Female sexual dysfunction has been reported in up to 40% of women, and described as causing actual distress in approximately 12% of women.
Therefore, it is an important topic to familiarize with and screen for as a primary care physician, as many patients may not report these symptoms unless they are elicited during the history taking process of the patient encounter. Female sexual dysfunction is often multifactorial and complex; it is affected by such factors as depression and anxiety disorders, life stressors, interpersonal conflict between the couple, medication side effects, age, religious concerns, personal health, privacy issues, personal body image, substance and alcohol abuse, and hormonal influences.
In order to understand the necessary treatment options, it is important to understand the normal female sexual cycle. There are four phases:
1. Libido: the desire for sexual intimacy, through images or thoughts.
2. Arousal: the increase in heart rate, blood pressure, and respiratory rate, along with increased genital blood flow.
3. Orgasm: the peak of sexual pleasure, with rhythmic contractions of the pelvic muscles.
4. Resolution: the return to baseline with pelvic muscle relaxation.
However, there may be overlap, they may be out of sequence, absent, or a phase may even be repeated in the normal female sexual cycle. Also, many women with dysfunction are impacted in more than one phase of the cycle. Therefore, the main categories producing female sexual dysfunction consist of the lack of desire, impaired arousal, the inability to achieve orgasm, and sexual pain disorders. However, it is considered a medical disorder only when it is perceived as distressing to the patient.
Treatment is often initiated with non-pharmacologic modalities first. Medications are reserved in those who fail the following:
• Discontinuation of offending medications: Medications such as beta blockers used to treat high blood pressure, or those with depression or anxiety disorders being treated with Selective Serotonin Reuptake Inhibitors (SSRI’s) are two of the most prescribed groups of medications that may contribute to sexual dysfunction. It is important to review and discuss all medications being taken by the patient.
• Lifestyle Changes: Lack of privacy, life stressors, or personal body image may contribute to sexual dysfunction in many women. This can be alleviated by the introduction of regular exercise, relaxation techniques, support groups, yoga, or establishing scheduled “alone time” for the couple away from family and daytime responsibilities.
• Counseling: Consider in those with interpersonal conflict within the relationship, or for those with underlying depression or anxiety disorders.
• Sex Therapy: Many insurance plans cover the visit to the sex therapist, who may be a physician, psychologist, or highly trained social worker. You can find a certified sex therapist through the American Association of Sex Educators, Counselors, and Therapists at: www.aasect.org.
• Lubrication: For those experiencing vaginal dryness or pain with intercourse, over the counter lubrication jelly may be of benefit if used during intercourse.
• Devices: There is also a clitoral suction vacuum device, EROS CTDT, that is FDA approved for those with female sexual dysfunction. This is similar to the device designed for males, and allows better genital blood flow. However, it may be no more effective than other less costly devices, such as the vibrator.
If the above treatments do not yield results, and if the dysfunction is found to cause personal distress for the patient, the next step is to consider pharmacologic therapy. However, it is important that patients understand that the data on many of the hormonal treatments are limited, that there is a lack of long-term studies on hormonal methods, and that many are not approved by the United States Food and Drug Administration (FDA):
• Androgens:
1. DHEA: is found over the counter without a prescription. It is found to improve sexual satisfaction in women with adrenal insufficiency, however, no change was found in other women without this diagnosis.
2. Testosterone: Most data is on postmenopausal women, and has not been found effective in pre-menopausal women. There are two preparations that are currently the most affective: one is the topical compounded 1% cream applied at about 0.5 grams daily to the skin of the arms, legs, or abdomen. Then, there is a 300mcg patch that is applied twice a week, yet is only available in Europe at this time.
3. Potential Risks: Oral testosterone is currently limited in use due to its adverse effects on the liver and cholesterol levels. However, topical and transdermal preparations should be used with caution in those with cardiovascular disease, liver disease, a history of endometrial hyperplasia or cancer, and those with breast cancer. Also, the issue of pregnancy prevention should be addressed, as there is a risk to the developing fetus in those with androgen exposure. In addition, androgens may cause hirsutism and acne, yet these effects are mild and usually reversible.
• Estrogen:
1. Vaginal Creams: for those with vaginal dryness or pain with intercourse. However, it is contraindicated in those same patients with contraindications to oral estrogens as well, such as those with a history of breast cancer.
2. Oral Estrogen: The Women’s Health Initiative (WHI) study found that oral estrogen does not improve sexual functioning in postmenopausal women, and may even be harmful.
• Non-Hormonal:
1. Sildenafil (Viagra): For those requiring SSRI’s for depression or anxiety disorders, phosphodiesterase inhibitors (PDE-5) such as Sildenafil have shown to be effective in limited studies. However, they have not been shown to be successful in women not being treated with SSRI’s. Studies are currently limited.
2. Buproprion (Wellbutrin): Has been shown to effectively treat women with sexual dysfunction even without depression.
3. Zestra T Oil: This is an herbal feminine massage oil that may be applied to the female genitals, and reported to improve sexual functioning in a small study.
Please make sure you consult your personal physician prior to initiating any kind of treatment for female sexual dysfunction.
Editor’s note: This is meant to be general information only, and not to be used as medical advice. Please note the disclaimer.
Jill of All Trades is a family physician who blogs at her self-titled site, Jill of All Trades, MD.
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