Female sexual arousal disorder

Definition

Female sexual arousal disorder (FSAD) refers to the persistent or recurrent inability of a woman to achieve or maintain an adequate lubrication-swelling response during sexual activity. This lack of physical response may be either lifelong or acquired, and either generalized or situation-specific. FSAD has both physiological and psychological causes. The results of FSAD are often sexual avoidance, painful intercourse, and sexual tension in relationships.

Description

FSAD results from the body's inability to undergo specific physiological changes, called the lubrication-swelling response, in response to sexual desire and stimulation. This lack of response then affects the woman's desire for and satisfaction obtained from intercourse. To understand FSAD, it is helpful to have an outline of the physiological changes that normally take place in a woman's body during sexual arousal.

William Masters and Virginia Johnson were the first researchers to examine extensively the physical components of human sexual arousal. They recorded four stages of sexual response: excitement, plateau, climax (or orgasm), and resolution. Since then, other models have been suggested that include the emotional aspects of arousal. One model suggests three stages: desire, arousal, and orgasm. FSAD affects the excitement or arousal stage of sexual activity.

Normally, when a woman is aroused and sexually excited, the first physiological change that she experiences is expansion of the blood vessels in the pelvic region, allowing more blood to flow to her lower abdomen and genitals. Some women notice this as a feeling of fullness in the pelvis and either consciously or involuntarily contract the muscles in the genital area.

The increased blood flow also causes a phenomenon called transudation, which refers to the seepage of fluid through the walls of the blood vessels. In this case, the fluid seeps into the vagina to provide lubrication before and during intercourse. Often this moisture is noticeable to the woman and her partner. Lubrication of the vagina can happen very rapidly, within a minute.

The increase in blood flow produces other changes in the tissues of the female genitals. The upper part of the vagina, the uterus, the cervix, and the clitoris all expand. At the same time, the lower third of the vagina and the outer labia swell, so that the opening to the vagina becomes smaller. The inner labia also swell, and push apart the opening to the vagina. These changes taken together make up the lubrication-swelling response and are designed to facilitate the entry of the penis into the vagina.

A woman with FSAD either does not have these physical responses or does not maintain them through completion of sexual activity. The lack of arousal and lubrication may result in painful intercourse ( dyspareunia ), emotional distress, or relationship problems.

Causes and symptoms

The symptoms of FSAD include lack of or insufficient transudation. A woman diagnosed with FSAD does not produce enough fluid to lubricate the vagina. As a result, intercourse is often painful and unsatisfactory. The woman may then avoid sexual activity and intimacy, creating relationship difficulties.

The causes of FSAD are quite complex. For some women, FSAD is a lifelong disorder; they have never experienced a normal lubrication-swelling response. For other women FSAD develops after illness or emotional trauma, through physiological changes, or as a side effect of surgery, radiation therapy for cancer, or medication. FSAD can be generalized, occurring with different partners and in many different settings, or it can be situation-specific, occurring only with certain partners or under particular circumstances. In addition, FSAD may be due either to psychological factors or to a combination of physiological and psychological factors.

Physiological causes of FSAD include:

damage to the blood vessels of the pelvic region resulting in reduced blood flow
damage to the nerves in the pelvic area resulting in diminished arousal
general medical conditions that damage blood vessels (coronary artery disease, high blood pressure, diabetes mellitus)
nursing a baby (lactation)
general medical conditions that cause changes in hormone levels (thyroid disorders, adrenal gland disorders, removal of the ovaries)
lower levels of sex hormones due to aging (menopause)
side effects of medications (antidepressants, antipsychotic drugs, drugs to lower blood pressure, sedatives, birth control pills, or other hormone-containing pills)

Psychological causes of FSAD include:

chronic mild depression (dysthymia)
emotional stress
past sexual abuse
emotional abuse
bereavement
self-image problems
relationship problems with partner
other mental health disorders (major depression, post-traumatic stress disorder or obsessive-compulsive disorder )

The physical and psychological factors leading to FSAD often appear together. For example, a woman who does not experience arousal because of illness or the side effects of medication may then develop self-image and relationship problems that reinforce her difficulty in reaching arousal.

Demographics

It is difficult to determine the incidence of FSAD, because many women are reluctant to seek help for this problem. FSAD may also be present concurrently with other female sexual dysfunctions and be difficult to distinguish from them. In addition, there is some disagreement in the medical community on the exact descriptions of different female sexual dysfunctions. A recent review of the medical literature, however, found that 22–43% of women experience some form of sexual dysfunction. One study that looked specifically at lubrication found that about 20% of women reported problems in this area. Both of these estimates include women whose dysfunction arises from physiological and psychological causes.

