may influence a woman’s arousal, both genital and subjective:

  • • Lack of desire.
  • • Sexual inhibition.
  • • Lack of awareness of genital responses.
  • • Anxiety fear, lack of energy.
  • • Lack of intimacy or sufficient sexual stimulation.
  • • Partner’s sexual problems.
  • • Contextual factor, which may be past, current, or medical (for example, life situation, negative upbringing, losses, trauma, risk of unwanted pregnancy or of STI, lack of privacy, the situation is inappropriate, time of day, interpersonal problems, substance abuse).

Clinical Approach

Loss of arousal is multifactorial and might be caused by biologic, motivational, relational, and cognitive factors. A thorough medical and sexologic history and a medical examination is therefore of great importance when evaluating the women. Focus should be on biologic, sexologic, psychologic, and relational factors, as well as predisposing, precipitating, and maintaining factors. Finally, the degree of distress should be evaluated. Table Questions of importance when evaluating women with sexual arousal disorder contains suggestions for questions that can be helpful in initiating assessment of the problem.

Table Questions of importance when evaluating women with sexual arousal disorder

1 Can you describe your problem in your own words?

 — When she describes the problems ask clarifying question in order to find out whether it is the primary problem or secondary to other sexual disorders. Arousal disorders are very often secondary to desire disorders.

2 Has the problem always been there?

 — If yes, checkpsychosexual and relational factors first and awareness/lack of awareness of signs of genital arousal.

— If not, ask when it appeared and what — in the patient’s opinion — might have triggered the problem. Did it come slowly or suddenly?

3 Are you sexually active? With or without a partner?

 — If she is regularly sexually active, is she pleased with the activity? Are there differences in her response?

— Does she enjoy intercourse?

— Does she masturbate? If yes, is the problem also present when she masturbates?

4 Is the problem limited to your partner and/or to a special context or situation ?

 — If yes, check relational and contextual factors.

— If no, and the problem is generalized, check personal psychosexual factors and biologicf actors.

5 Does your partner have a sexual problem?

 — For example, erectile dysfunction, desire problem, orgasm problem, or rapid or delayed ejaculation? Be aware that she can be the “carrier” of the partner’s sexual dysfunction.

6 Whatdoesthe problem mean to you?

 — To estimate the degree of distress. Does it lead to frustration, guilt, shame or other feelings?

7 Whatdoesthe problem mean to your partner?

 — What does it mean for the relationship?

Sexologic history

What type of arousal disorder does she have?

• Is she mentally sexual excited from, for example:

— reading, viewing, hearing erotica?

— stimulating the partner?

— receiving sexual stimulation to non-genital and genital areas?

— deliberate sexual fantasy or recall of sexual memories?

• Direct awareness of genital congestion:

— tingling, pulsing, throbbing in response to the above stimuli, vaginal lubrication?

• Indirect evidence of genital congestion:

— progressively intense sexual sensation from direct massaging of vulval structures with her or partner’s fingers, partner’s body, oral stimulation, dildo, penile-vulval contact?

• Is there co-morbidity with other sexual disorders?

— Is there a desire problem, a pain problem, or an orgasm problem?

— What came first? Is the arousal problem secondary to other sexual problems or the primary problem?

• Is she distressed by the condition?

Psychologic and relational history

• Cognitive and affective evaluation:

— Clarify her thoughts: is she feeling distracted, feeling tired, feeling sexually substandard, worried that the outcome would be negative, unsafe situation (pregnancy, STIs), feeling used, not being considered, unhappy about their sexual intimacy/practices?

— Clarify her emotions: is there sadness, embarrassment, guilt, awkwardness, displeasure?

• Relational evaluation:

— Does the partner have a sexual dysfunction? (erectile dysfunction, low desire, rapid or delayed ejaculation or orgasmic disorders)

— Is she attracted to her partner? Are there relational problems? (e.g. Is she disturbed by inadequacy of his personal hygiene, is there conflict, aggressiveness, abuse, or limited privacy?)

Medical and gynecologic history

• Menstrual cycle, menopause (natural or surgical), pregnancy/breastfeeding:

— related to menstrual irregularities, breastfeeding, the menopause, or oral contraceptives?

— gynecologic and obstetric history?

• Somatic problems: Does she have any disease known to predispose to lubrication problems?

— diabetes, recurrent lower urinary tract infections, recurrent vaginal infections, neurologic diseases (multiple sclerosis, neuropathies, Sjogren’s syndrome)?

• Iatrogenic causes:

— surgical procedures in the genital area, the pelvis or lower abdomen with damage of the genitalia as well as vasculature or nerves, for example, hysterectomy, pelvic cancer, episiotomy/ rraphy with retracted/painful scarring?

