Dr. S.M.Sadikot.
Hon. Endocrinologist,
Jaslok Hospital and Research Centre,
Mumbai 400026

As a woman, if you feel that you have been discriminated against in so far as managing your sexual problems are concerned, you would be absolutely right. Our knowledge about female sexual dysfunction, especially in women with diabetes, has been minimal. Little progress has been accomplished in the past 30 years. Although it is universally appreciated that long-standing diabetes is associated with sexual dysfunction in men, the state of inquiry into sexual dysfunction in diabetic women is rudimentary. A literature search of the articles published in the last 5 years on sexual dysfunction in diabetic men yields numbers in the thousands; a similar computer search directed toward diabetic women results in 13 articles.

But as Bob Dylan sang, "The times… they are a changing!" As changes in philosophy of health care emerge female sexual dysfunction management is coming into prominence with many women asking that their problem be addressed. Much more research is being done in investigating this aspect and with the knowledge which is coming in, it would seem that there is much more that can be done for you.

It is for you to ask!

For you to be able to discuss your problem with your doctor, it is essential that you understand the basics of both, the normal female anatomy and the females sexual response cycle, as well as the causes which can lead to sexual dysfunction, or dissatisfaction, as it is often called.

The clinical definition of the female sexual response cycle consists of four stages of arousal, marked by physiological and psychological changes.

The first stage is excitement, is usually triggered by psychological or physical stimulation. With onset of sexual excitement there are emotional changes as well as vasoconstriction, vaginal lubrication and overall body changes. In line with the theory that sexual activity is stressful emotionally and physically, the body responds with an increase in heart rate, blood pressure and respiration. In combination with vasoconstriction, this can result in some women developing an uneven skin color during the excitement stage. There is mild vasocongestion within the clitoris that results in swelling to the point in some women that the clitoris noticeably elevates. There is vaginal swelling and lubrication due to increased blood flow. There may also be slight swelling in the breasts and the nipples may become erect.

Some of these changes occur within seconds. For example, vaginal lubrication, which results from a vascular engorgement of the vaginal wall, occurs sometimes as quickly as 15 seconds after onset of sexual stimulation. It has also been shown that, due to accumulation of blood, the uterus enlarges slightly and may change its position in the pelvis.

The plateau is the second stage. It is actually a continuation of the excitement stage. In fact, the plateau stage happens when vasocongestion reaches its maximum. Vaginal swelling, heart rate, and muscle tension may increase further as long as stimulation continues. The breasts enlarge, the nipples become more erect, and the uterus dips.

Cycle of sexual dysfunction. Example showing how a patient can enter the cycle of sexual dysfunction in one area (i.e., decreased orgasm) and proceed to another area (i.e., decreased desire) so that the presenting complaint may not represent the problem that actually requires evaluation and treatment.

The third stage is orgasm, which involves synchronized vaginal, anal, and abdominal muscle contractions, the loss of involuntary muscle control, and intense pleasure. The orgasmic phase is both the most intense and short-lived stage.

Studies have shown that during this phase, some of the vaginal and perineal muscle fibers undergo contraction.

If women achieve orgasm, it is most often the result of clitoral stimulation. Some individuals have suggested a role for the cervix in feeling a "deep" orgasm, however, most women report that bumping of the cervix during intercourse is an unpleasant feeling and can contribute to a cramping sensation after intimacy.

Because they do not become unresponsive to stimulation immediately after orgasm the way a man does, some women are able to continue having orgasms, one right after another. Many women report, however, that after the first orgasm, the clitoral area becomes more sensitive, and that any type of heavy touch can feel painful.

The final phase, resolution, involves a rush of blood away from the vagina, shrinking breasts and nipples, and a reduction in heart rate, respiration, and blood pressure. As its name implies, this is when the body returns back to its non-aroused state. It is thought that, as a result of blood draining from the genital area, the labia turn back to their normal coloration and the vagina returns to its normal size and position. The clitoris also resumes its normal size and consistency, which may happen immediately after orgasm.

