Arousal disorders. In women, arousal disorders are characterized by an inability to achieve or maintain sexual excitement, which manifests itself as a lack of subjective pleasure or a lack of genital or other somatic responses.10 Complicating the diagnosis is the fact that the physiologic changes that occur when women are aroused often are difficult to separate from those linked to desire. In general, however, when diminished desire precedes decreased arousal, HSDD is the diagnosis. Even so, just as in men, diseases affecting blood flow or innervation to the genitals can cause arousal disorders in women. Unfortunately for Ob/Gyns, it is much easier to assess these problems in males, since the physiological lack of responsiveness is quite obvious in men.
Women may complain of dryness or decreased sensation in the genitals, or they may experience pain with intercourse. Any of these may be related to reduced engorgement of the tissues and diminished transudation of lubrication across the vaginal epithelium. Estrogen deficiency is a common cause of recent-onset arousal disturbance in patients with a normal level of sexual desire. In perimenopausal and menopausal women, oral or transdermal estrogen replacement in doses sufficient to relieve vasomotor symptoms may not reach the epithelium of the urogenital tissues to correct atrophic changes. In these women, as well as breastfeeding mothers, topical estrogen may improve vaginal elasticity, lubrication, and engorgement. Women taking OCs or long-acting progestational agents also should be carefully assessed for vaginal atrophy. If it is present, topical estrogen will bring dramatic improvement.
Medications known for causing erectile dysfunction in men also should be assessed in women. These include antihypertensives and some antidepressants. In addition, disease states such as hypertension, diabetes mellitus, and peripheral vascular disease may diminish vasodilation and sensation in women as well as men (Table 2). Drugs such as sildenafil may help increase local blood flow in women when erotic stimuli and the central desire for sexual activity remain intact, although the use of sildenafil in women is still in the experimental stages. Recent studies questioning the effectiveness of sildenafil in women may have been limited by the difficulty of clearly distinguishing arousal from desire disorders. Sildenafil will do nothing to improve libido.
As I mentioned earlier, it often is difficult and not particularly useful clinically to distinguish desire from arousal dysfunction. Also, women may be unaware of vascular congestion and lubrication occurring in the genitals, particularly if they have experienced sexual assault. Dissociation is a common defense mechanism in victims of physical violence, and close physical contact and genital touching may trigger this response.
Women also may be distracted from bodily sensations when other factors—e.g., a crying baby, noisy teenagers, financial concerns, or fatigue—interfere with intimacy. I commonly ask patients how they respond when they are alone with their partners on vacation. If the arousal response is normal under those conditions, I reassure the patient that the cause of her complaint is neither hormonal nor physical. Rather, I encourage her to take time to create opportunities for sensuality and closeness with her partner without external distractions.
Inability to achieve orgasm. Of the 4 categories of dysfunction, this is probably the easiest to assess. First, I ascertain whether the patient has ever experienced orgasm. Women who haven’t will likely require referral to a licensed sexual therapist.
Sexual abuse: a hidden factor in female dysfunction
At least 25% of women have been physically or sexually molested at some time during their lives.1 These episodes of violence can create significant barriers to psychological and physical well-being, particularly in women who were molested as young children. Feelings of arousal often go unrecognized because these women are dissociated from their bodies—a defense mechanism learned in early childhood. If they experienced significant pain with their initial sexual experience, their bodies may respond with natural avoidance, muscle spasm, and withdrawal. Even when a relationship is safe and loving, these responses may remain unconscious and difficult to control.
For these reasons, I always inquire about a history of physical or sexual violence, although patients often won’t admit to such a history. For example, they may not define their experience as “abuse” if it involved date-rape, forced sexual intercourse in the context of a steady relationship, or inappropriate touching and molestation without penetration. To explore the subject, I repeat key questions after the nurse takes the initial history, watching for any degree of hesitation or other subtle changes in body language, as these may yield clues about a significant past event. In addition, women who suffered childhood abuse often have multiple tension-related complaints such as irritable bowel syndrome, migraine headaches, urinary frequency, poor sleep, and chronic pelvic pain.
Sometimes I drop the issue of abuse during the history (which I always conduct in my office with the patient fully clothed), but raise the subject again while conducting the physical examination, especially if I note significant embarrassment or difficulty with breast or pelvic exams. I then might say something like: “You know, we often see this kind of tenseness and anxiety with exams in people who have been hurt in the past. Are you sure no one has ever hurt you—perhaps during an exam?” This can defuse the situation and allow a patient to open up, encouraged by your expertise and interest in her. She may feel safe enough to discuss experiences that have haunted her for many years.
—Barbara S. Levy, MD
REFERENCE
1. American College of Obstetricians and Gynecologists. Women’s Health Stats and Facts. Washington, DC: ACOG; 2002;11.-