1. Female Sexuality and
Female Psychosexual Dysfunction
Dr Süleyman E. Akhan
Istanbul University School of Medicine
Department of Obstetrics and Gynecology

2. Sexuality is a multi-
dimensional concept with
ethical, psychological,
biological and cultural
dimensions.
Sexuality reflects human
character and the way in
which people interact.

3. Sexuality is the lifelong process of
acquiring information and
developing values about one’s
identity, relationships and intimacy.
It includes learning sexual
development, reproductive health,
interpersonal relationships, affection,
body image, and gender roles.

4. genotype
 The main organ that affects male and female
sexual response is the BRAIN.
learning process
pre-and postnatal
hormonal environment
experience

5. Estradiol
aromatization
Sex Steroids
Testosterone
ER-b
Progesterone
PR
isoforms
DHTAR
Genomic &
Non-Genomic
Mechanism
P metabolites
Gaba
Res.
ER-a
Neurotransmitter
Neuropeptide
Neuromodulator
Growth Factors
Cytokines
Other factors....
Psychosocial
Factors
Experience
Partner
Sexual attitude of partner
Sexual Behavior

6. The perception of sexuality is
different for each individual.
Is unique.
The main factors affecting this individuality is
how we spend our adolescence and form
our relationship with the opposite sex.

7. Activated Areas During “Sexual Arousal”
Medial insula
Anterior cingulate cortex
Hippocampus
Striatum
Nucleus accumbens
Hypothalamus
Concentration of dopamine is high in all these areas.

8. Inactivated Areas During “Sexual Arousal”
Amygdala
Frontal cortex
Prefrontal cortex
Temporal pole
Prefrontal cortex is responsible for control mechanism.
Amygdala acts like our emotional memory. Our fears, emotional
moments, events that cause our worry are all evaluated and
stored.

9. Sexually Sensitive Areas
Clitoris
Vagina
Nipples (areola)
Breasts
Labium

10. Sexual Response Cycle of the Woman
 Sexual response cycle of woman consists of 5 phases:
1. Sexual desire phase: Can last for days. Fantasies, dreams about
the sexual object.
2. Arousal phase: Can last from 1-2 minutes to hours.
3. Plato phase: Between 30 seconds to 3 minutes.
4. Orgasm phase: 3-15 seconds
5. Relaxation phase: 10-15 minutes
 In this cycle, there are two basic physiologic processes:
Vasocongestion
Neuromuscular tension– Myotonia
 Vasocongestion takes place in lower and upper genital organs and
breasts, while myotonia takes place in the whole body.

11. Sexual Desire Phase
Motivation to be sexual
Subjectivity (Experience)
Adequate neuroendocrine function
Sexual orientation
Choice
Psychological status
Environmental factors

12. Arousal Phase
 Can last from 1-2 minutes to hours. As a result of parasympathetic
stimulation.
Changes in organs that take place during arousal phase:
 Nipples: Harden. Length can go up to 1cm. In addition, breast volume
increases due to congestion.
 Clitoris: Length of clitoris increase with venous congestion.
 Labium majus: Labium majus moves upward and opens outward with
erection.
 Labium minus: Increase in size 2-3 times both in nullipara and
multipara. Finally, vagina goes out of vault, passes labium majus by
1cm and becomes visible. In nullipara, its color is bright pink, while its
color is dark red in multipara.

13. Vagina:
 When there is an effective sexual stimulation, there is a light colored
vaginal secretion 10-20 seconds after the initiation of the stimulation.
 The stimulation can by physical or psychological. Secretion is in
transuda form. When venous plexus that surrounds vagina fills up
with venous congestion and dilated, capillary permeability increases.
Then, droplets are formed in vagina and vaginal secretion is released.
 Secretion has two purposes:
1. Providing vaginal lubrication
2. Neutralizing vaginal acidity.
 Another important change is the increase of length up to 3 cm in
vagina.

14. Plato Phase
 Lasts around 30 seconds to 30 minutes. In 75% of women, there will
be red spots, known as sexual flash, on the breasts and the skin. In
reality, these spots start in the late section of the arousal phase and
continue in the plate phase.
 It is argued that the red areas are correlated to the intensity of the
sexual arousal.
 Breasts are tense and increase in size.
 Clitoris becomes erect and only mechanical stimulus can be enough to
reach orgasm.
 Uterus re-locates in this phase. It is lengthened to the vagina.
 Near the end of this phase, uterus starts to contract.

15. Orgasm Phase
 Orgasm can be described as the conclusion of the
vasocongestion, release of the collected blood and following
stage of myotonia.
 It is the shortest phase of all phases. It can only be reached
when there is maximum sexual tension.
 Uncontrolled muscle contractions happen every 0.8 seconds.
3-15 contractions can happen. During this phase, uterus also
contracts.