How women experience these stages varies; for example, some progress from excitement to orgasm rapidly, and others alternate between plateau and orgasm several times before reaching resolution.

A normal or healthy response cycle may be as poorly defined as a dysfunctional one.

Hypoactive Sexual Desire Disorder is the absence or occasional absence of sexual fantasies or thoughts, and the lack of receptivity to sexual activity. This disorder may cause personal distress or interpersonal difficulties.

Sexual Adversion Disorder is the avoidance of genital sexual contact with a partner. The marked personal distress and interpersonal difficulty characterize the psychological or emotional attitude of the individual. Sexual adversion disorder generally affects women who have experienced some type of sexual abuse and who women from religious orders that have strict taboos on sexual activity.

Sexual Arousal Disorder is the inability to obtain or maintain sufficient adequate lubrication or swelling response during the excitement phase of sexual activity. A disorder common in postmenopausal women, sexual arousal disorder may cause extreme personal distress and interpersonal difficulties in all women affected.

Orgasmic Disorder is the persistent or recurrent delay in, or absence of attaining orgasm following sexual stimulation and arousal. Orgasmic disorder may be present in women who have never achieved an orgasm or may be present as a result of surgery, trauma or hormone deficiencies. Orgasmic disorder may cause extreme personal distress and interpersonal difficulties.

Sexual Pain Disorders
• Dyspareunia: recurrent or persistent genital pain associated with sexual intercourse
• Vaginismus: recurrent or persistent involuntary spasm of the musculature of the outer third the vagina that interferes with vaginal penetration, which causes personal distress.
Other Sexual Pain Disorders

• Recurrent or persistent genital pain induced by non-coital sexual stimulation. Dyspareunia can develop secondary to medical problems such as vestibulitis, vaginal atrophy, or vaginal infection can be either physiologically or psychologically based, or a combination of the two. Vaginismus usually develops as a conditioned response to painful penetration, or secondary to psychological/emotional factors.

Even this classification has come in for criticism as laying undue stress on the emotional aspects without giving due importance to somatic causes.

It would be worthwhile to for you to take a FSFI test which would allow you to judge if you have an element of sexual dysfunction and if so, it may help you judge the severity, as well as, the major factor involved in causing the dysfunction.

Click here to access test for Female Sexual Dysfunction.

Vascular

High blood pressure, high cholesterol levels, diabetes, smoking, and heart disease are associated with sexual complaints in men and women. Any traumatic injury to the to the genitals or pelvic region, such as pelvic fractures, blunt trauma, surgical disruption, extensive bike riding, for instance, can result in diminished vaginal and clitoral blood flow and complaints of sexual dysfunction. Although, other underlying conditions, either psychological or physiologic may also manifest as decreased vaginal and clitoral engorgement, blood flow, or vascular insufficiency is one causal factor that should be considered.

The same neurological disorders that cause erectile dysfunction in men can also cause sexual dysfunction in women. Spinal cord injury or disease of the central or peripheral nervous system, including diabetes, can result in female sexual dysfunction. Women with spinal cord injury have significantly more difficulty achieving orgasm than able-bodied women. The effects of specific spinal cord injuries on female sexual response is being investigated, and will hopefully lead to improved understanding of the neurological pieces of orgasm and arousal in normal women.

Dysfunction of the hypothalamic/pituitary axis, surgical or medical castration, natural menopause, premature ovarian failure, and chronic birth control pills, are the most common causes of hormonally based female sexual dysfunction. The most common complaints in this category are decreased desire and libido, vaginal dryness, and lack of sexual arousal.

Medications used to treat depression can also significantly effect the female sexual response. The most frequently used medications for uncomplicated depression are the Serotonin Re-uptake Inhibitors. Women receiving these medications often complain of decreased sexual interest.

During menopause, a woman's ovaries stop producing the hormone estrogen. This can lead to changes that affect her sexual function. The main change is vaginal dryness. Lack of vaginal lubrication can make sex painful. Low levels of estrogen may also cause the walls of the vagina to thin and be more prone to sexual discomfort and injury. This can be corrected through estrogen-replacement therapy. The hormone is taken as a pill or absorbed through a patch. Locally applied vaginal cream can also be used.

