Female Sexual Problems

K. B. Stefanovic, M.D., Ph.D
Virginia Mason Medical Center (Seattle, WA)

 

Introduction

Sexual problems are more common in women than men. According to the National Health and Social Life survey, 42% of women vs. 31% of men experience some kind of sexual difficulties during their adult lives. In both genders, sexual problems can occur at any age. However, probability of having difficulties in male sexual performance increases with age and perseverance of comorbidities. In contrast, majority of women notice change in their sexual capacity at a young age, many years before approaching menopause. Another striking difference is a unidimensional manifestation of sexual problems in men (ex: erectile dysfunction or premature ejaculation) vs. multidimensional coexistence of dysfunctional sexual domains in female (ex: low or no sexual arousal and pain during intercourse and low or no orgasmic pleasure.)

 

Causes

Sexual behavior is extremely complex and always multifactorial. It is influenced by genetic, physiological stages, emotions, relationship, personality, religious, culture and previous experience. It can be affected by medications, alcohol, drugs, physical and psychological health. Of note, availability and attractions of sexual partners play a significant role at any stage of our sexual cycle. Furthermore, sexual problems of one partner inevitably create sexual struggle vs. sexual adjustment of another partner.

Evaluation

The evaluation of female sexual problems starts with taking a good sexual history. The best history can be taken with straightforward inquiries while the patient feels comfortable, safe, accepted and unjudged by an investigator. Some patients prefer if the assessment starts with the written questionnaire that can help pinpoint sexual problems at the very beginning.

A physical examination, including detailed gynecological exam, is an essential part of the evaluation and should not be skipped under any circumstances. The skilled investigator can gather tremendously important information by conducting systematic evaluation of genital apparatus.

Laboratory testing is guided by history and physical examination, but in the majority of patients included is the comprehensive hormonal panel completed at specialty laboratories.

 

Treatment Options

Treatment begins with an education usually when evaluation is completed and diagnosis is established. Frequently, reassurance and education alone improve positive attitude and improve capacity for sexual enjoyment. There are a number of proven educational techniques effective in improving sexual thoughts, fantasies, communication and enhancing sexual relationship with sexual partner.

Lifestyle changes may have a great impact. These include a healthful diet, limited alcohol intake, smoking cessation, aerobic exercise, weight control, pelvic floor muscle exercises, relaxation techniques, meditation and improvement of self image.

Besides education, attitude and lifestyle changes, the treatment may include non-hormonal, hormonal medications, physical devices or surgery. Non-hormonal treatments include knowledgeable use of vaginal lubricants, moisturizers, Zestra oil or Argin Max. Change of contraceptive methods or SSRIs also may improve sexual initiation and response. Hormone supplementation can be helpful for specific subset of patients. This may include the use of DHEA, estrogen, progesterone and/or testosterone. Recent trends are toward the use of transdermal delivery products. Also, use of bio-identical hormones theoretically offers benefits over use of non-identical sexual hormones. Some other tools are helpful adjunct in improving female sexual interest and response. These devices range from vaginal weights to vaginal dilators and vibrators. Patients who can afford seeing licensed sexual therapists can further optimize personal, relationship or marital sexually related issues.

Surgery has a limited role in the treatment of very specific conditions such as refractory vestibulitis, vaginal strictures, clitoral neurinoma and clitoral phymosis.

 

Future Prospective

Currently, there is no single FDA approved treatment option for female sexual problems. Several new medications are in investigational clinical trials including Tibolone, Apomorphone, Passion and testosterone patch. Hopefully, effective and safe new products will be available for the treatment of highly prevalent women’s sexual problems in the near future.

 

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