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An Assessment of Sexual Desire and Arousal Disorders in Women
Reviewed and Abstracted from a paper by Rosemary Basson, M.D., New England Journal of Medicine, 2006; 354:3497-506.
Ernest H. Rosenbaum, MD

The problem of decreasing sexual desire, arousal and sexual activity over the latter part of one's life, often after 35 or 40. Both fantasies and orgasms become more rare, and, often, lubrication does not allow for satisfactory intercourse because of pain.

Too little sexual desire is a common problem that has been reported in between 10 and 51% of women in various countries. This is usually accompanied by low levels of arousal and sexual excitement with orgasms, often leading to major sexual dissatisfaction.

Only recently has there been a greater understanding of what a normal sexual response is. The idea of going through the sexual phases of desire, arousal, orgasm and resolution often overlap and are variable. It also is a reflection of the sexual environment and stimuli, which can promote or diminish sexual expression. The advantage of sex and desire is the need for emotional closeness that often diminishes with established relationships. In a study of some 24 multiethnic midlife women - Hispanic, White, African-American, Chinese and Japanese, a questionnaire revealed that about 40% felt that they never had or infrequently had sexual desire, but with stimulation were capable of arousal, but only 13% expressed content of their sexual experience.

In summarizing disorders of sexual dysfunction, it was found that in women failing to feel desire at any stage, data was uncertain. It was found that a lot depends on sexual thoughts; although, these are infrequent in many women without the satisfaction, and often sexual fantasies or thoughts had little correlation with their satisfaction. Arousal was related to desire. This was often found to be related to vaginal dryness.

What are the factors that influenced desire or arousal?
1. This was poorly understood, but it appears to involve a combination of interactions, including sex hormones, neurotransmitters, and environmental factors.
2. The physiology of genital vasoconstrictive response occurs in women a few seconds after erotic stimulation. Much of this is a hormonal response that often promotes the endothelial surface of the vagina to release nitric oxide.
3. Other hormones, such as adrenaline, which is vasoconstrictive, are released from the sympathetic nerves.
4. There is vasocongestion when women have sexual stimulation, which increases the response to erotic stimuli, even in the presence of low or high estrogen levels. This changes the volume of the vaginal wall and clitoris in response to sexual stimulation both before and after menopause. Estrogen deficiency does not always limit vaginal lubrication if stimuli is sufficient.
5. It has been estimated that about 40% of women have sympathetic vaginal atrophy that does have an adverse effect on sexual function.
It is been shown that there is a poor subjective arousal that poorly correlates with genital response. Thus, an increase in genital vasocongestion, responding to erotic videos, are similar among women who report problems with arousal and women who report no problems with arousal.

In MRI (magnetic resonance) studies, it was found that there is a poor correlation between brain activation in areas controlling genital response in the brain and subjective arousal.

It was also found that testosterone and dopamine play a role in the sexual response, and testosterone has been used. The dopamine agonist can help the response. When a person has a comorbid disease, bilateral oophorectomy (removal of ovaries), or during aging, reduced sexual desire and arousal often occur. Of note was that there was a poor correlation between sexual function and serum testosterone levels, as it was felt that certain levels may not reflect the intracellular production of testosterone from the adrenal and ovaries.

Several additional factors are associated with reduced arousal:
1. Distractions or a negative experience, such as painful intercourse, if the partner has a sexual dysfunction, such as ED-erectile dysfunction with difficulty with an erection for vaginal penetration, or fatigue, anxiety, and depression.
2. Oral contraceptives increase the level of sexual hormone-binding globulin, which reduces free testosterone in some women who are sensitive to these effects. Many discontinued use of oral contraceptives for this reason.
3. It is important to have a good mental health attitude, an emotionally positive way of living, and a good self image with positive expectations for a good relationship.

Unfortunately, many diseases limit sexual response, such as multiple sclerosis, renal failure, and premature menopause induced by chemotherapy, leading to a high level of sexual dysfunction. It appears women don't have the same problems as men. Women with vascular disease related to age do not have reduced sexual satisfaction.

