Female sexual disorder is a complex condition affected by physiologic and psychological factors. This condition can prove physically, emotionally, and socially disturbing. According to the results of the National Health and Societal Life Survey in 1999,1 sexual dysfunction actually is more prevalent in women than in men, with 43% of women reporting dysfunction, compared with 31% of men. The survey also found that one quarter of women did not experience orgasm, and one third lacked sexual interest. Twenty percent of women reported that they did not find sex pleasurable, and 20% reported lubrication difficulties. Despite the high incidence of female sexual dysfunction, this disorder has received minimal attention in the medical community. This lack of attention may be due to the fact that female sexual dysfunction is less obvious and is multidimensional. It has only recently started receiving attention due to the advances made in the treatment of male sexual disorder.
The Sexual Function Health Council of the American Foundation for Urologic Disease convened a consensus panel to establish a classification system for the diagnosis of these disorders. The work of this panel led to the inclusion of these disorders in International Consensus Development2 and Diagnostic and Statistical Manual of Mental Disorders (fourth edition)3 classifications. Female sexual dysfunction is divided into 4 classifications: sexual desire disorder, sexual arousal disorder, orgasmic disorder, and sexual pain disorder.
Sexual desire disorder is the persistent or recurrent deficiency or absence of sexual fantasies, thoughts, and/or desire for sexual activity, which causes personal distress.2 It is the most common form of dysfunction. Desire disorders may result from psychological factors?including relationship issues and a stressful career or life?or physical factors?including poor health or medical disorders, depression, adverse medication effects, or alcohol and illicit drug abuse.
Sexual arousal disorder is the persistent or recurrent inability to attain or maintain sufficient sexual excitement, which causes personal distress.2 It may be a lack of excitement or decreased genital lubrication due to physiologic or psychological factors. The most common physiologic cause is hypo-estrogenism.
Orgasmic disorder is the persistent or recurrent difficulty, delay in, or absence of attaining orgasm after sufficient sexual stimulation and arousal, which causes personal distress.4 Fifty percent of women report intermittent or situational difficulty achieving orgasm, whereas 10% of women report never experiencing orgasm.4 Unfortunately, it is difficult to differentiate women with true orgasmic disorder from those who cannot achieve orgasm due to lack of adequate stimulation. Primary anorgasmia is the lack of ever having achieved orgasm due to medical factors, emotional trauma, or sexual abuse. Secondary anorgasmia usually is due to surgery, trauma, hormone imbalance, or medications.
Sexual pain disorder, also known as dyspareunia, is defined as persistent or recurrent genital pain associated with intercourse.2 Pain can be divided into 3 categories: superficial, vaginal, and deep. Superficial dyspareunia occurs with attempted penetration and usually is due to anatomic conditions, whereas vaginal dyspareunia is pain associated with friction due to lack of lubrication. Deep dyspareunia is pain associated with thrusting and often is due to pelvic disease.
Causes of Dysfunction
Chronic medical conditions, medications, and life changes can precipitate female sexual dysfunction. Any condition that alters hormones, the central and peripheral nervous systems, or the circulatory system can potentially alter sexual response. Medical conditions commonly implicated as causes of female sexual dysfunction include diabetes mellitus, urinary incontinence, and depression. Women with diabetes mellitus may experience decreased arousal due to vascular disease. Because of embarrassment about their condition, women with urinary or bowel incontinence may experience decreased desire for sex. Depression and other mood disorders may lead to decreased desire and arousal. More than 70% of depressed patients report loss of sexual interest when unmedicated.5
Conditions that alter a woman's feeling of femininity also may lead to decreased desire and arousal. Among these conditions are menopause, hysterectomy, breast cancer, or gynecologic cancers or abnormalities.
The pharmacist should consider possible medication adverse effects when a woman complains of sexual dysfunction, because many medications are associated with sexual dysfunction (although most reports involve male dysfunction). The classes of medications most commonly associated with dysfunction include antihypertensives, antipsychotics, and antidepressants. Dysfunction also is often caused by beta-blockers, lipid-lowering agents, selective serotonin reuptake inhibitors, benzodiazepines, and tricyclic antidepressants. Conversely, angiotensin-converting enzyme inhibitors, calcium-channel blockers, bupropion, and nefazodone do not appear to alter sexual function. In addition, OTC products?such as antihistamines, nonsteroidal anti-inflammatory agents, and St. John's wort?may contribute to sexual dysfunction.
