Ashley Bateman PGY 3

 Define the stages of female sexual response cycle.  Identify and define the types of female sexual dysfunction (FSD)  Understanding the basics of diagnosing FSD

 Rate varies according to studies ◦ About 40 percent (19-50%) of women have sexual problems ◦ Approximately 12 percent of women have a sexual problem associated with distress. ◦ Single/divorced women higher rate ~ 35 % FSD than married women ~29% FSD ◦ Education College lower rate FSD 24% than High School with a higher rate 42% FSD  Prevalence has been found to be highest among middle aged women

 Relationships and sociocultural factors  Physiological and psychological problems  A history of physical or sexual abuse  Menopause ◦ Consistently associated with dyspareunia.  Sexual problems increase with aging  Distressing sexual problems peak in midlife women.

 Hormonal contraception unlikely to interfere with female sexual function.  Depression and anxiety: ◦ Strongly associated with FSD  Other associated medical conditions associated with FSD ◦ May Include cancer, urinary incontinence, vaginal atrophy, end stage renal disease, alcohol or other substance abuse, anemia, thyroid disorders and diabetes.  Medications associated with FSD ◦ Anti- depressants especially SSRIs ◦ Beta blockers ◦ Antipsychotics

 Understanding the female sexual response cycle is important to the evaluation and treatment of FSD  Four Stages ◦ Desire ◦ Arousal ◦ Orgasm ◦ Resolution

 A patient’s libido.  Desire to have sexual activity ◦ Includes sexual thoughts, images and wishes

 A patient’s excitement.  Arousal ◦ Sense of sexual pleasure accompanied by physiologic changes  Including genital vasocongestion and increases in heart rate, blood pressure, and respiratory rate

 Patient’s peaking of sexual pleasure and release of sexual tension, with rhythmic contractions of the perineal muscles and reproductive organs

 Patient’s muscular relaxation and a sense of general well-being following sexual activity

 Sexual dysfunction includes dysfunction in: ◦ Desire ◦ Arousal ◦ Orgasm ◦ Sex pain disorders  dyspareunia and vaginismus

 1. Hypoactive Sexual Desire Disorder  2. Sexual Arousal Disorder  3. Orgasmic Disorder

 Hypoactive sexual desire disorder (HSDD) ◦ Deficient (or absent) sexual fantasies and desire for sexual activity  Most Common Cause of FSD  Cause: ◦ Some postulations as to association with low testosterone

 Female sexual arousal disorder ◦ Inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement  This is the female equivalent of impotence  Cause ◦ Usually psychological ◦ Some postulations as to association with deficiency of estrogen

 Female orgasmic disorder ◦ Delay in, or absence of, orgasm following a normal sexual excitement phase  In women, orgasm is a learned, not an automatic response  5-15% of women never have an orgasm ◦ Anorgasmia  Cause: ◦ Usually the result of sexual inexperience, performance anxiety or past experiences that have led to inhibition of the sexual response ◦ Hormones not implicated

 Dyspareunia  Vaginismus

 Dyspareunia ◦ Genital pain that is associated with sexual intercourse  Superficial ◦ Occurs with attempted penetration ◦ Usually due to anatomic or irritating condition.  Vaginal ◦ Related to pain from friction

 Vaginismus ◦ Involuntary contraction of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with penis, finger, tampon, or speculum is attempted  Often related to sexual phobias or past abuse  Can be complete or situational

 Define the dysfunction  Presence of more than one dysfunction should be ascertained  Identifies causative medical or gynecologic conditions  Elicit psychosocial information

 Ask routine gynecological health questions ◦ Including contraception and safe sex practices  Ask open ended questions ◦ e.g. Do you have any sexual concerns?  Menopausal women should be asked specifically about vaginal dryness and dyspareunia

Four Stages Female Sexual Response Cycle: ◦ Desire ◦ Arousal ◦ Orgasm ◦ Resolution Three Cycle Specific Disorders: 1. Hypoactive Sexual Desire Disorder 2. Sexual Arousal Disorder 3. Orgasmic Disorder  Pain Specific Disorders: ◦ Dyspareunia ◦ Vaginismus  An accurate diagnosis of FSD:  Thorough medical and sexual history including;  Issues of sexual preference, domestic violence and fears of pregnancy, human immunodeficiency virus and sexually transmitted disease.

 Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res 1998;10(suppl 2):S  American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, American Psychiatric Association, Arlington, VA 2000  Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999; 281:537.  Phillips N. Female sexual dysfunction: evaluation and treatment. American Family Physician

Basson proposed a different theory for the female sexual response cycle, suggesting that the sexual response is driven by the desire to enhance intimacy.(From Basson R: Human sex- response cycles. J Sex Marital Ther 2001;27:33-43.)