Monday, October 15, 2007

Sexual problems in women

INTRODUCTION — Sexual problems can occur in women of any age. Sexual dysfunction is a term used to describe difficulties in libido (sex drive), arousal, orgasm, or pain with sex that is bothersome to an individual or their sexual partner. It can occur in men or women at any age, though women in midlife are at higher risk of changes that can cause sexual dysfunction. In this topic review, midlife refers to the middle part of a woman's chronological years, between 35 and 65 years.

For most women, the earliest changes begin when they are in their 30s and continue through the menopause. The years before menopause are commonly referred to as the perimenopause or menopausal transition, which can precede a woman's final menstrual period by 10 years (show figure 1).

A host of hormonal, vascular, and other changes occur prior to the menopausal transition and continue in postmenopause; these changes can affect sexuality in a number of ways. To describe these changes, it will be helpful to review the basic elements of the normal sexual response.

OVERVIEW OF THE NORMAL SEXUAL RESPONSE — Two models have been proposed to describe the human sexual response. While they differ in many ways, both acknowledge that the brain is the most important sex organ in the human body, and that nerves and blood vessels are critical components in initiating and maintaining the human sexual response.

Masters and Johnson model — Masters and Johnson first described the human sexual response as a linear progression through a series of phases. They describe the response as follows: Excitement — At the start of the excitement phase, the brain stimulates nerves in the body, which causes changes in blood flow. This increases flow to the genital area; in women, the vaginal wall becomes lubricated and expands, the labia increase in size and spread open, and the clitoris enlarges. Other areas of the skin may be affected by the increased blood flow, resulting in nipple erection and flushing of the skin, sometimes known as the "sex flush." Plateau — Changes in the genital area progress and an increase in muscle tension occurs. Blood flow to the labia increases, glands in the labia produce secretions, and the vagina elongates. Orgasm — In the orgasm phase, vaginal, uterine, and other muscle contractions occur. There is a massive release of muscle tension. Regularly orgasmic women will achieve orgasm 50 to 70 percent of the time; other times women may experience a satisfying prolonged plateau phase. Resolution — The final phase is often characterized as a gradual, pleasant diminishing of sexual tension and response, differing in the time it lasts among individuals.

The Masters and Johnson model was later altered by Kaplan. Excitement was divided into desire followed by arousal. This highlights the differences between a cerebral event (desire) and a peripheral event (arousal). Some questioned whether women followed this linear sequence of events. Newer theories have concluded that the female sexual response is quite different from the male response, and does not follow a linear progression.

Biopsychosocial sexual response model — Another way to think about the female sexual response focuses on the complex interplay among four major components in a woman's life, rather than the more linear phases described by Masters and Johnson. These components are: Biology Psychology Sociocultural influences Interpersonal relationships

Using this model, sexual function or dysfunction can be defined using a combination of components. Thus, using medication to treat a biological factor without addressing other factors is unlikely to be successful for a woman with sexual dysfunction.

Proponents of this model believe that a large component of a woman's sexual desire is "responsive" versus "spontaneous." That is, desire may not occur spontaneously, but rather in response to an interplay of the factors listed above. Spontaneous desire may occur for some women, but is not essential. Therefore, a woman who does not have spontaneous desire does not necessarily have sexual dysfunction. The goal of sexual activity is satisfaction for both partners, which may or may not include orgasm.

SEXUAL CHANGES IN MIDLIFE — Sexuality and sexual capacity evolve over a lifetime and are based on personal experiences, interests, cultural attitudes, interpersonal relationships, desires, behaviors, physiology, and other factors. As midlife approaches, this foundation of sexuality can be altered by changes that affect many aspects of sexuality and sexual function. In learning about these changes, it is important to remember that they do not occur in isolation; a change in one is likely to affect other areas.

Understanding how the changes in midlife affect sexual response is an important first step in the treatment of sexual dysfunction. This can help to eliminate the fear and embarrassment that might otherwise occur, and which sometimes causes further detrimental changes in the sexual response.

Changes in estrogen — Estrogen is a female hormone produced by the ovaries. During the perimenopause, erratic ovarian function leads to estrogen levels that fluctuate. After menopause, estrogen levels begin to decline, causing a decrease in blood flow to the genitalia. This can lead to changes that affect sexual function. These include: Changes in the vagina, including narrowing, dryness, an increase in pH (which can lead to infections), and a decrease in elasticity of the vaginal wall. Changes in the bladder, which can lead to increased frequency of urination and, in some women, predispose them to loss of urine (incontinence). (See "Patient information: Urinary incontinence"). Changes in the clitoris, with decreased blood flow to the area and shrinkage of the structure. Nerve changes such as decreased sensitivity to touch and delayed reaction time to physical stimulation.