Women do not lose their sexual drive during or after menopause. Most women continue to enjoy a sexually fulfilling life throughout their later years. Factors that could interfere with this include health and relationship problems, availability of partners, and emotional concerns that may accompany menopause.

The nature of a woman's sexual activity may change as she ages. She may take longer to become aroused and may need more stimulation to have an orgasm. Some older women have fewer vaginal contractions during orgasm. Older men may have difficulty getting or keeping an erection. As their sexual needs change with age, couples may move their focus away from the traditional genital-focused approach to other forms of sexual pleasure. These may include manual stimulation, oral-genital stimulation, and rubbing the external genitals against each other. For many couples, although the physical form of their lovemaking may change, the intensity, satisfaction and frequency remain unchanged.

Older couples who are not comfortable with creative diverse experiences of sexual behavior may find their sexual activity limited. At some point, couples may be content to stop having sex. If both partners are comfortable with this situation, it does not have a negative effect on their relationship.

Cancer and its treatment can affect a woman's sexuality. In addition to the anxiety produced by the diagnosis, a woman may have concerns about its effect on her future sexual capability. Cancer can also affect a woman's appearance and self-esteem, particularly if it involves loss of an organ. Emotionally, a woman is faced with the possibility of death, disfigurement, and the possible rejection by her partner, and physically, she must confront the rigors of surgery, radiation, and chemotherapy.

At the same time, there is no denying the role played by psychology. In women, despite the presence or absence of organic disease, emotional and relational issues significantly effect sexual arousal.

Issues such as self-esteem, body image, her relationship with her partner, and her ability to communicate her sexual needs with her partner, all impact sexual function. In addition psychological disorders such as depression, obsessive compulsive disorder, anxiety disorder, etc., are associated with female sexual dysfunction.

It remains a moot point in many instances where one sees both a somatic as well as a psychological cause as to which is the main factor. A women with an emotional problem may also have an associated somatic problem contributing to the dysfunction. Conversely, it is also true that sexual dysfunction brought on by a somatic problem is bound to have a psychological overlay.

Less than a decade ago, over 90% of erectile disorders were considered psychological in origin. We now know that this is not true and that somatic causes which have a known association with female sexual dysfunction must be ruled out.

The availability of certain therapies which have shown promise in managing female sexual dysfunction in no way means that your diabetes should not be well controlled.

A good clinical history along with specific testing can diagnose many of the medical conditions. It is essential that you are frank with your doctor about your problem. This is often the most crucial aspect which will help your doctor in judging the most optimal treatment for you.

You must also tell your doctor all the medications which you are taking. It may be that one of the medications which you are taking may be adding to your problem and a change to another medication may be all that may be required.

A good local examination will help in diagnosing local causes which may be the reason for the dysfunction. Your doctor may refer you to a gynaecologist for this.

There are some very evolving specialized tests are available at only some very specialized clinics, but these are rarely required in most cases.

Treatment of female sexual dysfunction is gradually evolving as more clinical and basic science studies are dedicated to evaluating the problem.

Provide Education

Provide information and education (e.g. about normal anatomy, sexual function, normal changes of aging, pregnancy, menopause). Provide booklets, encourage reading; discuss sexual issues when a medical condition is diagnosed, a new medication is started, and during pre- and postoperative periods; give permission for sexual experimentation.

Encourage use of erotic materials (videos, books); suggest masturbation to maximize familiarity with pleasurable sensations; encourage communication during sexual activity; recommend use of vibrators; discuss varying positions, times of day or places; suggest making a "date" for sexual activity.

Encourage erotic or nonerotic fantasy; recommend pelvic muscle contraction and relaxation (similar to Kegel exercise) exercises with intercourse; recommend use of background music, videos or television.

