Reproductive and Sexual Health Handbook

Female sexual function will vary depending on age, stage of relationship, gender, cultural or religious background and degree of personal comfort. Often normality in relation to female sexual function is defined in terms of sexual frequency per week, but ‘normal’ can also encompass the type of activity that individuals feel is acceptable. For example, in the past, masturbation was considered to be abnormal or ‘sinful’, whereas we now consider masturbation to be a ‘normal’ activity within the range of sexual activities that a person or couple might utilise. Sometimes there may be external pressure to conform to a ‘normal’ sexual frequency or to agree to an activity that makes an individual uncomfortable. Saying ‘no’ to something does not mean that person is not ‘normal’.

The Female Sexual Response Cycle was originally described by Masters and Johnson in the 1960s.⁽¹⁾ The lineal model is characterised by a gradual sequential progression of events culminating in orgasm. Helen Kaplan added the concept of ‘desire’ to the beginning of this graph in 1979 to be more representative.⁽²⁾ See Figure 17.1 below.

Figure 17.1 Sexual response cycle

 

This linear model has been found to be only marginally useful for describing the sexual response in women, which can include many variables and outcomes. However, it is from this graph of sexual function that the categories of female sexual dysfunction were first described in the Diagnostic and Statistical Manual of Mental Disorders (DSM 2) in 1968.⁽³⁾

A more recent model (Figure 17.2), described in 2000 by Rosemary Basson,⁽⁴⁾ was developed in recognition of the importance of intimacy, respect, touch and communication in women’s sexual response. Rather than relying purely on physical changes such as genital engorgement with a linear approach from desire to orgasm and resolution, Basson’s model recognises a range of different responses and motivations for engaging in sexual intercourse that results in a more circular pattern.⁽⁴⁾

 

Female sexual function is complex, as can be appreciated by the evolution of our understanding and models of function (described above). Logically, sexual dysfunction in women is therefore also often multifaceted, usually with several factors contributing to the problem. When diagnosing and treating sexual dysfunction in women, it is important to identify the particular issues and contributing factors in each individual case and employ targeted strategies. Consider what is driving the presentation, and whether these issues are causing them distress or if they are distressing to their partner and/or relationship.

The most common female sexual dysfunctions are:

lack of libido (reduced desire) lack of arousal orgasmic disorders sexual pain/dyspareunia

It is common to have more than one female sexual disorder present. Any overlap may make it difficult to attribute symptoms and signs to different diagnostic categories (see Table 17.1 and Table 17.2).

Table 17.1 Medical Conditions that may affect female sexual function

Conditions Effect  Diabetes  Impaired arousal and orgasm  Hypothyroidism  Decreased desire  Hypertension⁽⁷⁾ Reduced vaginal lubrication

Less frequent orgasm

Increased sexual pain Cardiovascular disease⁽⁸⁾ Reduced desire 

Impaired blood flow 

Reduced arousal response  Neurological disease e.g. Parkinson’s disease, multiple sclerosis, injury  Impaired arousal and orgasm  Decreased androgens e.g. age  Decreased desire  Decreased oestrogens e.g. menopause, chemotherapy  Vaginal atrophy and dryness  Hyperprolactinaemia e.g. prolactinoma, medications  Decreased arousal and orgasm  Pelvic floor weakness or injury  Decreased arousal

It is often difficult for women to distinguish between desire and arousal. If relevant, these may need to be discussed and distinguished by the clinician.

Decreased desire, previously known as hypoactive sexual desire disorder (HSDD), is common in women and is often difficult to treat. Desire is an element of a sexual relationship that is often discrepant, i.e. one partner has a higher desire than the other, and in the past the couple may have compromised more, however it has now become a problem.

Sexual desire naturally decreases with age and with the length of a relationship.

Pregnancy, lactation and child rearing can also have an impact on both the time and the opportunity for having sex. A woman’s attitude to their body and to sexual intercourse may be affected by their self-esteem, and past or current physical, emotional or sexual abuse can also result in a lack of desire.

If a patient has low desire but enjoys sex once they are engaged in sexual activity then the outcome is more likely to be positive. In dealing with issues of desire it is important to explore any issues within the relationship as well as the patient’s perception of themselves and their attitude to sex.

The most common clinical presentation for decreased arousal is genital sexual arousal disorder of menopause. This responds clinically to the use of systemic and/or topical oestrogen for genital symptoms of vaginal dryness and dyspareunia.

In premenopausal women it is more common to have combined subjective and genital arousal disorder. Subjective arousal is the change in a woman’s feelings and interest in initiating or continuing sexual activity, whereas genital arousal is the physical response to stimuli such as engorgement of the clitoris on clitoral touch, vaginal expansion or ballooning and erection of nipples following nipple stimulation.

In younger women, a lack of initial desire can often be overridden during foreplay and the genital response will allow penetrative sex to be pleasurable, whereas in older women the genital response may be diminished or lacking as well as the subjective interest.

