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This page has moved. Click here to view. Sexuality and Sexual DysfunctionSexuality is an important and integral part of every woman's life. Questions and concerns about sexuality span a woman's entire lifetime, from questions about contraception during adolescence to concerns about changes in sexual function with menopause and aging sexuality, sexual dysfunction, vaginismus, impotence, low libido, painful intercourse, painful sex, dysparunia, disparunia. The obstetrician-gynecologist, as a primary health care provider for women, should include a sexual history as a routine part of a woman's periodic health assessment. In addition, obstetrician-gynecologists should obtain information about a history of Sexual Practices Two recent comprehensive surveys provide an interesting and useful description of the sexual behavior of Americans. Sexual activity among American adolescents has increased significantly during the past 20 years. The average age for first intercourse in both men and women is 16 years. By age 19 years, most women and men will have had intercourse. Most young men and A survey of American men and women between the ages of 18 and 59 years revealed that most women have concerns, that most (87%) are satisfied with their sex life (even those who rarely have sex), and that marriage is the most common setting for sexual relations. More than 90% of Americans marry, and about 40% divorce. There has been a slight increase in the lifetime number of sexual partners for Most Americans are monogamous. Seventy-five percent of the married men and 85% of the married women surveyed said they had never been unfaithful. There may be fewer men and women who are exclusively homosexual than previously thought. Kinsey and others estimated the incidence of exclusive homosexuality at about 10% of the population. About 3% of the men and 1.3% of the women surveyed said they had a homosexual partner in the past year. Since puberty, 7.1% of the men and 1.3 % of the Sexual History Despite the importance of sexuality in their lives, many women find it difficult to talk to their physicians about sexual concerns, and many physicians are uncomfortable with or unable to discuss sexual issues with their patients. Surveys of primary care physicians reveal that fewer than half ask their new patients about sexual practices and concerns. Many physicians make The Sexual-Response Cycle in Women The sexual-response cycle in women is mediated by the complex interplay of psychologic, environmental, and physiologic (hormonal, vascular, muscular, and neurologic) factors. The initial phase of the sexual-response cycle is desire, followed by For most women the clitoris is the most sexually sensitive part of their anatomy, and stimulation of the clitoris produces the greatest sexual arousal and the most intense orgasms. Other sexually sensitive areas are the nipples, breasts, labia, and to a lesser extent, the vagina. Whereas the lower third of the vagina is responsive to touch, the upper two-thirds of the vagina are sensitive primarily to Factors Affecting Sexual Response Intrapsychic Factors Sexuality can be inhibited by performance anxiety, low self-esteem, depression and anxiety, fear of intimacy, or guilt about sex and pleasure. Other causes include religious orthodoxy, anhedonic or obsessive-compulsive personality (these patients may lack the capacity for play and find it difficult to display emotion and "let themselves go"), transsexualism, concerns about pregnancy or Relationship Factors The way a couple functions sexually is often a good barometer of how things are going in the rest of the relationship. Therefore, whenever a woman presents with sexual concerns or sexual dysfunction, it is important to inquire about the relationship in The Sexual-Response Cycle Desire: Sexual desire is the motivation and the inclination to be sexual. It is a subjective feeling that may be triggered by both internal (fantasy) and external (an interested partner) sexual cues and depends on adequate neuroendocrine functioning. Desire is Arousal: The arousal (excitement) phase is mediated by the parasympathetic nervous system and is characterized by erotic feelings and the appearance of vaginal lubrication in women and erection in men. Sexual arousal increases blood flow to the Plateau: During the plateau phase, sexual tension, erotic feelings, and vasocongestion and the physiologic changes noted during arousal reach maximum intensity. Eventually, with adequate sexual stimulation, women reach the point of orgasmic inevitability (threshold point). Orgasm: Orgasm is a myotonic response mediated by the sympathetic nervous system and is experienced as a peak, then sudden release, of the tension that has built up during the arousal and plateau stages. Orgasm is the most intensely pleasurable of the sexual sensations. Orgasm consists of multiple (3-15) 0.8-second reflex rhythmic contractions of the Unlike men, who experience a refractory period after orgasm and are unresponsive to sexual stimulation for a variable length of time, woman are potentially multiorgasmic and are capable of experiencing more than one orgasm during a single sexual-response cycle. Thus, they can experience orgasms before, during, and after intercourse, provided that enough clitoral stimulation is provided. Resolution: After the sudden release of sexual tension brought about by orgasm, women experience a feeling of relaxation and well-being. The physiologic changes that took