Although the entire relationship remains unclear, hormones play a role in sexuality. Estrogen therapy relieves dyspareunia and increases arousal by improving urogenital atrophy, vaginal dryness, and vasomotor symptoms. Testosterone has been shown to improve sexual desire disorders. One study of 75 posthysterectomy women found significant improvement in sexual activity, pleasure, sexual fantasies, and orgasm in women receiving transdermal testosterone.6
Despite the availability of prescription estrogen and testosterone products, many women do not wish to discuss their sexual disorders with their doctor, preferring to find an OTC remedy. Many products are currently on the market claiming to relieve female sexual dysfunction, through increased lubrication, clitoral blood, or androgenic and estrogenic effects.
For women suffering with inadequate lubrication despite sufficient stimulation, the pharmacist can offer a variety of options. Water-based lubricants, such as K-Y brand products, provide lubrication without jeopardizing the integrity of condoms. Vitamin E?based lubricants also work well. Some lubricants now have menthol added for increased sensation. In addition, women can try biofeedback, Kegel exercises, or a warm bath before intercourse to reduce pain.
Women with decreased desire and arousal often turn to herbal preparations for relief. A multitude of products are marketed directly to this patient population. These products contain a variety of herbs, including saw palmetto, dehydroepiandrosterone (DHEA), and epimedium. The effectiveness of these preparations is mostly anecdotal.
The use of saw palmetto (Serenoa repens) in the management of genitourinary disorders, to increase breast size, and to increase sexual desire has been described for centuries. Beta-sitosterol, which can be isolated from the berries, has exhibited estrogenic activity. Unfortunately, beta-sitosterol is poorly absorbed in the gastrointestinal tract, so its effectiveness has not been proven. Saw palmetto extract prevents the conversion of testosterone to dihydrotestosterone, along with inhibiting binding to cells.
DHEA, a naturally produced hormone, also can be extracted from the Mexican yam. In the body, DHEA is converted to estrogens and androgens. In one study, patients reported an overall improvement in well-being but did not report increased libido.7 Theoretically, it may result in gynecomastia and hirsutism. DHEA is inhibited by oral contraceptives, P-450 enzyme inhibitors, steroids, and anticonvulsants.
Epimedium, commonly called horny goat weed extract or Yin Yang Huo, increases desire and arousal through moderate androgen-like effects. It has been used for 2000 years as an aphrodisiac in Chinese medicine.
Fenugreek (Trigonella foenumgraecum) and parsley (Petroselinum crispum) have long been used for their estrogenic effects to increase libido. Fenugreek can cause hypoglycemia and reduce cholesterol. Both agents can induce labor; therefore, they should be avoided in pregnant women.
Anise (Pimpinella anisum), due to its high concentration of anethole, exhibits effects similar to those of estrogen, reportedly increasing libido. Because anise is abortifacient, women should use adequate birth control while taking it. Large doses of anise may interfere with anticoagulant or monoamine oxidase inhibitor therapy.
Yohimbe (Pausinystalia yohimbe), rich in the alkaloid yohimbine, often is hailed as an aphrodisiac. Through its vasodilatory and central nervous system (CNS) stimulant effects, it leads to engorgement of the clitoris. Yohimbe can cause orthostatic hypotension and may inhibit monoamine oxidase. Yohimbe should not be used in patients with renal or hepatic dysfunction.
Dong quai (Angelica polymorpha) is among the most widely used herbs for women in Chinese medicine. Its usefulness in female sexual disorders is through stimulation of the uterus and the CNS as well as vasodilatory effects. Dong quai, due to coumarin derivatives in the herb, affects platelet aggregation and suppresses immune activity. It also has been shown to cause photosensitivity and skin cancer.
Despite the lack of prescription products marketed exclusively for the treatment of female sexual dysfunction, OTC preparations are abundant. With the large number of herbs and lubricants available, it would seem that a large amount of information would be readily available for women interested in these products. Unfortunately, this is not true. Although pharmacists are not trained to differentiate sexual disorders, they should take the opportunity to educate patients about the safest options for them.
Dr. Schlesselman is a clinical pharmacist based in Niantic, Conn.
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