16. Relaxation Phase
Last phase of the sexual response. It is the phase
with the most varying length.
If orgasm is reached, it can last up to 15 minutes. If
orgasm is not reached, it can last up to 1 day.
Clitoris can turn into normal shape in 10-15
seconds. It will take 15 minutes to turn back to
totally normal function. If orgasm is not reached,
this period can go up to 6 hours.

17. Sexual Response
Cycle of the Woman
1. Sexual desire phase: Can last for
days. Fantasies, dreams about the
sexual object.
2. Arousal phase: Can last from 1-2
minutes to hours.
3. Plato phase: Between 30 seconds to
3 minutes.
4. Orgaxm phase: 3-15 seconds.
5. Relaxationp phase: 10-15 minutes.
ParasimpaticSimpatic

18. Biopsychosocial Approch to
Female Sexual Function Cycle
Basson R. Obstet Gynecol 2001;98:350–353
Emotional and
physical
satisfaction
Arousal and
sexual desire
Sexual arousal
Emotional
intimacy
Sexual stimuli
+
+
motivates the sexually
neutral woman to
find/be responsive to
psychological and
biological factors
govern “arousal”
“Spontaneous”
sexual drive
“hunger”

19. Hormones that Influence Female Sexuailty
1. Estrogen
 Sexual Identity: Secondary sexual characteristics
 Functional Influence:
a. Sexual desire: indirect influence (direct
influence??)
b. Arousal: Vasocongestion, vasodilation,
lubrication
c. Orgasm: Matures the orgasmic platform.
 Influence on the Relation: Builds up woman’s unique
scent (??)

20. 5. Androgens
 Basic hormones that have central influence and triggers
sexual desire and central arousal.
 Modulate peripheral arousal.
 Influence secretion of NO.
 Increase clitoral arousal.
 Increase “life energy”. Induce self-esteem.
 Influence pheromone (??).

21. Sexual Desire
Arousal,
Desire for arousal
Orgasm
Experience-
Satisfaction
Systemic Androgens
Systemic
Estrogens
Graziottin A. 2005
Basic Flow Diagram of
Female Sexual Oritentation

22. Oxytocin Vasopressin
Known as coupling and love hormones
Oxytocin and V1a type vasopressin receptors are located at
dopaminergic areas that are activated during romantic love.
Oxyitocin; anxiolytic. Named as the trust hormone. Increases in
the beginning of romantic love.
Vasopressin increases response to fear and stress. Induces man’s
claiming urge.

23. Oxytocin - Vasopressin
Field Rat
Monogamous
One partner lifelong
More oxytocin receptors at
prelimbic cortex, nucleus
accumbens and amigdaloid
complex
Mountain Rat
Polygamous
 Randomized partner
selection
Less vasopression
receptors (V1a) at lateral
amigdala, ventral pallidum
Vazopressin reseptörleri
Vasopressin
V1a
receptor
Lim 2004

24. Oxytocin - Vasopressin
Oxytocin
Vasopressin
Oxytocin
Vasopressin

25. Dopamine
 D1 receptors are important after coupling
Increase in number
Avoids new coupling
Beninger & Miller, 1998; Edwards & Self, 2006
Dopamine
antagonist

26. When we live so synthetically
in the modern world, can
sexuality and love be
manipulated with hormones?
Should we?
Shouldn’t we?

27. Female Sexual
Dysfunction
Organic
• Neurological problems
• Cardiovascular diseases
• Cancer, gynecological
cancers
• Urogynecologic pathologies
• Drugs
• Hormonal disorders
Psychological
• Depression/anxiety
History of sexual and/or
physical assault
• Stress
• Alcohol and/or drug
addictions.
Sociocultural Factors
• Inadequate education
• Conflict with religious,
personal, family values
Social taboos
Relationship Level
• Performance of the partner
• Loss of the partner
• Quality of the relation
• Loss of specialness

28. Reasons for Female Sexual Dysfunction
 Female sexual dysfunction can be temporary, episodic or
continuous
 Can resolve by itself or need treatment
 Reasons are evaluated in 2 headings.
I- Psychosocial Factors
 Mental inhibition, education that refused sexuality during
growing-up: pleasure regarded as a sin ethically.
 Past psychosexual trauma.
 Fears: unwanted pregnancy, somebody finding out about the
cohabitation, pain during coitus
 Problems with the partner: Not desiring intimacy with the
partner, relations that are falling apart.

