The DSM-IV defines female sexual arousal disorder as persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate physiologic response (lubrication, swelling) of sexual excitement.’ It is analogous to erectile dysfunction in men. In women, however, it may be difficult to distinguish this condition from primary desire disorder, particularly in cases in which a pattern of poor arousal, dryness, and dyspareunia has developed. The hallmark of female sexual arousal disorder is a failure to lubricate.
A few simple questions
Among the questions you might ask the patient:
- Do you feel interested in sexual activity?
- Do you have a problem lubricating well?
- Do you use a lubricant for sexual activity? If so, does it work to make sexual intercourse comfortable?
Other variables to consider.
Arousal occurs secondary to genital vasodilation and tissue engorgement. It may be disturbed by any physiologic condition that reduces blood flow, such as smoking, hypertension, diabetes, and hypoestrogenism. Decreased sensation sometimes may contribute to arousal disorder. For example, when the vagina and external genitalia experience decreased sensation, the cause may be physiologic, neurologic, or supratentorial. Unlike men, women experience very little direct feedback regarding arousal. A disconnect between the sensory afferent input and higher-level awareness is not unusual. A thorough physical and neurologic exam may be necessary to assess the sensory nerves, integrity of the skin (signs of any inflammation), and blood flow to the genitalia. Referral to a therapist also may be necessary so that other barriers to intimacy and sexuality can be determined.
Pain during sex can trigger desire and arousal disorders
Pain during sexual activity can lead to disorders of desire as well as arousal. When a patient reports pain during sex, pay careful attention to her medical history and perform a detailed physical examination. Patience is vital. Successful treatment of pain disorders requires commitment from the patient and her partner as well as the medical team.Consider asking the following questions:
- Over the past 4 weeks, how often have you experienced discomfort or pain during vaginal penetration?
- How often have you experienced discomfort or pain following vaginal penetration?
- How would you rate your degree of discomfort or pain during or following vaginal penetration?
Consider pain as a cause when any patient reports low libido, as pain is a potent suppressor of desire. A meticulous clinical history is required to determine the cause. For example, it is important to uncover whether the pain is of recent onset or of long duration, or whether it is related to childbirth, lactation, or menopausal changes.Pain upon penetration could be caused by chemical, infectious, or atrophic vulvo-vaginitis. Dryness and pain upon penetration are often caused by:
- contact dermatitis
- irritation from soaps or scrubbing
- daily use of panty liners
- use of so-called feminine hygiene products
- regular use of swimming pools or hot tubs that contain chemicals.
Another cause of pain to consider is vulvar dystrophy. When lichen sclerosis or hypertrophic dystrophy goes untreated, the result may be fibrosis, lack of elasticity, painful fissures, and loss of normal architecture. These changes usually occur in post-menopausal women, so it is important that treatment address both the fibrosis and the hypoestrogenic atrophy.
If treated early, vulvar vestibulitis may not require surgery.
Vulvar vestibulitis is poorly understood. It tends to occur most often in premenopausal women, frequently as a result of vulvar infection or during the postpartum period.
Vulvar vestibulitis involves point tenderness-sometimes experienced as a burning, searing sensation-around the introitus, specifically, the vestibular glands. When this condition is suspected, examine the vulva and vestibule with a moistened cotton swab to assess whether the classic distribution of pain is present. The necks of the vestibular glands may appear inflamed and erythematous.
If the condition is treated early enough with topical steroids and, in some cases, hydroxyzine, surgery may be avoided, provided the patient also avoids topical irritants. In many women, however, vestibulectomy is required to eliminate symptoms.
Vulvodynia may be associated with other pain syndromes.
This disorder is a more generalized pain syndrome that involves the entire vulvar region. Like vulvar vestibulitis, it can cause painful penetration. It is also associated with other pain syndromes, including interstitial cystitis and endometriosis. Sensitization to pain at a central level may lead to hyperesthesia and allodynia. Also consider pudendal neuropathy, especially if the patient is a regular bicycle rider.
Treatment usually consists of off-label use of neuromodulators, such as gabapentin, tricyclic antidepressants, or duloxetine. The use of topical local anesthetic creams or gels may also permit pain-free sexual activity.
Vaginismus may indicate a history of sexual abuse
When the perineal muscles surrounding the outer third of the vagina contract involuntarily upon contact with a penis, speculum, or other item, vaginismus may be present. This disorder can be primary or secondary. In primary vaginismus, the patient may be unable to tolerate any vaginal penetration at all, not even a single digit or tampon. When this is the case, the patient may have a history of childhood sexual abuse. Explore her history, includin any medical examinations that may have been painful or generated fear and anxiety. Also be aware that women with sexual aversion disorder may present with primary vaginismus.
Secondary vaginismus can occur even after years of satisfying sexual activity when a woman undergoes pelvic reconstructive surgery or develops vulvar dystrophy or vulvovaginal atrophy. Pain or the fear of pain can trigger a powerful reflex spasm of the levator animusculature. Also keep in mind that secondary vaginismus may not be reproducible during the pelvic examination.Treatment of both primary and secondary vaginismus includes physical therapy.