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Female sexual dysfunction: a vexing problem in women's health.

Sexual intimacy is an integral part of life and is closely linked to emotional and physical well-being. Indeed, in a global survey of the importance of sexuality and intimacy in 27,000 men and women aged 40 to 80 years, 83% of men and 63% of women rated sex as extremely important, very important, or moderately important in their lives. (1) Sex also appears to remain an important aspect of life as one ages. In a survey of 1,300 adults over age 60 in the United States, approximately half reported being sexually active, and of those, 79% of men and 66% of women said that sex was an important component of their relationship with their partners. (2) Despite the importance of a healthy sex life to most people, research suggests that sexual dysfunction is common. It is estimated that 43% of women and 31% of men have some sexual complaint, and these numbers may be even higher in the older population. (3,4)

Sexual complaints in women take many forms and the etiology is often complex. Diagnosis of female sexual dysfunction (FSD) is based on a comprehensive history, psychosocial assessment, and physical examination. Treatment is often multidimensional and may encompass several different disciplines. This article discusses the etiology and diagnosis of FSD and offers basic therapeutic approaches to the management of sexual complaints.

Sexual response cycle

Based on their landmark research in the 1960s, Masters and Johnson developed a linear, 4-stage model of sexual response, which included the phases of excitement, plateau, orgasm, and resolution. Kaplan proposed an alternate model in 1979 and introduced the concept of desire as the first stage of the normal sexual response cycle. In this model, desire leads to arousal, then plateau, followed by orgasm and resolution. This model has been widely accepted, and most definitions view sexual dysfunction as an interruption of 1 or more phases of this response cycle. This model was intended to reflect sexual response for males and females; however, researchers have recognized that some women do not experience all 5 phases of the cycle and/or may not do so in the sequential progression described. As such, this model has been criticized since it may not reflect a woman's actual experiences. (6,7)

Basson proposed an alternative model to the traditional linear model to account for the complexity of female sexuality and its core need for closeness and emotional intimacy. This cyclic model is based on intimacy and incorporates integral sexual stimuli, which can be influenced by biological and psychological factors. Spontaneous desire, such as sexual thoughts and conscious wanting and fantasizing, can augment the cycle as well. This model reflects the dependency on the interaction of mind and body of sexual functioning in women. (8) Spontaneous sexual drive may or may not be present, especially as a woman ages. (5) For many women, the goal of sexual activity is intimacy, and they may seek out sexual encounters for this purpose. In response to sexual stimuli, arousal may ensue and desire may then follow. The peak emotional experience and emotional and physical satisfaction may or may not coincide with the physiological release that occurs during orgasm. Indeed, there may be an infinite variety of sexual responses for women.

Predisposing factors

The vast majority of sexual problems are caused by a variety of factors, often a combination of biological, psychological, and relationship issues. Some medical and surgical conditions can cause or contribute to sexual difficulties (TABLE 1) as can gynecologic causes (TABLE 2). Conditions that affect energy and overall well-being may indirectly affect sexual desire and response as well. Also, conditions that alter the hormonal milieu can impede the sexual response. Neoplastic disease and its treatment, including chemotherapy, radiation, and surgery, can present mortality concerns, alter or remove physical and psychological symbols of femininity, and affect self-esteem, all of which may result in feelings of decreased sexuality. Treatment of non-neoplastic diseases or their treatment can change body image and self-esteem and can affect sexuality.

In addition, specific medications are known or believed to affect female sexual functioning (TABLE 3). Essentially, any medication that alters blood flow, affects the central nervous system, causes dryness of the skin and mucous membranes, or adversely affects the levels of bioavailable androgens can potentially interfere with normal sexual function.

Screening for sexual disorders

Although sexual dysfunction is common, it is a topic that many people--patient and physician alike--are hesitant to discuss. Although it is the responsibility of health care professionals to inquire about sexual function, data suggest that very few physicians bring up the topic with patients. In one study, only 14% of adults in the United States aged 40 to 80 reported that a physician had asked about their sexual concerns within the past 3 years. (1) In data obtained from the National Social Life, Health, and Aging Project (NSHAP), only 38% of men and 22% of women aged 57 to 85 reported having discussed sex with a physician since the age of 50, despite the high prevalence (>50%) of sexual problems. (4) Physician-initiated questioning about sexuality has been shown to significantly increase patient reporting of sexual dysfunction (9) and should, therefore, be incorporated into regular practice.