— radiation therapy of the pelvic/genital area?

• Psychiatric diseases that may influence the arousal response:

— phobias, anxiety, depression?

• Medication that may affect lubrication and/or desire? ()

Physical examination

A general physical examination is highly recommended and can be directed by the medical history and its outcome. However, a gynecologic examination is always recommended. For women with genital arousal disorder, the information will be limited, as the genitalia are in the non-aroused state, but vaginal dystrophy suggesting estrogen deficiency or rarer conditions can be identified, as described below. For women with subjective or combined arousal disorders, there most likely will be no abnormality. Nevertheless a “normal” examination can be highly informative for the woman.

The gynecologic examination should focus on:

• Inspection of vulvar anatomy. Are there any changes or abnormalities?

— For example, signs of inflammation, poor outcome of pelvic or perineal surgery, signs of lichen sclerosus or lichen planus, as well as involution or conglutination of the clitoris?

— Skin colour and quality. Is the skin thin and dry, or pink, supple and elastic? Are there fissures, eczema, papules, pustules, vesicles, or ulcerations?

— Does the vaginal mucosa appear estrogenized and moistened or does it appear atrophic with inflammation, fissures, erosions, and ulcers?

— Does the speculum examination show signs of atrophy (e.g. petechiae or atrophy discharge)?

• Palpation:

— Signs of myogenic or referred pain, or associated urogenital and rectal pain? If the woman experiences pain, the pain map should be identified as described in Chapter 25. Pain is a strong reflex inhibitor of lubrication and therefore an important point to investigate.

— Pelvic floor trophism, muscular tone and strength?

— Scarring?

• Sampling:

— Determination of pH, which gives indirect evidence of tissue estrogen level and related vaginal ecosystems.

— Sampling and culture of discharge when infection is suspected.

Laboratory tests

Laboratory tests may be directed by relevant symptoms or findings in the general medical assessment. If low desire is co-morbid or suspected as the reason for low arousal (genital as well as subjective or combined), measuring testosterone status is recommended (including free testosterone).

Plasma levels of estrogens can give information on the endocrine component of arousal disorder and the menopausal status. However, plasma levels are not sufficient indicators of the experienced degree of vaginal dryness, Prolactin levels should be checked if there is co-morbidity with marked oligomenorrhea or amenorrhea, and/or if bilateral breast milky discharge is present (not related to lactation). If the clinical history or objective findings suggest hypothyroidism, TSH should be evaluated.

Investigational tests

Vaginal plethysmography may be used to quantify the hemodynamic changes with female sexual arousal. The everyday use of the method in clinical work is questionable. This is due to the lack of a true baseline, the limited number of studies comparing women with disorders and functional women, and the difficulties in drawing conclusions on findings from one measurement. Furthermore, several studies have not found a correlation between the subjective report of arousal and the objective measured by the method. As such the method is at the present time mostly investigational.

Duplex doppler ultrasound can be used to measure changes in the clitoral, vaginal, labial, and ure-thral blood flow; for example, it can be measured before and after sexual stimulation. Use of this method as a standard part of the evaluation is uncertain as larger studies still need to be conducted to identify cut-off values, normative data, correlation between disorder and objective parameters, as well as correlation between subjective and objective data. In the future it may have a role in diagnosis, for example, in women with atherosclerotic changes leading to genital arousal problems.

Principles of Treatment of Sexual Arousal Disorder

If possible, treatment should be based on the etiologic diagnosis directed toward biologic, psychologic/relational or combined factors. In the clinical situation, arousal disorder is often combined with desire and/or orgasmic disorders, and a more integrative treatment will then focus on the other disorders that may lead to arousal disorder. Furthermore, different treatment modalities should be chosen depending upon the type of arousal disorder.

Women with subjective or combined arousal disorder may benefit from a treatment focusing on awareness of genital responses and becoming subjectively aroused. The techniques that can be used are cognitive-behavioral techniques and/or traditional sex-therapy with sensate focus or psychodynamic treatment. Women with genital arousal disorder may benefit from pharmacologic treatment enhancing genital congestion and lubrication.

Non-pharmacologic treatment of arousal disorder

There are no published outcome studies describing psychologic treatment of arousal disorders in women.

Pharmacologic treatment of arousal disorder

Pharmacologic treatment can be hormonal and non-hormonal.

Hormonal treatment

For women who are estrogen-deficient, several studies have shown that local or systemic estrogens may improve vaginal lubrication and decrease vaginal irritation and dryness.

A Cochrane review showed that local estrogen in women with vaginal atrophy had a positive effect on dryness and dyspareunia, no matter how the local estrogens were applied (creams, tablets, vaginal ring, or pessaries) compared to placebo when given regularly and continuously.

