Women’s Sexual Health in Midlife and Beyond – Female Sexual Arousal Disorders

(Published May 2005)

The diagnosis and treatment of arousal disorders are complicated by the multiplicity of psychological/cultural/relationship variables that can interfere with arousal, and by the lack of correlation between women’s objective and subjective feelings of arousal. As previously discussed, many studies show that women who demonstrate genital swelling and lubrication with stimulation may not be aware they are physically aroused.^1,2

Diagnostic Criteria

In the National Health and Social Life Survey, approximately 20 percent of women reported a lack of vaginal lubrication during sexual stimulation.³ Women often require more time and stimulation to become aroused as they age.⁴ Menopause-associated vulvar atrophy can also lead to decreased sensation with decreased arousal, while medical conditions can lessen sensation.⁴

The American Foundation for Urologic Disease consensus panel led by Basson that recently reconsidered definitions and categories of female sexual disorders divides these disorders into the following categories:¹

Subjective Sexual Arousal Disorder

The panel defines this disorder as the “absence or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation. Vaginal lubrication or other signs of physical response still occur.” The group created this new category based on data that suggest most women who complain of arousal problems demonstrate genital vasocongestion comparable with that seen in women who don’t complain of a loss of subjective arousal.

Genital Sexual Arousal Disorder

This disorder is described as “Absent or impaired genital sexual arousal. Self-report may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitals. Subjective sexual excitement still occurs from nongenital stimuli.” This clinical diagnosis pertains mostly to women with autonomic nerve damage and estrogen deficiency who don’t demonstrate vasocongestion (although there may or may not be a demonstrable physical pathology). Women who complain of genital arousal disorder report being aroused by sexual stimulation but have a marked loss of intensity of any genital response, including orgasm.

Combined Genital and Subjective Arousal Disorder

“Absence or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation as well as complaints of absent or impaired genital sexual arousal (vulval swelling, lubrication).” The panel noted that this is the most commonly seen clinical presentation for female arousal disorders. The patient usually also complains of a lack of libido. This diagnosis can be distinguished from genital arousal disorder based on the lack of both subjective and genital excitement from any type of sexual stimulation.

Persistent Sexual Arousal Disorder

“Spontaneous, intrusive, and unwanted genital arousal (e.g., tingling, throbbing, pulsating) in the absence of sexual interest and desire. Any awareness of subjective arousal is typically but not invariably unpleasant. The arousal is unrelieved by one or more orgasms and the feelings of arousal persist for hours or days.” The panelists reported that this syndrome is poorly understood, but it may not be as rare as previously believed. This is a provisional definition offered to facilitate research into its prevalence and etiology.

Treating Sexual Arousal Disorders

Some of the same therapeutic approaches may be recommended for disorders of desire and arousal, and therapy needs to focus on both partners in a couple, whether heterosexual or homosexual, and not just the patient with the problem. Addressing psychosocial and relationship issues is critical to successful treatment. For example, couples need to be educated that as they age, both men and women require more focused, direct, and lengthy stimulation to become sufficiently aroused. New and stimulating sexual routines may need to be implemented to make sex interesting again to long-standing partners, because repetitive, boring, and short routines may lead to lack of interest and arousal. Anxiety and inhibitions that can affect arousal also may need to be addressed.^4,5

Vaginal Lubricants

A variety of lubricants are available over the counter to reduce vaginal irritation during stimulation and intercourse.⁴ Regular penetration also appears to increase vaginal lubrication in and of itself.⁴

Vaginally Administered Estrogen

Estrogen therapy can be of benefit to postmenopausal women who experience a lack of lubrication and genital vasocongestion.^2,4 Treating atrophy with estrogen may increase sensation, but the Women’s Health Initiative findings about the increased risks of cardiovascular events and breast cancer associated with hormone therapy make recommendation of oral estrogen therapy controversial.6 Estrogen delivered vaginally (in which case it is minimally absorbed systemically) appears to be as effective as oral estrogen therapy to relieve menopause-related vaginal symptoms.⁴

Phosphodiesterase Inhibitors

Sildenafil (Viagra^®) has been investigated for the treatment of female sexual arousal disorders. Although sildenafil increases the vasocongestive response to sexual stimulation, studies have produced inconsistent results in terms of subjective arousal, solidifying the idea that women may demonstrate physical signs of arousal but not feel aroused emotionally.^4,7–11 Pfizer Inc. announced in 2004 that it would not pursue Food and Drug Administration (FDA) approval of the drug for use in women.¹² Sildenafil may still have a role in treating selective serotonin reuptake inhibitor-induced sexual problems.^13,14

