Arousal Disorder (Lack of Lubrication)

Content written by Irwin Goldstein MD

OVERVIEW:

Women with female sexual arousal disorder have a persistent or recurrent inability to attain, or maintain until completion of the sexual activity, an adequate lubrication swelling response of sexual excitement, that causes marked distress or interpersonal difficulty and is not better accounted for by such conditions as depression, anxiety, bipolar disorder, attention deficit hyperactivity disorder, etc, and is not due exclusively to the direct physiological effects of a drug of abuse, or a medication such as an anti-androgen, etc or a general medical condition.

Women with female sexual arousal disorder can be subclassified as having a subjective sexual arousal disorder. A subjective sexual arousal disorder is consistent with an absence or markedly diminished feeling of sexual excitement or sexual pleasure from any type of sexual stimulation, however, vaginal lubrication or other signs of physical response, such as throbbing, pulsations, engorgement, and swelling still occur.

Women with female sexual arousal disorder can be subclassified as having a genital sexual arousal disorder. A genital sexual arousal disorder is consistent with an absence or impaired genital sexual arousal that may include problems with limited vulvar swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from stroking or touching the genitalia, however, subjective sexual excitement still occurs from non-genital sexual stimuli, such as from the breast.

Women with female sexual arousal disorder can be subclassified as having a combined genital and subjective arousal disorder. A combined genital and subjective arousal is consistent with an absence or markedly diminished feeling of sexual excitement or sexual pleasure from any type of sexual stimulation as well as complaints of absent or impaired genital sexual arousal involving problems with vulval swelling, throbbing, pulsations, engorgement and/or vaginal lubrication.

In a national survey of women in heterosexual relationships. over 30% of the sample complained of lubrication while 7% reported personal distress about poor lubrication. Often women female sexual arousal disorder will complain that they have dead genitals. The prevalence of the female sexual arousal difficulties, with lack of “lubrication-swelling response” has been reporte range between 11% and 31%. The prevalence of subjective sexual arousal difficulties is less well known except for one study which found a prevalence of approximately 17%. Like desire complaints, when distress is also considered, the prevalence of arousal impairment drops markedly to approximately 6-7%.

CAUSES:

Sexual arousal, especially subjective sexual arousal, may be the result of a multifaceted balance of brain excitatory and inhibiting neurochemicals. The most important brain neurochemicals involved in excitatory subjective arousal include norepinephrine, dopamine, oxytocin, and melanocortins. The most important brain neurochemicals involved in inhibitory subjective arousal include serotonin, prolactin, opioids and endocannabinoids. The actions of these facilatory neurochemicals are modi?ed and in?uenced by the endocrine milieu provided by testosterone, estrogen and progesterone.

Psychological issues, such as sexual abuse, emotional neglect in childhood, traumatic experiences during puberty, perceived stress, distraction/attention, self-focused attention, anxiety, depression, personality variables, and body image self-consciousness may cause subjective arousal problems in various ways. There may be problems with motivation to have sexual activity especially concerns with the need to be emotionally close to the partner, to satisfy the partner, to feel like a woman, or to feel accepted. There may be problems with cognitive pathways referring to the meaning given to the sexual activity, where previous experiences may have provided negative memories.

Biologic issues may cause genital arousal problems in various ways. There have been research studies showing the negative impact on genital sexual arousal of chronic medical illness, hypothyroidism, metabolic syndrome, obesity, hyperlipidemia, diabetes, testosterone deficiency syndrome, childbirth, cancer surgery, chemotherapy, radiation therapy, menopause, oral contraceptives, antidepressants, and infertility treatments

SYMPTOMS:

Women with female sexual arousal disorder from a subjective sexual arousal disorder complain of an absence or markedly diminished feeling of sexual excitement or sexual pleasure from any type of sexual stimulation, however, vaginal lubrication or other signs of physical response, such as throbbing, pulsations, engorgement, and swelling still occur.

Women with female sexual arousal disorder from a genital sexual arousal disorder complain of an absence or impaired genital sexual arousal. These women complain of problems with achieving sexually arousal such as a wet vulva, engorged labia, nipple erection, vaginal lubrication, congestion of the vaginal walls, tumescence and erection of the clitoris, and swelling of the labia.

Women with female sexual arousal disorder from a combined genital and subjective arousal disorder complain of absence or markedly diminished feeling of sexual excitement or sexual pleasure from any type of sexual stimulation as well as complaints of absent or impaired genital sexual arousal involving problems with vulval swelling, throbbing, pulsations, engorgement and/or vaginal lubrication.

DIAGNOSTIC TESTS:

Women with female sexual arousal disorder should undergo a biopsychosocial evaluation. This begins with a thorough and comprehensive clinical interview that includes discussion of the presenting problem of lack of subjective arousal, lack of genital arousal or a combination of the two and the predisposing, precipitating, and maintaining factors. Among these factors are life stage stressors such as childbirth, infertility, divorce or partner loss, unemployment, extra-relationship affairs, humiliating or traumatic sexual experiences, partner sexual inadequacy or clumsiness, and relationship discord.

It is helpful to attempt to determine what the immediate triggers or precipitating factors are for the sexual arousal complaints as these are likely to be important areas to address in the early stages of treatment. Assessment of perpetuating or maintaining factors includes the current contextual factors that affect sexual expression such as relationship satisfaction, privacy issues, current health of self and partner, medical or psychiatric issues, use of medications or recreational drugs/alcohol that may affect sexual expression, and current stressors.

