Overview of Female Sexual

Dysfunction for the Primary Care

Physician
WVU WOMENS HEALTH CURRICULUM – Revisions 9/2008

Stanley Zaslau, MD, MBA, FACS

Program Director & Associate Professor
Division of Urology
West Virginia University
 Objectives - 1
 In this lecture, participants will learn:
– Incidence, epidemiology and pathophysiology
of Female Sexual Dysfunction
– Female pelvic anatomy
– AFUD Classification of Female Sexual
Disorders
– Clinical Evaluation of the Female Sexual
response
 Objectives - 2
 In this lecture, participants will learn:
– Treatment of FSD
 Oral agents
 Neutraceuticals

 Vacuum Clitoral Erection Device

 Potential novel therapies

 Incidence
 30 million men with compromised erectile
function
 Paucity of epidemiologic data regarding
incidence of female sexual dysfunction
– multi-causal
– multi-dimensional
– age-related
– progressive
– highly prevalent
 Incidence
 National Health and Social Life Survey
(1999)
– 1749 Women
 33% of women lack sexual interest
 25% of women do not experience orgasm

 20% of women report lubrication difficulties

 20% of women report sex is not pleasurable

Laumann E, Paik A, Rosen R. Sexual dysfunction in the United States:

Prevalence and predictors, JAMA 1999;281;537-544.
 Incidence
 Sexuality in Older Women (Diokno, 1990
and Mooradian 1990)
– 448 women over the age of 60
 66% are sexually inactive
 12% of married women had difficulty with
intercourse; 14% experienced dyspareunia
 Sexuality positively correlated with marital status

 Less likely to have sex if partners in poor health

Diokno AC, et al. Sexual function in the elderly. Archives of Internal Medicine
1990;150:197-200.
 Incidence
 Rosen (1993) Study
– 329 women age 18 to 73 years
– Most common areas of dysfunction
 38% lack of desire
 16% lack of pleasure

– Age and relationship status predict FSD

– single and older women highest incidence
Rosen (1993) Journal of Sexual and Marital Therapy
 Female Pelvic Anatomy
 Vagina
– Vascular supply, innervation and physiologic
changes
 Clitoris
– Vascular supply, innervation and physiologic
changes
 Vestibular bulbs
 Uterus
 Pelvic Floor Muscles
 Vagina-Anatomy & Blood Supply
 Labia minora surrounds vagina; protected by outer labia majora
 Labia minora enclose the vestibule which contains:
– Clitoris
– Vaginal opening
-- Urethral opening
 Innervation
– Autonomic
– Somatic motor fibers of S2-S4 innervate bulbocavernosis and
ischiocavernosus muscles
– Pudendal nerve—sensory to introitus
 Main arterial supply (extensive anastomosis)
– Vaginal branches of the uterine arteries
– Vaginal branches of the pudendal arteries
– Ovarian arteries
 Clitoris-Anatomy & Blood
Supply
 Erectile organ similar to the penis
 Blood supply
– Iliohypogastric-pudendal arterial bed
– Internal pudendal artery branches to form common
clitoral artery --> dorsal and cavernosal clitoral arteries
 Consists of fused midline corpora cavernosa
– Unable to trap venous blood
– With sexual stimulation, engorgement, rather than
erection occurs
 Vestibular Bulbs
 Paired, 3-cm structures along the vaginal orifice
 Homologous to corpus spongiosum of the penis
 Composed of vascular smooth muscle
 Arterial supply: branches of internal pudendal
artery
 Sensory innervation: posterior branches of the
pudendal nerve
 Uterus
 Uterine/cervical glands secrete mucus during
sexual arousal
 Uterine/pelvic procedures interrupt vaginal
innervation --> negative impact on later sexual
health
 Disruption of uterosacral and cardinal ligaments
can result in genital arousal and orgasm difficulties
 Role for nerve sparing procedures as similar to
those performed in men
 Pelvic Floor Muscles
 Pelvic diaphragm formed by:
– Levator ani muscles
– Urogenital diaphragm
– Peroneal membrane, composed of
 ischiocavernosus, bulbocavernosus and superficial
transverse perinii muscles
 Muscles pull rectum, vagina and urethra
anteriorly towards pubic bone
 Pelvic Floor Muscles
 Non-voluntary spasm of pelvic floor=vaginismus
 Laxity or hypotonia of pelvic floor, associated
with
– vaginal hypoanesthesia
– anorgasmia
– incontinence
 Question all women with voiding dysfunction
about their sexual function!!
Female Sexual Physiology:
Normal
 Physiological changes during arousal
– Enlargement of clitoris
– Dilation of arterioles, increased vaginal and clitoral
blood flow
– Seeping of vascular transudate across vaginal
membrane ---> lubrication
– Expansion and tenting of upper 1/2 of vagina
– Response mediated by nitric oxide (role for
sildenafil)
 AFUD Classification and
Definition of Female Sexual
Disorders
 Consensus classification (AFUD Consensus Panel,
1998)
– Hypoactive Sexual Desire Disorder
– Sexual Aversion Disorder
– Orgasmic disorders
– Sexual pain disorders
 Dyspareunia