place during arousal are reversed, and the body returns to a Relationship causes of sexual dysfunction include lack of sexual attraction for the partner, poor lovemaking skills or sexual inexperience in one or both partners, marital conflict, or fear of closeness due to distrust of the partner or a sense of vulnerability. Couples may be sexually incompatible, with one partner making sexual demands the other is unable or unwilling to accommodate. Couples may have difficulty with the timing or means of initiating sexual activity, or they may have incompatible or very different levels of sexual desire. Spouse abuse, financial problems, concerns about children, and marital power and Gynecologic Problems Infertility evaluation and treatment can have a significant effect on a woman's body image and feelings of self-worth and self-esteem. Infertility may cause her to feel depressed, helpless, hopeless, unattractive, and sexually undesirable. The loss of sexual spontaneity, a goal-directed approach to sex, and the need for scheduled intercourse may lead to sexual dysfunction in both men and women. Breast cancer diagnosis and treatment also affect sexuality. However, most women cope well with the stress of breast cancer treatment and do not develop significant sexual dysfunction. A number of studies have compared women who undergo mastectomy with women who have conservative breast surgery (lumpectomy) and have found little difference between the two Aging and Menopause Aging and the cessation of ovarian function accompanying menopause can significantly affect the sexual-response cycle of women. Sexual desire and frequency of intercourse decrease as women age, although women remain interested in sex and continue to have the potential for sexual pleasure for their entire lives. A survey of healthy men and women living in Medical Problems Both acute illness (myocardial infarction) and chronic illness (renal disease or arthritis) can create depression, a distorted body Drugs A variety of prescription and nonprescription medications and illicit drugs can alter the sexual response in men and women. These include antihypertensives, thiazide diuretics, antidepressants (especially the selective serotonin reuptake inhibitors [SSRIs]), antipsychotics, antihistamines, barbiturates, narcotics, benzodiazepines, oral contraceptives, and recreational drugs like cocaine and marijuana. Alcohol also can affect sexual response. A number of hypertensive medications affect men. Sexual dysfunction, impotence, or anorgasmia can occur with SSRI use, especially with sertraline (16% of users versus 6.5% for paroxetine, 2% for fluvoxamine, and 1.9% for fluoxetine). Sexual Dysfunction The sexual dysfunctions include sexual-desire disorders (eg, hypoactive or inhibited sexual desire and sexual aversion), sexual-arousal disorders, orgasmic disorders, sexual-pain disorders (eg, vaginismus and dyspareunia), and sexual disorders due Although many physicians have some anxiety about discussing sexual issues with their patients and believe that they lack the basic skills to provide sexual counseling, most sexual concerns can be treated by a caring and concerned obstetrician-gynecologist. The PLISSIT (permission, limited information, specific suggestions, intensive therapy) model is a useful sexual counseling and Desire-Phase Disorders Inhibited sexual desire is the most common sexual dysfunction in both women and men and the most difficult to treat. Inhibited sexual desire is a deficiency or absence of sexual fantasies and desire for sexual activity, often leading to marked distress and interpersonal difficulty. Patients with inhibited sexual desire have Some individuals may experience sexual aversion, which is complete avoidance of all sexual activity with a partner. Desire-phase disorders are often accompanied by another sexual dysfunction like dyspareunia or anorgasmia. Physiologic causes of inhibited sexual desire include medications, chronic medical illnesses, depression, stress, substance abuse, aging, and hormonal alterations. There are physiologic reasons to believe that testosterone may be helpful in treating inhibited sexual desire in a certain subset of women, but clinical trials are needed. Androgens, which enhance sexual motivational activities, increase sexual desire, the number of fantasies, and the general level of arousal. Androgen titers need to be closely monitored to avoid masculinization and alterations in serum lipids. Some postmenopausal patients who experience dyspareunia secondary to vaginal atrophy may avoid intercourse. This condition will resolve with systemic or vaginal estrogen replacement therapy. Studies of sildenafil, used to treat erectile dysfunction in men, are currently being conducted to assess its effectiveness in treating women. Treatment of patients with inhibited sexual desire may require both individual therapy and relationship counseling. Insight-oriented psychotherapy may allow the patient to identify the negative feelings that inhibit her erotic impulses and to gain insight into the Orgasmic Dysfunction Orgasmic dysfunction in women is characterized by persistent or recurrent delay in or absence of orgasm after a normal sexual-arousal phase. Orgasmic dysfunction is more prevalent in younger and less sexually experienced women. Primary (lifelong) anorgasmia is found in approximately 5-10% of women and is more common than secondary (acquired) anorgasmia. Some women develop secondary anorgasmia because of relationship problems, depression, substance