Desire and arousal disorders have been merged and re-named as “Female Sexual Interest and Arousal Disorder (FSIAD)”.  In order to make a diagnosis, the problem(s) must be causing an element of distress.

Sexual aversion disorder has been deleted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) due to limited empirical data and the strong link to other phobias and anxiety disorders. Sexual aversion disorder was defined as the persistent or recurrent extreme aversion to, and avoidance of, genital sexual contact with a sexual partner.⁽²⁰⁾ Distinguish from FSIAD by careful history taking; ask if sexual contact provokes withdrawal, aggression, disgust, tears, panic or other negative feelings or behaviours. The patient may have a history of sexually negative experiences such as sexual abuse or sexual assault. In many cases, specialist referral for psychological/psychiatric treatment is required.

A diagnosis of female orgasmic disorder (FOD) requires that in 75-100 per cent of occasions of sexual activity there is an experience of markedly delayed, markedly infrequent or absent orgasms, or markedly less intense orgasms. The symptoms must be present for six months and not be explained by other causes. Clinically this involves difficulty achieving orgasm, substantially decreased intensity of orgasm, or both.

 

The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) has merged dyspareunia and vaginismus into a new category of genito-pelvic pain/penetration disorder.

To qualify, one of the following should be persistent or recurrent:

difficulty in vaginal penetration marked vulvovaginal or pelvic pain during penetration, or attempt at penetration fear or anxiety about pain in anticipation of, during, or after penetration tensing or tightening of pelvic floor muscles during attempted penetration

This represents a spectrum from dyspareunia to vaginismus. The patient’s history may include a range of penetration difficulties including inability to use tampons, inability to achieve finger penetration of the vagina, difficulty with gynaecological examinations, difficulty with intercourse and inability to achieve penetration.

It is important to exclude underlying physical causes, including:

pelvic floor muscle dysfunction vulvodynia (mostly chronic pain and does not usually lead to pain with penetration) vestibulodynia imperforate hymen infection such as Candida, chronic Group B streptococcal infection (not colonisation) pelvic infection (usually deep dyspareunia not superficial penetration) trauma (sexual assault, rough sex, dermatological conditions) menopausal atrophy endometriosis (usually deep pain not superficial entry pain)

For more information also see Chapter 4: The Vagina and Vulva.

Genito-pelvic pain disorders usually benefit from a multidisciplinary team approach. Women’s health physiotherapists are very skilled in the measurement and management of increased pelvic tension

Clinical presentation of vaginismus consists of severe pain with penetration or where penetration is impossible due to involuntary spasm/contraction/reflex of the muscles surrounding the entrance to the vagina. It is important to differentiate between primary vaginismus which is present from the first attempts at penetration, and secondary vaginismus where there has been a previous history of successful penetration. Primary vaginismus is often associated with a history of sexual abuse or sexual trauma. If sexual aversion disorder is also present referral for psychological counselling is required as well as the use of vaginal trainers to learn to relax the pelvic muscles.

The use of vaginal trainers or dilators as a desensitisation program is the first line treatment for both primary and secondary vaginismus. Refer the patient to a specialist physician, psychologist or pelvic floor physiotherapist who specialises in this treatment. Reasons for failure to progress with vaginal trainers may include the following:

relationship issues fear of pregnancy power dynamics lack of priority dislike of self-touch resentment at having to do this feelings of failure lack of belief in change

As a second line therapy, psychological counselling may be useful if any of the above is present.

Injection of botulinum toxin into the pelvic floor muscles is a third line option. This is performed

As women age, they may experience a marked decrease in sexual activity and interest in sex than men. They may also experience less distress than men or younger women with the same symptoms, which may well reflect various psychosocial factors. For women, life stressors, contextual factors, and past sexuality and mental health problems are more significant predictors of older women maintaining their sexual interest than physiological status alone.^{(21, 22, 23)} These include the presence or absence of a partner, their health, and their relationship and life satisfaction.

The clinician’s role is to evaluate both psychosocial factors and the physical status of patients. Questions you might ask to explore any difficulties being experienced in sexual functioning include:

“Some people find their sexual functioning has changed as they age. Has this happened for you?” “Many people explore intimacy in their relationships in other ways if they experience any sexual problems or difficulties with intercourse. Is this something you have considered?”

Normal changes in sexual function in older women can include:

decreased clitoral engorgement decreased vaginal lubrication decreased breast swelling decreased vasovaginal congestion diminished preorgasmic sweating diminished orgasm intensity vulvovaginal atrophy related to diminished oestrogen levels

Common diseases in ageing and their treatments may also impact on sexual

Australia New Zealand Vulvovaginal Society – patient information leaflets

Australian Physiotherapy Association – to find a Women’s Health physiotherapist

Mayo Clinic

Diseases and conditions: Anorgasmia in Women

Cornell Health

Sensate focus

Vaginismus: Hope & Her – helping women overcome sexual pain

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