All patients should be screened for sexual dysfunction, and perhaps the most natural time to do so is at the annual or periodic health visit. In addition, particular events are associated with an increased risk of sexual disorders and provide opportunities for screening. These include visits prior to gynecologic or other surgery, menopause-related visits, prenatal and postnatal visits, and visits for infertility, chronic illnesses, and depression. (10) In terms of screening, a brief sexual status history can be covered with 4 basic questions:

1. Are you sexually active?

2. Is your sex life satisfying to you?

3. Is your sexual activity satisfying for your partner?

4. Do you have any concerns about your sex life or functioning?

A questionnaire can also be incorporated into a patient intake form and used as a preconsultation screening tool if desired.

The evaluation of a patient complaining of sexual dysfunction should include a detailed medical and sexual history, a complete physical examination, and laboratory tests, if indicated. Areas that may be assessed during a complete sexual history include details about any pain or discomfort, any previous treatment, first sexual experience, early teaching regarding sexuality, sexually transmitted infections, pregnancies, and history of sexual problems. Psychological, social, and relationship histories are also needed. The patient should be evaluated for anxiety and depression because of their potential effect on intimacy and desire. Life stressors including--but not limited to--financial pressures, employment situations, and family and social responsibilities should be identified, as these can affect interest in sex. Questions regarding domestic and sexual abuse as well as substance abuse must also be raised.

The partner can often be an important source of information. Therefore, it may be beneficial to have the partner present at some point during the office visit and during the education process.

Classification and treatment of sexual disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) conceptualizes sexual disorders as "disturbances in the processes that characterize the sexual response cycle or by pain associated with sexual intercourse" and includes: (1) sexual desire disorders, (2) sexual arousal disorders, (3) orgasmic disorders, and (4) sexual pain disorders, which include dyspareunia, vaginismus, and noncoital sexual pain. (11) All classifications are further specified as lifelong or acquired, generalized or situational, and due to psychological or combined factors. In addition, the psychological distress and interpersonal difficulty caused by the sexual disorder is included in the definition. (11)

In 1998, The American Foundation for Urological Disease (AFUD) convened an interdisciplinary panel to develop a classification system that would encompass both the psychological and biological factors involved in FSD. The categories outlined in DSMIV were retained and expanded to include organic causes. (12) The AFUD system includes personal distress as a critical component in the diagnostic criterion, one which must be present in order for dysfunction to be diagnosed. These definitions continue to distinguish between dysfunctions that are lifelong and those that are acquired. (12) More than one dysfunction may be present, and there may be interdependence among the disorders. These classification systems have been criticized because they are generally based on the traditional linear model of sexual response. In fact, subsequent publications have recommended changes, suggesting that these categories and their definitions will continue to evolve and take contextual factors into consideration. (12)

General approaches to treatment

Patients should be educated about normal anatomy, the female sexual response cycle, and normal changes in sexual functioning that may occur throughout the life cycle. Special attention to the effects of aging and menopause may be important as well. In addition to education offered directly by the health care provider, patients can obtain valuable information in the form of books, pamphlets, videos, and reputable web sites. Education can inform the patient and "normalize" her experiences.

Recommendations to enhance communication and improve relationships may be offered. Communicating sexual likes and dislikes, in a nonjudgmental manner, can reinvent novelty and improve satisfaction. It is often necessary to help a couple reestablish intimacy. One such approach includes the use of behavior therapy in the form of sensate-focus exercises or sensual massage, where one partner provides the massage and the other partner provides feedback. There is initially no involvement of sexual areas. The idea is to enhance comfort and communication between partners, eliminate performance expectations, augment awareness of bodily sensations, remove the genital focus, and broaden the sexual repertoire. (13)

Basic treatment strategies may also include ways to increase stimulation, encourage creativity, and eliminate routine. This may begin with lifestyle changes, including rest, minimizing fatigue and stress, and aerobic and strength-training exercises. Viewing erotic materials and fantasizing can be used to enhance libido and arousal. Suggestions for varying the time of day or place in which sexual activity occurs, or varying positions or types of sexual activity, can be offered. Self-pleasure and the use of vibrators can increase stimulation and may also help to maximize familiarity with pleasurable sensations.