For women with sexual arousal disorder, a thorough assessment should include an in-depth interview during which adequacies of sexual stimuli are assessed. Validated self-report measures may be helpful to corroborate information obtained from the interview.

Laboratory investigations may be considered in women with sexual arousal disorders. Estrogen defciency is detected by taking a history and performing a physical examination. Measurements of estradiol, leutinizing hormone and follicle stimulating hormone are indicated in some women especially, in amenorrheic young women or in women with irregular menstrual patterns or to evaluate menopausal status in hysterectomized women. Measurements of testosterone and sex hormone binding globulin may also be indicated in women with female sexual arousal disorder. Testosterone replacement treatment in women with testosterone deficiency syndrome has been shown to improve sexual arousal. Measurements of thyroid function and prolactin may also be indicated in women with female sexual arousal disorder who have symptoms or signs of thyroid disease or hyperprolactinemia.

A carefully focused genital/pelvic examination is needed when there are complaints of loss of genital sensitivity or vulvo-vesibular pain or lack of vaginal swelling or lubrication to rule out or identify medical factors. A physical examination

should include an evaluation of the level of voluntary control of the pelvic ?oor muscles, pelvic ?oor muscle tonus, presence of vaginal wall prolapse, signs of vaginal atrophy, size of introitus, presence of discharge, or evidence of infection (acute or chronic), epithelial disorders, and/or pain.

There are some additional diagnostic laboratory studies that have been proposed in women with female sexual arousal disorder. These include dynamic sonography, magnetic resonance imaging of the pelvic area, thermal imaging, clitoral color Doppler ultrasonography, measurement of vaginal pH, and clitoral photoplethysmography. More research needs to be performed on the value of these studies in women with female sexual arousal.

TREATMENT:

General issues should be addressed related to well-being, diet, exercise, alcohol and chemical substance abuse, sleep, advice on prescription and nonprescription medications, vitamins and herbal supplements, and recreational drugs. Referral to appropriate medical or specialty providers may be necessary. The early stage of treatment might also include providing information on basic genital anatomy and physiology, and a discussion of sexual stimulation and the variety of sexual activities.

Psychological treatment of sexual arousal problems generally consists of sensate focus exercises and masturbation training, with the emphasis on becoming more self-focused and assertive. There are limited well-controlled randomized trials of psychological treatments for female sexual arousal disorder.

Biologic treatment of women with female sexual arousal disorder includes use of hormones. There is evidence that treatment with local and systemic estrogen bene?ts vulvo–vaginal atrophy and relieves vaginal dryness and dyspareunia. The most abundant and potent estrogen before menopause is 17 beta-estradiol. The primary source of estradiol in premenopausal women is the granulosa cells of the ovaries. After menopause, estradiol is produced in extragonadal sites from androgens.

An adequate estradiol level is important for maintaining vaginal lubrication and avoiding dyspareunia, however, low estradiol levels not invariably result in dyspareunia. There are some human data linking improved genital sensitivity to estrogenized tissue.

Lack of estradiol has been found related to dyspareunia and vaginal dryness. However, many women with low estradiol do not have dyspareunia. An association between reduced estradiol and decreased sexual desire has been only described clinically. There is some limited evidence to af?rm that there is an association between reduced vulvar sensitivity to pressure/touch and estradiol de?ciency.

A limited number of studies have investigated potential bene?cial effects of testosterone on sexual arousal. In a placebo-controlled study in women with low testosterone, treatment with testosterone for two months enhanced genital arousal. The androgens include testosterone, dehydroepiandrosterone, androstenedione, dihydrotestosterone. Of the androgens, testosterone and dihydrotestosterone have the most potent biological activity. Dehydroepiandrosterone, and androstenedione are adrenal and ovarian precursor androgens that can be metabolized into testosterone and dihydrotestosterone, and estradiol in peripheral tissues. Testosterone circulates in the body bound by a variety of proteins, including albumin, and most importantly, sex hormone-binding globulin (SHBG). Testosterone bound to sex hormone-binding globulin is essentially not biologically available. Testosterone levels peak when women are in their 20s and drop gradually with age, so that women in their 40s have approximately half the level of circulating total testosterone as women in their 20s. Testtosterone levels do not decline consistently during or after menopause. Testosterone is known to act on multiple tissue and receptor sites throughout the body, including clitoris, minor vestibular glands, vaginal muscularis and pelvic floor striated muscles.

Testosterone insufficiency in women with adequate estrogen levels could lead to a diminished sense of well-being and energy, fatigue, and decreased sexual desire.

The brain uses neurosteroids that strongly influence sexual interest and motivation. Sex steroid production and action within the brain may be as relevant to women’s sexual function as peripheral testosterone.

The great variability in the responsiveness of women to treatment with testosterone is another confounding factor that may relate to polymorphic variations of the androgen receptor.

A recent study studied the effect of the vaginal application of dehydrotestosterone on vaginal atrophy in postmenopausal women. There was a rapid bene?cial change in the maturation of the vaginal epithelial cells and vaginal pH with positive effects on sexual arousal, desire, orgasm, and pain as measured by validated sexual function questionnaires.

The effects of phosphodiesterase type 5 inhibitors such as sildenafil in women with female sexual arousal have been investigated in several controlled and uncontrolled studies.

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