A. Disorders of Sexual Desire
Sexual desire in women is a complex and poorly understood phenomenon. Emotion is a key factor. Relationship conflict, fear or anxiety related to previous sexual encounters, or history of sexual abuse or violence may contribute to a lack of desire. Physical factors such as chronic illness, fatigue, depression, and specific medical disorders (such as diabetes mellitus, thyroid disease, or adrenal insufficiency) may also contribute. Menopause and attitudes toward aging may play a role. In addition, sexual desire may be influenced by other sexual dysfunction, such as arousal disorders, dyspareunia, or anorgasmia.
B. Sexual Arousal Disorders
Sexual arousal disorders may be both subjective and objective. Sexual stimulation normally leads to genital vasocongestion and lubrication. Some women may have a physiologic response to sexual stimuli but may not subjectively feel aroused because of factors such as distractions; negative expectations; anxiety; fatigue; depression; or medications, such as SSRIs or oral contraceptives. Other women with vaginal atrophy may lack both a subjective and physiologic response to sexual stimuli.
In spite of subjective and physiologic arousal, women may experience a marked delay in orgasm, diminished sensation of an orgasm, or anorgasmia. The etiology of orgasmic disorders is complex and typically multifactorial, but the cause of a particular patient’s orgasmic disorder is usually amenable to treatment.
Dyspareunia and vaginismus are two subcategories of sexual pain disorders.
Dyspareunia is defined as recurrent or persistent genital pain associated with sexual intercourse that is not caused exclusively by lack of lubrication or by vaginismus and that causes marked distress or interpersonal difficulty. Vulvodynia is the most frequent cause of dyspareunia in premenopausal women. It is characterized by a sensation of burning along with other symptoms, including pain, itching, stinging, irritation, and rawness. The discomfort may be experienced as either constant or intermittent, focal or diffuse, and deep or superficial. There are generally no physical findings except minimal erythema that may be associated in a subset of patients with vulvodynia, ie, those with vulvar vestibulitis. Vulvar vestibulitis is normally asymptomatic but pain may be associated with touching or pressure on the vestibule, such as with vaginal entry of the examiner’s finger or even with insertion of a tampon. Pain occurring with deep thrusting during coitus is usually due to acute or chronic infection of the cervix, uterus, or adnexa; endometriosis; adnexal tumors; or adhesions resulting from prior pelvic disease or operation.
Vaginismus is defined as recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse, resulting from fear, pain, sexual violence, or a negative attitude toward sex, often learned in childhood, and causing marked distress or interpersonal difficulty. Other medical causes of sexual pain may include vulvovaginitis; vulvar disease, including lichen planus, lichen sclerosus, and lichen simplex chronicus; pelvic disease, such as endometriosis or chronic PID; or vaginal atrophy.