Diagnosis

FSAD is usually diagnosed when a woman reports her concerns to her doctor, usually a gynecologist (a doctor who specializes in women's health issues); although she may also discuss it with a family doctor or a psychotherapist. The doctor will take a complete medical and psychological history, including a list of the medications that the patient is currently taking. The doctor will then give the patient a physical examination to evaluate medical aspects of the disorder; if necessary, blood and urine samples may be taken for laboratory testing to rule out previously undiagnosed diabetes or other medical conditions. In order to be diagnosed with FSAD, the lack of lubrication-swelling response must happen persistently or intermittently over an extended period. It is normal for women to have occasional problems with arousal, and these occasional difficulties are not the same as FSAD. The lack of sexual response must cause emotional distress or relationship difficulties for the woman and be caused either only by psychological factors or by a combination of psychological and physical factors to meet the criteria for a diagnosis of FSAD.

According to the mental health professional's handbook, the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision (2000), which is also called DSM-IV-TR , a diagnosis of FSAD is not appropriate if problems with arousal are caused only by physiological factors. These factors may include injuries to the genital area, illness, or menopause. When the causes are only physiological, a diagnosis of sexual dysfunction due to a general medical condition is appropriate. If lack of arousal is caused by the side effects of medication or substance abuse, a diagnosis of substance-induced sexual dysfunction would be made. FSAD is also not diagnosed if it is a symptom of another major psychological disorder. If a woman receives inadequate sexual stimulation from a partner, that also is not considered a cause of FSAD.

Treatments

Treatment varies depending on the cause of FSAD. When there are physical causes, the root problem or disease is treated. Many women who have difficulties with lubrication due to naturally decreasing hormone levels associated with aging are helped by hormone replacement therapy (HRT). There are also nonprescription preparations available in pharmacies for supplementing the woman's natural lubricant. Many women find these preparations quite satisfactory, particularly if they have only occasional problems with arousal.

The United States Food and Drug Administration has approved one medical device for treating FSAD. The Eros-Clinical Therapy Device (Eros-CTD) is a small vacuum pump that fits over the clitoral area. The pump produces a gentle sucking action that stimulates blood flow in the area. In clinical trials the device proved safe and effective in increasing blood flow, sensation, and vaginal lubrication. In May 2000, it was approved for the treatment of FSAD. As of 2002, clinical trials are underway to investigate whether sildenafil (Viagra) can increase blood flow to the genital area in women as it does in men.

Psychotherapy , or talk therapy , is most commonly used to treat the psychosocial aspects of FSAD. Sex therapy focuses primarily on the sexual dysfunction. Sex therapists have special training to help individuals and couples overcome their sexual difficulties. Traditional psychotherapy focuses on problems in relationships, seeking to clarify problems, identify emotions, improve communication, and promote problem-solving strategies. Therapy can involve either the woman alone or the woman and her partner ( couples therapy ). Many couples experiencing sexual dysfunction develop relationship problems related to sexual expectations, and benefit from traditional psychotherapy even when difficulties with sexual arousal are resolved.

Prognosis

Because FSAD has multiple causes, individual response to treatment varies widely. Difficulties with lubrication related to the menopause generally have a good prognosis. Stress-related difficulties with arousal typically resolve when the stressor is no longer present. Couples often need to work through relationship issues that have either caused or resulted from sexual dysfunction before they see an improvement in sexual arousal. This process takes time and a joint commitment to problem-solving.

Prevention

There are no sure ways to prevent FSAD. Eating a healthy, well-balanced diet, getting enough rest, having regular gynecological check-ups, and seeking counseling or psychotherapy when problems begin to appear in a relationship can help minimize sexual arousal problems.

Resources

BOOKS

American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington DC: American Psychiatric Association, 2000.

Berman, Jennifer, M.D., and Laura Berman, Ph. D. For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life. New York: Henry Holt, 2001.

Greenwood, Sadja, M.D. Menopause Naturally: Preparing for the Second Half of Life. 3rd ed. Volcano, CA: Volcano Press, 1992.

Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry. 7th ed. Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.

PERIODICALS

Everaerd, Walter and Ellen Laan. "Drug Treatments for Women's Sexual Disorders." Journal of Sex Research 37 (August 2000): 195-213.

Goldstein, I. "Female Sexual Arousal Disorder: New Insights." International Journal of Impotence Research 4 (12 October 2000): S152-7.

ORGANIZATIONS

American Association of Sex Educators, Counselors, and Therapists (AASECT). P. O. Box 238, Mount Vernon, IA 53214-0238. (319) 895-8407. <www.aasect.org> .

Sexual Information and Education Council of the United States (SIECUS). West 42nd Street, Suite 350, New York, NY 10036-7802, <www.siecus.org> .

Tish Davidson, A.M.