Desire disorders

Hypoactive sexual desire disorder (HSDD) is defined as the persistent or recurrent deficiency or absence of sexual fantasies, thoughts, and/or desire for, or receptivity to, sexual activity, which causes personal distress. (12) Diagnosis of HSDD requires that the loss of sexual desire causes personal distress (or is an issue) for the patient and/or her partner and therefore requires treatment. HSDD is the most common of the female sexual disorders and has been shown to have a strong positive correlation with low feelings of physical and emotional satisfaction as well as low levels of overall happiness?

Though common, desire disorders are often difficult to diagnose in women because there are no reliable physical markers of sexual desire. In addition, women will often engage in sexual activity despite a lack of innate or spontaneous desire and/or they may fail to initiate sexual encounters when they do experience desire. Therefore, objective measures of sexual desire, such as frequency of intercourse, may not be reliable indicators and may not reflect the true presence or absence of desire.

Desire may readily be diminished or destroyed by interpersonal or relationship difficulties, psychological issues and stressors, medical problems, including estrogen-deficient dyspareunia, and medications, and these underlying causes must be fully evaluated. HSDD may also be a result of coexisting arousal disorder. Postmenopausal women are often thought to be at an increased risk of experiencing HSDD as a result of decreasing androgen levels, although the role of testosterone in sexual desire remains somewhat controversial.

Androgen is important in the regulation of sexual response. Because the ovaries are one of the major producers of androgens in women, a decline in androgen synthesis often occurs with aging. Women in their forties have been shown to have approximately half the level of testosterone of women in their twenties. (14) This age-related decline in androgen synthesis and circulating levels has been thought to lead to a decrease in sexual desire and well-being. Indeed, a syndrome of female androgen insufficiency was proposed by the Princeton Consensus Panel in 2002, in which a pattern of clinical symptoms was described, including a diminished sense of well-being or dysphoric mood; persistent, unexplained fatigue; and sexual function changes such as decreased libido, sexual receptivity, and pleasure, in the presence of decreased bioavailable testosterone and normal estrogen status. (15) Other potential signs of female androgen insufficiency the panel noted were bone loss, decreased muscle strength, and decreased cognitive function. (15) Based on this pattern, an algorithm of care was developed in which a trial of testosterone therapy could be considered if the patient was adequately estrogenized and was not found to have any other cause(s) for her persistent symptoms.

Despite this international consensus panel statement, the classification of androgen insufficiency as a medical syndrome and the use of androgen therapy in women are controversial and not universally accepted. Accumulating data, primarily in women who have undergone oophorectomy, indicate that testosterone therapy with concomitant estrogen therapy improves sexual function--specifically sexual desire--in postmenopausal women. (16-19)

The North American Menopause Society (NAMS) position statement on the role of testosterone therapy in postmenopausal women concludes that there is consistent evidence that in postmenopausal women with sexual complaints, adding either oral testosterone or testosterone given by other routes of administration (eg, transdermal patch, implants, injections) to estrogen therapy results in positive effects on sexual function, primarily an increase in sexual desire. (20) NAMS further states that such therapy can be considered in postmenopausal women if they present with decreased sexual desire associated with personal distress and no other identifiable cause for their sexual complaint. Finally, NAMS states that laboratory testing of testosterone levels should not be used to diagnose testosterone insufficiency. Laboratory assays are not accurate for detecting testosterone concentrations at the low values typically found in postmenopausal women. (20) For additional information visit: www.menopause. org/portals/0/content/pdf/pstestosterone05.pdf.

