The Complexities of Female Sexual Dysfunction

by Darline Turner Lee, Physician Assistant, ACSM Exercise Specialist

Article Last Reviewed: Sept. 9, 2006

“Men have their little blue pill,” states the pleasant looking thirty something woman in the television commercial. It’s the latest advertisement for a new “all natural” pill touted as the answer to decreased libido in women. It promises to restore desire and passion to women no longer interested intimacy. As if it were only that easy.

Female Sexual Dysfunction (FSD) is the global definition given to the terms used to describe female sexual dissatisfaction causing personal or relational distress. This global term has four subcategories delineated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV, American Psychiatric Association, 1994). These are the modified definitions proposed by Rosemary Basson et al (2000) in Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and Classifications. The Journal of Urology, 163: 888-893.

Hypoactive Sexual Desire Disorder (HSDD)-The persistent or recurrent lack of interest, thoughts about, desire for or receptivity to sexual activity.
Sexual Arousal Disorder-The persistent or recurrent inability to become or remain sexually stimulated.
Orgasmic Disorder-The persistent or recurrent difficulty, delay in attaining or complete absence of orgasm following sufficient sexual arousal.
Dyspareunia- Persistent or recurrent genital pain associated with sexual intercourse.

A woman faced with FSD can be afflicted with any one or a combination of the above disorders. These various presentations account for the difficulty that researchers, clinicians and pharmaceutical companies encounter as they try to develop effective treatments for women seeking sexual satisfaction.

Sexual arousal initiates a series of physiologic changes that are similar in men and women. Increased blood flow to the genitals results in engorgement of the genital tissue. As arousal increases, engorgement leads to enlargement of the genitals-penile erection in men and clitoral enlargement and retraction and vaginal lubrication in women.

The chain reaction culminates in ejaculation (climax) in men. Viagra and other medications work to enhance this chain of events. When men are able to obtain and sustain an erection sufficient enough to engage in sexual intercourse to the point of ejaculation, they report a satisfactory sexual response. This is a direct correlation.

In women, this direct correlation does not exist. Researchers have shown cases where women are stimulated and are experiencing the physical changes of increased blood flow, engorgement, clitoral enlargement and retraction and vaginal lubrication and yet still lack desire for sexual intercourse or report no feelings of sexual arousal. Because the correlation between physical arousal and a woman’s perception of arousal and desire don’t directly correlate, researchers and clinicians alike have been unable to develop one specific treatment for female sexual dysfunction.

Cindy Meston, PhD is an Associate Professor of Clinical Psychology at the University of Texas at Austin who has studied FSD extensively. The main focus of her work is this incongruence between physical arousal and psychological arousal in women.

“We have found that Viagra-like substances help with physiologic arousal, i.e. vaginal lubrication, but they don’t improve the psychological aspects of arousal in women. This has been stunning news to the scientific community and to the pharmaceutical companies in particular who had hoped to extend their successful treatment of sexual dysfunction to women.”

What seems to be the difference in women, why is sexual arousal and satisfaction so complex and so difficult to achieve in some women?

“There is a huge psychological component to sexuality in women. This is very different than what occurs in men,” says Meston.

Shelley Imholte is an independent clinical research coordinator in women’s sexuality for Professional Quality Research and for Women Partners in Health (WPIH), a local Obstetric/Gynecology practice.

“Until very recently, women did not talk about sexuality. Most mothers did not tell their daughters sex is something that they can enjoy. Women were not encouraged to explore what gives them pleasure or how to even enjoy being sexually stimulated. While this is all starting to change, there are very few places where women can get information about female sexuality or where she can talk about her sexual concerns. That is where I come in.” says Imholte.

“Patients coming in for their annual examinations often have concerns about sexuality but are reluctant to ask questions,” says Imholte. “Consequently, as the physician completes her exams and is about to leave, patients hastily ask questions about sexuality. Until our research unit was established, the physicians had to try to manage these complex issues within the scope and limited timeframe of an office visit. Now we have a whole system by which the physicians and nurse practitioners call me in, I talk with the patients, offer information and if necessary, arrange for a referral into Austin Center for Sexual Medicine (ACSM).”

ACSM and WPIH participate in numerous clinical studies exploring female sexuality and female sexual dysfunction. Patient N was on such a study.

“I had been experiencing decreased libido for about a year and then I had to have a hysterectomy due fibroids and endometriosis. That wiped out any desire that I had left. I was able to achieve orgasm, but the effort that it took to stimulate my body made it not worth it. I felt badly because I wanted to want sex, but I didn’t want it. When I heard about a study on female sexual dysfunction I signed up to see if I would be a candidate. I was one of few women chosen for the study and I had a great experience. My husband and I are doing great.”

According to Meston, Patient N’s situation is not uncommon. “Who would want to have sex if she’s experiencing pain?”

Patient N states she tried to discuss her discomfort and her sexual problems with her primary physician and was told to drink more water and to exercise.

It is very common for women to receive misinformation or no viable information with which to address their problems. They don’t know where to turn. Patient N was fortunate. Many more women are not so fortunate.

Patient K has also been fortunate enough to be referred to WPIH and has had the opportunity to address her sexual issues with Imholte.

“I have sexual desire and interest. It just seems that my body is slow to respond. I discussed this with Shelley (Imholte) and she gave me Kegel exercises to do and provided me with some lubricants that I use. What has been most beneficial is the information she has provided. After talking with Shelley I realized that I had some emotional issues and embedded beliefs about sex that I needed to address. She encouraged me to speak with a therapist and I am working on those issues currently. I have had some of these issues for many years but never felt comfortable speaking to my former OB/GYN about them. I am really impressed that WPIH offers this type of service. It’s so beneficial and so needed.”

A woman trying to determine whether or not she has a form of sexual dysfunction should speak with a knowledgeable professional. It is also important that her partner be involved in the process. A husband had this to share.

“My wife and I were having some problems because it seemed like I wanted to have sex more than she did. I started to wonder if there was something wrong and we asked her doctor. We spoke with Shelley but what was most helpful for me was learning from some of my married guy friends that none of them were having as much sex as they wanted. Now after talking with my friends, I’m realizing that this is a common problem. We also noted a decrease in her libido when she started birth control pills. So she is going to stop taking them and hopefully things will improve.”

“Women are affected by a myriad of environmental triggers,” states Dr. Meston. “It’s often hard to discern what is truly affecting a woman sexually.” She adds,

“It would be great if we had some sort of test that would tell us what is happening. With the exception of hormone tests, there aren’t tests available to diagnose FSD. There is nothing that takes into consideration all of the complexities of female sexual arousal that we can measure and detect an abnormality. My dream is that some day someone will develop a comprehensive, succinct work up that will quickly evaluate all of the physical aspects of female sexual response. If that work up comes back completely normal, then a woman will be referred to a psychologist for further assessment and treatment. I don’t know if it will happen in my lifetime, but I hope it happens someday.”