Female sexual dysfunction: A potential minefield.

Female sexual health is a much-neglected aspect of the overall well-being of women, especially in patriarchal cultures. In addition to physiological factors, emotional, physical, and social aspects also play a role in maintaining sexual health. Although under-reported, female sexual dysfunction (FSD) is very prevalent and involves a complex interplay of psychosocial and physiological factors. In this article, we attempt to discuss FSD and explore the various causes and treatment options available suitable to the Indian cultural context.

There are small-scale questionnaire-based studies sporadically reported in Indian literature; none are based on self-reporting by females. One study found FSD to occur at an earlier age and more frequently in women with depression.[ 8 ] One of the earliest studies states that “frigidity was found to be associated with sexual ignorance, marital strife, fear of pregnancy, and tiredness.”[ 9 ] Another south Indian study reported orgasmic dysfunction in 28.6% of women.[ 10 ] A study of 149 married women reports FSD in 73.2%, with difficulties in lubrication (96.6%), arousal (91,3%), orgasm (86.6%), desire (77.2%), and pain (64,4%) predominating. Older age and lesser education were found to be significantly associated.[ 11 ] A study in 153 married women found the prevalence to be 55.55%, with associated factors being the longer duration of marriage (>16 years), upper-middle-class status, and middle-grade education.[ 12 ] In postmenopausal women, 80.9% had sexual dysfunction, with joint family structure, lower socioeconomic and educational factors being major determinants.[ 13 ] All the studies stressed up on counseling and treating the underlying etiology.

Cosmetic procedures such as laser treatments for vaginal tightening and surgical labiaplasty for symmetrical labia are useful in subsets of dysfunction associated with low self-esteem. The “O shot” comprises autologous platelet-rich plasma (PRP) injected into the lower anterior vaginal wall, slightly bulging it up to aid “vaginal orgasms.” Intraclitoral and intravaginal PRP, though not statistically significant, has shown improvement in pain, overall sexual functioning, and patient satisfaction.[ 36 37 ] Botulinum injection and onabotulinum toxin A (50-300 U) transvaginal injection into the pelvic floor nerves prevents vaginal muscle spasm, thereby helping in the treatment of vaginismus and dyspareunia.[ 38 ] “Monalisa fractional micro-ablative carbon-dioxide laser” has given good results in all FSD categories. Three treatments are scheduled 4 weeks apart.[ 14 ] This depends on the underlying cause and whether the dysfunction is primary or secondary, or situational; it also depends on psychosocial interaction between partners and compliance to treatment. Treatment is often prolonged. Lacunae in FSD management and Recommendation for Indian context: Most Indian females are ignorant about their sexual functioning and are reluctant to approach caregivers due to embarrassment, social stigma, and hesitancy to disclose to the partner. Female sex education, raising community awareness about sexual health and a scientific and empathetic approach actively involving both partners in treatment will go a long way in improving the scenario. The use of appropriate questionnaires and checklists stresses the importance of the condition and helps the patient be at ease. Management should be multifaceted and include behavioral, physical, and pharmacological treatment. The establishment of FSD liaison clinics involving dermatologists, gynecologists, urologists, psychiatrists as well as clinical psychologists is imperative for a holistic approach. More research needs to be done for the development of regional and culture-specific questionnaires and treatment options. Nil. There are no conflicts of interest.

The aim is to establish the type of dysfunction and assess the predisposing, precipitating, and maintaining factors.[ 5 ] The art of history taking is very important to circumvent the social stigma, embarrassment, and psychosocial conditioning of Indian women. Rapport is established by beginning with nonthreatening general questions, and it is important to appear calm, confident, sympathetic, and nonjudgmental. The patient should be asked to describe her problem in her own words. Has it always been there, or has occurred recently? Is it present in all situations, or in certain situations and with certain persons, whether she has had a normal sexual relationship prior, and can a certain incidence or event be associated with the onset of the problem, are some pertinent questions to be asked after gaining the confidence of the woman. Specific and screening questionnaires[ 16 17 18 19 ] may be given, depending upon the patient's level of education and understanding [ Table 4 ]. Evaluation of female sexual distress FSDS=Female sexual distress scale, FSFI=Female sexual function index, STIs=Sexually Transmitted Infections, PTSD=Post Traumatic Stress Disorder TSH=Thyroid Stimulating Hormone Patient's as well as partner's attitude to sexual intercourse should be understood: whether she is frightened, repulsed, or feels guilty. Other pertinent history like past sexual abuse and trauma should be sought. Duration of the condition, whether it was sudden in onset or gradual, any relationship to childbirth, sexual abuse, pelvic surgery, or menstrual problems should be noted. A detailed medical and psychiatric history in self and partner should be obtained [ Table 4 ].

We collated and extracted data on FSD worldwide after putting in the search words, “female sexual dysfunction,” “sexual health” into various medical search engines.