How to evaluate and strategize ways to improve sexual dysfunction:
1. A detailed history and assessment is needed for both partners. This will also include a history of the sexual problems:
    a. why they need help
    b. how long these problems have existed
    c. the priority, as well as the description of the sexual problems.

Each partner's history is evaluated in relation to the other partner's problem, and an assessment of the partner's assessment and sexual response with some stimulation is elicited. A review of the past sexual experiences, successes, and failures, and each partner's emotional evaluation as well as that of sexual and physical abuse. An assessment of health, such as fatigue, impaired physical function, and self image, and an assessment of mood is important.
1. It is important to assess a woman's mental and emotional health and really review what quality they achieved in prior sexual relationships. A pelvic physical examination is routine, evaluating non-genital, external, vaginal, and an internal pelvic evaluation.
2. Often, the physical examination may reveal why there is painful intercourse (dyspareunia). Pelvic examinations often cause a lot of anxiety and should be handled with great care.
3. A laboratory examination of hormones has a low value. A better test for estrogen deficiency is by taking a history and physical examination, and it is often not a true cause of sexual dysfunction. Serum testosterone also does not correlate with sexual function.
4. A psychological evaluation often reveals cognitive behavior deficiencies that can contribute to sexual dysfunction. This often includes - maladaptive thoughts and unreasonable expectations, behaviors that reduce the partner's interest or trust, such as a lack of honesty or a partner's interest that can lead to insufficient erotic stimuli and non-genital stimuli.
5. Trust in your partner is essential for a good relationship and promotes better sexual satisfaction. It is important to have sufficient erotic stimuli, and insufficient non-genital physical stimulation promotes dissatisfaction.
6. Ways to improve emotional closeness and communication promotes erotic stimulation. Having sessions with a counselor and both partners for sex therapy focuses on sensate techniques that initially are not sexual with progression towards touching with feedback that is pleasurable. This promotes better orgasms for both partners.

It was noted that a combination of cognitive behavioral therapy and sex therapy helped 74% of women improve sexual and marital satisfaction. This was maintained in 64% of the people at one year.

Short-term psychotherapy is often focused on poor sexual self image and non-sexual experiences in childhood that may release current sexual dysfunction problems, such as a chaotic upbringing or the need to be in control and not being able to let go.

There are some pharmacointerventions that can be helpful for dyspareunia when related to genitourinary atrophy. No medications are currently approved by the FDA for sexual dysfunction treatment in women.

There are several off-label drugs that might be effective, including buprion, which is a dopamine and nor-epinephrine agonist, testosterone often plus estrogen, dehydroepiandrosterone, which is a precursor both to estrogen and testosterone, tibolone, which is an estrogenic, progesterone and androgenic steroid, the phosphodiesterase inhibitors, including sildenafil, tadalafil, and vardenafil, which is generic for Viagra, Cialis, and Levitra for erectile dysfunction. In addition, Yohambine and epinephrine have been of help for some women.

There are non-hormonal therapies that involve nitric oxide in neurogenic vasodilation, such as Viagra, Cialis, and Levitra, which may help reduce genital arousal disorders. 50 mg of Viagra increases subjective arousal, genital sensations, and ease of orgasm in some women with a genital arousal disorder. This was observed only in those with a marked reduction in normal vasocongestive response to arousal by visual erotic stimulation. Viagra did not improve arousal and desire disorders and did not affect sensation, lubrication, or satisfaction.

There are several hormonal therapies, including androgens, which have been prescribed since the 1930s and now at lower doses in women who had natural or surgically-induced menopause. A dose of 0.625 mcg of esterified estrogen daily and 1.25 mg of methyl testosterone improved sexual responsiveness and the level of desire, but the frequency of the desire was not affected, and the measure of sexual function was not significantly improved in the follow-up study. Methyl testosterone does lower the good lipoprotein, HDL cholesterol.

In a placebo controlled, randomized study to show the efficacy of a 300-mcg testosterone patch applied twice weekly, with all patients treated with estrogen delivered as a transdermal patch or orally, women were assessed for sexual satisfaction. Those receiving testosterone had 1.9 more sexually satisfying events per month than those at baseline, with 0.9 more among those receiving the placebo. The studies showed a significant increase in sexual desire and response and reduction in sexual distress.

