Jennifer Berman

FEMALE SEXUAL DYSFUNCTION

The focus of this book is men and their sexual function and dysfunction, however, many women will also develop some degree of sexual health problems concerned with sexual desire, arousal, orgasm, and/or pain. The goal is to make relevant evidence-based clinical information to help identify and treat specific biologically based pathophysiologies available to the motivated health care professional. The prevalence of sexual problems among adult women is estimated to be 43%. A basic physiological principle is that the structure-function of a woman’s genitalia is highly dependent on the sex steroid hormonal milieu. As a woman ages, her supply of sex steroid hormones diminishes significantly. Biologically focused management of women’s desire, arousal, and orgasm sexual health concerns operates under the premise that physiological processes can be altered by pathology, for example, hormonal deficiency. From the perspective of biology-focused clinicians, the essential principle guiding their medical decision making is identification of the underlying pathophysiology of the sexual dysfunction. If the biological basis of the desire, arousal, and orgasm dysfunction can be diagnosed, management outcome may be successfully directed to the source pathophysiology using various evidence-based available treatment options.

Seeking help for sexual function complaints: what gynecologists need to know about the female patient's experience.

OBJECTIVE To further explore the patient experience of seeking help for a sexual function complaint. DESIGN Survey administered on a Web-based instrument. SETTING Healthy volunteers visiting an online Website. PATIENT(S) The majority of participants were married (73%), Caucasian (88%), and premenopausal (67%). Most commonly reported sexual complaints included low desire (77%), low arousal (62%), and difficulty achieving orgasm (56%). INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Patient experience survey on a womens sexual health website. RESULT(S) Although 40% of the women reported that they did not seek help from a physician for sexual function complaints, 54% reported that they would like to. Although only a minority of the women internalized their experience with extremely negative emotions like shame, devaluation, or disgust, the experience was not a particularly emotionally positive one along the lines of relief, optimism, or confidence, and a great deal of frustration and anxiety about treatment was reported. CONCLUSION(S) The extent to which health professionals currently receive exposure to training in human sexuality as well as the way in which female sexual complaints are handled in the medical setting remain ambiguous. The inflow of patients with sexual function complaints only will increase, and it is time for physicians to start to acknowledge womens sexuality with the same importance their patients do.

Anatomy and Physiology of Female Sexual Function and Dysfunction

Female sexual dysfunction is a significant age–related, progressive and highly prevalent problem that affects a substantial number of women in the United States. The female sexual response cycle is initiated by neurotransmitter–mediated vascular and nonvascular smooth muscle relaxation resulting in increased pelvic blood flow, vaginal lubrication, and clitoral and labial engorgement. These mechanisms are mediated by a combination of neuromuscular and vasocongestive events. Physiological impairments that interfere with the normal female sexual response bring about complaints associated with diminished sexual arousal, libido, vaginal lubrication, genital sensation, and ability to achieve orgasm. Therapy aimed at restoring hormone levels as well as genital blood flow will be discussed.

Female sexual dysfunction: anatomy, physiology, evaluation and treatment options.

It has been estimated that up to 76% of women, depending upon their age, have complaints of sexual dysfunction, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm. Female sexual dysfunction is a significant problem that affects the quality of life of many women. This review addresses the etiologies and incidence of female sexual complaints, as well as new findings in the evaluation and treatment of female sexual dysfunction.

Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and Classifications

83 Address correspondence to Rosemary Basson, Echelon Bldg., Vancouver Hospital, 855 W. 12th Avenue, Vancouver, B.C., Canada V5Z 1M9. E-mail: sexmed@interchange.ubc.ca Supported by the Sexual Function Health Council of the American Foundation for Urologic Disease through educational grants provided by Affiliated Research Centers, Eli Lilly/ICOS Pharmaceuticals, Pentech Pharmaceuticals, Pfizer Inc., Procter & Gamble, Schering-Plough, Solway Pharmaceuticals, TAP Pharmaceuticals, and Zonagen. Financial interest and/or other relationship with Affiliated Research Centers, Astra, Bayer AG, Bristol-Myers, Eli Lilly, Fournier Group, Glaxo Wellcome, Lilly/ICOS, Matrix Pharma, NexMed, NitroMed, Pentech, Pfizer Inc., Pfizer Canada Ltd., Pfizer UK, Pharmacia & Upjohn, Procter & Gamble, Scherling-Plough, Senetek, Shwarz-Pharma, Solvay Pharmaceuticals, Syntec, Syntex, TAP Pharmaceuticals, Vivus and/or Zonagen. This article originally appeared in The Journal of Urology, volume 163, pages 888–893 and is reprinted with permission of the publisher. Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and Classifications

Correlation of androgen receptors, aromatase, and 5-α reductase in the human vagina with menopausal status