A task force of the Endocrine Society, however, recommended against establishing a diagnosis of androgen insufficiency in women because of the lack of a well-defined clinical syndrome and reliable data on testosterone levels that could be used to define the disorder. (21) Furthermore, the task force recommended against the widespread use of testosterone in women because of the lack of clear indications as well as concerns over long-term safety. (21)

No testosterone product is approved by the US Food and Drug Administration (FDA) for the treatment of sexual dysfunction in women. A few testosterone-containing products are FDA-approved for use in women, but would be used off-label to treat sexual desire disorders. Compounded preparations of testosterone are also available by prescription, but they are not subject to the same quality control as FDA-approved products and may result in inconsistent dosing. Attempts to use testosterone products approved for use in men by modifying the dose or amount applied is difficult and could result in delivery of excessive doses. All of these off-label uses lack efficacy and, perhaps more importantly, safety data. Potential side effects include acne, hirsutism, voice deepening, alopecia, liver toxicity, and adverse effects on lipoproteins. Concerns about the consequences of long-term androgen use focus on possible cardiovascular disease, development or worsening of the metabolic syndrome, thromboembolic disease, and malignancies involving the breast and uterus, although there are few controlled long-term data to definitively support or negate these concerns. (22) DHEA dietary supplements have not been studied in large, well-designed clinical trials. Therefore, there is a lack of efficacy data for such use in treating female sexual dysfunction. Possible androgen therapy includes oral, topical, injection, and implant options.

Understanding the connection between sexuality and physical, psychological, relationship, and sociocultural factors is essential for treating all types of FSD, but especially HSDD. Key components of treatment include recommendations for reestablishing intimacy, changing sexual routines, sensatefocus exercises, use of female-centered erotica, and the development of sexual fantasies.

Arousal disorders

AFUD defines Female Sexual Arousal Disorder (FSAD) as the persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress. This may be expressed as a lack of subjective excitement, genital response (eg, lubrication, swelling), or other somatic responses. (12) To understand the etiology of the arousal disorders and to implement appropriate treatment, one must distinguish between the subtypes of FSAD. Generalized arousal disorder includes lack of mental excitement as well as lack of genital engorgement or congestion. (8,10) Genital arousal disorder implies that mental excitement is present, but genital engorgement is absent or minimal. (8,10) In "missed arousal," genital engorgement occurs, but the woman does not attend to it, and in "dysphoric arousal," genital engorgement is felt to be unpleasant. (8,10)

The psychological aspects of FSAD should be addressed with psychosocial counseling. For women with missed arousal, it is especially important to consider past negative experiences, distractions, expectations of negative outcome, problematic stimuli or context of sexual activity, and depression. (10) Similarly, for those with dysphoric arousal, past negative experiences should be reviewed, including abuse, negative messages from childhood regarding sex, and guilt about sexuality. (10)

Medical factors are frequently implicated in the development of arousal disorders and should be addressed and treated as indicated. Such factors include vascular diseases (eg, atherosclerotic disease, coronary artery disease, diabetes), tobacco abuse, medication effects, postsurgical changes, and menopause.

Urogenital atrophy is perhaps the most common cause of arousal disorders in postmenopausal women. Treatment of atrophy with a local vaginal estrogen cream, ring, or tablet can be effective. Systemic estrogen therapy can be considered if there are no contraindications to its use and may be superior to local therapy alone when there is coexisting HSDD. The transdermal route of administration may be preferred to oral estrogen supplementation to avoid an increase in sex hormone-binding globulin levels and a subsequent decrease in bioavailable testosterone. (10)

Nonpharmacologic approaches to the treatment of FSAD usually focus on erotica and over-the-counter lubricants, vitamin E oil, and mineral oil, which should be used on a regular basis rather than solely with intercourse. Decreased vasocongestion during arousal can create the need for increased tactile stimulation to achieve adequate clitoral, labial, and vaginal response. Providing an explanation of the need for more stimulation, whether manual, oral, or with the use of vibrators, and encouraging extended foreplay, especially in older women, can have a positive effect on their sexual response and relationship.