Recommend sensual massage, sensate-focus exercises (sensual massage with no involvement of sexual areas, where one partner provides the massage and the receiving partner provides feedback as to what feels good; aimed to promote comfort and communication between partners); oral or noncoital stimulation, with or without orgasm.

Female astride for control of penetration, topical lidocaine, warm baths before intercourse, biofeedback. Vaginal: same as for superficial dyspareunia but with the addition of lubricants. Deep: position changes so that force is away from pain and deep thrusts are minimized, nonsteroidal anti-inflammatory drugs before intercourse.

Disorders of desire in premenopausal patients may be secondary to lifestyle factors (e.g. careers, children), medications or another sexual dysfunction (e.g. pain or orgasmic disorder). Women with disorders of desire are difficult to treat.

Occasionally, decreased desire in patients is secondary to boredom with sexual routines. Your doctor may suggest changes in positions or venues, or the addition of erotic materials. No medical treatment is available specific to patients with disorders of desire. If no underlying medical or hormonal etiology is discovered, individual or couple counseling may be helpful.

In peri- and postmenopausal women, the relationship between hormones and sexuality is unclear. Nonetheless, estrogen replacement therapy has been shown to correlate positively with sexual activity, enjoyment and fantasies--the latter thought to represent desire.

Current treatment of patients with arousal disorders is limited to the use of commercial lubricants, although vitamin E and mineral oils are also options. Arousal disorders may be secondary to inadequate stimulation, especially in older women who require more stimulation to reach a level of arousal that was more easily attained at a younger age.

Encouraging adequate foreplay or the use of vibrators to increase stimulation may be helpful. Taking a warm bath before intercourse may also increase arousal. Anxiety may inhibit arousal, and strategies to alleviate anxiety by employing distraction techniques are helpful.

Urogenital atrophy is the most common cause of arousal disorders in postmenopausal women, and estrogen replacement, when appropriate, is usually effective therapy. However, women taking systemic estrogens occasionally require supplementation with local therapy.

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.

Investigators recognize that small-vessel atherosclerotic disease of the vagina and clitoris may contribute to arousal disorders and are exploring vasoactive medications as treatment. Small studies 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, is not recommended, although anecdotal success has been reported.

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.

Potential Uses

Increased pubococcygeal tone
Improved orgasmic intensity
Correction of orgasmic urine leakage
Distraction technique during intercourse
Improved patient awareness of sexual response

Teaching Kegel Exercises

Instructional examination with examiner's finger in vagina
Initial patient home exercise with patient's finger in vagina
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
Consider vaginal weights, biofeedback clinics

Maintaining Kegel Exercises

Advise repetitions during routine activities (standing in line, at stop lights etc.) Schedule follow-up appointments to discuss progress.

Treatment relies on maximizing stimulation and minimizing inhibition. 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. 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 referred to an appropriate therapist.

Dyspareunia can be divided into three types of pain: superficial, vaginal and deep. 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.

Aside from hormone replacement therapy, medical management of female sexual dysfunction remains in early experimental phases. Nonetheless, it is crucial to understand that not all female sexual complaints are psychological, and that there are possible therapeutic options.

Studies are in progress accessing the effects of vasoactive substances on the female sexual response. Aside from hormone replacement therapy, all medications listed below, while useful in the treatment of male erectile dysfunction, are still in experimental phases for use in women.

There are two widely divergent schools of thought as to the proper treatment of female sexual dysfunction but as with everything else in life, the best solution probably falls somewhere in between. The most important factor is recognizing that the problem exists and then taking steps to get optimal management.

One school of thought is the hormonal theory, which proposes that low levels of sex hormones cause female sexual dysfunction and that supplementing the deficient hormones will resolve the dysfunction. The other school, the vascular theory, is based on the premise that sexual dysfunction in women is related to decreased blood flow seen with age and certain medical conditions. This, in turn, leads to a decrease in pelvic congestion and vaginal blood flow that causes dryness and subsequent female sexual dysfunction. There is probably a great deal of crossover between these two schools of thoughts and there are probably a fair number of patients who will require both types of treatments to restore proper sexual functioning.