The five Es of successful sexual questioning/counseling include: experience, etiquette, empathy, ethnic/cultural understanding, environment, which is suitable.[ 16 ]

The following should be undertaken: Assess medical, endocrinological, and uro-gynecological health Pelvic and genital examination to rule out rare cases of hermaphroditism, genital defects, pelvic floor abnormalities, and any vulvovaginal diseases, estrogen deficit atrophy A focused and detailed examination is highly indicated in dyspareunia, vaginismus, previous pelvic trauma Tone of pelvic and vaginal muscles Test for perineal sensation, pain on touching, or vaginal insertion of gloved finger Cotton swab test (gently touching the perineum and vulva with a Q tip or cotton swab in an orderly manner to denote areas of pain and tenderness) in suspected vulvodynia[ 20 ] Rule out the following before labeling as vulvodynia/dyspareunia Infections (candidiasis, postherpetic neuralgia) Inflammation (early lichen sclerosus or lichen planus) Malignancy (vulvar Paget's, vulvar intraepithelial neoplasia) Neurological or pelvic trauma, previous obstetric and gynecological surgeries Iatrogenic factors (chemotherapy, radiotherapy) Hormonal problems. A bimanual pervaginal palpation and speculum examination of the vagina and cervix Pap smear and tests for STIs (if indicated) Laboratory investigations - fasting blood glucose, TSH, lipid profile, serum sex hormone assays. Assess medical, endocrinological, and uro-gynecological health Pelvic and genital examination to rule out rare cases of hermaphroditism, genital defects, pelvic floor abnormalities, and any vulvovaginal diseases, estrogen deficit atrophy A focused and detailed examination is highly indicated in dyspareunia, vaginismus, previous pelvic trauma Tone of pelvic and vaginal muscles Test for perineal sensation, pain on touching, or vaginal insertion of gloved finger Cotton swab test (gently touching the perineum and vulva with a Q tip or cotton swab in an orderly manner to denote areas of pain and tenderness) in suspected vulvodynia[ 20 ] Rule out the following before labeling as vulvodynia/dyspareunia Infections (candidiasis, postherpetic neuralgia) Inflammation (early lichen sclerosus or lichen planus) Malignancy (vulvar Paget's, vulvar intraepithelial neoplasia) Neurological or pelvic trauma, previous obstetric and gynecological surgeries Iatrogenic factors (chemotherapy, radiotherapy) Hormonal problems. A bimanual pervaginal palpation and speculum examination of the vagina and cervix Pap smear and tests for STIs (if indicated) Laboratory investigations - fasting blood glucose, TSH, lipid profile, serum sex hormone assays. Tone of pelvic and vaginal muscles Test for perineal sensation, pain on touching, or vaginal insertion of gloved finger Cotton swab test (gently touching the perineum and vulva with a Q tip or cotton swab in an orderly manner to denote areas of pain and tenderness) in suspected vulvodynia[ 20 ] Rule out the following before labeling as vulvodynia/dyspareunia Infections (candidiasis, postherpetic neuralgia) Inflammation (early lichen sclerosus or lichen planus) Malignancy (vulvar Paget's, vulvar intraepithelial neoplasia) Neurological or pelvic trauma, previous obstetric and gynecological surgeries Iatrogenic factors (chemotherapy, radiotherapy) Hormonal problems. Infections (candidiasis, postherpetic neuralgia) Inflammation (early lichen sclerosus or lichen planus) Malignancy (vulvar Paget's, vulvar intraepithelial neoplasia) Neurological or pelvic trauma, previous obstetric and gynecological surgeries Iatrogenic factors (chemotherapy, radiotherapy) Hormonal problems. A bimanual pervaginal palpation and speculum examination of the vagina and cervix Pap smear and tests for STIs (if indicated) Laboratory investigations - fasting blood glucose, TSH, lipid profile, serum sex hormone assays. A methodical and thorough history and examination, as summarized in [ Table 4 ], goes a long way to reassure the patient that her concern is genuine, even though no pathology is detected.

Conclusive data on the prognosis of FSD are not available. A systematic review of various treatment modalities and prognosis concluded that the most substantial effect was with hormonal regimes, and though specific domains of FSD improved no treatment, either pharmacologic or psychotherapeutic, demonstrated complete disease resolution.[ 14 ] Prognosis depends upon the ability of the female and her partner to recognize and seek help, type of FSD, i.e., whether primary or secondary, whether situational or generalized and on the severity of FSD.[ 15 ] The best possible response is in younger individuals and those with partner support, whereas FSD due to structural deficit in older women and those without partner support tend to persist. Sequelae of FSD include psychological distress in both partners, psychosomatic symptoms, aversion to sex, and in the extremes of cases, childlessness.

