Female Sexual Arousal Disorder - Treating Common Sexual Problems: Womens Sexual Health

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Female sexual arousal disorder

When a woman becomes aroused through thoughts and fantasies, physical stimulation, or both, blood flows to her pelvic region, causing her genital tissues to swell and her vagina to moisten (see "The phases of sexual response"). These changes indicate her physical readiness for sexual intercourse. With female sexual arousal disorder, however, the sequence breaks down, and the woman's body doesn't produce the necessary response.

Because for years this problem was considered evidence of either a psychological issue or a hormone imbalance, treatment was either counseling or estrogen therapy. Then medical researchers examined another possibility. Since blood flow plays a crucial role in arousal, researchers speculated that blood flow problems might produce arousal disorders in women, much the same way that diminished blood flow can cause erectile dysfunction in men. The search for a female Viagra was on.

However, researchers soon learned that arousal is more complex in women than in men. Pfizer, the maker of Viagra, tested the drug in women and found that it did alter blood flow to the genitals, but it did not improve libido in most women. Still, researchers are looking at other drugs and products aimed at increasing genital blood flow in the hopes that these will be effective treatments for female arousal problems.

Making a diagnosis

Your doctor will first want to hear your account of any problems you have becoming aroused and achieving and maintaining vaginal lubrication in response to sexual excitement. To find an effective treatment, your doctor must determine the possible causes. He or she will try to identify the influencing factors by asking you detailed questions about your general physical and emotional health, the stresses in your life, your relationship with your partner, your expectations about sex based on your upbringing, the amount of foreplay and direct stimulation you receive during lovemaking, the medications you're taking, and whether you've gone through menopause. It's likely that your doctor will also perform tests to check for blood flow issues or hormone imbalances, as these are principal sources of arousal disorders.

Treating vaginal dryness

Vaginal dryness is a common cause of female sexual arousal disorder. Decreased lubrication or lack of lubrication and loss of elasticity can make intercourse uncomfortable. These changes can be approached from two directions: using lubricants to treat the symptom of dryness, or using hormones to treat the cause of the problem.

Using artificial lubrication to ease vaginal discomfort is straightforward. A certain amount of vaginal elasticity will return naturally once adequate lubrication allows a woman to engage in regular intercourse. By contrast, hormone treatments — either topical or systemic — are designed to address the problem at its source. Decreased estrogen levels diminish vaginal secretions; thus, replacing estrogen after menopause can increase lubrication. Hormone therapy for menopausal symptoms, including vaginal dryness, is available in many different combinations and preparations, such as pills, patches, and vaginal creams. Vaginal hormone treatments — in which estrogen is applied directly to vaginal tissues — are often quite effective in reversing age-related thinning and dryness.

When weighing the right approach for treating vaginal dryness, carefully consider the severity of your symptoms, your medical history and health risks, and any other menopausal symptoms you may be having. The following information may help guide your choice.

Lubricants

If vaginal dryness is your primary or only concern, a lubricating liquid or gel that temporarily alleviates vaginal discomfort may be your best solution. The following products are available over the counter.

Astroglide. This is a clear, thin, odorless liquid with a slippery feel that closely approximates natural vaginal secretions. You can apply it to the vaginal opening or to the penis before intercourse. Astroglide is nonstaining and has a neutral pH, so it won't irritate the vagina or promote vaginal infections.

K-Y Silk-E. This gel was developed by the makers of K-Y Jelly especially for vaginal lubrication. Because it was formulated to mimic a woman's natural vaginal moisture, it's a better alternative than K-Y Jelly for treating vaginal dryness.

Replens. This lotion-like vaginal moisturizer clings to the vaginal lining, simulating natural secretions. Each application lasts 48 to 72 hours. Replens is a good option if your dryness is bothersome even when you're not engaged in sexual activity. Although it may make intercourse more comfortable, Replens is not a substitute for vaginal lubricants such as Astroglide or Silk-E. This lotion does, however, have the added benefit of making your vaginal environment more acidic, which helps ward off infections. Gyne-Moistrin is a similar product.

Hormone therapy

For perimenopausal and postmenopausal women, reintroducing estrogen into the vaginal tissues can reverse vaginal dryness, thinning, shortening, and other age-related changes, as opposed to the temporary relief of dryness offered by a lubricant. Estrogen can also ease other symptoms of menopause, such as hot flashes, night sweats, palpitations, headaches, and insomnia, but it carries some risks as well. Some studies have found that women taking certain hormone products, particularly those in which estrogen is taken orally, have a higher risk of heart attack, stroke, blood clots, and breast cancer. However, these studies have their critics, who point out that since only a few specific hormone preparations have been examined, it's unclear whether other hormone products carry the same risks (see "Postmenopausal hormone therapy: Your questions answered").

Estrogen comes in several forms with a range of doses and formulations. The benefits, risks, and side effects vary depending on the form of hormone replacement therapy used. Estrogen applied directly to the vaginal area (through a cream, gel, tablet, or ring) has fewer effects on the rest of the body because the hormone doesn't enter the bloodstream to the same degree as it does with pills or patches.

The following provides a brief overview of the different kinds of hormone preparations. Some doctors also prescribe Estratest, a pill that combines estrogen and testosterone, to treat menopausal symptoms and desire or arousal problems (see "Testosterone for women").