29. II – Organic Problems
Gynecologic and Systemic Diseases:
 Vulvitis, kolpitis, atrophy, vaginal stenosis
 Endometriosis, intra-abdominal adhesions
 Gynecologic surgeries, specially radical surgeries
 Systemic disease: Malignant tumors, diabetes, stress related
exhaustion, depression, multiple sclerosis
 Drugs: Contraceptives, tricyclic antidepressant, MAO
inhibitors, antihypertensive drugs

30. Sup. Hipogastrik pleksus
(sempatik innervasyon)
İnf. Hipogastrik pleksus
(parasempatik innervasyon)

31. Radical Hysterectomy
Oophorectomy
Pelvic Radiotherapy
Chemotherapy
Vulvectomy
 Damage to the innervation of the pelvic
floor musculature
 Shortness of the vagina
 Decreased lubrication
 Dyspareunia
 Decrease in desire???
 Decreased lubrication
 Dyspareunia
 Fibrosis and stenosis
 Tiredness
Nausea, vomiting
Depression
 Anatomic anomalies

32. Female Sexual Dysfunction
1999 Consensus Classification System
(The Journal of Urology. Basson R. 2000)
 Sexual Desire Disorders
Decreased Sexual Desire (hypoactive)
Sexual Aversion Disorder
 Sexual Arousal Disorder
 Orgasm Related Disorders
 Sexual Pain Disorders
Dyspareunia
Vaginismus
Other sexual pain disorders

33. What should we do to identify the problem?
High sexual orientation
High motivation
Normal sexual desire and
motivation
High sexual orientation
Low motivation
Question the quality of the sexual intercourse
and the relation with the partner
Low sexual orientation
High motivation
Evalute the hormone profile
Primarily the androgens and
PRL
Low sexual orientation
Low motivation
Which one comes first?
Question depression, biochemical
environment and the quality of the
relationship Derogatis 2002

34. Female Sexual Dysfunction
1999 Consensus Classification System
(The Journal of Urology. Basson R. 2000)
 Sexual Desire Disorders
Decreased Sexual Desire (hypoactive)
Sexual Aversion Disorder
 Sexual Arousal Disorder
 Orgasm Related Disorders
 Sexual Pain Disorders
Dyspareunia
Vaginismus
Other sexual pain disorders

35. Female Sexual Dysfunction
1999 Consensus Classification System
(The Journal of Urology. Basson R. 2000)
 Sexual Desire Disorders
 Decreased Sexual Desire (hypoactive)
 Sexual Aversion Disorder
 Sexual Arousal Disorder
 Orgasm Related Disorders
 Sexual Pain Disorder
 Dyspareunia
 Vaginismus
 Other sexual pain disorders
Subjective
Genital

36. The Factors Affecting Female Sexual Function and
the Relation with Different Contraception Methods
Süleyman Engin Akhan, Ümran Oskay, Ebru Alıcı, Funda Güngör, Samet
Topuz, Cem İyibozkurt, Önay Yalçın
Department of Obstetrics and Gynecology,
Istanbul University School of Medicine, Istanbul

37. Results
 Totally 349 cases were taken into consideration.
 They were 32,59±7.04 old on average and the number
of weekly intercourse were 2,36±1,34 on average.
6.6% (23/349) were single.
 While 39.8% of women used coitus interruptus as a
contraception method,
 21.5% used IUD,
 16.3% preferred condom,
 10% used oral contraceptive,
 5.2% preferred tubal ligation
 7.2% used none of the methods.

38. 24.6% of them were masturbating in different
frequencies, 5% were performing anal sex and
26.1% were performing oral sex.
36.7% were complaining of dyspareunia. Sexual
dysfunction was identified in 24.4% of the
partners.

39. It is interesting that women performing oral sex was an
independent factor which had a positive effect on
arousal (p=0.02; RR=0.54; [95%CI: 0.32-0.909]),
orgasm (p=0.0045; RR=0.48; [95%CI:0.29-0.8]) and
total score (p=0.016; RR=0.505; [95%CI:0.28-0.88]).
Woman performing oral sex, can be a sign of woman
being capable of sexuality (motivated sexually or
having a good sexual drive) and have a healthy
relationship with her partner on a sexual level. So, the
arousal and orgasm scores of women performing oral
sex are affected positively.

40. Number of sexual intercourse showed negative correlation with
age (-0.151; p=0.005) and the number of deliveries (-0.140;
p=0.009). As the number of deliveries increases, the number of
sexual intercourse decreases and the domains of desire, arousal
and satisfaction were influenced negatively.
Desire Arousa
l
Lubrication Orgasm Satisfaction Pain Total Score
Age
Pearson coeff.
p
- 0,91
0,0001
- 0,125
0,02
- 0,018
0,027
- 0,106
0,047
- 0,204
0,0001
- 0,94
0,078
- 0,138
0,01
Partus
Pearson coeff.
p
- 0,147
0,006
- 0,109
0,042
- 0,077
0,154
- 0,061
0,253
- 0,145
0,007
0,94
0,81
- 0,092
0,085
Education
Pearson coeff.
p
- 0,68
0,208
0,41
0,443
0,069
0,201
0,033
0,538
0,023
0,666
0,094
0,081
- 0,092
0,085
Number of coitus
/week
Pearson coeff.
p
0,181
0,001
0,189
0,0001
0,171
0,001
0,17
0,001
0,186
0,0001
0,012
0,828
0,203
0,0001

41. Factors that directly affect
female sexuality
Age
Physical and
Emotional Health Education
Quality of the relationship
with the partner
Sexual Performance
of the Partner
Hormonal Status