Vasoactive medications and devices

Use of vasoactive medications, either systemically or locally, for patients with genital arousal disorder seems to make sense theoretically. Treatment with phosphodiesterase (PDE5) inhibitors, such as sildenafil (Viagra), however, has generally not been shown to be effective in larger, randomized, placebo-controlled trials of women with FSD. Lack of focused, patient-selection criteria may have limited potential demonstration of efficacy, as these trials involved women in whom arousal and desire disorders rather than genital arousal disorder were diagnosed. (13,23)

Though some smaller studies of women with genital arousal disorder seem to show favorable results, further studies of PDE5 inhibitors in treating FSAD have been discontinued and there is no ongoing effort to seek FDA approval for use of these agents in FSD. (10,13,23) Use of PDE5 inhibitors in women, even on a case-by-case basis, is off-label. Two formulations of the topical vasodilator alprostadil are under investigation.

A vacuum device, EROS-CTD (clitoral therapy device), is FDA-approved for the treatment of FSAD and orgasmic disorder. It works by improving blood flow to the clitoris and external genitalia. A small, multicenter prospective cohort study suggests that the device is associated with increased vaginal lubrication, genital sensation, orgasm frequency, and overall sexual satisfaction. (24) A follow-up study of 19 women showed significant changes in women with FSD as well as women without complaints of sexual dysfunction. (25) The device is relatively expensive and may not be reimbursed by insurance.

Orgasmic disorder

Female orgasmic disorder is the persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation. In general, desire and arousal must be present in order for a woman to reach orgasm. Most women seeking care for orgasmic disorder also have low arousal. Orgasmic disorders may be primary (lifelong) or secondary (acquired). Etiologies associated with lifelong female orgasmic disorder include fear of losing control or being vulnerable, prior deliberate curtailing of high arousal (eg, for religious or moral reasons), lack of trust of others, or fear of intimacy. (10) Contributing factors to acquired orgasmic disorder include medication-associated orgasmic disorder, especially with use of selective serotonin reuptake inhibitors (SSRIs) and sedatives; use of alcohol; neurologic diseases or autonomic nerve damage; testosterone insufficiency (although this is more often associated with low desire and arousal); and control issues. (10)

Orgasmic disorders are quite responsive to therapy. Among women for whom sexual inexperience and insufficient stimulation play a role, minimizing inhibition and maximizing stimulation are important. The patient should be encouraged to explore and practice self-stimulation as well as assert her preferences for stimulation with her partner. Vibrators may be helpful, and the use of vaginal weights may strengthen pelvic floor muscles and improve awareness of sexual response. Referral to a sex therapist is often necessary and success rates are high. A multidisciplinary approach, including counseling, behavior therapy, and pelvic floor physical therapy or rehabilitation, should be considered.

Sexual pain disorders

Female sexual pain disorders include dyspareunia, vaginismus, and noncoital sexual pain. Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse. Penile-vaginal penetration may be impossible because of the pain caused by partial or complete penile entry. A complete history and careful physical examination are of paramount importance in determining possible causes, which include estrogen deficiency, genitourinary atrophy, infection, vulvar vestibulitis, interstitial cystitis, vulvar dystrophies, endometriosis, and anatomic changes following surgery, radiation, trauma, or childbirth.

Vaginismus is the recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration. Physical causes and gynecologic disease are absent, and this condition generally has a significant psychological component.

A discussion of the detailed evaluation and management of dyspareunia and vaginismus is beyond the scope of this article; however, diagnosis of an underlying etiology for the pain should be sought. Both disorders can benefit from education, pelvic floor physical therapy (including biofeedback and massage), and psychological counseling. Couples may need encouragement to engage in sexual activities that exclude intercourse, at least in the initial stages of treatment. In postmenopausal women, administration of vaginal or systemic estrogen can decrease pain on insertion, improve lubrication, and decrease vaginal burning. Women with vaginismus often respond very well to treatment with the daily use of dilators in graduated sizes.

Referral for sex therapy

There are several situations in which referral to a sex therapist can be helpful in treating female sexual dysfunction. Long-standing or lifelong sexual dysfunction is often associated with anger, performance anxiety, and sex-avoidance behaviors and may require counseling. If a patient presents with more than one dysfunction, it may be difficult to identify the initial cause of the sexual problems.

Psychological problems such as depression, anxiety, interpersonal difficulties, current or past sexual abuse, and substance abuse have a negative impact on sexual function and complicate treatment strategies. Finally, lack of response to behavioral and pharmacologic interventions may necessitate psychological evaluation to identify additional contributing factors.