The hormonal school of thought is based on the fact that during a woman's lifetime, sex hormones produced in the body play a vital role in the sexual development and functioning, including both sexual and reproductive behaviors.

With aging and menopause, and the decreasing estrogen levels, a majority of women experience some degree of change in sexual function. Common sexual complaints include loss of desire, decreased frequency of sexual activity, painful intercourse, diminished sexual responsiveness, difficulty achieving orgasm, and decreased genital sensation.

Hormones play a significant role in regulating female sexual function. In animal models, estrogen administration results in expanded touch receptor zones, suggesting that estrogen effects sensation. Symptoms of low lubrication and poor sensation are in part secondary to declining estrogen levels, and that there is a direct correlation between the presence of sexual complaints and low levels of estrogen. Symptoms markedly improve with estrogen replacement.

In post-menopausal women, estrogen replacement restores clitoral and vaginal vibration and sensation to levels close to those of pre-menopausal women. Estrogens also have protective effects which result in increased blood flow to the vagina and clitoris. This helps to maintain female sexual response over time.

This treatment is indicated in menopausal women (either spontaneous or surgical). Aside from reliving hot flashes, preventing osteoporosis, and lowering risk of heart disease, estrogen replacement results in improved clitoral sensitivity, increased libido, and decreased pain during intercourse. Local or topical estrogen application relieves symptoms of vaginal dryness, burning, and urinary frequency and urgency. In menopausal women, or oophorectomized women, complaints of vaginal irritation, pain or dryness, can be relieved with topical estrogen cream. A vaginal estradiol ring is now available that delivers low-dose estrogen locally, which may benefit breast cancer patients and other women unable to take oral or transdermal estrogen.

Testosterone has always been considered the "male hormone," also plays a vital role in the normal functioning of women. It is testosterone that triggers the onset of puberty, which in an adolescent girl is the growth of pubic and axillary hair. Sexual sensitivity in the nipples and genital area and the susceptibility to stimulation is a testosterone-related function.

Male hormones are collectively known as androgens in contrast to the female hormones known as estrogens, which can be responsible for a woman's desire. Testosterone is extremely important to a woman. In addition to contributing to proper sexual functioning, it has also been shown that it contributes dramatically to a woman's ability to maintain the proper bone growth and bone density.

Testosterone is produced in a woman's body and it peaks during a woman's reproductive years. Most of the hormones that circulate in a woman's body are bound to something called sex hormone binding globulin or SHBG. This means that only a very small amount of testosterone is available for use by the body to maintain these vital functions. This fact is important because if we measure the total testosterone in an obese woman, it may be artificially high; but there is a large amount of testosterone that is bound to the SHBG in fat tissue and is not available for use by the body.

Your physician can measure available testosterone by ordering both a free and total testosterone blood test, which can provide both of these levels and aid in the correct diagnosis.

As a woman gets closer to menopause, the ovary makes a substantially lower amount of female hormone, estrogen, but also a great deal lower amount of testosterone, as well. As a woman goes through menopause and begins using estrogens in cream or pill form, the estrogens can use up the ability of this sex hormone binding globulin to bind the testosterone. This makes the actual amount of testosterone available for use by the body even less.

Some of the signs and symptoms of testosterone deficiency in a woman may include a loss of sexual desire and sexual fantasies or dreams, and decreased response to sexual stimulation in the nipples and the genital area, particularly the clitoris. There may be decreases in the ability to become aroused and the ability to achieve an orgasm.

Additionally, there may be a decrease in the sense of well being and a particularly noticeable loss of muscle tone. On examination one may notice thinning or loss of pubic hair and genital atrophy may be present, which is the thinning of the tissues surrounding the vagina. This may include both scarring and cracking that is not typically responsive to female hormones applied to the area in cream form. This condition can lead to extreme difficulty during penetration as well as severe pain. Finally, dry scalp with a loss of hair over certain parts of the head as in so-called male-pattern baldness can be apparent as well.