 Vaginismus

– Other sexual pain disorders

 Hypoactive Sexual Desire
Disorder
 Hypoactive sexual desire disorder
– Persistent or recurrent deficiency (or absence)
of sexual fantasies/thoughts or desire for a
receptivity to sexual activity
– Causes personal distress
– Differential diagnosis:
 surgical or medical menopause
 endocrine disorders
 Sexual Aversion Disorder
 Sexual Aversion Disorder
– Persistent or recurrent phobic aversion to and
avoidance of sexual contact with a sexual
partner
– Causes personal distress
– Results from:
 childhood trauma (physical or sexual abuse)
 Sexual Arousal Disorder
 Persistent or recurrent inability to attain or
maintain sufficient sexual excitement
 Causes personal distress
 Differential diagnosis: medical causes, prior
pelvic trauma, pelvic surgery, medications
 May be expressed as
– lack of subjective excitement or lack of genital
lubrication/swelling
 Orgasmic Disorder
 Persistent or recurrent difficulty, delay in or absence
of attaining orgasm following sexual stimulation
 Causes personal distress
 Primary (never attained orgasm)--emotional trauma
or sexual abuse
 Secondary
– Surgery
– Hormone deficiency
-- Trauma
 Sexual Pain Disorders
 Dyspareunia
– Recurrent or persistent genital pain with sexual
intercourse
– Consider:
 vestibulitis
 vaginal atrophy

 vaginal infection
 Sexual Pain Disorders
 Vaginismus
– Recurrent or persistent involuntary spasm of the
musculature of the outer third of the vagina that
interferes with vaginal penetration.
– Conditioned response to painful penetration
(?psychological or emotional)
Other Sexual Pain Disorders
 Herpes Simplex Virus
 Vestibulitis
 Prior genital mutilation
 Trauma
 Endometriosis
 Interstitial cystitis
Interstitial Cystitis (IC) and Female
Sexual Dysfunction (FSD)
 Pain associated with intercourse
– Entry dyspareunia
– Deep dyspareunia
 IC and FSD
 100 patients with IC
 FSFI administered
– Assess 6 domains of sexual function
 Desire
 Arousal
 Orgasm
 Lubrication
 Satisfaction
 Pain
Zaslau, et al. WVMJ 2008
 IC and FSD
 Results:
– Mean age 39 years
– Impairment in all domains “50-75% of the
time”
 Conclusions
– FSD in IC involves more than pelvic pain

