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.

Female Anatomy

Female Sexual Response Cycle
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.

Classifications & Definitions of Female Sexual Dysfunction

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.

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.