Educational Objectives

At the conclusion of this activity, participants should be able to:

* Describe sexual function as it applies to women and define female sexual disorders

* Outline techniques for office evaluation of the woman with sexual complaints

* Discuss management strategies for the initial treatment of female sexual problems

References

(1.) The Pfizer Global Study of Sexual Attitudes and Behaviors. Selected results from the Pfizer Global Study of Sexual Attitudes and Behaviors, http://www.pfizerglobalstudy.com/study/study-results.asp. Accessed July 29, 2008,

(2.) The National Council on Aging. Half of older Americans report they are sexually active; 4 in 10 want more sex, say new survey, http://www.ncoa.org/content.cfm?sectionID=105&detail=128. Accessed July 19, 2008.

(3.) Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281:537-544.

(4.) Lindau ST, Schumm LE Laumann EO, et al. A study of sexuality and health among older adults in the United States. N Engl J Med. 2007;357;8:762-774. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve& db=pubmed&dopt=Abstract&list_uids= 10022110.

(5.) Dennerstein L, Dudley E, Burger H. Are changes in sexual functioning during midlife due to aging or menopause? Fertil Steril. 2001;76:456-460.

(6.) Masters EH, Johnson VE. Human Sexual Response. Boston, MA: Little Brown & Co; 1966.

(7.) Kaplan HS. Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy. NewYork, NY: Brunner/Mazel Publications; 1979.

(8.) Basson R. Female sexual response: the role of drugs in the management of sexual dysfunction. Obstet Gynecol. 2001;98:350-353.

(9.) Bachmann GA, Leiblum SR, Grill ]. Brief sexual inquiry in gynecologic practice. Obstet Gynecol. 1989;73:425-427.

(10.) Basson R. Sexuality and sexual disorders in women. Clinical Updates in Women's Health Care. 2003;2:1-94.

(11.) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2003.

(12.) Basson R, Berman L Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol. 2000;163:888-893.

(13.) Basson R. Clinical practice. Sexual desire and arousal disorders in women. N Engl J Med. 2006;354; 14:1497-1506.

(14.) Zurnoff B, Strain GW, Miller LK, et al. Twenty-four-hour mean plasma testosterone concentration declines with age in normal premenopausal women. J Clin Endocrinol Metab. 1995;80:14291430. http://www.ncbi.nlm.nih.gov/entrez/query.fegi?cmd=Retrieve& db=pubmed&dopt=Abstract&list_uids=7714119.

(15.) Bachmann G, Bancroft J, Braunstein G, et al. Female androgen insufficiency: the Princeton consensus statement on definition, classification, and assessment. Fertil Steril. 2002;77:660-665.

(16.) Shifren JL, Braunstein GD, Simon JA, et al. Transdermal testosterone treatment in women with impaired sexual function after oopborectomy. N Engl J Med. 2000;343:682-688.

(17.) Simon J, Braunstein G, Nachtigall L. Testosterone patch increases sexual activity and desire in surgically menopausal women with hypoactive sexual desire disorder. J Clin Endocrinol Metab. 2005;90:5226-5233.

(18.) Braunstein GD, Sundwall DA, Katz M, et al. Safety and efficacy of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo-controlled trial. Arch Intern Med. 2005;165:1582-1589.

(19.) Buster JE, Kingsberg SA, Aguirre O, et al. Testosterone patch for low sexual desire in surgically menopausal women: a randomized trial. Obstet Gynecol. 2005; 105:944-952.

(20.) North American Menopause Society. The role of testosterone therapy in postmenopausal women: position statement of The North American Menopause Society. Menopause. 2005; 12:496-511.

(21.) Wierman ME, et al. Androgen therapy in women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrin Metab. 2006;91:3697-716.

(22.) Schover LR. Androgen therapy for loss of desire in women: is the benefit worth the breast cancer risk? Fertil Steril. 2008;90:129-140.

(23.) Perelman MA. Clinical application of CNS-acting agents in FSD. J Sex Med. 2007;4(suppl 4):280-290.