Zaslau, S et al FSFF, Vancouver, BC 2002

 FSD in IC: 1st 400 Patients
 400 IC patients
 FSFI administered on line at IC-Network
 Compared to two groups
– Controls (131)
– Female sexual arousal disorder (129)
 FSD in IC 1st 400 Patients
 Results
– Statistically significant decrease in all domains
when compared to controls
– Stastically significant decrease in all domains
when compared to Arousal Disorder Group
– Lowest scores: pain
Zaslau, et al AUA 2003, Chicago, IL.
 Conclusions: IC and FSD
 Global sexual dysfunction affecting all
domains
 May be age related and progressive
 Pain domain has lowest scores
 Treatment is multimodal and may involve
counseling, sex therapy and physical
therapy
Etiologies of Female Sexual
Dysfunction
 Vasculogenic
 Neurogenic
 Hormonal/Endocrine
 Musculogenic
 Psychogenic
 Vasculogenic
 Risk factors: hypertension, hypercholesterolemia, smoking,
heart disease
 Associated with ED in men and sexual dysfunction in
women
 Diminished vaginal and clitoral blood flow
(atherosclerosis)
 Results in symptoms of vaginal dryness and dyspareunia
 Alteration of circulating estrogen levels: atrophy of vaginal
and clitoral smooth muscle
 Traumatic arterial disruption: pelvic fracture, blunt trauma,
surgical disruption, chronic perineal pressure (bicycle
riding)
 Neurogenic
 Spinal cord injury (SCI) to the central or
peripheral nervous system
 Diabetes mellitus
 Complete upper motor neuron lesions of the
sacral cord
 Incomplete SCI: capacity for psychogenic
arousal and vaginal lubrication
 Hormonal/Endocrine
 Disorders of the hypothalamic-pituitary axis
 Medical or surgical castration
 Premature ovarian failure
 Chronic birth control use
 Symptoms: decreased desire, vaginal dryness, lack
of sexual arousal
 Musculogenic
 Lavator ani muscles
 Perineal membrane
– bulbocavernosus and ischiocavernosus muscle
 Contraction contributes to arousal and orgasm
 Hypertonicity ---> vaginismus or dyspareunia
 Hypotonicity ---> vaginal hypoanesthesia, coital
anorgasmia, urinary incontinence during sexual
intercourse or orgasm
 Psychogenic
 Emotional and relational issues
– self esteem
– body image
– quality of the relationship with the partner
 Medications
– serotonin re-uptake inhibitors
 Clinical Evaluation of the
Female Sexual Response

 Medical/Physiologic Evaluations
 Psychosocial/Psychosexual Assessment
Medical/Physiologic Evaluations
 Full history, physical exam, pelvic exam
 Hormonal profile (FSH, LH, prolactin, free
testosterone, SHBG, estradiol)
 Evaluation of the sexual response
– Genital blood flow (Duplex doppler ultrasound)
– Vaginal pH
– Vaginal compliance/elasticity
– Genital sensation by vibratory perception
threshold
Psychosocial/Psychosexual
Assessment
 Address emotional and relational issues
 Subjective assessment of sexual function
– Brief Index of Sexual Function (BISF-W)
– Inventory of Female Sexual Function (IFSF)
 Therapy
 Sildenafil
 Dehydroepiandesterone (DHEA)
 Alprostadil (PGE1)
 Apomorphine
 L-arginine and Yohimbine
 Vacuum Clitoral Therapy Device
 Sildenafil and Female Sexual
Dysfunction
 33 post menopausal women in prospective study
 Excluded: heart disease, uncontrolled psych
disorder, poorly controlled DM, alcohol abuse,
CVA, history of MI or concurrent nitrate therapy
 Took sildenafil 50 mg 1 hour prior to planned
sexual activity
 Given a 9 item Index of Female Sexual Function
Questionnaire
 Sildenafil and Female Sexual
Dysfunction
 Results
– 3 patients dropped out because of adverse
effects
 Clitoral hypersensitivity in 7 (21%)
 Headache, dyspepsia, dizziness

– No differences in intercourse satisfaction and

sexual desire after 3 months of therapy
– Women on HRT had an increased overall score
(not statistically significant)
 Sildenafil and Female Sexual
Dysfunction
 Comments
– No placebo arm
– Raises several questions
 What is the potential role for other oral agents such
as phentolamine and apomorphine?
 Would higher doses of sildenafil produce a better
response?
 Role for combination therapy?

