Female Sexual Dysfunction (FSD)
It is estimated that approximately that at least 40 million American women are affected by FSD. Some investigators have found that sexual dysfunction is more prevalent in women (43%) than in men (31%), and increases as women. It has also been noted that married women have a lower risk of sexual dysfunction than unmarried women. Racial differences have also been noted. Hispanic women consistently report lower rates of sexual problems, whereas African American women have higher rates of decreased sexual desire and pleasure than do white women. Sexual pain (dyspareunia), however, is more likely to occur in white women.
Although the exact cause of FSD remains unknown, both physiologic and psychological components are believed to play a part. I order to better understand FSD is imperative to first understand the normal female sexual. Many changes occur in the female external and internal genitalia during sexual arousal. Increased blood flow promote what is called “ vasocongestion of the genitalia”. Secretions from uterine and vaginal glands lubricate the vaginal canal. Vaginal smooth muscle relaxation allows for lengthening and dilation of the vagina. As the clitoris is stimulated, its length and diameter increase and engorgement occurs. In addition, the labia minora becomes also engorged because of increased blood flow.
FSD is psychologically complex. While the female sexual response cycle was first characterized by Masters and Johnson in 1966 and included four phases: excitement, plateau, orgasm, and resolution, in 1974, Kaplan modified this theory and characterized it as a three-phase model that included desire, arousal, and orgasm. Other investigators have proposed that the female sexual response is driven by the desire to enhance intimacy. Currently, it is believed that various biologic and psychological factors can negatively affect this cycle, thereby leading to FSD. Hormonal changes, such has a drop in estrogen, seen in post-menopausal women, can also greatly affect sexual desire and vaginal lubrication. Nerve and small vessel disorders seen in conditions such as diabetes can also affect sexual function. Women with hypertension, vascular problems are at very high risk because of diminished blood flow going to the genitalia.
TreatmentFor many reasons, treatment options are more difficult and less established in women than in men. Firstly, the exact cause of FSD remains elusive. Secondly, dual psychologic and physiologic causes are often operative. While the oral tablets which fall in the category of phosphodiasterase-inhibitors (PDE-5) have been useful in male erectile dysfunction, they have little value in FSD. Hormonal manipulation, while often helpful in FSD, must be weighed very carefully against possible side effects such as weight gain or cardiovascular risks. Vacuum erection devices while available in women have not been widely used for clitoral engorgement and arousal disorders. Women with lubrication disorders can be treated with estrogen vaginal cream or lubricants. This often alleviates dyspareunia when present. Psychological counseling and sexual therapy have remained at the forefront of FSD related to sexual intimacy or psychologic disorders. Often, a multispecialty approach is most effective. Women suffering from FSD who desire treatment are best treated with clinicians specialized in the area.