(24.) Billups KL, Berman L, Berman J, et al. Vacuum-induced clitoral engorgement for treatment of female sexual dysfunction, http://www.urometrics.com/products/ eros/bilfupsetal-results.cfm. Accessed July 2, 2008.

(25.) Wilson SK, et al. Treating symptoms of female sexual dysfunction with the EROS-Clitoral "Therapy Device. Presented at: Female Sexual Function Forum; Oct 26-29, 2000; Boston, MA. http://www.urometrics.com/pruducts/eros/wilson-results.cfm. Accessed July 29, 2008.

Andrea J. Singer, MD

Associate Professor

Medicine and Obstetrics and Gynecology

Georgetown University Medical Center

Washington, District of Columbia

Judy Smith

Medical Editor

Credit Designation:

Omnia Education, Inc., designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s)[TM]. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Disclosure:

Dr Singer has disclosed affiliation with Procter & Gamble Pharmaceuticals and sanofi-aventis Pharmaceuticals. Ms Smith has nothing to disclose.
TABLE 1 Medical and surgical causes of female
sexual dysfunction

Cardiovascular

* Hypertension
* Coronary artery disease
* Angina
* Previous myocardial
  infarction

Endocrine

* Diabetes
* Thyroid disorders
* Hyperprolactinemia
* Adrenal disorders
* Pituitary disorders

Neurologic

* Multiple sclerosis
* Spinal cord damage
* Parkinson's disease
* Peripheral neuropathies
* Cerebrovascular events
* Dementia

Renal

* Chronic renal disease
* Renal failure
* Dialysis

Musculoskeletal

* Arthritis
* Sjogren's syndrome
* Autoimmune diseases

Urinary

* Incontinence

Other

* Breast cancer/mastectomy
* Colostomy
* Urostomy
* Skin disorders
* Alcohol and substance
  abuse
* Tobacco abuse

Source: Developed from various resources by Andrea J. Singer, MD

TABLE 2 Gynecologic causes of sexual dysfunction

* Infections (Bartholin's or Skene's gland infections, cystitis,
  focal vulvitis)
* Intact hymen or thick hymeneal tags
* Vulvar dystrophy, dermatitis
* Vaginal atrophy
* Scarring (from episiotomy, vaginal surgery, or radiation)
* Vulvar vestibulitis
* Vaginismus
* Pelvic infection (pelvic inflammatory disease, endometritis)
* Pelvic masses (including fibroids)
* Endometriosis
* Interstitial cystitis
* Cystocele, rectocele, uterine prolapse
* Oophorectomy
* Gynecologic malignancies and treatment

Source: Developed from various resources by Andrea J. Singer, MD

TABLE 3 Effects of some medications
on sexual function

Medication                        Disorder

Antihypertensives

* Beta blockers                   Desire, arousal

* Thiazide diuretics              Arousal

* Other diuretics                 Desire, arousal
  (spironolactone,
  acetazolemide)

* Centrally acting agents         Arousal

* Lipid medications               Desire, arousal
  Psychoactive medications

* Selective serotonin             Desire, arousal, orgasmic
  reuptake inhibitors

* Tricyclic antidepressants       Desire, arousal, orgasmic

* Benzodiazepines                 Desire, arousal, orgasmic

* Antipsychotics                  Desire, orgasmic

* Lithium                         Desire, arousal

* Monoamine oxidase inhibitors    Arousal

Hormonal agents

* GnRh agonists                   Desire, arousal

* Oral and non-oral               Desire
  contraceptives

* Progestins                      Desire

* SERMS                           Vaginal dryness, dyspareunia

* Danazol                         Desire

Anticholinergics                  Arousal

Antihistamines                    Desire, arousal
(H1 and H2 blockers)

Amphetamines                      Arousal, orgasmic
and related drugs

Narcotics                         Desire, arousal, orgasmic

Sedatives (including alcohol)     Desire, arousal, orgasmic

Adapted from: Drugs that cause sexual dysfunction: an update. Med Lett
Drugs Ther. 1992;34:73-78.
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Author:Singer, Andrea J.; Smith, Judy
Publication:OBG Management
Geographic Code:1USA
Date:Sep 1, 2008
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