abuse, prescription medication (eg, SSRIs), chronic medical illness (eg, diabetes), estrogen deficiency, or Many women who are orgasmic with masturbation and during noncoital sex may be distressed because they are not orgasmic during intercourse, do not have multiple orgasms or an orgasm with every sexual encounter, or do not have an orgasm at the same time as their partner. Surveys of sexual behavior demonstrate, however, that most couples do not experience orgasm simultaneously, that many women achieve sexual satisfaction without having orgasms, and that many women are more likely to be orgasmic during foreplay, when they receive more direct and intense clitoral stimulation, than The most common psychologic cause of anorgasmia is obsessive self-observation and monitoring during the arousal phase (spectatoring), often accompanied by anxiety and distracting, negative, and self-defeating thoughts. A woman with orgasmic dysfunction may be so busy monitoring her own and her partner's responses and so concerned about "failing" that she is unable to relax enough to allow her natural reflexes to take over and trigger an orgasm. Inhibited orgasm may be related to a past history of sexual abuse, negative feelings toward sexuality, relationship problems, low self-esteem, poor body image, or fear of losing control. Numerous programs have been proposed for the treatment of orgasmic dysfunction. Treatment approaches include evaluation and treatment of medical and psychiatric disorders (including substance abuse), sex education, communication and sexual-skills training, marital therapy, group therapy, erotic fantasy, and counseling to reduce sexual anxiety and performance anxiety. The most effective treatment for primary anorgasmia is a program of directed masturbation with erotic fantasy. Success rates of 80-90% have been reported with this technique. Several excellent self-help books are available to help women learn how to Vaginismus Vaginismus is the recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with a penis, finger, tampon, or speculum is attempted. Vaginismus is an involuntary reflex precipitated by real or imagined attempts at vaginal penetration and can be global (the woman cannot place anything inside her vagina) or Medical conditions are rarely the cause of vaginismus, but conditions such as endometriosis, chronic PID, partially imperforate hymen, vulvodynia, and vaginal stenosis should be ruled out by a careful pelvic examination. The pelvic examination--which should be done, if possible, in the presence of the woman's partner--allows the physician to help educate the couple about normal female anatomy and may help dispel misconceptions about the size of the introitus and vagina. Providing the patient with a mirror so she can observe the examination is helpful. Because the etiology of vaginismus is usually psychophysiologic, patients with this condition should not have surgery to "enlarge'' their introitus unless they have a partially imperforate hymen or another valid indication for surgery. Treatment of vaginismus is directed toward extinguishing the conditioned involuntary vaginal spasm. This can be accomplished by helping the woman become more familiar with her anatomy and more comfortable with her sexuality, teaching her techniques to Dyspareunia Dyspareunia is genital pain that occurs before, during, or after intercourse in the absence of vaginismus. The repeated experience of pain during intercourse can cause marked distress, anxiety, and interpersonal difficulties, leading to anticipation of a negative sexual experience and eventually to decreased frequency of intercourse or to sexual avoidance. As with other sexual dysfunctions, dyspareunia can be generalized or situational, lifelong or acquired. Secondary dyspareunia occurs, on Patients who are anxious about sexuality because of sexual misconceptions, guilt, fear of pregnancy or STDs, or prior unpleasant sexual experiences may be unable to relax during lovemaking, leading to impaired arousal and Vulvar vestibulitis syndrome is a constellation of symptoms consisting of severe pain or burning on vestibular touch and attempted vaginal entry. Other symptoms that may be present include the following:
Psychologic factors can contribute to dyspareunia. Examples of psychologic causes include developmental factors such as an upbringing that invested sex with guilt and shame, traumatic factors such as sexual assault or childhood sexual abuse, and Erectile Dysfunction Erectile dysfunction is the inability to develop an erection or to maintain a rigid erection long enough for completion of intercourse. The term "erectile dysfunction" is preferable to impotence. Erectile dysfunction is common, affecting 10% of all men, and is age dependent, increasing as men age. The prevalence of erectile dysfunction in men aged 40-70 years is The oral medication sildenafil was recently introduced in the United States for the treatment of erectile dysfunction. It works by preventing the breakdown of cyclic guanosine monophosphate in the corpus cavernosum. Penile erections occur when sensory and tactile sexual stimulation initiates release of nitric oxide from the corpora cavernosa. Sildenafil prolongs the duration and increases the extent of cavernosal smooth muscle relaxation and blood flow, thereby enhancing and prolonging erection. Sildenafil (Viagra) does not enhance libido. To be active, sildenafil requires sexual stimulation and at least a partially intact penile nervous system. Its effect is |