 Role for topical therapy?

 Sildenafil in SCI Women
with FSD
 50% of women achieve orgasm regardless of
injury type (complete vs. incomplete)
 Sildenafil given to 19 women with SCI
 Results in significant increases in
– subjective arousal
– sexual stimulation
– heart rate and decreases in blood pressure
Sipski M, Grand Master Lecture #2, Female Sexual Function Forum, 2000
Sildenafil for FSD in Women
with Depression
 50% of patients on SSRI have some sexual
dysfunction
 Study: 10 women with depression on SSRI with
FSD
 50 mg sildenafil prior to sexual activity
 Results: 9/10 had reversal of anorgasmia or
delayed orgasm; most with 1st dose of sildenafil
Hensley et al. Sildenafil for Iatrogenic Seritonergic antidepressant medication induced sexual
dysfunction. Female Sexual Function Forum, 2000.
 Sildenafil after
Hysterectomy?
 35 women evaluated after hysterectomy
 BISF-Q survey used for pre/post treatment assessment
 100 mg sildenafil given for 6 weeks
 Results:
– “Improved” sensation
– “Improved” ability to reach orgasm
– “Decreased” pain and discomfort
Berman, et al. Hysterectomy and Sexual Function: A Role for Sildenafil?, Female Sexual Function Forum,
2000.
 Dehydroepiandosterone
(DHEA)
 Adrenal gland hormone, precursor to sex steroids testosterone and
estradiol
 Given in daily doses of 50, 75 and 100 mg
 Included women with sexual dysfunction for more than 6 months and low
testosterone levels
 Treatment duration 2 to 6 months
 Results:
– Increase in mean and free testosterone levels
– Improvement in Sexual Distress Scale Scores
Suggests: DHEA may be useful for women with FSD and low
testosterone
Munnariz, et al. Lowered Personal Sexual Distress Scale Scores Following DHEA Treatment for
Multi-dimensional FSD and Low Testosterone. Female Sexual Function Forum, 2000.
 Topical Alprostadil
 1% alprostadil formulation (0.25 mL gel)
 Placed on glans penis, allowed to dry, then vaginal
intercourse
 36 healthy volunteer couples (16 treatment; 16 controls).
All men had Erectile Dysfunction
 Results:
– No changes in vital signs in either partner
– Females: some noted improved clitoral/vaginal
sensation

Taintor, et al. Tolerance of Topical PGE1 Gel as a Topical Treatment for Erectile Dysfunction
during Vaginal Intercourse, Female Sexual Function Forum, 2000.
 Alprostadil (PGE1) Pellets
 2 women with vaginismus
 Given 1000 mcg alprostadil pellets to insert
vaginally prior to sex
 Evaluated after for improvement in vaginal muscle
spasm
 Results:
– both able to have intercourse without difficulty

Benet, A. Intravaginal Alprostadil Pellets for Treatment of Vaginismus, Female Sexual

Function Forum, 2000.
 Intranasal Apomorphine
 Acts centrally to facilitate erectile response
 12 healthy women studied at 3 doses of
Apomorphine
 Pharmacokinetics, nasal tolerance well tolerated
thus far.
 Efficacy studies “at-home” currently underway

Khan, et al. Evaluation of Nasal Apomorphine for FSD and Male ED as a function of dose, Female
Sexual Function Forum, 2000.
 Neutraceutical Therapy
 Contents: Gingko balboa, Korean ginseng, L-
arginine, calcium, iron, zinc and multi-vitamins
 93 women (age 22-73 years); 46 treatment and 47
controls
 Subjects:
– 58 premenopausal women
– 16 perimenopausal women
– 19 post menopausal women
 Neutraceutical Therapy
 Results:
– PERI:
 73% improvement in sexual desire

