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Created: Monday, November 12, 2007

Women with arousal disorders

Premenopausal women with arousal disorders, women who do not respond to estrogen therapy and women who are unable or unwilling to take estrogen represent difficult patient groups because few treatment options are available.

TABLE 8
Kegel Exercises
Potential uses
pubococcygeal tone Improved orgasmic intensity Correction of orgasmic urine leakage Distraction technique during intercourse  awareness of sexual response
Teaching Kegel exercises
Instructional examination with hand on buttockInitial patient home exercise Slow count to 10, with movement directed "in and up" Hold for count of 3 ,Slow release to count of 10 ,Repeat 10 to 15 times daily
Maintaining Kegel exercises
Advise repetitions during routine activities (standing in line, at stop lights, etc.)

Investigators recognize that small-vessel atherosclerotic disease of the vagina and clitoris may contribute to arousal disorders and are exploring vasoactive medications as treatment.28Small studies29,30 have been conducted with favorable results, but larger studies are needed. Currently, treatment of arousal disorder in women who are taking these medications, including sildenafil (Viagra), is not recommended, although anecdotal success has been reported.30Orgasmic Disorders
Anorgasmia is quite responsive to therapy. This condition is caused by sexual inexperience or the lack of sufficient stimulation and is common in women who have never experienced orgasm. Orgasmic disorders may also be psychologic ("involuntary inhibition" of the orgasmic reflex) or caused by medications or chronic disease.

Treatment relies on maximizing stimulation and minimizing inhibition.31 Stimulation may include masturbation with prolonged stimulation (initially up to one hour) and/or the use of a vibrator as needed, and muscular control of sexual tension (alternating contraction and relaxation of the pelvic muscles during high sexual arousal). The latter is similar to Kegel exercises (Table 8). Methods to minimize inhibition include distraction by "spectatoring" (observing oneself from a third-party perspective), fantasizing or listening to music. Women who do not respond to therapy should be treated for depression.

Sex Pain Disorders
Dyspareunia can be divided into three types of pain: superficial, vaginal and deep (Table 6). Superficial dyspareunia occurs with attempted penetration, usually secondary to anatomic or irritative conditions, or vaginismus. Vaginal dyspareunia is pain related to friction (i.e., lubrication problems), including arousal disorders. Deep dyspareunia is pain related to thrusting, often associated with pelvic disease or relaxation. Treat with antibiotics Doxycycline 100mg daily for a week Treatment of orgasmic disorders relies on maximizing stimulation and minimizing inhibition. Diagnosis of an underlying etiology should be aggressively sought, even if surgical investigation (laparoscopy) is required. The physical examination must include meticulous detail, with the physician's focus on recreating the pain. Treatment of the underlying etiology is fundamental, but as in long-term pain disorders, counseling and pain control strategies are essential. General recommendations for improved sexual function are discussed in

Table 6 and are similar despite sexual orientation.

TABLE 9
Female Sexual Dysfunction: When to Refer Longstanding dysfunction

Multiple dysfunctions Abuse

Psychologic disorder or acute psychologic event

No response to therapyVaginismus, the involuntary contraction of the muscles of the outer one third of the vagina, is often related to sexual phobias or past abuse or trauma.10,32 Vaginismus treat with antibiotics or lubrication with olive oil.

 Women with vaginismus can achieve vaginal dilatation with the use of commercial dilators or tampons of increasing diameter, placed into the vagina for 15 minutes twice daily. Once the patient can easily accept an equivalent-sized dilator into the vagina, penile penetration by the partner can occur. Success rates approach 90 percent.31,32 Patients who do not respond to this therapy should be referred to a sex therapist who specializes in the treatment of women with this disorder (Table 9).

The Author

NANCY A. PHILLIPS, M.D.,

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