There is a great deal of scientific evidence that androgens, specifically the male hormone testosterone, are responsible for the sexual drive in females. The real question is when should a clinician recommend male hormone replacement, specifically testosterone, in women? Clinicians that are very knowledgeable would generally agree that in postmenopausal women with decreasing sex drive, testosterone is a very reasonable alternative, especially when a laboratory test shows a low serum testosterone.

You may be wondering why I have discussed estrogen replacement and especially androgen replacement in so much detail. This is not to preclude any decision taken by your doctor.

The decision to offer estrogen and/or androgen replacement will be made by your doctor after discussing all the pros and cons of the therapy. It should be a joint decision and therefore, I have discussed this aspect in some detail so that you have some background of the general consensus when discussing this aspect with your doctor.

The second theory of the origin of female sexual dysfunction, that of decreased blood flow, is based on the concept that female sexual dysfunction is related to a loss of blood flow to the pelvic tissues and a decrease in muscle relaxation in the tissues that comprise the vaginal tube and clitoris. These changes result in a decrease in vaginal lubrication and changes in the shape and diameter of the vaginal tube. Basically, this means the vaginal tube fails to dilate adequately in preparation for penetration. This theory is based on the idea that the female clitoris is very similar to the male penis and since erectile dysfunction in men is associated with a decreased blood flow, the problem must have a similar cause in women.

When a woman experiences a decrease in blood flow to the vagina, it can be manifested by a decrease in engorgement of the vagina with blood and a decrease in vaginal lubrication, which results in painful intercourse, diminished vaginal sensation, and an inability to achieve an orgasm.

Unfortunately, this is a very difficult theory to test in real life. In men it's easy. When blood flow to the penis is restored, one need only to measure the erection, its rigidity, and the length of time it took to create the erection, to know if the medication worked. This is not as easy in women. One could ask, "How much lubrication is there?" It is not well known that the lubrication in a woman's vagina is a transudate from the blood stream. A transudate is made up of the fluid part of blood that leaks from the blood vessels. How can one know what is a normal amount? It is generally agreed that roughly a teaspoon or 5 cc is about the amount of fluid produced by a woman when she becomes aroused. Decreased fluid production is a direct response to decreased blood flow.

• Sildenafil: This medication serves to increase relaxation of clitoral and vaginal smooth muscle and blood flow to the genital area. Sildenafil may prove useful alone or possibly in combination with other vasoactive substances for treatment of female sexual arousal disorder. Clinical studies evaluating safety and efficacy of this medication in women with sexual arousal disorder are in progress. Several studies are already published demonstrating efficacy of sildenafil for treatment of female sexual dysfunction secondary to SSRI use. Another study was recently published describing subjective effects of sildenafil in a population of post-menopausal women.
• L-arginine: This amino acid functions as a precursor to the formation of nitric oxide, which mediates relaxation of vascular and non-vascular smooth muscle. L-arginine has not been used in clinical trials in women; however preliminary studies in men appear promising. The standard dose is 1500mg/day.
• Phentolamine: Currently available in an oral preparation, this drug causes vascular smooth muscle relaxation and increases blood flow to the genital area. This drug has been studied in male patients for the treatment of erectile dysfunction. A pilot study in menopausal women with sexual dysfunction demonstrated enhanced vaginal blood flow and improved subjective arousal with the medication.

The future of female sexual dysfunction is extremely exciting. Perhaps the most exciting part is that it is just now coming of age. No longer will female sexual problems be considered psychiatric in origin and remain unaddressed. Doctors have finally realized that these problems usually have an organic basis and are not all in a patient's head.

Women who complain of sexual problems will now undergo a careful history and physical examination and may undergo various noninvasive tests that will pinpoint the exact diagnosis. Following an accurate diagnosis there are treatment options available which can dramatically improve one's sex life. Hormone supplements may also improve a whole host of other conditions in her body including her bone mineral density to prevent osteoporosis, her cardiovascular functioning, and possibly reverse the aging process.

Truly, "The times… they are a changing!"