In another study using 450 mcg testosterone versus the lower dose patch had no benefits. There were unwanted androgenic side effects including hirsutism and acne. These were uncommon, but depilatation (hair loss) rates were not assessed. There were no changes in blood lipids.

Results were generalized to women in whom menopause was surgically induced and who received estrogen therapy. Some had natural menopause, and it is important to note that the ovaries continued to be important as a source of androgens, but there may be a difference between androgen supplementation and women whose ovaries had been surgically removed.

There were some risks associated with long-term use of conjugated estrogen, which were concerning for use in any postmenopausal estrogen therapy over time. When testosterone was prescribed in women who lacked estrogen, there was a rise in the ratio of androgens to estrogen, but there was no safety or efficacy data for testosterone supplementation in estrogen-deficient women.
There was a long-term concern about androgen use, which had the potential of an increase in insulin resistance, which could predispose women to a metabolic syndrome, such as a low level of sex-binding globulin and a higher circulating level of androgen noted to be associated with a metabolic syndrome, including:
1. High body mass index.
2. High waist-to-hip ratio.
3. Presence of glucose intolerance.
4. Hypertriglyceridemia or hypertension.
5. A low level of HDL cholesterol.

Dehydroepiandrosterone was evaluated and found to be increased by as much as 70%, and although there were suggestions that supplementation might improve sexual function, there was no data to prove this. Randomized trials on dehydroepiandrosterone supplementation were inconsistent.

The role of systemic estrogen to increase desire and arousal is still unclear. If patients have vasomotor symptoms and insomnia or reduced levels of desire, they often have dyspareunia due to genital atrophy. The supplementation could increase sexual motivation; although, this still needs more testing. In the Women's Health Initiative Trial, there was no difference between estrogen and placebo for sexual satisfaction and activity. This function was not a primary focus of this trial.

The role of antidepressants and sexual dysfunction is estimated to be somewhere between 22 and 58%, especially for the SERMS - selective estrogen receptor modulators - with lower rates for bupropion, which was used to ameliorate dysfunction associated with antidepressants. No specific drug was recommended, but adding bupropion had apparent value. While trying to use drug holidays, say over weekends, may sound logical, it is not recommended, and there are often withdrawal symptoms.

There is a lot of uncertainty about understanding the endogenous and environmental factors for desire and arousal. This needs further study.

Guidelines have been set up for assessment and management of sexual dysfunction in women by the American College of Obstetricians and Gynecologists, North American Menopausal Society, the 20th International Consensus on Sexual Medicine and the International Society for Sexual Medicine, which advocate attention to mental and overall health, as well as interpersonal and personal psychology issues. They recommended local estrogen therapy for dyspareunia associated with vaginal atrophy, which results in reduced sexual motivation.

In addition, testosterone therapy was viewed as investigational and only to be prescribed by clinicians who are knowledgeable about sexual dysfunction in women. In appropriate doses via transdermal patch, topical gels or creams administered at the lowest dose for the shortest time could meet some treatment goals. Counseling was very important, and the benefits of testosterone use was advocated for low levels of desire, both physical and psychological factors and mitigations pretreatment.

In conclusion, women who have an arousal or desire disorder need counseling along with their partners after an assessment of mental health, including self image feelings, relationships, medical history, and thoughts and emotions during sexual activity. Cognitive behavioral therapy and sex therapy in three to six sessions has been valuable when they they focus on adoptive maladaptive thoughts, unreasonable expectations, and information about women's sexuality, as well as trying to provide strategies to cope with these problems and hopefully improve emotional closeness, communication and enhance a erotic stimulation. Non-genital stimulation should be first and try to reduce interpersonal problems before sexual therapy is pursued. Pharmacological therapy was not highly recommended until better data to support its use in treatment.

Rosemary Bzasson, MD British Columbia Center for Sexual Medicine
Vancouver General Hospital
855 W 12TH AVE
Vancouver, BC V5Z1M9
Sexmed at

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First appeared July 12, 2007