Systemic treatment with estrogens without or with progesterones has been shown to decrease vaginal dryness, irritation, and pain compared to placebo in surgical and natural postmenopausal women, although a large interpatient variability has been observed. As discussed in site, the latest knowledge on adverse events related to long-term hormone therapy (HT) after the menopause has changed the recommendations on how and for how long HT should be used. It is therefore important to individualize recommendations and treatment of women with arousal problems who may benefit from HT. If HT is recommended for sexual problems and there is no effect, it should also be considered whether it should be continued.

Tibolone is a synthetic steroid with estrogen, progesterone, and some androgenic effect. In one large study it has been demonstrated to improve lubrication, but it is doubtful whether the effect on lubrication is better than estrogen substitution. However, as tibolone has a weak androgenic effect, it may be a choice for women with decreased desire and arousal, although larger-scale studies are still needed.

Non-hormonal treatment

At the time of writing (January 2006) there are no approved non-hormonal pharmacologic treatments for arousal disorders.

The success of vasoactive agents (PDE-5 inhibitors) in the treatment of male sexual arousal dysfunction (ED) has encouraged the search for vasoactive agents that enhance women’s genital congestion and vaginal lubrication. However, the results until today are limited and are mainly on postmenopausal women. The explanation is most likely that there is a lack of recognition of the need to distinguish between genital arousal and subjective arousal; women may have impaired genital congestion that can be reversed by drugs, but they not necessarily identify this as decreased arousal.

Sildenafil has been investigated in several studies for treatment of female sexual problems. In a few studies of women identified with arousal disorder, benefit has been shown; however, in women with hypoactive desire disorder there is limited effect. As such, sildenafil (and other phosphodiesterase inhibitors) may be beneficial in specific groups of women with genital arousal disorder who recognize the effect on vasocongestion.

Local lubricants applied intravaginally can be useful for women with genital arousal disorder and are often used in the clinical setting. Oil-based lubricants should not be used with latex products that are being used for birth control (such as the male condom) or for safer sex (such as a dental dam or male condom). The latex will be destroyed by oil-based products and will not be effective.

The EROS-CTD device (clitoral therapy device) has been approved by the FDA as therapy for FSD. The EROS-CTD is a small, battery-powered device designed to enhance clitoral engorgement and increase blood flow to the clitoris and vascular response. Only a few, small, non-controlled studies exist on the effect and no data exist on the long-term effect.

Conclusion

Arousal disorders with impaired arousal response can be defined as genital, subjective, or combined arousal disorder. The prevalence varies and is increased with increasing age, especially at the time of menopause. Arousal disorders are often co-morbid with desire disorder or orgasm and pain disorders. In the evaluation, a thorough sexologic history as well as medical and gynecologic history and examination should be carried out. Treatment should be based on type of arousal disorder and clinical findings. PDE-5 inhibitors and HT may be of benefit if there is genital arousal disorder. Women with subjective or combined arousal disorder may benefit from a treatment focusing on awareness of genital responses and becoming subjectively aroused. The techniques that canbe used are cognitive-behavioral techniques, traditional sex-therapy with sensate focus, or psychodynamic treatment and vaginal lubricants.

Persistent Sexual Arousal Disorder

PSAD is a poorly documented condition characterized by persistent genital arousal in the absence of conscious feeling of sexual desire, which has recently been included as a provisional diagnosis. The literature on persistent sexual arousal disorder is limited and is mainly based on case reports.

Prevalence

The prevalence of persistent sexual arousal disorder is unknown.

Pathophysiology

To date the pathophysiology is unknown and no obvious hormonal, vascular, neurologic, or psychologic causes have been identified. However, the major etiologic hypothesis are: (1) central neurologic changes; (2) peripheral neurologic changes; (3) vascular changes; (4) mechanical pressure against genital structures; (5) medication-induced changes; (6) psychologic changes, or combinations of all five.

Clinical approach

As very little is known about the condition, it is difficult to give clear guidelines for the clinical approach. As women may be very embarrassed by the condition, it is important that the physician is aware of it and we recommend a medical and gynecologic history and examination, as described above for decreased arousal disorder. Many women may benefit from realizing that they are not alone with the symptoms and can be referred to a website (www.twshf.org).

If the condition is caused by abnormal clitoral blood flow, a duplex ultrasound may help identifying this.

Principle of treatment

As no single cause for persistent sexual arousal disorder has been identified and there is a lack of substantial experience with treatment, no single treatment can be recommended.

Conclusion

PSAD is a poorly documented condition with unknown prevalence and etiology. No accepted treatment can be recommended. In the clinical evaluation it is important to be aware of the condition, to perform a thorough medical and gynecologic examination, to help the woman to feel that she is not alone with this condition.

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