Estrogen and progestogen pills. These medications contain one or both hormones. They are quite effective in treating vaginal changes. Because these medications enter the bloodstream and have systemic effects, they also reverse bone loss and relieve hot flashes, insomnia, and other symptoms of menopause. Estrogen alone (called unopposed estrogen) is recommended only for women who have had a hysterectomy because taking the hormone by itself can raise the risk of developing uterine cancer. Adding a progestogen (a version of the hormone progesterone) to the formula protects against this risk.

Hormone patches. Applied like a Band-Aid, patches deliver a continuous dose of estrogen for up to a week. Patches are worn on the abdomen or buttocks and are replaced every three to seven days. Typically, an oral progestogen is used along with the patch, although some patches contain both estrogen and progestogen. Because this method delivers hormones systemically, it has some of the same benefits and drawbacks as hormone pills. But since the estrogen enters the bloodstream without passing through the liver, it may be a more natural way to take estrogen. It may not improve cholesterol levels to the same extent as products taken orally, but it avoids blood clotting and gallbladder problems seen with the pills. Some users report that the patch can itch or fall off.

Vaginal estrogen creams. In this therapy, a dose of cream is inserted into the vagina with an applicator two to seven days a week. Only small doses are needed to relieve vaginal dryness. Creams treat vaginal changes directly, so typically they don't address other menopausal symptoms, such as hot flashes. Initially, most of the estrogen is taken up in the vaginal tissue. However, as the vaginal lining is replenished, more of it is absorbed into the bloodstream. The use of vaginal estrogen cream has given way to more controlled delivery methods, such as an estrogen ring or patch. Estrogen cream should not be used as a lubricant before intercourse because it can be absorbed through a partner's skin.

Transdermal gels and creams. In these therapies, hormones are applied to the skin and work systemically to treat all menopausal symptoms. One product, EstroGel, comes in a clear, odorless, alcohol-based gel that's delivered from a metered-dose pump. The gel is applied once a day on one arm from the wrist to the shoulder. The gel dries completely in two to five minutes. Another product, Estrasorb, is a cream that comes in individual foil packets and is rubbed into the thighs and buttocks.

Estrogen rings. For this therapy, you insert a ring into the vagina in much the same way that you insert a diaphragm. The ring releases estrogen gradually and needs replacement about every three months. Two types of rings are currently available: one that offers local effects and one that is systemic. Estring releases a low dose of estrogen that is not absorbed into other areas of the body — which means you avoid the effects associated with hormone pills and patches, but you won't get relief from hot flashes and other menopausal symptoms. Femring contains higher doses of estrogen and offers systemic effects, so it treats hot flashes and other menopausal systems in addition to vaginal dryness. Although both rings can be removed temporarily and reinserted, neither type has to be removed before sexual intercourse.

Vaginal estrogen tablets. An estrogen tablet, sold as Vagifem, inserted into the vagina with an applicator twice a week, can relieve dryness and irritation. This form of medication treats only vaginal symptoms. Since very little estrogen is absorbed into the body, the tablet doesn't carry the risks of systemic medications and won't relieve other symptoms of menopause.

Testosterone cream. If vulvar atrophy is advanced, your genital tissue may respond to a low-dose testosterone cream. The cream is rubbed directly into the vulva three nights a week. Because the FDA has not approved testosterone creams for use in women, they are available only through compounding pharmacies, which assemble ingredients to make medications prescribed by doctors.

Increasing genital blood flow

Speculation that women's arousal difficulties may be related to insufficient blood flow opened another possible avenue of treatment for female sexual arousal disorder. But efforts to find a female Viagra haven't panned out thus far. The drug company Pfizer had long hoped to prove that Viagra improved sexual function in women. But after eight years of testing failed to yield the desired results, Pfizer announced in 2004 that it would no longer test Viagra on women. Interestingly, studies found that the drug increased genital blood flow, but for most women that didn't translate into a greater desire to have sex. Still, other researchers and companies are studying and selling products aimed at increasing genital blood flow in women. Here's a closer look at a few of them.

Topical medications. Researchers are studying several creams and gels that deliver medication to widen blood vessels. These products are rubbed into the genital tissues before intercourse to enhance arousal. One such gel, made with prostaglandin E-1, is undergoing clinical trials under the brand name Femprox. Prostaglandin E-1, a naturally occurring substance, is the active ingredient in the drug alprostadil, which is used for penile injection therapy. A small 2005 study conducted by the maker of the cream found that the cream was helpful, but more study is needed. Researchers are also investigating the effectiveness of a vaginal suppository that delivers phentolamine, another medication used in penile injection therapy. Additionally, the over-the-counter supplement Zestra claims to enhance sexual function in part by increasing genital blood flow (see "Alternative therapies for sexual problems").

Mechanical devices. A small pumplike device — consisting of a small plastic cup that fits over the clitoris and surrounding tissue — uses suction to draw blood into the clitoris, causing it to swell. This FDA-approved unit is sold by prescription to women with arousal disorders under the brand name Eros-CTD (clitoral therapy device).

Sex therapy techniques

If your doctor feels your problem has emotional roots, he or she will recommend sex therapy as the first step in treatment. The sex therapist's role is to help you identify the thoughts, feelings, and behaviors that might be interfering with your sexual enjoyment. He or she will also help you become more in touch with your erotic feelings and grow more comfortable with your sexuality. In addition to sensate focus exercises, the therapist will encourage you to try a range of techniques, such as sexual fantasy training, masturbation exercises, and the use of erotica and vibrators. Because many women find that being able to share their feelings with their partner is a prerequisite for arousal, therapy will also concentrate on improving communication and enhancing feelings of intimacy between you and your partner.

Last updated:	January 23, 2007