Mechanical Devices

The EROS™ Clitoral Therapy device is the only FDA-approved device currently available to treat female arousal disorders. The prescription-only device produces clitoral vascular engorgement using a vacuum system and can be used during masturbation and partnered sexual activity. A small trial showed significant improvement in all symptoms of female sexual arousal disorder in women with and without the disorder.¹⁵ Another trial of seven subjects with sexual arousal disorder showed that EROS therapy was associated with significant increases in clitoral engorgement; all subjects also reported either slight-to-moderate pleasure or orgasm.¹⁶

Alternative Treatments

Zestra™

A botanical feminine massage oil formulated to enhance female sexual pleasure and arousal when applied to the vulva, Zestra was compared in a randomized, double-blind, crossover study with placebo oil in 10 women with and 10 women without female sexual arousal disorder (FSAD). Both women with and without FSAD showed statistically significant improvements compared with placebo in levels of arousal and desire, satisfaction with arousal, genital sensation, the ability to have orgasms, and sexual pleasure. A greater response was found in women with the disorder compared with women who did not complain of arousal problems.¹⁷

ArginMax™

An herbal supplement, ArginMax has been shown in a small study to improve clitoral sensation and other parameters of sexual arousal and well-being.¹⁸ (See section on desire disorders for further information.)

References

1. Basson R, Leiblum S, Brotto L, et al. Definitions of women’s sexual dysfunction reconsidered: advocating expansion and revision. J Psychosom Obstet Gynecol 2003;24:221-229.
2. Walton B, Thorton T. Female sexual dysfunction. Curr Wom Health Rep 2003;3:319-326.
3. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537-544.
4. Bachmann GA, Leiblum SR. The impact of hormones on menopausal sexuality: a literature review. Menopause 2004;11:120-130.
5. Phillips NA. Female sexual dysfunction: evaluation and treatment. Am Fam Physician 2000;62:127-136, 141-142.
6. Hays J, Ockene JK, Brunner RL, et al. Effects of estrogen plus progestin on health-related quality of life. N Engl J Med 2003;348:1839-1854.
7. Seagraves RT. Emerging therapies for female sexual dysfunction. Expert Opin Emerg Drugs 2003;8:515-522.
8. Berman JR, Berman LA, Toler SM, et al. Safety and efficacy of sildenafil citrate for the treatment of female sexual arousal disorder: a double-blind, placebo controlled study. J Urol 2003;170 (Pt 1 of 6):2333-2338.
9. Basson R, Brotto LA. Sexual psychophysiology and effects of sildenafil citrate in oestrogenised women with acquired genital arousal disorder and impaired orgasm: a randomized controlled trial. BJOG 2003;110:1014-1024.
10. Laan E, van Lunsen HW, Everaerd W, et al. The enhancement of vaginal vasocongestion by sildenafil in healthy premenopausal women. J Women’s Health Gend Based Med 2002;11:357-365.
11. Kaplan SA, Reis RB, Kohn IJ, et al. Safety and efficacy of sildenafil in postmenopausal women with sexual dysfunction. Urology 1999;53:481-486.
12. Mayor S. Pfizer will not apply for a license for sildenafil for women. BMJ 2004;328:542.
13. Shen WW, Urosevich Z, Clayton DO. Sildenafil in the treatment of female sexual dysfunction induced by selective serotonin reuptake inhibitors. J Reprod Med 1999;44:535-542.
14. Anastasiadis AG, Salomon L, Ghafar MA, et al. Female sexual dysfunction: state of the art. Curr Urol Rep 2002;3:484-491.
15. Billups KL, Berman L, Berman J, et al. A new non-pharmacological vacuum therapy for female sexual dysfunction. J Sex Marital Ther 2001;27:435-441.
16. Munarriz R, Maitland S, Garcia SP, et al. A prospective duplex Doppler ultrasonographic study in women with sexual arousal disorder to objectively assess genital engorgement induced by EROS therapy. J Sex Marital Ther 2003;29(suppl 1):85-94.
17. Ferguson DM, Steidle GP, Singh GS, et al. Randomized, placebo-controlled, double blind, crossover design trial of the efficacy and safety of Zestra for Women in women with and without female sexual arousal disorder. J Sex Marital Ther 2003;29(suppl 1):33-44.
18. Ito TY, Trant AS, Polan ML. A double-blind placebo-controlled study of ArginMax, a nutritional supplement for enhancement of female sexual function. J Sex Marital Ther 2001;27:541-549.