Vaginal dryness and decreased elasticity can result in discomfort or pain during sex. The decrease in blood flow to the genital organs can lead to diminished vascular congestion in the vagina and clitoris, thereby contributing to delayed arousal, delayed or absent orgasm, or diminished intensity of orgasm.

Changes in androgens — Women make more testosterone than estrogen; all of the estrogen made by the ovary is a by-product of testosterone. It is known to be important for the development of libido in men, but its role in women is not well understood. For example, blood levels of testosterone are not a good predictor of libido in women.

Other things can decrease androgen levels, including medications, such as birth control pills and oral estrogen replacement therapy, which are taken by many women in midlife.

The impact of male sexuality — Midlife changes in a woman's male sex partner can affect her sexual response. Male sexual dysfunction, (erectile dysfunction, diminished libido, or abnormal ejaculation), first emerges as a problem for men in their early 40s and increases with advancing age (show figure 2).

Changes in libido — Decreased libido or sexual desire is a common problem among women in the perimenopause or menopausal transition, but women of any age may experience it. Decreased libido refers to a decrease in sexual appetite, drive, and fantasy. Sexual arousal is best understood in physiologic and vascular terms while libido is more psychosocial and behavioral and is impacted by a multitude of factors in daily life and relationships. A desire for intimacy can be diminished in spite of normal levels of testosterone. Many factors may be involved, including:

Partner availability — Women tend to live longer than men, resulting in a natural shortage of males 50 years of age and older. At the same time, many men seek out younger partners, further affecting the availability of partners for women in midlife and beyond.

Personal well-being — A woman's sense of personal well being is important to sexual interest and activity. A woman who does not feel her best physically or emotionally may experience a decrease in sex drive.

Health and socioeconomic circumstances — Studies have shown that sexual dysfunction is highest in women with poor health, low income, and a history of infrequent sexual interest. It is also more common among women and men with poor physical and emotional health.

Performance anxiety — Women may fear pain during sex because of vaginal dryness or other changes in the vagina. This fear can diminish lubrication, causing further pain. Women may also develop anxiety if they are not satisfied by a sexual experience or feel they have not satisfied their partner. Women may avoid sexual contact with their male partner if he has a history of sexual dysfunction; avoiding sex prevents his potential sexual failure and her perceived inability to arouse him.

Medical issues — A host of medical issues in midlife can impact a woman's sexual desire and responsiveness. Problems such as coronary artery disease and arthritis can diminish the physical ability to perform sex. Indeed, arthritis has been identified in some studies as the most common cause of sexual inactivity in the United States. Other conditions such as Parkinson's disease, complications of diabetes, or alcohol and drug abuse can impair arousal and ability to experience orgasm. A psychiatric or emotional problem may impact sexual function, either due to the disorder itself or its treatment (see below).

Medications — Both prescription and nonprescription medications can alter sexual desire, arousal, and orgasm. As an example, medicines that alter blood flow (such as blood pressure medicines), those that affect the nervous system (such as some psychiatric medicines), or those that dry the skin or mucous membranes (such as cold or allergy medicines) can affect sexual function. As mentioned before, birth control pills, patches, and rings, as well as oral hormone replacement therapy can affect testosterone levels in women and decrease sexual desire.

Antidepressants — Selective serotonin reuptake inhibitors, or SSRIs, which are commonly used to treat depression, premenstrual syndrome, and anxiety frequently cause sexual dysfunction in both men and women; side effects can include diminished sexual desire, arousal, and orgasm. Examples of SSRIs include fluoxetine (Prozac®) and paroxetine (Paxil®).

Patients with sexual side effects from SSRIs should speak with their healthcare provider about trying a drug holiday or alternate medication to reduce or eliminate their symptoms. A drug holiday involves stopping the SSRI for two to three days, which decreases the amount of drug in the body and may improve a patient's ability to become aroused and experience orgasm. Drug holidays have not been proven to be consistently helpful for all patients and should only be tried after consulting with a healthcare provider.

Patients with sexual side effects may benefit from a change in dose or type of antidepressant medication, or from the addition of a second medication. Bupropion (Wellbutrin®) has been shown to have few or no sexual side effects, and may be used in addition to or in place of an SSRI in certain carefully selected patients.