A combined approach utilizing pharmacotherapy, psychotherapy, and targeted sexual therapy is required[ 5 21 22 23 ] [ Table 5 ]. Outline of therapy of female sexual distress FOD=Female orgasmic disorder, FSAID=Female sexual interest/arousal disorder, SERM=Selective estrogen receptor modulator, CTD=Clitoral therapy device, HRT=Hormone replacement therapy, CBT=Cognitive Behaviour Therapy Lack of a single causative factor, overlap of multiple dysfunctions, and limited expertise complicate management. It calls for a patient-centered and “couple centric” approach with an understanding of the patient's background, knowledge, attitude, and misconceptions about sexuality and fertility. Interpersonal issues with a partner should be addressed before starting medical management. Marital counseling should aid improved communication in sexual and general areas. The role of religion in FSD should be explored (premarital sex is sinful, sex should be only for procreation, and religious treatments sought earlier) and negative influence mitigated by proper psychotherapy. Attention to general health and well-being, abstinence from smoking and alcohol should also be advocated. Psychotherapy by trained personnel can mitigate sexual stigma to a great extent. It is mainly used in female sexual interest/arousal disorder and Genitopelvic Pain/Penetration Disorders[ 21 22 ] [ Table 6 ]. Hormonal treatment is based on hormone replacement with estrogen (topical or systemic), androgen supplementation, and the use of selective estrogen receptor modulators like tibolone[ 24 ] and Ospemifene.[ 25 ] Drugs used in female sexual distress SERM=Selective estrogen receptor modulator, NDRI=Norepinephrine/dopamine-reuptake inhibitor, FSD=Female sexual distress, HRT=Hormone replacement therapy, NHT=Non Hormonal Therapy, HSIAD=, PDE=Phosphodiesterase, cGMP=cyclic guanosine monophosphate Hormone replacement therapy is mostly used in postmenopausal vaginitis and not primarily for FSD. Tibolone, though available is costlier, and Ospemifene is not available in the Indian drug market. Nonhormonal treatment includes bupropion, fibanserin,[ 21 22 26 ] prostaglandins,[ 21 ] apomorphine,[ 27 28 ] phentolamine mesylate.[ 29 ] Bremalanotide[ 30 ] Supplements such as Gingko Biloba Extract,[ 31 ] ArginMax (containing ginseng, ginkgo, damiana, L-arginine, multivitamins, and minerals),[ 32 ] L-arginine have been tried in FSD. L-arginine (nitric oxide precursor) Yohimbine (alpha-2 blocker) combination is currently undergoing investigation in female arousal disorders.[ 33 ]

Female sexual response has various phases [ Table 1 ], which are affected by emotional, neurovascular, endocrine, and psychosocial responses, all of which overlap[ 1 ] [ Figure 1 ]. Female arousal and orgasm depend more on cognitive, emotional, and behavioral aspects, as opposed to male arousal, which is more physiological.[ 2 ] Pathophyisology of female sexual dysfunction Phases of female sexual response There is no refractory phase in women, and they can experience repeated and multiple orgasms if sufficiently stimulated, These phases may be non-orderly and incomplete. It is difficult to establish the exact incidence or prevalence of FSD. The most common age group to be affected is 51–59 years, i.e., perimenopausal. It may be associated with lower educational status, interpersonal conflict with partner, comorbidity such as diabetes mellitus, hypertension, and vulvar inflammatory diseases.

Eros-Clitoral Therapy Device (Eros-CTD, NuGen, Inc.), which increases blood flow to clitoris by gentle suction is an FDA-approved device for FSAD. This improves arousal. Intravaginal introduction of dilators with progressively increasing diameters aid women with vaginismus. These dilators are used twice daily for 15 min each, and once comfort is achieved with reasonable sized dilators, penile penetration by the partner may be attempted.[ 34 ] Physiotherapy involving gentle massage of introitus and clitoris, pelvic muscle exercises, which include alternative contraction and relaxation[ 35 ] are also tried. Progressive muscle relaxation involves the patient alternatively contacting and relaxing her pelvic floor muscles around the examiner's finger.

The latest Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, DSM-5 classification of FSD[ 3 4 ] include major types being include female orgasmic disorder, female sexual interest/arousal disorder and genito-pelvic pain/penetration disorder. Categories common to both genders include substance/drug induced and other unspecified subsets [ Table 2 ]. Classification of female sexual dysfunction The symptoms have persisted for a minimum duration of approximately 6 months and cause clinically significant distress in the individual, and the sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition. Along with these broad categories, DSM 5 has included the following subcriteria common to all disorders. Specify whether: Lifelong: the disturbance has been present since the individual became sexually active, Acquired: The disturbance began after a period of relatively normal sexual function. Specify whether: Generalized: Not limited to certain types of stimulation, situations, or partners, Situational: Only occurs with certain types of stimulation, situations, or partners. Specify if: Never experienced an orgasm under any situation. Specify current severity: Mild: Evidence of mild distress over the symptoms in criterion, Moderate: Evidence of moderate distress over the symptoms in criterion, Severe: Evidence of severe or extreme distress over the symptoms in criterion. Credit: “(DSM-5), Criteria for Female Sexual Dysfunction.” DSM-5=Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, GnRH=Gonadotrophin Releasing Hormone