 73% improvement in clitoral sensation

 73% improvement in sexual satisfaction

– POST:
 64% improvement in sexual satisfaction

– PRE:
 71% increase in sexual desire

 68% increase in sexual satisfaction

Trant A. Clinical Study on a Nutritional Supplement for the enhancement of Female Sexual
Function, Female Sexual Function Forum, 2000.
 L-arginine & Yohimbine
 6 g arginine and 6mg yohimbine
 23 post menopausal women with female sexual arousal
disorder
 Physiological arousal measured by vaginal pulse amplitude
 Subjective arousal measured by questionnaire
 Erotic film shown after medication given
 Results:
– Increased VPA responses vs. placebo at 60 minutes but
not 30 or 90 min.
– Drugs reach peak plasma levels at 40 min

Meston CM. The effects of L-arginine and Yohimbine in Sexual Arousal in

Postmenopausal Women with Female Sexual Arousal Disorder, Female Sexual
Function Forum, 2000.
 Vacuum Clitoral Therapy
Device
 Treatment designed to increase clitoral blood flow,
enhance clitoral engorgement and improve arousal
 32 subjects (20 with FSD and 12 without FSD)
 Results:
Parameter FSD No FSD
Greater sensation 90% 58%
Increase lubrication 80% 33%
Ability to achieve orgasm 55% 42%
Increased sexual satisfaction 80% 25%
 Vacuum Clitoral Therapy
Device
 Results:
– No side effects noted with use of device
– Study by same authors in 5 diabetic women
with FSD
Parameter Diabetic with FSD
Greater sensation 4/5 (80%)
Increase lubrication 3/5 (60%)
Ability to achieve orgasm 3/5 (60%)
Increased sexual satisfaction 4/5 (80%)

Billups et al. Vacuum Induced Clitoral Engorgement for treatment of Female Sexual Dysfunction,
female Sexual Function Forum, 2000.
 Conclusions
 An exciting area applicable to all
physicians.
 Physicians need to learn through research
and patient care about:
– Epidemiology
– Diagnosis
– Pathophysiology
– Treatment
 References
 Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et
al. The female sexual function index (FSFI): A multidimensional
self-report instrument for the assessment of female sexual function.
J Sex Marital Ther . 2000;26:191-208.
 Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy
J, et. al. Report of the International Consensus Development
Conference on Female Sexual Dysfunction: Definitions and
classifications. J Urol. 2000;163:888-893.
 Nicolosi A, Laumann EO, Glasser DB, Moreira ED, Pail A, and
Gingell C. Sexual Behavior Sexual Dysfunctions Age 40: The
Global Study of Sexual Attitudes and Behaviours. Urology.
2004;54(5): 991-997.
 References
 Laumann EO, Paik A, Rosen RC: Sexual Dysfunction in
the United States: Prevalence and Predictors. JAMA. Feb
10, 1999: Vol 281, No 6: 537-544.
 Peters KM, Killinger KA, Carrico DJ, Ibrahim IA, Diokno
AC, and Graziottin A: Sexual Function and Sexual Distress
in Women with Interstitial Cystitis: A Case Control Study.
Urology. 2007; 70(3): 543-547.
 Zaslau S, Triggs J, Morgan L, Osborne J, Subit M, Riggs
D: “Characterization of Female Sexual Dysfunction in
Patients with Interstitial Cystitis.” Presented at the
American Urological Society Meeting, Chicago, IL, April
27, 2003.
 References
 Zaslau S, Subit MJ, Mohseni HF, Riggs D, Jackson B,
Kandzari S: “Sexual Dysfunction in Patients with
Interstitial Cystitis.” Presented at the American
Urogynecology Meeting, Hollywood, FL, September 12,
2003.
 Zaslau S, Subit MJ, Mohseni HF, Riggs D, Jackson B,
Kandzari S. “Sexual Dysfunction in Patients with
Interstitial Cystitis: Initial Analysis of Under 40 Cohort.”
Presented at the Mid-Atlantic Section of the American
Urological Society Meeting, Boca Raton, FL, October 26-
29, 2003.