Erectile dysfunction medications — The medications commonly used for men with erectile problems, including Sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®), do not improve sexual function for most women.

Surgery — Operations commonly performed on women at midlife may have an effect on sexual response. In particular, those affecting the breasts or the genital tract may have an impact related to altered body image and function, as well as the psychological impact of an underlying diagnosis such as cancer.

Hysterectomy — Contrary to popular belief, hysterectomy, or removal of the uterus, may result in improved sexual function. (See "Patient information: Vaginal hysterectomy" and see "Patient information: Abdominal hysterectomy"). Relief from symptoms such as bleeding or pain may spark a renewed interest in sex. One study followed over 1000 women for two years after hysterectomy. The percentage of women who engaged in sexual relations increased from about 71 percent before the surgery to 77 percent at one and two years after the operation. Before surgery, 19 percent of women reported painful sex; after surgery, only 4 percent reported this problem. The number of women who experienced orgasm increased from 92 to 95 percent; libido increased as well. However, some women note a decrease or total absence of orgasm after hysterectomy.

Oophorectomy — Removal of the ovaries during hysterectomy is not always necessary. After menopause, the ovaries continue to produce testosterone, though they no longer produce estrogen. In the past, women have been advised to have their ovaries removed since the uterus was also being removed, they were near or beyond menopause, and to avoid a future risk of ovarian cancer. Although there is a risk for ovarian cancer if the ovaries are not removed, this risk may be acceptable depending upon the woman's risk profile. The average woman's lifetime risk of ovarian cancer is small, approximately two percent.

Removal of the cervix — Hysterectomy does not necessarily require removal of the cervix. Supracervical hysterectomy removes the lower part of the uterus through an incision in the abdomen, but leaves the cervix in place. Some clinicians believe that leaving the cervix maintains the blood vessel and nerve supply to the top of the vagina, which actively participates in orgasm. By this theory, the cervix contributes to orgasmic response. However, studies have demonstrated that sexual satisfaction does not appear to differ between women with and without a cervix after hysterectomy. Patients should discuss plans for surgery with their doctor.

TREATMENT — A number of treatments are available for women with sexual dysfunction. Treatments that do not involve medications may be tried first. In some women, treatment with medicine may also be recommended.

Non-pharmacologic treatments — One of the major points to remember when sexual dysfunction occurs is that decreasing the frequency of sex is likely to make the problem worse. In their early work, Masters and Johnson discovered that regular sexual activity helps maintain a woman's sexual capacity because it actually affects the chemical balance in the vagina and maintains blood flow to the genitalia. If possible, a treatment plan should address the issue of regular sexual activity. The benefits of regular activity do not require a partner; similar benefits are seen with sexual activity of any kind, including masturbation or sexual fantasy, all of which increase blood flow.

Vaginal weights — In some women, vaginal weights are useful to help strengthen the muscles in and around the genital area. This may improve awareness of sexual response in some women with orgasmic disorders. Vaginal weights can also decrease or eliminate urine leakage during sexual activity. (See "Patient information: Urinary incontinence", section on vaginal pessaries).

Vaginal weights are usually available in sets of five weights. The woman inserts the lightest weight and remains upright for 15 minutes, twice a day. With the weight in place, she should feel the urge to hold it in. After a number of days, she should not longer feel the urge to hold in the weight because an improvement in muscle tone has occurred. She then moves up to the next weight.

Increased tactile stimulation — Men and women can have decreased blood flow to the genitals during midlife. Increasing manual and/or oral stimulation can be helpful to achieve or maintain an erection in the male or arousal in the female.

Sexual frequency — The "optimal" frequency for sexual contact is what each pair of partners finds comfortable. Women do not need to initiate contact to enjoy sex; many women can respond to their partner's sexual signals, become aroused, and enjoy a sexual experience that is initiated by their partner. Ejaculation and/or orgasm is not required with each sexual encounter.

Treatment with medications — Non-pharmacologic treatments may not be sufficient to provide sexual satisfaction in some women. Medications may be tried in these women, with the goal being to maintain hormone levels and increase blood flow to the genitals.

Estrogen — Estrogen may positively affect sexual function by helping to maintain normal lubrication and elasticity of the vagina. It can also improve mood and affect nerve growth and response, which may impact arousal. In one study, estrogen was shown to increase clitoral sensitivity, rate of orgasm, and sexual desire. In another, the rate of orgasm and sexual arousal were not affected, but women treated with estrogen reported an increase in satisfaction with the frequency of sexual activity, sexual fantasies, enjoyment of sex, vaginal lubrication, and the level of discomfort during sex.