OBJECTIVE To determine whether aromatase and 5alpha-reductase mRNAs are expressed in human vagina and to evaluate the presence of androgen receptors in human vaginal tissue based on age and menopausal status. DESIGN Prospective study. SETTING Specimens obtained from clinical renal urology practice. PATIENT(S) Premenopausal and postmenopausal women undergoing surgery for prolapse or incontinence. MAIN OUTCOME MEASURE(S) Expression of aromatase and 5alpha-reductase type 1 and 2 mRNAs was evidenced by reverse transcriptase-polymerase chain reaction (RT-PCR), and the density of androgen receptors was measured by semiquantitative immunohistochemistry. RESULT(S) The mRNAs for aromatase and 5alpha-reductase isotypes 1 and 2 were detected in vaginal specimens. Androgen receptors were present in vaginal mucosa, submucosa, stroma, smooth muscle, and vascular endothelium. Expression was significantly greater in vaginal submucosa. A negative correlation existed between age and androgen receptor density. CONCLUSION(S) Expression of genes encoding for enzymes involved in testosterone metabolism in the human vagina, as well as androgen receptor location, density, and changes with menopausal status, suggests that androgens may play a role in regulating vaginal smooth muscle and vaginal blood flow.

Female Sexual Dysfunction: New Perspectives on Anatomy, Physiology, Evaluation and Treatment

Abstract Female sexual dysfunction is age-related, progressive and highly prevalent, affecting 30–50% of American women. While there are emotional and relational elements to sexual function, it has become increasingly evident that female sexual dysfunction can occur secondary to medical problems and has an organic basis. A plethora of different female sexual dysfunctions exist and in order to obtain a greater understanding of the possible treatments for these problems, it is essential to have a strong knowledge base of female pelvic anatomy, the neurogenic mediators of female sexual response, the impact of hormones on female sexual function and the etiologies of female sexual dysfunction. Currently, there are potential therapeutic options for the treatment of female sexual dysfunction and these options include both hormonal and pharmacological therapy. However, therapeutic agents may not prove to be enough and the ideal approach to female sexual dysfunction is thus a collaborative effort between therapists and physicians, which should include a complete medical and psychosocial evaluation, as well as inclusion of the partner or spouse in the evaluation and treatment process.

Impact of pelvic floor disorders and prolapse on female sexual function and response

Pelvic floor disorders and FSD are prevalent and challenging problems. These disorders include prolapse of the uterus, cervix, vagina, bladder, and rectum and incontinence. These diseases likely affect womens sexual well-being through physical and emotional effects. Women with pelvic floor disorders often have co-existing urologic and sexual complaints. Patients who present with these urologic problems should be questioned about their sexual function. Surgical treatment in these patients may be curative of their sexual disorders (e.g., by repairing incontinence) but may also have undesired effects on sensation, blood flow, and the anatomy. These effects can affect sexual arousal and orgasm or cause dyspareunia. It is hoped that a better understanding of the anatomy of this area will guide us in a more targeted approach to management of these conditions.

Hemodynamic Evaluation of the Female Sexual Arousal Response in an Animal Model

The goal of this study was to assess the utility of existing and new techniques for characterizing and measuring hemodynamic changes in the vagina and clitoris in response to pelvic nerve stimulation (PNS) in an animal model. Using female New Zealand White rabbits, we measured the following parameters before, during, and after PNS at 4, 16, and 32 hertz (Hz): clitoral hemoglobin (Hb) content by laser oximetry, clitoral blood flow by laser Doppler flowmetry, vaginal luminal pressure of upper and lower segments, and clitoral intracavernosal pressure. Clitoral tissue concentrations of total and oxygenated hemoglobin (oxy-Hb) increased in a frequency-dependent manner while deoxygenated hemoglobin (deoxy-Hb) concentration decreased. The duration of the responses at 16 and 32 Hz were significantly greater than at 4 Hz. Clitoral blood flow increased significantly only at 32 Hz with a prolonged response duration, relative to 4 Hz. PNS caused vaginal luminal pressure changes that were highly variable, but qualitatively different, between the upper and lower regions. Clitoral intracavernosal pressure did not change significantly in response to PNS. Measurement of changes in tissue Hb content by the novel technique of laser oximetry provides a direct assessment of blood flow in a noninvasive manner and may prove to be a powerful tool in evaluating hemodynamic aspects of the female genital sexual response.

The role of androgens in hormone replacement therapy

In recent years, increased attention to women’s sexual health has propelled basic scientific research and clinical trials investigating treatment paradigms for improving sexual well-being. As the prevalence of female sexual dysfunction has become manifest, knowledge of the intricate pathophysiological role of androgens in maintaining sexual function has fostered a clearer understanding of the effect of age on androgen status, the role of androgens in the postmenopausal ovary, and aetiological mechanisms of androgen insufficiency in premenopausal and postmenopausal women. Understanding the long-term safety and efficacy of physiological androgen replacement and the development of sensitive testosterone assays for specific use in women will better characterise women who are most likely to respond to androgen therapy and, thereby, optimise their quality of life.