In general, women with symptoms of vaginal dryness should use topical (vaginal) estrogen rather than oral estrogen since it is far more effective for the sexual symptoms. Treatment with oral estrogen can decrease testosterone levels; topical estrogen avoids this negative effect.

Progestogens — Progestogens are progesterone-like medications that are an important component of hormone replacement therapy in women with a uterus. A number of studies have shown that treatment with certain potent synthetic progestogens can increase sexual problems in women. Studies are underway to determine if various combinations of estrogens with synthetic progestogens alters sexual response.

Androgens — Although androgens (such as testosterone) may be important in the female sexual response, treatment with androgen replacement is highly controversial. Estratest®, a combination of estrogen and testosterone, is the only androgen therapy currently available. It is available for the treatment of hot flashes that do no respond to estrogen alone.

There are no adrogen products that are approved for use in women with sexual dysfunctions, thus use of androgen therapy remains investigational. Studies have shown mixed results; those that carefully select participants with sexual dysfunction have shown statistically significant but clinically modest improvements when compared to placebo. Of note, in all of the transdermal testosterone trials, clinical improvement is seen only with higher than normal blood levels of testosterone. The long-term risks of these higher testosterone levels are unknown.

Side effects remain a concern, as these medicines can decrease HDL (good cholesterol) levels significantly. Masculinizing effects, such as body hair growth, scalp hair loss, oily skin, and acne can also occur.

Studies on the use of DHEA (dehydroepiandrosterone), available as a nutritional supplement in the United States, is beneficial for improving libido in women with adrenal insufficiency. DHEA is not proven to be safe or effective for other patients, and is not generally recommended.

Herbal therapies — The literature on herbal therapies for the treatment of sexual dysfunction in women is sparse. A small number of studies have shown that treatment with St. John's wort, ginseng, or dong quai did not have a significant effect on sexual function. Herbal products such as yohimbine and ginkgo biloba have been reported to enhance desire, arousal, and orgasm in both women and men, but the data is limited. Sex creams that contain menthol are available for application to the clitoris, and are promoted for their ability to enhance sensation. However, there are no studies that show these creams to be effective. In addition, some have ingredients that can cause irritation of vulvar or vaginal tissues.

More studies are needed to ensure herbal therapies are safe and effective. The production of herbs is not regulated by the government, and it is not always possible to know that an herbal product contains the type and quantity of ingredient that the label indicates, or that it is free of potentially dangerous additives. Patients who wish to use herbal therapies are urged to do so with caution.

Surgical treatments — Surgery is very rarely necessary to make the vagina "better" for sex. Women with congenital abnormalities of the vagina, who have had female circumcision (also known as female genital mutilation), and those with traumatic injuries from childbirth are a few groups that may benefit from careful surgical treatment. All women should be wary of advertisements for "vaginal rejuvenation surgery"; these procedures can be costly and painful, are permanent, and are unlikely to improve a woman or her partner's sexual enjoyment.

Future directions — A number of products are undergoing research and development for use in women with sexual dysfunction: Tibolone, currently available in Europe and Australia, may gain FDA approval in the United States soon. It is taken by mouth as hormone replacement therapy and may also help improve sexual function. Use of Sildenafil (Viagra®) in women is also undergoing evaluation. Preliminary findings demonstrate positive effects in some women with adequate testosterone levels who have problems with arousal and orgasm.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
Mayo Clinic

(www.mayoclinic.com)
The Hormone Foundation

(www.hormone.org)
American Academy of Family Physicians

(www.familydoctor.org, search for sexual problems)


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3. Nathorst-Boos, J, Wiklund, I, Mattsson, LA, et al. Is sexual life influenced by transdermal estrogen therapy? A double blind placebo controlled study in postmenopausal women. Acta Obstet Gynecol Scand 1993; 72:656.
4. Myers, LS, Dixen, J, Morrissette, D, et al. Effects of estrogen, androgen, and progestin on sexual pscychophysiology and behavior in postmenopausal women. J Clin Endocrinol Metab 1990; 70:1124.
5. Masters, WH, Johnson, VE. Human Sexual Response. Boston, Mass. Little, Brown, 1966.
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7. Rhodes, JC, Kjerulff, KH, Langenberg, PW, Guzinski, GM. Hysterectomy and sexual functioning. JAMA 1999; 282:1934.

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